Integrated primary care: help for both Alzheimer’s and anxiety

August 6th, 2018

Newly married in their 50s, Trisha and Brian Washburn planned to move to Colorado to grow old together.

Trisha Washburn poses at the top of a mountain with a view behind her. She's coping with Alzheimer's and anxiety and is getting help through integrated care at her primary care clinic.
Trisha Washburn is doing her best to live a full life after a devastating Alzheimer’s diagnosis that robbed her of her confidence. Photo courtesy of Trisha Washburn.

Both were avid skiers and dedicated ski instructors. For decades, each had taught at a tiny ski hill in Connecticut, passing along a love of skiing to generations of children and perfecting their teaching techniques.

Finally, in 2016, the Washburns were fulfilling their dream of coming to the Rockies, where the big mountains beckoned.

Then, just two weeks before their move, Trisha received a devastating diagnosis: early-onset Alzheimer’s. She was only 56. She had coped since age 10 with Type 1 diabetes, and later had heart problems. But her bubbly personality and a love of sports keep her fit and relatively healthy.

‘Like a funnel had sucked out everything familiar’

The Washburns arrived in Colorado full of hope, but Trisha’s challenges soon became apparent. She felt lost in her new surroundings. Near their apartment on a ridge in Broomfield, they had a stunning view of Boulder’s Flatirons and the mountains beyond. But, Trisha had trouble telling the doors to the garage and the breezeway apart. Confusion flooded her as she drove.

Her memory problems spurred anxiety. An expert on the slopes, she nonetheless was afraid to ski or work as a ski instructor. She worried she’d get lost or lead young children astray.

Trisha and Brian Washburn in a photo on a chairlift durign ski season. Both are ski instructors who moved to Colorado from Connecticut so they could ski the biggest mountains.
Trisha and Brian Washburn are both ski instructors. They married in 2013, then weeks before moving to Colorado, Trisha was diagnosed with Alzheimer’s. Photo courtesy of Trisha Washburn.

“It was like a funnel had sucked everything familiar out of me,” Trisha said.

A crisis with her blood sugar levels then led to a five-day hospitalization in February at UCHealth University of Colorado Hospital on the Anschutz Medical Campus. Doctors stabilized Trisha’s diabetes, gave her a pump that helps her automatically regulate her insulin levels and treated her for pneumonia.

After recovering, Trisha followed up with her primary care team at the clinic close to her home, UCHealth Family Medicine Clinic – Westminster. And a welcome surprise greeted her. Along with her trusted primary care provider, Dr. Michael Dewey, she could also get help from a behavioral health specialist, Lauren Tolle, who has a doctorate in clinical psychology and works in tandem with Trisha’s primary care team.

“Our whole team wrapped around her,” Tolle said. “The lovely thing about primary care is that we see everybody. There are a lot of common referrals for depression, anxiety, insomnia and chronic pain.”

By working closely with Tolle, Trisha has been taming her anxiety so she can feel comfortable in life and on the slopes again.

Integrated care: better outcomes, reduced stigma

UCHealth’s Denver-area primary care clinics recently have added behavioral health providers so patients easily can get help for common challenges. (Click here to read a related story, Bipolar disorder: The torture and beauty of an unquiet mind.)

Lauren Tolle, left, a clinical psychologist, meets with patient, Trisha Washburn, right, at the UCHealth Family Medicine Clinic in Westminster. Tolle is helping Washburn cope with anxiety.
Lauren Tolle, a clinical psychologist and an expert in integrated primary care, meets with Trisha Washburn regularly at the primary care office close to her home, UCHealth Family Medicine Clinic – Westminister. Tolle works closely with Trisha’s primary care provider.

For decades, patients who needed both physical and mental health care had to navigate deeply divided systems. The splintered care dated back to times long ago when doctors had few treatments for little-understood mental health disorders like schizophrenia. Unable to get help, people with severe mental illnesses often ended up in institutions.

Better medications and a greater understanding of mental health challenges have led to improved care.

Today, the most innovative health systems provide integrated physical and behavioral health in primary care clinics to better serve patients, reduce stigma and improve access to care.

Providing much better behavioral health care is critical to better health outcomes for patients since people with serious mental illnesses and substance use challenges also have higher rates of chronic physical illnesses and die earlier than others. At the same time, people like Trisha, who have serious physical health challenges, also cope with higher rates of mental health illnesses, according to the National Institute of Mental Health.

A devastating diagnosis

When Trisha first met Tolle, she was instantly comfortable.

