Screening for Dementia: A Podcast with Anna Chodos, Joseph Gaugler and Soo Borson

Eric 00:00

Welcome to the GeriPal podcast. This is Eric Widera.

Alex 00:03

This is Alex Smith.

Eric 00:04

And Alex, today we’re going to be talking about cognitive screening and dementia screening. Who do we have with us today?

Alex 00:09

We are delighted to welcome Soo Borson, who is a primary care oriented geriatric psychiatrist. I think she’s the creator of the mini cog. Is that right, Soo?

Soo 00:19

Yeah, that’s right.

Alex 00:20

And she’s professor of family medicine at USC, deputator at JAGS, and co lead of the bold center of Excellence in early detection of dementia. Soo, welcome to the GeriPal podcast.

Soo 00:32

Thanks. It’s great to be here.

Alex 00:34

Our next guest is Anna Chodos, who is a repeat guest on GeriPal. She’s a geriatrician, she’s associate professor of medicine at UCSF, and she’s PI of Dementia Care Aware. Anna, welcome back to GeriPal.

Anna 00:49

Thank you. Lovely to be here.

Alex 00:50

And our third guest today is Joe Gaugler, who is a gerontologist and editor in chief of the Gerontologist – wonderful sister journal to jags. We’re all friendly in the world of geriatrics, gerontology publication here and professor at the University of Minnesota School of Public Health and leader of the Bold center of Excellence on Dementia caregiving. Joe, welcome to the GeriPal podcast.

Joe 01:15

Yes. Thank you so much for having me.

Eric 01:17

So we got a lot to talk about with cognitive screening, dementia screening. But before we do, we always ask for a song request. Who has a song request for Alex?

Soo 01:24

Oh, yes, I do have a song request. It is Sarah McLaughlin’s song I will remember you.

Eric 01:31

I usually ask, why did you pick this song? But it seems very apropos to the topic.

Soo 01:37

It’s a little obvious.

Anna 01:38

Yeah.

Alex 01:38

And I love that Sarah McLaughlin’s having a comeback. She’s doing a tour. There’s an article about her in New York Times. I saw her when I was in college two or three times. So this is great. Thank you for this stroll down memory lane, so to speak. Here we go.

Alex 01:52

(singing)

Eric 03:13

Wonderful. Well, more of the song at the end. Let’s jump straight into the topic. So we’re going to be talking about dementia screening. Cognitive screening. The last I read, I was the United States Preventative Task Force, USPSDF. I always get that confused with the post office recommended that there wasn’t enough evidence to recommend for or against cognitive screening. And I’d like to hear from you all. Is early detection of dementia or cognitive screening, like, how important is it? Should we be doing it? So I’m going to turn to Joe first. Joe, your thoughts?

Joe 03:55

You know, my thoughts are screening is important for a variety of reasons, and certainly Doctor Boris and Soo and Anna, Doctor chodos can provide a lot greater clinical insight than I. But to me, the question is never about is screening in and of itself effective? To me, it’s more that if we screen, and if we screen accurately, what do we do then? And it’s that latter aspect of screening that I think sometimes is missed and isn’t always emphasized when efforts are made to try to improve, for example, administration or implementation of, of valid and accurate screening tools. And so certainly from a family’s perspective, a family caregiver perspective, the last thing we want to have when it comes to good dementia care is a diagnose and audio scenario, or in this case, some type of screening result, and then we’ll see you again in six months. There has to be effective support provided behind any type of screening strategy in order for it to truly be effective. And to me, that that gets more at the question of whether screening is effective or not. And I know, Soo, you probably have a lot to weigh in on this question.

Alex 05:15

Yeah, Soo, I mean, this is important because we’re identifying people for aducanumab and lecanumab and dynanumab. Is that right, Soo?

Soo 05:25

No, I mean, that is one use of screening, but it’s probably not a very good use of screening, since those agents, the application of those agents is limited to people with very early Alzheimer’s disease, and that’s just one form of brain disease that causes dementia. Yes, the most common form, but it’s just one form. And most people, frankly, who have early stage Alzheimer’s disease, most people will probably not qualify for treatment with those agents anyway. So I think that what’s really, I’d like to talk a little about what motivated me to create a simple screening tool, because that explains kind of what I think matters about it.

Eric 06:13

So is that simple screening tool the mini cog, which we talked about?

