What Can Behavioral Health Providers Do? Improving Primary Care of

Dementia Through Integration

Laura O. Wray, PhD - Director of Education, VA Center for Integrated HealthcareChristina L. Vair, PhD – Clinical Research Psychologist, VA Center for Integrated

Healthcare

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session #A5aOctober 18, 2014

Faculty Disclosure

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

Learning Objectives

At the conclusion of this session, the participant will be able to:

1. Recognize warning signs and risk factors for dementia in older primary care patients.

2. Discuss ways to improve detection of dementia in primary care.

3. Describe evidence-based strategies to improve recognition of dementia in primary care, including description of validated screening tools that can be readily integrated into primary care assessment for dementia.

• American Academy of Neurology (2004) Guideline Summary for Clinicians http://tools.aan.com/professionals/practice/pdfs/dementia_guideline.pdf

– See also: American Academy of Neurology: Other dementia resources, including questionnaires for patients and CGers re: driving https://www.aan.com/Guidelines/Home/ByTopic?topicId=15

• Alzheimer’s Association Warning Signs (2009) http://www.alz.org/alzheimers_disease_know_the_10_signs.asp

• Borson, S., Frank, L., Bayley, P. J., Boustani, M., Dean, M., Lin, P. J., et al. (2013). Improving dementia care: the role of screening and detection of cognitive impairment. Alzheimer's & Dementia, 9(2), 151-159.

• Goy E., Kansagara D., Freeman M. A. Systematic Evidence Review of Interventions for Non-professional Caregivers of Individuals with Dementia [Internet]. Washington (DC): Department of Veterans Affairs; 2010 Oct. Available from: http://www.ncbi.nlm.nih.gov/books/NBK49194/

• Hurd, M. D., Martorell, P., Delavande, A., Mullen, K. J., & Langa, K. M. (2013). Monetary costs of dementia in the United States. New England Journal of Medicine, 368,1326-1334.

• Lin, J.S., O'Connor, E., Rossom, R.C., Perdue, L.A., Ekstrom, E. (2013) Screening for cognitive impairment in older adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med, 159, 601-612.

• Wray, L. O., Wade, M., Beehler, G. P., Hershey, L. A., & Vair, C. L. (in press). A program to improve detection of undiagnosed dementia in primary care and its association with health care utilization. American Journal of Geriatric Psychiatry. DOI: 10.1016/j.jagp.2013.04.018

References

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Disclosure

The views expressed in this presentation are those of the authors and do not necessarily

reflect the position or policy of the Department of Veterans Affairs or the United States

government.

• What brings you to our talk?

Question for Audience

Established Practice Gaps

• Costs of care for patients with dementia are significantly greater

• 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

Dementia Recognition in Primary Care (PC)

USPSTF (2013): “Insufficient evidence to recommend for or against screening” Annual Wellness Visit (Affordable Care Act) requires assessment to detect cognitive impairment along with other routine measuresHowever, 25-40% cases moderate to severe dementia are not recognized

What delays dementia detection?Provider

• Time constraints• Absence of family informant

• Provider attitudes Dementia is untreatable

Patient

• Agnosagnosia• Acceptability of screening

• Family discomfort with raising concerns

Barriers to Detection

Successful Integration Will Improve Quality, Satisfaction and Cost

Older Patients

Medical and Behavioral

Health Providers Family

Caregivers

AAN Guidelines* • Know and Share the 10 Warning Signs

• Be alert to cognitive impairment– Know and use 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 *http://tools.aan.com/professionals/practice/pdfs/dementia_guideline.pdf

Alzheimer’s Association Warning Signs*

1. Memory loss that affects job skills2. Difficulty with familiar tasks3. Problems with language4. Disorientation to time and place5. Poor or decreased judgment6. Problems with abstract thinking7. Misplacing things8. Changes in mood or behavior9. Changes in personality10. Loss of initiative

* http://www.alz.org/alzheimers_disease_10_signs_of_alzheimers.asp

How Do We Improve Detection?• In absence of endorsement for routine screening,

advocate for case finding • Utilize known risk factors, clinical observation to

guide next steps• Consider differential diagnosis

– Depression vs. Dementia?

