Objec*ves. Alzheimer s Disease: Challenges and Opportuni*es. Base Rates 10/17/17. Best Prac*ces for Detec*on and Early Management of Demen*a

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1 ACKNOWLEDGEMENTS This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administra*on (HRSA), Department of Health and Human Services (DHHS) under Grant Number UB4HP19196 to the Minnesota Area Geriatric Educa*on Center (MAGEC) for $2,192,192 (7/1/2010 6/30/2015). This informa*on or content and conclusions are those of the author and should not be construed as the official posi*on or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government. Best Prac*ces for Detec*on and Early Management of Demen*a Minnesota Area Geriatric Educa*on Center (MAGEC) Grant #UB4HP19196 Director: Robert L. Kane, MD Associate Director: Patricia A. Schommer, MA Terry R. Barclay, PhD HealthPartners Center for Memory and Aging Adjunct Associate Professor of Neurology, University of Minnesota Objec*ves 1. Understand the ra*onale for early diagnosis 2. Use evidence-based tools to improve demen*a detec*on 3. Review best prac*ces for demen*a work-up and disease management 4. Learn how to help pa*ents and family access services to improve func*on and promote wellness 3 Alzheimer s Disease: Challenges and Opportuni*es Alzheimer s: A Public Health Crisis Scope of the problem 5.3M Americans with AD in 2015 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) Base Rates 1 in 9 people 65+ (11%) 1 in 3 people 85+ (32%) Alzheimer s Disease by Age in the United States Some popula*ons at higher risk Older African Americans (2x as whites) Older Hispanics (1.5x as whites) Alzheimer s Association Facts and Figures Alzheimer s Association Facts and Figures

2 Challenges & Opportuni*es AD under-recognized by providers <50% of pa*ents receive formal diagnosis Millions unaware they have demen*a Diagnosis typically delayed on average by 6+ years ager symptom onset Significant impairment in func*on by *me it is recognized Poor *ming: diagnosis frequently at *me of crises, hospitaliza*on, failure to thrive, urgent need for ins*tu*onaliza*on Boise et al., 2004; Boustani et al., 2003; Boustani et al., 2005; Silverstein & Maslow, Poor Detec*on Signs ogen not recognized un*l quite obvious: Ajribu*on error: Ager all she s 80 years old! Changes missed due to familiarity with the pa*ent Focused nature of out-pa*ent visits Compensa*on or cover-up by family Lack of support resources 8 ACT on Alzheimer s statewide 60+ ORGANIZATIONS 600+ INDIVIDUALS volunteer driven Provider Tools: ACT on Alzheimer s collaborative IMPACTS OF ALZHEIMER S BUDGETARY SOCIAL PERSONAL 10 Focus on Quality Health Care ACT Tool Kit 11 Evidence and consensusbased, best prac*ce standards for Alzheimer s care Tools and resources for: Primary care providers Care coordinators Community agencies Pa*ents and families 12 2

3 Case Finding / Detec*on 14 Alzheimer s is Insidious Ra*onale for Timely Detec*on 1. Improve management of co-morbid condi*ons 2. Reduce ineffec*ve, expensive, crisis-driven use of healthcare resources 3. Op*mize quality of life Setng proper/realis*c expecta*ons for the future Decrease burden on family and caregivers 4. Priori*ze shared decision making 5. Promote a safe and happy environment that supports independence The message: You have a bad disease but there are things we can do to make life bejer for you and your family. Accumulation of neuropathology in the brain years before symptoms appear Base Rates Myth: People don t want to know they have Alzheimer s disease 1 in 9 people 65+ (11%) 1 in 3 people 85+ (32%) Alzheimer s Disease by Age in the United States Studies Agree: Most people want to know % Alz-Eu Harvard Turnbull Holroyd Alzheimer s Association Facts and Figures Blendon et al., 2012; Holroyd et al., 2002; Turnbull et al.,

