Gala Professional Education Symposium: “Transforming...

Utah Chapter

Gala Professional Education Symposium:

“Transforming Primary Dementia Care in an Era of Health Care Reform”

Saturday,March5,2011,8:00to12:00Salt Lake City Marriott Downtown

75 South West Temple

PROGRAM:

7:45 Registration, Continental Breakfast and Exhibitor Break

8:00 Welcome by Jack Jenks, Executive Director of the Alzheimer’s Association Utah Chapter

8:05 ALEXA Presentation: “Dementia: From Diagnosis to Autopsy” - Daniel D. Christensen, M.D., 2011 ALEXA Honoree

8:50 Keynote Presentation: “Implementing Dementia Care Models in Primary Care: The Wishard Healthy Aging Brain Center Experience” - Malaz Boustani, M.D, MPH

9:50 Exhibitor Break

10:05 “Translating Advances in Dementia Care to the Intermountain West: The Medical Home And the University of Utah Multidisciplinary Cognitive Disorders Clinic” - Norman L. Foster, M.D.

10:35 “The Cognasium Approach: Improving Dementia Care by Facilitating a Partnership of Disease Recipient, Caregiver and Physician” - Sonnie Yudell, Sylvia Brunisholz, LCSW, CMC, and Nick Zullo, MPA, MC

11:05 Exhibitor Break

11:15 “Strategies for Quality Dementia Care – What Will and Won’t Work in Utah: Audience Reaction and Discussion” - Daniel D. Christensen, M.D. (Moderator), Malaz Boustani, M.D., MPH, Randall Rupper, M.D., MPH, Norman L. Foster, M.D. (audience and physician interaction)

12:00 Conclusion, Certificates of Course Completion

The conference organizers thank Garden Terrace of Utah for their generous support of this activity

To download an electronic copy of the symposium syllabus, please visit http://uuhsc.utah.edu/cacir/professional.html


Saturday,March5,2011Salt Lake City Marriott Downtown

CME & CEU STATEMENTS

CME ACCREDITATION: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of The University of Utah School of Medicine and the Alzheimer’s Association, Utah Chapter. The University of Utah School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. AMA CREDIT: The University of Utah School of Medicine designates this live activity for a maximum of 3.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. NONDISCRIMINATION AND DISABILITY ACCOMMODATION STATEMENT: The University of Utah does not exclude, deny benefits to or otherwise discriminate against any person on the basis of race, color, national origin, sex, disability, age, veteran’s status, religion, gender identity/expression, genetic information, or sexual orientation in admission to or participation in its programs and activities. Reasonable accommodations will be provided to qualified individuals with disabilities upon request, with reasonable notice. Requests for accommodations or inquiries or complaints about University nondiscrimination and disability/access policies may be directed to the Director, OEO/AA, Title IX/Section 504/ADA Coordinator, 201 S President’s Circle, RM 135, Salt Lake City, UT 84112, 801-581-8365 (Voice/TTY), 801-585-5746 (Fax).

CEU ACCREDITATION: CEU credit for Registered Nurses and Nursing Home Administrators will be provided by the Utah Nurses Association. CEU credit also will be available for Social Workers and Licensed Professional Counselors.

Revised 2/16/2011



CME SELF-REPORTING ATTENDANCE FORM

In order to receive CME credit, you must complete and return this form to the

registration desk at the end of the conference.

Title of Activity: Gala Professional Education Symposium:

“Transforming Primary Dementia Care in an

Era of Health Care Reform”

Date(s): Saturday March 5, 2011

Location: Salt Lake City Marriott Downtown

Name: ___________________________________

E-mail Address (for sending certificate): ___________________________________

Degree/Title (MD, DO, PA, APRN, etc.): ___________________________

The University of Utah School of Medicine designates this Live activity for a maximum of 3.5 AMA PRA Category 1 Credit(s)TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

I claim the following number of credits:_______________.

tandyjensen

Typewritten Text

"Transforming Primary Dementia Care in an Era of Health Care Reform"

tandyjensen

Typewritten Text

Mar 5, 2011

tandyjensen

Typewritten Text

Salt Lake City Marriott Downtown

tandyjensen

Typewritten Text

Please complete and return this form to the registration desk at the end of the symposium.



STANDARD UUCME EVALUATION: “COMMITMENT TO CHANGE”

Upon conclusion of this activity, please complete the online evaluation at http://www.surveymonkey.com/s/ZTZFHC6

(the survey should take < 5 minutes of your time).

Please keep this form for your records. You may use the space below to make notes.

In six (6) weeks we will email you to see how you are progressing. This tool will help demonstrate the efficacy of this CME activity, as reflected in improvements in your competence, performance or improvements in patient care that have actually been accomplished.

As a result of what I learned, I intend to make the following changes in my practice (NOTES):

☐ I now have a strategy or plan that I will implement regarding when and

how to refer patients with suspected dementing illness to subspecialists

☐ I will employ the assessment tools learned in order to

comprehensively discuss psychosocial needs of dementia patients and their family caregivers

☐ I will utilize available community resources and educational and

psychosocial interventions in dementia management ☐ Other:

MEET OUR SPEAKERS

Daniel D. Christensen, M.D. Dr. Christensen is Clinical Professor of Psychiatry, Clinical Professor of Neurology and Adjunct Professor of Pharmacology at the University Of Utah School of Medicine in Salt Lake City, Utah. He was born in Chicago, grew up in Utah and has been at the University of Utah since 1965 – as a student from 1965 to 1972, a resident in Psychiatry from 1972 to 1976 and since as a

member of the faculty.

His research career began as a student in the Department of Chemistry where he completed projects in high-temperature thermodynamics and organic synthesis, receiving research awards from the American Chemical Society and University of Utah Department of Chemistry. Through medical school years he had the privilege of serving on the research team of the renowned hematologists Maxwell Wintrobe and George Cartwright where his work on Iron Metabolism received the Student American Medical Association and Bush Memorial Research Awards. Research interests have since included basic science problems, such as the use of STM/AFM microscopy to define the structure of brain receptors and clinical practice questions such as the safety and efficacy of various new medications for depression, anxiety, schizophrenia and dementia. Recent projects have center on psychiatric genetics and Alzheimer’s Disease. He has served as a consultant to three genetic biotechnology firms, for five years as Executive Director of the Alzheimer’s Program at Myriad Genetics and for 10 years as Medical Director of the University of Utah Neuropsychiatric Institute.

He is the recipient of numerous teaching awards including twice being named “Outstanding Professor” at the University of Utah School of Medicine. His schedule of invited lectures number over 100 per year and have included every state and many foreign countries. Dr. Christensen is the 2011 recipient of the A Lifetime of Extraordinary Achievement (ALEXA) award given by the Alzheimer’s Association, Utah Chapter.

Malaz A. Boustani, M.D., MPH Dr. Boustani is Associate Professor of Medicine in the Division of General Internal Medicine and Geriatrics and Adjunct Associate Professor in Public Health at Indiana University. He is also the Associate Director at the Indiana University Center for Aging Research, Research Director of the Healthy Aging Brain Center, Chief Research Officer of

the Indianapolis Discovery Network for Dementia, and an investigator at the Regenstrief Institute.

