Surrogate Decision-Making After Stroke in a Community Setting: The OASIS Project

BACKGROUND

Patients with severe stroke often rely on surrogate decision-makers for life-sustaining treatment decisions. We investigated ethnic differences between Mexican Americans (MAs) and non-Hispanic White (NHW) individuals in surrogate reports of physician quality of communication and shared decision-making from the OASIS study (Outcomes Among Surrogate Decision Makers in Stroke) project.

METHODS

Patients had ischemic stroke or intracerebral hemorrhage in Nueces County, TX. Surrogates self-identified as being involved in decisions about do-not-resuscitate orders, brain surgery, ventilator, feeding tube, or hospice/comfort care. Surrogate reports of physician quality of communication (scale score, range from 0 to 10) and shared decision-making (CollaboRATE scale score, binary score 1 versus 0) were compared by ethnicity with linear or logistic regression using generalized estimating equations, adjusted for prespecified demographics, clinical factors, and confounders.

RESULTS

Between April 2016 and September 2020, 320 surrogates for 257 patients with stroke enrolled (MA, 158; NHW, 85; and other, 14). Overall quality of communication score was better among surrogates of MA patients than NHW individuals after adjustment for demographics, stroke severity, and patient survival though the ethnic difference was attenuated (β, 0.47 [95% CI, -0.17 to 1.12]; P=0.15) after adjustment for trust in the medical profession and frequency of personal prayer. High CollaboRATE scale scores were more common among surrogates of MA patients than NHW individuals (unadjusted odds ratio, 1.75 [95% CI, 1.04-2.95]). This association persisted after adjustment for demographic and clinical factors though there was an interaction between patient age and ethnicity (P=0.04), suggesting that this difference was primarily in older patients.

CONCLUSIONS

Surrogate decision-makers of MA patients generally reported better outcomes on validated measures of quality of communication and shared decision-making than NHW individuals. Further study of outcomes among diverse populations of stroke surrogate decision-makers may help to identify sources of strength and resiliency that may be broadly applicable.

Barriers to Surrogate Application of Patient Values in Medical Decisions in Acute Stroke: Qualitative Study in a Biethnic Community

BACKGROUND

The objective of this study was to identify barriers to surrogate decision-maker application of patient values on life-sustaining treatments after stroke in Mexican American (MA) and non-Hispanic White (NHW) patients.

METHODS

We conducted a qualitative analysis of semistructured interviews with stroke patient surrogate decision-makers completed approximately 6 months after hospitalization.

RESULTS

Forty-two family surrogate decision-makers participated (median age: 54.5 years; female: 83%; patients were MA [60%] and NHW [36%], and 50% were deceased at the time of the interview). We identified three primary barriers to surrogates' applications of patient values and preferences when making decisions on life-sustaining treatments: (1) a minority of surrogates had no prior discussion of what the patient would want in the event of a serious medical illness, (2) surrogates struggled to apply prior known values and preferences to the actual decisions made, and (3) surrogates felt guilt or burden, often even in the setting of some knowledge of patient values or preferences. The first two barriers were seen to a similar degree in MA and NHW participants, though guilt or burden was reported more commonly among MA (28%) than NHW (13%) participants. Maintaining patient independence (e.g., ability to live at home, avoid a nursing home, make their own decisions) was the most important priority for decision-making for both MA and NHW participants; however, MA participants were more likely to list spending time with family as an important priority (24% vs. 7%).

CONCLUSIONS

Stroke surrogate decision-makers may benefit from (1) continued efforts to make advance care planning more common and more relevant, (2) assistance in how to apply their knowledge of patient values to actual treatment decisions, and (3) psychosocial support to reduce emotional burden. Barriers to surrogate application of patient values were generally similar in MA and NHW participants, though the possibility of greater guilt or burden among MA surrogates warrants further investigation and confirmation.

Abstract WP72: Psychological Distress Is Prevalent Among Family Surrogate Decision Makers In The Year After Stroke And Differs By Ethnicity

Introduction: We investigated long-term psychological distress among stroke family surrogate decision makers in Mexican Americans (MAs) and non-Hispanic Whites (NHWs).

Methods: Ischemic and hemorrhagic stroke patients from the Brain Attack Surveillance in Corpus Christi (BASIC) project and their family surrogate decision makers from the Outcomes Among Surrogate Decision Makers in Stroke (OASIS) were enrolled. Family surrogates completed validated measures of post-traumatic stress (NSESSS), anxiety (GAD-7), and depression (PHQ-8) at discharge, 3, 6, and 12 months. Ethnic differences were assessed with multilevel linear mixed models, sequentially adjusted for pre-specified covariates as shown in the table.

