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Matthew Alcusky, PharmD, PhD, received a 3 year R01 from the National Institute on Aging to study antidementia and psychotropic medication use and associated health outcomes among older nursing home residents with Alzheimer’s disease

Assistant Professor Matthew Alcusky PharmD, PhD received NIH funding for an R01 grant entitled, “Antidementia medication use, safety, and effectiveness among nursing home residents with Alzheimer’s disease.”

This study examines the use, safety, and effectiveness of antidementia medications for older nursing home residents with Alzheimer’s disease. The number of Americans living with Alzheimer’s disease is projected to more than double from 5.6 million in 2019 to 13.8 million by 2050. Many older adults living in nursing homes have Alzheimer’s disease, which causes loss of cognitive and daily functioning. For most nursing home residents with Alzheimer’s disease, treatment with antidementia medication is recommended, but historically, the majority of residents have not received treatment.

Only two available classes of medications, cholinesterase inhibitors (ChEIs) and memantine have been demonstrated to slow symptomatic progression of Alzheimer’s disease. Donepezil (the most widely used ChEI) has FDA indications for mild, moderate, and severe Alzheimer’s disease, while memantine is indicated for moderate to severe Alzheimer’s disease and has evidence supporting possible benefits in mild disease. Historically (2006), only ~40% of residents were treated with either medication class at the time of nursing home admission, and a small minority (10%) received combination therapy. Nursing home residents may be at higher risk for adverse drug events from drug-drug and drug-disease interactions due to a high burden of polypharmacy and comorbidities. Yet in the DOMINO clinical trial conducted among community dwelling patients, discontinuation of a ChEI before the end stages of the disease was associated with worse clinical outcomes. Nearly a quarter of nursing home residents treated with ChEIs and/or memantine at the time of admission discontinued treatment shortly after admission (regardless of dementia severity) and were potentially at risk for clinical worsening and the need to use more hazardous drugs such as antipsychotics.

Using contemporaneous, national, federally-mandated Minimum Data Set 3.0 linked to Medicare Part A and D claims, study aims are to:
1) examine contemporary patterns of ChEI, memantine, and psychotropic medication use in NH residents with Alzheimer’s disease;
2) compare long-term effectiveness, safety, and survival between residents initiating combination therapy, monotherapy, and no treatment with ChEIs and memantine; and
3) identify resident characteristics (e.g., dosing, comorbid conditions, concurrent medications, dementia stage) for whom treatment with ChEIs and/or memantine confers a net clinical benefit.

We hypothesize that:
1) antidementia medications are being underutilized in NH residents with Alzheimer’s disease;
2) the net clinical benefit is more likely to be positive for those with mild/moderate disease;
3) for those with advanced disease the net clinical benefit is more likely to be positive owing to reduced use of psychotropic drugs which confer increased risks for falls, cardiovascular events, and mortality.

By expanding the evidence base to facilitate a dynamic resident-centered decision-making process regarding Alzheimer’s disease treatment in an aged nursing home population, this this study fulfills the goals of The National Plan to Address Alzheimer’s Disease to effectively treat Alzheimer’s disease and to optimize care quality and efficiency. This research is also closely aligned with the National Institute on Aging’s Strategic Goal to improve the safe use of medications.