2019 – 2020
Greg Ouellet, MD – Yale University
Understanding decisions about anticoagulation in patients with atrial fibrillation and dementia
Guidelines for the management of atrial fibrillation suggest anticoagulation for those at highest risk, which includes many older adults with dementia. However, the clinical trajectory of dementia may curtail the benefits of stroke prevention, and some anticoagulated patients with atrial fibrillation and dementia may be exposed to unnecessary harms and treatment burdens. The objective of this study is to explore how older adults with dementia and their caregivers understand the role of dementia trajectory in decisions regarding anticoagulation. Study procedures will comprise in-depth, semistructured interviews with patients with early dementia who retain decision-making capacity and with caregivers of patients with dementia of varying levels of severity. Participants will be purposively sampled from consultative geriatrics clinics and a Federally Qualified Health Center. Projected enrollment will be 20-30 participants, with the final sample size determined by thematic saturation. Interview transcripts will analyzed according to the principles of grounded theory, using the constant comparative method. Results will help to develop strategies to optimize decisions about anticoagulation in patients with dementia and may provide insight into other treatment decisions for these patients.
Ariel Green, MD, MHS – Johns Hopkins University
Nancy Schoenborn, MD – Johns Hopkins University
Words matter: Older adults’ attitudes and preferences about how deprescribing recommendations are discussed
The way clinicians communicate during the clinical encounter can affect what patients and caregivers understand and how they participate in decision-making about medication use. Preliminary qualitative work has found that older adults with multiple chronic conditions have specific preferences about what language clinicians should and should not use when presenting recommendations about deprescribing. The objective of this study is to assess older adults’ and caregivers’ preferred communication strategies for clinicians to use when discussing deprescribing. Study procedures will include across-sectional survey of 500 people 65 years and older from KnowledgePanel, a probability-based web panel designed to be representative of the US adult population. Using an online survey platform, best-worst scaling methods will be used to test participants’ preferences for different phrases that a clinician may use to explain why a patient should not take (i.e., stop or not start) a potentially harmful or unnecessary medication. Sample phrases will be based on qualitative data from the interview studies noted above. The results will inform the development of future interventions to optimize prescribing for older adults.
Jennifer Kuntz, PhD – Kaiser Permanente Northwest
Intensification and deintensification of glucose-lowering therapies among older adults with tightly-controlled diabetes mellitus and multiple chronic conditions
Despite emerging evidence of over-treatment among older adults with diabetes mellitus, we know little about who experiences intensification and deintensification of their glucose-lowering therapy, how often these changes occur, and what factors are associated with treatment modification. The objective of this study is to characterize patterns in glucose-lowering medication use and predictors of treatment deintensification among older adults with diabetes and tight glycemic control. The study population will comprise a retrospective cohort of Kaiser Permanente Northwest (KPNW) patients aged 65 years and older who have diabetes and who are receiving at least one glucose-lowering medication. Pharmacy dispensing data will be used to describe the patterns of intensification and deintensification of glucose-lowering therapy over a 2-year period, particularly among those with hemoglobin A1c ≤7% who are receiving glucose-lowering medications, and will identify patient and provider characteristics associated with treatment changes. The results will inform an R01 application that focuses on defining the harms and benefits of glucose-lowering therapies and identifying specific patient subgroups that would benefit from deintensification.