Presentation on theme: "An A- Z Guide to Simplify and Optimize Dementia Care"— Presentation transcript:
1 An A- Z Guide to Simplify and Optimize Dementia Care Alternative Titles:Best Practices for Optimal Care in Alzheimer’s and Dementia Dementia Made Easy: Tools for Your PracticeDementia Made Easy:An A – Z Guide for Working with Patients with Memory Loss and DementiaAn A- Z Guide to Simplify and Optimize Alzheimer’s and Dementia Care
2 ObjectivesUnderstand the value of timely detection and learn simple approaches to cognitive screening in routine practiceTools for health equity and cultural competenceGain knowledge of best practices in medication and non-medication treatments for patients with dementiaRecognize key management priorities throughout the continuum of dementiaUnderstand the risks associated with caregiving and how to connect caregivers to evidence-based therapies, resources and servicesLeave with a full clinical toolboxObjectives for Physician session
3 Alzheimer’s Disease: Challenges and Opportunities Alternative Titles:Best Practices for Optimal Care in Alzheimer’s and Dementia Dementia Made Easy: Tools for Your PracticeDementia Made Easy:An A – Z Guide for Working with Patients with Memory Loss and DementiaAn A- Z Guide to Simplify and Optimize Alzheimer’s and Dementia Care
4 Alzheimer’s: A Public Health Crisis Scope of the problem5.2M Americans with AD in 2013Growing epidemic expected to impact 13.8M Americans by 2050 and consume 1.1 trillion in healthcare spendingAlmost 2/3 are women (longer life expectancy)If disease could be detected earlier incidence would be much higherPre-clinical stage 1-2 decadesSome populations at higher riskOlder African Americans (2x as whites)Older Hispanics (1.5x as whites)Alzheimer’s Association Facts and Figures 2014
5 The Lens of Health Equity Take into consideration health disparities and inequitiesSeek the attainment of the highest level of health for all peopleHelp create a new style of “curb cut” by promoting cultural competenceAlternative Titles:Health equity refers to the attainment of the highest level of health for all peopleCultural competency is critical to reducing health disparities and improving access to high-quality health care, health care that is respectful of and responsive to the needs of diverse patients. When developed and implemented as a framework, cultural competence enables systems, agencies, and groups of professionals to function effectively to understand the needs of groups accessing health information and health care—or participating in research-in an inclusive partnership where the provider and the user of the information meet on common ground. (National Institutes of Health)
6 Percent with Alzheimer’s Base Rates1 in 9 people 65+ (11%)1 in 3 people 85+ (32%)Age RangePercent with Alzheimer’s< 654%65 -7413%75 -8444%85 +38%Speaker Notes:Emphasize how broadly this disease impacts the populationConsider how many other conditions are this common in geriatric patients?Base rates are surprisingly high, so not chasing a needle in a haystackDementia is more common than most realizeAlzheimer’s Association Facts and Figures 2014
7 Patients with Dementia A population with complex care needsIndisputable correlation between chronic conditions and costs2.5 chronic conditions (average)5+ medications (average)3 times more likely to be hospitalizedMany admissions from preventable conditions, with higher per person costsSpeaker Notes:While rarely characterized as such, dementia is a chronic condition and disease that we must pay attention to in the new paradigm in the same way we address other chronic conditions such as diabetes and heart diseasePeople with dementia who receive primary care have on average 2.5 chronic conditions and take five or more medications. They are also three times more likely to be admitted to hospitals at higher per person payment rates and for a variety of often preventable conditions including dehydration, urinary tract infection, pneumonia, and delirium.What do we know about the relationship between costs and chronic conditions? They are indisputably correlated. (http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf)Alzheimer’s Association Facts and Figures 2014
8 Challenges & Opportunities AD under-recognized by providersOnly 50% of patients receive formal diagnosisMillions unaware they have dementiaDiagnosis often delayed on average by 6+ years after symptom onsetSignificant impairment in function by time it is recognizedPoor timing: diagnosis frequently at time of crises, hospitalization, failure to thrive, urgent need for institutionalizationSpeaker Notes:Main point is that we currently do not do a very good job as providers detecting dementia when we rely on subjective signs and symptoms based on conversation alone.Populations experiencing health disparities, such as African Americans, are diagnosed even later in the disease process which further limits the opportunity to enhance their quality of life.Boise et al., 2004; Boustani et al., 2003; Boustani et al., 2005; Silverstein & Maslow, 2006
9 Diagnostic Challenges SocietalAgeism, lack of understanding re: normal agingFear and stigmaHealthcare inequitiesExpectation that MD will identify/diagnose health problemsSystemic/InstitutionalLow priorityFew incentivesLack of procedural supportFew dementia specialists availableMay lack access to (or awareness of) community resourcesSpeaker Notes:Healthcare providers and lay people alike have not been educated about what healthful brain aging looks likeIf we do not have a good understanding of healthy brain aging, how can we detect unhealthy brain aging in a timely manner?
10 Diagnostic Challenges For ProvidersTimeLack of definitive testsMany patients unaware, do not report symptomsLimited efficacy of medication treatmentsLimited cultural competenceLack of awareness re: benefits of non-medication interventionsFear of delivering wrong diagnosis, bad newsImplications for physician/patient relationship
11 Myth: People don’t want to know they have Alzheimer’s disease Studies Agree:Most people want to know.%Speaker Notes:Studies have repeatedly demonstrated that 80% or more of adults do, in fact, want to know if they have Alzheimer’s disease or a related condition.Blendon et al., 2012; Holroyd et al., 2002; Turnbull et al., 2003
12 Diagnostic Challenges International Physician SurveyLack of definitive tests (65%, top barrier)Lack of communication between patients / caregiver and physicians75% reported discussion initiated by patients/caregivers44% “after they suspected the disease had been present for a while”40% said patients/caregivers did not provide enough information to help them make a diagnosisPatient / Family denial (65%) & social stigma (59%)Speaker Notes:Physicians in this study asked what barriers they encounter that make diagnosis of AD and related conditions difficultInternational Alzheimer’s Disease Physician Survey, 2012
13 Diagnostic Challenges “Beyond mountains, there are mountains.”Haitian ProverbSpeaker Notes:This proverb sums up the challenges for many healthcare providersDoing a diagnostic work-up seems like an up-hill battleWhen you do reach the first mountain peak by making a diagnosis of AD, seems like all you see are more mountains to climb (safety concerns, driving, behavior problems, caregiver support, etc.)
14 If we don’t diagnose, does it still exist? Speaker Notes:Alzheimer’s disease is not a needle in a haystack, it is commonIf we choose to ignore it, it doesn’t go awayIt is still there, will worsen over time, and will cause significant disruption to the patient’s life and to their ability to follow treatment recommendations for any and all health conditions
15 Rationale for Timely Detection Patient Care / OutcomesTimeMoneySpeaker Notes:When considering any change in clinical practice, most of us consider these 3 factors to be most importantWill paying more attention to my patients’ cognitive health make any difference in their overall health outcomes?Can the change be implemented in a time efficient manner?Will it be cost effective for me, the patient, the healthcare system?
