Prescribing cascades in older adults with and without dementia

为患有或不患有痴呆症的老年人开级联药

基本信息

批准号：
10571857
负责人：
MICHAEL A. STEINMAN
金额：
$ 17.84万
依托单位：
UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
依托单位国家：
美国
项目类别：
财政年份：
2015
资助国家：
美国
起止时间：
2015-04-01 至 2026-01-31
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10571857
关键词：
5 Alpha-Reductase Inhibitor Accidents Address Adrenergic alpha-Antagonists Adverse drug effect Adverse effects Affect Alzheimer&apos s disease related dementia Amiodarone Bladder Caring Chronology Clinical Communication Complex Control Groups Data Data Sources Decision Making Dementia Disease Diuretics Edema Elderly Elements Epidemiology Event Frequencies General Population Goals Health Health system Impaired cognition Individual Internet Link Medicare Mentors Methods Mid-Career Clinical Scientist Award (K24)Modeling Morbidity - disease rate Nature Neurofibrillary Tangles Outcome Pathway interactions Pattern Peripheral Persons Pharmaceutical Preparations Polypharmacy Population Predisposition Prevalence Process Public Health Reporting Research Research Personnel Retinal blind spot Retrospective cohort Risk Risk Factors Scholarship Side Signs and Symptoms Spasmolytics Symptoms Thyroxine Time combat gabapentin indexing men multiple chronic conditions palliative pregabalin prevent research study symptom management urinary

项目摘要

PROJECT SUMMARY / ABSTRACT Background: In older adults, individual prescribing decisions may appear reasonable in isolation yet can lead to a tangled web of complications. A key exemplar of this is prescribing cascades. These occur when a medication causes an adverse effect, and rather than changing the offending drug, a second medication is given to manage the symptoms. This in turn may cause more adverse effects that are managed with a third medication, and so forth. While relevant for all older adults, cascades may be particularly common and harmful in people with dementia, in part because communication challenges may increase the risk that clinicians will not recognize that an adverse drug effect has occurred, and instead interpret new signs or symptoms as the manifestation of an underlying disease. Although prescribing cascades are likely common and can confer substantial morbidity, there has been remarkably little scholarship on this topic. In this proposal we will explore two potential cascades that are models of this problem: (A) gabapentin and pregabalin  peripheral edema  loop diuretics, and (B) loop diuretics  urinary symptoms  medications used to treat urinary symptoms. Aims: (1) To determine the prevalence and risk factors for a prescribing cascade involving gabapentinoids and loop diuretics, and how these differ between older adults with and without dementia; (2) To determine the prevalence and risk factors for a prescribing cascade involving loop diuretics and urinary symptom medications, and how these differ between older adults with and without dementia; (3) To characterize the pathways through which the gabapentinoid-loop diuretic cascade occurs in these populations. Methods: Using national data from VA and Medicare, for Aims 1 and 2 we will assemble a retrospective cohort of older adults who were non-users of both the index medication (the one that starts the cascade) and the outcome medication (the one used to treat adverse effects caused by the index medication). We will then identify which subjects subsequently started the index medication and which did not start the index medication but instead started another type of medication (i.e., a control group). We will compare use of the outcome medication between these groups using multivariable time-to-event approaches that account for competing risks. Interaction terms and stratified analyses will be used to compare outcome rates and risk factors among people with and without dementia. For Aim 3, we will conduct chart review on 500 subjects (250 with dementia and 250 without) with the gabapentinoid-loop diuretic cascade and evaluate elements of decision-making that contributed to the cascade. The proposed research will provide tremendous opportunities for mentoring junior investigators and supporting the mentoring aims of this K24 award. Relevance / public health significance: Understanding prescribing cascades and the patterns of decision- making that lead to them will inform strategies to prevent and mitigate these potentially harmful practices.

项目概要/摘要背景：对于老年人，个人处方决策可能单独看来是合理的，但可能会导致一个关键的例子是在出现以下情况时发生级联。药物会引起不良反应，因此无需更换有问题的药物，而是使用第二种药物这反过来可能会导致更多的不良反应，而这些不良反应可以通过第三种方法来控制。虽然与所有老年人相关，但级联反应可能特别常见且有害。对于痴呆症患者来说，部分原因是沟通方面的挑战可能会增加新来者患痴呆症的风险没有认识到药物不良反应已经发生，而是将新的体征或症状解释为尽管处方级联可能很常见并且可以带来潜在疾病的表现。尽管发病率很高，但关于这个主题的学术研究却非常少，我们将在本提案中进行探讨。作为该问题模型的两个潜在级联：(A) 加巴喷丁和普加巴林 → 外周水肿 → 袢利尿剂，以及 (B) 袢利尿剂 → 泌尿系统症状 → 用于治疗泌尿系统症状的药物。目的：(1) 确定涉及加巴喷丁类药物和药物的级联处方的患病率和风险因素袢利尿剂，以及这些利尿剂在患有和不患有痴呆症的老年人之间有何不同；（2）确定涉及袢利尿剂和泌尿系统症状的处方级联的患病率和危险因素药物治疗，以及患有和不患有痴呆症的老年人之间的差异；(3) 描述加巴喷丁环利尿级联反应在这些人群中发生的途径。方法：使用 VA 和 Medicare 的国家数据，针对目标 1 和 2，我们将组建一个回顾性队列既不使用指标药物（启动级联药物）又不使用结果药物（用于治疗指标药物引起的不良反应的药物）。确定哪些受试者随后开始了指标药物治疗，哪些受试者没有开始指标药物治疗而是开始使用另一种药物（即对照组），我们将比较结果的使用情况。使用多变量事件发生时间方法在这些组之间进行药物治疗，以考虑竞争将使用交互项和分层分析来比较结果率和风险因素。对于目标 3，我们将对 500 名受试者（其中 250 名患有痴呆症）进行图表审查。和 250 没有）加巴喷丁环利尿剂级联并评估决策要素拟议的研究将为指导初级学生提供巨大的机会。调查人员并支持 K24 奖项的指导目标。相关性/公共卫生意义：了解处方级联和决策模式实现这些目标将为预防和减轻这些潜在有害做法的战略提供信息。