The Feasibility of AgileNudge+ Software to Facilitate Positive Behavioral Change: A Mixed Methods Design.

BACKGROUND: In today's digital age, web-based applications have become integral to daily life, driving transformative shifts in human behavior. "AgileNudge+" is a web-based solution to simplify the process of positive behavior change using nudging as an intervention. By integrating knowledge from behavioral economics with technology, AgileNudge+ organizes multiple steps, simplifies complex tasks, minimizes errors by enhancing user engagement, and provides resources for creating and testing nudge interventions. OBJECTIVE: This paper outlines the design process, methodologies, and usefulness of "AgileNudge+" for the development of evidence-based nudges. It employs a mixed methods approach to evaluate the software's interface usability and usefulness for creating and testing nudge interventions. METHODS: AgileNudge+ was developed through iterative processes integrating principles from behavioral economics and user-centered design. The content of AgileNudge+ operationalizes Agile Science-based process to efficiently design, embed, and disseminate evidence-based nudges that encourage positive behavior change without limiting choice. Using a mixed methods approach, we tested AgileNudge+ software's ability to organize and simplify the nudge intervention process, allowing a diverse range of scholars with limited knowledge of Agile science to employ nudges. Usability testing assessed the tool's usefulness and interface with a sample of 18 healthcare professionals, each asked to interact with the software and create a nudge intervention to solve a problem within their professional projects sphere. RESULTS: The study was funded in August 2022, with data collection occurring from June 2023 to July 2024. As of July 2024, we have enrolled 18 participants. Quantitative results found a mean usefulness rating of AgileNudge+ of 3.83 with a 95% confidence interval of (3.00, 4.66). Qualitative results highlighted ways to modify the language used in AgileNudge+ to be more comprehensible to a diverse user base and promoted modifications to the software that facilitate real-time assistance and prioritize time-efficiency in user interactions. Feedback further supported the positive impact of gamification on participant motivation when using the software. CONCLUSIONS: AgileNudge+ is an effective assistive tool for simplifying the positive behavior change process using nudge interventions, with tailored content and interactions to meet users' needs and demands. Building onto the current design, future iterations of AgileNudge+ will use artificial intelligence to process large volumes of data while reducing the time and mental energy required to scan for existing cognitive biases and nudge prototypes. The software is also being upgraded to build on current gamification efforts, encouraging more sustained motivation by increasing the temporal resolution of the digital interface. These modifications stay true to the agility and user-centered aspects of AgileNudge+, emphasizing the novelty of the constantly evolving software design process.

Outcomes with single-agent gilteritinib for relapsed or refractory FLT3-mutant AML after contemporary induction therapy.

Gilteritinib is the current standard of care for relapsed or refractory FLT3-mutated AML in many countries, however outcomes for patients relapsing after contemporary first-line therapies (intensive chemotherapy with midostaurin, or non-intensive chemotherapy with venetoclax) are uncertain. Moreover, reported data on toxicity and healthcare resource use is limited. Here we describe a large real-world cohort of 152 patients receiving single-agent gilteritinib in 38 UK hospitals. Median age was 61 and 36% had received 2 prior lines of therapy, including a FLT3 inhibitor in 41% and venetoclax in 24%. A median of 4 cycles of gilteritinib were administered, with 56% of patients requiring hospitalisation in the first cycle (median 10 days). Over half of patients required transfusion in each of the first 4 cycles. Complete remission (CR) was achieved in 21% and CR with incomplete recovery in a further 9%. Remission rates were lower for patients with FLT3-TKD or adverse karyotype. Day 30 and day 60 mortality were 1% and 10.6% and median overall survival was 9.5 months. On multivariable analysis, increasing age, KMT2A rearrangement and complex karyotype were associated with worse survival while RUNX1 mutations were associated with improved survival. Twenty patients received gilteritinib as first salvage having progressed following first-line therapy with venetoclax, with CR/CRi achieved in 25% and median survival 4.5 months. Real-world results with gilteritinib mirror those seen in the clinical trials but outcomes remain suboptimal, with more effective strategies needed.

Examining timing of periorbital interventions in patients with upper division facial paralysis.

