D09 – Integrating a Care Pathway for Detecting and Managing Mild Cognitive Impairment, Depression and Anxiety in Seniors in Primary Care

Summary

With the high prevalence and burden of anxiety depression and mild cognitive impairment in later life, earlier detection and treatment could both improve well being and modify the risk for Alzheimer’s disease. As most individuals with these conditions present in primary care, rarely reaching specialised services, we examined whether collaborative approaches between primary care and mental health care clinicians could support the introduction of integrated care pathways to assist with recognition and assessment, and standardize care. We introduced an integrated pathway – adapted for primary care – to diagnose and manage anxiety, depression and MCI in 5 primary care practices in Ontario. We looked at three measures – a) the detection rates for depression anxiety and MCI and primary care; b) the time to treatment for individuals identified with one of these problems, and c) outcomes for individuals in the integrated pathway methods. The main assessment tools were an PHQ9 GAD 7 MOCA and QOL. 69 participants were enrolled in the ICP arm and 76 in the Treatment as Usual (TAU) arm, in 5 different practices. The ICP included medication, patient education and social activation. Follow-up assessments were conducted at baseline and then every 6 months for up to 2 years. At the same time, we tracked changes made by the practices to incorporate the pathway, held focus groups with participating practices to learn about their experiences and conducted a chart review to identify possible changes in detection rates. Participants did not differ in age, gender, marital status, education, or employment status. Participants assigned to the ICP experienced more persistent improvement on measures of depression, anxiety and quality of life than those assigned to TAU. They were also more likely to access the right treatment and faster than those in TAU. With active screening, detection rates of anxiety, depression, or MCI increased 5-fold compared to before starting the study. However, rates of detection went back to before the study after the withdrawal of research support. Factors facilitating its introduction included an identified lead for the project in the practice, physician engagement, and limiting the demands made of physicians. The ICP was seen positively by most family physicians despite the increasing time demands. Physicians emphasised the need to keep this to a minimum when introducing a new program. A dedicated person in the practice to coordinate the initiative and screening is important and other system changes are required to accommodate an ICP. The algorithm may need to be adapted for individual practices and outcomes were positively affected by greater physician buy in and engagement. A shorter time to treatment indicated that physicians were using the algorithm. There may be benefits in providing consumer education and physician training materials electronically.