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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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Niznik JD, Shmuel S, Pate V, Thorpe CT, Hanson LC, Rice C, Lund JL. Validating claims-based definitions for deprescribing: Bridging the gap between clinical and administrative data. Pharmacoepidemiol Drug Saf 2024; 33:e5784. [PMID: 38556843 PMCID: PMC11145562 DOI: 10.1002/pds.5784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 03/05/2024] [Accepted: 03/13/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Limited research has evaluated the validity of claims-based definitions for deprescribing. OBJECTIVES Evaluate the validity of claims-based definitions of deprescribing against electronic health records (EHRs) for deprescribing of benzodiazepines (BZDs) after a fall-related hospitalization. METHODS We used a novel data linkage between Medicare fee-for-service (FFS) and Part D with our health system's EHR. We identified patients aged ≥66 years with a fall-related hospitalization, continuous enrollment in Medicare FFS and Part D for 6 months pre- and post-hospitalization, and ≥2 BZD fills in the 6 months pre-hospitalization. Using a standardized EHR abstraction tool, we adjudicated deprescribing for a sub-sample with a fall-related hospitalization at UNC. We evaluated the validity of claims-based deprescribing definitions (e.g., gaps in supply, dosage reductions) versus chart review using sensitivity and specificity. RESULTS Among 257 patients in the overall sample, 44% were aged 66-74 years, 35% had Medicare low-income subsidy, 79% were female. Among claims-based definitions using gaps in supply, the prevalence of BZD deprescribing ranged from 8.2% (no refills) to 36.6% (30-day gap). When incorporating dosage, the prevalence ranged from 55.3% to 65.8%. Among the validation sub-sample (n = 47), approximately one-third had BZDs deprescribed in the EHR. Compared to EHR, gaps in supply from claims had good sensitivity, but poor specificity. Incorporating dosage increased sensitivity, but worsened specificity. CONCLUSIONS The sensitivity of claims-based definitions for deprescribing of BZDs was low; however, the specificity of a 90-day gap was >90%. Replication in other EHRs and for other low-value medications is needed to guide future deprescribing research.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Shahar Shmuel
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Virginia Pate
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
| | - Colleen Rice
- Translational and Clinical Sciences Institute, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
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Wang J, Shen JY, Conwell Y, Podsiadly EJ, Caprio TV, Nathan K, Yu F, Ramsdale EE, Fick DM, Mixon AS, Simmons SF. Implementation considerations of deprescribing interventions: A scoping review. J Intern Med 2024; 295:436-507. [PMID: 36524602 DOI: 10.1111/joim.13599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Over half of older adults experience polypharmacy, including medications that may be inappropriate or unnecessary. Deprescribing, which is the process of discontinuing or reducing inappropriate and/or unnecessary medications, is an effective way to reduce polypharmacy. This review summarizes (1) the process of deprescribing and conceptual models and tools that have been developed to facilitate deprescribing, (2) barriers, enablers, and factors associated with deprescribing, and (3) characteristics of deprescribing interventions in completed trials, as well as (4) implementation considerations for deprescribing in routine practice. In conceptual models of deprescribing, multilevel factors of the patient, clinician, and health-care system are all related to the efficacy of deprescribing. Numerous tools have been developed for clinicians to facilitate deprescribing, yet most require substantial time and, thus, may be difficult to implement during routine health-care encounters. Multiple deprescribing interventions have been evaluated, which mostly include one or more of the following components: patient education, medication review, identification of deprescribing targets, and patient and/or provider communication about high-risk medications. Yet, there has been limited consideration of implementation factors in prior deprescribing interventions, especially with regard to the personnel and resources in existing health-care systems and the feasibility of incorporating components of deprescribing interventions into the routine care processes of clinicians. Future trials require a more balanced consideration of both effectiveness and implementation when designing deprescribing interventions.
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Affiliation(s)
- Jinjiao Wang
- Elaine, Hubbard Center for Nursing Research on Aging, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Jenny Y Shen
- Department of Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Yeates Conwell
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York, USA
| | - Eric J Podsiadly
- Harriet J. Kitzman Center for Research Support, School of Nursing, University of Rochester, Rochester, New York, USA
| | - Thomas V Caprio
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- UR Medicine Home Care, University of Rochester Medical Center, Rochester, New York, USA
- University of Rochester Medical Center, Finger Lakes Geriatric Education Center, Rochester, New York, USA
| | - Kobi Nathan
- Department of Medicine, Division of Geriatrics & Aging, University of Rochester Medical Center, Rochester, New York, USA
- St. John Fisher College, Wegmans School of Pharmacy, Rochester, New York, USA
| | - Fang Yu
- Edson College of Nursing and Health Innovation, Arizona State University, Phoenix, Arizona, USA
| | - Erika E Ramsdale
- Department of Medicine, Division of Hematology/Oncology, University of Rochester Medical Center, Rochester, New York, USA
| | - Donna M Fick
- Ross and Carol Nese College of Nursing, Penn State University, University Park, Pennsylvania, USA
| | - Amanda S Mixon
- Department of Medicine, Division of General Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Sandra F Simmons
- Department of Medicine, Center for Quality Aging, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Geriatric Research, Education and Clinical Center (GRECC), VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
- Department of Medicine, Division of Geriatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Lapane KL, Ott BR, Hargraves JL, Cosenza C, Liang S, Alcusky M. Changes in Antidementia Medications upon Admission to the Nursing Home: Who Decides and Why? Results From a National Survey of Nursing Home Administrators. J Am Med Dir Assoc 2024; 25:41-46.e5. [PMID: 38173265 PMCID: PMC10783796 DOI: 10.1016/j.jamda.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVE Little is known about who is involved and what factors influence changes in antidementia medications for older adults living in nursing homes. The study sought to describe factors associated with initiation and discontinuation of antidementia medications in nursing home residents with dementia. DESIGN National survey of nursing homes with ≥30 beds; homes with dementia units were oversampled. SETTINGS AND PARTICIPANTS Nursing home administrators [eg, Directors of Nursing (DoNs)]. METHODS In 2022, 1293 homes were surveyed (response rate: 26.6%, n = 340). Weighted analyses provided nationally representative results corrected for nonresponse (n = 14,455). RESULTS DoNs reported that people always/almost always involved in antidementia medication decisions included nursing home prescriber (84.4%), nursing staff (33.2%), family (23.4%), resident (13.8%), community primary care provider (12.1%), and dementia specialist (5.8%). DoNs reported that antidementia medications were much more likely to be initiated if residents (55.8%) and family members (53.2%) wanted antidementia medications, a dementia specialist was involved (51.9%), resident had aggressive behaviors (44.8%), resisted care (31.6%), or had severe physical/cognitive impairment (22.3%). DoNs reported that antidementia medications were much more likely to be discontinued with dementia specialist involvement (46.5%), progression to severe impairment (39.2%), hospice involvement (31.5%), <6 months' prognosis (28.5%), emergence of aggressive behaviors (25.2%), or resisting care (19.0%) and much less likely to be discontinued if residents (30.2%) and family (27.3%) were reluctant to discontinue. One in 6 homes reported that residents had no immediate family/caregivers usually or almost always/always. CONCLUSIONS AND IMPLICATIONS DoNs report that family/caregivers and dementia specialists have significant influence on antidementia medication decisions in nursing homes, but many residents lack their involvement. Real-world evidence on the risks and benefits of antidementia medications in nursing homes is needed to inform clinical guidance about appropriate use of antidementia medications in nursing homes.
