CareCare Process Process Model Model FEBRUARY MONTH 2015 2017 DIAGNOSIS AND MANAGEMENT OF Mild Cognitive Impairment (MCI) and Dementia minor update - 12 / 2020 The Intermountain Cognitive Care Development Team developed this care process model (CPM) to improve the diagnosis and treatment of patients with cognitive impairment across the staging continuum from mild impairment to advanced dementia. It is primarily intended as a tool to assist primary care teams in making the diagnosis of dementia and in providing optimal treatment and support to patients and their loved ones. This CPM is based on existing guidelines, where available, and expert opinion. WHAT’S INSIDE? Why Focus ON DIAGNOSIS AND MANAGEMENT ALGORITHMS OF DEMENTIA? Algorithm 1: Diagnosing Dementia and MCI . 6 • Prevalence, trend, and morbidity. In 2016, one in nine people age 65 and Algorithm 2: Dementia Treatment . .. 11 older (11%) has Alzheimer’s, the most common dementia. By 2050, that Algorithm 3: Driving Assessment . 13 number may nearly triple, and Utah is expected to experience one of the Algorithm 4: Managing Behavioral and greatest increases of any state in the nation.HER,WEU One in three seniors dies with Psychological Symptoms . 14 a diagnosis of some form of dementia.ALZ MCI AND DEMENTIA SCREENING • Costs and burdens of care. In 2016, total payments for healthcare, long-term AND DIAGNOSIS ...............2 care, and hospice were estimated to be $236 billion for people with Alzheimer’s MCI TREATMENT AND CARE ....... HUR and other dementias. Just under half of those costs were borne by Medicare. MANAGEMENT .................8 The emotional stress of dementia caregiving is rated as high or very high by nearly DEMENTIA TREATMENT AND PIN, ALZ 60% of caregivers, about 40% of whom suffer from depression. CARE MANAGEMENT ...........9 • Physician support needs. Dementia goes undetected in 50% of patients at Medication Tables . 15 Intermountain who likely suffer from its effects. Based on an Intermountain RESOURCES ...................19 internal needs assessment, a majority of internal medicine physicians identified Patient / Caregiver Education . 19 support for cognitively impaired patients as a top practice need, and 88% of Screening / Staging / Driving primary care physicians felt that a care process model addressing cognitive Assessment Forms . 21 impairment would be helpful.SKI REFERENCES ..................30 • Importance of identification and treatment. While there is no cure for dementia, treatment (both pharmacologic and non-pharmacologic) has been MEASUREMENT & GOALS shown to improve quality of care, quality of life for patients, caregiver assistance, • Complete a Mini-Cog™ cognitive screening for a minimum of 75% of and caregiver mental health as well as to delay nursing home placement and Annual Wellness Visit (AWV) patients decrease costs to healthcare systems.DOO1, VIC, GAL1, MIT1, BAS, SPI, CAL, FRE, MCL In addition, • Administer a MoCA or SLUMS follow- more timely diagnosis better dementia patients have voiced a need for , up cognitive screening for at least education about dementia management, and better support and follow-up 50% of patients whose Mini-Cog™ for patients and caregivers from healthcare providers (Alzheimer's Association score showed potential cognitive focus group). decline • Increase the rate of Indicates an Intermountain diagnosis of dementia measure INTERMOUNTAIN BEST PRACTICE RECOMMENDATION by 5% system wide All Medicare annual wellness visits (AWVs) should include a brief, two- to three-minute cognitive screening with the Mini-Cog™ cognitive screening tool. Training links (page 3) and forms (pages 21–22) are included in this CPM. Intermountain will begin measuring rates of AWV Mini-Cog™ screening in 2017. MILD COGNITIVE IMPAIRMENT (MCI) AND DEMENTIA FEBRUARY 2017 MILD COGNITIVE IMPAIRMENT AND DEMENTIA SCREENING AND DIAGNOSIS Mild cognitive impairment (MCI) and dementia are both clinical syndromes with KEY RECOMMENDATIONS multiple causes that affect memory and other cognitive functions. Both are diagnosed • Screen patients to determine if clinically, using cognitive screening tools to detect and measure possible impairment they meet criteria for mild cognitive (see Cognitive screening tools: The Mini-Cog™ , MoCA, and SLUMS on page 3) and a impairment or dementia using validated history and physical exam to rule out treatable factors that can influence cognition such as screening tools (Mini-Cog™ and MoCA). depression, infection, nutrition deficiency, and medication side effects (see algorithm 1 • Complete Mini-Cog™ and MoCA on page 6). training prior to first use, and be sure to administer the screenings the same The importance of diagnosis for these syndromes may be overlooked in some way every time. healthcare