Prescribing cascades in older adults with and without dementia

项目总结/摘要 背景：在老年人中，单独的处方决定可能看起来是合理的，但可能导致 一个错综复杂的网络这方面的一个关键例子是处方级联。当一个 药物会引起不良反应，而不是改变违规药物，第二种药物是 来控制症状。这反过来可能会导致更多的不利影响，这是管理与第三 药物，等等。级联反应虽然与所有老年人有关，但可能特别常见和有害 在痴呆症患者中，部分原因是沟通方面的挑战可能会增加临床医生 没有认识到已经发生了药物不良反应，而是将新的体征或症状解释为 潜在疾病的表现。尽管处方级联可能很常见， 虽然发病率很高，但关于这一主题的学术研究非常少。在本提案中，我们将探讨 两个潜在的级联反应是这个问题的模型：（A）加巴喷丁和普瑞巴林-外周水肿 袢利尿剂，和（B）袢利尿剂缓解泌尿系统症状，即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的处方级联的患病率和风险因素， 袢利尿剂，以及老年痴呆症患者和非老年痴呆症患者之间的差异;（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风险因素 药物，以及这些在老年人与非老年痴呆症之间的差异;（3）描述 这些人群中发生加巴喷丁环利尿级联反应的途径。 方法：使用VA和Medicare的全国数据，针对目标1和2，我们将组建一个回顾性队列 老年人谁是非用户的指标药物（一个开始级联）和 结局药物（用于治疗索引药物引起的不良反应的药物）。然后我们将 确定哪些受试者随后开始使用索引药物，哪些未开始使用索引药物 而是开始另一种类型的药物治疗（即，对照组）。我们将比较结果的使用 使用多变量至事件发生时间方法在这些组之间进行药物治疗， 风险将使用相互作用术语和分层分析比较以下人群的结局率和风险因素： 患有和没有痴呆症的人。就目的3而言，我们将对500名受试者（250名患有痴呆症）进行病历审查 和250没有）与加巴喷丁环利尿级联反应，并评估决策要素， 造成了连锁反应拟议的研究将为指导初级 调查人员和支持这个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- 通过这一途径，将为预防和减少这些潜在有害做法的战略提供信息。

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.