Epidemiology and Clinical Outcomes of Electroconvulsive Therapy Use in Nursing Home Residents with Dementia

项目摘要 阿尔茨海默病和相关痴呆(ADRD)是最常见的、使人衰弱的神经退行性疾病 老年性疾病，以及神经精神症状(NPS)的当前治疗方法(例如，激越、攻击、 和抑郁症)的ADRD是混合的。而非药理学行为干预是推荐的 作为ADRD这些NPS的一线治疗，它们需要大量的时间和资源，而且可能更少 对患有ADRD的严重烦躁、攻击性或抑郁的老年患者有效。 电休克疗法(ECT)是一种有效而安全的治疗一系列精神疾病的方法， 包括难治性抑郁症、分裂情感障碍和双相情感障碍。案例系列和 不受控制的自然主义研究支持了ECT治疗严重激越的疗效的初步证据， 抑郁，或ADRD中的其他NPS。电休克治疗与NPS和老年患者远期改善的关系 综合症(例如，功能残疾和虚弱)以及老年人的全因死亡率 在养老院使用ADRD的情况在很大程度上是未被探索的。建议的全国队列研究明确 解决这些知识差距。 使用医疗保险和医疗补助服务中心2018-2020年的联邦医疗保险索赔数据(A、B和 D)链接到多个数据源(例如，最低数据集[MDS]和国家死亡指数[NDI])，这 拟议的研究具有以下具体目标：1)检查使用ECT的发生率和流行率 以及与ECT使用相关的社会人口学和临床因素；2)调查纵向关联 ECT与NPS和老年综合征的差异；以及3)通过以下方式检查全原因死亡率的不同风险 在养老院环境中患有ADRD的老年人中使用ECT。纵向数据分析，例如 目标2和目标3将使用广义线性混合建模和竞争风险回归方法。 这项全国性的队列研究，我们将使用倾向-分数匹配和工具变量技术 对观察到的和未观察到的混杂因素进行调整。意向治疗分析和AS治疗分析也将 指挥。早期的研究支持ECT与ADRD患者NPS的改善以及我们的分析 显示同时存在抑郁症和ADRD患者使用ECT与ALL-ALL的可能性较低相关。 导致死亡率；因此，我们假设ECT也可能对老年综合征具有保护作用。 这是第一项调查电疗长期有效性和安全性的全国性队列研究。 养老院中患有ADRD的老年人。拟议的研究是创新的，因为它将提供更好的 了解ECT的使用及其与NPS、老年综合征和其他相关健康的关系 结果。这项研究的结果将为老年ADRD患者使用ECT提供临床指导 养老院环境。

Project Abstract Alzheimer’s disease and related dementias (ADRD) are the most prevalent, debilitating neuro-degenerative diseases of aging, and current treatments for neuropsychiatric symptoms (NPS) (e.g., agitation, aggression, and depression) of ADRD are mixed. While non-pharmacological behavioral interventions are recommended as first-line treatments for these NPS of ADRD, they require substantial time and resources, and may be less effective for severely agitated, aggressive, or depressed older patients with ADRD. Electroconvulsive therapy (ECT) is an effective and safe treatment for a range of psychiatric disorders, including treatment-resistant depression, schizoaffective disorder, and bipolar disorder. Case series and uncontrolled naturalistic studies support preliminary evidence for the efficacy of ECT to treat severe agitation, depression, or other NPS in ADRD. Associations of ECT with long-term improvement in NPS and geriatric syndromes (e.g., functional disability and frailty), as well as with all-cause mortality rates among older adults with ADRD in nursing home settings are largely unexplored. The proposed nationwide cohort study explicitly addresses these knowledge gaps. Using the Centers for Medicare and Medicaid Services’ 2018-2020 Medicare claims data (Parts A, B, and D) linked to multiple data sources (e.g., Minimum Data Set [MDS] and National Death Index [NDI]), this proposed study features the following specific aims: 1) to examine incidence and prevalence rates of ECT use and socio-demographic and clinical factors associated with ECT use; 2) to investigate longitudinal associations of ECT with NPS and geriatric syndromes; and 3) to examine differential risks of all-cause mortality rates by ECT use among older adults with ADRD in nursing home settings. Longitudinal data analyses, such as generalized linear mixed modeling and competing-risk regression methods, will be used for Aims 2 and 3. In this nationwide cohort study, we will employ propensity-score matching and instrumental variable techniques to adjust for both observed and unobserved confounders. Intent-to-treat and as-treated analyses will also be conducted. Earlier studies support that ECT is associated with improvement in NPS of ADRD and our analyses show that ECT use with presence of both depression and ADRD was associated with a lower likelihood of all- cause mortality rates; we thus hypothesize that ECT may also be protective against geriatric syndromes. This is the first nationwide cohort study investigating the long-term effectiveness and safety of ECT among older adults with ADRD in nursing home settings. The proposed study is innovative since it will provide a better understanding of ECT use and its association with NPS, geriatric syndromes, and other related health outcomes. Findings from this study will inform clinical guidance on ECT use in older adults with ADRD in nursing home settings.