An A- Z Guide to Simplify and Optimize Dementia Care

Objectives Understand the value of timely detection and learn simple approaches to cognitive screening in routine practice – Tools for health equity and cultural competence Gain knowledge of best practices in medication and non-medication treatments for patients with dementia Recognize key management priorities throughout the continuum of dementia Understand the risks associated with caregiving and how to connect caregivers to evidence-based therapies, resources and services Leave with a full clinical toolbox 2

Alzheimer’s Disease: Challenges and Opportunities

Alzheimer’s: A Public Health Crisis Scope of the problem – 5.2M Americans with AD in 2013 – 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) 4 Alzheimer’s Association Facts and Figures 2014

The Lens of Health Equity Take into consideration health disparities and inequities Seek the attainment of the highest level of health for all people Help create a new style of “curb cut” by promoting cultural competence 5

Base Rates 1 in 9 people 65+ (11%) 1 in 3 people 85+ (32%) 6 Age RangePercent with Alzheimer’s < 654%4% % % % Alzheimer’s Association Facts and Figures 2014

A population with complex care needs Indisputable correlation between chronic conditions and costs Patients with Dementia 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

Challenges & Opportunities AD poorly 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 8 Boise et al., 2004; Boustani et al., 2003; Boustani et al., 2005; Silverstein & Maslow, 2006

Diagnostic Challenges Societal – Ageism, lack of understanding re: normal aging – Fear and stigma – Healthcare inequities – Expectation that MD will identify/diagnose health problems Systemic/Institutional – Low priority – Few incentives – Lack of procedural support – Limited specialists available (e.g., neurology, neuropsychology) – May lack access to (or awareness of) community resources 9

Diagnostic Challenges Medical – Time – Lack of definitive tests – Many patients unaware, do not self-identify symptoms – Skepticism re: efficacy of medication treatments – Limited cultural competence – Lack of awareness re: benefits of non-medication interventions – Fear of delivering wrong diagnosis, bad news – Implications for physician/patient relationship 10

Myth: People don’t want to know they have Alzheimer’s disease Blendon et al., 2012; Holroyd et al., 2002; Turnbull et al., 2003 % Fact : Most people want advanced notice

Diagnostic Challenges International Physician Survey Lack of definitive tests (65%, top barrier) Lack of communication between patients / caregiver and physicians – 75% reported discussion initiated by patients/caregivers – 44% “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 diagnosis Patient / Family denial (65%) & social stigma (59%) International Alzheimer’s Disease Physician Survey, 2012

“Beyond mountains, there are mountains.” Haitian Proverb Diagnostic Challenges

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

Rationale for Timely Detection 1.Patient Care / Outcomes 2.Time 3.Money 15

1.Improved management of co-morbid conditions – Underlying dementia = risk factor for poor compliance with ALL treatment goals (e.g., diabetes, hypertension, CHF, anticoagulation) 2.Reduce ineffective, expensive, crisis-driven use of healthcare resources – Unnecessary hospitalization (dehydration/malnourishment, medication mismanagement, accidents and falls, wandering, etc.) Patient Outcomes 16

3.Treat reversible causes – NPH, TSH, B12, hypoglycemia, depression 4.Improve quality of life – Patients can participate in decisions regarding their future care – Decrease burden on family and caregivers 5.Intervene to promote supported independence as long as possible – RTC support/counseling intervention – Non-pharm intervention reduces NH placement by 30% and delays placement for others by 18+ months Patient Outcomes 17 Mittelman et al., 2006

Time Simple screening tests can be done by rooming nurse – Brain as 6 th 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 18 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 19 Alzheimer’s Association Facts and Figures 2014; Long et al., 2014

Impact of Optimal Practices 16 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

Changing National & Local Landscape National Alzheimer’s Project Act (NAPA) – Awareness, readiness, dissemination, coordination Annual Wellness Visit – For first time, “detection of cognitive impairment” is core feature of the exam MN healthcare systems implementing tools – HealthPartners – Park Nicollet – Essentia – Allina 21

