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Helen Kales, MD

Posted on by Erin Luers

University of California, Davis

Reducing Inappropriate Medication use for Behavioral and Psychological Symptoms of Dementia and Improving Health Outcomes in People Living with Dementia

Health Care Systems

UC Davis Community Physician Network

Pilot Study Snapshot

Dr. Kales is chair of Psychiatry and Behavioral Sciences at University of California, Davis. As a fellowship-trained, board-certified geriatric psychiatrist, Dr. Kale’s research program is directly informed by clinical work and experiences with patients, families, providers, and systems to diminish the barriers to effective and high-quality care for older patients with mental health issues and/or dementia and their care partners. She is a national and international expert in outcomes related to later-life depression, the risks of using antipsychotic and other psychotropic medications in older adults, and in researching ways to improve dementia care. Dr. Kales was named to the standing Lancet Global Commission on Dementia Care in recognition of her work in the field of dementia care.

RATIONALE: Managing behavioral and psychological symptoms of dementia (BPSD) is one of the most challenging aspects of caring for people living with dementia (PLWD). Behavioral and environmental interventions are the preferred first-line treatment approach to reduce excessive and inappropriate medication use to manage BPSD in PLWD. Despite the promise of these evidence-based interventions, there is relatively little translation into real-world clinical management, particularly in the primary care setting.

OBJECTIVE: To embed and test the feasibility and acceptability of delivering the DICE (Decide-Investigate-Create-Evaluate) model into primary care to manage BPSD among PLWD.

SETTING: Four primary care practices in the Primary Care Network at University of California, Davis.

POPULATION: PLWD and care partner dyads with upcoming appointments identified using electronic medical records or by clinic staff.

INTERVENTION: The DICE model is a low-cost, practical, patient- and care partner-centric,   evidence-informed approach that systematically guides clinicians and care partners through the assessment and management of BPSD and teaches new problem-solving skills. DICE is comprised of in-person and online module-driven training, including a DICE manual, designed for clinicians and care partners of PLWD. The clinical social worker embedded at each primary care clinic serves as the onsite DICE coordinator and meets with PLWD-care partner dyads in-person or by zoom using the DICE approach to assess and manage BPSD.

OUTCOMES: The primary clinical outcome is the rate of psychotropic medication use at 6 months post intervention. Secondary outcomes include hospitalizations, emergency department visits and nursing home placement. Implementation endpoints include feasibility, time required to deliver DICE, and acceptability to PLWD and care partners.

IMPACT: Embedding the DICE model into primary care has high potential to ensure a systematic approach to provide evidence-based care for managing BPSD and reduce psychotropic medication use. Findings from this pilot study for an embedded pragmatic clinical trial (ePCT) will inform the design of a full-scale ePCT to test the effectiveness of the DICE approach to improve outcomes for PLWD in primary care settings.

Donovan Maust, MD, MS

Posted on by Erin Luers

University of Michigan

A Patient-Facing Tool to Reduce Opioid, Psychotropic Polypharmacy in People Living With Dementia

Health Care Systems

• University of Michigan – Department of Internal Medicine
• Henry Ford Health System

Pilot Study Snapshot

Dr. Maust is an associate professor of psychiatry at the University of Michigan Medical School and research scientist with the Center for Clinical Management Research of the VA Ann Arbor Healthcare System. Dr. Maust is a board-certified geriatric psychiatrist and health services researcher. His research focuses on understanding determinants and outcomes of potentially inappropriate psychotropic prescribing to older adults, with particular interest in benzodiazepines, antipsychotics, and psychotropic/opioid polypharmacy in both the outpatient and long-term care settings. His other area of interest is in understanding how caregivers of people living with dementia shape how the person with dementia interacts with the health care system. Dr. Maust earned his medical degree from Johns Hopkins University and completed his training in psychiatry and geriatric psychiatry at the University of Pennsylvania.

