Technology Intervention to Support Caregiving for Alzheimer's Disease (I-CARE)

Study Overview
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Brief Summary
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The specific aims of this study are 1) to test the trial and intervention feasibility of Brain Care Notes (BCN) app, 2) To estimate the effect size of BCN on reducing informal caregiver burden at 6 months, and 3) To estimate the effect size of BCN on reducing patient behavioral and psychological symptoms of dementia (BPSD) at 6 months. Subjects will be recruited from the Aging Brain Care (ABC) program of Eskenazi Health and Indiana University Health located in central Indiana.

Detailed Description
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Informal caregivers of patients with Alzheimer's disease and related dementia (ADRD) manage a complex spectrum of patient behavioral and psychological symptoms of dementia (BPSD). BPSD are major contributing factors to caregivers' burden and adverse health outcomes, leading to an increase of unplanned hospitalizations and a decrease in quality of life. The National Alzheimer's Project Act recognizes the need for interventions that enable family caregivers to continue to provide care while maintaining their own health and well-being. Furthermore, recommendations from 2015 and 2018 Alzheimer's Disease Research Summits include the application of technology to improve caregiving research and ADRD care This pilot randomized controlled trial, will test the feasibility and estimate the effect size of integrating mobile health technology BrainCare Notes (BCN) into an existing, fully operational, and self-sustaining clinical program (Aging Brain Care; ABC) and IU Health primary care physician clinics (IUHP). BCN is a mobile application (app) for informal caregivers of patients with Alzheimer's Disease and related dementia (ADRD). The BCN app delivers 24/7 psychoeducation and caregiver support, assessment of informal caregiver status and patients' behavioral and psychological symptoms of dementia (BPSD), and engagement tools for self-management and communication. Over a 15 month accrual period, we propose to enroll from the ABC clinical program and IUHP 60 dyads consisting of an adult patient with ADRD and one (primary) informal caregiver. The intervention will continue for 6 months and final assessments will be completed at 6 months. Feasibility data will be collected throughout the study and assessed at the end of the study by computing: (a) recruitment rate; (b) data completion; (c) BCN usability; (d) BCN acceptance; and (e) BCN use. Caregiver burden and patient BPSD will be collected at baseline, 3, and 6 months and evaluated for changes from baseline to 6 months in each group. Means, standard deviations, and confidence intervals will be computed to test feasibility hypotheses. Mixed linear models will be used to test hypotheses comparing the two conditions at 6 months.

Official Title
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Technology Intervention to Support Caregiving for Alzheimer's Disease (I-CARE)

Conditions
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Dementia, Alzheimer Type

Intervention / Treatment
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* Behavioral: ABC Clinical Program
* Behavioral: BCN


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patient has received a diagnosis of possible or probable Alzheimer's disease and Related Dementia from a physician in the ABC Clinical Program; Caregiver is at least 18 years of age and does not have a visual impairment significant enough to interfere with his/her ability to use BCN; Both patient and caregiver are community-dwelling in central Indiana; and Both patient and caregiver are willing to participate in the ABC Clinical Program (including receiving home visits). Exclusion Criteria: Either the patient or his/her informal caregiver does not have the ability to communicate in English.

