Transcript Timing - Minnesota Board on Aging

Dementia Made Easier:
Tools for working with physicians & clinics
Terry R Barclay, PhD
Director, HealthPartners Neuropsychology
Outline
• Epidemiology and base rates
• Challenges to diagnosis
• Risks/benefits of early detection
• Why screen?
• Assessment and management tools
• Easy and efficient screening tools
• ACT on Alzheimer’s guidelines
• Working with physicians
Alzheimer’s Epidemic
• Epidemiological Concerns
• 5.2M Americans with AD in 2013
• Growing epidemic expected to impact 13M Americans
by 2050 and consume 1.1 trillion in healthcare
spending
• AD Diagnostic Challenges
• Only 50% of pts receive formal dx
• Diagnosis delayed on average by 6+ Years
• Sig. impairment in function by time it is recognized
Base Rates
• 1 in 9 people 65+ (11%)
• 1 in 3 people 85+ (32%)
• Of those with Alzheimer’s disease:
• 4%
<65
• 13% 65 -74
• 44% 75-84
• 38% 85+
Base Rates
• Almost 2/3 are women (longer life expectancy)
• Minority populations at higher risk (health/lifestyle
factors)
• Older African Americans (2x as whites)
• Older Hispanics (1.5x as whites)
• AD 6th leading cause of death in 2013
• If disease could be detected earlier (pre-clinical
stages) incidence would be much higher
Alzheimer’s Epidemic
• Numbers in Minnesota
• 2010
94,000
• 2025
110,000 projected
• Projected % increase in AD between 2000-2025
is 25%
Today, Alzheimer’s Disease Is …
• Prevalent
• Expensive
• Fatal
• Misunderstood
• Under-diagnosed
• Under-treated
• Poorly Managed
• Stigmatized
• On the rise
Diagnostic Challenges
Diagnostic Challenges
• Cultural
• Ageism and defining “normal” aging
• MD will bring health problems to my attention
• Associated stigma
• Medical
• Heterogeneous baseline
• Many patients unaware of problem
• Time
• No lab test (only rule outs)
• Treatment options/efficacy
• Wrong diagnosis?
• Fear of delivering bad news
• Implications for physician/patient relationship
Myth:
Most people
don’t want to
know if they
have
Alzheimer’s
disease
Fact:
Most Americans want
advanced notice
%
Surveys of US adults
Diagnostic Challenges
• Systemic/Institutional
• Low priority
• Few incentives
• Lack of procedural support
• Few specialists available (neurology, neuropsychology)
• Few community resources
Diagnostic Challenges
International Alzheimer’s Disease Physician Survey
• Lack of definitive tests (65%, top barrier)
• Lack of communication between patients / caregiver and
physicians
• 75% reported discussion initiated by patients/caregivers
• 44% “after they suspect the disease has been present for a while”
• 40% said patients/caregivers did not provide enough information to help
them make a diagnosis
• Patient / Family denial (65%) & social stigma (59%)
International Alzheimer’s Disease Physician Survey, 2012
“Beyond mountains, there are mountains.”
Haitian Proverb
Why Screen?
Does Screening Make Sense?
•
•
•
Money
Time
Patient care / outcomes
Money
•
Cost effectiveness of early assessment and
treatment?
Large scale studies ongoing
•
Getsios et al (2012)
• Projections based on clinical trial and follow-up
registry data
• Compared to no assessment / no treatment:
•
•
Reduction in healthcare costs by $5,300 /pp
Reduction in societal costs by $11,400 / pp
Time
•
Physician does not administer screen
•
•
Rooming nurse
Length of screen varies
•
Recommended tool takes 1.5 – 3 minutes
•
Only conducted annually
•
Mini-Cog does not disrupt workflow &
increases capture rate of cognitive impairment
in primary care
• Borson JGIM 2007
Patient Outcomes: Rationale for Early
Detection
1. Improve quality of life

Early treatment is more effective
 Stabilization vs. improvement



Delay functional decline
Patients can make decisions regarding care
Decrease burden on family and caregivers
2. 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
Patient Outcomes: Rationale for Early
Detection
3. Treat reversible causes

