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10/6/2011

1

• S. Liliana Oakes, MD, CMD

• Melissa A. Talamantes, M.S., PHD

Sponsored by

Stanford Geriatric Education Center

in conjunction with

American Geriatrics Society,

California Area Health Education Centers,

12:30 PM Pacific Time

Dementia Assessment, and Family Caregiving Part 1: Latino

October 6, 2011

This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS) under UB4HP19049, grant title: Geriatric Education Centers, total award amount: $384,525. This information or content and conclusions are those of the author and should not be construed as the official position

or policy of, nor should any endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.

California Area Health ducation Centers,

and

Natividad Medical Center

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NatividadMedical Center CME Committee Planner Disclosure Statements:

The following members of the CME Committee have indicated they have no conflicts of interest to disclose

“Dementia Assessment, and Family Caregiving Part 1: Latino”

to the learners: Kathryn Rios, M.D.; Valerie Barnes, M.D.; Anthony Galicia, M.D.; Sandra G. Raff, R.N.; SueLindeman; Janet Bruman; Jane Finney; Tami Robertson; Judy Hyle, CCMEP; Christina Mourad and KevinWilliams.

Stanford Geriatric Education Center Webinar Series Planner Disclosure Statements:

The following members of the Stanford Geriatric Education Center Webinar Series Committee have indicatedthey have no conflicts of interest to disclose to the learners: Gwen Yeo, Ph.D. and John Beleutz, MPH.

Faculty Disclosure Statement:

As part of our commercial guidelines we are required to disclose if faculty have any affiliations or financialAs part of our commercial guidelines, we are required to disclose if faculty have any affiliations or financialarrangements with any corporate organization relating to this presentation. Drs. Talamantes and Oakes haveindicated they have no conflicts of interest to disclose to the learners, relative to this topic.

Drs. Talamantes and Oakes will inform you if they discuss anything off‐label or currently under scientificresearch.

10/6/2011

2

S. Liliana Oakes, MD, CMD

S. Liliana Oakes, MD is an Associate Professor in the Department of Family and Community Medicine, at the University of Texas Health Science Center at San A t i T D O k i th G i t i f ll hi di t f GACAAntonio, Texas. Dr. Oakes is the Geriatrics fellowship director, a former GACA awardee (Geriatric Academic Career Award). As a clinician educator she has expertise in curriculum development and evaluation. She is actively involved in leading the first ACE unit (Acute Care of Elderly) in South Texas to improve the care of hospitalized older adults. One of her passions is interdisciplinary teaching around hospital care topics, effective communication, cross‐cultural competence and teaching palliative care to interdisciplinary teams. Her funded research also has focused on caring for patients and families coping with Alzheimer’s disease and on developing culturally competent care for Hispanic elders and theirand on developing culturally competent care for Hispanic elders and their caregivers (Alzheimer’s Association and TARC). Dr. Oakes has a define role as a mentor for fellows, residents and students assisting with curriculum development, and educational faculty development. She is a native of Bogota Colombia.

MELISSA A. TALAMANTES, M.S., PHD

Dr. Talamantes currently is a Palliative Care Psychology Fellow at the South Texas Veterans Health Care Administration (STVHC). She completed her Psychology i t hi i P h l ith i l h i i G h l t th STVHCinternship in Psychology with a special emphasis in Geropsychology at the STVHC. She has Master’s degree in Gerontology and has research and practice expertise working with Mexican American elderly and their caregivers. Her current research project involves developing a dissemination plan for the Cuidando con Respeto Spanish and English language caregiver training program. Prior to internship and postdoctoral training Dr. Talamantes conducted research in the Department of Family and Community Medicine at University of Texas Health Science at San Antonio. Her other research interests include, Palliative Care and End of Life Issues and Intimate Partner Violence with Older Couplesand Intimate Partner Violence with Older Couples.

10/6/2011

3

Thank You for Participating!

