The Brain Trust - Episode 6: Early Detection in Rural Communities

 In today's episode, Eukesh Ranjit, MD talks with  Sharon Smaga, MD about the unique challenges faced by providers serving in rural patient populations. They discuss the barriers, solutions and provide successful tips on how to improve early diagnosis clinic practices in rural communities. 

Learning Objectives:

1 - Describe barriers to early detection of Alzheimer’s Disease and related dementias in rural communities

2 - Name ways family physicians can create a supportive environment for early detection of Alzheimer’s disease and related dementias for patients living in rural communities
 
Host: 

Dr. Eukesh Ranjit, MD, Assistant Professor of Family Medicine and Director, Division of Geriatric Medicine at SIU Center for Family Medicine in Springfield, IL

Guest:
Sharon Smaga, MD, SIU Family Medicine Carbondale

This CME activities will meet the  State of Illinois Continuing Medical Education Requirements for Physician License Renewal for Recognizing Dementia. Every licensed healthcare professional who has direct patient interaction with adults age 26 and above must take one hour of training on the diagnosis, treatment, and care of individuals with Alzheimer’s disease and other dementias.

Accreditation

The Illinois Academy of Family Physicians (IAFP) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

AMA PRA Category 1 – The Illinois Academy of Family Physicians designates each Online enduring material for a maximum of 0.50 AMA PRA Category 1 credit™

Healthcare practitioners other than physicians (PAs, NPs) will be issued a certificate of participation to submit to their respective boards to be used toward their continuing education requirements.

Visit www.thebraintrustproject.com for more information

Visit The Brain Trust project to claim CME credit for this podcast, listen to other episodes, and view the toolkit for resources on managing Alzheimer’s and other related dementia’s in your practice.

Visit The Brain Trust project to claim CME credit for this podcast, listen to other episodes, and view the toolkit for resources on managing Alzheimer’s and other related dementia’s in your practice.

Visit The Brain Trust project to claim CME credit for this podcast, listen to other episodes, and view the toolkit for resources on managing Alzheimer’s and other related dementia’s in your practice. 

Transcript

The Brain Trust Podcast |Episode #6: Rural Communities 

Transcript

 Speaker 1: Kate Rowland, MD

Welcome to the Brain Trust, A Physician's Guide to Diagnosing Alzheimer's Disease and Related Dementias. Brought to you from the Illinois Academy of Family Physicians. I'm Dr. Kate Rowland, family physician, member of the IAFP and faculty at Rush University. Funding for this podcast series was provided by a grant from the Illinois Department of Public Health. The goal of the Brain trust in this podcast series is to educate and empower the primary care clinician in the early detection, diagnosis and management of Alzheimer's disease and related dementias.

Clinical resources, Free CME and other educational materials are available online at theBrainTrustProject.com. CME Credit is available for each podcast. The Illinois Academy of Family Physicians is accredited by the Accreditation Council of Continuing Medical Education to provide continuing medical education for physicians. Information on how to receive credit can be found on the Brain Trust Project website.

Thank you for joining us. As we empower each other and provide training on the early detection of Alzheimer's disease and related dementias. And now today's episode.

00;01;07;27 - 00;01;36;25

Speaker 2: Eukesh Ranjit, MD

Hi, everyone, and welcome to today's episode of The Brain Trust A Physician's Practical Guide to Alzheimer's and Related Dementias. Today's episode is Dementia Care in Rural Communities. I'm your host. You guessed it. I'm the director of division of geriatrics at Southern Illinois University Center of Family Medicine in Springfield, Illinois. Today, our guest is Dr. Sharon Spargo. She's a geriatrician and professor emeritus of family medicine.

Family and community medicine at Southern Illinois University in Carbondale. In today's episode, we will be discussing early detection of Alzheimer's disease and related dementia, as in rural communities. Welcome to the podcast, Dr. Smaga.

00;01;51;09 - 00;01;51;24

Speaker 3: Sharon Smaga, MD

Thank you.

00;01;51;25 - 00;01;59;18

Speaker 2: Eukesh Ranjit, MD

It's really nice having you here with us today. I'm excited about talking with you to talk about all these issues with you for a long time.

00;02;00;11 - 00;02;04;16

Speaker 3: Sharon Smaga, MD

I know we do meet every once in a while, but don't really get to sit down and talk to each other.

00;02;04;22 - 00;02;22;14

Speaker 2: Eukesh Ranjit, MD

And though we do know that I would like to pick your brain today and learn more about your experiences of working with. I know that the patients with dementia in rural communities. So tell me a little bit about your community and the prevalence of Alzheimer's and dementia and then the proposition that you serve.

