A Case of Rapidly Progressive Dementia--and the Surprisingly Easy Fix

Maureen K. McCamley, MD, PhD


September 11, 2017

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I'm Maureen McCamley. I'm an internal medicine primary care resident at Emory University. I am happy to be presenting a clinical vignette on a case of rapidly progressive dementia.

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Let's meet our patient. Ms R is a 56-year-old African American woman who presented for routine follow-up at a primary care clinic. She has a history of hypertension and diabetes, and a possible history of schizoaffective disorder. When I was sitting in clinic with the patient, there was a knock on the door. A nurse walked in and said that the patient's daughter was on the phone and wanted to speak with me. I got permission from my patient and stepped out.

The patient's daughter was very concerned about her mother. She reported that over the past couple of months, her mother had just not "been herself." She described her as not able to cook or complete her daily tasks on her own, and that she seemed to be confused a lot of the time.

I walked back into the clinic with my patient and completed a Montreal Cognitive Assessment (MoCA). At this point in time, her MoCA score was a 6 out of a possible maximum of 30. I ordered some routine labs for her and referred her to the neurology clinic.

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Approximately 1 week later, she was admitted to the hospital. I only knew that she was admitted because I was on call that night and I happened to see her on my list. Her daughter had been so concerned about her mother's memory loss and weakness that she had brought her to the emergency room (ER) before her neurology appointment follow-up. Her admission history and physical exam were notable for increased tone, cogwheeling, and, most concerning, that she was oriented only to person and time. She had the full list of imaging listed here and a complete laboratory workup, including an autoimmune panel and a paraneoplastic panel. All of this was unrevealing for any reversible cause of her dementia. She was discharged again with neurology follow-up.

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Two weeks later, her daughter again brought her to the ER, reporting that her mother's symptoms had persisted and she "just wasn't getting any better." The daughter was very concerned. This time, she noted that her mother had also had some falls. Her exam today was notable for tremors of both hands, rigidity, a wide-based gait and, again, the same memory problems. She had another CT scan of her head which was negative. Neurology was again consulted and they concluded that her symptoms were most likely due to a neurodegenerative process. At this point she was discharged home with home health, physical therapy, and a rolling walker for her safety.

The Case for a Home Visit

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Because of my experience with Ms R and a couple of other clinic patients like her, I decided to do a home visit elective during my second year of residency. The blue dots on this map are the homes that I've visited over the course of a month.

Ms R lives in the southwest corner of Atlanta, where we have recently been known for our traffic issues. You may have heard of the fire on the Interstate that caused a collapse that shut down the highway for a couple of months. We also had a toxic chemical spill which shut down the main thoroughfare through the City of Atlanta; a buckling of the Interstate on the east side of town; and, my personal favorite, a truckload of Atlanta Braves foam fingers that spilled on the Interstate and shut it down for a whole day.

Needless to say, my mentor and I made it past all of these roadblocks—which made traveling around Atlanta very difficult—and to our patient's house. We arrived in the early afternoon and were greeted by Ms R and her daughter. The TV was blaring and her daughter, who had just completed a workout, was still sweaty and in her workout clothes. We sat down on the couch and I interviewed Ms R, asked her a number of questions, did my physical exam, and then said, "Can I see your medication bottles?"

She hands me two bottles. This surprised me, as I was sure that she was taking more medications. Her daughter then said, "Hey, Mom, where's that bag of meds?"

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The daughter went into the hall closet and brought out this bag of medicines.

There were 21 different bottles of 14 different medications, including multiple antipsychotics and anticholinergics, as can be seen in the handwritten list shown above. I had been unaware that she had been taking any of these. For reference, in the right-hand column, I have included the list that was in her electronic medical record the day I last saw her in clinic.

I performed a full medication reconciliation and left her with only three medications, plus insulin, at her home. I took all of the others back to the hospital, called her pharmacy, and stopped those prescriptions.

