The Journal of Nutrition, Health & Aging© Volume 17, Number 2, 2013

MULTIDISCIPLINARY TEAM MEETINGS (MDTM) IN DETECTION OF ALZHEIMER’S DISEASE: DATA FROM THE IDEM STUDY

Y. Rolland1,2, n. Tavassoli1, s. GilleTTe-GuYonneT1,2, a. PeRRin1, s. HeRmabessieRe1, P.-J. ousseT1,2, F. nouRHasHemi1,2, P. CesTaC3, b. vellas1,2 and THe idem invesTiGaToRs

1. Gérontopôle de Toulouse, département de médecine interne et Gérontologie Clinique, 170 avenue de Casselardit, Centre Hospitalo-universitaire de Toulouse, F-31300 Toulouse, France; 2. inserm u1027, 37 avenue Jules Guesde, F-31073 Toulouse, France; 3. Pôle Pharmacie CHu Toulouse and inseRm u1027. Corresponding author: Professor Yves Rolland, Gérontopôle de Toulouse, Pavillon Junod, 170 avenue de Casselardit. Hôpital la Grave-Casselardit, 31300 Toulouse, France, Tel.: (33) 5 61 77 64 06 Fax: (33) 5 61 77 64 75 e-mail: [email protected]

Abstract: Introduction: The national institute for Health and Clinical excellence (niCe) in the united Kingdom, the institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (iQWiG) in Germany and the Haute autorité de santé (Has) in France have recently set out guidelines on prescription of anti-dementia medication. The Has proposes in particular that continuation of these drugs for longer than one year should be decided in multidisciplinary team meetings (mdTm). Objective: To assess the feasibility of mdTm and the satisfaction of coordinating physicians from institutions for the dependent elderly (nursing home, nH) and expert physicians from memory clinics who have participated in the meetings. Methods: survey carried out among physicians who had participated in the mdTm held as part of the idem study (interest of systematic tracking of dementia cases in nH: analysing the contribution of mdTm in alzheimer's disease and related diseases; PHRC national 2009, Code 0910701). The survey evaluated the organization of mdTm and the physicians' opinion of these meetings. Results: The cases of 574 patients were discussed in mdTm involving 133 healthcare professionals (32 coordinating physicians, 48 expert physicians, 4 general practitioners and 49 other health professionals). The mean number of participants was 4.2±1.6. about 16 minutes were spent discussing the case of each resident. about 90% of physicians considered that the meetings were useful. overall assessment of their efficacy was 11.5/20 for the coordinating physicians and 14.1/20 for the expert physicians. The benefits of mdTm in relation to the work entailed were considered important by 60% of expert physicians and 33% of coordinating physicians. Conclusions: our survey confirmed the feasibility of mdTm in the field of alzheimer’s disease. The overall benefit/workload ratio of the meetings was considered to be favorable for the expert physicians. The benefits of mdTm were turned out to be less appreciated by the coordinating physicians according to high workload involved. Key words: alzheimer, anticholinesterase drugs, multidisciplinary team meeting, institutions for the elderly.

Introduction

The national institute for Health and Clinical excellence (niCe) in the united Kingdom and the institut für Qualität und Wirtschaftlichkeit im Gesundheitswesen (iQWiG) in Germany recently examined the value of anti-dementia drugs and their prescribing procedures. similarly, the Haute autorité de santé (Has), in France, recently underlined the importance of a multidisciplinary approach by validating the continuation of prescription of anti-dementia treatments for more than one year, subject to the decision being taken in a multidisciplinary meeting in the presence notably of the general practitioner (1). among other objectives of the multidisciplinary meeting will be assessment of the risks and benefits of continuation of treatments with acetylcholinesterase inhibitors (achei: donepezil, galantamine, rivastigmine) or by n-methyl-daspartate (nmda) receptor antagonists (memantine). a multidisciplinary approach is usually recommended for the management of complex disorders such as alzheimer’s disease (2-4). such an approach is one of the specific characteristics of geriatric medicine and its pertinence is underlined by expert guidelines on the management of Received February 22, 2012 Accepted for publication April 27, 2012

