UNIVERSITY OF SASKATCHEWAN Saskatoon, Saskatchewan, Canada. usask

Utilizing Community Partnerships with a Utilizing Community Partnerships with a Rural and Remote Memory Clinic to Develop Rural and Remote Memory Clinic to Develop Assessment Instruments and Protocols Assessment Instruments and Protocols Appropriate for Aboriginal SeniorsAppropriate for Aboriginal Seniors

UNIVERSITY OF SASKATCHEWANUNIVERSITY OF SASKATCHEWANSaskatoon, Saskatchewan, Canada. www.usask.ca

Aboriginal Experiences in AgingSaskatoon, SKSeptember 17-19, 2008

Rural and Remote Memory ClinicRural and Remote Memory Clinic

Debra Morgan Associate Professor, Canadian Centre for

Health & Safety in Agriculture Margaret Crossley

Associate Professor, Department of Psychology

Shawnda Lanting Doctoral Student, Department of Psychology Travel support: Northern Scientific Training

Program, Northern Medical Services


Canadian Institutes of Health Research Canadian Institutes of Health Research CIHR New Emerging Team (2003-2009)CIHR New Emerging Team (2003-2009)

Strategies to Improve the Care of Persons with Dementia in Rural and Remote Areas Interdisciplinary research Interprofessional training Capacity development


CIHR New Emerging Team Co-Investigators

Norma Stewart, PhD, RNProfessorAssociate Dean Graduate Studies & ResearchCollege of Nursing

Margaret Crossley, PhDAssociate Professor Director, Aging Research & Memory ClinicDepartment of Psychology

Carl D’Arcy, PhDProfessor & DirectorApplied Research/Psychiatry

Jay Biem, MD, MSc, FRCPLakeshore General Hospital, Montreal

Andrew Kirk, MD, FRCPC Professor & Head, Division of NeurologyDepartment of Medicine

Dorothy Forbes, PhD, RN Associate Professor, School of NursingUniversity of Western Ontario

Lesley McBain, PhDAssistant Professor, First Nations University of Canada

Sheri Harder, MD, FRCPCAssociate Professor, Department of Medical Imaging

Jenny Basran, MD, FRCPCAssistant Professor & Head, Department of Geriatrics

Vanina Dal Bello-Haas, PhD, PTAssociate ProfessorSchool of Physical Therapy


Funding Partners: Funding Partners:

-CIHR Institute of Aging-CIHR Institute of Health Services &

Policy Research-CIHR Rural & Northern Health Initiative-University of Saskatchewan-Saskatchewan Health Research Foundation -Alzheimer Society of Saskatchewan-Telehealth Saskatchewan (in-kind support)


Objectives of this presentation Objectives of this presentation To describe the development & implementation

of a telehealth-supported interdisciplinary Rural and Remote Memory Clinic

To describe the community partnerships that were essential to the development of instruments and protocols for assessing cognitive impairment in Aboriginal seniors.


What is Dementia?What is Dementia?

A progressive and typically irreversible loss of intellectual abilities, including memory, due to brain-based changes that are severe enough to interfere with daily functioning

Alzheimer’s disease is the most common form of dementia, accounting for up to 70% of all cases


What do we know?What do we know? seniors are over-represented in rural

areas 22% of towns vs. 15 % of cities

47% of seniors live in rural areas with moderate to no metropolitan influence

Estimated prevalence of dementia in SK is 18,000 and growing

Limited access to specialized dementia care services in rural and remote areas

Rural and Remote Memory ClinicRural and Remote Memory Clinichttp://www.hc-sc.gc.ca/seniors-aines/pubs/fpt_docs/fed_paper/index_e.htm


Prevalence of Dementia (Percentage) Prevalence of Dementia (Percentage) in Canada by Age Groupin Canada by Age Group

8

2.4

11.1

34.5

0

5

10

15

20

25

30

35

Age Group

65+65-7475-8485+

CSHA. 1994


““It was like climbing a It was like climbing a mountain to get a diagnosis”mountain to get a diagnosis”

“Strategy for AD and Related Dementias in Saskatchewan”

(2004), focus group comment.


Importance of Early DiagnosisImportance of Early Diagnosis

Reduced stress and burden to patient and family/caregivers

Treatment initiated early; implications for quality of life & cost to healthcare system

Decision making and planning for the future, prevent crisis events


Rural & Remote Memory Clinic Rural & Remote Memory Clinic

Research goals:

1) Development & evaluation of streamlined, integrated, 1-stop clinic for assessment, differential diagnosis, and management of early stage dementia

2) Evaluation of telehealth delivery format

3) One focus is on Aboriginal seniors


Importance of Investigating Dementia Importance of Investigating Dementia in Aboriginal Seniorsin Aboriginal Seniors

Aboriginal persons (First Nations, Inuit, Metis) make up approximately 4% of Canadian population

13% of population in Saskatchewan is Aboriginal

Aboriginal seniors are one of the most rapidly growing demographic group in Canada

Little research has been conducted regarding dementia in Aboriginal seniors


Barriers for Aboriginal and other Barriers for Aboriginal and other Remote or Minority Culture SeniorsRemote or Minority Culture Seniors

