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An A- Z Guide for Working with Patients

with Memory Loss and Dementia

Objectives

1. Gain proficiency in brief cognitive screening to help improve detection of memory loss among older patients

2. Describe evidence-based medication and non-medication interventions known to improve outcomes among patients with dementia and their care partners

3. Learn how to best support patients and care partners in accessing services throughout the continuum of the disease

4. Identify common health risks associated with caregiving and address the unique needs of dementia caregivers

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Introduction to

ACT on Alzheimer’s

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What is ACT on Alzheimer’s?

statewide

collaborative

volunteer

driven

60+ O R G A N I Z AT I O N S

500+ I N D I V I D U A L S

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

BUDGETARY SOCIAL PERSONAL

Collaborative Goals/Common Agenda

5 shared goals with a Health Equity perspective

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ACT Tool Kit

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

• Tools and resources for:

– Primary care providers

– Care coordinators

– Community agencies

– Patients and care partners

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www.actonalz.org/provider-practice-tools

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Health Care Settings: Care Coordination

www.actonalz.org/provider-practice-tools

Dementia and Alzheimer’s

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FAQ

What is the difference between dementia and Alzheimer’s

disease?

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Dementia Diagnoses

Alzheimer’s Disease

Vascular Dementia

Lewy Body Dementia

FTD

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

Lewy Body Dementia: 10-25 % – Parkinson spectrum

Vascular Dementia: 6-10 % – Stroke related

Frontotemporal Dementia: 2-5 % – Personality or language

disturbance

Alzheimer’s Disease: Challenges and Opportunities

Alzheimer’s: A Public Health Crisis

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

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

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

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

• Pre-clinical stage 1-2 decades

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

– Older Hispanics (1.5x as whites)

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Alzheimer’s Association Facts

and Figures 2015

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Base Rates

• 1 in 9 people 65+ (11%)

• 1 in 3 people 85+ (32%)

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Age Range Percent with Alzheimer’s

< 65 4%

65 -74 13%

75 -84 44%

85 + 38%

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

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

• A population with complex care needs

• Indisputable correlation between chronic conditions and costs

Patients with Dementia

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2.5 chronic conditions (average)

5+ medications

(average)

3 times more likely to be hospitalized

Many admissions from preventable conditions, with higher per person costs

Alzheimer’s Association Facts

and Figures 2014

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Case Study: Colleen

• 66 y/o presents to primary care with memory complaints • Daughter c/o short-term memory is poor • Began 1-2 years ago, getting worse • Hx Low blood sugar, history of heart attack, repeat

hospitalizations for atrial flutter • Frequent medication changes, managing independently • Patient is a retired accountant for family business • Lives with husband who is still running the family

business

• Referred to Care Coordination

Cognitive Impairment ID

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

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Practice Tips

• Red flags

– Chart Review: memory concerns, forgetfulness, memory complaints; emergency contact is main contact; Aricept / Donepezil or other ACHI in record

– Ask “How are you xxx?” instead of “Are you xxx?” – 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

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Cognitive Screening

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Screening Measures

• Wide range of options

– Mini-Cog™ (MC)

– Mini-Mental State Exam© (MMSE)

– St. Louis University Mental Status Exam™ (SLUMS)

– Montreal Cognitive Assessment™ (MoCA)

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

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

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

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Mini-Cog™

Contents • Verbal Recall (3 points)

• Clock Draw (2 points)

Advantages • Quick (2-3 min)

• Easy

• High yield (executive fx, memory, visuospatial)

Subject asked to recall 3 words Leader, Season, Table

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

+3

+2

Borson et al.,

2000

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DATE_________ ID_________________________AGE____GENDER M F LOCATION ______________________TESTED BY________

MINI-COG ™

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

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

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

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

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

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

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

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

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

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

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

Abnormal clock 0 points

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

4 or 5 = clinically important cognitive impairment unlikely

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CLOCK SCORING

NORMAL CLOCK

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

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

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

ABNORMAL.

