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Starting the Conversation: Practical Strategies for Integrating Cognitive Health Into Everyday Care

Introduction

Nicola Hanson (Decera Clinical Education): Hi, everybody. Welcome to this. This is Starting the Conversation: Practical Strategies for Integrating Cognitive Health Into Everyday Care. And this is the second of three lunch webinars in which we're bringing together two clinicians from different specialties and practice settings to discuss their approaches to cognitive health with their ageing patients. This is provided by us, Decera Clinical Education. And this activity is supported by an educational grant from Lilly. So, I will - let's see if I can advance to the next slide.

[00:09:33]

Faculty and Disclosures

There we go. So, today, with us today we have our two faculty who are, Carolyn Clevenger, who is Founding Dean and Professor of the brand new University of Georgia School of Nursing. She is a Geriatrician and a dementia expert, and our very good friend, Jeremy Schreiber, who is from Enlighten Health Care and West Liberty University in West Virginia. Jeremy is a - a general mental healthcare practitioner. So, we are delighted to have both of you here with us today.

[00:10:13]

Learning Objectives

And I'm trying to show the learning objective. Here we go. The learning objectives for today. These focus on a very key part of brain health care, which is strategies for patient communication, as these discussions with patients to provide education and to establish a relationship that can be built upon in, over time, hopefully.

Clinical Case Discussion 1: The Missed Opportunity

I will go ahead and give it over to - to Jeremy to discuss our first patient case.

Dr. Jeremy Schreiber (Enlighten Health Care and West Liberty University): Well, thank you so much, Nicola. I really do appreciate that. And I - as we were looking at these cases, I - I really liked them a lot. This first case is the missed opportunity.

[00:12:19]

Patient Case: Lucas

So the question is, when we're looking at this case, is there something that where we're not getting to? So let's talk about Lucas. Lucas is a 59-year-old man. He works shifts at the factory. He comes to the office with his primary complaint being depression and insomnia. And I think this is pretty classic, what we see in patients with depression. We often see sleep problems as well.

His BMI is 32. His blood pressure is probably like mine, 135/85. And he has diabetes, but that diabetes is also managed with metformin. He shows at the office. He reports symptoms of depression, down. He's lethargic. He has a lack of motivation. And on top of this kind of this energy stuff, he also feels that he's cognitively slow. Now, he can fall asleep quickly, but he awakens, and he can't get back to sleep. He feels tired during the waking hours, and it also is reported that he snores, sometimes even wakes himself up by snoring. The way it happens at my house is my wife tends to elbow me, but we have the snoring here, and he attributes his brain fog to this lack of sleep. He drinks a little bit after work, one to two beers a day, and sometimes uses benzodiazepines that he - that he obtains from his co-workers to help him sleep. So this is Lucas.

[00:13:40]

Poll 3

Let's take a polling question here. Let's vote on this. In your current practice, would you use a cognitive screening tool as part of the initial assessment of a patient who reported cognitive symptoms related to depression? Is it

1. Never;
2. Rarely;
3. Sometimes;
4. Often; or
5. Always.

All right. Thank you for getting those answers in. I see that, how this is selected, we definitely have some people that are using some of these cognitive tools, probably the majority, but this is not an all the time thing for the majority of you.

[00:14:35]

Pretest 1

That being said, let's take a pre-test question here. So, you tell Lucas that you will work with his primary care to establish a treatment plan that addresses his overall health as well as his sleep problems. You demonstrate a cognitive assessment app that he can use regularly to track his brain function, and say that you expect he will see increases as his health improves. He sees older patients pictured in the app tutorial and says, is this an Alzheimer's test? You don't think I could have Alzheimer's, do you? I'm not old enough. What would be the best response? Is it

1. Tell him that testing his cognition now will make it possible to detect small changes as he ages, including early signs of Alzheimer's disease;
2. Tell him that it is possible he has early-onset Alzheimer's disease, and that this app can track and diagnose him;
3. Explain that his current symptoms are not severe enough to raise concern for Alzheimer's disease, but it will help track his sleep condition; or
4. Assure him that he does not need to worry about age-related cognitive decline until he's older.

Oh, it looked like we're doing pretty good there with the - with the answers we have the - the bulk of you - I don't know if you all can see this, but the bulk of you are right on point here already. And Nicola, if I should be discussing these - these answers now, you can feel free to chime in and let me know.

Nicola Hanson: Sure. Go right ahead. It's fine after everybody's answered the first time.

Dr. Schreiber: Okay, great. So, really what we're looking for here is, you know, to tell him that the - the testing now can make it really possible to detect the small changes and that we're looking for this. And it gives us really a good baseline. We definitely don't want to tell him that he doesn't have to worry until he's older. I think that would be - that would be a problem. So, we're really looking at A being the correct answer here. So, well done - well done.

[00:17:02]

Discussion: Lucas

All right. So, let's talk about Lucas. How can mental behavioral health care providers best communicate and collaborate with primary healthcare providers to manage chronic health issues, which contribute to brain symptoms? And if we can have Carolyn come in here too, we can - Carolyn and I can chat about this. Carolyn gets to be the expert here.

I was telling my wife that, as I was preparing for this, that I get to be the one who volunteers to not know as much as the other person that's presenting. And Carolyn is the - is the expert. But one of the things that I think about when we talk about how mental and behavioral health care providers can communicate and collaborate with primary healthcare providers, a lot of times is, I just pick up the phone and call, and I have a close relationship with a lot of the primary care providers in my area. And so, Carolyn, I don't know if that's the same case with you as - as - as the specialist in the area of cognitive decline.