16 Patient Outcomes Improve quality of life Patients can participate in decisions regarding their future careDecrease burden on family and caregiversIntervene to promote a safe and happy environment that supports independenceRTC support/counseling interventionNon-pharm intervention reduces NH placement by 30% and delays placement for others by 18+ monthsThe message: You have a bad disease. We can help you make life better for you and your family.Speaker Notes:Common scenario: Patient’s poor mental status only recognized at time of crisis, during a hospitalization. Discharge provider does not feel patient should be released home independently. Social worker has to call around and see what facilities have an “open bed”. Patient gets stuck going wherever there is an opening instead of going to a place they would have preferred. I do not know about you, but I don’t want my future to be based upon where an “open bed” exists. I want to have a say in where I live, who takes care of me, etc. Early, timely diagnosis gives patients the gift of being able to participate in decisions that directly impact the course of their life.Non-pharmacological interventions that focus solely on providing education and support to patients and families have been shown to have considerable benefits and positive outcomes. We can dramatically improve outcomes by connecting families to these resources as soon as possible. Again, diagnosis has very little to do with meds.This intervention, studied extensively by Mary Mittelman, is offered widely across MN under the name “Family Memory Care” and can be a “game changer” for familiesMittelman et al., 2006
17 Patient Outcomes Improved management of co-morbid conditions Underlying dementia = risk factor for poor compliance with ALL treatment goals (e.g., diabetes, hypertension, CHF, anticoagulation)Reduce ineffective, expensive, crisis-driven use of healthcare resourcesUnnecessary hospitalization (dehydration/malnourishment, medication mismanagement, accidents and falls, wandering, etc.)The message: We want to provide you with high quality care that is proactive and cost effectiveSpeaker Notes:One has to consider the fact that underlying cognitive impairment (dementia) is an obvious risk factor for our patients’ ability to effectively manage any health conditionTherefore, detecting dementia is not just about treating dementia. It is about removing a hidden barrier to good compliance with other conditions (e.g., diabetes)Common scenario: 80 y/o woman comes in for routine visit. She has a hx of diabetes. Her A1C is significantly elevated, suggesting her diabetes is not well managed. When asked if she is checking her blood sugar and taking her insulin regularly, the patient says “yes, I am” (she offers what most patients do in that situation = a socially acceptable response). So, the provider responds by increasing her insulin or adding medication to address the problem. The elephant in the room, however, is that the patient in fact is not checking her blood sugar or dosing her insulin correctly because she has unrecognized dementia and can’t remember to do these things on a regular basis (nor can she juggle numbers or do the simple math required to draw the right amount of insulin). Instead of removing this barrier (i.e., getting support for her medication administration), we are adding more complication and risk by changing meds.Many times unrecognized dementia also leads to unnecessary and very expensive healthcare utilization because of issues, like medication mismanagement, which could be avoided by calling out the underlying dementia
18 Patient Outcomes Treat reversible causes NPH, TSH, B12, hypoglycemia, depressionThe message: Maybe you don’t really have a bad disease after all!Speaker Notes:Common scenario: Patient’s poor mental status only recognized at time of crisis, during a hospitalization. Discharge provider does not feel patient should be released home independently. Social worker has to call around and see what facilities have an “open bed”. Patient gets stuck going wherever there is an opening instead of going to a place they would have preferred. I do not know about you, but I don’t want my future to be based upon where an “open bed” exists. I want to have a say in where I live, who takes care of me, etc. Early, timely diagnosis gives patients the gift of being able to participate in decisions that directly impact the course of their life.Non-pharmacological interventions that focus solely on providing education and support to patients and families have been shown to have considerable benefits and positive outcomes. We can dramatically improve outcomes by connecting families to these resources as soon as possible. Again, diagnosis has very little to do with meds.This intervention, studied extensively by Mary Mittelman, is offered widely across MN under the name “Family Memory Care” and can be a “game changer” for families
19 Time Simple screening tests can be done by rooming nurse Brain as 6th vital signRecommended tool takes 1.5 – 3 minutesOnly conducted annually and in context of signs and symptomsMini-Cog does not disrupt workflow & increases capture rate of cognitive impairment in primary careSpeaker Notes:Emphasize how little time screening actually takes (there are a variety of good tools, several are quite short) and that screening can be done by an allied health professional (e.g., nurse)Studies have already looked at implementing screening practices in primary care and result show it does not disrupt the normal workflowBorson et al., 2007
20 Money AD most expensive condition in the nation $203 billion in 2013, $1.2 trillion in 2050Cost effectiveness of early dx/tx?Large scale studies ongoingEconomic ModelsNo med known to alter costs of careDisease education/support interventions increase caregiver capability, save money, and delay NHEven if assume small # of people benefit (5%), $996 million in potential savings for MN over 15 yearsSpeaker Notes:Last bullet refers to the Family Memory Care program. Even if only 5% of caregivers in Minnesota were connected to the program (remember – it is simply education and support and has nothing to do with medication), the potential cost savings for the state is exceptionally robustAlzheimer’s Association Facts and Figures 2014; Long et al., 2014
21 Impact of Optimal Practices Reduces utilization through comorbidity managementTimely DetectionReduces behavioral symptomsDelays institutionalizationIncreases treatment plan compliancePost-DiagnosisEducation and SupportDelays institutionalizationReduces neuropsychiatric symptomsReduces costsEffective Care ManagementTeam-Based CareReduces acute episodesImproves health outcomesSpeaker Notes:Timely detection:-Dementia as an Organizing Principle of Care (we can facilitate better management of all of a patient’s comorbid conditions through assessment of their cognitive status)Counseling and support after diagnosis:Research and clinical practice establish that counseling, education, and support services to individuals in early stages of the disease, and to caregivers throughout the disease, may result in the following direct benefits for care: 1) reducing behavioral symptoms; 2) promoting compliance with treatment plans; 3) providing a support system for people who often feel isolated from their communities, family, and friends; 4) improving moods in individuals with the disease and their family members; and 5) delaying institutionalization (Doody, 2001), (Guerriero, 2004), (Gallahger-Thompson & Coon, 2007), (Mittleman, 1996), (Mittleman, 2004), (Mittelman, 2006), (Mittelman, 2007), (Callahan, 2006), (Cherry 2004), (Pinquart & Sörensen, 2006), (Vickrey, 2006).Care managementeffective dementia care management is a critical element of care and can: 1) delay institutionalization, 2) reduce neuropsychiatric symptoms, and 3) be cost effective (Callahan, et al., 2006), (Mittelman, et al., 2006), (Wolf, et al., 2009). Care coordination typically encompasses the assessment of a patient’s needs, development and implementation of a plan of care, and evaluation of the care plan (NTOCC, 2008). A team-based approach to coordination has a positive impact on individuals with dementia, their caregivers, and overall care costs and outcomes (Callahan, et al., 2006).Care team approachOne way in which providers can improve outcomes and prevent medical crises in dementia care is to coordinate care through collaborative teams within the clinic and have close ties and referral paths to supportive community-based care (Vickery, et al., 2006), (Guerriero, et al., 2004).Good transitionsTransitional care support is essential for persons with complex care needs, including those with dementia. Many evidence-based models of transitional care exist and have been shown to make a significant difference on health outcomes, quality, and cost of care compared with individuals who do not receive transitional care, including lower rates of hospitalization and emergency room visits (Coleman, et al., 2001), (Coleman, et al., 2003), (Coleman, et al., 2006), (Naylor, et al., 1994), (Naylor, et al., 1999), (Naylor, et al., 2004).Referral to community based programs and supportsThe primary care provider plays a critical role in directing individuals with dementia and their caregivers to services and resources that may improve the quality of life for both the individual with dementia and the caregiver (Lyketsos et al., 2006), (Winslow, 2003). Examples include wellness and risk reduction programs including adult day services, exercise clubs, therapy referrals (OT, PT, Speech), and clinical evaluation for sensory aids (vision, hearing).In-person care-giver support and recognition of caregiver as integral part of health care team-- Caregivers of people with dementia are more likely to provide a higher level of care for a longer period of time, greatly increasing their sense of burden (National Alliance for Caregiving and American Association for Retired Persons, 2009), sometimes providing more than 80 hours of care per week (National Alliance for Caregiving and American Association for Retired Persons, 2004).Value of caregiver support and maintaining health of caregiver in order to benefit the person with diseaseCaregivers play a critical role in supporting individuals with dementia and without them the health care system could not sustain the costs of care for persons with dementia. Currently, 70% of individuals with Alzheimer’s disease and related dementias live at home. Eighty percent of care provided at home is delivered by family caregivers; fewer than 10 percent of older adults receive all of their care from paid workers.Caregivers’ health and well-being is critical to their ability to continue to provide the vital caregiving role. For example, depression reduces a caregiver’s ability to continue to provide for an individual with dementia (Mok, et al., 2007) and may lead to increased depression in the care recipient, which can further impair health and function associated with dementia itself (Eisendorf, et al., 2003). Likewise, caregivers who report feeling stressed because of the impaired person’s behavioral symptoms are more likely to place their care recipient in a nursing home (Alzheimer’s Association, 2014).The close connection between caregiver health and well-being and caregiver ability to fulfill the caregiving role calls for assuring the availability of effective caregiver supports to assist caregivers in maintaining their health and well-being.Care TransitionsImproves health outcomesImproves care qualityReduces hospital, ER utilization, and care costsCaregiver Engagement & SupportImproves overall well-being of person w/ dementiaIncreases caregiving longevity and well-being