Soo 06:17

That’s the mini cog and the mini cog. The origin of the mini cog was twofold. I’m a dementia specialist, and so what I was experiencing was that many people were coming to see me to get a diagnosis of a very straightforward case of mild Alzheimer’s or moderate Alzheimer’s disease, whose doctors had told them there was nothing wrong with them or that their memory was better than my own, says the doctor. And I thought, gee, remember, this is now over 20 years ago. This is 25 years ago that the mini cog came into being. But the idea was I wanted to give primary care docs a really simple approach to detecting, robustly detecting dementia, so that people didn’t have to wait to see a specialist in order to get launched on a process of understanding what they might be going through with cognitive decline.

So the task force, USPSTF, that you mentioned has weighed in against universal population screening, but it’s also endorsed the fact that there are a number of cognitive screening tools that are effective once you have a reason to use them. So the challenge has always been in, well, do you have a reason to use a cognitive assessment or screening tool and then to launch a workup?

Eric 07:41

If I remember that document, that USPSTF document, the place that had the most evidence was actually on the screening tools to use. Yes, but the rest of the stuff was less evidence based.

Alex 07:54

But if I could push back a little bit, is that screening? I mean, when we think about. I talked to Louise Walter about this. You know, we were talking about cancer screening, and she says, if it’s symptomatic and you’re doing the colonoscopy, that’s not a screening test.

Soo 08:07

No, it’s a case finding tool. And so that’s our quibble. And you said, this isn’t meant to be too wonky, and so I don’t want to get too wonky between screeners and case finders.

Alex 08:18

Okay.

Soo 08:19

But what we, the bottom line is cognitive tools can be very brief and identify people who have a very high likelihood of cognitive impairment. That counts, that matters in their life, that’s causing them trouble in everyday life and the benefits of it. What hasn’t been shown, Eric, is that if you apply tools like this, clinical outcomes down the road are better for patients. They aren’t going to be better unless we have health systems that actually respond to detection of cognitive impairment with good care plans and follow through, as Joe was talking about. Anna, I know you have a lot to say about this, too.

Anna 09:02

Thank you, Soo. Yeah, I guess I’m sort of on the more practical side of things that helping to bridge some of this, that it’s just such a common condition that has so many pervasive implications for people who are living with the condition and their caregivers that I’m not really sure why we’re so unmotivated to find it. And I think Joe’s point really is ringing really loudly, because that’s what you certainly hear when you approach primary care and say, we’d love to help you figure out how to screen for dementia. They obviously don’t want to stop there. They want to know, well, what else are we going to do? We need all the next steps.

But then you’ve immediately, from a practical standpoint, taken on a much larger effort to support practice change in a lot of different ways. So it is a really. I can understand why there’s resistance. Cause it’s tricky to just implement per se and say, hey, we’re gonna screen everybody, you know, use a population health approach or a age cutoff and just start screening everybody if you don’t have those next steps figured out as well.

But the thing that really motivates me is seeing, you know, and trying to manage later stage, you know, we can call them complications of people who haven’t had a diagnosis are now really in, you know, a world of complexity around other conditions, around managing life and managing practical things. The caregivers are certainly very frustrated and overwhelmed if, you know, if there are caregivers. And it just seems so impractical not to try to detect early, and I would say screen, I mean, this is a highly prevalent condition. I’m not sure what sort of prevalence cutoff you need to consider screening. I know that’s not the only consideration, but it is notable to at least, as we get much older, in our eighties and above, it becomes so prevalent, it’s surprising not to screen, in my view, which means truly at least going through a short screen with everybody annually and seeing if there’s something to further work up when they’re truly asymptomatic.

Alex 11:11

Yeah, I think this point we’ve been discussing is really critical that Joe brought up at the beginning. It can’t be diagnosed and adios. There has to be some follow up. I used to be against screening for cognitive impairment because I felt like we didn’t have the systems like, what’s the next step? And that we didn’t have the comprehensive dementia care programs in place. We didn’t have medications that were effective with a few side effects. And I feel like maybe that’s shifted somewhat in the favor of screening to help people prepare because there are more systems in place. We still don’t have robust programs. But I remember back to our podcast with Lee Jennings and Chris Callahan. It’s time for comprehensive dementia care. And they sort of convinced me that we’re at a state where we need to, we should be screening and we should at the other end, be funding systems of care to help people with dementia and their caregivers, which I know is an area of interest of all of yours and Joe’s in particular.

Anna 12:12

Can I say, you know, you mentioned the. As a provocative move, Alex, if I may. You mentioned that the drugs. I know it’s potentially not accessible to everybody, in fact, that’s certain. But things like the guide model, so new care navigation programs, it’s not going to totally change the world. But I do think there’s advancements in the care models as well that will be more obviously accessible to more people. So that should motivate. Now there’s more we can do.