Dr. Carolyn Clevenger (University of Georgia School of Nursing): Yeah. I think this is one of the fun things about being in primary care is being connected to various people, especially in your system. So, this is like, this is the reason I make time to go to those after-hours events at work or in my community, so that I can do this exact thing.

Because here's the thing about like cognitive symptoms. They are vague. You know, onset of like a true dementia is insidious at any age. And so - and you just never know where things are going to pop up. I mean, I - in my memory care practice, we had a family member who said that, as a dentist, they would hear concerns that maybe should sort of be prompting back to for a cognitive impairment, specifically because that's what, you know, our practice was doing. But I think you know, the more that we're in contact with each other, sometimes patients sort of see us as the health system, and they bring a concern, even if it's vague, that they presented it to the system. And so then, for us to make sure we're communicating that back and forth.

And, you know, the thing about brain symptoms and blood pressure and diabetes is, you know, your brain is connected to the rest of it. It's not like things don't, you know, cut off here at the neck.

Dr. Schreiber: Yeah, you're absolutely right. And you know, patients - you know, when I think about psychiatry, I think about my patients living a very holistic life. And it's not just from the - from the neck up, right? It's the entirety of the patient. We want to see exercise. We want to see good sleep hygiene. We want to make sure that all of their - their blood pressure is controlled, the cholesterol, and whatnot. Now, I don't generally manage those things, but it's certainly something that our patients need to have managed overall because it has to do with the whole patient.

Now, if you have patients that come in to see you, Carolyn, are there ways that you communicate blood pressure concerns, diabetes concerns to the primary care there? Are there pathways for this for you?

Dr. Clevenger: Well, in our practice, we were also their primary care provider. So, and that's really why, because, you know, we know from some recent trials that, in terms of modifiable risk factors, right, the vascular factors, the endocrine factors weigh very heavily as well as other lifestyle and daily activities people do, which, like exercise and diet, which also have a relationship to blood pressure and diabetes.

And so, the reason that we designed the practice that way is because you know, managing blood pressure well, particularly at this age, at Lucas's age, has a direct impact on cognitive symptoms and progression over time. And so, whether that is a call to PCP, if you're not necessarily doing the primary care, whether that is you know, a secure messaging through your you know, EMR or if you're using something else like secure messaging and something like Doximity you know, it is sort of what we know, hey, saw your patient for this, but also wanted to make sure you knew this. And let me just add, you know, for those people who are like, well, you know, maybe I'm seeing this person, I don't have that connection. Back to PCPs. You know, our patients also have agency in this space. And so sometimes also helping them understand this might be a good conversation. And here's why I want you to have that conversation. So, that may stick a little bit better than just, hey, let your PCP know when you see them that your blood pressure was up a little bit, because there's a specific reason we want to make sure they do that.

Dr. Schreiber: Yeah. And I think you're right on point there. I think educating the patient prior to, you know, telling them to inform their primary care is a very good way to go because it gives the patient that basis of understanding as to why they need to talk about this. And I see the same thing when I talk to patients about, you know, that snore or whatever it is. If I'm not ordering a sleep study, if I talk to them about having their potentially having their primary care, and I usually with sleep studies, I frame it out like, you should discuss this and see if your primary carer wants to order a sleep study for you. You know, if you're telling me about your snoring, especially in these patients that are lethargic and so forth.

But at the same time, you know, we also have to look at this cognitive progression. And, you know, when I think about, you know, blood pressure not being controlled, I often think about, you know, stroke, cardiovascular outcomes, these sorts of things. But I don't always equate this in my mind to cognitive challenges that are going to continue to develop for these patients.

Dr. Clevenger: That's fair. When you - all you secret people living with dementia, clinically, everything gets connected back to cognitive symptoms for me. So, I realize I have a bit of a skewed perspective on it.

Dr. Schreiber: Well, you know, one of the other questions that we have on this - on this particular topic is how do we address current alcohol and benzodiazepine use? And when - when I think about this, I obviously want to reduce these things, right? Two drinks a night, one to two drinks a night every night, isn't something that's going to be particularly beneficial for this patient. And especially the benzodiazepine use that he's kind of obtaining from people that he's working with to help him with sleep.

So, we definitely should address hopefully the insomnia. But when I - when I look at this, I also look at motivational interviewing and talking to the patients about their goals, what they want, and see if we can get the choices to adjust. I oftentimes joke in psychiatry and say, if we just had a pill that would enable our patients to make good choices, we would be so much better off. You know, we'd do so much - so much of life is - is done with good choices.

And I think that's also things that we're talking about today, is making good choices to make sure that we are providing good care for our patients. Are there particular ways that you address, you know, kind of alcohol and benzodiazepine use in your patients?

Dr. Clevenger: I think this person is using both of these substances for a purpose, right? They're meeting a need, or they're meeting a goal for him. And so, I think to your point about motivational interviewing, what is that motivation that's behind it? And how motivated are they to change? A couple things I would say, particularly around benzodiazepine use, right? So, we're using this for sleep. Sometimes I can say, well, I actually have better options for you. And you know, because I also want them to have better sleep, and I have better ways of accomplishing this.

And I, you know, sometimes we can come at people to say, well, you know, you have all of these risks associated with this. These are all the negative effects. And we think if they just understood that there's this bad side, that's fine. But there's also a positive for them, you know, in their mind anyway, that this is - this is meeting the need that this is helping them at least fall asleep or whatever that is.