alzheimer’s patients (5). in particular, it makes for optimal prevention of the various medical, psychiatric or social complications of the disease. in a general manner, its value in the prevention of functional decline in the frail elderly has long been reported in numerous works (6). nevertheless, the concept of multidisciplinary meetings for all patients with alzheimer’s disease who have been treated for one year with anti-dementia drugs raises questions of feasibility. as far as we are aware, the organization of mdTm relating specifically to the prescription of anti-dementia treatments has not previously been studied. The aim of our work is to describe and report our experience of the mdTm that are held with a view to the detection of dementia in patients living in institutions for the dependent elderly (nursing home, nH) in France. We describe the organization of the meetings and report the subjective opinion of the physicians who take part. Methods

our work concerns the data collected in the course of mdTm held according to the protocol of the idem study (interest of systematic tracking of dementia cases in nH: 137

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analysing the contribution of mdTm in alzheimer’s disease and related diseases). The idem study is a usual-care study, prospective, multicenter and randomized by center (nH) that is currently under way. idem receives national funding as a hospital clinical research project (Projet Hospitalier de Recherche Clinique, PHRC 2009, Code 0910701). The principal objective of this study is to evaluate the impact on the emergency hospitalization rate at 18 months of systematic identification during mdTm of cases of dementia in the nH. idem compares two parallel groups: an intervention group, corresponding to institutions that have set up mdTm to identify patients with dementia and to discuss an appropriate care plan, and a control group corresponding to institutions that continue their usual practice. events (hospitalizations, emergency department admissions, therapeutic modifications) are recorded monthly. This study involves 89 nH (44 in the intervention group and 45 in the control group), 8 memory resource and research centers (mRRC) and 26 memory clinics (mC). all the nH participate on a voluntary basis and are located in various regions of France. When the project was set up, each coordinating physician of an nH designated a mRRC (or a mC) with which the institution wished to work. The designated mRRC (or mC) is considered by the nH as the associated reference center. Recruitment started on may 1, 2010 and was completed on march 31, 2012. The residents included will be followed for 18 months. The investigating physician (coordinating physician of the nH) includes all the residents of his/her institution who meet the study criteria: age ≥60 years, without diagnosed or documented dementia, not totally dependent (Groupe iso-Ressource [GiR] >1), living in the institution for at least one month at inclusion, with a life expectancy of more than one year and without any disease likely to jeopardize his/her participation in the study. after a 3month preselection period, the preselected residents in both groups have an inclusion visit in the nH with the coordinating physician. sociodemographic and medical data (medical history, cognitive history, family history of dementia, hospitalizations, pharmacological and non-pharmacological treatments, anticipated prescriptions) and level of dependence (aGGiR questionnaire) (7) are collected in both groups. The residents in the intervention group also undergo a comprehensive geriatric assessment. This comprises the administration of the mini-mental state (mmse) (8), clockdrawing test (9), borson’s mini-Cog (10), 5-word test (11), test of categorical verbal fluency (12), confusion assessment (Confusion assessment method, Cam) (13), assessment of nutritional status (mini-nutritional assessment, mna) (14), risk of falls (one-leg standing balance test) (15), behavioral disturbances (neuropsychiatric inventory, caregiver version) (16), risk of depression (mini Geriatric depression scale, miniGds) (17), a quality of life scale (Quality of life–alzheimer’s disease, Qol-ad) (18) and a dependency scale (instrumental activities of daily living, iadl) (19).