Alex 12:44

Yeah. Can you just say briefly what the guide model is?

Eric 12:47

We’ll have a link to that on our podcast because we actually did a full episode on the guide model.

Alex 12:52

Yeah.

Anna 12:53

Okay. Well, then I’ll refer you to the podcast, but really briefly, it’s a eight year pilot program from CMS. So people who have Medicare mostly fee for service in a dementia diagnosis should have access to a care, essentially a care navigator for the duration of their condition, or at least the duration of the program. And it includes things like some minor small amount for, like respite care for caregivers. You’re forced or mandated required to provide caregiver training to some extent, including in the home. So it’s really, it’s based on evidence based dementia care models over several dementia care models that have been shown to improve outcomes in people with dementia and has multiple components that really shift focus to the needs of someone with dementia, including caregivers needs, which is really cool.

Soo 13:48

So I could mention, too, that you can think of it as a bridge between health and social care, and that’s a real step forward. But I also wanted to touch on something that I think Alex brought up about systems of care. As far as I’m concerned, we have ample evidence from a wide range of tested interventions that doing something comprehensive with people who have dementia in their families makes a difference for them. And we can quibble about exactly what kind of difference and how much, and it’s hard to measure some of these. So we measure things like hospitalizations and ed visits and the like, and those data are a bit weaker, but they’re also, you know, I think they need to be contextualized in what, why we would even want to reduce hospitalizations right. Why would we want to?

Well, because they’re hard on people with dementia and they can be very hard on families, and they’re a form of crisis. So I think we’re poised now with the guide model and with the evidence we have about healthcare utilization, impact on caregivers, course of dementia, comorbidity management and all of that. There’s plenty more to learn, but within the knowledge base that we currently have, we can do a lot of good for people. And this is not about treating dementia as a disease of the brain in isolation from the person. I heard this beautiful thing the other day, which was to an electronic medical record, I am not a whole person. And what we’re trying to do is bring back whole person thinking, whole person care with dementia as kind of at the leading edge of doing that.

Eric 15:36

All right, I got some questions about, specifically, though, we’re going to be talking about what do we do about it? But let’s drill down on the screening part or the case finding part. I don’t even know what to title this. Is this screening or case finding for cognitive impairment, or screening for dementia in particular. And this is the question about where does MCI fit into all of this? Given that dementia, you get dementia, you kind of know that it’s going to progress. You get MCI, 10%, a third will actually resolve maybe in five years, what, 40, 50% will progress. What are we actually calling this? Am I looking for dementia? Am I looking for MCI or any cognitive impairment?

Soo 16:17

Soo thoughts, depends where you sit. I think this is where there are two parallel pathways here that are implied in your question. The first is where I started with it, which was, I want to do a better job of taking care of my patients, and if I’m going to do that, I’m going to be dealing with people who are at various risks associated with cognitive decline. Now, there’s not a lot of major medical risk associated with MCI, as we think of it today, but there’s quite a bit of medical risk and behavioral risk and social risk and family risk once you head into the more severe cognitive states, where dependency is a part of the problem. So by definition, if you have MCI, you’re not dependent on other people. You can get along without too much help or any. It might be easier if somebody else does something for you, like fills your med box, but you can do it.

By definition, you have dementia, you may not be able to. You need somebody else always there to help you, and that you need them with you in your doctor visits, because you’re not going to remember what to tell and what the doctor said and what you should be telling the doctor. So I think my motivation for case finding is to do a better job of caring for people. And this gets translated into, really, a whole person care model. And there are several of these. I have my own, but it’s. But they’re all very closely connected to each other. That’s what I was after. And we have a frontier there, too, because we are very disease focused. We’re very datified. We want to treat that disease, and we need to code that disease. And so you can’t code a whole person. As my colleague mentioned, I am not a whole person to my medical record, I am a collection of codes.

So MCI to detect MCI, the jury is a lot more out about that, except that for families and patients who understand something is changing with them, it always helps to have a way to understand why things are changing. There’s great relief to people in having an explanation for what they’re experiencing.

Joe 18:38

Yeah, you know, it’s interesting, Soo, I’m doing a county by county visit here in Minnesota where I actually give a presentation on the basics of dementia and Alzheimer’s disease. We talk about diagnosis, et cetera, but it’s almost more of a community conversation. And one question I always ask of my audience is, if I could tell you you’re going to have dementia today, what do you want to know? And I think this question comes even more relevant with the advent of blood tests and those types of new tools that might be available, and almost without fail, maybe 40 at best, 50% will raise their hand and I ask, well, why or why not?

