Primary Dementia Care

EARLY AND TIMELY DIAGNOSIS

Hunter Medicare Local

The University of Newcastle

UnitingCare Ageing

Helga Merl NP

Acknowledgements

• Prof. Dimity Pond University of Newcastle (UoN)

• Dr Bernard Walsh Hunter New England Local Health District

• Hunter Medicare Local Tony Maher, Keith Drinkwater, John

Bailey, Lisa Craig and their teams

• Multidisciplinary Support Committee members

• Research team at UoN

• Research team at Canberra University

• Dr Julian Hughes

• UnitingCare Ageing Tracey Osmond and Sindu Summers

• Australian Govt Department of Health & Ageing

Today

1. Role of Primary Care – GP & NP in Dementia

Care

2. Overview of successful DCRC pilot

3. Results of the “NP Mobile Memory Clinic”

• Can the NP provide early and timely diagnosis

and management, to improve outcomes and

QoL for patients and carer

Who cares for PWD? Primary Care does

332,000 Australians, 1,700 diagnosed weekly [1]

• Approx 55% live in residential care

• 174,000 living in the community [2]

• GPs see 85% of the pop annually (120 million

consults)

• Medical care is provided by GPs RACF &

Community with PNs & NPs increasingly important

role

PC Role - Risk Reduction

5 year delay = reduction of 50%

RCT of giving patients a dementia risk reduction pamphlet

Patients receiving the intervention were significantly more likely than controls to be aware of dementia risk reduction strategies [3]

"If we could delay Dementia until after we died, that would be perfect” Prof. Henry Brodaty.

High risk – Age, Head injury LOC, ETOH & APOE4

Lower RR 1.5 group: Diabetes, Physical inactivity, Obesity, Smoking, Hypertension, Depression

Alcohol in middle age and subsequent risk of MCI

and dementia in old age [4] (a prospective population based study, 1464 persons, 23 years average F/U)

0

0.5

1

1.5

2

2.5

3

3.5

4

Never Low Frequent

E4 absent

E4 present

Odds Ratio (Compared to Never & E4 absent)

Primary Care role

Identification & Diagnosis

• GPs identified 48-67% for mild dementia and 76 – 85% for moderate to severe dementia.

• Australian GPs same rates of dementia

identification as GPs in other countries

• 2012 Newcastle study by Pond, 45% baseline and 65% post intervention of PWD - early – Intervention consisting of audit and two 30 minute visits /

education, screening patients, significantly improving identification rates

The Diagnosis of dementia is the challenge. • GPs lack time, knowledge and skills to

diagnose dementia early. • AMA does not support GPs in this • GPs find it difficult to distinguish Dementia

from Depression • GPs miss 50% of early, 30% of Mod

dementia and poorly refer to services • 3 year plus (37 mths) wait from GP first

report to diagnosis • Double this time if YOD • Double the time taken in many European

countries • Approx 6 000 Hunter residents remain

undiagnosed and unsupported

Identification

Australian GPs are as good as any in the world at identifying people at risk of dementia. • Our GPs identify between

48-67% for mild dementia

• 76 – 85% for moderate to severe dementia

• PN also ID risk –over 75s Health assessment

Diagnosis

Improving GP Identification: 2012 Pond UoN • 45% baseline and 65% post intervention

consisting of audit and two 30 min visits / education, screening patients, significantly improved identification rates

Why Diagnose Early ?

Consumer and carer groups prefer a diagnosis of

Dementia early in order to improve QoL and health

outcomes including;

• Identification and treatment of reversible causes

• Medical treatment and management

• Information and education – LWMLP

• Advance Care Planning

• Carer support - 47% mental ill vs 7% other {BB]

• Mobilisation of services and other supports

• BPSD management [5]

The role of the GP - QoL

• Satisfaction with GP communication was positively associated with psychological QoL in the dementia group and all domains in the non-dementia group.

