Parkinson disease (PD) is the second most common neurodegenerative disease worldwide, with estimates suggesting that PD prevalence and incidence will increase with aging populations. Therapeutic options and clinical guidelines for PD have significantly changed over the past 15 years; however, pharmacoepidemiology data in PD are lacking, especially regarding adverse effects of non-ergot dopamine agonists (DAs) and outcomes associated with anticholinergic burden. The objectives of this doctoral research are threefold: 1) examine patterns of antiparkinson drug use in relation to clinical guideline publication, drug availability, and emerging safety concerns; 2) determine whether PD patients treated with non-ergot DAs are at increased risk of adverse cardiovascular or cerebrovascular outcomes; and 3) determine whether anticholinergic burden is associated with adverse outcomes in PD. Specific research questions were investigated using epidemiological methods and electronic health data from Cerner Health Facts®, an electronic medical record database that stores time-stamped patient records for more than 300 Cerner subscribing facilities across the United States. Findings from this work are reported in a series of manuscripts, all of which have been published. Key findings include: 1) DA use began declining in 2007, from 34% to 27% in 2012. The decline followed publication of the American Academy of Neurology’s practice parameter refuting levodopa toxicity, pergolide withdrawal, and pramipexole label revisions; 2) heart failure was the only adverse cardiovascular or cerebrovascular outcome that demonstrated a significant association with non-ergot DA use, mainly pramipexole; and 3) anticholinergic burden in PD was associated with the diagnosis of fracture and delirium, and significantly increased the risk of emergency department visit and readmission post inpatient discharge. Reported antiparkinson prescribing trends suggest that safety and best practice information may be communicated effectively in PD. Although findings warrant replication, individuals with PD and independent risk factors for or a history of heart failure may benefit from limited use of pramipexole. Similarly, individuals with PD may benefit from substituting non-PD medications with anticholinergic effects for equally effective non-anticholinergic agents. Additional pharmacovigilance studies are needed to better understand health risks and the impact of population health interventions in PD.

The goal of this investigation was to assess service use, self-management strategies, and health status of older adults (60+ years) with perceived need who sought assistance from the Virginia Medicaid Elderly and Disabled Consumer-Direction (EDCD) waiver services. A sequential explanatory mixed method design was used to address the overall research question: How do older adults manage unmet needs? Using health services data from two independent State agencies, regression techniques were used to examine predictors of service use, hospitalization, and mortality among 1,008 individuals. A purposive subsample of eight rural-dwelling waiver-ineligible individuals was identified for follow-up semi-structured telephone interviews to explore self-management strategies for confronting functional care needs. Waiver-ineligible individuals were at risk for hospitalization and mortality; rural-dwelling individuals were more likely to be waiver-ineligible and had increased risk of mortality. Analysis of interviews revealed individuals had ongoing unmet needs and relied on family and community services and used internal and external strategies to manage them; plans were not in place should their health continued to decline. For this group of near-risk older adults who are waiver-ineligible and do not have financial means to pay for more help, accessible preventive services are necessary to reduce risk of adverse health outcomes. Policymakers are encouraged to advocate for preventive services that assist individuals before care needs become unmanageable. Agencies responsible for service delivery need to target efforts toward this group, particularly those residing in rural areas. Researchers must continue forging partnerships that permit use of health services data to identify when and how older adults use services, and explore how self-management strategies influence health and functioning over time. / Ph. D. / The purpose of this research was to advance understanding of help-seeking behaviors of lowincome older adults who were deemed ineligible to receive state-funded assistance. I used health services data from two independent state agencies to assess factors associated with service use and health status; follow-up interviews were conducted to explore self-management strategies of rural older adults with unmet needs. Older adults who did not receive help were at increased risk for hospitalization and mortality compared to individuals who received helped. Rural older adults were significantly more likely to not receive help and were at increased risk for mortality, placing them in a vulnerable position. Interviews with rural-dwelling older adults that were not receiving help highlighted the challenges associated with living with unmet needs but demonstrated resilience through their use of physical and psychological coping mechanisms to navigate daily challenges and maintain health and well-being. They had to deal with numerous difficulties performing instrumental activities of daily living (IADL); mobility was an underlying problem that led to subsequent IADL limitations, such as difficulty with household chores and meal preparation. Policymakers need to advocate for services that allow older adults to address preemptively their care needs before they become unmanageable. Ensuring the availability of services for near-risk older adults who are proactive in addressing their functional care needs would benefit individuals and caregivers on whom they rely. Such services not only support older adults’ health, functioning, and well-being but may be cost-effective for public programs. Policies should reduce unmet needs among older adults by increasing service access in rural communities because even if services exist, they may not be available to this near-risk population of older adults.