The Brain Trust - Episode 12: Early Detection in Latino Communities

In today’s episode host Raj Shah, MD chats with Evelyn Figueroa, MD to discuss ways family physicians can improve early detection of Alzheimer’s disease in their Latino patients.

Learning Objectives:

• Describe specific challenges affecting the Latino communities that exacerbate the burden of Alzheimer’s disease.
• Name one way family physicians can create a supportive environment for early detection of Alzheimer’s disease and related dementias in their Latino patients.

Host:  Raj Shah, MD - Professor, Family & Preventive Medicine at the Rush Alzheimer’s Disease Center at Rush University
Guest: Evelyn Figueroa, MD - Professor of Clinical Family and Community Medicine;  
Director of Community Engagement, Department of Family & Community Medicine- University of Illinois at Chicago College of Medicine; President, UI Health Medical Staff Office; Director, Pilsen Food Pantry

This CME activity 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. 

Transcript

The Brain Trust Podcast |Episode #12

Transcript

Moderator: 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.

Host:  Raj Shah, MD

Welcome today to our next podcast in the series called The Brain Trust about early detection of dementia and Alzheimer's disease. Today, we're going to be talking about the early detection in the Latino community.

And I'm going to be your moderator. I'm Dr. Raj Shah, and I'm a professor in the Department of Family and Preventive Medicine and the Rush Alzheimer's Disease Center. And the great news about today's presentation is I don't have to travel many miles in my car. I actually got to just walk from my offices at Rush University Medical Center back to where I graduated from medical school at the University of Illinois at Chicago.

And I'm going to be meeting with Dr. Evelyn Figueroa, a good friend and colleague for many years. She's the professor of clinical family and community medicine at the University of Illinois at Chicago College of Medicine. Evelyn, Thank you for having me here today. It was really great to see you. 

Guest: Evelyn Figueroa, MD

Hi, Raj. Good afternoon. I'm glad we have a chance to meet and catch up

Host:  Raj Shah, MD

 on all the wonderful things you've been doing to support the Latino community over your entire career, and especially around the area of working with older adults.

00;02;18;05 - 00;02;41;23

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But before I get into that, just for our audience, can you tell us a little bit about you and kind of your role at UIC and a little bit about the population you serve as in your practice? UIC 

Guest: Evelyn Figueroa, MD

So like you, I am a graduate of the University of Illinois at Chicago, Class of 99, and while I was a medical student at UIC, I was very involved in the Latino Medical Student Association called La Rama.

Back then, the president, while I was an RN too, did a lot of community centered work in the Pilsen neighborhood, left UIC and during residency had a very large Spanish speaking practice at Lutheran General. I was the only Spanish speaker in the whole residency program. After that, took a job at a county hospital in Northern California. Again, lots of work with immigrants, especially Latin immigrants, and expanded my scope into more reproductive and maternity care, which is what I spent a long time in my career doing.

But I returning back to UIC in 2005 and getting to build the residency, build my practice there. I realized that as much as I loved clinical care, I also loved the intersection of social determinants of health with clinical, with clinical practice and through continued intentional work with the Pilsen community eventually started a501 C3 the Figaro Family Foundation, which started in late 2017 and through the Figaro Family Foundation, we formed a number of anti-poverty projects, including our largest one, the Pilsen Food Pantry, that services about 50/50 Latin and Chinese clients, because those are the two biggest communities that are right in the neighborhood where we operate.

I really love doing my community facing work because it, you know, I use the word intersection and because it really is if you are not addressing social determinants like language barriers, immigration status, financial status, etc., it's very, very hard to take good medical care of folks. So building this community centered organization has really helped me feel like a better family physician.

Host:  Raj Shah, MD

Yeah, no, that's been amazing to see that trajectory of your growth and all the important work you've been doing in the communities at multiple levels. I really appreciate you bringing up the concepts of what we're facing in many of our communities in urban areas and even in rural areas, especially with Latinos. And that's the idea around the structural determines and social determinants of health.

And then it kind of brings me to, you know, as you think about your care and your patients that are older that might be at risk for a dementia and you evaluated them and saw the family structure and a structure. What are some of those barriers or those social determinants barriers you're sort of dealing with and trying to make an early diagnosis of dementia?

Guest: Evelyn Figueroa, MD

There are so many of course you had mentioned structural and social and also for folks that are immigrants, which many Latinx folks are, are also political determinants of health that people have to face on a daily basis. The social determinants that I really experience the most regarding our Latinx community has to do with literacy, language proficiency and financial status.

All of these things really do control the resources and a person's ability to navigate through available resources. Chicago is a great can be a very great city for social services if you know how to navigate them. But the devil is in the details and that's the work that I do, is not only myself directly navigating patients, but also working with our staff to empower our clients, working advocacy students on my rotation, and also with the core family medicine clerks.