00;02;23;01 - 00;02;44;29

Speaker 3: Sharon Smaga, MD

Well, as you said, I, I live and work in Carbondale, which is probably one of the larger communities in southern Illinois. But it is, you know, part of rural southern Illinois. The prevalence of Alzheimer's is hard to say. I even actually spoke with our local Alzheimer's Association director and really couldn't give numbers specifically for this part of the state.

However, we do know that the population of elderly geriatric patients is higher in southern Illinois compared to the rest of Illinois. And so just looking at that, we have to also then assume that the prevalence of Alzheimer's is higher since we have a higher population of elderly people here.

00;03;02;09 - 00;03;29;04

Speaker 2: Eukesh Ranjit, MD

That is really interesting to ask my guy and this is something we have not really talked about much. And then I think our mainstream medicine, the fact that rural communities and smaller communities often tend to not be served as well as the urban communities. It's hard to even find numbers of people with Alzheimer's. And we have to related to people with elders that that is a very interesting thing that I hear from you.

So working with this community without even getting a proper data, there must be a number of challenges that you face on a regular basis. Could you please tell us more about some of the challenges that you face on a regular basis with early detection of Alzheimer's in your community?

00;03;44;29 - 00;04;03;27

Speaker 3: Sharon Smaga, MD

Well, I think there are a lot of challenges actually, starting with number one and a lot of denial with the patients themselves. They're reluctant to, you know, even talk with their own physicians about it. They often won't bring it up. You know, it'll often take a family member to try to contact their physician to say, hey, I think there's a problem here.

And once, you know, you're you think there may be a problem. First of all, the physician in their office may feel they don't have the time or the resources to really truly evaluate this person for Alzheimer's. If they don't feel they can do it, they don't they don't feel that there's a lot of specialists in the area who would be very knowledgeable in this area.

You know, we don't have a whole lot of neurologists, geriatricians, etc., you know, in southern Illinois. And so really the resources are not as good as if there would be an urban area and just the physician having time in their office to feel that they can really take care of the problem.

00;04;37;20 - 00;04;46;18

Speaker 2: Eukesh Ranjit, MD

Sure. And then the physicians there, they're taking care of a wide variety of patients. We have a lot of physicians, our family physicians and community patients that would say. Is that correct, Ex-smoker?

00;04;46;21 - 00;04;56;13

Speaker 3: Sharon Smaga, MD

That is correct. They're seeing a lot of different people and they, you know, have short ten, 15 minute time to see the patient and so, you know, what can they get done in that amount of time to evaluate this problem?

00;04;56;27 - 00;05;20;12

Speaker 2: Eukesh Ranjit, MD

Now, that is a big problem. And I find that problem not just in southern Illinois, but I've worked in rural Louisiana. And then the problem is the same. Basically, we have limited number of providers, and the limited number of providers can only do so much. And the time you have is limited. And you know, you have so many different comorbidities that you are actually taking care of, that you have one slice of that 10 minutes.

00;05;20;12 - 00;05;38;07

Speaker 2: Eukesh Ranjit, MD

And it's it's very hard to assess for dementia and Alzheimer's disease in that slice of time with your population and your practice down there in Carbondale. What efforts have you made, you know, with regards to early detection in a given all these barriers that you have.

00;05;38;28 - 00;06;01;11

Speaker 3: Sharon Smaga, MD

There are community resources that could be used once people know that they're there. There's community resources such as we have Shawnee Alliance that takes care of a large amount of counties in southern Illinois, and they will come and do some assessments for the patient. We also have the Egyptian area agency on Aging, and they have some resources. There's also local Alzheimer's Association.

So these resources can be utilized to help with the evaluation. There's also things such as we're actually part of the the sue memory aging clinic that people can refer to, and it's the whole SEIU and the statewide, at least in central and southern Illinois. There's a whole memory and aging network that you can go online and look that up and see, which if there's a clinic that would be near your practice that you could use.

You can also see your own local social worker network and go through them because they often have things available.

00;06;32;23 - 00;06;50;12

Speaker 2: Eukesh Ranjit, MD

Absolutely. We do tend to talk a lot about specialists and subspecialists, but at the end of the day, a lot of the brunt is actually borne by the caregivers and the local community. Basically, it's it's it's almost like it it's a new thing now. It takes a village to take care of. And Alzheimer's and dementia.

00;06;50;14 - 00;06;51;06

Speaker 3: Sharon Smaga, MD

Exactly.