2011OCT

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10/5/2011

1

S Lili O k MD AGSF CMDS. Liliana Oakes MD, AGSF, CMD

Associate Professor, UTHSCSA

Family and Community Medicine‐Internal Medicine

Geriatrics Division

Stanford Geriatric Education Center

October 6,2011

Objectives Define the “Demographic Imperative” for dementia care and delineate the effects of how aging Baby Boomers are stressing the current support systemsupport system

Investigate the specific effects of Alzheimer’s Disease on the Hispanic

Discuss how physicians and caregivers can best cope with increased caseloads

Outline of the session Overview of the prevalence of dementia in Latinos

Review the etiology of dementia and risk factors in Latinos

R i h di ’ i h i Review the disease’s impact on the community

List pearls and challenges: how to diagnose and educate our Latino community, testing limitations

Review programs meeting the Latino need in relation to dementia

10/5/2011

2

The New York Times

More Alzheimer’s Risk for Hispanics, Studies Find ( October 20, 2008)

Jessica Kourkounis for The New York TimesAfter Antonio Vasquez, 63, in North Philadelphia with granddaughter Alexandra Martinez,learned that he had Alzheimer's, he and his wife moved in with a daughter. More Photos >

Latino with DementiaThe Alzheimer’s Association :

Today, 200,000 Latinos in the United States have Al h i ’ Alzheimer’s

By 2050, Alzheimer’s prevalence in Latinos could reach 1.3 million.

By 2050, total number of Alzheimer’s patients will grow from current 5 million to 16 million.

Census Bureau data 2000

Percent of U.S. Population Over 65 by Race & Hispanic Origin

Adapted from U.S. Census Bureau (2001)

10/5/2011

3

Diversity Among Latino Populations in the United States

Mexico Central America

Courtesy of Dr. Dolores Gallagher‐Thompson, Ph.D., ABPPConsuelo Juarez, Health Educator

South AmericaPuerto RicoCuba

Latino Sub Group Variances

Cultural Traditions

Values

Religions


g

Belief Systems

Dialect

Education

Literacy

Latino Risk Factors

Several factors, many linked to low income or cultural dislocation, may

Hi i put Hispanics at greater risk for dementia, including higher rates of diabetes, obesity, cardiovascular disease, stroke and possibly hypertension.

(NY times, Oct 2008)

10/5/2011

4

Risk FactorsAGE: Prevalence doubles every 5

years 65 + / 47% of persons 85 and older have AD

Hispanics are the fastest growing elderly group in the country

Their life expectancy will increase to age 87 by 2050, surpassing all other ethnic groups in the

United States. Valle, R and Lee. B, Research Priorities in the Evolving Demographic Landscape of Alzheimer’s Disease and Association Dementias. Alzheimer’s Disease and Associated Disorders. 2002. 16(2):S64‐76..

Earlier onset?Earlier Onset of Alzheimer Disease Symptoms in

Latino Individuals Compared

With Anglo Individuals (Clark, Decarli et al)

Latino patients had a mean age at symptom onset 6.8 years earlier (95% confidence interval, 3.5‐10.3 years earlier) than Anglo patients after adjustment for sex, education, or NIA center.

Earlier Onset of Alzheimer Disease Symptoms in Latino Individuals Compared With Anglo IndividualsChristopher M. Clark, MD; Charles DeCarli, MD; Dan Mungas, PhD; Helena I. Chui, MD; Roger Higdon, PhD;Jessica Nuñez; Henrique Fernandez, MD; Mirna Negrón, BSW; Jennifer Manly, PhD; Steven Ferris, PhD;Angelica Perez, PhD; Migdalia Torres, MSW; Douglas Ewbank, PhD; Guila Glosser, PhD; Gerald van Belle, PhDArch Nuero 2005

Risk Factors Education appears to have some protective

effect against Alzheimer’s.

Hispanics have the lowest education levels of any Hispanics have the lowest education levels of any group in the United States.

Approximately one in 10 Hispanic elders has

no formal education.

50% have less than 8 years of educationUS Census Bureau. Educational Attainment in the UnitedStates. March 2000. Detailed Tables.

10/5/2011

5

Risk factorsVascular disease risk factors

Diabetes, Stroke and Hypertension are risk factors for d l i Al h i ' d h d ideveloping Alzheimer's and other dementias

High incidence of DM: 64 % higher than in Non‐Hispanic Whites

Haan, M et al. Prevalence of Dementia in Older Latinos:The Influence of Type 2 Diabetes Mellitus, Stroke andGenetic Factors. JAGS 2003. 51:169‐177. Wu, CC at al.Brain Structure and Cognition in a Community Sample ofElderly Laitnos. Neurology. August 2002. 59(3):383‐391.

