OBJECTIVES : Guardianship is court decided for persons incapable of caring for themselves and communicating medical decisions. Local judicial courts vary in the amount of supervision they provide guardians, which makes the practice of guardianship uneven and, at its worst, has the potential for elder abuse. To begin to address the evidence gap for persons under guardianship care, this study examines the issues of polypharmacy and prescribing patterns for four therapeutic classes most commonly targeted for deprescribing for older adults – proton pump inhibitors (PPIs), benzodiazepines, antipsychotics, and antihyperglycemics.

METHODS : Facility-dwelling Medicare beneficiaries are identified within the Medicare Current Beneficiary Survey (MCBS) for 2015 and 2016 to examine those under guardianship compared with those that are not. Administrative claims data merged with the MCBS sample provide prescription drug utilization; patient co-morbidities, demographic, socioeconomic, and geographic data; and facility characteristics. Logistic regression is used to examine association of polypharmacy outcomes and guardianship care controlling for patient and facility characteristics. Statistical models are adjusted using Fay’s Method with replicate weights for the MCBS complex survey design.

RESULTS : Approximately 12% of the facility-dwelling Medicare population in 2015 and 2016 are persons under guardianship care. Persons under guardianship were more likely to have polypharmacy or to be prescribed 5 or more medications (Odd Ratio (OR)=1.168, 95% Confidence Interval (CI)=1.156 to 1.180, p<0.001) than facility-dwelling Medicare beneficiaries not under guardianship care. Medicare beneficiaries under guardianship were more likely to be prescribed PPIs (OR=1.229, 95% CI=1.222 to 1.237, p<0.001) or antipsychotic medications (OR=1.240, 95% CI=1.232 to 1.247, p<0.001) but less likely to be prescribed benzodiazepines (OR=0.920, 95% CI=0.913 to 0.927, p<0.001) or antihyperglycemics (OR-0.726, 95% CI=0.721 to 0.731, p<0.001).

CONCLUSIONS : Medical decision support services, such as guardianship care, are increasing in importance as shared decision making between patients and physicians evolves to address polypharmacy and deprescribing for older adults.