PowerPoint - ACT on Alzheimer`s
Download
Report
Transcript PowerPoint - ACT on Alzheimer`s
Best Practices for
Optimizing Dementia Care
for Care Coordinators
Rev 04-29-16
Objectives
• Understand the value of timely detection
• Employ simple approaches to assessing cognition among
older patients and communicating assessment results
• Describe medication and non-medication treatments
• Employ best practices in care coordination for patients
with Alzheimer’s disease
• Identify caregiving risks and connect patients and
caregivers to evidence-based therapies, resources and
services
2
Introduction to
ACT on Alzheimer’s
Focus on Quality Health Care
www.ACTonALZ.org
4
ACT Tool Kit
• Evidence- and consensusbased best practice standards
for Alzheimer’s care
• Tools and resources for:
– Primary care providers
– Care coordinators
– Community agencies
– Patients and care partners
www.actonalz.org/provider-practice-tools
5
Health Care Settings: Care
Coordination
www.actonalz.org/provider-practice-tools
Dementia and Alzheimer’s
7
FAQ
What is the difference between
dementia and Alzheimer’s
disease?
Dementia Diagnoses
FTD
Alzheimer’s disease: 60-80 %
• Includes mixed AD + VD
Lewy Body
Dementia
Lewy Body Dementia: 10-25 %
Vascular
Dementia
– Parkinson spectrum
Alzheimer’s
Disease
Vascular Dementia: 6-10 %
– Stroke related
Frontotemporal Dementia: 2-5 %
– Personality or language
disturbance
Disease Education: What is AD?
http://youtu.be/ECbjK4Ra-Ys
10
Stages of Alzheimer’s Disease
Alzheimer’s Disease:
Challenges and Opportunities
Alzheimer’s: A Public Health Crisis
• Scope of the problem
– 5.4M Americans with AD in 2016
– Growing epidemic expected to impact 13.8M Americans by
2050 and consume 1.1 trillion in healthcare spending
– Almost 2/3 are women (longer life expectancy)
• Some populations at higher risk
– Older African Americans (2x as whites)
– Older Hispanics (1.5x as whites)
Alzheimer’s Association Facts
and Figures 2016
13
The Lens of Health Equity
• Take into consideration health
disparities and inequities
• Seek the attainment of the
highest level of health for all
people
• Help create a new style of
“curb cut” by promoting
cultural competence
14
Base Rates
• 1 in 9 people 65+ (11%)
• 1 in 3 people 85+ (32%)
Ages of People with Alzheimer’s
Disease in the United States
Alzheimer’s Association Facts
and Figures 2016
15
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
Schubert, Boustani, et al., JAGS, 2006; Alzheimer’s
Association Facts & Figures Report 2014.
16
Challenges & Opportunities
• AD under-recognized by providers
– Fewer than 50% of patients receive formal diagnosis
• Millions unaware they have dementia
– Diagnosis often delayed on average by 6+ years after
symptom onset
– Significant impairment in function by time it is
recognized
• Poor timing: diagnosis frequently at time of crises,
hospitalization, failure to thrive, urgent need for
institutionalization
Boise et al., 2004; Boustani et al., 2003; Boustani et al., 2005; Silverstein & Maslow, 2006
17
Disease Education: Facts & Figures
https://youtu.be/kcI5UVwFyN0
18
Identifying Cognitive Impairment
19
Practice Tips
• Often signs and symptoms are not recognized
until they are quite pronounced
– Attribution error: “What do you expect? She is 80
years old.”
– Red Flag: Subjective impressions FAIL to detect
dementia in early stages
Practice Tips
• Chart Review
– Red Flag: memory concerns, forgetfulness, memory
complaints
– Red Flag: missed appointments
– Red Flag: emergency contact is main contact for all
communication with patient
– Red Flag: Patient has been prescribed on
Aricept/Donepezil or other cholinesterase inhibitors
but no Alzheimer’s disease diagnosis on Problem List
Practice Tips
• Clinical interview
– Social skills remain largely intact until later stages of
dementia
• Easy to be fooled by: sense of humor, reliance on old memories,
quiet/affable demeanor
• Red Flag: Patient who frequently defers answers to family member
– Let patient answer questions without help
• “I am going to talk with you, Mr. Jones first, then your wife Mrs.
Jones will have a chance to talk to me in a few minutes.”
Practice Tips
• Clinical Interview (in-person or telephone)
– Many patients know the correct answer for the “YES” and “NO”
questions that are asked on our patient flows.
• Red Flag: CM: “Are you taking your mediation? Do you forget to
take it?”
• Red Flag: Pt.: “Oh No! I never forget to take my medication
• “Explain to me how you take your medication? How do you
remember? When do you take it? What is _____Rx for?”
– Watch and record repetition (not normal in 7-10 min
conversation)
– Note tangential, circumstantial responses
– Does the patient loose track of the conversation?