And so, we can't just remove or reduce or titrate that down. It's going to be, let's replace it with something that actually is more effective and doesn't have as much risk. And then, you know, in particular, both of these, you know, this is a slow and gradual progression, right? You're not going to hand someone sort of a handout and say, and here's how you wean yourself off. We're probably going to have some follow-up.

And maybe there are also other folks who need to be part of the team to - to support this, right? So, whatever those other resources might be in your community-based organizations, or whether that's back with primary care, or may or may not necessarily be a follow-up with you, but there are follow-ups along the way, including with you as part of maybe a larger team. These are complex issues.

Nicola Hanson: So, if I could, if I could jump in with a question from the audience, and this is - this is a question that we see frequently, is what would you recommend as a better option for a sleep aid?

Dr. Clevenger: Yeah. Well, we always have to start with something as basic as sleep hygiene. And depending on the generation and the culture of patients you're caring for, sometimes those are two words my patients have never heard put together. So, we talk about all of the things that we know as providers make good sense, right? That the room is cool, that your bed is only used for sex and sleep, and nothing else. That you sort of train your body to wind down.

Winding down might involve reducing screen time at some point. It might - I have patients who like to watch very lively and aggressive-sounding news shows into the evening, and then wonder why they can't sort of settle down. Right? So like, what's happening in the two hours and the four hours leading to training this? I can begin with something as I think reasonable as chamomile tea, right, or sleepy time tea.

We - and then I also am going to avoid PM drugs, right? So I'm not trying to replace the over-the-counter diphenhydramine, that's also got lots of down-the-road, cognitive risks to be concerned about. I am wondering if this is a part of their anxiety, part of their depression, making sure that those are really well managed as well.

Dr. Clevenger: Do they have restless legs? We're going to address that with the appropriate therapy, sort of working our way up that ladder as well. Is it pain? Is it a matter of an NSAID or - or acetaminophen that we want to use because arthritic pain is creating the other problems?

If I get all through all of those things, and I want something specific for sleep, especially for someone who's having depressive symptoms, trazodone is often my go-to if I'm going to use a pharmacologic intervention here, but that's sort of my work, my way through it. And then we, I think, have already talked a little bit about, you know, is there also a sleep apnea issue here? And do we need to intervene specific to that?

So, I think there's a root cause that we need to get at. You know, for any - any symptom, I cannot stand as a geriatric specialist when people say, well, I'm just a little older, so X is happening to me, including having problems with sleep. It's, you know - that's you're old because you're old. You're having sleep problems because you're having sleep problems. Those are separate issues.

Dr. Schreiber: Yeah. And Carolyn, I wholeheartedly agree with you about sleep hygiene. It's something I talk to my patients about all the time. I usually recommend no screen time two hours before bed. That's televisions, smartphones, tablets of any sort. On top of that, I usually recommend that people don't drink caffeine eight hours prior to bed. You know, caffeine can keep us awake, and it can hang out for quite some time. And I will also say that in terms of the bed with sleeping and sex, I usually tell them reading is okay, but provided it's, you know, a book or a magazine. And so, those are things that I look at.

And I also talk to patients. You know, if you talk about the underlying cause, like anxiety. People are worried about things. Sometimes people are up, and I talk about journaling. Sometimes people need to get things off their chest as well. And journaling can be good for patients prior to bed which is also - which is also, I think a - a strategy that we want to look at utilizing. Because, like you said, the first thing we want to do is look at sleep hygiene before we start looking at pharmacotherapies.

And I'm - I'm like you, I - I use a lot of trazodone in patients with sleep problems, depression. I also look at things like mirtazapine. And there's some other things I try to do, especially before I even consider some of these scheduled agents. And some of our SSRIs also have some more, you know, kind of sedative-type properties, side effects, associated with those medications, and dosing them at night sometimes can be beneficial.

And for me, it also depends on if it's kind of sleep onset that's a problem or sleep maintenance that’s a problem, or is it a combination of both onset and maintenance? When I'm looking at tailoring the regimen that I'm using to help this patient, if it's beyond that of sleep hygiene interventions.

Nicola Hanson: Could either of you speak as well about sleep changes that sometimes happen around perimenopause or post menopause?

Dr. Schreiber: Carolyn, I'm going to allow you to field goal that one to start.

Dr. Clevenger: Yeah. So well, that kind of builds on two things. I was thinking about just adding to this conversation about sort of where we begin with sleep. So, the other opposite, so there's both SSRIs that have that sleepiness as a side effect. So, using that to your benefit and then or looking at your anti-anxiety or antidepressant agent, if it is a more activating, making sure you're not taking that before bed, that you move that to a morning. So similarly.

I was about to say we capitalize on our natural hormones, which is sort of a transition into the question around perimenopause, meaning that, you know, in the morning, you really do want that sunlight to hit the back of your eyes, to kind of set your circadian rhythm. And then melatonin, if that's in deficit, may be helpful. It may not be if that's not really a deficit for you.

Hormonal changes broadly, just that to say that will have an impact on sleep. In fact, you know, if you think about like perimenopause symptoms, if you're, like most of us who went through our medical and nursing educational programs and had, you know, maybe one hour lecture or zero time training on understanding menopausal symptoms, you may also arrive like the rest of the general public, where you think perimenopause is about hot flashes. And if they don't have hot flashes that they're not having perimenopausal, you know, symptoms, which is obviously one of many symptoms that occur in perimenopause, including brain fog, including sleep changes, including joint pain, and so forth.

