Prescribing without a guide: A national study of psychotropic and opioid polypharmacy among persons living with dementia

在没有指导的情况下开药：一项关于痴呆症患者精神药物和阿片类药物复方用药的全国研究

• 批准号: 10608057
• 负责人: DONOVAN T MAUST
• 金额: $ 67.01万
• 依托单位: UNIVERSITY OF MICHIGAN AT ANN ARBOR
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-04-15 至 2026-12-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10608057
• 关键词: Accounting; Address; Agitation; Agonist; Alzheimer' s disease related dementia; American; Antidepressive Agents; Antiepileptic Agents; Antipsychotic Agents; Attitude; Behavior Control; Behavioral Symptoms; Belief; Benzodiazepine Receptor; Benzodiazepines; Caregivers; Caring; Central Nervous System; Cessation of life; Characteristics; Clinical; Combination Medication; Communities; Complex; Data; Data Set; Decision Making; Delusions; Dementia; Dementia caregivers; Distress; Drug Prescriptions; Elderly; Exposure to; Funding; Future; Geriatrics; Goals; Healthcare; Healthcare Systems; Impaired cognition; Intervention; Interview; Knowledge; Life; Link; Medical; Medicare; Memory impairment; Methods; Opioid; Pain; Patients; Persons; Pharmaceutical Preparations; Pharmacological Treatment; Policies; Polypharmacy; Population; Process; Regimen; Research; Resources; Risk; Sampling; Sleeplessness; Societies; Structure; Surveys; Symptoms; Time; Vacuum; Work; beneficiary; clinical decision-making; cohort; evidence base; experience; fall injury; follow-up; hypnotic; improved; insight; multidisciplinary; prevent; provider factors; psychological symptom; psychosocial; respiratory; symposium; therapy design

PROJECT ABSTRACT The U.S. health care system is poorly equipped to deal with the growing number of persons living with dementia (PLWD) in the U.S. and their complex medical and psychosocial needs. While memory impairment is the cardinal feature of Alzheimer’s disease and related dementias (ADRD), behavioral and psychological symptoms (e.g., apathy, delusions, agitation) are common during all stages of illness and cause significant caregiver distress. Despite limited high-quality evidence of efficacy for pharmacological treatment, our work has shown that clinicians prescribe psychotropic medications to community-dwelling PLWD at rates that far exceed use in the general older adult population. Unfortunately, this includes a high burden of psychotropic and opioid (central nervous system [CNS]- active) polypharmacy (i.e., overlapping use of ≥3 medications from among antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, or opioids)— which is considered potentially inappropriate for older adults given serious associated risks including fall-related injury, impaired cognition, and respiratory suppression or death when involving opioids. Goal C-1 of the NIA’s Strategic Directions for Research highlights the need to improve safe use of medications for older adults, while the NIA ADRD Milestone 8.A Summit noted “a research and policy vacuum for interventions specifically aimed at improving life for persons with ADRD.” Minimizing CNS polypharmacy is a critical opportunity to improve safe medication use for PLWD, both through preventing new CNS polyRx and deprescribing—i.e., identifying and discontinuing drugs [where] existing or potential harms outweigh existing or potential benefits—among PLWD already exposed. However, the design of interventions to reduce CNS polypharmacy cannot proceed without understanding why clinicians decide to prescribe these medications. In this explanatory mixed methods study, we will first characterize patient characteristics associated with incident and continued CNS polyRx in a unique cohort of all community-dwelling Medicare beneficiaries living with dementia in the U.S., combining both traditional and managed Medicare. We will use these Medicare data to profile the CNS prescribing of the clinicians that care for these PLWD, and then, through a national survey and detailed follow-up qualitative interviews, we will characterize the prescribing decision-making process, including the underlying knowledge, norms, facilitators, and barriers associated with prescribing intent. Finally, with input from a multidisciplinary Expert Panel including a PLWD-caregiver dyad, we will identify critical remaining knowledge gaps and possible intervention targets. With the new insights gained, we will chart a way forward to address the critical but previously underrecognized challenge of potentially inappropriate CNS polypharmacy among PLWD living in the community.

项目摘要 美国医疗保健系统非常等同于应对越来越多的人 美国的痴呆症（PLWD）及其复杂的医疗和社会心理需求。记忆 损害是阿尔茨海默氏病和相关痴呆症（ADRD）的基本特征 和心理症状（例如，冷漠，妄想，躁动）在所有疾病的各个阶段很常见 并造成严重的护理人员困扰。尽管高质量的效率证据有限 药理学治疗，我们的工作表明，临床医生开了精神药物 社区居住的PLWD的速度远远超过了一般老年人的使用。 不幸的是，这包括精神病和阿片类药物的高燃烧（中枢神经系统[CNS] - 活性）多药（即，在抗抑郁药中使用≥3种药物的使用， 抗精神病药，抗癫痫药，苯二氮卓类药物，非苯二氮卓类苯并二氮卓受体激动剂激动剂 催眠药或阿片类药物） - 这被认为是对老年人的可能不合适的 相关风险，包括与跌倒有关的伤害，认知受损以及呼吸抑制或死亡 涉及阿片类药物时。 NIA研究的战略方向的目标C-1强调了需要 改善对老年人的安全使用，而NIA ADRD里程碑8.一次峰会指出“ 针对干预措施的研究和政策真空，专门用于改善 adrd。“最小化中枢神经系统一多型药物是改善安全用药使用的关键机会 PLWD，通过防止新的CNS polyrx和Deblecting -I.E。，识别和中断 毒品[现有或潜在损害的地方超过现有或潜在的益处 - PLWD已经 裸露。但是，减少中枢神经系统多药的干预措施的设计无法没有进行 了解为什么临床医生决定准备这些药物。在这种爆炸性的混合方法中 研究，我们将首先表征与事件和持续CNS相关的患者特征 Polyrx在所有社区居住的Medicare受益人的独特队列中都有痴呆症 美国，结合了传统和托管的医疗保险。我们将使用这些Medicare数据进行个人资料 中枢神经系统开处方照顾这些PLWD的临床医生，然后通过全国调查和 详细的随访定性访谈，我们将描述处方决策过程， 包括基本知识，规范，促进者以及与处方意图相关的障碍。 最后，随着跨学科专家小组的投入，包括PLWD养护者二元组，我们将 确定关键的剩余知识差距和可能的干预目标。有了新的见解 获得的，我们将绘制一条前进的道路，以应对关键但以前未经认可的挑战 居住在社区中的PLWD中可能不适当的中枢神经系统多药。