Dr. Boustani’s main research interest relates to improving the quality of life and care of older adults with acute and chronic cognitive disorders such as delirium and dementia. He is currently designing a system-based approach across the different settings of care, including the community, primary care, hospital, and long-term care settings. Dr. Boustani has been the author of multiple papers with significant policy implications such as the United States Preventive Services Task Force guideline for dementia screening in primary care setting, the only population-based description of mental illness in assisted living. He has also been instrumental in developing a new innovative dementia care standard in long-term care.

Dr. Boustani obtained his MD from the University of Damascus. He completed the internal medicine residency program at Mt. Sinai Medical Center in Cleveland and a three-year geriatric research fellowship at the University of North Carolina at Chapel Hill, during which he completed the two-year translational clinical research curriculum fellowship as one of the first scholars in the UNC K30 program. He also attended the core curriculum for the Robert Wood Johnson Clinical Scholar Program at UNC and obtained an MPH in health care and prevention from the University of North Carolina School of Public Health.

Norman L. Foster, M.D. Dr. Foster is Professor in the Department of Neurology, Senior Investigator in the Brain Institute, and Director of the Center for Alzheimer’s Care, Imaging & Research (CACIR) at the University of Utah.

Dr. Foster has specialized in brain imaging and dementing diseases for over 30 years. His research has focused primarily on brain imaging, clinical drug trials, and the clinical features and pathophysiology

of dementing diseases. Dr. Foster is a Fellow of the American Academy of Neurology, and a chartered member of the Alpha Omega Alpha Honorary Medical Society and American Neurological Association.

Dr. Foster graduated summa cum laude from MacMurray College in Illinois with a dual Bachelor’s in Biology and Chemistry, before completing his M.D. and internship at Washington University. Dr. Foster completed his neurology residency at the University of Utah and a three-year fellowship in Experimental Therapeutics at the National Institute of Neurological and Communicative Disorders and Stroke (NINCDS). Dr. Foster spent the next 20 years in the Department of Neurology at the University of Michigan, where he led the Clinical Core and was Associate Director of the NIH-funded Michigan Alzheimer's Disease Research Center and established the first dementia clinic in Michigan, which he directed from 1984-2005.

Sonnie Yudell, BS Sonnie serves as the statewide program manager for the Utah Caregiver Support Program at the Division of Aging and Adult Services. She develops programs throughout Utah to assist caregivers of the elderly population in obtaining resources and services. In this capacity she has brought together many community organizations and individuals to develop the Utah Coalition for Caregiver Support – creating additional awareness about the needs of Utah’s aging

population and their caregivers.

Sylvia Brunisholz, LCSW, CMC Sylvia provides counseling to individuals and families caring for loved ones coping with Alzheimer’s disease and related dementias. They are supported through the disease process with education, resources and referrals. Sylvia is a Geriatric Care Manager, Psychiatric Crisis Worker and Forensic Therapist who previously worked as a medical and hospice LCSW with Dementia patients. She

received her BSW and MSW from the University of Utah.

Nick Zullo, MPA, MC Nick Zullo is Director of Programs and Advocacy of the Alzheimer's Association Utah Chapter. He is a geriatric counselor and enjoys working directly with individuals and groups with Alzheimer's disease and related dementias. He teaches the Foundations of Dementia Care to

professional care organizations. He has masters degrees in public administration and mental health counseling.

Randall Rupper, M.D., MPH Dr. Randall (Rand) Rupper was born and raised in Payson, Utah. He received his medical degree from Stanford, where he also participated in basic immunology research. He subsequently completed a Primary Care Internal Medicine residency at the University of Washington in Seattle. Following residency, Rand was selected by the Robert Wood Johnson Foundation to be a Clinical Scholar at the

University of North Carolina at Chapel Hill. During this time, he also completed an MPH in Public Health Leadership. Rand was recruited to the University of Utah Department of Medicine in 2003. Over the subsequent two years, he completed the requirements for a Board Certification in Geriatrics. He is currently an Assistant Professor in the Division of Geriatrics, the Associate Director, Clinical at the SLC Geriatric Research, Education, and Clinical Center, and the Aging Domain Lead at the Veterans Rural Health Resource Center – Western Region.



Speaker and Planning Committee Disclosure Summary The University of Utah School of Medicine Continuing Medical Education Office meets the Accreditation Council for Continuing Medical Education expectations regarding the identification and resolution of conflicts of interest that arise from financial relationships with commercial interests. Financial relationships are those relationships in which the individual benefits by receiving a salary, royalty, intellectual property rights, consulting fee, honoraria, ownership interest (e.g., stocks, stock options or other ownership interest, excluding diversified mutual funds), or other financial benefit. Financial benefits are usually associated with roles such as employment, management position, independent contractor (including contracted research), consulting, speaking and teaching, membership or advisory committees or review panels, board membership, and other activities from which remuneration is received, or expected. We consider relationships of the person involved in the CME activity to include financial relationships of a spouse or partner. Everyone in control of content, including all speakers and planners are expected to disclose any relevant financial relationships in any amount within the past 12 months. Speakers are also expected to openly disclose intent to discuss any off-label, experimental, or investigational use of drugs, devices, or equipment in their presentations.

Speaker(s) or Planner(s) Name

Speaker (S) or

Planner (P)

Grants/ Research Support

Consultant Stock Shareholder

(directly purchased)

Honorarium Other Financial or Material Support

Norman L. Foster, M.D.

S, P Pfizer, Janssen Alzheimer Immunotherapy, Eli Lilly &

Company, Baxter Bioscience

GE Healthcare, Janssen Alzheimer Immunotherapy

No No Bristol-Myers Squibb

Nick Zullo, MPA, MC

S, P No No No No No

Sonnie Yudell S, P No No No No No Sylvia Brunisholz, LCSW, CMC

S, P No No No No No

Tandy Jensen P No No No No No Kevin Duff, Ph.D. COI

Review No No No No No

Malaz Boustani, M.D., MPH

S Novartis No No Pfizer No

Randall Rupper, M.D.

S No No No No No

Daniel D. Christensen, M.D.

S Abbott, Bristol-Myers Squibb, Designer Genes, Eccles

Institute of Human Gen etics, GlaxoSmithKline, Janssen, Myriad Genetics, Novartis,

NPS Pharmaceuticals, Organon USA, Pfizer,

RiboMed, Solvay, Wyeth-Ayerst

Bayer, Bristol-Myers-Squibb, Designer Genes,

Glaxo-SmithKline, Janssen, Eli Lilly,

Medivation, Myriad Genetics, Novartis, NPS Pharmaceuticals, Pfizer, RiboMed, Solvay, Wyeth-

Ayerst

No Abbott, Bayer, Bristol-Myers Squibb, Eisai,

GlaxoSmithKline, Janssen, Eli Lilly, Novartis, Pfizer,

Solvay, Upjohn Inc., Wyeth-Ayerst

No

No one in The University of Utah Continuing Medical Education Office in control of content for the Gala Professional Education Symposium has any relevant financial relationship

with commercial products or services discussed during this conference.