Which we can get into. But then when I talk about this holistic, whole person centered, holistic care approach, like the guide model or many of our collaborative care models offer, everyone gets very enthusiastic and excited about it. Everyone says, why can’t we have that for our family? And so to me, the big isSoo here is how do we get from the point of the screening procedure to services and programs that clearly a lot of people want and a lot of people could benefit from? And maybe there is a need for a paradigm shift of moving away from screening for dementia versus a brain health type of approach.

Eric 19:56

Okay, but I’m a primary care provider. I don’t have access to change the levers of government. Ana chodos, what should I be? Who should I be screening for? Again, acknowledging, yeah, wouldn’t it be great if I had all these resources? But I don’t. Should I just give up on screening, then if not, who should I be doing it for and why? You talk to a lot of private care providers, right? Anna?

Anna 20:24

Yeah, I think we probably all do. And what I’m sensitive to is the fact that, you know, it’s important. I think most primary care providers feel it’s really important. They’re dedicated, committed, they’re there for their patients and they understand it’s really important. What we usually hear, though, is obviously I don’t have the time and then secondly, I don’t know what to do if I’m just screening. So I think generally speaking, we have to help them answer those questions. So how can we make it more integrated with other activities in the clinic? So it’s a healthcare maintenance task that the whole team, medical assistance nurses are also a part of, or it’s something the patient themselves is helping to participate in with a survey or something they’re doing before they get in the clinic room. And then what is next?

Especially, and especially if there is really limited access to all the things that we love to have to make us feel better about the diagnostic process after that. So neurologists, neuropsychologists, geriatricians, imaging and resources. So I think we, if you’re going to really ask that primary care do this or forgive the way I’m about to phrase this, but like constantly insist that this is their job, you know, you really need to think about the whole picture. And I guess partly what I don’t understand though is as more and more interventions become available, and I mean that in the sense of community resources guide model type things, other brain health kind of package deals that are out there, I mean, there’s sort of multi intervention brain health interventions that more people, I think, are studying and showing have good effect to help prevent progression or prevent dementia in the first place.

But sort of, you know, as we, if we do take a more brain health approach, I don’t know how the argument of like, we don’t have time for this gets maintained as we have more and more evidence of all the benefit we could be providing people. I think the evidence is already there. But as we continue to show that this is really beneficial and the earlier we do this for folks, the better it is and things like helping people access smoking and alcohol cessation, which we’re already doing, helping people be more socially and physically active in ways that really support their brain.

Eric 22:40

All right, the syndicate in me says, why not do that without cognitive screening?

Anna 22:46

I actually think you could. I think, and you would and you could is a valuable approach and I would say also if we think about a lot of times that we spend a year and a half, two years getting to a diagnosis where we feel comfortable saying, yep, you definitely have unique criteria for dementia. It’s almost certainly related to microvascular disease in your brain, whatever it is. We do the same package of things we could have done earlier to help mitigate those symptoms all along. So I actually think one of the best reasons for screening or early detection or case finding or whatever it is, even in the mildest stages, is because all of those things that we sort of wait for to do at the end when we feel like we have a nice little bow on a diagnosis, if we ever do, right, that’s the lucky one who sort of gets that diagnosis. We could have upfronted that two to three years earlier anyway and really helped with progression. And, yeah, it’s things like hearing, you know, activity reducing anticholinergic med burden, which you’re going to look at me and say, we should do all of that anyway.

Soo 23:41

Yes, agree, we should do all of that. But there’s plenty of evidence that, that having dementia is associated with many adverse health outcomes. And the farther along a caregiver goes in the caregiving journey for somebody with dementia, the more the potential for adverse health outcomes. And so if we wanted. I mean, let’s focus for a minute on multi morbidity. It’s common, you know, many, many people with dementia, especially those, you know, the average age of actual detection in healthcare systems is a lot older than it is in Alzheimer’s disease research centers. It’s closer to 80. Right. Whereas in Alzheimer’s disease research centers, it’s about 70, average age. So the difference between 70 and 80 or 70 and 85 in terms of morbidity profiles is big.