BACKGROUND: Facial paralysis is a life-altering condition that may arise from various etiologies, ranging from trauma to malignancy. Permanent facial paralysis may occur secondary to facial nerve sacrifice or irreversible damage to the nerve. In these particularly devastating cases, protection and maintaining function of the eye is paramount. There are many effective lagophthalmos corrective surgical procedures available for these patients. While placement of eyelid weights and lid tightening surgeries are the cornerstone of eyelid rehabilitation, limited information exists on whether the timing of eyelid interventions in the setting of permanent facial paralysis impact outcomes, including need for revision surgery. METHODS: A single-center retrospective chart review was performed for patients with irreversible facial paralysis treated with an upper eyelid weight between 2013 to 2022. Electronic health records were acquired to obtain facial paralysis etiology, associated clinical characteristics, the type of intervention, and the timing of intervention. Patients were classified as immediate if the eyelid weight operation occurred within 29 days of the initial facial paralysis and delayed if the surgery occurred 30 days or more after initial presentation. Outcomes were assessed in terms of revision procedures and surgical complications. RESULTS: There were 70 patients in total, with 35 patients in the immediate category and 35 patients in the delayed category. The most common etiology related to parotid gland pathology, and 58.6% of patients had facial paralysis from cancer-related surgeries. There were no significant differences in revision rates (p < 0.208) or in the types of procedures (p = 0.077) between the two groups. The complication rates also did not differ significantly between groups; however, there were only complications in the delayed intervention group. CONCLUSIONS: These findings suggest there is no difference in postoperative complications between groups, including the need for revision surgeries when comparing groups with immediate or delayed intervention. Thus, treatment plans should be customized based on patient and provider preferences.

A Consensus Statement on the Administration of Systemic Bevacizumab in Patients with Recurrent Respiratory Papillomatosis.

OBJECTIVE: To provide detailed guidance on the administration of systemic bevacizumab in patients with recurrent respiratory papillomatosis (RRP) based on a detailed review of the scientific literature and a consensus of experts with real-world clinical experience. METHODS: A bevacizumab consensus working group (N = 10) was composed of adult and pediatric otolaryngologists, adult and pediatric oncologists, and a representative from the RRP Foundation (RRPF), all with experience administering systemic bevacizumab in patients with RRP. After extensive review of the medical literature, a modified Delphi method-based survey series was utilized to establish consensus on the following key areas: clinical and patient characteristics ideal for treatment candidacy, patient perspective in treatment decisions, treatment access, initial dosing, monitoring, guidelines for tapering and discontinuation, and reintensifying therapy. RESULTS: Seventy-nine statements were identified across nine critical domains, and 45 reached consensus [clinical benefits of bevacizumab (3), patient and disease characteristics for treatment consideration (7), contraindications for treatment (3), shared decision-making (incorporating the patient perspective) (5), treatment access (3), initial dosing and administration (8), monitoring (7), tapering and discontinuation (6), and reintensification (3)]. CONCLUSION: This consensus statement provides the necessary guidance for clinicians to initiate systemic administration of bevacizumab and represents a potential paradigm shift toward nonsurgical treatment options for patients with RRP. LEVEL OF EVIDENCE: 5 Laryngoscope, 2024.

Role of 18F-FDG PET/CT in the management of head and neck cancer patients with persistent cervical lymphadenopathy following chemoradiation.

BACKGROUND: We aim to describe the management and outcomes of patients with persistent lymphadenopathy (LAD) after primary chemoradiation for head and neck squamous cell carcinoma (HNSCC) based on post-treatment PET/CT results. METHODS: Retrospective chart review was conducted of all patients who underwent primary concurrent chemoradiation for HNSCC at a tertiary care center from 2010 to 2022 and had persistent post-treatment LAD. RESULTS: Nearly 62% of patients were managed conservatively, and 27.0% underwent neck dissection. PET-positive patients were more likely to undergo neck dissection than PET-negative patients (p = 0.042). Positive predictive value (PPV) and negative predictive values (NPV) of PET/CT in detecting residual disease in the neck were 48.0% and 73.7%, respectively. CONCLUSIONS: PPV and NPV of PET/CT for detecting residual neck disease in patients with post-treatment LAD was lower than those of HNSCC patients with and without persistent LAD reported in other studies.

Alzheimer disease blood biomarkers: considerations for population-level use.

In the past 5 years, we have witnessed the first approved Alzheimer disease (AD) disease-modifying therapy and the development of blood-based biomarkers (BBMs) to aid the diagnosis of AD. For many reasons, including accessibility, invasiveness and cost, BBMs are more acceptable and feasible for patients than a lumbar puncture (for cerebrospinal fluid collection) or neuroimaging. However, many questions remain regarding how best to utilize BBMs at the population level. In this Review, we outline the factors that warrant consideration for the widespread implementation and interpretation of AD BBMs. To set the scene, we review the current use of biomarkers, including BBMs, in AD. We go on to describe the characteristics of typical patients with cognitive impairment in primary care, who often differ from the patient populations used in AD BBM research studies. We also consider factors that might affect the interpretation of BBM tests, such as comorbidities, sex and race or ethnicity. We conclude by discussing broader issues such as ethics, patient and provider preference, incidental findings and dealing with indeterminate results and imperfect accuracy in implementing BBMs at the population level.