Practice Tips
• Red Flags: Issues of Case Management
ON THE PHONE: how much of the picture are we getting?
IN THE CLINIC: if the patient is alone, how much of the
picture are we getting? If the caregiver does not feel free to
speak, how much of the picture are we getting?
IN THE HOME: if we don’t use a different lens, how much of
the picture are we getting?
Practice Tips
• Family observations – know the patient better than
anyone else and must be used as a historian to
understand the patient’s issues
–
–
–
–
–
Red Flag: getting lost while driving
Red Flag: trouble following a recipe
Red Flag: asking same questions repeatedly
Red Flag: mistakes paying bills
Red Flag: reading the same paper or book over and over
• By the time family report problems, symptoms
have typically been present for quite a while
and are getting worse
Practice Tips
• Provide “real examples” to pt. and family
members to help frame the issues the patient
is living with:
– Pt. is alone on a domestic flight across the country and the
trip required a layover with an unexpected gate change,
would he be able to manage that kind of mental task on his
own?
• Red Flag: “Not likely” for a patient of any age; this is an issue worth
exploring deeper
Practice Tips
• Intact older adult should be able to:
– Describe at least 2 current events in adequate detail (who,
what, when, why, how)
– Describe events of national significance
• 9/11, New Orleans disaster, etc.
– Name or describe the current President and an immediate
predecessor
– Describe their own recent medical history and report the
conditions for which they take medication
Identifying Cognitive Impairment
28
Cognitive Impairment ID
Workflow: The Big Picture
1.
2.
3.
4.
Administer cognitive assessment tool
Discuss results with client/patient
Recommend next steps, follow-up
Consider providing written documentation
to:
– Client/patient and family
– Physician/medical provider
30
Preparation
• Before using an assessment tool:
– Make sure you practice and are comfortable with
all administration and scoring guidelines of the
tool(s)
– Use parts or all of the scripts provided in this
webinar as a basis for providing feedback to
clients/patients and other healthcare providers
regarding assessment results
• Your script may vary, in part, on your unique
professional role and whether you are working inside a
medical clinic or in a community healthcare
agency/setting
31
Preparation
• Write down your scripts and practice delivering
them until you can:
– Provide the information clearly and succinctly
– Offer feedback calmly, in a matter-of-fact tone,
without anxiety
• Any tension/anxiety you have will be projected
onto clients/patients
• Keep your scripts on hand at all times (with your
screening tools) so you always have them for
reference, when needed
32
Preparation
• Never use the words “dementia” or
“Alzheimer’s disease”
– Screening tools are not diagnostic
– Using these terms is premature at this stage and
can contribute to anxiety/fear
• Avoid
– Being unnecessarily wordy
– Over-explaining or rationalizing the process
33
Administration Best Practices
• Try not to:
– Use the words “test” or “memory”
• Instead: “We’re going to do something next that
requires some concentration”
– Allow patient to give up prematurely or skip
questions
– Deviate from standardized instructions
– Offer multiple choice answers
– Be soft on scoring
– Score ranges already padded for normal errors
– Deduct points where necessary – be strict
Cognitive Assessment Tools
• Wide range of options
–
–
–
–
–
Mini-Cog™ (MC)
Mini-Mental State Exam© (MMSE)
St. Louis University Mental Status Exam™ (SLUMS)
Montreal Cognitive Assessment™ (MoCA)
Rowland Universal Dementia Assessment (RUDAS)
• All but MMSE free, in public domain, and online
www.actonalz.org/screening-diverse-populations
Borson et al., 2000; Folstein et al., 1975; Nasreddine 2005; Tariq et al., 2006
Alternative Tools
• Virtually all cognitive assessment tools based
upon a euro-centric cultural and educational
model
• Consider: country and language of origin,
type/quality/length of education, disabilities
(visual, auditory, motor)
• Alternative tools my be less biased
36
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
www.actonalz.org/sites/default/files
/documents/Mini-Cog_.pdf
38
Mini-Cog
Pass
• >4
Fail
• 3 or less
NOTE: A cut point of <3 on the Mini-Cog has been validated for dementia screening, but many individuals with
clinically meaningful cognitive impairment will score higher. When greater sensitivity is desired, a cut point of <4 is
recommended as it may indicate a need for further evaluation of cognitive status.
