Objecves Alzheimer’s Disease: Challenges and Opportuni*es

10/17/17

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BestPrac*cesforDetec*onandEarlyManagementofDemen*a

TerryR.Barclay,PhD

HealthPartnersCenterforMemoryandAgingAdjunctAssociateProfessorofNeurology,UniversityofMinnesota

ACKNOWLEDGEMENTS

Thisprojectis/wassupportedbyfundsfromtheBureauofHealthProfessions(BHPr),HealthResourcesandServicesAdministra*on(HRSA),DepartmentofHealthandHumanServices(DHHS)underGrantNumberUB4HP19196totheMinnesotaAreaGeriatricEduca*onCenter(MAGEC)for$2,192,192(7/1/2010—6/30/2015).Thisinforma*onorcontentandconclusionsarethoseofthe

authorandshouldnotbeconstruedastheofficialposi*onorpolicyof,norshouldanyendorsementsbeinferredbytheBHPr,HRSA,DHHSortheU.S.Government.

MinnesotaAreaGeriatricEduca*onCenter(MAGEC)

Grant#UB4HP19196Director:RobertL.Kane,MD

AssociateDirector:PatriciaA.Schommer,MA

Objec*ves

1.  Understandthera*onaleforearlydiagnosis2.  Useevidence-basedtoolstoimprove

demen*adetec*on

3.  Reviewbestprac*cesfordemen*awork-upanddiseasemanagement

4.  Learnhowtohelppa*entsandfamilyaccessservicestoimprovefunc*onandpromotewellness

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Alzheimer’sDisease:ChallengesandOpportuni*es

Alzheimer’s:APublicHealthCrisis

•  Scopeoftheproblem–  5.3MAmericanswithADin2015–  Growingepidemicexpectedtoimpact13.8MAmericansby2050andconsume1.1trillioninhealthcarespending

–  Almost2/3arewomen(longerlifeexpectancy)

•  Somepopula*onsathigherrisk–  OlderAfricanAmericans(2xaswhites)–  OlderHispanics(1.5xaswhites)

5 Alzheimer’s Association Facts and Figures 2015

BaseRates

•  1in9people65+(11%)•  1in3people85+(32%)


Alzheimer’s Disease by Age in the United States

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Challenges&Opportuni*es

•  ADunder-recognizedbyproviders– <50%ofpa*entsreceiveformaldiagnosis

•  Millionsunawaretheyhavedemen*a– Diagnosistypicallydelayedonaverageby6+yearsagersymptomonset

– Significantimpairmentinfunc*onby*meitisrecognized

•  Poor*ming:diagnosisfrequentlyat*meofcrises,hospitaliza*on,failuretothrive,urgentneedforins*tu*onaliza*on

7 Boise et al., 2004; Boustani et al., 2003; Boustani et al., 2005; Silverstein & Maslow, 2006

PoorDetec*on

•  Signsogennotrecognizedun*lquiteobvious:•  Ajribu*onerror:“Agerallshe’s80yearsold!”

•  Changesmissedduetofamiliaritywiththepa*ent

•  Focusednatureofout-pa*entvisits

•  Compensa*onorcover-upbyfamily

•  Lackofsupportresources8

ProviderTools:

ACTonAlzheimer’s

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statewide

collaborative

volunteer driven

60+ O R G A N I Z A T I O N S 600+

I N D I V I D U A L S

I M P A C T S O F A L Z H E I M E R ’ S

BUDGETARY SOCIAL PERSONAL

ACTonAlzheimer’s

FocusonQualityHealthCare

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www.ACTonALZ.org

ACTToolKit

•  Evidenceandconsensus-based,bestprac*cestandardsforAlzheimer’scare

•  Toolsandresourcesfor:– Primarycareproviders– Carecoordinators– Communityagencies– Pa*entsandfamilies

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www.actonalz.org/provider-resources

CaseFinding/Detec*on

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Alzheimer’sisInsidious

15 Accumulation of neuropathology in the brain 10-20 years before symptoms appear

1.  Improvemanagementofco-morbidcondi*ons

2.  Reduceineffec*ve,expensive,crisis-drivenuseofhealthcareresources

3.  Op*mizequalityoflife•  Setngproper/realis*cexpecta*onsforthefuture•  Decreaseburdenonfamilyandcaregivers

4.  Priori*zeshareddecisionmaking

5.  Promoteasafeandhappyenvironmentthatsupportsindependence

Themessage:Youhaveabaddiseasebuttherearethingswecandoto

makelifebejerforyouandyourfamily.

