This interactive Rhode Island Physician Ebook contains 20 hours of continuing education. To complete click the Complete Your CE button at the top right of the screen.
Rhode Island Continuing Medical Education
RHODE ISLAND MEDICAL LICENSURE PROGRAM
MANDATORY CME REQUIREMENTS FOR RHODE ISLAND LICENSE RENEWAL
ENCLOSED PROGRAM INCLUDES: • 3 CREDIT HOURS Alzheimer’s Disease and Dementias (Mandatory) • 10 CREDIT HOURS Opioid Use Disorder (Mandatory) • 2 CREDIT HOURS Frontotemporal Dementia (Elective) • 5 CREDIT HOURS Medical Marijuana (Elective)
INCLUDES: DEA’s One- time MATE Act Requirement
In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
CME FOR:
AMA PRA CATEGORY 1 CREDITS ™
MOC STATE LICENSURE
RENEWAL DEADLINE: 6/30/2026
AVAILABLE ONLINE AT: RI.CME.EDU
RHODE ISLAND PHYSICIAN
Dear Colleagues,
All physicians licensed to practice allopathic or osteopathic medicine are required to document to the Board of Medical Licensure and Discipline that they have earned a minimum of forty (40) hours of American Medical Association (AMA) Category 1 or American Osteopathic Association (AOA) Category 1a continuing medical education (CME) credits. For the 2024 medical license renewal cycle, continuing medical education requirements may be met by 40 hours of ACCME-accredited training in any topic areas over a two-year period. There are no specific topics required by the Rhode Island Board of Medical Licensure and Discipline for this license renewal cycle. Effective August 1, 2019, every physician has to complete one hour (per career) of CME training regarding Alzheimer’s disease. Additionally, effective June 27, 2023, any new or renewing DEA registrants, upon submission of their application, are required to fulfill at least eight (8) hours of education on the treatment or management of patients with opioid or other substance use disorder. The InforMed Rhode Island Medical Licensure Program is designed to fulfill this legislative CME requirement for physicians in Rhode Island. Completion of this program satisfies the Alzheimer’s Disease training requirement, eight (8) hours on the DEA MATE Act Requirement, as well as seven (7) elective credit hours of education.
Thank you for choosing lnforMed as your CME provider. We strive to create a high-quality, streamlined program for our colleagues. Please contact us with any questions, concerns, or suggestions.
Best Regards,
The lnforMed CME Team
We are a nationally accredited CME provider. For all board-related inquiries please contact:
Department of Health | 3 Capitol Hill | Providence, RI 02908 | (401) 222-5960
BOOK.CME.EDU
BOOK CODE: MDRI2026
1-800-237-6999
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What’s Inside
01
ALZHEIMER’S DISEASE AND DEMENTIAS: INSIGHTS FOR EARLY DETECTION AND CARE PLANNING COURSE ONE | 3 CREDIT HOURS SATISFIES THE ALZHEIMER’S DISEASE TRAINING REQUIREMENT Alzheimer’s disease and other forms of dementia are complex conditions that impact cognitive function and daily life. Early detection and diagnosis are crucial for effective management and improving quality of life. Key concepts covered in this course include recognizing early warning signs, utilizing cognitive assessment tools like the MMSE and MoCA, and understanding both pharmacological and nonpharmacological treatments. Developing comprehensive care plans and involving caregivers in the process are essential for providing holistic care and staying informed about emerging treatments and ongoing research is vital for advancing dementia care. By integrating these key concepts, healthcare professionals can better support patients and their families through the ongoing and evolving challenges of dementia.
