Pharmacological Management of Pain in Alzheimer's Disease and Related Dementia

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Summary: My career goal is to become an independent geriatric pharmacoepidemiologist with expertise in pharmacotherapy quality measurement and outcomes evaluation in the fields of pain and aging. The clinical focus of my research has centered on the management of multi-morbidity in older adults and particularly, the interplay of mental and physical disease and its treatment. One example of combination of health problems is elderly patients who live with Alzheimer's disease and related dementia (ADRD) and also suffer from chronic pain. To date, data on quality of pain medication prescribing and the sequelae of poor pain control in patients with ADRD are scarce. Studies investigating these associations are limited by small sample size, and none has attempted to establish the effect of adequate pain control on preventing mental health (MH) disorders. The goal of my K01 proposed research is to provide preliminary data that improve our understanding of current pain medication prescribing and potential discrepancies between practices and pain guidelines, and to formulate hypotheses for future research regarding the role of pain control in reducing MH problems in ADRD. We propose a longitudinal design using 4 years (2011-2014) of Medicare 5% sample whose billing records are linked to nursing home resident assessment data (Minimum Data Set, MDS, 3.0). Because it is unclear whether MDS 3.0 can accurately detect patients with pain and MH disorders, we first conduct a feasibility study of validating MDS-based pain, depression, and behavioral symptoms against medical records at two nursing homes (Aim 1). With the nationally representative Medicare-MDS data, we explore the quality of pharmacological pain management and its determinants among ADRD and non-ADRD residents with non- cancer pain (Aim 2). The quality will be examined based on five common clinical standards--pain medication selection, pain medication scheduling, pharmacological prevention of drug adverse event, contraindicated medication use, and overall pain control. We then explore the extent to which pain control is associated with a decreased risk for select MH disorders, including depression, behavioral symptoms, anxiety, and sleep disorders in ADRD (Aim 3). This project is well tailored for me to apply the knowledge and skills that will be obtained from training activities with my Primary Mentor, Dr. Almut Winterstein (pharmacoepidemioloy, quality measurement and outcome assessment) and Co-Mentors: Drs. Roger Fillingim (pain), Marco Pahor (aging), Babette Brumback (advanced methods for longitudinal data), and Laurence Solberg (clinical geriatric care and assessment). For further guidance, I enlist the expertise of Dr. Siegfried Schmidt in the field of pain medicine and Dr. Steven DeKosky in ADRD. This K01 award will provide protected time for me to receive training needed to prepare an R01 grant application to examine pain medication practices and their impact on health outcomes in ADRD. The results from this line of research are expected to lead to better pharmacological pain management and improved pain and health outcomes in older adults with cognitive impairments.