Risk Factors DM and HTN contribute more to the dementia in this ethnic group than in European –Americans

% ld i h d i l h DM d HTN i 43% elders with dementia also have DM2 and HTN in this study

APOE allele plays lesser role than in other groups

Haan, M et al. Prevalence of Dementia in Older Latinos:The Influence of Type 2 Diabetes Mellitus, Stroke andGenetic Factors. JAGS 2003. 51:169‐177. Wu, CC at al.Brain Structure and Cognition in a Community Sample ofElderly Laitnos. Neurology. August 2002. 59(3):383‐391.

Research findings on Latinos

Significantly higher incidence of Alzheimer’s in Caribbean Hispanics in Manhattan, independent of co morbidities and education. (Tang X.M,2001)( g , )

Increased incidence of AD in the Latino

population in New York, NY and Houston ,TX compared with Anglo individuals (Gurland, Tang 2000)

10/5/2011

6

Challenges in RecognitionMemory loss seen as part of normal aging

Memory loss seen as mental illness

Memory loss seen as leading to loss of role

Challenges in diagnosis Lack of culturally appropriate diagnostic tools

Not enough professionals with bilingual skills

Academic centers with interest in research, but few opportunities to translate research into practice

Facts…The diagnostic value of common screening instruments is affected by:

Ageg

Education

Language biases

Low sensitivity

Specialized training or equipment

10/5/2011

7

Caution Instruments retain Cultural Bias even when accounting for Age, Education, Gender and SES

Hispanics Tend to Score Lower Than NHW

Translator Use Questionable

Time!

Low vision issues:

small print, fonts with

serif, reverse color text (white on black)

ABC’s: The Key Symptom Domains of Alzheimer’s Disease

Activities of Daily Living

BehaviorCognition

EF Executive Function

ABC’s: The Key Symptom Domains of Alzheimer’s Disease

Activities of Daily Living: ADLs, IADLs

Behavior;

Delusions, paranoia,Halluciantions

Cognition:

MMSE,Mini COG

CLOX

EF Executive Function

10/5/2011

8

MMSE: designInstrument developed in western country

Includes 12 interviewing questions

Covers multiple cognitive domains: orientation, registration, memory, attention, calculation, visual g , y, , ,spatial function, and praxis

Two items are reading and writing dependent (reading and following command‐ “close your eyes”‐ and writing a sentence)

Folstein et al. J Psych Res 12:189, 1975

MMSE

Possible score: 0 to 30

25‐30 for normal

21‐24 for mild AD 4

14‐20 for moderate AD

and less than 13 in severe AD

Folstein 1975, Royall et al,1998

MMSE

What do you think are the limitations of the MMSE?

10/5/2011

9

MMSE

Lack of items that measure Executive Function

Sensitivity 79%

Items dependent in educational level, literacy

CLOX I‐ CLOX II Clock‐drawing tests are relativelysimple / EF

Screening appear less vulnerable to socio‐cultural i flinfluences.

CLOX has been translated into Spanish and validated in multipleelderly populations, including Mexican‐Americans.

Royall DR, Mulroy A, Chiodo LK, et al: Clock drawing is sensitive to executive control: a comparison of six methods. J Gerontol Psychol Sci 1999; 54B:328‐333 Royall DR, Espino DV, Polk MJ, et al: Validation of a Spanish translation of the CLOX for use in Hispanic samples: the Hispanic EPESE study. Int J Geriatr Psychiatry 2003; 18:135–141[

Columbia Center for Active Life of Minority Elders (CALME)

10/5/2011

10

Montreal Cognitive Assessment (MoCA) The MoCA is a brief cognitive screening tool with high

sensitivity and specificity for detecting Mild Cognitive Impairment

Intended for use by busy clinicians

It is free, and translated versions are available free from It is free, and translated versions are available free from website: http://www.mocatest.org (including Spanish)

Clinical Implications: (1) Useful screening tool for the detection of mild AD and MCI –

thus allowing intervention to begin sooner; (2) Useful predictive tool for the development of dementia in

clients with MCI – again, early intervention is then possible. Limitation: May not be sensitive to change over a 6‐month

period – this is still being researched.