00;06;51;10 - 00;07;21;21

Speaker 2: Eukesh Ranjit, MD

And knowing the resources that you have locally plays a big role in how we treat our patients with Alzheimer's and dementia. And I could mention that the memory and eating network, I believe it's it's a part of the whole Illinois system, if I'm not mistaken. And I think that they have clinics throughout the state, as far as I know, also Alzheimer's chapters, local chapters, they do have a lot of resources and I use some of the resources over here in Springfield myself as well.  All of these are great research, this I would say.

00;07;25;01 - 00;07;33;00

Speaker 3: Sharon Smaga, MD

Yeah, and the families can get on and you know, there's online tools for them to also see if they think there's a problem going on with their family member.

00;07;33;01 - 00;07;45;10

Speaker 2: Eukesh Ranjit, MD

Yes. You talked about the family members. And, you know, if you think if there's a problem with the patient, what tips do you have for early detection? You know, as as a part of regular visitor for family members per se.

00;07;45;25 - 00;08;13;09

Speaker 3: Sharon Smaga, MD

As far as tips for early detection? As far as the physician themselves, you know, they could have specific times that they would actually do some screening. I think most providers try to provide the Medicare annual wellness visits. And of course, some of the dementia screening is part of that. Other times would be like if the physician thinks, you know, the patient comes in and they have a concern about the patient or the patient or family member comes and has some concern, you know, that's obviously a time to do some evaluation.

But yes, if any time the family member is concerned, they should also call their provider. You know, and say, hey, I want to at least tell them about this so that the provider can can go from that and call the patient and kind of evaluate them further.

00;08;26;09 - 00;08;46;10

Speaker 2: Eukesh Ranjit, MD

Yes, that is always important just to know those red flags. And this is someone who has a thinking problem that is not healing, for lack of a better word. The fact that they're being more forgetful and all this red flags that do help us in an early detection a lot. Let me ask, is there something more clinical, I guess, where I just something that I find interesting.

So where are the tools and resources that are there that utilized in their clinic? And what are the tools that might be there for our primary care physicians who are not necessarily geriatrics trained, but that are working and serving our communities throughout the rural parts of Illinois?

00;09;01;18 - 00;09;20;13

Speaker 3: Sharon Smaga, MD

There's a several different tools that could be used by providers to aid in this. Some of them would be, as I had mentioned, using your annual Medicare Wellness visit to do some of the screening and setting aside maybe some other yearly time, you know, to do some kind of screening. There's a few different tools that are out there that can be used for screening.

I think most people are aware of the M.S. that's been around for many years. That's been a traditional screening. It has kind of changed to a proprietary form. And so some people are not using it as much now. And there's also one called the MOCA, the Montreal Cognitive Assessment, that's out there. But again, most providers are probably not going to be starting with something like that.

What is out there that could be used? And it's pretty simple. So the mini cog where it's the screen where you ask three questions, ask the patient to remember the three words, I'm sorry, and they have to repeat that to you later and you have them draw a clock. So it's a pretty efficient screening tool to use in the office.

Another one is the slums of St Louis University mental status exam that is free to use and it's also, you know, a relatively quick assessment that can be used in the office. And not only those, you know, those tests all look at cognitive test, but I think when you're evaluating these, it's also good to look at the patients, what we call the functional assessment.

And so, you know what these memory problems are they having problems now driving, taking care of their bills, cooking, you know, the activities of daily living. I think throwing in the assessment for that is also important.

00;10;33;26 - 00;10;55;01

Speaker 2: Eukesh Ranjit, MD

Yes. You bring a very important point of view here. Oftentimes we tend to think about dementia or memory issues or Alzheimer's as just as this cognitive decline. We do not focus so much on function assessments. And it's a combination of both. Basically, it's a there has to be a decline in cognition and it has to be severe enough to affect their activities of daily living.

And I think I mean, if we can combine both of these, I think we can detect Alzheimer's and dementia at an earlier stage and also trace their decline actually, like and if there's a functional ability that they're capable of performing six months ago but they cannot perform it right now. We know that they're declining.

00;11;12;18 - 00;11;31;18

Speaker 3: Sharon Smaga, MD

And it also helps, I think like we say, sometimes the families are concerned and you do the testing. They don't see you know, they don't they score pretty well on the tests. But from what the family is saying and the patient admits functionally they're not doing well at home. And so this is a person that may need, you know, intervention a little earlier than, say, somebody that doesn't score as well.

But he and the family are like, oh, everything's great. We're we're doing fine at home, you know, and don't need much. So you have to take both into consideration.

