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An A-Z Guide to Simplify and Optimize Dementia Care

Terry R. Barclay, PhD

Director, HealthPartners Neuropsychology

Overview: Dementia is a broad term describing a variety of diseases and conditions that damage brain cells and impair brain function. Alzheimer’s disease is the most common type of dementia. More than ninety percent of Alzheimer’s disease and related dementia cases occur in people age sixty and older and more than 5.4 million Americans were estimated to be affected by Alzheimer’s disease and related dementias in 2012. There are currently no medications or other interventions that can prevent or cure these conditions although significant advancements have been made to facilitate more timely and accurate detection, improved patient outcomes, and greater quality of life for patients. Objectives Following this learning activity, participants will be able to: • Discuss ACT on Alzheimer’s evidence-based practice tools for dementia detection and

management • Identify the rationale for timely detection of dementia • Recognize key management priorities throughout the dementia continuum

A to Z Guide to Simplify and Optimize Dementia Care

Planning Committee

Ann Brombach, Research Manager

HealthPartners Center for Memory & Aging

Leah Hanson, PhD., Sr. Director,

Neuroscience Research

HealthPartners Center for Memory & Aging

Debbie Richman, BS, ACC, Vice President

Education and Outreach

Alzheimer's Association

Michael Rosenbloom, MD, Interim

Neurology Head and Clinical Director

HealthPartners Center for Memory & Aging

Taylor Showalter

Park Nicollet Institute

The planning committee has no conflict of interest in relation to this activity.

Dr. Barclay has indicated no potential conflict of interest in relation to his presentation.

He does not intend to discuss any unapproved/investigative use of a commercial

product/device.

Faculty: Terry R. Barclay, PhD, Clinical Director, HealthPartners Neuropsychology

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How to Claim CME Credit:

To receive CME credit you must complete the on-line sign-in and evaluation

form. To do this you may enter the following Survey Monkey link into your web

browser or you have also received this link in an e-mail sent to you. The

survey will be available for 2 weeks following this program, and will close after

that.

Park Nicollet Institute is accredited by the Accreditation Council for Continuing

Medical Education to provide continuing medical education for physicians.

The Office of Continuing Medical Education, Park Nicollet Institute, designates

this live activity for a maximum of 1 AMA PRA Category 1 Credit(s)™.

Physicians should claim only the credit commensurate with the extent of their

participation in the activity.

https://www.surveymonkey.com/s/VLKPP68

Accreditation

Policies

Disclosure Policy As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), Park Nicollet Institute, Office of Continuing Medical Education requires all faculty, planning committee members and others in a position to control the content of an educational activity to disclose all relevant financial relationships with commercial interests, occurring within the past 12 months, that create a conflict of interest. Any conflict of interest is reviewed and resolved prior to the program as part of our commitment to present content that is scientifically-based, accurate, balanced and objective.

Content Validation Policy In addition to the resolution of conflict of interest, the Office of Continuing Medical Education routinely conducts a content review to ensure that program materials promote improvements and quality in healthcare, are scientifically-based, accurate, balanced and objective in order to meet ACCME standards and requirements for accreditation.

Because of interactive sessions and time for questions and answers, information may be presented that reflects the opinions and recommendations of individual faculty members or participants. Information should be verified before using to diagnose medical conditions or prescribe treatment.

Commercial Support There is no commercial support for this activity.

Alzheimer’s Disease: Challenges and Opportunities

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Alzheimer’s: A Public Health Crisis

• Scope of the problem – 5.3M Americans with AD in 2015

– Growing epidemic expected to impact 13.8M Americans by 2050 and consume 1.1 trillion in healthcare spending

– Almost 2/3 are women (longer life expectancy)

– If disease could be detected earlier incidence would be much higher

• Pre-clinical stage 1-2 decades

• Some populations at higher risk – Older African Americans (2x as whites)

– Older Hispanics (1.5x as whites)

7 Alzheimer’s Association Facts

and Figures 2015

Base Rates

• 1 in 9 people 65+ (11%)

• 1 in 3 people 85+ (32%)

