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Physician's Newsletter
Our
Mission:
To develop a coordinated and efficient system of service
delivery for clients and families living with dementia.
Contents:
Page
1 - 3:
Rural Mobile Dementia Care
Page 4:
Role of the Dementia Care Network
We
would like to acknowledge the generous support of our
sponsor
for making this newsletter possible.
For further Information please contact:
Alzheimer
Society of
Lanark County
(613) 264-0307 or
1 800 511-1911
alz@superaje.com
Alzheimer
Society of
Leeds-Grenville
(613) 345-7392
1 866 576-8556
administrator@alzheimerleedsgrenville.ca
VOLUME
1, ISSUE 1, SPRING 2003
Dementia
Care Network
for Lanark, Leeds & Grenville
Physicians' Newsletter
Rural
Mobile Dementia Care:
A Resource for Family Physicians and their patients
in Lanark, Leeds & Grenville
Michael
J. Kelly, MD, FRCPC
Clinical Director
Geriatric Psychiatry Community Outreach Program
Brockville Psychiatric Hospital
a division of the Royal Ottawa Health Care Group
The
Rideau and St. Lawrence Valleys are rich in natural
resources, heritage and beauty providing a high quality
of life and a mecca for retirees. The counties of Lanark,
Leeds and Grenville have a higher proportion of seniors
(15%) relative to the provincial population (12%). While
the majority is handy and resourceful, an aging subgroup
is vulnerable to cognitive impairment and dementia.
To assist this group, and other seniors with significant
mental health difficulties, family physicians in Leeds
and Grenville may consult the Geriatric Psychiatry Community
Outreach (GPCO) Service of Brockville Psychiatric Hospital
(BPH), a division of the Royal Ottawa Health Care Group,
and those in Lanark may consult the Seniors Resource
Team of Lanark County Mental Health (LCMH).
While urban areas have limited mental health services,
the elderly population in many rural communities is
vastly under-serviced. The BPH/LCMH Outreach Programs
are cognizant of these difficulties and have developed
effective programs to assess and treat seniors in their
homes. Team members visit seniors at their residence,
assessing and managing mental health concerns, chronic
mental illness, behaviour disturbances/mental health
problems associated with cognitive impairment, while
actively pursuing partnerships to assist seniors through
their illness. The comprehensive service provides a
bio-psychosocial assessment, advocacy, intensive home
monitoring as necessary, counseling, crisis intervention,
support and education to caregivers through a shared
care model with the primary care physician. The multi-disciplinary
team, consisting of RNs, social work, psychology, administrative
and clerical support, and psychiatrists, strives to
advocate for the rights of the elderly, promote understanding
of their unique needs, reduce suffering, while respecting
the wishes and values of people in their senior years,
in order to enhance their quality of life and that of
their families.
The
involvement of the community psychiatric nurse as an
integral and indispensable part of the multi-disciplinary
team has made it possible to offer mental health services
to a large number of elderly in a vast geographical
area. Assessment and triage for persons suffering with
problematic cognitive symptoms and associated behaviour
problems are made possible through the nurse's intervention.
Patients, families, caregivers, agencies and family
physicians report a high degree of satisfaction with
the service delivery offered by the team. The location
of team members in rural communities promotes an appreciation
of local heritage, culture, health challenges and attitudes
towards psychiatric intervention.
In
urgent situations, individuals can be seen within 24
hours for most referrals, and in almost all circumstances
the assessment is commenced, if not actually completed,
within a few weeks. For the year of 2001, the combined
teams assessed over 600 seniors and over half of these
were followed on an ongoing basis in order to assist
the family physician in monitoring and achieving treatment
goals including compliance, support, and education for
patient and family. The majority was assessed in their
homes; and approximately 50% were assessed for possible
cognitive impairment and/or for behaviour or psychological
symptoms associated with dementia, such as agitation,
aggression or confusion.
There
are a number of resources available to which family
physicians may refer their patient with possible or
probable dementia. There are excellent memory disorder
clinics at Elisabeth Bruyère Health Centre (75
Bruyère St, Ottawa, ON K1N 5C8, (613) 562-4235)
and Providence Continuing Care Centre (340 Union St,
Kingston, ON K7L 5A2, (613) 548-2222). Advantages include
neurological and/or geriatric medical multi-disciplinary
consultations and a full battery of tests usually completed
through the institution. They also provide the option
for research and clinical trials. Neurology can be helpful
for individuals with unusual or atypical dementias,
including those with movement disorders or focal neurological
findings. Geriatric medicine is beneficial for those
with complex co-morbid medical illnesses and the "geriatrics
giants" such as postural instability and falls,
immobility, incontinence, social breakdown and mental
confusion.
