1. IMPLEMENTING THE HCH FOR PATIENTS WITH AD: EARLY IDENTIFICATION, CARE COORDINATION & CAREGIVER SUPPORT Health Care Homes Learning Day, November 1, 2012 1

2. Session Overview  Introduction to Health Care Home (HCH)  Overview  Successful HCH: physician & care coordinator perspectives  Alzheimer’s Disease and HCH  Overview  AD in HCH: physician & care coordination roles  Alzheimer’s Disease: Firsthand experience  Conclusion / Q&A

3. Successful HCH  Dr. Johnson presentation  Panel discussion

4. AD Overview 4

5. Facts & Figures& Figures Alzheimer’s Association 2011

6. Today, Alzheimer’s Disease Is:  Fatal  Prevalent  Expensive  Misunderstood  Stigmatized  Under-diagnosed  Under-treated  ON THE RISE….

7. Alzheimer’s Epidemic  By 2050:  13 million to 16 million Americans will have AD  Consume 1.1 trillion in healthcare spending

8. Today  Fewer than 50% of patients receive formal diagnosis Diagnosis often delayed by 6+ Years Impairment in function by time it is recognized  Fewer than 50% of those diagnosed receive any treatment

9. Why is Early Diagnosis Important? 1. Optimize current medical management 2. Relief gained from better understanding 3. Maximize decision-making autonomy 4. Access to services 5. Risk reduction 6. Plan for the future* 7. Improve clinical outcomes* 8. Avoid or reduce future costs 9. Diagnosis as a human right World Alzheimer Report 2011 *Top benefits endorsed by physicians, International Alzheimer’s Disease Physician Survey, 2012

10. Alzheimer’s Disease: Course, Prevention, Treatment Strategies 10 INTERVENTION Primary Prevention Secondary Prevention Treatment CLINICAL STATE Normal Pre- symptomatic AD Mild Cognitive Impairment AD Numbers of people ??? 20 to 60 mil 10 to 15 mil 5.3mil BRAIN PATHOLOGIC STATE No disease No symptoms Early AD brain changes No symptoms AD brain changes Mild symptoms Mild, moderate or severe impairment STRATEGIES Identify at-risk Prevent AD Prevent or delay emergence of symptoms Stimulate memory Slow progression Treat cognition Treat behaviors Slow progression DISEASE PROGRESSION

11. AD: Physician Perspective 11

12. Alzheimer’s, the Scope of the Problem  Most significant Risk Factor  Age  Prevalence of Cognitive Impairment  50% of those >85  Co-morbidities  At least one present in 95%

13. Easy Practice Tips

14. Practice Tips  Red flags  Repetition (not normal in 7-10 min conversation)  Tangential, circumstantial responses  Losing track of conversation  Frequently deferring to family  Over reliance on old information/memories  Inattentive to appearance  Unexplained weight loss or “failure to thrive”

15. Practice Tips  Family observations:  ANY instances whatsoever of getting lost while driving, trouble following a recipe, asking same question repeatedly, mistakes paying bills  Ask:  “Let’s suppose your family member was alone on a domestic flight across the country and the trip required a layover with a gate change. Would he/she be able to manage that kind of mental task on his/her own?”

16. Practice Tips  Intact older adult should be able to:  Describe 2 current events in some detail  Describe what happened on 9/11, New Orleans disaster  Name the current President and 2 immediate predecessors  Describe medical history and names of some medications

17. Dementia Care  Screening  Diagnosis  Management

19. Rationale for Early Detection 1. Improve quality of life  Early treatment is more effective  Stabilization vs. improvement  Patients can make decisions regarding care  Patients can get to their “bucket list”  Decrease burden on family and caregivers 2. Connection to services that promote independent (supported) living as long as possible  RTC support/counseling intervention (Mittelman et al. Neurology 2006)  Non-pharm interventions reduce NH placement by 30% and delay placement for others by 18+ months