22 Changing National & Local Landscape National Alzheimer’s Project Act (NAPA)Awareness, readiness, dissemination, coordinationAnnual Wellness VisitFor first time, “detection of cognitive impairment” is core feature of the examMN healthcare systems implementing toolsHealthPartnersPark NicolletEssentiaAllinaSpeaker Notes:Including “detection of cognitive impairment” in the annual wellness visit represents a major philosophical shift in Medicare toward the importance of routine monitoring of brain healthMore and more local health systems are adopting cognitive screening and ACT tools
23 Rethinking Everyday Practice Brain historically ignored, not a focus of routine examIs this logical? Consider base rates of dementiaDementia is simply “brain failure”Heart failureKidney failureLiver failureBrain as 6th Vital Sign
25 Impacts of Alzheimer’s ACT on Alzheimer’s300+individuals60+organizationsstatewidevolunteer drivencollaborativeImpacts of Alzheimer’sSpeaker Notes:ACT on Alzheimer’s is a statewide, volunteer driven collaboration.ACT started with 50 organizations and 150 individuals.It’s now comprised of over 60+ organizations and hundreds of individuals.All working together to prepare Minnesota for the budgetary, social and personal impacts of Alzheimer’s disease.No single organization owns, finances or controls the collaboration.Additional background if needed:In 2009, Minnesota Legislature charged the Minnesota Board on Aging to establish the Alzheimer’s Disease Working Group (ADWG) and make recommendations for policies and programs that would prepare Minnesota for the increasing number of residents with the disease and family members impacted by the disease.The Working Group filed its report in January 2011, offering a set of recommendations for change.Although the legislative mandate had been fulfilled, a voluntary coalition formed to focus on implementing the recommendations.Originally called Prepare Minnesota for Alzheimer’s 2020 (PMA 2020), it is now call ACT on Alzheimer’s and is focused on implementing the recommendations found in the report.budgetarysocialpersonal
26 Collaborative Goals/Common Agenda Five shared goals with a Health Equity perspectiveSpeaker Notes:ACT works toward five interconnected goals. To make progress toward these goals, ACT is organized into leadership groups.Identify and invest in promising approaches to Alzheimer’s disease that reduce costs and improve care.ACT commissioned an economic model on what the potential cost savings would be if an evidence based caregiver support intervention were made available state wide. The model's analysis and results are reflected in a Health Affairs article, and a subsequent net savings analysis has been done. Details of both are available on the ACT website.Increase detection of Alzheimer’s disease and improve ongoing care and support.ACT has created practice tools that provide guidance in assessing patients and serving clients with cognitive impairment. The group has also created a curriculum for students and professionals wanting to learn more about Alzheimer’s disease.Sustain caregivers by offering them information, resources and in-person support.This leadership group offered expert input into the development of dementia capability training for MN’s caregiver consultants and Senior LinkAge Line staff. Also developed ACT’s first consumer resource – After a Diagnosis. Aligns with the recommendations in the professional practice tools and offers tips and suggestions for the person with the disease, caregivers, and family members after receiving a diagnosis.The last two goals combine naturally…they are about equipping communities to be “dementia capable” to support residents who are touched by Alzheimer’s disease and to raise awareness and reduce stigma by engaging communities.Languages on the Health Equity visual are (from top, clockwise): English, Spanish, Hmong, Somali, German, American Sign Language
27 ACT Tool KitEvidence and consensus-based, best practice standards for Alzheimer’s careTools and resources for:Primary care providersCare coordinatorsCommunity agenciesPatients and families
28 ACT Tools Speaker Notes: This is a quick snap shot of some of the ACT tools and resources that are available to difference audiences (physicians/providers, care coordinators, community agencies, patients and families, etc.)All of the resources are available online, are FREE, and can be modified to fit into any existing healthcare system
29 ACT Tools Speaker Notes: This is a quick snap shot of some of the ACT tools and resources that are available to difference audiences (physicians/providers, care coordinators, community agencies, patients and families, etc.)All of the resources are available online, are FREE, and can be modified to fit into any existing healthcare system
30 www.actonalz.org Speaker Notes: The ACT website is simple and easy to use. Tools are downloadable as PDF documentsInstructional videos are also available (e.g., how to conduct cognitive screening, deliver a dementia diagnosis, how to coordinate care, etc.)
32 Case Study: Sam 76 y/o retired teacher (master’s degree) Daughter c/o short-term memory is poor, patient acknowledges problem but does not feel it is significantRepeats himself, multiple phone calls b/c can’t find belongingsOther family members have noticed changesBegan 2 years ago, getting worseHx of hypertension and DM, both fairly well controlledWife died unexpectedly last year, lives aloneConversational presentation fairly intactOriented x3 but vague awareness of current eventsSpeaker Notes:Use only 1 of the 2 available case studies for discussion and interactive exercises (Sam or Colleen)Sam videos include: Mini-Cog, MoCA, and delivering an Alzheimer’s diagnosisColleen videos include: Mini-Cog, SLUMS, and care coordination
33 Case Study: Colleen 66 y/o retired accountant for family business Presents to primary care with memory complaintsDaughter agrees that short-term memory is poorBegan 2 years ago, seems to be worseningHx of Low blood sugar, heart attack x1, repeat ER visits and hospitalizations for atrial flutterFrequent medication changes, managing independentlyLives with husband who is still running the family businessSpeaker Notes:Use only 1 of the 2 available case studies for discussion and interactive exercises (Sam or Colleen)Sam videos include: Mini-Cog, MoCA, and delivering an Alzheimer’s diagnosisColleen videos include: Mini-Cog, SLUMS, and care coordination
34 Signs and Symptoms of AD Memory lossConfusionDisorientation to time or placeGetting lost in familiar locationsImpairment in speech/languageTrouble with time/sequence relationshipsDiminished insightPoor judgment/problem solvingChanges in sleep and appetiteMood/personality/behavior changesWanderingDeterioration of self care, hygieneDifficulty performing familiar tasks, functional declineAlzheimer’s Association, 2009
35 Practice TipsUnfortunately, most of us do not recognize signs and symptoms until they are quite pronouncedAttribution error: “What do you expect? She is 80 years old.”Subjective impressions FAIL to detect dementia in early stagesClinical interviewLet patient answer questions without helpRemember: Social skills remain intact until late stage dementiaEasy to be fooled by a sense of humor, reliance on old memories, or quiet/affable demeanorSpeaker Notes:Conversations with patients and subjective evaluations of mental status have extremely low reliability in detecting dementia until advanced stages
36 Practice Tips Red flags Repetition (not normal in 7-10 min conversation)Tangential, circumstantial responsesLosing track of conversationFrequently deferring answers to family memberOver reliance on old information/memoriesInattentive to appearanceUnexplained weight loss or “failure to thrive”
37 Practice Tips Raise your expectation of older adults: Family observations:ANY instances whatsoever of getting lost while driving, trouble following a recipe, asking same questions repeatedly, mistakes paying billsTake these concerns seriously: by the time family report problems, symptoms have typically been present for quite a while and are getting worseRaise your expectation of older adults:If this patient was alone on a domestic flight across the country and the trip required a layover with a gate change, would he/she be able to manage that kind of mental task on his/her own?If answer is “not likely” for a patient of any age: RED FLAG
38 Practice Tips Intact older adult should be able to: Describe at least 2 current events in adequate detail (who, what, when, why, how)Describe events of national significance9/11, New Orleans disaster, etc.Name or describe the current President and an immediate predecessorDescribe their own recent medical history and report the conditions for which they take medication
40 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 there is no empirical evidence that screening improves decision making.Speaker Notes:Emphasize that this review does NOT say cognitive screening should not be used or be part of routine practiceIn fact, they find that screening works for its intended purpose – it identifies people with cognitive impairment (adequately detects dementia)The question as to whether cognitive screening impacts provider decision making could not even be evaluated because of a lack of research on the topicIf one chooses to do cognitive screening, it makes sense that you would want to use the information to inform the care of your patientLong et al., 2014
41 Provider Perspective Family Practice Physician “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, MDFamily Practice PhysicianSpeaker Notes:This is just one point of view meant to highlight the fact that ignoring a serious medical condition can have unintended negative consequences and may not be the most ethical way to practice.One can make an argument that we should be moving away from paternalistic medicine. Why should we as providers decide for our patients whether or not they should be informed about a serious and life altering health condition? Shouldn’t the choice to act on the information be in the hands of each patient? If some choose not to act, that is their choice. Disclosing a diagnosis of dementia is in line with person-centered care.
42 Clinical Provider Practice Tool Easy button workflow for:ScreeningDementia work-upTreatment / careSpeaker Notes:Emphasize that care of patients with cognitive impairment and dementia is simplified by these “easy button” toolsThe provider practice tool is only 3 pages. One page on cognitive screening, one page on the dementia work-up, and one page on treatment/intervention.
43 Cognitive Screening Initial considerations Timing Research Routine, annual check-ups or only when patients become obviously symptomatic?Best practice recommendation: Annual screening at 65+Screening meant to uncover insidious diseaseDoesn’t add much if you can already detect impairment in basic conversationResearchWhich tools are best?Balance b/w time and sensitivity/specificity
44 Cognitive Screening Clinic flow Who will administer screen? Rooming nurses, social workers, allied health professionals, MDsWhat happens when patients fail?