• Participants in the dementia group who had been given a diagnosis of a memory problem had significantly higher physical and environmental QoL. [6]

Impact - GPs average 20 deaths per

year

organ failure 6

cancer 5

Dementia / frailty 7-8

sudden death 1-2

PC- End stage Rx is difficult

• One of the most challenging groups within palliative care (National Palliative Care Strategy pg 6)

• Prolonged trajectory

• Co morbidities may hasten death

• Rx complex due to medical, cognitive, emotional, ethical and social considerations

Current reality

76% of people who die from dementia do so in RACF or hospital

Most common symptoms are pain (64%) and breathlessness

then constipation, nausea, loss appetite.Similar to CA but experienced symptoms longer.

• 25 % received no analgesics

• Only 15% had analgesics in previous 24 hours.

Aside: Cog. Intact people receive 3 x the opiods that PWD do post op. [7,8]

Nurse Practitioner

Mobile Memory Clinic

Project Partnership

The UoN and HML partnered a successful application for one of the

DoHA funded Aged Care NP Models of Practice projects 2012-2014.

The University of Newcastle

The University of Canberra

National project aims to:

1. Demonstrate effective,

economical &

sustainable MoP;

2. Facilitate the growth of

the aged care NP

workforce;

3. Improve access to

primary health care.

Assess costs,

requirements and financial

sustainability &

effectiveness

Hunter project aims to assess

Role in PC for diagnosis, care,

Integration

• Collaboration & GP

preferences,

• Assessment, differentials,

testing, diagnosis, follow

up and referral,

• Communication,

• Carer assessment &

involvement

Project lead Professor Dimity Pond

“NP Mobile Memory Clinic”

Implementation

• GP surgery recruitment

• Target geographical regions of most need

• DACNP, UoN team & PCLO - meet and greet session

• PN & GP, Connecting Care, Specialists

• Develop resources and share info

• Clinical pathway – diagnosis & management

• Business case

• Electronic referral form – best practice, MD

• Education

• Formal evening dinners & education calendar

• Feedback

• Report to GP, PN, CC, client/carer

• Case conference

KGOWS - Age adjusted Rate - ALL 60+ 21% (4)

Australia 60+ 6.8% (2)

KGOWS

Australia

Age 60-64 65-69 70-74 75-79 80+ Total

10

50

40

30

20

%

Referring agents, GPs, PNs, CC &

Aboriginal Health workers

Dementia Rate = 3 x non-Indigenous rate of 6.8% Dementia affects Indigenous Australians at earlier age 45yrs and 69 yrs [1]

Dementia Prevalence by Age Group

Flyer to recruit aboriginal people to the Memory Clinic

“Mobile Memory Clinic”

Dementia NP Role

• Comprehensive assessment

• Physical, cognitive, functional, QoL & pain

CamCog, GAI, CSDD, QoL AD,

• Investigations for differential diagnosis

• Carer assessment

• Informant questionnaires,

e.g. CBI-R, Zarit, DASS 21, QoL

• Medication review and prescribing

• Referral to health practitioners

• 6 week follow up Advance Care Planning

• Care planning

• Service liaison to ensure PCC

• Recommendations to GP

• driving

• case conferences;

• 75 years or older (n=1059)

Results. • Approx. 60% of the dementia group (n=87) and

40% of the non-dementia group (n=972) were on at least one anticholinergic drug.

• The dementia group was exposed to a significantly

greater anticholinergic load (determined by level)

(1.47±0.20 vs 0.75±0.04; P<0.001). anticholinergic load adjusted for dose significantly higher in the dementia group (1.70±0.28 vs 0.90±0.06; P<0.005).

Anticholinergic load in community dwelling elderly Australians with dementia Kerr, Mate, Williams, Pond & Magin 2013.

HMR recommendation

by Dementia NP common to assess anticholinergic load.