"You just have to be careful how you do it": A qualitative study of the Healthwise decision aid for older drivers.

OBJECTIVE: Decisions about driving retirement are difficult for older adults, their families, and health care providers. A large randomized trial found that an existing online Healthwise decision aid decreased decision conflict and increased knowledge about driving decisions. This study sought to discover how, when, and where the tool might be most effective for older drivers, their family members, and their health care providers. METHODS: We used one-on-one, semistructured interviews (June-December 2023) to explore perspectives on the content of the Healthwise online driving decision aid and its potential use. Participants were health care providers or subject matter experts in older driver research or policy. Transcribed interviews were coded and analyzed with a team-based approach to identify emerging themes. RESULTS: Across interviews (16 health care providers; 15 experts), emerging themes related to considerations (barriers, benefits, and settings for use) that were (1) individual or interpersonal or (2) institutional or cultural, as well as feedback on (3) decision aid content and structure. Findings included concerns over agism and damaging provider-patient relationships, along with identified benefits of integrating tools into electronic health records and a need for consolidated, easy-to-access resources for both providers and patients. CONCLUSION: Attention to individual, interpersonal, institutional, and cultural factors may enhance the use and dissemination of an online decision aid about driving, as well as its effectiveness in decision making. Future work should include views of additional stakeholders and studies on implementation of decision aids into real-world settings.

Loneliness in older primary care patients and its relationship to physical and mental health-related quality of life.

BACKGROUND: Loneliness is a significant public health challenge in the United States, especially among older adults. The epidemiology of loneliness among older adults in primary care is lacking, and specific research is needed on how loneliness impacts older primary patients' physical, mental, and cognitive health. A large sample of older primary care patients were recruited for a trial during the COVID-19 pandemic to measure the relationship between loneliness and physical and mental quality of life (QOL). METHODS: Baseline data come from the Caregiver Outcomes of Alzheimer's Disease Screening (COADS) study, an ongoing randomized controlled trial evaluating benefits and risks of Alzheimer's disease and related dementias screening among primary care patients ages 65 and older, collected April 2020 to September 2021. Loneliness was measured with the 5-item, Loneliness Fixed Form Ages 18+ from The NIH Toolbox Emotion Battery, physical and mental health-related QOL was measured with the SF-36v2, and depression and anxiety severity were measured with the PHQ-9 and GAD-7, respectively. RESULTS: Spearman correlation analyses revealed that loneliness was moderately correlated with mental health QOL (r[601] = -0.43, p < 0.001), anxiety severity (r[601] = 0.44, p < 0.001), and depression severity (r[601] = 0.42, p < 0.001), while weakly correlated with physical health QOL (r[601] = -0.15, p < 0.001). After conducting unadjusted and adjusted linear regression models, we found that loneliness was significantly associated with both lower mental (p < 0.001) and physical (p < 0.001) QOL. Furthermore, loneliness remained significantly associated with worse mental QOL after adjusting for age, gender, race, ethnicity, educational level, perceived income status, neighborhood disadvantage, severity of comorbidities, and comorbid depression and anxiety. CONCLUSION: Primary care providers should discuss loneliness with their older adult patients and provide resources to help patients develop and maintain meaningful social relationships.

Association Between Subjective Cognitive Decline and Twice-Weekly Muscle-Strengthening Activities in Middle-Aged and Older US Adults: An Analysis of the 2019 Behavioral Risk Factor Surveillance System.

