Medicating distress: Use of psychotropic medications among patients with dementia receiving hospice care

药物困扰：接受临终关怀的痴呆患者使用精神药物

• 批准号: 10322426
• 负责人: Lauren Beth Gerlach
• 金额: $ 19.66万
• 依托单位: UNIVERSITY OF MICHIGAN AT ANN ARBOR
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-01-01 至 2025-12-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10322426
• 关键词: Accounting; Address; Adverse event; Age; Agitation; Antidepressive Agents; Antipsychotic Agents; Anxiety; Award; Behavior; Behavioral Symptoms; Benefits and Risks; Benzodiazepines; Caregivers; Characteristics; Clinical; Clinical Trials; Consensus; Data; Data Set; Decision Making; Delirium; Dementia; Dementia caregivers; Distress; Drug Prescriptions; Elderly; Enrollment; Equilibrium; Evaluation; Foundations; Geriatric Psychiatry; Goals; Growth; Hallucinations; Haloperidol; Hospice Care; Individual; Inpatients; Interview; K-Series Research Career Programs; Knowledge; Life; Link; Measures; Medical; Medicare; Mental Health Services; Mental disorders; Mentors; Mentorship; Methods; Modeling; Mortality Decline; Nursing Homes; Outcome; Palliative Care Nursing; Palliative Medicine; Patient Care; Patient-Focused Outcomes; Patients; Pharmaceutical Preparations; Pharmacoepidemiology; Policies; Population; Provider; Psychiatrist; Qualitative Research; Quality of Care; Research; Research Methodology; Research Personnel; Risk; Scientist; Services; Social support; Standardization; Statistical Methods; Structure; Surveys; Symptoms; Terminally Ill; Training; Training Programs; Variant; Work; advanced dementia; base; beneficiary; career; dementia care; design; end of life; end of life care; evidence base; functional decline; functional disability; geriatric mental health; hospice environment; improved; innovation; loved ones; male; mortality; multilevel analysis; off-label use; preference; programs; public health relevance; sex; skills; stakeholder perspectives; symptom management

ABSTRACT The goal of this Mentored Career Development Award is to prepare Dr. Lauren Gerlach for a career as an independent investigator focused on measuring and improving the quality of end-of-life care for older adults with psychiatric disorders and dementia. Dr. Gerlach’s long-term career goal is to establish herself as an independent investigator in geriatric mental health services and mixed methods research. Behavioral symptoms in advanced dementia are common, and despite limited evidence to support their use, the mainstay of such symptom management in hospice is off-label use of psychotropic medications such as antipsychotics. However, recent clinical trial evidence suggests that use of antipsychotics at end of life may be associated with worse outcomes for patients—raising concerns that the very medications prescribed to alleviate distress in fact exacerbate it. Little is known about how widely psychotropics are prescribed during end-of-life care for dementia, the factors that influence this prescribing, or the outcomes of such use. These critical knowledge gaps—including which patients are at greatest risk of potential harm—limit the ability to develop a consensus on best practices to address distressing behavioral symptoms in hospice care for dementia. Dr. Gerlach’s clinical training as a geriatric psychiatrist and prior research in pharmacoepidemiology provide the critical foundation for this work, but her transition to independence requires new skills and knowledge that will be gained through a coordinated program of research, mentorship, and coursework during the 5-year award period. This will include training in: 1) hospice-based dementia care, 2) use of Medicare and Minimum Data Set (MDS) data to examine end-of-life care, 3) advanced statistical methods for pharmacoepidemiology research, and 4) qualitative research methods. The proposed study will use Medicare data for all older adults with dementia enrolled in hospice in 2015 to determine the array of patient, provider, and hospice characteristics that influence psychotropic prescribing (Aim 1). In partnership with a local hospice organization, an exploratory sub-aim will examine the indications for psychotropic prescribing at end of life—information not available in claims data. Aim 2 will use linked Medicare and MDS data to examine outcomes associated with psychotropic prescribing (e.g., functional impairment, behavioral symptoms, mortality). Finally, Aim 3 will include interviews with patients with early-stage dementia, caregivers, and hospice providers to elicit stakeholder perspectives on the goals of hospice care. Study findings will inform how to best manage behavioral symptoms at the end of life. Given that not all patients with dementia utilize hospice, this K23 is designed to lay the foundation for a subsequent R01 to examine broader end-of-life care among all patients with dementia and to determine how hospice enrollment impacts outcomes. The R01 study will use Medicare and linked survey data to determine factors that impact the care patients receive in the last year of life and to identify the extent of potentially inappropriate treatments and impact on caregiver outcomes to better inform hospice care models for dementia.

摘要