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

10

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

62

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

69

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