mgs webinar - mngero.org … · note: a cut point of

MGSWEBINAR:

BestPrac*cesforCogni*veScreening&Demen*aCarePlanning

Basedon:

BestPrac*cesforOp*mizingDemen*aCareforCareCoordinators

Objec*ves

•  Understandthera*onaleforusingcogni*veassessmentinstrumentswitholderclients

•  Learnhowtoadminister,score,andinterprettheMini-Cog

•  Learnhowtocommunicateassessmentresultstoclientsandpreparethemforadoctor’svisitandmemorywork-up

•  Employbestprac*cesincareplanningandcarecoordina*onforpa*entswithdemen*aandtheircarepartners

3

Introduc*onto

ACTonAlzheimer’s

WhatisACTonAlzheimer’s?

statewide

collaborative

volunteer driven

60+ O R G A N I Z A T I O N S 500+

I N D I V I D U A L S

I M P A C T S O F A L Z H E I M E R ’ S

BUDGETARY SOCIAL PERSONAL

FocusonQualityHealthCare

6

www.ACTonALZ.org

ACTToolKit

•  Evidence-andconsensus-basedbestprac*cestandardsforAlzheimer’scare

•  Toolsandresourcesfor:– Primarycareproviders– Carecoordinators– Communityagencies– Pa*entsandcarepartners

7 www.actonalz.org/provider-pracLce-tools

HealthCareSeXngs:CareCoordina*on

www.actonalz.org/provider-pracLce-tools

Demen*aandAlzheimer’s

9

Demen*aDiagnoses

Alzheimer’sDisease

VascularDemen*a

LewyBodyDemen*a

FTD Alzheimer’sdisease:60-80%•  IncludesmixedAD+VD

LewyBodyDemen*a:10-25%–  Parkinsonspectrum

VascularDemen*a:6-10%–  Strokerelated

FrontotemporalDemen*a:2-5%–  Personalityorlanguage

disturbance

DiseaseEduca*on:WhatisAD?

11 hbp://youtu.be/ECbjK4Ra-Ys

StagesofAlzheimer’sDisease

Alzheimer’sDisease:ChallengesandOpportuni*es

Alzheimer’s:APublicHealthCrisis

•  Scopeoftheproblem–  5.4MAmericanswithADin2016–  Growingepidemicexpectedtoimpact13.8MAmericansby2050andconsume1.1trillioninhealthcarespending

–  Almost2/3arewomen(longerlifeexpectancy)–  Ifdiseasecouldbedetectedearlierincidencewouldbemuchhigher

•  Pre-clinicalstage1-2decades

•  Somepopula*onsathigherrisk–  OlderAfricanAmericans(2xaswhites)–  OlderHispanics(1.5xaswhites)

14 Alzheimer’s Association Facts and Figures 2016

BaseRates

•  1in9people65+(11%)•  1in3people85+(32%)

15 Alzheimer’s Association Facts and Figures 2016

Ages of People with Alzheimer’s Disease in the United States

•  Apopula*onwithcomplexcareneeds

•  Indisputablecorrela*onbetweenchroniccondi*onsandcosts

Pa*entswithDemen*a

16

2.5chroniccondiLons(average)

5+medicaLons(average)

3Lmesmorelikelytobehospitalized

ManyadmissionsfrompreventablecondiLons,withhigherperpersoncosts

Alzheimer’s Association Facts and Figures 2014

Challenges&Opportuni*es

•  ADunder-recognizedbyproviders– Fewerthan50%ofpa*entsreceiveformaldiagnosis

•  Millionsunawaretheyhavedemen*a– Diagnosisokendelayedonaverageby2-5yearsakersymptomonset

– Significantimpairmentinfunc*onby*meitisrecognized

•  Poor*ming:diagnosisfrequentlyat*meofcrises,hospitaliza*on,failuretothrive,urgentneedforins*tu*onaliza*on

17 Boise et al., 2004; Boustani et al., 2003; Boustani et al., 2005; Silverstein & Maslow, 2006

1.  Improvedmanagementofco-morbidcondi*ons

2.  Reduceineffec*ve,expensive,crisis-drivenuseofhealthcareresource

3.  Improvequalityoflife•  Pa*entscanpar*cipateindecisions•  Decreaseburdenonfamilyandcaregivers

4.  Intervenetopromoteasafeandhappyenvironmentthatsupportsindependence

Ra*onaleforTimelyDetec*on

18

Iden*fyingCogni*veImpairment

19

HowYouCanHelp

•  Firststepsareawarenessandrecogni*on– Beawareoftheprevalenceofdemen*a&importanceofgeXngadiagnosis

– Facilitatemedicalwork-up

•  Assesscogni*on•  Provideresourcesandinforma*ontopa*entsandfamilymembers

20

Prac*ceTips

•  Okensignsandsymptomsarenotrecognizedun*ltheyarequitepronounced– Abribu*onerror:“Whatdoyouexpect?Sheis80yearsold.”

