Resident 2018 - cog care in primary care

Cognitive Care in Primary Care
Practical approaches
Nancy Isenberg, MD MPH FAAN
May 3rd 2018

Presentation Overview
Washington State has the third highest rate of death from
Alzheimer’s disease of any state. This is expected to increase
40% in next 10 years. In many practices in Washington State, there
are no guidelines to increase quality of care for screening, diagnosis, or
treatment of Alzheimer’s disease and other dementias
Virginia Mason Cognitive Care in Primary Care is a Leader in WA
• Detection…Screening….Why
• The Clinical Value Stream, where we are now
• Resources, and Implementation Roadmap, Toolkit
with Multidisciplinary management
Future Directions

Bree recommendations
Nov 2017
4
In many practices in Washington State, there are no guidelines to
increase quality of care for diagnosis or care for patients with
Alzheimer’s disease and other dementias. This is costly to the
health care system and overly burdensome to primary care
clinicians, and patients, their caregivers, and the community.
Goals to Improve:
1. Diagnosis
2. Ongoing care and support
3. Advance care planning and palliative care
4. Need for increased support and/or higher levels of care
5. Preparing for potential hospitalization
6. Screening for delirium risk
http://www.breecollaborative.org/wp-content/uploads/Alzheimers-Dementia-Recommendations-
Final-2017.pdf
https://www.dshs.wa.gov/sites/default/files/ALTSA/stakeholders/documents/AD/Dementia%20
Road%20Map%20-%20A%20Guide%20for%20Family%20and%20Care%20Partners.pdf
Also practice guideline update from AAN on MCI
https://www.aan.com/Guidelines/Home/GetGuidelineContent/882

2017 Facts and Figures
5,500,000 Americans with Alzheimer’s
10% general risk after age 65
– 65-74 = 3%
– 75-84 = 17%
– 82+ = 32%

Years
Cognitive
Function
Presymptomatic
Prodromal
Dementia
~5-20? years
~1-10? years
~2-20 years
Progression of Alzheimer’s Disease
Mild Cognitive Impairment (MCI)
VCI/SCI/BCI

MRI Volumetric Analysis

FDG-PET Normal vs AD

Amyvid Imaging

Vascular Cognitive Impairment
(VCI)
Some degree of cognitive impairment
+ evidence cerebral vascular disease
(CVD)
VCI embraces a spectrum of severity
– Ranges from mild cognitive impairment
(MCI) to dementia
– Related to a range of vascular injury
(i.e. subclinical vascular injury to
poststroke)
11
(Smith, 2016)

Why is VCI important?
2nd most common cause of cognitive
impairment.
May be the most preventable and
treatable causes of dementia.
12
(Smith, 2016)
http://www.npr.org/sections/health-shots/2014/05/27/316325223/when-older-people-walk-now-they-stay-independent-later
https://en.wikipedia.org/wiki/Smoking_ban
www.bicycling.com/food/build-better-diet

What causes VCI?
VCI is typically found in 2 forms:
1. Poststroke VCI
2. Nonstroke-related VCI
(i.e. cerebral small vessel disease)
VCI often coexists with other
neurodegenerative neuropathologies
such as Alzheimer’s disease = Mixed
dementia
13
(Smith, 2016)

How to diagnose VCI?
1. Assess for cognitive impairment
2. Complete work-up for the presence
of vascular disease.
– Neuroimaging: consider location, size,
and severity of lesions
– Underlying cause and CVD risk factors.
3. Consider whether the vascular
disease is sufficient to partly or
wholly explain the cognitive
impairment.
14
(Smith, 2016)

Assessing Cognition
Executive function and speed
processing are frequently affected in
patients with VCI
– Why these areas of cognition?
• Frontal lobe difficulty, reduced verbal fluency
on testing, difficulty organizing and planning a
trip, or learning a hand sequence.
Neuropsychological testing when clinical
uncertainty exists
15
(Smith, 2016)
(https://www.epilepsydiagnosis.org/seizure/frontal-lobe-overview.html)

How to assess for CVD?
Clear history of stroke(Smith, 2016)
More difficult with absent history of stroke
Risk factors:
– Hypertension
– Hyperlipidemia
– Diabetes Mellitus and Metabolic Syndrome
– Obesity
– Smoking
– Sleep apnea
– Delirium during hospitalization
– Medical conditions: Thyroid disorders, chronic kidney
disease, depression, traumatic brain injury, hearing and
vision loss
– Medications: Anticholinergics, antihistamines,
16

