Laura O. Wray, PhD, Director of Education, VA Center for Integrated Healthcare
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Transcript of Laura O. Wray, PhD, Director of Education, VA Center for Integrated Healthcare
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A Dementia Case Finding Program for ‐Veterans: Applying
Lessons Learned to Improve Dementia Recognition in Primary
CarePractice
Laura O. Wray, PhD, Director of Education, VA Center for Integrated HealthcareDavid A. Hunsinger, MD, MSHA, Medical Director, Binghamton VA Outpatient Clinic
Collaborative Family Healthcare Association 13th Annual ConferenceOctober 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Session #F4 - 20October 29, 201110:50 AM
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Faculty DisclosureWe have not had any relevant financial relationships
during the past 12 months.
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Need/Practice Gap & Supporting Resources
• Costs of care for patients with dementia are significantly greater than costs for similarly aged
• 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
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Objectives• Describe the experience of VA Upstate New York Veteran’s
Integrated Health Care System (VISN 2) in using an electronic medical record based system to identify Veterans to be
screened for dementia• Review guidelines for recognition of dementia
• Discuss how medical and behavioral health providers can work collaboratively to address this challenge
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Expected OutcomeAttendees will be able to discuss how common risk factors can
be used to improve the detection of dementia in primary care
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Dementia Recognition in Primary Care (PC)
USPSTF: “Insufficient evidence to recommend for or against screening”25-40% cases recognized: typically when moderately impairedWhat delays dementia diagnosis?`
Provider• Time constraints
• Absence of family informant• Provider attitudes: Dementia is
untreatable
Patient• Agnosagnosia
• Acceptability of screening• Family discomfort with raising
concerns
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Highlights of American Academy of Neurology Guidelines
Know and Share the 10 Warning SignsBe alert to cognitive impairment– Know and use a
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
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Ten Warning Signs of AD1. Memory loss that affects job skills2. Difficulty with familiar tasks3. Problems with language4. Disorientation to time and place5. Poor or decreased judgment6. Problems with abstract thinking7. Misplacing things8. Changes in mood or behavior9. Changes in personality10. Loss of initiative
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VISN 2 RAPID* Goals:Promote early recognition of cognitive impairment and diagnosis of dementiaProvide access to comprehensive assessment for Veterans who screen positive for cognitive assessmentOffer education and support to caregiversProvide access to dementia care management
*RAPID = Recognizing and Assessing Progression of cognitive Impairment and Dementia
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Prim
ary
Car
e Pr
ovid
er
VISN 2 RAPID Program Overview
Behavioral Health Assessment Center
(BHAC)*
DementiaCare
Coordinator
Geriatric Evaluation & Management
(GEM)
Clinical Reminder used to generate monthly RAPID eligible list +
+
+
+/-
+/-
+/-
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RAPID Case Finding Approach:Use of Dementia Red Flags1. Electronic Medical Record:
– Age (Over 70)*– And one or more of the following:
2 or More ER visits in past yearHistory of CVA Taking more than 1 anticholinergic medication
2. Behavioral Health Assessment Center (BHAC) performs cognitive screen
3. Dementia Care Manager calls veteran and family informant and reviews medical record– Medication adherence problems– More than 7 prescribed medications– Agitation– Multiple falls in past year– More than 2 hospitalizations– Attending office visit with caregiver– More than 2 missed appointments in past year– DX of Diabetes + hypertension + CAD + hyperlipidemia
Adapted from the work of Callahan, Boustani, Unverzagt et al., Ann of Int Med (2006)
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RAPID Screening CallsMonthly call lists – clinical reminder technology– Adaptable to adjust # of patients to be
screenedBlessed Orientation Memory and Concentration Test (BOMC)– Validated for use over the phone– Routinely used as part of BHL software– New introduction script created– Score = Total Errors; Range = 0 - 28– ≥10 is suggestive of dementia
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RAPID Case-Finding StrategyCall List Criteria– Primary Care appointment within the coming month– No prior dementia diagnosis– Veterans 70* years and older
And Either– One or more anticholinergic medication
OR– History of CVA
OR– Two or more ER visits in last year
BHAC calls veteran– Positive BOMC (11 or greater) referred to DCM– Negative BOMC healthy brain questions and feedback about
preserving memory via lifestyle
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Program Evaluation Methods - Sample
All VISN 2 Veterans aged 70 and overAt least 1 appointment at any VISN 2 medical center primary care FY07 - FY09Exclusions:– Diagnosis of dementia in FY05 – FY07– Prescription for Cholinesterase Inhibitor of
NMDA receptor antagonist– Missing any data for any risk factor
Example: PHQ-2 (2,881 Veterans)
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Program Evaluation Methods - SampleSample Categorization– RAPID Eligible Veterans
70 yrs and older and any of the following:– 2 or more ER Visits– History of CVA– 1 or more anticholinergic medications
Within RAPID Eligible:– BOMC + Veterans: Score 10 or greater– BOMC – Veterans: Score of less than 10– Unscreened Veterans: no evidence of a RAPID
screening call in EMR
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Program Evaluation Methods
Index Date: to track time to diagnosis– Unscreened Group: first medical appointment
after 10/1/07– Screened Group: date of the RAPID call
Incidence of New Dementia Diagnosis– 1st occurrence of visit encounter coded for
dementia following Index Date
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Within RAPID Eligible Veterans, is a BOMC+ associated with a new dementia diagnosis?