Ra*onaleforTimelyDetec*on

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BaseRates

•  1in9people65+(11%)•  1in3people85+(32%)


Alzheimer’s Disease by Age in the United States

Myth:Peopledon’twanttoknowtheyhave Alzheimer’sdisease

Blendon et al., 2012; Holroyd et al., 2002; Turnbull et al., 2003

0 10 20 30 40 50 60 70 80 90

100

Alz-Eu Harvard Turnbull Holroyd

%

Studies Agree: Most people want to know.

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ClinicalProviderPrac*ceTool

•  Easybujonworkflowfor:1.  Casefinding2.  Demen*awork-up3.  Treatment/care

www.actonalz.org/provider-prac*ce-tools19

Workflow

•  Step1:TriggerA.  Annualexam(e.g.,MedicareAWV)B.  SignsandsymptomsC.  Pa*ent/familyreport

•  Step2:Objec*veassessment•  Step3:Work-up•  Step4:Referral

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Cogni*veImpairmentIden*fica*onFlowChart

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Detec*onTools

•  Widerangeofop*ons– Mini-Cog™(MC)– Mini-MentalStateExam©(MMSE)–  St.LouisUniversityMentalStatusExam™(SLUMS)– MontrealCogni*veAssessment™(MoCA)–  RowlandUniversalDemen*aAssessment(RUDAS)

•  AllbutMMSEfree,inpublicdomain,andonline

Borson et al., 2000; Folstein et al., 1975; Nasreddine 2005; Tariq et al., 2006

Mini-Cog™

Contents•  VerbalRecall(3points)•  ClockDraw(2points)

Advantages•  Quick(2-3min)•  Easy•  Highyield(execu*vefx,

memory,visuospa*al)

Subjectaskedtorecall3wordsLeader,Season,Table

Subjectaskedtodrawclock,sethandsto10past11

+3

+2

Borson et al., 2000

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www.mini-cog.com

Mini-Cog™

Pass•  >4

Fail•  3orless

Borson S., Scanlan J, Brush M et al. 2000. The Mini-Cog: A cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 15, 1021-1027.

Mini-CogResearch

•  Performancelessaffectedbyeduca*onorlanguage•  BorsonIntJGeriatrPsychiatry2000

•  Goodsensi*vityandspecificity•  BorsonJAGS2003

•  Doesnotdisruptworkflow&increasesrateofdiagnosisinprimarycare

•  BorsonJGIM2007

•  Failureassociatedwithinabilitytofillpillbox•  AndersonetalAmSocConsultPharmacists2008

Mini-CogImproves Physician Recognition

***

*** ***

CDR Stage MCI Mild Mod Sev

% C

orre

ct

Borson S et al. Int J Geriatr Psychiatry 2006; 21: 349

0

20

40

60

80

100

0.5 1 2 3

Mini-Cog Patient’s own physician

*** p < .001

Case:Sam•  76y/ore*redteacher(master’sdegree)•  Daughterc/oshort-termmemoryispoor

–  Began2yearsago,getngworse–  Otherfamilymembershaveno*cedchanges–  Repeatshimself,mul*plephonecallsb/ccan’tfindbelongings

•  Samacknowledgesproblembutdoesnotfeelitissignificant

•  HxofhypertensionandDM,bothfairlywellcontrolled•  Wifediedunexpectedlylastyear,livesalone•  Conversa*onalpresenta*onintact,orientedx3•  Seemsokayatbedside

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Case:Sam

•  Nextsteps?•  Howtomakesenseofconflic*ngdata?•  Isademen*awork-upneeded?