– RedFlag:Subjec*veimpressionsFAILtodetectdemen*ainearlystages

– Useofanobjec*vetooltoevaluatecogni*onisfarsuperiortopersonalopinion

Mini-CogImproves Physician Recognition

***

*** ***

CDR Stage MCI Mild Mod Sev

% C

orre

ct

Borson S et al. Int J Geriatr Psychiatry 2006; 21: 349

0

20

40

60

80

100

0.5 1 2 3

Mini-Cog Patient’s own physician

*** p < .001

Iden*fyingCogni*veImpairment

23

Cogni*veImpairmentID

Cogni*veAssessmentTools

•  Widerangeofop*ons– Mini-Cog™(MC)– Mini-MentalStateExam©(MMSE)–  St.LouisUniversityMentalStatusExam™(SLUMS)– MontrealCogni*veAssessment™(MoCA)–  RowlandUniversalDemen*aAssessment(RUDAS)

•  AllbutMMSEfree,inpublicdomain,andonline

www.actonalz.org/screening-diverse-popula*ons

Borson et al., 2000; Folstein et al., 1975; Nasreddine 2005; Tariq et al., 2006

Administra*onBestPrac*ces

•  Trynotto:– Usethewords“test”or“memory”

•  Instead:“We’regoingtodosomethingnextthatrequiressomeconcentra.on”

– Allowpa*enttogiveupprematurelyorskipques*ons

– Deviatefromstandardizedinstruc*ons– Offermul*plechoiceanswers– Besokonscoring

– Scorerangesalreadypaddedfornormalerrors– Deductpointswherenecessary–bestrict

Mini-Cog™

Contents•  VerbalRecall(3points)•  ClockDraw(2points)

Advantages•  Quick(2-3min)•  Easy•  Highyield(execu*vefx,

memory,visuospa*al)

Subjectaskedtorecall3wordsLeader,Season,Table

Subjectaskedtodrawclock,sethandsto10past11

+3

+2

Borson et al., 2000

28

www.actonalz.org/sites/default/files/documents/Mini-Cog_.pdf

Mini-Cog

Pass•  >4

Fail•  3orless

Borson et al., 2000; Borson, Scanlan, Chen et al., 2003; Borson, Scanlan, Watanabe et al., 2006; Lessig, Scanlan et al., 2008; McCarten, Anderson et al., 2011; McCarten, Anderson et al., 2012; Tsoi, Chan et al., 2015

NOTE:Acutpointof<3ontheMini-Coghasbeenvalidatedfordemen.ascreening,butmanyindividualswithclinicallymeaningfulcogni.veimpairmentwillscorehigher.Whengreatersensi.vityisdesired,acutpointof<4isrecommendedasitmayindicateaneedforfurtherevalua.onofcogni.vestatus.

Mini-CogResearch

•  Performanceunaffectedbyeduca*onorlanguage•  BorsonIntJGeriatrPsychiatry2000

•  Sensi*vityandspecificitysimilartoMMSE(76%vs.79%;89%vs.88%)

•  BorsonJAGS2003

•  Failureassociatedwithinabilitytofillpillbox•  AndersonetalAmSocConsultPharmacists2008

Mini-Cog:Colleen

31

http://youtu.be/DeCFtuD41WY

Colleen’sClock

Colleen’sScore

Communica*ngResultsofCogni*ve

AssessmenttoPa*entsandHealthcareProviders

Workflow:TheBigPicture

1.  Administercogni*veassessmenttool2.  Discussresultswithclient/pa*ent3.  Recommendnextsteps,follow-up4.  Considerprovidingwribendocumenta*on

to:– Client/pa*entandfamily– Physician/medicalprovider

35

Prepara*on

•  Beforeusinganassessmenttool:– Makesureyouprac*ceandarecomfortablewithalladministra*onandscoringguidelinesofthetool(s)

