TREATMENT DECISIONS FOR PEOPLE WITH LIFE LIMITING ILLNESSES: AN ANALYSIS OF TREATMENT VARIATION IN SECONDARY PREVENTIVE CARE FOR CARDIOVASCULAR DISEASE AMONG ELDERLY MEDICARE PATIENTS WITH DEMENTIA

摘要

This dissertation examines the effect of dementia on the treatment of coronary heart disease (CHD) in elderly Medicare beneficiaries. It specifically tests whether rates of utilization of evidence-based secondary preventive medication treatment (chemoprophylaxis) for CHD are different in patients with dementia compared to those without dementia. Data from the Cardiovascular Health Study were used to investigate the long-term effect of dementia on the use of four types of low burden and low risk chemoprophylaxis for CHD over time (ACE inhibitors, beta-blockers, lipoid-lowering medications and antiplatelet medications). The multivariate analyses employed a range of predictors including predisposing patient characteristics such as age, race, sex, education and the interaction of age and dementia status. Enabling variables included in the analyses are study site, income, supplemental insurance status, and residence in a nursing home. The care need variables include functional status, measured by activities of daily living, and comorbidites. The main findings reveal that the presence of any type of dementia, comorbid with CHD, has an effect on the use of beta-blockers and lipid-lowering medications. Additionally, patients with CHD and vascular type dementia are less likely to report taking beta-blockers, lipid-lowering medications, and antiplatelet medications, but more likely to report using ACE inhibitors. The results are mixed regarding the effect of timing of dementia onset of the use of chemoprophylaxis. Those who developed dementia before CHD were less likely to report using a beta-blocker and lipid-lowering mediation, yet, those who developed dementia after CHD did not discontinue use of chemoprophylaxis after the onset of dementia. The results of this dissertation provide new empirical evidence of the difference in the rate of secondary chemoprophylaxis for CHD among elderly patients with dementia compared to those without dementia. Information about the effect of dementia on the treatment of CHD, as well as factors that predict utilization, could inform health policy to improve care for the millions of Americans living with dementia and CHD.