Patterns of Dementia Treatment and Frank Prescribing Errors in Older Adults With Parkinson Disease

Abstract

Importance: Dementia is common in Parkinson disease (PD), but there is little data on dementia treatment patterns or the concomitant use of cholinesterase inhibitors (ACHEI) and anticholinergic medications (ACH), a frank prescribing error. Objective: To determine the prevalence of dementia treatment and to quantify and characterize inappropriate administration of a high-potency ACH (ACHhigh) drug and an ACHEI among persons with PD. Design, Setting and Participants: This cross-sectional analysis included participants in the U.S. Medicare Prescription Program in 2014 diagnosed with Parkinson Disease. Main Outcomes/Measures: Our primary outcomes were (1) prescription fill for a dementia drug (2) concomitant prescription fills for an ACHEI and an ACHhigh drug. Descriptive analyses and multivariable logistic regression models determined the extent to which patient characteristics and comorbid conditions were associated with dementia treatment or with an ACHhigh-ACHEI event. Results: 268,407 Medicare beneficiaries diagnosed with PD met inclusion criteria; 73,093 (27.2%) were prescribed at least one anti-dementia medication. The commonest medication was donepezil (n=46,027; 63.0% of users) followed by memantine (n=30,578, 41.8%), rivastigmine (n=19,278, 26.4%). Compared to whites, dementia medications were more likely to be prescribed to Blacks (adjusted odds ratio [AOR] 1.33, 95% confidence interval [CI] 1.28–1.38) and Hispanics (AOR 1.28, 95%CI 1.22–1.35) and less likely to be prescribed to Native Americans (AOR 0.62, 95%CI 0.51–0.74). Women were less likely to be prescribed a dementia medication (AOR 0.85, 95%CI 0.84–0.87, compared to men). Of the 64,017 PD patients receiving an ACHEI, 44.5% (n=28,495) had at least one ACHhigh-ACHEI event. Hispanics (AOR 1.11, 95%CI 1.00–1.23) and women (AOR 1.30, 95%CI 1.25–1.35) had greater odds of this ‘never event’. There was statistically significant clustering in the prevalence of this prescribing error (Moran’s I = 0.24; p < 0.001), with clusters of high ACHhigh-ACHEI prevalence in the Southern and Midwestern United States. Conclusions and Relevance: Dementia medication use varies by race and sex among persons with PD. Potentially inappropriate prescribing is common among PD patients being treated for cognitive impairment, and varies substantially by race, sex and geography. These data provide national and local targets for improving care quality and outcomes for persons with PD.

Ethnic Variation in the Manifestation of Parkinson’s Disease: A Narrative Review

“…Similar findings have been observed for Hispanic patients in some settings [23]. Hispanic patients may have a more severe form of PD dementia and/or an increased severity of behavioural and psychological symptoms in dementia [122]. The evidence regarding Asian PD patients and cognitive dysfunction is more conflicting.…”

“…This finding has been replicated [157,159] and there is evidence the inequalities extend to the treatment of depression and advanced therapies in PD patients as well [160][161][162]. Amongst the minority ethnic patients that do receive treatment prescribing errors are more likely; Hispanic PD patients have an increased probability of being co-prescribed an anticholinesterase inhibitor and a high potency anticholinergic; a frank prescribing error [122]. To summarise, PD patients from minority ethnic backgrounds in the USA are less likely to be cared for by a neurologist, receive a diagnosis and be treated adequately for their PD.…”

“…70% of the whole sample was diagnosed with dementia by the end of the study, and the proportion was highest in Black patients [23]. Black PD patients also have higher odds of bring prescribed dementia medications (OR 1.33, 95% CI 1.28-1.38) compared with White PD patients which may reflect increased cognitive dysfunction [122]. Overall, unlike the inconsistencies of other non-motor and motor symptoms, current evidence supports the notion that Black patients are more at risk of dementia and cognitive impairment than White patients.…”

Anticholinergics May Carry Significant Cognitive and Gait Burden in Parkinson's Disease

“…Among our patients, 58.4% had exposure to significant anticholinergic burden defined as total ACB score > 3. This is similar to cohorts from Canada (57.8%), 1,2,35 Spain (53.6%), and France (3 of 5 prescriptions) (Table 2). Concomitant anticholinergic use was also a common prescription error in patients with PD with dementia treated with cholinesterase inhibitors 35 .…”

Evolution of Initial Pharmacologic Treatment of Newly Diagnosed Parkinson’s Disease Patients over a Decade in Singapore

“…In addition, it is increasingly recognized that PD patients may have cognitive impairment even early in their disease course [14]. A recent study showed that inappropriate prescribing patterns are common in older PD patients who may be on anticholinergics and dementia treatment at the same time [15].…”