Borson et al., 2000; Borson, Scanlan, Chen et al., 2003; Borson, Scanlan, Watanabe et al., 2006; Lessig, Scanlan et al., 2008;
McCarten, Anderson et al., 2011; McCarten, Anderson et al., 2012; Tsoi, Chan et al., 2015
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
Borson S et al. Int J Geriatr Psychiatry 2006; 21: 349
2
Mod
3
Sev
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
• Fails discharged to facility (vs. home) had lower
readmission rates within first 30 days
42
Case Study: Colleen
•
•
•
•
•
•
•
•
66 y/o presents to primary care with memory complaints
Daughter c/o short-term memory is poor
Began 1-2 years ago, getting worse
Hx Low blood sugar, history of heart attack, repeat
hospitalizations for atrial flutter
Frequent medication changes, managing independently
Patient is a retired accountant for family business
Lives with husband who is still running the family
business
Referred to Care Coordination
Mini-Cog: Colleen
http://youtu.be/DeCFtuD41WY
44
Colleen’s Clock
Colleen’s Score
Mini-Cog Exercise
Form groups of 2
• Review Mini-Cog Form
• Administer Mini-Cog to each other
• Score sample clocks
47
Clock #1
Clock #2
Clock #3
Clock #4
Clock #5
Clock #6
Clock #7
SLUMS
Tariq et al., 2006
SLUMS
High School Diploma
Less than 12 yrs education
Pass
> 27
> 25
Fail
26 or less
24 or less
Tariq SH, Tumosa N, Chibnall et al. 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. 2006
Nov;14(11):900-10.
56
SLUMS: Colleen
http://youtu.be/jyp0ShPiUH8?list=UUOPv8U5bHcdDCm4edmQDY9g
57
SLUMS Scoring: Colleen
58
SLUMS Scoring: Colleen
59
SLUMS Scoring: Colleen
60
MoCA
Nasreddine et al., 2005
MoCA
Pass
• > 26
Fail
• 25 or less
Nasreddine 2005
62
MoCA: Sam
http://youtu.be/ryf8SG0NQLQ?list=UUOPv8U5bHcdDCm4edmQDY9g
63
MoCA Scoring: Sam
• Interactive scoring exercise
64
MoCA Scoring: Sam
65
MoCA Scoring: Sam
66
MoCA Scoring: Sam
67
MoCA Scoring: Sam
68
Objective Measure 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 2012; Nasreddine et all, 2005; Tariq et al., 2006; Ismail et al., 2010
Family Questionnaire
www.actonalz.org/pdf/Family-Questionnaire.pdf
RUDAS
• Developed intentionally for
patients with low levels of
education, limited language
fluency, & diverse cultural
backgrounds
• Measures wide variety of
cognitive abilities
• Score range of 0-30 useful for
tracking change over time
• Strong psychometric
properties
• 10-15 minutes to administer
71
RUDAS
72
RUDAS
73
AD8 Dementia Interview
http://knightadrc.wustl.edu/About_Us/PDFs/AD8form2005.pdf
Communicating Results of Cognitive
Assessment to Patients and Healthcare
Providers
Client Reactions
• You should plan for a wide range of client
reactions to assessment results
• Responses may range from acceptance to
rejection
– Some already worried about their memory and
are interested in getting answers
– Others may be surprised by results, but willing to
follow-up
– Some may not be aware of problem (forgetting
they are forgetful) or ready to accept the
information
76
Client Reactions
• Lack of acceptance can be an effective
mechanism to:
– Preserve sense of self (idea of cognitive impairment
may pose threat to identity, self-worth)
– Manage fear and anxiety about the future
• Readiness to act
– May be a gradual process requiring multiple
interactions with the client/patient
• Positive outcomes are possible in a context in
which some negative reactions/feelings occur
77
Sample Script: The Purpose
• Regardless of a passing or failing score, explain
the patient’s test result by first reminding
them of the assessment purpose:
• “The purpose of this task was to check on the
health of the brain and determine if there is
any need for further evaluation of your
thinking or memory.”
78
Sample Script: Passing Score
• “You obtained a normal score on this
measure, which is good news. No additional
action is needed.”
• “However, if you have concerns about your
thinking or memory or thinking, talk to
[contact] your doctor.”
79
Sample Script: Failing Score
• Outside clinic
– “Your score on the measure was a little bit low today. This
means it would be good to contact your doctor so that
he/she can be proactive and take a closer look at how you
are doing.”
– “There are many reasons why someone might receive a low
score. A person might be tired, have a lot on their mind,
feel stressed or be distracted. In other cases, they might be
taking medications, have a shortage of certain vitamins or
nutrients, or have a medical condition that is causing
problems with thinking or memory.”
– “Contacting your doctor is important so potential problems
can be identified as early as possible. This is a vital part of
staying healthy.”
80
Opening Up Conversation
• Use the assessment process as a opportunity
to discuss memory issues openly and to work
from the perspective of your patient/client:
– “Are you having any trouble with your memory or
thinking?”
– If yes, “What do you think might be causing this?”
– “Have you talked with anyone about it?”
– “Have you talked with your doctor about this?” If
so, “What happened?”
81
Care Coordination
• Help facilitate an appointment with the doctor
as much as the client/family will allow and/or
as much as you are able to within your role.
