Attitudes about Cognitive Screening: A Survey of Home Care Physical Therapists

Transcription

1 Attitudes about Cognitive Screening: A Survey of Home Care Physical Therapists Jean D. Miles, PT, DPT William H. Staples, PT, DHSc, DPT, GCS Daniel J. Lee PT, DPT, GCS APTA Combined Sections Meeting New Orleans, LA February 23, 2018 PURPOSE OF THE STUDY Examine attitudes and practices of home care therapists regarding cognitive screening HYPOTHESES Clients present with symptoms without diagnosis Screening is done inconsistently Screening could lead to earlier intervention Home care therapy outcomes are adversely affected by lack of diagnosis 1

2 INTRODUCTION: FACTS AND FIGURES Home care population is high risk for cognitive deficits Cost of dementia management increased 38% between AD remains 6 th leading cause of death No treatment, no cure Some cognitive deficits caused by treatable conditions Why screen? Mounting evidence: Cognitive screening = critical component fall prevention assessment. Blackwood J, Martin A. Screening for cognitive impairment as a part of falls risk assessment in physical therapist practice. J Geriatr Phys Ther. 2017;40(4): Requirements of Outcome and Assessment Information Set (OASIS) Home care therapy case managers must assess for depression and barriers to learning. including cognitive deficits. 2

3 METHODS HOW: 5 POINT LIKERT TYPE SURVEY 5) strongly agree (4) agree (3) neutral (2) disagree (1) strongly disagree WHERE: ONLINE DISTRIBUTION VIA SURVEY MONKEY NO DIRECT CONTACT WITH THERAPISTS PRIVATE HOME CARE AGENCIES STATE HOME CARE ASSOCIATIONS (CT, FL, TX) APTA LIST SERVS (AGPT, Home Health Section) WHEN: SUMMER 2016 WHY: NEED FOR EVIDENCE WHO: IRB, UNIVERSITY OF HARTFORD, WEST HARTFORD, CONNECTICUT RESULTS/Participants 233 completed surveys 210 currently employed in home care 43 States 183 female, 53 male Age: 25 77, median GCS (2,418 nationally) (20.6%) 46 CEEAA (1,215 nationally) (19.7%) 18 both GCS, CEEAA (7.7%) 3

4 RESULTS/Experience General Experience Range 1 55 years Median 23 years < 10 years (31) 13% >31 years (74) 31.8% Home Care Experience Range 1 45 years Median 12.5 years < 10 years (90) 38.6% >21 years (51) 21.9% Necessary Skills? Q 16 Do you already possess necessary skills to effectively assess and treat persons with dementia? 17.2% disagreed/strongly disagreed Almost 30% neutral Nearly 50% of practicing therapists feel some uncertainty Post entry level? Role of Entry level programs? 52.8% agreed/strongly agreed CEEAA more likely to believe possess necessary skills (p=0.041) compared to without 4

5 Where do I Start? Just over 19% of respondents were neutral, while 22.3% agreed and 2.1% strongly agreed with the statement about uncertainty where to begin when a client is suspected of having dementia in the absence of a diagnosis (Q17) Slightly over half of respondents (55.8%) disagreed/strongly disagreed with the statement. Attitudes about Dementia Certifications Question 24: Do therapists work harder to make improvements in patients with dementia? 43% (n=99) answered neutrally Close division between agreement (n=75, 32.4%) and disagreement (n=58, 25.0%) More likely to agree vs disagree with/without GCS (p=.017) AND with/without a CEEAA (p=.004) Those with any certification were more likely to agree/strongly agree (p =.004) 5

6 Results/Impact of Degree Degree holders BS, MS least likely to have specialization (p=.003) (compared to tdpt, DPT, PhD or equivalent.) DPT significantly different (p=.001) as younger than BS. DPT less experience in PT and home care (p=.001) Attitudes about Dementia Gender differences Survey question 21: My expectations for a positive outcome with patients with dementia are less. Significant difference according to gender (p =.011) Pairwise post hoc comparisons showed females significantly more likely to select disagree over neutral compared to males (p =.002) 6

7 Attitudes about Dementia Gender differences Correlation with Q 21: Question 20: A dementia diagnosis negatively impacts functional recovery similar responses to Q 21 Significant gender differences (p=.019) Males more likely than females to believe dementia has a negative impact. Attitudes about Knowledge Base Q 11: Research exists linking exercise and cognitive function Nearly unanimous Strong agreement: 65.2% (n=150) Agreement: 31.3% (n=72) Neutral: 3.5% (n=8) Q 4: Dementia is growing issue with significant impact for home care therapy Strong agreement: 78.9% (n=183) Agreement: 20.3% (n=47) Neutral: 0.9% (n=2) 7

8 Have I Taken Continuing Education? 2 questions (6,7) asked whether therapists had attended training to learn about dementia or using screening tools within past 2 years 67% affirmative training within 2 years for cognitive screening tools (Q6) 76.6% affirmative: training within 2 years for intervention/ communication techniques (Q7) More Education Means I Need More Education? CEEAA certification: significantly more likely to agree/strongly agree to both Q 6 and 7 compared to those without the CEEAA certification (p <.001, p =.041, respectively). CEEAA specifically includes training regarding dementia education. 8

9 Do I need More Education? Yes, 64.8% of respondents strongly disagreed/ disagreed/neutral when asked whether they receive sufficient continuing education from their employers regarding dementia (Q13) The survey indicates home care therapists perceive a need for increased dementia training regardless of entry level degree. Should entry level programs be teaching this? Attitudes about Resources Survey question 13: Availability of sufficient continuing education related to dementia? Perception of employer provision Significant uncertainty 22.3% neutrality 34.5% (n=79) Strongly agreed/ agreed 43.2% (n=99) Strongly disagreed or disagreed 9

