Potentially Inappropriate Medication Use and Access to Medication Management Services in Older Adults Living with Alzheimer's Disease and Related Dementia
Type of DegreePhD Dissertation
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Background: Older adults living with Alzheimer's disease and related dementia (ADRD) have a higher risk of using potentially inappropriate medication (PIM) than those without ADRD. Even though Medication Therapy Management (MTM) services could help reduce PIM use, people living with ADRD were excluded from most MTM studies. In addition, the effectiveness of MTM services is inconsistent across different interventions and subgroups of populations. The inconsistent effectiveness might be explained by different perceptive factors from stakeholders and disparities in MTM eligibility. Objectives: The purpose of this mixed methods study is to (1) qualitatively explore facilitators and barriers of the receipt and the delivery of MTM services from multiple perspectives including caregivers, community pharmacists and local aging agency social workers, (2) quantitatively assess PIM use patterns and factors associated with PIM use among older adults living with ADRD, and (3) assess the association between MTM-eligibility and having ADRD with PIM use among Medicare beneficiaries. Methods: Semi-structured telephonic interviews were conducted to identify facilitators and barriers to the receipt and the delivery of MTM services from multiple perspectives including family caregivers, community pharmacists and local aging agency social workers. Next, a serial cross-sectional study and a retrospective cross-sectional study were conducted to assess the annual trends of PIM use and risk factors influencing PIM use among older adults living with ADRD. Moreover, a retrospective cohort study was used to evaluate the association between MTM eligibility and having ADRD with PIM use. Results: First, Analysis of qualitative interviews uncovered that many family caregivers had a difficulty conveying patients' conditions to healthcare providers and were reluctant to challenge healthcare providers' decisions because they did not want to jeopardize their relationship with the healthcare providers or appear that they doubted providers' advice. Second, pharmacists were willing to help older adults living with ADRD but had limited knowledge about how best to communicate with this population and standard reimbursement mechanisms. Third, social workers had expertise working with older adults living with ADRD and their caregivers but needed more medical knowledge and resources that they could help facilitate the care and share relevant resources with patients and caregivers. In addition, the quantitative analyses revealed that the proportion of PIM use significantly decreased from 2013 to 2019. We also found that the likelihood of PIM use was strongly associated with beneficiaries' age, education, number of conditions, number of medications, medication costs, individual income level, living regions, quality level and whether having dual eligibility for Medicare and Medicaid. Moreover, MTM-eligible older adults living with ADRD were more likely to use at least one PIM compared to their MTM-ineligible counterparts. Among MTM-eligible older adults, individuals living with ADRD had a similar likelihood of PIM use compared to those without ADRD. Conclusions: First, two key factors that could affect the patient care process for older adults living with ADRD included effective communication between patients/caregivers and providers and flexibility of patient care services being offered. Next, this study provided a more comprehensive understanding of PIM use patterns and factors associated with PIM use in older adults living with ADRD. Third, this study assessed the association between MTM-eligibility status and PIM use and the association between having ADRD with PIM use among Medicare beneficiaries. Implications: Results suggest that training programs and multidisciplinary MTM services involving caregivers, pharmacists and social workers could improve communication between patients and caregivers with healthcare providers, reduce PIM, and subsequently benefit older adults living with ADRD. In addition, further quantitative research is needed to assess actual MTM service utilizations and PIM use among this population.