So, I would say I think I'm a proponent of a couple of things. One, taking stock of the total package of perimenopausal symptoms someone may be experiencing. You may not know, like spot checking levels of hormones is not appropriate or helpful because those change so frequently. And so, you know, your level at 8 AM may be different than 4 PM, so that makes it a little more challenging. As a clinician, you're really treating to symptoms. So, you'd have to then measure those symptoms and then treat accordingly.

I know that there are, you know, some of the medications that do help with the psychomotor symptoms may be helpful as well for sleep. Hormone supportive therapies may also be helpful for sleep symptoms, among other symptoms. And so, the second thing I would say is, in cases where I think this, like in primary care, things get a bit beyond your specialty. We've tried first line, second line, patient is not having significant symptom relief, then I'm going to find a certified menopause specialist to really get in there and make the best and most tailored, individualized recommendation for that patient.

Nicola Hanson: Okay, guys. Well, it's probably about time to move on to the second case, just to make sure we can get through everything.

Dr. Clevenger: All right, I think I get the next one.

[00:32:15]

Clinical Case Discussion 2: I Don't Have Time for This

Let's talk about clinical case discussion two. I don't have time for this.

[00:32:20]

Patient Case: Linda

So, this is a slightly older patient. This is getting more in my - my wheelhouse, guys. We have a 73-year-old retired nurse, Linda, who lives alone, has a history of hypertension and diabetes, which are well medicated, excuse me, well managed with medication and diet. And she takes daily walks for her exercise with her dog. Enjoys spending time in a neighborhood park. She's getting outside.

Now, she's reporting some memory problems, and they're giving her some anxiety. She's been forgetting the day of the week, forgetting names of the neighbors that she sees regularly on her walks. She's misplacing things more frequently at home, and she's finding them in, them in like weird locations. So, like, didn't just lose her glasses, she finds them in the refrigerator.

Recently, she got lost in her neighborhood, which should be familiar to her, right? And had to ask someone for directions home. So she now sticks to a simple route. She admits she's noticed her memory has been worsening for a few years, but she's been afraid to bring it up until the symptoms became too worrying that she could keep ignoring them. Her adult children live in different states. They do speak regularly, but she hasn't mentioned this because she doesn't want to be a bother. And she has no past cognitive assessments on her primary care record for you to make a comparison.

[00:33:35]

Poll 4

So let's just do this polling question. I'm hoping I'll be able to see your responses. What proportion of your patients over 65 have a family member or another informant available to you as a resource in performing a cognitive assessment? Is it

1. None or almost none;
2. Fewer than half of them;
3. About half;
4. More than half of your patients; or
5. Almost, excuse me, all or almost all of them.

And for whatever reason, I'm not getting the pop-up with the poll. But my chat is open. If somebody wants to tell me if somebody else can see it, if you want to tell us when we can move on.

Nicola Hanson: So, the answers are mostly about half or fewer than half, is the common - the common answer from the audience.

Dr. Clevenger: Okay. I would say that's definitely true. If I consider who's available to me, as who comes to the appointments and who is maybe makes it easy to contact them. In my experience, when you start looking around because you need to find an informant, depending on how motivated you are, you probably will find more than you expect. But that is part of that cognitive assessment is getting that informant to weigh in as well.

[00:35:04]

Pretest 2

Linda's been pretty forthcoming. So, let's talk about this pre-test for Linda. So, you perform a MoCA Montreal Cognitive Assessment, and Linda scores a 20, indicating mild cognitive impairment. So, the deductions that she received were on the serial sevens, on the sentence repetition, on verbal fluency, abstraction, and delayed recall. So, you plan to refer her to a dementia specialist for an assessment. What would you say to her regarding potential diagnosis and treatment?

1. If she tests positive for Alzheimer's pathology, she may be offered treatment to improve her dementia;
2. If she tests positive for Alzheimer's pathology, she may be offered treatment to slow dementia progression, although it cannot be reversed;
3. She will likely not be eligible for disease-modifying treatment for dementia, but she may be offered medications to improve her symptoms; or
4. She will likely not be eligible for any medication, but the specialist will assess for any non-dementia conditions that are treatable.

We call those modifiable. And I do not have the option for polls and quizzes on my screen, so I can't see this one either.

Nicola Hanson: Not a problem. I will let you know the answers when they come in. All right, so we've got 83% of the audience picked B, which is the correct choice.

Dr. Clevenger: Sure is. Yeah. So, if she tests positive, then maybe offered some of those anti-amyloid targeted therapies, which will slow progression, but they are not a cure. They do not reverse those symptoms yet.

[00:36:49]

Discussion: Linda

So, Jeremy, you and I are going to talk about Linda. So, she should have had a cognitive screening and an ADL or activities of daily living and instrumental, like a functional assessment, those should have been done as part of her annual wellness visits in the past. Because, you know, even - she's experienced these for a while and now they're sort of to the level that she's finding them more difficult to ignore.

So, she finally sort of comes forward. But we probably could have gotten, you know, some of this earlier, especially on something like a MoCA, where in conversation, I think the numbers are 70% of us as clinicians will miss cognitive impairment in that conversation where we all seem to think we're going to like detect it and pick it up. But turns out we actually are not that - that strong at doing that. Or maybe even some structured assessment questioning in that - in that interview, that's a little bit more targeted to get at that daily - that day to day function.