Composite 3 item recall and clock drawing

Developed to be administered in older adults from culturally, linguistically and educationally diverse backgrounds

MINI ‐ COG

backgrounds

Minimal language interpretation and training

The mini-Cog:a cognitive “vital sign "measure for dementia screening in multi –lingual elderly. Borson, S. et al. Int J Geriatr Psychiatry 15,1021-1027.2000

MINI ‐ COG

Scoring ‐ normal vs abnormal

Clock drawing test (CDT) normal ‐ abnormal

Subjects recalling none of the words dementedSubjects recalling none of the words ‐ demented

Subjects recalling all three words ‐ non demented

Subjects recalling 1 or 2 words (intermediate) ‐abnormal

10/5/2011

11

Mini‐Cog scoring algorithmMini‐cog

3 item recall = 0 3 item recall = 1‐2 3 item recall = 3

CDT Abnormal CDT normal

Family Role Drives Care

More Complex than pIt Appears

Needs Time!

Family Structure

Multiple generations often live under one roof

Emphasis on whole family inclusion

Nuclear family with large extended family Nuclear family with large extended family

Compadrazo (Godparents) may play a significant role or take on role of caregiver


10/5/2011

12

Cultural Beliefs Associated with Memory Loss

Etiology is often attributed to: Locura (craziness) Nervios (nerves) Punishment from god Poor nutrition Poor nutrition Stress earlier in life

Diagnosis of AD is interpreted as a result of: a family tragedy (Ortiz, Simmons, & Hinton, 1999)

lack of social support (Levy, Hillygus, Lui & Levkoff, 2000)

normal aging (Ortiz, Simmons, & Hinton, 1999; Levy et al., 2000)

Diagnosis is difficult: Few distinctions between physical illness, emotional disorders, and social problems


What is the current and future directions Research and clinical practices

Education and awareness

Professional development

Partnerships

Research opportunities TARC (Texas Alzheimer's Research Consortium)

More academic centers interested in minority interested in minority groups and dementia

More funds to do research in diagnostic tools and treatments

Include more Latinos in research

10/5/2011

13

Clinical practice Aggressive management of the risk factors in mid‐life DM‐ HTN

Addressing health disparities

Screening for dementia? How this looks?

Clinical Practice Offer the current treatments to our Latinos

New treatments :

Targeting the known Start earlier the

Targeting the known neuropathologic hallmarks:

amyloid plaques

tau‐based

neurofi brillary tangles.

treatments when diagnosis is highly suspected vs waiting

An Update on Treatment and Prevention Strategies for Alzheimer’s DiseaseJudith Neugroschl, MD, and Mary Sano, PhD Current Neurology and Neuroscience Reports 2009, 9:368–376

Pathology begin Onset symptoms Loss of ADLs

Death

Mild Cognitive Impairment Mild – moderate AD Severe

55 60 65 70 75 80 85 90

Mild Cognitive Impairment Mild-moderate AD Severe

Normal Prodromic Symptomatic NH

Death

100

Treatment

Courtesy of Dr. Chris Clark

10/5/2011

14

Education and awareness

More media involvement in reaching our community and addressing dementia

For the public

and addressing dementia

More appropriate materials addressing health literacy issues with our Latinos

Empowerment of community partners, caregivers

Education and awarenessHealth Literacy and Cognitive Performance in Older Adults. Sano,M et al. JAGS June 8,2009

Memory and verbal fluency are strongly associated with health literacy independent of education and with health literacy, independent of education and health status, even in those with subtle cognitive

dysfunction.

Reducing the cognitive burden of health information might mitigate the detrimental

effects of limited health literacy in older adults.

Professional Development

More training for health care professionals about dementia and dementia in Latinos

Screening? When ? How? Who?

