Medicating distress: Use of psychotropic medications among patients with dementia receiving hospice care

药物困扰：接受临终关怀的痴呆患者使用精神药物

基本信息

批准号：
10322426
负责人：
Lauren Beth Gerlach
金额：
$ 19.66万
依托单位：
UNIVERSITY OF MICHIGAN AT ANN ARBOR
依托单位国家：
美国
项目类别：
财政年份：
2021
资助国家：
美国
起止时间：
2021-01-01 至 2025-12-31
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10322426
关键词：
Accounting Address Adverse event Age Agitation Antidepressive Agents Antipsychotic Agents Anxiety Award Behavior Behavioral Symptoms Benefits and Risks Benzodiazepines Caregivers Characteristics Clinical Clinical Trials Consensus Data Data Set Decision Making Delirium Dementia Dementia caregivers Distress Drug Prescriptions Elderly Enrollment Equilibrium Evaluation Foundations Geriatric Psychiatry Goals Growth Hallucinations Haloperidol Hospice Care Individual Inpatients Interview K-Series Research Career Programs Knowledge Life Link Measures Medical Medicare Mental Health Services Mental disorders Mentors Mentorship Methods Modeling Mortality Decline Nursing Homes Outcome Palliative Care Nursing Palliative Medicine Patient Care Patient-Focused Outcomes Patients Pharmaceutical Preparations Pharmacoepidemiology Policies Population Provider Psychiatrist Qualitative Research Quality of Care Research Research Methodology Research Personnel Risk Scientist Services Social support Standardization Statistical Methods Structure Surveys Symptoms Terminally Ill Training Training Programs Variant Work advanced dementia base beneficiary career dementia care design end of life end of life care evidence base functional decline functional disability geriatric mental health hospice environment improved innovation loved ones male mortality multilevel analysis off-label use preference programs public health relevance sex skills stakeholder perspectives symptom management

项目摘要

ABSTRACT The goal of this Mentored Career Development Award is to prepare Dr. Lauren Gerlach for a career as an independent investigator focused on measuring and improving the quality of end-of-life care for older adults with psychiatric disorders and dementia. Dr. Gerlach’s long-term career goal is to establish herself as an independent investigator in geriatric mental health services and mixed methods research. Behavioral symptoms in advanced dementia are common, and despite limited evidence to support their use, the mainstay of such symptom management in hospice is off-label use of psychotropic medications such as antipsychotics. However, recent clinical trial evidence suggests that use of antipsychotics at end of life may be associated with worse outcomes for patients—raising concerns that the very medications prescribed to alleviate distress in fact exacerbate it. Little is known about how widely psychotropics are prescribed during end-of-life care for dementia, the factors that influence this prescribing, or the outcomes of such use. These critical knowledge gaps—including which patients are at greatest risk of potential harm—limit the ability to develop a consensus on best practices to address distressing behavioral symptoms in hospice care for dementia. Dr. Gerlach’s clinical training as a geriatric psychiatrist and prior research in pharmacoepidemiology provide the critical foundation for this work, but her transition to independence requires new skills and knowledge that will be gained through a coordinated program of research, mentorship, and coursework during the 5-year award period. This will include training in: 1) hospice-based dementia care, 2) use of Medicare and Minimum Data Set (MDS) data to examine end-of-life care, 3) advanced statistical methods for pharmacoepidemiology research, and 4) qualitative research methods. The proposed study will use Medicare data for all older adults with dementia enrolled in hospice in 2015 to determine the array of patient, provider, and hospice characteristics that influence psychotropic prescribing (Aim 1). In partnership with a local hospice organization, an exploratory sub-aim will examine the indications for psychotropic prescribing at end of life—information not available in claims data. Aim 2 will use linked Medicare and MDS data to examine outcomes associated with psychotropic prescribing (e.g., functional impairment, behavioral symptoms, mortality). Finally, Aim 3 will include interviews with patients with early-stage dementia, caregivers, and hospice providers to elicit stakeholder perspectives on the goals of hospice care. Study findings will inform how to best manage behavioral symptoms at the end of life. Given that not all patients with dementia utilize hospice, this K23 is designed to lay the foundation for a subsequent R01 to examine broader end-of-life care among all patients with dementia and to determine how hospice enrollment impacts outcomes. The R01 study will use Medicare and linked survey data to determine factors that impact the care patients receive in the last year of life and to identify the extent of potentially inappropriate treatments and impact on caregiver outcomes to better inform hospice care models for dementia.

抽象的该指导职业发展奖的目标是让 Lauren Gerlach 博士为作为一名独立调查员专注于衡量和提高老年人临终关怀的质量格拉赫博士患有精神疾病和痴呆症，她的长期职业目标是将自己打造成一名精神疾病和痴呆症患者。老年心理健康服务和混合方法研究的独立调查员。晚期痴呆症的症状很常见，尽管支持其使用的证据有限，但主要手段临终关怀中此类症状管理的一个重要部分是超适应症使用抗精神病药物等精神药物。然而，最近的临床试验证据表明，临终时使用抗精神病药物可能与患者的结果更糟——引起人们的担忧，实际上是为了减轻痛苦而开的药物人们对临终关怀期间精神药物的使用范围知之甚少。痴呆症、影响该处方的因素或此类使用的结果。差距（包括哪些患者面临最大的潜在伤害风险）限制了达成共识的能力关于解决老年痴呆症临终关怀中令人痛苦的行为症状的最佳实践。作为老年心理学的临床培训和药物流行病学的先前研究提供了关键的这项工作的基础，但她向独立的过渡需要新的技能和知识，这些技能和知识将通过五年奖励期间协调的研究、指导和课程作业获得这将包括以下方面的培训：1) 基于临终关怀的痴呆症护理，2) 医疗保险和最低数据集的使用。 (MDS) 用于检查临终关怀的数据，3) 用于药物流行病学研究的先进统计方法， 4) 定性研究方法本研究将使用所有患有老年痴呆症的老年人的医疗保险数据。痴呆症患者于 2015 年加入临终关怀中心，以确定患者、提供者和临终关怀中心的一系列特征影响精神药物处方（目标 1）。子目标将审查临终时精神药物处方的适应症——信息不可用目标 2 将使用关联的 Medicare 和 MDS 数据来检查与精神药物相关的结果。最后，目标 3 将包括访谈。与早期痴呆症患者、护理人员和临终关怀服务提供者一起，征求利益相关者的观点临终关怀的目标研究结果将告知如何在临终关怀结束时最好地管理行为症状。鉴于并非所有痴呆症患者都会使用临终关怀中心，K23 旨在为未来的生活奠定基础。随后的 R01 旨在检查所有痴呆症患者更广泛的临终关怀，并确定如何 R01 研究将使用 Medicare 和相关调查数据来确定临终关怀登记的影响。影响患者在生命最后一年接受护理的因素，并确定潜在的程度不适当的治疗及其对护理人员结果的影响，以更好地为痴呆症临终关怀模型提供信息。