Medicating distress: Use of psychotropic medications among patients with dementia receiving hospice care

摘要 这个指导职业发展奖的目标是为Lauren Gerlach博士的职业生涯做好准备 独立调查员专注于衡量和改善老年人临终关怀的质量 患有精神障碍和痴呆症。Gerlach博士的长期职业目标是将自己确立为 老年精神卫生服务和混合方法研究的独立研究员。行为 晚期痴呆症的症状很常见，尽管支持其使用的证据有限，但主要的 临终关怀中这种症状管理的一种方式是在标签外使用精神药物，如抗精神病药物。 然而，最近的临床试验证据表明，在生命末期使用抗精神病药物可能与 对患者来说更糟糕的结果--引发了人们的担忧，即实际上开出的缓解痛苦的药物 加剧了它的影响。在临终关怀期间，精神药物的处方范围有多广，目前知之甚少 痴呆症，影响这种处方的因素，或这种使用的结果。这些批判性知识 差距--包括哪些患者面临最大的潜在伤害风险--限制了达成共识的能力 关于解决痴呆症临终关怀中令人痛苦的行为症状的最佳做法。Gerlach医生的 作为老年精神病学家的临床培训和先前在药物流行病学方面的研究提供了关键 为这项工作奠定了基础，但她向独立的过渡需要新的技能和知识 在五年的获奖期间，通过研究、指导和课程工作的协调计划获得 句号。这将包括以下方面的培训：1)以临终关怀为基础的痴呆症护理；2)使用医疗保险和最低数据集 (MDS)用于检查临终关怀的数据，3)药物流行病学研究的高级统计方法， (4)定性研究方法。这项拟议的研究将使用医疗保险数据，适用于所有患有 痴呆症在2015年登记到临终关怀中心，以确定患者、提供者和临终关怀中心的一系列特征 影响精神药物处方的因素(目标1)。与当地一家临终关怀组织合作，一个探索性的 次级目标将审查生命末期精神药物处方的适应症-信息不在 索赔数据。AIM 2将使用关联的Medicare和MDS数据来检查与精神药物相关的结果 处方(例如，功能障碍、行为症状、死亡率)。最后，《目标3》将包括采访。 与早期痴呆症患者、照顾者和临终关怀提供者一起征求利益相关者对 临终关怀的目标。研究结果将告诉我们如何更好地管理行为症状 生活。鉴于并非所有痴呆症患者都使用临终关怀，这款K23旨在为 随后的R01检查所有痴呆症患者的更广泛的临终关怀，并确定如何 安宁疗养院的登记人数会影响结果。R01研究将使用联邦医疗保险和相关调查数据来确定 影响患者在生命最后一年接受护理的因素，并确定潜在的 不适当的治疗和对照顾者结局的影响，以更好地为痴呆症的临终关怀模式提供信息。

ABSTRACT The goal of this Mentored Career Development Award is to prepare Dr. Lauren Gerlach for a career as an independent investigator focused on measuring and improving the quality of end-of-life care for older adults with psychiatric disorders and dementia. Dr. Gerlach’s long-term career goal is to establish herself as an independent investigator in geriatric mental health services and mixed methods research. Behavioral symptoms in advanced dementia are common, and despite limited evidence to support their use, the mainstay of such symptom management in hospice is off-label use of psychotropic medications such as antipsychotics. However, recent clinical trial evidence suggests that use of antipsychotics at end of life may be associated with worse outcomes for patients—raising concerns that the very medications prescribed to alleviate distress in fact exacerbate it. Little is known about how widely psychotropics are prescribed during end-of-life care for dementia, the factors that influence this prescribing, or the outcomes of such use. These critical knowledge gaps—including which patients are at greatest risk of potential harm—limit the ability to develop a consensus on best practices to address distressing behavioral symptoms in hospice care for dementia. Dr. Gerlach’s clinical training as a geriatric psychiatrist and prior research in pharmacoepidemiology provide the critical foundation for this work, but her transition to independence requires new skills and knowledge that will be gained through a coordinated program of research, mentorship, and coursework during the 5-year award period. This will include training in: 1) hospice-based dementia care, 2) use of Medicare and Minimum Data Set (MDS) data to examine end-of-life care, 3) advanced statistical methods for pharmacoepidemiology research, and 4) qualitative research methods. The proposed study will use Medicare data for all older adults with dementia enrolled in hospice in 2015 to determine the array of patient, provider, and hospice characteristics that influence psychotropic prescribing (Aim 1). In partnership with a local hospice organization, an exploratory sub-aim will examine the indications for psychotropic prescribing at end of life—information not available in claims data. Aim 2 will use linked Medicare and MDS data to examine outcomes associated with psychotropic prescribing (e.g., functional impairment, behavioral symptoms, mortality). Finally, Aim 3 will include interviews with patients with early-stage dementia, caregivers, and hospice providers to elicit stakeholder perspectives on the goals of hospice care. Study findings will inform how to best manage behavioral symptoms at the end of life. Given that not all patients with dementia utilize hospice, this K23 is designed to lay the foundation for a subsequent R01 to examine broader end-of-life care among all patients with dementia and to determine how hospice enrollment impacts outcomes. The R01 study will use Medicare and linked survey data to determine factors that impact the care patients receive in the last year of life and to identify the extent of potentially inappropriate treatments and impact on caregiver outcomes to better inform hospice care models for dementia.