Establish more partnerships with local networks

10/5/2011

15

Driving retirement or Driving While Demented “DWD” Everyone with dementia must retire from driving, the key is

WHEN

Begin discussion and planning early

Family agreement documents (loss of insight/awareness may interfere))

Observation is key – of driving and car condition

Consider comprehensive on‐road assessment

“The grandchild rule”: If a patient’s children don’t want the grandchildren in the car when the patient is driving, he or she needs to relinquish the keys before hurting someone else’s grandchildren. Gary Kennedy, MD

Sensitivity – giving up the keys is a huge loss

Provide alternatives

The need to plan: legal issues Involve your loved one as much as possible:

KEY Arrangements: Living will (Advance Care Plan) The completion of advanced directives

as an act of family love (minimizing second‐guessing, family conflicts and guilt feelings)

Health Care Agent

Durable Financial Power of attorney

Protection of assets and avoidance of financial losses/ scams/errors

Elder care attorneys may help plan for long term care costs

Participation in research

Consider Hospice

10/5/2011

16

We all need to complete advance directives – for our families’ sake

This is best avoided

“An 80 year old great grandmother makes her wishes absolutely clear”

May 18, 2006© WorldNetDaily.com

PartnershipsAlzheimer's Association:

http://www.alz.org

We Speak Spanish

1.800.272.3900 ‐ Call us anytime for free, confidential guidance and reliable information.

Message Boards‐ Find bilingual support and advice in a caring community.

Partnerships Alzheimer's Association

MedicAlert® + Alzheimer’s Association Safe Return®A 24‐hour emergency response service for wandering and medical emergencies.

Cuidando con Respeto: Dr. Oakes ,Dr. Talamantes et al. UTHSCSA/ AA of California/ AoA grant

Community Centers ; non –profit organizations

Hospices

Home Health Agencies

Multiple reading materials for caregivers

10/5/2011

17

Recommended Readings

The Alzheimer's Action Plan. P Murali Doraiswamy, MD L P G h MSW T Adl MD, L.P. Gwyther MSW, T Adler

The 36 Hour Day (30 years the classic)

Coach Broyles’ Playbook for Alzheimer’s Caregivers: A Practical Tips Guide – offered through www.alz.org

Resources Alzheimer’s Association www.alz.org

1‐800‐356‐5502 Geriatric Mental Health Foundation American Association for Geriatric Psychiatry Alzheimer’s Society Alzheimer s Society ADEAR Alzheimers Disease Education and referral Center of the

National Institute on Aging: www.nia.nih.gov/Alzhimers/ 1‐800‐438‐4380

Family Caregiver Alliance National Center on Elder Abuse National Senior Citizens Law Center United States Administration on Aging TrialMatch (Alzheimer’s Association) http://hartfordauto.the hartford.com

10/5/2011

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From Frank Broyles My best advice to you is to treasure each day and live it to the fullest. Cherish the time you spend together, and perhaps most important, love each other. I hope you find peace in knowing that it is still possible to live and love when someone you love is living with Alzheimer's disease.

Sincerely,Frank Broyles University of Arkansas, Razorback Athletic Director Emeritus

Questions?

Melissa A. Talamantes, PsyDPalliative Care Psychology Fellow

South Texas Veterans Health Care SystemSan Antonio, TX

.

10/5/2011

19

Acknowledgments

Stanford School of Medicine‐Geriatric Education CenterEducation Center

Dr. Dolores Gallagher & Dr. Gwen Yeo

ObjectivesDescribe Latino Caregiving Characteristics & Relevant Research

Present Core Cultural Concepts

Describe Current Caregiver Interventions for Latinos

Demographics

Over 27% of Latino households provide informal caregiving to family member or friend (NAC, AARP, y1997;AoA, 2003)

Latino caregivers, average age 40 and in sandwich generation (NAC, AARP,

1997;AoA, 2003)

10/5/2011

20

Caregivers

Average age of AD caregivers was 49

80% AD caregivers are working

80% of women are between 25‐54 are 5 54working caregivers

27% of Latino households provide informal caregiving

Latina caregivers begin caregiving at earlier age compared to EA caregivers

(Mausbach, et al., 2004; Aranda & Knight, 1997; Alzheimer’s Association, 2011)

