What Can Behavioral Health Providers Do? Improving Primary Care of Dementia Through Integration

1. Session #A5a October 18, 2014 What Can Behavioral Health Providers Do? Improving Primary Care of Dementia Through Integration Laura O. Wray, PhD - Director of Education, VA Center for Integrated Healthcare Christina L. Vair, PhD – Clinical Research Psychologist, VA Center for Integrated Healthcare Collaborative Family Healthcare Association 16th Annual Conference October 16-18, 2014 Washington, DC U.S.A.

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

3. Learning Objectives At the conclusion of this session, the participant will be able to: • Recognize warning signs and risk factors for dementia in older primary care patients. • Discuss ways to improve detection of dementia in primary care. • 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.

4. References • 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

5. Learning Assessment • A learning assessment is required for CE credit. • A question and answer period will be conducted at the end of this presentation.

6. 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.

7. Question for Audience • What brings you to our talk?

8. 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

9. Barriers to Detection Dementia Recognition in Primary Care (PC) • USPSTF (2013): “Insufficient evidence to recommend foror againstscreening” • Annual Wellness Visit (Affordable Care Act) requires assessment to detect cognitive impairment along with other routine measures • However, 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

10. Successful Integration Will Improve Quality, Satisfaction and Cost Older Patients Medical and Behavioral Health Providers Family Caregivers

11. 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

12. Alzheimer’s AssociationWarning Signs* • Memory loss that affects job skills • Difficulty with familiar tasks • Problems with language • Disorientation to time and place • Poor or decreased judgment • Problems with abstract thinking • Misplacing things • Changes in mood or behavior • Changes in personality • Loss of initiative * http://www.alz.org/alzheimers_disease_10_signs_of_alzheimers.asp

13. 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!

14. Brief Screening Measures* * VA Evidence Based Synthesis citation (Kansagara & Freeman, 2010)

15. Brief Screening Measures* * VA Evidence Based Synthesis citation (Kansagara & Freeman, 2010)

16. 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

17. Review of Findings

18. 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

19. Working Collaboratively

20. Working Collaboratively with Family Caregivers

21. Case Example

22. Case Discussion

23. Questions and Answers

24. Session Evaluation Please complete and return theevaluation form to the classroom monitor before leaving this session. Thank you!