Cognitive Aging: Progress in Understanding and Opportunities for Action (2015)

5

Health Care Response to Cognitive Aging

As a result of the aging of the population, older adults constitute an increasingly larger portion of the patients seen by health care professionals both in acute and ambulatory care settings. Moreover, with increased public awareness of and concern about cognitive impairment and dementia in older age, individuals and families are turning to health care professionals for information and advice about brain health. Approximately one in three American adults identifies Alzheimer’s disease as the disease they fear most (MetLife Foundation and Harris Interactive Inc., 2011). An American Society on Aging-MetLife survey (ASA et al., 2006) found that a majority of American adults view having a memory checkup as being as important as having routine physical checkups; that 76 percent of women and 68 percent of men identify doctors as the best resource for information about brain fitness; and that more than 74 percent would advise a close friend or a family member who is concerned about memory to see a general practitioner. With individuals and families seeking assistance from practitioners to understand and manage cognitive aging, the health care system must be prepared to respond effectively.

This chapter focuses on the health care response to cognitive aging, including attitudes and practices of health care professionals and the health system, needs for improving the health care response through provider education and training, and opportunities for using medical visits to assess and to address cognitive aging.

ATTITUDES AND PRACTICES OF HEALTH PROFESSIONALS AND THE HEALTH SYSTEM

Despite the increasing frequency of concerns regarding memory and cognitive aging in routine care, few studies have examined physician practices and attitudes regarding advising patients about cognitive aging and reducing the risks for cognitive impairment or dementia. A survey of 1,000 primary care physicians and internists found that 40 percent of providers reported discussing issues related to preventing and reducing the risk of cognitive impairment and dementia with their adult patients (those with no known dementia) “often” or “very often” during the prior 6 months (Day et al., 2012). Approximately 20 percent reported “rarely” discussing this topic. Day and colleagues found that providers’ recommendations depended on their perception of the strength of the evidence regarding cognitive health. While a slight majority (54 percent) rated the evidence for reducing cognitive impairment as “moderate” to “very strong,” 39 percent rated it as “weak” or “very weak.” When physicians reported giving advice about preventing or delaying cognitive impairment and dementia, their most commonly reported recommendations (reported by more than 50 percent of respondents) were be physically active, get intellectual stimulation, eat a healthy diet, be socially active, limit the use of alcohol, and attain/ maintain a healthy weight.

Health care practitioners view addressing prevention and risk reduction concerning cognitive impairment and dementia in clinical practice as a challenge. As is the case with addressing prevention in routine care for other conditions, the major barriers include a lack of reimbursement and finding enough time to address both behavioral counseling and patients’ more immediate health issues (Day et al., 2012; Yarnall et al., 2009). The main barriers to cognitive health counseling specifically are the perceived limited availability of scientific evidence or proven treatments in the field and the presence of inconclusive research (Day et al., 2012; Warren-Findlow et al., 2010).

A small number of studies have examined the sources of providers’ information and evidence about cognitive health and aging, and their preferences for education and training. In a qualitative study that included focus groups and interviews with physicians, physician assistants, and nurse practitioners, continuing medical education (CME) was viewed as perhaps the easiest way to disseminate cognitive health information to providers (Warren-Findlow et al., 2010), CME can be offered through journals, online services, and in-person opportunities in order to reach providers in different settings. Online professional websites or services were identified by physicians, but not by non-physician participants, as a source of information.

Popular media, while recognized as having an impact on the public awareness of preventive behavior for some diseases, was not endorsed as a means for educating health care professionals (Warren-Findlow et al., 2010). In a survey, providers identified the following as important sources of information about new evidence and practice guidelines related to cognitive impairment or dementia: professional journals (42 percent), CME (17 percent), and professional websites or listservs (16.5 percent) (Day et al., 2012). Other sources endorsed infrequently included brochures and booklets, scientific meetings or conferences, information accessible by phone, popular media, and drug or pharmaceutical representatives.

