Indianapolis Discovery Network for Dementia Translating PREVENT Into Your Practice Caring for your patients with dementia J. Eugene Lammers, MD, MPH Clarian Health Senior Health for the IDND

The Main Message Dementia diagnosis in primary care is a challenge that can be overcome. A primary care clinic can implement interventions to improve the symptoms of AD. Treatment of AD can help both the patient and caregiver.

Who do we screen? –Asymptomatic –Symptomatic Memory loss, Functional decline Non-compliance Family/social reports

Asymptomatic patient aged 65 and older Risk Factor profiling: - Age > 75 - First degree relative with dementia - Head trauma - Vascular risk factors -HTN -DM -Hyperlipidemia -CVA/TIA At least one risk factors is present No Re-evaluate in One year Yes Fail screening test Yes MMSE ≤ 24 (adjusted for age/education) Yes Full Diagnostic Work-Up Adapted from Boustani & Ham, In Primary Care Geriatrics 2006

Patient with cognitive problems based on patient's, caregiver’s, or physician’s reports Delirium Assessment - + Treat delirium + reassess Dementia diagnostic Work-Up Reversible Work-up: CBC Metabolic panel Vit B12 TSH Syphilis CT Brain scan Anticholinergic Burden: -Re-evaluate indication for Anticholinergic Medications and Discontinue if possible Neurological Examination: -Asymmetrical Finding. -Parkinsonian Sign. Cognitive Assessment: -Determine prominent deficit domain -Determine pattern of cognitive decline: -Gradual -Fluctuating -Stepwise Caregiver-based Functional Assessment: -I-ADL deficit from Baseline -Occupational deficit from baseline -Social deficit from baseline Adapted from Boustani & Ham, In Primary Care Geriatrics 2006

How do we do this in the office? Divide into steps –Step 1 screening –Step 2 focused history and physical –Step 3 medication review –Step 4 diagnostics –Step 5 present diagnosis/initiate treatment

How do we do this in the office? Use the nurse/medical assistant in the process Standardized forms, lab requests etc Use the telephone

After the diagnosis, what next? Adapted from Callahan et al, JAMA 2006 Talk with Caregiver about support group, counseling, respite care. –Learn local resources –Alzheimer’s Association programs and website Detect and modify vascular risk factors. –Stop smoking, control diabetes, lipids, blood pressure, aspirin Decrease anticholinergic burden –Especially benadryl, elavil, oxybutinin, etc

After the diagnosis, what next? Enhance medication adherence Cholinesterace inhibitors +/- Memantine –Goal of stability –Use standard handouts for instructions and side effects –Early follow-up with the nurse/np/pa to promote compliance

After the diagnosis, what next? Detect and treat depression –Can be seen early or late –Responds to treatment SSRI first line Detect and treat agitation –Non-behavioral if possible –Pain? –Illness Uti, dehydration, constipation

After the diagnosis, what next? Detect and treat psychosis –Does it really need treatment –Risk of antipsychotics Discuss driving and safety issues –Driving eval –Pros/cons of staying home alone –Moving target

Standardized Protocols Psychological symptoms –delusions –hallucinations –paranoia –depression –anxiety –misidentifications –disinhibition Adapted from Austrom et al, Gerontologist 2004

Standardized Protocols Behavioral symptoms –aggression wandering –sleep disturbances –inappropriate eating –constant questioning –shadowing –amotivation

Handouts available on-line ocols.htmlhttp://iucar.iu.edu/research/behavioralprot ocols.html

Cases

Summary Primary care physicians are able to make important impacts on patients with dementia and caregivers. A step-wise, multiple visit approach, utilizing non-physician staff is feasible. Using standardized materials from programs such as SUPPORT and the Alzheimers Association can help with management of dementia.