8

Age Range Percent with Alzheimer’s

< 65 4%

65 -74 13%

75 -84 44%

85 + 38%

Alzheimer’s Association Facts

and Figures 2014

• A population with complex care needs

• Indisputable correlation between chronic conditions and costs

Patients with Dementia

9

2.5 chronic conditions (average)

5+ medications

(average)

3 times more likely to be

hospitalized

Many admissions from preventable conditions, with higher per person costs

Alzheimer’s Association Facts

and Figures 2014

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Challenges & Opportunities

• AD under-recognized by providers – Only 50% of patients receive formal diagnosis

• Millions unaware they have dementia

– Diagnosis often delayed on average by 6+ years after symptom onset

– Significant impairment in function by time it is recognized

• Poor timing: diagnosis frequently at time of crises, hospitalization, failure to thrive, urgent need for institutionalization

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

Introduction to

ACT on Alzheimer’s

12

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

ACT on Alzheimer’s

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Collaborative Goals/Common Agenda

Five shared goals with a Health Equity perspective

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ACT Tool Kit

• Evidence and consensus-based, best practice standards for Alzheimer’s care

• Tools and resources for:

– Primary care providers

– Care coordinators

– Community agencies

– Patients and families 14

ACT Tools

15

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ACT Tools

16

17 www.actonalz.org

Cognitive Screening

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Is Screening Good Medicine?

2014 US Preventative Services Task Force (USPSTF)

• Purpose: Systematically review the diagnostic accuracy of brief cognitive screening instruments and the benefits/harms of medication and non-medication interventions for early cognitive impairment.

• Limitation: Limited studies in persons with dementia other than AD and sparse reporting of important health outcomes.

• Conclusion: Brief instruments to screen for cognitive impairment can adequately detect dementia, but whether screening improves clinical decision making is unknown.

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Provider Perspective

“Avoiding detection of a serious and life changing medical condition just because there is no cure or ‘ideal’ medication therapy seems, at worst, incredibly unethical, and, at best, just bad medicine.”

George Schoephoerster, MD Family Practice Physician

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If we don’t diagnose, does it still exist?

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“Beyond mountains, there are mountains.”

Haitian Proverb

Diagnostic Challenges

1. Improved management of co-morbid conditions

2. Reduce ineffective, expensive, crisis-driven use of healthcare resource

3. Improve quality of life • Patients can participate in decisions • Decrease burden on family and caregivers

4. Intervene to promote a safe and happy environment that supports independence

The message: You have a bad disease. We can help you make life

better for you and your family.

Rationale for Timely Detection

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Base Rates

• 1 in 9 people 65+ (11%)

• 1 in 3 people 85+ (32%)

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Age Range Percent with Alzheimer’s

< 65 4%

65 -74 13%

75 -84 44%

85 + 38%

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Myth: People don’t want to know they have Alzheimer’s disease

Blendon et al., 2012; Holroyd et al., 2002; Turnbull et al., 2003

0

10

20

30

40

50

60

70

80

90

100

Alz-Eu Harvard Turnbull Holroyd

%

Studies

Agree: Most people

want to

know.

Time

• Simple screening tests can be done by rooming nurse

– Brain as 6th vital sign

• Recommended tool takes 1.5 – 3 minutes – Only conducted annually and in context of signs and

symptoms

• Mini-Cog does not disrupt workflow & increases capture rate of cognitive impairment in primary care

26 Borson et al., 2007

Money

• AD most expensive condition in the nation – $203 billion in 2013, $1.2 trillion in 2050

• Cost effectiveness of early dx/tx? – Large scale studies ongoing

• Economic Models – No med known to alter costs of care

– Disease education/support interventions increase caregiver capability, save money, and delay NH

– Even if assume small # of people benefit (5%), $996 million in potential savings for MN over 15 years

27 Alzheimer’s Association Facts and Figures 2014; Long et al., 2014

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Impact of Optimal Practices

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• Reduces utilization through comorbidity management

Timely Detection

• Reduces behavioral symptoms • Delays institutionalization • Increases treatment plan compliance