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Affiliation(s)
- Kate L Lapane
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA.
| | - Brian R Ott
- Department of Neurology, Alpert Medical School of Brown University, Providence, RI, USA
| | - J Lee Hargraves
- Center for Survey Research, University of Massachusetts Boston, Boston, MA, USA
| | - Carol Cosenza
- Center for Survey Research, University of Massachusetts Boston, Boston, MA, USA
| | - Shiwei Liang
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Matthew Alcusky
- Division of Epidemiology, Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA, USA
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Niznik J, Colón-Emeric C, Thorpe CT, Kelley CJ, Gilliam M, Lund JL, Hanson LC. Prescriber Perspectives and Experiences with Deprescribing Versus Continuing Bisphosphonates in Older Nursing Home Residents with Dementia. J Gen Intern Med 2023; 38:3372-3380. [PMID: 37369891 PMCID: PMC10682438 DOI: 10.1007/s11606-023-08275-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND Few guidelines address fracture prevention medication use in nursing home (NH) residents with dementia. OBJECTIVE We sought to identify factors that influence prescriber decision-making for deprescribing of bisphosphonates for older NH residents with dementia. METHODS We conducted 12 semi-structured interviews with prescribers who care for older adults with dementia in NHs. MAIN MEASURES Interview prompts addressed experiences treating fractures, benefits, and harms of bisphosphonates, and experiences with deprescribing. Coding was guided by the social-ecological framework including patient-level (intrapersonal) and external (interpersonal, system, community, and policy) influences. RESULTS Most prescribers were physicians (83%); 75% were female and 75% were White. Most (75%) spent less than half of their clinical effort in NHs and half were in the first decade of practice. Among patient-level influences, prescribers uniformly agreed that a prior bisphosphonate treatment course of several years, emergence of adverse effects, and changing goals of care or limited life expectancy were compelling reasons to deprescribe. External influences were frequently discussed as barriers to deprescribing. At the interpersonal level, prescribers noted that family/informal caregivers are diverse in their involvement in decision-making, and frequently concerned about the adverse effects of bisphosphonates, but perceive deprescribing as "withdrawing care." At the health system level, prescribers felt that frequent transitions make it difficult to determine duration of prior treatment and to implement deprescribing. At the policy level, prescribers highlighted the lack of guidelines addressing residents with limited mobility and dementia or criteria for deprescribing, including uncertainty in the setting of prior fractures and lack of bone densitometry in NHs. CONCLUSION Systems-level barriers to evaluating bone densitometry and treatment history in NHs may impede person-centered decision-making for fracture prevention. Further research is needed to evaluate the residual benefits of bisphosphonates in medically complex residents with limited mobility and dementia to inform recommendations for deprescribing versus continued use.
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Affiliation(s)
- Joshua Niznik
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA.
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA.
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA.
| | - Cathleen Colón-Emeric
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
- Division of Geriatrics, Duke University School of Medicine,, Durham, NC, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
| | - Casey J Kelley
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
| | - Meredith Gilliam
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
| | - Jennifer L Lund
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
- Durham VA Geriatric Research Education and Clinical Center, Durham, NC, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Durham, NC, USA
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Thorpe C, Niznik J, Li A. Deprescribing research in nursing home residents using routinely collected healthcare data: a conceptual framework. BMC Geriatr 2023; 23:469. [PMID: 37542226 PMCID: PMC10401751 DOI: 10.1186/s12877-023-04194-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 07/24/2023] [Indexed: 08/06/2023] Open
Abstract
BACKGROUND Efforts are needed to strengthen evidence and guidance for appropriate deprescribing for older nursing home (NH) residents, who are disproportionately affected by polypharmacy and inappropriate prescribing. Given the challenges of conducting randomized drug withdrawal studies in this population, data from observational studies of routinely collected healthcare data can be used to identify patients who are apparent candidates for deprescribing and evaluate subsequent health outcomes. To improve the design and interpretation of observational studies examining determinants, risks, and benefits of deprescribing specific medications in older NH residents, we sought to propose a conceptual framework of the determinants of deprescribing in older NH residents. METHODS We conducted a scoping review of observational studies examining patterns and potential determinants of discontinuing or de-intensifying (i.e., reducing) medications for NH residents. We searched PubMed through September 2021 and included studies meeting the following criteria: conducted among adults aged 65 + in the NH setting; (2) observational study designs; (3) discontinuation or de-intensification as the primary outcome with key determinants as independent variables. We conceptualized deprescribing as a behavior through a social-ecological lens, potentially influenced by factors at the intrapersonal, interpersonal, organizational, community, and policy levels. RESULTS Our search in PubMed identified 250 potentially relevant studies published through September 2021. A total of 14 studies were identified for inclusion and were subsequently synthesized to identify and group determinants of deprescribing into domains spanning the five core social-ecological levels. Our resulting framework acknowledges that deprescribing is strongly influenced by intrapersonal, patient-level clinical factors that modify the expected benefits and risks of deprescribing, including index condition attributes (e.g., disease severity), attributes of the medication being considered for deprescribing, co-prescribed medications, and prognostic factors. It also incorporates the hierarchical influences of interpersonal differences relating to healthcare providers and family caregivers, NH facility and health system organizational structures, community trends and norms, and finally healthcare policies. CONCLUSIONS Our proposed framework will serve as a useful tool for future studies seeking to use routinely collected healthcare data sources and observational study designs to evaluate determinants, risks, and benefits of deprescribing for older NH residents.
