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1 IMPLEMENTING THE HCH FOR PATIENTS WITH AD: EARLY IDENTIFICATION, CARE COORDINATION & CAREGIVER SUPPORT Health Care Homes Learning Day, November 1, 2012 Session Overview Introduction to Health Care Home (HCH) Overview Successful HCH: physician & care coordinator perspectives Alzheimer’s Disease and HCH Overview AD in HCH: physician & care coordination roles Alzheimer’s Disease: Firsthand experience Conclusion / Q&A Successful HCH Dr. Johnson presentation Panel discussion AD Overview 4 Facts & Figures& Figures Alzheimer’s Association 2011 Today, Alzheimer’s Disease Is: Fatal Prevalent Expensive Misunderstood Stigmatized Under-diagnosed Under-treated ON THE RISE…. Alzheimer’s Epidemic By 2050: 13 million to 16 million Americans will have AD Consume 1.1 trillion in healthcare spending Today Fewer than 50% of patients receive formal diagnosis Diagnosis often delayed by 6+ Years Impairment in function by time it is recognized Fewer than 50% of those diagnosed receive any treatment Why is Early Diagnosis Important? 1. 2. 3. 4. 5. 6. 7. 8. 9. Optimize current medical management Relief gained from better understanding Maximize decision-making autonomy Access to services Risk reduction Plan for the future* Improve clinical outcomes* Avoid or reduce future costs Diagnosis as a human right *Top benefits endorsed by physicians, International Alzheimer’s Disease Physician Survey, 2012 World Alzheimer Report 2011 Alzheimer’s Disease: Course, Prevention, Treatment Strategies 10 INTERVENTION CLINICAL STATE Numbers of people Primary Prevention Normal Presymptomatic AD ??? 20 to 60 mil Secondary Prevention Treatment Mild Cognitive Impairment AD 10 to 15 mil 5.3mil BRAIN PATHOLOGIC STATE No disease No symptoms Early AD brain changes No symptoms AD brain changes Mild symptoms Mild, moderate or severe impairment STRATEGIES Identify at-risk Prevent AD Prevent or delay emergence of symptoms Stimulate memory Slow progression Treat cognition Treat behaviors Slow progression DISEASE PROGRESSION AD: Physician Perspective 11 Alzheimer’s, the Scope of the Problem Most significant Risk Factor Prevalence of Cognitive Impairment Age 50% of those >85 Co-morbidities At least one present in 95% Easy Practice Tips Practice Tips Red flags Repetition (not normal in 7-10 min conversation) Tangential, circumstantial responses Losing track of conversation Frequently deferring to family Over reliance on old information/memories Inattentive to appearance Unexplained weight loss or “failure to thrive” Practice Tips Family observations: ANY instances whatsoever of getting lost while driving, trouble following a recipe, asking same question repeatedly, mistakes paying bills Ask: “Let’s suppose your family member was alone on a domestic flight across the country and the trip required a layover with a gate change. Would he/she be able to manage that kind of mental task on his/her own?” Practice Tips Intact older adult should be able to: Describe 2 current events in some detail Describe what happened on 9/11, New Orleans disaster Name the current President and 2 immediate predecessors Describe medical history and names of some medications Dementia Care Screening Diagnosis Management Rationale for Early Detection Improve quality of life 1. 2. Early treatment is more effective Stabilization vs. improvement Patients can make decisions regarding care Patients can get to their “bucket list” Decrease burden on family and caregivers Connection to services that promote independent (supported) living as long as possible RTC support/counseling intervention (Mittelman et al. Neurology 2006) Non-pharm interventions reduce NH placement by 30% and delay placement for others by 18+ months Rationale for Early Detection May find reversible causes 3. NPH, TSH, B12, hypoglycemia, depression Improve management of co-morbid conditions 4. Underlying dementia = a primary risk factor of poor compliance in the elderly Chronic disease (diabetes, hypertension, anticoagulation) Integrity of the brain related to one’s ability to manage health Dementia as the Organizing Principle of Care Rationale for Early Detection 5. Reduce ineffective and expensive crisis-driven use of healthcare resources 6. Unhelpful emergency room visits and hospitalizations Prevent diagnosis during crises (wandering, hospitalization, car accidents, bankruptcy) More time to participate in clinical trials and important scientific studies Knowledge gap re: earlier stages Find a cure Screening Initial considerations Balance b/w time and sensitivity/specificity How will your practice incorporate screening? Who will administer tests? MDs, Nurses, social workers, allied health professionals What happens when screen is positive? Annual Wellness Visit: Medicare Took effect January 1, 2011 Affordable Care Act Medicare will cover an annual wellness visit which will include the creation of a personalized prevention