– Usepartsorallofthescriptsprovidedinthiswebinarasabasisforprovidingfeedbacktoclients/pa*entsandotherhealthcareprovidersregardingassessmentresults

•  Yourscriptmayvary,inpart,onyouruniqueprofessionalroleandwhetheryouareworkinginsideamedicalclinicorinacommunityhealthcareagency/seXng

36

Prepara*on

•  Writedownyourscriptsandprac*cedeliveringthemun*lyoucan:–  Providetheinforma*onclearlyandsuccinctly–  Offerfeedbackcalmly,inamaber-of-facttone,

withoutanxiety•  Anytension/anxietyyouhavewillbeprojected

ontoclients/pa*ents•  Keepyourscriptsonhandatall*mes(withyour

screeningtools)soyoualwayshavethemforreference,whenneeded

37

Prepara*on

•  Neverusethewords“demen*a”or“Alzheimer’sdisease”– Screeningtoolsarenotdiagnos*c– Usingthesetermsisprematureatthisstageandcancontributetoanxiety/fear

•  Avoid– Beingunnecessarilywordy– Over-explainingorra*onalizingtheprocess

38

ClientReac*ons

•  Youshouldplanforawiderangeofclientreac*onstoassessmentresults

•  Responsesmayrangefromacceptancetorejec*on– SomealreadyworriedabouttheirmemoryandareinterestedingeXnganswers

– Othersmaybesurprisedbyresults,butwillingtofollow-up

– Somemaynotbeawareofproblem(forgeXngtheyareforgezul)orreadytoaccepttheinforma*on

39

ClientReac*ons

•  Lackofacceptancecanbeaneffec*vemechanismto:–  Preservesenseofself(ideaofcogni*veimpairmentmayposethreattoiden*ty,self-worth)

– Managefearandanxietyaboutthefuture

•  Readinesstoact– Maybeagradualprocessrequiringmul*pleinterac*onswiththeclient/pa*ent

•  Posi*veoutcomesarepossibleinacontextinwhichsomenega*vereac*ons/feelingsoccur

40

SampleScript:ThePurpose

•  Regardlessofapassingorfailingscore,explainthepa*ent’stestresultbyfirstremindingthemoftheassessmentpurpose:

•  “Thepurposeofthistaskwastocheckonthehealthofthebrainanddetermineifthereisanyneedforfurtherevalua*onofyourmemory.”

41

SampleScript:PassingScore

•  “Youobtainedanormalscoreonthismeasure,whichisgoodnews.Noaddi*onalac*onisneeded.”

•  “However,ifyouhaveconcernsaboutyourthinkingormemory,talkto[contact]yourdoctor.”

42

SampleScript:FailingScore

•  Outsideclinic–  “Yourscoreonthemeasurewasaliblebitlowtoday.Thismeansitwouldbegoodtocontactyourdoctorsothathe/shecanbeproac*veandtakeacloserlookathowyouaredoing.”

–  “Therearemanyreasonswhysomeonemightreceivealowscore.Apersonmightbe*red,havealotontheirmind,feelstressedorbedistracted.Inothercases,theymightbetakingmedica*ons,haveashortageofcertainvitaminsornutrients,orhaveamedicalcondi*onthatiscausingmemoryloss.”

–  “Contac*ngyourdoctorisimportantsopoten*alproblemscanbeiden*fiedasearlyaspossible.Thisisavitalpartofstayinghealthy.”

43

OpeningUpConversa*on

•  Usetheassessmentprocessasaopportunitytodiscussmemoryissuesopenlyandtoworkfromtheperspec*veofyourpa*ent/client:– “Areyouhavinganytroublewithyourmemoryorthinking?”

–  Ifyes,“Whatdoyouthinkmightbecausingthis?”– “Haveyoutalkedwithanyoneaboutit?”– “Haveyoutalkedwithyourdoctoraboutthis?”Ifso,“Whathappened?”

