Session #F4 - 20
October 29, 2011
10:50 AM
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 13th Annual Conference
October 27-29, 2011 Philadelphia, Pennsylvania U.S.A.
Faculty Disclosure
We have not had any relevant financial relationships
during the past 12 months.
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
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
Expected Outcome
Attendees will be able to discuss how common risk factors can
be used to improve the detection of dementia in primary care
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
Patient
•Time constraints
•Absence of family informant
•Provider attitudes: Dementia is
untreatable
•Agnosagnosia
•Acceptability of screening
•Family discomfort with raising
concerns
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: MiniCog 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
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
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
Clinical Reminder
used to generate
monthly RAPID
eligible list
Behavioral Health
Assessment Center
(BHAC)*
+/-
+
Dementia
Care
Coordinator
+/-
+
+
Geriatric Evaluation
& Management
(GEM)
+/-
Primary Care Provider
VISN 2 RAPID Program Overview
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)
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
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
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)
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
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
Within RAPID Eligible Veterans, is a
BOMC+ associated with a new dementia
diagnosis?
Incidence of Dementia among RAPID Screen Positive Veterans
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
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
Within RAPID Eligible Veterans, is a
BOMC+ associated with a new dementia
diagnosis?
Cumulative Dementia-free Probability
1.00
Probability of Remaining Dementia-free
0.98
BOMC (n = 543)
0.96
0.94
P < 0.001
0.92
BOMC +
(n = 543)
0.90
0.88
0.86
0.84
0.82
0.80
0
6
12
18
24
(n = 1036)
(n = 612)
(n = 359)
(n = 136)
(n = 0)
Months Since BOMC Administration
HR = 4.97 (95%CI: 2.32 –10.66)
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)
What are EMR risk factors are
most effective identifying
dementia?
Risk Model for Incidence of New Dementia Diagnosis
Predictor
Df
Beta (SE)
OR
95%CI
P-Value
Intercept
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
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
Working Collaboratively
Medical 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
Questions for the presenters?
Group Discussion:
How can the detection of
dementia be improved in
primary care?
Session Evaluation
Please complete and return the
evaluation form to the classroom monitor
before leaving this session.
Thank you!