20. Rationale for Early Detection 3. May find reversible causes  NPH, TSH, B12, hypoglycemia, depression 4. Improve management of co-morbid conditions  Underlying dementia = a primary risk factor of poor compliance in the elderly  Chronic disease (diabetes, hypertension, anticoagulation)  Integrity of the brain related to one’s ability to manage health  Dementia as the Organizing Principle of Care

21. Rationale for Early Detection 5. Reduce ineffective and expensive crisis-driven use of healthcare resources  Unhelpful emergency room visits and hospitalizations  Prevent diagnosis during crises (wandering, hospitalization, car accidents, bankruptcy) 6. More time to participate in clinical trials and important scientific studies  Knowledge gap re: earlier stages  Find a cure

22. Screening  Initial considerations  Balance b/w time and sensitivity/specificity  How will your practice incorporate screening?  Who will administer tests? MDs, Nurses, social workers, allied health professionals  What happens when screen is positive?

23. Annual Wellness Visit: Medicare  Took effect January 1, 2011  Affordable Care Act  Medicare will cover an annual wellness visit which will include the creation of a personalized prevention plan  For first time, “detection of cognitive impairment” is core feature of the exam  Diagnosis of dementia requires a decline in function over time, so screen provides a baseline on cognition

24. Screening Measures  Wide range of options  Mini-Cog (MC)  Mini-Mental State Exam (MMSE)  St. Louis University Mental Status Exam (SLUMS)  Montreal Cognitive Assessment (MoCA)  All but MMSE free online in public domain  Utilize “Family Questionnaire (if family available)

25. Mini-Cog Contents Verbal Recall (3 points) Clock Draw (2 points) Advantages Quick (2-3 min) Easy High yield (executive fx, memory, visuospatial) Subject asked to recall 3 words Leader, Season, Table Subject asked to draw clock, set hands to 10 past 11 +3 +2

26. Mini-Cog  Performance unaffected by education or language Borson Int J Geriatr Psychiatry 2000  Sensitivity and Specificity similar to MMSE (76% vs. 79%; 89% vs. 88%) Borson JAGS 2003  Does not disrupt workflow & increases rate of diagnosis in primary care Borson JGIM 2007  Failure associated with inability to fill pillbox Anderson et al Am Soc Consult Pharmacists 2008

27. Mini-Cog  Pros  Easy to administer  Minimal time commitment  Clock sensitive to visuospatial & executive dysfunction  Simple scoring and interpretation  Cons  Not as sensitive for MCI or early dementia when compared to longer screens  Brevity means less information to interpret

29. Screen Failure  MiniCog = <4  OR memory complaints by patient/family  Schedule follow-up appt Insist on family collateral Perform more complex test (MOCA, SLUMS, MMSE)

30. MMSE

31. Pass  > 26 Fail  25 or less

32.  Pros  Widely accepted and validated for dementia screening  30-point scale well known and score easily interpretable  Measures orientation, working memory, recall, language, praxis  Cons  Scale developed 40 years ago, before MCI criteria and when early dementia less well understood  Lacks sensitivity to MCI and early dementia  Takes 7+ min. to administer  Copyright issues MMSE

33. SLUMS

34.  Pros  More measures of executive functioning  Good balance between easy and difficult items  More sensitive than MMSE in detecting MCI and early dementia  30-point scale similar to MMSE  Score range for MCI and dementia  Free online  Cons  Takes 10 min. to administer  Slightly more complex directions than MMSE  Less name recognition than MMSE SLUMS

35. Pass  > 26 Fail  25 or less

36. MoCA

37. Pass  > 26 Fail  25 or less

38.  Pros  Much more sensitive than MMSE for MCI and early dementia  More content tapping higher level executive fx  30-point scale similar to MMSE  Translations available in 35+ languages  Free online  Cons  Takes 10-14 min. to administer  More complex administration and directions than MMSE MoCA

