Deprescribing Bisphosphonates in Older Nursing Home Residents with Dementia

停用患有痴呆症的老年疗养院居民的双磷酸盐处方

• 批准号: 10380865
• 负责人: Joshua David Niznik
• 金额: $ 14.53万
• 依托单位: UNIV OF NORTH CAROLINA CHAPEL HILL
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-04-01 至 2026-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10380865
• 关键词: Address; Adult; Adverse effects; Age; Alzheimer' s Disease; Alzheimer' s disease related dementia; Award; Benefits and Risks; Caregivers; Caring; Clinical; Clinical Trials; Communities; Complex; Cost Effectiveness Analysis; Data; Decision Making; Decision Modeling; Deglutition Disorders; Dementia; Development; Diagnosis; Elderly; Enrollment; Esophagitis; Family; Family Caregiver; Fracture; Future; Goals; Guidelines; Health Services; Healthcare; Impaired cognition; Individual; Intervention; Interview; Knowledge; Life Expectancy; Measures; Medical; Medicare; Medicare claim; Methods; Nursing Homes; Observational Study; Outcome; Perception; Pharmaceutical Preparations; Pharmacists; Polypharmacy; Population; Positioning Attribute; Prevention; Preventive; Principal Investigator; Provider; Qualitative Research; Quality of life; Quality-Adjusted Life Years; Randomized; Recommendation; Research; Research Methodology; Research Personnel; Sampling; Severities; Structure; Subgroup; Techniques; Time; Training; Uncertainty; base; bisphosphonate; bone turnover; clinical heterogeneity; cost; cost effective; cost effectiveness; cost-effectiveness evaluation; cost-effectiveness ratio; disorder prevention; end of life; fracture risk; gastrointestinal; health care service utilization; improved; incremental cost-effectiveness; informal caregiver; osteoporosis with pathological fracture; patient oriented; prevent; programs; residence; side effect; skills

PROJECT SUMMARY/ABSTRACT. Polypharmacy is a highly prevalent problem in older adults, particularly in those with Alzheimer’s Disease (AD) and AD-Related Dementias (AD/ADRD) and those residing in the nursing home (NH). Many older adults continue to receive medications originally prescribed for disease prevention until the end of life, despite a lack of sufficient evidence to justify their continued use in advanced age. The use of bisphosphonates for fracture prevention is one example. Although bisphosphonates are effective in reducing fractures in healthier, community-dwelling individuals, there is insufficient evidence of continued benefits that is generalizable for NH residents with AD/ADRD. There is also substantial clinical heterogeneity in this population with regards to fracture risk, mobility, and life expectancy, creating further uncertainty as to whether all NH residents with AD/ADRD benefit from bisphosphonate use. Deprescribing is a patient-centered approach to reduce or stop medications that are no longer appropriate considering goals of care, time until benefit, and life expectancy. Considering the lack of strong generalizable evidence and potential for side effects, bisphosphonates may be targeted for deprescribing in NH residents with AD/ADRD. Deprescribing may also be justifiable considering the extended period of benefit of bisphosphonates, which may last for up to 2 years after discontinuation exceeding the life expectancy of many residents with AD/ADRD. However, no studies to date have evaluated the appropriateness of deprescribing bisphosphonates as a means to reduce the burden of polypharmacy and adverse effects in this population. Large observational studies of secondary data are uniquely positioned to evaluate the benefits and harms of medication use and deprescribing in older NH residents with AD/ADRD, given the barriers to conducting randomized studies in this population. This study will evaluate determinants, clinical outcomes, and cost-effectiveness of deprescribing bisphosphonates in NH residents with AD/ADRD. In Aim 1, we will conduct a qualitative study using semi-structured interviews to identify determinants of deprescribing bisphosphonates from the perspectives of family/informal caregivers and prescribers of NH residents with AD/ADRD. In Aim 2, we will conduct an observational study of Medicare administrative data to evaluate clinical outcomes (fractures and adverse effects) associated with deprescribing bisphosphonates in a sample of older NH residents with AD/ADRD. In Aim 3, we will evaluate the cost-effectiveness of deprescribing bisphosphonates in NH residents with AD/ADRD, considering medication costs and utilization for fractures and adverse effects. This study will address a critical gap in knowledge and inform future recommendations for optimizing bisphosphonate use to prevent fractures in this vulnerable and medically complex population. This award will also provide the principal investigator with protected time to develop skills in qualitative research methods, advanced techniques to reduce confounding in observational studies, and methods for cost-effectiveness analyses.

项目摘要/摘要。 多重用药是老年人中非常普遍的问题，尤其是患有阿尔茨海默病 (AD) 的老年人 AD 相关痴呆症 (AD/ADRD) 以及居住在疗养院 (NH) 的患者。许多老年人 尽管缺乏，但继续接受最初用于预防疾病的药物直至生命结束 有足够的证据证明在高龄继续使用它们是合理的。双膦酸盐治疗骨折的应用 预防就是一个例子。尽管双磷酸盐可以有效减少健康人的骨折， 对于居住在社区的个人，没有足够的证据表明 NH 可以普遍获得持续的益处 患有 AD/ADRD 的居民。该人群在以下方面也存在显着的临床异质性： 骨折风险、活动能力和预期寿命，从而进一步不确定所有新罕布什尔州居民是否患有 AD/ADRD 受益于双磷酸盐的使用。取消处方是一种以患者为中心的方法，旨在减少或停止 考虑到护理目标、受益时间和预期寿命，不再适合的药物。 考虑到缺乏强有力的普遍证据和潜在的副作用，双磷酸盐可能是 针对患有 AD/ADRD 的新罕布什尔州居民取消处方。考虑到取消处方也可能是合理的 延长双膦酸盐的获益期，停药后可持续长达 2 年 超过了许多患有 AD/ADRD 的居民的预期寿命。然而，迄今为止还没有研究评估 取消双膦酸盐处方作为减轻多药治疗负担的一种手段是否合适，以及 对该人群产生不利影响。对二手数据的大型观察研究具有独特的定位 评估患有 AD/ADRD 的老年新罕布什尔州居民使用药物和取消处方的益处和危害， 考虑到在这一人群中进行随机研究的障碍。这项研究将评估决定因素， 患有 AD/ADRD 的 NH 居民停用双磷酸盐的临床结果和成本效益。在 目标 1，我们将使用半结构化访谈进行定性研究，以确定影响因素 从家庭/非正式护理人员和处方者的角度取消双膦酸盐处方 患有 AD/ADRD 的新罕布什尔州居民。在目标 2 中，我们将对 Medicare 进行一项观察性研究 评估与相关的临床结果（骨折和不良反应）的管理数据 在患有 AD/ADRD 的老年新罕布什尔州居民样本中停用双磷酸盐。在目标 3 中，我们将 评估患有 AD/ADRD 的 NH 居民停用双磷酸盐的成本效益， 考虑药物费用以及骨折的使用和不良反应。这项研究将解决一个 知识上的关键差距，并为未来优化双膦酸盐使用的建议提供信息，以预防 这个脆弱且医学复杂的人群的骨折。该奖项还将提供校长 研究者有受保护的时间来培养定性研究方法的技能、先进的技术 减少观察研究和成本效益分析方法中的混杂因素。