Summary: Study reveals racial disparities in access to the correct medications for Alzheimer’s patients. Asian and black patients are less likely to be prescribed anti-dementia medications and have an increased likelihood of being prescribed antipsychotic medications.
Disparities in drug prescribing suggest that black and Asian people with dementia are not receiving the same quality of care as their white peers, according to a new UCL-led study in the UK.
Asian people with dementia are less likely to receive anti-dementia drugs, and take them for shorter periods, according to the findings published in Clinical Epidemiology.
Dementia patients from black ethnic groups who are prescribed antipsychotic drugs, which are mainly used to treat dementia-related distress rather than the primary symptoms, take them for around four weeks longer per year compared to white people in the UK, exceeding suggested limits on how long they should be taken for.
“Our new findings are concerning as they appear to reflect inequalities in the care people receive to treat symptoms associated with dementia,” said the study’s lead author, Professor Claudia Cooper.
Researchers analysed data from 53,718 people across the UK who had a dementia diagnosis, and 1,648,889 people without dementia, drawing from The Health Improvement Network primary care database and collected between 2014 and 2016.
They found that Asian people with dementia were 14% less likely than white patients to be prescribed anti-dementia drugs when they were potentially beneficial, and received them for an average of 15 fewer days per year.
Anti-dementia drugs – cholinesterase inhibitors or memantine – are the only class of medication available for treating dementia, as they can help with memory and other cognitive abilities, while other medications such as antipsychotics are sometimes prescribed to treat some of the associated behavioural and psychological symptoms.
Previous studies in the USA and Australia have also found disparities in drug treatment for dementia for minority ethnic groups, but this is the first time the issue has been investigated in a large UK study.
The researchers say that the greater socioeconomic disadvantages experienced by minority ethnic groups may lead to barriers to accessing care, while language and cultural barriers could also contribute to disparities.
The researchers found that both black and Asian people with dementia were prescribed antipsychotic drugs for longer than white patients, by 27 and 17 days more, respectively, which could put them at greater risk of harmful side effects.
As they did not identify differences in rates of an initial prescription of antipsychotics, the researchers say the findings may reflect differences in the likelihood of medication being reviewed and stopped when no longer needed.
“Rates of antipsychotic prescribing in all ethnic groups exceeded recommendations for treating the often very distressing behavioural and psychological symptoms of dementia, such as agitation or challenging behaviours, which are the most common reasons antipsychotic drugs are prescribed to people living with dementia,” explained Professor Cooper.
“While there has been a very sharp reduction in antipsychotic prescribing in the UK over the past 10 years, these figures suggest there is still work to do to ensure that people with dementia only receive potentially harmful antipsychotic drugs if there are no acceptable alternatives.”
Dr Mary Elizabeth Jones (UCL Institute of Epidemiology & Health Care), first author of the study, commented: “While we have yet to find out whether taking antipsychotic drugs for a few weeks more increases the associated risks, which can include falls, cognitive decline, strokes and even death, it’s a potentially significant inequality which we should take seriously. More work may need to be done to ensure that guidelines are being consistently met, and that dementia services are culturally competent.”
Co-author Professor Jill Manthorpe of the NIHR Health & Social Care Workforce Research Unit, King’s College London, said that health professionals should question whether antipsychotic drugs are being prescribed instead of other forms of support that could address causes of the distressing symptoms.
“Families too should ask if there are other alternatives such as social prescribing that may put people in contact with activities and sensory experiences which may help reduce feelings of distress. Culturally meaningful activities may be particularly helpful, such as hearing or playing music or enjoying the experience of tactile objects,” she said.
A previous study also led by Professor Cooper found that dementia rates are higher among black people compared to the UK average, and ethnic minority groups may be less likely to be diagnosed in a timely manner. She has also led a study finding that women with dementia have fewer GP visits, receive less health monitoring and take more potentially harmful medication than men with dementia.
Funding: This work was funded by The Dunhill Medical Trust.
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Differences in Psychotropic Drug Prescribing Between Ethnic Groups of People with Dementia in the United Kingdom
Purpose: To test hypotheses that minority ethnic people with dementia in the UK receive fewer anti-dementia drugs and more psychotropic and anticholinergic drugs associated with harms.
Patients and Methods: We analyzed UK primary care electronic health records from The Health Improvement Network (THIN) database (2014– 2016), comparing psychotropic drug prescribing initiation and duration between people with dementia from White, Black, and Asian ethnic groups. We repeated analyses in people (aged 50+) without dementia, to explore whether any differences found reflected prescribing patterns in the general older population, or were specific to dementia.
Results: We included 53,718 people with and 1,648,889 people without dementia. Among people with dementia, compared to White ethnic groups, Asian people were less likely to be prescribed anti-dementia drugs when they were potentially indicated (adjusted prevalence rate ratio 0.86 (95% Confidence Interval 0.76– 0.98)), and received them for on average 15 days/year less. Compared to White groups, Asian and Black individuals with dementia were no more likely to take an antipsychotic drug, but those that had were prescribed them for 17 and 27 days/year more, respectively (190.8 (179.6– 199.1) and 200.7 (191.1– 206.5) days). Black people were less likely to be prescribed anxiolytics/hypnotics (0.60 (0.44– 0.8)), but the duration these drugs were prescribed was similar across ethnic groups. Asian people were more likely to be prescribed anticholinergic drugs (1.43 (1.19– 1.73)), in analyses unadjusted for cardiovascular comorbidities. Among people without dementia, those in the Asian and Black ethnic groups were less likely to be prescribed psychotropic drugs, relative to people from White groups.
Conclusion: Among people with dementia, Asian groups received less potentially beneficial symptomatic treatments, and Asian and Black groups were prescribed antipsychotic drugs for longer than White ethnic groups. Our findings may indicate care inequalities.
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