RATIONALE: Central nervous system-active polypharmacy (CNS polyRx; i.e., overlapping prescriptions of ≥3 psychotropic and opioid medications) is common among people living with dementia (PLWD) even though the evidence base to support use of even single agents in this population is limited. Direct-to-patient education (e.g., EMPOWER) has demonstrated efficacy to prompt deprescribing among older adults but has not focused on PLWD and their care partners previously.

OBJECTIVE: To adapt direct-to-patient education to use with PLWD and engaged care partners and specifically address CNS polyRx; pilot the feasibility of using the electronic health record to identify PLWD experiencing CNS polyRx with engaged care partners and then implement the direct-to-dyad education; and ascertain any prescribing changes in the electronic health record.

SETTING: Four primary care clinics at the University of Michigan Health and Henry Ford Health systems.

POPULATION: Primary care patients living with dementia experiencing CNS polyRx with engaged care partners.

INTERVENTION: A direct-to-dyad educational tool sent by mail that presents potential risks of the currently prescribed regimen, with the goal of prompting a conversation with their pharmacist or prescribing clinician.

OUTCOMES: The primary clinical outcome is a change in the burden of CNS-active prescriptions. Implementation endpoints include: establishing enrollment feasibility (i.e., PLWD experience CNS polyRx for whom we can also identify a care partner) and implementation feasibility (i.e., documented evidence of discussion with a clinician about these medications after the tool is sent to those eligible).

IMPACT: If successful, this pilot study will establish the feasibility of a large-scale embedded pragmatic clinical trial to test this type of direct-to-dyad education to address potentially inappropriate prescribing. Given the potential harms and related costs associated with CNS polyRx, this low-touch intervention could have significant impact even if the effect is relatively small.

Elizabeth Phelan, MD, MS

Posted on by Erin Luers

University of Washington

Deprescribing to Reduce Injurious Falls among Older Adults with Dementia (STOP-FALLS-D)

Health Care Systems

Kaiser Permanente Washington
Benjamin Balderson, PhD, Site PI

Pilot Study Snapshot

Dr. Phelan is professor of gerontology and geriatric medicine at the University of Washington (UW) School of Medicine, adjunct professor of health systems and population health at UW School of Public Health, and affiliate investigator at Kaiser Permanente Washington Health Research Institute. She is director of the Northwest Geriatrics Workforce Enhancement Center and founding director of the UW Medicine Fall Prevention Clinic. She is a clinically active, board-certified geriatrician whose clinical work encompasses the inpatient and outpatient settings and involves teaching principles of internal medicine and geriatric medicine to students, residents, and fellows. Dr. Phelan's research aims to promote health and prevent functional decline in community dwelling older adults by improving quality of care for geriatric syndromes (falls, dementia). She worked closely with the Centers for Disease Control and Prevention (CDC) as their content expert to develop the STEADI (Stopping Elderly Accidents Deaths and Injuries) fall prevention toolkit for healthcare providers. Her research typically involves collaborative partnerships with healthcare and community organizations that serve older persons.

RATIONALE: Falls among older adults are a major public health concern, and older people living with dementia (PLWD) have disproportionately higher fall rates. The use of medications that affect the central nervous system (CNS) is a key modifiable risk factor for falls. CNS-active medications are often considered potentially inappropriate for older adults, especially for older PLWD, and guidelines recommend avoiding their use. However, use remains common and is higher among older PLWD compared to those without dementia. Few deprescribing interventions have targeted older PLWD in primary care.

OBJECTIVE: Adapt an evidence-based, health-system-embedded, patient-centered deprescribing intervention called STOP-FALLS, which focuses on reducing use of CNS-active medications among older adults living with dementia, and conduct a pilot study for an embedded pragmatic clinical trial (ePCT) with older PLWD, their care partner(s), and their primary care providers (PCPs).

SETTING: Kaiser Permanente Washington, an integrated healthcare delivery system in the Northwest United States.