IMPROVING THE HEALTH CARE RESPONSE

Several key national initiatives launched over the past decade address cognitive aging and the various health behaviors that can reduce risk (CDC and Alzheimer’s Association, 2007). In addition, the research establishment has worked to produce the evidence needed to support public health and health care efforts to promote cognitive and emotional health in older adults (Hendrie et al., 2006). These efforts have emphasized the need for resources, tools, and education to aid providers in translating evidence into public health and practice. For health care providers, the primary needs include practice recommendations to guide assessment and counseling regarding cognitive aging, access to tools for evaluating cognition and advising patients regarding normal aging performance patterns, knowledge of effective interventions and recommendations for patient and family counseling, and decision aids to help identify when to refer patients for further evaluation and diagnosis or intervention. For health care systems and private and public health insurance companies there are numerous opportunities to provide educational materials and programs for older adults and family members and training for health care professionals to discuss cognitive aging and to promote cognitive health.

Education and Training for Providers in Cognitive Aging

One way to increase health care providers’ preparedness for treating an aging population’s cognitive health challenges is to provide formal education and training. To that end, new initiatives need to be designed and implemented aimed at increasing providers’ awareness, knowledge, and skills for addressing the public’s concerns regarding cognitive aging. Several health care disciplines specialize in aging and cognition (e.g., physicians, nurses, and others who specialize in geriatrics and geriatric neuropsychology), and these practitioners receive formal coursework and practice-based training in cognitive aging. However, because cognitive changes with age

are a commonly identified concern among older adults, it is not just these specialists who need to have basic competencies in cognitive aging but rather the broad spectrum of professionals and disciplines working with adult and older adult populations. In addition, because cognition in later life is affected by life exposures and risk factors across the life span, efforts should be made to help practitioners serving all age groups understand potential cognitive impacts, even if little immediate harm is evident.

Several training programs and CME courses are designed to educate health care professionals in cognitive aging. For example, Eckstrom and colleagues (2008) designed a faculty CME workshop in which teaching faculty at two internal medicine training programs attended a 1-day workshop on geriatric knowledge and assessment of cognition and function. Kovacich and colleagues (2006) described a certificate program on cognitive vitality offered by the Meharry Consortium Geriatric Education Center. The program focuses on dispelling myths that dementia is a normal part of the aging process. Williams and colleagues (2007) reported on the Collaborative Centers for Research and Education in the Care of Older Adults Initiative, sponsored by John A. Hartford Foundation and administered by the Society for General Internal Medicine, which brings geriatricians and internists together to discuss the care of older adults.

In addition, a number of websites have been established as resources for improving training for health care professionals in the topics of aging populations and clinical practice. These websites include some content on cognition and aging, although it is not always the core focus. Examples include

• The Portal of Geriatrics Online Education (ADGAP, 2014), which was established on behalf of the Association of Directors of Geriatric Academic Programs, provides training modules on a broad spectrum of topics, including cognitive aging. One program related to cognitive aging is directed toward medical students, with specific learning objectives that include distinguishing between normal and abnormal aging changes in the brain, and systematic methods for assessing patients presenting with memory loss (Overbeck et al., 2014).
• Aging Q3, an initiative described by Moran and colleagues (2012), was developed to improve internal medicine residents’ knowledge, skills, and clinical care capabilities relating to older adults. The training employs multiple intervention strategies—including a didactic curriculum and tools that can be accessed online, rounds, and health system interventions (e.g., electronic health record prompts)—designed to change how physicians practice. Although

• cognitive aging is not a designated subject within the curriculum, cognition appears as a topic in the practice-based experience.
• Geri-EM (Melady et al., 2013) is a continuing education website begun in Ontario, Canada, that provides free information about improving care for older patients that is aimed at health care providers and interested members of the general public. By completing the website’s modules, providers can earn CME credits through the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, or the American Medical Association. The website offers six modules covering medication management, trauma and falls, atypical presentations, functional assessment, end-of-life care, and cognitive impairment.

Reviewing the available literature and electronic resources reveals that a number of important steps have been taken toward designing content to increase health care professionals’ awareness of and education in cognition and aging. However, the variability in the topics and scope of coverage indicates a need to identify core competencies in cognitive aging as part of the development and dissemination of educational strategies in this area.