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OPIOID USE DISORDER COURSE TWO | 10 CREDIT HOURS SATISFIES THE DEA MATE ACT REQUIREMENT
Morphine and heroin were first synthesized and used medicinally in the nineteenth century, and recreational and illicit use followed. Historically, heroin dependence has been difficult to treat successfully, with poor outcome being attributed to patient characteristics, environmental factors, and the powerful reinforcing effects of the drug. Agonist-replacement therapy was introduced more than 40 years ago and represented a breakthrough in the management of heroin addiction. Advances in treatment have included newer pharmacotherapies, psychosocial therapy, and the growth and accessibility of 12-step programs such as Narcotics Anonymous. This course will provide the most pertinent, up-to-date information regarding the characteristics of the patients with opioid use disorder; the mechanism of opioid action and the neurobiology of opioid addiction; the epidemiology, diagnosis and risk factors of opioid abuse and dependence; and pharmacologic, psychosocial, 12-step/self-help, and alternative therapies that are effective in treating opioid use disorders. Additionally, the demographics, characteristics, comorbidity and treatment of synthetic and prescription opioid use disorder will be addressed.
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FRONTOTEMPORAL DEMENTIA COURSE THREE | 2 CREDIT HOURS
Frontotemporal dementia (FTD) is a group of degenerative brain disorders causing progressive deterioration in behavior, language, and/or movement. There are presently approximately 60,000 people with FTD in the United States. Onset generally occurs between 50 and 70 years of age, making FTD one of the most common presenile dementias. FTD affects the frontal and temporal lobes of the brain, which control emotions, judgment, personality, memory and language. The clinical diagnosis of FTD can be challenging, as some symptoms overlap with Alzheimer disease and other forms of dementia. FTD can be categorized based on its primary symptoms into three basic types: behavioral variant FTD, primary progressive aphasia, and progressive motor decline. Although most FTD does not appear to be inherited, genetics does play a role in a significant minority of cases. There is no effective treatment or cure for FTD, but there are strategies for management of symptoms. This course will discuss the possible causes and pathophysiology, diagnosis, and management strategies for FTD.
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MEDICAL MARIJUANA AND OTHER CANNABINOIDS COURSE FOUR | 5 CREDIT HOURS
A large body of clinical trials has now been published on cannabis and other cannabinoids in the treatment or management of a wide range of diseases and conditions. This course will review the body of research on medicinal cannabis to provide the learner with the most recently available information on potential indications, pharmacology and mechanism of action, acute and chronic side effects, and patients for whom medicinal cannabis is contraindicated. Also discussed will be a comparison between medicinal and recreational cannabis users, and how differences between the two groups in background characteristics and patterns of cannabis ingestion may differentially influence the development of side effects such as cannabis abuse and dependence. An evaluation of the strength and the quality of the research evidence will also be provided, as well as a discussion of how the cannabinoid mechanism of action may interact with disease pathogenesis to produce clinical benefit. The use of cannabis for medicinal purposes throughout recorded human history will also be presented.
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FINAL EXAMINATION ANSWER SHEET REQUIRED TO RECEIVE CREDIT
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MOC CREDIT INFORMATION
Participants can earn MOC points equivalent to the amount of CME credits claimed for designated activities. InforMed currently reports to the following specialty boards: ABA, ABIM, ABS, ABPath and ABP. To be awarded MOC points, you must obtain a passing score, complete the corresponding activity evaluation, and provide required information necessary for reporting.