46 Alternative Screening Tools Virtually all screening tools based upon a euro-centric cultural and educational modelConsider: country and language of origin, type/quality/length of education, disabilities (visual, auditory, motor)Alternative tools my be less biasedSpeaker Notes:In some cases there may not be an ideal tool availableMay have to rely more heavily on the clinical history (report from collateral re: changes in cognitive and functional status from baseline) and longitudinal/serial assessment (observed decline in mental status and cognitive screening score over time)
47 Screening Administration Try not to:Use the words “test” or “memory”Instead: “We’re going to do something next that requires some concentration”Allow patient to give up prematurely or skip questionsDeviate from standardized instructionsOffer multiple choice answersBe soft on scoringScore ranges already padded for normal errorsDeduct points where necessary – be strictSpeaker Notes:It is important not to raise a patient’s anxiety by using words like “test” or “memory”The screen can be introduced as a “check-up from the neck up” or by talking with patients about how medicine is moving more and more toward prevention. “Just like the nurse monitors your blood pressure, heart, and lungs on a routine basis when you come to the doctor (vital signs), we now know that it is also important to monitor the health of the brain on a routine basis. This is something we are doing routinely now.”
48 Mini-Cog™ Contents Advantages +3 +2 Verbal Recall (3 points) Clock Draw (2 points)AdvantagesQuick (2-3 min)EasyHigh yield (executive fx, memory, visuospatial)Subject asked to recall 3 wordsLeader, Season, Table+3Subject asked to draw clock,set hands to 10 past 11+2Speaker Notes:Ask the audience why setting the time for “ten past eleven” is a sensitive marker of cognitive decline? Answer: time is an abstract concept. Ten after is symbolically represented by the 2. Our brains do this type of mental gymnastic easily because we do not have dementia. But, patients with early Alzheimer’s disease lose symbolic, abstract thinking. A common response on this part of the task is to draw one line to the ten and one line to the eleven because those are the two numbers you mentioned in the instructions. Their thinking becomes more concrete.The clock is scored all or nothing, 0 or 2 points, because it has been shown to be a very sensitive marker of early cognitive decline.Borson et al., 2000
49 Speaker Notes:This is screen shot of one of a variety of Mini-Cog forms available (many of which can be found online)Forms are also available from the Alzheimer’s Association and the creator of the instrument, Soo Borson
50 Speaker Notes:This is screen shot of one of a variety of Mini-Cog forms available (many of which can be found online)Forms are also available from the Alzheimer’s Association and the creator of the instrument, Soo Borson (her address is on the bottom of the screen)Note that this version includes helpful scoring guidelines
51 Mini-CogPass> 4Fail3 or lessBorson et al., 2000
52 Mini-Cog Research Performance unaffected by education or language Borson Int J Geriatr Psychiatry 2000Sensitivity and specificity similar to MMSE (76% vs. 79%; 89% vs. 88%)Borson JAGS 2003Does not disrupt workflow & increases rate of diagnosis in primary careBorson JGIM 2007Failure associated with inability to fill pillboxAnderson et al Am Soc Consult Pharmacists 2008Speaker Notes:Mini-Cog is a good tool for minimizing bias associated with education and culture (although no tool is perfect)Although it only takes 1/3 as long to administer, the Mini-Cog has the same or better sensitivity and specificity as the MMSEEmphasize that research has shown if a patient cannot pass the Mini-Cog, they can not fill a pill box correctly. So, not only is this a very quick measure of cognitive function, it is also a good indication about the patient’s functional status and ability to comply with general treatment recommendations
53 Mini-Cog: Sam http://youtu.be/CRQEighdb0w http://youtu.be/CRQEighdb0w Speaker Notes:Watch this video as an example of how to introduce and perform the Mini-Cog with a patient in the primary care settingPay attention to how Sam answers the questionsKeep track of his score as the video moves alongThis is a real patient and real provider (no actors)
54 Mini-Cog Scoring: Sam Speaker Notes: This clock is scored as a 0 The numbers are all present and in their correct locations but the hands are set incorrectly (in a manner betraying the fact that Sam is losing some degree of abstract reasoning and symbolism)
55 Mini-Cog Scoring: Sam Speaker Notes: One could give Sam the benefit of the doubt when it comes to the word recall portion of the test. Although he initially could not remember any of the 3 words, he did recall one of the words less than a minute after he was asked for them and before the conversation moved on to another topic. Therefore, he would receive 1 point.His total score is a 1/5. He has failed the screen. This suggests that further work-up is indicated to rule out dementia.
56 Mini-Cog: Colleen http://youtu.be/DeCFtuD41WY Speaker Notes:Watch this video as an example of how to introduce and perform the Mini-Cog with a patient in the primary care settingPay attention to how Colleen answers the questionsKeep track of her score as the video moves alongThis is a real patient and real provider (no actors)
57 Colleen’s Clock Speaker Notes: This clock is scored a 0. While at first glance all the numbers are present and seem to be in their correct locations on the clock face, notice that Colleen transposed the numbers 4 and 5. If any numbers are out of sequence, missing, or are included more than once, the clock is given 0 points. This mistake is important to factor in because it may suggest early underlying difficulty with numbers and sequencing which are common symptoms in Alzheimer’s disease.
58 Colleen’s Score Speaker Notes: Colleen receives 2 points for list recall. Her clock score is 0.Total score is 2/5. Colleen has failed the screen. Her score suggests that further work-up is indicated to rule out dementia.
59 Mini-Cog Exercise Form groups of 2 Administer MiniCog to each other Score sample clocks
60 Clock #1Speaker Notes:Ask the audience how they would score this clockScore = 0 pointsRationale: Visuospatial problems which have affected the spacing or location of the numbers. Look at the anchor numbers (12, 6, 3, and 9). The 10 is where the 9 should be. Therefore, this is a 0 point clock. It is important to take spacing of the anchor numbers into account because this is how we incorporate evaluation of patients’ visuospatial functions, which often deteriorate early in the course of Alzheimer’s.
61 Clock #2Speaker Notes:Ask the audience how they would score this clockScore = 0 pointsRationale: Clear spacing deficits (see anchor numbers) and time is represented by a single hand. This is a common response observed by patients with early dementia.
62 Clock #3Speaker Notes:Ask the audience how they would score this clockScore = 2 pointsRationale: A small percentage of patients will draw the numbers on the outside of the clock. This is considered a normal variation so this is not counted against them. All numbers are represented and the anchor numbers are in their correct locations. There is a slight gap between 2 and 3 but it does not affect the position of the anchor numbers. The hands are set appropriately. Note that the length of the hands does not matter when scoring the Mini-Cog.
63 Clock #4Speaker Notes:Ask the audience how they would score this clockScore = 0 pointsRationale: The time is represented by an “x” instead of hands of the clock. This is another common response observed by patients with early dementia. It becomes difficult for them to think abstractly so they compromise by making a little mark like this one between the 10 and 11.
64 Clock #5Speaker Notes:Ask the audience how they would score this clockScore = 0 pointsRationale: Not all the numbers of the clock are represented. Sometimes, patients will lose steam and stop short of completing the clock because of confusion. Alternatively, some become “stuck” in a certain process (such as numbering) and will keep adding numbers past 12 (13, 14, 15, etc.).
65 Clock #6Speaker Notes:Ask the audience how they would score this clockScore = 2 pointsRationale: This clock is tricky to score. First, look at the numbers. All are represented and there are no missing or duplicate numbers. The 12 and 6 are in their correct locations. There is a space between the 3 and 4 where the 3 should be positioned. Because another number (other than 3) is not occupying the anchor position, we would give the patient the benefit of the doubt and ignore this issue. Points are only deducted when it is clear that the anchor position is occupied by another number. Now look at the 8 and 9. The patient drew two #8s but recognized and self-corrected the error by scribbling one of the 8s out. This error forced them to draw the #9 a bit higher than normal. Because the patient self-corrected their error we would also give them a pass here as well. They have successfully set the time for 10 past 11. Note that the fulcrum of the hands does not need to be centered in the middle of the clock face. This is a full-point clock.
66 Clock #7Speaker Notes:Ask the audience how they would score this clockScore = 2 pointsRationale: The 6 is slightly out of position but not enough to take away points. Remember, unless another number occupies the anchor position, mild spacing issues are not considered errors.
67 Clock #8Speaker Notes:Ask the audience how they would score this clockScore = 0 pointsRationale: Although the time is set correctly, the numbers 4 and 5 are out of sequence. Remember to look very carefully when scoring the clock as some errors may not jump out at your right away.
