>> My approach is going to be slightly different
and deal with one of the common quandaries
we have in medicine today, which is,
what do you do when you've got a terrible chronic disease
but you're working really hard to find a cure
but you don't have one quite yet.
How do you approach that?
And so I've decided to change my title
a little bit to what you see up there
which says, dementia care works.
The main message being that in dementia
and Alzheimer dementia especially,
there are lots of estimates about when we're gonna see
a cure but there's really a lot that can be done
to change the lives of patients and family members
with what we know now.
So this figure gives you a sense of counts.
You could get percentages
but they're not terribly helpful to get a sense of counts.
Ultimately when we provide care,
when we're estimating the burden of the disease,
we need to know how many people
we're gonna be taking care of.
And this illustrates dramatically how the counts
of people with Alzheimer's and other dementia's
is going to grow starting in 2010.
It's projected to double every 20 years.
Simply because the population is aging on a worldwide basis.
So the number in 2010 was around 35 million.
It's going to hit 70 and then well over 100 million
by the time we reach 2050.
Which isn't that far away, if you think about it.
And then, of course, the question becomes,
when will we have a cure?
So there obviously is a lot of effort
ongoing in this direction.
The disappointing part is in the last decade or so,
approximately 95 clinical trials have failed to produce
an effective curative type therapy for Alzheimer's.
Now, we always learn from such failures
and there is evidence that these new therapies
that are in pipeline might come on to the market.
So it's always worth a consideration
of what are they likely to do?
And how might their presence change the equation
that we were just talking about?
So what's in the pipeline that might hit in the market
in the next three to five, maybe 10 years?
For the most part are drugs that impact on the production
and accumulation of a brain protein called
amyloid, or A-Beta, that's involved in the damage of
the brain that leads to the Alzheimer's symptoms.
Pretty much every one of those drugs
that are in the pipeline don't have good evidence
they're going to stop the disease in it's tracks.
For the most part, they're gonna change it's trajectory,
bend it's curve if you will, in a positive direction.
So in fact, what might that mean is that if they make
it on to the market, the numbers that I gave you
will be under estimates.
Because we will be changing the curve,
not stopping the disease,
and therefore extending the life of people.
And the uncertainty, of course, will be
at what stage are we going to do that
and how are we going to impact the period of disability
which we expect people will still have.
Will we make it take longer and be milder?
So the good news is, there will be a cure at some point.
But in the next few decades we're not likely to see
a cure that stops the disease.
So if anything, we'll be looking after more people
with dementia then we estimated.
Now, from a large population study that we did in Utah
quite a while back, Cash County study,
we were able to look at the trajectories of people
with dementia in a systematic way
in many hundreds of people.
And this slide I think illustrates for you
that there's a lot of variability
in how people progress with dementia.
We have individuals here, who even after half a decade,
really don't change very much.
And then we have people, a minority,
who get worse very, very fast.
And then intermediate groups, perhaps with slow progression
at first and then acceleration.
And a number of patterns in between.
So one of the interesting questions is
has been for developing treatments for now,
is to understand what are the variables that influence
these changes in trajectory?
How could we, for example, find out what variables make
you go like this or like that as opposed to like that?
And can we do more of that so instead of that,
you have that kind of a trajectory.
That's sort of the background, if you will.
Now, ultimately this has been called dementia care.
It did start in memory clinics, Hopkins
and many other places have put this together.
Have large memory care centers
where we take care of patients.
And from the conceptual point of view,
there are common patterns,
they're all interdisciplinary.
In our particular case, we involve neurologists,
psychologists, geriotritionists, nurses,
psychologists, occupational therapists, physical therapists.
The second common theme is
that everything we do is personalized.
We involve medical management,
we put a lot of energy in taking care of caregivers,
and we improve access to research protocols.
And therefore, the specific activities of what we do is here
and these come from what we learn in Cash County.
It's critical to impact comorbidities,
manage heart disease, blood pressure,
blood pressure at the right level,
manage colds, dehydration, constipation,
the kinds of things that frail, older people develop.
It's critical to reduce the amount
of medicines that patients are.
We try to minimize the use or avoid the use of anesthesia,
especially general anesthesia.
We judiciously use medication for cognitive
or behavioral symptoms.
But we spend a lot of time
supporting patients and caregivers.
That's probably the essential piece.