4 Clinical Provider Prac*ce Tool Workflow Easy bujon workflow for: 1. Case finding 2. Demen*a work-up 3. Treatment / care 19 Step 1: Trigger A. Annual exam (e.g., Medicare AWV) B. Signs and symptoms C. Pa*ent / family report Step 2: Objec*ve assessment Step 3: Work-up Step 4: Referral 20 Cogni*ve Impairment Iden*fica*on Flow Chart Cogni*ve Impairment Iden*fica*on Flow Chart Detec*on Tools Mini-Cog Wide range of op*ons Mini-Cog (MC) Mini-Mental State Exam (MMSE) St. Louis University Mental Status Exam (SLUMS) Montreal Cogni*ve Assessment (MoCA) Rowland Universal Demen*a Assessment (RUDAS) All but MMSE free, in public domain, and online Contents Verbal Recall (3 points) Clock Draw (2 points) Advantages Quick (2-3 min) Easy High yield (execu*ve fx, memory, visuospa*al) Subject asked to recall 3 words Leader, Season, Table +3 Subject asked to draw clock, set hands to 10 past Borson et al., 2000; Folstein et al., 1975; Nasreddine 2005; Tariq et al., 2006 Borson et al.,

5 Mini-Cog Pass > 4 Fail 3 or less 25 Borson S., Scanlan J, Brush M et al The Mini-Cog: A cognitive vital signs measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 15, Mini-Cog Research Mini-Cog Improves Physician Recognition Performance less affected by educa*on or language Borson Int J Geriatr Psychiatry 2000 Good sensi*vity and specificity 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 % Correct CDR Stage *** *** *** MCI Mild Mod Sev Mini-Cog Patient s own physician *** p <.001 Borson S et al. Int J Geriatr Psychiatry 2006; 21: 349 Case: Sam 76 y/o re*red teacher (master s degree) Daughter c/o short-term memory is poor Began 2 years ago, getng worse Other family members have no*ced changes Repeats himself, mul*ple phone calls b/c can t find belongings Sam acknowledges problem but does not feel it is significant Hx of hypertension and DM, both fairly well controlled Wife died unexpectedly last year, lives alone Conversa*onal presenta*on intact, oriented x3 Seems okay at bedside Case: Sam Next steps? How to make sense of conflic*ng data? Is a demen*a work-up needed?

6 Mini-Cog: Sam Scrip*ng *ps available on ACT website Demen*a Work-up and Diagnosis Cogni*ve Impairment Iden*fica*on Flow Chart Demen*a Work-Up Demen*a: Differen*al Dx Vascular Demen*a Lewy Body Demen*a FTD Alzheimer s disease: % Includes mixed AD + VD Alzheimer s Disease Lewy Body Demen*a: % Parkinson spectrum Vascular Demen*a: 6-10 % Stroke related Frontotemporal Demen*a: 2-5 % Personality or language disturbance 35 6

7 Delivering the Diagnosis: Sam Demen*a Care and Treatment Care and Treatment The care for pa*ents with Alzheimer s has very lijle to do with drugs Medica*ons are not disease modifying Modest benefit in slowing expression of cogni*ve/ func*onal symptoms in some pa*ents Use of demen*a meds should be personcentered Minimize polypharmacy and bad drugs An*cholinergics, benzos 39 Care and Treatment Focus on psychosocial interven*ons Involve care coordinator Connect pa*ent/family to community resources Care for both pa*ent and caregiver Examples: Alzheimer s Associa*on, Senior Linkage Line Refer every *me, at any stage of disease, and for every kind of demen*a Stress this is part of their treatment plan and you expect to hear about their progress at next visit 40 Care and Treatment Care and Treatment

8 ACT EMR Tools Labs and Orders Use EMR to automate and standardize: Cogni*ve assessment Work-up Ager visit summary with demen*a educa*on Orders and referrals Community supports Consults and Referrals Pharmacological Treatment #1 Promote Wellness Educa*on, Resources & Support Type Living Well in search box

