Prescribing without a guide: A national study of psychotropic and opioid polypharmacy among persons living with dementia

项目摘要 美国的医疗保健系统装备不足，无法处理越来越多的人生活在 痴呆症（PLWD）及其复杂的医疗和心理社会需求。虽然存储器 损伤是阿尔茨海默病和相关痴呆症（ADRD）的主要特征，行为 和心理症状（例如，冷漠、妄想、激动）在疾病的各个阶段都很常见 并造成严重的看护者痛苦。尽管有限的高质量证据表明， 药物治疗，我们的工作表明，临床医生处方精神药物， 社区居住的PLWD的使用率远远超过一般老年人的使用率。 不幸的是，这包括精神药物和阿片类药物（中枢神经系统[CNS]- 活性）多药（即，抗抑郁药中≥3种药物重叠使用， 抗精神病药、抗癫痫药、苯二氮卓类、非苯二氮卓类苯二氮卓受体激动剂 催眠药或阿片类药物）-这被认为是可能不适合老年人给予严重 相关风险包括跌倒相关损伤、认知受损和呼吸抑制或死亡 当涉及阿片类药物。NIA的研究战略方向的目标C-1强调需要 改善老年人的药物安全使用，而NIA ADRD里程碑8.A峰会指出“ 专门针对改善残疾人生活的干预措施的研究和政策真空 ADRD。”最大限度地减少CNS多药治疗是改善安全用药的关键机会， PLWD，通过预防新的CNS polyRx和取消处方，即，识别和中止 现有或潜在危害超过现有或潜在益处的药物--在PLWD中， 暴露了然而，如果不进行干预设计， 理解为什么临床医生决定开这些药物。在这种解释性的混合方法中， 在这项研究中，我们将首先描述与事件和持续CNS相关的患者特征， polyRx在一个独特的队列中的所有社区居住的医疗保险受益人生活与痴呆症， 美国，结合传统和管理的医疗保险。我们将使用这些医疗保险数据来分析 中枢神经系统处方的临床医生，照顾这些PLWD，然后，通过全国调查， 详细的后续定性访谈，我们将描述处方决策过程， 包括与处方意图相关的基本知识、规范、促进者和障碍。 最后，在多学科专家小组（包括艾滋病病毒携带者-护理者二元组）的投入下，我们将 确定关键的剩余知识差距和可能的干预目标。随着新的见解 我们将制定一条前进的道路，以应对关键但以前未被认识到的挑战， 在社区中生活的PLWD中可能不适当的CNS多药治疗。

PROJECT ABSTRACT The U.S. health care system is poorly equipped to deal with the growing number of persons living with dementia (PLWD) in the U.S. and their complex medical and psychosocial needs. While memory impairment is the cardinal feature of Alzheimer’s disease and related dementias (ADRD), behavioral and psychological symptoms (e.g., apathy, delusions, agitation) are common during all stages of illness and cause significant caregiver distress. Despite limited high-quality evidence of efficacy for pharmacological treatment, our work has shown that clinicians prescribe psychotropic medications to community-dwelling PLWD at rates that far exceed use in the general older adult population. Unfortunately, this includes a high burden of psychotropic and opioid (central nervous system [CNS]- active) polypharmacy (i.e., overlapping use of ≥3 medications from among antidepressants, antipsychotics, antiepileptics, benzodiazepines, nonbenzodiazepine benzodiazepine receptor agonist hypnotics, or opioids)— which is considered potentially inappropriate for older adults given serious associated risks including fall-related injury, impaired cognition, and respiratory suppression or death when involving opioids. Goal C-1 of the NIA’s Strategic Directions for Research highlights the need to improve safe use of medications for older adults, while the NIA ADRD Milestone 8.A Summit noted “a research and policy vacuum for interventions specifically aimed at improving life for persons with ADRD.” Minimizing CNS polypharmacy is a critical opportunity to improve safe medication use for PLWD, both through preventing new CNS polyRx and deprescribing—i.e., identifying and discontinuing drugs [where] existing or potential harms outweigh existing or potential benefits—among PLWD already exposed. However, the design of interventions to reduce CNS polypharmacy cannot proceed without understanding why clinicians decide to prescribe these medications. In this explanatory mixed methods study, we will first characterize patient characteristics associated with incident and continued CNS polyRx in a unique cohort of all community-dwelling Medicare beneficiaries living with dementia in the U.S., combining both traditional and managed Medicare. We will use these Medicare data to profile the CNS prescribing of the clinicians that care for these PLWD, and then, through a national survey and detailed follow-up qualitative interviews, we will characterize the prescribing decision-making process, including the underlying knowledge, norms, facilitators, and barriers associated with prescribing intent. Finally, with input from a multidisciplinary Expert Panel including a PLWD-caregiver dyad, we will identify critical remaining knowledge gaps and possible intervention targets. With the new insights gained, we will chart a way forward to address the critical but previously underrecognized challenge of potentially inappropriate CNS polypharmacy among PLWD living in the community.