Post-Diagnosis Education and Support

• Delays institutionalization • Reduces neuropsychiatric symptoms • Reduces costs

Effective Care Management

Team-Based Care • Reduces acute episodes • Improves health outcomes

Care Transitions

• Improves health outcomes • Improves care quality • Reduces hospital, ER utilization, and care costs

Caregiver Engagement & Support

• Improves overall well-being of person w/ dementia • Increases caregiving longevity and well-being

Rethinking Everyday Practice

• Brain historically ignored, not a focus of routine exam

– Is this logical? Consider base rates of dementia

• Dementia is simply “brain failure”

– Heart failure

– Kidney failure

– Liver failure

• Brain as 6th Vital Sign

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Clinical Provider Practice Tool

• Easy button workflow for:

1. Screening

2. Dementia work-up

3. Treatment / care www.actonalz.org/provider-practice-tools

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Cognitive Screening

• Unfortunately, most of us do not recognize signs and symptoms until they are quite pronounced

– Attribution error: “What do you expect? She is 80 years old.”

– Subjective impressions FAIL to detect dementia in early stages

• Clinical interview

– Let patient answer questions without help

– Remember: Social skills remain intact until late stage dementia

– Easy to be fooled by a sense of humor, reliance on old memories, or quiet/affable demeanor

Cognitive Screening

• Initial considerations

– Timing

• Routine, annual check-ups or only when patients become obviously symptomatic?

– Best practice recommendation: Annual screening at 65+

– Screening meant to uncover insidious disease

– Doesn’t add much if you can already detect impairment in basic conversation

– Research

• Which tools are best?

• Balance b/w time and sensitivity/specificity

Cognitive Screening

– Clinic flow

• Who will administer screen? – Rooming nurses, social workers, allied health professionals,

MDs

• What happens when patients fail?

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Screening Measures

• Wide range of options

– Mini-Cog (MC)

– Mini-Mental State Exam (MMSE)

– St. Louis University Mental Status Exam (SLUMS)

– Montreal Cognitive Assessment (MoCA)

• All but MMSE free, in public domain, and online

Screening Administration

• Try not to: – Use the word “test”

• Instead: “We’re going to do something next that requires some concentration”

– Allow patient to give up prematurely or skip questions

– Deviate from standardized instructions

– Offer multiple choice answers

– Be soft on scoring – Score ranges already padded for normal errors

– Deduct points where necessary – be strict

Mini-Cog

Contents • Verbal Recall (3 points)

• Clock Draw (2 points)

Advantages • Quick (2-3 min)

• Easy

• High yield (executive fx, memory, visuospatial)

Subject asked to recall 3 words Leader, Season, Table

Subject asked to draw clock, set hands to 10 past 11

+3

+2

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DATE_________ ID_________________________AGE____GENDER M F LOCATION ______________________TESTED BY________

MINI-COG ™

1) GET THE PATIENT’S ATTENTION, THEN SAY: “I am going to say three words that I want you to remember now and later. The words are

Banana Sunrise Chair. Please say them for me now.” (Give the patient 3 tries to repeat the words. If unable after 3 tries, go to next item.)

(Fold this page back at the TWO dotted lines BELOW to make a blank space and cover the memory words. Hand the patient a pencil/pen).

2) SAY ALL THE FOLLOWING PHRASES IN THE ORDER INDICATED: “Please draw a clock in the space below. Start by drawing a large

circle.” (When this is done, say) “Put all the numbers in the circle.” (When done, say) “Now set the hands to show 11:10 (10 past 11).” If

subject has not finished clock drawing in 3 minutes, discontinue and ask for recall items.

-------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- --------------

-------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------

3) SAY: “What were the three words I asked you to remember?”

_ (Score 1 point for each) 3-Item Recall Score

Score the clock (see other side for instructions): Normal clock 2 points Clock Score

Abnormal clock 0 points

Total Score = 3-item recall plus clock score 0, 1, 2, or 3 = clinically important cognitive impairment likely;

4 or 5 = clinically important cognitive impairment unlikely

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CLOCK SCORING

NORMAL CLOCK

A NORMAL CLOCK HAS ALL OF THE FOLLOWING ELEMENTS: All numbers 1-12, each only once, are present in the correct

order and direction (clockwise). Two hands are present, one pointing to 11 and one pointing to 2.

