A Dementia Case Finding Program for ‐Veterans: Applying

Lessons Learned to Improve Dementia Recognition in Primary

CarePractice

Laura O. Wray, PhD, Director of Education, VA Center for Integrated HealthcareDavid A. Hunsinger, MD, MSHA, Medical Director, Binghamton VA Outpatient Clinic

Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.

Session #F4 - 20October 29, 201110:50 AM

Faculty Disclosure

We have not had any relevant financial relationships during the past 12 months.

Need/Practice Gap & Supporting Resources

• Costs of care for patients with dementia are significantly greater than costs for similarly aged

• Significant impairment in medical adherence can occur long before dementia is recognized

• Rates of detection of dementia in primary care are low• Undiagnosed dementia is a missed opportunity to improve

quality of care and quality of life for our older patients• First step in improving care is to increase recognition

Objectives

• Describe the experience of VA Upstate New York Veteran’s Integrated Health Care System (VISN 2) in using an electronic

medical record based system to identify Veterans to be screened for dementia

• Review guidelines for recognition of dementia• Discuss how medical and behavioral health providers can

work collaboratively to address this challenge

Expected Outcome

Attendees will be able to discuss how common risk factors can be used to improve the detection of dementia in primary care

Dementia Recognition in Primary Care (PC)

USPSTF: “Insufficient evidence to recommend for or against screening”

25-40% cases recognized: typically when moderately impairedWhat delays dementia diagnosis?`

Provider• Time constraints

• Absence of family informant• Provider attitudes: Dementia is

untreatable

Patient• Agnosagnosia

• Acceptability of screening• Family discomfort with raising

concerns

Highlights of American Academy of Neurology Guidelines

Know and Share the 10 Warning Signs

Be alert to cognitive impairment– Know and use a

brief mental status measure (example: Mini-Cog Borson S, et al. Int J Geriatr Psychiatry. 2000; 15: 1021-1027.)

Clinical Criteria for AD are reliable

Include routine evaluation of:– CBC– Glucose– Depression Screening– Thyroid Function– Serum electolytes– BUN/creatine– Serum B12– Liver function

Ten Warning Signs of AD1. Memory loss that affects job skills

2. Difficulty with familiar tasks

3. Problems with language

4. Disorientation to time and place

5. Poor or decreased judgment

6. Problems with abstract thinking

7. Misplacing things

8. Changes in mood or behavior

9. Changes in personality

10. Loss of initiative

VISN 2 RAPID* Goals:

Promote early recognition of cognitive impairment and diagnosis of dementia

Provide access to comprehensive assessment for Veterans who screen positive for cognitive assessment

Offer education and support to caregivers

Provide access to dementia care management

*RAPID = Recognizing and Assessing Progression of cognitive Impairment and Dementia

Pri

mar

y C

are

Pro

vid

er

VISN 2 RAPID Program Overview

Behavioral Health Assessment Center

(BHAC)*

DementiaCare

Coordinator

Geriatric Evaluation & Management

(GEM)

Clinical Reminder used to generate monthly RAPID eligible list +

+

+

+/-

+/-

+/-

RAPID Case Finding Approach:Use of Dementia Red Flags1. Electronic Medical Record:

– Age (Over 70)*– And one or more of the following:

2 or More ER visits in past yearHistory of CVA Taking more than 1 anticholinergic medication

2. Behavioral Health Assessment Center (BHAC) performs cognitive screen

3. Dementia Care Manager calls veteran and family informant and reviews medical record– Medication adherence problems– More than 7 prescribed medications– Agitation– Multiple falls in past year– More than 2 hospitalizations– Attending office visit with caregiver– More than 2 missed appointments in past year– DX of Diabetes + hypertension + CAD + hyperlipidemia

Adapted from the work of Callahan, Boustani, Unverzagt et al., Ann of Int Med (2006)

RAPID Screening CallsMonthly call lists – clinical reminder technology– Adaptable to adjust # of patients to be

screened

Blessed Orientation Memory and Concentration Test (BOMC)– Validated for use over the phone– Routinely used as part of BHL software– New introduction script created– Score = Total Errors; Range = 0 - 28– ≥10 is suggestive of dementia

RAPID Case-Finding StrategyCall List Criteria– Primary Care appointment within the coming month– No prior dementia diagnosis– Veterans 70* years and older

