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准备博士劳伦盖拉赫的职业生涯作为一个 一名独立调查员专注于衡量和改善老年人临终关怀的质量 患有精神疾病和痴呆症盖拉赫博士的长期职业目标是使自己成为一名 老年心理健康服务和混合方法研究的独立调查员。行为 晚期痴呆症的症状是常见的，尽管支持其使用的证据有限，但主要是 临终关怀中的这种症状管理是精神药物如抗精神病药的标签外使用。 然而，最近的临床试验证据表明，在生命结束时使用抗精神病药物可能与 更糟糕的结果对病人提出的关注，非常药物处方，以减轻痛苦， 人们对精神药物在临终关怀中的使用范围知之甚少。 痴呆症、影响这种处方的因素或这种使用的结果。这些批判性的知识 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实践。盖拉赫医生 作为老年精神病学家的临床培训和药物流行病学的先前研究提供了关键的 这是这项工作的基础，但她向独立的过渡需要新的技能和知识， 在5年的奖励期间，通过研究，指导和课程的协调计划获得 期这将包括培训：1）基于临终关怀的痴呆症护理，2）使用医疗保险和最小数据集 (MDS)检查临终关怀的数据，3）药物流行病学研究的先进统计方法， （4）质的研究方法。这项拟议的研究将使用所有老年人的医疗保险数据， 2015年，痴呆症患者在临终关怀中登记，以确定患者、提供者和临终关怀的特征 影响精神药物处方的因素（目标1）。在与当地临终关怀组织的合作下， 次级目标将研究在生命结束时处方精神药物的适应症-资料未在 索赔数据。目标2将使用关联的医疗保险和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将包括面试 与早期痴呆症患者、护理人员和临终关怀提供者一起， 临终关怀的目标研究结果将告知如何最好地管理行为症状结束时， 生活鉴于并非所有痴呆症患者都使用临终关怀，K23旨在为 随后的R 01，以检查所有痴呆患者中更广泛的临终关怀，并确定如何 临终关怀登记影响结果。R 01研究将使用Medicare和相关调查数据来确定 影响患者在生命的最后一年接受护理的因素，并确定潜在的 不适当的治疗和对护理人员结果的影响，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.