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

Abnormal Hands Missing Number

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

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

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

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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: Colleen

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http://youtu.be/DeCFtuD41WY

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Colleen’s Clock

Colleen’s Score

Clock #1

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Clock #2

Clock #3

Clock #4

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Clock #5

Clock #6

Clock #7

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Clock #8

Clock #9

SLUMS

Tariq et al., 2006

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SLUMS

High School Diploma Less than 12 yrs education

Pass > 27 > 25

Fail 26 or less 24 or less

43

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

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

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

Nov;14(11):900-10.

MoCA

Nasreddine et al., 2005

MoCA

Pass

• > 26

Fail

• 25 or less

45 Nasreddine 2005

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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

www.actonalz.org/pdf/Family-Questionnaire.pdf

AD8 Dementia Interview

http://knightadrc.wustl.edu/About_Us/PDFs/AD8form2005.pdf

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Dementia Work-up, Diagnosis and Treatment for

Providers

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Dementia Work-Up

• H&P

• Objective cognitive measurement

• Diagnostics – Labs

– Imaging ?

– More specific testing (e.g., neuropsychometric)?

• Diagnosis

• ‘Family’ meeting

Treatment: Medications

• Anticholinergics

– 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

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Treatment: Medications

• Antipsychotics

• Antidepressants

• Mood stabilizers

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Care and Treatment

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

• Care Coordination

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Dementia Care Coordination

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Care Coordination

What are some of the challenges you face when working with people with dementia and their families?

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ACT Practice Tool

Dementia Care Plan Checklist

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Identify Care Partner(s)

• Inform the patient that this disease requires a team approach

• Ask the patient to identify team members or care partners – Be task specific (e.g., doctor visits, medication

management)

– Think outside the box / family (e.g., friends, neighbors, religious congregation members, colleagues, community organization volunteers or workers)

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Comprehensive Assessment

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Comprehensive Assessment

HCH Care Coordination Tool Kit: http://www.health.state.mn.us/healthreform/homes/collaborative/lcdocs/cliniccarecoordtoolkit.pdf

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Comprehensive Assessment

• Patient & Primary Care Partner / Caregiver

– Identify language, cultural, health equity barriers

– Identify physician(s)

– Assess substance use / misuse

– Behavioral health, depression

• PHQ9, CES-D, GDS

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Comprehensive Assessment

• Primary Care Partner / Caregiver

– Consider assessing cognition (if over 65 or signs / symptoms present)

– Caregiver burden (Zarit Burden Interview Short) http://www.uconn-aging.uchc.edu/patientcare/memory/pdfs/zarit_burden_interview.pdf

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Care Plan

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Care Plan Tool Highlights

• Disease Education

• Medication Therapy and Management

• Maximize Abilities

• Health, Wellness and Engagement

• Home & Personal Safety

• Legal Planning

• Advance Care Planning

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Disease Education

• ASK the patient / care partner:

– What the doctor told them about their memory loss / diagnosis

– What they know about the disease / questions about the diagnosis / disease

– Biggest concerns; barriers to care / health

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Education Resources for Patients & Caregivers

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Disease Education: Print Materials

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After A Diagnosis

- Partner with doctors - Understand the disease - Use team approach - Plan ahead - Ask for help - Use community

resources - Role of care coordinator

http://www.actonalz.org/sites/default/files/documents/ACT-AfterDiagnosis.pdf

Disease Education

69 http://youtu.be/zEst_VxwA4U

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Taking Action Workbook

- Understanding the disease

- Partnering with doctors - Telling others about the

diagnosis - Strategies for managing

symptoms & coping - Safety - Legal / financial issues

http://www.alz.org/documents/mndak/taking_action_workbook.pdf

Stages of Alzheimer’s Disease

Maximize Abilities

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• Identify / treat conditions that may worsen symptoms or lead to poor outcomes • Diabetes, HTN, sleep dysregulation

• Encourage patient to stop smoking / limit alcohol • Refer to OT to maximize independence (e.g.,

simplify environment, maximize independence & self-care abilities)