Host:  Raj Shah, MD

And I guess I'd be curious like, how do you go about in the residency program as you're seeing, older patients may be at risk for developing a dementia and thinking through how do you maybe screen or evaluate if there's cognitive issues that are going on. Sometimes we know our like screening tools may not be perfect because either we don't have it translated or, you know, but literacy and education levels, they might not work as well.

But is there a kind of a process you try to instill or do as you're seeing persons like maybe what the annual wellness visit to try to engage them? 

Guest: Evelyn Figueroa, MD

I certainly learned the hard way. I have to say, I wish I could say that I have done it right or right way from the beginning. But the first time I actually realized a patient of mine was illiterate, the patient who did later develop Alzheimer's dementia, or maybe already had dementia at the time, was with a resident of mine who actually I percept up the residence every Thursday.

That's my standing clinic and one of my personal panel went in through the resident's clinic because I wasn't accessible. And that resident very quickly realized my patient couldn't read. And this was a patient who had been my patient for several years. And I was very humbled by the fact that a resident could see them for one time. And she basically figured it out because the patient she asked the patient what she did for fun, and the patient talked about watching TV, and then she screened more saying, What about reading books or doing crossword puzzles or something like that in the patient, You know, just looked away.

And then she said, Do you have any trouble reading? And uncovered it very quickly. And the you know, the research is really clear about Latin X folks. LatinX, immigrants have a lower literacy level than the greater general cohort. So the average Latin next immigrant has a fourth grade education, which also lends to not only just regular literacy, but language fluency, numeral literacy, financial literacy, And then their ability to learn another language and adapt in Chicago is a city like like it is for people that speak Polish, for people that speak Cantonese.

It is a city where you can hide and never have to learn English. But there are also some pretty severe structural barriers that preclude those folks from learning these additional languages. And then that means that there are delays and even, you know, the communication may not be as sophisticated. And then the families and the clinicians may not even use such advanced vocabulary to start noticing some of those gaps.

What I changed after what happened with that resident and just really being surprised to not know that about my patient, who again had been my patient for several years.  is just a start really being firm with my firm, but setting expectations to bring medications to every clinic for all of my patients. That was a really easy way.

And having the patient tell me what they were using them for and if they were describing pills and not telling me names, that made me more curious. I also got a lot better at just trying to destigmatize asking about literacy. You know, if someone grows up in poverty and doesn't have the same access to education, although we individualize that blame, it really isn't their fault.

It's a system that has been designed to work that way. So if I don't validate the shame that the patient expresses when they say they can't read, instead saying, Well, you were working for your family or your parents were you were orphaned, you you needed to step in and help. It really helps. I found that it's a very disarming type of segway to make with them and then to help them understand that I just I'm not there to out or embarrass them, that we just need to have a frank discussion and that I want to make sure that the discharge papers make sense and I want to make sure that their medications are really lined up properly. So that was a really great thing that the resident did for me and helped me. So in clinic I have my folks bring it. I also, if someone isn't answering questions and the family member continues to answer questions from them, of course, you know, I'm sure you do the same thing. You start redirecting and saying, you know, in a nice way, but saying, I want to hear what they have to say about it, even if they take longer.   I want to hear that. 

Host:  Raj Shah, MD

Yeah. And I think you bring up a good point about, you know, creating a safe environment. Right. Because even when people are concerned about their memory, they don't always like to talk about it because they're worried that people are going to take advantage of them, going to look less of them. And so I really do like that idea of what you were saying to create sort of a safe zone that, you know, we're going to talk about this.

It's common. And, you know, in some ways we know in the Latino community the risks are a little bit higher for developing Alzheimer's disease and then the general white population in the United States. So, yeah, it's really key to create that environment. Now, many of our listeners also may not be in environments where they're seeing more. They're seeing more Latino patients, older patients coming in, maybe with their families, right, for care in primary care.

But they may not have bilingual staff in the office, just where they're located. And what are some of your suggestions maybe in trying to work through not only literacy piece, but the language piece so that we don't get overly dependency on a family member, especially a teenager who's the, you know, the one who's translating in English because an older adult may not say something to that teenager.

The teenager may not ask, especially when it comes about memory. 

Guest: Evelyn Figueroa, MD

Yeah, I think one thing that's really important for is for us to actually understand the resources that are available at our health institutions. Oftentimes, translation services are available. It's just that folks view it to be quicker and more convenient to use family members, or they assume their Spanish is adequate enough to get by.

I used to teach medical Spanish to my co-residents in residency and then in the residency for a while, and I made sure that they understood what I was teaching them was yes, no Spanish. This was not this was not Spanish that would substitute for having an interpreter. It would buy you time until the interpreter was present. So I found that that's a definitely a very big issue and also reassuring the families that it's okay, that they not interpret we Latino culture by just by tradition.