But at this point, we've got a MoCA, where would you - what would you do next in terms of where you would - where you would start with this - the further evaluation?

Dr. Schreiber: Yeah. So, I'll tell you first thing is if I have a - as a general psychiatric provider, when I see an issue in the MoCA, I'm already thinking that there's cognitive impairment. So, I might be thinking about A, prescribing something, but my next step is actually probably to look at a neurology referral, where I oftentimes send patients out to neurology. Have someone get a look at them, see if the MRIs or the scans that they're doing are going to reveal any particular pathology that we can see.

Oftentimes, I'll tell you, though, when patients come back, oh, they looked at my brain, everything's good. You know, everything's good. So I'm in good shape, which is really kind of a bizarre thing because it's not the reality of what's happening with the patient sitting in front of me. I mean, and especially with this patient, her MoCA is a 20, you know, this is - that's, you know, you got to be 26 or more to be normal. This is six points down on the MoCA. To me, there's - there's probably some significant issues going on with this patient.

And I may be starting to think about what options do I have? Am I going to be looking at you know, encouraging my patient to exercise, do things that I think are healthy for the brain puzzles, these sorts of things? Am I going to be looking at medications? What - what is it that I'm going to be doing?

And part of that I really want to be - and this is just because I'm, I get to be the one who doesn't know as much as you do on this call. You know, this is where it's like, I want someone else to help me manage this because in psychiatry, I'm predominantly looking at behavioral things. But the reality is, is that I often do find cognitive issues in my patients. And it's just a function of what do we do?

Dr. Clevenger: Yeah - yeah. I will say, in our system, and I think this is because, if you are trying to refer to like a subspecialist for a diagnosis, they're full. I mean, they just are. And - and that's been the case, honestly, for 20 years. So, this is not like a new phenomenon, at least where I'm - where I'm - where I've been practicing. And so what is required now, but will always, I think, maybe be just a more streamlined experience for your patient, is to have done a couple of things before you make that referral.

And then what you might find is, it's crystal clear just from these first three things. So, the first three things, I think MoCA is - MoCA is great. Yeah. I mean, like, better than just like somebody has subjective cognitive decline and you send them right out for the workup. So, we got a MoCA at least. The next thing, though, neuropsych testing is going to be really helpful, right? So like, exactly where her deficits, and how significant are they?

So, a good neuropsych testing battery is helpful. This is a relationship that I had cultivated over time with my local neuropsych team, they were able to hold spots for us, so I could get somebody in within a few weeks because we had discussed what a good quality referral was for them. They also get lots of inappropriate referrals, you can imagine. So, that's something you can do yourself and your patients a favor to like work with a particular practice. But neuropsych testing, yes, you do need structural imaging, right? And you can order the MRI.

And then the third thing that we've been offering, this is a relatively new thing, but we've been doing this partly because it's required to get the referral approved, which is doing the blood-based biomarker testing. So, in our system, we have the p-tau217. I think we're all kind of moving toward more of a panel, so you're not just getting one measure. We're now looking at ratios and so forth. This is not a specialized - specialized test. Your Labcorp, your quest, they have these as well. We're using the p-tau217 there, I think all processed at Mayo.

But you at least have some - you have got some objective pieces here, right? So you have this patient's concern. You have these three things. Now that objective package is really going to be helpful to your specialist, even if they just can do an e-consult for you and say, I've reviewed the chart and here's back.

But the piece that they're going to be missing is the second bullet here, which is you really are, on the clinical practice guidelines, you should ask for, try to pursue an observer's rating of your patient's performance. And that's because functional assessments, you know, individually we tend to overestimate how independent we are. Now, I've also seen family members underestimate how independent a person could be. The truth, you know, is probably somewhere in the middle. But all of your like FAQ Functional Assessment Questionnaire, your ADL, IADL, those are validated assessments based on an observer rating, not self-rating. So, trying to get that piece of it.

The other thing that you're supposed to get from those observers are neuropsychiatric symptoms. So, that's a little bit of the repetition, the changes in mood, agitation, anxiety, any delusions, hallucinations and - and so forth. So, those are the two that you want to you want to sort of get by.

And, you know, many patients, when I say, look, we're going to do a more of a valuation for you, we want to talk more about this. It would be a good idea if you want to bring someone with you who can support you in this visit. It's helpful to me as the clinician, and it's for your support as well. Something like 85% of people who are living with a diagnosed cognitive disorder do have someone in their life who is supporting them.

So, some people may say, I don't have anyone like that or I'm not comfortable bringing them, but you know, we have to open the door because remember, our health system is very much based on an individual coming in, like individually schedule. I show up by myself. There's one seat at the check-in desk, so we might have to be a little bit more intentional to say others are invited to be with you. In fact, we support it.

You get into some real dicey questions here. I don't know what you - with this question of like independence when somebody being diagnosed with a - with a cognitive impairment, like being able to live alone. I'm curious how you sort of engage in those kinds of conversations when they come up.

Dr. Schreiber: Well, a lot of times, I talk to the family members, and this assumes that the patient has family or people that care for them. And these are things where I generally ask, you know, like, is the patient roaming around? Are they leaving the stoves on? Have they - have they wandered away from the house? If they're outside, do they get lost? These types of questions. And other things that the - the patients may, or their caregivers may, tell me about.

