Optimizing Prescribing Among Older Adults with Cognitive Impairment
GREEN-DISSERTATION-2019.pdf (1.100Mb) (embargoed until: 2023-05-01)
Green, Ariel R.
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An estimated 11 million Americans are living with cognitive impairment,1,2 a condition that ranges from mild, measurable deficits without functional impairment to severe dementia. People with cognitive impairment, who are mostly older adults, have a high burden of coexisting medical conditions, making them likely to experience polypharmacy, potentially inappropriate medication (PIM) use, medication side effects, adverse drug events and treatment burden. Decisions about medication use in such patients are extremely complex, as they often carry trade-offs between quality and length of life, or between different facets of quality of life. In addition, cognitive impairment has a prolonged and variable time course and patients often have diminished decision making capacity and communication di fficulties. Patients, family caregivers and clinicians are forced to make medication decisions with little guidance, as data on safety and effectiveness of most medications is typically extrapolated from healthier older adults. The overall goal this dissertation is to develop a foundation for fostering shared decision making about medication use for the growing number of people with cognitive impairment. In Chapter 1, we examine the use of an illustrative example, bladder antimuscarinics, to describe the current utilization pattern of a potentially inappropriate medication among older adults with varying levels of cognition. This was a cross-sectional study using data collected over 10 years from 24106 community-dwelling people with and without cognitive impairment in the National Alzheimer’s Coordinating Center Uniform Data Set. We found that use of bladder antimuscarinics was more common among older adults with impaired cognition than normal cognition – despite guidelines advising clinicians to avoid prescribing antimuscarinics in patients with dementia due to these patients’ heightened vulnerability to anticholinergic-induced adverse cognitive and functional effects. We also found that patients with cognitive impairment who received bladder antimuscarinics frequently received other strongly anticholinergic medications as well, further increasing their risk of adverse effects. In Chapter 2, we explore these utilization patterns more deeply by investigating clinician-perceived barriers and facilitators of reducing polypharmacy and potentially inappropriate medication use in people with cognitive impairment. This aim consisted of in-depth interviews with primary care and specialist clinicians who provide care for people with dementia in the outpatient setting. In addition to bladder antimuscarinics, clinicians cited decisions regarding the following drug classes as particularly challenging: oral anticoagulants, antihyperglycemic agents, statins and antipsychotics. Perceived enablers of optimizing prescribing included access to interdisciplinary services, and guidelines for non-dementia illnesses (e.g., diabetes) addressing the care of people with dementia. Barriers included: the lack of data on efficacy and safety of most medications in people with dementia; difficulty assessing medication effects in an individual patient; and the perception that stopping medications is seen as “giving up.” Clinicians said they felt uncertain about how best to approach conversations about risks and benefits of medications and foster shared decision making. In Chapter 3, we characterize how primary care clinicians currently discuss medications during encounters with older adults with cognitive impairment and their family companions. In this qualitative, observational study involving 93 audio-recorded primary care encounters, we identified numerous examples in which clinicians introduced patients and caregivers to key principles of optimal prescribing and deprescribing, as well as barriers they faced in doing so. The examples identified in these transcripts can be used to create conversation guides for clinicians, as well as patient-directed educational materials. Remarkable advances in medical science have enabled people to live longer. Providing guideline-directed care often means adding more medications, which may lead to polypharmacy and potentially inappropriate medication use among older adults with multiple competing health risks. There is, to date, little evidence to guide deprescribing and shared decision making about medication use in this population, especially in people with cognitive impairment. The three studies that comprise this dissertation make meaningful contributions to these relatively new fields. Informed by this work, we point to avenues for future research and strategies to engage patients and caregivers in meaningful, patient-centered communication and enable them to make well-informed decisions about their treatments.