The Case for Advance Care Planning. Advance care planning is a series of conversations that a patient and you, their care provider, have about end of life wishes. Continue reading
Written by: Scott Endsley, MD, MSc., Associate Medical Director for Quality
Dementia is a terminal illness, like cancer or advanced heart disease. Dementia is rapidly increasing in the U.S. and worldwide. In 2012, there were over 5.2 million Americans with Alzheimer’s Disease (AD). By 2025, the number is expected to grow by almost 30% to 6.7 million. Along with the prevalence expanding at epidemic proportions, mortality also continues to increase. It is the 5th leading cause of death in the U.S.
Dementia is a progressive disease with seven stages (figure 1). Alzheimer’s Disease may last for decades, though the mean in eight years. The Global Deterioration Scale is a validated instrument that is helpful in staging the patient along the progression timeline. Memory and function loss proceeds inexorably across the stages until Stage 7 in which the patient has very limited words, incontinence, severe function loss requiring assistance for ADLs, and total disorientation. Median survival in Stage 7 is 1.3 years. Over 80% of patients in this stage have significant eating problems, often requiring assistance. Resultant weight loss is common. Infections, primarily pneumonia and urinary tract infections, are common and carry a high risk of mortality (40% or greater in the CASCADE study)
Palliative care is appropriate at any point after diagnosis and may be provided along with symptom management as early as Stage 2. Caregivers and providers are often confronted with the agonizing decision of anticipating death and entering the patient into hospice. Prognostication in advanced dementia is a problematic endeavor. The ADEPT tool has been developed to assist in predicting survival based upon eleven variables in demographics, cognitive status, functional status, active diagnoses. Risk scores greater than 16 (scale 1-32) suggests a six month probability of dying of > 50%. The Medicare Hospice guidelines requires the patient to have significant functional limitation (Stage 7 or beyond of Functional Assessment Staging (FAST) scale) AND at least one of six medical complications in the preceding year including aspiration pneumonia, pyelonephritis, septicemia, multiple decubitus ulcer, recurrent fevers after antibiotics, or inadequate hydration and caloric intake with 10% body weight during previous 6 months (or serum albumin less than 2.5 g/dl). When compared to the ADEPT prognostic tool, the Medicare Hospice guidelines perform less reliability in predicting 6 month mortality.
Recommendations. As your patients with dementia of any type (Alzheimer, vascular, Lewy body) progress through the seven stages, consider the following:
- Educate caregivers on the nature of dementia as a progressive and ultimately fatal disease
- Initiate advance care planning conversations early (stage 1 or 2)
- Ensure that a surrogate has been identified to medical decision making
- Start palliative care in addition to other medical care early or at least by Stage 5 or 6.
- Manage symptoms (neuropsychiatric, incontinence, insomnia) appropriately
- Recommend caregiver assistance early to avoid burn-out and depression
- Consider hospice evaluation at Stage 7
Resources. Many dementia management resources are available. Consult these as needed.
Alzheimer Association: www.alz.org
National Institute for Aging: www.nia.nih.gov/health/alzheimers-dementia-resources-for-professionals
National Hospice and Palliative Care Organization: www.nhpco.org/resources-access-outreach/dementia-resources
 Tejada-Vera B. “Mortality from Alzheimer’s disease in the United States. NCHS Data Brief. National Center for Health Statistics, Hyattsville, MD 2013
 Reisberg B, Ferris SH, de Leon JJ, Crook T. “The Global Deterioration Scale for assessment of primary degenerative dementia”. Am J. Psychiatry (1982), 139: 1136
 Mitchell SL, Teno JM, Kiely DK et al. “The Clinical Course of Advanced Dementia”, NEJM, (2009), 361:1529
CASE: One of your patients brings in her mother who she reports is having increasing forgetfulness. She is 82 years old, with longstanding hypertension and heart disease. No history of stroke. The forgetfulness was starting to be noticed in her late 60’s and has progressed gradually since then.
Does this patient have dementia? The Alzheimer’s Association recommends looking for the ten warning signs of dementia that include:
- Memory loss that affects daily living or work
- Difficulty performing familiar tasks
- Problems with language
- Disorientation in time and space
- Poor or decreased judgement
- Problems with abstract thinking
- Misplacing things
- Changes in mood or behavior
- Changes in personality
- Loss of initiative
Dementia is very common, affecting up to 50% in patients over 85 years of age, and 10% in patients 65 years. As we all age, our memories decline. However, primary care physicians should be alert to patients who are experiencing memory loss without other signs of cognitive impairment. This is defined as mild cognitive impairment (MCI). Unfortunately up to 81% of patients who meet the criteria for dementia never receive a documented diagnosis. Up to 25% of patients with MCI progress to full dementia each year, and should be evaluated and managed.
Key diagnostic studies include a CBC, serum glucose, serum electrolytes with BUN and creatinine, serum B12 levels, liver function tests, thyroid screening with TSH and depression screening. The latter is crucial as many patients with depression present with mild cognitive impairment. At the present time, there is little evidence to screen for syphilis (unless specific risk factors exist), doing EEGs, APOE genotyping, MR or CT scans or SPECT scanning. Use of PET scans or genetic screening for Tau mutations are controversial.