One other thing, too, that I wanted to say, I want to just go back for a moment, and I know we should have kind of a secondary reporter, someone to kind of give us an outside observer's perspective, but it's also very interesting in psychiatry, a lot of times with my patients, if they don't have anyone else with them, I will oftentimes ask them, what would your spouse say about you? And the patients, you know, because they might say, oh, I'm great. My spouse will tell you I can't remember anything, I’m mean, all the time, this sort of stuff. But it's not true. That's just what - and they start to say kind of the things that their - their spouse is saying about them. And you could almost get somewhat of a spousal report or a caregiver report just by asking the patient what the - the outside observer might say, which I also think is a nice technique.

Dr. Clevenger: That's a - I love that question so much. I want to touch on two more things. And then I think we're going to move on to the next case. So, this last question about driving and firearms. These are kind of the things I think about as my like biggest risk, probably the biggest reward for actually addressing them. So, the question of does this person, are they able to live alone? Are they able to do various things? Driving is kind of its own unique question. And that's a different evaluation.

So, your neuropsych testing may give you some insight into driving ability. But if you truly are concerned, if the - if you say, what would you, you know, do your kids let you drive the grandkids? You know, like those kinds of questions about driving, then I might do a referral for a driving evaluation. That's what the certified driving rehab specialist. That's a specialized kind of occupational therapist. It is typically out of pocket unless they are a VA-connected person with benefits. Those tend - those tend to be free.

And then the question of do they own firearms or guns? And even beginning with like, let's - let's just - as a larger conversation, we need a life plan for those guns. So, like advanced care planning for your healthcare decisions, you want to make advanced care plans for those guns. So, if you were in a situation where you were not able to safely continue to own them or house them, how many - does somebody know what the inventory is, and what would you like to have happen with them when you no longer feel safe managing them? Just let's have that advanced conversation about those as well. Again, takes a little bit of a few minutes in your visit. That's a big payoff with the - otherwise a very big - big risk.

Dr. Schreiber: Absolutely.

Nicola Hanson: Well, before we go on, can I just bring in one question I think this will actually lead into the next case, is for patients who don't have cognitive complaints, what age do you recommend starting cognitive screening with MoCA or something similar, if in primary care or psychiatry?

Dr. Clevenger: So, what I've been using and what I've seen used a bit is this is more possible with digital cognitive assessment testing, and so there are a couple of tools available. I think most of them are targeted toward primary care settings. And the cost, I think, has come down, and the logistics have really made it more accessible.

And so in that space, because you're not referring someone for neuropsych or you're not. So you could, you know, add, if you're old enough for a Medicare annual wellness visit, whether that's the welcome to Medicare or the subsequent, that's a good opportunity to do testing of any kind.

If you're not doing annual wellness visit, the uptake is just not good in your practice for whatever reason, and you want to do something that's just a bit more like their physical, then I think the digital testing is very helpful. You can begin - I mean, you - you can begin at 55. You can begin at 60.

The really powerful thing is then you're comparing your score and performance on the same test against yourself, not against like population norms, which I always think is much more helpful to identify when there's been a meaningful change. But there's not a guideline. You're not going to see a US Preventive Services Task Force give you a certain age that we're - we are not there.

Nicola Hanson: Could you name any of those digital tools that you usually you recommend?

Dr. Clevenger: So I have some experience with BrainCheck. I have more peripheral experience with Linus Health, and I have colleagues who use the Neurotrack, which I think those probably are progressively - I think BrainCheck is probably the lowest barrier to entry from my experience. It can be used on any tablet. Neurotrack, I think, requires maybe some equipment. So, there's probably easiest I think to maybe more complex to implement.

Nicola Hanson: All right. Thanks. I think we can move on.

[00:48:32]

Clinical Case Discussion 3: They Never Bring it Up

Dr. Schreiber: All right. Perfect. So, we'll talk about our clinical case number three. This is where they never bring it up. Patients just don't bring it up.

[00:48:41]

Patient Case: Linda (5 Yr Earlier)

So, we're actually going to take a look at Linda here. This is just her five years earlier. And I don't know if you noticed her picture, but her hair's a little bit darker. She's not as grey this - in this particular picture. She is a 68-year-old at this time. She's still retired, lives alone. And when she's coming in, she has a history of hypertension and diabetes.

It's well managed with medication and diet. She's making good choices there. She takes daily walks with her dog. She enjoys spending time in the neighborhood park. She has adult children, but they live in different states. But they do speak with her regularly. They FaceTime and - and with the grandchildren, these sorts of things.

She's had some regular cognitive screening, which has been performed previously, since age 65, as part of her Medicare scheduling, and her clinic has been using the MoCA for that. On today's visit, so this is five years earlier. She scores a 25. And, if you remember, I talked about the MoCA. I said that you're 26 and above is considered normal. 25 is going to tell us that we have a decrease here.

So, her 25 at this visit is a consistent decrease over several years. 30 at age 65, 29 at 66, 27 at 67. And here she is at 68 with a 25. And when you tell her that her score indicates that she may have mild cognitive impairment, she seems embarrassed, and she says, sure, I'm just having a bad day. I was a little distracted while I was taking that test. And so, this is, you know, kind of putting things off, and it's not bad, and this sort of stuff.

