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Ott BR, Hollins C, Tjia J, Baek J, Chen Q, Lapane KL, Alcusky M. Antidementia Medication Use in Nursing Home Residents. J Geriatr Psychiatry Neurol 2024; 37:194-205. [PMID: 37715795 PMCID: PMC10947315 DOI: 10.1177/08919887231202948] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/18/2023]
Abstract
BACKGROUND Antidementia medication can provide symptomatic improvements in patients with Alzheimer's disease, but there is a lack of consensus guidance on when to start and stop treatment in the nursing home setting. METHODS We describe utilization patterns of cholinesterase inhibitors (ChEI) and memantine for 3,50,197 newly admitted NH residents with dementia between 2011 and 2018. RESULTS Overall, pre-admission use of antidementia medications declined from 2011 to 2018 (ChEIs: 44.5% to 36.9%; memantine: 27.4% to 23.2%). Older age, use of a feeding tube, and greater functional dependency were associated with lower odds of ChEI initiation. Coronary artery disease, parenteral nutrition, severe aggressive behaviors, severe cognitive impairment, and high functional dependency were associated with discontinuation of ChEIs. Comparison of clinical factors related to anti-dementia drug treatment changes from pre to post NH admission in 2011 and 2018 revealed a change toward lower likelihood of initiation of treatment among residents with more functional dependency and those with indicators of more complex illness as well as a change toward higher likelihood of discontinuation in residents having 2 or more hospital stays. CONCLUSIONS These prescribing trends highlight the need for additional research on the effects of initiating and discontinuing antidementia medications in the NH to provide clear guidance for clinicians when making treatment decisions for individual residents.
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Affiliation(s)
- Brian R. Ott
- Department of Neurology, Brown University Warren Alpert Medical School, Providence, RI
| | - Carl Hollins
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jennifer Tjia
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Jonggyu Baek
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Qiaoxi Chen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Kate L. Lapane
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Matthew Alcusky
- Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
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Rabinovici GD, Carrillo MC, Apgar C, Gareen IF, Gutman R, Hanna L, Hillner BE, March A, Romanoff J, Siegel BA, Smith K, Song Y, Weber C, Whitmer RA, Gatsonis C. Amyloid Positron Emission Tomography and Subsequent Health Care Use Among Medicare Beneficiaries With Mild Cognitive Impairment or Dementia. JAMA Neurol 2023; 80:1166-1173. [PMID: 37812437 PMCID: PMC10562987 DOI: 10.1001/jamaneurol.2023.3490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/11/2023] [Indexed: 10/10/2023]
Abstract
Importance Results of amyloid positron emission tomography (PET) have been shown to change the management of patients with mild cognitive impairment (MCI) or dementia who meet Appropriate Use Criteria (AUC). Objective To determine if amyloid PET is associated with reduced hospitalizations and emergency department (ED) visits over 12 months in patients with MCI or dementia. Design, Setting, and Participants This nonrandomized controlled trial analyzed participants in the Imaging Dementia-Evidence for Amyloid Scanning (IDEAS) study, an open-label, multisite, longitudinal study that enrolled participants between February 2016 and December 2017 and followed up through December 2018. These participants were recruited at 595 clinical sites that provide specialty memory care across the US. Eligible participants were Medicare beneficiaries 65 years or older with a diagnosis of MCI or dementia within the past 24 months who met published AUC for amyloid PET. Each IDEAS study participant was matched to a control Medicare beneficiary who had not undergone amyloid PET. Data analysis was conducted on December 13, 2022. Exposure Participants underwent amyloid PET at imaging centers. Main Outcomes and Measures The primary end points were the proportions of patients with 12-month inpatient hospital admissions and ED visits. One of 4 secondary end points was the rate of hospitalizations and rate of ED visits in participants with positive vs negative amyloid PET results. Health care use was ascertained from Medicare claims data. Results The 2 cohorts (IDEAS study participants and controls) each comprised 12 684 adults, including 6467 females (51.0%) with a median (IQR) age of 77 (73-81) years. Over 12 months, 24.0% of the IDEAS study participants were hospitalized, compared with 25.1% of the matched control cohort, for a relative reduction of -4.49% (97.5% CI, -9.09% to 0.34%). The 12-month ED visit rates were nearly identical between the 2 cohorts (44.8% in both IDEAS study and control cohorts) for a relative reduction of -0.12% (97.5% CI, -3.19% to 3.05%). Both outcomes fell short of the prespecified effect size of 10% or greater relative reduction. Overall, 1467 of 6848 participants (21.4%) with positive amyloid PET scans were hospitalized within 12 months compared with 1081 of 4209 participants (25.7%) with negative amyloid PET scans (adjusted odds ratio, 0.83; 95% CI, 0.78-0.89). Conclusions and Relevance Results of this nonrandomized controlled trial showed that use of amyloid PET was not associated with a significant reduction in 12-month hospitalizations or ED visits. Rates of hospitalization were lower in patients with positive vs negative amyloid PET results.