Pt Health and Caregiving Research

Health risks increased risk vascular dementia (Han et al, 2003); Higher rates of diabetes leading to complications (Flores diabetes leading to complications (Flores, 2002)

MA caregivers typically do not utilize formal dementia evaluation or make use of available resource until later stages (Neary & Mahoney, 2005; Morano & Bravo, 2002)

Pt Health and Caregiving Research

Studies from H‐EPESE showed that despite increased disability including physical and emotional impairment, elderly MA’s continue to live in the e de y s co t ue to e t ecommunity (Angel, Angel, Aranda, Miles, 2004)

• MA elderly continue to rely on family for support (Angel & Angel, 1998); other studies show MA elderly identified fewer social support networks (Phillips et al, 2000)

10/5/2011

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Psychological Impact

Women had higher levels of burden

or strain than men (Yee & Schultz, 2000).

Depression most important potential d f i adverse consequences for caregivers

(Covinsky, Newcomer, Fox, Wood, Sands, Dane, & Yaffe, 2003, p. 1006).

Predictors for institutionalization:

‐Burden, pt deterioration

Predictors for not placing in NH:

‐Race & Ethnicity (Schultz et al., 2004).

Health Literacy

a person’s understanding of a specific health technical language and its language and its accompanying instructions

.

Disparity in Health Literacy• Minority older adults have lower health literacy skills compared to European Americans.

Over half have 8 years of schooling or less & 1 i L i ld h f l d i in 10 Latino elders has no formal education. (Alzheimer’s Association, 2004)

Latinos are not receiving health care information needed to reduce their risk for dementia and/or to reduce associated CG stress

10/5/2011

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Role of Culture in CaregivingLatino/Hispanic caregivers: higher levels of self‐efficacy compared to EA caregivers

Latina daughters higher self‐efficacy:g g yseeking respiteresponding to disruptive behaviorscontrolling upsetting thoughts about caregiving

(Depp et. al., 2005)

Cultural Competency

The knowledge and interpersonal skills that allows providers to understand, appreciate, and work with individuals from cultures other than their own

It i lIt involves:

acceptance of cultural differences

self‐awareness

knowledge of the patient’s culture

adaptation of skills and changing interventions

Davis BJ, Voegtle KH. Culturally Competent Health Care for Adolescents: A Guide for Primary Health Care Providers.Chicago, IL: American Medical Association, (1994)

Cultural Competence in Service Delivery

Language

Culture

Inclusion of all family not just primary caregiver (e.g. shift care dynamics)

Continuity in Outreach Efforts

Education‐interactive, audiovisual, visual

10/5/2011

23

Acculturation Continuum

Retention of values & beliefs from one’s own

culture

Adoption of mainstream values & beliefs

Valle, 1989

Core Cultural Themes Familismo

Personalismo

Jerarquismo

Espiritismo

Presentismo

Respeto

Table 1. Hispanic/Latino Cultural Themes That Can

Influence Beliefs and Practices Concerning Caregiving

DecisionsTheme Meaning Implications for

Practioners

Familismo Emphasis on the well‐

being of the family

over the individual

Include family

members in pt

care decision‐

making

Source: Adapted from Cuellar (1990) & Perkins, Supik & Hazuda, (1993)

Learn about pts

and culture

Providers should

start discussions

about LTC planning

early in diagnosis

10/5/2011

24

Jeraquismo Respect for Hierarchy Check whether pts

are not just saying

yes out of

deference to

physician

Families might

Table 1. Hispanic/Latino Cultural Themes That Can

Influence Beliefs and Practices Concerning

Caregiving Issues

g

expect physicians,

providers to bring

up education and

resources available

for caregivers


Presentismo Emphasis on the

present, not on future

Can hinder

acceptance of

diagnosis care

planning

Espiritismo Belief in spirits (good

& evil) can affect well‐

Caregivers may

use traditional

Table 1. Hispanic/Latino Cultural Themes That

Can Influence Beliefs and Practices Concerning

Caregiving Issues

being of pt healing practices

to supplement

other medical

interventions

Use of herbal

remedies, spiritual

healers,

curandero (as)


Respeto

Usted Vs Tu

Encourage the asking of questions

Associated with a cultural taboo against expressing negative feelings directly

10/5/2011

25

Use of alternative medicineHispanic patients may bring quite a broad definition of health to the clinical or diagnostic.