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Affiliation(s)
- Carolyn Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
| | - Joshua Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
- Division of Geriatric Medicine and Center for Aging and Health, University of North Carolina at Chapel Hill, School of Medicine, 5003 Old Clinic CB#7550, Chapel Hill, NC, 27599, USA.
| | - Anna Li
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
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Niznik JD, Ernecoff NC, Thorpe CT, Mitchell SL, Hanson LC. Operationalizing deprescribing as a component of goal-concordant dementia care. J Am Geriatr Soc 2023; 71:1340-1344. [PMID: 36550635 PMCID: PMC10089936 DOI: 10.1111/jgs.18190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 11/22/2022] [Accepted: 11/26/2022] [Indexed: 12/24/2022]
Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
- UNC Center for Aging and Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Natalie C Ernecoff
- RAND Corporation, Pittsburgh, Pennsylvania, USA
- Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Susan L Mitchell
- Hebrew SeniorLife, Hinda and Arthur Marcus Institute for Aging Research, Boston, Massachusetts, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, School of Medicine, Chapel Hill, North Carolina, USA
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Twarowski B, Herbet M. Inflammatory Processes in Alzheimer's Disease-Pathomechanism, Diagnosis and Treatment: A Review. Int J Mol Sci 2023; 24:6518. [PMID: 37047492 PMCID: PMC10095343 DOI: 10.3390/ijms24076518] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
Alzheimer's disease is one of the most commonly diagnosed cases of senile dementia in the world. It is an incurable process, most often leading to death. This disease is multifactorial, and one factor of this is inflammation. Numerous mediators secreted by inflammatory cells can cause neuronal degeneration. Neuritis may coexist with other mechanisms of Alzheimer's disease, contributing to disease progression, and may also directly underlie AD. Although much has been established about the inflammatory processes in the pathogenesis of AD, many aspects remain unexplained. The work is devoted in particular to the pathomechanism of inflammation and its role in diagnosis and treatment. An in-depth and detailed understanding of the pathomechanism of neuroinflammation in Alzheimer's disease may help in the development of diagnostic methods for early diagnosis and may contribute to the development of new therapeutic strategies for the disease.
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Affiliation(s)
| | - Mariola Herbet
- Chair and Department of Toxicology, Faculty of Pharmacy, Medical University of Lublin, Jaczewskiego 8b Street, 20-090 Lublin, Poland
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Gromek KR, Thorpe CT, Aspinall SL, Hanson LC, Niznik JD. Anticholinergic co-prescribing in nursing home residents using cholinesterase inhibitors: Potential deprescribing cascade. J Am Geriatr Soc 2023; 71:77-88. [PMID: 36206324 PMCID: PMC9870851 DOI: 10.1111/jgs.18066] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 08/22/2022] [Accepted: 09/03/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Polypharmacy may result from inappropriate prescribing of medications to treat adverse drug reactions (ADRs), i.e., "prescribing cascade." A potentially harmful prescribing cascade affecting those with severe dementia can result when anticholinergics are prescribed to manage side effects of cholinesterase inhibitors (ChEIs). We investigated 1) factors associated with co-prescribing of anticholinergics and ChEIs and 2) whether discontinuation of ChEIs was associated with subsequent discontinuation of anticholinergics-a potentially beneficial reversal or "deprescribing cascade." METHODS We conducted a retrospective analysis of linked Medicare Part A/B/D claims, Master Beneficiary Summary File, Minimum Data Set, Area Health Resource File, and Nursing Home Compare from 2015 to 2016. Subjects were Medicare beneficiaries residing in nursing homes, ≥65 years old with severe dementia admitted for non-skilled stays, who were prescribed ChEIs. Cross-sectional analysis evaluated factors associated with co-prescribing of anticholinergics with ChEIs. Longitudinal Cox proportional hazards regression examined whether discontinuation of ChEIs was associated with subsequent discontinuation of anticholinergics over a 1-year period. RESULTS We found 15% of our sample experienced co-prescribing of anticholinergics and ChEIs. Several resident and facility-level factors were associated with co-prescribing anticholinergics. Advancing age, minority race or ethnicity, end-stage renal disease, heart failure, and poor appetite were associated with a decreased likelihood of co-prescribing. Female sex, polypharmacy, and non-geriatric prescriber-type were associated with a higher likelihood of co-prescribing. In longitudinal analyses, we observed that discontinuation of ChEIs was associated with a reduced likelihood (HR 0.58 [95% CI, 0.47-0.71]) of discontinuing any medications with anticholinergic properties, except for bladder antimuscarinics (HR 1.32 [95% CI, 0.83-2.09]). CONCLUSIONS Younger, healthier older adults with dementia were more likely to experience co-prescribing anticholinergics and ChEIs. Discontinuation of anticholinergics was infrequent. Further research is needed to understand prescribers' ability to recognize and reverse potential prescribing cascades through deprescribing.