– The more you can do, the more likely follow-up
will occur
• Sit with family while a call is made to set up doctor
appointment and/or
• Call client/family in 1 week to check on progress
• Accompany client to the doctor
82
Care Coordination
• Promote positive, health-focused messages
• Encourage involvement of family members
– Family member(s) should accompany patient/client
and participate in doctor visit
– Write down their observations re: cognitive,
behavioral, and functional changes in bullet point
style and give to doctor during appointment
• Close the loop
– “I would like to see/talk with you again after you
follow-up with your doctor about this. Does that
sound reasonable to you?”
83
Care Coordination
• Consider providing written documentation to
the client/family and/or their doctor, if
appropriate
– Sample letters are available for download at
www.actonalz.org/video-tutorials next to the
thumbnail for this webinar
– Follow your organization’s existing HIPAA
guidelines
84
Client Letter
85
Provider Letter
86
Provider Letter:
Check-box
87
Care Coordination
• Clinics have to cope with a lot of paperwork
and sometimes letters get lost
– Encourage patient/family to bring a copy of the
letter to their doctor appointment
– You may find that, in some circumstances, you
have to fax or mail the provider letter to the clinic
more than once
88
Q&A
• What will the doctor do when I see him/her?
– He/she will work with you to decide what additional
tests or follow-up care is needed to address this issue
and keep you well. Sometimes a work-up involves:
• Answering questions about your health history, including any
observations you might have about your memory or thinking
• Medication review
• Performing blood tests to see if you have a shortage of
certain vitamins or nutrients in your body that could be
causing changes in your memory or thinking
• Completing an x-ray of your head so the doctor can take a
closer look at how your brain is doing
89
Q&A
• Do you think I have dementia/Alzheimer’s disease?
– The tool we used today does not tell us what is causing a
person’s memory difficulties and cannot be used to
diagnose dementia/Alzheimer’s disease.
– There are many reasons why someone might be
experiencing trouble with their memory or thinking.
He/She may not be getting adequate sleep at night or
might be under a lot of stress or be depressed. Other
causes include medication side effects, medical problems
like an infection in the body, and vitamin deficiencies.
– Not all memory / thinking problems are caused by
dementia/Alzheimer’s disease. But, it is important to see a
doctor so we can identify the cause and find out what, if
any, treatment might be needed.
90
Q&A
• My family complains about my memory but I do
not have a problem. Everyone my age is a little
forgetful.
– You are right that a lot of people experience memory
changes as they get older. How much varies from
person to person. We all want to stay as healthy as
possible and maintain our independence as long as
possible. Having a brain check-up is a part of staying
healthy (and might be a good way to show your family
there is nothing wrong with you - to put this issue to
rest once and for all).
91
Q&A
• I think I am doing fine. Why should I see a
doctor?
– It is important to check the health of the brain as
we get older, just like we routinely check on the
health of other organs, such as the heart.
Sometimes, memory difficulties can be reversed
with treatment. In other cases, early diagnosis of
a problem offers the best chance to treat
symptoms and stay well.
92
Dementia Work-up,
Diagnosis and Treatment for
Providers
93
Dementia Work-Up
• H&P
• Objective cognitive measurement
• Diagnostics
– Labs
– Imaging ?
– More specific testing (e.g., neuropsychometric)?
• Diagnosis
• ‘Family’ meeting
Treatment: Medications
• Anticholinergics
– Donepezil, Rivastigmine, Galantamine, Cognex
– Possible side effects: nausea, vomiting, syncope,
dizziness, anorexia
• NMDA receptor antagonist
– Memantine
– Possible side effects: tiredness, body aches,
dizziness, constipation, headache
95
Treatment: Medications
• Antipsychotics
• Antidepressants
• Mood stabilizers
Managing Behaviors Flow Chart:
actonalz.org/pdf/Figure1.pdf
96
Care and Treatment
• The care for patients with Alzheimer’s has
very little to do with pharmacology and
much to do with psychosocial interventions
• Care Coordination
97
Dementia Care Coordination
98
Care Coordination
What are some of the challenges
you face when working with people
with dementia and their families?
99
ACT Practice Tool
Dementia Care Plan Checklist
Identify Care Partner(s)
• Educate the patient: Dementia dx. require a
team approach
• Ask the patient to identify a support system
– Think outside the box:
• Family, friends, neighbors, religious congregation
members, colleagues, community organization
volunteers or workers)
– Task specific (e.g., doctor visits, managing meds.)
