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

3/3/2018 I have no disclosures to make. 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 The Optimizing Aging Collaborative at UCSF is supported by the UCSF Geriatrics Workforce Enhancement Program: Health Resources and Services Administration (HRSA) Grant Number U1QHP28727. Are older adults inherently vulnerable? Learning Objectives • At risk for abuse, neglect, and self-neglect • List 2 ways to assess for cognitive • Cognitive disability is a 2x risk factor for impairment abuse • Physical disability increases with age • List 2 ways to assess function • Need caregiving • Describe 1 way in which you can • Carry large burden of informal caregiving (incr incorporate caregivers into your care plan mortality risk) • Lower health literacy related to normal cognitive aging Wiglesworth, JAGS,2010; 58 (3), 493-500. Acierno, Am J Public Health, 2010 100(2), 292-297. Kobayashi, BMJ Open. 2015 Apr 23;5(4):e007222. Schulz, JAMA. 1999;282(23):2215-9. 1

3/3/2018 Dementia in Vulnerable Populations Dementia in Vulnerable Populations Managem Managem Detection Detection Diagnosis Diagnosis ent ent Screen or Detect? A Case: Ms. H • No formal guidelines to say to screen • 77 yo W, Spanish-speaking, who asymptomatic adults -> ⊘ Screening presents to you in clinic with her 2 daughters – There is still a high pretest probability… • 1 lives with her, 1 is her primary • Entry points to detection: caregiver – Patient concern • The patient reports that she feels like her memory is “terrible” – Caregiver/informant concern – Your concern • PMH: rheumatic MS, htn, a flutter after severe epistataxis, DM, osteoporosis • Meds: dilt, warfarin, atorvastatin, vit D, lisinopril 2

3/3/2018 Is detection different between certain Red flags for Dementia groups? • Repetition (not normal in span of a clinic visit) Examples: • Losing track of conversation • How do I detect cognitive impairment in • Frequently deferring to caregiver/family someone with severe substance use disorder • Unexplained medical decompensation who is never sober? • Hospitalizations • Patients and informants may report differently • Unexplained weight loss – African-American informants less likely to report • Missing appointments concerns • Inattentive to appearance, behavioral – “What is this for?” - mistrust of health care changes providers • Falls or injury • Paucity of content, detail in conversation 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 Cognitive impairment unrecognized in ~50% of affected patients in primary care. 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 Mayeda, Alzheimers Dement. 2016 Mar; 12(3): 216–224. 3

3/3/2018 She has a concern. So, what do I ask Ms. H next? Diagnosis of dementia= acquired cognitive impairment + Diagno Managem Detection acquired functional sis ent impairment Dementia Dementia Dementia (Major Neurocognitive Disorder): Dementia (Major Neurocognitive Disorder), cont’d: • Evidence of significant cognitive decline from a previous level of performance in • The cognitive deficits interfere with independence in one or more cognitive domains: everyday activities.  Part II • The cognitive deficits do not occur exclusively in the – Learning and memory  Part III context of a delirium. – Language • The cognitive deficits are not better explained by another – Executive function mental disorder (e.g. major depressive disorder, – Complex attention  Part III schizophrenia) – Perceptual-motor – Social cognition = behavior  Part IV: Collateral DSM-V (2013)  Part I 4

3/3/2018 Diagnosing Dementia in Primary Care General Principles of Assessment of 4 step process Older People • Ask about accommodations that might help with their comprehension I. Cognitive trajectory and testing – Low voice II. Functional history and/or testing – Repeat yourself verbatim if you are not III. Rule out reversible causes or other understood syndromes – Speak directly to the person IV. Collateral information How does this change in an underserved population? Chesser A, et al. Gerontol Geriatr Med. 2016 Jan-Dec; 2: 2333721416630492. Dementia Assessment: General Principles of Assessment of Part I Older People 1) Cognitive: Cont’d – History and trajectory – Get hearing and vision aides in clinic (magnifying of: glass, pocket talker) • Memory – Minimize distractions • Executive Function – Ask and state things plainly • Visuospatial • Language • At some point separate patient and their • Motor informant and interview separately. • Psychiatric/Behavioral 5

3/3/2018 Ms. H Dementia Assessment: Part I- objective Spontaneous complaints: • Neurologic exam: mental status, motor, • Cannot remember where she put things tone, tremor, balance and gait, apraxia, • Can’t sleep and has bags under her eyes following commands • “I worry a lot.” On questioning: • Cognitive Testing for most other domains. • No falls. • Not cooking anymore because ”daughters do – What tools are you familiar with? it.” – What do you have time to do? • Feels a deep sadness at times. • No getting lost. No changes in language. Screening Method: Mini-Cog Mini-Cog: 3 item recall/clock draw 1-2 min Mini-Cog Recall=3 Recall=0 No Cognitive Impairment 3 item recall (3 points) Cognitive impairment Recall=1-2 + CLOCK DRAW (2 points) Clock Normal Clock Abnormal http://www.alz.org/documents_custom/minic Cognitive impairment No Cognitive Impairment og.pdf Tested in multi-lingual populations. **Can be used in multiethnic and multilingual populations Sensitivity 76-97% Specificity 89-95% 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. 6

3/3/2018 GP-COG Ms. H 5-8 min Recall 0/3 • Part 1- Patient (memory) Clock 2/2 • Part 2- Informant (function) • Available in Spanish, Chinese, Korean. http://gpcog.com.au/ Score = 2  More testing MOCA Test MOCAn’t 10-20min • Initial norms for the MOCA are from a small cohort in Montreal (n=94) • Should scores be education and age- adjusted? • Positive screen if score 25 or below. • There is a growing number of validation • Positives: Many languages, Many cognitive domains studies in other languages and countries. • 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 ) Nazreddine, J Am Geriatr Soc. 2005 Apr;53(4):695-9. 7

3/3/2018 MOCAn’t • Cognitively normal • Cognitively normal Spanish-speaking African-American with lower levels of cohort: education: – Mean 22 pts (mean age 45) – 3-4 points needed for more – 80% were below accomodation <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. Rossetti. Neurology 2011;77:1272–1275 Challenges in the Our Case COGNITIVE ASSESSMENT with underserved populations • Neurologic exam normal except for slow • Assessment can be challenging when: gait: – No norms! – Community ambulatory is 0.8m/s or faster – Non-concordant language – 10 foot (3m) walk test: ~3sec or Timed Up and – Different cultural context, particularly around Go <12sec education – Severe vision and hearing impairment • MOCA test: 18/30 (raw 17/30) – Severe mental illness or active substance use – 4 years of primary education in rural El • Note these things and do your best! Salvador. • Ask for neuropsych help if needed 8

3/3/2018 Assessing Function Dementia Assessment: Part II- Function: • ADLs: Impacted late • IADLs: Impacted early – Bathing – Driving/transportation • Activities of Daily Living (ADLs), – Dressing – Using phone Instrumental Activities of Daily Living – Toileting, continence – Shopping for food (IADLs) – Transferring – Finances – Feeding – Cooking – Housework How the person is doing is the most – Taking meds important part of this diagnosis. Ms. H Assessing Function • ADLs: Impacted late • IADLs: Impacted early – Bathing – Driving/transportation • Function: – Dressing – Using phone – ADLs: indep in all – Toileting, continence – Shopping for food – IADLs: daughter who is her caregiver does – Transferring – Finances cleaning, shopping, meal prep and laundry – Feeding – Cooking • This is new in the last 2-3 years. – Housework – Taking meds 9