Evaluating routine clinical decisions in providing primary care for people living with Alzheimer's Disease or Alzheimer's Related Disorders: using electronic health records to provide timely evidence

PROJECT SUMMARY Growing emphasis on the early diagnosis and treatment of Alzheimer’s disease and related dementias (ADRD) increases the demand for providers to make informed care decisions. Most of the care for people recently diagnosed with ADRD falls on primary care physicians (PCPs), as frontline providers for older adults. Many of

the clinical decisions PCPs must make to care for patients with ADRD are not currently supported by robust evidence. Given the heterogeneity of ADRD, we cannot rely on randomized trials to provide evidence for clinical decisions across the range of conditions and unique patient/family considerations. Unclear guidelines

on treatment strategies lead to large inconsistencies in how patients are treated, potentially causing harm and exacerbating health inequities. There is a large and growing need for evidence on best practices in early dementia care using accessible, timely data, and rigorous methods. This F31 career development proposal is

designed to prepare the candidate for a career focused on this critical area, delivering much-needed evidence to guide common clinical decisions to provide the best possible care for individuals with early ADRD. The research plan evaluates three important clinical decisions commonly encountered by PCPs caring for patients

experiencing cognitive decline. Aim 1 will evaluate whether referral to dementia specialty care delays onset of patient frailty using electronic health record (EHR) data from University of California, San Francisco (UCSF) primary care clinics. The candidate will use both traditional observational methods and an instrumental variable

analysis with physician preference for referral as an instrument. Aim 2 investigates whether prescriptions of an antidementia drug (memantine) are associated with incident frailty using both traditional observational methods and an emulated target trial design analysis using UCSF EHR data. Finally, many conditions, including urinary

tract infections (UTIs), are not specific to patients with ADRD but are more common among older adults with cognitive decline. In the context of emerging cognitive declines, inappropriate UTI management (especially if drug resistant) may be especially harmful. In Aim 3, we will examine whether early treatment of UTIs caused

by drug-resistant E. coli is associated with reduced risk of incident ADRD and patient frailty using EHR data from UCSF and the San Francisco safety net public healthcare system. This proposal will demonstrate use of EHR data to evaluate the efficacy of current and future innovations in dementia care across diverse patients,

with the goal of contributing to informed clinical guidelines for PCPs. This research will directly contribute to the NIA’s goal to provide evidence to delay ADRD progression. Guided by an interdisciplinary and expert mentorship team, the proposed training will enhance the candidate’s knowledge of clinical care for ADRD,

advanced causal inference and econometric methods, and clinical informatics. Facilitated by the supportive training environment at UCSF, executing this F31 research and training plan will prepare the candidate to succeed in a career as an independent translational researcher in dementia epidemiology.