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$$PLAIN_TEXT_PREVIEW$$
Quarterly Newsletter For Health Care Providers
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With only a few days remaining in 2024, we are excited to share our latest newsletter on everything dementia-related! As always, continue to provide us with topics of interest and feedback on how this newsletter can help your practice.
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Our second location continues to offer timely assessments. As a reminder, any individual with a physician or nurse practitioner referral can be assessed. Location:
231 Oak Park Blvd Unit 110, Oakville, ON L6H 758 Eligibility:
Must be able to attend in-person appointments.
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NEW Better Together Dementia program for Personal Support Workers
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We recognize the challenges that come with caring for those with memory concerns. Unfortunately, most personal support workers (PSW) are not provided with the proper training or resources to safely provide such care. Our Better Together Dementia program aims to educate and empower PSWs to provide safe and patient-centered care for those with memory challenges. Our team has successfully provided training to PSWs across several sites in Southern Ontario - with more to come! Interested in learning more? Contact us!
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Upcoming Annual MINT Symposium and Best Practice Days + 2025 MINT Training & Mentorship
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The annual MINT Symposium Best Practice Days is a great opportunity to stay up to date with the latest dementia news and connect with the MINT community. You can expect practical and evidenced-based presentations from top dementia specialists across Canada as well as experienced allied health professionals such as pharmacists, nurses, and occupational therapists. For more information and to register, visit: https://www.mintmemory-conference.ca/
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2025 MINT Training & Mentorship
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No slowing down in 2025 - additional sites are set to go live in the New Year in Ontario and Eastern provinces! Interested in offering a MINT clinic in your community? Contact us!
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WHAT IS NEW IN DEMENTIA CARE?
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Interpreting an MRI for the Non-Physician Of all the questions we receive, this is the most common one. Therefore, we decided to provide you with a summary of what you should pay attention to when reviewing MRIs in practice. MRI reporting has progressed drastically in recent years as the management and treatment of dementia becomes increasingly individualized. As pharmacists or other allied health team members, our role is not to interpret the MRI report from a diagnostic perspective. However, it often influences drug therapy and, therefore, it is important to be aware of key points. Further, it is helpful to gain insight into the physician’s thought process to anticipate their diagnostic decisions. Here are the main elements we look for and how they guide drug therapy recommendations: Read the entire report. Secondary stroke prevention: This should not be a surprise to anyone, however there are still a few factors to consider: Etiology: Is the stroke atherosclerotic or cardioembolic? Most patients should be treated with an antiplatelet such as ASA or clopidogrel, unless contraindicated Individuals with atrial fibrillation should be treated with an anticoagulant such as warfarin or a direct oral anticoagulant (DOAC), unless contraindicated A statin, unless contraindicated, should also be recommended.
b. Lacunar infarcts: these often-asymptomatic strokes that impact small vessels are important when it comes to memory loss. Historically, these were generally disregarded and thought to be of little relevance, however recent research finds they may play a larger role in the development and progression of dementia. Our clinic will treat these as a typical stroke or TIA. PRACTICE POINT #1: Initiate ASA and a statin for lacunar infarcts, unless contraindicated. * If you are interested in reading more about the evidence supporting and refuting this, see this great paper by Bilski et al. https://pmc.ncbi.nlm.nih.gov/articles/PMC10421561/ c. Hemorrhagic strokes: 1. ASA should not be prescribed. 2. Blood pressure control should be emphasized, targeting at least < 140/90 mmHg. Cerebral amyloid angiopathy (CAA): the accumulation of amyloidogenic proteins (most commonly Aβ) in cerebral blood vessels leads to weakened blood vessels that are more likely to cause bleeding in the brain. CAA is often associated with Alzheimer’s pathology. Anticoagulation and/or antiplatelet therapy: there is still uncertainty on how to manage anticoagulants or antiplatelets in individuals with CAA due to the increased risk of intracranial hemorrhage (ICH). There is a greater risk of bleeding with anticoagulants than with antiplatelets, however the risk-benefit profile should always be reviewed. Often, consultation with geriatric medicine or cognitive neurology is helpful in weighing the benefits versus risk if anticoagulants or antiplatelets are required for other medical indications. Blood pressure control should be emphasized, targeting at least < 140/90 mmHg.
PRACTICE POINTS #2 and #3 Anticoagulation: DOACs have been shown to have a lower risk of ICH compared to warfarin, therefore individuals should generally be switched from warfarin to a DOAC, unless contraindicated. If you are unsure, reach out to a specialist for guidance. Antiplatelet therapy: generally considered safe to continue despite CAA, however it is wise to confirm with a specialist in these cases. Discontinue ASA for primary prevention.