68 Clock #9Speaker Notes:Ask the audience how they would score this clockScore = 0 pointsRationale: Anchor numbers (9 and 3) are out of position and other numbers occupy the spaces in their place (10 and 4)
69 SLUMSSpeaker Notes:The SLUMS is much more sensitive to early cognitive decline when compared to older instruments, such as the MMSE. The reason is that the tool incorporates more questions involving “working memory” and executive functions which are typically early markers of dementia. The tool’s questions are a bit more rigorous than the MMSE, more in keeping with our current understanding of how high the bar should be set to measure brain health in an aging cohort.You will notice that some of the questions are worth more than one point. This relative weighting of certain questions also makes the instrument more sensitive by putting greater emphasis on certain cognitive functions that are good early indicators of cognitive impairment.The SLUMS is scored out of a possible 30 points, just like the MMSE. The similar score range is helpful for providers who are used to interpreting scores on the MMSE.Tariq et al., 2006
70 Less than 12 yrs education SLUMSHigh School DiplomaLess than 12 yrs educationPass> 27> 25Fail26 or less24 or lessSpeaker Notes:The SLUMS takes into account level of education. On this instrument, the cut-off score is lower if a patient has not graduated from high school (giving them extra room for normal mistakes on the test).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 Nov;14(11):
71 SLUMS: ColleenSpeaker Notes:Watch this video as an example of how to introduce and perform the Mini-Cog with a patient in the primary care settingPay attention to how Colleen answers the questionsKeep track of her score as the video moves alongThis is a real patient and real provider (no actors)
72 SLUMS Scoring: Colleen Interactive scoring exerciseSpeaker Notes:Take a few minutes on your own to score Colleen’s SLUMS
73 SLUMS Scoring: Colleen Speaker Notes:Review Colleen’s answers to each question with the audience (if time allows). Alternatively, focus on items where there may be questions or disagreement. The screen shot shows the gold standard score.
74 SLUMS Scoring: Colleen Speaker Notes:Ask the audience how they would score this clock.Score = 2 points. No problems are identified.
75 SLUMS Scoring: Colleen Speaker Notes:Colleen’s total score is 17/30.She has a high school education and the cut-off for normal is 27. She has failed the screen. Her score suggests that further work-up to rule out dementia is indicated.
76 MoCASpeaker Notes:The MoCA is considered by many to be the most sensitive cognitive screening tool in existence at the current time.The instrument incorporates many more measures of executive functioning and, like the SLUMS, raises the bar of normal aging to a higher (and more appropriate) level.The MoCA is translated into over 30 languages and there is even a version for the vision-impaired. This is very helpful when working with patients who are not native English speakers or who have disabilities.All forms and scoring material can be downloaded for free online (Google “MoCA test”)Although the test is a very sensitive measure of dementia, it takes approximately 15 minutes to administer so is not considered the best tool for front-line screening. More often, the MoCA is used once a patient fails the Mini-Cog if there are any questions about whether or not the patient is actually impaired (to avoid false positive identifications).Like the MMSE and SLUMS, the MoCA is scored out of a possible 30 points.Nasreddine et al., 2005
78 MoCA: Sam http://youtu.be/ryf8SG0NQLQ?list=UUOPv8U5bHcdDCm4edmQDY9g Speaker Notes:Watch this video as an example of how to introduce and perform the MoCA with a patient in the primary care settingPay attention to how Sam answers the questionsKeep track of his score as the video moves alongThis is a real patient and real provider (no actors)
79 MoCA Scoring: Sam Interactive scoring exercise Speaker Notes: Take a few minutes on your own to score Sam’s MoCA
80 MoCA Scoring: Sam Speaker Notes: Review Sam’s answers to each question with the audience (if time allows). Alternatively, focus on items where there may be questions or disagreement. The screen shot shows the gold standard score.
81 MoCA Scoring: Sam Speaker Notes: The MoCA clock is worth a total of 4 points. Sam’s clock is awarded 2 points. Keep in mind that the scoring criteria for the MoCA is very different from that used with the Mini-Cog. Read the directions for the MoCA carefully before scoring.Sam receives 1 point for the outer contour of the clock (circle). He receives 1 point for having all the numbers represented and in their correct location on the clock face. However, he receives 0 points for the hands because he set the time incorrectly.
83 MoCA Scoring: Sam Speaker Notes: Sam’s total score is 21/30. He has a Master’s degree and the cut-off for normal is 26. He has failed the screen. His score suggests that further work-up to rule out dementia is indicated.
84 Screening Tool Selection Montreal Cognitive Assessment (MoCA)Sensitivity: % for MCI, 100% for dementiaSpecificity: %St. Louis University Mental Status (SLUMS)Sensitivity: % for MCI, 100% for dementiaSpecificity: %Mini-Mental Status Exam (MMSE)Sensitivity: % for MCI, 78% for dementiaSpecificity: %Speaker Notes:Notice the poor psychometric properties of the MMSE compared to the SLUMS and MoCA.The MMSE is only able to correctly identify MCI and dementia in 18 and 78 of 100 cases, respectively.Compare this to the robust ability of both the SLUMS and MoCA to detect early cognitive impairment in the same population.The MMSE is a dull instrument and should be replaced by a more sensitive tool.Larner 2012; Nasreddine et all, 2005; Tariq et al., 2006; Ismail et al., 2010
85 Family Questionnaire www.actonalz.org/pdf/Family-Questionnaire.pdf Speaker Notes:The Family Questionnaire can be used (if a family member is present) to gauge what and how many signs and symptoms of dementia caregivers have observed.Note that this is not an objective measure of the patient’s cognitive status. It simply reflects the opinion of one caregiver. Therefore, it does not take the place of objective measurement. As caregivers are not experts in brain health, they too are susceptible to bias and over-attribution of memory difficulties as “normal aging”This tool is used as supplementary information for the provider to consider along with an objective cognitive screen.If a patient passes the Mini-Cog but family express concern about declining abilities, a longer more rigorous screen like the SLUMS or MoCA can be used to rule out underlying cognitive impairment.Some patients, particularly those who are well educated, can sometimes pass a simpler screen such as the Mini-Cog but will not perform normally on a more rigorous cognitive exam. The Family Questionnaire is therefore a way to incorporate family observation into clinical decision making.
86 Cognitive Screening Flow Chart Speaker Notes:This is the top part of the first page of the Provider Practice tool which guides the provider through the cognitive screening process.The recommended first line tools (e.g., Mini-Cog) are listed in the red banner at the top. The idea is to start with a quick screen that can capture most cases of early dementia.If the patient passes the Mini-Cog and there are no concerns expressed by family members, follow-up with annual cognitive screening.If the patient fails the Mini-Cog and/or family express significant concern about their mental status (Family Questionnaire > 2), the provider has the OPTION of administered a second, more robust screening measure.This second screen is not always necessary but can be used if there are any questions about the patient’s cognitive status or if the provider is concerned about a possible false positive on the Mini-Cog.Update this slide when health equity recommendations are integrated
87 Cognitive Impairment Identification Flow Chart Speaker Notes:IF a second cognitive screening tool is used, the instrument offers guidelines about which tools to use as well as associated scoring parameters.When a patient fails a second cognitive screen, the possibility of underlying cognitive impairment is very high and a dementia work-up is strongly recommended.Providers can do the work-up themselves if they are comfortable (another appointment is scheduled for this purpose) OR the patient can be referred to a colleague or memory specialist according to available resources in their system.Update this slide when health equity recommendations are integrated
89 Dementia Work-Up Speaker Notes: The second page of the Provider Practice Tool offers an easy button guide to the dementia work-up.Discuss the way in which the tool provides helpful information to providers along the way, such as education about what types of patients typically benefit from more elaborate or extensive work-ups (including neuropsychological testing) and which are appropriate for a more basic exam and fewer orders.Update this slide when health equity recommendations are integrated
90 Speaker Notes:Note that the bottom half the page provides reminders about key features of different types of dementia.Although 75% of all dementias are Alzheimer’s there are other dementias that are frequently overlooked and misdiagnosed.Having caregiver(s) present at the time of dementia diagnosis is critical to ensure information is retained by someone in the family and steps are taken to follow through on your recommendations.Update this slide when health equity recommendations are integrated
91 Dementia Work-Up H&P Objective cognitive measurement Diagnostics LabsImaging ?More specific testing (e.g., neuropsychometric)?DiagnosisFamily meetingSpeaker Notes:An MRI is not always necessary, although neurologists and dementia experts typically prefer it over the CT. If a patient has had neuroimaging in the last year and there have not been any acute events since then, repeating neuroimaging in the dementia work-up is not necessary. Neuroimaging is often negative in the case of Alzheimer’s. It is only later in the disease process that significant atrophy is visualized. Neuroimaging is used primarily to rule out other causes of cognitive disturbance, such as stroke, lesion, or normal pressure hydrocephalus. A normal CT or MRI does not rule out Alzheimer’s.