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 6 th Vital Sign 22

Introduction to ACT on Alzheimer’s

ACT on Alzheimer’s statewide collaborative volunteer driven 60+ ORGANIZATIONS 300+ INDIVIDUALS IMPACTS OF ALZHEIMER’S BUDGETARYSOCIAL PERSONAL 24

Collaborative Goals/Common Agenda Five shared goals with a Health Equity perspective 25

ACT Tool Kit Consensus-based, best practice standards for Alzheimer’s care Tools and resources for: – Primary care providers – Care coordinators – Community agencies – Patients and families 26

ACT Tools 27

ACT Tools 28

Clinical Practice Tips 30

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 significant – Repeats himself, multiple phone calls b/c can’t find belongings Other family members have noticed changes Began 2 years ago, getting worse Hx of hypertension and DM, both fairly well controlled Wife died unexpectedly last year, lives alone Conversational presentation fairly intact Oriented x3 but vague awareness of current events 31

Case Study: Colleen 66 y/o retired accountant for family business Presents to primary care with memory complaints Daughter agrees that short-term memory is poor Began 2 years ago, seems to be worsening Hx of Low blood sugar, heart attack x1, repeat ER visits and hospitalizations for atrial flutter Frequent medication changes, managing independently Lives with husband who is still running the family business

Signs and Symptoms of AD Memory loss Confusion Disorientation to time or place Getting lost in familiar locations Impairment in speech/language Trouble with time/sequence relationships Diminished insight Poor judgment/problem solving Changes in sleep and appetite Mood/personality/behavior changes Wandering Deterioration of self care, hygiene Difficulty performing familiar tasks, functional decline 33 Alzheimer’s Association, 2009

Practice Tips 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

Practice Tips Red flags – Repetition (not normal in 7-10 min conversation) – Tangential, circumstantial responses – Losing track of conversation – Frequently deferring answers to family member – Over reliance on old information/memories – Inattentive to appearance – Unexplained weight loss or “failure to thrive”

Practice Tips Family observations: – ANY instances whatsoever of getting lost while driving, trouble following a recipe, asking same questions repeatedly, mistakes paying bills – Take these concerns seriously: by the time family report problems, symptoms have typically been present for quite a while and are getting worse Raise 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

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 significance 9/11, New Orleans disaster, etc. – Name or describe the current President and an immediate predecessor – Describe their own recent medical history and report the conditions for which they take medication

Cognitive Screening 38

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. 39 Long et al., 2014

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 40

Clinical Provider Practice Tool Easy button workflow for: 1.Screening 2.Dementia work-up 3.Treatment / care

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? 43

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

Alternative Screening Tools Virtually all screening tools based upon a euro-centric cultural and educational model Consider: country and language of origin, type/quality/length of education, disabilities (visual, auditory, motor) Alternative tools my be less biased 45

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 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 Borson et al., 2000

48

49

Mini-Cog Pass > 4 Fail 3 or less Borson et al., 2000

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 52

Mini-Cog Scoring: Sam

Mini-Cog: Colleen 55

Colleen’s Clock

Colleen’s Score

Mini-Cog Exercise Form groups of 2 Administer MiniCog to each other Score sample clocks 58

Clock #1

Clock #2

Clock #3

Clock #4

Clock #5

Clock #6

Clock #7

Clock #8

Clock #9

SLUMS Tariq et al., 2006

SLUMS High School DiplomaLess than 12 yrs education Pass> 27> 25 Fail26 or less24 or less 69 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):

