1. A Dementia Case‐Finding Program for Veterans: Applying Lessons Learned to Improve Dementia Recognition in Primary Care Practice Laura O. Wray, PhD, Director of Education, VA Center for Integrated Healthcare David A. Hunsinger, MD, MSHA, Medical Director, Binghamton VA Outpatient Clinic Collaborative Family Healthcare Association 13 th Annual Conference October 27-29, 2011 Philadelphia, Pennsylvania U.S.A. Session #F4 - 20 October 29, 2011 10:50 AM

2. Faculty Disclosure We have not had any relevant financial relationships during the past 12 months.

3. 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

4. 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

5. Expected Outcome Attendees will be able to discuss how common risk factors can be used to improve the detection of dementia in primary care

6. Dementia Recognition in Primary Care (PC) USPSTF: “Insufficient evidence to recommend for or against screening” 25-40% cases recognized: typically when moderately impaired What 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

7. Highlights of American Academy of Neurology Guidelines Know and Share the 10 Warning Signs Be 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

8. Ten Warning Signs of AD 1. Memory loss that affects job skills 2. Difficulty with familiar tasks 3. Problems with language 4. Disorientation to time and place 5. Poor or decreased judgment 6. Problems with abstract thinking 7. Misplacing things 8. Changes in mood or behavior 9. Changes in personality 10. Loss of initiative

9. VISN 2 RAPID* Goals: Promote early recognition of cognitive impairment and diagnosis of dementia Provide access to comprehensive assessment for Veterans who screen positive for cognitive assessment Offer education and support to caregivers Provide access to dementia care management *RAPID = Recognizing and Assessing Progression of cognitive Impairment and Dementia

10. Primary Care Provider VISN 2 RAPID Program Overview Behavioral Health Assessment Center (BHAC)* Dementia Care Coordinator Geriatric Evaluation & Management (GEM) Clinical Reminder used to generate monthly RAPID eligible list + + + +/-

11. RAPID Case Finding Approach: Use of Dementia Red Flags 1. Electronic Medical Record: –Age (Over 70)* –And one or more of the following: 2 or More ER visits in past year History 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)

12. RAPID Screening Calls Monthly call lists – clinical reminder technology –Adaptable to adjust # of patients to be screened Blessed 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

13. RAPID Case-Finding Strategy Call 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

14. Program Evaluation Methods - Sample All VISN 2 Veterans aged 70 and over At least 1 appointment at any VISN 2 medical center primary care FY07 - FY09 Exclusions: –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)

15. Program Evaluation Methods - Sample Sample 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

16. 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 –1 st occurrence of visit encounter coded for dementia following Index Date

17. 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 Dementia No. (%) 38 (7.0)8 (1.5)147 (5.9)<0.001 Age (mean ± SD) 81.7 ± 5.5 0.501 Follow-up (months) 8.3 ± 6.48.8 ± 6.812 ± 6.8<0.001 BOMC Score (mean ± SD) 12.8 ± 3.33.1 ± 2.7---<0.001 Incidence of Dementia among RAPID Screen Positive Veterans

18. Within RAPID Eligible Veterans, is a BOMC+ associated with a new dementia diagnosis? HR = 4.97 (95%CI: 2.32 –10.66)

19. Which Risk Factors Predict Dementia Diagnosis? EMR Risk Factors: –Age –Gender –ER Visits –Diabetes –Hypertension –Head Trauma –CVA –TIA –Health Screens for: Tobacco Alcohol Use (Audit-C) Depression (PHQ-2)

20. What are EMR risk factors are most effective identifying dementia? PredictorDfBeta (SE)OR95%CIP-Value Intercept1-9.32 (.726)---------<.001 Age1.072 (.009)1.0741.055-1.093<.001 ER Visit1.417 (.057)1.5181.358 – 1.696<.001 CVA1.825 (.172)2.2821.629 – 3.196<.001 PHQ-21.106 (.039)1.1111.029 – 1.200.007 Risk Model for Incidence of New Dementia Diagnosis

21. Summary Age, 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 screening Program activities following a BOMC+ associated with a 5x increase in new dx –Supporting identification of dementia can improve PC recognition rates

22. Working Collaboratively Medical ProviderBehavioral Health Provider 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 ADSupport family and help with management of behavioral symptoms Treat psychiatric of dementia symptoms as needed Encourage family caregivers to get involved with education/support

23. Questions for the presenters? Group Discussion: How can the detection of dementia be improved in primary care?

24. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!