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Affiliation(s)
- Kimberly R. Gromek
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina, United States
| | - Carolyn T. Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States
| | - Sherrie L. Aspinall
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States
- VA Center for Medication Safety, Hines, Illinois, United States
- Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, United States
| | - Laura C. Hanson
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States
| | - Joshua D. Niznik
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina at Chapel Hill Eshelman School of Pharmacy, Chapel Hill, North Carolina, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States
- Department of Medicine, Division of Geriatrics and Center for Aging and Health, University of North Carolina School of Medicine, Chapel Hill, North Carolina, United States
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Nielsen RE, Grøntved S, Lolk A, Andersen K, Valentin JB. Real-world effects of anti-dementia treatment on mortality in patients with Alzheimer´s dementia. Medicine (Baltimore) 2022; 101:e31625. [PMID: 36397447 PMCID: PMC9666173 DOI: 10.1097/md.0000000000031625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
To examine the real-world effects of the cholinesterase inhibitors (AChEI) on all-cause mortality. A nationwide, retrospective cohort study. Participants were diagnosed with incident AD in Denmark from January 1, 2000 to December 31, 2011 with follow-up until December 31, 2012. A total of 36,513 participants were included in the current study with 22,063 deaths during 132,426 person-years of follow-up. At baseline, patients not treated with AChEI (n = 28,755 [9961 males (35%)]) had a mean age ± standard deviation (SD) of 80.33 ± 7.98 years (78.97 ± 8.26 for males and 81.04 ± 7.98 for females), as compared to 79.95 ± 7.67 (78.87 ± 7.61 for males and 80.61 ± 7.63 for females) in the group exposed at baseline. Patients treated with AChEI had a beneficial hazard ratio (HR) of 0.69, 95% confidence interval (CI) (0.67-0.71) for all-cause mortality as compared to patients not treated, with donepezil (HR 0.80, 95% CI [0.77-0.82]) and galantamine (HR 0.93,95% CI [0.89-0.97]) having beneficial effects on mortality rate as compared to non-treatment, whereas rivastigmine (HR 0.99, 95% CI [0.95-1.03]) was associated with a mortality rate comparable to non-treatment with AChEI. Patients were primarily exposed to donepezil (65.8%) with rivastigmine (19.8%) and galantamine (14.4%) being used less often. These findings underscore the effect of AChEI on not only reducing speed of cognitive decline but also directly prolonging life, which could result in changes in treatment recommendation for when to stop treatment.
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Affiliation(s)
- René Ernst Nielsen
- Aalborg University Hospital - Psychiatry, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- *Correspondence: René Ernst Nielsen, Psychiatry - Aalborg University Hospital, Unit for Psychiatric Research, Mølleparkvej 10, 9000 Aalborg, Denmark (e-mail: )
| | - Simon Grøntved
- Aalborg University Hospital - Psychiatry, Aalborg, Denmark
| | - Annette Lolk
- Department of Clinical Research, University of Southern Denmark, Department of Mental Health, Odense, Region of Southern Denmark, Denmark
| | - Kjeld Andersen
- Department of Clinical Research, University of Southern Denmark, Department of Mental Health, Odense, Region of Southern Denmark, Denmark
| | - Jan B. Valentin
- Aalborg University Hospital - Psychiatry, Aalborg, Denmark
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Roh E, Cota E, Lee JP, Madievsky R, Eskildsen MA. Polypharmacy in Nursing Homes. Clin Geriatr Med 2022; 38:653-666. [DOI: 10.1016/j.cger.2022.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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12
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Niznik J, Ferreri SP, Armistead L, Urick B, Vest MH, Zhao L, Hughes T, McBride JM, Busby-Whitehead J. A deprescribing medication program to evaluate falls in older adults: methods for a randomized pragmatic clinical trial. Trials 2022; 23:256. [PMID: 35379307 PMCID: PMC8981935 DOI: 10.1186/s13063-022-06164-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/09/2022] [Indexed: 11/18/2022] Open
Abstract
Background Opioids and benzodiazepines (BZDs) are some of the most commonly prescribed medications that contribute to falls in older adults. These medications are challenging to appropriately prescribe and monitor, with little guidance on safe prescribing of these medications for older patients. Only a handful of small studies have evaluated whether reducing opioid and BZD use through deprescribing has a positive impact on outcomes. Leveraging the strengths of a large health system, we evaluated the impact of a targeted consultant pharmacist intervention to deprescribe opioids and BZDs for older adults seen in primary care practices in North Carolina. Methods We developed a toolkit and process for deprescribing opioids and BZDs in older adults based on a literature review and guidance from an interprofessional team of pharmacists, geriatricians, and investigators. A total of fifteen primary care practices have been randomized to receive the targeted consultant pharmacist service (n = 8) or usual care (n = 7). The intervention consists of several components: (1) weekly automated reports to identify chronic users of opioids and BZDs, (2) clinical pharmacist medication review, and (3) recommendations for deprescribing and/or alternate therapies routed to prescribers through the electronic health record. We will collect data for all patients presenting one of the primary care clinics who meet the criteria for chronic use of opioids and/or BZDs, based on their prescription order history. We will use the year prior to evaluate baseline medication exposures using morphine milligram equivalents (MMEs) and diazepam milligram equivalents (DMEs). In the year following the intervention, we will evaluate changes in medication exposures and medication discontinuations between control and intervention clinics. Incident falls will be evaluated as a secondary outcome. To date, the study has enrolled 914 chronic opioid users and 1048 chronic BZD users. We anticipate that we will have 80% power to detect a 30% reduction in MMEs or DMEs. Discussion This clinic randomized pragmatic trial will contribute valuable evidence regarding the impact of pharmacist interventions to reduce falls in older adults through deprescribing of opioids and BZDs in primary care settings. Trial registration Clinicaltrials.govNCT04272671. Registered on February 17, 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06164-5.
