Dementia in the Underserved Medical Care of Vulnerable and - - PowerPoint PPT Presentation

3/3/2018 1

The Optimizing Aging Collaborative at UCSF is supported by the UCSF Geriatrics Workforce Enhancement Program: Health Resources and Services Administration (HRSA) Grant Number U1QHP28727.

Dementia in the Underserved

Medical Care of Vulnerable and Underserved Populations CME, 2018

Anna Chodos, MD MPH Division of General Internal Medicine, ZSFG Division of Geriatrics University of California, San Francisco

I have no disclosures to make.

Learning Objectives

• List 2 ways to assess for cognitive

impairment

• List 2 ways to assess function
• Describe 1 way in which you can

incorporate caregivers into your care plan

Are older adults inherently vulnerable?

• At risk for abuse, neglect, and self-neglect
• Cognitive disability is a 2x risk factor for

abuse

• Physical disability increases with age
• Need caregiving
• Carry large burden of informal caregiving (incr

mortality risk)

• Lower health literacy related to normal cognitive

aging

Acierno, Am J Public Health, 2010 100(2), 292-297. Kobayashi, BMJ Open. 2015 Apr 23;5(4):e007222. Wiglesworth, JAGS,2010; 58 (3), 493-500. Schulz, JAMA. 1999;282(23):2215-9.

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Dementia in Vulnerable Populations

Detection Diagnosis Managem ent

Dementia in Vulnerable Populations

Detection

Diagnosis Managem ent

A Case: Ms. H

• 77 yo W, Spanish-speaking, who

presents to you in clinic with her 2 daughters

• 1 lives with her, 1 is her primary

caregiver

• The patient reports that she feels like

her memory is “terrible”

• PMH: rheumatic MS, htn, a flutter after

severe epistataxis, DM, osteoporosis

• Meds: dilt, warfarin, atorvastatin, vit D,

lisinopril

Screen or Detect?

• No formal guidelines to say to screen

asymptomatic adults -> ⊘ Screening

– There is still a high pretest probability…

• Entry points to detection:

– Patient concern – Caregiver/informant concern – Your concern

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Red flags for Dementia

• Repetition (not normal in span of a clinic visit)
• Losing track of conversation
• Frequently deferring to caregiver/family
• Unexplained medical decompensation
• Hospitalizations
• Unexplained weight loss
• Missing appointments
• Inattentive to appearance, behavioral

changes

• Falls or injury
• Paucity of content, detail in conversation

Is detection different between certain groups?

Examples:

• How do I detect cognitive impairment in

someone with severe substance use disorder who is never sober?

• Patients and informants may report differently

– African-American informants less likely to report concerns – “What is this for?”- mistrust of health care providers

Rovner, Alzheimer Dis Assoc Disord. 2012 Jan-Mar;26(1):44-9.

Dementia

• 1 in 9 adults age 65+, and ~1 in 3 age 85+ have

dementia

Alzheimers Association Facts and Figures 2015; Yaffe K et al. BMJ 2013;347; Van Rensbergen G, Nawrot T. BMC Geriatrics 2010; Cordell Alz and Dementia 2013

Cognitive impairment unrecognized in ~50% of affected patients in primary care.

Mayeda, Alzheimers Dement. 2016 Mar; 12(3): 216–224.

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She has a concern. So, what do I ask Ms. H next?

Detection

Diagno sis

Managem ent

Diagnosis of dementia= acquired cognitive impairment + acquired functional impairment

Dementia

Dementia (Major Neurocognitive Disorder):

• Evidence of significant cognitive decline

from a previous level of performance in

• ne or more cognitive domains:

– Learning and memory – Language – Executive function – Complex attention – Perceptual-motor – Social cognition = behavior  Part I

Dementia

Dementia (Major Neurocognitive Disorder), cont’d:

• The cognitive deficits interfere with independence in

everyday activities.

• The cognitive deficits do not occur exclusively in the

context of a delirium.

• The cognitive deficits are not better explained by another

mental disorder (e.g. major depressive disorder, schizophrenia)

 Part IV: Collateral

DSM-V (2013)

 Part II  Part III  Part III

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Diagnosing Dementia in Primary Care 4 step process

I. Cognitive trajectory and testing

• II. Functional history and/or testing
• III. Rule out reversible causes or other

syndromes

• IV. Collateral information

How does this change in an underserved population?