BOMC+(n=543)
BOMC-(n=543)
No BOMC(n=2496)
p Value
DementiaNo. (%)
38 (7.0) 8 (1.5) 147 (5.9) <0 .001
Age(mean ± SD)
81.7 ± 5.5 81.7 ± 5.5 81.7 ± 5.5 0.501
Follow-up(months)
8.3 ± 6.4 8.8 ± 6.8 12 ± 6.8 <0 .001
BOMC Score(mean ± SD)
12.8 ± 3.3 3.1 ± 2.7 --- <0 .001
Incidence of Dementia among RAPID Screen Positive Veterans
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Within RAPID Eligible Veterans, is a BOMC+ associated with a new dementia diagnosis?
Cumulative Dementia-free Probability
Months Since BOMC Administration
0 6 12 18 24
Prob
abili
ty o
f Rem
aini
ng D
emen
tia-fr
ee
0.80
0.82
0.84
0.86
0.88
0.90
0.92
0.94
0.96
0.98
1.00
P < 0.001
BOMC -(n = 543)
BOMC +(n = 543)
(n = 1036) (n = 612) (n = 359) (n = 136) (n = 0)
HR = 4.97 (95%CI: 2.32 –10.66)
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Which Risk Factors Predict Dementia Diagnosis?
EMR Risk Factors:– Age– Gender– ER Visits– Diabetes– Hypertension– Head Trauma– CVA
– TIA– Health Screens for:
TobaccoAlcohol Use (Audit-C)Depression (PHQ-2)
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What are EMR risk factors are most effective identifying
dementia?
Predictor Df Beta (SE) OR 95%CI P-ValueIntercept 1 -9.32 (.726) ----- ---- <.001
Age 1 .072 (.009) 1.074 1.055-1.093 <.001
ER Visit 1 .417 (.057) 1.518 1.358 – 1.696 <.001
CVA 1 .825 (.172) 2.282 1.629 – 3.196 <.001
PHQ-2 1 .106 (.039) 1.111 1.029 – 1.200 .007
Risk Model for Incidence of New Dementia Diagnosis
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SummaryAge, ER use, and History of CVA continue to be strong risk factors. Depression is also an important predictor– Older adults with PHQ+ or in MH treatment
should be considered for dementia screeningProgram activities following a BOMC+ associated with a 5x increase in new dx–Supporting identification of dementia
can improve PC recognition rates
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Working CollaborativelyMedical Provider Behavioral Health Provider
Be alert to warning signs and behavioral changes in older patients
Be alert to warning signs and behavioral changes in older patients
Involve BHP for screening of depression and dementia
Involve family informant when possible
Order recommended medical evaluations
Be skilled and perform brief mental status assessment
Evaluate for possible reversible medical causes
Evaluate for possible depression and/or dementia
Develop a plan for expert consultation and/or management
Feedback information to PCP and develop plan; Know community resources for dementia care
Treat cognitive symptoms of AD Support family and help with management of behavioral symptoms
Treat psychiatric of dementia symptoms as needed
Encourage family caregivers to get involved with education/support
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Questions for the presenters?
Group Discussion:
How can the detection of dementia be improved in primary care?
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Session Evaluation
Please complete and return theevaluation form to the classroom monitor
before leaving this session.
Thank you!