Improving Dementia Care Assessment and Communications -Training for Clinicians and Students

July 5, 2018

Rollin Wright, MD, MA, MPH, has worked extensively over the last five years not only to improve the ability of clinicians to assess patients for dementia, but also to provide them with the communication skills needed to better connect them to, and develop therapeutic relationships with, demented individuals who have lost language skills along with memory.

 

In the third year of a Health Resources and Services Administration (HRSA) Geriatric Workforce Enhancement Program (GWEP) grant (1U1QHP28736-D1-00), Dr. Wright and collaborators have been designing and testing curricula for medical students, residents, and geriatric fellows to teach these trainees not only how to communicate with people with dementia, but how to educate families about the disease and likely trajectories. "One of our aims is to give students and clinicians the ability to provide anticipatory guidance to patients and families about its likely trajectories as the disease progresses," says Dr. Wright.

Providers do not receive much specialized training to work with dementia patients who have language deficits, and families of patients at the outset simply do not understand how a person's brain changes as a consequence of the disease and how these changes may result in significant behavior changes - changes that will likely evolve as time goes on.

Families and even a large proportion of primary care physicians often do not recognize that dementia is developing until it progresses sufficiently to cause readily apparent deficits and behavioral changes. Since dementia-related behavior changes will occur in 60 to 96 percent of demented individuals, and since family members play such a big role in caring for their loved ones with dementia, the care.giver burden can be enormous. "Helping families prepare for and cope with these behavior changes is crucial to managing the disease progression. It is really at the heart of the curriculum we are developing," says Dr. Wright.

Dementia Simulation Training

Dr. Wright is also the author of two interactive training simulation modules available to physicians for CME credit via the American College of Physicians. The modules are divided into the early and latter stages of dementia. The modules begin by having the physician work through an understanding of the disease via a virtual case, which forces the learner to make decisions about the patient's assessment and ultimate care, and the case unfolds in a variety of directions depending upon the choices made. "Every decision has a consequence for the patient, but ultimately the training leads the user back to the appropriate or answer for a given situation. Quizzes are built into the case at intervals to reinforce the learning," says Dr. Wright.

The second training module went live in September 2017. This module proposes to the user a comprehensive dementia care strategy from the beginning to the end of the disease. "We built the module so that the case unfolds with a template for how a clinician would attempt to manage the disease as the person transitions from one phase to the next, through the various stages of care needs and milestones in a case of progressive dementia," says Dr. Wright.

Geriatric and Interprofessional Training for Medical School Students

Dr. Wright's educational leadership efforts also include her role as course director for the geriatrics course that is required of all medical students at the University of Pittsburgh. This innovative one-week course during the third year delves into all aspects of geriatric medicine and is the only required offering for medical students that teaches how to function in interprofessional teams. Roughly 150 medical students take the course each year, and another 60-70 students from other disciplines - physical medicine and rehabilitation, dentistry, advance practice providers, etc. - also take part in the course. The 200-plus member group is divided into 24 teams that pursue team-based learning activities focused on geriatrics.

"Only three to four hours of the course are spent in lectures. The rest of the time is devoted to immersive, interactive, and experiential learning," says Dr. Wright. One of the activities entails students working in pairs or trios at nine different health fairs and providing geriatric assessments at a number of UPMC Senior Communities independent and assisted living facilities. Students prepare for the assessments by taking part in a type of skills fair at the beginning of the course, where they learn 12 types of geriatric assessments in 15 minute sessions over three and a half hours.

Students are immersed in other activities that cover a wide range of necessary skills and knowledge when dealing with older adult health care. The 2017 edition of the course featured case discussions about geriatric syndromes, multimorbidity, geriatric pharmacology, the pathophysiology and everyday living with changes in the brain, advance care planning, and visits to long-term care facilities with resident and provider interactions.

"2017 was my third year as course director. It is a very intense process to plan and execute, and it is equally intense, if not more so, for the students who take it. A huge interprofessional team effort is necessary to its success, but we have an outstanding committee that is incredibly invested in making every activity applicable and relevant for the students."