Table 1. MOC Recognition Statements Successful completion of certain enclosed CME activities, which includes participation in the evaluation component, enables the participant to earn up to the amounts and credit types shown in Table 2 below. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit. Board Programs
American Board of Anesthesiology’s redesigned Maintenance of Certification in Anesthesiology TM (MOCA®) program, known as MOCA 2.0®
ABA
ABIM American Board of Internal Medicine’s Maintenance of Certification (MOC) program
ABS American Board of Surgery’s Continuous Certification program
ABPath American Board of Pathology’s Continuing Certification program
ABP American Board of Pediatrics’ Maintenance of Certification (MOC) program
Table 2. Credits and Type Awarded
AMA PRA Category 1 Credits T M
Activity Title
ABA
ABIM ABS
ABPath
ABP
Alzheimer's Disease and Dementias: Insights for Early Detection and Care Planning
3 AMA PRA Category 1 Credits TM
3 Credits LL
3 Credits MK
3 Credits SA + AC
3 Credits LL
3 Credits LL
10 AMA PRA Category 1 Credits TM 2 AMA PRA Category 1 Credits TM 5 AMA PRA Category 1 Credits TM
10 Credits LL 2 Credits LL 5 Credits LL
10 Credits MK 2 Credits MK 5 Credits MK
10 Credits SA + AC 2 Credits SA + AC 5 Credits SA + AC
10 Credits LL 2 Credits LL 5 Credits LL
10 Credits LL+SA 2 Credits LL 5 Credits LL+SA
Opioid Use Disorder
Frontotemporal Dementia
Medical Marijuana and Other Cannabinoids
Legend: LL = Lifelong Learning, MK = Medical Knowledge, SA = Self-Assessment, LL+SA = Lifelong Learning & Self-Assessment, AC = Accredited CME
DATA REPORTING: Federal, State, and Regulatory Agencies require disclosure of data reporting to all course participants. InforMed abides by each entity’s requirements for data reporting to attest compliance on your behalf. Reported data is governed by each entity’s confidentiality policy. To report compliance on your behalf, it’s mandatory that you must achieve a passing score and accurately fill out the learner information, activity and program evaluation, and the 90-day follow-up survey. Failure to accurately provide this information may result in your data being non-reportable and subject to actions by these entities.
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How to complete
Please read these instructions before proceeding. Read and study the enclosed courses and answer the final examination questions. To receive credit for your courses, you must provide your customer information and complete the mandatory evaluation. We offer two ways for you to complete. Choose an option below to receive credit and your certificate of completion.
ONLINE
FASTEST AND EASIEST!
• Go to BOOK.CME.EDU and enter code MDRI2026 in the book code box, then click GO.
Enter book code
• Proceed to your exam. If you already have an account, sign in with your username and password. If you do not have an account, you’ll be able to create one now. • Follow the online instructions to complete your final examination. Complete the purchase process to receive course credit and your certificate of completion. Please remember to complete the online evaluation.
MDRI2026
GO
IF YOU’RE ONLY COMPLETING CERTAIN COURSES IN THIS BOOK: • Go to BOOK.CME.EDU and enter the code that corresponds to the course below, then click GO. Each course will need to be completed individually, and the specified course price will apply.
Complete the answer sheet and evaluation found in the back of this book. Include your payment information and email address. Mail to: InforMed, PO Box 997432, Sacramento, CA 95899
BY MAIL
Mailed completions will be processed within 2 business days of receipt, and certificates emailed to the address provided. Submissions without a valid email address will be mailed to the postal address provided.
Program Options Price
Option
Code
Credits
$110
ENTIRE PROGRAM (INCLUDES ALL COURSES)
MDRI2026
20
Alzheimer's Disease and Dementias: Insights for Early Detection and Care Planning
$30
MDRI03AD 3
$80
Opioid Use Disorder
MDRI10OD 10
$30
Frontotemporal Dementia
MDRI02FD
2
$50 Medical Marijuana and Other Cannabinoids
MDRI05MM 5
Note: Prices are subject to change
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_______________________________ Alzheimer Disease and Dementias: Early Detection and Care Planning MDRI03AD — 3 CREDIT HOURS R elease D ate : 09/01/24 E xpiration D ate : 08/31/27 Alzheimer Disease and Dementias: Early Detection and Care Planning In addition to receiving AMA PRA Category 1 Credit TM , physicians participating in Maintenance of Certification will receive the following points appropriate to their certifying board: 3 ABIM MOC Points, 3 ABS MOC Points, 3 ABPath CC Points.
