Understanding decisions about anticoagulation in patients with atrial fibrillation and dementia

了解房颤和痴呆患者的抗凝决策

• 批准号: 9811224
• 负责人: Gregory Michael Ouellet
• 金额: $ 12.56万
• 依托单位: YALE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-08-15 至 2021-04-30
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9811224
• 关键词: Address; Adult; Adverse effects; Affect; Age; Alzheimer' s Disease; Alzheimer' s disease related dementia; American; Anticoagulants; Anticoagulation; Arrhythmia; Atrial Fibrillation; Attention; Attenuated; Award; Caring; Chronic; Chronic Disease; Clinical; Clinical Trials; Cognition; Cognitive; Comorbidity; Complex; Computerized Medical Record; Data; Decision Making; Dementia; Diagnosis; Disease; Drug Interactions; Elderly; Fostering; Geriatrics; Goals; Growth; Guidelines; Hemorrhage; Impaired cognition; Impairment; Individual; Interview; Life Expectancy; Medical; Medication Management; Mentors; Mentorship; Methods; Modeling; Oral; Patient-Focused Outcomes; Patients; Pharmaceutical Preparations; Physicians; Population; Process; Qualitative Methods; Research; Risk; Stroke; Stroke prevention; Structure; Training; Uncertainty; United States; Vulnerable Populations; Work; base; career; clinical decision-making; cognitive function; dementia care; electronic data; functional decline; functional status; improved; insight; mortality; older patient; prevent; skills; sociodemographics; stroke risk

Over 5.5 million Americans over 65 have Alzheimer’s Disease (AD) and Alzheimer’s Disease-related dementias (ADRD), and many of them have multiple coexisting chronic conditions. Decision-making for chronic conditions often defaults to disease-specific guidelines, which may be inappropriate in the setting of AD/ADRD. Clinical trials often exclude older adults with AD/ADRD, and the benefits and harms of treatments may be quite different than in younger, healthier individuals due to declines in life expectancy, cognition and function. Importantly, guidelines may not address the variable outcomes that patients value most. The decision regarding whether or not to prescribe anticoagulation for a patient with atrial fibrillation is an exemplar of a complex clinical decision often made in the context of coexisting AD/ADRD. Atrial fibrillation is the most common arrhythmia in older adults, and places those affected at significantly increased stroke risk. The current decisional paradigm regarding anticoagulation relies on weighing the risk of stroke versus the risk of bleeding. By virtue of their age, nearly all patients with atrial fibrillation and AD/ADRD have stroke risk scores that meet the threshold for prescription of an oral anticoagulant. However, the appropriateness of anticoagulation may change with shifting benefits and harms and goals of care over the course of AD/ADRD. Little is currently known about the factors involved in clinical decision-making about anticoagulation for atrial fibrillation in the context of comorbid AD/ADRD. Although a few studies have demonstrated that an AD/ADRD diagnosis is associated with lower levels of anticoagulation, there is a paucity of evidence about how dementia progression influences decisions to continue or discontinue anticoagulant prescription. There has also been little work to understand how clinicians ultimately make these decisions. The proposed work will redress these gaps with a mixed-methods approach to understand the decisions made by clinicians regarding anticoagulation for patients with atrial fibrillation and comorbid AD/ADRD, and how they arrived at these decisions. Contemporary data from the electronic medical record (EMR) of a large dementia care practice will be leveraged to understand functional, clinical, and sociodemographic factors associated with anticoagulant use and discontinuation over the course of AD/ADRD progression. This work will also employ rigorous qualitative methods to capture the range of factors physicians consider and how they integrate these factors when making decisions about anticoagulation for this vulnerable population. This work represents a first step in a research career devoted to promoting optimal decision-making about comorbid chronic conditions for patients with Alzheimer’s Disease and Alzheimer’s Disease-related dementias. This GEMSSTAR Award would allow the candidate, a geriatrician, to obtain the training and mentorship to further his quantitative and qualitative analysis skills and develop expertise in using EMR data to pursue research at the forefront of clinical geriatrics.

超过 550 万 65 岁以上的美国人患有阿尔茨海默病 (AD) 和阿尔茨海默病相关痴呆 (ADRD)，其中许多人患有多种并存的慢性病。慢性病的决策通常默认针对特定疾病的指南，这可能是不合适的。在 AD/ADRD 的背景下，临床试验通常排除患有 AD/ADRD 的老年人，并且由于预期寿命、认知和功能下降，治疗的益处和危害可能与年轻、健康的个体有很大不同。重要的是，指南可能无法解决患者最看重的可变结果。 关于是否对房颤患者进行抗凝治疗的决定是在同时存在 AD/ADRD 的情况下经常做出的复杂决定的一个例子。房颤是老年人中最常见的心律失常，并且使受影响的患者处于显着的状态。目前关于抗凝治疗的决策范式依赖于权衡中风风险与出血风险，几乎所有房颤患者都考虑到他们的年龄。 AD/ADRD 的卒中风险评分符合口服抗凝药处方的阈值。然而，抗凝治疗的适当性可能会随着 AD/ADRD 过程中益处、危害和护理目标的变化而变化。 目前对于 AD/ADRD 合并症的房颤抗凝临床决策所涉及的因素知之甚少，尽管一些研究表明 AD/ADRD 诊断与较低水平的抗凝治疗相关。关于痴呆症进展如何影响继续或停止抗凝处方的决定的证据也很少，关于冠军最终如何做出这些决定的研究也很少。 拟议的工作将通过混合方法来弥补这些差距，以了解圣人对心房颤动和共病 AD/ADRD 患者进行抗凝治疗的决定，以及他们如何从电子病历 (EMR) 中得出这些决定。 ）将利用大型痴呆症护理实践来了解 AD/ADRD 进展过程中与抗凝药物使用和停用相关的功能、临床和社会人口统计学因素。这项工作代表了致力于促进阿尔茨海默病患者合并慢性疾病的最佳决策的研究生涯的第一步。该 GEMSSTAR 奖将使老年病学家获得培训和指导，以进一步提高他的定量和定性分析技能，并发展使用 EMR 数据进行临床前沿研究的专业知识。老年病学。