Think Out Loud

Oregon clinic in Sherman County tests tool kit to help patients with cognitive decline

By Elizabeth Castillo (OPB)
Aug. 8, 2023 5:20 p.m.

Broadcast: Tuesday, Aug. 8

The Sherman County Medical Clinic in Moro is using a pilot tool kit to talk to patients about cognitive decline, which includes diseases like Alzheimer’s. Health care can be difficult to access in rural areas and patients needing care from a specialist face long wait times. The American Academy of Physician Associates has collaborated with health care organizations across the country to test the tool kit. PAs, also known as physician assistants, are often on the frontlines of a patient’s health care and can have these conversations about brain disorders early on. We hear more about the pilot program from Erin Haines, a PA at the Sherman County Medical Clinic and Lisa Gables, the CEO of the academy.


This transcript was created by a computer and edited by a volunteer.

Dave Miller:  This is Think Out Loud on OPB. I’m Dave Miller. Primary care providers at the Sherman County Medical Clinic in Moro are testing out a new way to talk to patients about cognitive decline. The pilot tool kit was developed by a collaboration of healthcare organizations to promote the earlier diagnosis of Alzheimer’s Disease or other forms of dementia. Erin Haines is using the tool kit right now. She is a PA at the Sherman County Medical Clinic. Lisa Gables is a CEO of the American Academy of Physician Associates. They both join me now.

Welcome to Think Out Loud.

Lisa Gables, first. Why was this tool kit created?

Lisa Gables:  Well, as you probably are aware, Alzheimer’s is a big disease in this country. About 6.7 million Americans currently live with Alzheimer’s according to the Alzheimer’s Association. And we are looking at a number more like 14 million people by 2060. Specifically in Oregon, 69,000 people are currently aged 65 and older and live with Alzheimer’s. This number is expected to grow to more than 84,000 by 2025. And according to the CDC, Alzheimer’s is the sixth leading age-adjusted cause of death in Oregon today. But it is a national problem. So we felt it was very important to be involved on the front line of this disease and teaching PAs how to better utilize and, as you mentioned in your opening statement, earlier detection of cognitive decline.

Miller:  Why focus on PAs in particular? We’re talking here about a group of healthcare providers who have, in the past, been called physician assistants. Now, physician associates is becoming more common. But why focus on PAs?

GablesWell, really if you think about it, PAs are often one of the first health care providers that a patient sees. Regardless of the setting, but specifically in primary care, they’re often the person that people can get an appointment with faster and they’re uniquely positioned to screen patients for this cognitive decline early on and, if necessary, refer the patient on for further tests or do the test themselves.

PAs are the fastest growing healthcare profession in the country and play a critical role in improving healthcare access for patients across the country. Today, there are more than 168,000 PAs nationwide, practicing in every specialty in every setting. And they account for more than 500 million patient visits a year across the country. So it’s a perfect place for this kind of tool kit and this kind of observational work to be done in a place where people can see a PA first.

Miller:  Erin Haines, why did you want to take part in this program?

Erin Haines:  I joined the Sherman County Medical Clinic in 2021 and I came from an orthopedic background. So in doing that, my experience with evaluating patients with possible dementia or memory decline was really related back to years prior. I knew that I needed more knowledge. I needed up-to-date knowledge. And when this was presented to me, the idea of a module that was going to give me the ability to assess patients, maybe make it part of my practice and just provide better care, made absolute sense.

Miller:  How common has it been in the last two years of your practice for patients to volunteer that they’re concerned about their own memory decline or cognitive decline?

Haines:  It varies. It comes either from the patient or maybe a family member or a caregiver for the patient. And it often comes about in a conversation where I raise the topic and they go, ‘oh, so speaking of that, I’ve been a little worried doc’ and then maybe elaborate a little bit further. But if I’m not instigating that conversation, I would say it is more rare than it should be. But if I instigate the conversation and open that doorway, then I’m having that discussion with the majority of my patients in the population of 65 and older.

Miller:  And is that something that you were in the habit of doing before you started up trying out this pilot tool kit?

Haines:  It was not nearly to the degree that I use now. That was an absolute change that this tool kit made in my practice.

Miller:  Can you give us a sense for how those conversations go now? How you broach the subject?


Haines:  Oh, absolutely. So, once a year I have patients that come to visit me and what we do is an annual visit. And in that visit, we check in with how they’re doing, what our goals are for their healthcare and what preventative medicine we can really take a look at. So when we’re talking about assessing for dementia or mild cognitive impairment or cognitive decline in the early phases, what we’re really discussing is preventative care. And normalizing a conversation with a patient about how you’re trying to help them prevent an issue that is potentially very scary to them or they are worried about in the back of their mind, is part of my once a year visit with that patient.