102
Comprehensive Assessment
103
Comprehensive Assessment
HCH Care Coordination Tool Kit
http://mn4a.org/wpcontent/uploads/HCH-ClinicCoordinator-Toolkit_3-1915_ADA-FINAL.pdf
104
Comprehensive Assessment
• Patient & Primary Care Partner / Caregiver
Identify language, cultural, health equity barriers
Identify physician(s)
Assess substance use / misuse
Behavioral health, depression
• PHQ9, CES-D, GDS
105
Comprehensive Assessment
• Primary Care Partner / Caregiver
– Consider assessing cognition (if over 65 or signs /
symptoms present)
– Caregiver burden (Zarit Burden Interview Short)
http://www.uconnaging.uchc.edu/patientcare/memory/pdfs/zarit_
burden_interview.pdf
106
Care Plan
107
Dementia Care Planning
•
•
•
•
•
•
•
•
Build a care team (patient & care partners)
Educate, support & connect to resources
Maximize abilities
Promote health, wellness & social
engagement
Encourage planning, preparedness
Ensure safety
Reduce excess disability
Avoid unnecessary hospitalization
108
Disease Education
• ASK the patient / care partner:
What the doctor told them about their memory
loss / diagnosis
What they know about the disease / questions
about the diagnosis / disease
Biggest concerns; barriers to care / health
109
Home & Personal Safety
• Develop a plan for the 6 F’s:
Falls
Fire
Finances
Firearms
Freedom
Freeways
110
Home & Personal Safety
• Refer to OT or PT
Fall risk assessment
Sensory / mobility aids
Home safety inspection / modifications
Driving evaluation
• Encourage Medic Alert® Safe Return®
6 out of 10 people with dementia will wander at
some point during the disease
www.alz.org/care/dementia-medic-alert-safereturn.asp
111
Home & Personal Safety
• Encourage emergency plans
Key phone numbers labeled / programmed
Fire plan
• Ask: What would you do if there was a fire at your
house?
ER / Hospital Medical Emergency Kit - @ bedside
POLST, POA, Health Care POA, Living Will
Updated Medication List + allergy list
Slippers / Clothes (including adult diapers, if worn)
List of important contact numbers (doctors, family,
minister, helpful friends)
Comfort objects (music, photos, blanket, etc.)
112
Medication Therapy & Management
• Discuss prescribed and OTC medications
simplify medication regimen
reduce / eliminate anticholinergics,
benzodiazepines, hypnotics, narcotics
• Create plan with care team
Family plan for managing meds
Med management aids (pill boxes, alarms)
Create & review medication log
113
Medication Therapy & Management
114
Dementia & Hospitalization
• Reduce Unnecessary Hospitalization
– Falls
– UTI / other medical conditions
– Medications / medication
mismanagement
– Dementia-related behavior
– Hospitalization alternatives
• Hospitalization – Pre-Planning
– http://www.nia.nih.gov/alzheimers/publicati
on/hospitalization-happens
115
Dementia & Hospitalization
– More preventable hospitalizations
– Higher rates of:
delirium, falls, new incontinence, indwelling urinary catheters,
pressure ulcers, functional decline & new feeding tubes
– Significantly less likely to regain preadmission
functional abilities at 1, 3, or 12 months after
discharge
– 3-7 times more likely to be living in a nursing
home 3 months after discharge
116
Maximize Abilities
• ID/treat conditions that may worsen symptoms or
lead to poor outcomes
Diabetes, HTN, sleep dysregulation
• Refer to OT to maximize independence
simplify environment, maximize independence & self-care
abilities
• Offer strategies to reduce behavioral symptoms
Communication strategies, wellness & social engagement,
routine
117
Dementia-Related Behavior
• Studies identify that 50%-90% of persons with
dementia will develop “challenging behaviors”
• Anxiety is the most prominent in the earlier
stages of dementia
• 42% become physically aggressive
• 50% have depressive symptoms
• Prevalence of behavior is directly associated
with the approach used by the care partner
118
Common Dementia-Related
Behaviors
•
•
•
•
•
•
•
•
Repeating
Anger, Anxiety, Agitation
Daytime sleeping / night-time wakefulness
Wandering, Pacing, Shadowing
Apathy
Resisting Care
Aggression (yelling, hitting, biting)
Socially inappropriate behaviors (e.g., things that
may be ok in private, but not in public – like
disrobing)
119
Causes of Challenging Behaviors
• Physical Health (Medical)
Pain
Urinary Tract Infection
Illness
• Environment
Unfamiliar surroundings/environment
Over/under stimulation
• Other
Communication
Unmet needs/boredom
Task-related
Emotional health
120
Reduce Behavioral Symptoms
• REMEMBER:
– behavior is communication
– communication impacts behavior
• Think like a behavioral analyst
– Detective work, ask:
•
•
•
•
•
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? Has anything changed recently?)
121
Considerations
• Ask: Is this behavior really a problem?
– Is it hurting anyone?
• Help care partners know what to expect
and normalize these reactions.
