Screening for Depression & Dementia in the Clinical Setting. Janet Cellar DNP, PMHCNS-BC Emory Alzheimer s Disease Research Center

Transcription

1 Screening for Depression & Dementia in the Clinical Setting Janet Cellar DNP, PMHCNS-BC Emory Alzheimer s Disease Research Center

2 Disclaimer No financial conflicts of interest to declare

3 Goals Improve understanding of the challenges of identifying older adults with possible depression & dementia Improve understanding of the potential consequences of failure to recognize both depression & dementia Identify screening tools & strategies to address depression & dementia in a clinic setting

4 Growing Problem U.S. population is aging Health conditions associated with aging Dementia Depression 1 in 8 individuals in US 65 have dementia 15% estimated lifetime prevalence of depression in elderly Hebert, Scherr, Bienias, Bennett & Evans, 2003; Lapid & Rummans, 2003

5 Shared Challenges Depression Dementia Failure to recognize >50% in primary care 25%-90% in primary care Issues related to poor recognition Costs Early symptoms subtle PCP visits brief More acute problems take precedence Symptoms attributed to aging Presentation Lack of collateral information Reluctance to identify Cost of medical care Personal costs Early symptoms subtle PCP visits brief More acute problems take precedence Symptoms attributed to aging Presentation Lack of collateral information Reluctance to identify Cost of medical care Personal costs Bradford et al., 2009; Boustani et al., 2003; Callahan, Hendrie & Tierney, 1995; Ganguli et al., 2004; Kerr, 2001; Valcour, Masaki, Curb & Blanchette, 2000; Bynum et al.,

6 Shared Challenges Depression Consequences Medication & treatment non-compliance Difficulty managing comorbid medical conditions Inappropriate contacts Poor nutrition/failure to thrive Treatment is delayed resulting in mortality Higher rates of suicide in elderly depressed Dementia Medication & treatment non-compliance Difficulty managing comorbid medical conditions Inappropriate contacts Poor nutrition/failure to thrive Inability to accurately communicate symptoms rate of falls & ER visits Safety Boise et al., 2004; Callahan et al., 1995

7 Goals Goals of screening Early identification Early initiation of treatment Improve quality of life

8 Cognition Recognition and stages of disease Preclinical Stage Mild Cognitive Impairment Mild Dementia Isolated memory loss common Functionally independent Variable recognition by patient and family Excellent quality of life Moderate Dementia Worsening memory, other domains Depression common Early functional limitations Needing more supervision and support Profound loss of memory, language, etc. Dependent in many activities Behavioral problems common Increasing caregiver burden Age Severe Dementia End-stage cognitive decline Dependent in all activities Little meaningful quality of life Often institutionalized

9 Cognition Disease modifying therapies require early detection Disease Modifying Therapies Depression/AD Pathology Preclinical Stage Mild Dementia Moderate Dementia Severe Dementia Age

10 Screening Traditional view of screening catch it early and cure or control Depression & dementia screening instruments have been developed for use in primary care setting Studies have demonstrated utility of screening tools in improving recognition with questionable change in response to symptoms of depression or dementia Moore, Siu, Partridge, Hays & Amans, 1997; Wenger et al., 2009

11 Affordable Care Act Current guidelines recommend early recognition Affordable Care Act Personalized Prevention Plan: Medical & family history, current meds, ht, wt, bmi, BP, review of functional ability & level of safety including an assessment of any cognitive impairment and screening for depression, establishment of written screening schedule for next 5-10 yrs., risk factors, personalized health advice & preventive counseling AHRQ, 2003; Ashford et al., 2006; Peterson et al., 2001; HealthCare.gov, 2010

12 Response to Depression/Dementia Screening Acceptance of screening by older adults Most primary care patients (81%) desire screening to identify dementia early Highest in those with family history Factors that promote screening Increased knowledge & self-efficacy Preventive health behaviors Werner, 2003; Galvin, 2008; Holsinger, 2010

13 Screening Tools Geriatric Depression Scale (GDS) Center for Epidemiological Studies Depression Scale (CES-D) Depression Screening Short version (15 items) scored yes/no Scores- range Normal 5-8 Mild depression 8-11 Moderate depression Severe depression 20 items scored 0-3 Scores range Significant or mild depression Patient Health Questionnaire (PHQ-9) 10 items- scored 0-3 Scores Range None 5-9 Mild depression Moderate depression Moderately severe depression Severe depression

14 Geriatric Depression Scale Are you basically satisfied with your life? Yes/No Have you dropped many of your activities/interests? Yes/No Do you feel your life is empty? Yes/No Do you often get bored? Yes/No Are you in good spirits most of the time? Yes/No Are you afraid something bad is going to happen to you? Yes/No Do you feel happy most of the time? Yes/No Do you often feel helpless? Yes/No Do you prefer to stay at home rather than going out & doing new things? Yes/No Do you feel you have more problems with memory than most? Yes/No Do you think it is wonderful to be alive now? Yes/No Do you feel pretty worthless the way you are now? Yes/No Do you feel full of energy? Yes/No Do you feel that your situation is hopeless? Yes/No Do you think most people are better off than you? Yes/No Sheikh, J.I., Yesavage, J.A. (1986)