ANY CLOCK MISSING ANY OF THESE ELEMENTS IS SCORED ABNORMAL. REFUSAL TO DRAW A CLOCK IS SCORED

ABNORMAL.

SOME EXAMPLES OF ABNORMAL CLOCKS (THERE ARE MANY OTHER KINDS)

Abnormal Hands Missing Number

................................ ................................ ................................ ................................ ................................ ................................ ................................ .

Mini-CogTM, Copyright S Borson. Reprinted with permission of the author, solely for clinical and teaching use. May not be modified or

used for research without permission of the author (soob@uw.edu). All rights reserved.

Mini-Cog

Pass

• > 4

Fail

• 3 or less

Borson S., Scanlan J, Brush M et al. 2000. The Mini-Cog: A cognitive “vital signs”

measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 15,

1021-1027.

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Mini-Cog Improves Physician Recognition

***

***

***

CDR Stage

MCI Mild Mod Sev

% C

orr

ect

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

Mini-Cog Research

• Performance unaffected by education or language • Borson Int J Geriatr Psychiatry 2000

• Sensitivity and specificity similar to MMSE (76% vs. 79%; 89% vs. 88%)

• Borson JAGS 2003

• Does not disrupt workflow & increases rate of diagnosis in primary care

• Borson JGIM 2007

• Failure associated with inability to fill pillbox • Anderson et al Am Soc Consult Pharmacists 2008

Mini-Cog: Sam

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http://youtu.be/CRQEighdb0w

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SLUMS

SLUMS

High School Diploma Less than 12 yrs education

Pass > 27 > 25

Fail 26 or less 24 or less

44

Tariq SH, Tumosa N, Chibnall et al. Comparison of the Saint Louis University mental

status examination and the mini-mental state examination for detecting dementia

and mild neurocognitive disorder--a pilot study. Am J Geriatr Psychiatry. 2006

Nov;14(11):900-10.

MoCA

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MoCA

Pass

• > 26

Fail

• 25 or less

46

Nasreddine ZS, Phillips NA, Bédirian V, et al. The Montreal Cognitive Assessment

(MoCA©): A Brief Screening Tool For Mild Cognitive Impairment. J Am Geriatr Soc

53:695–699, 2005

Screening Tool Selection

Montreal Cognitive Assessment (MoCA) • Sensitivity: 90% for MCI, 100% for dementia

• Specificity: 87%

St. Louis University Mental Status (SLUMS) • Sensitivity: 92% for MCI, 100% for dementia

• Specificity: 81%

Mini-Mental Status Exam (MMSE) • Sensitivity: 18% for MCI, 78% for dementia

• Specificity: 100%

Larner et al Int Psychogeriatr 2012; Nasreddine et al J Am Geriatr Soc 2005; Tariq et al Am J Geriatr Psychiatry

2006; Ismail et al Int J Geriatr Psychiatry 2010

Cognitive Screening Flow Chart

48

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Cognitive Impairment Identification Flow Chart

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Dementia Work-up and Diagnosis

50

Dementia Work-Up

51

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52

Dementia Diagnoses

Alzheimer’s Disease

Vascular Dementia

Lewy Body Dementia

FTD

Alzheimer’s disease: 60-80 % • Includes mixed AD + VD

Lewy Body Dementia: 10-25 % – Parkinson spectrum

Vascular Dementia: 6-10 % – Stroke related

Frontotemporal Dementia: 2-5 % – Personality or language

disturbance

Delivering the Diagnosis: Sam

54

https://www.youtube.com/watch?v=vy2ZC5ZSZL8

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Delivering the Diagnosis

• General guidelines:

– Include a family member in the visit if at all possible

– Talk directly to the person with dementia

– Speak at a slower, relaxed pace using plain words • Try not to fill the time with words – less is more