Education and Training for Providers in Reversible Contributors to Cognitive Decline

While many medical risk factors for cognitive decline were identified in Chapter 4B, recommended interventions for most of these risk factors remain premature or uncertain at this time. However, there are two essential areas where the role of the health care professional is unequivocal; the prevention of delirium and medication monitoring. Given the high incidence of delirium, its preventable nature, and its contributions to cognitive decline (Inouye et al., 2014; see also Chapter 4B), health care professionals play a critical role in identifying patients at moderate to high risk for delirium, particularly in such high-risk clinical settings as pre-surgery, intensive care, and post-acute care. Screening for the well-established delirium risk factors and implementing delirium-prevention strategies as soon as possible after admission are important responsibilities of health care professionals caring for vulnerable older patients (Inouye et al., 2014; NICE, 2010).

A clinical guideline for delirium issued by the National Institute for Health and Care Excellence (NICE) listed risk factors for delirium, including age greater than 65 years, chronic cognitive impairment or dementia, current hip fracture, and severe illness (NICE, 2010). Other risk factors commonly cited in studies include multimorbidity, depression, cerebrovascular disease, and alcohol abuse (Inouye et al., 2014). Older adults with one or more of these risk factors at baseline should receive non-pharmacologic

delirium preventive strategies, such as those outlined in the Hospital Elder Life Program (HELP, 2015a) or NICE guidelines, including cognitive reorientation, non-pharmacologic sleep enhancement, early mobilization, vision and hearing adaptations, nutrition and fluid replenishment, pain management, medication monitoring for appropriate use, adequate oxygenation, and prevention of constipation (see also Chapter 4B). In addition, these guidelines direct that, during their hospitalization, high-risk patients should receive daily cognitive screenings that assess attention and orientation (HELP, 2015b; Marcantonio et al., 2014).

Monitoring medications in older adults—and, avoiding the use of inappropriate medications—is a critical role for health care professionals, particularly primary care providers. Such medication reviews should be performed at each appointment, and especially at times of transition of care, such as post-surgery or post-hospital discharge. As noted in Chapter 4B, older individuals take an average of 14 prescription drugs per year (ASCP, 2015), which leads to a heightened risk of adverse drug reactions as well as drug–drug and drug–disease interactions. Health care professionals should regularly review their patients’ comprehensive medication listings, including over-the-counter medications and herbal remedies. Assessing for any potentially inappropriate medication use is an essential task for the health care professional (AGS, 2012), particularly in the case of high-risk psychoactive medications, such as anticholinergic drugs, tricyclic antidepressants, benzodiazepines, antipsychotics, oral corticosteroids, H2 blockers, meperidine, and sedative hypnotic drugs. The involvement of a clinical pharmacist to review potential interactions is an important strategy for assuring the optimal management of more complex drug regimens.

Practice Guidelines and Core Competencies

A review of the resources necessary for minimum geriatric competencies in various health disciplines, including medicine, nursing, and social work, finds few competencies that are specific to normal cognitive aging. Some physician and nursing organizations include practice recommendations about working with older adults and about issues of cognition; however, the knowledge and skills necessary for addressing cognitive aging are often not delineated (POGOe, 2014).

The current practice guidelines and competencies that have been developed on cognition and aging can be used to inform core competencies for the broad spectrum of health care providers. Guidelines from organizations such as the American Psychological Association (APA) and the American Occupational Therapy Association (AOTA) provide standards and recommendations for conducting cognitive assessment of older adults, counseling older adults about cognitive changes, and working with older adults on

functional changes associated with cognitive aging. Box 5-1 lists examples of resources for cognitive aging–related practice guidelines and competencies. Although many of the guidelines focus on dementia, they may have relevance to cognitive aging.

Core competencies should incorporate key information reflecting the current state of evidence about cognitive aging, as is reported in Chapters 4A, 4B, and 4C. In general, cognitive aging competency should include what is known about such topics as patterns of changes in cognition with

aging, risk and protective factors, implications for functioning, and assessment tools. Such competency would help move the health care system toward more effective response to cognitive aging.

