P2‐391: Development of a Primary Care Protocol for the Diagnosis and Treatment of Mild Cognitive Impairment and Dementia

Abstract

and training. We will present a care strategy and pathway to address these three areas. Conclusion: Patients with dementia who are admitted to acute care hospitals may have better outcomes with attention to three elements of care. These three elements should form the basis for improvement efforts for these patients.Background:Intermountain Healthcare is the largest healthcare system in the Intermountain West, delivering care in 185 clinics and 22 hospitals across Utah and the surrounding regions. Queries of our electronic medical record indicated that prevalence of dementia was below expectations based on population-based estimates. Thus, we suspected underreporting of cognitive impairment and wide variation in clinical care. The Neurosciences Cognitive Care Development Team created a system-wide approach to diagnosing and treating mild cognitive impairment and dementia. Our aim was to determine whether a primary-care focused protocol would improve both the detection of cognitive impairment as well as the quality of care provided. Methods: The cognitive care team invited stakeholder participation from neurology, psychology, mental health, geriatrics, primary care, nursing, home care, hospice, care management, radiology, administration, patients, caregivers, and local community and governmental organizations. Our team was supported with a data manager, outcomes analyst, and technical writer. Data for analysis was retrieved from the Intermountain Enterprise Data Warehouse. We developed a standardized protocol to evaluate cognitive impairment, including how primary care providers screen for dementia at the Medicare annual wellness visit (AWV). A positive Mini-Cog at the AWV or physician, patient, or family concern about cognitive impairment prompt a diagnostic workup that includes focused history from the patient and a knowledgeable informant, objective cognitive exam (Montreal Cognitive Assessment), functional assessment, medication reconciliation, and screening for delirium. Guidance regarding diagnosis, neuroimaging, indications for specialty referral, and non-pharmacologic treatment for mild cognitive impairment and dementia, as well as pharmacologic treatment by specific diagnosis was provided as part of the protocol. We created tools to record results of screenings, assessments, and interventions in the electronic medical record such that pre-and post-implementation comparisons could be made. We disseminated the new protocol via trainings at the leadership, regional, and clinic levels. Adherence to the cognitive care protocol, increase in detection rate of dementia, and primary care provider satisfaction will be analyzed. Conclusions: By standardizing our primary care approach to cognitive disorders, we leveraged limited resources to improve cognitive care delivery to one third of patients aged 65 and older in Utah.

Cognitive Screening Tools for Late Career Physicians: A Critical Review

“…The MoCA is a 10-minute paper-and-pencil screening tool offered in dozens of languages by minimally trained registered examiners ( https://www.mocatest.org/ ). Originally designed to improve detection of mild cognitive impairment (MCI) in clinical settings, it has been in wide use among primary care providers, often used as a standard in care process models 22 among or (in the United States) to meet Medicare Annual Wellness Visit requirements to screen for cognitive impairment among elderly individuals. Criterion validity, test–retest reliability, internal consistency, sensitivity, specificity, positive, and negative predictive values were described by Nasreddine and colleagues.…”