Results: There were 301 family surrogates for 241 stroke patients. MA patients were younger and less likely than NHWs to have died before the initial outcome interview (43% vs 56%, p=0.05), with no difference in baseline severity. MA family surrogates had lower educational attainment, income, and less use of advance care plans than NHWs. High scores on measures of psychological distress were common at all time points (Table). All psychological outcomes were worse among MAs on unadjusted analyses (Table). Symptoms of post-traumatic stress remained worse among MAs in the fully-adjusted model. Ethnic differences in anxiety were attenuated after adjustment for family demographics. Ethnic differences in depression were attenuated after adjustment for socioeconomic factors. Advance care plans were not associated with outcomes after accounting for other covariates and did not seem to confound any ethnic differences.

Conclusions: Psychological distress is prevalent among family surrogate decision makers in the year after stroke and may be worse among MAs. Efforts are needed to support family members of all ethnic groups after severe strokes.

Abstract TMP46: Physician Quality Of Communication And Shared Decision Making After Stroke In A Bi-ethnic Community: The Oasis Project

Objective: To explore ethnic differences in stroke patient surrogate decision makers’ (e.g. family) impressions of physician quality of communication (QOC) and shared decision making (SDM) in Mexican Americans (MAs) and non-Hispanic Whites (NHWs).

Methods: Surrogate decision makers who discussed life-sustaining treatments for severe stroke patients (ischemic or intracerebral hemorrhage) from the Brain Attack Surveillance in Corpus Christi (BASIC) project completed validated measures of physician QOC (QOC-overall, QOC-general, and QOC-end-of-life) and SDM (collaboRATE). Regression models with Generalized Estimating Equations were used to investigate ethnic differences in outcome adjusted for pre-specified demographics, severity, mortality, and identified confounders.

Results: From 4/2016 to 9/2020, 320 surrogates for 257 stroke cases were enrolled. Patient characteristics: median age 75 (IQR 64-87), female 52%, Race-ethnicity (MA 61%, NHW 33%, Other 5%), ICH 25%, median NIHSS 12 (IQR 5-20), deceased 45%. Surrogates had a median age of 57 (IQR 46-66) and were mostly female (77%). Compared to NHW surrogates, MA surrogates were more often women, had lower education, and less use of advance directives, but had more trust in physicians and were more likely to pray daily. Regression results for QOC are shown in the table. MA surrogates reported higher unadjusted scores for QOC-overall and QOC-end-of-life. These associations were stronger after adjustment for demographics, severity, and patient survival, though were no longer significant in the final fully adjusted models. A generally similar pattern was seen for SDM.

Conclusions: MA surrogates tended to report better physician communication and more SDM than NHWs, though no difference was seen after adjustment for factors such as trust, daily prayer, or advance care planning. Further study of contributions to positive outcomes among diverse populations of stroke surrogates are warranted.

Advance Care Planning and Transitions to Comfort Measures after Stroke

Background: Advance care planning (ACP) is recommended to align treatment with patient goals, although there has been little study of the impact of ACP on in-hospital stroke treatment. Objective: To examine the association between ACP and transitions to comfort measures after stroke. Design: Prospective cohort study. Setting/Subjects: Hospitalized stroke patients 45 years and older and surrogate decision makers from a population-based study in Corpus Christi, TX. Measurements: Surrogates were interviewed to assess presence of patient prestroke ACP, categorized as none, informal conversations only, or formal documentation. Patient records were reviewed for time from admission to transition to comfort measures only (CMO) (defined as in-hospital comfort measures or discharge with hospice services). Cox proportional-hazards models assessed the relationship between ACP and time to transition to CMO. Results: Of 148 included stroke patients, 37% transitioned to CMO (median time five days). For ACP, 44% had only informal conversations, 38% had formal documentation (98% of which also reported informal conversations), and 18% had neither. After adjustment for age, severity, and baseline disability, informal conversations alone (hazard ratio [HR] 3.55; 95% confidence interval [CI]: 1.35-9.33) and formal documentation (HR 2.85; 95% CI: 1.05-7.72) were associated with earlier transition to comfort measures compared to no ACP. There was no difference between formal documentation and informal conversations on time to comfort measures (HR 0.80, 95% CI: 0.40-1.63). Conclusions: There was no additional association of formal ACP documentation over informal conversations on time to transition to comfort measures after stroke. Further study of formal ACP is warranted.