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: ABC Clinical Program Only and Usual Care<br>Patients and informal caregivers randomized to the comparison group will receive care provided by the ABC Clinical Program and IUHP. The ABC Clinical Program is the standard of ADRD care at Eskenazi Health and Primary Care Visits at Indiana University Health is the usual care. | Behavioral: ABC Clinical Program<br>* The goal of the ABC Clinical Program is to help primary care physicians achieve the standard of care in the diagnosis, evaluation and management of patients with ADRD. The ABC Clinical Program is delivered by an interdisciplinary team led by a care coordinator. The informal caregiver is also enrolled in the program and caregiver burden is assessed and managed. The ABC team collects all relevant data and formulates an individualized care plan in collaboration with the informal caregiver. The care coordinator communicates the team's recommendations to the primary care physician and finalizes a collaborative plan of action. During the next year, the ABC team uses face-to-face and telephone interactions with the patient and caregiver to monitor and modify implementation of the care plan. The goal of IUHP Usual Care is to provide preventive care services to their patients. Older adults are assessed for ADRD during clinic visits and refered to brain care specialty as necessary.<br>* Other names: IUHP Usual Care;|
| Experimental: BCN Mobile App Plus ABC and BCN Mobile app only<br>Patients and caregivers randomized to the intervention group will continue to receive care in ABC clinical program and IUHP, and have the BCN software installed on either the caregiver's personal mobile device (assuming it meets minimal technical requirements) or a device provided by the study, per participant preference. A research assistant will orient participants to the device, provide training on the BCN software, and troubleshoot technical issues. Participants will receive daytime technical support by phone, electronic support request through a separate app, or printed and in-app help manuals. Hardware, software, and connectivity check-ups will be provided by study research personnel. | Behavioral: ABC Clinical Program<br>* The goal of the ABC Clinical Program is to help primary care physicians achieve the standard of care in the diagnosis, evaluation and management of patients with ADRD. The ABC Clinical Program is delivered by an interdisciplinary team led by a care coordinator. The informal caregiver is also enrolled in the program and caregiver burden is assessed and managed. The ABC team collects all relevant data and formulates an individualized care plan in collaboration with the informal caregiver. The care coordinator communicates the team's recommendations to the primary care physician and finalizes a collaborative plan of action. During the next year, the ABC team uses face-to-face and telephone interactions with the patient and caregiver to monitor and modify implementation of the care plan. The goal of IUHP Usual Care is to provide preventive care services to their patients. Older adults are assessed for ADRD during clinic visits and refered to brain care specialty as necessary.<br>* Other names: IUHP Usual Care;Behavioral: BCN<br>* BCN is a mobile application (app) for informal caregivers of patients with Alzheimer's Disease and related dementias (ADRD). The BCN app delivers the following behavioral support: 24/7 psychoeducation and caregiver support on a variety of ADRD related topics, presented as a browse-able library of stories and advice cards or Notes; Assessment of informal caregiver status and patients behavioral and psychological symptoms of dementia (BPSD), in the form of the selfadministered HABC Monitor, along with reporting and historical tracking of HABC Monitor scores; Engagement tools, in particular, (i) a toolkit for saving, sorting, creating/editing, and sharing Notes and (ii) a bi-directional messaging tool for communicating with clinicians or trusted others.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Feasibility: Recruitment rate | Recruitment rate will be collected continually and computed at the end of the accrual period by calculating # approached, # agreeing, # consenting, and # consenting / # approached. We will also calculate the monthly rate. | 15 month accrual period | 
| Feasibility: Data completeness | Data completion will be collected continually and computed after the final assessment by calculating # complete caregiver burden and BPSD assessments per consenting participant / total possible assessments. We will separately compute missing data and attrition for all causes vs. death in the intervention vs. control groups. | 21 month outcome assessment period | 
| Feasibility: BCN usability | BCN usability will be assessed in the BCN intervention group at 3 months by a modified System Usability Scale (SUS), a validated 10-item scale (e.g., Learning to use Brain CareNotes was quick for me) with a 5-point response scale (strongly disagree to strongly agree). | 3 months | 
| Feasibility: BCN usability | BCN usability will be assessed in the BCN intervention group at 6 months by a modified System Usability Scale (SUS), a validated 10-item scale (e.g., Learning to use Brain CareNotes was quick for me) with a 5-point response scale (strongly disagree to strongly agree). | 6 months | 
| Feasibility: BCN acceptance | BCN acceptance will be assessed in the BCN intervention group at 3 months as the mean score on a Behavioral Intention scale (e.g., If it were up to you, to what extent would you want to use the BCN app?). The 4-item scale, adapted for health IT, uses a 7-point response scale from 0 (not at all) to 6 (a great deal). Behavioral intention is the canonical assessment for user acceptance of technology. | 3 months | 
| Feasibility: BCN acceptance | BCN acceptance will be assessed in the BCN intervention group at 6 months as the mean score on a Behavioral Intention scale (e.g., If it were up to you, to what extent would you want to use the BCN app?). The 4-item scale, adapted for health IT, uses a 7-point response scale from 0 (not at all) to 6 (a great deal). Behavioral intention is the canonical assessment for user acceptance of technology. | 6 months | 
| Feasibility: BCN use | BCN use will be collected continually from server activity (via API server queries) for log-in; survey initiation; survey completion; Notes browsed, saved, created, edited; assessment graph used; and message sent and received. We will compute daily and weekly use rates for each use type and for any use at 3 months. | 3 months | 
| Feasibility: BCN use | BCN use will be collected continually from server activity (via API server queries) for log-in; survey initiation; survey completion; Notes browsed, saved, created, edited; assessment graph used; and message sent and received. We will compute daily and weekly use rates for each use type and for any use at 6 months. | 6 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Caregiver Burden | Informal caregiver burden will be assessed by calculating the NPI-Caregiver Distress score (possible range from 0-60) from the researcher administered Neuropsychiatric Inventory (NPI) at baseline. | baseline. | 
| Caregiver Burden | Informal caregiver burden will be assessed by calculating the NPI-Caregiver Distress score (possible range from 0-60) from the researcher administered Neuropsychiatric Inventory (NPI) at 3 months. | 3 months | 
| Caregiver Burden | Informal caregiver burden will be assessed by calculating the NPI-Caregiver Distress score (possible range from 0-60) from the researcher administered Neuropsychiatric Inventory (NPI) at 6 months. | 6 months | 
| Patient BPSD severity | Patient behavioral and psychological symptoms of dementia (BPSD) will be assessed by calculating the NPI total score (possible range from 0-144) from the researcher- administered Neuropsychiatric Inventory (NPI) at baseline. | baseline | 
| Patient BPSD severity | Patient behavioral and psychological symptoms of dementia (BPSD) will be assessed by calculating the NPI total score (possible range from 0-144) from the researcher- administered Neuropsychiatric Inventory (NPI) at 3 months. | 3 months | 
| Patient BPSD severity | Patient behavioral and psychological symptoms of dementia (BPSD) will be assessed by calculating the NPI total score (possible range from 0-144) from the researcher- administered Neuropsychiatric Inventory (NPI) at 6 months. | 6 months | 
| Acute care utilization | After patient and caregiver have been consented, all-cause hospital and emergency room admissions during the study period will be collected from electronic medical records and the Indiana Network for Patient Care (INPC), the clinical data repository of the regenstrief built regional health information exchange and computed as a rate at 3 months. | 3 months | 
| Acute Care Utilization | After patient and caregiver have been consented, all-cause hospital and emergency room admissions during the study period will be collected from electronic medical records and the Indiana Network for Patient Care (INPC), the clinical data repository of the regenstrief built regional health information exchange and computed as a rate at 6 months. | 6 months |