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，无法应对日益增多的艾滋病患者 美国的痴呆症(PLWD)及其复杂的医疗和心理社会需求。而记忆 损害是阿尔茨海默病和相关痴呆(ADRD)的基本特征，行为 心理症状(如冷漠、妄想、激动)在疾病的各个阶段都很常见 并给照顾者带来极大的痛苦。尽管有效治疗的高质量证据有限 药物治疗方面，我们的工作表明，临床医生会开出精神药物来 社区居住的PLWD的比率远远超过一般老年人口的使用率。 不幸的是，这包括高负担的精神药物和阿片类药物(中枢神经系统[CNS]- 主动)多药联用(即，重叠使用抗抑郁药中的≥3药物， 抗精神病药物、抗癫痫药物、苯二氮卓类、非苯二氮卓类苯二氮卓类受体激动剂 催眠药，或阿片类药物)--这被认为可能不适合老年人，因为严重 相关风险包括与跌倒相关的损伤、认知障碍和呼吸抑制或死亡 当涉及阿片类药物时。NIA研究战略方向的目标C-1强调有必要 改善老年人的药物安全使用，而NIA ADRD里程碑8.一次峰会指出 研究和政策真空，特别是旨在改善老年人生活的干预措施 阿德勒。“最大限度地减少中枢神经系统多药联用是改善安全用药的关键机会 PLWD，通过预防新的CNS PolyRx和停药--即识别和停用 现有的或潜在的危害超过现有的或潜在的好处的药物--在已有的PLWD中 暴露了。然而，减少中枢神经系统多药联用的干预措施的设计不能没有 了解临床医生决定开这些药物的原因。在本说明性混合方法中 研究中，我们将首先描述与突发事件和持续中枢神经系统相关的患者特征 PolyRx在所有居住在社区的患有痴呆症的联邦医疗保险受益人中的独特队列中 美国，将传统医疗保险和管理医疗保险结合起来。我们将使用这些联邦医疗保险数据来分析 CNS对护理这些PLWD的临床医生进行处方，然后通过全国调查和 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潜在知识、规范、促进者和障碍。 最后，在多学科专家小组的支持下，我们将 确定关键的剩余知识差距和可能的干预目标。拥有新的洞察力 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 在社区生活的PLWD中可能不适当的中枢神经系统多药。

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.