Integrating, Educating, and Implementing Systems of Care Around Brain Health - Part 2

In part two 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 imperfect but practical brain health metrics, patient-centered assessment strategies, and future directions in brain health assessment. 

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. Stacey Clardy:
Hi, this is your Podcast Editor, Stacey Clardy. Today we feature part two of the brain health discussion that took place at the AAN annual meeting a few months ago. If you have not yet, take a listen to part one from this past Thursday's podcast. For this episode, we pick up with the discussion focusing on plans for how to implement and measure effectiveness of brain health interventions, the sort we can all undertake easily in our clinic visits.
And then, we wrap up the episode with comments and questions from the audience who were present at the Brain Health Talk. I hope you take away some inspiration and some ideas on how to encourage your patients to be proactive about protecting their brain. Thanks. Enjoy.

Dr. Gregg Day:
Hello, this is Gregg Day from Mayo Clinic, and welcome to this special conversation. Today's episode is 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. 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.
One thing that we acknowledge on the Brain Health Committee, one thing that the AAN is committed to fix as we move forward, there's a lack of validated brain health metrics and biomarkers when we talk about brain health. So what does it mean to be healthy? Or maybe a better question, what does it mean to be healthier than I was a year ago headed in the right direction or trending in the right direction? Joel, your thoughts, what should neurologists measure today, even if it's imperfect, that can help us move brain health from concept to more of an accountable practice?

Dr. Joel Salinas:
This point about imperfect is actually really critical. I think when we're thinking about measurements, there's a trap that we tend to fall into, which is trying to identify the perfect measurement. And I often see that as an excuse to not measure at all. And so, thinking about what is it that you can most practically take into account today. And there's so many different measures for so many different elements, and I would just encourage you to think about what's most relevant to the patient in that moment, and that would be the ideal tool.
There's things like the PHQ-9. There's all these cognitive screening assessments. There's different measures related to cardiovascular risks that are out there. Even though none of those are perfect, right? None of those are perfect, we've been able to move healthcare forward quite a lot using these imperfect measures. So I would encourage you to find what is your toolkit of measures that are most helpful for you.
Actually, one of my favorite measures, going back to sleep, is actually not metric itself. It's actually just asking, how are you sleeping? And getting that qualitative data because we forget that metrics don't have to be quantitative, they can be qualitative as well. We often will collect things like the GAD-7, the PHQ-9. There's a UCLA 3-item Loneliness Scale. But when I'm in clinic, I'll often just ask, "Have you been feeling lonely?" Or, "How often are you feeling lonely?" And that in and of itself gives you a lot of really valuable information.

Dr. Gregg Day:
Simply asking that question about physical, mental, social well-being and where do you think you are compared to last year? We've spent a lot of money, a lot of investment to try to develop a tool that performs better than asking someone directly, "Do you feel depressed?" It's hard to do that. So yeah, let's not forget our patients in the room as maybe the greatest arbitrators of that progress. Sarah, any other things that you're thinking of along these lines?

Dr. Sarah Song:
I still go back to what Joel was saying earlier about individualizing it to the patient and getting more details on something that they happen to mention about if they're feeling lonely or if they mention their sleep, and then delving further into that. As a stroke neurologist, what's really easy for me is I always ask how they're sleeping, I ask how their mood is, and I just go into the markers of depression that we all learn about that are not necessarily just mood. But I ask, obviously, how they're sleeping, how they're eating, do they have energy, what exercise are they doing, what therapy are they doing?
And those for me are natural as part of the conversation of post-stroke, but that they touch upon a lot of the elements of brain health already. That's what's really key. Brain health isn't something new, it's actually something that we're already measuring and we're already looking for and we're already asking. Being able to put any sort of, I know it's not qualitative, but putting any sort of number to it or any sort of marker that we can use to measure it and even asking, "Last year you mentioned that you weren't sleeping very well. Do you think that you're sleeping better now or is it worse?" or, "What changed?" Right?

Dr. Gregg Day:
I think we're talking about setting goals with our patients that we can then ask, "Are we attaining those goals? Are we maintaining those goals?" We can begin that process together. That's really important, very practical. Thank you, guys.
We talk about brain health, we talk about quality, and quality of evidence here, and we can appreciate that really matters and is challenged by the multitude of sources of evidence and various levels of quality that we have.
Joel, you hit the nail on the head with this encouragement to not let perfect become the enemy of good. And so recognizing that, how do we navigate some of these challenges when we're talking about interventions that patients are bringing forward or maybe that we're interested in trying out?
We think there might be some role for those, albeit imperfect. So how do we navigate the uncertainty while maintaining credibility and building trust with our patients about making these recommendations towards brain health?