Sudden onset of stroke-like symptoms:
• Balance difficulty
• Diplopia or vision loss
• Facial droop
• Arm weakness
• Difficulty speaking
17

Presence of vascular risk factors
– Increases suspicion only, does NOT prove
VCI.
– Present opportunities for risk factor
modification.
Do not rely solely on clinical history or
exam
– Not highly sensitive or specific to diagnosis
VCI in the absence of neuroimaging
confirmation. Neuroimaging is
recommended for diagnosis!
18
(Smith, 2016)

MRI without contrast is preferred over head
CT
Neuroimaging shows:
– Strokes, silent strokes, small vessel disease,
or amyloid angiopathy.
– Presence, location, and severity of lesions
help determine clinical significance.
– Also helps rules out other differential
diagnoses
Neuroimaging + cognitive profile for
diagnosis 19
(Smith, 2016)

Poststroke VCI: Neuroimaging
Findings
Single, strategic lesions in eloquent
locations are associated with poststroke
VCI:
– Left hemisphere perisylvian language
areas, thalamus, midbrain, medial
temporal lobe, and medial frontal lobe.
– Caution relating cognitive impairment to
single, small or moderate infarcts outside
these regions.
Multi-infarcts:
– VCI from the combined effect of multiple 20
(Smith, 2016)

Clinical Vignette
71 yo F, h/o obesity, HLD, and
smoking, presented with confusion,
vomiting, left hemianopia, and left
hemiparesis.
CTA showed basilar artery occlusion
d/t thrombus formation on an
athersclerotic plaque.
Pt was treated with tPA and
endovascular thrombectomy
21
(Smith, 2016)

Clinical Vignette
Diffusion-weighted MRI
showed acute
infarctions (bright
signal) in the right
occipital and bilateral
medial temporal lobes
Strategic infarcts in the
bilateral medial
temporal lobes
22
(Smith, 2016)

Clinical Vignette
The pt’s motor and oculomotor
findings resolved after treatment.
Residual cognitive impairment, with
deficits in verbal learning and recall.
3 months later: persistent
forgetfulness that interferes with
shopping, finances, and driving.
MoCA: 17/30
Diagnosis: Poststroke dementia
23
(Smith, 2016)

Cognitive rehabilitation for poststroke
VCI
Cognitive rehabilitation through speech
therapy.
– Compensatory strategies
– Cognitive skills training
Many patients with poststroke
cognitive impairment improve, even
resolve deficits
Novel learning
24
(Smith, 2016)
http://www.yourtrainingedge.com/megatrends-in-moocs-5-lifelong-learning/

VCI vs Alzheimer’s disease
VCI often presents more with
executive function (ex. Organizing and planning a
trip) and processing speed
impairment.
– However, it can present with some degree of
memory impairment as well.
– Because CVD can very greatly in location and
severity, clinical presentation can vary.
AD tends to presents more with
episodic memory impairment
– Ex. Struggle with delayed recall
25

Prevention and Interventions
• Treatment of Modifiable Risk Factors
• Cardiovascular: HTN, HLD, DM, Obesity
• Sedentary lifestyle
• Sleep disorders/disruption
• Alcohol
• Cardiovascular Exercise
• Cognitive Activation and Rehabilitation
• Dietary Interventions
• Meditation/Mindfulness-Based Stress Reduction
• Community Engagement and Socialization
• Early interdisciplinary involvement

Life’s Simple 7
27Figure 1: AHA guidelines for optimal vascular health. (Source: Gardener H, et al. Nat Rev Neurol
2015;11:651-657. Used with permission.)

v
• N = 923
• Age 58-98
• 4.5 years
• DASH + Mediterranean
• One glass of wine
• 53% reduction in incidence

Diet Soda triples risk of stroke and
dementia

Rapid Access TIA Clinic
Stroke prevention Group Visit
A specialized clinic within neurology that expedites care
for low-risk patients from emergency department with
possible TIAs.
It relocates patient care from the hospital setting to
the outpatient setting and improves outcomes at
lower costs.
In the United States, most TIA patients are routinely
admitted to the hospital despite substantial evidence
that for low-risk TIAs, patients achieve improved
outcomes at a lower costs at specialized rapid-access
TIA clinics, now w/ referrals from primary care.
The American Heart Association and the American Stroke
Association in 2014 published a report that called for the relocation
of care for low-risk TIA patients from the hospital to specialized
outpatient TIA clinics.