Core competencies should encompass:

• The importance of cognitive health in basic medical care across all settings of care;
• The features and typical trajectories of cognitive aging, including an understanding of the differences between expected changes and those that may signal deficits related to disease and also an acknowledgment of the wide variability in changes in cognitive function over time among older adults;
• Assessment methods;
• Monitoring the effects of medications and combinations of medications on delirium and cognitive decline;
• Reversible conditions that contribute to cognitive deficits and declines, including depression, thyroid disease, and delirium;
• Interventions to minimize cognitive decline associated with medical conditions such as stroke, diabetes, head trauma, renal insufficiency, vision and hearing losses, and cardiac disease;
• Screening for delirium risk factors and implementing delirium prevention strategies for older persons in high-risk settings, such as preadmission or pre-surgery;
• Vulnerabilities associated with daily living, including driving, health care management and decision making, and financial responsibility, as well as strategies to mitigate those vulnerabilities;
• Health-promoting behaviors that may reduce the risks of cognitive decline, including exercise and social and intellectual engagement;
• Unhealthy behaviors that increase the risk of cognitive decline, such as cigarette smoking, excessive alcohol consumption, and a sedentary lifestyle;
• Evidence-based information regarding products that may be harmful or without benefit, including nutraceuticals and other interventions; and
• Perceptions, fears, and common misunderstandings about aging and cognitive decline.

The coordination of care takes on increasing importance in older individuals, particularly in the presence of cognitive aging and multimorbidity. As the older individual’s needs and number of providers increase, care becomes quite complex, with multiple medications and a greater risk for fragmentation and errors. Care coordination has been identified as a priority for health care quality improvement (AHRQ, 2014; IOM, 2003).

USING MEDICAL VISITS TO ADDRESS COGNITIVE AGING

Currently, there is no consensus regarding the benefits of screening for cognitive aging in the general population of older adults. In a 2014 report, the U.S. Preventive Services Task Force (USPSTF) examined the benefits and harms of screening for cognitive impairment and concluded that, for the population of community-dwelling people over 65 years of age who are not experiencing symptoms of cognitive impairment, there is insufficient evidence to assess whether screening is helpful, and thus the task force did not issue a recommendation (Moyer, 2014). The USPSTF acknowledged that clinical decisions are needed on the individual level. Within the health care setting, which is designed to meet the needs of a diverse population of patients, there are opportunities to respond to the varying concerns of individuals and their families and to address cognitive aging through screening, diagnostic assessment, and patient education and counseling.

The Medicare Annual Wellness Visit

The Medicare Annual Wellness Visit (CMS, 2014b) was instituted in 2011 as an opportunity for preventive care that includes a provider assessment of cognitive aging. As part of a national priority on prevention included in the Affordable Care Act, all Medicare beneficiaries are eligible for this visit, which is available at no out-of-pocket cost (Koh and Sebelius, 2010). During the visit, preventive screenings are to be conducted and they are meant to result in the development of a personalized prevention plan to prevent or reduce disease and disability that is based on the individual’s assessed health risk factors, including his or her medical and exposure history. A formal cognitive assessment is required for the detection of cognitive impairment. In developing a personalized prevention plan, providers are to offer feedback and educate the patient about risks, including risks for cognitive aging, when indicated. Providers can access a quick reference guide to the components of the visit and procedures (CMS, 2015).

There are limitations to the impact the Annual Wellness Visit can have in promoting cognitive aging and the early detection of cognitive impairment. In 2013, of the more than 35 million enrollees in Medicare Part B nationally, only 11 percent used the Annual Wellness Visit (CMS, 2014a). Although the detection of cognitive impairment is a required assessment component of the annual visit, no cognitive assessment procedures were specifically indicated or recommended to guide providers. Given the complexity of the issues pertaining to cognitive assessment in primary care, Cordell and colleagues (2012) conducted a review of the available tools and recommended a cognitive assessment toolkit, with provider training modules, for the Annual Wellness Visit and for other health visits. Other

tools and resources are available as well (see Box 5-2). However, there have been no reports concerning the providers’ awareness of, use of, or satisfaction with these cognition assessment recommendations and procedures. Moreover, data from Annual Wellness Visits have not been aggregated and reported in order to determine the cognitive status of Medicare beneficiaries seeking these preventive services or to gauge the effectiveness of the visits in addressing the cognitive aging needs of these individuals.

Resources for Cognitive Aging Assessment in Health Care

Older adults and their families frequently share with health care providers their complaints and concerns about changes in cognition and questions about whether the changes they perceive are normal or are a sign of dementia. Answering these questions requires an evaluation of the reported symptoms and the patient’s cognitive performance and function to determine whether the individual’s cognitive and functional patterns meet the established criteria for mild cognitive impairment or dementia. Health care professionals encounter questions of when and how to assess, which instruments to use, and when to refer the patient for a further comprehensive evaluation and workup. Box 5-2 provides some examples of resources intended to answer such questions and help equip practitioners with tools and instruments.