Faculty Candace Pierce, DNP, RN, CNE, COI , is a nurse leader committed to ensuring nurses are well-prepared and offered abundant opportunities and resources to enhance their skills acquisition and confidence at the bedside. With 15 years in nursing, she has worked at the bedside, in management, and in nursing education. She has demonstrated expertise and scholarship in innovation and design thinking in health care and education, and collaborative efforts within and outside of healthcare. Scholarship endeavors include funded grants, publications, and presentations. As a leader, Dr. Pierce strives to empower others to create and deploy ideas and embrace their professional roles as leaders, change agents, and problem solvers. In her position as the lead nurse planner for Elite, she works as a project engineer with subject matter experts to develop evidence-based best practices in continuing education for nurses and other healthcare professionals. Faculty Disclosure Contributing faculty, Candace Pierce, DNP, RN, CNE, COI, has disclosed no relevant financial relationship with any prod- uct manufacturer or service provider mentioned. Division Planner John M. Leonard, MD Senior Director of Development and Academic Affairs Sarah Campbell Division Planner/Director Disclosure The division planner and director have disclosed no relevant financial relationship with any product manufacturer or service provider mentioned. Accreditations & Approvals In support of improving patient care, NetCE is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Mention of commercial products does not indicate endorsement.
HOW TO RECEIVE CREDIT
• Read the enclosed course. • Complete the final examination questions at the end. A score of 70% is required. • Return your customer information/answer sheet, evaluation, and payment to InforMed by mail or complete online at BOOK.CME.EDU.
Audience This course is designed for physicians, PAs, and nursing profes- sionals who are involved in the care of patients who have or may develop dementia. Course Objective The purpose of this course is to provide healthcare profession- als with a clear understanding of Alzheimer disease and other dementias, including early signs, stages, and progression, in order to support effective early diagnosis, care planning, and management that improves patients’ quality of life. Learning Objectives Upon completion of this course, you should be able to: 1. Identify the warning signs and symptoms of Alzheimer disease and other forms of dementia. 2. Recognize the importance of early detection and diagnosis of dementia. 3. Recognize a variety of tools to assess a patient’s cognition. 4. Identify cognitive assessment and care planning billing codes. 5. Identify current treatments available for patients with dementia.
6. Apply appropriate communication techniques for discussing memory concerns with patients and their caregivers.
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Designations of Credit NetCE designates this enduring material for a maximum of 3 AMA PRA Category 1 Credit(s) ™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Successful completion of this CME activity, which includes par- ticipation in the evaluation component, enables the participant to earn up to 3 MOC points in the American Board of Internal Med- icine’s (ABIM) Maintenance of Certification (MOC) program. Par- ticipants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit. Comple- tion of this course constitutes permission to share the completion data with ACCME. Successful completion of this CME activity, which includes partic- ipation in the evaluation component, enables the learner to earn credit toward the CME and Self-Assessment requirements of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider’s responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit. Successful completion of this CME activity, which includes partici- pation in the activity with individual assessments of the participant and feedback to the participant, enables the participant to earn 5 MOC points in the American Board of Pediatrics’ (ABP) Main- tenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion infor- mation to ACCME for the purpose of granting ABP MOC credit. Through an agreement between the Accreditation Council for Continuing Medical Education and the Royal College of Physi- cians and Surgeons of Canada, medical practitioners participating in the Royal College MOC Program may record completion of accredited activities registered under the ACCME’s “CME in Sup- port of MOC” program in Section 3 of the Royal College’s MOC Program. About the Sponsor The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare. Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice. Disclosure Statement It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distrib- uting or providing access to this activity to learners.
Sections marked with this symbol include evidence-based practice recommendations. The level of evidence and/or strength of recommendation, as provided by the evidence-based source, are also included
so you may determine the validity or relevance of the information. These sections may be used in conjunction with the course material for better application to your daily practice.
