Improving Care Planning and Well-being in Older Adults with Macular Degeneration

描述(申请人提供)：年龄相关性黄斑变性(AMD)是导致老年人不可逆性失明和严重视力丧失的主要原因，在美国有1000多万人受到影响。人口老龄化导致一些人预测AMD将流行。丧失独立性和有价值的活动会增加AMD患者抑郁、焦虑和残疾的风险。许多人很悲观，不愿为未来的住房和与视力丧失相关的流动性问题做计划。患者对AMD的情绪和行为反应可能会加剧这种疾病的长期健康威胁，并导致可预防的医疗成本、生产力损失和家庭成员的负担。我们提出了一项心理-社会干预的随机对照试验，旨在解决三个心理健康促进目标：(1)增加情绪幸福感，(2)改善未来前景，(3)保护或增强当前和面向未来的功能。我们的预防性问题解决干预(PREPSI)是对问题解决疗法的简短、标准化的修改，培训参与者识别和明确定义当前和未来的问题，然后生成、评估、选择和实施解决方案。此外，我们还提供疾病管理方面的团体教育。我们的目标是改善风险感知、对选项的认识、偏好形成和对未来关注的积极决策，例如护理环境、社会需求和居住调整。我们研究计划的长期目标是通过开展预防性未来规划的基础研究和转化研究来提高成年后期的生活质量。这项拟议的研究考察了400名60岁及以上的AMD患者使用PREPSI的效果，这些患者的最佳矫正视力为20：60。他们将被随机分成8个PREPSI课程，由硕士级别的培训师进行培训，或者被分配到一个增强的注意力控制臂，医学生在那里进行“生活和健康回顾”。所有研究参与者将接受4节视力教育课程和资源信息。对治疗情况视而不见的评估者将在整个干预过程中的4个时间点测量心理健康(主要结果)、未来展望、日常功能和未来护理准备(次要结果)，并在24个月的随访中每6个月测量一次。我们的干预将改善AMD患者的生活质量，并可能为其他慢性病项目提供参考。PREPSI设计为可运输，只需最少的培训即可在低视力诊所由工作人员实施。下一步可能包括多点试验或传播到眼科诊所网络。这项建议建立在NIA K01对PI的基础上，该K01侧重于PFC对老年人主观幸福感和日常功能的影响的观察性研究。这是申请人的第一份R01申请。与公共卫生相关：老年性黄斑变性(AMD)是导致老年人不可逆性失明和严重视力丧失的主要原因；其下降过程被很好地描述，许多患者随后遭受情绪困扰、消极的未来前景和功能障碍。有效的问题解决、对未来护理和住宿需求的规划以及疾病管理教育可以解决AMD的情绪和行为影响，并防止随之而来的不良健康后果，如跌倒、急诊室就诊和增加的医疗保险费用。由于大多数AMD患者不主动为长期护理或未来的住院需求做计划，本应用程序提出了一项心理教育健康促进干预的随机对照试验，名为“预防性问题解决培训”，以确定解决问题和未来计划干预是否可以改善患有这种和其他慢性进展性疾病的患者的情绪健康、功能和规划。

DESCRIPTION (provided by applicant): As the leading cause of irreversible blindness and severe vision loss among older adults, Age-related Macular Degeneration (AMD) affects more than 10 million people in the US. The aging of the population has led some to forecast an epidemic of AMD. Loss of independence and valued activities places AMD patients at increased risk for depression, anxiety, and disability. Many are pessimistic and reluctant to plan for future housing and mobility problems associated with vision loss. Patients' emotional and behavioral responses to AMD can exacerbate the long-term health threat of the disease and contribute to preventable health care costs, loss of productivity, and burden to family members. We propose a randomized controlled trial of a psycho-social intervention that addresses three mental health promotion goals: (1) increase emotional well-being, (2) improve future outlook, and (3) protect or enhance current and future-oriented functioning. Our Preventive Problem Solving Intervention (PREPSI) is a short, standardized modification of problem- solving therapy that trains participants to identify and clearly define current and future problems, and then generate, evaluate, choose, and implement solutions. In addition, we provide group-based education on disease-management. We aim to improve risk perception, awareness of options, preference formation, and active decision-making for future concerns, e.g., care settings, social needs, and residential adjustments. The long-term goal of our research program is to improve quality of life in late adulthood by conducting basic and translational research on preventive future planning. The proposed study examines the effects of the PREPSI on 400 AMD patients 60 and older, who have best corrected vision acuity of 20:60 in their better eye. They will be randomized to 8 PREPSI sessions with master's level trainers or to an enhanced attention control arm in which medical students conduct "Life and Health Review." All study participants will receive 4 vision education classes and resource information. Assessors blind to treatment condition will measure Psychological Well-being (primary outcome), Future Outlook, Everyday Functioning, and Preparation for Future Care (secondary outcomes) at 4 time points throughout the intervention and every 6 months in a 24 month follow-up. Our intervention will improve AMD patients' quality of life and could inform programs for other chronic diseases. PREPSI is designed to be transportable and could be implemented in low vision clinics by staff with minimal training. Next steps could include multi-site trials or dissemination into eye clinic networks. This proposal builds on a NIA K01 to the PI that focused on observational studies of the effect of PFC on subjective well-being and everyday functioning for older adults. This is the applicant's first R01 submission. PUBLIC HEALTH RELEVANCE: Age-related Macular Degeneration (AMD) is the leading cause of irreversible blindness and severe vision loss among older adults; its down-hill course is well-described, and many patients suffer from subsequent emotional distress, negative future outlook and functional impairments. Effective problem-solving, planning for future care and residential needs, and disease management education could address the emotional and behavioral effects of AMD and prevent the consequent adverse health outcomes, such as falls, emergency room visits and increased Medicare costs. Because most AMD patients do not plan proactively for long-term care or future residential needs, this application proposes a randomized controlled trial of a psycho-educational health- promotion intervention, "Preventive Problem Solving Training" to determine whether problem-solving and future planning interventions can enhance emotional well-being, functioning, and planning in patients with this and other chronic progressive illnesses.