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Implementing the HCH for Patients with AD: Early Identification, Care coordination & caregiver support
Health Care Homes Learning Day,November 1, 2012
1
Session Overview
Introduction to Health Care Home (HCH) Overview Successful HCH: physician & care coordinator
perspectives Alzheimer’s Disease and HCH
Overview AD in HCH: physician & care coordination roles
Alzheimer’s Disease: Firsthand experience Conclusion / Q&A
Successful HCH
Dr. Johnson presentation Panel discussion
AD Overview4
Facts & Figures& Figures
Alzheimer’s Association 2011
Today, Alzheimer’s Disease Is:
Fatal Prevalent Expensive Misunderstood Stigmatized Under-diagnosed Under-treated ON THE RISE….
Alzheimer’s Epidemic
By 2050: 13 million to 16 million Americans will have
AD Consume 1.1 trillion in healthcare spending
Today
Fewer than 50% of patients receive formal diagnosisDiagnosis often delayed by 6+ Years Impairment in function by time it is recognized
Fewer than 50% of those diagnosed receive any treatment
Why is Early Diagnosis Important?
1. Optimize current medical management2. Relief gained from better understanding3. Maximize decision-making autonomy4. Access to services5. Risk reduction6. Plan for the future*7. Improve clinical outcomes*8. Avoid or reduce future costs9. Diagnosis as a human right
World Alzheimer Report 2011
*Top benefits endorsed by physicians, International Alzheimer’s Disease Physician Survey, 2012
Alzheimer’s Disease: Course, Prevention, Treatment Strategies
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INTERVENTIONPrimary
Prevention
Secondary
Prevention
Treatment
CLINICAL STATE NormalPre-
symptomatic AD
Mild Cognitive Impairme
nt
AD
Numbers of people ??? 20 to 60 mil 10 to 15 mil 5.3mil
BRAIN PATHOLOGIC STATE
No diseaseNo symptoms
Early AD brain changesNo symptoms
AD brain changesMild symptoms
Mild, moderate or severe impairment
STRATEGIES
Identify at-riskPrevent AD
Prevent or delay emergence of symptoms
Stimulate memorySlow progression
Treat cognitionTreat behaviorsSlow progressionDISEASE PROGRESSIONDISEASE PROGRESSION
AD: Physician Perspective11
Alzheimer’s, the Scope of the Problem
Most significant Risk Factor Age
Prevalence of Cognitive Impairment 50% of those >85
Co-morbidities At least one present in 95%
Easy Practice Tips
Practice Tips
Red flags Repetition (not normal in 7-10 min conversation) Tangential, circumstantial responses Losing track of conversation Frequently deferring to family Over reliance on old information/memories Inattentive to appearance Unexplained weight loss or “failure to thrive”
Practice Tips
Family observations: ANY instances whatsoever of getting lost while driving,
trouble following a recipe, asking same question repeatedly, mistakes paying bills
Ask: “Let’s suppose your family member was alone on a
domestic flight across the country and the trip required a layover with a gate change. Would he/she be able to manage that kind of mental task on his/her own?”
Practice Tips
Intact older adult should be able to: Describe 2 current events in some detail Describe what happened on 9/11, New Orleans disaster Name the current President and 2 immediate
predecessors Describe medical history and names of some
medications
Dementia Care
Screening Diagnosis Management
Rationale for Early Detection
1. Improve quality of life Early treatment is more effective
Stabilization vs. improvement Patients can make decisions regarding care Patients can get to their “bucket list” Decrease burden on family and caregivers
2. Connection to services that promote independent (supported) living as long as possible
RTC support/counseling intervention (Mittelman et al. Neurology 2006) Non-pharm interventions reduce NH placement by 30% and
delay placement for others by 18+ months
Rationale for Early Detection
3. May find reversible causes NPH, TSH, B12, hypoglycemia, depression
4. Improve management of co-morbid conditions Underlying dementia = a primary risk factor of poor compliance in
the elderly Chronic disease (diabetes, hypertension, anticoagulation) Integrity of the brain related to one’s ability to manage health Dementia as the Organizing Principle of Care
Rationale for Early Detection
5. Reduce ineffective and expensive crisis-driven use of healthcare resources
Unhelpful emergency room visits and hospitalizations Prevent diagnosis during crises (wandering, hospitalization,
car accidents, bankruptcy)
6. More time to participate in clinical trials and important scientific studies
Knowledge gap re: earlier stages Find a cure
Screening
Initial considerations Balance b/w time and sensitivity/specificity How will your practice incorporate screening? Who will administer tests?
MDs, Nurses, social workers, allied health professionals What happens when screen is positive?
