Neglected By The Evidence: The Intersection of Medical Complexity and Dementia

描述（由申请人提供）：申请人是罗得岛医院阿尔茨海默病和记忆障碍中心的研究助理。她在老年精神药理学和疗养院医学方面的广泛临床背景是她成为独立卫生服务研究人员的长期目标的基础。这项建议的重点是在一个经常被忽视的人群-生活在养老院的痴呆症患者中进行比较有效性研究。研究问题旨在调查与痴呆和共病医学疾病患者使用或停用某些精神活性药物相关的认知，功能和神经行为结果。拟议的培训计划将通过以下方式开发额外技能：1）流行病学课程，以扩展方法学和分析技能; 2）与导师团队（包括卫生服务研究和痴呆症研究专家）互动; 3）利用大型自动化交联数据集完成两项观察性药物流行病学研究。这些研究的结果将提供临床相关信息，为老年痴呆患者的治疗提供信息;这一人群被系统地排除在临床试验之外。使用最先进的方法估计非实验性研究的治疗效果，目的是1）评价与持续CHEI治疗相比，在患有痴呆的护理机构居民中，停止稳定的胆碱酯酶抑制剂（CHEI）治疗的纵向行为、认知和功能效果，2）确定在髋部骨折修复术期间接受异氟烷全身麻醉的认知受损个体在何种程度上经历了更大的术后与接受其他类型全身麻醉的患者相比，手术后一年内的手术认知和功能下降，和3）量化异氟烷麻醉与其他全身或局部麻醉相比的效果（脊髓或硬膜外）麻醉对术后髋部骨折修复术后一年认知功能受损患者的手术认知和功能下降。

DESCRIPTION (provided by applicant): The applicant Is a Research Associate at the Alzheimer's Disease and Memory Disorders Center at Rhode Island Hospital. Her extensive clinical background in geriatric psychopharmacology and nursing home medicine is the foundation for her long term goal to become an independent health services researcher. This proposal focuses on comparative effectiveness research in an oft neglected population - persons with dementia living in nursing homes. The research questions seek to investigate the cognitive, functional, and neurobehavioral outcomes associated with the use or discontinuation of certain psychoactive drugs in individuals with dementia and comorbid medical illness. The proposed training plan will develop additional skills through 1) coursework in epidemiology to expand methodologic and analytic skills, 2) interaction with the mentorship team, including experts in health services research and dementia research, and 3) completion of two observational pharmacoepidemiologic studies utilizing large automated cross-linked datasets. Findings from these studies will provide clinically relevant information to inform treatment of elderly patients with dementia; a population systematically excluded from clinical trials. Using state of the art methods for estimating treatment effects from non-experimental studies, the aims are 1) to evaluate the longitudinal behavioral, cognitive, and functional effects of discontinuing stable cholinesterase inhibitor (CHEI) therapy compared to continuous CHEI therapy in nursing facility residents with dementia, 2) to determine the extent to which cognitively impaired individuals who receive isoflurane general anesthesia during hip fracture repair experience greater post-operative cognitive and functional decline in the year after surgery compared to patients receiving other types of general anesthesia, and 3) to quantify the effects of isoflurane anesthesia vs. other general or regional (spinal or epidural) anesthesia on the rate of post- operative cognitive and functional decline in cognitively impaired patients in the year after hip fracture repair surgery.