INTRODUCTION Dementia, including Alzheimer disease, is a significant and growing concern globally, particularly among the elderly population. According to the World Health Organization (WHO), more than 55 million people worldwide are living with dementia, and this number is expected to rise to 88 mil- lion by 2030 and 139 million by 2050 [1]. Alzheimer disease is the most common form of dementia, accounting for 60% to 70% of cases. In the United States alone, the Alzheimer’s Association reports that more than 6 million Americans older than 65 years of age are living with Alzheimer disease, a num- ber projected to reach nearly 13 million by 2050 [2; 3]. This condition not only leads to a progressive decline in cognitive function, severely impacting memory, thinking, and social abilities, but also places a substantial emotional, physical, and financial burden on families and caregivers. Early detection and diagnosis are crucial for managing symptoms, planning for the future, and improving the quality of life for those affected. Understanding the different types of dementia, their symptoms, and the importance of early intervention is essential for providing compassionate and effective care to those living with these conditions. OVERVIEW OF DEMENTIA Dementia is a term for a decline in cognitive function severe enough to interfere with daily life and activities [4; 5]. It includes symptoms affecting memory, thinking, and social abilities, making everyday tasks challenging. Dementia is a syndrome resulting from various conditions, such as Alzheimer disease, vascular dementia, Lewy body dementia, and fron- totemporal dementia. Each type has unique symptoms and progression, but common signs include memory loss, difficulty with problem-solving, impaired judgment, and changes in behavior and personality ( Table 1 ). IMPACT ON PATIENTS AND FAMILIES The impact of Alzheimer disease and related dementias (ADRDs) extends beyond the individual, profoundly affecting families and caregivers emotionally, physically, and financially.
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TYPES OF DEMENTIA
Disease
Symptoms
Attributes/Causation
Parkinson disease
Poor executive function Trouble walking, unstable gait Impaired responsiveness to visual cues Speech impairment Impaired affect/modified facial expression Decreased eye blinking Depression Confusion Insomnia Rigidity/freezing, tremor Alzheimer disease traits (memory loss, confusion, and language changes) Frontal lobe brain cell damage due to nerve damage Diagnosis confirmed postmortem Drastic change in behavior and personality Aggression Loss of speech Loss of decision-making ability Loses sense of self-awareness Patient will become completely dependent Progressive dementia Affects ability to think, reason, and process information Impaired movement, mood, and behavior
Basal ganglia cells die, causing dopamine levels to drop Progressive, chronic disease Personalized treatments for symptom relief Exercise can improve symptoms and may protect the brain No cure
Frontotemporal dementia (FTD)
Frontal lobe controls language and personality Also known as Pick disease No cure
Lewy body dementia (LBD)
1.4 million people living with this disease Due to unusual deposits of alpha-synuclein protein on brain Initial diagnosis may be mental/psychological health No cure Caused by constriction or breakdown of blood vessels in and around the brain Can be the result of a stroke(s) Lifestyle factors (diet, lack of movement, smoking) contribute to disease progression Disease can be allayed by exercise, diet, avoiding alcohol and smoking Originally referred to as punch drunk syndrome Caused by extensive hits to the head Brain has tau protein like Alzheimer disease, but presents uniquely in CTE Some symptoms can be addressed with medication Diagnosed postmortem No cure
Parkinsonian-like rigidity Hallucinations, paranoia
Vascular dementia
Problems with reasoning Impacted judgement, memory, and other thought processes Symptoms vary by location of actual constriction
Chronic traumatic encephalopathy (CTE)
Memory loss, confusion Mood disorder, personality changes, rage Can present in mid-life Person becomes erratic and unpredictable
Atypical Alzheimer disease
Amnestic problems Unusually early symptoms impacting executive and motor functioning Similar to Alzheimer disease or other form of dementia Varied symptoms suggest multiple forms of dementia
Frontal variant of Alzheimer disease Posterior cortical atrophy
Mixed dementia
Most often diagnosed as Alzheimer disease Co-existing pathology, such as blood clots or vascular disease, found postmortem Impacted by relationship between cognitive function and underlying brain abnormalities
Table 1 continues on next page.