General Principles of Assessment of Older People

• Ask about accommodations that might help

with their comprehension

– Low voice – Repeat yourself verbatim if you are not understood – Speak directly to the person

Chesser A, et al. Gerontol Geriatr Med. 2016 Jan-Dec; 2: 2333721416630492.

General Principles of Assessment of Older People

Cont’d – Get hearing and vision aides in clinic (magnifying glass, pocket talker) – Minimize distractions – Ask and state things plainly

• At some point separate patient and their

informant and interview separately.

Dementia Assessment: Part I

1) Cognitive:

– History and trajectory

• f:
• Memory
• Executive Function
• Visuospatial
• Language
• Motor
• Psychiatric/Behavioral

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• Ms. H

Spontaneous complaints:

• Cannot remember where she put things
• Can’t sleep and has bags under her eyes
• “I worry a lot.”

On questioning:

• No falls.
• Not cooking anymore because ”daughters do

it.”

• Feels a deep sadness at times.
• No getting lost. No changes in language.

Dementia Assessment: Part I- objective

• Neurologic exam: mental status, motor,

tone, tremor, balance and gait, apraxia, following commands

• Cognitive Testing for most other domains.

– What tools are you familiar with? – What do you have time to do?

Screening Method: Mini-Cog 1-2 min

3 item recall (3 points) + CLOCK DRAW (2 points) http://www.alz.org/documents_custom/minic

• g.pdf

Tested in multi-lingual populations.

Borson S, et al.. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15(11): 1021–1027.

Mini-Cog: 3 item recall/clock draw

**Can be used in multiethnic and multilingual populations

Sensitivity 76-97% Specificity 89-95% Mini-Cog Recall=0 Recall=3 Recall=1-2 Clock Abnormal Clock Normal Cognitive impairment No Cognitive Impairment Cognitive impairment No Cognitive Impairment

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• Ms. H

Recall 0/3 Score = 2  More testing Clock 2/2

GP-COG

5-8 min

• Part 1- Patient (memory)
• Part 2- Informant (function)
• Available in Spanish, Chinese, Korean.

http://gpcog.com.au/

MOCA Test

10-20min

• Positive screen if score 25 or below.
• Positives: Many languages, Many cognitive domains
• Negatives: +1 education < HS, unclear if this is enough
• USE THE INSTRUCTIONS the first few times you use it

www.mocatest.org (need to register)

MOCAn’t

• Initial norms for the MOCA are from a

small cohort in Montreal (n=94)

• Should scores be education and age-

adjusted?

• There is a growing number of validation

studies in other languages and countries.

Nazreddine, J Am Geriatr Soc. 2005 Apr;53(4):695-9.

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• Rossetti. Neurology 2011;77:1272–1275

MOCAn’t

• Cognitively normal

Spanish-speaking with lower levels of education:

– 3-4 points needed for more accomodation

• Cognitively normal

African-American cohort:

– Mean 22 pts (mean age 45) – 80% were below <26 pt cutoff

Dement Geriatr Cogn Dis Extra. 2015 Jan-Apr; 5(1): 85–95. Arch Clin Neuropsychol. 2017 Mar 1;32(2):238-244.

Our Case

• Neurologic exam normal except for slow

gait:

– Community ambulatory is 0.8m/s or faster – 10 foot (3m) walk test: ~3sec or Timed Up and Go <12sec

• MOCA test: 18/30 (raw 17/30)

– 4 years of primary education in rural El Salvador.

Challenges in the COGNITIVE ASSESSMENT with underserved populations

• Assessment can be challenging when:

– No norms! – Non-concordant language – Different cultural context, particularly around education – Severe vision and hearing impairment – Severe mental illness or active substance use

• Note these things and do your best!
• Ask for neuropsych help if needed

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Dementia Assessment: Part II- Function:

• Activities of Daily Living (ADLs),

Instrumental Activities of Daily Living (IADLs) How the person is doing is the most important part of this diagnosis. Assessing Function

• ADLs: Impacted late

– Bathing – Dressing – Toileting, continence – Transferring – Feeding

• IADLs: Impacted early

– Driving/transportation – Using phone – Shopping for food – Finances – Cooking – Housework – Taking meds

Assessing Function

• ADLs: Impacted late

– Bathing – Dressing – Toileting, continence – Transferring – Feeding

• IADLs: Impacted early

– Driving/transportation – Using phone – Shopping for food – Finances – Cooking – Housework – Taking meds

• Ms. H
• Function:

– ADLs: indep in all – IADLs: daughter who is her caregiver does cleaning, shopping, meal prep and laundry

• This is new in the last 2-3 years.

