Transcript Older Hispanics and Latinos (1.5x as whites)

An A- Z Guide for Working with Patients
with Memory Loss and Dementia
Objectives
• Understand the value of timely detection
• Review best practices in medication and non-medication
interventions
• Understand how to connect caregivers to evidence-based
therapies, resources and services
• Identify key steps in the continuum of dementia care,
including management of behavioral symptoms
• Leave with a full clinical toolbox
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Quick Facts on AD
Of those with Alzheimer’s disease:
Certain populations
at higher risk:
Older African Americans
(2x as whites)
Older Hispanics and Latinos
(1.5x as whites)
Source: Alzheimer’s Association Facts and Figures 2014
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Patients with Dementia
• A population with complex care needs
2.5 chronic
conditions
(average)
5+
medications
(average)
3 times more
likely to be
hospitalized
Many
admissions
from
preventable
conditions,
with higher
per person
costs
• Indisputable correlation between chronic conditions and costs
Alzheimer’s Association Facts
and Figures 2014
4
Are we ready for dementia?
• Low recognition/diagnosis rates (~ 50%)
• Care partners not identified
• Care approach unsystematic,
uncoordinated
• Poor clinician support for complex care
• Low consensus around care quality
Targets for Improving Quality of
Dementia Care
Discontinuity of care
Poor chronic
disease control
Medication
mismanagement
Safety risks
Preventable hospitalizations,
readmissions, and complications
Unnecessary crises
Family breakdown
Caregiver stress, poor health
Missed diagnoses
Inappropriate Rx
© S. Borson
Bluestone Physician Services
DEFINE THE PROBLEM
IN NEW WAYS
CREATE NEW
SOLUTIONS
Rethinking Everyday Practice
• Brain historically ignored, not a focus of
routine exam
– Is this logical? Consider base rates of dementia
• Dementia is simply “brain failure”
– Heart failure
– Kidney failure
– Liver failure
• Brain as 6th Vital Sign
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Dementia-capable health care:
The Patient’s Perspective
• Timely recognition and diagnosis of cognitive
impairment
• Systematic engagement of care partners
• Goal-focused, systematic, proactive health care
• Focus on living well, non-medication strategies
• Care coordination and integration of medical
care and psychosocial services
Dementia-capable health care:
The Clinician’s Perspective
• Clinician engagement and support
• Incentives for providing high quality care
• Care coordination, dedicated teams, and
functional communication systems
• Systematic use of health system data to
find quality gaps and target improvements
Provider Tools:
ACT on Alzheimer’s
ACT on Alzheimer’s
statewide
300+
60+
O R G A N I Z AT I O N S
INDIVIDUALS
volunteer
driven
collaborative
I M PA C T S O F A L Z H E I M E R ’ S
BUDGETARY
SOCIAL
PERSONAL
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Collaborative Goals/Common
Agenda
Five shared
goals with a
Health Equity
perspective
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ACT Tool Kit
• Evidence and consensusbased, best practice
standards for Alzheimer’s
care
• Tools and resources for:
– Physicians
– Care coordinators
– Community agencies
– Patients and families
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ACT Tools
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ACT Tools
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Clinical Provider Practice Tool
• Easy button workflow for:
1. Screening
2. Dementia work-up
3. Treatment / care
www.actonalz.org/provider-practice-tools
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Mini-Cog: Sam
www.actonalz.org/videos
18
Delivering the Diagnosis: Sam
www.actonalz.org/videos
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After A Diagnosis
- Partnering with
doctors
- Understanding the
disease
- Planning ahead
- How to ask for help
- Using community
resources
- Role of care
coordinator
www.actonalz.org
21
Detecting Dementia
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Rationale for Timely Detection
1. Improved management of co-morbid conditions
2. Reduce ineffective, expensive, crisis-driven use
of healthcare resources
3. Improve quality of life
•
•
Patients can participate in decisions
Decrease burden on family and caregivers
4. Intervene to promote a safe and happy
environment that supports independence
The message: You have a bad disease. We can help you make life
better for you and your family.
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Mini-Cog™
Contents
• Verbal Recall (3 points)
• Clock Draw (2 points)
Advantages
• Quick (2-3 min)
• Easy
• High yield (executive fx,
memory, visuospatial)
Borson et al., 2000
Subject asked to recall 3 words
Leader, Season, Table
+3
Subject asked to draw clock,
set hands to 10 past 11
+2
DATE_________ ID_________________________AGE____GENDER M F LOCATION ______________________ TESTED BY________
MINI-COG ™
1) GET THE PATIENT’S ATTENTION, THEN SAY: “I am going to say three words that I want you to remember now and later. The words are
Banana
Sunrise
Chair.
Please say them for me now.” (Give the patient 3 tries to repeat the words. If unable after 3 tries, go to next item.)
