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: 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)
4Alzheimer’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 Range Percent with Alzheimer’s
< 65 4%
65 -74 13%
75 -84 44%
85 + 38%
Alzheimer’s Association Facts and Figures 2014
• A population with complex care needs
• Indisputable correlation between chronic conditions and costs
Patients with Dementia
7
2.5 chronic conditions (average)
5+medications
(average)
3 times more likely to be
hospitalized
Many admissions from preventable conditions, with higher per person costs
Alzheimer’s Association Facts and Figures 2014
Challenges & Opportunities
• AD under-recognized by providers– Only 50% of patients receive formal diagnosis
• Millions unaware they have dementia
– Diagnosis often delayed on average by 6+ years after symptom onset
– Significant impairment in function by time it is recognized
• Poor timing: diagnosis frequently at time of crises, hospitalization, failure to thrive, urgent need for institutionalization
8Boise 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– Few dementia specialists available– May lack access to (or awareness of) community resources
9
Diagnostic Challenges
• For Providers– Time– Lack of definitive tests– Many patients unaware, do not report symptoms– Limited 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
Alz-Eu Harvard
Turnbull Holroyd0
102030405060708090
100
%
Studies Agree:
Most people want to know.
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
1. Improve quality of life– Patients can participate in decisions regarding their future care– Decrease burden on family and caregivers
2. Intervene to promote a safe and happy environment that supports independence
– RTC support/counseling intervention – Non-pharm intervention reduces NH placement by 30% and delays
placement for others by 18+ months
The message: You have a bad disease. We can help you make life better for you and your family.
Patient Outcomes
16Mittelman et al., 2006
3. Improved management of co-morbid conditions
– Underlying dementia = risk factor for poor compliance with ALL treatment goals (e.g., diabetes, hypertension, CHF, anticoagulation)
4. Reduce ineffective, expensive, crisis-driven use of healthcare resources
– Unnecessary 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 effective
Patient Outcomes
17
5. Treat reversible causes– NPH, TSH, B12, hypoglycemia, depression
The message: Maybe you don’t really have a bad disease after all!
Patient Outcomes
18
Time
• Simple screening tests can be done by rooming nurse
– Brain as 6th vital sign
• Recommended tool takes 1.5 – 3 minutes– Only conducted annually and in context of signs and
symptoms
• Mini-Cog does not disrupt workflow & increases capture rate of cognitive impairment in primary care
19Borson 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
20Alzheimer’s Association Facts and Figures 2014; Long et al., 2014
Impact of Optimal Practices
16
• Reduces utilization through comorbidity managementTimely 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
22
Rethinking Everyday Practice
• Brain historically ignored, not a focus of routine exam– Is this logical? Consider base rates of dementia
• Dementia is simply “brain failure”– Heart failure– Kidney failure– Liver failure
• Brain as 6th Vital Sign
23
25
ACT on Alzheimer’s
statewide
collaborative
volunteer driven
60+O R G A N I Z A T I O N S
300+I N D I V I D U A L S
I M P A C T S O F A L Z H E I M E R ’ S
BUDGETARY SOCIAL PERSONAL
27
ACT Tool Kit
• Evidence and consensus-based, best practice standards for Alzheimer’s care
• Tools and resources for:– Primary care providers– Care coordinators– Community agencies– Patients and families
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
32
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 34Alzheimer’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
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.
40Long 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 Physician41
Clinical Provider Practice Tool
• Easy button workflow for:1. Screening2. Dementia work-up3. Treatment / care
www.actonalz.org/provider-practice-tools
42
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?
44
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
46
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 wordsLeader, Season, Table
Subject asked to draw clock, set hands to 10 past 11
+3
+2
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
53
http://youtu.be/CRQEighdb0w
Mini-Cog: Colleen
56
http://youtu.be/DeCFtuD41WY
Mini-Cog Exercise
Form groups of 2• Administer MiniCog to each other• Score sample clocks
59
SLUMS
High School Diploma Less than 12 yrs education
Pass > 27 > 25
Fail 26 or less 24 or less
70
Tariq SH, Tumosa N, Chibnall et al. Comparison of the Saint Louis University mental status examination and the mini-mental state examination for detecting dementia and mild neurocognitive disorder--a pilot study. Am J Geriatr Psychiatry. 2006 Nov;14(11):900-10.
SLUMS: Colleen
71
http://youtu.be/jyp0ShPiUH8?list=UUOPv8U5bHcdDCm4edmQDY9g
MoCA: Sam
78
http://youtu.be/ryf8SG0NQLQ?list=UUOPv8U5bHcdDCm4edmQDY9g
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
Dementia Work-Up
• H&P• Objective cognitive measurement• Diagnostics
– Labs– Imaging ?– More specific testing (e.g., neuropsychometric)?
