Dementia-Related Medication Disparities Persist for Racial, Ethnic Minority Patients

As outpatients, Black patients who are living with dementia received the appropriate medications to help manage their progressive neurological disorder less frequently compared with White patients, according to retrospective study findings presented today at the American Academy of Neurology 2023 annual meeting.

The utilization of 5 classes of medications was evaluated by investigators from Mount Sinai and the James J. Peters VA Medical Center, both in New York: cholinesterase inhibitors and N-methyl-D-aspartate receptor (NMDA) antagonists, both cognitive enhancers, and selective serotonin reuptake inhibitors (SSRIs), antipsychotics, and benzodiazepines, which are prescribed for behavioral and psychological management. Of interest were outcomes among 4 age groups and 5 racial and ethnic identities):

• Ages: younger than 65, 65 to 74, 75 to 84, and at least 85 years
• Racial/ethnic identities: non-Hispanic White; non-Hispanic Black or African American; Hispanic; non-Hispanic Asian; and non-Hispanic Native American, Pacific Islander, or other

Overall, most of the 25,930 study participants were female (61.0%); spoke English as their primary language (85.1%); were married/partnered (37.7%) or single (31.8%); and were non-Hispanic White (49.7%) or Hispanic (22.1%). Medicare and commercial insurance were the most common coverage types, at 66.7% and 18.9%, respectively, and most specialty referrals were ordered by clinicians providing neuropsychology or neurological care, at 21.3% and 27.5% overall.

This 5-year analysis took place from January 1, 2016, to December 31, 2021, and International Classification of Diseases, Tenth Revision (ICD-10) codes and associated billing diagnoses showed Alzheimer disease (AD) or AD-related dementia in all participants. The electronic medical record (EMR) was used to source self-reported race and ethnicity, age, sex, primary language, marital status, insurance type, and comorbid ICD-10 codes.

“There is evidence for disparities along racial and ethnic lines in the use of cholinesterase inhibitors and NMDA antagonists in the treatment of dementia in Medicare beneficiaries and research setting,” the study authors wrote. “However, to date, there is limited evidence for such disparities with regards to the use of these and other adjunctive therapies, such as SSRIs, antipsychotics, and benzodiazepines in the treatment of dementia in the outpatient setting.”

Non-Hispanic White patients used 4 of the 5 medication classes more often than the other ethnic groups, with the exception being antipsychotics.

Cholinesterase inhibitors were used by 30.0% of non-Hispanic White patients compared with approximately 20.0% of non-Hispanic Black or African American patients, close to 26.0% of Hispanic patients, 23.5% of non-Hispanic Asian patients, and 24.0% of non-Hispanic Native American, Pacific Islander, or other patients. Statistically significant associations were seen for the results between non-Hispanic White and non-Hispanic Black or African American patients (odds ratio [OR], 0.785; P < .001), Hispanic patients (OR, 0.909; P = .042), and non-Hispanic Native American, Pacific Islander, or other patients (OR, 0.800; P < .001).

NMDA antagonists, although the least used drug class overall, still were used by close to 17.0% of non-Hispanic White patients vs 10.0% of non-Hispanic Black or African American patients, 16.0% of Hispanic patients, 11.0% of non-Hispanic Asian patients, and 14.0% of non-Hispanic Native American, Pacific Islander, or other patients. The results comparing use between non-Hispanic Native American, Pacific Islander, or other patients (OR, 0.840; P = .006), non-Hispanic Asian patients (OR, 0.654; P < .001), and non-Hispanic Black or African American patients (OR, 0.708; P < .001) vs non-Hispanic White patients were considered statistically significant.

SSRIs were the most often utilized medication class overall, with the results showing use by 40.0% of non-Hispanic White patients, 37.0% of Hispanic patients, approximately 24.0% each of non-Hispanic Black or African American and non-Hispanic Asian patients, and close to 30.0% of non-Hispanic Native American, Pacific Islander, or other patients. Statistically significant findings were seen for all other racial and ethnic groups compared with White patients (all P < .001):

• Non-Hispanic Black or African American: OR, 0.452
• Hispanic: OR, 0.823
• Non-Hispanic Asian: OR, 0.503
• Non-Hispanic Native American, Pacific Islander, or other: OR, 0.627

For antipsychotic medications, the usage rates were closest overall, at approximately 22.0%, 23.0%, 21.0%, 18.0%, and 16.0% of non-Hispanic White; Hispanic; non-Hispanic Native American, Pacific Islander, or other; non-Hispanic Black or African American; and Non-Hispanic Asian patients, respectively. Compared with White patients, however, statistically significant usage rates were seen just with non-Hispanic Black or African American patients (OR, 0.761; P < .001) and non-Hispanic Asian patients (OR, 0.744; P = .002).

Benzodiazepines had the widest variation in use between White patients and the 4 other cohorts. These medications were used by close to 37.0% of White patients vs approximately 23.5% of Hispanic patients, 21.5% of non-Hispanic Native American, Pacific Islander, or other patients, 18.5% of non-Hispanic Asian patients, and 17.5% of non-Hispanic Black or African American patients. As with SSRIs, the results between White patients and the 4 other racial and ethnic groups were determined to be statistically significant (all P < .001):

• Non-Hispanic Black or African American: OR, 0.314
• Hispanic: OR, 0.530
• Non-Hispanic Asian: OR, 0.360
• Non-Hispanic Native American, Pacific Islander, or other: OR, 0.478

Overall, however, after controlling for potential confounders, significant dearths were seen in the usage rates for all medication classes when comparing outcomes for non-Hispanic Black patients living with dementia compared with White patients. And this finding was considered statistically significant for all medication categories for non-Hispanic Black or African American patients, the study authors wrote, “even after controlling for the sociodemographic factors of insurance type and Elixhauser comorbidity status.”

They added that the disparate usage rates they saw may be attributable to high out-of-pocket costs, limited access to information, and poor patient-provider communication.

“Patient perspectives in seeking dementia care can play a role as well, with qualitative data showing that minoritized groups (particularly African Americans) experience minimization of symptoms and disrespect for concerns when being evaluated for dementia,” the authors wrote. “These types of experiences erode trust in the medical system and the treatments it offers, which results in decreased engagement with the medical system and there medication use.”

They noted several limitations to the application of their findings to a wider audience, chief among them being that data were obtained from a single health system, demographic details were self-reported by patients, the findings were not stratified by dementia severity, and medication data may not accurately represent the full picture of patient use or prescriber behavior because the information came from reported medication lists within the EMR.

Therefore they recommend more research that focuses on understanding root causes of these medication use disparities and designing programs to eliminate them.

Reference

Jette N, Hawkins A, Isaac E, Agarwal P, Naasan G. Health disparities in medication use for the treatment of dementia in the outpatient setting. Presented at: AAN 2023; April 22-27, 2023; Boston, MA. Accessed April 24, 2023. https://cattendee.abstractsonline.com/meeting/10872/Presentation/7216