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Collaborative Care Model GPs and Specialist Care

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Introduction: Dr Jane Allan MOSS MHSOP 0.3FTE Liaison/clinical advisor at primary/secondary interface TDHB as a demonstration site in the management of Uncomplicated Dementia (no BPSD) using a Collaborative Care Model-GPs ands Specialist Care Part of the Better, Sooner, More Convenient Strategy MOH MHSOP All referrals in category uncomplicated dementia Collated by MHSOP, discussed at MDT MOSS Allocated to MOSS to liaise with primary referrer Provide education, guidance, treatment direction GP Liaison support and education from Older Peoples Health Managing uncomplicated dementia in primary care.

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Scope of the problem Growing aged population Dementia affects 5% of people over 65 20% of people over 80 In 2002 12% of NZ pop > 65 In 2051 25 % of NZ pop > 65 NZ over 40,000 people have dementia Local demographic information?

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Types of Dementia Alzheimers Disease: 50 to 60 % Vascular Dementia: 10 to 20 % Mixed:10 % Lewy Body Dementia: 10 to 20 % Fronto-temporal Dementia:

Survey Results: 44% Response 60% GPs confident diagnosing, informing & referring Less confident in providing treatment, resources & advice, follow up and management in a primary care setting. 80% low confidence re CEM & CT scan interpretation. GPs are keen to have support from specialists: 96% would use E-mail consultation with specialist >80% guidelines, and further resources 71% a phone/e-mail liaison with a specialist MHSOP nurse >50% attend workshop or refer patients/caregiver to group

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Is this memory loss normal? A 65 year old male presents complaining of increased forgetfulness. He is worried that he is developing dementia. What would you do?

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Uncomplicated or Complicated? Assessment Rule out other causes: depression, delirium, red flags Consider performing a memory test A provisional diagnosis Age-related cognitive decline or early stage dementia Make a plan Follow-up, investigations, advice, review, referral

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Rule out other causes for memory loss Depression/Delirium/Drugs Depression Pseudo dementia Commonly causes memory impairment Often co-exists with dementia. Memory selective or patchy, rather than generally impaired. Duration weeks or months rather than gradual decline Screening tool e.g. Geriatric Depression Scale Past History Low energy, anxiety, sleep, appetite, suicidal ideas

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Other Mental Health Problems Anxiety Stress Substance misuse/dependence (alcohol, BZD, opiates) Sleep Disorder

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Medications Sedatives: BZD, zopiclone Analgesics: Opiates, NSAID Anticholinergics: Antihistamines, antiparkinsons; antispasmodics, TCAs, neuroleptics Cardiac: antiarryhthmics, antihypertensives, digoxin Gastro-intestinal: H2 agonists, prochlorperazine, metoclopramide Others: Anticonvulsants, corticosteroids, lithium, antibiotics, SSRIs (serotonergic syndrome)

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Medical Conditions Cerebrovascular disease Neurodegenerative disease Brain tumour and infections Head injury Epilepsy Thyroid disease Malnutrition, vitamin deficiencies Chronic pain

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Consider neurological /medical/surgical referral Patient Less than 60 years History Rapid decline (1-2mths) in cognition or function Unexplained neurological symptoms (severe headache, seizures) Anticoagulants/bleeding disorder History of cancer Family history of neurodegenerative disease e.g. Huntingtons Examination New localising signs Atypical cognitive symptoms or presentation Gait disturbance

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Investigations To rule out potentially reversible factors FBC, LFTs Serum electrolytes, calcium & glucose TSH Vitamin B12 & folate CRP ?Referral for CT/MRI- white matter changes associated with worsening cognitive function (Survey showed 18% GPs are confident in interpreting scan results)

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Memory and Ageing: Whats Normal? Harder to pay attention distractions, hearing, vision Slower at processing information ( new learning, retrieval e.g. of names) 85% forget names 60% lose keys 50% cant remember what has just been said 40% forget faces or directions

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Normal age-related memory decline Subjective memory concern Mild episodic memory impairment Preserved procedural & semantic memory Possible mild non memory cognitive dysfunction (e.g. attention) No functional impairment or behavioural abnormalities

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Symptoms Changes in memory Reasoning Judgement Recognition Language Orientation Mood Motivation Personality Ability to perform ADLs

