New opioid use in older adults with dementia is associated with a significantly increased risk of death, including an elevenfold increase in the first two weeks, according to research reported on July 18, at the Alzheimer’s Association International Conference® (AAIC®) 2023, in Amsterdam, Netherlands, and online.
According to the AAIC press release, the study population included everyone in Denmark aged 65 and older who was diagnosed with dementia between Jan. 1, 2008, and Dec. 31, 2018, including those living at home and nursing home residents. Of that group, 42 percent (31,619) of those diagnosed with dementia redeemed a prescription for an opioid at a pharmacy.
The researchers followed study participants for 180 days after their first opioid prescription. They also followed a group of older adults with dementia who did not receive an opioid prescription and compared risk of death between the two groups.
- 10,474 (33.1 percent) study participants died within 180 days after initiating their first opioid prescription, compared with 3,980 (6.4 percent) of the unexposed. After adjusting for potential differences between groups, researchers found a fourfold increased excess mortality risk.
- The risk was greatest in the first 14 days, where mortality for all opioids was increased elevenfold.
- Strong opioids were associated with a sixfold increased mortality risk.
- Among those who used fentanyl patches as their first prescription, 64.4 percent died within the first 180 days compared with 6.4 percent in the unexposed (an eightfold increased risk of dying).
The researchers defined strong opioids as morphine, oxycodone, ketobemidone, hydromorphone, pethidine, buprenorphine, and fentanyl.
“In our study, starting on an opioid after getting a dementia diagnosis was frequent and associated with a markedly increased risk of death, which is worrisome,” said Christina Jensen-Dahm, M.D., Ph.D., of the Neurology Department, Danish Dementia Research Centre, Copenhagen University Hospital — Rigshospitalet, Denmark. “The use of strong opioids has increased considerably over the past decade among older people with dementia. Our study shows the importance of careful evaluation of risk and benefits to the patient when considering initiating opioid therapy among elderly individuals with dementia.”
The press release can be accessed here.
Compliance Perspective
Issue
According to the Centers for Disease Control and Prevention’s (CDC) 2022 guidelines, opioid therapy should only be considered for pain if benefits are anticipated to outweigh risks. F757 in the Centers for Medicare & Medicaid Services (CMS) State Operations Manual, Appendix PP, states that each resident’s drug regimen must be free from unnecessary drugs. Any medication or combination of medications—or the use of a medication without adequate indications, in excessive dose, for an excessive duration, or without adequate monitoring—may increase the risk of a broad range of adverse consequences such as medication interactions, depression, confusion, immobility, falls, hip fractures, and death. The Beers Criteria for Potentially Inappropriate Medication Use in Older Adults provides information on safely prescribing medications for older adults, http://www.healthinaging.org/medications-older-adults/.
Discussion Points
- Review your policies and procedures on medication management, including the safe use of opioids. Update as needed.
- Train all clinical staff about your medication policies and procedures, including the risks and benefits of this classification of drugs and how to conduct appropriate monitoring of residents receiving these medications. Your consultant pharmacist is a valuable resource in this effort. Document that the training occurred and file the signed document in each employee’s education file.
- Periodically audit to ensure that opioids are not unnecessarily prescribed without careful evaluation of risk vs benefit. Adding these and similar medications to a resident’s regimen should follow the cautionary process of starting low and going slow. If decreasing or discontinuation of the opioids is not feasible, ensure that there is complete documentation of interventions that have been tried and were unsuccessful with a rationale for continuing use.
*This news alert has been prepared by Med-Net Concepts, LLC for informational purposes only and is not intended to provide legal advice.*