– Avoid: unrealistic, non-dementia expectations,
arguing, correcting, rushing
– Advise: Take a deep breath, slow down, step back,
simplify, smile, redirect, reassure, try again later
122
Maximize Abilities: Routine
123
Health, Wellness & Engagement
Encourage lifestyle changes that may reduce
disease symptoms or slow progression
Exercise
Nutrition
Stress reduction
Meaning & purpose
Relationships
Health management
Routine
www.alz.org/mnnd/documents/15_ALZ_Living_Well_Workbook_Web.pdf
124
Health, Wellness & Engagement
Understanding the disease
Partnering with doctors
Telling others about the
diagnosis
Strategies for managing
symptoms & coping
Safety
Legal / financial issues
http://www.alz.org/mnnd/documents/15_ALZ_Taking_Action_Workbook.pdf
Patient Engagement:
Research Participation
• Alzheimer’s Association Trial Match
– Free, easy-to-use clinical studies matching
service that connects individuals with
Alzheimer's, caregivers, healthy volunteers and
physicians with current studies.
– http://www.alz.org/research/clinical_trials/find
_clinical_trials_trialmatch.asp
• National Institute of Health (NIH)
– http://clinicaltrials.gov
126
Legal & Financial Planning
• Encourage patient / care partner to assign
durable POA
Refer to Elder law attorney
• Encourage patient / care partners to talk
about long-term care and when they would
access support
http://www.alz.org/i-havealz/downloads/worksheet_financial_legal.pdf
127
Advance Care Planning
• Encourage patient to discuss / document
preferences for care in a health care
directives
Connect patient with advance care planning
facilitator
Document choices (Honoring Choices, MN
Healthcare Directive)
• Discuss palliative and hospice options
Palliative Care Consultation Program
When is the right time?
128
Care Coordinator:
Visit Frequency & Communication
• Schedule regular check-ins
• Educate patient / care partner WHEN to
contact you
Change in condition
Assistance with med management
Before / after hospitalization
Change in living environment
New needs
129
Care Coordinator:
Visit Frequency & Communication
• Facilitate physician appointments
Reminders, transportation
• Educate on physician engagement
strategies
Encourage care partner(s) to attend medical
appointments
Educate about HIPAA, as needed
Educate on use of appointment log,
medication log
130
Appointment Log
HIPAA Q & A
• HIPAA (Health Insurance Portability and
Accountability Act)
• Federal law that protects medical information
• Allows only certain people to see information
– Doctors, nurses, therapists and other health care
professionals on the patient’s medical team
– Family caregivers and others directly involved with
a patient’s care (unless the patient says he/she does
not want this information shared with others)
www.nextstepincare.org/Caregiver_Home/HIPAA/
United Hospital Fund, 2002
132
HIPAA: Sharing Patient Information
• If the patient is present and has the capacity to make
health care decisions, a health care provider may
discuss the patient’s health information with a family
member, friend, or other person if the patient agrees
or, when given the opportunity, does not object.
• If the patient is not present or is incapacitated, a
health care provider may share the patient’s
information with family, friends or others as long as
the health care provider determines, based on
professional judgment, that it is in the best interest of
the patient.
www.nextstepincare.org/Caregiver_Home/HIPAA/
United Hospital Fund, 2002
133
Care Plan: Caregiver Support
• Providing support for dementia caregivers is a
societal imperative
– 70% of individuals with Alzheimer’s disease live at
home
– In 2012, an estimated 15 million unpaid caregivers
provided an estimated 17.5 billion hours of unpaid
care
– The health care system could not sustain the cost
of care without unpaid caregivers
Dementia Caregiving Risks
• Physical risks:
risk of health problems
• Social risks:
feelings of social isolation
• Psychological risks:
risk of depression and burden
• Financial risks:
financial burden due to lost wages & cost of care
Common Caregiver Challenges
•
•
•
•
•
•
•
•
•
•
Lack of disease knowledge / education
Emotional stress, burden
Need for support and respite
Role changes
Challenging family dynamics
Communication difficulties
Neglected health
Putting patient needs first
Challenging patient behaviors
Planning for the future
136
Caregiver Support
• There is a strong correlation between the
health and well-being of a care partner and
the quality of care that she can provide.
• A care partner with a balanced outlook and
good self-care practices can provide care for
longer periods of time while maintaining his
own health and well-being.
