Health Outcomes of Discontinuing Aspirin in Older Adults with Alzheimer's Disease and Related Dementias

患有阿尔茨海默病和相关痴呆症的老年人停用阿司匹林的健康结果

• 批准号: 10662129
• 负责人: Carolyn Timberlake Thorpe
• 金额: $ 64.96万
• 依托单位: UNIV OF NORTH CAROLINA CHAPEL HILL
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-04-15 至 2027-01-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10662129
• 关键词: Accident and Emergency department; Address; Admission activity; Adult; Age; Alzheimer' s disease related dementia; Anti-Inflammatory Agents; Aspirin; Atherosclerosis; Attention; Bar Codes; Behavioral; Benefits and Risks; Cardiovascular system; Caregivers; Clinical; Cognition; Data; Data Set; Decision Making; Dementia; Demographic Factors; Dependence; Dose; Drug Interactions; Elderly; Electronic Health Record; Emergency department visit; Epidemiologic Methods; Event; Exclusion; Family; Future; Goals; Guidelines; Health; Health Status; Health system; Healthcare; Hemorrhage; Hospitalization; Impaired cognition; Life Expectancy; Link; Medicare; Methods; Modeling; National Institute on Aging; Non-Prescription Drugs; Nursing Homes; Observational Study; Outcome; Palliative Care; Patient-Focused Outcomes; Patients; Pattern; Pharmaceutical Preparations; Pharmacoepidemiology; Policies; Polypharmacy; Population; Positioning Attribute; Practice Guidelines; Predictive Factor; Prevention; Prevention trial; Preventive; Primary Prevention; Probability; Prognosis; Provider; Quality of Care; Randomized; Recommendation; Records; Regimen; Research; Research Priority; Retrospective cohort study; Risk; Secondary Prevention; Selection Bias; Signal Transduction; Structural Models; Time; Translating; Uncertainty; United States Department of Veterans Affairs; Variant; World Health; adverse drug reaction; atherosclerosis risk; cardiovascular disorder prevention; cardiovascular disorder risk; cardiovascular risk factor; care providers; cognitive function; cohort; design; disability; discontinuation trial; empowerment; experience; frailty; functional decline; health assessment; human old age (65+); improved; medication administration; mortality; patient oriented; prevent; psychological symptom; randomized trial; socioenvironmental factor; thrombotic; treatment duration; treatment guidelines

PROJECT SUMMARY/ABSTRACT Reducing polypharmacy by discontinuing medications with reduced benefits and increased risks is a priority in older adults (OAs) with Alzheimer’s Disease and Related Dementias (ADRD). Low-dose aspirin for primary or secondary prevention of atherosclerotic cardiovascular disease (ASCVD) has been proposed as a target for discontinuation, with limited real-world data suggesting high variation in prescribing and discontinuation. Guidelines recommend against aspirin for primary prevention in OAs, while supporting its use for secondary prevention; however, applicability to OAs with ADRD is questionable. Reduced life expectancy for OAs with ADRD may translate into lower long-term ASCVD benefits, while increased potential for drug interactions may increase short-term bleeding risk. On the other hand, higher ASCVD risk among OAs with ADRD may position them for greater risk of ASCVD events previously observed in other populations in weeks after discontinuing aspirin, and the anti-inflammatory and anti-thrombotic effects of aspirin could also protect against further progression of cognitive or functional decline. The exclusion of OAs with ADRD from randomized trials of aspirin and limited availability of observational data on aspirin use (a non-prescription drug) leaves patients, providers, and caregivers with little evidence about benefits and harms to guide informed decisions about aspirin discontinuation. Our long-term goal is to improve decision-making, care quality, and outcomes for OAs with ADRD, through improved evidence and treatment guidelines about medications optimization as ADRD progresses. The proposed retrospective cohort study will use records on daily aspirin use uniquely available for a national cohort of Veterans Affairs (VA) nursing home (NH) residents with ADRD, linked to Minimum Data Set (MDS) assessments, electronic health records, and VA and Medicare utilization data over 2016-2023. Specific aims are to (1) Identify clinical and socio-environmental factors predicting aspirin discontinuation in OAs with ADRD after NH admission, stratified by ASCVD status; (2) Examine effects of discontinuing aspirin on ASCVD events, major bleeding, emergency department/hospital admissions, and mortality, stratified by ASCVD status; and (3) Examine effects of discontinuing aspirin on cognitive function, functional dependence, and behavioral/psychological symptoms of dementia. To focus our aims on generating robust, clinically- and policy-relevant evidence, we will use pharmacoepidemiologic methods to reduce selection bias and confounding. Aim 2 is a prevalent new-user study applying covariate balancing methods and competing risk models, with supplementary analyses to address time-varying aspirin exposure and confounders. Aim 3 will assess time-varying exposures and confounding using inverse-probability-weighted marginal structural models. This study will inform future practice guidelines to address if aspirin can be safely discontinued in OAs with ADRD and empower patients, caregivers, and providers to make informed decisions.

项目概要/摘要 通过停止使用效益降低和风险增加的药物来减少多重用药是优先考虑的问题 患有阿尔茨海默病和相关痴呆症 (ADRD) 的老年人 (OA) 低剂量阿司匹林用于治疗原发性或 动脉粥样硬化性心血管疾病（ASCVD）的二级预防已被提议作为 停药，有限的现实数据表明处方和停药的差异很大。 指南建议不要将阿司匹林用于 OA 的一级预防，同时支持将其用于二级预防 预防；然而，对于患有 ADRD 的 OA 的适用性值得怀疑。 ADRD 可能会转化为较低的长期 ASCVD 益处，而药物相互作用的可能性可能会增加 另一方面，患有 ADRD 的 OA 患者的 ASCVD 风险可能会增加。 此前在其他人群中观察到的 ASCVD 事件在停药后数周内发生的风险更大 阿司匹林，阿司匹林的抗炎和抗血栓作用也可以预防进一步的 将患有 ADRD 的 OA 排除在随机试验之外。 阿司匹林和阿司匹林（一种非处方药）使用观察数据的有限性使患者， 提供者和护理人员几乎没有关于益处和危害的证据来指导明智的决策 我们的长期目标是改善 OA 的决策、护理质量和结果。 ADRD，通过改进关于 ADRD 药物优化的证据和治疗指南 拟议的回顾性队列研究将独特地使用每日阿司匹林使用记录。 适用于全国退伍军人事务部 (VA) 疗养院 (NH) 患有 ADRD 的居民，与 最小数据集 (MDS) 评估、电子健康记录以及 VA 和 Medicare 利用率数据 2016-2023 年的具体目标是 (1) 确定预测阿司匹林的临床和社会环境因素。 NH 入院后因 ADRD 导致 OA 停药，按 ASCVD 状态分层 (2) 检查 在 ASCVD 事件、大出血、急诊室/医院入院时停用阿司匹林，以及 死亡率，按 ASCVD 状态分层；以及 (3) 检查停用阿司匹林对认知功能的影响， 功能依赖和痴呆症的行为/心理症状。 强有力的、临床和政策相关的证据，我们将使用药物流行病学方法来减少 选择偏差和混杂因素是一项流行的新用户研究，应用协变量平衡方法和 竞争风险模型，通过补充分析来解决随时间变化的阿司匹林暴露和 目标 3 将使用逆概率加权评估随时间变化的暴露和混杂因素。 这项研究将为未来的实践指南提供信息，以解决阿司匹林是否可以安全使用的问题。 在患有 ADRD 的 OA 中停止使用，并使患者、护理人员和提供者能够做出明智的决定。