“Dementia: From Diagnosis to Autopsy”Daniel D. Christensen, M.D.

Dementia: fromDiagnosis to Autopsy

Daniel D. Christensen, M.D.Neuropsychiatric Institute

University of Utah

Dementia of the AlzheimerType

DSM IV Diagnostic Criteria• Memory impairment• One or more of:

aphasia, apraxia, agnosia, impaired execfunction

• Impaired function• Insidious onset with gradual decline• Other possible causes excluded

J Am Geriatric Society 1999; 47: 564 - 569Alz Disease and Assoc Disorders 1996; 10: 180 - 188

Neurology 1995; 45: 461 - 466Neurology 2000; 55: 1854 - 1862

J Am Geriatric Society 1999; 47: 564 - 569Alz Disease and Assoc Disorders 1996; 10: 180 - 188

Neurology 1995; 45: 461 - 466Neurology 2000; 55: 1854 - 1862

Predictive value of clinicaldiagnostic criteria for Alzheimer’s

Predictive value of clinicaldiagnostic criteria for Alzheimer’s

About 85% of those who meet diagnosticcriteria during life will meet neuropathologiccriteria for Alzheimer’s Disease at autopsy.

(Range 75 - 97%)

About 85% of those who meet diagnosticcriteria during life will meet neuropathologiccriteria for Alzheimer’s Disease at autopsy.

(Range 75 - 97%)


Family History and the risk oflate-onset Alzheimer’s

Meta-analysis of 10 studies (1982 - 1990)Relative risk of AD in those with one firstdegree relative with AD was 3.5 (95% CI

2.6-4.6)

RR in those with two or more first degreerelatives with AD = 7.5

VanDuijn et al, Int J of Epidemiology, 1991, 20VanDuijn et al, Int J of Epidemiology, 1991, 20

MIRAGE Study(Multi-Institutional Research in

Alzheimer’s Genetic Epidemiology Study)17,639 first-degree relatives and 2474 spouses

(controls) of 2339 white AD probandsRelative risk of AD vs. controls = 2.6

2281 first-degree relatives and 257 spouses(controls) of 255 black AD probands

Relative risk of AD vs. controls = 2.4

JAMA 2002: 287, 3; 329 - 336JAMA 2002: 287, 3; 329 - 336


Head Injury and Alzheimer’sMIRAGE Study

AD Patients 10 x more likely to have a hx ofhead injury with loss of consciousness

(Neurology, March 14, 2000)

Experimental brain injury in animals β amyloid / tau accumulation andplaque formation evident 3 - 10 days

post-injury(J Neuropath Exp Neurol 1999;58:982-92)

2000+ World War II VeteransDocumented head injuries during 1944 -

1945

(Neurology, 55:1158 - 1166, Oct 24, 2000)

Head Injury and Alzheimer’s

Severe head injury (unconsciousnesslasting more than 24 hours) correlated

with four times the likelihood ofdeveloping Alzheimer’s in later years

Moderate head injury (1/2>24 hr) - twice therisk

14 BoxersAverage 15 head hits / match – No

knockoutsCSF tau – a marker for axonal degeneration

Head Injury and Boxing

(Blennow K, International Psychogeriatric Association,Annual Meeting, Stockholm, Sweden, Sept 24, 2005)


Survival after Alzheimer’sDiagnosis

82827272

7878

Non-Alzheimer’sNon-Alzheimer’s

Alzheimer’sAlzheimer’s7373

9393

Brookmeyer et al, Arch of Neurology, Nov. 18, 2002Brookmeyer et al, Arch of Neurology, Nov. 18, 2002

“Implementing Dementia Care Models in Primary Care:The Wishard Healthy Aging Brain Center Experience”

Malaz A. Boustani, M.D., MPH

School of MedicineDepartment of Medicine

Division of General Internal Medicine and GeriatricsCenter for Aging Research IU GeriatricsIU Geriatrics

Implementing Dementia Care Models in Primary Care:The Wishard Healthy Aging Brain Center

Experience

Malaz A. Boustani, MD, MPHAssociate Professor of Medicine, Indiana University School of Medicine

Associate Director, Indiana University Center for Aging ResearchNetwork Director, Indianapolis Discovery Network for Dementia

3/4/11

0

2

4

6

8

10

12

No Trx Delay Slow Combined

mild

severe

total

Million

Sloane, Boustani et al, Ann Rev PH 2002

Introducing three new AD drugs in 2010Their Impact on AD cases in 2050

www.indydiscoverynetwork.com

Objectives

1. Share the HABC Story at Wishard

– The needs

– The scientific model

– The implementation



• 2000 pts pts > 65: 300

3 chronic conditions: 150 Musculoskeletal pain: 195 Feeling anxious: 93 Hospitalized every year: 78 CI: 45

– Dementia: 24» Recognized 8

PCP Patient Panel

Boustani, Sachs, & Callahan JGIM 2007

• Older patient with three chronic conditionsReceives 12 medicationsPay $400 per monthAdhere to complex non-pharmacological regimens

• PCP needs (per day) 10 hours for chronic care management additional 7 hours for preventive services

Boyd et al, JAMA 2005; Ostbye et al, Ann Fam Med 2005

Adhere to Disease-Specific Guidelines

Quality of Acute Care Services (~1000 primary care patients with CI or depression in 2008)

Boustani et al, Aging and Mental Health 2011

% patients with 1 ER visit per year: 50%

% patients with 7 day return ER visit: 15%

% patients with 1 hospitalization per year: 26%

% patients with 30 day re-hospitalization: 20%

Mean Length of Hospital days: 7



Quality of Ambulatory Care Services (~1000 primary care patients with CI or depression in 2008)

Boustani et al, Aging and Mental Health 2011

% receive inappropriate Anticholinergics (Bad) 40%

% receive appropriate dementia drug (Good) 13%

% receive both dementia and anticholinergic (Bad) 32%

% receive appropriate depression drug (Good) 48%

% LDL < 130 (Good) 23%

% Hg A1c < 8 (Good) 51%

% SBP < 160 (Good) 24%

Primary Care Clinician:-detect and treat delirium-detect and treat BPSD-Enhance cholinergic system by -Prescribe ChEIs -Discontinue Anticholinergic

Caregiver Focus:-Problem solving skills-Counseling-Respite care-Support group

General Environmental Modification:-Medication adherence support-Home safety assessment

Clinical Liaison

Expert Team:-Geriatrician-Social Psychologist-GeroPsychiatrist

DynamicFeedback

DynamicFeedback

Coordinate and Deliver

Coordinate and Deliver

The CollaborativeDementia CarePREVENT Model

Callahan et al, JAMA 2006; Austrom et al, Gerontologist 2004; Boustani et al, JCIA 2006

43

71

80

55

45

28

13

710 10

0

10

20

30

40

50

60

70

80

90

100

% NPI > 4 % ChEI % SSRI % AP % Hypnotic

I

UC

The Impact of PREVENT



The Impact of PREVENT

• NNT = 3.7• Each 1 point decline in

NPI = $250-$400 inhealth care expenses.