P…
Mi
g…
St
r…
O…
Expansion of Rapid-Access Transient Ischemic Attack (TIA) Clinic Referrals From Emergency
Department to Primary Care: Improving Outcomes and Reducing Costs
• Sarah Hermanson, DNP, ARNP1; Nirali Vora, MD2; Nancy Isenberg, MD, MPH, FAAN1
Neurology, 1Virginia Mason Seattle, WA and 2Stanford University Medical Center, CA
METHODS
CONCLUSIONS
OBJECTIVE
Key elements in the development and implementation of the Rapid-
Access TIA Clinic include:
• Standardized patient triage protocol tools (Figures 1 and 2)
• Direct scheduling from the ED and PC to the Neurology Clinic with
commitment to complete appointments within 72 hours
• Multi-disciplinary collaboration between stakeholders, including ED,
PC, Neurology and Radiology.
• Strong emphasis on risk factor reduction, secondary stroke
prevention, and medication adherence.
The Rapid-Access TIA Clinic at Virginia Mason relocates care for
low-risk patients from the hospital setting to the outpatient setting
and improve outcomes at lower costs. We aim to expand the clinic to
include timely, high value referrals directly from Primary Care (PC)
in addition to referrals from the Emergency Department (ED). The
expanded clinic continues to breaks down specialty silos by working
across departments to reduce unnecessary, costly ED visits, and
improve value and care for patients.
RESULTS
• 3 (3.7%) patients lost to follow-up in clinic, but did complete
telephone follow-up at 2 days
• No patients had recurrent admission for stroke at 90 days
• An estimated cost savings of at least $304,000 in approximately
over 2 years was achieved.1
Figure 3. Emergency Department triage
tool
Figure 4. Final diagnosis by neurologist
of patients seen in Rapid-Access TIA
Clinic
Patients achieve improved outcomes at lower costs at our
specialized outpatient Rapid-Access TIA Clinic by establishing safe
triage protocols to identify appropriate patients and collaborating
across departments to create safe patient pathways.
This value-added, efficient strategy is feasible for direct referral from
PC allowing appropriate, low-risk patients to bypass the ED directly.
Key points to establish a successful Rapid-Access TIA Clinic with
referral from either ED or PC include:
• Stakeholder identification from each department (ED, PC,
Neurology, Radiology) at every step of planning and
implementation
• Collaborative process with commitment from key stakeholders.
• Importance of continual education and communication
• Allocated time to design and implement plan.
BACKGROUND
TIA is a warning sign for stroke, a leading cause of disability and
health-related societal cost. The evaluation of TIA is urgent and
necessitates rapid diagnostics and early initiation of treatment for
secondary stroke prevention. In the United States, many patients
with suspected TIA are routinely admitted to the hospital and ED
despite substantial evidence that for low-risk TIAs, patients can
achieve improved outcomes at lower costs through utilization of
specialized rapid-access TIA clinics.1,2,3
REFERENCES
1. Kalanithi L, Tai WA, Conley J, et al. Better Health, Less Spending. Stroke.
2014;45(10):3105-3111.
2. Sacco RL, Rundek T. The Value of Urgent Specialized Care for TIA and
Minor Stroke. New England Journal of Medicine. 2016;374(16):1577-1579.
3. Amarenco P, Lavallée PC, Labreuche J, et al. One-year risk of stroke after
transient ischemic attack or minor stroke. New England Journal of
Medicine. 2016;374(16);1533-1542.
RESULTS (Continued)
Figure 2. Primary Care triage tool
Referral Origin 2016 2017 2018 Total n (%)
Emergency Department 28 23 3 54 (69%)
Primary Care N/A 15 7 22 (28%)
Other: Neurosurgery,
Ophthalmology
N/A 1 1 2 (3%)
Table 2. Time to scheduling clinic and MRI by referral origin
Table 1. Number of referrals to Rapid-Access TIA Clinic by
origin
Patient presents to clinic with resolved transient
neurological symptoms > 24 hours ago
Neurologist confirms patient is appropriate for
Rapid-Access TIA Clinic, orders neuroimaging, and
ensures clinic appointment within 24-72 hours
PCP or PC RN pages on-call outpatient neurologist
• From 3/2016-3/2018, 78 patients were triaged to the Rapid-
Access TIA clinic, of which 22 (28%) were referred directly from
PC.
Referral Origin
Days to Clinic,
median (IQR)
Days to MRI,
median (IQR)
Emergency Department 1 (0.5, 2.5) 1 (0.5, 2.5)
Primary Care 2 (1.5, 3) 2 (1, 3)
Other: Neurosurgery, Ophthalmology 1 (0, 2) 2 (N/A, N/A)
• 100% of patients who followed up were scheduled within 72
hours