So if you start to think about the high frequency of multimorbidity in people who have cognitive impairment, what does it mean? They have complex medical regimens. If they are in care, if they have a care, a stable care provider system, they are likely to be on multiple meds. They’re going to forget their meds. That’s going to be a problem. They’re going to have a fall because they were hypotensive from a med, or nobody paid attention to the fact that they weren’t coordinating very well. Also common in dementia. And so if you try to look at the patient care side of it, we don’t know very much about how to prevent exacerbations of most chronic diseases, but we know a few things, and I want to highlight just one report from Canada which showed that in a population, people with dementia who had high continuity of care with their doctor had lower rates of emergency room and hospital visits. Now, we would believe this from a primary care perspective.

I think that’s not hard to accept this conclusion, that if you know your patient, which is what you get with high continuity, you know your patient, you’re going to pick up on problems that they have before they get so bad that they end up in the emergency room or the hospital. Not all of them, but you’ll pick up on some. And so these kinds of ideas, we can do this today. We have the ability, Medicare allows us multiple different ways of getting reimbursed for every component of this, but we aren’t using them.

Eric 26:16

I would also say, having tried to find a primary care doctor out there in the wild, you can’t. And the ones that you can find are now mostly concierge and rarely see you. And there’s no continuity of care. It comes down to, again, like brass tacks, what are we doing? Let’s say I believe that screening actually does something. It works. Who should I be screening? Like, let’s drill down into the specifics. Who are you recommending, Anna, when you’re going out there talking to these primary care folks systems, who are you recommending screening for?

Anna 26:53

Well, there’s that haunting, sticky number of 65 and up. Right.

Alex 26:58

I.

Anna 26:58

That’s kind of. So that’s what we’re saying. Because it’s easy, it’s digestible. It’s sort of exciting.

Alex 27:04

You don’t sound enthusiastic about that recommendation, Anna.

Anna 27:09

Actually, I don’t mind it. I don’t mind it. And you’re gonna think I’m gonna say something even weirder, which is, I think where I work, we could go lower. We have a lot of, like a lot of people in my memory clinic are in their early sixties, so I think we have a population of a high concentration of all the risk factors we know about.

Eric 27:27

So maybe lower. Joe, who do you think we should be screening?

Joe 27:31

You know, at first glance, this, this is a challenging question. I would like to say we should be screening those people who actually indicate that they’re having more problems with their memory and thinking now than they used to, regardless of age.

Eric 27:49

So more case finding when they’re bringing up, when they’re bringing up concerns that we’re actually doing that.

Joe 27:57

I think so. I think so. Now, again, this might be a moot question. If we’re moving into an era of a blood test that can detect amyloid plaque accumulation in the brain.

Eric 28:08

But we’ll get that. We’ll get to that question.

Eric 28:11

Soo, you also were part of a workgroup from Alzheimer’s association about primary care and screening. Who do you think we should be screening?

Soo 28:22

Well, again, we’re quibbling about screening. Screening anybody? I think we should be asking all our patients, asking what? A question about memory and thinking.

Eric 28:34

A 25 year old, a 50 year old, the 65 year old?

Soo 28:38

Well, the reason for 65 has only to do with Medicare eligibility. That’s the reason why 65 is the number we all have in our heads. So it’s obviously related to actual risk. And there are other risks for cognitive symptoms in younger people than in older people. And we’ve known this for now, decades, that people who complain about cognitive changes are complaining about cognitive changes due to different things depending on the age bracket they’re in. So young people who say, yes, I’m having trouble, trouble with concentration. These are people who are likely to be anxious or depressed, or they’ve recently undergone a major stressor of some kind, and they’re preoccupied, and this is interfering with day to day cognition and goal directed cognitive activity, whereas people at 85 who say they are having trouble with their memory are much more likely to have a brain disease that are the cause of this. So I think, realistically, we have to bring some scholarship to this, too, because the pragmatics of it is that dementia is quite rare in people under 70, actually.

I was surprised to see a paper recently that was defining early onset dementia. Not as dementia under age 65 or 60, but under age 70. If you’re less than 70 years old and you have dementia, that’s now classified as an early, early age of onset. Okay, early age of onset. So I want to do. I want to mention a couple things, though. There are, as I know all of us on this call know, there are various devices to try to concentrate a population into subgroups of people who are more and less likely to have significant cognitive impairment. One of those tools is eradar from UCSF and Deborah Barnes work, but there are several others of a similar kind that takes readily available information from an electronic medical record for patients who have them, who are in care and uses various associations with cognitive impairment to create clusters of individuals.

So there are some studies going on in that direction as well. If you just screen people who are at higher risk based on an algorithm from medical records that includes age, comorbidities and, increasingly, zip code of residence or area deprivation index or some other indicator, you will find more people, you will be concentrating, you will be increasing the take, if you will, if you use those tools effectively. That’s a way to think about it, too.

