Evaluating Cognitive Impairment in a Large Health Care System: The Cognition in Primary Care Program.

Background: The prevalence of Alzheimer's disease and related disorders (ADRD) is rising. Primary care providers (PCPs) will increasingly be required to play a role in its detection but lack the training to do so. Objective: To develop a model for cognitive evaluation which is feasible in primary care and evaluate its implementation in a large health system. Methods: The Cognition in Primary Care Program consists of web-based training together with integrated tools built into the electronic record. We implemented the program among PCPs at 14 clinics in a large health system. We (1) surveyed PCPs to assess the impact of training on their confidence to evaluate cognition, (2) measured the number of cognitive assessments they performed, and (3) tracked the number of patients diagnosed with mild cognitive impairment (MCI). Results: Thirty-nine PCPs completed the training which covered how to evaluate cognition. Survey response rate from those PCPs was 74%. Six months after the end of the training, they reported confidence in assessing cognition (mean 4.6 on 5-point scale). Cognitive assessments documented in the health record increased from 0.8 per month before the training to 2.5 in the six months after the training. Patients who were newly diagnosed with MCI increased from 4.2 per month before the training to 6.0 per month in the six months after the training. Conclusions: This model for cognitive evaluation in a large health system was shown to increase cognitive testing and increase diagnoses of MCI. Such improvements are essential for the timely detection of ADRD.

Developing a cognitive assessment toolkit for primary care: qualitative assessment of providers' needs and perceptions of usability in clinical practice.

BACKGROUND: Burden of dementia is expected to substantially increase. Early dementia is underdiagnosed in primary care. Given the benefits of active management of dementia, earlier detection in primary care is imperative. The aim of this study was to understand primary care provider (PCP) perceptions of implementing a cognitive assessment toolkit in primary care. METHODS: PCPs in a large health system in the US were recruited to a qualitative study utilizing semi-structured interviews. Interviews captured provider perceptions of options for implementing a cognitive assessment toolkit derived from the Gerontological Society of America (GSA) KAER (Kickstart, Assess, Evaluate, Refer) toolkit, including a workflow and adapted clinical tools. A content analysis approach distinguished themes and exemplary quotes. RESULTS: Ten PCPs were interviewed. They found the toolkit useful, felt the term Kickstart was not specific to dementia care, and stressed that addressing cognitive evaluation would need to be easy to implement in a clinical workflow. Finally, providers knew many resources for referral but were unsure how to help patients navigate options. CONCLUSIONS: Providers stressed simplicity, ease, and efficiency for implementation of a cognitive assessment toolkit. Incorporating these findings into the development of clinical tools and workflows may increase cognitive evaluations conducted by PCPs.

Advance Care Planning During the COVID-19 Pandemic.

Advance care planning (ACP) is especially important during the COVID-19 pandemic. Previously identified barriers to ACP include lack of time during patient visits, billing, clinician and patient discomfort and lack of resources, and difficulties with documenting and accessing ACP documents. Here we describe new challenges and new opportunities for ACP that have arisen from the COVID-19 pandemic, both due to the complexities of the illness and expedited changes in some of the stagnancies in the health care system. The shared risk for COVID-19 that all people face brings urgency to institutional policy changes to ACP form completion. However, research should assess acceptability and effectiveness of these strategies.

Varicose Veins: Diagnosis and Treatment.

Varicose veins are twisted, dilated veins most commonly located on the lower extremities. The exact pathophysiology is debated, but it involves a genetic predisposition, incompetent valves, weakened vascular walls, and increased intravenous pressure. Risk factors include family history of venous disease; female sex; older age; chronically increased intra-abdominal pressure due to obesity, pregnancy, chronic constipation, or a tumor; and prolonged standing. Symptoms of varicose veins include a heavy, achy feeling and an itching or burning sensation; these symptoms worsen with prolonged standing. Potential complications include infection, leg ulcers, stasis changes, and thrombosis. Conservative treatment options include external compression; lifestyle modifications, such as avoidance of prolonged standing and straining, exercise, wearing nonrestrictive clothing, modification of cardiovascular risk factors, and interventions to reduce peripheral edema; elevation of the affected leg; weight loss; and medical therapy. There is not enough evidence to determine if compression stockings are effective in the treatment of varicose veins in the absence of active or healed venous ulcers. Interventional treatments include external laser thermal ablation, endovenous thermal ablation, endovenous sclerotherapy, and surgery. Although surgery was once the standard of care, it largely has been replaced by endovenous thermal ablation, which can be performed under local anesthesia and may have better outcomes and fewer complications than other treatments. Existing evidence and clinical guidelines suggest that a trial of compression therapy is not warranted before referral for endovenous thermal ablation, although it may be necessary for insurance coverage.

Attitudes and Barriers Encountered in Training Family Medicine Residents in Nursing Home Care: A National Survey of Program Directors: A CERA Study.