There was a question asked earlier on
about enriching environments and activities.
And that's a big part of what we do.
So we have operationalized this
in a system called maximizing independence at home,
or Mind at Home.
Mind at Home was conceived by Roy Hoffberger,
a major Baltimore philanthropist,
who raised a number of funds to get us going many years back
to develop the Mind at Home project.
Mind at Home is about knowing the kinds of needs that
people have with dementia that influence the course
of their illness.
Surveying a given patient who's living at home
at a given point of time, what needs they have
that are not met and putting together a systematic
protocol for that person to meet their needs.
To reevaluate that protocol over time.
And this is ultimately spearheaded by this new workforce
that we're developing who are are care coordinators
who we chose largely based on attitude and compatibility
with working with mostly the older people
who we take care of.
As opposed to being experienced or skilled clinicians.
They so become under our training
and as they work with the patients.
So what are the outcomes?
Well, the kinds of things that matter to patients are
can I stay at home as long as possible?
Set the median we can delay leaving home
to nursing home by almost 10 months.
That is very impactful from day to day life point of view,
but also very impactful from the cost point of view.
We can improve life quality.
Very few studies in dementia have actually shown that
you can make life quality better.
Most of them show that an intervention
might change the trajectory of life quality
but not necessarily make it better.
Importantly, from the point of view of caregivers,
we can change the amount of time per week
that they have to spend in taking care
of the person they look after.
And the delta, the difference at one year,
is on the order of 16 hours per week difference.
Which is, if you think about it,
a lot of hours of less caregiving.
And this translates as well to a reduction
in the burden that caregivers experience.
So Mind at Home is very much in
it's expansion phases right now.
We several projects ongoing trying to refine it,
working to introduce technology in it's application,
why should we be having to go in to the home
all the time to monitor when we could, for example,
use technology to provide activities,
to interact with patients and caregivers.
And we're hoping that while we're waiting for the cure,
that will hopefully come sooner than later and be real,
that there's a whole lot that we can do at this point
to take care of the 100 million people who
are going to develop dementia in the next 20 to 30 years.
Thank you.
(audience applauds)
>> Very inspiring, Costas.
Questions?
>> Sally: Thank you, Sally Squires, freelance.
I'm interested in how many people are
participating in Mind at Home right now.
And how this fellow got interested in doing the work.
Hoffberger.
>> So I can't tell you the count today.
Over time we've touched about 1200 patients
and family members, largely in
the Baltimore/Washington area.
Roy Hoffberger, I think, started in this because
of his early career as a philanthropist,
he was the chair of the board of what was at the time
the Baltimore City Hospital.
And also of the nursing home that
had been started called Levendale.
So he always interested in making sure
that older people get better care.
And he realized in 2002 that he wanted that
to happen in the community.
>> Kevin: Kevin Sodin.
We know that Medicare pays horribly for geriatricians
and also pays very poorly for a lot of services.
How do you pay for this service?
And do you think insurers will,
because of the benefit, have an impact on it?
>> One of the projects that Mind at Home
has been engaged in is funded by CMS
through an innovations grant,
which is precisely attempting to estimate
the cost saving that believe will accrue.
And then we believe that Medicare will hopefully evolve
and shift from fee for service payments
for individual physicians, clinicians
to bundle payments that relate to managing
a disease over a chronic period.
That's how I think it's gonna happen.
And the savings will probably come from Medicaid.
So part of what's gonna have to happen
is a crosstalk so that when Medicaid accrues savings
that Medicare can pay a little bit more to offset that.
That's a big dream for the future
that I think that's how it'll get paid.
>> Margaret: Thank you, Margaret Crane, freelance.
Also, the role of community health workers
that you eluded to.
That would seem to be part of
the mix that would lower costs.
I wonder if the models taken from developing countries
with poor resources, restricted resources,
and the way they've managed to use
community health workers to deliver care.
I wonder whether we can learn from them
or whether we already have.
>> So it's a complicated answer, as I pointed out to you,
developing countries are going to face
the greatest burden of dementia care.
But they haven't yet because
their population isn't quite aged.
So most of what has been learned
has been coming from our sister english speaking nations,
Australia, New Zealand, UK, and to a great extent, France.
It is a community care worker based model,
as you correctly point out.
>> Thank you, Costas.
>> Thanks.