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.

认知能力下降恶化是轻度认知障碍 (MCI) 患者的一个标志性问题 阿尔茨海默氏病和相关痴呆症 (ADRD) 尽管认知能力恶化是众所周知的。 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）的负担，以及 镇静催眠药在该人群中的使用量仍然较多，其原因有很多。 幸运的是，过度使用，包括临床惰性和需要护理人员参与，已经取消了处方。 研究表明，这种药物可以改善 MCI/ADRD 患者的预后，但是，取消处方的努力往往效果不佳。 由于缺乏初级保健提供者 (PCP) 的参与以及在基层医疗机构给予的支持不足，取得的成果有限。 成功的护理点干预措施都是资源密集型的，因此难以规模化。 相比之下，电子健康记录 (EHR) 系统为不断变化的提供商提供了可扩展的策略 可能有助于减少现有文献中加重负担的药物的行为。 展示了基于 EHR 的工具改善处方取消的潜力，特别是在增强时 行为科学的见解也可以用来让护理人员参与其中。 尽管具有很高的可扩展性，但以前从未进行过取消处方过程。 电子病历中针对 PCP 的具体处方工具有限，特别是对于 MCI/ADRD 人群。 为了克服这一差距，我们建议 R21 开发和试点测试新的 EHR 处方工具 MCI/ADRD 患者的 PCP 也涉及护理人员，我们将利用 NUDGE 的经验教训。 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减少情况，并针对 MCI/ADRD 人群进行调整，以提供试点 随后进行的大型实用试验的数据以及有关护理人员参与策略的普遍证据。 具体目标是：（1）利用行为科学设计和试点测试 EHR 工具，以减少患者的处方。 患有 MCI/ADRD 的患者以及 (2) 确定让护理人员参与 EHR 工具的策略。 包括面向 PCP 的 EHR 仪表板，可识别需要取消处方的患者并促进 与护理人员沟通，通过行为原则增强警报，鼓励取消处方、命令 提供更轻松地订购剂量逐渐减少和替代药物以及就诊后监测工具的套件。 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，以 展示电子病历工具的可行性和可用性，同时评估实施结果以确定 此外，我们将评估使用护理人员参与护理人员的能力障碍。 面临通过 E​​HR 患者门户、电子邮件、电话和邮寄通信提供的调查。 这项创新提案的预期总体影响是，它将推动电子病历的优化 改善 MCI/ADRD 患者的处方，以高度可扩展的方式减轻认知负担。