NPH, TSH, B12, hypoglycemia, depression
4. Improve management of co-morbid conditions



Underlying dementia = primary risk factor of poor compliance in
the elderly
Affects management of ALL chronic diseases (diabetes,
hypertension, anticoagulation)
Brain as 6th Vital Sign
Patient Outcomes: Rationale for Early
Detection
5. Reduce ineffective and expensive crisis-driven
use of healthcare resources


“good” vs. “bad” healthcare
Prevent diagnosis during crises (wandering, hospitalization, car
accidents, bankruptcy)
6. More time to participate in clinical trials and
important scientific studies


Knowledge gap re: earlier stages
Find a cure
National Priorities
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
• However, no guidance regarding:
• What screening tools to use
• What to do if patient fails screening
National Alzheimer’s Project Act (NAPA)
• Law signed into effect January 4, 2011
• US Dept of Health and Human Services
responsible for:
• Creating national plan to address Alzheimer’s disease epidemic
• Improve early diagnosis, care coordination and treatment
• Recommendations include:
• Physician education
• Dissemination of assessment tools
• Collaboration at state and local level to advance awareness and
readiness across public and private sectors
Local Health Systems
Numerous systems already screening
• HealthPartners
• Annual Wellness Visit Pilot
• Neurology, Ophthalmology, Pharmacy
• Allina
• 30,000+ screens to date
• Essentia Health (Duluth)
• Piloting with plans to roll out across entire system
• ACMC
• Piloting in one clinic with plans for expansion
Easy Practice Tips
Practice Tips
• Raise your expectation of the older patient
• Clinical interview
• Let patient answer questions without help
• Remember: Social skills remain intact
• Easy to be fooled by a sense of humor, irritability,
reliance on old memories, or quiet/affable demeanor
• Subjective interviews FAIL to detect dementia in early
stages
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
Cognitive Screening Tools
Screening
• Initial considerations
• Research findings re: early detection
• 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?
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
Screening Measures
• Do NOT
• Allow patient to give up prematurely or skip
questions
• Deviate from standardized instructions
• Offer multiple choice answers
• Bias score by coaching
• Be soft on scoring
• Score ranges already padded for normal errors
• Deduct points where necessary – be strict
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
Pass
•>4
Fail
• 3 or less
Borson S., Scanlan J, Brush M et al. 2000. The Mini-Cog: A cognitive “vital signs”
measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 15,
1021-1027.
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
Mini-Cog
Mini-Cog
Mini-Cog
Mini-Cog
Mini-Cog
Mini-Cog
Mini-Cog
• 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
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
• Cons
 Widely accepted and
 Scale developed 40 years
validated for dementia
screening
 30-point scale well known
and score easily
interpretable
 Measures orientation,
working memory, recall,
language, praxis
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
Pass
• > 26
Fail
• 25 or less
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
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
ACT on Alzheimer’s Tools
• Provider Toolkit
What is ACT on Alzheimer’s?
statewide
150+
50+
O R G A N I Z AT I O N S
INDIVIDUALS
collaborative
Impacts of Alzheimer’s
BUDGETARY
SOCIAL
PERSONAL
voluntary
Genesis of ACT on Alzheimer’s
•
2009 Legislative Mandate for Alzheimer’s
Disease Working Group (ADWG)
•
Legislative Report Filed in
January 2011
•
ACT on Alzheimer’s is second generation of
work focusing
on implementation
Goals of ACT on Alzheimer’s
identify &
invest in
promising
approaches
increase
detection &
improve care
sustain
caregivers
raise
awareness
& reduce
stigma
equip communities
www.actonalzheimers.org
Provider Practice Tools
• Cognitive screening flow
chart
• Dementia work-up
• Intervention Checklist
Diagnostic Workup
• History & physical
• Objective cognitive measurement
• Diagnostics
• Labs
• Imaging ?
• More specific testing (e.g., neuropsychological exam)?
• Diagnosis
• Family meeting
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
Intervention / Management
• Medication treatment
