Intermediate care and Dementia: Predicting the local burden

1. Intermediate care and Dementia: Predicting the local burden Emma Reynish

2. Format • Numbers of people affected and characteristics of the population with dementia Dementia Prevalence in Europe: EUROCODE • Levels of dependency and behavioural disturbancePatient characteristics in Alzheimer's Disease : ICTUS • Patient characteristics acute general hospital admissionsFront door Comprehensive Geriatric Assessment: Fife CGA Reynish et al. Alzheimer's and Dementia 2009 Reynish et al. Neuroepidemiology 2007

3. EUROCODE “European Collaboration on Dementia”Funded by EUCoordinated by Alzheimer Europe European Dementia Prevalence rates: Systematic review with collaborative analysis

4. Age and Sex specific prevalence

7. Fife totalpopulation 361,890 3rd largest council population in Scotland (after city of Glasgow and city of Edinburgh)

8. Number of people with dementia in Fife: • Predicted from EUROCODE: 5748 • Currently on GP databases: 2211 (approx 40%) • Difference probably represents undiagnosed dementia

9. Predicted Age distribution of patients in Fife with Dementia Using figures from EUROCODE (* EURODEM)

10. Key findings • With the advent of studies reporting prevalence in the oldest old it appears that this figure may have previously been under-estimated. • Up to 2/3 of the population with dementia are over the age of 80 yrs. • A large number of patients with dementia do not have a formal diagnosis

11. Alzheimer’s disease treatment and management across EuropeICTUS studyA longitudinal observational study of 1380 AD patients Reynish et al. Neuroepidemiology 2007;29:29-38

12. Description of Baseline Cohort Demographics Patients with AD are able to live independantly

13. Description of Baseline CohortMedical Characteristics Patients with AD have significant comorbidity

14. Description of Baseline CohortPatient assesment: Dependancy ADL scale(Katz S et al. JAMA 1963; 185: 914–919.) • Personal hygiene • Dressing • toileting • transfers • Continence • feeding Patients with AD need minimal assistance with basic ADL Score 1= independent 0.5=needs assistance 0=fully dependant

15. Neuropsychiatric inventory (NPI) • assesses behavioural symptoms in dementia • evaluates 12 disturbances/ domains • examines whether symptoms have occurred over the past month • informant asked about frequency of symptoms on a 4-point scale;1 (occasionally; <1/ week) to 4 (very frequently; >1/ day). • informant asked to rate the severity (disruptiveness, burden) of the behaviour on a three-point scale (mild, moderate, or severe). • Domain rating = severity X frequency (range of 1–12). • total NPI score sum of the scores of all the items. • Range 0 (no disturbance) to 144 (severe impairment all domains). • For symptom to be considered clinically relevant it is felt that the score for that domain must be greater than 3 Schneider LS, et al. Am J Geriatr Psychiatry 2001

16. Prevalence (NPI domain score ≥4) of clinically relevant neuropsychiatric symptom in each NPI domain

17. A B Prevalence of clinically relevant symptom / syndrome Majority of patients with AD do not have symptoms associated with challenging behaviour

18. Findings • A large proportion of Patients with AD do live independent lives • In those with AD living at home impairment of basic activities of daily living (ADL) is minimal even in the moderate stages of dementia • Neuropsychiatric symptoms associated with challenging behaviour are not common in the majority of patients with mild to moderate AD

19. Intermediate Care: Definition • Intermediate care is the care provided following a crisis to help a patient maintain and regain as much of previous independence as possible. This care can include both health and social care prevention of avoidable admissions and supported discharge) • Front door comprehensive geriatric assessment (CGA) recently introduced in Fife (Joint health and social care project) • CGA provides an snap shot of the needs of those patients being admitted acutely to hospital

20. Comprehensive geriatric assessment (CGA) “A multidimensional interdisciplinary diagnostic process focused on determining a frail elderly person’s medical, psychological and functional capability in order to develop a coordinated and integrated plan for treatment and long term follow-up” LZ Rubenstein, JAGS, 1991;39:8-16

21. CGA: the principal domains • Physical health: geriatric-specific. vision, hearing, continence, gait, and balance plus medical evaluation. • Functional ability: Review of ADL’s and their change over time • Cognitive and mental health: Screening for cognitive impairment and delirium, plus liaison with psychiatric services. • Socio-environmental situation: Liaison with social services.