Top 5 Resources for
Patients and Families
138
Disease Education: After a Diagnosis
http://youtu.be/zEst_VxwA4U
139
#1 Promote Wellness &
Function
http://www.actonalz.org/sites/default/files/
documents/ACT-AfterDiagnosis.pdf
www.alz.org/mnnd/documents/15_ALZ_Livi
ng_Well_Workbook_Web.pdf
http://www.alz.org/mnnd/documents/15
_ALZ_Taking_Action_Workbook.pdf
140
#2 Manage Behavioral Challenges
• Coping with Behavior
Change in Dementia
• Coach Broyle’s Playbook for
Alzheimer’s Caregivers
• The Alzheimer’s Action Plan
• ACT on Alzheimer’s
resources, “Mid-Late Stage
Practice Tool”
•
•
•
http://actonalz.org/pdf/Table1.pdf
http://actonalz.org/pdf/Table2.pdf
http://actonalz.org/pdf/Figure1.pdf
141
#3: Address the 6 F’s
Alzheimer’s Association Driving Center:
www.alz.org/care/alzheimers-dementia-and-driving.asp
Falls, Finances, Fire, Firearms,
Freedom, Freeways
http://www.thehartford.com/sites/t
hehartford/files/at-the-crossroads2012.pdf
142
#4 Assist with Planning
143
#5 Connect to Resources
Alzheimer’s Association
24/7 Helpline | 800.272.3900
www.alz.org/mnnd
Senior LinkAge Line
800-333-2433
www.minnesotahelp.info
144
Case Studies
145
Case Study: Colleen
•
•
•
•
•
•
•
•
66 y/o presents to primary care with memory complaints
Daughter c/o short-term memory is poor
Began 1-2 years ago, getting worse
Hx Low blood sugar, history of heart attack, repeat
hospitalizations for atrial flutter
Frequent medication changes, managing independently
Patient is a retired accountant for family business
Lives with husband who is still running the family
business
Referred to Care Coordination
Case Example: Medications
https://youtu.be/3lp0n9DOEWQ
147
Care Coordination: Colleen
• Discussion
–
–
–
–
–
Observations? What did you notice?
What was done well?
What could have been done differently, better?
What might you incorporate into your practice?
What recommendations / referrals would you make to
Colleen?
– What might you do differently if Colleen was not a
native English speaker or was from a diverse cultural
community?
148
Case Example: Legal Planning
https://youtu.be/a-gIojhzGOY
149
Care Coordination: Colleen
• Discussion
–
–
–
–
–
Observations? What did you notice?
What was done well?
What could have been done differently, better?
What might you incorporate into your practice?
What recommendations / referrals would you make to
Colleen?
– What might you do differently if Colleen was not a
native English speaker or was from a diverse cultural
community?
150
Watch the Complete Session:
https://youtu.be/5Kxj-5Ezlzw?list=PLGu3PyEblnIKVrTqVj9NzR5f_fcCbTd9T
151
Care Plan Exercise
In small groups, develop a 3-5 step care plan for Colleen
and her family.
Consider:
• Which areas of the care plan tool should be incorporated in the
plan?
• What educational materials would you give?
• What referrals would you make?
• When would you like to see the patient again?
• How would you communicate the plan to the care team
(physicians, family, patient, etc.)
Questions?
• Download ACT on Alzheimer’s practice tools at:
www.ACTonALZ.org/provider-practice-tools
• For more information
– email: [email protected]
– Web: www.ACTonALZ.org
153
Questions
154
Evaluation
155
ACKNOWLEDGEMENTS
This presentation was created by ACT on Alzheimer’s, an award-winning, nationally recognized,
volunteer-driven collaborative seeking to create supportive environments for everyone touched by
Alzheimer’s disease and to prepare Minnesota for its impacts.
ACT on Alzheimer’s®
Executive Co-Leads: Olivia Mastry, JD, MPH, Michelle Barclay, MA & Emily Farah-Miller, MS
Lead Presentation Authors: Terry Barclay, PhD and Michelle Barclay, MA
Special thanks to the ACT on Alzheimer’s Detection and Quality Health Care Leadership Group and
Medical Speaker’s Bureau Members
Visit www.actonalz.org/provider-practice-tools for
more information and to access supportive tools and
resources.
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
•
•
•
•
•
•
•
•
•
•
•
•
•
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.
Balasa M, et al. Neurology. 2011;76:1720-1725.
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, et al. Am J Alzheimer's Dis. 1999:20-26.
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.
Borson, S., Scanlan, JM, Watanabe, J et al. (2006). Improving identification of cognitive impairment in primary care. Int J
Geriatr Psychiatry; 21: 349-355.
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.
158
References & Resources
•
•
•
•
•
•
•
•
•
•
•
•
•
Ferri CP, Prince M, Brayne C, et al. (2005). Alzheimer’s Disease International Global prevalence of dementia: A Delphi
consensus study. Lancet, 366: 2112–2117.
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.
Holzer C, Warshaw G. Arch Fam Med. 2000; 9:1066-1070.
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.
Lessig, M, Scanlan, J et al. (2008). Time that tells: Critical clock-drawing errors for dementia screening. Int Psychogeriatr;
20(3): 459-470.
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
159
University Caregiver Intervention In Minnesota. Health Affairs, 33(4), 596-604.