Cognitive Self-Assessment Tools for Use by Patients

Because the public has an interest in ascertaining cognitive functional status and dementia risk, tools and technologies are being investigated that will allow individuals to conduct cognition self-assessments to identify risk factors related to cognitive aging and to test discreet cognitive skills such as memory, and that will help guide discussions with their health care providers (e.g., Brandt et al., 2013, 2014). While self-assessment may have certain advantages, such as enabling large numbers of interested people to have easy access to cognitive evaluation, significant cautions should be kept in mind. For instance, the reliability and validity of these tests and the interpretations of their results are greatly improved when appropriately trained health care professionals administer them (AERA et al., 2014). While such cautions pertain to any cognitive testing, self-assessment may be particularly vulnerable to mishandling. Given the known potential disadvantages, cognition self-assessment products will require a great deal of research, monitoring, and long-term evaluation. Among the issues concerning self-assessment that require thorough exploration are the degree of accuracy of the self-assessment tools within and across diverse populations and groups (such as varying levels of educational achievement); the rates

of false positives (i.e., people whose cognitive performance does not represent abnormal change, but who are informed it is abnormal); the rates of false negatives (i.e., people whose cognitive performance does represent abnormal change, but who are informed it is normal); and the effects of the inaccurate interpretation of cognitive status on clinical, functional, and quality-of-life outcomes. Ultimately, this research will need to yield reliable, well-validated tools that aid concerned individuals and families as well as their health care providers.

Resources for Educating and Counseling Patients on Cognitive Aging

Although each medical encounter potentially is an opportunity to discuss cognitive aging and to address prevention and risk and protective factors, a survey of health care providers discussed earlier in the chapter indicates that these discussions often do not occur (Day et al., 2012). Box 5-3 gives examples of some of the resources available for patient education specifically on brain health and implications of cognitive aging on functioning and safety in older adults. To date the literature has not addressed the

impact of provider counseling about cognitive aging on patient and family decision making, functioning, or quality of life.

One of the important roles of health care professionals is to counsel patients about safe medication use and the need to avoid long-term use of psychoactive medications, if possible, and to enable patients to monitor and report any potential cognitive side effects of the medications they use. In particular, patients need to know that episodes of acute confusion, memory loss, falls, motor vehicle accidents, and agitation may represent side effects of medications. Patients also need to know to avoid over-the-counter medications, such as antihistamines (diphenhydramine) found in allergy, sinus, and sleep (PM) formulations as much as possible because they may have important cognitive side effects that are readily overlooked. Resources for safe medication use in older adults are outlined in Chapter 6 (see Box 6-1).

In addition to the resources available to increase and improve counseling about the effects of aging on cognition, there are patient education resources aimed at teaching patients how to achieve healthy lifestyles, which can protect against poor cognitive aging. One example is the American Heart Association’s Life’s Simple 7^® (AHA and ASA, 2014). The National Institute on Aging’s Toolkit on provider and patient communication provides booklets to aid providers (“Talking with Your Older Patient: A Clinician’s Handbook”) and to aid patients (“Talking with Your Doctor: A Guide for Older Adults”) with discussions in the health care setting. The toolkit also contains a presentation for small group learning, materials focused on memory and thinking changes with age, and recommendations for collaborative decision making (NIA, 2014b).

RECOMMENDATIONS

Recommendation 7: Promote Cognitive Health in Wellness and Medical Visits

Public health agencies (including the Centers for Disease Control and Prevention and state health departments), health care systems (including the Veterans Health Administration), the Centers for Medicare & Medicaid Services (CMS), health insurance companies, health care professional schools and organizations, health care professionals, and individuals and their families should promote cognitive health in regular medical and wellness visits among people of all ages. Attention should also be given to cognitive outcomes during hospital stays and post-surgery.

