The advanced stage of Alzheimer’s disease and other dementias is characterized by the onset infections, which prior work suggests are widely mismanaged. Antimicrobials are extensively prescribed, most often without evidence to support a bacterial infection. Antimicrobial exposure is the main factor leading to multidrug- resistant organisms (MDROs); a growing public health threat. Moreover, the benefits of antimicrobials remain unclear for patients with advanced dementia, for whom infections are often a terminal event and comfort is most commonly the goal of care. In 2015, our group completed a prospective study of nursing home (NH) residents with advanced dementia, the Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia (SPREAD) (parent NIH R01 for this competing renewal). Antimicrobials were prescribed for 72% of suspected infections, but only 44% episodes met guideline-based criteria for treatment. Criteria were more likely to be met when proxies were counseled about antimicrobials. Two-thirds of residents were colonized with MDROs. Antimicrobial use was the major risk factor for MDRO acquisition. Motivated by these findings, the PIs conducted a pilot study (NIH R21) of an intervention to improve management of suspected urinary (UTIs) and lower respiratory tract infections (LRIs). With this foundation, the goal of this proposal, TRAIN-AD (Trial to Reduce Antimicrobial Use In Nursing home residents with Alzheimer’s disease and other Dementias), is to conduct a cluster randomized controlled trial of the intervention among 480 residents with advanced dementia (N=240/arm) in 16 Boston-area NHs (N=8/arm). The intervention has two main components: 1. Provider Training: In-person training, on-line course, management algorithms, and prescribing feedback, and 2. Proxy Education: booklet. Unlike most antimicrobial stewardship programs, the intervention merges best practices in infectious diseases and palliative care, and targets a unique population for whom the need to improve infection management is particularly compelling. The Aims are to compare the following 12-month outcomes between residents in the intervention and control arms (usual care) related to suspected UTIs and LRIs: Aim 1. total number of antimicrobial courses/person-year (10 outcome); Aim 2. number of antimicrobial courses prescribed when guideline-based criteria for treatment are absent/person-year (20 outcome), and Aim 3. i. advance care planning about infection management, and ii. burdensome procedures/person-days used to evaluate these episodes/person-year (20 outcomes). IMPLICATIONS: Prior work by our group has demonstrated a critical need to improve the quality of care for suspected infections in advanced dementia patients. A cluster RCT of an intervention to optimize infection management is the next logical step. This proposal addresses 3 federal research priorities: Alzheimer’s disease, palliative care, and antibiotic stewardship. Thus, it has the potential to make clinical and policy-relevant contributions by promoting patient-centered end-of-life care for millions of Americans with advanced dementia, and reducing the growing public health threat of MDROs in NHs.

A body of research conducted by our group has demonstrated a critical need to improve the quality of care for suspected infections among nursing home residents with advanced Alzheimer’s disease and related dementias. As the next logical step, we will conduct a cluster randomized controlled trial of an intervention to optimize infection management in this population. This work addresses 3 federal research priority areas: Alzheimer’s disease, palliative care, and infection management, including initiatives to expand antibiotic stewardship activities in NHs. Thus, this work has the potential to make clinical and policy-relevant contributions by promoting patient-centered end-of-life care for millions of Americans with advanced dementia, and reducing the growing public health threat of MDROs in the nursing home setting.