9 10/17/17 #2 Address Behavioral Challenges #3 Support Caregivers Alzheimer s Associa*on 24/7 Helpline One stop shop for: Care Consulta*on (social work interven*on) Support Groups 24/7 Helpline 49 #4 Review Medica*on 50 #5 Tackle Driving PharmD Consult Medica*on review, simplifica*on Reminder strategies Family support, supervision Alzheimer s Associa*on Driving Center: hjp:// ord.com/sites/thehar ord/files/at-the-crossroads-2012.pdf 51 What Pa*ents & Families Need 52 ACKNOWLEDGEMENTS This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administra*on (HRSA), Department of Health and Human Services (DHHS) under Grant Number UB4HP19196 to the Minnesota Area Geriatric Educa*on Center (MAGEC) for $2,192,192 (7/1/2010 6/30/2015). This informa*on or content and conclusions are those of the author and should not be construed as the official posi*on or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government. Minnesota Area Geriatric Educa*on Center (MAGEC) Grant #UB4HP19196 Director: Robert L. Kane, MD Associate Director: Patricia A. Schommer, MA Timely detec*on of cogni*ve impairment Clear diagnosis Proac*ve management Team approach that involves care partner(s) Opportunity to par*cipate in planning and decision making 6. Access to care coordina*on 7. Referral to educa*on and support services 53 9