Some
communities in the counties are fortunate to have visiting
neurologists or geriatric medical specialists. (REGAP,
Regional Geriatric Assessment Program, Kingston location
- Providence Continuing Care Centre (PCCC), St. Mary's
of the Lake Hospital, 340 Union St. Kingston, ON K7L
5A2, (613) 544-7767, toll free 1-800-214-5848; Ottawa
East Location - Elisabeth Bruyère Health Centre,
43 Bruyère St, Ottawa, ON K1N 5C8, (613) 562-6362;
Ottawa West Location - Queensway-Carleton Hospital,
3045 Baseline Rd, Nepean, ON K2H 8P4, (613) 721-0041).
The
BPH/LCMH Geriatric Psychiatry Community Outreach Programs
are local resources that will assist family physicians
in the assessment and/or management of the patients
suffering from cognitive impairment, including dementia-related
behaviours. These programs offer particular strength
in ongoing monitoring in the home or long-term care
facility and liaising with the family physician through
a shared care model. This approach ensures that family
physicians, in partnership with patients and their families,
are the ultimate providers in the spirit of the principles
of family medicine.
Leeds & Grenville patients can be referred to:
Geriatric Psychiatry Community Outreach
through Judy Einfeldt, Referral Coordinator
Brockville Psychiatric Hospital (BPH), a division of
the Royal Ottawa Health Care Group
10 Oxford Avenue, PO Box 1050
Brockville, ON K6V 5W7
Telephone: (613) 498-1493 ext 2304
Facsimile: (613) 498-1495
The program office is staffed
Monday to Friday 8:15 a.m. to 4:30 p.m.
Emergency services are available after hours, weekends
and holidays by telephoning the BPH at 345-1461 ext
2277.
Lanark
patients can be referred to:
Geriatric Psychiatry Community Outreach
Seniors Resource Team,
Lanark County Mental Health
Senior Resource Team is a partnership between Lanark
County Mental Health and the Brockville Psychiatric
Hospital.
88 Cornelia St W, Unit A2
Smiths Falls, ON K7A 5K9
Telephone: (613) 283-2170 Facsimile: (613) 283-9018
Emergency services are available after hours, weekends
and holidays by telephoning the BPH at 345-1461 ext
2277.
What
is a Dementia Care Network?
Initiative #9 of the Ontario Strategy for Alzheimer
Disease and Related Dementias refers to the development
of a local, specialized network to support persons with
dementia, their families and caregivers.
The
purpose of the Dementia Care Network is to serve as
a vehicle to facilitate people and resources coming
together locally, regionally and provincially to improve
the system of care, including service delivery, education
and research. Improved linkages through a network are
needed as the illness is progressive and requires a
continuity of care and accessibility of specialized
services at various times, across different sectors.
Benefits
of a Dementia Care Network
- Persons
with dementia: benefit from improved access, and more
timely and appropriate services, information and support
to enhance their quality of life.
- Families
and caregivers: benefit from improved access to information,
and a continuum of care and support.
- Providers:
benefit from enhanced education and support to improve
the delivery of care, and client/family/caregiver
satisfaction.
- Health
System: benefits from sharing expertise and utilization
of resources.
- Locally,
Regionally and Provincially: networks serve as a forum
for system-wide planning, problem-solving and evaluation.
Our
local Dementia Care Network met for the first time on
March 20, 2002. Invited to the inaugural meeting were
caregivers, organizations and service providers in Lanark,
Leeds and Grenville that provide care to persons with
dementia and their families. Presently, the local network
meets every two months (dedicated date is the 2nd Wednesday,
every other month), the locations alternate between
Leeds, Grenville and Lanark Counties.
The
initial tasks of our local network were to take an inventory
of services, and to identify gaps and problem areas,
with the understanding that each community has strengths
and resources to build upon. Key service priorities
were identified based on community needs and focused
on the client, resulting in the following Task Groups:
-
Public Awareness and Early Diagnosis
- Education
for Service Providers
- Ethical,
Legal & Financial Issues: Respite is the current
focus
By analyzing the current system of services for persons
with dementia, their families and caregivers, it is
possible to compare existing services to the "ideal"
model for the community.