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Affiliation(s)
- Gil D. Rabinovici
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco
- Associate Editor, JAMA Neurology
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco
| | | | - Charles Apgar
- Center for Research and Innovation, American College of Radiology, Reston, Virginia
| | - Ilana F. Gareen
- Center for Statistical Sciences, Brown University School of Public Health, Providence, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
| | - Roee Gutman
- Center for Statistical Sciences, Brown University School of Public Health, Providence, Rhode Island
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | - Lucy Hanna
- Center for Statistical Sciences, Brown University School of Public Health, Providence, Rhode Island
| | - Bruce E. Hillner
- Department of Medicine, Virginia Commonwealth University, Richmond
| | - Andrew March
- Center for Research and Innovation, American College of Radiology, Reston, Virginia
| | - Justin Romanoff
- Center for Statistical Sciences, Brown University School of Public Health, Providence, Rhode Island
| | - Barry A. Siegel
- Edward Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Karen Smith
- Department of Neurology, Memory and Aging Center, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco
| | - Yunjie Song
- Center for Statistical Sciences, Brown University School of Public Health, Providence, Rhode Island
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
| | | | - Rachel A. Whitmer
- Department of Public Health Sciences and Neurology, University of California, Davis, Davis
| | - Constantine Gatsonis
- Center for Statistical Sciences, Brown University School of Public Health, Providence, Rhode Island
- Department of Biostatistics, Brown University School of Public Health, Providence, Rhode Island
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Knehtl M, Petreski T, Piko N, Ekart R, Bevc S. Polypharmacy and Mental Health Issues in the Senior Hemodialysis Patient. Front Psychiatry 2022; 13:882860. [PMID: 35633796 PMCID: PMC9133494 DOI: 10.3389/fpsyt.2022.882860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Hemodialysis (HD) is the most common method of chronic kidney failure (CKF) treatment, with 65% of European patients with CKF receiving HD in 2018. Regular two to three HD sessions weekly severely lower their quality of life, resulting in a higher incidence of depression and anxiety, which is present in one third to one half of these patients. Additionally, the age of patients receiving HD is increasing with better treatment and care, resulting in more cognitive impairment being uncovered. Lastly, patients with other mental health issues can also develop CKF during their life with need for kidney replacement therapy (KRT). All these conditions need to receive adequate care, which often means prescribing psychotropic medications. Importantly, many of these drugs are eliminated through the kidneys, which results in altered pharmacokinetics when patients receive KRT. This narrative review will focus on common issues and medications of CKF patients, their comorbidities, mental health issues, use of psychotropic medications and their altered pharmacokinetics when used in HD, polypharmacy, and drug interactions, as well as deprescribing algorithms developed for these patients.