SLUMS: Colleen 70

SLUMS Scoring: Colleen Interactive scoring exercise 71

SLUMS Scoring: Colleen 72

SLUMS Scoring: Colleen 73

SLUMS Scoring: Colleen 74

MoCA Nasreddine et al., 2005

MoCA Pass > 26 Fail 25 or less 76 Nasreddine 2005

MoCA: Sam 77

MoCA Scoring: Sam Interactive scoring exercise 78

MoCA Scoring: Sam 79

MoCA Scoring: Sam 80

MoCA Scoring: Sam 81

MoCA Scoring: Sam 82

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 2012; Nasreddine et all, 2005; Tariq et al., 2006; Ismail et al., 2010

Family Questionnaire f

Cognitive Screening Flow Chart 85

Cognitive Impairment Identification Flow Chart 86

Dementia Work-up and Diagnosis 87

Dementia Work-Up 88

89

Dementia Work-Up H&P Objective cognitive measurement Diagnostics – Labs – Imaging ? – More specific testing (e.g., neuropsychometric)? Diagnosis Family meeting

Dementia Diagnoses Alzheimer’s disease: % Includes mixed AD + VD Lewy Body Dementia: % – Parkinson spectrum Vascular Dementia: 6-10 % – Stroke related Frontotemporal Dementia: 2-5 % – Personality or language disturbance

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 at least 3 times whether the patient / family has any questions – Acknowledge how overwhelming the information feels; provide empathy, support, reassurance 92

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 93 Zaleta & Carpenter 2010

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 94

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? 95

Delivering the Diagnosis: Sam 96

Delivering the Diagnosis: Sam Discussion – Observations? 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? 97

Dementia Care and Treatment 98

Care and Treatment 99

100 Care and Treatment

Treatment: Medications Cholinesterase inhibitors – Donepezil, Rivastigmine, Galantamine, Cognex – Possible side effects: nausea, vomiting, syncope, dizziness, anorexia NMDA receptor antagonist – Memantine – Possible side effects: tiredness, body aches, dizziness, constipation, headache 101

Care and Treatment The care for patients with Alzheimer’s has very little to do with pharmacology and more 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 102

After A Diagnosis -Partnering with doctors -Understanding the disease -Planning ahead -How to ask for help -Using community resources -Role of care coordinator

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

Screening 105

Labs and Orders 106

Consults and Referrals 107

Consults and Referrals 108

Pharmacological Treatment 109

Managing Mid to Late Stage Dementia 110

Managing Dementia Across the Continuum 111

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 et al., 2005; Jeste et al.,

Decreased quality of life Increased hospital length of stay Increased system-wide costs Increased caregiver distress, depression, burnout Independently associated with NH placement ? Increased mortality Jeste et al., 2008; Finkel et al., Adverse Outcomes

114

ACT to the Rescue! 115

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 116

Step 1:Define Behavior Examples – Attention seeking behaviors Verbal outbursts – Aggression during cares – Hitting, pushing, kicking – Sexual disinhibition – Restless motor activity, pacing, rocking – Calling out 117

Step 2:Categorize Target Symptom Psychosis – Delusions – Hallucinations Mood symptoms – Anxiety – Dysphoria – Irritability – Lability Aggression Spontaneous disinhibition 118

Step 3:Identify Reversible Causes Delirium Untreated medical illness (e.g., UTI) Medication side effects, polypharmacy Environmental triggers Undiagnosed psychiatric illness Inexperienced caregivers Unrealistic expectations 119

Step 3:Identify Reversible Causes Common root causes: – Anxiety, fear or uncertainty – Touch or invasion of personal space – Loss of control, lack of choice – Lack of attention to personal needs or wishes – Frustration, grief due to loss of function or ability – Pain or fear of pain

Step 3:Identify Reversible Causes Unmet needs – Boredom – Meaning, purpose – Over/under stimulation – Safety – Environmental stressors Caregiver reactions – Limited knowledge about disease process or behaviors 121

Step 4: Non-pharmacologic Interventions REMEMBER: behavior is communication Think like a behavioral analyst – Detective 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) 122