• Educate families on communication and approach to prevent or reduce dementia-related behavioral symptoms

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Medication Therapy & Management

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• Discuss prescribed and OTC medications • simplify medication regimen • reduce / eliminate anticholinergics,

benzodiazepines, hypnotics, narcotics

• Create plan with care team • Family plan for managing meds • Med management aids (pill boxes, alarms) • Create & review medication log

Medication Therapy & Management

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Health, Wellness & Engagement

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Encourage lifestyle changes that may reduce disease symptoms or slow progression

- Exercise - Nutrition - Stress reduction - Meaning & purpose - Relationships - Health management - Routine

http://www.alz.org/documents/mndak/alz_living_well_workbook_2011v2_web.pdf

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Maximize Abilities: Routine

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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

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Home & Personal Safety

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• Educate & develop a plan for 5 F’s: fire, falls, firearms, finances, freeways

• Refer to OT or PT • Fall risk assessment • Sensory / mobility aids • Home safety inspection / modifications • Driving evaluation

• Encourage emergency plans (phone numbers, hospital, fire, POLST/med list by bed, etc.)

• Encourage enrollment in Medic Alert® Safe Return®

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Role of Hospitalization

• More preventable hospitalizations • Higher rates of delirium, falls, new

incontinence, indwelling urinary catheters, pressure ulcers, functional decline & new feeding tubes

• Significantly less likely to regain preadmission functional abilities at 1 month, 3 months, or 1 year after discharge

• 3-7 times more likely to be living in a nursing home 3 months after discharge.

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Role of Hospitalization

• Reduce Unnecessary Hospitalization – Falls – UTI / other medical conditions – Medications / medication mismanagement – Dementia-related behavior – Hospitalization alternatives

• Hospitalization – Pre-Planning – http://www.nia.nih.gov/alzheimers/publication/hosp

italization-happens – http://www.aaa1c.org/docs/healthtips/Hospital_Visi

ts_for_People_with_ALZ.pdf

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Legal & Advance Care Planning

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• Encourage patient / care partner to assign health care and durable POA • Refer to elderlaw attorney

• Encourage patient to discuss / document preferences for care • Honoring Choices • MN Healthcare Directive • POLST

• In mid-stage, discuss palliative and hospice options

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Visit Frequency & Communication

82

• Schedule regular check-ins • Educate patient / care partner WHEN to

contact you • Changes in condition • Assistance with med management • Before / after hospitalization • Change in living environment • New needs

Visit Frequency & Communication

83

• Facilitate physician appointments • Reminders, transportation

• Educate on physician engagement strategies • Encourage care partner(s) to attend medical

appointments • Educate about HIPAA, as needed

• Educate on use of appointment log, medication log

Appointment Log

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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)

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www.nextstepincare.org/Caregiver_Home/HIPAA/

United Hospital Fund, 2002

Caregiver Support

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Care Plan: Caregiver Support

• Providing support for dementia caregivers is a societal imperative

– 70% of individuals with Alzheimer’s disease live at home

– In 2012, an estimated 15 million unpaid caregivers provided an estimated 17.5 billion hours of unpaid care

– The health care system could not sustain the cost of care without unpaid caregivers

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Common Caregiver Challenges

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• Lack of disease knowledge / education • Emotional stress, burden • Need for support and respite • Role changes • Challenging family dynamics • Communication difficulties • Neglected health • Putting patient needs first • Challenging patient behaviors • Planning for the future

Caregiver Support

• There is a strong correlation between the health and well-being of a care partner and the quality of care that she can provide.

• A care partner with a balanced outlook and good self-care practices can provide care for longer periods of time while maintaining his own health and well-being.