So I’m gonna say this multiple times because I think it is the most important thing. But normalizing preventative care is the key to assessing and bringing about a conversation open to both myself and them and maybe a family member.

Miller:  What does preventative care look like when we’re talking about a progressive disease like Alzheimer’s?

Haines:  It plays a role in the earlier phases. So if you can identify early mild cognitive impairment, which the average is about five years, that could convert from mild cognitive impairment into Alzheimer’s or dementia. In that time frame changes that you can make to your lifestyle, potential medication changes, that can lead to a delay in the progress of the condition. So that’s what we’re talking about with prevention there. You take a step back and are talking to a patient who has no problem with their memory impairment, but maybe is living a lifestyle that would put them at increased risk. For example with alcohol or, in rural communities, isolation from other people can be a risk. Having those things brought to the attention and maybe discussed, could then change the way that they’re gonna view their own healthcare. And that’s preventative care.

Miller:  Lisa Gables, in a report I saw about this pilot program, there was a quote from a PA in a rural part of Maryland who said that where she was practicing, there are very few neurologists. So primary care providers like her are the ones who are providing a lot of care for conditions that more urban providers would be more likely to refer to specialists. How do rural practices play into what we’re talking about here?

Gables:  Well, as you might be aware, there’s a real problem with rural health care in America today where there aren’t enough providers to go around and many places across the United States don’t have healthcare at all. My personal experience is in my home state of Missouri, it’s the case there. Where my parents live, there are no health care providers. And so it’s a 75 mile drive just to get healthcare. So it’s very, very important that PAs in particular, who tend to work in these areas at times, really understand many conditions that may come to face them. Patients come in to present with all sorts of diseased states and conditions that they need help with.

And what Erin said is right. Preventive care can help go a long way in making sure that people, particularly in rural areas who don’t get those yearly checkups as often as we’d like them to, or maybe delay care because they can’t afford to drive 75 miles. It’s important that PAs who are there and easy to access, so to speak, really are there to help them. And so we intentionally added rural clinics into these testing sites so that we can understand what the differences are between urban areas and rural clinics and how they approach early cognitive decline and identification. So this is why it’s very important to have rural clinics involved in this test.

Miller:  Erin Haines, you mentioned earlier that you really want to reiterate that normalizing these conversations is maybe the key, in terms of your practice. My understanding is that that’s sort of to address the stigma or fear that could be associated with this diagnosis or fear on the part of people who fear that diagnosis. I’m curious what kinds of responses you’ve gotten from patients so far as you have been talking about this more.

Haines:  It is important to recognize that my goal for this is to keep people independent in their life. In rural settings, in rural regions, the folks that are out here have a different mindset than in urban environments. But one part of that mindset is a desire to live on their property to be responsible for themselves and their family and to be able and capable to take care of themselves for the long term. And for the entirety of their life would be their ultimate goal.

Miller:  I would say in a lot of ways those seem like nearly universal desires that cut across urban and rural areas.

Haines:  Wonderful. In my setting, how that translates is people who are living independently 50 miles, 75 miles, three hours away from other people. That takes on a different viewpoint in terms of getting aid to them. Or being able to even go grocery shopping takes on a different meaning. So when I have these conversations and am approaching this, I make it very clear that I want to address this in order to maintain their goals, their goal of good healthcare in general, good memory care, good independent living, longevity, and quality of living.

Miller:  Lisa Gables, just briefly, what’s next? What are you gonna do with the feedback that you get from this pilot?

Gables:  So we are in the final stages of the pilot program and we will be finishing this up and a tool kit and reports and resources will be released publicly on November 1st. I have already started conversations with the Davos Alzheimer’s Collective on what’s next and where we can be involved if possible, in the next steps of their big goal to try to eradicate, actually, Alzheimer’s Disease in this country over time. So we are very excited about getting the final results from all the sites, putting it all together in a report and a final tool kit.

We will be releasing all the reports as well as disseminating all of the information we know and have learned across the entire United States and to all the PA that practice no matter what setting they are practicing in. So that’s our plan. Our next steps.

Miller: Lisa Gables and Erin Haines, thanks very much.

Haines:  Thank you.

Gables:  Thank you.

Miller:  Lisa Gables is the CEO of the American Academy of Physician Associates. Erin Haines is a PA at the Sherman County Medical Clinic in Moro.

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