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Mini-Cog:Sam

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www.actonalz.org/videos

Scrip*ng*psavailableonACTwebsite

Demen*aWork-upandDiagnosis

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Demen*aWork-Up

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Demen*a:Differen*alDx

Alzheimer’sDisease

VascularDemen*a

LewyBodyDemen*a

FTD Alzheimer’sdisease:60-80%•  IncludesmixedAD+VD

LewyBodyDemen*a:10-25%–  Parkinsonspectrum

VascularDemen*a:6-10%–  Strokerelated

FrontotemporalDemen*a:2-5%–  Personalityorlanguage

disturbance

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DeliveringtheDiagnosis:Sam

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https://www.youtube.com/watch?v=vy2ZC5ZSZL8

Demen*aCareandTreatment

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CareandTreatment

•  Thecareforpa*entswithAlzheimer’shasverylijletodowithdrugs– Medica*onsarenotdiseasemodifying– Modestbenefitinslowingexpressionofcogni*ve/func*onalsymptomsinsomepa*ents

•  Useofdemen*amedsshouldbeperson-centered

•  Minimizepolypharmacyand“bad”drugs– An*cholinergics,benzos

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CareandTreatment

•  Focusonpsychosocialinterven*ons•  Involvecarecoordinator•  Connectpa*ent/familytocommunityresources– Careforbothpa*entandcaregiver

•  Examples:Alzheimer’sAssocia*on,SeniorLinkageLine– Referevery*me,atanystageofdisease,andforeverykindofdemen*a

•  Stressthisispartoftheirtreatmentplanandyouexpecttohearabouttheirprogressatnextvisit

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CareandTreatment

41 42

CareandTreatment

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ACTEMRTools

•  UseEMRtoautomateandstandardize:– Cogni*veassessment– Work-up– Agervisitsummarywithdemen*aeduca*on– Ordersandreferrals– Communitysupportswww.actonalz.org/provider-prac*ce-tools

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LabsandOrders

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ConsultsandReferrals

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PharmacologicalTreatment

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Educa*on,Resources&Support

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#1PromoteWellness

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www.alz.org/mnnd/ Type “Living Well” in search box

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#2 AddressBehavioral Challenges

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#3 SupportCaregivers

Alzheimer’sAssocia*on 24/7Helpline800.272.3900|www.alz.org/mnnd Onestopshopfor:– CareConsulta*on(socialworkinterven*on)– SupportGroups– 24/7Helpline

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#4 ReviewMedica*on

PharmDConsult•  Medica*onreview,simplifica*on•  Reminderstrategies•  Familysupport,supervision

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#5TackleDriving

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Alzheimer’sAssocia*onDrivingCenter:www.alz.org/care/alzheimers-demen*a-and-driving.asp

hjp://www.thehar�ord.com/sites/thehar�ord/files/at-the-crossroads-2012.pdf

WhatPa*ents&FamiliesNeed

1.  Timelydetec*onofcogni*veimpairment2.  Cleardiagnosis3.  Proac*vemanagement4.  Teamapproachthatinvolvescarepartner(s)5.  Opportunitytopar*cipateinplanningand

decisionmaking6.  Accesstocarecoordina*on7.  Referraltoeduca*onandsupportservices

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ACKNOWLEDGEMENTS

Thisprojectis/wassupportedbyfundsfromtheBureauofHealthProfessions(BHPr),HealthResourcesandServicesAdministra*on(HRSA),DepartmentofHealthandHumanServices(DHHS)underGrantNumberUB4HP19196totheMinnesotaAreaGeriatricEduca*onCenter(MAGEC)for$2,192,192(7/1/2010—6/30/2015).Thisinforma*onorcontentandconclusionsarethoseofthe

authorandshouldnotbeconstruedastheofficialposi*onorpolicyof,norshouldanyendorsementsbeinferredbytheBHPr,HRSA,DHHSortheU.S.Government.

MinnesotaAreaGeriatricEduca*onCenter(MAGEC)

Grant#UB4HP19196Director:RobertL.Kane,MD

AssociateDirector:PatriciaA.Schommer,MA

10/17/17

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References&Resources•  Alzheimer’sAssocia*on(2014).Alzheimer’sDiseaseFactsandFigures,Alzheimer’s&Demen/a,Volume10,Issue2.•  AndersonK,JueS&Madaras-KellyK2008.Iden*fyingPa*entsatRiskforMedica*onMismanagement:UsingCogni*ve

ScreenstoPredictaPa*ent'sAccuracyinFillingaPillbox.TheConsultantPharmacist,6(14),459-72.•  BarryPJ,GallagherP,RyanC,&O‘mahonyD.(2007).START(screeningtooltoalertdoctorstotherighttreatment)--an

evidence-basedscreeningtooltodetectprescribingomissionsinelderlypa*ents.AgeandAgeing,36(6):632-8.•  BlendonRJ,BensonJM,Wikler,EM,Weldon,KJ,Georges,J,Baumgart,M,KallmyerB.(2012).Theimpactofexperience

withafamilymemberwithAlzheimer’sdiseaseonviewsaboutthediseaseacrossfivecountries.Interna/onalJournalofAlzheimer’sDisease,1-9.