Dr. Joel Salinas:
Neurology, in particular, we all develop an expertise in navigating uncertainty. When it comes to brain health, it's just bringing some of those tools and perspectives into that space as well, right? Because we're always talking about prognosis and what to expect and building trust with patients. They're not really looking for you to be certain. Right? They're looking for you to be honest about that uncertainty. The more you're able to actually very clearly articulate to them, "This is what we know about this, this is what we don't know, and this is directionally what we think is helpful." And that applies within the brain health space as well. Right?
We don't have huge randomized clinical trials around all the different intervention. The U.S. POINTER study from last year was really helpful in pointing in that direction. From all the literature that we have, we do have a sense of direction. Maybe we don't know the magnitude of effect quite yet, but we can at least point people in the right direction towards things that can be most helpful for them. And then, couch it within how certain we are based off of the evidence. And I will say, most of the time that I bring up issues of uncertainty, patients will respect and trust more me as a clinician than I'm being honest about what I know and what I don't know, and how we're navigating things together.

Dr. Gregg Day:
Excellent advice. Do you want to add anything to that?

Dr. Sarah Song:
Neurology is a field that inherently has a lot of uncertainty. We have to be honest and truthful, and we have to listen to our patients. And ideally, we want to be able to promise just good things. Right? I always do caveat with strokes. I'm like, "We're going to do everything we can to help prevent another stroke. Nothing brings the risk down to zero, but we're going to do everything we can to move that needle in your favor." And being honest and truthful does go a long way, but you should never assume that you're God, and that you can fix everything. Nobody can.

Dr. Gregg Day:
There's that element of humility that we're all expressing here, which is very important. This is a great opportunity to hear from you guys. It can be a question for the panel, that's totally fine. It can be a story that you want to share, your own experience to brain health. Maybe it's the challenges that you're dealing with in clinic. Or maybe it's a success and just an incremental move in the right direction, something that you've already seen.
So if you would like to share something, you just put up your hand, and be prepared to catch because this square is coming your way. That's the goal. So we're really hoping we get to see somebody actually catch this. Oh, here we go. Our first candidate, Dr. Lazar. Yes.

Dr. Lazar:
Hi, everyone. So PGY-3, neurology resident. And I recently did my rotation in Generative Psychiatry, and it was a very important case. We have a demented patient who were just, like, demented but suffers for a major depression. And inpatient psychiatric unit with treatment, we handled the depression and his MoCA score improved. So it's very important to really realize that how much the psych component can affect these people.
And all three of you mentioned the mental issue when it comes to dementia patients. But in our practice it's less established to work with psychiatrists altogether or having a comprehensive group of people. For example, the patient who has an ALS, they have a comprehensive group of people like speech therapy, movement, and PT. We need that too when it comes to dementia. And we need to work closer with psychiatric issues and correct cognitive elements.

Dr. Gregg Day:
You're pointing to, generally, the later life stage, the senescence life stage, which has its own complications in neurodegenerative disease patients developing dementia, and that need for partnership as well with other groups. But this reminder that it looks attaining or maintaining your brain health looks different at every stage of life. And so, you want to pick up on any elements of that and how we can better engage partners at that life stage?

Dr. Joel Salinas:
Yeah, you brought up a really important point about the role of psychiatric care within that patient and how it influenced their neurologic care. And it really speaks to what I would envision to be part of the future of brain health is where we have a lot more alliances across the different specialties and disciplines. Mental health is brain health, right? We're all trying to help to support the same organ system here.
And if we, as a neurologist, could come into the picture and say, "That's depression, that's not my camp." Right? If we had missed that, helping to improve that person's mood is actually going to help to improve their cognitive functioning and their independence, then we're not actually doing our role as a neurologist.

Dr. Lazar:
I also want to mention that atypical dementia and Alzheimer can present as agitation or anxiety, and they're just like atypical Alzheimer's. So it's very important to have a good assessment from a psychiatrist that we do know is dementia, not something else.

Dr. Gregg Day:
Agreed.

Dr. Joel Salinas:
Agreed.

Dr. Gregg Day:
Anyone else interested in catching? Evelyn, how's your arm? You want to throw all the way. This is brain health, laughter, exercise. We're getting it all. That's great.

Vineeta Singh:
Can you all hear me?

Dr. Gregg Day:
Yeah.

Vineeta Singh:
Great.

Dr. Gregg Day:
Please, go Ahead. Thank you.

