NEW YORK — People over 65 with dementia were four times more likely to die within the first six months after starting to take an opioid for pain, and six times more likely to die If the opioid was a strong one, such as morphine, oxycodone or fentanyl, according to a new study.
Death was 11 times more likely to occur within the first two weeks after beginning any opioid prescription, according to the unpublished study, which was presented Tuesday at the 2023 Alzheimer’s International Conference in Amsterdam.
“Potent analgesics can affect impact automatic functions, such as heart rate, breathing and swallowing, and older individuals may already have challenges with those things,” said Maria Carrillo, chief medical officer of the Alzheimer’s Association, who was not involved in the study.
The opioid crisis in the United States is a national “public health emergency,” the Administration for Strategic Preparedness and Response reports. Overdoses have skyrocketed, jumping from 47,600 in 2019 to over 80,000 in 2021, with no end in sight, according to statistics from the National Institute on Drug Abuse and the US Centers for Disease Control and Prevention.
During that time frame the use of strong opioids — particularly transdermal formulations, which are applied to the skin — has become increasingly common among the elderly with dementia, said study lead author Dr. Christina Jensen-Dahm, a neurologist and senior research scientist at the Danish Dementia Research Centre at Rigshospitalet hospital in Cophenhagen, Denmark.
“Elderly with dementia are often frail and have a severe brain disorder and we suppose this is the reason why they cannot tolerate opioids,” Jensen-Dahm said in an email. “We don’t assume that they are taking the drugs recreationally. We assume that they die because they, due to their brain disorder, are unable to tolerate opioids.”
Stronger opioids raised risk
The study analyzed data on over 75,000 Danish people over 65 diagnosed with dementia over a 10-year period between 2008 and 2018. Of those, 42% had redeemed a prescription for opioids. The study followed that group for 180 days after they began to take the opioids, comparing their death rate to people with dementia in the study who had not taken opioids.
Over 33% of the group who started an opioid died within the 180-day period, compared to only 6.4% of those with dementia who were not on pain killers, the study found.
Strong opioids raised the risk of death six-fold and rose even higher if a transdermal fentanyl patch was used, according to the study. If people were prescribed transdermal fentanyl as their first prescription, the death rate rose to 65.3% within the first 180 days — an eightfold greater risk of dying.
The greatest risk of dying from any opioid, however, was during the first 14 days after starting to take the drug — people with dementia were 11 times more likely to die during the first two weeks. Prior studies have found that can also occur in the general population who start an opioid, Jensen-Dahm said, but those studies “have not found the excess mortality risk to be of the same magnitude as in our study.”
The findings should raise an alarm for clinicians and families of people with dementia, said neurologist Dr. Nicole Purcell, the senior director of clinical practice for the Alzheimer’s Association, in a statement.
“These new findings further emphasize the need for discussion between the patient, family and physician. Decisions about prescribing pain medication should be thought through carefully, and, if used, there needs to be careful monitoring of the patient,” Purcell said.
The first choice for pain management should always be non-pharmacological therapy such as exercise, heat or physiotherapy, Jensen-Dahm said, followed by weak analgesics such as acetaminophen or another non-steroidal anti-inflammatory drug if appropriate for that patient.
“As stated in CDC’s guideline from 2022, opioid therapy should only be considered for pain (acute, subacute or chronic) if benefits are anticipated to outweigh risks to the patient,” Jensen-Dahm said.
“Making decisions for a loved one in pain is difficult because with dementia our loved ones cannot perhaps convey what they are feeling,” Carrillo said.
“The message here is that we have to be extraordinarily careful when we, as family members and clinicians, are making decisions to prescribe opioids to individuals that are not only older but who are also impacted by dementia,” she added. “We could be putting that loved one at an increased risk.”