44

CareCoordina*on

•  Helpfacilitateanappointmentwiththedoctorasmuchastheclient/familywillallowand/orasmuchasyouareabletowithinyourrole.– Themoreyoucando,themorelikelyfollow-upwilloccur

•  Sitwithfamilywhileacallismadetosetupdoctorappointmentand/or

•  Callclient/familyin1weektocheckonprogress•  Accompanyclienttothedoctor

45

CareCoordina*on

•  Promoteposi*ve,health-focusedmessages•  Encourageinvolvementoffamilymembers

–  Familymember(s)shouldaccompanypa*ent/clientandpar*cipateindoctorvisit

– Writedowntheirobserva*onsre:cogni*ve,behavioral,andfunc*onalchangesinbulletpointstyleandgivetodoctorduringappointment

•  Closetheloop–  “Iwouldliketosee/talkwithyouagainakeryoufollow-upwithyourdoctoraboutthis.Doesthatsoundreasonabletoyou?”

46

CareCoordina*on

•  Considerprovidingwribendocumenta*ontotheclient/familyand/ortheirdoctor,ifappropriate– Samplelebersareavailablefordownloadatwww.actonalz.org/video-tutorials

– Followyourorganiza*on’sexis*ngHIPAAguidelines

47

CareCoordina*on

•  Clinicshavetocopewithalotofpaperworkandsome*meslebersgetlost– Encouragepa*ent/familytobringacopyofthelebertotheirdoctorappointment

– Youmayfindthat,insomecircumstances,youhavetofaxormailtheproviderlebertotheclinicmorethanonce

48

Q&A

•  WhatwillthedoctordowhenIseehim/her?– He/shewillworkwithyoutodecidewhataddi*onaltestsorfollow-upcareisneededtoaddressthisissueandkeepyouwell.Some*mesawork-upinvolves:

•  Answeringques*onsaboutyourhealthhistory,includinganyobserva*onsyoumighthaveaboutyourmemoryorthinking

•  Medica*onreview•  Performingbloodteststoseeifyouhaveashortageofcertainvitaminsornutrientsinyourbodythatcouldbecausingchangesinyourmemoryorthinking

•  Comple*nganx-rayofyourheadsothedoctorcantakeacloserlookathowyourbrainisdoing 49

Q&A

•  DoyouthinkIhavedemen*a/Alzheimer’sdisease?–  Thetoolweusedtodaydoesnottelluswhatiscausingaperson’smemorydifficul*esandcannotbeusedtodiagnosedemen*a/Alzheimer’sdisease.

–  Therearemanyreasonswhysomeonemightbeexperiencingtroublewiththeirmemory.TheymaynotbegeXngadequatesleepatnightormightbeunderalotofstressorbedepressed.Othercausesincludemedica*onsideeffects,medicalproblemslikeaninfec*oninthebody,andvitamindeficiencies.

–  Notallmemoryproblemsarecausedbydemen*a/Alzheimer’sdisease.But,itisimportanttoseeadoctorsowecaniden*fythecauseandfindoutwhat,ifany,treatmentmightbeneeded.

50

Q&A

•  MyfamilycomplainsaboutmymemorybutIdonothaveaproblem.Everyonemyageisalibleforgezul.–  Youarerightthatalotofpeopleexperiencememorychangesastheygetolder.Howmuchvariesfrompersontoperson.Weallwanttostayashealthyaspossibleandmaintainourindependenceaslongaspossible.Havingabraincheck-upisapartofstayinghealthy(andmightbeagoodwaytoshowyourfamilythereisnothingwrongwithyou-toputthisissuetorestonceandforall).

51

Q&A

•  IthinkIamdoingfine.WhyshouldIseeadoctor?–  Itisimportanttocheckthehealthofthebrainaswegetolder,justlikewerou*nelycheckonthehealthofotherorgans,suchastheheart.Some*mes,memorydifficul*escanbereversedwithtreatment.Inothercases,earlydiagnosisofaproblemoffersthebestchancetotreatsymptomsandstaywell.

52

Demen*aCareCoordina*on

53

ACTPrac*ceTool

Demen*aCarePlanChecklist

Demen*aCarePlanning

•  Buildacareteam(pa*ent&carepartners)

•  Educate,support&connecttoresources•  Maximizeabili*es•  Promotehealth,wellness&socialengagement

•  Encourageplanning,preparedness•  Ensuresafety•  Reduceexcessdisability•  Avoidunnecessaryhospitaliza*on

56

Iden*fyCarePartner(s)

•  Educatethepa*ent:Demen*adx.requireateamapproach

•  Askthepa*enttoiden*fyasupportsystem– Thinkoutsidethebox:

•  Family,friends,neighbors,religiouscongrega*onmembers,colleagues,communityorganiza*onvolunteersorworkers

– Taskspecific(e.g.,doctorvisits,managingmeds.)