• PREVENT reached 7 NPIpoint improvement =$1750-$2800.

• Improvement in CGstress.

-4

-2

0

2

4

6

8

change in

NPI

CG Stress

NPI

I

UC

P=0.012

P=0.003

Callahan, Boustani et al, JAMA 2006

0

200

400

600

800

1000

1200

in b

illio

ns

2007

2010

2015

2020

2025

2030

2035

2040

2045

2050

Medicare Spending for People with Alzheimer

Disease

Report of the Lewin Group to the Alzheimer’s Association, 2007

0

3

6

9

12

15

in b

illio

ns

2007

2010

2015

2020

2025

2030

2035

2040

2045

2050

Potential Savings with Collaborative Care

Intervention for People with Alzheimer's Disease

Boustani et al, AAGP Conference 2009



Translational CycleFrom Discovery To

DeliveryBasic science

LabEpidemiology Clinical Observation

Promising Intervention

Clinical trial testing

Approved Intervention

Post-Marketing testing

Guideline Development

System and Provider ImplementationTime: 17 yrs

Cost: $800 millionAD recruitment rate: < 1%

T1

T2 T3

Westfall et al, JAMA 2007; Boustani et al, JCIA 2010

IU Geriatrics

A. Selecting an overall content that is based on a systematic evidence reviewof past research or guidelines.

B. Develop a Reflective Adaptive Process implementation team to

- Localize the content

- Localize and or invent the delivery process

- Monitor the delivery process

- Monitor the system’s members interactions

- Detect emergent behaviors

- Evaluate the impact of the selected change

Selecting a change in a complex adaptive healthcare delivery system

Boustani et al, JCIA 2010

• Vision, mission, and shared values (Standardized Minimum Care).

• Time and space for learning and reflection ($$$).

• Tension and discomfort are essential.

• Diverse improvement teams.

• Supportive leadership.

Stroebel et al, JCJQ&PS 2005; Boustani et al, JCIA 2010; callahan et al, Aging & Mental Health 2010

The Reflective Adaptive Process ofImplementation Science



ABC-MedHome

PCC A & B

ABC-MedHome

?????

ABC-MedHome????????

ABC-MedHome

????????

From “JAMA” to Wishard in less than two years!

www.indydiscoverynetwork.com

Standardized Minimum HABC Care

1. Extend patient definition to family caregiver

2. Adequate diagnosis of emotional and cognitive health

3. Periodic biopsychosocial needs assessment (HABC-Monitor)

Boustani et al, Aging &Mental Health 2010; Boustani, Sachs, Callahan, JGIM 2007



4. Biopsychosocial interventions to prevent or reducecaregiver burden• Routine caregiver time off• Support group• Coping strategies• Knowledge acquisition• Stress management• Crisis management• Self-management tools

Managing dementia disability Navigating the health care system


Boustani et al, Aging & Mental Health 2010; Boustani, Sachs, Callahan, JGIM 2007

5. Biopsychosocial interventions to reduce pt’s disability• Cholinergic neurotransmission enhancement

prescribing cholinesterase inhibitors

decreasing exposure to anticholinergics

• Reducing excitatory insult:

Memantine

• Medication adherence enhancement

• Vascular burden reduction

• Prevention and management of syndromes super-imposed on

dementia (delirium, depression, and psychosis)



6. Care coordination with community resources

• ER and hospital coordination

• Adult day care

• Respite care

• Support groups

7. Modification of the patient’s physical home environment

to accommodate dementia disability





8. An increasing focus on palliative care needs as the

illness progresses

• Advance care planning

• Attentive management of pain and other symptoms

• Avoidance of burdensome and undesired medical treatments

• Discussion of referral to hospice



Variable Mean (SD) Variable Mean (SD)Age 73.8 (9.5) MMSE 21.9(6.5)

Female 67% GDS 10.2 (6.9)

African American 40% Interested in Research 60%

Less than HS education 42% Caregiver Burden 4.0 (4.0)

Caregiver types- Spouse- daughter- other caregivers- None

29%35%18%18%

- Hypertension- Depression- Urinary Incontinence- Diabetes- Cardiac disease

63%55%44%28%26%

Reasons for referral*- Memory problem- Behavioral problem- Physical problem- Other

81%12%6%19%

Cognitive Status- Normal Cognition- MCI- Dementia

14%39%46%

HABC Population

Boustani et al, Aging & Mental Health 2010

The Acute Care Service Utility Domain HABCN=208

PCCN=1009

% patients with at least one ER visit 28% 49%

Total number of ER visits 124 1143

% patients with at least one hospitalization 13% 26%

Total number of hospitalizations 45 438

Mean length of hospital day 5 7

HABC Performance




The Quality of Care Indicator Domain HABC PCC% seen at ER again within one week 14% 15%% re-hospitalized within 30 days of discharge 11% 20%% with at least one order of definite anticholinergics 19% 40%% with at least one order of anti-dementia drugs 55% 13%

% with at least one order of antidepressant drugs 68% 48%% with at least one order of definite anticholinergics and anti-dementia drugs 16% 32%% of patients with LDL < 130 45% 23%% of patients with HbA1c < 8 78% 51%% with last systolic BP < 160 27% 24%

HABC Performance


HABC Potential Savings

• Assumptions Serving 500 pts Using 2008 data Focusing on ER visit, LOS, 30-day re-hospitalization only Personnel cost of $315,000.00 HABC could save > $1,161,000.00 (one million)

• Cost saving $846,000.00• Cost saving per pt = $1,692.00

IU Geriatrics

IU Geriatrics

“Open Access Resource”

http://www.indydiscoverynetwork.org/HABCInitiative.html

“Translating Advances in Dementia Care to the Intermountain West: The MedicalHome and the University of Utah Multidisciplinary Cognitive Disorders Clinic”


TRANSLATING ADVANCES IN DEMENTIACARE TO THE INTERMOUNTAIN WEST:THE MEDICAL HOME AND THEUNIVERSITY OF UTAHMULTIDISCIPLINARY COGNITIVEDISORDERS CLINIC

Norman L. Foster, M.D.Director, Center for Alzheimer’s Care, Imaging and ResearchProfessor, Department of NeurologySenior Investigator, The Brain Institute, University of UtahSenior Investigator, The Brain Institute, University of Utah

Advisory Board / Consultant: GEHealthcare, Janssen Alzheimer Immunotherapy,Bristol-Myers SquibbResearch Grants: NIH, Veteran’sAdministration, Anonymous Foundation, MargolisFoundation, CMSClinical Trials Support: Pfizer, JanssenAlzheimer Immunotherapy, Eli Lilly & Company,Baxter Bioscience

Potential Conflicts of Interest

AD Prevalence 2000 - 2025

Ref: Hebert et al., Neurology 2004;62:1645



AlzheimerAlzheimer’’s Disease will Increases Disease will IncreaseMore in Utah than Any OtherMore in Utah than Any Other

State, in the Intermountain WestState, in the Intermountain WestMore than any Other RegionMore than any Other Region

Ref: Hebert et al., Neurology 2004;62:1645

Quality of Dementia Care –Evidence from RecentResearch

What is Standard Care for Dementia?

