Integrating, Educating, and Implementing Systems of Care Around Brain Health - Part 1

In part one of this two-part series, recorded at this year's AAN Annual Meeting, Dr. Gregg Day talks with Drs. Joel Salinas and Sarah Song about the evolving landscape of brain health, practical approaches to incorporating brain health assessments into routine care, and the importance of collaboration across specialties.

Visit the newly launched BrainHealth.com to access trusted brain health information and stay informed. 

Disclosures can be found at Neurology.org. 

 

Show transcript: 

Dr. Jose Merino:
This is Jose Merino, editor-in-chief of the Neurology Family of Journals. The Neurology Podcast provides practical information to neurologists and other clinicians to help them provide better care for their patients. Thanks for listening and have a great week.

Dr. Gregg Day:
Hello, this is Gregg Day from Mayo Clinic, and welcome to this special conversation. Today's episode was recorded live at the Brain Health Hub during this year's AAN Annual Meeting in Chicago. Because it was recorded on site, the audio may sound a little different from our usual episodes, but bear with us because it's absolutely worth it. In this conversation, our panel explores the evolving landscape of brain health, including growing use of wearables, digital tools, direct to consumer tests, and artificial intelligence. We discuss how neurologists can help patients to navigate brain age scores, consumer health data, and emerging technologies while integrating brain health into everyday clinical care. This panel discussion is totally aligned with AAN's mission of bringing brain health to all, and on point with the release of brainhealth.com, AAN's new website, bringing together our resources for clinical practice and for research in this space. We hope you enjoy this panel discussion as much as we enjoyed recording it.
We appreciate people joining this special session on integrating, educating, and implementing systems of care around brain health for the practicing neurologist. I've got a great team of practicing neurologists here as well. We're looking forward to sharing some of this discussion with lots of opportunities for questions as well. And we're going to kick into the contact right away. I'm Gregg Day. I'm a behavioral neurologist at Mayo Clinic in Florida. I'm joined by Joel Salinas and Sarah Song. I'm going to let them introduce themselves and then I'll provide a bit of scope for our discussion.

Dr. Joel Salinas:
Great. Thank you, Gregg. So I'm Joel Salinas. I'm a behavioral neurologist, and then I'm also a clinical associate professor of neurology at NYU Langone Health.

Dr. Sarah Song:
My name is Sarah Song. I'm a stroke neurologist here at Rush University in Chicago, and my favorite job is at the editor-in-chief of Brain and Life, soon to be brainhealth.com.

Dr. Gregg Day:
Over the past few years, the AAN has definitely taken a clear and very intentional position. Brain health is part of the central nervous system of our academy. It is not meant to be on the periphery, and it's going to become increasingly central to what we do in our practice. And so along with that call, we're really seeing this shift in our field being called to move beyond simply episodic disease management towards a launch of a comprehensive brain health platform and a development of a shared definition of brain health, which we want to conceptualize as this continuous state of attaining and maintaining optimal neurological function to meet the needs of our patients. So this vision raises some real questions in clinical practice. What does preventive neurology look like when we integrate it into our clinic visit? How do we integrate health screening into the clinic visit?
We all have time constraints and we're going to be honest and open about that. And what's the future? How do we start educating people on how to actually do this in practice? And maybe even a little bit more challenging, how do we address some of those social structural problems that are often a bit beyond our immediate control, but we all know are critically important here? So today we're going to talk about some of these questions head on. We do want this to be a bit of a dialogue. We want to invite perspectives. We want to hear other perspectives from the audience as well. And we're not here to debate whether brain health is important. I'm going to argue if you're sitting here joining us, you already know why it's important. And if you don't think it's important, you're in the wrong place, but that's okay.
Instead, we're going to focus on some of the realistic challenges and maybe strategies to address this. And this key question, what's the AAN going to look like if we're successful in this mission moving forward? So I've asked Joel and Sarah not just to share successes here, but we're going to be candid about the challenges. And so some of these things we just don't know yet about, but we do recognize what we need to be doing to move things forward. And we're going to begin by reframing the neurologist's role in brain health and what that shift means for the people that we care for. So as we've said, the AAN has a definition of brain health. It's changing our view on clinical practice on research and education. So love to hear from Sarah first on your perspective on how this definition has changed or maybe challenged your role as a neurologist in day-to-day practice.