Annual Wellness Visit: Medicare
Took effect January 1, 2011 Affordable Care Act
Medicare will cover an annual wellness visit which will include the creation of a personalized prevention plan
For first time, “detection of cognitive impairment” is core feature of the exam
Diagnosis of dementia requires a decline in function over time, so screen provides a baseline on cognition
Screening Measures
Wide range of options Mini-Cog (MC) Mini-Mental State Exam (MMSE) St. Louis University Mental Status Exam (SLUMS) Montreal Cognitive Assessment (MoCA)
All but MMSE free online in public domain Utilize “Family Questionnaire (if family available)
Mini-Cog
Contents Verbal Recall (3 points) Clock Draw (2 points)
Advantages• Quick (2-3 min)• Easy• High yield (executive fx,
memory, visuospatial)
Subject asked to recall 3 wordsLeader, Season, Table
Subject asked to draw clock, set hands to 10 past 11
+3
+2
Mini-Cog
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
Pros Easy to administer Minimal time
commitment Clock sensitive to
visuospatial & executive dysfunction
Simple scoring and interpretation
Cons Not as sensitive for
MCI or early dementia when compared to longer screens
Brevity means less information to interpret
Screen Failure
MiniCog = <4 OR memory complaints by patient/family
Schedule follow-up appt Insist on family collateral Perform more complex test (MOCA, SLUMS, MMSE)
MMSE
MMSE
Pass > 26
Fail 25 or less
Pros Widely accepted and
validated for dementia screening
30-point scale well known and score easily interpretable
Measures orientation, working memory, recall, language, praxis
Cons Scale developed 40 years
ago, before MCI criteria and when early dementia less well understood
Lacks sensitivity to MCI and early dementia
Takes 7+ min. to administer
Copyright issues
MMSE
SLUMS
Pros More measures of
executive functioning Good balance between
easy and difficult items More sensitive than MMSE
in detecting MCI and early dementia
30-point scale similar to MMSE
Score range for MCI and dementia
Free online
Cons Takes 10 min. to
administer Slightly more complex
directions than MMSE Less name recognition
than MMSE
SLUMS
SLUMS
Pass > 26
Fail 25 or less
MoCA
MoCA
Pass > 26
Fail 25 or less
Pros Much more sensitive than
MMSE for MCI and early dementia
More content tapping higher level executive fx
30-point scale similar to MMSE
Translations available in 35+ languages
Free online
Cons Takes 10-14 min. to
administer More complex
administration and directions than MMSE
MoCA
Screening Tool Selection
Montreal Cognitive Assessment (MoCA) Sensitivity: 90% for MCI, 100% for dementia Specificity: 87%
St. Louis University Mental Status (SLUMS) Sensitivity: 92% for MCI, 100% for dementia Specificity: 81%
Mini-Mental Status Exam (MMSE) Sensitivity: 18% for MCI, 78% for dementia Specificity: 100%
Larner et al Int Psychogeriatr 2012; Nasreddine et al J Am Geriatr Soc 2005; Tariq et al Am J Geriatr Psychiatry 2006; Ismail et al Int J Geriatr Psychiatry 2010
Dementia Care
Screening Diagnosis Management
Diagnostic Workup
H&P Diagnostics
Labs Imaging Neuropsychological assessment
Diagnosis Family meeting
History & Physical
History (with collateral) Onset, duration, course Examples of memory difficulties Impact on function
$ management, meds, driving, cooking Mood, personality or behavior changes Drug or alcohol use Medication side effects
Physical + brief neuro exam Do depression screening (PHQ-9), if not already
completed
Diagnostics: Labs
Routine Labs CBC Electrolytes BUN/creatinine Glucose Calcium LFTs--??
Dementia screening Vitamin B12, folate TSH
Contingent labs RPR or MHA-TP HIV Heavy metals
Diagnostics: Imaging
CT adequate for pts with clinical history consistent with AD
MRI helpful for determining pattern of focal atrophy Request radiologist comment on hippocampal volume
Scans often unremarkable in patients with early AD
Rule out focal lesions, trauma, ischemia, NPH No need to repeat if pt. had recent scan
Within 12 months No recent hx of trauma
Diagnostics: Neuropsych Testing
Helpful in distinguishing normal aging from MCI and dementia
Atypical presentations Rule out:
Pseudodementia, substance abuse factors, etc.