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13
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Niznik JD, Aspinall SL, Hanson LC, Gilliam MA, Li X, Kelley CJ, Thorpe CT. Patterns of oral bisphosphonate deprescribing in older nursing home residents with dementia. Osteoporos Int 2022; 33:379-390. [PMID: 34480586 PMCID: PMC8813888 DOI: 10.1007/s00198-021-06141-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/28/2021] [Indexed: 02/03/2023]
Abstract
UNLABELLED In a national sample of Medicare nursing home residents with dementia treated with bisphosphonates, 20% had bisphosphonates deprescribed. Residents with clinical characteristics representing decreased likelihood for long-term benefit were more likely to have bisphosphonates deprescribed. Future studies are needed to evaluate outcomes of deprescribing bisphosphonates in this population. INTRODUCTION To determine incidence of deprescribing bisphosphonates among nursing home (NH) residents with dementia and identify factors associated with deprescribing. METHODS 2015-2016 Medicare claims, Part D prescriptions, Minimum Data Set (MDS) 3.0, and Nursing Home Compare for non-skilled NH residents aged 65 + with dementia and prescriptions for oral bisphosphonates overlapping the first 14 days of the stay. Our primary definition for deprescribing was a 90-day gap in medication supply; we also explored the reliability of different deprescribing definitions (30-, 90-, 180-day gaps). We estimated associations of NH, provider, and resident characteristics with deprescribing bisphosphonates using competing risks regression models. RESULTS Most NH residents with dementia treated with bisphosphonates (n = 5312) were ≥ 80 years old (72%), white (81%), and female (90%); about half were dependent for transfers (50%) or mobility (45%). Using a 90-day gap in supply, the 180-day cumulative incidence of deprescribing bisphosphonates was 14.8%. This increased to 32.1% using a 30-day gap and decreased to 11.7% using a 180-day gap. Factors associated with increased likelihood for bisphosphonate deprescribing were age ≥ 90 years, newly admitted (vs. prevalent stay), dependent for mobility, swallowing difficulty, > 1 hospitalization in the prior year, CCRC facility, and nurse practitioner primary provider (vs. physician). Cancer and western geographic region were associated with reduced likelihood for deprescribing. CONCLUSION In a national sample of NH residents with dementia, bisphosphonate deprescribing was uncommon, and associated with clinical characteristics signifying poor prognosis and decreased likelihood for long-term benefit. Future studies should evaluate clinical outcomes of deprescribing bisphosphonates in this population.
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Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA.
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina At Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA.
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA.
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
- VA Center for Medication Safety, Hines, IL, USA
- University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Meredith A Gilliam
- Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Xintong Li
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina At Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDROMS), University of Oxford, Oxford, UK
| | - Casey J Kelley
- Division of Geriatric Medicine, Center for Aging and Health, School of Medicine, University of North Carolina At Chapel Hill, 5003 Old Clinic, CB# 7550, Chapel Hill, NC, 27599, USA
| | - Carolyn T Thorpe
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina At Chapel Hill, Eshelman School of Pharmacy, Chapel Hill, NC, USA
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, PA, USA
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Quigley DD, Estrada LV, Alexander GL, Dick A, Stone PW. Differences in Care Provided in Urban and Rural Nursing Homes in the United States: Literature Review. J Gerontol Nurs 2021; 47:48-56. [PMID: 34846259 DOI: 10.3928/00989134-20211109-09] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Despite evidence acknowledging disadvantages in care provided to older adults in rural nursing homes (NHs) in the United States, since 2010, no literature review has focused on differences in care provided in urban versus rural NHs. In the current study, we examined these differences by searching U.S. English-language peer-reviewed articles published after 2010 on differences in care quality in urban and rural NHs. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and used the Newcastle-Ottawa Scale for quality appraisal. We conducted full-text abstraction of 56 (of 286) articles, identifying 10 relevant studies. Metric specification of urban/rural location varied, and care quality measures were wide-ranging, making it difficult to interpret evidence. Limited evidence supported that rural NHs, compared to urban NHs, provided sparse mental health support and limited access to hospice care after controlling for facility and resident characteristics. Our review highlights the need for more research examining differences in quality of care between urban and rural NHs and raises several issues in current research examining urban/rural NH differences where future work is needed. [Journal of Gerontological Nursing, 47(12), 48-56.].
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15
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Moo LR, Martinez E, Padala K, Dunay MA, Scali RR, Chen S, Thielke SM. Unexpected Findings During Double-blind Discontinuation of Acetylcholinesterase Inhibitor Medications. Clin Ther 2021; 43:942-952. [PMID: 34127273 DOI: 10.1016/j.clinthera.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/19/2021] [Accepted: 05/20/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The long-term effects of acetylcholinesterase inhibitors (AChEIs) used in the treatment of patients with various types of dementia remain unclear, largely due to challenges in the study of their discontinuation. We present several unexpected results from a discontinuation trial that might merit further investigation. METHODS This double-blind, placebo-controlled study of the discontinuation of AChEI medications was conducted in 62 US veterans. Participants were randomized to receive continued treatment with their medication (sham-taper group) or to treatment discontinuation via tapering (real-taper group), over a period of 6 weeks. The primary end point was the patient's/family caregiver's decision to discontinue the study medication. FINDINGS The study was underpowered to detect a significant between-group difference in the primary end point, but examination of the discontinuation process generated several unexpected results: (1) recruitment proved extremely challenging for a variety of reasons, with <5% of potentially eligible participants enrolled; (2) all 3 patients with Parkinson disease-associated dementia showed a worsening of symptoms when they discontinued their AChEI medication, but they showed improvement after they restarted it; (3) changes in symptom-scale scores varied quite broadly across participants, regardless of treatment arm; (4) unusual effects were noted in the sham-taper arm; and (5) the only significant predictor of the decision to discontinue the study medication was a worsening in the caregiver's mood. IMPLICATIONS These findings argue for the use of caution in discontinuing AChEIs in patients with Parkinson disease-associated dementia, although there may be potential benefits of a "drug holiday." The findings also urge the consideration of distress on the part of the caregiver while making medication treatment decisions in dementia. Future research must address challenges with recruitment and symptom fluctuations. (Clin Ther. 2021;43:XXX-XXX) © 2021 Elsevier Inc.