39. Screening Tool Selection Montreal Cognitive Assessment (MoCA)  Sensitivity: 90% for MCI, 100% for dementia  Specificity: 87% St. Louis University Mental Status (SLUMS)  Sensitivity: 92% for MCI, 100% for dementia  Specificity: 81% Mini-Mental Status Exam (MMSE)  Sensitivity: 18% for MCI, 78% for dementia  Specificity: 100% Larner et al Int Psychogeriatr 2012; Nasreddine et al J Am Geriatr Soc 2005; Tariq et al Am J Geriatr Psychiatry 2006; Ismail et al Int J Geriatr Psychiatry 2010

40. Dementia Care  Screening  Diagnosis  Management

42. Diagnostic Workup  H&P  Diagnostics  Labs  Imaging  Neuropsychological assessment  Diagnosis  Family meeting

43. History & Physical  History (with collateral)  Onset, duration, course  Examples of memory difficulties  Impact on function $ management, meds, driving, cooking  Mood, personality or behavior changes  Drug or alcohol use  Medication side effects  Physical + brief neuro exam  Do depression screening (PHQ-9), if not already completed

44. Diagnostics: Labs  Routine Labs  CBC  Electrolytes  BUN/creatinine  Glucose  Calcium  LFTs--??  Dementia screening  Vitamin B12, folate  TSH  Contingent labs  RPR or MHA-TP  HIV  Heavy metals

45. Diagnostics: Imaging  CT adequate for pts with clinical history consistent with AD  MRI helpful for determining pattern of focal atrophy  Request radiologist comment on hippocampal volume  Scans often unremarkable in patients with early AD  Rule out focal lesions, trauma, ischemia, NPH  No need to repeat if pt. had recent scan  Within 12 months  No recent hx of trauma

46. Diagnostics: Neuropsych Testing  Helpful in distinguishing normal aging from MCI and dementia  Atypical presentations  Rule out:  Pseudodementia, substance abuse factors, etc.  Determine type of dementia, stage, capacity, most appropriate level of support  Consider particularly when: MoCA 19-27 SLUMS 18-27 MMSE 18-28

48.  Loss of Memory  Plus one of the following  Impairment in handling complex tasks (balancing a check book, calendars, clock drawing)  Impairment in reasoning ability  Impaired spatial ability and orientation (lost)  Impaired language (word finding)  Severe enough to impact daily life and is a decline from previous function Dementia Diagnosis

49. Diagnosis Alzheimer’s disease: 60-80 % Includes mixed AD + VD Lewy Body Dementia: 10-25 %  Parkinson spectrum Vascular Dementia: 6-10 %  Stroke related Frontotemporal Dementia: 2-5 %  Personality or language problems

50. Vascular Dementia  Clinical Features  Focal neurological signs  Stepwise progression  Often overlaps with AD (6-10% dementia related to pure VD)  Neuropsychological Testing  Predominant deficits in executive function, attention, and processing speed  Neuroimaging  Cerebrovascular Disease Large vessel stroke Periventricular/subcortical white matter disease

51. Dementia with Lewy Bodies  Clinical Features  Parkinsonism, hallucinations, cognitive fluctuations, REM behavioral sleep disorder  Neuropsychological Testing  Predominant visuospatial dysfunction with relative sparing of verbal memory  Neuroimaging  Non-specific MRI atrophy pattern  Occipital hypometabolism on FDG-PET

52. Frontotemporal Dementia  Clinical Features  Typical onset prior to age 65  Behavioral symptoms Disinhibition, apathy, loss of empathy, repetitive stereotyped movements, hyperorality  Language symptoms Expressive aphasia, anomia, surface dyslexia  Neuropsychological Testing  Impairments on executive function/language with relative sparing of episodic memory and visuospatial function  Neuroimaging  Atrophy of frontal and anterior temporal cortex