Dr. Sarah Song:
So I think as a stroke neurologist, my biggest challenge was moving from a reactive to a proactive preventive situation. So I see people on their worst day when they're having a stroke in the hospital, in the ER. I show up and the effects of whatever they've been doing to their brain has ultimately reached some sort of conflict. I think in that sense I was always, okay, how do we prevent a recurrent stroke? But less so thinking on the front end, less so thinking about the lifespan. When we talk about brain health, it starts from prenatal all the way to senescent. It doesn't start when you're 75 and you show up in the ER and I meet you. It should really be starting before you have disease. What can we do upfront? What can we tell your mother before you're even born? So that was the biggest takeaway for me was thinking not just reactive, but proactive, preventive.

Dr. Gregg Day:
Expanding the scope for sure. Joel, what would you like to add to that?

Dr. Joel Salinas:
Yeah, with this definition of brain health, which bears repeating again, and it's like over here on one of the posters over here, it's a continuous state of attaining and maintaining the optimal neurologic function that best supports one's physical, mental, and social wellbeing through every stage of life. And as a neurologist, I'm coming from the lens of a behavioral neurologist, it can seem a little overwhelming to feel like you have to now tackle all these different elements of a person's care, but it's really just more than anything reframing something that we've already been doing in practice, which is really claiming responsibility over helping to prevent disease, prevent risks, managing those risks, really being much more proactive. And it's a little bit more of a public health framing, but it's helpful to really claim that responsibility of things that happen before the patient presents in the hospital in the acute state. And there's so much that we can do, which I know we'll get to, but it's an important framing for neurologists in particular to own.

Dr. Gregg Day:
And this emphasis on prevention, obviously very important. That's the best way to manage disease is going to be to prevent it, certainly best for our patients. But Sarah, as you pointed out, the lifespan perspective isn't within any one of our reaches. So of course the importance of working as a team. Thankfully, we have amazing representation of neurologists here at the AAN, and we all have our own contacts, people that we work with, and so can broaden this mission. Thinking about preventive neurology though, this implies this earlier, broader, sometimes non-traditional interventions to improve our patient's ability to maintain and attain the function that they need. So Sarah, what aspects of brain health promotion feel most natural for you in your clinical environment? Maybe which are some of the areas where you think as a field or as a neurologist, we're going to have more struggles or we're going to hesitate?

Dr. Sarah Song:
So think as a stroke neurologist, the first thing that really comes up is risk factor management. You both were essential in creating the safest brains, and I'll just refer to some of it. I'll let you guys talk more about that. But for me, it's blood pressure. Above and beyond anything, blood pressure causes strokes of hemorrhagic and ischemic strokes. So talking about risk factor control, especially blood pressure. And then the other one that among risk factor control, just there are so many other risk factors that contribute to stroke. More interesting to me though is the other end, the things that I don't think neurologists are comfortable with. So the addressing mental health, for example. Mental health is something that we learn about, of course, in neurology. We do psychiatry rotations, but we're not necessarily equipped with all of the medication wherewithal or the social strategies that we can use to help so with mental health.
And I also think in that same sense, we're not necessarily given the tools to deal with the disparities in health, so socioeconomic disparities that really do affect brain health outcomes as we've learned. So approaching those sorts of situations that we're not comfortable and finding a solution upfront, whether in training or whether in CME or something like that, that we can become more proficient in will actually help us to become more of a well-rounded brain health practitioner.

Dr. Gregg Day:
And you referenced the safest brains. And Joel, thank you for joining the team in writing that article. Of course, we should credit our lead author, Dr. Selwa, who really coined that term. It's a little hard to remember all of the elements, but when you actually read them or think about them, they really do frame that comprehensive approach to prevention in our patient population. And so we're talking about here screening at every neurological visit, or at least thinking about it in your patients, the importance of sleep, affect, food, exercise, supportive, social interactions, trauma avoidance, blood pressure control. It gets its own statement there. And then other risks attributed to metabolic and genetic factors and affordability and adherence to medication recommendations, infection prevention, negative exposures, that's where drugs and alcohol, tobacco come into place.
And last, definitely not least, those structural and social determinants of health. And so it's a long list. It's a daunting list for any of us to tackle on our own, but an important list to think about. What's one brain health domain that you believe neurologists could realistically and meaningfully integrate into a routine visit back in their offices?