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Affiliation(s)
- Lauren R Moo
- Geriatric Research, Education, and Clinical Center, Veterans Affairs Bedford Healthcare System, Bedford, Massachusetts; Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts.
| | - Erica Martinez
- Puget Sound Veterans Affairs Medical Center, Seattle, Washington.
| | - Kalpana Padala
- Geriatric Research, Education, and Clinical Center, Central Arkansas Veterans Healthcare System, Little Rock, Arkansas; University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| | - Megan A Dunay
- Boise Veterans Affairs Medical Center, Boise, Idaho.
| | - Rachael R Scali
- The Department of Biomedical Sciences, Tufts University School of Medicine, Medford, Massachusetts.
| | - Sunny Chen
- Puget Sound Veterans Affairs Medical Center, Seattle, Washington.
| | - Stephen M Thielke
- Puget Sound Veterans Affairs Medical Center, Seattle, Washington; The Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington.
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16
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Thorpe CT, Sileanu FE, Mor MK, Zhao X, Aspinall S, Ersek M, Springer S, Niznik JD, Vu M, Schleiden LJ, Gellad WF, Hunnicutt J, Thorpe JM, Hanlon JT. Discontinuation of Statins in Veterans Admitted to Nursing Homes near the End of Life. J Am Geriatr Soc 2020; 68:2609-2619. [PMID: 32786004 DOI: 10.1111/jgs.16727] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 01/11/2023]
Abstract
BACKGROUND/OBJECTIVES Geriatric guidelines recommend against statin use in older adults with limited life expectancy (LLE) or advanced dementia (AD). This study examined resident and facility factors predicting statin discontinuation after nursing home (NH) admission in veterans with LLE/AD taking statins for secondary prevention. DESIGN Retrospective cohort study of Veterans Affairs (VA) bar code medication administration records, Minimum Data Set (MDS) assessments, and utilization records linked to Medicare claims. SETTING VA NHs, known as community living centers (CLCs). PARTICIPANTS Veterans aged 65 and older with coronary artery disease, stroke, or diabetes mellitus, type II, admitted in fiscal years 2009 to 2015, who met criteria for LLE/AD on their admission MDS and received statins in the week after admission (n = 13,110). MEASUREMENTS Residents were followed until statin discontinuation (ie, gap in statin use ≥14 days), death, or censoring due to discharge, day 91 of the stay, or end of the study period. Competing risk models assessed cumulative incidence and predictors of discontinuation, stratified by whether the resident had their end-of-life (EOL) status designated or used hospice at admission. RESULTS Overall cumulative incidence of statin discontinuation was 31% (95% confidence interval [CI] = 30%-32%) by day 91, and it was markedly higher in those with (52%; 95% CI = 50%-55%) vs without (25%; 95% CI = 24%-26%) EOL designation/hospice. In patients with EOL designation/hospice (n = 2,374), obesity, congestive heart failure, and admission from nonhospital settings predicted decreased likelihood of discontinuation; AD, dependency in activities of daily living, greater number of medications, and geographic region predicted increased likelihood of discontinuation. In patients without EOL designation/hospice (n = 10,736), older age and several specific markers of poor prognosis predicted greater discontinuation, whereas obesity/overweight predicted decreased discontinuation. CONCLUSION Most veterans with LLE/AD taking statins for secondary prevention do not discontinue statins following CLC admission. Designating residents as EOL status, hospice use, and individual clinical factors indicating poor prognosis may prompt deprescribing.
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Affiliation(s)
- Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Florentina E Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Sherrie Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Mary Ersek
- Veterans Experience Center and the Center for Health Equity Research and Promotion; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sydney Springer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,University of New England College of Pharmacy, Portland, Maine
| | - Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina.,Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Michelle Vu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jacob Hunnicutt
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
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Niznik JD, Zhao X, Aspinall SL, Hanlon JT, Hanson LC, Nace D, Thorpe JM, Thorpe CT. Reply to: Acetylcholinesterase Inhibitors and Dementia: Over Both Sides of the Atlantic Ocean. J Am Geriatr Soc 2020; 68:2412-2413. [PMID: 32776517 DOI: 10.1111/jgs.16746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/03/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Joshua D Niznik
- Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA.,VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania, USA
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Sherrie L Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois, USA
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania, USA.,Geriatric Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Laura C Hanson
- Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - David Nace
- Geriatric Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joshua M Thorpe
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA.,VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania, USA
| | - Carolyn T Thorpe
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA.,VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania, USA
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18
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Niznik JD, Zhao X, He M, Aspinall SL, Hanlon JT, Hanson LC, Nace D, Thorpe JM, Thorpe CT. Risk for Health Events After Deprescribing Acetylcholinesterase Inhibitors in Nursing Home Residents With Severe Dementia. J Am Geriatr Soc 2020; 68:699-707. [PMID: 31769507 PMCID: PMC7477721 DOI: 10.1111/jgs.16241] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 09/24/2019] [Accepted: 09/27/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND/OBJECTIVE Reevaluation of the appropriateness of acetylcholinesterase inhibitors (AChEIs) is recommended in older adults with severe dementia, given the lack of strong evidence to support their continued effectiveness and risk for medication-induced adverse events. We sought to evaluate the impact of deprescribing AChEIs on risk of all-cause events (hospitalizations, emergency department visits, and mortality) and serious falls or fractures in older nursing home (NH) residents with severe dementia. DESIGN Analysis of 2015 to 2016 data from Medicare claims, Part D prescriptions, Minimum Data Set (MDS) version 3.0, Area Health Resource File, and Nursing Home Compare. Marginal structural models with inverse probability of treatment weights were used to evaluate the association of deprescribing AChEIs and all-cause negative events as well as serious falls or fractures. SETTING US Medicare-certified NHs. PARTICIPANTS Nonskilled NH residents, aged 65 years and older, with severe dementia receiving AChEIs within the first 14 days of an MDS assessment in 2016 (n = 37 106). RESULTS The sample was primarily white (78.7%), female (75.5%), and aged 80 years or older (77.4%). Deprescribing AChEIs was associated with an increased likelihood of all-cause negative events in unadjusted models (odds ratio [OR] = 1.17; 95% confidence interval [CI] = 1.11-1.23; P < .01), but not in fully adjusted models (adjusted OR [aOR] = 1.00; 95% CI = 0.94-1.06; P = .94). By contrast, deprescribing was associated with a reduced likelihood of serious falls or fractures in unadjusted models (OR = 0.59; 95% CI = 0.52-0.66; P < .001) and remained significant in adjusted models (aOR = 0.64; 95% CI = 0.56-0.73; P < .001). CONCLUSION Deprescribing AChEIs was not associated with a significant increase in the likelihood for all-cause negative events and was associated with a reduced likelihood of falls and fractures in older NH residents with dementia. Our findings suggest that deprescribing AChEIs is a reasonable approach to reduce the risk of serious falls or fractures without increasing the risk for all-cause events. J Am Geriatr Soc 68:699-707, 2020.