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The mdTm in the idem study are organized in line with the recommendations of the Has20 with regard to oncology. Their aim is to provide a multidisciplinary diagnostic and therapeutic opinion concerning the residents included in the study. The meeting is held on the premises of the mRRC or the mC. The case records of all the residents in the intervention group are discussed during the meeting. The coordinating physician presents the case of the resident and his/her comprehensive geriatric assessment. all members of the team caring for the resident and the personnel of the mRRC or mC can take part in the meeting. To meet the quality criteria laid down by the Has and to be qualified as multidisciplinary, under optimal conditions at least three different specialties must be represented at the meeting. in view of the specific nature of the mdTm of the idem study, at least one expert physician in the field of dementia (memory expert from a mRRC and/or mC) as well as the coordinating physician, the geriatrician from the nH, must be present. all the general practitioners of the participants give their agreement for their patient to participate in the study and are invited to take part in the meeting. They are informed of the date and time of the meeting. information on the case history, results of comprehensive geriatric evaluation and the treatment received by the resident is entered in a case report form filled in by the coordinating physician. This information is presented orally at the meeting by the coordinating physician and then discussed by all those present. minutes are written. a diagnosis is proposed, based on the dsm iv-R. The treatments proposed are based on the Has practice guidelines (1). a summary of the conclusions and proposals made during the meeting (minutes of the mdTm) is sent to the general practitioner. This report is also included in the clinical file of the nH. Two mdTm are organized in each nH in the intervention group with its associated mRRC or mC. The first meeting takes place in the first month after the end of the inclusion period and the second between the 10th and the 14th month of the resident’s follow-up. The case of each resident is thus discussed twice at an interval of about one year. no financial compensation is proposed to those who take part in the meeting. The coordinating physician is responsible for organizing the meeting with the mRRC or the mC. He/she sends all the general practitioners concerned a letter of invitation. after the meeting, he/she informs the general practitioners of the conclusions reached by sending them a copy of the written report. The opinion of the coordinating physicians and expert physicians of the mRRC and mC concerning the mdTm was collected by questionnaire. Two types of questionnaire were prepared. The first was designed for the coordinating physicians of the nH and the second for the expert physicians of the mRRC and mC. The questionnaires were sent to them one month after the first meeting. The questionnaires explored the following fields: 1. General: request for information on the work time of the coordinating physician in the nH and the time devoted to the

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mdTm. 2. appreciation of the efficacy of the mdTm: 10 questions were posed to coordinating physicians and 6 to expert physicians about their opinion on the efficacy of mdTm. each question was noted on a scale of 1 to 10 giving an overall score of 100 for coordinating physicians and 60 for expert physicians (table 1). To better compare the two scores, they were finally expressed on a scale of 1 to 20 (100/5 for coordinating physicians and 60/3 for expert physicians). 3. The future of the mdTm: opinion on the continuation of regular meetings for all residents of the nH including those who already have a diagnosis of dementia. 4. satisfaction with the mdTm: data on the physicians’ satisfaction with the organization, the way the meetings were conducted, their quality and the time devoted to the meetings. 5. added value of the mdTm in the management proposed to the residents (questions for coordinating physicians only). 6. benefits of the mdTm in relation to the work involved: physicians were invited to give their opinion on the benefits yielded by the meetings in relation to the workload they involve, on a four-level scale: important, moderate, low, nil. Results

at the time of writing, 32 nH in the intervention group have held their first mdTm involving 4 mRRC and 12 mC. The cases of 574 patients have been discussed in these meetings. a total of 133 persons have taken part, including 32 (24%) coordinating physicians, 48 (36%) expert physicians (of whom 11 have taken part in several meetings), 4 (3%) general practitioners and 49 (37%) other healthcare professionals (nurses, psychologists, nursing auxiliaries). The mean number of participants in the mdTm was 4.2±1.6 (2 to 8 participants per meeting). The coordinating physicians worked a mean of 3.3±1.7 half-days a week as coordinating physician and 1.3±2.2 half-days a week as general practitioner in the nH participating in the study. Table 1 presents all the data obtained from the questionnaires. Twenty-seven coordinating physicians (84%) and 33 expert physicians (89%) responded. The mean overall score for efficacy of mdTm in the various domains was 57.7/100 (or 11.5/20) for coordinating physicians and 42.2/60 (or 14.1/20) for expert physicians. mdTm should be continued in the nH in the future for over 85% of physicians and should be extended to the management of residents who already have a dementia diagnosis for more than 75% of physicians. The benefits of mdTm in relation to the work they entail were considered “important” by 60% of expert physicians and 33% of coordinating physicians. benefits were considered “moderate” by 30% of expert physicians and 56% of coordinating physicians. seven to 10 percent of physicians assessed this ratio as “low”. a single coordinating physician (4%) found that this ratio was “nil”.