Specifically, health care professionals should use patient visits to:

• identify risk factors for cognitive decline and recommend measures to minimize risk; and review patient medications, paying attention to medications known to have an impact on cognition;
• provide patients and families with information on cognitive aging (as distinct from dementia) and actions that they can take to maintain cognitive health and prevent cognitive decline; and
• encourage individuals and family members to discuss their concerns and questions regarding cognitive health.

In addition, other components of the health care system have a cognitive health promotion role:

• CMS should develop and implement demonstration projects to identify best practices for clinicians in assessing cognitive change and functional impairment and in providing appropriate counseling and prevention messages during, for example, the Medicare Annual Wellness Visit or other health care visits.
• Health care systems and private and public health insurance companies should develop evidence-based programs and materials on cognitive health across the life span.
• During and after hospital stays and post-surgery, health care providers, patients, and families should be alert to potential cognitive changes and delirium.

REFERENCES

AACN (American Association of Colleges of Nursing), The John A. Hartford Foundation Institute for Geriatric Nursing, and the National Organization of Nurse Practioner Faculties. 2010. Adult-gerontology primary care nurse practitioner competencies. http://www.aacn.nche.edu/geriatric-nursing/adultgeroprimcareNPcomp.pdf (accessed December 15, 2014).

ADGAP (Association of Directors of Geriatric Academic Programs). 2014. POGOe: The Portal of Geriatrics Online Education. http://www.pogoe.org (accessed January 27, 2015).

AERA, APA, and NCME (American Educational Research Association, American Psychological Association, and National Council on Measurement in Education). 2014. Standards for educational and psychological testing. Washington, DC: AERA Publications.

AGS (American Geriatrics Society). 2012. AGS Beers criteria for potentially inappropriate medication use in older adults. http://www.americangeriatrics.org/files/documents/beers/PrintableBeersPocketCard.pdf (accessed January 8, 2015).

———. 2014. American Geriatrics Society clinical practice guideline for postoperative delirium in older adults. http://geriatricscareonline.org/ProductAbstract/american-geriatricssociety-clinical-practice-guideline-for-postoperative-delirium-in-older-adults/CL018 (accessed January 29, 2015).

AGS Expert Panel on Postoperative Delirium in Older Adults. 2014. Postoperative delirium in older adults: Best practice statement from the American Geriatrics Society. Journal of the American College of Surgeons 220(2):136-148.

AHA and ASA (American Heart Association and American Stroke Association). 2014. Life’s simple 7: Heart health factors. http://mylifecheck.heart.org/Multitab.aspx?NavID=3&CultureCode=en-US (accessed December 15, 2014).

AHRQ (Agency for Healthcare Research and Quality). 2014. Care coordination. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination (accessed February 13, 2015).

Alzheimer’s Association. 2009. 10 early signs and symptoms of Alzheimer’s. http://www.alz.org/alzheimers_disease_10_signs_of_alzheimers.asp (accessed December 15, 2014).

———. 2014. Brain health. http://www.alz.org/we_can_help_brain_health_maintain_your_brain.asp (accessed December 15, 2014).

———. 2015. Health Care Professionals and Alzheimer’s. http://www.alz.org/health-careprofessionals/cognitive-tests-patient-assessment.asp (accessed February 2, 2015).

AOTA (American Occupational Therapy Association). 2011. Occupational therapy’s role in adult cognitive disorders. http://www.aota.org/-/media/Corporate/Files/AboutOT/Professionals/WhatIsOT/PA/Facts/Cognition%20fact%20sheet.pdf (accessed February 11, 2015).

APA (American Psychological Association). 2012. Guidelines for the evaluation of dementia and age-related cognitive change. American Psychologist 67(1):1-9. http://www.apa.org/practice/guidelines/dementia-age.pdf (accessed December 12, 2014).

———. 2014. Older adults’ health and age-related changes: Reality versus myth. http://www.apa.org/pi/aging/resources/guides/older-adults.pdf (accessed December 15, 2014).

APA (American Psychiatric Association). 2013. Diagnostic and statistical manual of mental disorders, fifth ed. Arlington, VA: American Psychiatric Publishing.

ASA (American Society on Aging), MetLife Foundation, and Harris Interactive Inc. 2006. Attitudes and awareness of brain health poll. http://www.paulnussbaum.com/metlifedoc.pdf (accessed December 15, 2014).

