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Panel Discussion: Interdisciplinary dementia care in the community

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Panel Discussion: Interdisciplinary dementia care in the community Elizabeth Clark, MD Elizabeth Lindenberger, MD Jed Levine, MA Anne Feder, LMSW – PowerPoint PPT presentation

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Title: Panel Discussion: Interdisciplinary dementia care in the community


1
Panel Discussion Interdisciplinary dementia care
in the community
  • Elizabeth Clark, MD
  • Elizabeth Lindenberger, MD
  • Jed Levine, MA
  • Anne Feder, LMSW
  • Claudia Lee, LCSW
  • Cory Chen, PhD
  • Update on Dementia Assessment, Treatment
    Resources
  • 9th Annual VISN 3 GRECC and CNYGEC
    Videoconference
  • Co-sponsored by the VISN 3 Palliative Care
    Initiative
  • Host Facility James J. Peters VAMC
  • June 8, 2010

2
Learning Objectives
  • Describe the disease trajectory of dementia
  • Recognize the warning signs of dementia
  • Describe the impact of dementia on other medical
    conditions
  • Describe the role of skilled home care services
    for dementia and how this is paid for
  • List community and VA resources that may help
    people with dementia remain in the community
  • Outline an approach to advance care planning for
    patients with dementia

3
The Case of Marguerite Bennett
  • 85 year old retired nurse
  • Served in WW II field hospital worked in ICU
    until age 70
  • Very active in retirement until husbands death 2
    years ago
  • Recently moved to city to be near family
  • Medical history
  • Diabetes hypertension hypercholesterolemia
    spinal stenosis touch of arthritis
  • On insulin (lente and aspart) metformin
    lisinopril simvastatin tylenol

4
The Case of Marguerite
  • Claims functional independence
  • Adamant about managing her own medications and
    finances
  • Annoyed at daughters trying to take over my
    life
  • Physical exam
  • Unsteady gait elevated BP
  • Finger stick glucose 350

5
Questions for panel
  • What geriatric issues are you concerned about?
  • How would you evaluate them during this visit?

6
The Case of Marguerite
  • Cognitive assessment
  • GDS 9/15 refuses to participate in Mini-Cog
  • Declines referral for PT or cane
  • Daughters arrive
  • Had gone to pick patient up for her appointment
    but she wasnt at her apartment
  • Give more information on patients IADLs
  • Difficulty maintaining home driving problems
  • Most bills being paid automatically
  • Hgb A1C 16 (was 8 a year ago)

7
Questions for panel
  • What additional geriatric diagnoses do you
    suspect and how would you approach them?
  • How can you help her manage her diabetes?
  • What services would you put in place?
  • What services are available through the VA?
  • Which are only available outside of the VA?
  • How can Mrs. Bennett and her daughters pay for
    them?

8
The Case of Marguerite
  • Does well for most of next year
  • Daughter manages medications
  • Still declines treatment for depression
  • Uses shopping cart as walking aid
  • Last three months marked by insomnia and
    increased alcohol intake
  • Nighttime wandering, nightmares
  • Sleep aids melatonin, Tylenol PM, valerian
  • Daughters take turns staying with patient at
    night

9
The Case of Marguerite
  • Marguerite falls one night and fractures hip
  • Hospital course complicated by delirium
  • Doesnt recognize daughters
  • Doesnt recognize physician
  • In restraints
  • Very confused calling out for people not in room

10
Questions for panel
  • What are your immediate recommendations for this
    hospitalization and Mrs. Bennetts delirium?
  • How would you assess her dementia at this time?
  • In patients with dementia, how do you approach
    the assessment and management of
  • PTSD?
  • Alcohol abuse?

11
Questions for panel
  • What are your recommendations for peri-operative
    management?
  • What services will she need after surgery?
  • Who will pay for those services?
  • Once her delirium has cleared, what discussions
    about legal and financial planning and goals of
    care should you have with Marguerite and her
    family?
  • How do you assess her capacity to have those
    discussions?

12
The Case of Marguerite
  • Delirium clears
  • pain treated, restraints removed, reorientation,
    PT
  • Patient goes to sub-acute rehab
  • Patient gives daughters financial power of
    attorney
  • Patient, physician and family discuss advance
    care planning
  • Daughters use patients funds for 24 h x 7 days
    HHA
  • plan Medicaid application when funds run out
  • Patient enjoys improved quality of life

13
Questions for panel
  • What is Mrs. Bennetts prognosis?
  • What additional community or VA services could
    help Mrs. Bennett and her daughters?
  • At what point in the future would Mrs. Bennett
    qualify for hospice benefits?
  • What services does home hospice provide?
  • How is it paid for?

14
Take-home Points
  • Optimal dementia care requires an
    interdisciplinary geriatrics and palliative care
    approach
  • Skilled nursing and home hospice services can
    help support dementia patients living in the
    community
  • Many community resources are available for frail
    older adults with dementia and other chronic
    diseases
  • Advance care planning
  • involves discussions about patient goals and
    values
  • Is an ongoing process throughout the disease
    trajectory
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