“Botanicas, mal de ojo, empasto, culebrilla”

Different Latinos use different interpretations of language, customs, and beliefs

A Primer for Cultural Proficiency: Towards Quality Health Services for Hispanics. National Alliance for Hispanic Health 2001

Traditional Beliefs on Healing

Curanderas (herbal/traditional healer)

Espiritistas (spiritual healer)


Six Approaches for Bridging Language Barriers(most to least effective)

(1) Bilingual/Bicultural

Professional Staff

(2) Interpreters

4) Internal Language Banks

(only as a backup)

(5) Phone‐Based Interpreter (3) Language Skills

Training for Existing

Staff

Services

(emergency back‐up)

(6) Written Translations

A Primer for Cultural Proficiency: Towards Quality Health Services for Hispanics. National Alliance for Hispanic Health 2001

10/5/2011

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Latino Caregiver InterventionsEl Portal

Alzheimer’s Association

REACH I iREACH Interventions

REACH fotonovela

Cuidando con Respeto

Latino Caregiver Interventions

El Portal‐Model Program (Aranda, Villa, Trejo,

Ramirez, Ranney,2003)

Alzheimer’s Association Support ppGroups & Resources (Diversity Tool Kit)

On the Horizon: REACH II Intervention Program

Coping with Caregiving Program

Fotonovela Project 3‐year project (2010‐2012) designed to meet the needs of Latinos with low literacy for health care information

Funded by the national office of the Alzheimer’s Assn‐Collaborators :Dr. Ramon Valle (San Diego State Univ.) and Dr Ladson Hinton (UC Davis)Dr. Ladson Hinton (UC Davis)

Year 1: created the Fotonovela: 20 pages in Spanish & 20 pages English.

Content based on 10 focus groups held with professionals and Latino caregivers in northern and southern CA

10/5/2011

27

Managing Difficult Behaviors Fotonovela

Educational fotonovela is an adaptation of a

popular culture medium used extensively to impart p p y p

health care information

Combines “education” and “entertainment”

Has “vicarious modeling” potential

Specifically targets low‐literacy (6th grade & below)

Hispanics/Latino population

The Jiménez family…

The Storyline… Getting an Alzheimer’s diagnosis

Caregiver in stress, including scenarios like: reacting to a confused grandmother; safety concerns ‐ burning pots and pans; and dealing with a “not quite on board” brother.

Coping StrategiesTh “di t ti ” t h i The “distraction” technique

Seeking support from family, friends, and community resources (i.e. support group, adult day care center

Family meeting mediated by a social worker

Other Information What is dementia?

Tips on taking better care of YOURSELF

Depression checklist

Final Product – new Fotonovela

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CUIDANDO CON RESPETOS. Liliana Oakes M.D.

Melissa Talamantes PsyDJeanette Silva Ross M.D

Cindy Alford PhD

Cuidando con Respeto

Adapted from the Savvy Caregiver Program (SCP), a psychoeducational program for caregivers of persons with dementia in Minnesota

Program develops caregiver skill, knowledge, reduces caregiver burden and distress

Telenovela/Fotonovela SiempreViva—Story of Margarita who begins to have memory decline and her families response

Fotovelas/Telenovelaswere derived from Margarita’s character

Fotonovela’s/Telenovelas depict challenging situations and require open discussion by caregivers and active participation in activities

(Aranda, Siempre Viva, 1989; Oakes, Ross, Talamantes, Espino, 2006)

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Cuidando con Respeto Adaptation incorporated

relevant language & cultural content processes using Novela teaching approach drawn from approach drawn from Siempre Viva (Aranda, 1989)

3 additional mini novelaepisodes depicting a family struggling with AD

Interaction from participating caregivers regarding CG issues

Goals of Cuidando con Respeto To adapt a successful English language caregiver training program (Savvy caregiver Program) for Spanish Speaking Caregivers

To increase caregiver’s knowledge, improve attitudes, and develop knew skills in caregiving

To evaluate the use of the novela (soap opera) style as an innovative teaching method