10 References & Resources References & Resources Alzheimer s Associa*on (2014). Alzheimer s Disease Facts and Figures, Alzheimer s & Demen/a, Volume 10, Issue 2. Anderson K, Jue S & Madaras-Kelly K Iden*fying Pa*ents at Risk for Medica*on Mismanagement: Using Cogni*ve Screens to Predict a Pa*ent's Accuracy in Filling a Pillbox. The Consultant Pharmacist, 6(14), 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 pa*ents. Age and Ageing, 36(6): 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. Interna/onal Journal of Alzheimer s Disease, 1-9. Boise L, Neal MB, & Kaye J (2004). Demen*a assessment in primary care: Results from a study in three managed care systems. Journals of Gerontology: Series A; Vol 59(6), M Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. (2000). The mini-cog: a cogni*ve vital signs measure for demen*a screening in mul*-lingual elderly. Int J Geriatr Psychiatry, 15(11): Borson S, Scanlan JM, Chen P, Ganguli M. (2003). The Mini-Cog as a screen for demen*a: valida*on in a popula*on-based sample. J Am Geriatr Soc;51(10): Borson S, Scanlan J, Hummel J, Gibbs K, Lessig M, & Zuhr E (2007). Implemen*ng Rou*ne Cogni*ve Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior. J Gen Intern Med; 22(6): Boustani M, Peterson B, Hanson L, et al. (2003). Systema*c evidence review. Agency for Healthcare Research and Quality; Rockville, MD: Screening for demen*a. Boustani M, Callahan CM, Unverzagt FW, Austrom MG, Perkins AJ, Fultz BA, Hui SL, Hendrie HC (2005). Implemen*ng a screening and diagnosis program for demen*a in primary care. J Gen Intern Med. Jul; 20(7): Ferri CP, Prince M, Brayne C, et al. (2005). Alzheimer s Disease Interna*onal Global prevalence of demen*a: A Delphi consensus study. Lancet, 366: Finkel, SI (Ed.) (1996). Behavioral and Psychological Signs of Demen*a: Implica*ons for Research and Treatment. Interna/onal Psychogeriatrics, 8(3). Folstein MF, Folstein SE, & McHugh PR (1975). "Mini-mental state". A prac*cal method for grading the cogni*ve state of pa*ents for the clinician. J Psychiatr Res, Nov 12(3): Gallagher P & O Mahony D (2008). STOPP (Screening Tool of Older Persons poten*ally inappropriate Prescrip*ons): Applica*on to acutely ill elderly pa*ents and comparison with Beers criteria. Age and Ageing, 37(6): Gitlin LN, Kales HC, Lyketsos CG, & Plank Althouse E (2012). Managing Behavioral Symptoms in Demen*a Using Nonpharmacologic Approaches: An Overview. JAMA, 308(19): Holroyd S, Turnbull Q, & Wolf AM (2002). What are pa*ents and their families told about the diagnosis of demen*a? Results of a family survey. Int J Geriatr Psychiatry, Mar;17(3): Ismail Z, Rajji TK, & Shulman KI (2010). Brief cogni*ve screening instruments: An update. Int J Geriatr Psychiatry, 25: Jeste DV, Blazer D, Casey D et al. (2008). ACNP White Paper: Update on Use of An*psycho*c Drugs in Elderly Persons with Demen*a. Neuropsychopharmacology, 33(5): Larner AJ (2012). Screening u*lity of the Montreal Cogni*ve Assessment (MoCA): In place of or as well as the MMSE? Intern Psychogeriatrics, 24, Lin JS, O Connor E, Rossom RC, Perdue LA, Burda BU, Thompson M, & Eckstrom E (2014). Screening for Cogni*ve Impairment in Older Adults: An Evidence Update for the U.S. Preven*ve Services Task Force. Agency for Healthcare Research and Quality, Evidence Syntheses, 107. Long KH, Moriarty JP, Mijelman MS, & Foldes SS (2014). Es*ma*ng The Poten*al Cost Savings From The New York University Caregiver Interven*on In Minnesota. Health Affairs, 33(4), McCarten JR, Anderson P Kuskowski MA et al. (2012). Finding demen*a in primary care: The results of a clinical demonstra*on project. J Am Geritr Soc;60(2): References & Resources References & Resources Mijelman MS, Haley WE, Clay OJ, & Roth DL (2006). Improving caregiver well-being delays nursing home placement of pa*ents with Alzheimer disease. Neurology, November 14(67 no. 9), Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, & Chertkow H. (2005). The Montreal Cogni*ve Assessment, MoCA: A Brief Screening Tool For Mild Cogni*ve Impairment. J Amer Ger Soc, 53(4), Na*onal Chronic Care Consor*um and the Alzheimer s Associa*on Family Ques*onnaire. Revised Silverstein NM & Maslow K (Eds.) (2006). Improving Hospital Care for Persons with Demen*a. New York: Springer Publishing CO. Tariq SH, Tumosa N, Chibnall JT, Perry MH, & Morley E. (2006). Comparison of the Saint Louis University mental status examina*on and the mini-mental state examina*on for detec*ng demen*a and mild neurocogni*ve disorder: A pilot study. Am J Geriatr Psychiatry, Nov;14(11): Turnbull Q, Wolf AM, & Holroyd S (2003). Attudes 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). Pa*ent-Centered Communica*on During the Disclosure of a Demen*a Diagnosis. Am J Alzheimers Dis Other Demen, 25, Updated AGS Beers Criteria: hjp:// Alzheimer s Associa*on Family Ques*onnaire: hjp:// Alzheimer s Associa*on (2009). Know the 10 signs.hjp:// Coach Broyles Playbook on Alzheimer s: hjp:// Honoring Choices Minnesota:hjp:// Living Well workbook:hjp:// Medicare Annual Wellness Visit: hjp:// MM7079.pdf MiniCog hjp:// Montreal Cogni*ve Assessment (MoCA)hjp:// Na*onal Alzheimer s Project Act: hjp://aspe.hhs.gov/daltcp/napa/natlplan.pdf Next Step in Care: hjp:// Physician Orders for Life Sustaining Treatment (POLST): hjp:// St. Louis University Mental Status (SLUMS) examina*on hjp://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf The Alzheimer s Ac*on Plan:hjp:// Understanding Difficult Behaviors: hjp://