Vineeta Singh:
This is Vineeta Singh. I am at University of California, San Francisco. I'm a critical care neurologist. And I love the idea of expanding on social determinants of brain health. It's not one monolith. It can be so vast. I work at the county hospital, and I'm in a trauma critical care unit.
What I have recently started doing with my medical students, because as you all know, you're also an educator, and very limited amount of time with your ICU patient, the student almost never gets to connect with the patient. I have started asking them to write up a note, social determinants of health for the patient that they're following, because their notes don't count toward my billing, but it does highlight so many other issues.
As you can imagine, trauma settings, it's like you have mental health disorder, substance use, trauma that you can make all kinds of Venn Diagram, and there's so much overlap. And this is just last three months, and I have uncovered so many things on my patients that I would not have known that we have been able to connect them to the proper services, whether it was for addiction, whether it was just the fear with all that's going on in our country.
Family members not being able to come visit their loved ones, and we didn't even know. We though this person was unidentified. No, they had a whole family. They just could not come. Just wanted to bring another angle to it. When you have limited amount of time, critical care, education, you can still do advocacy.

Dr. Gregg Day:
Well, let me thank you on behalf of the panel because that is such a phenomenal example of both education. You're educating and bringing new people into the brain health discussion through the medical students. It's an effective use of time. They're contributing valuable information, but it also shows what happens when we actually ask these questions to patients.
If it's in your mind and thinking, "Oh, this could be a very awkward conversation," our patients are open to these lines of discussion if we're leading them. And we learn things that, in the ICU, improves the health of the patient in front of you, but also all of those connected to the patient in that whole unit. And a wonderful example of a very pragmatic way to roll out brain health in an ICU practice that involves other generations of medical trainees and hopefully future neurologists.

Dr. Joel Salinas:
I would also just add, we often hear that there's not enough time to cover everything in day-to-day. How do we expect to train the future of neurology that really cares about all elements of a patient if they haven't been taught to value all these elements? So I really love that suggestion to have the residents actually have a section in the note about social determinants.
So even throughout your care, you can do a lot of modeling by actually asking questions that relate to these factors or bring it up as they're presenting if they asked about it, because then that kind of communicates that this is important. And so as a field, as a clinician, you need to be thinking about these things.

Dr. Gregg Day:
Other comment, question here?

Hannah Noah:
Yeah. I'm Hannah Noah, Behavioral Neurology at UNC. So I'm blessed with hour-long appointment slots. And even then, it's a lot to get through. You have to tell this person they have Alzheimer's and to talk about that, the potential emotional fallout, and then you have to get through. But usually, my approach for talking about what we do about it is, let's talk about brain health, then let's talk about cholinesterase inhibitors, let's talk about infusions if those are applicable.
So even with my nice long appointment slots, it's still five, 10 minutes absolute maximum to go through all of brain health. And to get around this, I'm interested in actually starting a program, types of visits that are just solely dedicated to brain health and preventative neurology, not so much just the diagnostic, the medical treatment, just solely on that preventative space. So I've gotten to know a couple of people who have done this.
It seems like the group visit model is something that's worked well for some people. I'm trying to get to know a couple of people who are certified in lifestyle medicine who are doing similar things. So my question for you guys is, do you know anybody who has successfully done a brain health?

Dr. Joel Salinas:
Two points to what you said. I think the point that you made about not having enough time even though you have an hour. And actually, I recently heard about somebody that does behavioral neurology, and they get 90-minute slots, and I was like-

Dr. Gregg Day:
There's 90-minute slots out there.

Dr. Joel Salinas:
Yeah, that's wild. But yeah, some places do that. What a luxury. But one thing I learned from, this came from Allan Roper, was just don't try to boil the ocean in a single visit. And for those of you who worry about having enough time, what I will do in my note, the things that I couldn't get to, I put it as a part of my assessment and plan and say, "In follow-up, we'll address the following." That way when I do the follow-up, I can make sure, oh, yeah, this is my missing agenda that I can bring back into this visit.
But for doing these kind of brain health type of visits, so there's really great models in this within lifestyle medicine. And shared medical appointments, these kind of group appointments, there's been a lot of research around group level interventions. And the socialization aspect of it really helps with kind of group norms and with education, and people get to participate more and hear questions that others didn't ask. I would say that the coverage of it is actually probably better than you anticipate.
So you have to just really think through within your own clinical practice, what is the ideal system that you can put around it? It may take a little bit of training around staff to make sure that the workflow makes sense because you want it to be really smooth. We do it all via virtual visit because we're fully telehealth, and we found it helpful to set it up within a structured kind of modular program. And that's another lesson from U.S. POINTER, which is structured programs tend to do better.

