What Can Behavioral Health Providers Do? Improving Primary Care of Dementia Through Integration Laura O. Wray, PhD - Director of Education, VA Center for Integrated Healthcare Christina L. Vair, PhD – Clinical Research Psychologist, VA Center for Integrated Healthcare Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session #A5a October 18, 2014
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What Can Behavioral Health Providers Do? Improving Primary Care of Dementia Through Integration Laura O. Wray, PhD - Director of Education, VA Center for.
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What Can Behavioral Health Providers Do? Improving Primary Care of
Dementia Through Integration
Laura O. Wray, PhD - Director of Education, VA Center for Integrated HealthcareChristina L. Vair, PhD – Clinical Research Psychologist, VA Center for Integrated
Healthcare
Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.
• We have not had any relevant financial relationships during the past 12 months.
Learning Objectives
At the conclusion of this session, the participant will be able to:
1. Recognize warning signs and risk factors for dementia in older primary care patients.
2. Discuss ways to improve detection of dementia in primary care.
3. Describe evidence-based strategies to improve recognition of dementia in primary care, including description of validated screening tools that can be readily integrated into primary care assessment for dementia.
• American Academy of Neurology (2004) Guideline Summary for Clinicians http://tools.aan.com/professionals/practice/pdfs/dementia_guideline.pdf
– See also: American Academy of Neurology: Other dementia resources, including questionnaires for patients and CGers re: driving https://www.aan.com/Guidelines/Home/ByTopic?topicId=15
• Alzheimer’s Association Warning Signs (2009) http://www.alz.org/alzheimers_disease_know_the_10_signs.asp
• Borson, S., Frank, L., Bayley, P. J., Boustani, M., Dean, M., Lin, P. J., et al. (2013). Improving dementia care: the role of screening and detection of cognitive impairment. Alzheimer's & Dementia, 9(2), 151-159.
• Goy E., Kansagara D., Freeman M. A. Systematic Evidence Review of Interventions for Non-professional Caregivers of Individuals with Dementia [Internet]. Washington (DC): Department of Veterans Affairs; 2010 Oct. Available from: http://www.ncbi.nlm.nih.gov/books/NBK49194/
• Hurd, M. D., Martorell, P., Delavande, A., Mullen, K. J., & Langa, K. M. (2013). Monetary costs of dementia in the United States. New England Journal of Medicine, 368,1326-1334.
• Lin, J.S., O'Connor, E., Rossom, R.C., Perdue, L.A., Ekstrom, E. (2013) Screening for cognitive impairment in older adults: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med, 159, 601-612.
• Wray, L. O., Wade, M., Beehler, G. P., Hershey, L. A., & Vair, C. L. (in press). A program to improve detection of undiagnosed dementia in primary care and its association with health care utilization. American Journal of Geriatric Psychiatry. DOI: 10.1016/j.jagp.2013.04.018
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the end of this presentation.
Disclosure
The views expressed in this presentation are those of the authors and do not necessarily
reflect the position or policy of the Department of Veterans Affairs or the United States
government.
• What brings you to our talk?
Question for Audience
Established Practice Gaps
• Costs of care for patients with dementia are significantly greater
• 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
Dementia Recognition in Primary Care (PC)
USPSTF (2013): “Insufficient evidence to recommend for or against screening” Annual Wellness Visit (Affordable Care Act) requires assessment to detect cognitive impairment along with other routine measuresHowever, 25-40% cases moderate to severe dementia are not recognized
What delays dementia detection?Provider
• Time constraints• Absence of family informant
• Provider attitudes Dementia is untreatable
Patient
• Agnosagnosia• Acceptability of screening
• Family discomfort with raising concerns
Barriers to Detection
Successful Integration Will Improve Quality, Satisfaction and Cost
Older Patients
Medical and Behavioral
Health Providers Family
Caregivers
AAN Guidelines* • Know and Share the 10 Warning Signs
• Be alert to cognitive impairment– Know and use 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 *http://tools.aan.com/professionals/practice/pdfs/dementia_guideline.pdf
1. 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