Discussion

our work provides new, previously unpublished and practical information on the feasibility of multidisciplinary team meetings in the care of patients with alzheimer’s disease and on how these meetings are seen by the physicians taking part. about 90% of physicians who had participated considered that they were useful and should be continued. after this experience, the overall benefit/workload ratio of mdTm was favourable according to the physicians present. a mean of 16 minutes was devoted to the case of each resident and a mean of more than 4 persons attended the meeting. only 3% were general practitioners. in the field of oncology, the benefits of mdTm have led to their generalization for all treatment decisions. The relevance of this therapeutic strategy and its organizational feasibility have been clearly demonstrated (21-27). Conversely, few works have assessed the feasibility and added value of a multidisciplinary meeting in alzheimer’s disease, in particular with regard to drug prescription. For the diagnosis of dementia, collaboration between several disciplines makes it possible not only to better differentiate the various subtypes of dementia, but also to better detect psychiatric conditions (28). Furthermore, this approach appears to improve the patients’ quality of life (29). in clinical and therapeutic research studies, multidisciplinary meetings are also a frequent methodological approach to validate diagnoses or progression to mild cognitive impairment (mCi) or alzheimer’s disease (30). The latest recommendations of the Has suggest that multidisciplinary meetings should be held for the renewed prescription of anti-dementia drugs at one year (1). The actual benefit (ab) of the four anti-dementia drugs has in fact been evaluated as low and not demonstrated beyond this one-year period. in view of this, the Has recommends limiting their prescription to one year, with re-evaluation of the treatment after six months by the prescribing physician. after one year, renewal should be decided in a multidisciplinary meeting. such a procedure will aim at deciding on continuation of treatment, according to its efficacy, with the caregiver and the patient if possible, the general practitioner, the geriatrician, the neurologist or psychiatrist and in collaboration with those caring for the patient. The aim is also to re-evaluate and to adjust the diagnosis, the benefits and risks of any pharmacological treatment prescribed, and patient management. our results thus make it possible to envisage putting this recommendation into practice. in France, about 300,000 patients with alzheimer’s disease are treated with one of the four anti-dementia drugs. The future possibility of multidisciplinary meetings that would ideally bring together the patient, his/her caregiver, the general practitioner and the geriatrician (or the neurologist or psychiatrist) seems difficult to put into practice. our work stresses the interest of the physicians (coordinating physicians and expert physicians in

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Table 1 Results of questionnaires on satisfaction with mdTm, returned by the coordinating physicians and the expert physicians of the mRRC and mC

Variables General

Physicians who participated in mdTm, n (%) Total patient cases assessed, n (%) n° of participants in mdTm, mean±sd specialties of participants, n (%) Geriatrician neurologist Psychiatrist Physicians who responded to the questionnaire, n (%) Patient cases examined by physicians who responded to the questionnaire, n (%) duration of mdTm (hours), mean±sd Time spent on each case (minutes), mean±sd Opinion of the efficacy of MDTM are mdTm useful? yes, n (%) mdTm utility score, scale 0-10, mean±sd, for: detection of dementia identification of other disorders improved drug prescribing improved non-drug prescribing improved overall care of residents increasing GP awareness of dementia problems increasing Rn/na awareness of dementia problems Creating or developing links with mRRC or mC improved management of residents by care teams improved healthcare pathway in the event of hospitalization overall score for mdTm utility, scale 0 to 100 (coordinators) or 0 to 60 (experts), mean±sd Future of MDTM mdTm should be: Continued in the nH: yes, n (%) extended to management of patients already with a dementia diagnosis: yes, n (%) Satisfaction with the concept of MDTM are the meetings satisfactory in the following respects: organization: yes, n (%) Conduct of the meeting: yes, n (%) Time devoted to the meeting: yes, n (%) Quality: yes, n (%) Management proposed to the residents does the mdTm give weight to the management proposed to the residents ? vis-à-vis the family: yes, n (%) vis-à-vis the care teams: yes, n (%) vis-à-vis the GP: yes, n (%) Benefits of MDTM in relation to workload involved benefits of mdTm in relation to workload involved, n (%) important moderate low nil

Coordinators

Experts

na na na 27 (84)

26 (70) 9 (24) 2 (6) 33 (89)

32 (100) 574 (100) 4.2±1.6 (2-8)

37 (100) 574 (100) 4.2±1.6 (2-8)

470 (82) 4.3±1.9 (1.5-8.0) 15.8±7.0 (4.1-36.0)

518 (90) 3.7±1.7 (1.5-8.0) 16.0±6.6 (6.5-30.0)

6.5±2.4 (0-10) 5.7±2.9 (0-10) 5.9±3.0 (0-10) 5.3±2.9 (0-10) 5.8±2.7 (0-10) 5.0±2.8 (0-10) 5.8±3.0 (0-10) 7.0±2.7 (0-10) 5.8±2.8 (0-10) 5.4±2.9 (0-10)

