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

轻度认知障碍(MCI)患者的一个显著问题是认知功能减退。 阿尔茨海默病和相关痴呆(ADRD)。尽管认知能力的恶化是众所周知的 高风险药物如苯二氮卓类药物、有强烈抗胆碱能副作用的药物以及 镇静催眠药，它们在这一人群中继续被过量开出。许多因素导致了他们的 过度使用，包括临床惰性和需要护理人员参与。幸运的是，停药一直是 显示可改善MCI/ADRD患者的预后。然而，停药的努力往往有 由于缺乏初级保健提供者(PCP)的参与和在 护理点。成功的干预措施是资源密集型的，因此难以推广。 相比之下，电子健康记录(EHR)系统为更换供应商提供了可扩展的策略 可能有助于停用加重认知负担的药物的行为。现存文献 展示了基于电子病历的工具在改善停药方面的潜力，特别是在使用 来自行为科学的见解。还可以利用电子病历系统来吸引照顾者参与 取消处方的过程，但以前从未这样做过。尽管可伸缩性潜力很大，但应用 针对五氯苯酚的EHR中特定的停药工具一直有限，特别是对MCI/ADRD人群。 为了克服这一差距，我们建议使用R21来开发和试点测试新的EHR去处方药工具 MCI/ADRD患者的PCP，也涉及照顾者。我们将利用从我们的推动中获得的经验- EHR试验，一项由NIA资助的实用试验，评估EHR工具是否使用行为科学设计 改善一般老年人的停药情况，并使他们适应MCI/ADRD人群，以提供试点 随后的大型务实试验的数据和关于照顾者敬业度策略的普遍证据。 具体目标是：(1)利用行为科学设计和试行电子健康记录工具，用于在 MCI/ADRD患者和(2)确定让照顾者参与EHR工具的战略。新工具将 包括面向PCP电子病历仪表盘，识别需要停药的患者并促进 与照顾者沟通，使用行为原则增强警报以鼓励停药、订购 提供更容易订购剂量递减和替代药物的套装，以及访问后监测工具。 我们将在EHR系统内与初级保健医生和护理员进行定性访谈和试点测试，以 展示电子健康记录工具的可行性和可用性，并评估实施成果，以确定 干预可扩展性的障碍。此外，我们还将评估使用照顾者的能力- 面对通过电子病历患者门户、电子邮件、电话和邮寄通信提供的调查。这个 这一创新建议的预期总体影响是，它将推动企业人力资源如何优化，以 改善MCI/ADRD患者的处方，以高度可扩展的方式改善认知负担。

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.