Dr. Joel Salinas:
When you look at all of the different factors, it can, again, feel very overwhelming as a neurologist. How am I going to tackle all these things? It's helpful to frame it as the responsibility of the field or the whole care team, and everybody has their own favored factor that they go on the hill and preach about. Whatever your subspecialty, whatever condition, whatever specific area that you feel most confident to really speak to, whatever is most relevant to that patient in that moment, that's the one to really bring up. So when you are in that patient visit and your patient is mentioning how, "I don't do anything all day." That's an opportunity to maybe ask some more questions about physical activity or try to identify what limitations might be. If your patient mentions to you, "There's nobody for me at home." maybe talking about supportive social interactions and loneliness or social isolation is really relevant there. If you frame that also with identifying those which are most modifiable, that also becomes not just a moment of gathering data, but an empowering moment to really make an impact.

Dr. Sarah Song:
And I love that. So framing it in that individual moment to pivot to say, "For you, but let's focus on this right now or this today." That's just listening to the patient and having all those factors in the back of your mind, hitting upon them, but you don't feel like you need to hit each one with the same hammer stroke or whatever, reflex hammer. But I love that because then it's individualized for that person, for that patient, and it's more meaningful that way.

Dr. Gregg Day:
And it's a natural continuation of what we're all doing anyway, trying to optimize the care for our patients, but recognizing in ourselves that we're actually taking time for brain health promotion, for preventive health promotion, and sometimes tying that back to the patient as well. I tell all of my patients frequently that your work you're doing with your cardiologist to manage your heart disease, good news, you're also improving your brain health over time. We think that's important. And my favorite one to choose is sleep. Sleep is one of those ones that there's no area of neurology where it's not relevant. It's a common complaint and it affects more than just our patient as well. It affects everyone tied to them too, as we usually find out through that discussion.

Dr. Sarah Song:
I was just going to add, sleep is also a favorite of mine because it's very actionable. You can screen for it easily. You can just say, "How are you sleeping? How long are you sleeping?" Ask them about apnea stuff. And I know you guys address this in your paper, but what I love about it is you can actually do something by it. You can talk to them about sleep hygiene, you can refer them for a sleep study. So yeah, sleep's a good one.

Dr. Gregg Day:
It's a favorite for me. The AAN vision talks about some other actionable achievements, and what we'd really like to see, we want to see a brain health visit becoming a part of routine care at each of our life stages. And so Sarah, from your perspective, what structural or cultural changes within neurology practices would we actually need to see happen to make that feasible rather than aspirational?

Dr. Sarah Song:
Yeah, it's tough because our visits are all becoming shorter and we have less time to spend with patients. We're getting that squeeze. So one of the thoughts I had was whatever work that patients can do before they even show up in your office might be really beneficial. So a lot of times before you go to a doctor's office, they'll send you a list and they'll say, it's like a review of systems, but if you're able to do that before you even show up in your doctor's office, that takes the burden of collecting that information. And it can be simple questions like a PHQ-2 or four, a GAD score, something like GAD score, GAD. Yeah. So basically taking care of some of that upfront.
And then another idea would be having an MA collected as part of the check-in process, so going through some of those screens, creating a real brain health screen that you might be able to do in just under five minutes. And nothing like that has really been validated yet. Obviously, that we have a good handle on what the components are. Would it increase administrative burden? Possibly, but I do think that the more that we normalize collecting that information, the better off we're going to be to provide a longitudinal assessment of where somebody is going in terms of their brain health.

Dr. Gregg Day:
And that can provide that next steps to the discussion in the office of the framing of that as well. Yeah, really important suggestion. You will find the brain health article that we've referred to, it's included in the online content for this session if you're accessing it on your app. It does have some tools in there, basically beginning thoughts of how we might start to achieve some of this. The questions that you can ask, the surveys that could be filled out and other validated tools can all be a part of that as well. Most neurologists though, and you said it, we operate under pretty tight timelines, and that's partly by design. We want to see and provide care to the greatest number of patients. It's partly out of constraints of funding and return on investment and all the other things that hold our feet to the fire.
Joel, how do you make time for brain health conversations in that busy clinic practice while still remembering that our patients are usually coming to see us for a very important chief complaint that requires extensive time and commitment to solve?