If cognitive impairment exists, consider use of cholinesterase inhibitors or vitamin E in patients with mild to moderate dementia. Diagnose and treat depression and psychosis as appropriate. Many patients with dementia develop functional or behavioral problems. Consider the following:
- Behavioral modifications (scheduled toileting)
- Music especially during meals and bathing
- Walking or light exercise
- Pet therapy (yes with animals, not electrons)
- Cognitive exercise
Last year, approximately 33% of two year old members of Partnership Healthplan were not fully immunized. Continue reading
In examining how to improve patient outcomes we turn to population medicine to develop treatment strategies. Continue reading
Submitted by Jeff Ribordy, M.D.
In this edition of “Science, It Just Works – Vaccine Edition” we have some recent studies to report: Continue reading
Over the years, I tried to keep track of the health statistics for the county where I practiced. I knew that 11% of adults smoked, 18% had excessive alcohol consumption and 24% were obese Continue reading
The PHC Blog article on February 6, 2017 gave a very nice overview of the American College of Physicians (ACP) newly released guideline on treatment of Type 2 Diabetes (DM2). I will quickly summarize: start with metformin, then add another medication as needed based upon side effect profile and patient characteristics.
This guideline is very similar to the ADA guidelines. I appreciate the ACP attempt to look at side effects of the different classes of DM2 medications and to avoid certain medications in patients with pre-existing medical conditions. The guideline however doesn’t provide guidance on medication selection based upon cost.. Why does cost effective prescribing matter? Because for every dollar PHC spends on medications, we have to spend less on other health care or enhanced benefits. PHC is a non-profit organization with a 4% overhead. There is not much room for un-necessary spending.
Let’s start first with a simple table of the various choices:
|Class||Example||Action||Cost per month|
|Biguanide||Metformin||Decrease hepatic glucose, increase insulin sensitivity||< $5|
|Sulfonylurea||Glipizide||Increases pancreatic insulin secretion||< $5|
|Meglitinide||Repaglinide||Increases pancreatic insulin secretion||$60|
|Thiazolidinedione||Pioglitazone||Decrease hepatic glucose, increases insulin sensitivity||$10|
|DPP-4||Alogliptin||Increases pancreatic insulin secretion||$430|
|GLP-1 RA||Liraglutide||Increases pancreatic insulin secretion||$550+|
|SGLT-2||Canagliflozin||ncrease urinary glucose secretion||$430|
Metformin is the first choice in all guidelines. Metformin decreases hepatic glucose and increases insulin sensitivity. Start slow (500 mg with the evening meal) – Start slow with 500 mg once daily with the evening meal and, if tolerated, add a second 500 mg dose with breakfast. The dose can be increased slowly (one tablet every one to two weeks) as necessary (per UTD).. The longer acting ER formulation has fewer GI side effects and is on the PHC formulary. Metformin is contraindicated for patients with a GFR < 30. Consider dual therapy at the outset for patients with an A1c > 9% at diagnosis.
If not at target at 3 months with metformin, diet and exercise, add a sulfonylurea (SU) or basal insulin. Repaglinide is an option for patient who don’t reach goal with metformin and cannot take a sulfonylurea and who wish to avoid insulin. It is short acting and may be better for people who skip meals. Pioglitazone is another choice after metformin and a SU, but it should be avoided in patients with a history of heart failure. Generally, a third oral agent will not get a patient to goal however if the A1c is over 8% on metformin and a second oral agent.
Dipeptidyl-peptidase-4 inhibitor drugs, such as alogliptin, work to increase pancreatic insulin secretion and suppress hepatic glucose production. They may decrease an A1c by 0.5 to 1%. A DPP-4 drug may be considered when your patient is close to target, but not yet controlled on metformin and insulin. Alogliptin is a step agent for PHC and is covered if the Rx claims history shows fills for metformin and a second agent (oral or basal insulin).
GLP-1 Receptor Agonists:
Liraglutide is the preferred glucagon-like peptide-1 receptor agonist for PHC. GLP-1 agents increase insulin secretion, suppress hepatic glucose production and slow gastric emptying and thereby increase satiety. They can decrease an A1c by 1 to 1.5%. They may be appropriate agents for patients with a BMI > 30 for patients on metformin and a second oral agent or basal insulin.
Canagliflozin and other sodium-glucose cotransporter 2 inhibitors work by lowering the renal threshold for glucose and increase urinary glucose excretion. The dose has to be adjusted for renal insufficiency. Side effects include UTIs, yeast infections and weight loss. They may also increase LDL cholesterol.
Ultimately, your patient needs what he or she needs after treatment with diet and exercise. The medications will cost what they cost, but it is possible to make cost effective choices that get our patients to goal if we choose with care.
James Cotter, MD MPH; Linette Rey, PharmD
An established patient makes an appointment with her primary care provider to evaluate progressive shoulder pain, not getting better in spite of taking ibuprofen three times a day. Continue reading
California made huge strides in care for the uninsured since ACA implementation in 2014. California decreased the number of uninsured from 6.5 million in 2013 to only 3.3 million by 2015. Continue reading