(Fold this page back at the TWO dotted lines BELOW to make a blank space and cover the memory words. Hand the patient a pencil/pen).
2) SAY ALL THE FOLLOWING PHRASES IN THE ORDER INDICATED: “Please draw a clock in the space below. Start by drawing a large
circle.” (When this is done, say) “Put all the numbers in the circle.” (When done, say) “Now set the hands to show 11:10 (10 past 11).” If
subject has not finished clock drawing in 3 minutes, discontinue and ask for recall items.
-------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- --------------
-------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- ------------3) SAY: “What were the three words I asked you to remember?”
_
Score the clock (see other side for instructions):
(Score 1 point for each) 3-Item Recall Score
Normal clock
Abnormal clock
Total Score = 3-item recall plus clock score
2 points
0 points
Clock Score
0, 1, 2, or 3 = clinically important cognitive impairment likely;
4 or 5 = clinically important cognitive impairment unlikely
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CLOCK SCORING
NORMAL CLOCK
A NORMAL CLOCK HAS ALL OF THE FOLLOWING ELEMENTS:
All numbers 1-12, each only once, are present in the correct
order and direction (clockwise).
Two hands are present, one pointing to 11 and one pointing to
2.
ANY CLOCK MISSING ANY OF THESE ELEMENTS IS SCORED
ABNORMAL. REFUSAL TO DRAW A CLOCK IS SCORED
ABNORMAL.
SOME EXAMPLES OF ABNORMAL CLOCKS (THERE ARE MANY OTHER KINDS)
Abnormal Hands
Missing Number
.................................................................................................................................................................................................................................
Mini-CogTM, Copyright S Borson. Reprinted with permission of the author, solely for clinical and teaching use. May not be modified or
used for research without permission of the author ([email protected]). All rights reserved.
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Mini-Cog™
Pass
• >4
Fail
• 3 or less
Borson et al., 2000
Mini-Cog Research
• Performance unaffected by education or language
• Borson Int J Geriatr Psychiatry 2000
• 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 JGIM 2007
• Failure associated with inability to fill pillbox
• Anderson et al Am Soc Consult Pharmacists 2008
Mini-Cog Improves Physician
Recognition
100
***
***
60
***
% Correct
80
Mini-Cog
Patient’s own
physician
40
20
*** p < .001
0
CDR Stage
0.5
MCI
1
Mild
2
Mod
3
Sev
Borson S et al. Int J Geriatr Psychiatry 2006; 21: 349
Cognitive Impairment Predicts
Readmissions
Mini-Cog Performance Novel Marker of Post
Discharge Risk Among Patients Hospitalized for
Heart Failure (Patel, 2015; Cleveland Clinic)
• Method: 720 patients screened with MiniCog
during hospitalization for HF
• Results: 23% failed screen (M age 78, 49% men)
– MiniCog best predictor of readmission over 6 mos.
among 55 variables
• Stronger than length of stay, cause of HF, and even
comorbidity status
• Readmission rate 2 times higher among screen fails
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Pre-op cognitive impairment and
adverse post-op outcomes
Robinson TN, Wu DS, Pointer LF et al. J Am Coll Surg 2012; 215:12-18.
Mini-Cog Failure Predicts:
Length of stay
Long-term post-op
mortality
Delirium
ED visits, hospitalizations and 30-day readmissions
Elective surgery complications
Post-op nursing home
placement
Risk of medication
Everyday disability
mismanagement
Low health literacy
© S. Borson
Raising the Bar
• Be proactive: detect and disclose
• Develop comprehensive care plan
– Dementia as an organizing principle
• Systematically include care coordination
• Make friends with the family
– If in AL, connect patient/family to experts in the
community
• Alzheimer’s Association
Managing Mid to
Late Stage Dementia
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Managing Dementia Across the
Continuum
www.actonalz.org/provider-practice-tools
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Mood and Behavioral Symptoms
• Neuropsychiatric symptoms common:
– > 80% of nursing home residents with dementia
• Nearly all patients with dementia will suffer
from mood or behavioral symptoms during
the course of their illness
Ferri et al., 2005; Jeste et al., 2008
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5 Most Difficult Behaviors
Irritability
A/V hallucinations
Delusions
Hostility / Aggression
Extreme social withdrawal
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Behavior Is Communication
• Your first questions should be:
– Does this really require treatment?
– Who is most affected? Patient? Caregivers?
• Think like a behavioral analyst
–
–
–
–
–
Who (is involved/present)
What (exact description, be specific)
When (time dependent? only in morning? triggers?)
Where (location specific?)
Why (what happens right before, right afterwards? what
do family think is cause?)