– Explain why tests were ordered and what results mean

– Ask more than once whether the patient / family has any questions

– Acknowledge how overwhelming the information feels; provide empathy, support, reassurance

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Delivering the Diagnosis

• Focus on wellness, healthy living, and optimizing function

– Sleep

– Exercise

– Social and mental stimulation

– Nutrition and hydration

– Stress reduction

– Increase structure at home

56

Zaleta AK and Carpenter BD. Patient-Centered Communication During the Disclosure of a Dementia

Diagnosis. AM J ALZHEIMERS DIS OTHER DEMEN 2010, 25: 513

Delivering the Diagnosis

• Connect patient/family to community resources – Care for both patient and caregiver

– Examples: Senior linkage line, Alzheimer’s Association

• Discuss follow-up – Want to see patient and family member at regular

intervals (e.g., q 6 months) for proactive care

– Discuss involvement of care coordinator

• Provide written summary of visit 57

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Common Questions

• How is Alzheimer’s different from dementia?

• Is there any treatment? What can we do?

• How fast is this going to progress?

• How often do we see you?

• What’s next?

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Dementia Care and Treatment

59

Care and Treatment

60

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Care and Treatment

Care and Treatment

• The care for patients with Alzheimer’s has very little to do with pharmacology and much to do with psychosocial interventions

• Involve care coordinator • Connect patient and family to experts in the

community – Example: Alzheimer’s Association – Refer every time, at any stage of disease, and for

every kind of dementia – Stress this is part of their treatment plan and you

expect to hear about their progress at next visit

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ACT EMR Tools

• Use EMR to automate and standardize: – Screening – Work-up – After visit summary with dementia education – Orders and referrals – Community supports

• Smart Forms • Smart Sets (search: memory loss or dementia)

– Initial evaluation (work-up) – Follow-up (diagnosis, management, and referral)

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Initial Evaluation

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Initial Evaluation

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Follow-Up

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Follow-Up

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Managing Mid to Late Stage Dementia

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Managing Dementia Across the Continuum

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www.actonalz.org/provider-practice-tools

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Mood and Behavioral Symptoms

• Neuropsychiatric symptoms common: – 60% of community dwelling patients with

dementia

– > 80% of nursing home residents with dementia

• Nearly all patients with dementia will suffer from mood or behavioral symptoms during the course of their illness

Ferri, CP et al. Lancet 2005

Jeste, DV. ,Neuropsychopharmacology. 2008 70

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ACT to the Rescue!

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Systematic Approach to Management

• Step 1: Define behavior

• Step 2: Categorize target symptom

• Step 3: Identify reversible causes

• Step 4: Use non-drug interventions first to treat target symptoms

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Step 3: Identify Reversible Causes

• Unmet needs – Boredom – Meaning, purpose – Over/under stimulation – Pain/discomfort – Safety – Environmental stressors

• Caregiver reactions

– Limited knowledge about disease process or behaviors

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Step 4: Non-pharmacologic Interventions

• Teach family caregivers to:

– Validate Join Distract

– Understand that behavior = communication

– Think like a behavioral analyst • Is this really a problem, and for whom?

• What is the feeling or underlying message this behavior is trying to communicate?

• How can I address the underlying need?

• How long will this solution last?

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Optimizing Medication Therapy

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Top 5 Resources

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Top 5 Resources

• Promoting wellness and function

78 www.alz.org/mnnd/

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Top 5 Resources

• Addressing behavioral challenges

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Top 5 Resources

• One stop shop for caregiver support:

Alzheimer’s Association 800.272.3900 | www.alz.org/mnnd

Care Consultation

Support Groups (Memory Club)

24/7 Helpline

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Top 5 Resources

• Intensive Caregiver Training:

Family Memory Care

800.272.3900

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Top 5 Resources

• Polypharmacy:

PharmD Consult

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83 www.actonalz.org

ACKNOWLEDGEMENTS

This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health

Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS)

under Grant Number UB4HP19196 to the Minnesota Area Geriatric Education Center (MAGEC) for

$2,192,192 (7/1/2010—6/30/2015). This information or content and conclusions are those of the

author and should not be construed as the official position or policy of, nor should any

endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.