7.6±1.8 (3-10) 7.5±1.3 (5-10) 7.8±1.2 (5-10) 6.0±2.3 (0-9) na na na 7.1±2.5 (0-10) na 6.3±2.8 (0-10)

23 (85)

29 (88)

24 (89)

57.7±20.5 (9-93) 21 (78)

21 (78) 25 (93) 22 (82) 22 (82)

18 (67) 24 (89) 22 (82)

9 (33) 15 (56) 2 (7) 1 (4)

32 (97)

42.2±6.3 (25-56) 29 (88)

32 (97) 32 (97) 32 (97) 26 (79)

na na na

18 (60) 9 (30) 3 (10) 0 (0)

GP, general practitioner; mC, memory clinic; mdTm, multidisciplinary team meeting; mRRC, memory resource and research center; n, number; na, nursing auxiliary; nH, nursing home (institution for the dependent elderly); Rn, registered nurse; sd, standard deviation.

mRRC or mC) in such a procedure, but also the organizational constraints for general practitioners. although general practitioners expressed their interest, only 3% of them were able to attend the 32 meetings. other modes of organization, such as telemedicine links, need to be studied if the participation of general practitioners is considered indispensable. some points need to be debated. Firstly, the aims of the mdTm held as part of the idem study differ from the recommendations of the Has. The idem meetings are not restricted to discussion of the cognitive dimensions but also cover the classic geriatric dimensions (nutrition, affectivity and

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mood, risk of falls…). nor will the multidisciplinary meetings proposed by the Has evade the need for a global approach to the elderly person. For this reason, we believe that the meetings recommended by the Has should be similar to the model that we have set up in the idem study. in another respect, our approach makes it possible to envisage the therapeutic decision-making procedures that will probably become established in the near future. Thanks to advances in the knowledge of alzheimer’s disease, complex and costly treatments such as immunotherapy can now already be proposed as part of therapeutic trials (31). soon, therapeutic choices, their indications and their objectives will certainly be

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more complex than they are at the present time (32). dual (or triple) therapies will probably be proposed at different stages of the disease and for precise indications and prescribing procedures. expert meetings, like those already held in oncology or for aids or immune disorders such as rheumatoid arthritis will need to be organized to define the treatment project. We believe that the mdTm proposed in the idem study anticipate procedures of the future for complex discussions on treatment in alzheimer’s disease and related disorders. lastly, the idem study is a randomized study that is still continuing. The results of our survey on mdTm are not predictive of the final results, nor of the added values of the meetings, in particular with regard to choice of drugs. The final results of the idem study should be available in 2013. They will perhaps make it possible to confirm the relevance of mdTm in the follow-up of patients with alzheimer’s disease.

Acknowledgments: We would like to thank all the coordinating physicians, investigators in the idem study, and all the expert physicians of the mRRC or mC who took part in the multidisciplinary team meetings: mC agen: luc vogt; mC albi: alain Quinçon; mC auch: martine Camallières, serge sainte-Foie; mC Cambrai: Jean-François audusseau; mC Castres-mazamet: marie-noëlle Cufi; mC malestroit: Jean-Paul lembelembe; mC montauban: Philippe martinez; mC montpellier: Claude Jeandel; mRRC montpellier: Karim bennys, Jacques Touchon; mRRC nice: Philippe Robert; mC Paris: lisette volpe-Gillot; mRRC Paris: marc verny; Rodez: Jean-Pierre Calmels; mC saint-Gaudens: Caroline Parneix; mC saint Jean de verge: lawrence bories; mRRC Toulouse: Gabor abellan van Kan, Christophe arbus, Julien delrieu, stéphane Gérard, Christophe Hein, sophie Hermabessière, mathieu Houles, Fati nourhashemi, Pierre-Jean ousset, amélie Perrin, Yves Rolland, nathalie sastre, sandrine sourdet, Hélène villars, Thierry voisin. Conflicts of interest: Yves Rolland, neda Tavassoli, sophie Gillette-Guyonnet, amélie Perrin, Pierre-Jean ousset, Fati nourhashemi, bruno vellas have no conflits of interest related to this study. 1.

2. 3. 4. 5. 6.

7.

8.

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