[00:50:21]

Poll 5

So, let's start with a poll here. This is our fifth poll. How many of your older patients are reluctant to answer questions or engage in discussions about cognitive ageing? Is it

1. None or almost half;
2. Fewer than half;
3. About half;
4. More than half; or
5. All or almost all of these patients.

All right. The majority of the results here are showing up about more than half have some reluctance. And that's followed by about half with our second highest. So, there's the general consensus that our patients may not want to be communicating as much about the cognitive problems that they're experiencing.

[00:51:19]

Pretest 3

So, let's take our next pre-test question here. Linda's cognitive screening indicates she may have mild impairment. In speaking with her to further assess her current cognitive status, which of these areas would be most important to explore? Is it

1. Changes to her home routine, so for example, with meals and housekeeping; is it
2. Sleep patterns, example insomnia, napping; is it
3. Her psychological state with loneliness, anxiety; or
4. The level of physical activity, for example, her ability to walk without getting winded.

All right. About a third of you have this correct, where we're looking at really changes to her home routine being the - the - the answer to this question. So, this would be most important for us to explore is how her routine is adjusting. The other things are certainly pertinent, right? But when we're looking at cognitive impairment, we really want to be looking at that.

[00:52:48]

Discussion: Linda

So, let's pop over to this case a little bit more. So, here's Linda. And how do we normalize cognitive health conversations with patients? And in psychiatry, I'll tell you one of the things that I do when I - when I see my patients is I often times do cognitive health type assessments at every visit.

So, I may have patients recite, you know, the - the colors of the rainbow or tell me the last four presidents or remember three things, and then I kind of you know, a couple words that are unrelated tree, horse, phone, things like this. And then I have them repeat them back, and we kind of see where they are as part of their - their mental status exam just at baseline.

So, a lot of times with my patients, I'm just very proactive in discussing these types of things with my patients. And so, I'm asking them about cognitive things at every visit with kind of without waiting for my patients to bring it up. Now, I will say that sometimes, you know, when you're doing these types of things, and you're looking at the memory, just short-term memory, you’re asking people about their diet recall and things of that nature, if they can remember what they had for lunch yesterday or breakfast or the day before. Sometimes patients start bringing it up.

And I think when patients bring up their cognitive capacity, and they have concerns, this is really a place where we want to kind of hedge in, if that makes sense, because this is where we need to make sure that we are being very diligent with our assessments, and really looking deeper than what might be on the surface for our patients.

And Carolyn, I'll ask you, how do you feel about that? You know, when you talk about patients or to these patients, are you waiting for these patients to bring it up with you?

Dr. Clevenger: Oh, definitely not, right? This is an area I mean - there's so much stigma around cognitive impairment. And I mean, similar to a stigma around psychiatric concerns. And so, you know, this normalizing is part of the - the kick-starting the conversation, right? I'm asking you a question to ask all my patients. But you know, if you're concerned with memory or thinking, right? So, I don't isolate it only to memory for a variety of reasons.

I think sometimes, by the way, these conversations get prompted to you, but not by the patient. So, that's always an interesting sort of needle to thread, where, you know, you've gotten a note from a family member who called the front desk or passed it to the MA during rooming. And now you're sort of like, okay, so I need to have pointed questions here, which, you know, if you're sort of like work this into your workflow, you shouldn't need the reminder to ask very specific questions. And to ask more, like I said, more than memory. So, you know, issues with like bill paying, you know, any glitches where they thought they'd paid a bill or they realized they'd paid twice. You know, this is not specific to cognitive impairment, but falling prey to financial exploitation or scams might be something to also consider or to worry about.

Sometimes it is mood changes, sometimes it is sleep changes. And so, I would just add this to your review of symptoms systems in the same way that you think about asking about, you know, like vascular changes or joint issues, changes in digestion and the GI system. I think, but you just want to do more than probably just the cursory question.

And here's the thing, let's say nothing's going on today or next year or next year for their, you know, annual physicals, right? You've already opened the door to a conversation. And so, when they do notice things now, we've normalized the fact that she's going to ask me or I'll just bring it up before they even ask, because I know - I know, I'm going to get pointed questions about this.

Dr. Schreiber: Yeah. And - and I think that you're exactly right. It's making sure that we have questions that we're asking every patient, every visit. And patients will say to me like, why are you asking me if I'm suicidal every visit? I'm not. I've never been, you know, and I'm like, listen, this is part of my job. It's something that we have to do. And this, I think, is something that we should be doing as a - we have to do this where we're looking at cognitive capacity in our patients at every visit.

Dr. Clevenger: Absolutely. And I think, you know, then from the like primary care side of things, in the same way we have to ask about psychiatric symptoms, right? And as part of your cognitive assessment. But like, I think the same - the same - same questions that you need to be specifically asking about.

You know, even for us, agitation, we know agitation is such a huge concern. It's really challenging for people to continue to have a supporting person in their life if they have verbal aggression or if they, you know, if my spouse says, I'm angry all of the time or I'm - I have a short fuse or I fly off the handle, like this is going to make it really challenging for them to have the care and support that they need going forward.

Dr. Schreiber: Yeah. Well, I liked your, really, your points earlier about the, you know, problems with people that are doing something erroneous with their financial status, where they have issues with their bills, or they are more prey to kind of financial scams. I've even seen this in - I have a patient, and her mother has recently been a victim of a financial scam. And it's truly a shame, and it's detrimental that these patients can be victims.

But this is one of the reasons why we need to make sure that we're on top of this, because if we're assessing our patients, we can do our best to help our patients with - with reducing kind of the - the rapidity at which the symptoms occur.