•  BoiseL,NealMB,&KayeJ(2004).Demen*aassessmentinprimarycare:Resultsfromastudyinthreemanagedcaresystems.JournalsofGerontology:SeriesA;Vol59(6),M621-26.

•  BorsonS,ScanlanJ,BrushM,VitalianoP,DokmakA.(2000).Themini-cog:acogni*ve“vitalsigns”measurefordemen*ascreeninginmul*-lingualelderly.IntJGeriatrPsychiatry,15(11):1021-1027.

•  BorsonS,ScanlanJM,ChenP,GanguliM.(2003).TheMini-Cogasascreenfordemen*a:valida*oninapopula*on-basedsample.JAmGeriatrSoc;51(10):1451-1454.

•  BorsonS,ScanlanJ,HummelJ,GibbsK,LessigM,&ZuhrE(2007).Implemen*ngRou*neCogni*veScreeningofOlderAdultsinPrimaryCare:ProcessandImpactonPhysicianBehavior.JGenInternMed;22(6):811–817.

•  BoustaniM,PetersonB,HansonL,etal.(2003).Systema*cevidencereview.AgencyforHealthcareResearchandQuality;Rockville,MD:Screeningfordemen*a.

•  BoustaniM,CallahanCM,UnverzagtFW,AustromMG,PerkinsAJ,FultzBA,HuiSL,HendrieHC(2005).Implemen*ngascreeninganddiagnosisprogramfordemen*ainprimarycare.JGenInternMed.Jul;20(7):572-7.

•  FerriCP,PrinceM,BrayneC,etal.(2005).Alzheimer’sDiseaseInterna*onalGlobalprevalenceofdemen*a:ADelphiconsensusstudy.Lancet,366:2112–2117.

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References&Resources•  Finkel,SI(Ed.)(1996).BehavioralandPsychologicalSignsofDemen*a:Implica*onsforResearchandTreatment.

Interna/onalPsychogeriatrics,8(3).•  FolsteinMF,FolsteinSE,&McHughPR(1975)."Mini-mentalstate".Aprac*calmethodforgradingthecogni*vestateof

pa*entsfortheclinician.JPsychiatrRes,Nov12(3):189-98.•  GallagherP&O’MahonyD(2008).STOPP(ScreeningToolofOlderPersons’poten*allyinappropriatePrescrip*ons):

Applica*ontoacutelyillelderlypa*entsandcomparisonwithBeers’criteria.AgeandAgeing,37(6):673-9.•  GitlinLN,KalesHC,LyketsosCG,&PlankAlthouseE(2012).ManagingBehavioralSymptomsinDemen*aUsing

NonpharmacologicApproaches:AnOverview.JAMA,308(19):2020-29.•  HolroydS,TurnbullQ,&WolfAM(2002).Whatarepa*entsandtheirfamiliestoldaboutthediagnosisofdemen*a?

Resultsofafamilysurvey.IntJGeriatrPsychiatry,Mar;17(3):218-21.•  IsmailZ,RajjiTK,&ShulmanKI(2010).Briefcogni*vescreeninginstruments:Anupdate.IntJGeriatrPsychiatry,25:111–20.•  JesteDV,BlazerD,CaseyDetal.(2008).ACNPWhitePaper:UpdateonUseofAn*psycho*cDrugsinElderlyPersonswith

Demen*a.Neuropsychopharmacology,33(5):957-70.•  LarnerAJ(2012).Screeningu*lityoftheMontrealCogni*veAssessment(MoCA):Inplaceof–oraswellas–theMMSE?