53. Dementia Care  Screening  Diagnosis  Management

55. Overall Management  Goals;  Reduce suffering that accompanies the disease  Reduce the negative impacts that dementia has on both health & quality of life  Balancing independence & safety  Optimize the management of co-morbid conditions  Weighing benefits, burdens & risks of treatments  Care Plan for acute illness  Supporting the Caregiver

56. Management  Medication treatment  Small component of care plan  Education  Increase family’s dementia competence  Support / Referral  Connect to community resources

57. AD: Care Coordination 57

58. Intervention Model - Clinic Patient Care Partners Care Coordinator Physician / Clinic

59. Care Coordination  Identify cognitive impairment, facilitate diagnosis  Identify ‘team members’, including care partner  Conduct needs assessment  Develop & initiate care plan  Communicate with team  Monitor & re-evaluate  Termination 59

60. Clinic Care Coordination Needs  Care partner / team approach  Disease education  Assistance with medication management  Written materials / plans  POA / healthcare directive  Appointment reminders  Driving assessment / transportation options  Occupational therapy / home safety assessment, fall risk  Risk reduction strategies  Connection to community resources & programs 60

61. Risk Reduction  Genetic Factors: APP, Presinilin 1 &2 / APOE4  Environmental Factors: begins in mid-life (50%)  Mid-life HTN & Obesity (60%)  Physical Inactivity (40 – 80%)  Mid-life Depression (40 – 80%)  Low Education / Cognitive Reserve (60 – 80%)  Smoking (60%)  Alcohol – Late Life & Binge Drinking (2xmo)  Sleep Hygiene : quality & quantity

62. 62 Mild Cognitive Impairment (MCI) Current Services in Minnesota Medical Evaluation / Diagnosis / Pharmacological Treatment* Research / Clinical Trials* Care Coaching / Consultation / Counseling* Information / Education* MCI Support Groups* Engagement Programs (arts, social, creativity)* Exercise / Nutrition / Cognitive Habilitation* * limited availability

63. 63 Early Stage Current Services in Minnesota Medical Evaluation / Diagnosis / Pharmacological Treatment* Research / Clinical Trials* Care Coaching / Consultation Information / Education / Driving Evaluation* Early Stage Support Groups* Engagement Programs (arts, social, creativity)* Exercise / Nutrition / Cognitive Habilitation* Home Care / Companion Services* Assisted Living Medic Alert Safe Return ® * limited availability

65. 65

66. 66 Middle Stage Current Services in Minnesota Medical Evaluation / Diagnosis / Pharmacological Treatment Research / Clinical Trials* Care Coaching / Consultation / Counseling Information / Education / Driving Evaluation* Caregiver Support Groups* Adult Day Services* Meals on Wheels* Home Care / Home Health Care / Respite Services* Medic Alert Safe Return ® Assisted Living / Nursing Facility * limited availability

67. 67 Late Stage Current Services in Minnesota Medical Evaluation / Diagnosis / Pharmacological Treatment Care Coaching / Consultation / Counseling Information / Education Caregiver Support Groups* Adult Day Services* Meals on Wheels* Home Care / Home Health Care / Respite Services* Medic Alert Safe Return ® Assisted Living / Nursing Facility Hospice* * limited availability

68. 68 Research Minnesota Resources Alzheimer’s Disease Research Center – Mayo Clinic University of Minnesota VA Medical Center Alzheimer’s Research Center, Regions Hospital Health Partners Research Fund Healthcare Interactive (HCI) TrialMatch: http://www.alz.org/research/clinical_trials/find_clinical_tria ls_trialmatch.asp

69. 69 ACL Projects Minnesota Resources Family Memory Care: evidence-based consultation Systems Integration: dementia capability Telephone / Internet Resources Alzheimer’s Association 1-800-272-3900 alz.org Senior LinkAge Line® 1-800-333-2433 MinnesotaHelp.info®

70. AD: The Patient Experience 70

71. Conclusion / Q&A 71