Effective prescribing is a key part of enabling people living with dementia to live as well as possible. Approximately 90% of people with dementia have other medical conditions, impacting on decisions about care. It is more common for people living with dementia to be given medication that is not appropriate, with implications for health and quality of life. Better information on potentially inappropriate medicines would help us understand current practice and opportunities for improvement.
Potentially inappropriate medication for older people have been defined by experts. This project will use health records on medical consultations, medication and hospital visits, to:
- Identify the additional health conditions common in people living with dementia and compare with individuals not diagnosed with dementia.
- Understand how potentially inappropriate medication is prescribed to people diagnosed with dementia.
- Characterise continuity of care in people diagnosed with dementia.
- Understand the impact over time of medication and continuity of services, on survival and quality of life.
The large number of individuals diagnosed with dementia available in electronic health care records, allow for developing a better understanding of type of comorbidities associated with the condition and assess current standards for prescribing. We believe this project can make an important contribution to establishing what improvements health care services for dementia, in term of medication and continuity of GP, are needed. This will provide the foundation for developing interventions that aim to improve care. In addition, it should help to avoid unnecessary medication related difficulties in people living with dementia in the future.
In a preliminary analysis of electronic medical records from 598,631 older individuals we found that 92% of people with dementia had comorbidities. Co-morbidities often complicate care decisions by GPs, with high rates of potentially inappropriate prescribing (PIP, according to STOPP-START criteria) or under-treatment (which have been reported in people with dementia). This project will help quantify the scope for improving management of co-existing conditions for people with dementia in primary care. It includes the following phases:
Phase 1: Comorbidity, PIP and continuity of care
- Cross sectional design Analysis of co-morbidities of dementia. Latent class analysis (LCA) identifying patterns of comorbidities based on chronic conditions and indicators of frailty in old age.
- Cross sectional design Prevalence of potential inappropriate prescription (PIP) as defined by the STOPP-START criteria.
- Cross sectional design Characterizing Continuity of Care (COC) with dementia.
Phase 2: Impact of care quality on incidence rate of mortality and geriatric outcomes
- Longitudinal design Estimating the association between a health care quality: PIP (presence/absence) and COC (e.g. quintiles), and the incidence rates of all-cause mortality and major geriatric outcomes.
High quality treatment of comorbidities alongside dementia is critical for achieving the best outcomes for patients and caregivers. Findings from this fellowship will provide the foundation for future interventions to improve medication management.
The list of outcomes to be measured in the study are:
1. Prevalence of comorbidities of dementia. The list includes Asthma, Atrial Fibrillation, Cancer, Coronary Heart Disease, Chronic Kidney Disease (Stages 3 to 5), COPD, Depression, Diabetes type 2, Epilepsy, Heart Failure, Hypertension, Hypothyroidism, Mental Health, Stroke (medcodes and ICD10 codes defined in ISAC protocol 14_135).
It also includes conditions included the electronic Frailty Index: i.e. Activity limitation, Anaemia and haematinic deficiency, Arthritis, Dizziness, Dyspnoea, Falls, Foot problems, Fragility fracture, Hearing impairment, Heart valve disease, Housebound, Hypotension/syncope, Mobility and transfer problems, Osteoporosis, Parkinsonism and tremor, Peptic ulcer, Peripheral vascular disease, Requirement for care, Respiratory disease, Skin ulcer, Sleep disturbance, Social vulnerability, Thyroid disease, Urinary incontinence, Urinary system disease, Visual impairment, Weight loss and anorexia.
2. Potential inappropriate prescribing as defined by the STOPP/START criteria: focusing only on the STOPP portion as operationalised into CPRD by Bradley et al.(2014).
3. Characterisation of continuity of care in primary care as defined by the: Usual Provider Continuity (UPC) Index; Continuity of Care Index; and Modified Continuity Index (MMCI).
4. Geriatric outcomes: all-cause mortality, incontinence, falls, fractures, delirium or emergency hospital admissions for conditions possibly related to the prescriptions e.g. electrolyte imbalances. Major GO will be identified as a combination of medcodes, ICD10 and when applicable OPCS codes (e.g. fragility fractures). We will use as preliminary code lists, lists from our previous work with CPRD (ISAC protocols 14_135 (R), 14_159R2, 15_192R). These have been checked against CPRD 2018 medcode list and updated where new relevant codes were available (ANNEX 1).
Joao Delgado - Chief Investigator - University of Exeter
Joao Delgado - Corresponding Applicant - University of Exeter
clive Ballard - Collaborator - University of Exeter
David Melzer - Collaborator - University of Exeter
Jose M Valderas - Collaborator - University of Exeter
Linda Clare - Collaborator - University of Exeter
HES Accident and Emergency;HES Admitted Patient Care;ONS Death Registration Data;Patient Level Index of Multiple Deprivation