POPULATION: Community-dwelling older PLWD, their care partners, and their PCPs.

INTERVENTION: Educational brochures for PLWD and their care partners and decision support for the PCPs.

OUTCOMES: The primary clinical outcome is medically treated falls. Secondary outcomes include: all-cause emergency department visits and hospitalizations, and nursing home placement. Implementation endpoints include: feasibility of reaching older PLWD and their care partners, acceptability of the intervention, and whether the intervention was implemented as intended.

IMPACT: Improving the quality of prescribing is imperative to reduce adverse outcomes and optimize quality of life for older PLWD. With the rapid growth in numbers of PLWD, effective strategies are urgently needed. STOP-FALLS–D will provide important new evidence about the feasibility of deprescribing CNS-active medications in partnership with PLWD, their care partner(s), and their primary care providers. This work will lay the foundation for a future large-scale ePCT.

Ira Hofer, MD & Susana Vacas, MD, PhD

Posted on by Erin Luers

Icahn School of Medicine; Massachusetts General Hospital

Mitigation of Postoperative Delirium in High-Risk Patients

Health Care Systems

Mount Sinai Hospital System

Project Snapshot

Dr. Hofer is a practicing anesthesiologist and clinical informaticist at The Icahn School of Medicine at Mount Sinai. Dr. Hofer has been working in the field of big data analytics for over 15 years in a variety of leadership roles. His research interests involve leveraging the data from the electronic health records (EHR) to understand, quantify and ultimately mitigate risk in the perioperative period. His work includes some of the first papers to apply machine learning techniques for perioperative outcome prediction and has been featured on the covers of Anesthesiology and Anesthesia & Analgesia. Dr. Hofer has a K01 from the National Heart Lung and Blood Institute and serves as an associate editor for Anesthesia & Analgesia. His research focuses on creating featurization techniques to incorporate a wide range of EHR data into machine learning models to improve discrimination and calibration, and establishing multi-center perioperative collaboratives to better share raw and processed EHR data.

Dr. Vacas is a neuroanesthesiologist at the Massachusetts General Hospital, Harvard Medical School. She completed her postdoctoral work at the University of California, San Francisco, where her research focused on the underlying mechanisms and risk factors of perioperative neurocognitive disorders, including postoperative delirium. Incorporating her bench work with the advent of new and emerging technologies, Dr. Vacas seeks to improve patient outcomes after surgery by blocking and/or alleviating perioperative exacerbated inflammation and brain lesions. Her research focuses on vulnerable surgical populations, and her work is helping to understand the pathogenic mechanisms behind these devastating conditions. She seeks to develop strategies that can be applied to prospective surgical patients.

RATIONALE: Postoperative delirium is the most common complication after surgery and a major cause of morbidity in patients with cognitive impairment. Perioperative clinical decision support tools may decrease the incidence of this devastating and potentially preventable condition by increasing adherence to clinical best practices.

OBJECTIVE: To leverage our experience in informatics and postoperative delirium research to perform a prospective randomized controlled embedded pragmatic clinical trial to test the effectiveness of a clinical decision support system to promote adherence to best practices with the goal of decreasing postoperative delirium in patients with baseline cognitive impairment.

SETTING: Perioperative setting at Mount Sinai Health System, an integrated health system that encompasses 130 operating rooms.

POPULATION: Patients with cognitive impairment undergoing surgery.

INTERVENTION: The intervention consists of clinical decision support alerts in the electronic health record directed towards anesthesiologists caring for patients with preexisting cognitive impairment. This intervention will promote 12 evidence-based best practices during care for perioperative patients.

OUTCOMES: The primary clinical outcome is the incidence of postoperative delirium. We will also evaluate practice adherence and effectiveness to reduce postoperative delirium in key groups and study the influence of each practice on postoperative delirium prevention.