Minnesota Area Geriatric Education Center (MAGEC)

Grant #UB4HP19196

Director: Robert L. Kane, MD

Associate Director: Patricia A. Schommer, MA

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References & Resources

• Alzheimer’s Association (2014). Alzheimer’s Disease Facts and Figures, Alzheimer’s & Dementia, Volume 10, Issue 2.

• Anderson K, Jue S & Madaras-Kelly K 2008. Identifying Patients at Risk for Medication Mismanagement: Using Cognitive Screens to Predict a Patient's Accuracy in Filling a Pillbox. The Consultant Pharmacist, 6(14), 459-72.

• Barry PJ, Gallagher P, Ryan C, & O‘mahony D. (2007). START (screening tool to alert doctors to the right treatment)--an evidence-based screening tool to detect prescribing omissions in elderly patients. Age and Ageing, 36(6): 632-8.

• Blendon RJ, Benson JM, Wikler, EM, Weldon, KJ, Georges, J, Baumgart, M, Kallmyer B. (2012). The impact of experience with a family member with Alzheimer’s disease on views about the disease across five countries. International Journal of Alzheimer’s Disease, 1-9.

• Boise L, Neal MB, & Kaye J (2004). Dementia assessment in primary care: Results from a study in three managed care systems. Journals of Gerontology: Series A; Vol 59(6), M621-26.

• Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. (2000). The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry, 15(11):1021-1027.

• Borson S, Scanlan JM, Chen P, Ganguli M. (2003). The Mini-Cog as a screen for dementia: validation in a population-based sample. J Am Geriatr Soc;51(10):1451-1454.

• Borson S, Scanlan J, Hummel J, Gibbs K, Lessig M, & Zuhr E (2007). Implementing Routine Cognitive Screening of Older Adults in Primary Care: Process and Impact on Physician Behavior. J Gen Intern Med; 22(6): 811–817.

• Boustani M, Peterson B, Hanson L, et al. (2003). Systematic evidence review. Agency for Healthcare Research and Quality; Rockville, MD: Screening for dementia.

• Boustani M, Callahan CM, Unverzagt FW, Austrom MG, Perkins AJ, Fultz BA, Hui SL, Hendrie HC (2005). Implementing a screening and diagnosis program for dementia in primary care. J Gen Intern Med. Jul; 20(7):572-7.

• Ferri CP, Prince M, Brayne C, et al. (2005). Alzheimer’s Disease International Global prevalence of dementia: A Delphi consensus study. Lancet, 366: 2112–2117.

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References & Resources

• Finkel, SI (Ed.) (1996). Behavioral and Psychological Signs of Dementia: Implications for Research and Treatment. International Psychogeriatrics, 8(3).

• Folstein MF, Folstein SE, & McHugh PR (1975). "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res, Nov 12(3):189-98.

• Gallagher P & O’Mahony D (2008). STOPP (Screening Tool of Older Persons’ potentially inappropriate Prescriptions): Application to acutely ill elderly patients and comparison with Beers’ criteria. Age and Ageing, 37(6): 673-9.

• Gitlin LN, Kales HC, Lyketsos CG, & Plank Althouse E (2012). Managing Behavioral Symptoms in Dementia Using Nonpharmacologic Approaches: An Overview. JAMA, 308(19): 2020-29.

• Holroyd S, Turnbull Q, & Wolf AM (2002). What are patients and their families told about the diagnosis of dementia? Results of a family survey. Int J Geriatr Psychiatry, Mar;17(3):218-21.

• Ismail Z, Rajji TK, & Shulman KI (2010). Brief cognitive screening instruments: An update. Int J Geriatr Psychiatry, 25:111–20.

• Jeste DV, Blazer D, Casey D et al. (2008). ACNP White Paper: Update on Use of Antipsychotic Drugs in Elderly Persons with Dementia. Neuropsychopharmacology, 33(5): 957-70.

• Larner AJ (2012). Screening utility of the Montreal Cognitive Assessment (MoCA): In place of – or as well as – the MMSE? Intern Psychogeriatrics, 24, 391–396.