Prevention and Interventions
• Treatment of Modifiable Risk Factors
• Cardiovascular/Cerebrovascular
• Sleep disorders/disruption
• Alcohol/polypharm
• Cardiovascular Exercise
• Dietary Interventions MIND diet
• Caregiver support/CCT
• Community Engagement and Socialization
• Cognitive Reserve/lifelong learning
• Positive Mindset
• Early multi-disciplinary involvement

Aerobic Exercise Reduces Tau Protein in Older Adults
with Mild Cognitive Impairment (Baker et al., 2015)
• 65 sedentary adults
• 55-89 years old
• 6-month randomized controlled trial
• Aerobic exercise (70-80% max HR) vs stretching
(<35%)
• 45-60 minutes four times per week
• Reduced CSF tau
• Most prominent in age 70+
• Improved perfusion in frontal and temporal lobes
• Improved memory, attention and executive function
Prevention and Interventions: Exercise

Screening: VMCS
VM validation sample (N=150)
– GIM
– Neurology, referred by GIM
Age 55+
– Vascular risk factors
– Subjective/objective memory concerns
Consensus diagnosis
– Labs, neuro, imaging, neuropsych

Screening: VMCS
Equivalent sensitivity in AD
Minicog = .69
MoCA = .87
VMCS= .85

Screening: VMCS
Improved sensitivity in any impairment
(MCI +)
Minicog = .64
MoCA = .78
VMCS= .80

Current state - accomplished to date
• VMCS integrated into AWV, and cog screening in
select specialty venues (HCA Ortho pre-op bundle)
• Built ad hoc recorders for VMCS, MoCA
• .bca (brief cog assess) LIVE in PROD now!
• In KE 3/’16 Established follow up visit pathway,
synced with 99483 (former G0505) criteria, +
template, multiple operators
• > 4,000 AWV VMCS 3 sites in 6 months, yield 3%
lower than 90 day re-measures (12%), prompting
change in cutoff abnormal from 6 BACK to 7
• 76 pts had G0505
• All pts with VMCS score of 7 had abnl MoCA
40

Goals of Care across Continuum
41

Brain Health Continuum, and the CVS
42
Well Mild cognitive Impairment Dementia
SCREEN DIAGNOSE MANAGE
EVENT #1
• Screening
tool
• PDSA
• Hit targets
• EMR tools
EVENT #2
• Teaming
• Diagnostic
visit template
• Visit work
flow
SERIES OF EVENTS
• Planned care
• Quality of life improvement
• Slow progression
Cultural Revolution: Kaizen, Education, Training, Clinical Research

Operational elements of the CVS
• AWV, screening, abnl VMCS (7/10 or lower) 
• MoCA
• if indicated by abnl MoCA (25/30 or lower) 
• Labs
• functional assessment
• Driving assessment
• Primary Care MD diagnostic & planning visit
• Neurology referral for atypical features e.g.<65,
Parkinsonism
• MRI with hippocampal volumetrics if Neuro referral
(Neurologist, Neuropsychologist)
• Alternate head imaging for others
• Caretaker assessment, education (RN, MSW)
• Resources – Roadmap, toolkit (MSW)
43

Medication management
44

Future Directions
• GIM Integration
• MBWC-Primary Care Liaison Team
• Annual Medicare Wellness Visit
• Neighborhood Clinics
• Group interventions for MCI/early dementia
• Stroke Prevention Group visit
• Dementia-friendly Intergenerational Arts
• Exercise
• CCT
• Outcome Measurement
• Dementia Performance Measurement Set (AAN, 2011)

Resources
Dementia Action Collaborative/State Plan
– https://www.dshs.wa.gov/altsa/stakeholders/a
lzheimers-state-plan
– Dementia Road Map:
https://www.dshs.wa.gov/sites/default/files/ALTSA/stakeholders/documents/AD/De
mentia%20Road%20Map%20-
%20A%20Guide%20for%20Family%20and%20Care%20Partners.pdf

Summary
• Prevention is KEY, DNH is important as well.
• The follow up visit is time and resource
intensive, but generates 3.54 RVU
• Best sequence of case finding, diagnostic
testing, pt and family caregiver assessment and
education to require multiple return visits/Kaizen
47

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