PURPOSE: Adults with subjective cognitive decline (SCD), the self-reported concern of reduced cognitive function, are recommended to do physical activity for its brain health benefits. US adults aged ≥45 with SCD are less likely to meet the American College of Sports Medicine (ACSM) aerobic activity recommendations. Their engagement in muscle-strengthening activities is unknown. We aimed to identify if US adults aged ≥45 with SCD are less likely to do twice-weekly muscle-strengthening activities compared to those without SCD. DESIGN: Secondary analysis of the 2019 Behavioral Risk Factor Surveillance System (BRFSS) data. SAMPLE: 114 164 respondents, representing approximately 59 million US adults aged ≥45. MEASURES: SCD was indicated if the respondent reported confusion or memory loss during the past 12 months (yes/no). Respondents reported the frequency of muscle-strengthening activities, which we categorized as meeting the ACSM's recommendations (2+ times per week) or not (<2 times per week). ANALYSIS: Crude and adjusted logistic regression models controlling for variables associated with SCD and muscle-strengthening activities. The models used sample weights to represent US adults in the included 31 states and Washington D.C. RESULTS: US adults aged ≥45 with SCD were less likely to do twice-weekly muscle-strengthening activities than those without SCD (28.6% [SE: .8%] vs 33.5% [SE: .3%], adjusted OR, .9; 95% CI: .9-1.0). CONCLUSION: Primary care providers should encourage middle-aged and older patients to engage in muscle-strengthening and aerobic activities.

Relationship of Decisional Conflict About Driving Habits Between Older Adult Drivers and Their Family Members and Close Friends.

This study examines the relationship of decisional conflict about driving habits between older adult drivers (≥70 years old) and their family members and close friends. This secondary analysis utilizes data originating from a multi-site randomized controlled trial assessing the effect of a driving decision aid (DDA) intervention. Decisional conflict about stopping or changing driving habits for drivers was measured with the Decisional Conflict Scale (DCS). Dyadic associations between drivers' and study partners' (SPs') DCS scores were analyzed using an actor-partner interdependence model. Among 228 driver-SP dyads, Dyadic DCS was correlated at baseline (r = .18, p < .01), and pre-intervention DCS was associated with post-intervention DCS (p < .001 for SPs [ß = .73] and drivers [ß = .73]). Drivers' baseline DCS and SPs' post-intervention DCS were slighly correlated (ß = .10; p = .036). Higher decisional conflict about driving among older drivers is frequently shared by their SPs. Shared decisional conflict may persist beyond intervening to support decision-making about driving cessation.

Ibrutinib as first-line therapy for mantle cell lymphoma: a multicenter, real-world UK study.

ABSTRACT: During the COVID-19 pandemic, ibrutinib with or without rituximab was approved in England for initial treatment of mantle cell lymphoma (MCL) instead of immunochemotherapy. Because limited data are available in this setting, we conducted an observational cohort study evaluating safety and efficacy. Adults receiving ibrutinib with or without rituximab for untreated MCL were evaluated for treatment toxicity, response, and survival, including outcomes in high-risk MCL (TP53 mutation/deletion/p53 overexpression, blastoid/pleomorphic, or Ki67 ≥ 30%). A total of 149 patients from 43 participating centers were enrolled: 74.1% male, median age 75 years, 75.2% Eastern Cooperative Oncology Group status of 0 to 1, 36.2% high-risk, and 8.9% autologous transplant candidates. All patients received ≥1 cycle ibrutinib (median, 8 cycles), 39.0% with rituximab. Grade ≥3 toxicity occurred in 20.3%, and 33.8% required dose reductions/delays. At 15.6-month median follow-up, 41.6% discontinued ibrutinib, 8.1% due to toxicity. Of 104 response-assessed patients, overall (ORR) and complete response (CR) rates were 71.2% and 20.2%, respectively. ORR was 77.3% (low risk) vs 59.0% (high risk) (P = .05) and 78.7% (ibrutinib-rituximab) vs 64.9% (ibrutinib; P = .13). Median progression-free survival (PFS) was 26.0 months (all patients); 13.7 months (high risk) vs not reached (NR) (low risk; hazard ratio [HR], 2.19; P = .004). Median overall survival was NR (all); 14.8 months (high risk) vs NR (low risk; HR, 2.36; P = .005). Median post-ibrutinib survival was 1.4 months, longer in 41.9% patients receiving subsequent treatment (median, 8.6 vs 0.6 months; HR, 0.36; P = .002). Ibrutinib with or without rituximab was effective and well tolerated as first-line treatment of MCL, including older and transplant-ineligible patients. PFS and OS were significantly inferior in one-third of patients with high-risk disease and those unsuitable for post-ibrutinib treatment, highlighting the need for novel approaches in these groups.

The methodology of the Agile Nudge University.

