Prescribing cascades in older adults with and without dementia

为患有或不患有痴呆症的老年人开级联药

• 批准号: 10214412
• 负责人: MICHAEL A. STEINMAN
• 金额: $ 17.84万
• 依托单位: UNIVERSITY OF CALIFORNIA, SAN FRANCISCO
• 依托单位国家: 美国
• 财政年份: 2015
• 资助国家: 美国
• 起止时间: 2015-04-01 至 2026-01-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10214412
• 关键词: 5 Alpha-Reductase Inhibitor; Address; Adrenergic alpha-Antagonists; Adverse drug effect; Adverse effects; Affect; Alzheimer' s disease related dementia; Amiodarone; Bladder; Caring; Chronology; Clinical; Communication; Complex; Control Groups; Data; Data Sources; Decision Making; Dementia; Disease; Diuretics; Edema; Elderly; Elements; Epidemiology; Event; Frequencies; General Population; Goals; Health; Health system; Impaired cognition; Individual; Internet; Lead; Link; Medicare; Mentors; Methods; Mid-Career Clinical Scientist Award (K24); Modeling; Morbidity - disease rate; Nature; Neurofibrillary Tangles; Outcome; Pathway interactions; Pattern; Peripheral; Persons; Pharmaceutical Preparations; Polypharmacy; Population; Prevalence; Process; Reporting; Research; Research Personnel; Retinal blind spot; Retrospective cohort; Risk; Risk Factors; Scholarship; Side; Signs and Symptoms; Spasmolytics; Symptoms; Thyroxine; Time; combat; gabapentin; indexing; men; multiple chronic conditions; palliative; pregabalin; prevent; public health relevance; research study; symptom management; urinary

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.

项目摘要 /摘要 背景：在老年人中，个人处方决策可能孤立地看起来合理，但可以领导 到纠结的并发症网络。这是一个关键的示例是规定级联的。这些发生在一个 药物会导致不良影响，而不是改变有问题的药物，而是第二种药物是 管理症状。反过来，这可能会导致更大的不利影响 药物，等等。虽然与所有老年人有关，但级联可能是特别常见和有害的 在痴呆症患者中，部分原因是沟通挑战可能会增加临床医生的风险 不认识到已经发生了不良药物作用，而是将新的标志或符号解释为 潜在疾病的表现。尽管开处方的级联可能很普遍，并且可以进行会议 巨大的发病率，关于这个话题的奖学金很少。在此提案中，我们将探索 两个潜在的级联反应是该问题的模型：（a）加巴喷丁和gababalin外周水肿 循环利尿剂和（b）循环利尿剂泌尿症状用于治疗泌尿症状的药物。 目的：（1）确定开处方级联的患病率和风险因素，涉及gabapentinoid和 循环利尿剂，以及患有和没有痴呆症的老年人之间的不同； （2）确定 开处方级联的级联和尿液症状的级联的患病率和风险因素 药物，以及患有和没有痴呆症的老年人之间的不同； （3）表征 在这些人群中，gabapentinoid-loop利尿级联反复发生的途径。 方法：使用VA和Medicare的国家数据，目的1和2我们将组装回顾性队列 是指索引药物（开始级联的一种）和 结果药物（一种用于治疗由指数药物引起的不良影响的药物）。然后我们会 确定哪些受试者随后开始开始索引药物，哪些受试者未开始索引药物 而是开始另一种类型的药物（即对照组）。我们将比较结果的使用 这些小组之间使用多变量的活动方法来竞争的方法 风险。互动条款和分层分析将用于比较结果率和风险因素 患有和没有痴呆症的人。对于AIM 3，我们将对500名受试者进行图表审查（250名患有痴呆症的受试者 250没有）与gabapentinoid-loop利尿级联一起评估决策要素 为级联做出了贡献。拟议的研究将为少年提供巨大的机会 调查人员并支持该K24奖的心理目标。 相关性 /公共卫生的意义：理解开处方级联和决策模式 - 导致他们将为预防和减轻这些潜在的有害做法的策略提供信息。