Dr. Joel Salinas:
Even the question of how do you find time comes with its own assumptions is how do you add it in there into the visit? I think you're already coming from a place of adding the burden on it if you approach it that way. It's almost like thinking that brain health is something that comes after the real visit has happened rather than thinking about it as something that you add onto as an additional responsibility, really think about it how you integrate it within your practice because these questions about sleep and mood and diet, think about it, they're already in our visit, you're already asking these questions, especially based off of the chief complaint that's coming. If you're not asking them, you probably should be wondering why you aren't asking for risk factor related questions.
And at the end of the visit, when you're really wrapping things up and talking recommendations is where you have an opportunity to really reflect back as a part of your overarching care plan. If the patient told you that they're having a hard time with medications, that's an important point that you want to bring up at the end where you can say, "I heard that you had a hard time managing the dosing of the medication. Let's figure out how we can prescribe a more simpler dosing or make it extended release." Or if they brought up the point about mood, thinking about how you can prescribe a medication that might actually have a positive additional benefit on their mood as well. So I don't see it as one more thing to do. I see it as something that gets woven throughout your care and it's more about how you really think about the whole patient.

Dr. Gregg Day:
That's a perfect perspective. And we could of course think about stroke. Most people aren't there to find out, "What can I do about the stroke that I had?" They're in your office to make sure I don't want to have another stroke. We want to prevent that. And so this is really all consistent with that. And in our practice, we've got the patient there, but almost always somebody else providing that collateral history. And inevitably I'm going to be asked that question of what do I need to do to decrease my dementia risk? So you're right, this is an opportunity for us to build this into the assessment to provide better care with that more forward-thinking perspective. Sarah, I want to shift gears a little bit here. So we've all highlighted some of the ways we can already do it with the skills that we have now, but what are the other competencies related to brain health that might be a little bit lacking in neurologists that we want to be encouraging and that as the AAN, we want to be continuing to develop as we move forward?

Dr. Sarah Song:
That nutrition has become really important in brain health and certainly has received a lot of attention that we need to feel comfortable with that. And that means maybe bringing in some partners to help us with education if that's the case. I mentioned a little bit about mental health, so understanding what the issues are, taking in perspectives of family members and caretakers is really important. Part of what I was thinking about was when I was reading the article again, which is fabulous and I encourage all of you to read it, it'll be attached, but a lot of what has to do with brain health requires behavior change, that we are not necessarily equipped with those tools for motivational interviewing or how do you change someone's behavior? How do you track that over time? What do we say to elicit a behavior response from our patients or their families? So receiving education in that makes sense and is certainly something that we don't necessarily focus on so much. We're more focused on diagnosing and treating, but not necessarily how do we think about holistically, how do we change this patient's behavior for the better?

Dr. Joel Salinas:
I totally agree. I think the competencies of things like lifestyle medicine are really important, motivational interviewing. These are really concrete skills that we can teach, but I would suggest one more competency that is a little less obvious, which is systems thinking. Just thinking about what you recommend and how that person will interact with the rest of the healthcare ecosystem that they're in, because that really boils down to the reality of the patient. We do a really great job of training really excellent neurologists, but we could continue to do a better job to train neurologists who can change neurology.

Dr. Gregg Day:
That's two really important perspectives. And it may be that some of us develop skills in one area, some in another, some in all of the competencies. When do we begin training and teaching on this? Maybe we should all say as soon as possible, but at what level of our traditional training, how do we start to fill some of those gaps so that we are bringing up leaders in this area and continuing to train and develop our own competencies here?

Dr. Joel Salinas:
Some of it does begin at medical school where people do start to get an understanding of different systems and they learn about preventative care, highlighting where brain health fits into that because so much of what a lot of people get that education is coming from usually internists and people who have a lot of expertise within cardiometabolic risk factors. It'd be helpful whenever they get their neurology lectures or their brain and behavior lectures that there's a mention about risk factors and linking ideas together, making sure that people know that regardless of what specialty they go into, the central nervous system supports who we are. And so everybody should really care about that.
Within neurology residency specifically, it's helpful within all the different clerkships or rotations. Because again, it's like adding the specific module, adding a specific curriculum becomes a little bit more challenging, but it's something that we should be integrating throughout. So when you have a patient where they came in with a hemoglobin A1C of 10, that's a great moment for teaching about how important to bring in prevention early. And then what are the factors that came into play beyond just saying that it's the "patient's fault" for not following along with recommendations. Think about the system that they're in and how you can prevent in the future that they won't come in with another stroke.