Dr. Gregg Day:
Something else we need to remember, that 60-minute visit, I won't say that's a luxury. As you described, all the things we try to accomplish. How much does the patient really hear after we say the words Alzheimer Disease, or stroke, or multiple sclerosis or put your disease in there? For many patients, it becomes white noise after. It's overwhelming. And so, setting up and planning for this dedicated visit is really what we want to see for our patients, and there's many ways to do this.
This is a phenomenal way that you're doing it. Leveraging those virtual resources, that means other people can be involved in the discussion. They don't even have to be in the same location. They can come in from across the country, creates that time and that space. In our clinic, we do a brain health visit. It's funded through state level funding to advance brain health, which is unique. And we're really privileged to have that.
And it's run by a research educator who we've trained and worked through some of these goals as well. And so, there are many novel ways to do this. We want to see this moving forward. Well, we've got one more from Dr. Kingston. We're going to make sure he gets it in. And then, we're going to go back to our panel here. From the University of Toronto.

Dr. Kingston:
Yeah, so my lens is obviously a bit different because I see younger patients who have a lot of subjective complaints. And I'm also spoiled listening to this because we have 90-minute appointments for new patients that are paid for by the government, so it's actually very nice for us. But what I'll do is, a lot of migraine patients have heard it all. It's not the water you drank, it's not the sleep you got that's causing your migraine.
So it's a good opportunity to tell people with migraine that poor self-care is not causing your migraine, but how can we reframe this and use this as a good opportunity to maximize your general health? Because we know when your general health is better, so is migraine. And that can be a good way to get people involved in brain health when they're younger.

Dr. Gregg Day:
An amazing transition point. You're effectively preventing strokes and maybe preventing dementia and other visits down the road. I'm glad I haven't heard anyone express concern that if we do such a great job with this, we're all going to be out of a job. We appreciate that there's plenty of patients that need to see us, and it's a privilege to be able to engage in something that's going to advance their health and the health of their family.
Talking about success though, what would success look like? And the question that I wanted to end on, and I want to hear from both of you here, if we look 10 years ahead and we assume that this AAN Brain Health Initiative is wildly successful, what would be one visible way that the daily practice of neurology is going to look fundamentally different from today? And Sarah, I'll let you lead with that.

Dr. Sarah Song:
It would be great if we were able to actually track sort of a longitudinal path for each patient and say, "You know what? You were here. Last time I saw you six months ago, but now you're here for these reasons." Right? And that wouldn't be a weird thing for them to hear about how their brain health is doing or how their brain health has been improving because of different things that they have been doing. And that brain health would really just be part of the vernacular of just a normal visit. It's not stroke visit plus brain health check. It's just stroke and brain health, right? So it's all in one. That would be amazing.

Dr. Joel Salinas:
I would envision within 10 years, one really powerful way to see how brain health has impacted care is that we're not just thinking about what can I do today, but what have we helped to prevent in the future and having a way to really quantify that, just understanding the risk reduction. Or having maybe through the use of potentially being able to show kind of what the counterfactual would've looked like if we hadn't implemented these things, how much have we now benefited you or saved you from? I do think that there's a lot of hope for brain health.
But I do think that there's a lot of very real barriers that we still need to tackle for that to be successful. The pillars of brain health really speak to that. We do need better research really focused around that. We need to have better health systems that anchor around, a focus around health. We need payment models and payers to really see this as something really valuable, so that way, we can actually be compensated for that. To some degree, education and the culture of how we practice needs to change.

Dr. Gregg Day:
Just going to put a word to that. We want brain health to be top of mind for everyone at this meeting. It shouldn't be a new concept or a new vision. And the priorities that you've set are absolutely in line with what we're trying to achieve through the brain health committee and through the other AAN leaderships, and ultimately through our members.
As we wrap the panel discussion, I just want to conclude really remembering this central theme that we've been talking about today. Brain health is not that additional task. It's a framework that we can use to reorganize our visit, reorganize our approach, and ultimately continue to do what we're already committed to do across the lifespan.
What we've heard from our panelists, and thank you to many in the audience who have contributed to that as well, this clearly reflects the AAN's vision for brain health. Integrating brain health doesn't require us to do everything. That's not what we want you to leave with.
But I do want you to leave recognizing that you're a leader in this space, and that we are the best ones to lead, to help our patients prioritize what they can do next, and to walk with them along the treatment of disease, but also heading towards the prevention of neurologic disease and maintenance and attaining of their goals through the lifespan as we work on the system challenges, the environment, and education.
I do hope that today's discussion leaves each of you with maybe one practical thing that you can take home to expand the discussion with other people in your practice, maybe to make a difference, even if it's not a 90-minute visit. We've only got a few of those in the crowd here, but great space to continue to advocate and advance.
And on behalf of the American Academy of Neurology and certainly on behalf of the Brain Health Committee, I really want to thank each of our panelists, of course. I love the discussion with you guys. It's always a pleasure to talk about things that we're passionate about. Thanks.

Dr. Stacey Clardy:
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.