92 Dementia Diagnoses Alzheimer’s disease: 60-80 % Includes mixed AD + VDLewy Body Dementia: %Parkinson spectrumVascular Dementia: %Stroke relatedFrontotemporal Dementia: 2-5 %Personality or language disturbanceSpeaker Notes:Briefly mention the key features of non-Alzheimer’s dementiasNote the hallmark symptom triad in Lewy Body dementia: parkinsonism, early visual hallucinations, and significant fluctuations in cognitive status and alertness from day to dayPure vascular dementia is now known to be fairly rare. Most patients with vascular dementia also have comorbid Alzheimer’s disease because poor vascular health is a risk factor for AD.
93 Delivering the Diagnosis General guidelines:Family MUST be present whenever possibleEncourage inclusivenessTalk directly to the person with dementiaSummarize test results in plain languageAvoid complicated medical jargonTry not to fill the time with words – less is more
94 Delivering the Diagnosis General guidelines:Explain why tests were ordered and what results meanReview exam with family not present at initial assessmentProvide a specific diagnosis and prognosis
95 Delivering the Diagnosis General guidelines:Ask more than once whether the patient / family has any questionsAsk patient/family to repeat back what they have heardMake sure all family members hear the same message, are on the same pageAcknowledge how overwhelming the information feels; provide empathy, support, reassurance
96 Delivering the Diagnosis The message is tailored to each patient/familyFocus on wellness, healthy living, and optimizing functionSleepExerciseSocial and mental stimulationNutrition and hydrationStress reductionIncrease structure at homeZaleta & Carpenter 2010
97 Delivering the Diagnosis Connect patient/family to community resourcesCare for both patient and caregiverExamples: Senior linkage line, Alzheimer’s AssociationDiscuss follow-upWant to see patient and family member at regular intervals (e.g., q 6 months) for proactive careDiscuss involvement of care coordinatorProvide written summary of visitSpeaker Notes:Emphasize that patients and families should be connected to resources and services (such as the Alzheimer’s Association) immediately in all cases of dementia, no matter the stage or symptoms severity. The idea is to be proactive instead of reactive in care since this disease is slowly progressive.
98 Delivering the Diagnosis Address immediate problems:Management of medications, finances, mealsDrivingHome safetyCaregiver burnoutSocial isolationInactivity/lack of exerciseEncourage family involvement/assignmentsFamily need to accompany patient to doctor appts.
99 Delivering the Diagnosis Recommend future actionsCreate a ‘Plan B’What if primary caregiver is suddenly unavailable?Investigate home care, AL, LTC, other living optionsDevelop transportation optionsComplete Advance DirectivesConsider future medical care—how aggressive?Zaleta & Carpenter 2010
100 Common Questions How is Alzheimer’s different from dementia? Is there any treatment? What can we do?Does [latest news report] work?How fast is this going to progress?How often do we see you?What’s next?Speaker Notes:Providers should anticipate these common questions which are frequently asked by patients and caregivers.If time allows, ask the audience how they would respond to these or other questions they have received.
101 Delivering the Diagnosis: Sam https://www.youtube.com/watch?v=vy2ZC5ZSZL8Speaker Notes:Watch this video which is one example of how to disclose a diagnosis of Alzheimer’s disease to a patient and family member in primary care.Along the way, keep in mind what things the provider does well and what things could be done better or differently.This is a real patient, a real caregiver (family member), and real provider. No actors.https://www.youtube.com/watch?v=vy2ZC5ZSZL8
102 Delivering the Diagnosis: Sam DiscussionObservations? Reactions?What was done well?What could have been done differently, better?What elements would you incorporate into your practice?If Sam was American Indian what, if anything, would you do differently?Speaker Notes:The last question is intended to spark conversation about cultural competence and why it matters in the case of dementia. Providers may not be aware of the resources available to them concerning memory loss in patients from various cultural backgrounds. Remind audience that ACT tools and the website offer many resources on this topic.
104 Care and Treatment Speaker Notes: This is the third page of the Provider Practice tool which shows an easy-button approach to management of patients with dementia.Along the left had side in red banners are the top issues of concern that many providers will experience. On the right across from these banners are recommended guidelines and resources.Mention a few as examples
105 Care and Treatment Speaker Notes: Notice the very last category listed is medication. This is intentional and is meant to reflect the fact that medication treatment, while potentially important for some patients, does not represent the bulk of what patients and families need. In fact, medications are often a small piece of the overall care of these patients. What is typically most important is education about Alzheimer’s and connection to community resources.
106 Treatment: Medications Cholinesterase inhibitorsDonepezil, Rivastigmine, Galantamine, CognexPossible side effects: nausea, vomiting, syncope, dizziness, anorexiaNMDA receptor antagonistMemantinePossible side effects: tiredness, body aches, dizziness, constipation, headacheSpeaker Notes:Note that donepezil is approved for all stages of dementia.Memantine is typically an adjunct, add-on therapy for use in mid to late stage dementia.The goal of medication therapy is to lessen the slope of decline in patients’ cognitive and functional status. The drugs do not typically improve a patient’s condition per se but may keep them steady or their symptoms more stable for a longer period of time. Therefore, if “improvement’ is not readily observed by patients, family members, or providers it does not mean that medications are not having any benefit.
107 Care and TreatmentThe care for patients with Alzheimer’s has very little to do with pharmacology and more to do with psychosocial interventionsInvolve care coordinatorConnect patient and family to experts in the communityExample: Alzheimer’s AssociationRefer every time, at any stage of disease, and for every kind of dementiaStress this is part of their treatment plan and you expect to hear about their progress at next visitSpeaker Notes:Physicians do not need to be experts in all of the social services that exist for people with dementia in the community. Instead, they just need to refer families to a one-stop shop, such as a care coordinator in their system or to the local chapter of the Alzheimer’s Association. These professionals can then pick up where the physician leaves off.
108 After A Diagnosis Partnering with doctors Understanding the disease Planning aheadHow to ask for helpUsing community resourcesRole of care coordinatorSpeaker Notes:This tool speaks directly to patients and families and can be provided as a handout at the time of diagnosis.The tool guides the family in how to partner more effectively with doctors, empowers them to ask questions and seek out information and support, and educates them on the role of care coordinators.
109 ACT EMR Tools Use EMR to automate and standardize: Screening Work-up After visit summary with dementia educationOrders and referralsCommunity supportsSpeaker Notes:Few providers use paper charts anymore.All of the ACT provider tools (i.e., screening, work-up, and treatment guidelines) are not only available in paper form, but also for use directly in the electronic medical record.The guidelines or “order sets” can be used inside any EMR program. They can be modified and tailored according to each system’s preferences, available resources, and workflow.The ACT guidelines essentially provide a recipe for how to implement each component of the tools in the EMR.What follows is several screenshots of how the tools are used in the EMR, using EPIC as an example.
110 Screening Speaker Notes: This screenshot shows how cognitive screening, in this case with the MoCA, is integrated into the EMR.When you want to use the MoCA, you simply bring up this orderset on the screen. You can click on the link called “instructions for administering the MoCA” to immediately bring up the tool and instructions on the screen. These can be printed if needed. The order set also shows the cut-off score for the instrument and provides a working diagnosis should a dementia work-up be necessary.
111 Labs and Orders Speaker Notes: This screen shows components of the dementia work-up. Options such as CT and MRI are shown along with education about when these diagnostics are necessary and when they are not. An option to refer the patient to a colleague with dementia expertise or a specialist (e.g., neurologist or dementia center) is also shown.Note that all of these options can be changed and tailored according to what resources or preferences may exist in any given health system.
112 Consults and Referrals Speaker Notes:The treatment/intervention order set (which is used after a diagnosis of dementia is rendered) shows all kind of possible referrals for the patient and family.They are shown all together here but each one can be expanded for more detail which I will show you on the next slide.
113 Consults and Referrals Speaker Notes:In this example, you see that some of the referrals have been expanded.If your system has a preferred referral for driving evaluations you can include that in the order set. In this particular example, the health system has their own occupational therapist who provides these evaluations but the referral could just as easily reference an outside agency or program.This expanded view also shows potential orders for a PharmD consult for concerns about medication management. Again, this can be tailored to each system’s preferences.Note that the order set also includes helpful patient education. When one of the boxes is clicked, a print-out is auto-populated with relevant information that is then printed out in the form of an after visit summary.
114 Pharmacological Treatment Speaker Notes:Here is another screenshot showing the guidelines for medication treatment, including recommendations for initial dosing, titration instructions, as well as guidelines for treating depression and other neuropsychiatric symptoms in the setting of dementia.