• Use Evidenced Based screening measures – Simple & Brief – Validated– Optimal sensitivity and specificity – FREE!

Brief Screening Measures*

Test Pros ConsBlessed Orientation Memory Concentration (BOMC)

- Studied in a general population sample & 2 specialty clinic settings

- Low specificity (38-77%) in 2 of 4 studies

- Race and education biases in 1 study

General Practitioner Assessment of Cognition (GPCOG)

- Studied in a primary care setting - Education bias found absent - Combined score & 2-stage method

had higher sensitivity/specificity than patient and informant sections separately

- Informant section alone has low specificity (49-66%)

Mini-Cog - Shortest administration time (2-4 minutes)

- Studied in a general population sample

- High specificity (83-93%) in studies that excluded MCI from comparator group

- Education and language/race biases found absent in U.S. samples

- May be inappropriate for populations with extremely low levels of education or literacy

* VA Evidence Based Synthesis citation (Kansagara & Freeman, 2010)

Brief Screening Measures*

Test Pros ConsMontreal Cognitive Assessment (MoCA) - Studied in a memory clinic

population - High sensitivity (94-100%)

- Longest administration time (10- 15 minutes)

- Low specificity (35-50%) in 2 of 3 studies

- Education correction

St. Louis University Mental Status (SLUMS)

- Studied in a VA geriatric clinic population

- High sensitivity and specificity (98-100%)

- Adjusts cut-off score for education

- Longer administration time (7 minutes)

- Evaluated in only 1 study

Short Test of Mental Status (STMS) - Studied in a primary care setting - Shorter administration time (5

minutes) - High specificity (93.5%) using age-

adjusted cutoff scores

- Evaluated in 2 studies

* VA Evidence Based Synthesis citation (Kansagara & Freeman, 2010)

Importance of Collateral Interview

• Functional impairment is a key aspect of the diagnosis

• Patient unlikely to be able to report accurately• AWV indicates justification for assessment

based on informant report of concern • AD8

Review of FindingsCognitive Screen – Negative

Cognitive Screen – Positive

Functional Screen - Negative

Functional Screen – Positive

Depression versus Dementia

• Not mutually exclusive• Similar presentations• Consider validity of depression screen given a

positive cognitive screen– Geriatric Depression Scale

• Short form 15 items

• Families often interpret apathy as depression

Working Collaboratively Behavioral Health Provider

Be alert to warning signs and behavioral changes in older patients

Involve family informant whenever possible

Be skilled and perform brief mental status assessment

Evaluate for possible depression and/or dementia

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

Support family and help with management of behavioral symptoms

Encourage family caregivers to get involved with education/support

Medical Provider

Be alert to warning signs and behavioral changes in older patients

Involve BHP for screening of depression and dementia

Order recommended medical evaluations

Evaluate for possible reversible medical causes

Develop a plan for expert consultation and/or management

Treat cognitive symptoms of AD

Treat psychiatric of dementia symptoms as needed

Working Collaboratively with Family Caregivers

Behavioral Health ProviderTake family report seriously

Get permission from patient to talk to family member if possible

Help family member transition to caregiver role

Know community resources for dementia assessment and care

Be able to explain source of behavioral symptoms, understand what is typical

Support family and help with management of behavioral symptoms

Family Caregiver

May be first to notice symptoms

Needs to understand patient’s current abilities

Serves an important role in management of all medical conditions

Needs to know where to get more support: Community, family

May need help in understanding behavioral symptoms are not intentional

Likely to need help in avoiding behavioral symptoms

Case Example

Case Discussion

Questions and Answers

Session Evaluation

Please complete and return theevaluation form to the classroom monitor

before leaving this session.

Thank you!