Primary
care physicians in the community with a special interest
in dementia care are invited to join the dedicated group
of stakeholders at our local Dementia Care Network meetings
by contacting your local Alzheimer Society in Lanark
County at 264-0307 or Leeds-Grenville at 345-7392.
Upcoming
meeting of the local Dementia Care Network of Lanark,
Leeds & Grenville to be held on:
Wednesday June 11, 2003 1000-1200 hrs, Lanark Lodge,
Norm Ferrier Room, Perth
Both
the Ministry of Health and Long-Term Care (MOHLTC) and
the District Health Council (DHC) regional offices support
the development of Dementia Networks on all levels.
(A Guide for Developing a Dementia Network, 2002).
VOLUME
1, ISSUE 2, FALL 2003
Dementia
Care Network
for Lanark, Leeds & Grenville
Physicians' Newsletter
Assessment
of Cognitive Status
In The Elderly:
From Screening for Dementia to
Neuropsychological Evaluation
Christopher
R. Prince, Ph.D., C. Psych.
GPS Psychologist
Geriatric Psychiatry Community Outreach Program
Brockville Psychiatric Hospital
a division of the Royal Ottawa Health Care Group
The
Geriatric Psychiatry Community Outreach Service (GPCOS)
at Brockville Psychiatric Hospital (BPH) and the Senior's
Resource Team of Lanark County Mental Health provide
community-based assessment, diagnostic, treatment, and
follow-up services to elderly people with psychiatric
problems and/or dementia. Following receipt of a referral
from a family physician, an initial assessment is completed
by a registered nurse, psychiatrist, or social worker
usually working in teams of two. Typically, a semi-
structured interview is conducted to elicit biopsychosocial
difficulties. For clients suspected of dementia, cognitive
impairment is assessed using the Mini Mental State Examination
(MMSE)1, Clock Drawing Test (CDT), Confusion Assessment
Method (CAM)2, and the Kingston Standardized Cognitive
Assessment-Revised (KSCA-R)3. This article will review
briefly the initial screening battery administered by
the GPCOS to help determine a diagnosis of dementia.
Mini
Mental State Examination. The MMSE is probably the most
widely used cognitive screening test. It was first described
by Folstein in 1975 who recommended a cutoff score of
23/30 or less, for the presence of dementia in persons
with at least 8 years of education. It was called "mini"
because it did not test mood or thought disorders. It
was intended to assist psychiatric residents in the
cognitive part of the mental status exam but was never
meant to be used for diagnosis of dementia.
The
MMSE has been used extensively in the field of dementia
to screen for cognitive impairment, to estimate the
severity of cognitive impairment at a given point in
time, to follow the course of cognitive changes in an
individual over time, and to document an individual's
response to treatment. There have been many standardizations
and papers written about its use in clinical trials.
The benefits of the MMSE include its brevity (5-10 minutes
to administer). Domains assessed include: orientation
to time and place (10 points), registration of 3 words
(3 points), attention and calculation (5 points), recall
of 3 words (3 points), language (8 points) and visual
construction (1 point).
Among
the MMSE's many disadvantages are the limited number
of cognitive domains sampled, the widespread acceptance
of one cutoff score without taking into account factors
such as age and education, differences in administration
and scoring among examiners, and its insensitivity to
the early detection of Alzheimer's Disease. Examples
of inconsistent test administration include the choice
between serial 7s and spelling "world" backwards
(the latter being markedly easier to perform), the choice
of words for registration, and the amount of time that
lapses between registration and the recall of the 3
words on the memory portion of the test.
To
counter some of these limitations, the GPCOS adopts
a standardized approach and relies on normative data
provided by Crum et al.4 to adjust for the effects of
age and education. Generally speaking, in the well educated
elderly (i.e., those with high school education and
beyond), scores below 27/30 are thought to be abnormal
in 75% of the sample. For those with 0 to 4 years of
schooling, scores below 19/30 are thought to be abnormal
in 75% of this group (see Crum article for more detail).
The use of these norms helps reduce the MMSE's tendency
to incorrectly identify the elderly with poor education
as demented (i.e., high false positive rate). As the
MMSE is not a diagnostic test nor is it equivalent to
formal mental status testing, the GPCOS views the MMSE
as a starting point in the screening for dementia.
Clock
Drawing Test. The CDT is a useful addition to the GPCOS
screening battery because it provides information regarding
an individual's visual spatial abilities and executive
functions (e.g., motor capacity, planning, organization,
stimulus-bound responses, and perseveration).
