Neglected By The Evidence: The Intersection of Medical Complexity and Dementia

描述（由申请人提供）：申请人是罗德岛医院阿尔茨海默病和记忆障碍中心的研究助理。她在老年精神药理学和养老院医学方面的广泛临床背景是她成为一名独立卫生服务研究员的长期目标的基础。这一建议侧重于一个经常被忽视的人群的比较有效性研究-居住在养老院的痴呆症患者。研究问题旨在调查认知、功能和神经行为的结果与使用或停止某些精神活性药物与痴呆和合并症的医疗疾病的个体。拟议的培训计划将通过以下途径培养额外的技能：1)流行病学课程，以扩展方法和分析技能；2)与导师团队（包括卫生服务研究和痴呆症研究方面的专家）互动；3)利用大型自动交联数据集完成两项观察性药物流行病学研究。这些研究结果将为老年痴呆患者的治疗提供临床相关信息；被系统地排除在临床试验之外的人群。使用最先进的方法来评估非实验研究的治疗效果，目的是：1)评估停用稳定胆碱酯酶抑制剂（CHEI）治疗与持续CHEI治疗对老年痴呆症护理机构居民的纵向行为，认知和功能影响；2)确定在髋部骨折修复术中接受异氟醚全身麻醉的认知功能受损患者与接受其他类型全身麻醉的患者相比，在多大程度上经历了更大的术后认知和功能下降；3)量化异氟醚麻醉与其他全身或局部（脊髓或硬膜外）麻醉对认知功能受损患者髋部骨折修复术后一年内认知功能下降率的影响。

DESCRIPTION (provided by applicant): The applicant Is a Research Associate at the Alzheimer's Disease and Memory Disorders Center at Rhode Island Hospital. Her extensive clinical background in geriatric psychopharmacology and nursing home medicine is the foundation for her long term goal to become an independent health services researcher. This proposal focuses on comparative effectiveness research in an oft neglected population - persons with dementia living in nursing homes. The research questions seek to investigate the cognitive, functional, and neurobehavioral outcomes associated with the use or discontinuation of certain psychoactive drugs in individuals with dementia and comorbid medical illness. The proposed training plan will develop additional skills through 1) coursework in epidemiology to expand methodologic and analytic skills, 2) interaction with the mentorship team, including experts in health services research and dementia research, and 3) completion of two observational pharmacoepidemiologic studies utilizing large automated cross-linked datasets. Findings from these studies will provide clinically relevant information to inform treatment of elderly patients with dementia; a population systematically excluded from clinical trials. Using state of the art methods for estimating treatment effects from non-experimental studies, the aims are 1) to evaluate the longitudinal behavioral, cognitive, and functional effects of discontinuing stable cholinesterase inhibitor (CHEI) therapy compared to continuous CHEI therapy in nursing facility residents with dementia, 2) to determine the extent to which cognitively impaired individuals who receive isoflurane general anesthesia during hip fracture repair experience greater post-operative cognitive and functional decline in the year after surgery compared to patients receiving other types of general anesthesia, and 3) to quantify the effects of isoflurane anesthesia vs. other general or regional (spinal or epidural) anesthesia on the rate of post- operative cognitive and functional decline in cognitively impaired patients in the year after hip fracture repair surgery.