Advisory Council July 2017 Meeting Presentation: Managing Chronic Conditions

07/28/2017

ADVISORY COUNCIL ON ALZHEIMER'S RESEARCH, CARE, AND SERVICES

Friday, July 28, 2017

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Managing chronic conditions in people living with dementia

Deirdre Johnston, MB BCh
Assistant Professor, Department of Psychiatry and Behavioral Sciences
Co-Investigator and Clinical Intervention Director, MIND at Home

Disclosures

  • National Institute on Aging (grant)
  • National Institute of Mental Health (grant)
  • Centers for Medicare & Medicaid Services (grant)
  • The Associated (grant)
  • The Hoffberger Family Philanthropies (grant)
  • Richman Philanthropies (grant)
  • Broadmead Retirement Community (consultant)
  • Co-founder, MIND at Home Halo

Objectives

  • Briefly describe impact of dementia on chronic conditions, outcomes and costs
  • Provide overview of baseline comorbidities of MIND at Home enrollees
  • Brief comment on implications for practice

Chronic disease self-management

  • Dementia: progressive, irreversible, impairment of cognitive and executive function
  • Capacity to self-manage is progressively lost
  • Early intervention and caregiver education needed to prevent medication errors and complications
  • Commonly heard in clinic: "I don&'t want to take his/her independence away."

Multimorbidity in dementia

  • The average person with dementia has four comorbid chronic conditions. (Guthrie et al, BMJ 2012)
  • Clinical guidelines focus on one disorder
  • Fragmented care is the norm

Multimorbidity and polypharmacy

  • Older adults with dementia see
    • multiple providers
    • for multiple chronic conditions
    • in different settings (Callahan et al, 2014)
  • Each comorbid condition may have its own treatment protocol
    • including one or more medications

Most Frequent Co-morbid Conditions of MIND at Home Participants at Baseline
(CMS and NIA)

Line chart: Congestive heart failure disease 7.1, chronic objective pulmonary disease 8.8, translent schemic attack 9.4, B12 deficiency 9.7, arthritis 12.3, atrial fibriliation 12.8, thyroid disease 15.3, dental problems 27.2, diabetes 28.3, incontinence-bowel 28.4, falls with injury 34.1, allergies 34.5, depression 40.3, incontience-urinary 51.9, hypercholester olemia 53.5, hypertension 67.1, dementia 79.3.
All participants in CMMI MIND at Home demonstration project plus NIA randomized controlled trial (N=647)

Dementia Diagnosis at Baseline

Bar chart: dementia diagnosis 79.3, undiagnosed 20.7.
MIND at Home RCT and HCIA, pooled data (N= 647)

Number of Medications at baseline

  • Participants:
    • 8.23
  • Caregivers:
    • 5.07

Dementia is underdiagnosed

  • Cognitive impairment is under-recognized and under-documented (Brodaty et al., 1994; Callahan et al., 1995; Eefsting et al., 1996; Bush et al., 1997; Lo¨ppo¨nen et al., 2003)
  • Physicians' reasons for not diagnosing/documenting:
    • time constraints
    • cost
    • stigma
    • futility (Martin et al., BMC 2015)

Medications

Bar chart: diabetic 19.2, opiate 6.6, memantine 14, antidepress 37.2, antipsychotic 9.9, MD stabilizer 1.9, Benzo 5.8, anxiolytic 4.1, hypnotic 0.72, NSAID 10.2, thyroid 14.5, diuretic 22.5, aspirin 41.8
Figure 1: The percentage of MIND participants on some commonly prescribed medications at baseline. 43% had medication use and adherence needs

Cost implications of unmanaged chronic disease in dementia

  • Most care costs for acute in-patient and institutional/long stay care (Gitlin et al., 2007)
  • 25% of Medicare beneficiaries' costs are incurred in the last year of life (Hogan et al, Med Care, 2013)
  • People with dementia have 80% higher rates of potentially avoidable hospitalizations (Phelan et al, 2012)
  • Dementia diagnosis associated with higher costs of anti-dementia drug treatment, but with lower total medical care costs (Michalowsky et al., Int Psychogeriatr 2016)

Impact of dementia on co-existing chronic conditions

  • Loss of ability to self-manage chronic conditions
  • Associated with lower continuity of care, higher utilization:
    • ED visits
    • hospitalizations
    • testing
    • costs (Amjad et al, JAMA 2016).
  • Early diagnosis and pro-active management of chronic conditions needed
  • Caregiver education and support necessary

Reasons to screen and diagnose

  1. To treat and manage dementia
  2. Educate and support caregiver
  3. Address and manage comorbid conditions by:
    • Eliminating unnecessary medications
    • Helping caregiver cope
    • Educating caregiver on managing the dementia and the comorbidities
    • Reducing caregiver burden
      • E.g, Some CGs make multiple trips to pharmacy per month

Summary and recommendations

  • Dementia can be treated and managed
  • Management of dementia includes managing the comorbidities
    • Caregiver education
    • Identification of high risk dyads
    • Support and coaching
    • Adaptation of care plan to changing needs
  • Provider education/awareness to increase detection and treatment
  • Workforce adaptation (e.g., Memory Care Coordinators)
  • Attention to diversity and sensitivity to end of life care needs

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