BACKGROUND AND OBJECTIVES: The purpose of this study is to evaluate program director perceptions of influences on resident decisions to practice long-term care (LTC) medicine. Family physicians are well suited to provide nursing home care, but limited available data suggests a decline in the number of family physicians who do so. Family medicine residencies need to address the need for long-term care providers. BACKGROUND AND OBJECTIVES: The purpose of this study is to evaluate program director perceptions of influences on resident decisions to practice long-term care (LTC) medicine. Family physicians are well suited to provide nursing home care, but limited available data suggests a decline in the number of family physicians who do so. Family medicine residencies need to address the need for long-term care providers. RESULTS: We found that support and perceived preparedness for residency graduates practicing in nursing homes was high. We found that barriers to training were few, with resident interest being the largest barrier. Census region and community size correlated significantly to program directors' estimates of the percentage of residents to be practicing in nursing homes after graduation. CONCLUSIONS: Family medicine residency directors acknowledge the need for family medicine residents to be trained in nursing home care. Further research and policy development are needed to support family physicians in playing key roles in providing care to patients in American nursing homes.

A Curriculum on Care for Complex Patients: Resident Perspectives.

BACKGROUND AND OBJECTIVES: Caring for patients with a challenging mix of medical, psychological, and social problems may easily overwhelm residents. We developed a month-long "Care for Complex Patients" curriculum for second-year residents to improve their ability to care for this group of patients by increasing their understanding of why the care is complex and by building communication, teamwork, and resource management skills. METHODS: Surveys and focus groups were used to assess the impact of the curriculum. Quantitative and qualitative methods were used to evaluate responses. RESULTS: Between 2008 and 2010, 24 residents completed our rotation. Eighty-three percent completed the pre-curriculum and post-curriculum surveys. Residents' self-ratings significantly improved in all 11 complex care management skills, and residents reported increased confidence when working with patients whose care was complex. Residents were surprised to learn about all the community resources and began using these resources when providing care for these patients. Despite rating themselves improved, a large number of residents still rated themselves as not competent in many of the skills. CONCLUSIONS: A curriculum for residents focused on education in 11 key skill areas in the care of complex patients led to increased self-confidence and willingness to provide complex care. However, 1 month of training is an insufficient amount of time to help most learners achieve self-assessed ratings of capable and competent in using these key skills when caring for complex patients.

Common Questions About Pressure Ulcers.

Patients with limited mobility due to physical or cognitive impairment are at risk of pressure ulcers. Primary care physicians should examine at-risk patients because pressure ulcers are often missed in inpatient, outpatient, and long-term care settings. High-risk patients should use advanced static support surfaces to prevent pressure ulcers and air-fluidized beds to treat pressure ulcers. Physicians should document the size and clinical features of ulcers. Cleansing should be done with saline or tap water, while avoiding caustic agents, such as hydrogen peroxide. Dressings should promote a moist, but not wet, wound healing environment. The presence of infection is determined through clinical judgment; if uncertain, a tissue biopsy should be performed. New or worsening pain may indicate infection of a pressure ulcer. When treating patients with pressure ulcers, it is important to keep in mind the patient's psychological, behavioral, and cognitive status. The patient's social, financial, and caregiver resources, as well as goals and long-term prognosis, should also be considered in the treatment plan.

Nursing home practice among recent family medicine residency graduates.

BACKGROUND AND OBJECTIVES: As the US population ages, nursing homes need more care providers. However, family physicians are narrowing their scope of practice. Characterizing family medicine practice patterns is essential for educational and workforce planning related to nursing home practice. METHODS: We analyzed a survey of 1,506 family medicine residency graduates from the Pacific Northwest between 1997 and 2009, examining whether they practiced in nursing homes and felt prepared for this practice. RESULTS: Nursing home practice among recent family medicine residency graduates declined from 61.4% in 1997 to 25.9% in 2009, despite no change in perceived level of preparedness for this practice. CONCLUSIONS: The Pacific Northwest has experienced a significant decline in nursing home practice among recent family medicine residency graduates. Further research is needed to elucidate the reasons for this workforce change and to plan for the increased need in nursing home providers.

A nondrug approach to dementia.

Nearly 9 out of 10 patients with dementia also suffer from behavioral symptoms. Several nonpharmaceutical interventions hold promise.

Review: two online curricula on transitions of care.

Transitional care is an important part of geriatric medicine that has not traditionally been taught to residents through formal curricula. This article reviews two online curricula available through the Portal of Geriatric Online Education. The two products reviewed here, appropriate for resident training, focus on care transitions from hospital to other care settings.

Clinical inquiries. Do patients at high risk of Alzheimer's disease benefit from early treatment?

Yes, but the extent of the benefit is unclear. Treating patients with early-stage Alzheimer's disease yields statistically significant, though perhaps not clinically significant, improvement in cognition and global function. In a few cases, it may delay loss of function and need for long-term care. Treating patients with mild cognitive impairment (MCI)-the most likely precursor to Alzheimer's disease-with cholinesterase inhibitors seems to have an initial, but perhaps unsustained, benefit over no treatment. Withdrawing anticholinergic drugs from patients taking them promises to reduce symptoms of MCI, but is unlikely to reduce rates of Alzheimer's.