• Diagnosis• Family meeting
Dementia Diagnoses
Alzheimer’s Dis-ease
Vascular Demen-
tia
Lewy Body
Demen-tia
FTD
Alzheimer’s disease: 60-80 %• Includes mixed AD + VD
Lewy Body Dementia: 10-25 % – Parkinson spectrum
Vascular Dementia: 6-10 %– Stroke related
Frontotemporal Dementia: 2-5 %– Personality or language
disturbance
Delivering the Diagnosis
• General guidelines:– Family MUST be present whenever possible
• Encourage inclusiveness
– Talk directly to the person with dementia– Summarize test results in plain language
• Avoid complicated medical jargon• Try not to fill the time with words – less is more
93
Delivering the Diagnosis
• General guidelines:– Explain why tests were ordered and what results
mean• Review exam with family not present at initial
assessment
– Provide a specific diagnosis and prognosis
94
Delivering the Diagnosis
• General guidelines:– Ask more than once whether the patient / family
has any questions– Ask patient/family to repeat back what they have
heard• Make sure all family members hear the same message,
are on the same page
– Acknowledge how overwhelming the information feels; provide empathy, support, reassurance
95
Delivering the Diagnosis
• The message is tailored to each patient/family• Focus on wellness, healthy living, and
optimizing function– Sleep– Exercise– Social and mental stimulation– Nutrition and hydration– Stress reduction– Increase structure at home
96Zaleta & 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
97
Delivering the Diagnosis
• Address immediate problems:– Management of medications, finances, meals– Driving– Home safety– Caregiver burnout– Social isolation– Inactivity/lack of exercise
• Encourage family involvement/assignments– Family need to accompany patient to doctor appts.
98
Delivering the Diagnosis
• Recommend future actions– Create a ‘Plan B’
• What if primary caregiver is suddenly unavailable?
– Investigate home care, AL, LTC, other living options– Develop transportation options– Complete Advance Directives– Consider future medical care—how aggressive?
99Zaleta & Carpenter 2010
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?
100
Delivering the Diagnosis: Sam
101
https://www.youtube.com/watch?v=vy2ZC5ZSZL8
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?
102
106
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
107
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
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
www.actonalz.org/provider-practice-tools
109
Managing Dementia Across the Continuum
116www.actonalz.org/provider-practice-tools
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., 2008 117
• 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., 1996 118
Adverse Outcomes
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
121
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
122
Step 2: Categorize Target Symptom
• Psychosis– Delusions– Hallucinations
• Mood symptoms– Anxiety– Dysphoria– Irritability– Lability
• Aggression• Spontaneous disinhibition
123
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
124
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
behaviors126
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)127
• 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
128Gitlin, et al., 2012
130
Pharmacological Treatment
• Antipsychotics• Antidepressants• Mood stabilizers• Cognitive enhancers
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., 2008 131
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.
132
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/discontinue133
134
Optimizing Medication Therapy
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)135
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
136
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.
– http://www.alz.org/research/clinical_trials/find_clinical_trials_trialmatch.asp
• National Institute of Health (NIH)– http://clinicaltrials.gov
137
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)
138www.nextstepsincare.org, 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.
139www.nextstepsincare.org, United Hospital Fund, 2002
#3 Caregiver Support
Alzheimer’s Association800.272.3900 | www.alz.org/mnnd
One stop shop for:– Care Consultation– Support Groups (Memory Club)– 24/7 Helpline
143
#4 In-depth Caregiver Training
Family Memory Care Program 800.272.3900
• 4+ months of 1:1 support, care coordination• Individual and family meetings• Dementia-capable trained clinician
144
#5 Medication Review
PharmD Consult
• Medication review, simplification• Reminder strategies• Family support, supervision
145
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, MDAssociate Director: Patricia A. Schommer, MA
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• Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, Cummings JL, & Chertkow H. (2005). The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment. J Amer Ger Soc, 53(4), 695-99.
• National Chronic Care Consortium and the Alzheimer’s Association. 1998. Family Questionnaire. Revised 2003.• Silverstein NM & Maslow K (Eds.) (2006). Improving Hospital Care for Persons with Dementia. New York: Springer Publishing
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References & Resources
References & Resources• 2012 Updated AGS Beers Criteria:http
://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf • Alzheimer’s Association Family Questionnaire: http://www.alz.org/mnnd/documents/Family_Questionnaire.pdf • Alzheimer’s Association (2009). Know the 10 signs.http://www.alz.org/national/documents/checklist_10signs.pdf • Coach Broyles Playbook on Alzheimer’s: http://www.caregiversunited.com • Honoring Choices Minnesota:http://www.honoringchoices.org • Living Well workbook:http://www.alz.org/documents/mndak/alz_living_well_workbook_2011v2_web.pdf • Medicare Annual Wellness Visit:
http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7079.pdf
• MiniCog™ http://www.alz.org/documents_custom/minicog.pdf • Montreal Cognitive Assessment (MoCA)http://www.mocatest.org • National Alzheimer’s Project Act: http://aspe.hhs.gov/daltcp/napa/NatlPlan.pdf• Next Step in Care: http://www.nextstepincare.org • Physician Orders for Life Sustaining Treatment (POLST): http://www.polst.org • St. Louis University Mental Status (SLUMS) examinationhttp
://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf • The Alzheimer’s Action Plan:http://www.amazon.com/The-Alzheimers-Action-Plan-Know/dp/0312538715 • Understanding Difficult Behaviors:http
://www.amazon.com/Understanding-Difficult-Behaviors-suggestions-Alzheimers/dp/0978902009
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