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Affiliation(s)
- Joshua D. Niznik
- University of North Carolina School of Medicine, Division of Geriatric Medicine, Chapel Hill, North Carolina
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Meiqi He
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sherrie L. Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
- VA Center for Medication Safety, Hines, Illinois
| | - Joseph T. Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- University of Pittsburgh School of Medicine, Geriatric Division, Pittsburgh, Pennsylvania
| | - Laura C. Hanson
- University of North Carolina School of Medicine, Division of Geriatric Medicine, Chapel Hill, North Carolina
| | - David Nace
- University of Pittsburgh School of Medicine, Geriatric Division, Pittsburgh, Pennsylvania
| | - Joshua M. Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Carolyn T. Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
- University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
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Ouslander JG. Improving Drug Therapy for Patients With Life‐Limiting Illnesses: Letʼs Take Care of Some Low Hanging Fruit. J Am Geriatr Soc 2020; 68:682-685. [DOI: 10.1111/jgs.16395] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 02/03/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Joseph G. Ouslander
- Clinical Biomedical Science Charles E. Schmidt College of Biomedical Science Boca Raton Florida
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20
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Niznik JD, Hunnicutt JN, Zhao X, Mor MK, Sileanu F, Aspinall SL, Springer SP, Ersek MJ, Gellad WF, Schleiden LJ, Hanlon JT, Thorpe JM, Thorpe CT. Deintensification of Diabetes Medications among Veterans at the End of Life in VA Nursing Homes. J Am Geriatr Soc 2020; 68:736-745. [PMID: 32065387 DOI: 10.1111/jgs.16360] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Many older adults with limited life expectancy and/or advanced dementia (LLE/AD) are potentially overtreated for diabetes and may benefit from deintensification. Our aim was to examine the incidence and predictors of diabetes medication deintensification in older Veterans with LLE/AD who were potentially overtreated at admission to Veterans Affairs (VA) nursing homes (community living centers [CLCs]). DESIGN Retrospective cohort study using linked VA and Medicare clinical/administrative data and Minimum Data Set assessments. SETTING VA CLCs. PARTICIPANTS A total of 6960 Veterans with diabetes and LLE/AD admitted to VA CLCs in fiscal years 2009 to 2015 with hemoglobin (Hb)A1c measured within 90 days of admission. MEASUREMENTS We evaluated treatment deintensification (discontinuation or dose reduction for a consecutive 7-day period) among residents who were potentially overtreated (HbA1c ≤7.5% and receiving hypoglycemic medications). Competing risk models assessed 90-day cumulative incidence of deintensification. RESULTS More than 40% (n = 3056) of Veteran CLC residents with diabetes were potentially overtreated. The cumulative incidence of deintensification at 90 days was 45.5%. Higher baseline HbA1c values were associated with a lower likelihood of deintensification (e.g., HbA1c 7.0-7.5% vs <6.0%; adjusted risk ratio [aRR] = .57; 95% confidence interval [CI] = .50-.66). Compared with non-sulfonylurea oral agents (e.g., metformin), other treatment regimens were more likely to be deintensified (aRR = 1.31-1.88), except for basal insulin (aRR = .59; 95% CI = .52-.66). The only resident factor associated with increased likelihood of deintensification was documented end-of-life status (aRR = 1.12; 95% CI = 1.01-1.25). Admission from home/assisted living (aRR = .85; 95% CI = .75-.96), obesity (aRR = .88; 95% CI = .78-.99), and peripheral vascular disease (aRR = .90; 95% CI = .81-.99) were associated with decreased likelihood of deintensification. CONCLUSION Deintensification of treatment regimens occurred in less than one-half of potentially overtreated Veterans and was more strongly associated with low HbA1c values and use of medications with high risk for hypoglycemia, rather than other resident characteristics. J Am Geriatr Soc 68:736-745, 2020.