IMPACT: Our rigorous and innovative approach, based on established methods and executed by an experienced multidisciplinary team with access to unique resources and tested platforms, will lead to insights that are clinically relevant and change clinical practice for postoperative delirium prevention in patients with cognitive impairment.

Healthcare-Generated Data to Identify People Living with Dementia for Embedded Pragmatic Trials

Posted on by Sonya Sutton

January 2022 – In Grand Rounds 23, Dr. Bynum describes the use of data to identify people living with dementia as well as strengths, challenges and potential equity gaps when using a healthcare-generated data approach in pragmatic clinical trials.

Speaker

Julie Bynum, MD, MPH

Julie Bynum, MD, MPH

Margaret Terpenning Professor of Medicine

University of Michigan

                     Download webinar slides

Learning Objectives

  • Understand the use of data to achieve pragmatic study aims
  • Identify strengths & challenges when use Healthcare-generated data (billing or electronic health record data) for participant identification
  • Identify threats to Health Equity and Generalizability related to choices about data use.

 

Podcast


Podcast Transcript: Download the transcript here.

Partnering with People Living with Dementia and Care Partners in Embedded Pragmatic Clinical Trials

Posted on by Sonya Sutton

December 2021 – Grand Rounds 22 features a panel of participants sharing their experiences in stakeholder engagement in ePCTs for people living with AD/ADRD and their care partners. Perspectives shared include that of a researcher, a stakeholder engagement expert and people living with dementia.

Download Webinar Slides

Speakers

Gary Epstein-Lubow, MD

Gary Epstein-Lubow, MD
Team Leader, IMPACT Engaging Partners Team
Associate Professor of Psychiatry and Human Behavior
Associate Professor of Medical Science, Alpert Medical School of Brown University
Associate Professor of Health Services, Policy and Practice, Brown University School of Public Health

 


Heidi GilHeidi Gil
Executive Committee Member,
IMPACT Engaging Partners Team

Chief Strategy Officer, LiveWell

Learning Objectives

    • Understand the need/benefits of engaging people living with dementia and care partners in every aspect of dementia care research
    • Identify how all stakeholders can be empowered and engaged as co-partners in research
    • Explore lessons learned and resources available to conduct research differently

Podcast

 

Podcast Transcript: Download the transcript here.

Elizabeth Ciemins, PhD, MPH, MA

Posted on by Erin Luers

AMGA

Implementation of MIND at Home Program in Primary Care for People Living with Dementia

Health Care Systems

  • McFarland Clinic
  • CommonSpirit

Study Snapshot

Dr. Ciemins is a health services research scientist and vice president of Research and Analytics at the American Medical Group Association (AMGA). In her role, she focuses on data-driven population health improvement through comparative and predictive clinical analytics. Prior to AMGA, she served for 10 years as director of the Center for Clinical Translational Research at Billings Clinic where her research focused on improving the quality of care and care transitions across a large, geographically disperse service area in the areas of diabetes, hypertension, palliative care, and health IT. Dr. Ciemins’ areas of research interest include chronic disease management, health information and telehealth technology, palliative care, childhood and adult obesity, care transitions, rural health, mental health, and complexity science approaches to behavior change in health care. Dr. Ciemins holds a PhD in Health Services and Policy Analysis from the University of California, Berkeley, an MPH in Population/Family Health, and MA in African Studies from University of California Los Angeles.

RATIONALE:  People living with dementia (PLWD) represent some of the highest-need and highest-cost individuals living in the community and primary care plays a pivotal in the detection, diagnosis, and delivery of services for this vulnerable patient group. Despite the availability of a range of evidence-based dementia and symptom management approaches, few American PLWD receive adequate care; embedding effective evidence-based interventions and dementia care best practices into primary care settings is needed, but not yet widely done.