116 Managing Dementia Across the Continuum Speaker Notes:This ACT tool is specifically tailored to guiding the provider in the management of patients with mid to late stage dementia.Quickly review the topics covered in the tool by reading the bullet points in the yellow box.Discuss dementia as an organizing principle in the management of patients’ health conditions
117 Mood and Behavioral Symptoms Neuropsychiatric symptoms common:60% of community dwelling patients with dementia> 80% of nursing home residents with dementiaNearly all patients with dementia will suffer from mood or behavioral symptoms during the course of their illnessSpeaker Notes:One of the issues that can be uncomfortable or challenging for providers is the management of neuropsychiatric symptoms in patients with dementia.This tool address common issues and simplifies the treatment approachFerri et al., 2005; Jeste et al., 2008
118 Adverse Outcomes Decreased quality of life Increased hospital length of stayIncreased system-wide costsIncreased caregiver distress, depression, burnoutIndependently associated with NH placement? Increased mortalityJeste et al., 2008; Finkel et al., 1996
119 Speaker Notes:Panic! This is how many providers feel when their patients with dementia present with difficult behaviors, hallucinations, delusions, agitation, and other neuropsychiatric symptoms.
121 Systematic Approach to Management Step 1: Define behaviorStep 2: Categorize target symptomStep 3: Identify reversible causesStep 4: Use non-drug interventions first to treat target symptomsSpeaker Notes:Addressing neuropsychiatric symptoms in a systematic manner can be extremely beneficial.One important lesson is that not all behaviors require treatment with medication. Many, in fact, can be addressed successfully by looking carefully at antecedents, triggers, and unmet needs.
122 Step 1: Define Behavior Examples Attention seeking behaviors Verbal outburstsAggression during caresHitting, pushing, kickingSexual disinhibitionRestless motor activity, pacing, rockingCalling outSpeaker Notes:Caregivers use different words to describe the behaviors they observe. They often add their own interpretation or attributions to these behaviors as well based upon their own experiences and unique perspective and biases. It is important to ask questions to clarify as specifically as possible what types of behaviors are occurring and in what setting.
123 Step 2: Categorize Target Symptom PsychosisDelusionsHallucinationsMood symptomsAnxietyDysphoriaIrritabilityLabilityAggressionSpontaneous disinhibitionSpeaker Notes:After adequately defining the behavior, in what category would the symptoms be best placed?
124 Step 3: Identify Reversible Causes DeliriumUntreated medical illness (e.g., UTI)Medication side effects, polypharmacyEnvironmental triggersUndiagnosed psychiatric illnessInexperienced caregiversUnrealistic expectationsSpeaker Notes:Before jumping immediately to medication treatment, consider common reversible causes of agitation and other neuropsychiatric symptoms
125 Step 3: Identify Reversible Causes Common root causes:Anxiety, fear or uncertaintyTouch or invasion of personal spaceLoss of control, lack of choiceLack of attention to personal needs or wishesFrustration, grief due to loss of function or abilityPain or fear of painSpeaker Notes:Behavior is a form of communication. As the person with dementia loses the ability to articulate their feelings and needs verbally, their behavior becomes the primary mode of communication.Ask, what is the patient trying to communicate with this behavior? Could it be related to anxiety, pain, or other factors?
126 Step 3: Identify Reversible Causes Unmet needsBoredomMeaning, purposeOver/under stimulationSafetyEnvironmental stressorsCaregiver reactionsLimited knowledge about disease process or behaviorsSpeaker Notes:Many patients with dementia have little to do to occupy their time. When people are bored and under-stimulated, restlessness and agitation is common.Sometimes it is important to ask yourself as a provider, is this patient’s behavior really a problem? And for whom (the patient or the caregiver)? Sometimes family members have unrealistic expectations that need to be managed. This is where a care coordinator, social worker at the Alzheimer’s Association, or similar referral can be very beneficial. Often times these resources can assist caregivers in thinking differently about the patient’s behaviors and brainstorming ways to address them through behavioral and environmental modifications.
127 Step 4: Non-pharmacologic Interventions REMEMBER: behavior is communicationThink like a behavioral analystDetective work, ask:Who (is involved/present)What (exact description, be specific)When (time dependent? only in morning? triggers?)Where (location specific?)Why (what happens right before, right afterwards? what do family think is cause?)ABC approach (antecedent, behavior, consequence)
128 Step 4: Non-pharmacologic Interventions Activity planningTap into preserved capabilities and previous interestsInvolve repetitive motionCommunicationSlow down, offer simple choicesHelp individual find words for self expressionSimplify EnvironmentRemove clutter, minimize stimuli during activityCaregiver supportSelf care, minimize confrontation/arguing with loved oneIdentify support networkSpeaker Notes:Be proactive: WRITE ORDERS FOR THESE INTERVENTIONSTrain caregivers to validate, reassure, and distractEmphasize routine, routine, routineOptimize level of stimulation. Educate family members that the optimal level of activity and stimulation for the person with dementia will change throughout the course of the illnessGitlin, et al., 2012
129 Speaker Notes:This resource is referenced in the mid-to-late stage management tool. It lists possible neuropsychiatric and other behaviors common in dementia on the left and non-pharmacological interventions for those behaviors on the right.
131 Antipsychotic Medications in Dementia 1952: First generation antipsychotic: haloperidolExtrapyramidal symptomsTardive dyskinesia1989: Second generation antipsychotic: clozapineAgranulocytosis1990’s: More second generation antipsychoticsRisperidone, olanzapine, quetiapine, ziprasidone, aripiprazoleLess motor side effects, better toleratedUtilization of these agents broadensTHEN in 2005 …Jeste et al., 2008
132 2005 FDA Box WarningElderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo.
133 Bottom Line with Atypical Antipsychotics Modest efficacy in the treatment of psychotic and neuropsychiatric symptomsIncreased risk of negative outcomes: DEATH, STROKE, HIP FRACTURE, FALLSShare the decision with healthcare proxiesMonitor:Falls, orthostatic BP, EPS, tardive dyskinesia, glucoseRegularly attempt to wean/discontinueSpeaker Notes:The main point here is that medication treatments are limited and can have serious consequences. Medications should not be the first-line intervention for behavioral symptoms in most cases. Environmental and non-pharmacological strategies are preferred when possible. Medication treatment is a back-up strategy when behaviors are more serious, cannot be modified with other techniques, and pose a risk to the safety or well being of the patient or others.
134 Optimizing Medication Therapy Professional ResourcesAGS Beers Criteria (2012)START (Screening Tool to Alert Doctors to the Right Treatment)STOPP (Screening Tool of Older Persons’ Potentially inappropriate Prescriptions)
135 Advanced Care Planning Discussion of goals of care, valuesIdentification AND engagement of HCPOAHonoring ChoicesPREPAREIntroduce concept of palliative care, educate about hospiceDocument in EMR, healthcare directiveProvider Orders for Life Sustaining Treatment (POLST)Speaker Notes:The tendency in medicine is to wait until patients are quite ill before discussing advanced care directives and palliative care.In the case of dementia and other chronic conditions, earlier discussion with the patient and/or family can be highly beneficial.More and more health systems are prioritizing advanced care planning and documentation of these discussions and directives in the chart
136 Assessing Caregiver/Family Needs Be alert for signs of:Burnout, depression, neglected self-care, elder abusePromote:Respite servicesSupport groupsActivities to optimize health and well-beingRefer to one-stop-shop for support:Alzheimer’s AssociationSenior Linkage Line
137 Patient Engagement: Research Participation Alzheimer’s Association Trial MatchFree, easy-to-use clinical studies matching service that connects individuals with Alzheimer's, caregivers, healthy volunteers and physicians with current studies. National Institute of Health (NIH)
138 HIPAA: Q & AHIPAA (Health Insurance Portability and Accountability Act)Federal law that protects medical informationAllows only certain people to see informationDoctors, nurses, therapists and other health care professionals on the patient’s medical teamFamily caregivers and others directly involved with a patient’s care (unless the patient says he/she does not want this information shared with others)Speaker Notes:Communicating with a Patient’s Family, Friends, or Others Involved in the Patient’s CareUS Department of Health & Human Services, Office for Civil RightsIf the patient is present and has the capacity to make health care decisions, a health care provider may discuss the patient’s health information with a family member, friend, or other person if the patient agrees or, when given the opportunity, does not object.If the patient is not present or is incapacitated, a health care provider may share the patient’s information with family, friends or others as long as the health care provider determines, based on professional judgment, that it is in the best interest of the patient.HIPAA does not require that a health care provider document the patient’s agreement or lack of objection. The patient’s health information may be shared face-to-face, over the phone, or in writing.HIPAA allows health care providers to use professional judgment and experience to decide if it is in the patient’s best interest to allow another person to pick up a prescription, medical supplies, X-rays, or other similar forms of information for the patient.HIPAA allows covered health care providers to share patient’s health information with an interpreter without the patient’s written authorization under the following circumstances:Can share with an interpreter who works for the providerCan share with an interpreter who is acting on the provider’s behalfCan share with an interpreter who is the patient’s family member, friend, other other person identified by the patient as his or her interpreterUnited Hospital Fund, 2002Family caregivers need medical information so that they can better manage and provide care for a patient. For example, they need to know what medical problem the person is being treated for. They need to know the names of the medications the doctor orders, why the doctor thinks the patient needs them, and what side effects to look out for.Sometimes there is more than one family caregiver. If so, it is a good idea to choose only one person to talk with the patient’s doctor or medical team. This person can then share important information with health care professionals or other family caregivers.Some hospitals or other health care facilities ask patients to sign written consent forms before doctors discuss medical information with family caregivers. This is NOT part of the HIPAA law, but may be part of the health care facility’s procedures.If families have a problem getting medical information, talk with the social worker, patient representative, or privacy officer.United Hospital Fund, 2002
