Prescribing cascades in older adults with and without dementia

项目摘要/摘要 背景：在老年人中，个人的处方决定可能在孤立的情况下看起来是合理的，但可能会导致 一张错综复杂的网络。这方面的一个关键例证是开出连锁药方。这些情况在以下情况下发生 服药会导致不良反应，第二种药物不是改变有害的药物，而是 被赋予管理症状的能力。这反过来可能会导致更多的负面影响，而这些负面影响是由第三方来管理的 药物治疗，等等。虽然与所有老年人相关，但瀑布可能特别常见和有害 在痴呆症患者中，部分原因是沟通障碍可能会增加临床医生 没有认识到药物的不良反应已经发生，而是将新的体征或症状解释为 潜在疾病的表现。尽管开出连锁药方很可能很常见，而且可以 尽管发病率很高，但关于这一主题的学术研究非常少。在这份提案中，我们将探讨 作为这个问题的模型的两个潜在的级联反应：(A)加巴喷丁和普瑞巴林外周水肿 环状利尿剂，和(B)环状利尿剂泌尿症状用于治疗泌尿症状的药物。 目标：(1)确定涉及加巴喷丁和加巴喷丁的处方连锁的患病率和危险因素 环状利尿剂，以及患有和不患有痴呆症的老年人之间的差异；(2)确定 环状利尿剂与尿路症状有关的级联处方的患病率和危险因素 药物，以及患有痴呆症和不患有痴呆症的老年人之间的差异；(3)描述 在这些人群中，加巴喷丁-环状利尿剂级联反应发生的途径。 方法：使用来自退伍军人事务部和联邦医疗保险的国家数据，针对目标1和目标2，我们将建立一个回顾队列 既不使用索引药物(引发级联反应的药物)又不使用 结果类药物(用于治疗指数类药物引起的不良反应的药物)。到时候我们会的 确定哪些受试者随后开始了索引药物治疗，哪些患者没有开始索引药物治疗 而是开始了另一种类型的药物治疗(即对照组)。我们将比较结果的使用情况 在这些组之间使用考虑竞争的多变量时间-事件方法的药物治疗 风险。将使用交互作用术语和分层分析来比较以下人群的结局发生率和风险因素 痴呆症患者和非痴呆症患者。对于目标3，我们将对500名受试者(250名痴呆症患者)进行图表复习 和250)与加巴喷丁-环状利尿剂级联反应，并评估决策要素 促成了这场瀑布。拟议的研究将为指导青少年提供巨大的机会 并支持这一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-- 导致这一点将为预防和减轻这些潜在有害做法的战略提供参考。

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.