57

DiseaseEduca*on

•  ASKthepa*ent/carepartner:! Whatthedoctortoldthemabouttheirmemoryloss/diagnosis

! Whattheyknowaboutthedisease/ques*onsaboutthediagnosis/disease

! Biggestconcerns;barrierstocare/health•  Refertocommunityagency

– Example:Alzheimer’sAssocia*on•  Offeraneduca*onalresource

– Example:TakingAc*onworkbook

58

Taking Action Workbook

!  Understandingthedisease!  Partneringwithdoctors!  Tellingothersaboutthe

diagnosis!  Strategiesformanaging

symptoms&coping!  Safety!  Legal/financialissues

hbp://www.alz.org/mnnd/documents/15_ALZ_Taking_Ac*on_Workbook.pdf

Medica*onTherapy&Management

60

•  DiscussprescribedandOTCmedica*ons!  Create&reviewmedica*onlog!  PharmDconsult:simplifymedica*onregimen

•  Createplanwithcareteam!  Familyplanformanagingmeds!  Medmanagementaids(pillboxes,alarms)

MaximizeAbili*es

61

•  IDcondi*onsthatmayworsensymptomsorleadtopooroutcomes!  Diabetes,HTN,sleepdysregula*on

•  RecommendOTtomaximizeindependence!  Simplifyenvironment,maximizeindependence&self-care

abili*es

•  Offerstrategiestoreducebehavioralsymptoms!  Communica*onstrategies,wellness&socialengagement,

rou*ne

CommonDemen*a-RelatedBehaviors•  Repea*ng•  Anger,Anxiety,Agita*on•  Day*mesleeping/night-*mewakefulness•  Wandering,Pacing,Shadowing•  Apathy•  Resis*ngCare•  Aggression(yelling,hiXng,bi*ng)•  Sociallyinappropriatebehaviors(e.g.,thingsthatmaybeokinprivate,butnotinpublic–likedisrobing)

62

CausesofChallengingBehaviors

•  PhysicalHealth(Medical)!  Pain!  UrinaryTractInfec*on!  Illness

•  Environment!  Unfamiliarsurroundings/environment! Over/unders*mula*on

•  Other! Communica*on! Unmetneeds/boredom! Task-related! Emo*onalhealth

63

ReduceBehavioralSymptoms•  REMEMBER:

–  Behavioriscommunica*on–  Communica*onimpactsbehavior

•  Thinklikeabehavioralanalyst–  Detec*vework,ask:

•  Who(isinvolved/present)•  What(exactdescrip*on,bespecific)•  When(*medependent?onlyinmorning?triggers?)•  Where(loca*onspecific?)•  Why(whathappensrightbefore,rightakerwards?whatdofamilythinkiscause?Hasanythingchangedrecently?)

64

Considera*ons

•  Ask:Isthisbehaviorreallyaproblem?–  Isithur*nganyone?

•  Helpcarepartnersknowwhattoexpectandnormalizethesereac*ons.– Avoid:unrealis*c,non-demen*aexpecta*ons,arguing,correc*ng,rushing

– Advise:Takeadeepbreath,slowdown,stepback,simplify,smile,redirect,reassure,tryagainlater

65

CaregiverSupport

•  Thereisastrongcorrela*onbetweenthehealthandwell-beingofacarepartnerandthequalityofcarethathe/shecanprovide.

•  Recommend:– Supportgroups– Selfcare,respite– Regulardoctorappointments

Health,Wellness&Engagement

67

Encouragelifestylechangesthatmayreducediseasesymptomsorslowprogression

!  Exercise!  Nutri*on!  Stressreduc*on!  Meaning&purpose!  Rela*onships!  Healthmanagement!  Rou*ne

www.alz.org/mnnd/documents/15_ALZ_Living_Well_Workbook_Web.pdf

Home&PersonalSafety

68

•  Developaplanforthe6 F’s:!  Falls !  Fire!  Finances !  Firearms!  Freedom !  Freeways

Home&PersonalSafety

•  RecommendOTorPT!  Fallriskassessment!  Sensory/mobilityaids!  Homesafetyinspec*on/modifica*ons!  Drivingevalua*on

