ObjecAves. Mrs. Smith 12/14/16. New Tools to Provide Op1mal Care to the Memory Impaired Individual

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1 New Tools to Provide Op1mal Care to the Memory Impaired Individual Terry R. Barclay, Ph.D. (HealthPartners) Ericka Tung, M.D. (Mayo Clinic) ObjecAves 1. Understand raaonale for early detecaon 2. Use evidence-based tools to improve demenaa detecaon and treatment 3. Detect and manage neuropsychiatric symptoms 4. Recognize key management prioriaes throughout the conanuum of demenaa 5. Leave armed with a full clinical toolbox 2 Mrs. Smith 76 y/o Presents to primary care Daughter c/o short-term memory is poor, paaent denies problem Other family members have noaced changes Began 1 year ago, gevng worse Hx of hypertension and DM, both fairly well controlled Husband died unexpectedly 3 yrs ago ConversaAonal presentaaon seems fairly intact Oriented x3 but vague awareness of current events 3 1

2 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 DiagnosAc Challenges Only 50% of pts receive formal dx Diagnosis delayed on average by 6+ Years a^er sx onset Sig. impairment in funcaon by Ame it is recognized 4 Base Rates 1 in 9 people 65+ (11%) 1 in 3 people 85+ (32%) Of those with Alzheimer s disease: 4% <65 13% % % 85+ Minority populaaons at higher risk Older African Americans (2x as whites) Older Hispanics (1.5x as whites) 5 DiagnosAc Challenges Cultural Ageism and defining normal aging MD will bring health problems to my afenaon Associated sagma Medical Heterogeneous cogniave baseline Many paaents unaware of problem Time Lack of definiave tests Treatment opaons/efficacy? Wrong diagnosis? Fear of delivering bad news ImplicaAons for physician/paaent relaaonship 6 2

3 DiagnosAc Challenges Systemic/InsAtuAonal Low priority Few incenaves Lack of procedural support Few specialists available (neurology, neuropsychology) Few community resources 7 Does Screening Make Sense? US PreventaAve Services Task Force (USPSTF) Purpose: To systemaacally review the diagnosac accuracy of brief cogniave screening instruments and the benefits and harms of pharmacologic and nonpharmacologic intervenaons for early cogniave impairment. Limita1on: Limited studies in persons with demenaa other than Alzheimer disease and sparse reporang of important health outcomes. Conclusion: Brief instruments to screen for cogniave impairment can adequately detect demenaa, but there is no empirical evidence that screening improves decision making. Whether intervenaons for paaents or their caregivers have a clinically significant effect in persons with earlier detected cogniave impairment is sall unclear. 8 RaAonale for Early DetecAon 1. PaAent Care / Outcomes 2. Time 3. Money 9 3

4 PaAent Outcomes 1. Improved management of co-morbid condiaons! Underlying demenaa = risk factor of poor compliance in the elderly! Affects chronic disease management (diabetes, hypertension, anacoagulaaon) 2. Reduce ineffecave and expensive crisis-driven use of healthcare resources! Prevent diagnosis during crises (wandering, hospitalizaaon, car accidents, bankruptcy) 3. ConnecAon to services that promote independent (supported) living as long as possible! RTC support/counseling intervenaon (Mifelman et al. Neurology 2006)! Non-pharm intervenaons reduce NH placement by 30% and delay placement for others by 18+ months 10 Time Physician does not administer screen Rooming nurse Length of screen varies Recommended tool takes minutes Only conducted annually or when symptomaac Mini-Cog does not disrupt workflow & increases capture rate of cogniave impairment in primary care Borson JGIM Money Cost effecaveness of early assessment and treatment? Large scale studies ongoing Getsios et al (2012) ProjecAons based on clinical trial and follow-up registry data Compared to no assessment / no treatment: ReducAon in healthcare costs by $5,300 /pp ReducAon in societal costs by $11,400 / pp Health Affairs (April, 2014) $996 million in savings over 15 years 12 4

5 NaAonal & Local Landscape NaAonal Alzheimer s Project Act (NAPA) Awareness, readiness, disseminaaon, coordinaaon Annual Wellness Visit For first Ame, detecaon of cogniave impairment is core feature of the exam MN healthcare systems HealthPartners Allina EssenAa ACMC 13 What is ACT on Alzheimer s? statewide 60+ ORGANIZATIONS 300+ INDIVIDUALS volunteer driven collaborative IMPACTS OF ALZHEIMER S BUDGETARY SOCIAL PERSONAL 14 Increase DetecAon and Improve Quality Care Consensus-based, best pracace standards for providers of Alzheimer s care Produce tools and resources for primary care, community-based services and care coordinaaon processes 15 5