“She has been so wonderful. She really took the time to get to know me,” Trisha said.

Trisha had worked for many years as an administrative assistant in Westport, a charming town in Connecticut. She loved the varied work and forging bonds with the many people who came in for help.

“I would meet with lawyers and prospective purchasers of property. I loved it. It was A to Z,” she said.

In the summers, she played tennis and every year, went to see the pros play nearby at the U.S. Open.

Two people ultimately prompted Trisha to check on her cognitive function.

“My sister said, ‘It’s painful to watch you try to find your keys or your pocketbook,’” Trisha recalled.

Then her boss of 10 years pulled her aside in 2016 and said, “You’re becoming very forgetful and you’re no longer getting things done.”

“I was absolutely devastated,” Trisha said. “I had trained a gal. We got along really nicely. My boss had begun to pull things off of my plate and give them to her.”

The town had an employee assistance program. Trisha booked an appointment, thinking perhaps she needed therapy. After a short time, the counselor told her she should probably be talking to a neurologist. She went to a neurologist, who delivered the Alzheimer’s diagnosis.

“It was horrific. I was in absolute shock. I had convinced myself I didn’t have it,” Trisha said.

‘More forgiving of myself’

Since her diagnosis, Trisha has been taking part in an Alzheimer’s study in Connecticut, flying back occasionally. While she has the amyloid protein markers associated with Alzheimer’s, Trisha’s cognitive function has remained relatively stable over the last two years.

Her neurologist at UCHealth, Dr. Christopher Filley, who is also a professor at the University of Colorado School of Medicine, is doing additional testing to determine whether Trisha truly has Alzheimer’s or a different type of cognitive impairment. She is eager to keep participating in research so she can get answers for herself and others.

Trisha poses with a Continental Divide sign at the top of a pass. She is new to Colorado and is trying to cope with anxiety after an Alzheimer's diagnosis.
Trisha and Brian Washburn both dreamed of moving to Colorado for years. Weeks before they made the move, Trisha was diagnosed with Alzheimer’s and suffered from anxiety as a result.

“I can face anything. Just let me know what I’m facing,” Trisha said.

While Filley continues to assess Trisha, he advised her to stop driving. Getting around Colorado without a car has been challenging at times, but Trisha found it a relief not to contend with navigating areas that were new to her. She now uses ride-sharing apps to get around.

That frees her up to focus her attention on issues that matter most, like regaining her confidence on the ski slopes.

Tolle taught Trisha to use breathing exercises to feel calmer in stressful circumstances. Tolle and Dewey also have worked together to help Trisha try various anti-anxiety medications. Despite her challenges, Trisha has an incredibly positive attitude and Tolle also has helped her make peace with her new circumstances.

“I’ve gotten to where I’m more forgiving of myself,” Trisha said.

Most of the time, she’s counting her blessings instead of mourning her losses.

“I’m the youngest of four and I came from a wonderful family,” Trisha said. “I always think, ‘it could be so much worse.’”

Her parents were both ski instructors and Trisha was on skis herself by age 3. Her mother taught skiing until age 80 and played golf until age 83. She died recently, but was able to see Trisha marry her husband in 2013. It was a first marriage for Trisha and she loves now having stepsons.

Feeling fantastic on the slopes

On a perfect ski day, it’s sunny and Trisha is effortlessly breezing down the bumps.

After working with Tolle, Trisha was able to get back on the slopes last spring.

“It felt fantastic, but very different. I wasn’t teaching anymore and that’s really tough,” she said. “I love teaching little kids and scared adult women. I do really well with them.”

Trish Washburn holds her hands out in a snowy landscape with a mountain behind her. Washburn is passionate about skiing. Thanks to help from a psychologsit at the UCHealth primary care clinic close to her home, she's regaining her confidence on the slopes. Photo courtesy of Trisha Washburn.
Trisha Washburn is passionate about skiing. Thanks to help from a psychologsit at the UCHealth primary care clinic close to her home, she’s regaining her confidence on the slopes. Photo courtesy of Trisha Washburn.

During her years as an instructor at Mount Southington in Connecticut, Trisha had trained hard to earn the highest level of certification with the Professional Ski Instructors of America.

Many years ago, she taught for two ski seasons at Vail. Then she returned home because of some problems with her heart and vision loss tied to diabetes. She was able to work weekends as an instructor at Mount Southington. The area boasts only a 425-vertical drop, compared to 3,450 at Vail, but Trisha said instructors there had “small mountain syndrome” and compensated for their limited terrain by creating an outstanding ski program.