plan For first time, “detection of cognitive impairment” is core feature of the exam Diagnosis of dementia requires a decline in function over time, so screen provides a baseline on cognition Screening Measures Wide range of options Mini-Cog (MC) Mini-Mental State Exam (MMSE) St. Louis University Mental Status Exam (SLUMS) Montreal Cognitive Assessment (MoCA) All but MMSE free online in public domain Utilize “Family Questionnaire (if family available) Mini-Cog Contents Verbal Recall (3 points) Clock Draw (2 points) Advantages • • • Quick (2-3 min) Easy High yield (executive fx, memory, visuospatial) Subject asked to recall 3 words Leader, Season, Table +3 Subject asked to draw clock, set hands to 10 past 11 +2 Mini-Cog Performance unaffected by education or language Sensitivity and Specificity similar to MMSE (76% vs. 79%; 89% vs. 88%) Borson JAGS 2003 Does not disrupt workflow & increases rate of diagnosis in primary care Borson Int J Geriatr Psychiatry 2000 Borson JGIM 2007 Failure associated with inability to fill pillbox Anderson et al Am Soc Consult Pharmacists 2008 Mini-Cog Pros Easy to administer Minimal time commitment Clock sensitive to visuospatial & executive dysfunction Simple scoring and interpretation Cons Not as sensitive for MCI or early dementia when compared to longer screens Brevity means less information to interpret Screen Failure MiniCog = <4 OR memory complaints by patient/family Schedule follow-up appt Insist on family collateral Perform more complex test (MOCA, SLUMS, MMSE) MMSE MMSE Pass > 26 Fail 25 or less MMSE Pros Widely accepted and validated for dementia screening 30-point scale well known and score easily interpretable Measures orientation, working memory, recall, language, praxis Cons Scale developed 40 years ago, before MCI criteria and when early dementia less well understood Lacks sensitivity to MCI and early dementia Takes 7+ min. to administer Copyright issues SLUMS SLUMS Pros More measures of executive functioning Good balance between easy and difficult items More sensitive than MMSE in detecting MCI and early dementia 30-point scale similar to MMSE Score range for MCI and dementia Free online Cons Takes 10 min. to administer Slightly more complex directions than MMSE Less name recognition than MMSE SLUMS Pass > 26 Fail 25 or less MoCA MoCA Pass > 26 Fail 25 or less MoCA Pros Much more sensitive than MMSE for MCI and early dementia More content tapping higher level executive fx 30-point scale similar to MMSE Translations available in 35+ languages Free online Cons Takes 10-14 min. to administer More complex administration and directions than MMSE Screening Tool Selection Montreal Cognitive Assessment (MoCA) Sensitivity: Specificity: 90% for MCI, 100% for dementia 87% St. Louis University Mental Status (SLUMS) Sensitivity: Specificity: 92% for MCI, 100% for dementia 81% Mini-Mental Status Exam (MMSE) Sensitivity: Specificity: 18% for MCI, 78% for dementia 100% Larner et al Int Psychogeriatr 2012; Nasreddine et al J Am Geriatr Soc 2005; Tariq et al Am J Geriatr Psychiatry 2006; Ismail et al Int J Geriatr Psychiatry 2010 Dementia Care Screening Diagnosis Management Diagnostic Workup H&P Diagnostics Labs Imaging Neuropsychological Diagnosis Family meeting assessment History & Physical History (with collateral) Onset, duration, course Examples of memory difficulties Impact on function $ management, meds, driving, cooking Mood, personality or behavior changes Drug or alcohol use Medication side effects Physical + brief neuro exam Do depression screening (PHQ-9), if not already completed Diagnostics: Labs Routine Labs Dementia screening CBC Vitamin Electrolytes TSH B12, folate BUN/creatinine Glucose Contingent labs Calcium RPR LFTs--?? HIV or MHA-TP Heavy metals Diagnostics: Imaging CT adequate for pts with clinical history consistent with AD MRI helpful for determining pattern of focal atrophy Request radiologist comment on hippocampal volume Scans often unremarkable in patients with early AD Rule out focal lesions, trauma, ischemia, NPH No need to repeat if pt. had recent scan Within 12 months No recent hx of trauma Diagnostics: Neuropsych Testing Helpful in distinguishing normal aging from MCI and dementia Atypical presentations Rule out: Pseudodementia, substance abuse factors, etc. Determine type of dementia, stage, capacity, most appropriate level of support Consider particularly when: MoCA SLUMS MMSE 19-27 18-27 18-28 Dementia Diagnosis Loss of Memory Plus one of the following Impairment in handling complex tasks (balancing a check book, calendars, clock drawing) Impairment in reasoning ability Impaired spatial ability and orientation (lost) Impaired language (word finding) Severe enough to impact daily life and is a decline from previous function Diagnosis Alzheimer’s disease: 60-80 % • Includes mixed AD + VD Lewy Body Dementia: 10-25 % Parkinson spectrum Vascular Dementia: 6-10 % Stroke related Frontotemporal