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: 10571857
• 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/10571857
• 关键词: 5 Alpha-Reductase Inhibitor; Accidents; 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; 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; Predisposition; Prevalence; Process; Public Health; 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; 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.

项目概要/摘要 背景：对于老年人，个人处方决策可能单独看来是合理的，但可能会导致 陷入错综复杂的复杂网络中。一个关键的例子是级联处方。这些发生在当 药物会引起不良反应，因此无需更换有问题的药物，而是使用第二种药物 用于控制症状。这反过来可能会导致更多的负面影响，而这些负面影响可以通过第三方来管理。 药物治疗等。虽然与所有老年人相关，但级联可能特别常见且有害 对于痴呆症患者来说，部分原因是沟通困难可能会增加临床医生 没有认识到药物不良反应已经发生，而是将新的体征或症状解释为 潜在疾病的表现。尽管级联处方可能很常见并且可以赋予 发病率很高，但关于这一主题的学术研究却非常少。在本提案中，我们将探讨 作为该问题模型的两个潜在级联：(A) 加巴喷丁和普加巴林 → 外周水肿 → 袢利尿剂，以及 (B) 袢利尿剂 → 泌尿系统症状 → 用于治疗泌尿系统症状的药物。 目的：(1) 确定涉及加巴喷丁类药物和药物的级联处方的患病率和风险因素 袢利尿剂，以及这些利尿剂在患有和不患有痴呆症的老年人之间有何不同； (2) 确定 涉及袢利尿剂和泌尿系统症状的处方级联的患病率和危险因素 药物治疗，以及患有和不患有痴呆症的老年人之间这些药物有何不同； (3) 表征 加巴喷丁环利尿级联反应在这些人群中发生的途径。 方法：使用 VA 和 Medicare 的国家数据，针对目标 1 和 2，我们将组建一个回顾性队列 未使用指示药物（启动级联药物）和 结果药物（用于治疗指标药物引起的不良反应的药物）。我们随后将 确定哪些受试者随后开始了指标药物治疗，哪些受试者没有开始指标药物治疗 但开始使用另一种药物（即对照组）。我们将比较结果的使用 使用多变量事件发生时间方法在这些组之间进行药物治疗，以考虑竞争 风险。将使用交互项和分层分析来比较结果率和风险因素 患有和没有痴呆症的人。对于目标 3，我们将对 500 名受试者（其中 250 名患有痴呆症）进行图表审查 和 250 没有）加巴喷丁环利尿剂级联并评估决策要素 为级联做出了贡献。拟议的研究将为指导初级学生提供巨大的机会 调查人员并支持 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 实现这些目标将为预防和减轻这些潜在有害做法的战略提供信息。