It's very close knit. Folks are very protective. It's very hierarchical. There's a lot of respect and explaining to them that I'm just trying to give grandma or grandpa his privacy and that it's really okay that you don't do this part of it. We can go over the discharge summary today together. You know, I need you to understand that part.

But for the history, it's totally normal. We asked for interpreters all the time. I think that really De-stigmatize is bringing interpreters in there even now. Free apps for interpretation. And I'm not meaning Google Translate, I meaning live interpreters that you can get free of charge. We use them at the shelters right now. So it's translation services are quite accessible.

And when we switched, when Mercy shut down for the time that they had shut down before they pivoted into their new health organization, we had a huge influx of Cantonese speaking patients. When our proficiency at UIC, it was really Mandarin. And what happened was that the physicians gave feedback to translation services at the hospital and not surprisingly, they added on Cantonese interpreters.

So often health systems will respond positively if they understand that what the you know, what the data is showing and what the what the needs are. So it's really also a matter of us being proactive and sharing back with our administration that these are important pieces of clinical care and that they need to be available. 

Host:  Raj Shah, MD

And that's definitely a nice example of, you know, a barrier or a structural barrier dealing with language access and us being able to actually have some agency and to solve that by asking for the interpreter, not depending on the family or trying to get by with limited, you know, Spanish speaking skills in an important area.

But that brings me to the other kind of barrier we were talking about a little while ago, which was sort of sometimes around insurance and insurance coverage well before I get to insurance, one of the problems can be on the literacy side is the skills that we create to do the screening. Right, like whether the mini mental state exam or the MOCA exam.

I mean, there are Spanish versions of it, but if somebody has a lower literacy and then you get a score that's low, but it might not represent that they have dementia. So how have you kind of dealt with that or, you know, not dependent so much on the actual number from the tool, but like using your sort of spidey sense skills, that's our family physician to kind of say, wait a minute, something's just not matching up here, right?  And how do I deal with that?

Guest: Evelyn Figueroa, MD

Right. You know, I'm fortunate because I have I grew up with a grandmother that had to drop out of school in third grade. She was orphaned, so she had a third grade reading. She had a third grade education in a rural country school in Puerto Rico. So that would have been cohort class, you know, classes with lots of different ages.

And I help my grandma complete these books to get an eighth grade graduation certificate and I taught her to write numbers, to write her own checks. And so there was a lot of first hand knowledge that I had about how inaccessible that is. And so it really has motivated me because I see my grandma when I see a lot of these folks.

She actually developed some senile dementia in her nineties but was pretty sharp as a tack for a long, long time because you have to compensate, right? If you can't read, you have to be able to memorize a lot. And that part that you mentioned before about people - being not wanting folks to know that they can't read or they are having some memory issues is significant because of that opportunity that people, other people can use to take advantage of them.

And a lot of the just financial ramifications of not being literate. So, in clinic, I think I think a lot about this, a lot about what I needed to do, you know, as a child to let my grandma feel okay with me helping her or learn. And in clinic you definitely use your intuition with patients, and you work on just like you would with someone who, you know, who has low back pain.

You work on function and trying to talk to them about how they're functioning or ADLs. Their relationship with their family members. Is their weight stable, what their what their sleep cycle like? There are lots of other measurements that you can use because the goals are all the same. The goals are to help this person continue to live up to their fullest potential.

And when you have concerns for any form of dementia, including Alzheimer's, you know, Alzheimer's has, you know, specific medications that we try to do to just like stay the progression of the disease. So that's what I view the most in clinic, is really knowing what hobbies my patient has, what they do to keep themselves occupied all day, and then really trying to assess what's happening because I've had just so many patients that had Alzheimer's plus vascular dementia.

It's Alzheimer's, plus NASH cirrhosis with hepatic encephalopathy. It's, you know, it's so intersectional that it's I wish it was just one for me. 

Host:  Raj Shah, MD

Yeah, you're right. It's always the mix of a lot of things, but I really I'm glad I had you brought up the idea of one of your best tools in your pocket is to ask people about their function.

What are they doing socially? What are they doing occupationally? What are they doing in their day to day lives? And especially if there's a change right from where they were before that might give you the clue, right? That something is different, that we have to look at this and it could be their cognition. So I'm really glad you brought that up.

And then if we can come back to that other part about the insurance status. Right, because there's sometimes this feeling like I'm in primary care, I've got to get a neuro psych test because I'm not sure or have I'm seen by a neuropsychologist or I've got to get an imaging study on them to really show if this is a dementia, how do you deal with that one individual that you serve in your communities and the Latino community and the Cantonese community where you deal with these barriers around insurance for some of these high end technological ways of diagnosing dementia?

Guest: Evelyn Figueroa, MD

And most of the time, my concerns about it have to do with co-pays and really understanding the extent of the testing, what it's going to ensue. You know, neuro psych testing can take 6 hours. It's very difficult to complete. And if someone doesn't have the mental stamina to get through that, they need to take several naps a day.