• Lin JS, O’Connor E, Rossom RC, Perdue LA, Burda BU, Thompson M, & Eckstrom E (2014). Screening for Cognitive Impairment in Older Adults: An Evidence Update for the U.S. Preventive Services Task Force. Agency for Healthcare Research and Quality, Evidence Syntheses, 107.

• Long KH, Moriarty JP, Mittelman MS, & Foldes SS (2014). Estimating The Potential Cost Savings From The New York University Caregiver Intervention In Minnesota. Health Affairs, 33(4), 596-604.

• McCarten JR, Anderson P Kuskowski MA et al. (2012). Finding dementia in primary care: The results of a clinical demonstration project. J Am Geritr Soc;60(2):210-217.

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• Mittelman MS, Haley WE, Clay OJ, & Roth DL (2006). Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease. Neurology, November 14(67 no. 9), 1592-1599.

• Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, & Chertkow H. (2005). The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment. J Amer Ger Soc, 53(4), 695-99.

• National Chronic Care Consortium and the Alzheimer’s Association. 1998. Family Questionnaire. Revised 2003.

• Silverstein NM & Maslow K (Eds.) (2006). Improving Hospital Care for Persons with Dementia. New York: Springer Publishing CO.

• Tariq SH, Tumosa N, Chibnall JT, Perry MH, & Morley E. (2006). Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder: A pilot study. Am J Geriatr Psychiatry, Nov;14(11):900-10.

• Turnbull Q, Wolf AM, & Holroyd S (2003). Attitudes of elderly subjects toward “truth telling” for the diagnosis of Alzheimer ’s disease. J Geriatr Psychiatry Neurol, Jun;16(2):90-3.

• Zaleta AK & Carpenter BD (2010). Patient-Centered Communication During the Disclosure of a Dementia Diagnosis. Am J Alzheimers Dis Other Demen, 25, 513.

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References & Resources

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References & Resources

• 2012 Updated AGS Beers Criteria:http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf

• Alzheimer’s Association Family Questionnaire: http://www.alz.org/mnnd/documents/Family_Questionnaire.pdf

• Alzheimer’s Association (2009). Know the 10 signs.http://www.alz.org/national/documents/checklist_10signs.pdf

• Coach Broyles Playbook on Alzheimer’s: http://www.caregiversunited.com

• Honoring Choices Minnesota:http://www.honoringchoices.org

• Living Well workbook:http://www.alz.org/documents/mndak/alz_living_well_workbook_2011v2_web.pdf

• Medicare Annual Wellness Visit: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7079.pdf

• MiniCog™ http://www.alz.org/documents_custom/minicog.pdf

• Montreal Cognitive Assessment (MoCA)http://www.mocatest.org

• National Alzheimer’s Project Act: http://aspe.hhs.gov/daltcp/napa/NatlPlan.pdf

• Next Step in Care: http://www.nextstepincare.org

• Physician Orders for Life Sustaining Treatment (POLST): http://www.polst.org

• St. Louis University Mental Status (SLUMS) examinationhttp://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf

• The Alzheimer’s Action Plan:http://www.amazon.com/The-Alzheimers-Action-Plan-Know/dp/0312538715

• Understanding Difficult Behaviors:http://www.amazon.com/Understanding-Difficult-Behaviors-suggestions-Alzheimers/dp/0978902009

88

How to Claim CME Credit:

To receive CME credit you must complete the on-line sign-in and evaluation

form. To do this you may enter the following Survey Monkey link into your web

browser or you have also received this link in an e-mail sent to you. The

survey will be available for 2 weeks following this program, and will close after

that.

Park Nicollet Institute is accredited by the Accreditation Council for Continuing

Medical Education to provide continuing medical education for physicians.

The Office of Continuing Medical Education, Park Nicollet Institute, designates

this live activity for a maximum of 1 AMA PRA Category 1 Credit(s)™.

Physicians should claim only the credit commensurate with the extent of their

participation in the activity.

https://www.surveymonkey.com/s/VLKPP68

Accreditation