OBJECTIVE: To embed and test the feasibility of a novel best practice-based approach, MIND at Home, within primary care to enhance and elevate the role of existing primary care staff to Memory Care Coordinators (MCCs), increase primary care access to interdisciplinary collaborative care, and systematically combine the benefits of clinic-based services with home-based assessment to support family-centered care planning and implementation for PLWD and their care partners.

SETTING: Three primary care clinics in two geographically and demographically diverse integrated health systems.

POPULATION: Community-residing primary care patients with an Alzheimer’s disease and related dementia (ADRD) diagnosis who have at least one caregiver/care partner.

INTERVENTION: MIND at Home is a comprehensive care coordination program that takes an interdisciplinary, collaborative care approach by systematically assessing and addressing a wide range of dementia-care related needs of both PLWD and their care partners that place both at increased risk for poor outcomes. MIND brings a home-based component to what is often exclusively clinic-based care delivery while providing ongoing education designed to build primary care team dementia management capacity through regular interdisciplinary collaboratives with dementia experts.

OUTCOMES: The primary clinical outcome is hospital transfers including admissions, ED visits, and observation stays. Secondary outcomes include overall number of medications, number of anti-psychotic medications, acetylcholinesterase inhibitors and memantine. EHR-based outcomes will be collected pre-, during-, and post-intervention for a total of 7 months.

IMPACT: Embedding a collaborative, best-practice based approach, such as MIND at Home, into primary care is a potentially powerful strategy to organize care, improve quality, reduce costs, and maximize benefit for PLWD.

Leah Hanson, PhD

Posted on by Erin Luers

HealthPartners Institute

Mindfulness-Based Dementia Care Partner Program to Reduce Depressive Symptoms

Health Care Systems

  • HealthPartners
  • Sutter Health
  • University of Michigan – Alzheimer’s Disease Research Center

Study Snapshot

Dr. Hanson is a senior research investigator and senior director of research at HealthPartners Neuroscience Center, HealthPartners Institute and co-director of research at the HealthPartners Center for Memory & Aging. For over 15 years, her research has focused on the development of novel therapeutic delivery methods for the treatment and prevention of neurologic diseases, especially those that impact older adults such as Alzheimer’s disease, Parkinson’s disease, and stroke. In 2010, she initiated the Minnesota Memory Project, a longitudinal cohort study of memory changes in adults and associated risk and protective factors, and she continues to serve as the principal investigator. Her experience includes recruitment for clinical research and trials in dementia via electronic medical record and healthcare claims data, conducting trials of non-medication interventions including education and support for patients and caregivers, mindfulness-based stress reduction, and aromatherapy.

RATIONALE: While caregiving and being a care partner to a person living with Alzheimer’s disease or related dementia (PLWD) can be rewarding, care partners often feel high levels of stress and burden, have low mood, and poor health.

OBJECTIVE: To test the feasibility of implementing a mindfulness program to reduce stress and symptoms of depression in care partners. We will pilot test a new way to collect real-world outcomes on care partners through an administrative set of data collected by a community non-profit organization that trains the program instructors.

SETTING: Three memory care clinics located in Minnesota, Michigan, and California.

POPULATION: Approximately 120 care partners of PLWD.

INTERVENTION: The intervention is an adaptation of Mindfulness-Based Stress Reduction for care partners of PLWD called Mindfulness Based Dementia Care (MBDC). Developed by the Presence Care Project (www.presencecareproject.com), a community-based non-profit organization, MBDC offers a bridge between mindfulness practice and the dementia care exchange.

OUTCOMES: The primary clinical outcome is symptoms of depression, and the secondary clinical outcome is care partner burden. Implementation outcomes will measure the feasibility of implementation including the rate of program registration and completion, number of sessions attended, acceptability of virtual instruction, and completeness of data collection.

IMPACT: Findings from this pilot study will guide the design a large real-world trial to test the potential benefits of MBDC.  Mindfulness has the potential to reduce stress and burden in care partners, reduce symptoms of depression, and ultimately improve overall health.