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Common Underlying Causes
•
•
•
•
•
•
•
•
•
Fear or uncertainty
Feeling lost
Boredom
Over/under stimulation
Environmental stressors
Loneliness
Bereavement
Depression
Memories
Common Underlying Causes
•
•
•
•
•
•
•
•
Pain or fear of pain
Caregiver reactions
Post-traumatic stress
Invasion of personal
space
Loss of control/choice
Depersonalization
Care transitions
Staff rotations
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10 Golden Rules
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#1 Acceptance is Unnecessary
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#2 Medication is a Last Resort
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Optimizing Medication Therapy
Professional Resources
• AGS Beers Criteria (2012)
• START (Screening Tool to Alert
Doctors to the Right
Treatment)
• STOPP (Screening Tool of
Older Persons’ Potentially
inappropriate Prescriptions)
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#3 Change Will Always Be
Disruptive
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#4 Cognitive Work Load Should
Match Cognitive Capacity
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#5 Validate and Redirect
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#6 Never Argue
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#7 Statements Are Better Than
Questions
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#8 Emotions are Contagious
https://www.youtube.com/watch?v=qCcxoG-n6PU
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#9 We All Need Meaning and
Purpose
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#10 Focus on Caregivers
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Resources for
Behavior Management
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#1 Understanding Difficult
Behaviors
• Authors: Robinson,
Spencer & White
• Published 2007
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#2 Coach Broyle’s Playbook
• Broylesfoundation.com
– Paperback or electronic
download
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#3 Alzheimer’s Action Plan
• Authors: Doraiswamy,
Gwyther, & Adler
• Published: 2009
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#4 Alzheimer’s Association
Alzheimer’s Association
800.272.3900 | www.alz.org/mnnd
One stop shop for:
– Care Consultation
– Support Groups
– 24/7 Helpline
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Bluestone Physician Services
DEFINE THE PROBLEM
IN NEW WAYS
CREATE NEW
SOLUTIONS
ACKNOWLEDGEMENTS
This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health
Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS)
under Grant Number UB4HP19196 to the Minnesota Area Geriatric Education Center (MAGEC) for
$2,192,192 (7/1/2010—6/30/2015). This information or content and conclusions are those of the
author and should not be construed as the official position or policy of, nor should any
endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.
Minnesota Area Geriatric Education Center (MAGEC)
Grant #UB4HP19196
Director: Robert L. Kane, MD
Associate Director: Patricia A. Schommer, MA
References & Resources
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Alzheimer’s Association (2014). Alzheimer’s Disease Facts and Figures, Alzheimer’s & Dementia, Volume 10, Issue 2.
Anderson K, Jue S & Madaras-Kelly K 2008. Identifying Patients at Risk for Medication Mismanagement: Using Cognitive
Screens to Predict a Patient's Accuracy in Filling a Pillbox. The Consultant Pharmacist, 6(14), 459-72.
Barry PJ, Gallagher P, Ryan C, & O‘mahony D. (2007). START (screening tool to alert doctors to the right treatment)--an
evidence-based screening tool to detect prescribing omissions in elderly patients. Age and Ageing, 36(6): 632-8.
Blendon RJ, Benson JM, Wikler, EM, Weldon, KJ, Georges, J, Baumgart, M, Kallmyer B. (2012). The impact of experience
with a family member with Alzheimer’s disease on views about the disease across five countries. International Journal of
Alzheimer’s Disease, 1-9.
Boise L, Neal MB, & Kaye J (2004). Dementia assessment in primary care: Results from a study in three managed care
systems. Journals of Gerontology: Series A; Vol 59(6), M621-26.
Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. (2000). The mini-cog: a cognitive “vital signs” measure for dementia
screening in multi-lingual elderly. Int J Geriatr Psychiatry, 15(11):1021-1027.
Borson S, Scanlan JM, Chen P, Ganguli M. (2003). The Mini-Cog as a screen for dementia: validation in a population-based
sample. J Am Geriatr Soc;51(10):1451-1454.
Borson S, Scanlan J, Hummel J, Gibbs K, Lessig M, & Zuhr E (2007). Implementing Routine Cognitive Screening of Older
Adults in Primary Care: Process and Impact on Physician Behavior. J Gen Intern Med; 22(6): 811–817.
Boustani M, Peterson B, Hanson L, et al. (2003). Systematic evidence review. Agency for Healthcare Research and Quality;
Rockville, MD: Screening for dementia.
Boustani M, Callahan CM, Unverzagt FW, Austrom MG, Perkins AJ, Fultz BA, Hui SL, Hendrie HC (2005). Implementing a
screening and diagnosis program for dementia in primary care. J Gen Intern Med. Jul; 20(7):572-7.
Ferri CP, Prince M, Brayne C, et al. (2005). Alzheimer’s Disease International Global prevalence of dementia: A Delphi
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References & Resources
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Finkel, SI (Ed.) (1996). Behavioral and Psychological Signs of Dementia: Implications for Research and Treatment.
