Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester.
Division of Geriatric Medicine, University of Massachusetts Medical School, Worcester.
JAMA Intern Med. 2014 Nov;174(11):1763-71. doi: 10.1001/jamainternmed.2014.4103.
Advanced dementia is characterized by severe cognitive impairment and complete functional dependence. Patients' goals of care should guide the prescribing of medication during such terminal illness. Medications that do not promote the primary goal of care should be minimized.
To estimate the prevalence of medications with questionable benefit used by nursing home residents with advanced dementia, identify resident- and facility-level characteristics associated with such use, and estimate associated medication expenditures.
DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of medication use by nursing home residents with advanced dementia using a nationwide long-term care pharmacy database linked to the Minimum Data Set (460 facilities) between October 1, 2009, and September 30, 2010.
Use of medication deemed of questionable benefit in advanced dementia based on previously published criteria and mean 90-day expenditures attributable to these medications per resident. Generalized estimating equations using the logit link function were used to identify resident- and facility-related factors independently associated with the likelihood of receiving medications of questionable benefit after accounting for clustering within nursing homes.
Of 5406 nursing home residents with advanced dementia, 2911 (53.9%) received at least 1 medication with questionable benefit (range, 44.7% in the Mid-Atlantic census region to 65.0% in the West South Central census region). Cholinesterase inhibitors (36.4%), memantine hydrochloride (25.2%), and lipid-lowering agents (22.4%) were the most commonly prescribed. In adjusted analyses, having eating problems (adjusted odds ratio [AOR], 0.68; 95% CI, 0.59-0.78), a feeding tube (AOR, 0.58; 95% CI, 0.48-0.70), or a do-not-resuscitate order (AOR, 0.65; 95% CI, 0.57-0.75), and enrolling in hospice (AOR, 0.69; 95% CI, 0.58-0.82) lowered the likelihood of receiving these medications. High facility-level use of feeding tubes increased the likelihood of receiving these medications (AOR, 1.45; 95% CI, 1.12-1.87). The mean (SD) 90-day expenditure for medications with questionable benefit was $816 ($553), accounting for 35.2% of the total average 90-day medication expenditures for residents with advanced dementia who were prescribed these medications.
Most nursing home residents with advanced dementia receive medications with questionable benefit that incur substantial associated costs.
晚期痴呆症的特点是严重的认知障碍和完全的功能依赖。在这种终末期疾病中，患者的护理目标应指导药物的开具。不促进主要护理目标的药物应尽量减少。
估计患有晚期痴呆症的养老院居民使用的有疑问益处的药物的流行率，确定与这种使用相关的居民和设施特征，并估计相关的药物支出。
设计、地点和参与者： 对 2009 年 10 月 1 日至 2010 年 9 月 30 日期间使用全国长期护理药房数据库（460 个设施）链接到最低数据集的患有晚期痴呆症的养老院居民使用药物的横断面研究。
根据先前发表的标准，使用被认为对晚期痴呆症有疑问益处的药物，并根据每位居民的这些药物的 90 天平均支出来确定。使用广义估计方程（使用对数链接函数），在考虑到养老院内的聚类后，确定与接受有疑问益处的药物的可能性相关的居民和设施相关因素。
在 5406 名患有晚期痴呆症的养老院居民中，有 2911 名（53.9%）至少使用了 1 种有疑问益处的药物（范围从大西洋中部地区的 44.7%到西南中部地区的 65.0%）。胆碱酯酶抑制剂（36.4%）、盐酸美金刚（25.2%）和降脂药（22.4%）是最常开的处方。在调整后的分析中，有进食问题（调整后的优势比 [OR]，0.68；95%置信区间，0.59-0.78）、喂养管（OR，0.58；95%置信区间，0.48-0.70）或不复苏医嘱（OR，0.65；95%置信区间，0.57-0.75），以及参加临终关怀（OR，0.69；95%置信区间，0.58-0.82）降低了接受这些药物的可能性。高设施级别的喂养管使用增加了接受这些药物的可能性（OR，1.45；95%置信区间，1.12-1.87）。有疑问益处的药物的 90 天平均支出为 816 美元（553 美元），占接受这些药物的患有晚期痴呆症的居民 90 天平均药物支出的 35.2%。
大多数患有晚期痴呆症的养老院居民都接受了有疑问益处的药物治疗，这些药物的治疗费用很高。