• Small component of care plan
• Referrals
• Senior LinkAge Line® the 1-stop shop for MN Seniors
• Alzheimer’s Association and other community organizations
• Goals
• Provide education
• Connect to programs and services
• Increase dementia competence
• For patient AND family
ACT on Alzheimer’s Tools
• Care Coordination Toolkit
Care Coordination Tools
• Care Coordinators in
Health Care Homes
• Care Coordination
Checklist
• Cognitive Status / Dx
• ID Care Partner
• Care Plan Checklist
• Disease Stages
ACT on Alzheimer’s Tools
• EMR Tools
EMR Tools
• Use EMR to automate:
• Screening
• Work-up
• AVS with dementia education
• Internal orders and referrals
• Community supports
Partnering with Physicians & Clinics
76
Barriers to Community Connection
1.
2.
3.
4.
5.
Under-diagnosis
Lack of understanding about benefits of non-drug
treatment
Lack of knowledge about available resources
Missed / delayed connection to resources
Unprepared communities
Partnering with Physicians
• Doctors are motivated by things/people who:
• Help them improve patient care / outcomes
• Show me the data
• Save them time
• Reduce their stress
• Improve reimbursement
• Enhance recognition and appreciation
• YOU CAN DO ALL OF THESE THINGS
Building Relationships
• Talk to all who will listen
• You never know how your information will be passed on
• Be AUTHENTIC
• Be yourself and talk about what you know
• Build trust and credibility
• Return calls
• Do what you say and in a timely manner
• They will remember if you don’t
Real World Objections
• Many objections revolve around these issues:
• Cost: “My patients can’t afford your fee for care / time with a consultant.”
• Fear of Change: “I’ve been using this screening tool for years, and I know
it like the back of my hand” or, “I don’t have time for new screens and
processes.”
• Complacency: “There aren’t any really good medications, why should I
diagnose?” and, “You can’t diagnose dementias properly with just these
screens.” “What is the point of diagnosis? There is little that can be done.”
• Timing: “We are going through a big change (EMR, management) here
right now; I don’t have time to make more changes.”
Real World Objections
• External input: “I need to talk to the clinic manager/my colleagues/nurse
before I can move forward.”
• Personal/Office politics: “We have our own way of doing things with
dementia patients. You’ll need to talk to our clinic manager.”
• Trust: “It sounds like you have something to offer but I’m not sure I have
the time to make this work” and “If my clinic gives you all of our patients,
how can you keep up?”
OBJECTIONS: Be Prepared
• Whatever organization you represent, you will get
objections.
• You are asking for change. Most will resist.
• If you are asked a tough question, you can always say
“I’m not sure about that answer; may I find out and
email/call you with an answer when I have it?”
• Sometimes, objections are red herrings to distract you or
put you off…then they don’t have to consider what you
have to offer any more.
How Can I Get Clinicians to ACT?
• Find out what is causing them PAIN/distress/frustration
regarding their geriatric/dementia patients
• They will not REALLY listen to you until you have
uncovered or acknowledged the challenges that are
causing them pain.
Partnering with Physicians
Patient
Care
Partner
Doctor
Partnership Goals



Strengthen physician/agency relationship
Encourage earlier diagnosis of dementia
Increase referrals to agency
Making Headway
• Work on your “Elevator Speech”…10-30 seconds
• Walk in to the clinic…don’t be afraid
• Get name and number of contact person from front desk
staff, and follow up
• Early mornings might be best for MD contact
• Always wear a name tag
• Have business cards ready
• Be prepared
• Try not to get frustrated, Don’t take it personally.
• Ask, “Are physicians my best target audience?”
Making Headway
• Ask patients / families for the name and number of their
physician
• Communicate the patient’s care plan back to the provider
• Call the clinic, ask for the doctor’s nurse
• Ask nurse how to get the patient’s care plan to the doctor
and in the patient chart / record
• Coach patient / family on how to partner with physicians
• Give the plan to the family and ask them to share with doctor
• Feedback loop
• Specific, concrete, brief, bullet points
651-254-7900
www.healthpartners.com/memoryloss