Family Perceptions of Quality of End-of-Life Care in Stroke

Background: Most end-of-life decisions after stroke are made by a surrogate decision maker, yet there has been limited study of surrogate assessment of the quality of end-of-life stroke care. Objective: To assess surrogate perceptions of quality of end-of-life care (QEOLC) in stroke and explore factors associated with quality. Design: Cross-sectional analysis of interviewer-administered survey. Settings/subjects: Surrogate decision makers for deceased stroke patients in a population-based study. Measurements: The primary outcome was the validated 10-item family version of the QEOLC scale. The univariate association between prespecified patient and surrogate factors and dichotomized QEOLC score (high: 8-10, low: 0-7) was explored with logistic regression fit using generalized estimating equations. Results: Seventy-nine surrogates for 66 deceased stroke cases were enrolled (median patient age: 76, female patient: 53%, Mexican American patient: 59%, median time from stroke to death: seven days, median surrogate age: 59, and female surrogate: 72%). The overall QEOLC was generally high (median 8.3, quartiles 6.1, 9.6) although several individual items had a high proportion (∼30%-50%) of surrogates who felt that the questions did not apply to the patient's situation. No hypothesized factors were associated with QEOLC score, including demographics, stroke type, location/timing of death, advance directives, health literacy, or understanding of patient wishes. Conclusions: Surrogates reported generally high QEOLC. Although this finding is encouraging, modifications to the QEOLC may be needed in stroke as some surrogates were unable to provide a valid response for certain items.

Abstract TMP106: Decisions on Life-Sustaining Treatments After Stroke: The OASIS Project

Introduction: Surrogate decision makers are commonly asked to make critical decisions after stroke, though there has been little formal study of stroke surrogates. We report initial results on surrogate decisions in a community that does not have an academic medical center from the Outcomes Among Surrogate decision makers In Stroke (OASIS) project.

Methods: Patients with ischemic stroke or intracerebral hemorrhage (ICH) from the Brain Attack Surveillance in Corpus Christi (BASIC) project, Texas, USA, were screened for presence of a surrogate decision maker. Surrogates self-identified as being involved in decisions about life-sustaining treatments: do-not-resuscitate (DNR), brain surgery, ventilator, feeding tube, or transition to hospice/comfort measures only. The scope of decisions including surrogate report of patient and healthcare team participation are presented.

Results: Between 4/2016 and 8/2018, 230 stroke patients with at least one eligible surrogate were identified; 199 surrogates for 160 stroke patients enrolled (160/230=70% enrolled). Patient characteristics were mean age 74, female 53%, Mexican American 56% ICH 24%, median NIHSS 11.5 (IQR 4, 21), ICU admission 51%, deceased at time of surrogate interview 38%. Surrogates had a mean age of 55 years, were mostly women (74%), and were most commonly the child of the patient (64%) followed by the spouse (21%). Treatments discussed with the healthcare team are shown in the table. DNR was the most common discussion (90%). While physicians typically discussed brain surgery, surrogates reported that a nurse or other non-physician was the primary person talking to them in nearly half of the other discussions about life-sustaining treatment.

Conclusions: Women are responsible for a large proportion of surrogate decision making after stroke. Further study of the role of nursing participation in decisions on life-sustaining treatment is warranted, particularly in non-academic medical centers.

Abstract TP297: Does Use of Telestroke Negatively Impact Family Perceptions of the Local Hospital?

Introduction: While telestroke use is increasing, little is known about its effect on the patient and family perceptions of quality of stroke care. We hypothesized that use of telestroke may negatively impact perceptions of the quality of communication with local physicians.

Methods: Stroke patients aged 45 years and older and their surrogate medical decision makers were identified (April 2016-August 2018). Surrogates were asked to rate the main physician in charge of the patient’s care using a validated scale for quality of communication (QOC, range 0-10). Using Tobit regression models, we assessed the relationship of telestroke and in-person neurology consultation with surrogate-rated QOC, adjusted for confounders (with a family-specific random intercept term to account for clustering in families). A subset of surrogates also participated in qualitative interviews about the stroke hospitalization; unprompted discussion of telestroke were summarized.

