Deprescribing Central Nervous System Medications in Hospitalized Older Adults

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This K23 Career Development Award in Aging focuses on the development of Dr. Juliessa Pavon, a hospital- based geriatrician, and on reducing central nervous system (CNS) medication use in hospitalized older adults. Dr. Pavon’s long-term goal is to improve the resilience of older adults against the acute stressors of hospitalization. She has built her research program on investigating hazards of hospitalization, and a major threat is high-risk medication exposure. Sub-optimal CNS medication use during hospitalization is a key modifiable risk factor for poor health outcomes; common classes include opioids, anxiolytics, anti-depressants, antipsychotics, and hypnotics. Our preliminary data suggests that nearly 40% of hospitalized older adults are exposed to anxiolytics and 60% to opioids during their hospital stay. De-prescribing is a systematic process of tapering or reducing medications. Interventions to facilitate de-prescribing that target specific medication classes, like CNS medications, or specific populations, like those with existing cognitive impairment, have not been well-studied in the inpatient setting. This gap represents a key opportunity to reduce potentially inappropriate CNS medications and their debilitating side effects in vulnerable patients--in line with the National Institute of Aging’s priorities to improve medication use in older adults. Dr. Pavon’s K23 award proposes to develop and pilot test a de-prescribing intervention that is informed by a theoretical model of behavioral change. Aim 1 results will inform the epidemiology of the problem and identify target populations for recruitment. Aim 2 will use qualitative methods to examine barriers and facilitators of hospital de-prescribing. Results will inform the intervention delivery strategies best suited to facilitate CNS medication de-prescribing in a well-tolerated, feasible manner. Aim 3 will develop and pilot test a multi-component hospital-based de- prescribing intervention that uses health informatics for content delivery, and provider behavior change and patient activation strategies. This work will advance understanding of 1) which patients and CNS medication classes to target for de-prescribing interventions, 2) whether there are unique barriers to de-prescribing in the hospital setting, and 3) the optimal delivery strategy for safely de-prescribing. During this K23 grant period, Dr. Pavon will also complete additional training in Markov modeling statistical techniques, intervention development, health informatics, and leadership. Dr. Pavon’s mentor team will provide scientific support with expertise in aging, pharmacology, hospital medicine, and research methodology. This career development plan will give Dr. Pavon the skills in conducting intervention development studies within the hospital setting. This training and resulting data will establish Dr. Pavon as a strong candidate for an R01 intervention designed to facilitate de-prescribing of CNS medications for the nearly 1 in 2 older adults that will experience exposure to a CNS medication during hospitalization.