Indianapolis Discovery Network for Dementia Current State of Dementia Care & Research In Indiana Malaz Boustani, MD, MPH Eugene Lammers, MD, MPH Indianapolis Discovery Network for Dementia

5/7/2015indydiscoverynetwork.com2 Dementia Memory impairment + Aphasia Apraxia Agnosia or Executive function + Decline in social or occupational baseline functioning. APA. DSM, Fourth Edition. Text Revision. Washington, DC: American Psychiatric Press; 2000:157.

5/7/2015indydiscoverynetwork.com3 Probable Alzheimer’s Disease Dementia Onset is gradual with continuing cognitive decline Absence of –Cerebrovascular disease; Parkinson disease; Huntington disease –Hypothyroidism; Vitamin B 12 deficiency; HIV infection –Persisting effects of a substance, such as alcohol Symptoms does not occur exclusively during delirium. APA. DSM, Fourth Edition. Text Revision. Washington, DC: American Psychiatric Press; 2000:157.

5/7/2015indydiscoverynetwork.com4 Mild Cognitive Impairment: Presence of one or more subjective cognitive complaints Presence of objective deficit in one or more of cognitive domains. Absence of impairment in ADL. Absence of dementia. Absence of delirium. Peterson et al, Neurology 2001

5/7/2015indydiscoverynetwork.com5 Dementia in Primary Care Clinic Boustani et al, JGIM 2005

5/7/2015indydiscoverynetwork.com6 Etiology Reversible: –No more than 1.5% of all dementia cases in memory clinics are fully reversed. Irreversible: –Neurodegenerative: Alzheimer’s Disease 50-70% Lewy Body Dementia 1-15% Fronto-Temporal Dementia 1-15% –Vascular: 10-25% –Mixed: 1-15% Boustani et al, AHRQ, 2003; Boustani et al, Annals IM 2003

5/7/2015indydiscoverynetwork.com7 Reversible Dementia: In 1970s, reversible dementia account for 25% of cases. In 1989, fully reversible dementia account for 3% of cases in subspecialist clinics. In 2002, fully reversible dementia account for less than 1.5% in subspecialist clinics. Currently reversibility is substituted by comorbid or associated conditions (potential improvement). Boustani et al, available at AHRQ web site 2003

5/7/2015indydiscoverynetwork.com8 Dementia Subtypes In general: –AD is memory dementia –VaD is executive dementia –LBD is attention, fluctuating, and PD dementia –FTD is language, personality and social dementia All late and severe cases of dementia are the same. Boustani & Ham, In Primary Care Geriatrics 2007

5/7/2015indydiscoverynetwork.com9 Dementia Symptomatology Cognitive Deficit Behavioral & Psychological Sx Functional Disability Caregiver Burden

5/7/2015indydiscoverynetwork.com10 Dementia Burden in the USA 3-11% of persons ≥ % of persons ≥ 85 Mean survival > 8 years (chronic disease) Contribute 11% of all years lived with disability by people ≥ 60. Lead to an annual societal cost of $100 billion –Long-term residential care –Lost of CG productivity –CG health care utilization –Acute care needs and complication –Impact on other diseases’ management Ferri et al, 2006; Boustani et al, 2003

5/7/2015indydiscoverynetwork.com11 Dementia in IN: 2000 – 2010 Boustani et al, JGIM, 2005; Alzheimer Disease Facts and Figures, 2007

5/7/2015indydiscoverynetwork.com12 Dementia Caregivers in IN Total Number in 2005 –208,817 Hours of unpaid care per year –180,250,419 Total value of unpaid care –$1,762,849,095 Alzheimer Disease Facts and Figures, 2007

5/7/2015indydiscoverynetwork.com13 The Current State of Dementia Care in IN Unrecognized cases –60% in acute setting; 80% in primary care Receive definitive Anticholinergics –22% in acute setting; 26% in primary care Receive ChEIs –< 5% in acute setting; < 10% in primary care Receive Psychotropics (no FDA indication) –> 25% in acute setting; ~ 25% in primary care ER or hospitalization in the last 6 months –Pt 38%; CG 24% CG PHQ-9 score: 4.4 Pt’s with BPSD: 80% Schubert et al, JAGS 2006; Boustani et al, JAGS 2005; Boustani et al, JAGS 2006

5/7/2015indydiscoverynetwork.com14 Basic research Genetics Imaging research Clinical trials Omega-3 fatty acids Antioxidants, vitamin E+C+alpha-lipoic acid, and Coenzyme Q. Passive immunization Amyloid target compounds Sleep disturbance Health Services & Epidemiology Research Prevention and treatment of delirium: e-CHAMP + e-CHAMP ICU Psychological interventions and support: PREVENT-II + PRISM + IDND Risk Factors: Indianapolis-Ibadan, CIND & RED Study Dementia Research In IN

5/7/2015indydiscoverynetwork.com15 Dementia Research: Prevent dementia: Not Yet Cure Dementia: Not Yet Slow Dementia: May be? Reduce or manage Disability: Yes –Cognition –Daily function –BPSD –Caregiver Burden

5/7/2015indydiscoverynetwork.com16 The Future! Million Sloane, Boustani et al, Ann Rev PH 2002 Projections of AD prevalence based on three models of the effects of significant therapy advances introduced in 2010

5/7/2015indydiscoverynetwork.com17 The State of Art in Dementia Care What does PREVENT, REACH II and South CA Studies inform us? Case Management / coordination: 1- community resources 2- various clinical providers 3- caregivers and family members Medical management: 1-Diagnsois 2-pharmacotherapy 3-comorbidity care Caregiver Interventions: 1- Education, 2- Skills to manage recipient BPSD, 3- Social support 4- Cognitive strategies for reframing negative emotional responses 5- Strategies for enhancing healthy behaviors and managing stress. Within a Health Care System (HCS): - PCP or and MCP Outside of HCS: - Alzheimer A or Area On Aging Within a HCS: - PCP with support (mild cases) -MCP for more complex (complex cases) -PCP and MCP ? Within HCS: - Pharmacotherapy at PCP Outside HCS: - Non-pharmacotherapy at AA Callahan et al, JAMA, 2006; Vickrey et al, Annals of IM, 2006; Belle et al, Annals of IM, 2006

5/7/2015indydiscoverynetwork.com18 Research Update in IN Interested in more information? is the Alzheimer's Disease Education and Referral (ADEAR) Center Web site of the NIHhttp:// is the Indiana University Alzheimer’s Centerhttp://iadc.iupui.edu/ Indianapolis Discovery Network for Dementiahttp://