And, you know, when I talk about, you know, when I think about memory loss, you know, and people that, you know, I can't remember the three words or, you know, there's other things that I look at too. It's, you know, can they not name items on my desk? You know, and some of the patients have no idea what a computer mouse is. They've never used a computer, but other people know what a computer mouse is. You pick it up, you know, they - they have a hard time naming it. You put it back down, and they don't remember that. That was one of the things that you picked up. So, memory can be there, but also the ability to find words and so forth can be problematic.

And in these patients, if it's harder for them to find words, I think that these are the patients where we're also seeing more kind of profound impairment and their ability to complete the tasks that they need to complete and maintain independent living, and these sorts of things, as the degree the - the it progresses, I guess I would say.

Dr. Clevenger: Yeah.

Nicola Hanson: And maybe close this one out with, could you discuss medication review a little bit? Because I think you mentioned that many medications - many common medications, potentially have cognitive side effects. And so, can you talk about what are some of the common ones and how would you - how would you evaluate this in a patient who's having - having symptoms?

Dr. Clevenger: Well, we've talked about a few already, including benzodiazepines and diphenhydramine. Those are two good ones. I also think about pain medication, particularly opioids, right? But thinking about like neuropathic pain medications. So for folks who are on like a gabapentin, these are things that we know sort of might slow or sort of cause a little bit of brain fog.

If there are, so anti-seizure medications or antiepileptics, kind of sort of more broad from the gabapentin out to other anti-seizure medications. And sometimes treatments for movement, including everything from like muscle relaxers, although that's not so much about brain fog as it is about other relaxation, more systemically, or mood stabilizers for people who have had more serious mental illness.

Those are all not necessarily things that you're going to stop per se, or even to decrease, because they may be serving another purpose, but understanding that this may be part of the overall context for why someone's MoCA is, you know, a 25 today versus a 28. And Jeremy, many of these medications fall in your space as well, so help me out.

Dr. Schreiber: Yeah, sure. They certainly do. I'll also add, you know, antipsychotic medications can have some cognitive impact as well. Antidepressant medications, SSRIs, SNRIs, they can have some cognitive impact, not all of them do, but certainly some of them can. We talked about the benzodiazepines, but also say the Z drugs can have cognitive impact, as can things like topiramate can have significant cognitive impact as well.

So, you know, a lot of the kind of the psychiatric medications can have these cognitive impact that's - that's a negative for our patients. But the other thing I'll say there too is, not all the time do these medications have cognitive impact. And one of the confounders is that, when patients are kind of being looked at for, are we having cognitive impairment, sometimes the, you know, it's like, I feel like in the world of psychiatry, someone has a problem and they just, everybody blames the psychiatric medicine. So, like, oh, it's the psychiatric medicines. Get off those, and you'll be fine.

And - and in reality, that's not the case. And I see psychiatric medications oftentimes being blamed for cognitive impairment when they really have nothing to do with the cognitive impairment that our patients are - are experiencing.

Dr. Clevenger: Both things can be true, right? They can have some impact and also have a neurodegenerative disease, so.

Dr. Schreiber: Exactly.

Nicola Hanson: All right.

[01:01:58]

Available Tools

Well, thanks in the interest of time, we then. Oh, would you like to just quickly mention these were a few tools? Carolyn-

Dr. Clevenger: I'd love to really quickly. So the KAER Toolkit, which is Kickstart, Assess, Evaluate, and then Refer, is the toolkit for brain health supported by the Gerontological Society of America. This is both a full website with examples, with guides, written by an expert group of clinicians. And now, hot off the press, with short five minute videos on how you do each one of those steps, including from the voice of primary care clinicians, dementia specialists, and patients and families caregivers themselves talking about how they want to be asked to kick start the conversation, for example. So, KAER Toolkit, that's an excellent resource.

And then the DETeCD-ADRD, this is the clinical practice guidelines supported by the Alzheimer's Association, another group of clinical experts, two publications, both Open Access, and Alzheimer's and dementia, and each of them have a decision tree like do this. And then if the answer result is this versus this, do this next. And there's one entire decision tree for primary care, and then there's a separate one for your specialists. And then I mentioned BrainCheck earlier.

Nicola Hanson: Okay. All right. Great. And I realize that we can't click those links in Zoom, but the slides are available to download. So, if you download the slides, these links will be included there.

Q&A

So, for our final, I'd just like to ask, is there anything that the two of you didn't cover today that you - final points that you'd like to make? Anything you wish you were asked that you weren't asked?

Dr. Clevenger: I was just going to add that I think one of the big concerns that your patients will have when they bring this up is they're worried about losing independence. And so, I just want to sort of have a thought in the back of your mind that that continuum between, you know, now we know we have a problem, does not necessarily mean this person no longer can be independent in doing that, like managing their finances, but it does give them the opportunity to make sure we put a safety net in place, maybe some oversight, for a bit of support. And so just kind of keep that in mind with your patients that that may be a big part of their hesitation. So, you'll want to address it.

Dr. Schreiber: And the other thing that I'll also say is too, is we are looking at patients getting a little bit more advanced in their years, estate planning, and that sort of stuff. We really want to look at kind of doing that early as opposed to later.

Nicola Hanson: All right. Well, very good points. I hope that this has been an enjoyable conversation for you. It was very interesting to listen to. And thank you again very much. Thank you for being with us here today. Thank you for your valuable experience.

Dr. Schreiber: Thank you for having me.

Dr. Clevenger: Thanks.