International Psychogeriatrics, 8(3).
Folstein MF, Folstein SE, & McHugh PR (1975). "Mini-mental state". A practical method for grading the cognitive state of
patients for the clinician. J Psychiatr Res, Nov 12(3):189-98.
Gallagher P & O’Mahony D (2008). STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions):
Application to acutely ill elderly patients and comparison with Beers’ criteria. Age and Ageing, 37(6): 673-9.
Gitlin LN, Kales HC, Lyketsos CG, & Plank Althouse E (2012). Managing Behavioral Symptoms in Dementia Using
Nonpharmacologic Approaches: An Overview. JAMA, 308(19): 2020-29.
Holroyd S, Turnbull Q, & Wolf AM (2002). What are patients and their families told about the diagnosis of dementia?
Results of a family survey. Int J Geriatr Psychiatry, Mar;17(3):218-21.
Ismail Z, Rajji TK, & Shulman KI (2010). Brief cognitive screening instruments: An update. Int J Geriatr Psychiatry, 25:111–20.
Jeste DV, Blazer D, Casey D et al. (2008). ACNP White Paper: Update on Use of Antipsychotic Drugs in Elderly Persons with
Dementia. Neuropsychopharmacology, 33(5): 957-70.
Larner AJ (2012). Screening utility of the Montreal Cognitive Assessment (MoCA): In place of – or as well as – the MMSE?
Intern Psychogeriatrics, 24, 391–396.
Lin JS, O’Connor E, Rossom RC, Perdue LA, Burda BU, Thompson M, & Eckstrom E (2014). Screening for Cognitive
Impairment in Older Adults: An Evidence Update for the U.S. Preventive Services Task Force. Agency for Healthcare Research
and Quality, Evidence Syntheses, 107.
Long KH, Moriarty JP, Mittelman MS, & Foldes SS (2014). Estimating The Potential Cost Savings From The New York
University Caregiver Intervention In Minnesota. Health Affairs, 33(4), 596-604.
McCarten JR, Anderson P Kuskowski MA et al. (2012). Finding dementia in primary care: The results of a clinical
demonstration project. J Am Geritr Soc;60(2):210-217.
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References & Resources
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Mittelman MS, Haley WE, Clay OJ, & Roth DL (2006). Improving caregiver well-being delays nursing home placement of
patients with Alzheimer disease. Neurology, November 14(67 no. 9), 1592-1599.
Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, & Chertkow H. (2005). The
Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment. J Amer Ger Soc, 53(4), 69599.
National Chronic Care Consortium and the Alzheimer’s Association. 1998. Family Questionnaire. Revised 2003.
Silverstein NM & Maslow K (Eds.) (2006). Improving Hospital Care for Persons with Dementia. New York: Springer Publishing
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Tariq SH, Tumosa N, Chibnall JT, Perry MH, & Morley E. (2006). Comparison of the Saint Louis University mental status
examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder: A pilot study.
Am J Geriatr Psychiatry, Nov;14(11):900-10.
Turnbull Q, Wolf AM, & Holroyd S (2003). Attitudes of elderly subjects toward “truth telling” for the diagnosis of Alzheimer’s
disease. J Geriatr Psychiatry Neurol, Jun;16(2):90-3.
Zaleta AK & Carpenter BD (2010). Patient-Centered Communication During the Disclosure of a Dementia Diagnosis. Am J
Alzheimers Dis Other Demen, 25, 513.
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References & Resources
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2012 Updated AGS Beers
Criteria:http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
Alzheimer’s Association Family Questionnaire: http://www.alz.org/mnnd/documents/Family_Questionnaire.pdf
Alzheimer’s Association (2009). Know the 10 signs.http://www.alz.org/national/documents/checklist_10signs.pdf
Coach Broyles Playbook on Alzheimer’s: http://www.caregiversunited.com
Honoring Choices Minnesota:http://www.honoringchoices.org
Living Well workbook:http://www.alz.org/documents/mndak/alz_living_well_workbook_2011v2_web.pdf
Medicare Annual Wellness Visit: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7079.pdf
MiniCog™ http://www.alz.org/documents_custom/minicog.pdf
Montreal Cognitive Assessment (MoCA)http://www.mocatest.org
National Alzheimer’s Project Act: http://aspe.hhs.gov/daltcp/napa/NatlPlan.pdf
Next Step in Care: http://www.nextstepincare.org
Physician Orders for Life Sustaining Treatment (POLST): http://www.polst.org
St. Louis University Mental Status (SLUMS)
examinationhttp://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf
The Alzheimer’s Action Plan:http://www.amazon.com/The-Alzheimers-Action-Plan-Know/dp/0312538715
Understanding Difficult Behaviors:http://www.amazon.com/Understanding-Difficult-Behaviors-suggestionsAlzheimers/dp/0978902009
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