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 美国医疗保健系统的能力很差，无法应对不断增长的患有这种疾病的人 美国的痴呆症（PLWD）及其复杂的医疗和社会心理需求。 损伤是阿尔茨海默病和相关痴呆症 (ADRD) 的主要特征 心理症状（例如冷漠、妄想、烦躁）在疾病的各个阶段都很常见 并导致严重的护理人员痛苦，尽管有效的高质量证据有限。 药物治疗，我们的工作表明，传教士会开精神药物 社区居住的 PLWD 的使用率远远超过一般老年人口的使用率。 不幸的是，这包括精神药物和阿片类药物（中枢神经系统 [CNS]- 主动）多药治疗（即重叠使用 ≥3 种抗抑郁药物， 抗精神病药、抗癫痫药、苯二氮卓类药物、非苯二氮卓受体激动剂 安眠药或阿片类药物）——考虑到严重的老年痴呆症，这被认为可能不适合老年人 相关风险包括跌倒相关伤害、认知受损、呼吸抑制或死亡 当 NIA 战略研究方向的目标 C-1 涉及需要时 改善老年人药物的安全使用，而 NIA ADRD 里程碑 8.A 峰会指出“ 专门旨在改善患有以下疾病的人的生活的干预措施的研究和政策真空 ADRD 的减少是改善中枢神经系统药物安全使用的一个重要机会。 PLWD，通过预防新的 CNS PolyRx 和取消处方（即识别和停止） [其中]现有或潜在危害超过现有或潜在益处的药物——在 PLWD 中已经 然而，如果没有减少中枢神经系统多重用药的干预措施的设计就无法进行。 了解为什么信徒决定在这种解释性的混合方法中开出这些药物。 研究中，我们将首先描述与事件和持续中枢神经系统相关的患者特征 PolyRx 在一个独特的队列中，该队列由居住在社区的所有患有痴呆症的医疗保险受益人组成 美国，结合传统和管理医疗保险，我们将使用这些医疗保险数据来分析。 CNS 为照顾这些 PLWD 的信徒开出处方，然后通过全国调查和 详细的后续定性访谈，我们将描述处方决策过程， 包括与处方意图相关的基础知识、规范、促进因素和障碍。 最后，根据包括 PLWD-护理人员二人组在内的多学科专家小组的意见，我们将 通过新的见解确定关键的剩余知识差距和可能的干预目标。 取得的成果后，我们将制定出一条前进的道路，以应对关键但以前未被充分认识到的挑战 生活在社区的 PLWD 可能不适合中枢神经系统多重用药。