And Either– One or more anticholinergic medication

OR– History of CVA

OR– Two or more ER visits in last year

BHAC calls veteran– Positive BOMC (11 or greater) referred to DCM– Negative BOMC healthy brain questions and feedback about

preserving memory via lifestyle

Program Evaluation Methods - Sample

All VISN 2 Veterans aged 70 and over

At least 1 appointment at any VISN 2 medical center primary care FY07 - FY09

Exclusions:– Diagnosis of dementia in FY05 – FY07– Prescription for Cholinesterase Inhibitor of

NMDA receptor antagonist– Missing any data for any risk factor

Example: PHQ-2 (2,881 Veterans)

Program Evaluation Methods - Sample

Sample Categorization– RAPID Eligible Veterans

70 yrs and older and any of the following:– 2 or more ER Visits– History of CVA– 1 or more anticholinergic medications

Within RAPID Eligible:– BOMC + Veterans: Score 10 or greater– BOMC – Veterans: Score of less than 10– Unscreened Veterans: no evidence of a RAPID

screening call in EMR

Program Evaluation Methods

Index Date: to track time to diagnosis– Unscreened Group: first medical appointment

after 10/1/07– Screened Group: date of the RAPID call

Incidence of New Dementia Diagnosis– 1st occurrence of visit encounter coded for

dementia following Index Date

Within RAPID Eligible Veterans, is a BOMC+ associated with a new dementia diagnosis?

BOMC+(n=543)

BOMC-(n=543)

No BOMC(n=2496)

p Value

DementiaNo. (%)

38 (7.0) 8 (1.5) 147 (5.9) <0 .001

Age(mean ± SD)

81.7 ± 5.5 81.7 ± 5.5 81.7 ± 5.5 0.501

Follow-up(months)

8.3 ± 6.4 8.8 ± 6.8 12 ± 6.8 <0 .001

BOMC Score(mean ± SD)

12.8 ± 3.3 3.1 ± 2.7 --- <0 .001

Incidence of Dementia among RAPID Screen Positive Veterans

Within RAPID Eligible Veterans, is a BOMC+ associated with a new dementia diagnosis?

Cumulative Dementia-free Probability

Months Since BOMC Administration

0 6 12 18 24

Probabil

ity o

f R

em

ain

ing D

em

enti

a-f

ree

0.80

0.82

0.84

0.86

0.88

0.90

0.92

0.94

0.96

0.98

1.00

P < 0.001

BOMC -(n = 543)

BOMC +(n = 543)

(n = 1036) (n = 612) (n = 359) (n = 136) (n = 0)

HR = 4.97 (95%CI: 2.32 –10.66)

Which Risk Factors Predict Dementia Diagnosis?

EMR Risk Factors:– Age– Gender– ER Visits– Diabetes– Hypertension– Head Trauma– CVA

– TIA– Health Screens for:

Tobacco

Alcohol Use (Audit-C)

Depression (PHQ-2)

What are EMR risk factors are most effective identifying

dementia?

Predictor Df Beta (SE) OR 95%CI P-Value

Intercept 1 -9.32 (.726) ----- ---- <.001

Age 1 .072 (.009) 1.074 1.055-1.093 <.001

ER Visit 1 .417 (.057) 1.518 1.358 – 1.696 <.001

CVA 1 .825 (.172) 2.282 1.629 – 3.196 <.001

PHQ-2 1 .106 (.039) 1.111 1.029 – 1.200 .007

Risk Model for Incidence of New Dementia Diagnosis

SummaryAge, ER use, and History of CVA continue to be strong risk factors.

Depression is also an important predictor– Older adults with PHQ+ or in MH treatment

should be considered for dementia screening

Program activities following a BOMC+ associated with a 5x increase in new dx–Supporting identification of dementia

can improve PC recognition rates

Working CollaborativelyMedical Provider Behavioral Health Provider

Be alert to warning signs and behavioral changes in older patients

Be alert to warning signs and behavioral changes in older patients

Involve BHP for screening of depression and dementia

Involve family informant when possible

Order recommended medical evaluations

Be skilled and perform brief mental status assessment

Evaluate for possible reversible medical causes

Evaluate for possible depression and/or dementia

Develop a plan for expert consultation and/or management

Feedback information to PCP and develop plan; Know community resources for dementia care

Treat cognitive symptoms of AD Support family and help with management of behavioral symptoms

Treat psychiatric of dementia symptoms as needed

Encourage family caregivers to get involved with education/support

Questions for the presenters?

Group Discussion:

How can the detection of dementia be improved in primary care?

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!