As Alzheimer’s disease and other dementias continue to rise nationwide, new research shows that equipping primary care providers with focused dementia training and embedding clinical decision-support tools directly into the electronic medical record (EMR) can significantly improve dementia diagnosis and care.
More than 7 million Americans are currently living with Alzheimer’s disease or dementia a number projected to rise to 13 million by 2050, according to the Alzheimer’s Association.
In the recent study, published in Cureus Journal of Medical Science, researchers at the University of California San Diego School of Medicine found that primary care providers are often the first to notice cognitive changes in older patients. The study identified when dementia training and EMR-integrated tools are introduced, there are measurable gains in provider confidence and a dramatic increase in screening rates.
Since the study’s completion, the San Diego Alzheimer’s Project has helped five San Diego health systems adopt EMR-integrated standards for cognitive screening and evaluation.
Ian Neel, MD, geriatrician at UC San Diego Health, co-chair of the San Diego Alzheimer’s Project and corresponding author of the study, has helped lead a county-wide effort to standardize dementia screening and improve early diagnosis across the region. During May’s Mental Health Awareness Month, Neel highlights research conducted by UC San Diego School of Medicine researchers, the San Diego Alzheimer’s Project and the broader work underway by a county-wide team to equip primary care physicians with the tools and training needed to detect and manage cognitive decline earlier:
With primary care providers typically being the first to notice cognitive changes in older patients, why are the findings of this study so important?
This study, lead by Daniel Sewell, MD, highlights the impact that systematic dementia training can have on screening and detection among primary care providers. Many view Alzheimer’s disease as a disorder to be managed by subspecialists, such as neurologists, geriatricians, and geriatric psychiatrists. While these specialists are essential in helping care for those with dementia, we face a true resource limitation not just in San Diego, but nationwide.
With Alzheimer’s disease affecting at least one in three people over the age of 85 and more than 100,000 people in San Diego living with dementia, there are not enough subspecialists to care for every patient with dementia. That reality makes the role of primary care providers essential. This study highlights the crucial work being done to educate primary care providers and providing tools to help prepare them to take care of those with cognitive impairment.
How could these findings improve patient care regionally?
We learned through this study that when primary care providers undergo specialized dementia training, they are more likely to perform screening and diagnostic visits and feel confident in conducting these visits. That confidence is key to sustaining earlier detection and better care.
Beyond this study, the San Diego Alzheimer’s Project has been working for more than a decade to improve dementia care regionally. The Alzheimer’s Project clinical roundtable brings together clinicians from UC San Diego Health, Scripps, Sharp, Kaiser, and community practitioners, along with representatives from the San Diego County board of supervisors and various Alzheimer’s care groups to advance a shared goal of improving screening, evaluation and treatment of patients with Alzheimer’s and other forms of dementia.
What specific dementia screening tools are now available in the EMR and how will this help provide new opportunities for early detection of dementia at routine doctor visits?
Numerous changes have been implemented into the EMR to help with integration, including smart phrases containing automated documentation and decision support tools for providers. These tools guide clinicians through a screening and evaluation algorithm in real time during patient visits.
Automated order lists and banner pop-ups suggesting actions to be taken have been added to the EMR along with links to resource information for clinicians such as a direct link to the digital version of the Alzheimer’s Project clinical guidelines. Additionally, resource information for caregivers populates in the after-visit summary. Many of these banners appear if a patient has an abnormal score on the self-reported symptom survey in their pre-visit questionnaire.
Why is early detection of dementia so important and how can early proactive steps make an impact on patient outcomes?
Early detection is essential for Alzheimer’s disease and dementia, as it allows for quicker initiation of treatment, education of caregivers, and advanced care planning to help patients and their families anticipate and prepare for necessary care ahead.
Beyond medications, many of which are most helpful at the earliest stages of disease, we have found that lifestyle interventions are most impactful for reducing risk of disease progression when started early. Lifestyle interventions and non-pharmacologic methods carry a higher probability of impacting disease than the currently approved dementia medications, including physical exercise, cognitive training, social engagement and caregiver education.
Are there mental health disorders that are key predictors of cognitive impairment and dementia risk?
We know that there is an intricate link between mental health and cognitive impairment. Untreated mental health disorders such as depression have a higher incidence of cognitive impairment later in life. Further, new onset of mental health disorders late in life in someone who does not have an earlier history of mental health problems may actually be the first sign of a cognitive disorder. These symptoms warrant careful evaluation and follow-up.
What care and services does UC San Diego Health provide for patients with dementia, and what are key symptoms to look out for?
UC San Diego Health provides comprehensive dementia care through several programs: the brain health and memory disorders clinic, inpatient and outpatient consultations for memory and cognitive health through the division of geriatric medicine, and mental health support via the Senior Behavioral Health geriatric psychiatry program. Our UC San Diego research presence includes the Shiley-Marcos Alzheimer’s Disease Research Center as well as the Stein Institute for Research on Aging.
Early cognitive changes can be difficult to detect and distinguish from normal forgetfulness. Warning signs can include any changes in memory, cognition or function. Sometimes we find patients begin having difficulty with problem solving or completing what once were familiar tasks. Changes in mood or late-life depression can also be signs of cognitive impairment. We worry most when there is a change in thinking or behavior compared to someone’s baseline. “10 Early Signs and Symptoms of Alzheimer’s and Dementia” from the Alzheimer’s Association is a helpful resource for assessing cognitive changes.
