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

通过开发和测试临床医生和护理人员处方工具，减少轻度认知障碍、阿尔茨海默氏病和相关痴呆症患者的认知能力下降

• 批准号: 10370471
• 负责人: Julie Christine Lauffenburger
• 金额: $ 51.1万
• 依托单位: BRIGHAM AND WOMEN'S HOSPITAL
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-02-01 至 2024-07-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10370471
• 关键词: Address; Adoption; Alzheimer' s disease related dementia; Anti-Cholinergics; Behavioral; Behavioral Sciences; Benzodiazepines; Caregivers; Clinical; Cognition; Communication; Data; Dose; Elderly; Electronic Health Record; Ensure; Evaluation; Funding; Impaired cognition; Intervention; Interview; Learning; Literature; Medication Management; Monitor; Patients; Pharmaceutical Preparations; Population; Process; Research Personnel; Resources; Surveys; System; Telephone; Testing; Visit; Work; base; behavior change; care providers; caregiving; clinical practice; cognitive load; dashboard; design; high risk; hypnotic; implementation evaluation; implementation outcomes; improved; improved outcome; innovation; insight; mild cognitive impairment; multidisciplinary; patient health information; patient portal; pilot test; point of care; pragmatic trial; provider behavior; research study; sedative; side effect; success; support tools; tool; usability

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.

认知功能下降恶化是轻度认知功能障碍（MCI）患者的标志性问题， 阿尔茨海默病和相关痴呆症（ADRD）。尽管认知功能的恶化是众所周知的， 高风险药物如苯二氮卓类药物，具有强烈抗胆碱能副作用的药物， 镇静催眠药，他们继续在这个人群中被过度使用。许多因素有助于他们的 过度使用，包括临床惰性和需要护理人员参与。幸运的是， 改善MCI/ADRD患者的预后。然而，取消处方的努力往往 由于缺乏初级保健提供者（PCP）的参与，以及在 护理点。成功的干预措施都是资源密集型的，因此难以推广。 相比之下，电子健康记录（EHR）系统为不断变化的提供者提供了可扩展的策略 这些行为可能有助于取消那些加重认知负担的药物。现有文献 证明了基于EHR的工具在改善取消处方方面的潜力，特别是在增加 行为科学的见解。EHR系统也可以用来让护理人员参与 这是一个取消的过程，但以前没有这样做过。尽管具有很高的可扩展性潜力， 在PCP的EHR中，特别是对于MCI/ADRD人群，特定的开药工具有限。 为了克服这一差距，我们建议这个R21开发和试点测试新的EHR取消处方工具， MCI/ADRD患者的PCP也涉及护理人员。我们将从我们的NUDGE学习， EHR试验，一项由NIA资助的实用性试验，评估EHR工具是否使用行为科学设计 改善一般老年人的处方，并使其适应MCI/ADRD人群，以提供试点 数据为随后的大型务实的试验和概括的证据照顾者的参与战略。 具体目标是：（1）利用行为科学设计和试点测试EHR工具， MCI/ADRD患者;（2）确定使护理人员参与EHR工具的策略。新工具将 包括一个面向PCP的EHR仪表板，用于识别需要取消处方的患者， 与护理人员沟通，通过行为原则增强警报，以鼓励取消处方， 提供更容易订购剂量递减和替代药物的套件，以及访视后监测工具。 我们将在EHR系统内与PCP和护理人员进行定性访谈和试点测试， 证明EHR工具的可行性和可用性，并评估实施结果，以确定 干预可扩展性的障碍。此外，我们还将评估使用护理人员- 面对通过EHR患者门户、电子邮件、电话和邮寄通信交付的调查。的 这一创新提案的预期总体影响是，它将推动如何优化EHR， 改善MCI/ADRD患者的处方，以高度可扩展的方式改善认知负担。