Eric 31:35

So let’s say I’ve been convinced to do the screening. I’ve thought about who I’m going to screen. I’m just going to screen everybody who’s over the age of 65 as part of my annual wellness visit for Medicare. What should I use?

Anna 31:50

Well, I just wanted to say that the whole idea of, like, see if people report a symptom and then do a workup, that is the annual wellness visit approach for most practices, I think, is just a question. Yeah. And so the screen would be that question, and then the additional, you know, evaluation would be sort of the next steps in case finding.

Joe 32:11

You know, Ann, I think it’s interesting, and maybe there’s research on this, is how often does the process stop after that question is asked and a yes response is given, and then nothing happens. That, to me, is interesting. What leads to nothing happening there.

Soo 32:29

Right. And we don’t have data about delays. We don’t know anything about that now, unfortunately. And that part of the reason for that is just the data in medical records are not very granular. You know, you report an annual wellness visit using tick boxes, and whoever’s doing your financial management, your billing people decide, does this meet the criteria for billing or not? So I think the question of what to use is really, you know, it’s interesting how much people are biased in favor of one or another kind of tool. And I would like to just go on record, which we do on our bold, in our bold materials, that there is no best screen. There is not a best single screen. There are, there are screens that are better for a given purpose and a screen that’s good for an annual wellness visit, that’s a first stage screen, would.

Eric 33:24

Be a brief screen, something less than a couple minutes.

Soo 33:30

Yeah, less than five minutes, something like that. Those are well adapted to that kind of use by non specialists. When you start to talk about the long tools, like the Montreal cognitive assessment, this is a very, very difficult test. It’s difficult for patients. It’s difficult for staff to give reliably and validly without a lot of supervision over time. And it has fairly well documented biases. And so you have to consider various aspects of different tools in terms of, are they biased in certain populations? What are the biases? Do we know what their biases are? And are they enough to steer us in the direction away from those tools or toward those tools? And so there is some technical, there are technical aspects of this. I like to think of it in terms of talking with potential screeners, if you will, about what they want to accomplish with the tests that they want to choose. What is your goal of doing this in the first place? And then I’ll help you figure out what tool might be most suitable for your purposes. Interested in other people’s thoughts about this?

Anna 34:53

Well, our dementia careware cognitive health assessment, that program trains people to think about three things, a symptom. So asking a question and the reason for that is that’s incorporated into a lot of annual surveys and questionnaires for patients, including sometimes annual wellness visit. And what’s the cognitive screen in a functional. The question is like, have you had any changes in your memory or thinking in the last year, or have you or others noticed? And then we recommend a cognitive screening tool and a functional screening tool. And either of those could be given to the patient or an informant. And we give a variety of validated tools. Mostly people use like a quick ADL IDL checklist and for function and a mini cog.

But something like the GP Cog or 88 are options as well. So I think there’s something called an faq for the functional screen. But, you know, we’ve had a lot of conversations. Do you consider the screen positive if someone just has functional impairment? And you might if, as Soo points out, you want to address and support and help that person, you may then do a secondary evaluation or a longer conversation and realize you’re not really worried about cognitive decline. This is all something else contributing to functional decline. But another reason for that is sort of thinking forward to next steps. It really helps people lay like the tracks of, I have to think about cognition, I have to think about function.

These are the two components of a dementia diagnosis, and they’re highly important for caring for the patient. We also added to the screen, ask somebody about their caregiver and support system, because the other piece we wanted to lay the track for or keep really centered is the fact that who that person support system is and or if they don’t have one, is going to be really, really important to working up and managing a dementia if it’s there. So it’s a little, that may sound a little more burdensome, but if you kind of get into the rhythm. We were just did a site visit at one of our sites that’s doing this cognitive health assessment process, and they really said that after time you get into a rhythm, you do a quick cognitive screen, quick functional screen, and ask them about their caregiver and document it, or who’s in their life supporting them.

Alex 37:08

Joe, thoughts about this, or sense of what our best practices or what’s happening in Minnesota?