22. Recording of Data-OASIS (PAS) Clinical Page EPR: Electronic Patient Record

23. CGA in the first 6 weeks; preliminary data • 793 emergency admissions to VHK over age 65 • 8 admissions to acute older persons mental health wards throughout Fife • CGA performed and data entry complete on 159 patients (20% of all acute admissions over 65 years)

24. CGA in the first 6 weeks; preliminary data Of those who have had CGA performed (n=159) • 42 (26.4%) had an AMT score of 7 or less (most likely to have dementia) • 13(8%) were too ill to have AMT performed • 104 (65%) had AMT score >7 (less likely to have dementia)

25. CGA in the first month; Patients with cognitive impairment (n=42) • Mean age 81.86 (range 66-96) • M:F ratio 1:1.8 • 7 patients from nursing home (17%) • 7 patients had a diagnosis of dementia (17%) • 13 patients prone to falls (31%) • 8 patients carers reported problems coping at home (23% of those admitted from home) • Ongoing analyses • Current ADL and change in ADL over preceding 3 months • Prevalence of delirium • Assessment of mobility (TUAG)

26. Findings from CGA • In crisis the majority of older people are admitted to general hospitals • A significant proportion have cognitive impairment but no dementia diagnosis • Of those patients with cognitive impairment there may have been opportunities for intermediate care team involvement to prevent admission

27. Key messages • Majority of people with dementia aged over 80 • Dementia is frequently undiagnosed • A significant proportion of patients with dementia are able to live independently • The prevalence of challenging behaviour is low • General hospital admission has become the default for elderly patients in crisis despite the potential for prevention of admission by IC team

28. A role for intermediate care? • Expertise in caring for the over 80’s with co-morbidity • Capacity to assess for dementia diagnosis • Aspiration to maintain independence at home • Patient focused service guided by comprehensive assessment • Supported by specialist mental health personnel when needs exist

29. Collaborators E Reynish, H Bickel, M Lambert ,L Fratiglioni, E Von Strauss, D Frydecka, A Kiejna, M Prince, J Georges and the EUROCODE study group. E Reynish, PJ Ousset, S Andrieu, B Vellas and the ICTUS study group.

30. EUROCODE Prevalence study group. • Manubens JM, Martinez-Lage JM, Lacruz F, Muruzabal J, Larumbe R, Guarch C et al. • Ott A, Breteler MM, van HF, Claus JJ, van der Cammen TJ, Grobbee DE et • Prencipe M, Casini AR, Ferretti C, Lattanzio MT, Fiorelli M, Culasso F. • Andersen K, Lolk A, Nielsen H, Andersen J, Olsen C, Kragh-Sorensen P. • Ferini-Strambi L, Marcone A, Garancini P, Danelon F, Zamboni M, Massussi P et al. • Azzimondi G, D'Alessandro R, Pandolfo G, Feruglio FS. • von SE, Viitanen M, De RD, Winblad B, Fratiglioni L. • Gabryelewicz T. • Vilalta-Franch J, Lopez-Pousa S, Llinas-Regla J. • Riedel-Heller SG, Busse A, Aurich C, Matschinger H, Angermeyer MC. • Ravaglia G, Forti P, Maioli F, Sacchetti L, Mariani E, Nativio V et al. • Gostynski M, jdacic-Gross V, Gutzwiller F, Michel JP, Herrmann F. • Borjesson-Hanson A, Edin E, Gislason T, Skoog I. • Tognoni G, Ceravolo R, Nucciarone B, Bianchi F, Dell'Agnello G, Ghicopulos I et al. • De RD, Berardi D, Menchetti M, Ferrari G, Serretti A, Dalmonte E et al. • Helmer C, Peres K, Letenneur L, Guttierez-Robledo LM, Ramaroson H, Barberger-Gateau P et al. • Bdzan LB, Turczynski J, Szabert K. • Gascon-Bayarri J, Rene R, Del Barrio JL, De Pedro-Cuesta J, Ramon JM, Manubens JM et al.

31. ICTUS STUDY Group B.Vellas (Toulouse), R.W.Jones (Bath), A.Burns (Manchester), R.Bullock (Swindon), A Malick (Warwick), E.Salmon (Liege), G.Waldemar /P Johannsen (Copenhagen), J.F.Dartigues (Bordeaux), F.Pasquier (Lille), J.Touchon (Montpellier), P.Robert (Nice), A.S.Rigaud (Paris), V.Camus (Tours), G. Stiens(Goettingen), L.Frölich (Mannheim), M.Tsolaki (Thessalonica), G.Frisoni (Brescia), G.Rodriguez (Genoa), A.Cherubini (Perugia), L.Spiru (Bucharest), M.Boada (Barcelona), A.Salva (Girona), E.Agüera-Morales (Cordoba), J.M.Ribera-Casado (Madrid),P.M.Lage (Pamplona), B.Winblad / (Stockholm), D Zekry (Geneva), P.Scheltens (Amsterdam), M.Olde-Rikkert (Nijmegen).