Medication review

Pharmacist $194.07

Case Conference

Item 735 15m $65.40 Item 739 20m $112.10 Item 743 40m $186.85

Dementia NP, GP & PN discuss assessment recommendations and actions. Note: NP cant charge

ACPlanning – Barrier, no item number

• ID goals

• Choice and control

• Respect = PCC

• Reduce family burden

• Pave the way for a good death

People with End Stage Dementia get more medical intervention and less

palliative care than any other group of terminally ill patients

“For two decades, care in the last year of life has represented over one-fourth of Medicare's

budget.”

Governance

• 10 board members

• 5 elected from the membership, with

no profession having a majority

• 5 skills based nominated by the board

• Membership – individual &

organisational

www.planningwhatiwant.com.au Dr Bauer & Helga

DRAFT CLINICAL PATHWAY FOR DIAGNOSIS, MANAGEMENT AND REFERRAL

EARLY STAGE DEMENTIA – Oct 12

Is cognitive impairment suspected in the older patient, often picked up with the over 75s health assessment? Younger

Onset Dementia is also possible under age 65.

YES

NO

If yes

Corroborative cognitive decline history

Family history of Dementia

Conduct Mini Mental Assessment

Assess for depression eg use Geriatric Depression Scale

Conduct physical examination.

Review of medications including OTC, illicit drugs and alcohol.

Check FBC, ESR/CRP, UEC, LFT, Ca, Phosphate, B12, Folate, TSH, BSL, lipids

Brain CT non contrast

ECG – exclude conduction defect

Capacity assessment including fitness to drive.

Carer support issues

Consider monitoring / support services

Discuss Advance Care Planning e.g. Enduring Power of Attorney, Enduring Guardianship & Advance Care Directives.

Is diagnosis complicated by multiple co-

morbidities with difficult to control symptoms or does diagnosis need to be confirmed for trial of

the cholinesterase inhibitors? If yes

Refer to Dementia

Nurse Practitioner Fax: 49252268

For assessment, diagnosis, capacity assessment and

management planning support.

Are cholinesterase inhibitors prescribed in consultation with a specialist?

If yes Consider Home Medication Review (HMR) and

dosage administration aid

Service support referrals: The Nurse Practitioner can advise the PN and GP on appropriate service referral and refer to a range of support services e.g. Community Dementia Nurse for comprehensive ACAT assessment, episodic case management, education, support and links to other services; DBMAS for behaviour management and DAS for Carer Stress. Contact Referral Information Centre (RIC) 4925 7990.

If other causes excluded

Consider other causes eg depression, delirium, CVA

Is additional support required for assessment, diagnosis and management?

If yes

Refer to Geriatrician: Fax

49246006 Neuropsychiatrist: Fax

40335606 For assessment, diagnosis and management planning

support.

PN & GP phone advice and consultation:

The Dementia Nurse Practitioner

For assessment, diagnosis, management

planning and referral support.

Phone: 0407 959 986

Office Hours Mon-Frid

Is this a gradual change?

CLINICAL PATHWAY FOR DIAGNOSIS, MANAGEMENT AND REFERRAL DEMENTIA NP Mobile Memory Clinic

Llllllllllllllllllllllllllllllllllllllllllllllll

DRAFT CLINICAL PATHWAY

FOR DIAGNOSIS, MANAGEMENT AND REFERRAL

EARLY STAGE DEMENTIA – Oct 12

FOR YOUR INTEREST

Common causes of reversible confusion and memory loss

n Medications with adverse effects on cognition n Chest, urine and other infections n Depression n Thyroid problems n Unstable blood sugar levels, prediabetes or diabetes n B12 & folate deficiency n Electrolyte disturbances n Hypercalcaemia n Anaemia n Alcohol or other drug overuse

n Hypoxia n Malnutrition n Renal failure n Intracerebral lesions (e.g. normal pressure hydrocephalus)

