Medicating Distress: Use of Psychotropic Medications among Patients with Dementia Receiving Hospice Care
My long-term career goal is to establish myself as an independent investigator in geriatric mental health services and mixed methods research, focused on measuring and improving the quality of care that patients with psychiatric disorders and dementia receive at the end of life. Behavioral symptoms in advanced dementia are common, and despite limited evidence to support their use, the mainstay of such symptom management in hospice is off-label use of psychotropic medications such as antipsychotics. However, recent clinical trial evidence suggests that use of an antipsychotic at end-of-life may be associated with worse outcomes for patients--raising the concern that the medications prescribed to alleviate patient distress may exacerbate it. Little is known about how widely psychotropics are prescribed during end-of-life care for dementia or the factors that influence this prescribing. These critical knowledge gaps limit the ability to develop consensus on best practices to address behavioral symptoms in hospice care for dementia. The proposed study will use Medicare data for all older adults with dementia enrolled in hospice in the U.S. in 2015 to determine the array of patient, provider, and hospice characteristics that influence psychotropic prescribing (Aim 1). Next, I will conduct semi-structured interviews with patients with early stage dementia, caregivers, and hospice providers to gain insight into how these stakeholders view the goals of hospice care for dementia and data which will inform how to best manage behavioral symptoms at end-of-life (Aim 2). This will be paired with a 2-year training plan, including goals in: 1) conducting observational analyses using large-scale claims data, 2) conducting qualitative data collection and analysis, and 3) guided exposure to dementia palliative and hospice care. This proposal will directly inform a future career development award application focused on examining the determinants and outcomes of hospice enrollment hospice for patients with dementia.
B. Gerlach, DO, MS, is a geriatric psychiatrist and assistant Professor in the
Department of Psychiatry at the University of Michigan. Dr. Gerlach's research
is focused on understanding trends and appropriate use of psychotropic
medications among older adults including evaluating how psychotropic
medications are utilized in end-of-life care. She has used national survey and
administrative claims data to evaluate the growth of central nervous system
(CNS) medication polypharmacy use among older adults and to understand how
health systems respond to warnings (e.g., from the U.S. FDA) for psychotropic
medications. Her work aims to inform safe and rationale psychotropic medication
prescribing among older adults—including understanding how to best target
appropriate treatment to patients that would benefit from treatment the most.