4. Standardized quantitative reporting: Use of standardized scoring is becoming increasingly common in MRI reports that assess changes consistent with mild cognitive impairment and dementia. Here are the most common scores to be aware of: a. Fazekas score (1, 2 or 3/3): measures the amount of white matter in the brain, generally due to small vessel ischemic changes. A higher Fazekas score suggests a vascular component to the cerebral changes. PRACTICE POINT #4: A high Fazekas score is not an indication for an antiplatelet such ASA in the absence of a documented stroke. b. Medial temporal atrophy (MTA) score (1, 2, or 3/3)*: among other findings, this could suggest the presence of an underlying Alzheimer’s pathology. *Some radiologists may score out of a total of 4 points* PRACTICE POINT #5: If there is functional impairment identified, i.e. a dementia is present, the physician may feel there is an underlying Alzheimer disease component and may consider initiating a cholinesterase inhibitor or memantine. Note though that early stage Alzheimer disease may not always show up as structural change on an MRI but this may become more evident as the disease advances. c. Global cortical atrophy (GCA) score (0, 1, 2, 3/3): more general compared to the MTA score, this measures the presence of atrophy in 13 separate brain regions. Higher scores are generally present with more advanced neurodegenerative diseases such as moderate to advanced dementia. d. Koedam score (0, 1, 2, or 3/3): also known as the posterior atrophy score, it specifically measures the amount of atrophy present in the parietal lobes. It has a positive predictive value in the diagnosis of AD, but but may also be abnormal in other conditions. Interpretation of MRIs should be left to physicians;
however, it is helpful to understand the contents of the report and how it may
impact drug therapy. It can be overwhelming at first, but like everything, it
improves with repetition. If you have any questions, feel free to reach out to
our team!
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Supporting Individuals with Hearing Loss in Practice Communication is the cornerstone of interaction. In healthcare, an added element is the need for communication to be conducted privately. Attempting to speak privately with a patient with confounding factors such as patient hearing loss, a noisy environment, and rooms that are not soundproofed, can render the conversation either ineffective or at a volume that compromises patient privacy. Many health care professionals are tasked with completing medical conversations in areas where speaking loudly compromises privacy. Recent observations of this include a physician having to speak very loudly with a patient in a nursing home room and a community pharmacist having to consult loudly with a patient about a new medication. In each case, while both were in closed rooms with the patient, the volume necessary to communicate, was audible to other outside the room. In our own clinic, we have successfully implemented a pocket talker or similarly styled device. This is a ‘walkman’ style speaker with an over the head earphone set. This is a style very familiar to this generation. This allows even extremely hard of hearing individuals to hear well despite low volume of the person speaking. We have used this successfully in our clinic environment, and in our visits to both nursing and retirement homes. They can be easily wiped down and have brought many smiles to patients for whom their hearing aids were ineffective in a loud environment, or simply not effective enough. The use of a pocket talker styled device has allowed us to speak at normal or even low volume to patients. This increased ability to easily bypass hearing loss and communicate effectively facilitates higher quality, respectful, and privately given care.
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Disability Tax Credits As we welcome the joys of the New Year, we will soon also welcome the lesser joys of tax season. However, an expected tax credit can make it more fun! In my work as an Occupational Therapist, I often meet patients who are unaware they qualify for the federal Disability Tax Credit (DTC). The goal of the DTC is to reduce the amount of income tax you may have to pay, thereby offsetting some of the extra costs related to the impairment. As pharmacists, nurse practitioners, occupational therapists, and other healthcare professionals (HCP), we are knowledgeable not only about the academic aspect of our patient’s health, but of the day-to-day functional implications of these health impairments. For example, pharmacists are well poised to understand that specific medications suggest a diagnosis of dementia, thereby very possibly making a patient eligible for the DTC under such categories as dressing, feeding, or speaking. If a patient is experiencing such significant shortness of breath that they ambulate at a speed three times slower than their same aged peers, they meet eligibility criteria. There are multiple areas of eligibility criteria, each with specific health care professionals designed to assess the individual’s health and functional status. Please refer to the table and website below for more information. In my own experience, at the time of my son’s diagnosis of type 1 diabetes, it was a proactive pharmacist, filling my first doses of insulin and diabetic supplies, who educated me about this tax credit. When as an overwhelmed mother learning to manage diabetes, I did not follow up on this, he reminded me again. Although pharmacists cannot complete a DTC application, they are well poised to have insight into the health of their patients, the corresponding functional implications of such conditions, and to the appropriate HCP to assist with this application. Patients and families are often unaware of their eligibility for this credit, and the financial support it may offer (hundreds, even thousands of dollars!). It can also be applied retroactively. As was my experience, a pharmacist is often a key front facing HCP who interacts with a variety of people. Finding out about an option for some financial relief of their disability or health condition is a very welcome addition to an individual’s trip to the pharmacy 😊 Table 1. Reference guide of eligibility categories, description, and authorized HCPs to complete a DTC form.
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References 1. Bilski AE, Aparicio HJ, Gutierrez J, de Leeuw FE, Hilkens NA. Antiplatelet Therapy or Not for Asymptomatic/Incidental Lacunar Infarction. Stroke. 2023 Jul;54(7):1954-1959. doi: 10.1161/STROKEAHA.122.040444. Epub 2023 May 16. PMID: 37191009; PMCID: PMC10421561. 2. https://radiopaedia.org/articles/fazekas-scale-for-white-matter-lesions 3. https://radiologyassistant.nl/neuroradiology/dementia/role-of-mri
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Whether it’s your first time reading this newsletter or you have been with us since the beginning, thank you! We hope you had a Merry Christmas, and wish you a happy and healthy 2025!
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