Improving Decision-Making for Invasive Mechanical Ventilation among Older Adults with Dementia Hospitalized with Pneumonia
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REVISED PROJECT ABSTRACT/SUMMARY This career development award will support Snigdha Jain, MD MHS, to become an independent investigator leading the development and testing of interventions that improve shared decision-making (SDM) about critical care interventions among older adults with Alzheimer’s disease and Alzheimer’s disease-related dementias (AD/ADRD). More than 100,000 older adults with AD/ADRD receive invasive mechanical ventilation (IMV) every year in the United States – a potentially burdensome treatment with uncertain benefit on long-term outcomes of patients and families. Noninvasive respiratory support treatments offer alternatives, however, their effectiveness in comparison with IMV when used for acute respiratory failure (ARF) is unknown. Consequently, clinicians lack crucial prognostic information desired by older adults and their families in making decisions about respiratory support when hospitalized with pneumonia and ARF. Dr. Jain is an Assistant Professor in Pulmonary and Critical Care Medicine. She hypothesizes that noninvasive treatments will be associated with improved long-term outcomes of older adults with AD/ADRD hospitalized with pneumonia and ARF compared with IMV and a communication intervention delivering prognostic information through scenario planning – a strategy using narrative description of plausible futures - can be delivered in the intensive care unit (ICU) to potentially improve SDM. She will test this hypothesis in three aims. In Aim 1, she will use electronic health record (EHR) data from the Veterans Affairs (VA) healthcare system linked with VA and Medicare claims to conduct a target trial emulation study, generating estimates of invasive versus noninvasive respiratory support treatment effects on patient and family outcomes. In Aim 2, she will use these estimates to adapt the Best Case/ Worst Case (BC/WC) communication tool – a strategy using scenario planning to improve SDM about acute, invasive medical and surgical treatments – to IMV use among older adults with AD/ADRD in the ICU. Finally, in Aim 3, she will conduct a pilot study to evaluate the feasibility and acceptability of the communication intervention using the BC/WC tool. With this award, she seeks further training in 1) advanced causal inference, 2) qualitative methods and 3) design of clinical trials in older adults to develop and evaluate behavioral interventions to improve SDM among older adults with AD/ADRD in the ICU. She will achieve these goals through targeted didactics, experiential research, and intensive mentoring over the 5-year career development award period supervised by her world-class mentorship team comprising experts in geriatric critical care, qualitative methods and shared decision-making among older adults with AD/ADRD, BC/WC communication tool, and clinical trials in older adults.