Results: 197 surrogates for 157 patients were included. Surrogates were a median age of 56, 74% female, and 58% Mexican American. 51 patients received telestroke. The mean overall QOC score was 6.7/10. Neither telestroke nor in-person consultation were associated with QOC. However, the direction of the effects suggested a positive association with QOC for in-person consultation and a negative association for telestroke (Table). 32 surrogates underwent qualitative interviews with 3 individuals spontaneously discussing telestroke. In 2 cases, use of telestroke may have highlighted concerns about the competence or lack of resources of the local hospital. The other surrogate felt surprised and “stupid” for not knowing telestroke was possible (Table).

Conclusions: We did not identify any association of telestroke use with QOC in the local hospital. However, the direction of the observed effect and unprompted reports of negative feelings about telestroke in qualitative interviews may warrant further study.

Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke

Background and Purpose- Do-not-resuscitate (DNR) orders are common after stroke, though there are limited data on trends over time. We investigated time trends in DNR orders in a community with a large minority population. Methods- Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the BASIC study (Brain Attack Surveillance in Corpus Christi) from June 2007 through October 2016. Cox proportional hazards models were used to assess time to DNR orders, with an interaction term added to allow separate hazard ratios for early (≤24 hours) and late (>24 hours) DNR. Stroke type-specific calendar trends were assessed with an interaction term between calendar year (linear) and stroke type. Results- Two thousand six hundred seventy-two cases were included (ICH, 14%). Mean age was 69, 50% were female, and race-ethnicity was Mexican American (58%), non-Hispanic white (37%), and African American (5%). Overall, 16% had a DNR order during the hospitalization. For ICH, DNR orders (early and late) were stable over the study period. However, early DNR orders became more common over time after ischemic stroke (hazard ratio for 2016 versus 2007: 1.89; 95% CI, 1.06-3.39), with no change over time for late DNR orders after ischemic stroke. Mexican Americans (hazard ratio, 0.65; 95% CI, 0.50-0.86) and African Americans (hazard ratio, 0.17; 95% CI, 0.04-0.71) were less likely than non-Hispanic whites to have early DNR orders, though there were no race-ethnic differences in late DNR orders. There was no change in race-ethnic difference in DNR orders over the time of the study (interaction P>0.60). Conclusions- Despite revised national guidelines cautioning against early DNR orders in ICH, presence of DNR orders after ICH was stable between 2007 and 2016, with only slight increases in early DNR orders after ischemic stroke. Mexican Americans and African Americans remain less likely than non-Hispanic whites to have early DNR orders after stroke.

Ethnic Differences in 90-Day Poststroke Medication Adherence

Background and Purpose- We assessed ethnic differences in medication adherence 3 months poststroke in a population-based study as an initial step in investigating the increased stroke recurrence risk in Mexican Americans compared with non-Hispanic whites. Methods- Ischemic stroke cases from 2008 to 2015 from the Brain Attack Surveillance in Corpus Christi project in Texas were followed prospectively for 3 months poststroke to assess medication adherence. Medications in 5 drug classes were analyzed: statins, antiplatelets, anticoagulants, antihypertensives, and antidepressants. For each drug class, patients were considered adherent if they reported never missing a dose in a typical week. The χ² tests or Kruskal-Wallis nonparametric tests were used for ethnic comparisons of demographics, risk factors, and medication adherence. A multivariable logistic regression model was constructed for the association of ethnicity and medication nonadherence. Results- Mexican Americans (n=692) were younger (median 65 years versus 68 years, P<0.001), had more diabetes mellitus ( P<0.001) and hypertension ( P<0.001) and less atrial fibrillation ( P=0.003), smoking ( P=0.003), and education ( P<0.001) than non-Hispanic whites (n=422). Sex, insurance status, high cholesterol, previous stroke/transient ischemic attack history, excessive alcohol use, tPA (tissue-type plasminogen activator) treatment, National Institutes of Health Stroke Scale score, and comorbidity index did not significantly differ by ethnicity. There was no significant difference in medication adherence for any of the 5 drug classes between Mexican Americans and non-Hispanic whites. Conclusions- This study did not find ethnic differences in medication adherence, thus challenging this patient-level factor as an explanation for stroke recurrence disparities. Other reasons for the excessive stroke recurrence burden in Mexican Americans, including provider and health system factors, should be explored.

Abstract WP431: Advance Directives and Comfort Measures Only During Stroke Hospitalization

Introduction: Advance directives are often promoted as a way to ensure that patient wishes are followed; however, the impact of advance directives on actual care is controversial, and little is known about the impact on in-hospital stroke treatment. We explored the association between pre-stroke advance directives and transition to comfort measures only (CMO) during stroke hospitalization among patients with surrogate-decision makers.