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TYPES OF DEMENTIA (Continued)
Disease
Symptoms
Attributes/Causation
Corticobasal syndrome (CBS)
Asymmetric limb rigidity, dystonia, muscle jerks (myoclonus), difficulty with motor planning (apraxia) Progressive difficulty with language (aphasia), executive functioning, and visuospatial impairments Changes in personality, irritability, and apathy Rapid cognitive decline with memory loss, confusion, and personality changes Muscle jerks (myoclonus), loss of coordination (ataxia), visual disturbances, and speech abnormalities Anxiety, depression, and psychosis Memory loss, difficulty concentrating, and executive dysfunction Slowed movements, clumsiness, and coordination problems Apathy, depression, and social withdrawal Involuntary jerking movements (chorea), dystonia, slowed movements (bradykinesia) Progressive decline in executive function, memory, and attention Depression, irritability, anxiety, and impulsivity Difficulty walking, shuffling gait, and balance problems Memory loss, confusion, and difficulty with attention and decision-making Urinary incontinence and urgency Difficulty with balance and walking, frequent falls, and stiffness Difficulty moving the eyes, particularly in the vertical direction Executive dysfunction, slowed thinking, and memory problems Apathy, depression, and personality changes
Associated with abnormal tau protein accumulation in the brain, leading to neuronal degeneration Often linked to corticobasal degeneration (CBD), a rare neurodegenerative disease
Creutzfeldt-Jakob disease (CJD)
Caused by prions, which are misfolded proteins that lead to brain damage Can be sporadic, inherited, or acquired through exposure to infected tissue
HIV-associated neurocognitive disorder (HAND)
Caused by the direct effects of HIV on the central nervous system, leading to inflammation and neuronal damage
Huntington disease
A genetic disorder caused by a mutation in the HTT gene, leading to the production of an abnormal huntingtin protein that causes neuronal death
Normal pressure hydrocephalus (NPH)
Caused by an abnormal buildup of cerebrospinal fluid (CSF) in the brain’s ventricles, leading to increased pressure and damage to brain tissues
Progressive supranuclear palsy (PSP)
Caused by the accumulation of tau protein in the brain, leading to the degeneration of specific brain regions, particularly those involved in movement and cognitive function
Source: [6; 7; 8; 9; 10; 11]
Table 1
Patients with dementia experience a progressive decline in cog- nitive function, leading to increased dependency on caregivers for daily activities. This results in significant stress, burnout, and a need for support among caregivers [4]. The economic burden of dementia is substantial. In the United States, the total cost of care for individuals with Alzheimer disease and other dementias was estimated at $321 billion in 2022, with projections reaching nearly $1 trillion by 2050 due to rising prevalence and healthcare costs. These costs include medical care, long-term care, and the value of unpaid caregiv- ing by family members [4].