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Affiliation(s)
- Maša Knehtl
- Department of Nephrology, University Medical Center Maribor, Maribor, Slovenia
| | - Tadej Petreski
- Department of Nephrology, University Medical Center Maribor, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Nejc Piko
- Department of Dialysis, University Medical Center Maribor, Maribor, Slovenia
| | - Robert Ekart
- Faculty of Medicine, University of Maribor, Maribor, Slovenia.,Department of Dialysis, University Medical Center Maribor, Maribor, Slovenia
| | - Sebastjan Bevc
- Department of Nephrology, University Medical Center Maribor, Maribor, Slovenia.,Faculty of Medicine, University of Maribor, Maribor, Slovenia
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Couch E, Mueller C, Perera G, Lawrence V, Prina M. The Association Between a Previous Diagnosis of Mild Cognitive Impairment as a Proxy for an Early Diagnosis of Dementia and Mortality: A Study of Secondary Care Electronic Health Records. J Alzheimers Dis 2020; 79:267-274. [PMID: 33285635 DOI: 10.3233/jad-200978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Dementia policy states that the early diagnosis of dementia can keep people living well for longer; however, there is little robust evidence to support this. Mild cognitive impairment (MCI) is considered a prodrome to dementia and can aid with the earlier diagnosis of dementia. OBJECTIVE The objective of this study was to use a previous diagnosis of MCI, before dementia, as a proxy for early diagnosis to investigate the relationship between an early diagnosis and mortality. METHODS A retrospective cohort study of electronic health care records from South London and Maudsley NHS. Patients aged 50+, diagnosed with dementia between January 2008 and November 2018, were divided into two groups: those with a previous diagnosis of MCI (early diagnosis) and those without. Cox regression models used to compare the risk of mortality between groups. RESULTS Of 18,557 participants, 5.6%(n = 1,030) had an early diagnosis; they had fewer cognitive, psychiatric, and functional problems at dementia diagnosis. The early diagnosis group had a reduced hazard of mortality (HR = 0.86, CI = 0.77-0.97). However, the magnitude of this effect depended on the scale used to adjust for cognitive difficulties. CONCLUSION A previous diagnosis of MCI is a helpful proxy for early diagnosis. There is some evidence that an early diagnosis is associated with a reduced risk of mortality; however, it is not clear how Mini-Mental State Exam scores affect this relationship. While these findings are promising, we cannot be conclusive on the relationship between an early diagnosis and mortality.
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Affiliation(s)
- Elyse Couch
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Christoph Mueller
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Gayan Perera
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Vanessa Lawrence
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Matthew Prina
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Möllers T, Perna L, Stocker H, Ihle P, Schubert I, Schöttker B, Frölich L, Brenner H. New use of psychotropic medication after hospitalization among people with dementia. Int J Geriatr Psychiatry 2020; 35:640-649. [PMID: 32100308 DOI: 10.1002/gps.5282] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 01/14/2020] [Accepted: 02/13/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVES Psychotropic medication is commonly used among people with dementia (PWD), but it shows modest efficacy and it has been associated with severe adverse events. Hospitalizations are an opportunity for medication management as well as treatment recommendations for outpatient physicians. The aim of this study was to asses factors associated with new use of psychotropic medication after hospitalization among PWD. METHODS We conducted a retrospective dynamic cohort study from 2004 to 2015 using claims data from a German health insurance company. PWD were identified by an algorithm that included ICD-10 diagnosis and diagnostic measures. The medication classes included were antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication. The assessment period was up to 30 days after discharge from the hospital across four hospitalizations. RESULTS The main predictors for new use of psychotropic medication were similar across medication classes. Neuropsychiatric symptoms (NPS) and the need of care were associated with higher odds of new use of antidepressants, antipsychotics, and anxiolytics or hypnotics/sedatives. A hospital stay due to dementia was an independent predictor for new use across medication classes as well. Delirium increased the odds for new use of antipsychotics and anxiolytics or hypnotics/sedatives. CONCLUSIONS Factors associated with new use of psychotropic medication included delirium, NPS, and the need of care in PWD. The findings highlight the need for preventive interventions and non-medical treatment options in regards to delirium and NPS as well as for a more intensive use of screening tools for inappropriate medication use among PWD. Key points The percentage of new users was 1.8%, 7.1%, 2.1%, and 2.5% across hospitalizations for antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication, respectively. 83.0%, 61.9%, 56.9%, and 88.1% of new users received antidepressants, antipsychotics, anxiolytics or hypnotics/sedatives, and Alzheimer's medication for more than 6 weeks. Delirium and neuropsychiatric symptoms were associated with significantly increased odds of new psychotropic medication use. Hospital stays due to dementia and the need of care were predictors for new use of psychotropic medication.
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Affiliation(s)
- Tobias Möllers
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Laura Perna
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Department of Translational Research in Psychiatry, Max Planck Institute for Psychiatry, Munich, Germany
| | - Hannah Stocker
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany.,Medical Faculty, Heidelberg University, Heidelberg, Germany
| | - Peter Ihle
- PMV Research Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ingrid Schubert
- PMV Research Group, Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Ben Schöttker
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
| | - Lutz Frölich
- Department of Gerontopsychiatry, Central Institute of Mental Health, Heidelberg University, Mannheim, Germany
| | - Hermann Brenner
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Heidelberg, Germany
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