ASCP (American Society of Consultant Pharmacists). 2015. ASCP fact sheet. https://www.ascp.com/articles/about-ascp/ascp-fact-sheet (accessed January 28, 2015).

Brandt, J., C. Sullivan, I. L. E. Burrell, M. Rogerson, and A. Anderson. 2013. Internet-based screening for dementia risk. PLoS ONE 8(2):e57476.

Brandt, J., J. Blehar, A. Anderson, and A. L. Gross. 2014. Further validation of the internet-based Dementia Risk Assessment. Journal of Alzheimer’s Disease 41(3):937-945.

CDC (Centers for Disease Control and Prevention) and Alzheimer’s Association. 2007. The Healthy Brain Initiative: A national public health road map to maintaining cognitive health. http://www.alz.org/national/documents/report_healthybraininitiative.pdf (accessed December 15, 2014).

CMS (Centers for Medicare & Medicaid Services). 2014a. Beneficiaries in original Medicare utilizing free preventative services by state. January-November 2013. http://downloads.cms.gov/files/Preventive_Services_Utilization_by_State_Jan-Nov_2013.pdf (accessed December 15, 2014).

———. 2014b. Quick reference information: The ABCs of providing the Annual Wellness Visit (AWV). http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/AWV_Chart_ICN905706.pdf (accessed December 15, 2014).

———. 2015. Preventative visit and yearly wellness exam. http://www.medicare.gov/coverage/preventive-visit-and-yearly-wellness-exams.html (accessed January 8, 2015).

Cordell, C. B., S. Borson, M. Boustani, J. Chodosh, D. Reuben, J. Verghese, W. Thies, L. B. Fried, and Medicare Detection of Cognitive Impairment Workgroup. 2012. Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimer’s and Dementia 9(2):141-150.

Day, K. L., D. B. Friedman, J. N. Laditka, L. A. Anderson, R. Hunter, S. B. Laditka, B. Wu, L. C. McGuire, and M. C. Coy. 2012. Prevention of cognitive impairment: Physician perceptions and practices. Journal of Applied Gerontology 31(6):743-754.

Eckstrom, E., S. S. Desai, A. J. Hunter, E. Allen, C. E. Tanner, L. M. Lucas, C. L. Joseph, M. R. Ririe, M. N. Doak, L. L. Humphrey, and J. L. Bowen. 2008. Aiming to improve care of older adults: An innovative faculty development workshop. Journal of General Internal Medicine 23(7):1053-1056.

Giles, G. M., M. V. Radomski, T. Champagne, M. A. Corcoran, G. Gillen, H. M. Kuhaneck, M. T. Morrison, B. Nadeau, I. Obermeyer, J. Toglia, and T. J. Wolf. 2012. Cognition, cognitive rehabilitation, and occupational performance. https://www.aota.org/-/media/Corporate/Files/AboutAOTA/OfficialDocs/Statements/Cognition%20Cognitive%20Rehabilitation%20and%20Occupational%20Performance.pdf (accessed December 15, 2014).

HELP (Hospital Elder Life Program). 2015a. Hospital Elder Life Program (HELP) for prevention of delirium. http://www.hospitalelderlifeprogram.org (accessed January 8, 2015).

———. 2015b. Delirium instruments. http://www.hospitalelderlifeprogram.org/delirium-instruments (accessed January 9, 2015).

Hendrie, H. C., M. S. Albert, M. A. Butters, S. Gao, D. S. Knopman, L. J. Launer, K. Yaffe, B. N. Cuthbert, E. Edwards, and M. V. Wagster. 2006. The NIH Cognitive and Emotional Health Project (CEHP): Report of the critical evaluation study committee. Alzheimer’s and Dementia 2(1):12-32.

Inouye, S. K., R. G. J. Westendorp, and J. S. Saczynski. 2014. Delirium in elderly people. Lancet 383(9920):911-922.

IOM (Institute of Medicine). 2003. Priority areas for national action: Transforming health care quality. Washington, DC: The National Academies Press.

Koh, H. K., and K. G. Sebelius. 2010. Promoting prevention through the Affordable Care Act. New England Journal of Medicine 363(14):1296-1299.

Kovacich, J., R. Garrett, and E. M. Forti. 2006. New learning programs in cognitive vitality, Alzheimer’s disease, and related dementias. Gerontology and Geriatrics Education 26(4):47-61.