● Today, in the Intermountain West, primary carephysicians usually care for patients withdementia unassisted

● Standard care is usually “Default Care”● Doing only what is required or expedient for a

single patient encounter● Responding to problems simply with a

medication change● Diagnosis by intuition “seems like Alzheimer’s”

rather than data-driven diagnosis



“Default Dementia Care”

● Reactive recognition – respond when patientor family voices a complaint●Physician and staff responses make a significant

difference in outcomes●May or may not address issue●Sometimes response is not just benign neglect,

but is damaging● Treatment not guided by specific diagnosis –

drugs given simply to do “something”

Franz et al., Alz Dis Assoc Disord 2007:21:241-8

Evidence “Default” Care” Doesn’t Work

There are real and serious consequences:● Delayed, inconsistent, and inappropriate

treatment● Duplicated and inconclusive studies● Uncoordinated care● Unnecessarily poor quality of life for patients and

families● High prevalence of preventable complications

such as delirium, sleep disturbance, disruptivebehavior, and medication side effects

● Expensive preventable crisesHaley et al., Gerontologist 1992; 32:219-226. Wenger et al., Ann Intern Med 2003;139:740-747

Why “Default” Dementia Care?

● Most primary care physicians are inadequatelyprepared to meet the needs of patients andfamilies unassisted because of:●Lack of training●Lack of inclination● Inadequate practice environment

● Even though primary care physicians want todo what is best for their patients, they fail toallocate adequate time for dementia care

Hinton et al., J Gen Intern Med 2007;22:1487-92



Informal Survey of PCPs(2nd Annual Cognitive Health Conference, Jackson, WY)

AUDIENCE SURVEY●How Much Time is Needed to

Evaluate a Patient with MemoryLoss?●15 minutes - 2 people●30 minutes - ~50%●>30 minutes - ~50%

Informal Survey of PCPs(2nd Annual Cognitive Health Conference, Jackson, WY)

● Their visit times are inadequate for memoryassessments. Their explanations:

● Peer pressure to see more patients● Pressure of seeing all patients needing care● Financial pressures●Short visits better reimbursed●Facility fees reimbursed per visit, not by time

● Institutional requirements●Family medicine residency by 3rd year expects

10-12 patient visits per half day, irrespective ofcomplexity

Two Minute Mental Health Care for theElderly

● Videotape interaction of patients with primarycare physicians

● 385 visits of 366 elderly patients with 35doctors

● Mental health topic arose in 22% of visits,although survey showed 50% of patients haddepression

● Median of 2 minutes spent addressingmental health (both patient and physicianverbal interactions)

Tai-Seale et al., JAGS 2007: 55: 1903-1911.



Hidden Unreimbursed Costs ofInadequate Visit Times

● More calls and crises● More prescriptions and more medication

adjustments● Bad public relations; patient and family

dissatisfaction● Lower provider satisfaction and comfort● Discourages visits of patients with chronic

disease, particularly dementia (explicit cherrypicking and subliminal or implicit choices)

The Role of Primary CarePhysicians and Subspecialistsin Memory Disorders

21st Century Dementia Care

● Early recognition - looking for mild problems andknowing when they are significant

● Identifying the specific cause of cognitive problemsusing (high quality) data-driven diagnosis

● Intervening early, when it is most effective● Assessing risk to prevent complications and crises● Supporting and guiding patients and their families to

make necessary life adjustments● Educating families so they become effective partners in

providing care● Coordinating care with all providers



Lessons from Streamlining andTargeting Referrals

● Review consultations to determine urgencyand appropriateness based upon providedcriteria; may discuss with referring physician

● Unrecognized depression is a major reason forreferrals and cause of memory disturbance(~30%)

● Inadequately addressed psychiatric disease iscommon and difficult to overcome

● Primary care providers often don’t examinememory in patient with memory complaints

The Patient-Centered MedicalHome and Collaborative Care

From Chaos to Team-Based Medicine

DeCapo Press, 2002

Former CEONon-ProfitKaiser-Permanente Health Care

Collaborative CareSpecialized TeamsWorking with PCPs



Need for Collaborative Care: ExampleStroke Prevention

● 1/3 of stroke survivors will have another strokewithin 5 years

● 501 patients hospitalized for acute stroke in 4urban hospitals, medical records reviewed

● Nearly all had ECG and brain imaging, 75%carotid studies and 70% lipids

● Complete inpatient evaluations 46% whites,38% Hispanics, 33% blacks; 46% men, 34%women

Tuhrim et al., J Stroke Cerebrovasc 2008;17:226-234

Need for Collaborative Care: ExampleStroke Prevention

● Appropriate discharge regimen in 60% whites,57% Hispanics, 41% blacks

● Adequate outpatient follow-up only in 33%whites, 37% Hispanics, 18% blacks

● At 6 months follow-up adequate preventivemeasures being used in 33% whites, 37.5%Hispanics, 17.4% blacks

● Conclusion: Better coordination of inpatientand outpatient care is key!

Tuhrim et al., J Stroke Cerebrovasc 2008;17:226-234

Patient-centered Medical Home

● Serves as the central hub for coordinating carefrom all providers

● Physician part of a multidisciplinary team thathelps the patient navigate the complex healthsystem

● Communication is facilitated by a healthinformation exchange through electronicmedical records

● Patient-centered education and empowerment● Pioneered in the 1970s for coordination of

care for special needs childrenLarson JAMA 2010;303:1644-1645.



Advantages of Medical Home

● Primary Care – able to provide all medicalneeds, obtaining consultations when needed

● Principal Care – provides all the complexneeds of a patient with a condition requiring aspecialist

● Consultative Care – provides evaluation andrecommendations

● Medical Home – reconciles medications,addresses family and social issues, providesimproved access

Kirschner, Chest 2010;137:200-204.Callahan, Aging Ment Health 2010:1-8.

Medical Home and Neurology

● PCMH principles endorsed by the AAN● PCMH “Neighbor” – effectively works in

conjunction with a medical home●Enhanced access, improved communication

● Improve consultant experience●Seeing patients not appropriately referred●Seeing patients without essential information●Having to overbook patients and “no-shows”

● “Neurologists should take ownership as healthsystem engineers”

Bever et al., Arch Neurol 2010;67:1386-1390.