Joe 37:15

I mean, I don’t know if Minnesota is any better than anywhere else in terms of this conundrum of, number one, doing screening, and number two, if screening is done connecting people to the resources and services that would work for them, not just within the healthcare system, but in the community writ large as well. I think the process that Anna laid out to me is best practice, particularly the latter point of identifying the caregiver, documenting it, and then using that to develop care planning beyond just that initial visit. And when we look in general of how dementia is approached, screened and treated in many healthcare systems, that latter part is often missing. Not understanding who the caregiver is, not understanding what the care network is like, and more broadly, I would argue, not understanding what is available outside of the parent healthcare system that could help support people where they’re going to receive most of their care in general, which is not going to be vis a vis a healthcare provider or some other service. It’s going to be at home what community resources are out there. And I certainly see a disconnect between what healthcare systems do and know with regards to these resources and what’s going on in the community itself.

Soo 38:25

I want to raise a point about that, Joe and Anna, and that it comes back to the question of responsibility, kind of an ethical responsibility of clinicians, which I think is not something that is shared across all kinds of service providers. There’s not the same sense of obligation physicians are trained to accept. I have an obligation to help you. If you come to me, I am obliged to do what I can to help you. And this is, of course, an old and foundational idea about clinical practice. We talk about fragmented care. I would say we have atomized care, and that part of what gets lost in the race to meet our time commitments and our billing commitments as physicians and all the rest of this is this idea that we have this obligation, and to meet our obligation to help our patients, we have to stand back and say, what are the things I can do to help this person, not just understand what their brain is doing or find a disease diagnosis to explain it, but what are the things I can do to help? And that’s where the functional assessment really becomes so important. I would mention that functional and cognitive screens tend to correlate very highly. There’s plenty of evidence for that. Where they’re discordant, there are usually explanations for why they are discordant, and I won’t go into those, but there’s a pretty high correlation. So when you’ve got cognitive impairment and functional impairment, you can be pretty sure that the probability of a significant dysfunction of the brain is present is very high.

Eric 40:07

Okay, I got a question. I’m busy. I’m in primary care. I got a lot to do.

Soo 40:13

Yep.

Eric 40:14

This sounds like it may take a lot. How much time does this take for the average person? Animals?

Anna 40:20

Like five minutes.

Eric 40:21

Five minutes? Okay, I can do that. Five minutes. Or I can do a checkbox and just order amyloid blood test. I got an answer back. They got some amyloid in their blood. Done. Diagnosis? Alzheimer’s disease.

Soo 40:39

No.

Eric 40:41

Why not?

Soo 40:42

We don’t have those names. We don’t have the answers. Primary care patient. Right. We don’t have those studies. And I think even the world, experts in blood based biomarkers will say we have gaps in our data still and can’t really. We can’t just go out and screen everybody. And there are various reasons why, but the data don’t support.

Eric 41:08

Well, I want to be clear that the Alzheimer’s association, their draft guidelines don’t say you shouldn’t do it. It says we don’t encourage it. It’s like if the Ten Commandments said, you know, we don’t really encourage murder.

Alex 41:23

How should it kill thy neighbor?

Eric 41:26

We don’t encourage killing thy neighborhood. It doesn’t say don’t do it.

Soo 41:31

Yeah, but I wouldn’t count that as fully vetted scientific evidence or a position that is based on fully vetted scientific evidence. I think this is, as you well know, and our audience no doubt knows, this is a very lively area of research, and there will be much more useful recommendations coming along. But I think where we have trouble is in focusing on that big picture and what we’re asking of our generalist positions, and really to be respectful of what they do and not try to turn them all into mini specialists, for God’s sake. That’s not an appropriate way to behave for us as scientists, researchers. We need to be rethinking how we’re. What we’re asking of who. And those conversations need to be more robust than they have been.

Joe 42:28

Yeah, that’s a really great point, Soo. And, you know, again, I keep reflecting on these county visits. I do. Because every once in a while, the local town primary care provider will attend those presentations. And when I talk about some of these isSoos about the screening, or lack thereof, in dementia, inevitably, you know, someone will talk to me after that presentation saying, well, you were kind of hard on, you know, the primary care providers, family med docs and such, and at some level, like Soo is alluding to, she’s right. How do we envision this working in a way that fits into what is already a very challenging workflow for primary care providers and yet still achieve these goals? We know that can be helpful for so many, and I certainly don’t have an answer. Anna, maybe you do, but that to me is an isSoo as well.

Anna 43:15

I mean, yeah, as I’ve had, I think in general, primary care doesn’t have a lot of information about how to use these things. And as it gets rolled out, I think just clarity insofar as it can be provided and how they’re supposed to incorporate it. So one thing that I worry a lot about is if it’s instead of being a screening test, which again, I’m not sure if that’s the appropriate use of those tests based on evidence, but if we’re screening clinically for dementia and then we’re assuming that these biomarkers are helping us identify people who actually have Alzheimer’s disease, what about everybody else?