15 CES-D Rarely < 1 day Some 1-2 days Occasionally 3-4 days Most of time 5-7 days I was bothered by things that usually don t bother me I did not feel like eating; my appetite was poor I felt that I could not shake off the blues even with help from my family or friends I felt I was just as good as other people I had trouble keeping my mind on what I was doing I felt depressed I felt that everything I did was an effort I felt hopeful about the future I thought my life had been a failure Radloff, L.S., 1977

16 CES-D Rarely < 1 day Some 1-2 days Occasionally 3-4 days Most of time 5-7 days I felt tearful My sleep was restless I was happy I talked less than usual I felt lonely People were unfriendly I enjoyed life I had crying spells I felt sad I felt that people dislike me I could not get going Radloff, L.S., 1977

17 PHQ-9 Not at all (0) Several days (1) > ½ days (2) Nearly q day (3) Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself-or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching TV Moving or speaking so slowly that other people could have notices. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead, or of hurting yourself Total Score Add columns Kroenke, K. & Spitzer, R.L., 2002

18 PHQ-9: Functional Impairment If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult

19 Dementia screening tools Screening Tools Mini Mental State Exam (MMSE) Scored 0-30 Mini-Cog MC-FAQ Most commonly used screening tool Educational & racial bias Recommended in two reviews of dementia screening tools for use in primary care Found to be free of educational & racial bias Combines Mini-Cog with Functional Assessment Questionnaire (FAQ) Brodaty, Low, Gibson & Burns, 2006; Folstein & Folstein, Milne, Culverwell, Guss, Tuppen & Whelton, 2008; Steenland et al.,

20 MMSE Item Orientation 10 items 10 Immediate recall 3 items 3 Attention 1 item 5 Delayed recall 3 items 3 Language 9 items 8 Construction 1 item 1 Total 0-30 Possible points Fostein, Folstein & McHugh, 1975

21 Mini-Cog Requirements for effective screening Quick & easy Cheap Mini-Cog 3-word recall Clock drawing ~3 min to perform No special training Good dementia screen Insensitive for MCI Borson et al., 2000

22 Mini-Cog 3 item registration Clock drawing 3 item recall Simplified scoring: 0/3 on 3 item recall - Impaired 3/3 on 3 item recall Intact 1-2/3 on 3 item recall include clock drawing Borson et al., 2000

23 Mini-Cog 3 Item Recall = 0 Impaired 3 Item Recall = 1-2 Score clock 3 Item Recall = 3 Intact Impaired Clock Drawing Impaired Intact Clock Drawing Intact Borson et al., 2000

24 Development of the MC-FAQ to improve early recognition Mini-Cog No change in administration Score range points for delayed recall 1 point all # s present 1 point - # s 3,6,9,12 on or near quadrant boundaries 1 point hands indicate 11:10 FAQ 10 questions to be completed by friend/family member Scoring Normal function = 0 Has trouble, but able = 1 Needs help = 2 Unable = 3 Steenland et al., J Alz Dis, 2008

25 Functional Assessment Questionnaire Writing checks, paying bills, balancing checkbook Assembling tax records, business affairs or other papers Shopping alone for clothes, household necessities, or groceries Playing a game of skill such as bridge or chess, working on a hobby Heating water, making a cup of coffee, turning off the stove Preparing a balanced meal Keeping track of current events Paying attention to & understanding a TV program, book or magazine Remembering appointments, family occasions holidays, medications Traveling out of the neighborhood, driving, or arranging to take public transportation N/A Normal Has difficulty but does by self Requires Assist Dependent Pfeffer, Kurosaki, Harrah, et al., 1982

26 Steenland et al., J Alz Dis, 2008

27 Is it depression or dementia? Symptoms of Depression Cognitive decline rapid Oriented to day, date, place & person Trouble concentrating Speech & motor functions may be slow but normal Is concerned about forgetfulness Occurs more frequently in context of medical illness Symptoms of Dementia Insidious cognitive decline Disoriented may become easily lost in familiar surroundings Forgetfulness short term memory loss Cognitive impairment may include problems finding words, verbal expression & accomplishing physical tasks Often does not recognize forgetfulness Medical illness/surgery may unmask symptoms