Also,
the CDT is usually well tolerated by the elderly. There
are several scoring protocols available. These scoring
systems typically rate the drawing from best to worst
often on a 10 point rank ordering scale, where 10 represents
a "good" representation of a clock. Again,
this test is thought to be insensitive in detecting
the early stages of dementia, and like the MMSE, its
sensitivity improves with increasing severity of dementia.
Confusion
Assessment Method. Because the prevalence of delirium
is high among elderly medical inpatients, the GPCOS's
initial screen includes the CAM. The CAM can be completed
in less than 5 minutes, and consists of nine operationalized
criteria. The instrument was validated in subjects residing
in general medicine wards and in outpatient geriatric
assessment centers. As it was also adopted for use by
the PIECES initiative, it is used by the team whenever
a delirium is suspected. Indeed, prompt recognition
and treatment of underlying causes of delirium bode
well for a full recovery.
Kingston Standardized Cognitive Assessment-Revised*.
Considerable weight is given to the results of the KSCA-R,
a psychometrically valid and reliable instrument designed
to diagnose dementia. The KSCA-R was developed to provide
a more reliable assessment of intellectual functioning
in the elderly. Its purpose is to identify changes in
cognition that are commonly associated with dementia.
The KSCA-R is a paper and pencil test taking 25-45 minutes
to administer. It is a standardized, cognitive assessment
battery comprising 17 different sections, such as concentration,
memory, language, calculation, psychomotor/spatial skills,
abstract thought, and perseveration. Demonstrated criterion-related
validity (i.e., behaviours related to concomitant brain
damage) and inter-rater reliabilities for the 17 sections
are high (i.e., Pearson r's > 0.81).
Normative
data for the KSCA-R were obtained from healthy independent
community-living volunteers aged 65-91, and from in-
and out-patients with a DSM-IV diagnosis of dementia.
The resulting means and standard deviations for both
normal and demented patients are used to derive percentiles
for the Total Score in each sample. Unlike other short
screening instruments (e.g., MMSE) that rely on "cutting
scores" to determine
dementia, the KSCA-R relies on the use of percentiles
to make comparisons both within and between the normed
groups. Thus, all scores are expressed as percentiles
and compared with the performance of normal elderly
controls and elderly patients with dementia. This feature
of the KSCA-R permits a more meaningful interpretation
of a patient's performance when consideration is given
to an individual's education and vocational achievement.
Additionally, Memory, Language, and Spatial-Motor subtotals,
reported in percentile ranks, improves the detection
of the early stages of dementia. Finally, the percentile
ranking on the KSCA-R is used to determine whether a
more detailed neuropsychological evaluation is warranted.
In
summary, the assessment process adopted by the GPCOS
involves an initial brief screening comprising the MMSE,
CDT, and CAM. On the basis of the referral question,
background information, patient interview, and the results
obtained, additional testing is completed using the
KSCA-R, which is considered a "lower level"
battery that provides more information regarding an
individual's cognitive functioning. In the event that
further detailed information is required to establish
a diagnosis or assess severity of impairment, "higher
level" neuropsychological testing is conducted.
Based on the outcome, the client may be either treated
and followed in the community or referred to community
support programs to preserve functioning.
References:
- Folstein
MF, Folstein SE, McHugh PR (1975). "Mini-Mental
state": a practical method for grading the cognitive
state of patients for the clinician. Journal of Psychiatric
Research, 12: 189-98.
- Inouye
SK, van Dyck CH, Alessi CA, Balkin S, Siegal AP, Horwitz
RI (1990). Clarifying confusion: the confusion assessment
method. A new method for detection of delirium. Annals
of Internal Medicine, 113(12): 941-48.
- Rodenburg,
M, Hopkins, RW, Hamilton, PF, Ginsburg, L, Nashed,
Y, & Minde, N (1991). The kingston standardized
cognitive assessment. International Journal of Geriatric
Psychiatry, 6: 867-74.
- Crum
RM, Anthony JC, Bassett SS, & Folstein MF (1993).
Population-based norms for the mini-mental state examination
by age and educational level. JAMA, 18: 2386-91.
*
The KSCA-R is available free of charge from:
Dr. Rob Hopkins, Department of Psychology
Geriatric Psychiatry Service, Providence Continuing
Care- Mental Health Services
752 King Street West, Kingston, ON K7L 4X3
Phone # 548-5567 ext 5941; Fax # 540-6128; hopkinsr@pccchealth.org
Dementia
Care Network Member Agency Abstract
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Call:
(613) 283-8012 or
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