00;11;40;07 - 00;12;07;04

Speaker 2: Eukesh Ranjit, MD

Absolutely. And then also, we have to remember that the tests that we do, these are screening tests and these are not diagnostic tests. We screen patients for dementia, but it's patient scores. Well, it does not mean that the patient does not have the means separate. Say, I actually was interested in these studies and I but we did a review on we actually got a published review on these different tests and the sensitivity and specificity of these tests are almost similar, like admissible come in ECOG slams.

Many clock tends to be much shorter. Basically, it's assessed, like you said, three remembering keywords and drawing a clock. So I find it to be more practical to use mini cog, especially if you have a large volume of patients that you're serving.

00;12;21;11 - 00;12;22;09

Speaker 3: Sharon Smaga, MD

I think you've.

00;12;23;00 - 00;12;38;21

Speaker 2: Eukesh Ranjit, MD

Done in 5 minutes and other 5 minutes to talk about function assessments. Now as a primary care, you know, you have a good idea of what the patient status is. I think that is a good approach to this. Why? How long have you been in practice now?

00;12;39;12 - 00;12;44;11

Speaker 3: Sharon Smaga, MD

Oh, boy, about 37 years, I think.

00;12;44;28 - 00;12;51;15

Speaker 2: Eukesh Ranjit, MD

Oh, wow. Okay. So you must have had a lot of experiences with the community all these years.

00;12;51;24 - 00;13;08;23

Speaker 3: Sharon Smaga, MD

I have. And some years ago I started off more as a I'll say, as a O.B. what I did a lot of deliveries and all once I got out of that, I kind of switched. It's like, okay, where else could I help out? And I looked at the geriatric population and thought, This is a big need in southern Illinois.

So since then I've worked a lot with geriatric patients in various forms of either nursing homes or in the memory clinic. And so I have dealt with these issues for quite a while and.

00;13;19;18 - 00;13;36;04

Speaker 2: Eukesh Ranjit, MD

How that is amazing. I mean, like so you have seen patients throughout the spectrum. They're like, yeah, and then you finally decided to do more for the geriatric patients because there was a need and even in geriatrics, you have seen patients throughout the whole spectrum of geriatrics. Nursing home.

00;13;36;16 - 00;13;37;18

Speaker 3: Sharon Smaga, MD

Definitely, yeah.

00;13;37;19 - 00;13;48;16

Speaker 2: Eukesh Ranjit, MD

Inpatient, outpatient home visits, the habitat is amazing. It was something about, you know, some of the positive experiences that have had, you know, with regards to dementia, early detection.

00;13;48;27 - 00;14;08;28

Speaker 3: Sharon Smaga, MD

I have had patients or they were reluctant and, you know, they didn't want to admit there was a problem, but the families actually saw some issue. And so, you know, once evaluated those option issue and by talking with the patient and saying, you know, look, we're not trying to make you feel bad, we're we're just trying to find a problem, just like if it were diabetes, if we catch it early, we can take care of the problem.

And one of the things we want, you know, you want to stay in your home. We want you to stay in your home. So by finding this early, we're going to do everything we can so that you can stay in your home and lead a productive life. And then, you know, when patients hear that they're willing and get the help they need and they do end up having a more productive life because they're able to stay home, kind of do things that they would really like to do.

00;14;31;09 - 00;14;45;29

Speaker 2: Eukesh Ranjit, MD

You bring up a really great point, actually, like a number of times patients when they hear the term dementia or Alzheimer's for that matter, even mild cognitive impairment, patients often just think, okay, I'm going to a nursing home and I'm going to have a life that I do not want. All right.

00;14;46;25 - 00;14;53;17

Speaker 3: Sharon Smaga, MD

So we we try to tell them that that's not the whole purpose of this, right. Where we're trying to keep every other part going for you.

00;14;54;01 - 00;15;11;04

Speaker 2: Eukesh Ranjit, MD

Yes. This is sometimes patients are like, what you don't know doesn't harm you, you know. So I just think that our approach as well or patients are reluctant to do that, but just letting them know that learning about their condition so early could actually make them independent for longer and have the quality of life they enjoy for longer.

It is something that has been helping in my practice as well, and I'm happy that they know this. It's the same with you as an obviously you have much more experience on these than I do, and I.

00;15;23;16 - 00;15;24;05

Speaker 3: Sharon Smaga, MD

Have a little bit.

00;15;26;14 - 00;15;47;06

Speaker 2: Eukesh Ranjit, MD

About I've learned so much from you about rural communities today and from the conversations we've had in the past as well. For clinicians who are just starting out, who are clinicians, who are amidst a busy practice where, you know, they have especially our family practitioners with so many different conditions that they have to tackle on a regular basis.