Introduction: The Agile Nudge University is a National Institute on Aging-funded initiative to engineer a diverse, interdisciplinary network of scientists trained in Agile processes. Methods: Members of the network are trained and mentored in rapid, iterative, and adaptive problem-solving techniques to develop, implement, and disseminate evidence-based nudges capable of addressing health disparities and improving the care of people living with Alzheimer's disease and other related dementias (ADRD). Results: Each Agile Nudge University cohort completes a year-long online program, biweekly coaching and mentoring sessions, monthly group-based problem-solving sessions, and receives access to a five-day Bootcamp and the Agile Nudge Resource Library. Discussion: The Agile Nudge University is evaluated through participant feedback, competency surveys, and tracking of the funding, research awards, and promotions of participating scholars. The Agile Nudge University is compounding national innovation efforts in overcoming the gaps in the ADRD discovery-to-delivery translational cycle.

Relationship between health-related quality of life, depression, and anxiety in older primary care patients and their family members.

OBJECTIVES: Patient-family member dyads experience transitions through illness as an interdependent team. This study measures the association of depression, anxiety, and health-related quality of life (HRQOL) of older adult primary care patient-family member dyads. METHODS: Baseline data from 1,808 patient-family member dyads enrolled in a trial testing early detection of Alzheimer's disease and related dementias in primary care. Actor-Partner Independence Model was used to analyze dyadic relationships between patients' and family members' depression (PHQ-9), anxiety (GAD-7), and HRQOL (SF-36 Physical Component Summary score and Mental Component Summary score). RESULTS: Family member mean (SD) age is 64.2 (13) years; 32.2% male; 84.6% White; and 64.8% being the patient's spouse/partner. Patient mean (SD) age is 73.7 (5.7) years; 47% male; and 85.1% White. For HRQOL, there were significant actor effects for patient and family member depression alone and depression and anxiety together on their own HRQOL (p < 0.001). There were significant partner effects where family member depression combined with anxiety was associated with the patient's physical component summary score of the SF-36 (p = 0.010), and where the family member's anxiety alone was associated with the patient's mental component summary score of the SF-36 (p = 0.031). CONCLUSION: Results from this study reveal that many dyads experience covarying health status (e.g. depression, anxiety) even prior to entering a caregiving situation.

Examining the relationship between COVID-19 and Bell's palsy: Experience of a single tertiary care center.

BACKGROUND: While the etiology of Bell's palsy (BP) is largely unknown, current evidence shows it may occur secondary to the immune response following a viral infection. Recently, BP has been reported as a clinical manifestation of coronavirus disease (COVID-19). OBJECTIVES: To investigate an association between COVID-19 infection and BP. Additionally, to evaluate the need for COVID-19 testing in patients who present with BP. METHODS: Hospital records of patients who presented to a single tertiary care center with BP in 2020 and 2021 were reviewed for presenting symptoms, demographics, COVID-19 infection and vaccination status. RESULTS: There was no statistically significant difference between patients with BP who had a positive or negative COVID test in terms of sex, BMI, age, race, smoking history or alcohol use. All 7 patients with BP and a positive COVID test were unvaccinated. Of the total cohort of 94 patients, 82 % were unvaccinated at the time of the study. None of the 17 patients who were vaccinated had a positive COVID test. A history of BP showed no statistical significance (10.3 % vs 14.3 %, p-value 0.73). CONCLUSION: We discovered a limited cohort of patients who underwent COVID-19 testing at the time of presentation for BP. Though there have been recent studies suggesting a COVID-19 and BP, we were unable to clearly identify a relationship between COVID-19 and BP. Interestingly, all patients with facial paralysis and COVID-19 were unvaccinated. To further study this relationship, we recommend consideration of a COVID-19 test for any patient that presents with facial paralysis.

Prognostic significance of time trends in treatment of head and neck squamous cell carcinoma.

PURPOSE: To analyze the impact of demographic, clinical, and management variables on time to treatment initiation (TTI) and overall survival (OS). STUDY DESIGN: Retrospective chart review. MATERIALS AND METHODS: Medical records of patients diagnosed with head and neck cancer from 2018 to 2020 were reviewed. Univariate linear and Cox-regressions identified predictors of TTI and OS. Kaplan Meier (KM) curves assessed the difference in survival by diagnostic year and TTI. RESULTS: 381 patients met eligibility criteria. Median TTI was 35.0 days (IQR: 25.0-49.0). Only 10.8 % of all patients reported any treatment delay, with TTI exceeding 90 days found in 3.7 % of patients. TTI increased with African American race (p = 0.02), ED referrals (p = 0.02), and direct admission status (p = 0.01). When compared to treatment with surgery alone, TTI was shorter in patients undergoing surgery with adjuvant radiation (p = 0.02), adjuvant chemoradiation (p = 0.04), and salvage surgery (p = 0.04). Univariate Cox-regressions found smoking (p = 0.01), direct admission status (p = 0.02), increased duration of symptoms (p = 0.02), placement of PEG tubes (p < 0.01) and tracheostomies (p < 0.01), combination treatment (p < 0.01), and surgery with adjuvant chemoradiation treatment (p = 0.01) to increase mortality risk. Disease characteristics, including tumor size (p < 0.01), presence of nodal disease (p = 0.02), and late-stage disease (p < 0.01), increased mortality risk. TTI and diagnostic year did not impact survival. CONCLUSIONS: Our analysis determined several demographic, referral, and treatment factors impacted TTI. However, increased TTI did not impact survival. Characteristics consistent with advanced disease worsened OS. Despite the pandemic burden, patients diagnosed in 2020 showed no difference in short-term survival compared to prior years.