Most common & recommended tests to find reversible causes of confusion and

memory loss. (Please fax results if available to 49252268)

n FBC n ESR n CRP n renal function & electrolytes

n liver function n TSH n fasting blood glucose n serum calcium & phosphate n serum B12 & folate levels n brain CT scan without contrast n CXR (if possible delirium) n MSU n If warranted STS n If warranted HIV testing (don’t fax this result through)

Other investigations: ECG to rule out conductive defects if a trial of cholinesterase inhibitors is warranted in the future

Client (N=61)

Gender

Female 57.4%

Male 42.6%

Diagnosis Age Range 50-93 Gender

Dementia 19 or 31.1% Mean age 79.9 F 68% M 32%

NoDementia 42 or 68.9%

Mean age 75.4

F 52% M48%

Cam Cog Total 105 Memory 37 Language 30

Mean 80.55 18.3 24.8

Range 40-98 3-26

17-29

Other tools Depression CSDD 38 Anxiety GAI 5 QoL AD – Dementia 52 QoL AD – NoDementia CBI & MM

Mean 7.3 2 36.6 34.4 MM 24.6 ND 26.6 D 20.3

Range 0-23 0-5

Carer (N = 22)

Gender

Female 85.5%

Male 14.5%

Age in years Mean 64.7

Range 47-78

WHO QoL 100 Physical Psych Social Environ

Mean 55 65 60 79

Range 29-75 46-96 8-100

56-100

Other tools ZBI 88 Brief Cope

Mean 18 D=20 ND=17.8

Range 0-47

NP Mobile Memory Clinic Results

Postal surveys back to date

• recommend the service,

• liked it a lot,

• assessment useful and

• that the NP “was nice”.

Results

Current Model of Primary Dementia Care

GPs recognize the limits of the cure

paradigm and articulate a caring, more

holistic model that addresses the

psychosocial needs of dementia patients.

However, this is difficult to uphold due to

time constraints, emotional burden, and

jurisdictional issues. Thus, the “care” model

remains secondary and temporary [9].

Future - Conclusion

• Early and timely dementia is possible

• We need to assist GPs and Primary

Care to make this happen

• Dementia Nurse Practitioners can

make a difference in this space

• Medicare Locals can provide the base

for DACNPs nationwide

• Funding is key

Email; hmerl@unitingcarenswact.org.au

Questions?

Thankyou

References

1. Australian Institute of Health and Welfare (2012) Dementia in Australia.

2. Australian Institute of Health and Welfare. Dementia among aged care residents, May 2011.

3. Millard, Kennedy, Baune, & Bernhard (2011). Australian Journal of Primary Health. 17(1), 89-94.

4. (2004). Alcohol drinking in middle age and subsequent risk of MCI and dementia in old age. British Medical Journal

5. Van den Dungen et al (2012). International Journal of Geriatric Psychiatry. 27(4):342-54..

6. Mate K et al 2012. Diagnosis and disclosure of a memory problem is associated with quality of life in community based older Australians with dementia. International Psychogeriatrics

7. Aminoff BZ. Overprotection phenomenon with dying dementia patients. American Journal of Hospice & Palliative Medicine. 2005;22(4):247-248.

8. Chang Esther et al Palliative Care Dementia Interface: Enhancing Community Capacity Project Final Report Sydney West Area Health Service May 2006

9. Apesoa-Varano, Barker & Hinton (2011). Curing and caring: the work of primary care physicians with dementia patients. Qualitative Health Research, 21(11), 1469-1483.

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• “Dementia in Australia”, AIHW (2012)

• Arkles RS, Jackson Pulver LR, Robertson H, Draper B, Chalkley S & Broe GA 2010. Ageing, cognition and dementia in Australian Aboriginal and Torres Strait Islander peoples: a life cycle approach. A review of the literature. Sydney: Neuroscience research Australia and Muru Marri Indigenous Health Unit, University of New South Wales. http://www.healthinfonet.ecu.edu.au/uploads/resources/19517_19517.pdf

• The Koori Growing Old Well Study https://neura.edu.au/research/projects/koori-growing-old-well-study

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