6 Clinical Provider PracAce Tool Easy bufon workflow for: 1. Screening 2. Work-up 3. Treatment / care 16 CogniAve Impairment IdenAficaAon Flow Chart 17 CogniAve Impairment IdenAficaAon Flow Chart 18 6

7 DemenAa Work-Up Care and Treatment 21 7

8 Care and Treatment 22 Physician Experience "As a demen*a champion within the Health Partners system, the CPP tool is a great handout when I am talking with primary care clinicians about trea*ng individuals with demen*a. The tool eliminates variability among clinicians and allows pa*ents to receive the highest standard of care for memory loss. Dr. Michael Rosenbloom, Clinical Director of the Health Partners Center for Memory and Aging 23 ACT on Alzheimer s EMR Tools Use EMR to automate: Screening Work-up AVS with demenaa educaaon Internal orders and referrals Community supports

9 Screening 25 Labs and Orders 26 Consults, Referrals, EducaAon & Support 27 9

10 Example 28 Pharmacological Treatment 29 EMR Guide to ImplementaAon Outlines benefits from using EMR tool 7 easy steps to implementaaon Two case studies 30 10

11 Care Coordination in Health Care Settings Cognitive Impairment Identification and Dementia Care Coordination Dementia Care Plan Checklist Symptoms and Duration of Disease 31 After A Diagnosis Persons with the disease, care partners and/or family members Tips and suggestions after a diagnosis Aligns with Practice Tools 32 Managing Demen1a Through the Con1nuum Ericka E. Tung, MD, MPH Division of Primary Care Internal Medicine Mayo Clinic College of Medicine 33 11

12 Managing DemenAa Across the ConAnuum 34 Promo1ng Posi1ve Behavioral Health 35 Behavioral and Psychological Symptoms of DemenAa: Scope of the Problem DemenAa affects nearly half of our oldest paaents CogniAve symptoms Non-cogniAve symptoms Behavioral and psychiatric symptoms: 60% of community dwelling paaents with demenaa > 80% of nursing home residents with demenaa Nearly all pa1ents with demen1a will suffer psychopathology during the course of illness Ferri, CP et al. Lancet 2005 Jeste, DV.,Neuropsychopharmacology

13 Behavioral and Psychological Symptoms of DemenAa: Adverse Clinical Repercussions Decreased quality of life Increased hospital length of stay Increased caregiver distress, depression, burnout Independently associated with NH placement Increased system-wide costs? Increased mortality No FDA-approved medica*on for these symptoms Jeste, DV. Neuropsychopharmacology, 2008 Finkel, SI et al. Int Psychogeriatrics Case: Jan 87 yo woman with history of probable AD and cerebrovascular disease MulAple transiaons a^er hip fracture Family and nursing staff distressed by behaviors and agitaaon Staff asks about starang some QueAapine or will need to leave ALC and transfer elsewhere

14 ACT to the rescue! 40 SystemaAc Approach to Management of Neuropsychiatric Symptoms of DemenAa Step 1: Define the behavior Step 2: Categorize target symptom Step 3: IdenAfy reversible condiaons Step 4: Use non-pharmacologic (and pharmacologic) therapies to treat target symptoms. 41 Step 1: Define the behaviors Interview all members of the care team Examples AfenAon seeking behaviors Verbal outbursts Aggression during cares HiVng, pushing, kicking Sexual disinhibiaon Focus on bathroom acaviaes Restless motor acavity, pacing, rocking Calling out 42 14

15 Step 1: Define the behaviors What is the paaent trying to tell us? Behaviors Language Skills Adapted with permission from G. Smith, Ph.D. 43 Step 2: Categorize the target symptom or cluster Psychosis Delusions HallucinaAons Mood symptoms Dysphoria Irritability Lability Aggression Spontaneous DisinhibiAons 44 Step 3: IdenAfy reversible condiaons Delirium Under-treatment of medical illness MedicaAon side effect Undiagnosed psychiatric illness Environmental factors Inexperienced caregivers UnrealisAc expectaaons 45 15

16 Step 4: Non-pharmacologic IntervenAons REMEMBER: Behavior is a means of communicaaon Unmet needs Boredom Over/under samulaaon Discomfort Environmental stressors Caregiver needs Limited knowledge about disease process or behaviors 46 Non-pharmacological IntervenAons Strategies AcAvity planning Tap into preserved capabiliaes and previous interests Involve repeaave moaon CommunicaAon Slow down, offer simple choices Help senior find the words for self expression Simplify Environment Remove clufer, minimize samuli during acavity Caregiver support Self care, minimize confrontaaon/arguing with loved one IdenAfy support network Gitlin, et al. JAMA, Non-pharmacologic IntervenAons Montessori-based Demen*a Programming Residents engaged in familiar tasks that they are interested in cannot be simultaneously engaging in agitated behaviors Task breakdown Guided repeaaon Match demands to level of competence RCT: 133 insatuaonalized LTC residents Treatment: Montessori acaviaes vs. Caregiver presence (control) Results: agitated behaviors, aggressive behaviors ease of care raangs Lin, LC, JAGS, 2009 Van der Ploeg, ES, BMC Geriatr

