Helga Merl, Hunter Medicare Local: The role of the GP and now the NP in early and timely diagnosis of dementia within the primary care context

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Information about Helga Merl, Hunter Medicare Local: The role of the GP and now the NP in...
Health & Medicine

Published on February 20, 2014

Author: informaoz

Source: slideshare.net


Helga Merl, Nurse Practitioner, Hunter Medicare Local delivered this presentation at the 2014 National Dementia Congress. The event examined dementia case studies and the latest innovations from across the whole dementia pathway, from diagnosis to end of life, focusing on the theme of "Making Dementia Care Transformation Happen Today. For more information on the annual event, please visit the conference website: http://www.healthcareconferences.com.au/dementiacongress2014

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% "If we could delay Dementia until after we died, that would be perfect” Prof. Henry Brodaty. 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] 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) 4 Odds Ratio (Compared to Never & E4 absent) 3.5 3 2.5 E4 absent E4 present 2 1.5 1 0.5 0 Never Low Frequent

Primary Care role Identification & Diagnosis Diagnosis Identification Australian GPs are as good as any in the world at identifying people at risk of dementia. The Diagnosis of dementia is the challenge. • Our GPs identify between 48-67% for mild dementia • • • 76 – 85% for moderate to severe dementia • • • • PN also ID risk –over 75s Health assessment 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 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

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 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 & The University of Newcastle 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

Referring agents, GPs, PNs, CC & Aboriginal Health workers % Dementia Prevalence by Age Group 50 40 30 KGOWS Australia 20 KGOWS - Age adjusted Rate - AL 60+ 21% (4) 10 Age 60-64 65-69 70-74 75-79 80+ Total Australia 60+ 6.8% (2) Dementia Rate = 3 x non-Indigenous rate of 6.8% Dementia affects Indigenous Australians at earlier age 45yrs and 69 yrs [1]

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;

Medication review Anticholinergic load in community dwelling elderly Australians with dementia Kerr, Mate, Williams, Pond & Magin 2013. • 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). Pharmacist $194.07 HMR recommendation by Dementia NP common to assess anticholinergic load.

Case Conference Dementia NP, GP & PN discuss assessment recommendations and actions. Note: NP cant charge Item 735 15m $65.40 Item 739 20m $112.10 Item 743 40m $186.85

ACPlanning – Barrier, no item number • • • • • “For two decades, care in the last year of life has represented over onefourth of Medicare's budget.” 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

www.planningwhatiwant.com 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

DRAFT CLINICAL PATHWAY FOR DIAGNOSIS, MANAGEMENT AND REFERRAL EARLY STAGE DEMENTIA – Oct 12 CLINICAL PATHWAY FOR DIAGNOSIS, MANAGEMENT AND REFERRAL Is cognitive impairment suspected in the older patient, often DEMENTIA picked up with the overis75s health assessment? Younger NP Mobile Memory Clinic Onset Dementia also possible under age 65. NO Consider other causes eg depression, delirium, CVA Is this a gradual change?     If other causes excluded    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       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. Are cholinesterase inhibitors prescribed in consultation with a specialist? If yes Consider Home Medication Review (HMR) and dosage administration aid YES DRAFT CLINICAL PATHWAY FOR DIAGNOSIS, MANAGEMENT AND REFERRAL EARLY STAGE DEMENTIA – Oct 12 Is additional support required for assessment, diagnosis and management? If yes FOR YOUR INTEREST Llllllllllllllllllllllllllllllllllllllllllllllll Common causes of reversible confusion and memory loss n n n n n Refer to Dementia Nurse Practitioner Fax: 49252268 For assessment, diagnosis, capacity assessment and management planning support. n n n n n n n n n Is diagnosis complicated by multiple comorbidities with difficult to control symptoms or does diagnosis need to be confirmed for trial of the cholinesterase inhibitors? If yes Most common & recommended tests to find reversible causes of confusion and memory loss. (Please fax results if available to 49252268) n n n n n n n Refer to Geriatrician: Fax 49246006 Neuropsychiatrist: Fax 40335606 For assessment, diagnosis and management planning support. 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. Medications with adverse effects on cognition Chest, urine and other infections Depression Thyroid problems Unstable blood sugar levels, prediabetes or diabetes B12 & folate deficiency Electrolyte disturbances Hypercalcaemia Anaemia Alcohol or other drug overuse Hypoxia Malnutrition Renal failure Intracerebral lesions (e.g. normal pressure hydrocephalus) n n n n n n n FBC ESR CRP renal function & electrolytes liver function TSH fasting blood glucose serum calcium & phosphate serum B12 & folate levels brain CT scan without contrast CXR (if possible delirium) MSU If warranted STS 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

NP Mobile Memory Clinic Results Client Carer (N=61) Gender Female 57.4% Diagnosis Gender Dementia 19 or 31.1% Mean age 79.9 F 68% M 32% Cam Cog Total 105 Memory 37 Language 30 Mean 80.55 18.3 24.8 Range 40-98 3-26 17-29 Mean 7.3 2 36.6 34.4 MM 24.6 ND 26.6 D 20.3 Range 0-23 0-5 Age Range 50-93 Other tools Depression CSDD 38 Anxiety GAI 5 QoL AD – Dementia 52 QoL AD – NoDementia CBI & MM Male 42.6% NoDementia 42 or 68.9% Mean age 75.4 F 52% M48% (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 Mean 18 D=20 ND=17.8 Range 0-47 Other tools ZBI 88 Brief Cope

Results Postal surveys back to date • recommend the service, • liked it a lot, • assessment useful and • that the NP “was nice”.