•  EncourageMedicAlert®SafeReturn®"  6outof10peoplewithdemen.awillwanderat

somepointduringthedisease"  www.alz.org/care/demen*a-medic-alert-safe-

return.asp

69

Demen*a&Hospitaliza*on

•  ReduceUnnecessaryHospitaliza*on– Falls– UTI/othermedicalcondi*ons– Medica*ons/medica*onmismanagement

– Demen*a-relatedbehavior– Hospitaliza*onalterna*ves

•  Hospitaliza*on–Pre-Planning–  hbp://www.nia.nih.gov/alzheimers/publica*on/hospitaliza*on-happens

70

Legal&FinancialPlanning

71

•  Encouragepa*ent/carepartnertoassigndurablePOA!  RefertoElderlawaborney

•  Encouragepa*ent/carepartnerstotalkaboutlong-termcareandwhentheywouldaccesssupport!  hbp://www.alz.org/i-have-alz/downloads/

worksheet_financial_legal.pdf

AdvanceCarePlanning

72

•  Encouragepa*enttodiscuss/documentpreferencesforcareinahealthcaredirec*ves!  Connectpa*entwithadvancecareplanning

facilitator!  Documentchoices(HonoringChoices,MN

HealthcareDirec*ve)

•  Discusspallia*veandhospiceop*ons!  Pallia*veCareConsulta*onProgram!  Whenistheright+me?

CareCoordinator:VisitFrequency&Communica*on

73

•  Scheduleregularcheck-ins

•  Educatepa*ent/carepartnerWHENtocontactyou!  Changeincondi*on!  Assistancewithmedmanagement!  Before/akerhospitaliza*on!  Changeinlivingenvironment!  Newneeds

Top5ResourcesforPa*entsandFamilies

74

#1 Promo*ngWellness& Func*on

75

#2 AddressingBehavioral Challenges

76

#3:AddressingDriving

77

Alzheimer’sAssocia*onDrivingCenter:www.alz.org/care/alzheimers-demen*a-and-driving.asp

hbp://www.theharzord.com/sites/theharzord/files/at-the-crossroads-2012.pdf

#4 PlanningfortheFuture

78

#5 Connec*ontoResources

79

Alzheimer’sAssocia*on24/7Helpline|800.272.3900www.alz.org/mnnd

SeniorLinkAgeLine

800-333-2433www.minnesotahelp.info

Ques*ons?

•  DownloadACTonAlzheimer’sprac*cetoolsat:www.ACTonALZ.org/provider-prac*ce-tools

•  Formoreinforma*on– email:info@ACTonALZ.org– Web:www.ACTonALZ.org

80

Acknowledgements

Authors/Presenters: TerryR.Barclay,Ph.D.Co-Chair,HealthcareLeadershipGroupACTonAlzheimer’s

MichelleBarclay,M.A.Execu*veCo-LeadACTonAlzheimer’s

81

ACKNOWLEDGEMENTS

ThistrainingwasmadepossiblethroughtheCentralMinnesotaCouncilonAginginpartnershipwithACTonAlzheimer’s,theMinnesotaGerontologicalSociety,theMinnesotaMedicalDirectorsAssocia*onandtheMinnesotaRuralHealthAssocia*onthroughfunding

fromtheOlderAmericansActandCentraCareHealthFounda*on.

ACTonAlzheimer’sisanaward-winning,na*onallyrecognized,volunteer-drivencollabora*veseekingtocreatesuppor*veenvironmentsforeveryonetouchedby

Alzheimer’sdiseaseandtoprepareMinnesotaforitsimpacts.

Visitwww.actonalz.org/provider-prac*ce-toolsformoreinforma*onandtoaccesssuppor*vetoolsand

resources.

ACKNOWLEDGEMENTS

Thisprojectis/wassupportedbyfundsfromtheBureauofHealthProfessions(BHPr),HealthResourcesandServicesAdministra*on(HRSA),DepartmentofHealthandHumanServices(DHHS)underGrantNumberUB4HP19196totheMinnesotaAreaGeriatricEduca*onCenter(MAGEC)for$2,192,192(7/1/2010—6/30/2015).Thisinforma*onorcontentandconclusionsarethoseofthe

authorandshouldnotbeconstruedastheofficialposi*onorpolicyof,norshouldanyendorsementsbeinferredbytheBHPr,HRSA,DHHSortheU.S.Government.

MinnesotaAreaGeriatricEduca*onCenter(MAGEC)

Grant#UB4HP19196Director:RobertL.Kane,MD

AssociateDirector:PatriciaA.Schommer,MA