Determine type of dementia, stage, capacity, most appropriate level of support
Consider particularly when: MoCA 19-27 SLUMS 18-27 MMSE 18-28
Loss of Memory Plus one of the following
Impairment in handling complex tasks (balancing a check book, calendars, clock drawing)
Impairment in reasoning ability Impaired spatial ability and orientation (lost) Impaired language (word finding)
Severe enough to impact daily life and is a decline from previous function
Dementia Diagnosis
Diagnosis
Alzheimer’s disease: 60-80 %• Includes mixed AD + VD
Lewy Body Dementia: 10-25 % Parkinson spectrum
Vascular Dementia: 6-10 % Stroke related
Frontotemporal Dementia: 2-5 % Personality or language problems
Vascular Dementia
Clinical Features Focal neurological signs Stepwise progression Often overlaps with AD (6-10%
dementia related to pure VD)
Neuropsychological Testing Predominant deficits in
executive function, attention, and processing speed
Neuroimaging Cerebrovascular Disease
Large vessel stroke Periventricular/subcortical white
matter disease
Dementia with Lewy Bodies
Clinical Features Parkinsonism, hallucinations, cognitive fluctuations,
REM behavioral sleep disorder
Neuropsychological Testing Predominant visuospatial dysfunction with relative
sparing of verbal memory
Neuroimaging Non-specific MRI atrophy pattern Occipital hypometabolism on FDG-PET
Frontotemporal Dementia
Clinical Features Typical onset prior to age 65 Behavioral symptoms
Disinhibition, apathy, loss of empathy, repetitive stereotyped movements, hyperorality
Language symptoms Expressive aphasia, anomia, surface dyslexia
Neuropsychological Testing Impairments on executive function/language with relative sparing
of episodic memory and visuospatial function
Neuroimaging Atrophy of frontal and anterior temporal cortex
Dementia Care
Screening Diagnosis Management
Overall Management
Goals; Reduce suffering that accompanies the disease Reduce the negative impacts that dementia has
on both health & quality of life Balancing independence & safety Optimize the management of co-morbid
conditions Weighing benefits, burdens & risks of treatments Care Plan for acute illness Supporting the Caregiver
Management
Medication treatment Small component of care plan
Education Increase family’s dementia competence
Support / Referral Connect to community resources
AD: Care Coordination57
Intervention Model - Clinic
Care Coordination
Identify cognitive impairment, facilitate diagnosis
Identify ‘team members’, including care partner
Conduct needs assessment Develop & initiate care plan Communicate with team Monitor & re-evaluate Termination
59
Clinic Care Coordination Needs
Care partner / team approach Disease education Assistance with medication management Written materials / plans POA / healthcare directive Appointment reminders Driving assessment / transportation options Occupational therapy / home safety assessment, fall risk Risk reduction strategies Connection to community resources & programs
60
Risk Reduction
Genetic Factors: APP, Presinilin 1 &2 / APOE4 Environmental Factors: begins in mid-life (50%)
Mid-life HTN & Obesity (60%) Physical Inactivity (40 – 80%) Mid-life Depression (40 – 80%) Low Education / Cognitive Reserve (60 – 80%) Smoking (60%) Alcohol – Late Life & Binge Drinking (2xmo) Sleep Hygiene : quality & quantity
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Mild Cognitive Impairment (MCI)
Current Services in Minnesota
Medical Evaluation / Diagnosis / Pharmacological Treatment*
Research / Clinical Trials*
Care Coaching / Consultation / Counseling*
Information / Education*
MCI Support Groups*
Engagement Programs (arts, social, creativity)*
Exercise / Nutrition / Cognitive Habilitation* * limited availability
63
Early Stage
Current Services in Minnesota
Medical Evaluation / Diagnosis / Pharmacological Treatment*
Research / Clinical Trials*
Care Coaching / Consultation
Information / Education / Driving Evaluation*
Early Stage Support Groups*
Engagement Programs (arts, social, creativity)*
Exercise / Nutrition / Cognitive Habilitation*
Home Care / Companion Services*
Assisted Living
Medic Alert Safe Return®
* limited availability
65
66
Middle Stage
Current Services in Minnesota
Medical Evaluation / Diagnosis / Pharmacological Treatment
Research / Clinical Trials*
Care Coaching / Consultation / Counseling
Information / Education / Driving Evaluation*
Caregiver Support Groups*
Adult Day Services*
Meals on Wheels*
Home Care / Home Health Care / Respite Services*
Medic Alert Safe Return®
Assisted Living / Nursing Facility* limited availability
67
Late Stage
Current Services in Minnesota
Medical Evaluation / Diagnosis / Pharmacological Treatment
Care Coaching / Consultation / Counseling
Information / Education
Caregiver Support Groups*
Adult Day Services*
Meals on Wheels*
Home Care / Home Health Care / Respite Services*
Medic Alert Safe Return®
Assisted Living / Nursing Facility
Hospice** limited availability
68
Research
Minnesota Resources
Alzheimer’s Disease Research Center – Mayo Clinic
University of Minnesota
VA Medical Center
Alzheimer’s Research Center, Regions Hospital
Health Partners Research Fund
Healthcare Interactive (HCI)
TrialMatch: http://www.alz.org/research/clinical_trials/find_clinical_trials_trialmatch.asp
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ACL Projects
Minnesota Resources
Family Memory Care: evidence-based consultation
Systems Integration: dementia capability
Telephone / Internet Resources Alzheimer’s Association 1-800-272-3900 alz.org
Senior LinkAge Line® 1-800-333-2433 MinnesotaHelp.info®
AD: The Patient Experience70
Conclusion / Q&A71
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