Activity planning – Tap into preserved capabilities and previous interests – Involve repetitive motion Communication – Slow down, offer simple choices – Help individual find words for self expression Simplify Environment – Remove clutter, minimize stimuli during activity Caregiver support – Self care, minimize confrontation/arguing with loved one – Identify support network Step 4:Non-pharmacologic Interventions 123 Gitlin, et al., 2012

124

Pharmacological Treatment Antipsychotics Antidepressants Mood stabilizers Cognitive enhancers 125

Antipsychotic Medications in Dementia 1952: First generation antipsychotic: haloperidol – Extrapyramidal symptoms – Tardive dyskinesia 1989: Second generation antipsychotic: clozapine – Agranulocytosis 1990’s: More second generation antipsychotics – Risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole – Less motor side effects, better tolerated – Utilization of these agents broadens THEN in 2005 … Jeste et al.,

2005 FDA Box Warning Elderly patients with dementia- related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo. 127

Bottom Line with Atypical Antipsychotics Modest efficacy in the treatment of psychotic and neuropsychiatric symptoms Increased risk of negative outcomes: DEATH, STROKE, HIP FRACTURE, FALLS Share the decision with healthcare proxies Monitor: – Falls, orthostatic BP, EPS, tardive dyskinesia, glucose – Regularly attempt to wean/discontinue 128

Optimizing Medication Therapy 129 Professional Resources AGS Beers Criteria (2012) START (Screening Tool to Alert Doctors to the Right Treatment) STOPP (Screening Tool of Older Persons’ Potentially inappropriate Prescriptions)

Advanced Care Planning Discussion of goals of care, values Identification AND engagement of HCPOA – Honoring Choices – PREPARE Introduce concept of palliative care, educate about hospice Document in EMR, healthcare directive Provider Orders for Life Sustaining Treatment (POLST) 130

Assessing Caregiver/Family Needs Be alert for signs of: – Burnout, depression, neglected self-care, elder abuse Promote: – Respite services – Support groups – Activities to optimize health and well-being Refer to one-stop-shop for support: – Alzheimer’s Association – Senior Linkage Line 131

Patient Engagement: Research Participation Alzheimer’s Association Trial Match – Free, easy-to-use clinical studies matching service that connects individuals with Alzheimer's, caregivers, healthy volunteers and physicians with current studies. – _clinical_trials_trialmatch.asp _clinical_trials_trialmatch.asp National Institute of Health (NIH) –

HIPAA:Q & A HIPAA (Health Insurance Portability and Accountability Act) Federal law that protects medical information Allows only certain people to see information – Doctors, nurses, therapists and other health care professionals on the patient’s medical team – Family caregivers and others directly involved with a patient’s care (unless the patient says he/she does not want this information shared with others) United Hospital Fund, 2002

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 United Hospital Fund, 2002

Top 5 Resources for Patients and Families 135

#1Promoting Wellness & Function 136

#2Addressing Behavioral Challenges 137

#3Caregiver Support Alzheimer’s Association | One stop shop for: – Care Consultation – Support Groups (Memory Club) – 24/7 Helpline 138

#4In-depth Caregiver Training Family Memory Care Program months of 1:1 support, care coordination Individual and family meetings Dementia-capable trained clinician 139

#5Medication Review PharmD Consult Medication review, simplification Reminder strategies Family support, supervision 140

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

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

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):

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 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, References & Resources

2012 Updated AGS Beers Criteria: Alzheimer’s Association Family Questionnaire: Alzheimer’s Association (2009). Know the 10 signs. Coach Broyles Playbook on Alzheimer’s: Honoring Choices Minnesota: Living Well workbook: Medicare Annual Wellness Visit: MLN/MLNMattersArticles/downloads/MM7079.pdfhttp:// MLN/MLNMattersArticles/downloads/MM7079.pdf MiniCog™ Montreal Cognitive Assessment (MoCA) National 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.pdfhttp://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf The Alzheimer’s Action Plan: Understanding Difficult Behaviors: Alzheimers/dp/ http:// Alzheimers/dp/