17 49 Pharmacologic Treatment of Behavioral Disturbances AnApsychoAcs AnAdepressants Mood Stabilizers CogniAve Enhancers 50 AnApsychoAc MedicaAons in DemenAa ConvenAonal First GeneraAon: Haloperidol EPS Tardive dyskinesia Second GeneraAon AnApsychoAc: Clozapine Agranulocytosis 1990 s- Second GeneraAon AnApsychoAc MedicaAons Risperidone, olanzapine, queaapine, ziprasidone, aripiprazole Less motor side effects, befer tolerated UAlizaAon of these agents broadens THEN.. Jeste, DV Am Journal of Geriatric Psychiatry 51 17

18 2005 FDA Boxed Warning Elderly pa1ents with demen1arelated psychosis treated with atypical an1psycho1c drugs are at an increased risk of death compared to placebo. 52 Bofom Line with Atypical AnApsychoAcs Modest efficacy in the treatment of psychoac symptoms and global neuropsychiatric sx. Increased risk of nega1ve outcomes: DEATH, STROKE, HIP FRACTURE, FALLS ParAcipate in shared decision making with healthcare proxies Monitoring: ECG- QT interval Falls, orthostaac BP, EPS, tardive dyskinesia, glucose Regularly afempt to wean/disconanue 53 Case: Jan Interviews with mulaple caregivers reveal: Step 1: Define symptoms Subacute development ResisAng cares Screaming, spivng, biang at bath Ame & PT FuncAonal decline Step 2: Categorize target sx. Physical aggression toward caregivers What is Jan trying to tell us? 54 18

19 Case: Jan Step 3: Rule out reversible causes PaAent was brought in for an office visit: Calm, eyes closed during interview Tearfulness and wincing during transfer from chair to examinaaon table ExaminaAon revealed pain and saffness in bilateral shoulders Step 4: UAlize therapies to treat TARGET behaviors Break down bathing into manageable steps with verbal prompts Allow Jan to paracipate in bath process OpAmize treatment of shoulder arthrias with injecaon and analgesics 55 Management Priori1es: Cri1cal Tasks 56 Task: OpAmize MedicaAon Therapy Op1mize Medica1on Therapy Professional Resources AGS Beers Criteria (2012) START (Screening Tool to Alert Doctors to the Right Treatment) STOPP (Screening Tool of Older Persons PotenAally inappropriate PrescripAons) Managing DemenAa Across the ConAnuum

20 Task: Assess Safety and Driving Crash rates are highest at the extremes of age Medical condiaons and medicaaons lead to impairment AfenAon and percepaon Response selecaon Mobility 4% of current drivers aged 75+ have demenaa 76% of seniors with mild demenaa can sall pass a formal road test 58 Assessing the CogniAvely Impaired Driver: Severity of Demen*a Clinical Demen1a Ra1ng (CDR) is a useful tool for idenafying paaents at risk for unsafe driving. (Level A) Consensus exists among Medical, TransportaAon, and Elder Advocacy groups that seniors with moderately severe demenaa (CDR 2) should NOT be driving. PaAents with milder impairment (CDR 0.5-1) require systemaac assessment Iverson DJ, et al. Neurology 2010 Carr D, NEJM PracAce Parameter Guideline American Academy of Neurology Iverson DJ. Neurology

21 Task: Facilitate Advance Care Planning Discussion of goals of care, values IdenAficaAon AND engagement of HCPOA Honoring Choices PREPARE Introduce concept of palliaave care, educate about hospice Document via EMR, healthcare direcave Provider Orders for Life Sustaining Treatment Provider Resources 61 Task: Assess Partner Needs Caregiver Assessment tools Risk Factors for burnout, elder abuse Resources for suspected abuse reporang Common entry point 62 Conclusions UAlize a strategic approach when managing neuropsychiatric symptoms Always look for non-pharmacologic intervenaons prior to ualizing a medicaaon Recognize key management prioriaes when caring for the cogniavely impaired paaent and their family Use ACT tools to ensure quality care! 63 21

22 QuesAons? Download ACT on Alzheimer s pracace tools at: For more informaaon, info@actonalz.org 64 22