Data we haveavailable and

Surgeries

ReferringPhysician

Diagnosis, ifincomplete

evaluation, then“cause

undetermined”

Thoseattending

visitidentified

Tips on Using Cognitive Disorders Clinic Notes: First Page



Tips on Using CognitiveDisorders Clinic Notes: Exam andAssessment

Detailedmental statusexamination

Interpretationof studies,

not just report

Detailedneurological

examination (notsimply template)

Explanationof findings

and rationale

Tips on Using Cognitive Disorders Clinic Notes: Recommendations

Copysent tofamily Copy sent to

PCP andother

providers

How tocontact us

Explicitfollow-up

plans

Some forPCP toaddress

Some forfamily toaddress

Some weare

ordering

Critical Pathway for DementiaCare and Proactive Care



Diagnosis and Drugs are Only theBeginning in Patient-Centered Care

Independent Home Care Institutional

Care

Institutional Care

Independent NeedsSupervision

Completely DependentLevel ofDependency

Duration(in years)

Level of Care

1 2 3 4 5 6 7 8 9 10Onset

$3,000

$150,000

$360,000

Type of Care AffectsCost of Alzheimer’s Disease

EducationPrescriptionwith RiskAssessment



Proactive Management Planof Early Intervention

● Typical issues addressed with dementia-specialist social worker●Broadening caregiver network immediately●Proactive use of respite●Detailed short- and long-term plan for unexpected●Prevent safety risks●Designee for power of attorney●Prepare for living arrangement transitions●Financial resources and future needs

Proactive Management PlanSocial Work Services

● Social work services are set up as anindependent service capable of receivingreferrals from other University physicians andcommunity providers

● CACIR has been successful in lobbying formedical social work services to bereimbursable by Medicare

Critical Pathway for Dementia Care

Early Recognitionand Referral

Diagnostic EvaluationCause and

Contributing Factors

Unified Plan ofProgressive Support

(UPPS)

Drug Treatmentand Management

Risk AssessmentSelf-ManagementEducation (SeME)

Discharge from Regular Care when1. Defined goals met or2. Goals achieved to the extent possible, or3. Evaluation can’t be completed

Available for PhoneConsultation and

Re-referral

Overview



Evidence Clinic Goals Achieved

● Defined, Limited, and Achievable Goals● Goals Explicitly Communicated● Specific Diagnosis● Drug Treatment and Management Plan● Low Risk of Complications● Proactive Dementia Care Milestones Met

Take Home Messages

● The quality of care for patients with dementiais often poor and needs to improve

● Coordinated care in a multidisciplinarysubspecialty clinic can take advantage of apatient-centered medical home and meet thegrowing challenges of treating dementingdiseases

● Early, proactive dementia care has thepotential to improve outcomes

•• Refer Patients OnlineRefer Patients Online(through the Clinical(through the ClinicalNeurosciences Center)Neurosciences Center)

•• Who & When to ReferWho & When to Refer

•• Calendar of LocalCalendar of LocalCME, ConferencesCME, Conferencesand Activitiesand Activities

•• For Patients:For Patients:•• Useful Links andUseful Links and

CommunityCommunityResourcesResources

•• Online Registry forOnline Registry forMemory and AgingMemory and AgingResearchResearch

Visit Our Website:www.utahmemory.org

“The Cognasium Approach: Improving Dementia Care by Facilitating aPartnership of Disease Recipient, Caregiver and Physician” – Sylvia Brunisholz,

LCSW, CMC, Nick Zullo, MPA, MC, Sonnie Yudell, BS

The The CognasiumCognasiumApproach: ImprovingApproach: Improving

Dementia Care byDementia Care byFacilitating aFacilitating a

Partnership of DiseasePartnership of DiseaseRecipient, CaregiverRecipient, Caregiver

and Physicianand Physician

The CognasiumThe CognasiumApproachApproach

Presented by Sylvia Presented by Sylvia BrunisholzBrunisholz, Nick , Nick ZulloZullo and and SonnieSonnie YudellYudellAlzheimerAlzheimer’’s Association Utah Chapters Association Utah Chapter

1. Do ederly people prefer watching TV or browsing Internet?

Gymnasium for the BrainGymnasium for the Brain

Popular with pre-clinical seniorPopular with pre-clinical senioradults for whom Alzheimeradults for whom Alzheimer’’s iss isgreatest health worrygreatest health worry

Basis for Brain HealthBasis for Brain HealthWorkshopsWorkshops

Nutrition, exercise, cognitionNutrition, exercise, cognitionand socialization may impactand socialization may impactAlzheimerAlzheimer’’s risks risk

The Cognasium Approach:The Cognasium Approach:Improving Dementia Care byImproving Dementia Care byFacilitating aFacilitating aPartnership of DiseasePartnership of DiseaseRecipient, Caregiver andRecipient, Caregiver andPhysicianPhysician

Phase 1 CognasiumPhase 1 Cognasium


Applicable to Early StageApplicable to Early StageAlzheimerAlzheimer’’s Patientss Patients

Including persons with MCIIncluding persons with MCI

Based on an individualizedBased on an individualizedCognasium Plan (ICP)Cognasium Plan (ICP)

Dyadic approach withDyadic approach withcaregiver - also supportscaregiver - also supportscaregiver self-efficacycaregiver self-efficacy

Phase 2 CognasiumPhase 2 Cognasium




Cognasium defeats nihilismCognasium defeats nihilism

Families come to theFamilies come to theAlzheimerAlzheimer’’s Association ands Association andlearn to copelearn to cope

The Caregiver / Care RecipientThe Caregiver / Care Recipientdyad is in disarray dyad is in disarray –– roles are roles areredefinedredefined

Communication with primaryCommunication with primarycare physician has been minimalcare physician has been minimal

CognasiumCognasium


Scene from “Diminished Capacity”

Provides a redirectionProvides a redirectionapproach for the home-approach for the home-dwelling disease recipientdwelling disease recipient

Is proactive, de-emphasizesIs proactive, de-emphasizesstress-burden, addressesstress-burden, addressescaregiver needscaregiver needs

Provides information usefulProvides information usefulto primary care physician to primary care physician ––assessments and actionassessments and actionplansplans

CognasiumCognasium


Cognasium Outcome: Links medicaland community-based services

PhysiciansPhysicians appear to be more comfortable appear to be more comfortablemanaging the medical components (e.g.,managing the medical components (e.g.,ordering tests, or discussing and prescribingordering tests, or discussing and prescribingmedications)medications)

They They have have inadequateinadequate knowledge about knowledge aboutcommunity resources and behavioralcommunity resources and behavioralmanagement to provide optimal care formanagement to provide optimal care forpatients with dementiapatients with dementia

The medical communityThe medical community and Alzheimer's and Alzheimer'sChapter operate independently in parallelChapter operate independently in parallelsystems, with little communication orsystems, with little communication orcollaboration.collaboration.

ProblemProblem……


Cognasium Goal: Orient primarycare physician to community-based services



But what about the other member of the AlzheimerBut what about the other member of the Alzheimer’’s dyad?s dyad?

Caregiver ImpactsCaregiver Impacts

Some caregivers have little Some caregivers have little emotional difficulty emotional difficulty

More than 40% have high More than 40% have high emotional stress emotional stress

About 1/3 have symptoms of About 1/3 have symptoms of depression depression

Caregiver stress is related to nursing home placement,Caregiver stress is related to nursing home placement,but caregiver stress is often just as high after nursingbut caregiver stress is often just as high after nursinghome placementhome placement

Cognasium Objective: Caregiver Intervention

What aboutWhat aboutAlzheimerAlzheimer’’s Caregiver Impacts?s Caregiver Impacts?