Top 5 Resources for Patients and Families

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#1 Promoting Wellness & Function

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#2 Addressing Behavioral Challenges

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#3: Addressing Driving

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Alzheimer’s Association Driving Center: www.alz.org/care/alzheimers-dementia-and-driving.asp

http://www.thehartford.com/sites/thehartford/files/at-the-crossroads-2012.pdf

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#4 Planning Assistance

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#5 Connect to Resources

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Alzheimer’s Association 24/7 Helpline | 800.272.3900 www.alz.org/mnnd

Senior LinkAge Line

800-333-2433 www.minnesotahelp.info

Case Studies

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Case Study: Colleen

• 66 y/o presents to primary care with memory complaints • Daughter c/o short-term memory is poor • Began 1-2 years ago, getting worse • Hx Low blood sugar, history of heart attack, repeat

hospitalizations for atrial flutter • Frequent medication changes, managing independently • Patient is a retired accountant for family business • Lives with husband who is still running the family

business

• Referred to Care Coordination

Case Example: Medications

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https://youtu.be/3lp0n9DOEWQ

Care Coordination: Colleen

• Discussion – Observations? What did you notice?

– What was done well?

– What could have been done differently, better?

– What might you incorporate into your practice?

– What recommendations / referrals would you make to Colleen?

– What might you do differently if Colleen was not a native English speaker or was from a diverse cultural community?

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Watch the Complete Session:

100

https://youtu.be/5Kxj-5Ezlzw?list=PLGu3PyEblnIKVrTqVj9NzR5f_fcCbTd9T

Questions?

• Download ACT on Alzheimer’s practice tools at: www.ACTonALZ.org/provider-practice-tools

• For more information

– email: info@ACTonALZ.org

– Web: www.ACTonALZ.org

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Evaluation

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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

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

• After a Diagnosis (ACT): http://www.actonalz.org/sites/default/files/documents/ACT-AfterDiagnosis.pdf

Alzheimer’s Association

• Basics of Alzheimer’s Disease: https://www.alz.org/national/documents/brochure_basicsofalz_low.pdf

• Caregiver Notebook - http://www.alz.org/care/alzheimers-dementia-caregiver-notebook.asp

• Driving Center: www.alz.org/care/alzheimers-dementia-and-driving.asp

• Facts & Figures video: http://youtu.be/waeuks1-3Z4

• Facts & Figures Report: https://www.alz.org/facts/downloads/facts_figures_2015.pdf

• Family Questionnaire: http://www.alz.org/mnnd/documents/Family_Questionnaire.pdf

• Know the 10 Signs. http://www.alz.org/national/documents/checklist_10signs.pdf

• Living with Alzheimer’s – Mid Stage: https://www.alz.org/documents_custom/middle-stage-caregiver-tips.pdf

• Living with Alzheimer’s – Late Stage: https://www.alz.org/documents_custom/late-stage-caregiver-tips.pdf

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

• Taking Action Workbook: http://www.alz.org/mnnd/documents/2010_taking_action_e-book(1).pdf

• Trial Match: http://www.alz.org/research/clinical_trials/find_clinical_trials_trialmatch.asp

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References & Resources

• AD8 Dementia Screening Interview: http://knightadrc.wustl.edu/About_Us/PDFs/AD8form2005.pdf

• At the Crossroads: http://www.thehartford.com/sites/thehartford/files/at-the-crossroads-2012.pdf

• Caring for a Person with Alzheimer’s Disease: http://www.nia.nih.gov/sites/default/files/caring_for_a_person_with_alzheimers_disease_0.pdf

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

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

• Health Care Directive (MN): http://www.ag.state.mn.us/pdf/consumer/healtcaredir.pdf

• Hospitalization Happens: http://www.nia.nih.gov/sites/default/files/hospitalization_happens_0.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

• MN Health Care Home Care Coordination Tool Kit: http://www.health.state.mn.us/healthreform/homes/collaborative/lcdocs/cliniccarecoordtoolkit.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

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References & Resources

• St. Louis University Mental Status (SLUMS) examination http://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

• Zarit Caregiver Burden Interview: http://www.uconn-aging.uchc.edu/patientcare/memory/pdfs/zarit_burden_interview.pdf

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References & Resources

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

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

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

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

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

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

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

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

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

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

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

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References & Resources

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