Methods: Ischemic stroke and intracerebral hemorrhage (ICH) stroke cases from the Brain Attack Surveillance in Corpus Christi (BASIC) project and their surrogate decision makers from the Outcomes Among Surrogate Decision Makers in Stroke (OASIS) were enrolled. Patient records were abstracted for time to CMO. Surrogates were asked about patient pre-stroke advance directives (advance directive, living will, or durable power of attorney for health care). Cox-proportional-hazards models assessed the relationship between advance directives and time to CMO (censored at death, discharge, or 30 days). Based on the available sample size, adjustment factors were pre-specified and included age, NIHSS, and stroke type.

Results: 144 stroke patients were included (ischemic 76%; ICH 24%; age ≥75 45%; female 52%; Mexican American (MA) 59%, NIHSS mean (SD) 13(11)). 22% of cases transitioned to CMO during the hospitalization (median time to CMO 3 days); 39% of patients had an advance directive. Younger individuals, MAs and men were less likely to have advance directives. After adjusting for stroke type, age, and NIHSS, advance directives were not associated with time to CMO (Table).

Conclusions: Fewer than half of stroke patients had advance directives; however, the presence of advance directives did not appear to impact in-hospital transitions to CMO, suggesting limited utility of advance directives. Further study in larger samples is needed to determine the best way to ensure patient wishes are followed after stroke.

Abstract WMP111: Family Perceptions of Quality of End-of-Life Care in Stroke: The OASIS Study

Introduction: Stroke remains the fifth leading cause of death in the US, yet there has been little effort to formally assess the quality of end-of-life stroke care. We explored family surrogate decision maker perceptions of the quality of end-of-life care in stroke and predictors of higher or lower quality.

Methods: Surrogate decision makers for stroke patients in the Brain Attack Surveillance in Corpus Christi (BASIC) study were invited to participate in the Outcomes Among Surrogate decision makers In Stroke (OASIS) study. We report findings from the validated Quality of End-of-Life Care (QEOLC) questionnaire, which assesses 10 elements of end-of-life care on a 0-10 scale. Responses to individual QELOC items were dichotomized into low (0-7) or high (8-10) scores. The univariate association between pre-specified patient and surrogate factors and overall QELOC score were explored with generalized estimating equations.

Results: 71 surrogates for 59 deceased stroke cases were enrolled. Characteristics were patient mean age 77, ischemic stroke (73%), patient female (56%), Mexican American (58%), surrogate mean age 58, surrogate female (70%), relationship (spouse 21%; child 68%; other 11%), and mean time from stroke to death 9.5 days. QELOC responses are summarized in the table. None of the hypothesized factors were associated with overall QEOLC score, including patient or surrogate demographics, stroke type, location of death, time to death, presence of advance directives, or surrogate self-reported confidence or understanding of patient wishes.

Conclusions: Although we did not identify patient or surrogate predictors of overall quality of end-of-life care, the relatively lower ratings on consistency of information and treating the whole person may represent opportunities for improvement. Further study in larger samples is warranted, though modifications to the QELOC may be needed in stroke due to a high proportion of non-response to several items.

Recurrent stroke in midlife is associated with not having a primary care physician

OBJECTIVE

To determine using a population-based study whether midlife stroke patients having a primary care physician (PCP) at the time of first stroke have a lower risk of stroke recurrence and mortality than those who do not have a PCP.

METHODS

First-ever ischemic stroke patients 45 to 64 years of age at stroke onset were ascertained through the Brain Attack Surveillance in Corpus Christi (BASIC) project from 2000 to 2013 in Texas. Cox proportional hazards models were used to examine the association between not having a PCP and stroke recurrence or all-cause mortality in separate models. Cases were followed up for up to 5 years or until December 31, 2013, whichever came first. Cases were censored for recurrence if they died before experiencing a recurrent event. We adjusted for clinical risk factors that could be associated with having a PCP and recurrence or mortality.

RESULTS

There were 663 first-occurrence ischemic stroke cases. Of these, 77% had a PCP, 43% were female, and average age was 55.6 years. Five-year recurrence risk was 14.6%, and mortality risk was 19.2%. Not having a PCP was associated with higher recurrence risk (adjusted hazard ratio 1.75, 95% confidence interval 1.02-3.02). Having a PCP was not associated with mortality. Sensitivity analyses showed that results were robust to different ways to adjust for chronic conditions.