139 HIPAA: Sharing Patient Information If the patient is present and has the capacity to make health care decisions:Health care providers may discuss the patient’s health information with a family member, friend, or other person if the patient agrees or, when given the opportunity, does not object.If patient is not present or is incapacitated:Health care providers may share the patient’s information with family, friends or others as long as the provider determines (based on professional judgment) that it is in the best interest of the patient.Speaker Notes:Communicating with a Patient’s Family, Friends, or Others Involved in the Patient’s CareUS Department of Health & Human Services, Office for Civil RightsIf the patient is present and has the capacity to make health care decisions, a health care provider may discuss the patient’s health information with a family member, friend, or other person if the patient agrees or, when given the opportunity, does not object.If the patient is not present or is incapacitated, a health care provider may share the patient’s information with family, friends or others as long as the health care provider determines, based on professional judgment, that it is in the best interest of the patient.HIPAA does not require that a health care provider document the patient’s agreement or lack of objection. The patient’s health information may be shared face-to-face, over the phone, or in writing.HIPAA allows health care providers to use professional judgment and experience to decide if it is in the patient’s best interest to allow another person to pick up a prescription, medical supplies, X-rays, or other similar forms of information for the patient.HIPAA allows covered health care providers to share patient’s health information with an interpreter without the patient’s written authorization under the following circumstances:Can share with an interpreter who works for the providerCan share with an interpreter who is acting on the provider’s behalfCan share with an interpreter who is the patient’s family member, friend, other other person identified by the patient as his or her interpreterUnited Hospital Fund, 2002Family caregivers need medical information so that they can better manage and provide care for a patient. For example, they need to know what medical problem the person is being treated for. They need to know the names of the medications the doctor orders, why the doctor thinks the patient needs them, and what side effects to look out for.Sometimes there is more than one family caregiver. If so, it is a good idea to choose only one person to talk with the patient’s doctor or medical team. This person can then share important information with health care professionals or other family caregivers.Some hospitals or other health care facilities ask patients to sign written consent forms before doctors discuss medical information with family caregivers. This is NOT part of the HIPAA law, but may be part of the health care facility’s procedures.If families have a problem getting medical information, talk with the social worker, patient representative, or privacy officer.United Hospital Fund, 2002
140 Top 5 Resources for Patients and Families Speaker Notes: There are many good services and programs available for people with dementia and their family members. Keeping track of them all can be difficult. This is why referring patients to a one-stop shop kind of resource can be very helpful.What follows is a list of 5 key resources and support services that offer direct benefits to patients and family members in the context of a dementia diagnosis.
141 #1 Promoting Wellness & Function Speaker Notes:This is a free resource (short booklet) published by the Alzheimer’s Association. You can call the local chapter for copies which can be distributed to patients and families.Two years of research went into its development. The book includes concrete recommendations based upon research on lifestyle modifications that have been shown to help people with dementia promote functional ability and brain health.It is empowering, action-oriented, and easy to read.It covers topics such as exercise, nutrition, health management (managing numbers in hypertension and diabetes, optimal sleep hygiene, alcohol use, etc.), stress reduction, meaning and purpose, establishing a routine, etc.Many patients and families ask what else they can do aside from take medication. This resource is their guide.
142 #2 Addressing Behavioral Challenges Speaker Notes:The first resource, “Understanding Difficult Behaviors”, was written for professionals although many family members also find it extremely useful. It is jam packed with descriptions of all kinds of behavioral challenges and offers many creative, useful non-pharmacologic strategies and interventions. Although it offers many ideas and strategies, the booklet is a manageable size (workbook length). This is really a gem. It can be ordered online through Amazon or other retail outlets.The second resource, “Coach Broyle’s Playbook for Alzheimer’s Caregivers”, is also an excellent go-to guide for family members. It is free and can be ordered online by Googling the title. Buyers pay only shipping charges. Clinics can order them in bulk for distribution to patients. Coach Broyles was a football coach and his wife had dementia. He offers many very loving approaches to dealing with a myriad of challenging behaviors and scenarios. The book is nicely organized into early, middle, and late stage dementia.The third resource, “The Alzheimer’s Action Plan”, is essentially an A-Z guide for all things related to Alzheimer’s disease. It answers many of the questions that caregivers have about dementia including everything from the biology to symptom progression to care and treatment.
143 #3 Caregiver Support Alzheimer’s Association |One stop shop for:Care ConsultationSupport Groups (Memory Club)24/7 HelplineSpeaker Notes:The Alzheimer’s Association is an excellent example of a one-stop shop for patients and caregivers.They provide an indescribable array of services that are tailored to each family.Most are free or very low cost.Describe what “care consultation” is as many providers are not familiar with the term (e.g., 1:1 meeting involving patient and family members or just the family and led by a social worker with dementia expertise to provide disease specific education, answer questions about Alzheimer’s or related dementia, clear up expectations, assess current needs, provide a link to resources and services, and begin thinking about and planning for the future).The Alzheimer’s Association helps patients and families dealing with any type of neurodegenerative disease, not just Alzheimer’s so those with Lewy Body dementia, FTD, vascular dementia, etc. can still be referred.
144 #4 In-depth Caregiver Training Family Memory Care Program4+ months of 1:1 support, care coordinationIndividual and family meetingsDementia-capable trained clinicianSpeaker Notes:Family Memory Care is Minnesota’s translation of an intervention that has been extensively studied and shown to significantly improve outcomes for both patients and family members.The program is available state-wide. Local Family Memory Care consultants can be identified by calling the Alzheimer’s Association at the number on the screen.A dementia expert who has been specifically trained in the intervention provides the service.It is often free or low cost (sliding fee scale).The program provides a minimum of 4 months of direct, 1:1 support (combination of in-person and phone contacts) for family members. Follow-up over many more months is also often included, as necessary.This can be a real game-changer for families and is essentially a training program to teach them how to be dementia capable at home.
145 #5 Medication Review PharmD Consult Medication review, simplification Reminder strategiesFamily support, supervisionSpeaker Notes:Many geriatric patients suffer ill effects from polypharmacy.In the setting of dementia, management of multiple medications becomes increasingly difficult.A referral to a PharmD for a medication review can be very useful in the context of a dementia diagnosis. Simplification of treatment is almost always a good thing.Many pharmacists will include recommendations for medication reminder strategies and offer instructions for family members for becoming more involved in the patient’s medication administration when needed.A PharmD consult is typically offered by health care systems at no charge to patients.
146 ACKNOWLEDGEMENTSThis 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 #UB4HP19196Director: Robert L. Kane, MDAssociate Director: Patricia A. Schommer, MA
147 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 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),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):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), MBorson 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):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):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.
148 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):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):Gitlin LN, Kales HC, Lyketsos CG, & Plank Althouse E (2012). Managing Behavioral Symptoms in Dementia Using Nonpharmacologic Approaches: An Overview. JAMA, 308(19):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):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):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),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):
149 References & Resources 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),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),National Chronic Care Consortium and the Alzheimer’s Association 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):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.
150 References & Resources 2012 Updated AGS Beers Criteria:http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdfAlzheimer’s Association Family Questionnaire:Alzheimer’s Association (2009). Know the 10 signs.http://www.alz.org/national/documents/checklist_10signs.pdfCoach Broyles Playbook on Alzheimer’s:Honoring Choices Minnesota:http://www.honoringchoices.orgLiving Well workbook:http://www.alz.org/documents/mndak/alz_living_well_workbook_2011v2_web.pdfMedicare Annual Wellness Visit:MiniCog™Montreal Cognitive Assessment (MoCA)http://www.mocatest.orgNational Alzheimer’s Project Act:Next Step in Care:Physician Orders for Life Sustaining Treatment (POLST):St. Louis University Mental Status (SLUMS) examinationhttp://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdfThe Alzheimer’s Action Plan:http://www.amazon.com/The-Alzheimers-Action-Plan-Know/dp/Understanding Difficult Behaviors:http://www.amazon.com/Understanding-Difficult-Behaviors-suggestions-Alzheimers/dp/