Language and cultural differences

Extremely high cost of travel

Lack of awareness of dementia as an illness

Assessment protocols have been developed with majority culture adults

Telehealth Sites Telehealth Sites in Saskatchewan in Saskatchewan

(September 2008)(September 2008)

2001000

kilometres

Kelsey Trail

Prince AlbertParkland

ReginaQu'Appelle

Five Hills

Sun Country

PrairieNorth

KeewatinYatthé

MamawetanChurchill River

Heartland

SwiftCurrent

Tisdale (2)

Porcupine Plain

Kelvington

Spiritwood

NorthBattleford (4)

Goodsoil

Meadow Lake

PrinceAlbert (7)

Hudson Bay

Fort Qu'Appelle (3)

Regina (12)

Outlook

Moose Jaw

Kipling

Weyburn (2)

Redvers

Estevan (2)

Arcola

Wawota

Broadview

Balcarres

Ile a la Crosse

Saskatoon (15)

Lloydminster

La Ronge (2)

Cumberland House

Creighton

Sandy Bay

GrenfellWolseley

Moosomin

Maple Creek

Leader

Gainsborough

Stony Rapids

Athabasca Health Authority

Cypress

Sunrise

Saskatoon

Oxbow

Assiniboia

Melville

Yorkton

Humboldt

KindersleyRosetown

Unity

Melfort

Nipawin

Big River

Pinehouse Lake

Beauval

Buffalo Narrows

La Loche

Bengough

Gravelbourg

PA VictoriaHospital(3)

MentalHealthInpatient

Addictions Office

Mental Health Outpatient

CityHospital (2)

RoyalUniversityHospital(5)

St Paul'sHospital

College of Medicine (5)

Saskatoon Cancer Centre

KinsmenChildren'sCentre

ParkridgeCentre

Wascana RehabilitationCentre (WRC) (2)

RQHR 2110 Hamilton Street

HISC Service Desk

TC Douglas

GeneralHospital

Pasqua Hospital

Allan BlairCancerCentre

Healthline

Regina Child & Youth

Telehealth locations in Saskatoon

Telehealth locations in Regina

Telehealth locations in Prince Albert

Current Telehealth Location

Planned Expansions for 2008

All communities have only one endpoint unless otherwise noted

Eligible patients must live >100 kms. from a tertiary care centre


1

8

11

3332

21

1511

33

15 3

2

3

NET Telehealth Community Visits Prior to Clinic Implementation:

Northern Communities Visited in Year 1 La RongePinehouse LakePelican NarrowsIle a la CrosseBeauvalLa Loche


REFERRALREFERRAL


CONTACTCONTACT


INITIAL TELEHEALTH VISITINITIAL TELEHEALTH VISIT


CLINIC DAYCLINIC DAY

RRMC Clinic Day RRMC Clinic Day AssessmentAssessment

1. Interprofessional clinical interview with patient and family

2. Assessment by:1. Neuropsychology2. Nursing3. Neurology4. Physical Therapy 5. Geriatric Medicine6. Neuroradiology (Brain Imaging)

3. End-of-day Team Conference and Teaching Rounds



Interprofessional Clinical Interview



Physical Therapy Assessment



CT scan



Neuropsychological Assessment


The challenge for clinical The challenge for clinical neuropsychology was to prepare a neuropsychology was to prepare a test battery for the RRMC that test battery for the RRMC that was…was…

1. Brief enough to accommodate the time constraints of an IP same-day clinic

2. Sensitive to early-stage dementia

3. Adequate for differential diagnosis

4. Appropriate for cross-cultural assessment of rural and remote residents


Interdisciplinary research Interdisciplinary research combining methods from combining methods from neuropsychology, human neuropsychology, human geography, and cultural geography, and cultural anthropologyanthropology

1. Focus groups with Aboriginal seniors at the Saskatoon Community clinic

2. Travel to Northern communities for consultation, and protocol and test development



Community Screening Interview for Dementia (CSI’D)

Cross-cultural instrument provides an alternate assessment protocol for patients from non-majority cultures including non-English speaking patients

Modified in consultation with the Aboriginal grandmothers & northern healthcare providers

Hall et al., 1993


Original Buschke Cued Recall Test Original Buschke Cued Recall Test


Pictorial Prairie Buschke Pictorial Prairie Buschke

National Geographic Magazine


“ “Grasshoppers & Geese”Grasshoppers & Geese”

Modification of Pyramids and Palm Trees based on harmonization approach

Culturally and geographically appropriate for older adults residing in rural and remote areas

Some examples…..







What we’ve learned so far about What we’ve learned so far about our modified assessment protocolsour modified assessment protocols

Modified neuropsychological tests (e.g., Grasshoppers and Geese) are extremely well received by all patients in our clinic

The modified screening protocols (CSI’D) still require some adjustment and ongoing work with our northern healthcare partners to ensure acceptability and sensitivity


What we’ve learned so far about What we’ve learned so far about our Interprofessional Clinic Modelour Interprofessional Clinic Model

Satisfaction ratings are high for telehealth and the streamlined 1-stop clinic model despite ongoing challenges related to cost and time of travel for remote northern patients and their families

We strongly promote this model of care for use with other chronic health concerns regardless of place of residence


Thank-you

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UNIVERSITY OF SASKATCHEWAN Saskatoon, Saskatchewan, Canada. usask