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Affiliation(s)
- Joshua D Niznik
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Jacob N Hunnicutt
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Florentina Sileanu
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Sherrie L Aspinall
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,VA Center for Medication Safety, Hines, Illinois.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Sydney P Springer
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Portland, Maine
| | - Mary J Ersek
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Veterans Experience Center; Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.,School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Loren J Schleiden
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joseph T Hanlon
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.,Geriatric Research Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
| | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Division of Pharmaceutical Outcomes and Policy, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina
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21
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Niznik JD, Zhao X, He M, Aspinall SL, Hanlon JT, Nace D, Thorpe JM, Thorpe CT. Impact of deprescribing AChEIs on aggressive behaviors and antipsychotic prescribing. Alzheimers Dement 2020; 16:630-640. [PMID: 32052930 DOI: 10.1002/alz.12054] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 10/04/2019] [Accepted: 12/04/2019] [Indexed: 01/09/2023]
Abstract
INTRODUCTION We evaluated the impact of deprescribing acetylcholinesterase inhibitors (AChEIs) on aggressive behaviors and incident antipsychotic use in nursing home (NH) residents with severe dementia. METHODS We conducted a retrospective study of Medicare claims, Part D, Minimum Data Set for NH residents aged 65+ with severe dementia receiving AChEIs in 2016. Aggressive behaviors were measured using the aggressive behavior scale (ABS; n = 30,788). Incident antipsychotic prescriptions were evaluated among antipsychotic non-users (n = 25,188). Marginal structural models and inverse probability of treatment weights were used to evaluate associations of AChEI deprescribing and outcomes. RESULTS The severity of aggressive behaviors was low at baseline (mean ABS = 0.5) and was not associated with deprescribing AChEIs (0.002 increase in ABS, P = .90). Incident antipsychotic prescribing occurred in 5.1% of residents and was less likely with AChEI deprescribing (adjusted odds ratio = 0.52 [0.40-0.68], P <.001]). DISCUSSION Deprescribing AChEIs was not associated with a worsening of aggressive behaviors or incident antipsychotic prescriptions.
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Affiliation(s)
- Joshua D Niznik
- Department of Medicine, Division of Geriatric Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.,VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Meiqi He
- University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA
| | - Sherrie L Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA.,University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania, USA.,VA Center for Medication Safety, Hines, Illinois, USA
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA.,Geriatric Division, Kaufmann Medical Building, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David Nace
- Geriatric Division, Kaufmann Medical Building, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA.,University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Pittsburgh, Pennsylvania, USA.,University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina, USA
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22
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Springer SP, Mor MK, Sileanu F, Zhao X, Aspinall SL, Ersek M, Niznik JD, Hanlon JT, Hunnicutt J, Gellad WF, Schleiden LJ, Thorpe JM, Thorpe CT. Incidence and Predictors of Aspirin Discontinuation in Older Adult Veteran Nursing Home Residents at End of Life. J Am Geriatr Soc 2020; 68:725-735. [PMID: 32052858 DOI: 10.1111/jgs.16346] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/22/2019] [Accepted: 01/01/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVES Continuation of aspirin for secondary prevention in persons with limited life expectancy (LLE) is controversial. We sought to determine the incidence and predictors of aspirin discontinuation in veterans with LLE and/or advanced dementia (LLE/AD) who were taking aspirin for secondary prevention at nursing home admission, stratified by whether their limited prognosis (LP) was explicitly documented at admission. DESIGN Retrospective cohort study using linked Veterans Affairs (VA) and Medicare clinical/administrative data and Minimum Data Set resident assessments. SETTING All VA nursing homes (referred to as community living centers [CLCs]) in the United States. PARTICIPANTS Older (≥65 y) CLC residents with LLE/AD, admitted for 7 days or longer in fiscal years 2009 to 2015, who had a history of coronary artery disease and/or stroke/transient ischemic attack, and used aspirin within the first week of CLC admission (n = 13 844). MEASUREMENTS The primary dependent variable was aspirin discontinuation within the first 90 days after CLC admission, defined as 14 consecutive days of no aspirin receipt. Independent variables included an indicator for explicit documentation of LP, sociodemographics, environment of care characteristics, cardiovascular risk factors, bleeding risk factors, individual markers of poor prognosis (eg, cancer, weight loss), and facility characteristics. Fine and Gray subdistribution hazard models with death as a competing risk were used to assess predictors of discontinuation. RESULTS Cumulative incidence of aspirin discontinuation was 27% (95% confidence interval [CI] = 26%-28%) in the full sample, 34% (95% CI = 33%-36%) in residents with explicit documentation of LP, and 24% (95% CI = 23%-25%) in residents with no such documentation. The associations of independent variables with aspirin discontinuation differed in residents with vs without explicit LP documentation at admission. CONCLUSION Just over one-quarter of patients discontinued aspirin, possibly reflecting the unclear role of aspirin in end of life among prescribers. Future research should compare outcomes of aspirin deprescribing in this population. J Am Geriatr Soc 68:725-735, 2020.
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Affiliation(s)
- Sydney P Springer
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Department of Pharmacy Practice, Portland, ME
| | - Maria K Mor
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA
| | - Florentina Sileanu
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania
| | - Xinhua Zhao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA
| | - Sherrie L Aspinall
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Mary Ersek
- Corporal Michael J. Crescenz VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA.,University of Pennsylvania School of Nursing, Department of Biobehavioral Health Sciences, Philadelphia, PA
| | - Joshua D Niznik
- University of North Carolina School of Medicine, Division of Geriatric Medicine, Chapel Hill, NC
| | - Joseph T Hanlon
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of Pittsburgh School of Medicine, Division of General Internal Medicine, Pittsburgh, PA
| | - Jacob Hunnicutt
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Division of Geriatric Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of New England College of Pharmacy, Department of Pharmacy Practice, Portland, ME
| | - Loren J Schleiden
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,Department of Pharmaceutical Sciences, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania
| | - Joshua M Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of North Carolina Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Chapel Hill, NC
| | - Carolyn T Thorpe
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, Pennsylvania.,University of North Carolina Eshelman School of Pharmacy, Division of Pharmaceutical Outcomes and Policy, Chapel Hill, NC
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