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Challenges in the FUNCTIONAL ASSESSMENT with underserved populations

• Assessment can be challenging when

functional needs are different

– For example, how do you do a functional assessment for:

• Jail or prison inmates
• Homeless adults

Dementia assessment: Part III- Reversible causes

• Delirium: acute, fluctuating,

inattentive

• Substance Use
• Depression
• Labs: TSH, B12, RPR and HIV
• Medication review

Medications Causing Cognitive Symptoms

• Benzodiazepines
• Anti-cholinergics: diphenhydramine,

hydroxyzine, chlorpheniramine

– Including OTC combination meds- tylenol PM

• Sleep medications: Z-drugs
• Muscle relaxants (cyclobenzaprine,

carisoprodol)

• Antispasmotics: oxybutynin, tolterodine
• TCA anti-depressants
• Anti-psychotics

Dementia: Head imaging

• When should I order head imaging?

Feldman HH, et al. CMAJ. 2008 Mar 25;178(7):825-36 Cordel CB, et al. Alzheimers Dement. 2013 Mar;9(2):141-50

• <65
• Rapid onset
• Other diagnoses:

cancer, HIV

• Head injury
• Focal neurologic

findings

• Meds: anti-coagulants

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Challenges in RULING OUT OTHER CAUSES in underserved.

• Serious mental illness
• Substance use disorders
• Medical complexity

– TBI – High burden of vascular risk factors

• Ms. H
• No delirium
• No substance use
• Depression: + depressed mood,

Geriatrics Depression Screen positive

• Labs wnl
• Not on offending medications
• No indication for head imaging

Dementia Assessment: Part IV- Collateral

• Ask all the same things of family,

contacts, caregivers

– Whoever is available and likely to know the most

Memory Executive fxn Language Visuospatial Motor Behavior FUNCTION

• Ms. H’s daughters
• Mostly new issues since Ms. H’s

husband died almost 3 years ago:

• Cognitive:
• Repetitive questions
• Can’t recall conversations
• Disoriented on the bus
• Stubborn, irritable
• Less stable gait
• Functional:

– Indep in ADLs – Dep in shopping, laundry, cleaning for ~2 years

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Challenges in COLLATERAL HISTORY with the underserved

• Lack of close friends or family to provide

collateral

• Reach out to whoever you can- case

managers, prior providers, etc.

Do we have a conclusion?

• Do you think she meets criteria for

dementia?

• Is there anything you still want to know?

Look, a Neuropsychologist!

• Neuropsychological testing is particularly

helpful when there is an unclear diagnosis

• r unusual symptoms, concurrent mental

illness, or tests you have don’t have norms (like low education)

• Ms. H’s Neuropsych Test
• Mood: “stressed”, cried during interview
• Used a test for Spanish-speaking adults with low

education.

• Possible slowing in terms of primarily visuomotor

processing speed and memory retrieval deficits.

• Memory: mild free recall difficulties verbally.
• Language: difficulties primarily with semantic retrieval
• n fluency and naming tasks.
• Abnormal and “largely incompatible with typical

Alzheimer’s disease given average performances on memory retention and slowed psychomotor processing speed with intact visuospatial processing”

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Diagnosis

• Certainly may have

dementia, but not a typical pattern and has prominent mood symptoms.

Dementia in Vulnerable Populations

Detection Diagnosis

Manage ment

Diagnosis and CARE

• Ms. H’s plan:
• Disclose our findings, including concern for

dementia.

• Treat depression and reevaluate symptoms

and function.

• Consider imaging to r/o vascular dementia.
• Support for patient and family.

– Education, support groups, respite if needed.

• Advance care planning.
• Monitoring cognition and function. Time is a

diagnostic.

Care Plan: Healthy Living

• Promote healthy living:

– discuss evidence in support of modifiable risk factors – regular physical activity and diet/ nutrition – socialization (stimulation, loneliness prevention) – Sensory impairment– correct vision and hearing

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Lifestyle Modifications

• More evidence for lifestyle modification

as the best protective strategies for the brain:

– Strategies that guard against cardiovascular risk

• Managing CV risk factors medically
• Tobacco cessation
• Weight management
• Regular physical exercise
• Diet, e.g. Mediterranean diet

Medications

MILD

Acetylcholinesterase Inhibitors (e.g. donepezil, rivastigmine, galantamine)

MODERATE

Acetylcholinesterase Inhibitors (e.g. donepezil, rivastigmine, galantamine) NMDA receptor- antagonist (memantine)

SEVERE

NMDA receptor- antagonist (memantine)

Curr Neuropharmacol. 2016 May; 14(4): 326–338.