Mild Cognitive Impairment is Associated with Poorer Everyday Decision Making.

BACKGROUND: Older adults are faced with many unique and highly consequential decisions such as those related to finances, healthcare, and everyday functioning (e.g., driving cessation). Given the significant impact of these decisions on independence, wellbeing, and safety, an understanding of how cognitive impairment may impact decision making in older age is important. OBJECTIVE: To examine the impact of mild cognitive impairment (MCI) on responses to a modified version of the Short Portable Assessment of Capacity for Everyday Decision making (SPACED). METHODS: Participants were community-dwelling, actively driving older adults (N = 301; M age = 77.1 years, SD = 5.1; 69.4% with a college degree or higher; 51.2% female; 95.3% White) enrolled in the Advancing Understanding of Transportation Options (AUTO) study. A generalized linear model adjusted for age, education, sex, randomization group, cognitive assessment method, and study site was used to examine the relationship between MCI status and decision making. RESULTS: MCI status was associated with poorer decision making; participants with MCI missed an average of 2.17 times more points on the SPACED than those without MCI (adjusted mean ratio: 2.17, 95% CI: 1.02, 4.61, p = 0.044). CONCLUSION: This finding supports the idea that older adults with MCI exhibit poorer decision-making abilities than cognitively normal older adults. It also suggests that older adults with MCI may exhibit poorer decision making across a wide range of decision contexts.

Biomarker disclosure protocols in prodromal Alzheimer's disease clinical trials.

INTRODUCTION: The development of biomarkers for Alzheimer's disease (AD) has allowed researchers to increase sample homogeneity and test candidate treatments earlier in the disease. The integration of biomarker "screening" criteria should be met with a parallel implementation of standardized methods to disclose biomarker testing results to research participants; however, the extent to which protocolized disclosure occurs in trials is unknown. METHODS: We reviewed the literature to identify prodromal AD trials published in the past 10 years. From these, we quantified the frequency of biomarker disclosure reporting and the depth of descriptions provided. RESULTS: Of 30 published trials using positron emission tomography or cerebrospinal fluid-based amyloid positivity as an eligibility criterion, only one mentioned disclosure, with no details on methods. DISCUSSION: Possible reasons for and implications of this information gap are discussed. Recommendations are provided for trialists considering biomarker screening as part of intervention trials focused on prodromal AD. HIGHLIGHTS: Few prodromal Alzheimer's disease (AD) trial papers discuss biomarker disclosure. Disclosure has implications for participants, family members, and trial success. Disclosure must be consistently integrated and reported in prodromal AD trials. Best practice guidelines and training resources for disclosure are needed.

Expanding the use of brief cognitive assessments to detect suspected early-stage cognitive impairment in primary care.

INTRODUCTION: Mild cognitive impairment remains substantially underdiagnosed, especially in disadvantaged populations. Failure to diagnose deprives patients and families of the opportunity to treat reversible causes, make necessary life and lifestyle changes and receive disease-modifying treatments if caused by Alzheimer's disease. Primary care, as the entry point for most, plays a critical role in improving detection rates. METHODS: We convened a Work Group of national experts to develop consensus recommendations for policymakers and third-party payers on ways to increase the use of brief cognitive assessments (BCAs) in primary care. RESULTS: The group recommended three strategies to promote routine use of BCAs: providing primary care clinicians with suitable assessment tools; integrating BCAs into routine workflows; and crafting payment policies to encourage adoption of BCAs. DISSCUSSION: Sweeping changes and actions of multiple stakeholders are necessary to improve detection rates of mild cognitive impairment so that patients and families may benefit from timely interventions.