Dementia: 2-5 % Personality or language problems Vascular Dementia Clinical Features Neuropsychological Testing Focal neurological signs Stepwise progression Often overlaps with AD (6-10% dementia related to pure VD) Predominant deficits in executive function, attention, and processing speed Neuroimaging Cerebrovascular Disease Large vessel stroke Periventricular/subcortical white matter disease Dementia with Lewy Bodies Clinical Features Neuropsychological Testing Parkinsonism, hallucinations, cognitive fluctuations, REM behavioral sleep disorder Predominant visuospatial dysfunction with relative sparing of verbal memory Neuroimaging Non-specific MRI atrophy pattern Occipital hypometabolism on FDG-PET Frontotemporal Dementia Clinical Features Typical onset prior to age 65 Behavioral symptoms Language symptoms Expressive aphasia, anomia, surface dyslexia Neuropsychological Testing Disinhibition, apathy, loss of empathy, repetitive stereotyped movements, hyperorality Impairments on executive function/language with relative sparing of episodic memory and visuospatial function Neuroimaging Atrophy of frontal and anterior temporal cortex Dementia Care Screening Diagnosis Management Overall Management Goals; Reduce suffering that accompanies the disease Reduce the negative impacts that dementia has on both health & quality of life Balancing independence & safety Optimize the management of co-morbid conditions Weighing benefits, burdens & risks of treatments Care Plan for acute illness Supporting the Caregiver Management Medication treatment Small component of care plan Education Increase family’s dementia competence Support / Referral Connect to community resources AD: Care Coordination 57 Intervention Model - Clinic Patient Care Partners Physician / Clinic Care Coordinator Care Coordination 59 Identify cognitive impairment, facilitate diagnosis Identify ‘team members’, including care partner Conduct needs assessment Develop & initiate care plan Communicate with team Monitor & re-evaluate Termination Clinic Care Coordination Needs 60 Care partner / team approach Disease education Assistance with medication management Written materials / plans POA / healthcare directive Appointment reminders Driving assessment / transportation options Occupational therapy / home safety assessment, fall risk Risk reduction strategies Connection to community resources & programs Risk Reduction Genetic Factors: APP, Presinilin 1 &2 / APOE4 Environmental Factors: begins in mid-life (50%) Mid-life HTN & Obesity (60%) Physical Inactivity (40 – 80%) Mid-life Depression (40 – 80%) Low Education / Cognitive Reserve (60 – 80%) Smoking (60%) Alcohol – Late Life & Binge Drinking (2xmo) Sleep Hygiene : quality & quantity Current Services in Minnesota 62 Mild Cognitive Impairment (MCI) Medical Evaluation / Diagnosis / Pharmacological Treatment* Research / Clinical Trials* Care Coaching / Consultation / Counseling* Information / Education* MCI Support Groups* Engagement Programs (arts, social, creativity)* Exercise / Nutrition / Cognitive Habilitation* * limited availability Current Services in Minnesota 63 Early Stage Medical Evaluation / Diagnosis / Pharmacological Treatment* Research / Clinical Trials* Care Coaching / Consultation Information / Education / Driving Evaluation* Early Stage Support Groups* Engagement Programs (arts, social, creativity)* Exercise / Nutrition / Cognitive Habilitation* Home Care / Companion Services* Assisted Living Medic Alert Safe Return® * limited availability 65 Current Services in Minnesota 66 Middle Stage Medical Evaluation / Diagnosis / Pharmacological Treatment Research / Clinical Trials* Care Coaching / Consultation / Counseling Information / Education / Driving Evaluation* Caregiver Support Groups* Adult Day Services* Meals on Wheels* Home Care / Home Health Care / Respite Services* Medic Alert Safe Return® Assisted Living / Nursing Facility * limited availability Current Services in Minnesota 67 Late Stage Medical Evaluation / Diagnosis / Pharmacological Treatment Care Coaching / Consultation / Counseling Information / Education Caregiver Support Groups* Adult Day Services* Meals on Wheels* Home Care / Home Health Care / Respite Services* Medic Alert Safe Return® Assisted Living / Nursing Facility Hospice* * limited availability Minnesota Resources 68 Research Alzheimer’s Disease Research Center – Mayo Clinic University of Minnesota VA Medical Center Alzheimer’s Research Center, Regions Hospital Health Partners Research Fund Healthcare Interactive (HCI) TrialMatch: http://www.alz.org/research/clinical_trials/find_clinical_tria ls_trialmatch.asp Minnesota Resources 69 ACL Projects Family Memory Care: evidence-based consultation Systems Integration: dementia capability Telephone / Internet Resources Alzheimer’s Association 1-800-272-3900 alz.org Senior LinkAge Line® 1-800-333-2433 MinnesotaHelp.info® AD: The Patient Experience 70 Conclusion / Q&A 71