It's not even worth sending them to do it because they're not going to make it through and it's going to be a very shaming event. So most of the insurance barriers that that I get just have to do with the co-pay. You know, now in Illinois, regardless of immigration status, if you have six months residency, you can be insured on Medicaid after 42 years of age, it is income based.

But a lot of these the aging population that is no longer working, they're able to get insured. So it's it's been a nice change for the last couple of years that it hasn't been so much of a barrier, but really making sure that you're sending the right patient for a test that they're going to be able to complete is more of my challenge.

Host:  Raj Shah, MD

It's a great point. And again, using the skills you do have and the environments you do have to make a working diagnosis and then to kind of follow somebody over time. That's the beauty of family medicine, is you can follow people over time and see how they're doing and if there's changes that have to happen. And then, yeah, I was just kind of curious as we're coming to a near end with our conversation, any thoughts about like a positive experience you've had in some of the early detection, its impact on not only that person or maybe their extended family, like they were seeing concerns about memory or you picked up some concerns about memory and then kind of, you know, help make a diagnosis and then help support that family through that journey.

Guest: Evelyn Figueroa, MD

Yeah, we have I have a really great sister act in my practice where there's the younger sister who's 70 and the older sister who's 83 and the youngest that 70 never had children or got work or coupled. So the family has she's one they're one of, I believe, nine children.

It's a very large family. So the 70 year old has really been entrusted with the care of this 83 year old and pretty burdened, to be honest. And so it's a very difficult situation. And but they moved from Mexico not very long ago because they needed to be closer to the family so that they would at least get some financial support and etc..

And I was able what's been really nice about it is just really focusing the treatment on her symptoms. So the sister wasn't sleeping at night. That was causing a lot of trouble. So just, you know, using very low dose risperidone that did wonders for this person and then setting up some services through the Pilsen and food pantry. So they get it.

They get they get food delivered every two weeks. They have befriended the driver. The driver, they call him. Everything is a really great guy. So then he'll send me messages from them because they have trouble getting through the central call center for UI Health. So they'll send me a message and say, you know, needs help with glasses. And I'll say, okay, and then I'll get my advocacy student on it.

Because usually I am an advocacy student who's Spanish speaking. So our staff has gotten better with support services for folks like them. And we really have. Yeah, and we have a physical therapy program at the pantry. And it wasn't that they would have not been able to go to another physical therapy place, but it was close and convenient, and they knew how to get there and we could get a ride from our person and those were those were really important things to do for them.

So that's a family I feel really, really good about because that that sister had really been having a lot of trouble, a lot of agitation issues. She once ate rat poison that she thought was handy because she was awake at night. There were all sorts of things that we were able to get very much under control because I had additional resources.

And I think they just felt like they were heard. 

Host:  Raj Shah, MD

Yeah. And I it's really an impressive story about that engagement with the community and almost creating a network of people that are what we call dementia friends is sort of the terminology that they also can recognize individuals that might be having troubles, help them out or reduce some of the stigmas and barriers and make a difference and serve out a community approach.

Those really great story. Thank you for sharing that. And in the final moments, we have any kind of recommendations or final comments you want to make about how we best work all over Illinois with primary care physicians to help with early diagnosis of dementia and Latino populations? 

Guest: Evelyn Figueroa, MD

Yeah, I have a couple suggestions. I think the first thing is to understand what the what your center or your Department of Aging for your county or your city offers for folks.

Families really don't know that Chicago is a great city, of course, for Center of aging. But yesterday I looked up something for Will County because I had someone who is caring for a family member with dementia and they were paying an agency $30 an hour to help. And that is just not same. And they said, we just have to I'm completely tapped out.

And I said, wait, wait, wait. Like and I was taking care of the caregiver, not the parent. And but I said, this part is so important. So all of us that are clinicians, we have to learn what those resources are in our specific communities. You can find that on findhelp.comcom. You can call 211. There are lots of different ways that you can find what's available and you can do it through the Alzheimer's Foundation.

But understanding what respite care available, what homemaker services is are available is really important for keeping seniors or other folks with Alzheimer's that want to stay in their home, because that really helps orient and anchor them. 

Host:  Raj Shah, MD

Yeah, no, that's terrific suggestions and I'm glad you brought up even that 211 number as a new resource that's been developed around social services that we should all get comfortable with.

But I really appreciate all the information you provided us today and our Brain Trust podcast. Evelyn And I'm continue to be amazed at all the work you've been doing and advancing in your career and supporting the next generation of individuals. So thank you again and thanks to our listeners for spending some time with us and the Brain Trust podcast.

We look forward to seeing you another day. Thank you. 

Guest: Evelyn Figueroa, MD

Thanks. Bye.

Moderatore: 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.