Early detection and diagnosis of dementia are crucial for man- aging symptoms, planning for the future, and improving the quality of life for those affected. Understanding the prevalence and impact of dementia is essential for developing effective strategies and support systems to address this growing public health challenge. ALZHEIMER DISEASE Alzheimer disease is a progressive neurodegenerative disorder affecting older adults, leading to significant cognitive decline that interferes with daily life. It is the most common form of
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dementia, accounting for 60% to 70% of cases [1]. The disease is marked by amyloid plaques and tau tangles in the brain, disrupting neuronal communication and causing cell death. Early symptoms include memory loss, difficulty in planning and problem-solving, and challenges with language and spatial awareness. As it progresses, individuals may experience severe memory impairment, confusion, mood changes, and difficulty with basic activities [12]. The exact cause of Alzheimer disease is not fully understood but is believed to involve genetic, environmental, and lifestyle factors. Major risk factors include age (primarily affecting those older than 65 years of age) and gender (more common in women). Other risks include family history, genetic muta- tions, and conditions like cardiovascular disease and diabetes. There is no cure, but treatments can temporarily slow symptom progression and improve quality of life. Ongoing research aims to uncover the disease’s mechanisms and develop more effective therapies [4; 10]. THE LONG PRECLINICAL PHASE OF ALZHEIMER DISEASE Research indicates that Alzheimer disease can begin 20 years or more before clinical symptoms appear [12; 13]. During this preclinical phase, amyloid-beta plaques and tau tangles accumulate in the brain, disrupting neuronal function and leading to gradual brain cell death. This period is marked by subtle brain changes that are not yet noticeable. Advanced imaging techniques and biomark- ers, like cerebrospinal fluid analysis, can detect these early changes, offering insights into disease progression [2]. Identi- fying individuals in this stage is crucial for early intervention and developing treatments to slow or halt the disease before significant cognitive impairment occurs. Recognizing that Alzheimer disease starts decades before symp- toms manifest highlights the importance of early detection and monitoring. It also emphasizes the need for ongoing research to develop preventive strategies and treatments targeting the disease’s earliest stages. By focusing on the preclinical phase, healthcare providers can better manage the eventual onset of symptoms, improving outcomes for patients and their families. STAGES OF ALZHEIMER DISEASE Alzheimer disease progresses through stages marked by increas- ing cognitive and functional decline. The Reisberg Scale, or Global Deterioration Scale (GDS), divides this progression into seven stages, grouped into early, middle, and late stages: • Early stages (1–3): Mild cognitive changes that may not be immediately recognized as Alzheimer disease • Middle stages (4–5): More pronounced cognitive decline and increased dependency on caregivers • Late stages (6–7): Severe cognitive and physical impair- ment, requiring comprehensive care and support
Recognizing these stages aids in planning appropriate inter- ventions and support for individuals with Alzheimer disease and their caregivers.
Early Stage (Stages 1–3) Stage 1: No Cognitive Decline
Description: No noticeable symptoms of cognitive impairment. The individual functions normally, with no memory problems or other signs of dementia. Fit into early stage: This stage represents normal cognitive function without any detectable signs of Alzheimer disease. Stage 2: Very Mild Cognitive Decline Description: Minor memory lapses, such as forgetting familiar words or the location of everyday objects. These lapses are not evident to friends, family, or medical professionals. Fit into early stage: This stage is often considered normal age-related memory decline and may not be recognized as Alzheimer disease. Stage 3: Mild Cognitive Decline Description: Noticeable difficulties in memory and concen- tration. Common symptoms include losing valuable objects, trouble remembering names, and difficulty performing tasks in social or work settings. Friends and family may notice these changes. Fit into early stage: This stage marks the beginning of notice- able cognitive impairment, often referred to as mild cognitive impairment. It is a critical period for early diagnosis and intervention. Middle Stage (Stages 4–5) Stage 4: Moderate Cognitive Decline (Mild or Early- Stage Alzheimer Disease) Description: Clear-cut symptoms of Alzheimer disease become apparent. Individuals may have difficulty with complex tasks such as managing finances, planning events, and remembering recent events. They may also become moody or withdrawn, especially in socially or mentally challenging situations. Fit into middle stage: This stage is characterized by a decline in cognitive abilities that affects daily life. It is often when a formal diagnosis of Alzheimer disease is made. Stage 5: Moderately Severe Cognitive Decline (Moderate or Mid-Stage Alzheimer Disease) Description: Significant gaps in memory and cognitive func- tion. Individuals may need help with daily activities such as dressing and grooming. They may forget important details like their address or phone number and may become confused about the date or time.