Compared with other unpaidCompared with other unpaidcaregivers of people withcaregivers of people withAlzheimerAlzheimer’’s and others and otherdementiasdementias

● Are more likely to report fair Are more likely to report fairor poor healthor poor health

● Are more likely to say that Are more likely to say thatcaregiving made their healthcaregiving made their healthworseworse

There areThere are

Factors that Worsen the ImpactFactors that Worsen the Impactof Alzheimerof Alzheimer’’s Caregivings Caregiving

Behavioral symptoms of the care recipientBehavioral symptoms of the care recipient

Co-existing medical conditions of the care recipientCo-existing medical conditions of the care recipient

Lack of perceived help from other family members andLack of perceived help from other family members andfriendsfriends

Belief that one has no choice about caregivingBelief that one has no choice about caregiving

Many personality characteristics of the caregiver andMany personality characteristics of the caregiver andthe care recipient and their prior relationshipthe care recipient and their prior relationship



The reality ofThe reality ofAlzheimerAlzheimer’’s Caregiver Impactss Caregiver Impacts

Many AlzheimerMany Alzheimer’’s/dementia advocates say that 40%,s/dementia advocates say that 40%,50%, 60% of caregivers dies before their care50%, 60% of caregivers dies before their carerecipientrecipient

There is no data to support that statementThere is no data to support that statement

One study of caregivers One study of caregivers in generalin general found that found thatcaregivers who were experiencing strain were 63%caregivers who were experiencing strain were 63%more likely to die than non-caregivers; over 4 years,more likely to die than non-caregivers; over 4 years,about 17% of the caregivers died compared withabout 17% of the caregivers died compared withalmost 11% of the non-caregiversalmost 11% of the non-caregivers

In our own state:In our own state:AlzheimerAlzheimer’’s Realities in Utahs Realities in Utah

In 2010, there were 32,000 persons with AlzheimerIn 2010, there were 32,000 persons with Alzheimer’’ssdisease in Utah (70% of all dementias)disease in Utah (70% of all dementias)

Utah will experience a 127% growth in AlzheimerUtah will experience a 127% growth in Alzheimer’’ssprevalence from 2000 to 2025, highest in the nationprevalence from 2000 to 2025, highest in the nation

There are 101,000 Utah dementia caregiversThere are 101,000 Utah dementia caregivers

They provided 115 million hours of unpaid careThey provided 115 million hours of unpaid care

This care was valued at $1.3 billionThis care was valued at $1.3 billion

According to 2010 Facts and Figures Report, reported to Congress in May, 2010

What caregivers tell us:What caregivers tell us:Top 10 Caregiver DilemmasTop 10 Caregiver Dilemmas

Why do AlzheimerWhy do Alzheimer’’s Caregivers reach out for help?s Caregivers reach out for help?A recent survey of Helpline calls, revealed the Top 10A recent survey of Helpline calls, revealed the Top 10Caregiver dilemmas Caregiver dilemmas (regarding the Alzheimer(regarding the Alzheimer’’s loved one)s loved one)

● 30% wanted to know, 30% wanted to know, ““Is it AlzheimerIs it Alzheimer’’ss??”” (What are(What arethe signs and symptoms?)the signs and symptoms?)

● 16% wanted to know how to get help caring for a 16% wanted to know how to get help caring for aloved one at homeloved one at home

● 11% wanted help due to burnout 11% wanted help due to burnout

● 11% needed help finding a diagnosis 11% needed help finding a diagnosis

● 9% were seeking help with disturbing behavior 9% were seeking help with disturbing behavior



Top 10 Caregiver DilemmasTop 10 Caregiver Dilemmas

Helpline survey continuedHelpline survey continued……

● 8% said they could not handle care at home 8% said they could not handle care at homeanymoreanymore

● 5% were seeking help with coping skills 5% were seeking help with coping skills

● 5% were in crisis and needed emergency help 5% were in crisis and needed emergency help

● 3% had questions about legal and financial issues 3% had questions about legal and financial issues

● 2% needed help dealing with family conflict 2% needed help dealing with family conflict

22% of Helpline callers22% of Helpline callerswere seeking a new physicianwere seeking a new physician

In 2009, over a 7-month survey period, 22% of callersIn 2009, over a 7-month survey period, 22% of callerswere seeking a primary care physician interested inwere seeking a primary care physician interested intreating cognitive impairmenttreating cognitive impairment

● because they were seeking care primarily for because they were seeking care primarily forcognitive impairment or were re-locatingcognitive impairment or were re-locating

● because they were dissatisfied with the cognitive because they were dissatisfied with the cognitivecare of their current physiciancare of their current physician

Little is known byLittle is known bysome physicians aboutsome physicians abouthow Alzheimerhow Alzheimer’’ssChapter servicesChapter servicesprovide advantagesprovide advantagesto care by supportingto care by supportingthe caregiver andthe caregiver andcare recipientcare recipient

These services are offered withoutThese services are offered withoutmaking the PCPmaking the PCP’’s role more complexs role more complex


Cognasium Goal: Link medical andcommunity-based services

HelplineCare Consultation



Yet physicians seek such servicesYet physicians seek such servicesNational Survey of PhysiciansNational Survey of Physicians

Physicians listed these unmet needs in caring forPhysicians listed these unmet needs in caring fordementia patients dementia patients (a variety of management needs not available for(a variety of management needs not available forpatients/caregivers through traditional medical practices)patients/caregivers through traditional medical practices)::

● More support of families of patients More support of families of patients

● Support groups, case management, financial Support groups, case management, financialmanagement management (we call it (we call it ““financial emotionsfinancial emotions””))

● Instrumental support, homecare services Instrumental support, homecare services(transportation and shopping)(transportation and shopping)

● Identifying appropriate living situations Identifying appropriate living situations(assisted living, long term care setting and treatment)(assisted living, long term care setting and treatment)

National Survey of PhysiciansNational Survey of PhysiciansContinuedContinued……

Physician listed these unmet needs in caring forPhysician listed these unmet needs in caring fordementia patients dementia patients (specific needs regarding patient safety were(specific needs regarding patient safety werementioned)mentioned)::

● Safety Safety (of living situation), home assessments,(of living situation), home assessments,respite or backup care, dispensing of medications,respite or backup care, dispensing of medications,unsafe drivingunsafe driving

● Help with patient wandering and dementia abuse Help with patient wandering and dementia abuse

● Psychiatric help available as rapidly as needed Psychiatric help available as rapidly as needed

● Concern about helpfulness of Adult Protective Concern about helpfulness of Adult ProtectiveServicesServices

Before CognasiumBefore Cognasium……These physicians estimated that about 40% of theirThese physicians estimated that about 40% of theirpatients were above age 65 and about 10% of theirpatients were above age 65 and about 10% of theirpatients had cognitive impairment, Alzheimerpatients had cognitive impairment, Alzheimer’’s disease,s disease,or another form of dementiaor another form of dementia

One physician stated, “We have not referred anypatients; it's usually family members who find theseresources. We do not know of much.”

Another physician stated, “I think what they do is givefamilies some information and resources for daycareand nursing homes that have Alzheimer's settings. Idon't know if there is an actual office to go in and gethelp.”