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



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.

• • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • References Pollit , P 2007; Indigenous views of Dementia. “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 KICA Kimberley Indigenous Cognitive Assessment http://www.wacha.org.au/kica.html NSW Health. (2012). Nurse Practitioners in NSW. Guideline for implementation of Nurse Practitioner Roles. NSW Health. North Sydney. Retrieved from www.health.nsw.gov.au/policies/gl/2012 KPMG. (2011). Dementia Services pathways - An essential guide to effective service planning. Commonwealth Department of Health and Ageing (DoHA). Australian Nursing and Midwifery Council Incorporated (ANMC). (2006). National Competency Standards for Nurse Practitioner 2010. Gardner, A., & Gardner, G. (2005) A trial of nurse practitioner scope of practice. Journal of Advanced Nursing, 49(2),135-145. Klein,T. (2005). Scope of practice and the Nurse Practitioner: Regulation, competency, expansion, and evolution. Advanced Practice Nursing e Journal, 5(2), Medscape. Lowe, G. (2010). Scope of emergency nurse practitioners practice: where to beyond clinical practice guidelines? Australian Journal of Advanced Nursing, 28(1), 74-82 Schober, M. (2009). An international perspective of advanced nursing practice. In P. McGee (Eds.), Advanced Practice in Nursing and the Allied Health Professions (3rd Ed) (pp.227-242). West Sussex, UK: Wiley-Blackwell. NSW Health (2009). NSW Health Population Projection Series 1. Department of Planning & Statewide Services Development Branch. North Sydney. Australian Bureau of Statistics. (2011). September quarter 2011 report. Hick, R. (2005). Ecological Health in the Hunter New England Area of New South Wales. Merl, H., & Morris, J.(2012). Dementia care for the Hunter, Dementia Services Implemenation Plan 2012-2015. Hunter New England Local Health District. Access Economics. (2011). Dementia Across Australia 2011-2050. Canberra. ABS. (2011). Population projections 2011. NSW Department of Planning. Cessnock Council. (2012). “Cessnock 2020”. Cessnock Coucil. Brodaty, H. (2007). Early Diagnosis of Dementia. Sydney: Alzheimer's Australia. Valcour, V., Masaki, K., Curb, J., & Blanchette, P. (2000). The detection of dementia in the primary care setting. Archives of Internal Medicine,160(19), 2964-2968. Stirling, C., Andrews, S., Croft, T., Vickers, J., Turner, P., & Robinson, A. (2010). Measuring dementia carers' unmet need for services - an exploratory mixed method study. BMC Health Services Research;10(122). Pond et al. (2012) abstract, International Psychogeriatrics Conference, Cairns, September 2012. Bridges-Webb, C., Wolk, J., Britt, H., & Pond, D. (2003). The management of dementia in general practice. A field test of guidelines. Australian Family Physician, 32,2835. Lyketsos, C., Colenda, C., Beck, C., Blank, K., Doraiswamy, M., Kalunian, D., & Yaffeet, K. (2006). Position Statement of the American Association for Geriatric Psychiatry Regarding Principles of Care for Patients with Dementia Resulting from Alzheimer’s Disease. American Association for Geriatric Psychiatry.14(7), 561-573 Abbey, J., Palk, E., Carlson, L. & Parker, D. (2008). Clinical Practice Guidelines and Care Pathways for People with Dementia Living in the Community. Brisbane: QUT Bayram, C., Britt, H., Miller, G., & Valenti, L. (2009). Evidence-practice gap in GP pathology test ordering: a comparison of BEACH pathology data and recommended testing. University of Sydney. Pond, D., & Brodaty, H. (2004). Diagnosis and management of dementia in general practice. Australian Family Physician, 33(10), 789-793. Australian Medical Association (AMA). (2010). Primary Health Care – 2010, retrieved 2nd June 2012 from http://ama.com.au/node/5992. Manthorpe, J., Keady, J., Abley, C., Bond, J., Campbell, S., Samsi, K. Robinson, L., Watts, S., Drennan, V., Goodman, C., Warner, J. & Iliffe, S. (2011). Placing the person at the centre in the diagnosis of dementia. Journal of Dementia Care, 19(4), 37-38. Watts, I., Foley, E., Hutchinson, R., Pascoe, T., Whitecross, L., & Snowdon, T. (2004). General Practice Nursing in Australia. Royal Australian College of General Practitioners and Royal College of Nursing, Australia. Nursing and Midwifery Board of Australia (NMBA), 2010. Registration standard for endorsement of nurse practitioners. Retrieved 8th June 2012 from. www.nursingmidwiferyboard.gov.au

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