References & Resources
•
•
•
•
•
•
•
•
•
•
•
•
•
•
McCarten JR, Anderson, P et al. (2011). Screening for cognitive impairment in an elderly veteran population: Acceptability and results
using different versions of the MiniCog. J Am Geriatr Soc; 59: 213-309.
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.
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), 695-99.
National Chronic Care Consortium and the Alzheimer’s Association. 1998. Family Questionnaire. Revised 2003.
Patel, A., Parikh, R. et al. (2015). Mini-cog performance: A novel marker of post discharge risk among patients hospitalized for heart
failure. Heart Failure; 8(1): 8-16.
Robinson, T., Wu, D., Pointer, L., Dunn, C. & Moss, M. (2012). Preoperative cognitive dysfunction is related to adverse postoperative
outcomes in the elderly. Journal American College of Surgeons, 215:12-18.
Scanlan, J & Borson, S (2001). The Mini-Cog: Receiver operating characteristics with the expert and naïve raters. Int J Geriatr
Psychiatry; 16: 216-212.
Schubert, C.C., Boustani, M., Callahan, C.M., Perkins, A.J., Carney, C.P., Fox, C., Unverzaget, F. & Hendrie, H.C. (2006). Comorbidity
profile of dementia patients in primary care: are they sicker? Journal of the American Geriatric Society, 54:104-109.
Silverstein NM & Maslow K (Eds.) (2006). Improving Hospital Care for Persons with Dementia. New York: Springer Publishing CO.
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.
Tsoi, K, Chan, J et al. (2015). Cognitive tests to detect dementia: A systematic review and meta-analysis. JAMA Intern Med; E1-E9.
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.
160
References & Resources
•
•
2012 Updated AGS Beers Criteria:
http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
After a Diagnosis (ACT): http://www.actonalz.org/sites/default/files/documents/ACT-AfterDiagnosis.pdf
Alzheimer’s Association
•
Basics of Alzheimer’s Disease: https://www.alz.org/national/documents/brochure_basicsofalz_low.pdf
•
Caregiver Notebook - http://www.alz.org/care/alzheimers-dementia-caregiver-notebook.asp
•
Driving Center: www.alz.org/care/alzheimers-dementia-and-driving.asp
•
Facts & Figures video: http://youtu.be/waeuks1-3Z4
•
Facts & Figures Report: http://www.alz.org/documents_custom/2016-facts-and-figures.pdf
•
Family Questionnaire: http://www.alz.org/mnnd/documents/Family_Questionnaire.pdf
•
Know the 10 Signs. http://www.alz.org/national/documents/checklist_10signs.pdf
•
Living with Alzheimer’s – Mid Stage: https://www.alz.org/documents_custom/middle-stage-caregiver-tips.pdf
•
Living with Alzheimer’s – Late Stage: https://www.alz.org/documents_custom/late-stage-caregiver-tips.pdf
•
Living Well workbook:http://www.alz.org/documents/mndak/alz_living_well_workbook_2011v2_web.pdf
•
Taking Action Workbook: http://www.alz.org/mnnd/documents/2010_taking_action_e-book(1).pdf
•
Trial Match: http://www.alz.org/research/clinical_trials/find_clinical_trials_trialmatch.asp
•
HOPE for Alzheimer’s ACT Fact Sheet:
http://act.alz.org/site/DocServer/hope_for_alz_fact_sheet.pdf?docID=3021
161
References & Resources
•
•
•
•
•
•
•
•
•
•
•
•
•
•
AD8 Dementia Screening Interview: http://knightadrc.wustl.edu/About_Us/PDFs/AD8form2005.pdf
At the Crossroads: http://www.thehartford.com/sites/thehartford/files/at-the-crossroads-2012.pdf
Caring for a Person with Alzheimer’s Disease:
http://www.nia.nih.gov/sites/default/files/caring_for_a_person_with_alzheimers_disease_0.pdf
Coach Broyles Playbook on Alzheimer’s: http://www.caregiversunited.com
Coping with Behavior Change in Dementia: A Caregier’s Guide: http://www.amazon.com/Coping-BehaviorChange-Dementia-Caregivers/dp/0692385444
Honoring Choices Minnesota:http://www.honoringchoices.org
Hospitalization Happens: http://www.nia.nih.gov/sites/default/files/hospitalization_happens_0.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
MN Health Care Home Care Coordination Tool Kit:
http://www.health.state.mn.us/healthreform/homes/collaborative/lcdocs/cliniccarecoordtoolkit.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
162
References & Resources
•
•
•
St. Louis University Mental Status (SLUMS) examination
http://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf
The Alzheimer’s Action Plan:http://www.amazon.com/The-Alzheimers-Action-Plan-Know/dp/0312538715
Zarit Caregiver Burden Interview: http://www.uconnaging.uchc.edu/patientcare/memory/pdfs/zarit_burden_interview.pdf
163