Trisha met her future husband at Mount Southington, where he was also an instructor. Brian is an environmental engineer, who went to Colorado School of Mines. He loves breaking down and understanding each step of skiing.

He describes Trisha, on the other hand, as a joyful, intuitive skier.

“She brings a lot of excitement and fun,” Brian said. “She’s a very strong skier.”

Since moving to Colorado, Brian has been teaching at Eldora. Trisha hopes she can find a role in future ski seasons as a volunteer or a lift operator.

“Factoring all that people go through, I’m doing pretty damn well. I can still laugh. What else am I going to do? My alternative is to sulk. And I don’t want to sulk.”

Reaching people who otherwise wouldn’t get help

At Trisha’s primary care clinic, Tolle said integrated care is critical for many patients.

“It’s the way care should be delivered. It cuts through so many barriers to accessing behavioral health,” she said.

A lone skier, Trisha Washburn, skies through a narrow valley with snow-covered pine trees surrounding her. Washburn loves skiing, but lost her confidence after an Alzheimer's diagnosis.
Trisha Washburn’s passion is skiing. Even though she’s an expert instructor, after an Alzheimer’s diagnosis, she lost her confidence on the slopes. Photo courtesy of Trisha Washburn.

In clinics where medical providers can only give patients referrals to outside mental health providers, patients often don’t get help.

“Even if you’re doing well, it can be too hard (to find behavioral health providers). If you’re not in a state where you’re feeling OK about things, you can give up,” Tolle said.

But, in an integrated setting, physical and mental health specialists can give each other what’s called a “warm handoff.” Doctors who have patients who are struggling can ask Tolle to pop in to a patient’s exam room.

“If someone is feeling ambivalent (about seeing a behavioral health specialist), it can be helpful to have a face-to-face meeting and see that we’re not scary,” Tolle said.

“We reach people who otherwise wouldn’t be seeking mental health care.”

Dewey, Trisha’s medical provider, is equally enthusiastic about integrating behavioral health into primary care clinics.

“I cannot put into words how beneficial it has been, not only for Trisha, but also for so many of my other patients,” Dewey said. “I send almost half of my patients to see them (Tolle and her team).

“For Trisha, it’s been really beneficial,” Dewey said. “Getting her back to skiing and getting her more engaged in her daily activities (is really helpful). She’s got a lot of complex medical issues. But what we’ve seen with her has been pretty impressive.”

Dewey said addressing mental health issues like anxiety and depression can correlate directly with better physical health. In Trisha’s case, the less anxious she’s feeling, the more she’s able to keep her diabetes and heart problems in check.

“Trisha is super sweet and I’m happy to have her as a patient,” Dewey said.

Outpacing Alzheimer’s

For this ski season, Trisha and Brian purchased Ikon Passes that will allow them to ski at Eldora and multiple other Colorado mountains, along with Jackson Hole in Wyoming, where they spent their honeymoon.

As they wait for the snow to fall, they are enjoying the beauty of the mountains in the summer.

The two have explored Chautauqua Park in Boulder along with Mt. Evans and Rocky Mountain National Park.

It’s also fun to see Trisha rediscover former passions. One recent day, Brian came home from work and found that Trisha had gone on a bike ride.

Trisha Poses in the summer on a high-altitude pass with a sign that says 12,000 feet above sea level.
After moving to Colorado, Trisha Washburn is enjoying the mountains both in the summer and in the winter. Photo courtesy of Trisha Washburn.

“When she does things like that, I know she’s feeling pretty good,” he said.

Despite the challenges, Brian said neither he nor Trisha regrets moving to Colorado. And they have appreciated the care she has received.

“We have great specialists at the Anschutz Medical Campus,” Brian said. “And Dr. Dewey pulls all of the pieces together. He’s a great doctor.”

With Tolle’s help, Trisha is hopeful that she can keep her worries at bay.

“She knows my history now. She feels like a friend,” Trisha said of Tolle. “I don’t have a lot of friends here yet, but I have a lot of wonderful acquaintances who are on my side.”

Brian said Trisha’s ebullient spirit carries her a long way.

“She’s a fighter. We try to stay positive and take it day by day,” Brian said.

On a beautiful day in the mountains, whether it’s summer or winter, both can forget for a little while about the health challenges they’re facing.

“I’ve been holding my own,” Trisha said. “I’m still skiing faster than my Alzheimer’s is moving.”