Leland, N., S. J. Elliot, and K. Johnson. 2012. Occupational therapy practice guidelines for productive aging community-dwelling older adults. Bethesda, MD: AOTA Press.

Marcantonio, E. R., L. H. Ngo, M. O’Connor, R. N. Jones, P. K. Crane, E. D. Metzger, and S. K. Inouye. 2014. 3D-CAM: Derivation and validation of a 3-minute diagnostic intervew for CAM-defined delirium: A cross sectional diagnostic test study. Annals of Internal Medicine 161(8):554-561.

Melady, D., Mount Sinai Emergency Associates, and LeaderLine Studios, Inc. 2013. Geri-EM: Personalized e-learning in geriatric emergency medicine. http://geri-em.com (accessed January 27, 2015).

MetLife Foundation and Harris Interactive Inc. 2011. What America thinks: MetLife Foundation Alzheimer’s survey. https://www.metlife.com/assets/cao/foundation/alzheimers-2011.pdf (accessed December 15, 2014).

Moran, W. P., J. Zapka, P. J. Iverson, Y. Zhao, M. K. Wiley, P. Pride, and K. S. Davis. 2012. Aging Q3: An initiative to improve internal medicine residents’ geriatrics knowledge, skills, and clinical performance. Academic Medicine 87(5):635-642.

Moyer, V. A. 2014. Screening for cognitive impairment in older adults: U.S. Preventive Services Task Force recommendation statement. Annals of Internal Medicine 160(11):791-797.

NIA (National Institute on Aging). 2008. Talking with your older patient: A clinician’s handbook. NIH 08-7105. http://www.nia.nih.gov/sites/default/files/talking_with_your_older_patient.pdf (accessed December 15, 2014).

———. 2014a. Assessing cognitive impairment in older patients: A quick guide for primary care physicians. http://www.nia.nih.gov/alzheimers/publication/assessing-cognitive-impairment-older-patients (accessed February 2, 2015).

———. 2014b. Health and aging: Talking with your doctor presentation toolkit. http://www.nia.nih.gov/health/publication/talking-your-doctor-presentation-toolkit (accessed December 15, 2014).

NICE (National Institute for Health and Care Excellence). 2010. Delirium: Diagnosis, prevention and management. https://www.nice.org.uk/guidance/cg103 (accessed January 8, 2015).

Overbeck, K., A. Chopra, P. Basehore, and R. Nagele. 2014. Medical student curriculum: Cognitive and behavioral disorders domain. http://www.pogoe.org/productid/21303 (accessed December 15, 2014).

POGOe (The Portal of Geriatrics Online Education). 2014. Geriatrics competencies by specialty. http://www.pogoe.org/geriatrics-competencies (accessed December 15, 2014).

Royal Australian College of General Practitioners. 2012. Preventive activities in older age. In Guidelines for preventative activities in general practice, Eighth ed. East Melbourne: Royal Australian College of General Practitioners. Pp. 28-33.

Thornlow, D. K., C. Auerhahn, and J. Stanley. 2006. A necessity not a luxury: Preparing advanced practice nurses to care for older adults. Journal of Professional Nursing 22(2):116-122.

Warren-Findlow, J., A. E. Price, A. K. Hochhalter, and J. N. Laditka. 2010. Primary care providers’ sources and preferences for cognitive health information in the United States. Health Promotion International 25(4):464-473.

Williams, B. C., V. Weber, S. F. Babbott, L. M. Kirk, M. T. Heflin, E. O’Toole, M. M. Schapira, E. Eckstrom, A. Tulsky, A. M. Wolf, and S. Landefeld. 2007. Faculty development for the 21st century: Lessons from the Society of General Internal Medicine-Hartford Collaborative Centers for the Care of Older Adults. Journal of American Geriatrics Society 55(6):941-947.

Yarnall, K. S., T. Østbye, K. M. Krause, K. I. Pollak, M. Gradison, and J. L. Michener. 2009. Family physicians as team leaders: “Time” to share the care. Preventing Chronic Disease 6(2):A59. http://www.cdc.gov/pcd/issues/2009/apr/08_0023.htm (accessed December 15, 2014).