After CognasiumAfter Cognasium……Physicians like the case management of practicePhysicians like the case management of practicepatients provided by the Alzheimerpatients provided by the Alzheimer’’s Associations Association

One physician stated, “We would evaluate the patient, thenneurology, and then the Alzheimer's Association can provide uswith the kind of help that they can provide. So if we can have thephysician, the Alzheimer's Association, and the family sittingtogether in one room it makes things better.”

Another physician described the ideal Alzheimer’sAssociation partnership: “a multidisciplinary network that youcan call on to go to the patient's house, make an assessment, giveus some feedback, and maybe provide a therapist to help the familyadjust and help with medications. [The goal would be] to have ateam that we can rely on and still be able to be in charge of themedical issues.”

Safe environment for anger,Safe environment for anger,shock and tears; hope andshock and tears; hope andsupport is providedsupport is provided

““There is life after diagnosisThere is life after diagnosis””through socialization, exercise,through socialization, exercise,nutrition and cognitivenutrition and cognitivestimulationstimulation

We are We are ““Making Sense ofMaking Sense ofAlzheimerAlzheimer’’ss”” (branded Utah (branded UtahSymphony collaboration)Symphony collaboration)

““Making Sense of AlzheimerMaking Sense of Alzheimer’’ss”” is a branded collaboration with is a branded collaboration withthe Utah Symphony that garnered national attention in 2010the Utah Symphony that garnered national attention in 2010


Activity-Based Dementia CareActivity-Based Dementia CareWhy Cognasium WorksWhy Cognasium Works

It is a form of the It is a form of the ““chronic carechronic caremodelmodel”” Patients (and their Patients (and theirfamilies) become more informedfamilies) become more informedand activatedand activated

Interventionists are moreInterventionists are moreproactive, which should result inproactive, which should result inimproved clinical and functionalimproved clinical and functionaloutcomesoutcomes

Intervention with caregiverIntervention with caregiverresults in improvedresults in improvedneuropsychiatric symptomsneuropsychiatric symptoms





Cognasium is a day retreat program forCognasium is a day retreat program forpersons with Alzheimerpersons with Alzheimer’’s and others and otherdementiasdementias

Participants have varying MMSE scoresParticipants have varying MMSE scoresbut socialize and support each otherbut socialize and support each other

Impacts on home environment Impacts on home environment –– less lessbehaviors, increased caregiver well-behaviors, increased caregiver well-being, delayed institutional placementbeing, delayed institutional placement

LTC placement by plan, not crisisLTC placement by plan, not crisis



Music and dementia care Music and dementia care –– annual annualcollaboration with the Utah Symphonycollaboration with the Utah Symphonyand Utah Operaand Utah Opera

Visual arts in dementia care Visual arts in dementia care –– engenders engenderssocialization and gives family members asocialization and gives family members anew appreciation for the patientnew appreciation for the patient’’s values valueand quality of life needsand quality of life needs

““I Remember Better When I PaintI Remember Better When I Paint””

““Meet Me at MoMA coming to Salt LakeMeet Me at MoMA coming to Salt Lake(Utah Fine Arts Museum and CACIR)(Utah Fine Arts Museum and CACIR)



Movement and dance in dementia care Movement and dance in dementia care ––Art Access funded by KennedyArt Access funded by KennedyFoundation emphasizes dance as aFoundation emphasizes dance as ameans of reminiscence therapymeans of reminiscence therapy

Cognitive stimulation Cognitive stimulation –– learning a foreign learning a foreignlanguagelanguage

Some dyads are utilizing Mind-BodySome dyads are utilizing Mind-BodyBridging program as part of their ICPBridging program as part of their ICP’’ss

This spring, Wheeler Farm excursionsThis spring, Wheeler Farm excursions

Presented by Sylvia Brunisholz, Nick Zullo and Sonnie YudellPresented by Sylvia Brunisholz, Nick Zullo and Sonnie YudellAlzheimerAlzheimer’’s Association Utah Chapters Association Utah Chapter





We have a long way to go yet inWe have a long way to go yet inUtahUtah……

In the area of communication with physicians, theirIn the area of communication with physicians, theirpreferences include:preferences include:

● a a standardized referral form with check boxes for physiciansstandardized referral form with check boxes for physicianswould be the best approach. Forms that could be faxed to thewould be the best approach. Forms that could be faxed to theAlzheimerAlzheimer’’s Association with information about age, insurances Association with information about age, insurancecoverage, and a checklist of requested servicescoverage, and a checklist of requested services

● referral telephone calls would be inefficient and should be referral telephone calls would be inefficient and should beused only in urgent casesused only in urgent cases

● physicians desired physicians desired follow-up communication by fax or emailfollow-up communication by fax or emailfrom the Alzheimerfrom the Alzheimer’’s Association after referrals are mades Association after referrals are made..These reports would be considered most helpful if theyThese reports would be considered most helpful if theyincluded assessments conducted by the Alzheimerincluded assessments conducted by the Alzheimer’’ssAssociation staffAssociation staff

Every step we take addresses CAUSE, CURE OR CARE of AlzheimerEvery step we take addresses CAUSE, CURE OR CARE of Alzheimer’’ss

Next Steps in UtahNext Steps in Utah

People + SciencePeople + Science

While Cognasium continues as directWhile Cognasium continues as directpatient interventionpatient intervention……

Utah Chapter will implement 2 evidenceUtah Chapter will implement 2 evidencebased interventions for caregivers overbased interventions for caregivers overthe next 3 years:the next 3 years:

● New York University Caregiver New York University CaregiverIntervention (NYUCI) from SL to St GeoIntervention (NYUCI) from SL to St Geo

● Counseling the Alzheimer Counseling the Alzheimer’’s Caregivers Caregiverto Improve Neuropsychiatric Symptomsto Improve Neuropsychiatric Symptoms(CTAC) from SL to Logan(CTAC) from SL to Logan

Partnerships with physicians, AreaPartnerships with physicians, AreaAgencies, VA and elder care providersAgencies, VA and elder care providerswill be an essential keywill be an essential key

UtahUtah’’s Alzheimers Alzheimer’’s Growth Rates Growth Rate

Source: AlzheimerSource: Alzheimer’’s Facts and Figures 2010, presented to Congress in March, 2010s Facts and Figures 2010, presented to Congress in March, 2010

45% increaseFrom 2000

To 2010

127% increaseProjectedfrom 2000

to 2025

Highest of anystate

Our challenges motivate us



Cognasium: Cognasium: Improving Brain Health forImproving Brain Health forPre-Clinical and Pre-Clinical and QoLQoL Post-Diagnosis Post-Diagnosis

““Honest doc Honest doc –– if I if I’’ddknown I wasknown I wasgonna live thisgonna live thislong, Ilong, I’’d haved havetaken better caretaken better careof myself.of myself.””

Every client, interventionist andEvery client, interventionist andpartner will be invited to developpartner will be invited to developthere own Individualized Cognasiumthere own Individualized CognasiumPlan (ICP) for brain fitnessPlan (ICP) for brain fitness

The compassion to care, the leadership to conquerThe compassion to care, the leadership to conquer

“When the Lord calls me home,I will leave with the greatest optimismfor the future” - Ronald Reagan

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