28 Goals Goals of screening Early identification Early initiation of treatment Improve quality of life

29 References Agency for Healthcare Research and Quality (2003, June). Screening for dementia: Recommendations and rationale. Retrieved February 14, 2010 from, Ashford, J.W., Borson, S., O Hara, R., Dash, P., Frank, L., Robert, P.,. Buschke, H. (2006). Should older adults be screened for dementia? Alzheimer s & Dementia, 2, doi: /j/jalz Boise, L., Neal, M.B., & Kaye, J. (2004). Dementia assessment in primary care: Results from a study in three managed care systems. Journal of Gerontology, 59A, 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. International Journal of geriatric Psychiatry, 15, Borson, S., Scanaln, J., Hummel, J., Gibbs, K., Lessig, M., & Zuhr, E. (2007). Implementing routine cognitive screening of old adults in primary care: Process and impact on physician behavior. Annals of Internal Medicine, 22, doi: /s Boustani, M., Callahan, C.M., Unverzagt, F.W., Austrom, M.G., Perkins, A.J., Fultz, B.A.,.Hendrie, H.C. (2005). Implementing a screening and diagnosis program for dementia in primary care. Journal of General Internal Medicine, 20, doi: /j x Boustani, M., Peterson, B., Hanson, L., Harris, R., & Lohr, K.N. (2003). Screening for dementia in primary care: A summary of the evidence for the U.S. preventive services task force. Annals of Internal Medicine, 138(11), Bradford, A., Kunik, M.E., Schulz, P., Williams, S.P. & Singh, H. (2009). Missed and delayed diagnosis of dementia in primary care: Prevalence and contributing factors. Alzheimer s Disease and Associated Disorders, 23(4), Brodaty, H., Low, L-F, Gibson, L & Burns, K. (2006). What is the best dementia screening instrument for general practitioners to use? American Journal of Geriatric Psychiatry, 14, doi: /01.JGP b2 Bynum, J.P.W., Rabins, P.V., Weller, W., Niefeld, M., Anderson, G.F. & Wu, A.W. (2004). The relationship between a dementia diagnosis, chronic illness, medicare expenditures, and hospital use. Journal of the American Geriatric Society, 52, doi: /j x Callahan, C.M., Hendrie, H.C. & Tierney, W.M. (1995). Documentation and evaluation of cognitive impairment in elderly primary care patients. Annals of Internal Medicine, 122, Folstein, M.S., Folstein, S.E. & McHugh, P.R., (1975). Mini-mental state a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, HealthCare.gov. (2010). Benefits for Seniors of New Affordable Care Act Rules on Expanding Prevention Coverage. (2010, July 10) Retrieved December 30, 2010 from

30 References Hebert, L.E., Scherr, P.A., Bienias, J.L., Bennett, D.A. & Evans, D.A. (2003). Alzheimer s disease in the US population: Prevalence estimates using the 2000 census. Archives of Neurology, 60, Kerr, L.K., Kerr, L.D. (2001). Culture and Medicine Screening Tools for Depression in Primary Care. Western Journal of Medicine, 175, Kroenke, K., Spitzer, R.L., (2002). The PHQ-9: A New Depression and Diagnostic Severity Measure. Psychiatric Annals, 32, Milne, A., Culverwell, A., Guss, R., Tuppen, J. & Whelton, R. (2008). Screening for dementia in primary care: A review of the use, efficacy and quality of measures. International Psychogeriatrics, 20, doi: /S Moore, A.A., Siu, A.L., Partridge, J.M., Hays, R.D. & Admans, J. (1997). A randomized trial of office-based screening for common problems in older persons. The American Journal of Medicine, 102, doi: /S (97) Peterson, R.C., Stevens, J.C., Ganguli, M., Tangalos, E.G., Cummings, J.L. & DeKosky, S.T. (2001). Practice parameter: Early detection of dementia: Mild cognitive impairment (an evidence-based review). Neurology, 56, Pfeffer, R.I., Kurosaki, T.T., Harrah, C.H.. et al. (1982). Measurement of functional activities of older adults in the community. Journal of Gerontology, 37, Radloff, L.S., (1977). The CES-D Scale: A Self-Report Depression Scale for Research in the General Population. Applied Psychological Measurement, 1 (3), Reuben, D.B., Roth, C.P., Frank, J.C., Hirsch, S.H., Katz, D. McCreath, H. Wenger, N.S. (2010). Assessing care of vulnerable elders Alzheimer s disease: A pilot study of a practice redesign intervention to improve the quality of dementia care. Journal of the American Geriatric Society, 58, doi: /j x Sheikh, J.I., Yesavage, J.A., (1986). Geriatric Depression Scale (GDS): Recent Evidence and Development of a Shorter Version. Clinical Gerontologist: The Journal of Aging and Mental Health, 5(1-2), Steenland, N.K., Auman, C.M., Patel, P.M.,Bartell, S.M., Goldstein, F.C., Levey, A.I. & Lah, J.J. (2008). Development of a rapid screening instrument for mild cognitive impairment and undiagnosed dementia. Journal of Alzheimer s Disease and Associated Disorders, 15(3), Turner, S., Iliffe, S., Downs, M., Wilcock, J., Bryans, M., Levin, E., O Carroll, R.O., (2004). General practitioners knowledge, confidence and attitudes in the diagnosis and management of dementia. Age and Ageing 33, doi: /ageing/afh140 Valcour, V.G., Masaki, K.H. & Blanchette, P.L. (2002). Self-reported driving, cognitive status, and physician awareness of cognitive impairment. Journal of the American Geriatric Society, 50, doi: /j x Wenger, N.S., Roth, C.P., Shekelle, P.G., Young, R.T., Solomon, D.H., Kamberg, C.J., Reuben, D.B. (2009). A practice-based intervention to improve primary care for falls, urinary incontinence, and dementia. Journal of the American Geriatric Society, 57, doi: /j x