Treatment Effect Size

Effect size: small, 0.2; moderate, 0.5; large, 0.8

Caregiver resources

• Family Caregiver Alliance

– Caregiver.org

• Local Alzheimer’s Association
• Respite services- additional caregiver

hours, temporary SNF stay, adult day health program

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Care Plan: Safety Issues

• Discuss driving, wandering, firearms, fire

hazards

• Recommend medical identification for

patients who wander

– www.medicalert.org

Care Plan: Goals of Care

• Dementia-> higher risk of incapacity
• Do advance health care directives,

Durable Power of Attorney for health care AND finances and other documents

• Vulnerable older people less likely to

have a surrogate

Talk with your surrogate!

• PREPARE

www.prepareforyourcare.org Videos to help people and their surrogates talk about goals and values. (In English and Spanish)

• Use any other tools you like! (Five Wishes,

etc.) Dementia: A Major Risk Factor for Elder Abuse

NEARLY 1 IN 2 PEOPLE WITH

DEMENTIA EXPERIENCE SOME FORM OF ABUSE BY OTHERS.

1 Cooper, C., et al. (2009). British Medical Journal, 338, b155 2 Wiglesworth, A., et al. (2010). JAGS, 58, 493-500 3 Alzheimer’s Association (2013). Alzheimer’s Facts & Figures

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2017 CDPH Guidelines for Alzheimer’s Disease Management

• https://www.cdph.ca.gov/Programs/CCDP

HP/DCDIC/CDCB/Pages/AlzheimersDisea seResources.aspx

• 2 pages
• Designed with clinical providers in mind
• Fairly comprehensive guide to care

planning

Summary

• There is a stepwise way to work through

concern for dementia in your patients.

– Special considerations at every point in underserved adults.

• Time is a helpful diagnostic.
• Talk with patients about your concerns and

work on advance care planning.

• Be alert to safety risks and elder abuse.

Any questions?

anna.chodos@ucsf.edu

For more information contact: OAC@ucsf.edu

Optimizing Aging Collaborative at UCSF

The Optimizing Aging Collaborative at UCSF is supported by the UCSF Geriatrics Workforce Enhancement Program: Health Resources and Services Administration (HRSA) Grant Number U1QHP28727.

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Extra slides: Relevant symptoms and findings by domain.

Cognitive Symptoms: Memory

• Problems with recent events – Trouble remembering

conversations, repeating things

• Remote events (generally remain intact until later in

disease)

• Misplacing objects
• Repetitive Questions
• Missing appointments
• Objective findings: Repeats complaint stated earlier in

visit, unable to do short-term recall exercise

Cognitive Symptoms: Executive Function

• Difficulty with planning or organization
• Multi-tasking
• Concentration/attention span
• Problem Solving
• Impulsivity (acting without thinking)
• Mental rigidity/inflexibility
• Objective findings: Difficulty following complex

instructions, difficulty with clock draw or trails

Cognitive Symptoms: Language

• Word finding trouble
• Poor articulation
• Impaired comprehension
• Impoverished speech (e.g. “thingie” instead of

specific word)

• Impaired reading/writing/spelling
• Mutism/ Decreased speech output
• Objective findings: Can name <11 words in 1

minute, poor score on Boston Naming Test (doesn’t know names of high frequency words)

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Cognitive Symptoms: Visuospatial

• Lost in familiar environments
• Difficulty recognizing faces
• Difficulty driving
• Difficulty parking
• Objective finding: Trouble drawing a cube

Cognitive Symptoms: Behavioral

• Changes in emotional expression (blunting/labile)
• Changes in personality/behavior
• Apathy/decreased motivation
• Obsessive/compulsive behaviors
• Agitation/aggression
• Depression
• Delusions/Hallucinations
• Impaired Hygiene/eating
• Changes in sleep

Cognitive Symptoms: Motor

• Difficulty with walking or balance
• Trouble using utensils (apraxia)
• Change in handwriting
• Tremor
• Weakness
• Involuntary movements
• Trouble Swallowing
• Objective findings: Falls, cannot demonstrate how to

brush teeth or hair (apraxia)