Indianapolis Discovery Network for Dementia Translating PREVENT Into Your Practice Caring for your...

Indianapolis Discovery Network for Dementia

Translating PREVENT Into Your Practice

Caring for your patients with dementia

J. Eugene Lammers, MD, MPHClarian Health Senior Health

for the IDND

www.indydiscoverynetwork.com

The Main Message

• Dementia diagnosis in primary care is a challenge that can be overcome.

• A primary care clinic can implement interventions to improve the symptoms of AD.

• Treatment of AD can help both the patient and caregiver.


• Who do we screen?– Asymptomatic– Symptomatic

• Memory loss,• Functional decline• Non-compliance• Family/social reports


Asymptomatic patient aged 65 and older

Risk Factor profiling:- Age > 75 - First degree relative with dementia- Head trauma- Vascular risk factors

-HTN-DM-Hyperlipidemia-CVA/TIA

At least one risk factors is present

No

Re-evaluate in One year

Yes Fail screening test

Yes

MMSE ≤ 24 (adjusted for age/education)

YesFull Diagnostic Work-Up

Adapted from Boustani & Ham, In Primary Care Geriatrics 2006


Patient with cognitive problems based on patient's, caregiver’s, or physician’s reports

Delirium Assessment

-+Treat delirium + reassess

Dementia diagnostic Work-Up

ReversibleWork-up:CBCMetabolic panel Vit B12TSHSyphilis CT Brain scan

Anticholinergic Burden:

-Re-evaluate indication for Anticholinergic Medications and Discontinue ifpossible

Neurological Examination:-Asymmetrical Finding.-Parkinsonian Sign.

Cognitive Assessment:-Determine prominent deficit domain-Determine pattern of cognitive decline: -Gradual -Fluctuating -Stepwise

Caregiver-basedFunctional Assessment:-I-ADL deficit from Baseline-Occupational deficitfrom baseline-Social deficit from baseline

Adapted from Boustani & Ham, In Primary Care Geriatrics 2006


How do we do this in the office?

• Divide into steps– Step 1 screening– Step 2 focused history and physical– Step 3 medication review– Step 4 diagnostics– Step 5 present diagnosis/initiate treatment


How do we do this in the office?

• Use the nurse/medical assistant in the process• Standardized forms, lab requests etc• Use the telephone


After the diagnosis, what next? Adapted from Callahan et al, JAMA 2006

• Talk with Caregiver about support group, counseling, respite care.

– Learn local resources

– Alzheimer’s Association programs and website

• Detect and modify vascular risk factors.

– Stop smoking, control diabetes, lipids, blood pressure, aspirin

• Decrease anticholinergic burden

– Especially benadryl, elavil, oxybutinin, etc


After the diagnosis, what next?

• Enhance medication adherence• Cholinesterace inhibitors +/- Memantine

– Goal of stability– Use standard handouts for instructions and

side effects– Early follow-up with the nurse/np/pa to

promote compliance



• Detect and treat depression– Can be seen early or late– Responds to treatment

• SSRI first line

• Detect and treat agitation– Non-behavioral if possible– Pain?– Illness

• Uti, dehydration, constipation



• Detect and treat psychosis– Does it really need treatment– Risk of antipsychotics

• Discuss driving and safety issues– Driving eval– Pros/cons of staying home alone– Moving target


Standardized Protocols• Psychological

symptoms– delusions– hallucinations– paranoia– depression– anxiety– misidentifications– disinhibition

Adapted from Austrom et al, Gerontologist 2004


Standardized Protocols• Behavioral symptoms

– aggression

• wandering– sleep disturbances– inappropriate eating– constant questioning– shadowing– amotivation


Handouts available on-line

• http://iucar.iu.edu/research/behavioralprotocols.html


Cases


Summary

• Primary care physicians are able to make important impacts on patients with dementia and caregivers.

• A step-wise, multiple visit approach, utilizing non-physician staff is feasible.

• Using standardized materials from programs such as SUPPORT and the Alzheimers Association can help with management of dementia.

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