The Trial to Reduce Antimicrobial Use in Nursing Home Residents With Alzheimer Disease and Other Dementias (TRAIN-AD)

Abstract

IMPORTANCE Antimicrobials are extensively prescribed to nursing home residents with advanced dementia, often without evidence of infection or consideration of the goals of care.OBJECTIVE To test the effectiveness of a multicomponent intervention to improve the management of suspected urinary tract infections (UTIs) and lower respiratory infections (LRIs) for nursing home residents with advanced dementia. DESIGN, SETTING, AND PARTICIPANTSA cluster randomized clinical trial of 28 Boston-area nursing homes (14 per arm) and 426 residents with advanced dementia (intervention arm, 199 residents; control arm, 227 residents) was conducted from August 1, 2017, to April 30, 2020. INTERVENTIONSThe intervention content integrated best practices from infectious diseases and palliative care for management of suspected UTIs and LRIs in residents with advanced dementia. Components targeting nursing home practitioners (physicians, physician assistants, nurse practitioners, and nurses) included an in-person seminar, an online course, management algorithms (posters, pocket cards), communication tips (pocket cards), and feedback reports on prescribing of antimicrobials. The residents' health care proxies received a booklet about infections in advanced dementia. Nursing homes in the control arm continued routine care. MAIN OUTCOMES AND MEASURESThe primary outcome was antimicrobial treatment courses for suspected UTIs or LRIs per person-year. Outcomes were measured for as many as 12 months. Secondary outcomes were antimicrobial courses for suspected UTIs and LRIs when minimal criteria for treatment were absent per person-year and burdensome procedures used to manage these episodes (bladder catherization, chest radiography, venous blood sampling, or hospital transfer) per person-year. RESULTSThe intervention arm had 199 residents (mean [SD] age, 87.7 [8.0] years; 163 [81.9%] women; 36 [18.1%] men), of which 163 (81.9%) were White and 27 (13.6%) were Black. The control arm had 227 residents (mean [SD] age, 85.3 [8.6] years; 190 [83.7%] women; 37 [16.3%] men), of which 200 (88.1%) were White and 22 (9.7%) were Black. There was a 33% (nonsignificant) reduction in antimicrobial treatment courses for suspected UTIs or LRIs per person-year in the intervention vs control arm (adjusted marginal rate difference, −0.27 [95% CI, −0.71 to 0.17]). This reduction was primarily attributable to reduced antimicrobial use for LRIs. The following secondary outcomes did not differ significantly between arms: antimicrobials initiated when minimal criteria were absent, bladder catheterizations, venous blood sampling, and hospital transfers. Chest radiography use was significantly lower in the intervention arm (adjusted marginal rate difference, −0.56 [95% CI, −1.10 to −0.03]). In-person or online training was completed by 88% of the targeted nursing home practitioners.CONCLUSIONS AND RELEVANCE This cluster randomized clinical trial found that despite high adherence to the training, a multicomponent intervention promoting goal-directed care for suspected U...

Identification of Hub Genes and Immune Cell Infiltration Characteristics in Alzheimer’s Disease

“…The course of Alzheimer's disease is about 5–10 years, and a few patients can survive for more than 10 years. Most of them die from complications such as lung infection, urinary tract infection, and pressure ulcers [ 13 – 15 ]. Therefore, it is key to identify the hub genes, explore the pathogenesis, and search for the therapeutic targets of AD.…”

BABEL (Better tArgeting, Better outcomes for frail ELderly patients) advance care planning: a comprehensive approach to advance care planning in nursing homes: a cluster randomised trial

“…This similarity might indicate that a vital component of ACP is establishing the nuanced spectrum of options and outcomes, which is counter to practice and regulations in many jurisdictions that mandate goals of care designations with few gradations [ 60 , 61 ]. Finally, a cluster randomised study in 28 American NHs found no effect of an intervention aimed at reducing antibiotic use in residents with severe dementia and suspected infection [ 62 ]. This negative result might reflect an intervention aimed at NH staff and limited to a single clinical issue, whereas the significant reduction in antibiotic use in BABEL may reflect it being an interactive intervention aimed at engaging residents and their proxies in a larger discussion about appropriate goals of care.…”

Provider adherence to training components from the Trial to Reduce Antimicrobial use In Nursing home residents with Alzheimer's disease and other Dementias (TRAIN-AD) intervention

“…The trial began in August 2017 and all data collection was complete by March 1, 2020, with the main findings published elsewhere [ 20 ]. This report leverages implementation data from the 14 NHs in the intervention arm.…”

“…Eligible NHs had greater than 60 beds and were located within 60 miles of Boston [ 20 ]. Study information was mailed to senior administrators, who were telephoned one week later by a research team member to solicit their facility's participation, including their agreement to randomize their facility to either the intervention or control arm.…”

“…The T rial to R educe A ntimicrobial use I n N ursing home residents with A lzheimer's disease and other D ementias (TRAIN-AD) was a cluster RCT evaluating a multicomponent program to improve infection management among NH residents with advanced dementia [ 19 , 20 ]. The objectives of this report are to describe and identify factors associated with NH provider adherence to two key training components of the TRAIN-AD intervention: 1.…”