Involving Family to Improve Primary Care Visits for Cognitively Impaired Patients

 描述(由申请人提供)：痴呆症是最严重的残疾和昂贵的健康状况之一。尽管造成了毁灭性的影响，但没有已知的治愈方法，卫生保健仍然是检测和治疗行为症状、启动社会服务转介以及规划未来需求的关键。痴呆症在初级保健中构成了特殊的沟通挑战，大多数人最初都是在初级保健中接受治疗的。由于痴呆症患者有很高的慢性疾病负担，沟通方面的挑战也会影响对同时发生的疾病的护理，导致过度负担的治疗、不适当的药物使用，以及潜在的可避免的医疗保健利用。家庭照顾者在痴呆症护理中发挥着至关重要的作用，他们通常在场并积极参与医疗访问。患者和提供者强烈支持让家人参与，以满足缺乏获取、处理和理解基本健康信息以做出适当健康决定的患者的沟通需求。然而，缺乏关于如何让家庭照顾者参与医疗探视的知识。这项研究将完善一项简短的干预措施，以便有效和有目的地让陪同认知障碍患者进行初级保健探视的家庭照顾者(“同伴”)参与进来。研究小组制定了一份核对表，供患者和他们的同伴在就诊前使用。该清单旨在引出患者和同伴对健康问题的看法，以便与医生讨论，并澄清同伴在探视中的作用。这份核对表在最近的一项支持概念的随机研究中很受欢迎。与那些接受常规护理但没有完成核对表的患者相比，完成核对表的患者-伴侣二人组在就诊时的沟通明显更以患者为中心。然而，有中度和重度认知障碍的人被排除在这项早期研究之外。因此，在我们前期工作的基础上，这项研究的总体目标是完善和评估患者-同伴清单，以满足具有一系列认知障碍的初级保健患者及其同伴的沟通需求。首先，我们将进行以用户为中心的设计过程，以完善和增强患有轻度、中度或严重认知障碍的老年人的清单。我们将通过对认知障碍老年患者(n=20)和他们的同伴(n=20；总共20个二元)进行深入访谈，纳入关于清单内容和交付特征(时间和给药方式)的反馈。第二，我们将进行两组试点随机试验，以评估提供精炼的老年初级保健认知障碍患者及其同伴清单的可行性，并在医疗沟通方面(从录音带)将清单方案与常规护理进行比较。这项干预措施有可能推动一种低成本和实用的方法来改善高度流行、脆弱和昂贵的患者群体的医疗沟通，这些患者的护理特别具有挑战性。研究活动将为在初级保健领域进行更大规模的多点试验铺平道路。

 DESCRIPTION (provided by applicant): Dementia is among the most profoundly disabling and costly health conditions. With devastating impacts and no known cure, health care is nevertheless pivotal to detection and treatment of behavioral symptoms, initiation of social service referrals, and planning for future needs. Dementia poses special communication challenges in primary care, where most persons are initially treated. As persons with dementia have a high burden of chronic medical conditions, communication challenges also affect the care of co-occurring medical conditions, resulting in excessively burdensome treatments, inappropriate medication use, and potentially avoidable health care utilization. Family caregivers play a vital role in dementia care, and are typically present and actively involved in medical visits. Patients and providers strongly endorse involving family to meet the communication needs of patients who lack the capacity to obtain, process, and understand basic health information to make appropriate health decisions. However, knowledge of how to involve family caregivers in medical visits is lacking. This study will refine a brief intervention to effectivelyand purposely involve family caregivers ("companions") who accompany persons with cognitive impairment to primary care visits. The study team has developed a checklist to be used by patients and their companions prior to medical visits. The checklist is designed to elicit and alig patient and companion perspectives concerning health concerns to discuss with the doctor, and to clarify the role of the companion in the visit. The checklist was well received in a recent proo-of-concept randomized study. Communication was significantly more patient-centered in visits of patient-companion dyads who completed the checklist versus those who received usual care and did not complete the checklist. However, people with moderate and severe cognitive impairment were excluded from this early phase study. Therefore, building from our preliminary work, the overall objective of this study is to refine and evaluate a patient- companion checklist to address the communication needs of primary care patients with a range of cognitive impairment and their companions. First, we will undertake a user-centered design process to refine and enhance the checklist for older adults with mild, moderate, or severe cognitive impairment. We will incorporate feedback regarding checklist content and delivery characteristics (timing and mode of administration) by undertaking in-depth interviews with older patients with cognitive impairment (n=20) and their companions (n=20; 20 dyads in total). Second, we will conduct a two-group pilot randomized trial to evaluate the feasibility of delivering the refined checklist older primary care patients with cognitive impairment and their companions and to compare the checklist protocol to usual care with respect to medical communication (from audiotapes). The intervention has the potential to advance a low cost and practical approach to improving medical communication for a highly prevalent, vulnerable, and costly patient population whose care is especially challenging. Study activities will pave the way for a larger multi-site trial in primary care.