Abstract

Alzheimer’s disease and related dementias (ADRD) and cancer impose a heavy burden on patients and their caregivers and are major contributors to US healthcare expenditures. Given the rapidly growing aging population at risk for both conditions, there is a critical need to understand how to improve care for those with comorbid cancer and cognitive impairment. Patients with dual diagnoses of cancer and cognitive impairment including ADRD have worse outcomes and unique care needs that require more person-centered care. The unique care needs of patients with comorbid cancer and cognitive impairment cannot be met with current oncology clinic workflow and staffing and time constraints. Oncology care must address the unique care needs of these patients through multi-dimensional interventions for the clinic environment, providers, patients, and caregivers that can be customized to different degrees of cognitive dysfunction and available supports. Increased telehealth use within VA hospitals has helped relieve some of the burdens on patients and caregivers, and telehealth oncology care is expected to be an integral, growing part of VA oncology care in the foreseeable future. However, there is limited evidence and guidance on telehealth use for complex patients like those with cancer and cognitive impairment including ADRD. In fact, the rapid telehealth expansion may unintentionally exacerbate the already complex care needs of high-need Veterans. There is a critical need to proactively design care processes to address the needs of these vulnerable patients. The goal of this project is to improve the telehealth delivery of cancer care for older, cognitively impaired Veterans on active cancer treatment by 1) understanding the telehealth oncology experiences of patients with cognitive impairment, their caregivers, and clinicians, and 2) developing and testing a multi-dimensional intervention that can be customized to different degrees of cognitive dysfunction and available supports. Eligible participants are clinicians providing telehealth oncology care and patients who meet the following inclusion criteria: age 65 or older, on active cancer treatment, has received any part of their care through telehealth (phone or video), Montreal Cognitive Assessment (MoCA) score <26, able to speak English and provide consent. We will start with a convergent parallel mixed-methods study to interview and survey clinicians, older Veterans with cancer and cognitive impairment undergoing active treatment via telehealth, and their caregivers (Aims 1-2). We will use these data to develop an intervention guided by principles of the Consolidated Framework for Implementation Research and Capability-Opportunity-Motivation model of Behavior change (Aims 1-2). We will then pilot test this multi-dimensional intervention using adaptive design principles (Aim 3). Cognitive impairment will be stratified by milder (MoCA 18<26) versus more severe cognitive impairment (MoCA <18) as care needs are expected to vary by severity of cognitive impairment. The primary endpoint is acceptability as assessed by System Usability Scale score ≥70, and the secondary endpoint is feasibility as assessed by recruitment rate ≥70%. We will also examine potential targetable outcomes such as subjective cognitive function, functional status, distress, treatment adherence, and caregiver burden. The proposed research is significant because it addresses a critical unmet need and helps advance scientific knowledge in how to improve care delivery for patients with two of the most common and morbid age-related diseases—cancer and ADRD. This project will be a high impact way to improve care for Veterans that is aligned with multiple VA Health Services Research and Development priorities. This work has many potential future applications, including conducting a larger efficacy trial to test the telehealth-focused intervention across other VA sites, expanding the intervention to include in-person oncology care, or adapting our telehealth-focused intervention for other complex chronic diseases that are often comorbid with ADRD.

NIH Reporter Project Information: https://reporter.nih.gov/project-details/10861674


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