Dr. Gregg Day:
The AAN obviously envisions brain health as fundamental to what we are doing, but we are going to need partners. We're going to need partners well outside of our specialty to engage the entire house of medicine. And we've got a lot of amazing staff and other advocates that are already involved in this important work. But we also want, as neurologists, we want to remain the vanguards of brain health. We are best positioned to lead in this area and to continue what the initiatives that's been started here. Sarah, when you're thinking about top priority partners though, who should we be looking to in our own practices, our own health systems as an AN organization? Who do we need to engage to really move this forward effectively?

Dr. Sarah Song:
The first partner that comes to mind is primary care physicians. So from every point of the life stage, whether it's OBs, pediatricians, all the way up to gerontologists, because they are for people at the touchpoint, we are the neurologists, so we're the caretakers of the brain itself, but they certainly see components of brain health in their practice. So making sure that we're connecting with them to help them in any way we can or to use our resources, pool our resources together to take care of that patient's brain health. Number two, psychiatrists, mental health professionals, so understanding psychiatric context of brain health and being able to work with them. And the third are therapists. So rehab physicians, people who can help support brain recovery is going to be really essential.

Dr. Gregg Day:
Joel, any other priority partners?

Dr. Joel Salinas:
I'll echo the importance of building that bridge with primary care, but I'll suggest one that's slightly controversial, which is to build better partnerships with health system administrators and payers. This kind of care is just not possible if you don't have the systems of care that are well aligned with being able to provide it and then you don't have the incentives, the financial incentives within that care to be able to promote the systems that'll then deliver that care. There's a lot of room for alternative payment models. I don't think we can solely rely on alternative payment models if that comes in partnership with health plans themselves.
As a practicing neurologist, it seems like how am I ever going to reach that payer? But if you start to build that alliance with your health system administrator, the person that runs your clinic, the admins of your department, and let them know this is important, at least they can begin to connect you with the right resources or they can connect you with the right advocacy to build that or figure out how can you be creative about our current codes and billing structures that are available so that way you can not only do that kind of care, but actually get credit for doing that care.

Dr. Gregg Day:
And of course we'd have to add our political partners as well and the important work that happens through Neurology on the Hill, our lobbyists in DC and at our state government levels. All of this really matters in gaining the recognition that we need. And importantly, helping our politicians to develop that longer term perspective, thinking about the lifespan, not the two, four, six-year reelection span. Obviously there's a lot of focus on. Joel, this is one that I know is close to your heart and the AAN recognizes the importance of social and structural determinants of health and certainly has big determinants in brain health. How do we, and again, in that clinic visit setting, how do we begin to responsibly address some of these factors without getting beyond our expertise or creating unrealistic expectations with our patients about what we can control and manage?

Dr. Joel Salinas:
When it comes to the structural and social determinants of health, and I'm always really keen on making sure that distinction is clear where social has more to do with the elements of the person's interactions with the world around them, their environment, structural has more to do with the factors and the built environment around them. And it can also be not necessarily built, but also the political structures, the economic structures that they're influenced by. Again, as a neurologist in the clinic, it can feel pretty disappointing when you realize that's an issue and it is more helpful to realize that you don't have to be that person who fixes that issue so much as you are the person who can identify that it exists and be honest about it and then help to pass that on to the next person in the situation that can help to make that better.
When you are chatting with your patient and they're bringing up issues related to lack of access to care or lack of finances or issues with insurance or difficulty with secure housing, again, you're not going to be that person who's going to bring the secure housing to them, but you need to be able to be honest that it's there, that it doesn't have an impact, that you document it in your note as a factor. And then think about what you have access to. Maybe in your department or in your clinic, you have access to social work. Maybe you have access to a local advocacy group specific to that person's condition that does have access to somebody who can then provide ways to connect them with local community-based resources.
We have care navigators who they do a lot of work. I almost think of them as the heartbeat of a person's care because they're helping to identify what the person has access to within their own communities and helping to understand what benefits they have access to so that way we can begin to address that. But from the clinician standpoint, we're not the ones who are making the phone calls to make sure that they get that kind of grant for respite care. We just have to say, "This is an issue and I'm going to help you with this issue by connecting to someone who can then help to point you in the right direction."

