Decision Making for Cardiovascular Therapy in Adults with Mild Cognitive Impairment

 描述(由申请人提供)：在了解轻度认知障碍(MCI)如何影响老年患者心血管疾病(CVD)等严重疾病的治疗和决策方面存在根本差距。缺乏对临床决策的理解是设计干预措施以改善老年MCI患者心血管疾病护理质量和结果的关键障碍。这项研究的长期目标是开发、测试和传播干预措施，旨在提高心血管疾病护理的质量和结果，并减少患有MCI的美国老年人的心血管疾病相关残疾。这项应用的目的是确定MCI患者在多大程度上接受了两种最常见的心血管事件--急性心肌梗死(AMI)和急性缺血性中风--的不符合标准的护理，从而增加了生活质量良好的人群的死亡率和发病率，并确定MCI如何影响患者的偏好和医生的治疗建议。急性心肌梗死和急性缺血性中风是严重、急性疾病的优秀模型，具有广泛的急性治疗、康复和二级预防的有效治疗方法。我们的中心假设是，患有MCI的老年人的心血管疾病治疗不足，因为患者和医生高估了他们患痴呆症的风险，低估了他们患心血管疾病的风险。这一假设是在申请者初步研究数据的基础上提出的。这项拟议研究的基本原理是，了解患者的喜好和医生的建议如何导致MCI患者的心血管疾病治疗使用不足，有可能转化为旨在改善护理质量和结果的有针对性的干预措施，从而产生治疗成人MCI患者的CVD和其他严重急性疾病的新的创新方法。在强大的初步数据的指导下，这一假设将通过追求两个具体目标来检验：1)比较MCI患者和认知正常患者之间的急性心肌梗死和中风治疗，并探索与治疗差异相关的临床结果的差异；以及2)确定MCI对患者和代理人的偏好以及对急性心肌梗死和中风治疗的医生建议的影响。在第一个目标下，将使用一种医疗服务研究方法--在申请者手中被证明是可行的--来量化MCI老年患者急性心肌梗死和急性缺血性中风治疗差异的程度和结果。在第二个目标下，多中心、混合方法和全国医生调查将被用来确定MCI对急性心肌梗死和中风治疗的患者偏好和医生建议的影响，这在申请者手中也已被证明是可行的。这项研究建议是创新的，因为它代表了一种新的和本质上不同的方式，通过确定MCI患者使用有效的心血管疾病治疗不足的程度和原因，来解决增进老年人健康的重要公共卫生问题。这项拟议的研究具有重要意义，因为它有望纵向推进和扩大对MCI如何影响老年患者的急性心肌梗死和缺血性中风的治疗和决策的理解。归根结底，这些知识有可能为制定有针对性的干预措施提供信息，这些干预措施将有助于提高心血管疾病护理的质量和结果，并减少美国老年人的心血管疾病相关残疾。

 DESCRIPTION (provided by applicant): There is a fundamental gap in understanding how mild cognitive impairment (MCI) influences treatment and decision making for serious illnesses, like cardiovascular disease (CVD), in older patients. Poor understanding of clinical decision making is a critical barrier to the design of interventions to improve the quality and outcomes of CVD care of in older patients with MCI. The long-term goal of this research is to develop, test, and disseminate interventions aimed to improve the quality and outcomes of CVD care and to reduce CVD-related disability in older Americans with MCI. The objective of this application is to determine the extent to which people with MCI are receiving sub-standard care for the two most common CVD events, acute myocardial infarction (AMI) and acute ischemic stroke, increasing the chance of mortality and morbidity in a population with otherwise good quality of life, and to determine how MCI influences patient preferences and physician recommendations for treatment. AMI and acute ischemic stroke are excellent models of serious, acute illnesses with a wide range of effective therapies for acute management, rehabilitation, and secondary prevention. Our central hypothesis is that older adults with MCI are undertreated for CVD because patients and physicians overestimate their risk of dementia and underestimate their risk of CVD. This hypothesis has been formulated on the basis of preliminary data from the applicants' pilot research. The rationale for the proposed research is that understanding how patient preferences and physician recommendations contribute to underuse of CVD treatments in patients with MCI has the potential to translate into targeted interventions aimed to improve the quality and outcomes of care, resulting in new and innovative approaches to the treatment of CVD and other serious, acute illnesses in adults with MCI. Guided by strong preliminary data, this hypothesis will be tested by pursuing two specific aims: 1) Compare AMI and stroke treatments between MCI patients and cognitively normal patients and explore differences in clinical outcomes associated with treatment differences; and 2) Determine the influence of MCI on patient and surrogate preferences and physician recommendations for AMI and stroke treatment. Under the first aim, a health services research approach- shown to be feasible in the applicants' hands-will be used to quantify the extent and outcomes of treatment differences for AMI and acute ischemic stroke in older patients with MCI. Under the second aim, a multi-center, mixed-methods approach and a national physician survey, which also has been proven as feasible in the applicants' hands, will be used to determine the influence of MCI on patient preferences and physician recommendations for AMI and stroke treatment. This research proposal is innovative because it represents a new and substantially different way of addressing the important public health problem of enhancing the health of older adults by determining the extent and causes of underuse of effective CVD treatments in those with MCI. The proposed research is significant because it is expected to vertically advance and expand understanding of how MCI influences treatment and decision making for AMI and ischemic stroke in older patients. Ultimately, such knowledge has the potential to inform the development of targeted interventions that will help to improve the quality and outcomes of CVD care and to reduce CVD-related disability in older Americans.