10 Attitudes about Resources Question 14: Perception of availability of time/equipment for adequate treatment for dementia care? 41.7% (n=96) strongly agreed/ agreed they receive sufficient time and equipment 24% (n=55) strongly disagreed/ disagreed they have sufficient time and equipment. 33.9% neutral PTs with GCCS significantly (p=0.025) different in a positive direction. Attitudes about Diagnosis Q 8 Importance of specific diagnosis when dementia symptoms present 44% agreed/strongly agreed 29% neutral 27% disagree/strongly disagree Q 19: Recognize differences in dementia, depression, delirium only 7.3% strongly agreed 45% agreed 20% neutral 28% disagreed Cont. ed? 10

11 ARE YOU USING COGNITIVE SCREENS???? Q1: ARE PHYSICAL THERAPISTS QUALIFIED TO ADMINISTER COGNITIVE SCREENS??? OVER 90% agreement (53% strongly agreed, 37.1% agreed) 40 respondents (17.2%) admitted they are NOT using any screens in practice. Therapists with CEEAA certification were significantly (p=.045) stronger in their attitude toward their ability to administer cognitive screens than those without that designation. Do therapists feel uncomfortable doing cognitive screening? (Q18) 2.1% (n=5) strongly agreed 10.7% (n=25) agreed 9% (n=21) neutral Total: 22% (n=51) 78.3% (n=183) disagreed/strongly disagreed Coincidence??? 17.2% (n=40) admitted they are not doing any screening. 11

12 Screening Tool Findings Mini Mental State Exam (MMSE) 48% Clock Drawing 49% Other tests: SLUMS, MoCA, Mini cog, BDS Non screeners: average 23.5 years as PT, average 13.1 years in home care DPTs=41% of all participants lowest rate of non screening (22.5%) 47% non screeners had a BS CONCLUSION: MORE EDUCATION/TRAINING ADDITIONAL CERTIFICATION= HIGHER EXPECTATION FOR OUTCOME (9/24 questions) DEGREE= NO IMPACT ON DESIRE FOR MORE TRAINING GENDER DOES IMPACT ATTITUDE MINI MENTAL AND CLOCK DRAWING UTILIZED MOST PROTOCOLS ARE LACKING LACK OF INFORMATION AVAILABLE 12

13 LIMITATIONS Small sample size High proportion of respondents with advanced certifications No question regarding reliance on other disciplines to do screening No information on decision making process for choice of screening tool Where are we on the scale? 13

14 REFERENCES Alzheimer s Association. Alzheimer s disease facts and figures. Alzheimers Dement. 2015;11(3): Wimo A, Guerchet M, Ali GC, Wu YT, Prina AM, Winblad B. The worldwide costs of dementia 2015 and comparisons with Alzheimers Dement. 2017;13(1):1 7. Rasmussen J. General practitioners should be conducting targeted screening for dementia in people aged J Prim Health Care. 2014;6(3): Ladika D, Gurevitz S. Identifying the most common causes of reversible dementias: a review. J Am Acad Phys Assist. 2011;24(3): Home health study report. Centers for Medicare and Medicaid Services. January 11, Fee for Service Payment/HomeHealthPPS/downloads/HHPPS_LiteratureReview.pdf. Accessed June 3, Fritz NE, Kegelmeyer DA, Kloos AD, et al. Motor performance differentiates individuals with Lewy body dementia, Parkinson's, and Alzheimer's disease. Gait Posture Oct;50: Accessed June 3, REFERENCES Farrell M. Using functional assessment and screening tools with frail older adults. Top Geriatr Rehabil. 2004;20(1): Lorio AK, Gore JB, Warthen L, Housley SN, Burgess EO. Teaching dementia care to physical therapy doctoral students: A multimodal experiental learning approach. Gerontol Geriatr Educ. 2017;38(3): Panel on prevention of falls in older persons, American Geriatrics Society and British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59(1): Avin KG, Hanke TA, Kirk Sanchez N, McDonough CM, Shubert TE, Hardage J, et al. Management of falls in community dwelling older adults: clinical guidance statement from the Academy of Geriatric Physical Therapy of the American Physical Therapy Association. Phys Ther. 2015;95(6): Hill KD, LoGiudice D, Lautenschlager NT, Said CM, Dodd KJ, Suttanon P. Effectiveness of balance training exercise in people with mild to moderate severity Alzheimer s disease: protocol for a randomized trial. BMC Geriatr. 2009;9(29):

15 REFERENCES Blackwood J, Martin A. Screening for cognitive impairment as a part of falls risk assessment in physical therapist practice. J Geriatr Phys Ther. 2017;40(4): Ecklund Johnson E, Miller S, Sweet J. Confirmatory factor analysis of the Behavioral Dyscontrol Scale in a mixed clinical sample. Clin Neuropsycol. 2004;18(3): Belanger HG, Wilder Willis K, Malloy P, Salloway S, Hamman RF, Grigsby J. Assessing motor and cognitive regulation in AD, MCI, and controls using the Behavioral Dyscontrol Scale. Arch Clin Neuropsychol. 2005;20(2): Blackwood J, Shubert T, Forgarty K, Chase C. Relationships between performance on assessments of executive function and fall risk screening measures in community dwelling older adults. J Geriatr Phys Ther. 2016;39(2):