CONCLUSION

This study found lower rates of stroke recurrence among those with a PCP at the time of first stroke. Future studies could determine the value of establishing a PCP before stroke hospital discharge for secondary stroke prevention.

Abstract TP296: Time Trends in Race-Ethnic Differences in Do-Not-Resuscitate Orders After Stroke

Introduction: Do-not-resuscitate (DNR) orders are common after stroke and have recently received increased attention. However, there has been little study of trends in DNR status. We investigated time trends in DNR use after stroke in a community with a large minority population.

Methods: Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) study from June 2007 through October 2016. Demographics, clinical characteristics, and DNR status were collected from medical charts by trained abstractors. Race-ethnic differences in DNR orders were assessed with logistic regression models and adjusted for potential confounders. Time trends were assessed with a linear term for time (years) and further explored with interaction terms between time and race-ethnicity or time and stroke type.

Results: After excluding cases with missing DNR status and recurrent events, 2,860 cases were available. Mean age was 69 (range 45-102), 50% were female, and race-ethnicity was Mexican American (MA, 58%), non-Hispanic White (NHW, 37%), and African American (AA, 5%). Overall, 17% had a DNR order during the hospitalization. Time trends in DNR orders differed for IS and ICH (interaction p=0.04, see Table). However, change in DNR status over time within each stroke type was modest (non-significant increase over time for IS and non-significant decrease for ICH). MAs were less likely than NHWs to have DNR orders (p=0.007) There was no evidence of interaction between time and race-ethnicity (p=0.57), suggesting that the race-ethnic disparity is stable over time.

Conclusions: Use of DNR orders after stroke has been largely stable over the past 10 years, with only slight differences in time trends comparing IS to ICH. Mexican Americans remain less likely than NHWs to use DNR orders after stroke with no evidence of change over time.

An Epigenetic Spin to ALS and FTD

Amyotrophic lateral sclerosis (ALS) and frontotemporal dementia (FTD) are two devastating and lethal neurodegenerative diseases seen comorbidly in up to 15% of patients. Despite several decades of research, no effective treatment or disease-modifying strategies have been developed. We now understand more than before about the genetics and biology behind ALS and FTD, but the genetic etiology for the majority of patients is still unknown and the phenotypic variability observed across patients, even those carrying the same mutation, is enigmatic. Additionally, susceptibility factors leading to neuronal vulnerability in specific central nervous system regions involved in disease are yet to be identified. As the inherited but dynamic epigenome acts as a cell-specific interface between the inherited fixed genome and both cell-intrinsic mechanisms and environmental input, adaptive epigenetic changes might contribute to the ALS/FTD aspects we still struggle to comprehend. This chapter summarizes our current understanding of basic epigenetic mechanisms, how they relate to ALS and FTD, and their potential as therapeutic targets. A clear understanding of the biological mechanisms driving these two currently incurable diseases is urgent-well-needed therapeutic strategies need to be developed soon. Disease-specific epigenetic changes have already been observed in patients and these might be central to this endeavor.

Conserved DNA methylation combined with differential frontal cortex and cerebellar expression distinguishes C9orf72-associated and sporadic ALS, and implicates SERPINA1 in disease

We previously found C9orf72-associated (c9ALS) and sporadic amyotrophic lateral sclerosis (sALS) brain transcriptomes comprise thousands of defects, among which, some are likely key contributors to ALS pathogenesis. We have now generated complementary methylome data and combine these two data sets to perform a comprehensive "multi-omic" analysis to clarify the molecular mechanisms initiating RNA misregulation in ALS. We found that c9ALS and sALS patients have generally distinct but overlapping methylome profiles, and that the c9ALS- and sALS-affected genes and pathways have similar biological functions, indicating conserved pathobiology in disease. Our results strongly implicate SERPINA1 in both C9orf72 repeat expansion carriers and non-carriers, where expression levels are greatly increased in both patient groups across the frontal cortex and cerebellum. SERPINA1 expression is particularly pronounced in C9orf72 repeat expansion carriers for both brain regions, where SERPINA1 levels are strictly down regulated across most human tissues, including the brain, except liver and blood, and are not measurable in E18 mouse brain. The altered biological networks we identified contain critical molecular players known to contribute to ALS pathology, which also interact with SERPINA1. Our comprehensive combined methylation and transcription study identifies new genes and highlights that direct genetic and epigenetic changes contribute to c9ALS and sALS pathogenesis.