Dr. Gregg Day:
And how powerful sometimes to just giving voice to those realities in that patient experience, building that relationship, acknowledging how some of the things that we feel are beyond our immediate control totally impact our health, our access to resources, our affordability and adherence with medications, nutrition, exercise and sleep and all of these other factors that are so important. Thank you for bringing more of a voice to that as well. Sarah, are there other partners in your mind that we should be trying to engage who can help to mediate this? We've talked about social work, some other people that can be the in betweens here, but in your experience, other thoughts to add to that?

Dr. Sarah Song:
The one important group to include obviously are the patients in the communities. Our patients don't live in silos, they live in communities. We need to build those bridges to them, let them know how can we help you? Here's what we have available. What are the resources that you need or the problems that you see in attaining ideal brain health in your community? And patients have that lived experience. They know what works for them or what hasn't worked for them. And it can be very powerful to reach out to patients, whether it's patient advocacy groups or nonprofits or the patients themselves in the community, like in the churches, in the apartment buildings, wherever people congregate within a community and ask them, "How can we help? How can we help you? These are what we see. What do you think about that? What is something that might work for you that might not work down the street two miles down?" So we're in Chicago.
Chicago is incredibly divided. There is a huge disparity of life expectancy within 10 miles. If we go north, you're going to hit the Gold Coast. People live to be quite old. And then you head southwest and the life expectancy drops by 15 years. Understanding what works in what community and making sure that we're sensitive to those needs is really the only way that doctors can bridge that gap toward ideal health to practical real health.

Dr. Joel Salinas:
I would just build on that. When it comes to partners, yeah, absolutely. The patient themselves, their care partner, they are key partners and it doesn't always come up as clearly within the clinic. There's more and more conversation around thinking about what is the unit of care and going beyond the patient, thinking about the family unit as that unit of care and really getting that alliance built across that family unit. I come from a Hispanic community and whenever I have patients that are also from the Hispanic community, I know how important it is to really get everybody who's in the home on board with the plan because everybody is a part of that person's care. There's been work also coming out of the Institute for Healthcare Improvement, which is really interesting, looking at how do you build systems that are better for older adults. And one of the things they promote is a thing called the 4M model, and that stands for what matters, mentation, mobility, and medication. Mentation, for us as behavioral neurologists, that's a key part of what we do, but mobility is something that applies to everybody and same thing with medication.
But what matters most, it gets missed a lot. And unless you've had very specific training or mentorship within your training, we often miss it. Rochelle Walensky, she's a former CDC director, she mentions when she was doing a lot of HIV counseling, whenever a patient would have a positive test result, she was trained to be quiet after you tell the result and just wait to see what the patient says. But whatever is the first thing that comes out of their mouth is their signal to that is what matters to them the most. There's something really valuable because as you're doing your counseling with your patients, listen to what they're saying. If what matters to them is not being a burden for their family, bring things back to that. If what matters to them is being independent, bring things back to them. If feeling more cheerful or being more engaged matters to them, find ways to connect your recommendations and your lens of care back to what really matters to them.

Dr. Gregg Day:
And of course by involving the family, involving the broader community, we're touching on the lifespan here. So dementia specialists affecting the youngest people in the room and the neonates that yet to become a part of the discussion. So great things to think about.

Dr. Stacey Clardy:
That wraps up part one of this fantastic discussion from the AAN Annual Meeting on Brain Health. We will pick up with part two in the next episode, focusing on practical suggestions on how to easily implement preventative brain health interventions in your clinic, and then wrap up with the comments and questions from the audience who were present at the Brain Health Talk at the annual meeting. This is Stacey Clardy, your podcast editor. If you've enjoyed the podcast, please take a few moments to subscribe, rate, and review the Neurology Podcast through Apple Podcasts, Google Podcasts, Spotify, or wherever you listen. And remember, you can always head to neurology.org/podcast for our full list of past episodes, or you can also search by keyword in your podcast app for any neurology specific topics you want to learn about.