What kind of encouragement or what kind of advice would you like to give them with regards to dementia?

00;15;53;15 - 00;16;17;02

Speaker 3: Sharon Smaga, MD

I try to tell it because we do train. A lot of physicians know I'm a, you know, a residency program. I try to tell them that, okay, you know, they always see that these older people all, by gosh, it's going to take a long time to evaluate them because they have so many problems and they have the memory issues, but says you don't have to tackle everything at one time if you're going to organize yourself, get a plan, do some things.

One visit, you have them come back, do some other things. You know, you could break it up so that it's you have more time to actually be able to sit down and do your mini cog and then be able to talk with them, try to get the the parents involved or the patient's families involved. Don't be afraid to use your local resources.

I think it's very important once you get into a community to find out what your local resources are and start using them early on. But again, take your time with it. It's a very rewarding part of medicine. You can feel that you're really doing a lot of good for this patient. And so, you know, look at it that way.

When you're seeing these patients and break it up into time management that that you can actually handle in your practice.

00;16;58;09 - 00;17;17;00

Speaker 2: Eukesh Ranjit, MD

That's a really amazing words of advice. You don't have to diagnose it all in one visit. It has to be it can be done, then it's status and well, we're taking care of other stuff that we could work on a long term basis with dementia and also finding the local community resources. It's such an amazing words. Hunter Smart guy.

If you had a magic wand, for example, if you had a magic wand and you could do something for the communities that is are especially the rural communities and everywhere with dementia, what would you do?

00;17;28;25 - 00;17;53;10

Speaker 3: Sharon Smaga, MD

Boy, that's a good question. If I had a magic wand. Well, one of the big problems, again is transportation. And in rural communities, getting patients to areas they need. So, you know, I think the rural areas are working at it where they're getting more transportation systems, you know, to help patients get to appointments, etc.. But if I had a magic wand, you know, I would increase that.

So we had much more help in getting transportation to these patients as well as more home health services. You know, we do have resources like Shawnee Alliance that do come to the home. But I have to say, you know, we probably don't have enough home health aides and, you know, that type of thing that people need. And so if I had a magic wand, I would increase the number of home health aides that we would have to help these people stay in their homes.

00;18;19;25 - 00;18;25;14

Speaker 2: Eukesh Ranjit, MD

That's amazing. Any other words, anything that would like to share with our listeners to understand rural communities better?

00;18;25;29 - 00;18;45;28

Speaker 3: Sharon Smaga, MD

Again, just the problem is a lot of them are very isolated. Some of these communities, you know, don't have even hospitals. They don't have very many physicians in some of the counties, especially to the south of us. And so the medical care is very I don't want to say fragmented, but it's just hard to get to some of the resources that the patients need.

I know I'll have to admit that I'm originally from the Chicago suburbs and most of my family is there. And so I'll say something like, Oh, you know, the person needs a neurologist. They go, Well, just, you know, why can't you see a neurologist? Like, well, you know, we have like one or two in southern Illinois. It's not like, you know, ten at this one hospital and ten at another hospital.

And so, you know, it's just not the same resource as in a rural area, is there? I was in an urban area like Chicago.

00;19;17;11 - 00;19;19;19

Speaker 2: Eukesh Ranjit, MD

Yes. The disparities are there.

00;19;19;28 - 00;19;20;11

Speaker 3: Sharon Smaga, MD

Yes.

00;19;20;17 - 00;19;41;19

Speaker 2: Eukesh Ranjit, MD

This is really nice talking to you. That's what I got today. Thank you so much for your insights and thank you so much for serving our community and that Carbondale and the surrounding rural area, especially with you being from Chicago, you know, and serving there for such a long period of time. Thank you. I'd like to thank you for all of the service that you provide that was at it.

With regards to our talk with Dr. Smart today. Thank you, everyone, for listening. And I hope all of you have a great day today.

00;19;55;11 - 00;20;19;25

Speaker 1: Kate Rowland, MD

Thank you to our expert faculty and to you, our listeners, for tuning in to this episode. If you have any comments, questions or ideas for future topics, please contact us at podcast at the Brain Trust dot com. For more episodes of the Brain Trust, please visit our website. The Brain Trust Project dot com You'll find transcripts, speaker disclosures, instructions to claim CME Credit and other Alzheimer's resources as well.   Subscribe to this podcast series on Health Care Now Radio, Spotify, Apple, Google Play for any major podcast platform. Thank you again and we hope you tune in to the next episode of The Brain Trust.