(Aranda, Siempre Viva, 1989; Oakes, Ross, Talamantes, Espino, 2006)

Culturally Interactive Program

Telenovela

Fotonovela

GamesGames

Videos

Small group activities

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Program Topics

Session 1

Introduction to AD

Effect of AD on Thinking

Effect of AD on Feelings

Session 2

Three Stages of AD (Video)

Strategies for Dealing g

Goal for the Work of Giving Care

Managing Illness Responses

with Daily Care & Complicated Behavior

Self‐Care of caregiver

Partnership with Alzheimer’s Association with funding from Administration on Aging –Evidence Based Latino Caregiver Intervention

Train the Trainer Program

Cuidando con Respeto in California

Train the Trainer Program

Disseminate Training to 300 Caregivers

Formative Evaluations and Qualitative follow up phone contact yielded strongest evidence for effectiveness of the class

Insert Cuidando telenovela

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Culturally Responsive Research & Interventions New Paradigm Shifts‐Compared to applying existing caregiving (EU) models to emphasize the cultural constructs and phenomena relevant to Latino caregiverscaregivers

Challenges‐understanding the cultural influences and how MA and other Latino caregivers understand & cope with AD and dementia

Selected References1. Alzheimer’s Association. (2004). Hispanics/Latinos and Alzheimer’s Disease.

Retrieved November 14, 2008, from http://www.alz.org/national/documents/report_hispanic.pdf

2. Centers for Disease Control and Prevention. (2007). The state of aging and health in America 2007. Retrieved November 14, 2008, from http://www.cdc.gov/aging/saha.htm

3. Family Caregiver Alliance. (2004). Cultural competency in working with Latino 3 y g 4 p y gfamily caregivers. Retrieved November 14, 2008, from http://www.caregiver.org/caregiver/jsp/content_node.jsp?nodeid=1095

4. Gallagher‐Thompson, D. & Coon, D.W. (2007). Evidence‐Based Psychological Treatments for Distress in Family Caregivers of Older Adults, Psychology and Aging, 22, 37‐51.

5. Hepburn, K., Lewis, M., Sherman, C.W., Tornatore, J. (2003). The Savvy Caregiver Program: Developing and Testing a Transportable Dementia Family Caregiver Training Program. The Gerontologist, 43 (6), 908‐915.

Selected References

6. Oakes, Hepburn K, Ross J., Talamantes, M., & Espino, D. (2006). Reaching the heart of the caregiver. Clinical Gerontologist, 30(2) 37‐ 49.

7. Pinquart, M., & Sorensen, S. (2005). Ethnic differences in stressors, resources, and psychological outcomes of family caregiving: A meta‐analysis. The Gerontologist, 45, 90‐106.

8 Talamantes M A & Aranda M P (2004) Cultural competency in working with 8. Talamantes, M.A. & Aranda, M.P., (2004). Cultural competency in working with Latino family caregivers. Monograph in Family Caregiver Alliance, National Center on Caregiving. http://caregiver.org

9. Talamantes, M. A., Trejo, L., Jiménez, D., & Gallagher‐Thompson, D. (2006). Working with Mexican American familias. In G. Yeo & D. Gallagher‐Thompson, D. (Eds.), Ethnicity and the dementias (2nd ed.), 327‐340. New York: Routledge Taylor and Francis Group.

10. US Census Bureau. (2005). 65+ in the United States: 2005. Retrieved November 14, 2008, from http://www.census.gov/prod/1/pop/p23‐190/p23‐190.html

11. Valle, R. (1988). Caregiving Across Cultures. Washington, DC: Taylor & Francis

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PartnershipsAlzheimer's Association:

http://www.alz.org

We Speak Spanish

1.800.272.3900 ‐ Call us anytime for free, confidential guidance and reliable information.

Message Boards‐ Find bilingual support and advice in a caring community.

For Further Information :

For Cuidando con Respeto information contact Dr. Liliana Oakes by email: [email protected] or Dr. Melissa Talamantes at [email protected]

For Fotonovela Project contact Dr. Dolores Gallagher Thompson by email: [email protected]

The National Office of the Alzheimer’s Assn has a 24‐hour helpline: 1.800.272.390 and excellent website: [email protected]

Questions

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