settings because approved medications have shown little benefit for • Conduct a Mini-Cog™ screening at each disease modification. However, nonpharmacological interventions and careful care Medicare annual wellness visit (AWV). management are effective in preserving patients' quality of life and independence and • Understand the overlap between in reducing caregiver burnout. depression and dementia. Patients with MCI may experience some difficulty with daily tasks but still manage • Interview a knowledgeable informant to function without assistance, whereas patients with dementia require ever more about the patient's functional status help from caregivers as they progress through stages of impairment from mild to BEFORE making a diagnosis. severe. Patients with MCI have a greater-than-normal risk of developing dementia in the future, but not all MCI cases progress to greater impairment; some even improve. The algorithm on page 6 details best practices for diagnosing dementia and MCI. DEPRESSION AND DEMENTIA Mild cognitive impairment (MCI) KAL1, DAL OVERLAP MCI is a condition marked by mild changes in memory, language, or another mental Depression and dementia are the function. However, patients with MCI can perform all activities of daily living two, most-diagnosed neuropsychiatric without any caregiving assistance. Cognitive changes are significant enough to be disorders in adults over age 65. Highly noticed by others and measured by cognitive screening assessments. Typical cognitive comorbid, either disorder may appear LAN1 first. Depression symptoms in older problems in MCI may include: adults (present in up to one-half of • Greater dependency on reminders and notes Alzheimer's disease cases) are often • Greater difficulties with multitasking overlooked and untreated because • they coincide with other problems More distractibility encountered by older adults (e.g., • Less flexibility low energy, somatic symptoms, and • New difficulties with problem-solving and word finding. cognitive complaints). MCI is typically a diagnosis of exclusion. If a patient shows measurable but mild A history of depression is associated with increased risk of dementia. impairment on screening tests with no potential causative factors (medication side effects, It can be difficult to determine infection, nutritional deficiencies, depression) and no functional impairment, the patient is whether cognitive impairment is diagnosed with MCI rather than mild dementia (see the diagnosis algorithm on page 6). due to depression or if dementia and depression are both present. Dementia In cognitive impairment that is due Dementia is defined as a decline in cognitive function from baseline that is not due to depression, it is more common to another medical or psychiatric cause and that causes impairment in ability to live for depressed individuals to display CHU lower motivation, be more concerned and function independently. Mild dementia is distinguished from MCI by an about their functioning, and to have impairment in the patient's ability to perform daily activities. Input from a caregiver greater self-complaints of difficulty or another knowledgeable informant who can give an accurate report of the patient's with concentration and attention than functional status is an absolute requirement for a dementia diagnosis. The diagnosis those with dementia. When symptoms is primarily clinical and relies heavily on the history and physical examination of depression are present in a patient RAB1 with cognitive impairment, the (including reports from a knowledgeable informant). While labs, imaging, and recommended approach is to treat for cognitive testing are helpful in making the diagnosis, they are not diagnostic in and depression and reevaluate cognition. of themselves. If a patient shows cognitive impairment but no functional impairment, Consultation with neuropsychology can the diagnosis is MCI rather than dementia. Once a diagnosis of dementia has been be particularly helpful. made, the cause and stage of the impairment should be determined (pages 4 – 5). 2 ©2017 INTERMOUNTAIN HEALTHCARE. ALL RIGHTS RESERVED. FEBRUARY 2017 MILD COGNITIVE IMPAIRMENT (MCI) AND DEMENTIA Cognitive screening tools: the Mini-Cog™, MoCA, and SLUMS MINI-COG™ TRAINING In diagnosing dementia, it is important to use validated screening tools for Access the computer-based training via the assessing the cognitive function for each patient early in the diagnostic process My Learning Catalog . The training takes about 12 minutes, not including videos of page 6 (see Algorithm 1 on ). Intermountain recommends three cognitive screening screening delivery. tools: the Mini-Cog™, the Montreal Cognitive Assessment (MoCA), and the St. Lous 1. Log into TalentLink. University Mental Status