Reducing cognitive decline in patients with mild cognitive impairment and Alzheimer's Disease and related dementias by developing and testing clinician and caregiver deprescribing tools

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Worsening cognitive decline is a hallmark problem in patients with mild cognitive impairment (MCI) and Alzheimer’s Disease and related dementias (ADRD). Despite the well-recognized worsening of cognitive burden by high-risk medications like benzodiazepines, medications with strong anticholinergic side effects, and sedative hypnotics, they continue to be overprescribed in this population. Many factors contribute to their overuse including clinical inertia and the need to involve caregivers. Fortunately, deprescribing has been shown to improve outcomes in patients with MCI/ADRD. However, deprescribing efforts have often had modest success due to lack of primary care provider (PCP) involvement and giving insufficient support at the point of care. Interventions that have been successful have been resource intensive and thus difficult to scale. In contrast, electronic health record (EHR) systems offer a scalable strategy for changing provider behavior that could be useful for deprescribing medications that worsen cognitive burden. Existing literature demonstrates the potential for EHR-based tools to improve deprescribing, especially when augmented with insights from behavioral science. EHR systems could also be leveraged to engage caregivers in the deprescribing process but has not been done before. Despite the high potential for scalability, application of specific deprescribing tools in EHRs for PCPs has been limited, especially for MCI/ADRD populations. To overcome this gap, we propose this R21 to develop and pilot test new EHR deprescribing tools for PCPs of patients with MCI/ADRD that also involve caregivers. We will leverage learnings from our NUDGE- EHR trial, an NIA-funded pragmatic trial evaluating whether EHR tools designed using behavioral science improves deprescribing in general older adults and adapt them for the MCI/ADRD population to provide pilot data for a subsequent large pragmatic trial and generalizable evidence about caregiver engagement strategies. The specific aims are: (1) to design and pilot test EHR tools using behavioral science for deprescribing in patients with MCI/ADRD and (2) to identify strategies for engaging caregivers in EHR tools. The new tools will include a PCP-facing EHR dashboard that identifies patients in need of deprescribing and facilitates communication with caregivers, alerts enhanced with behavioral principles to encourage deprescribing, order sets that provide easier ordering of dose-tapers and alternative medications, and post-visit monitoring tools. We will conduct qualitative interviews and pilot testing within the EHR system with PCPs and caregivers to demonstrate feasibility and usability of the EHR tools, also assessing implementation outcomes to identify barriers to intervention scalability. In addition, we will evaluate the ability to engage caregivers using caregiver- facing surveys delivered through EHR patient portal, emailed, phone, and mailed communications. The expected overall impact of this innovative proposal is that it will advance how EHRs can be optimized to improve prescribing for patients with MCI/ADRD to improve cognitive burden in ways that are highly scalable.