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Three months later, Ms R followed up with me in clinic and reported that she was feeling great. Her daughter said that she is doing wonderfully at home and has returned to her baseline. Both of them felt that she was back to her normal self. We repeated the MoCA, which was a 17 out of 30. She had increased from a 6 to a 17 over the course of 3 months, with the only intervention being a home visit with the removal of medications from her house.

Home Visits: Patient and Physician Outcomes

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The cost of this? The base Medicare reimbursement for her multiple hospital admissions was more than $30,000. The cost of the home visits, including billing for the visit, gas to and from, and a couple of lattes for my mentor and me: $127. Patient-centered care? Priceless.

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Patients love home visits, and there are some data that show that home visits are really good for patients, especially those who are homebound, have difficulty traveling, or rely upon a caregiver at home. They can improve quality of life and decrease safety risks in the home.

They can also make physicians happier, but we'll get to that in a little bit.

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Finally, home visits have been shown to be good for training. Home visits can provide a unique platform to help residents learn all of the Accreditation Council for Graduate Medical Education (ACGME) competencies.[7] The visits improve the knowledge base about geriatrics, especially for younger trainees who might not have had as much exposure to the elderly.[8] Most notably, they can help decrease the risk for hospital admission—and readmission—in that most critical time following discharge.[9]

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Are there barriers to doing home visits? Of course. Like most things in life, time and money present barriers.

Time: How do we fit home visits into an already jam-packed internal medicine residency program?

Money: If we don't have significant reimbursement reform, how do we justify pulling an attending and a resident out of a fully booked clinic?

There are other issues as well: safety concerns, logistics issues, and medicolegal issues.

Home visits are good for patients. They are good for residents. And now I want to tell you why they are really good for me.

Home Visits: A Personal Tale

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During my intern year I did 5 consecutive ward months. At the end of that, I was tired, frustrated, and burned out. I spent a lot of time reflecting on what it was that I loved most about medicine.

For me, it's two things: face-to-face time with patients and clinical decision-making. I realized during those 5 months that the time I had to be able to do the things I love had decreased significantly.

For example, last month I was an upper-level resident on a team at Grady Hospital. On my first call day, I saw 21 patients over 14 hours in the hospital. During that time, I used my phone to check the amount of time that I was in each room. I went into a patient room, clicked the timer button on my phone, and came out. The total was 47 minutes. Seeing 21 patients over 14 hours, I spent only 47 minutes face-to-face with patients.

What was I doing with the other 13 hours? If I wasn't answering pages or waiting on elevators, I was sitting in a call room behind a computer checking charts, running discharge summaries, and checking orders.

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Let me contrast that with a day of home visits. First of all, I don't have to be at the hospital at 6 AM. My mentor meets me. I drive, as she is newly arrived from Michigan and doesn't do very well with the Atlanta traffic. We pick up a couple of lattes and we drive to our first appointment. While we're driving, I get uninterrupted one-on-one time with an experienced clinical mentor. We discuss my focus and goals for the visit. I can bring up any concerns I have about my patient's clinical course and management decisions. After the visit, my mentor can give me immediate feedback on my communication with patients.

At the patient's home, I get uninterrupted one-on-one time with my patient and their family. For the entire course of this day or half-day, 100% of my time is spent doing the two things that I love most about medicine.

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In summary, polypharmacy is a frequent and easily reversible cause of rapidly progressive cognitive decline. Home visits can be especially useful in vulnerable populations. They can be both cost-effective and an effective training tool for residency. And they can help prevent burnout.

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Now I'd like to provide some follow-up about my patient, Ms R. I saw her a few months later in clinic. I told her that I was going to be telling her story at a national conference. She was so excited to hear that I was going to be talking about her, that she wanted to take a picture and asked me to use the picture that we took. She is doing great, and she especially wanted me to let you know that she is wearing her Prince T-shirt in the picture.

Thank you.

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