InternPsychogeriatrics,24,391–396.•  LinJS,O’ConnorE,RossomRC,PerdueLA,BurdaBU,ThompsonM,&EckstromE(2014).ScreeningforCogni*ve

ImpairmentinOlderAdults:AnEvidenceUpdatefortheU.S.Preven*veServicesTaskForce.AgencyforHealthcareResearchandQuality,EvidenceSyntheses,107.

•  LongKH,MoriartyJP,MijelmanMS,&FoldesSS(2014).Es*ma*ngThePoten*alCostSavingsFromTheNewYorkUniversityCaregiverInterven*onInMinnesota.HealthAffairs,33(4),596-604.

•  McCartenJR,AndersonPKuskowskiMAetal.(2012).Findingdemen*ainprimarycare:Theresultsofaclinicaldemonstra*onproject.JAmGeritrSoc;60(2):210-217.

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•  MijelmanMS,HaleyWE,ClayOJ,&RothDL(2006).Improvingcaregiverwell-beingdelaysnursinghomeplacementofpa*entswithAlzheimerdisease.Neurology,November14(67no.9),1592-1599.

•  NasreddineZS,PhillipsNA,BédirianV,CharbonneauS,WhiteheadV,CollinI,CummingsJL,&ChertkowH.(2005).TheMontrealCogni*veAssessment,MoCA:ABriefScreeningToolForMildCogni*veImpairment.JAmerGerSoc,53(4),695-99.

•  Na*onalChronicCareConsor*umandtheAlzheimer’sAssocia*on.1998.FamilyQues*onnaire.Revised2003.•  SilversteinNM&MaslowK(Eds.)(2006).ImprovingHospitalCareforPersonswithDemen*a.NewYork:SpringerPublishing

CO.•  TariqSH,TumosaN,ChibnallJT,PerryMH,&MorleyE.(2006).ComparisonoftheSaintLouisUniversitymentalstatus

examina*onandthemini-mentalstateexamina*onfordetec*ngdemen*aandmildneurocogni*vedisorder:Apilotstudy.AmJGeriatrPsychiatry,Nov;14(11):900-10.

•  TurnbullQ,WolfAM,&HolroydS(2003).Attudesofelderlysubjectstoward“truthtelling”forthediagnosisofAlzheimer’sdisease.JGeriatrPsychiatryNeurol,Jun;16(2):90-3.

•  ZaletaAK&CarpenterBD(2010).Pa*ent-CenteredCommunica*onDuringtheDisclosureofaDemen*aDiagnosis.AmJAlzheimersDisOtherDemen,25,513.

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References&Resources References&Resources•  2012UpdatedAGSBeersCriteria:

hjp://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf•  Alzheimer’sAssocia*onFamilyQues*onnaire:hjp://www.alz.org/mnnd/documents/Family_Ques*onnaire.pdf•  Alzheimer’sAssocia*on(2009).Knowthe10signs.hjp://www.alz.org/na*onal/documents/checklist_10signs.pdf•  CoachBroylesPlaybookonAlzheimer’s:hjp://www.caregiversunited.com•  HonoringChoicesMinnesota:hjp://www.honoringchoices.org•  LivingWellworkbook:hjp://www.alz.org/documents/mndak/alz_living_well_workbook_2011v2_web.pdf•  MedicareAnnualWellnessVisit:

hjp://www.cms.gov/Outreach-and-Educa*on/Medicare-Learning-Network-MLN/MLNMajersAr*cles/downloads/MM7079.pdf

•  MiniCog™hjp://www.alz.org/documents_custom/minicog.pdf•  MontrealCogni*veAssessment(MoCA)hjp://www.mocatest.org•  Na*onalAlzheimer’sProjectAct:hjp://aspe.hhs.gov/daltcp/napa/NatlPlan.pdf•  NextStepinCare:hjp://www.nextstepincare.org•  PhysicianOrdersforLifeSustainingTreatment(POLST):hjp://www.polst.org•  St.LouisUniversityMentalStatus(SLUMS)examina*on

hjp://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf•  TheAlzheimer’sAc*onPlan:hjp://www.amazon.com/The-Alzheimers-Ac*on-Plan-Know/dp/0312538715•  UnderstandingDifficultBehaviors:

hjp://www.amazon.com/Understanding-Difficult-Behaviors-sugges*ons-Alzheimers/dp/0978902009

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Documents

Objecves Alzheimer’s Disease: Challenges and Opportuni*es