与严重痴呆的老年疗养院居民中停止使用乙酰胆碱酯酶抑制剂相关的因素。
Factors Associated With Deprescribing Acetylcholinesterase Inhibitors in Older Nursing Home Residents With Severe Dementia.
机构信息
Department of Pharmacy and Therapeutics, University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania.
Geriatric Division, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
出版信息
J Am Geriatr Soc. 2019 Sep;67(9):1871-1879. doi: 10.1111/jgs.15985. Epub 2019 Jun 4.
BACKGROUND/OBJECTIVE: Uncertainty regarding benefits and risks associated with acetylcholinesterase inhibitors (AChEIs) in severe dementia means providers do not know if and when to deprescribe. We sought to identify which patient-, provider-, and system-level characteristics are associated with AChEI discontinuation.
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. Cox-proportional hazards models with time-varying covariates were used to identify patient-, provider-, and system-level factors associated with AChEI discontinuation (30-day or more gap in supply).
SETTING
US Medicare-certified nursing homes (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%). The most commonly prescribed AChEIs were donepezil (77.8%), followed by transdermal rivastigmine (14.6%). The cumulative incidence of AChEI discontinuation was 29.7% at the end of follow-up (330 days), with mean follow-up times of 194 days for continuous users of AChEIs and 105 days for those who discontinued. Factors associated with increased likelihood of discontinuation were new admission, older age, difficulty being understood, aggressive behavior, poor appetite, weight loss, mechanically altered diet, limited prognosis designation, hospitalization in 90 days prior, and northeastern region. Factors associated with decreased likelihood of discontinuation included memantine use, use of strong anticholinergics, polypharmacy, rurality, and primary care prescriber vs geriatric specialist.
CONCLUSION
Among NH residents with severe dementia being treated with AChEIs, the cumulative incidence of AChEI discontinuation was just under 30% at 1 year of follow-up. Our findings provide insight into potential drivers of deprescribing AChEIs, identify system-level barriers to deprescribing, and help to inform covariates that are needed to address potential confounding in studies evaluating the potential risks and benefits associated with deprescribing. J Am Geriatr Soc 67:1871-1879, 2019.
背景/目的：乙酰胆碱酯酶抑制剂（AChEIs）在重度痴呆症中的获益和风险尚不确定，这意味着医护人员不知道是否以及何时应停止处方。我们试图确定哪些患者、医护人员和系统层面的特征与 AChEI 的停药相关。
方法
对 2015 年至 2016 年来自医疗保险索赔、处方药物医疗保险部分（Part D）、最低数据集（MDS）版本 3.0、区域卫生资源档案和养老院比较的数据进行分析。使用具有时变协变量的 Cox 比例风险模型，确定与 AChEI 停药（供应中断 30 天或以上）相关的患者、医护人员和系统层面的因素。
地点
美国医疗保险认证的养老院（NHs）。
参与者
2016 年 MDS 评估后 14 天内接受 AChEI 治疗的 65 岁及以上非熟练 NH 居民，患有严重痴呆症（n = 37106）。
结果
该样本主要为白人（78.7%）、女性（75.5%）和 80 岁及以上（77.4%）。最常开的 AChEI 是多奈哌齐（77.8%），其次是透皮 Rivastigmine（14.6%）。在随访结束时（330 天），AChEI 停药的累积发生率为 29.7%，持续使用 AChEI 的患者平均随访时间为 194 天，而停药的患者平均随访时间为 105 天。与停药可能性增加相关的因素包括新入院、年龄较大、难以理解、攻击性行为、食欲不振、体重减轻、机械改变饮食、预后指定有限、90 天内住院和东北部地区。与停药可能性降低相关的因素包括使用美金刚、使用强抗胆碱能药物、多药治疗、农村地区和初级保健医生与老年专科医生。
结论
在接受 AChEI 治疗的 NH 重度痴呆症患者中，在 1 年的随访中，AChEI 停药的累积发生率接近 30%。我们的研究结果为 AChEI 停药的潜在驱动因素提供了深入了解，确定了 AChEI 停药的系统障碍，并有助于为评估与停药相关的潜在风险和获益的研究提供必要的协变量。美国老年医学会 67：1871-1879，2019。
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