So then we, you know, there’s, you’re going to find a ton of people at vascular, lewy body, whatever, you know, mixed Alzheimer’s disease and vascular. What we really want is primary care specifically to be really well supported and aware of what else they’re supposed to do, starting brain health plans, you know, taking care of all the maintenance stuff, supporting people more broadly, getting caregivers supported and continuing to work up and support dementia and all of its symptoms, no matter the cause. So I don’t see this like getting us out of doing a lot of training and support and practice change activity, even if somehow we get really highly specific around Alzheimer’s disease. I don’t know if that makes sense.

Soo 44:36

One of the things you said in another forum, Anna, that I totally agree with is that you’ve raised the isSoo of reportable measures. And, you know, those of us who’ve been involved in quality kind of thinking about the quality measurement isSoos in dementia for a long time, it’s like we don’t have a quality indicator for dementia. We’ve had numerous efforts over a couple of decades to produce them, and there hasn’t been any consensus on what we should be doing. And I would want to bring us back in that dialogue to the question of maybe what we need is to think more simply about what quality measures could be created and made reportable the way a cognitive health assessment is reportable in California for Medicaid recipients. Is that not the case? Isn’t it the case in California, Anna, that, that for Medicaid recipients of the right who qualify for this, that it’s required that their doctors do a cognitive health assessment? Yes.

Anna 45:44

I don’t know that’s required. What I know is required, and I think this may be a national requirement for the D SNP beneficiaries, for people in those programs, those people who are a D SNP enrollee, dual special needs plans, which are Medicare, Medicaid. Yeah, Medicaid program. Anyway, they’re going to have to report on who they’ve screened, their screening rates. So that is something. But there’s no benchmark.

Soo 46:07

Yeah.

Joe 46:08

Okay.

Eric 46:08

Okay. I want to. Just running out of time. I want to do kind of a little bit of a lightning round from each of your perspectives. So we’ve talked about screening like, if you had a magic wand, what would you want? Those who are listening, those primary care providers, those people who are seeing, what do we want them to do after that test is positive? And Anna, I’m going to start off with you just thinking about how you think about this in dementia careware, which is a California state program. Right. You’re going everywhere. What would you be really focusing on?

Anna 46:41

I would be focusing on early connection to brain health activities and support, making sure people have good hygiene around all their medications and getting support for that, and sort of early connection and involvement of caregivers if they’re there. I think that’s the window of opportunity that we have, that when we miss it, you know, we get what we get, which is a lot of crisis driven care, and I don’t think anybody wants that. So I have really high hopes that universal screening will mean more people are detected in a more equitable way, and then we can really support people early with all these nonspecific and may not be very fancy interventions, but things that really help improve quality of life. I think that’s what I hope for.

Eric 47:26

Joe.

Joe 47:27

Yeah. I don’t think I could add much on to what Anna had said. I really gravitate a lot towards this idea of reframing this according to Brain health. I think thinking of it in that perspective is more helpful to those who are screened, those who are doing the potential screening, etcetera. And finally looping us all back to what Soo had originally mentioned of thinking of this care and brain care or dementia care in a holistic way that requires integration between what’s happening in the visit and then what happens at home. And how that can be facilitated effectively, but also in a way that is palatable to the primary care provider given their workflow. So that’s, I think, what happened in an ideal world.

Eric 48:15

And Soo.

Soo 48:16

So I would add on to this that you make then the brain health maintenance plan part of the cadence of care, and you start thinking about how often you ought to be following up on this, because this is like, are people actually doing the things that you advise them to do and how are they doing? And we don’t have good benchmarks for cadence of care either. You know, how often should we see our patients with cognitive impairment and this or that or not multimorbidity or behavioral problems or caregiver stress or financial concerns, worries about paying their bills. So these are things that cadence of care is what I would add and follow up planning how we need to do some studies to establish what’s a reasonable way of thinking about this. We don’t have enough primary care docs. We don’t have enough specialists. We don’t have enough time, and we don’t have enough teams. So all of those things need to be brought together in a massive reform effort, which will be done tomorrow.

Eric 49:18

Wow. I want to be mindful of all of your time. I want to thank you for being on, but we got a little bit more Sarah McLaughlin to play right now.

Alex 49:26

(singing)

Eric 50:47

Soo, Joe, Anna, thanks for joining us on this podcast.

Soo 50:50

Thank you so much for having us.

Eric 50:53

And thank you to all of our listeners for continued support.