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Normal age-related forgetfulness Mild Cognitive Impairment Dementia Sometimes misplaces itemsFrequently misplaces itemsForgets what an item is used for. Puts it in an inappropriate place Momentarily forgets a persons name Frequently forgets names & slow to recall May not remember knowing a person Occasionally has to search for a word Finding words becomes more difficult Starts to lose language skills. Withdraws socially Occas. forgets an errandBegins to forget eventsLoses sense of day & time May forget event from distant past May forget more recent events or new info Working memory impaired. Difficulty learning or remembering new info Driving-may forget to turn, quickly re-orients Temporarily lost. Trouble with maps Easily lost in familiar places-st for hours Jokes about memory loss Worries about memory loss. Family & friends notice lapses. May have little or no awareness of cognitive problems

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Mild Cognitive Impairment Most maintain cognitive ability at a functioning level throughout life. 20% of 65 yr olds have MCI; 5 % have dementia MCI may be a precursor to dementia. Meta-analysis study reported annual conversion from MCI to dementia is 5-10% per yr Many people with MCI did NOT progress to dementia with 10 years follow-up. Objectively impaired memory testing (MMSE >=26 BUT ADLs INTACT)

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Criteria for Diagnosing Dementia Impairment of memory and one or more of Aphasia: production/understanding language disturbed Apraxia: trouble carrying out motor activities Agnosia: failure to recognise, identify objects, people, places Executive functioning: sequencing, planning, organising, judgements & abstracting

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Must interfere with work, social activities or relationships and represent a significant decline in the persons functioning (ask about managing money, using the phone, transport, taking medications ) Gradual onset and continuing decline. Other physical or mental conditions that can look like dementia have to be excluded * Person may not be aware of changes may have to ask permission to speak to someone who knows them well

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Describing Dementia-DSM 1V Early Onset: Before 65 years Late onset: After 65 years Uncomplicated: Alzheimers or vascular dementia with no BPSD or complex co-morbidities Complicated: with delusions, depressed mood or behavioural disturbance/or have signs of another neurodegenerative disorder e.g. gait disturbance, extra-pyramidal symptoms, focal or lateralising neurological signs (e.g. Parkinsons, Huntingtons)

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Mild (MMSE >20) 2-7yrs Moderate ( MMSE 10-20) 4-7 yrs Severe MMSE

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Vascular Dementia Gradual or sudden episodes of ischaemia Several small CVA, TIAs Course variable: sudden then leveling period More likely gait, urinary problems Predisposed: High blood pressure, diabetes, elevated lipids, smoking, family history of vascular disease. CT scan: indications of ischaemia

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Barriers to Early Detection Misidentification by the family of early signs as normal aging process Social skills often maintained Denial and lack of insight by patient Reluctance to report symptoms (patient and caregiver)stigma Lack of definitive screening tools

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Early Diagnosis and Discussion Benefits Risks Baseline & monitoring allows earlier intervention with support, reduces risks of accidents, driving, abuse and hospital admission People can prepare Enduring Power of Attorney, wills Move homes, visit family overseas Better understanding of changes No cure but treatment can alter the course of the illness Impact persons self-esteem Threaten their independence Affect relationships Employment Future Plans change Clinical judgement as to timing of discussion 62% reasonably/very confident

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Is a memory test needed? Diagnosis is mainly from the history provided by patient and informant Memory tests help confirm and quantify impairment Conversation Clues How did they answer questions? Hesitation to find words, recall facts, sequence events? Anomalies in language use? Is reported impairment beyond what you classify as normal.

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Which Memory Test? Brief, standardised screening appropriate in primary care setting Survey results showed 75% used MMSE (30) and 40% MMSE (12) 18% use mini-cog -repeat 3 words; draw clock, no.s & time; recall words 80% used a memory test if cognitive problems were suspected 13% cognitive screen patients over 74 for DRIVING medical 0% follow-up those with dementia 6 monthly with screening 60% perform cognitive screen themselves 17% have nursing staff perform memory screening (driving test)

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Which memory test? Test% GPs Time taken Interpreting ScoresSensitivity & specificity MMSE8-10mins Age, education, language & cultural bias, used for 30 years Insensitive to mild alzheimers (