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AGE-RELATED VERSUS POTENTIAL ADRD DIFFERENTIALS
Normal Age-Related Memory Issues Occasionally making a bad decision Misplacing or losing things occasionally Accidentally missing a bill payment
Potential ADRD
Making poor judgements and decisions occurs frequently Frequently losing items and being unable to locate them Getting the electricity or water shut off for lack of payment over a period of time Difficulties following or participating in a conversation Having an inability to track time; being unable to discern day or week or season
Occasionally lacking the ability to grasp a specific word
Momentarily forgetting the day of the week
Source: [14]
Table 2
Fit into middle stage: This stage involves more severe cogni- tive decline and increased dependency on caregivers for daily activities. Late Stage (Stages 6–7) Stage 6: Severe Cognitive Decline (Moderately Severe or Mid-Stage Alzheimer) Description: Memory continues to worsen, and personality changes may occur. Individuals may lose awareness of their surroundings and recent experiences. They often need exten- sive help with daily activities and may experience changes in sleep patterns, increased wandering, and difficulty recognizing loved ones. Fit into late stage: This stage marks a significant decline in cognitive and functional abilities, requiring substantial care- giving support. Stage 7: Very Severe Cognitive Decline (Severe or Late- Stage Alzheimer) Description: Individuals lose the ability to respond to their environment, carry on a conversation, and eventually control movement. They may need help with all daily activities, includ- ing eating and using the bathroom. Reflexes become abnormal, and muscles grow rigid. Swallowing can become impaired. Fit into late stage: This final stage of Alzheimer disease involves profound cognitive and physical decline, with individuals requiring around-the-clock care. EARLY WARNING SIGNS AND SYMPTOMS Early warning signs and symptoms of Alzheimer disease often manifest subtly and can be easily mistaken for normal aging ( Table 2 ). One of the most common early signs is memory loss, particularly difficulty remembering recently learned information or important dates and events [2]. Individuals may also experience challenges in planning or solving prob- lems, such as difficulty following a familiar recipe or managing monthly bills. Confusion with time or place, such as losing track of dates, seasons, and the passage of time, is another
early indicator. Additionally, people with early Alzheimer disease may have trouble understanding visual images and spatial relationships, leading to difficulties with reading, driv- ing, judging distance, and determining color or contrast [12]. Other symptoms include new problems with words in speaking or writing, misplacing things and losing the ability to retrace steps, decreased or poor judgment, withdrawal from work or social activities, and changes in mood and personality, such as increased confusion, suspicion, depression, or anxiety [10]. Recognizing these early signs is crucial for timely diagnosis and intervention, which can help manage symptoms and improve the quality of life for those affected. ADRDs can also present with symptoms like those of medical conditions that are potentially reversible. Recognizing these conditions is crucial, as addressing them can significantly improve cognitive function and quality of life. Table 3 iden- tifies some common conditions that can mimic dementia symptoms. Addressing these conditions through appropriate medical intervention can lead to significant improvement or complete resolution of symptoms that mimic dementia, highlighting the importance of thorough medical evaluation in individuals presenting with cognitive decline. IMPORTANCE OF EARLY DETECTION AND DIAGNOSIS Early detection of Alzheimer disease and other dementias offers significant benefits for patients and their families. It can improve quality of life by allowing access to treatments that slow symptom progression, helping individuals maintain independence longer [7]. Early diagnosis also enables better symptom management through personalized care plans that address cognitive, behavioral, and physical health needs [12]. Additionally, early detection allows for future planning, help- ing patients and families make informed decisions about legal, financial, and care arrangements, reducing stress and ensur- ing the patient’s wishes are respected [10]. It also provides opportunities for participation in clinical trials and research, contributing to advancements in treatment.
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CONDITIONS AND EVENTS THAT MAY MIMIC DEMENTIA SYMPTOMS
Condition/Event
Symptom(s)
Polypharmacy
Confusion, memory problems, cognitive impairment Hypoxia (low oxygen levels), causing confusion and cognitive decline
Respiratory infection
Urinary tract infection
Acute confusion, agitation, hallucinations
Sleep disorder
Daytime sleepiness, memory problems, decreased cognitive function
Dehydration
Confusion, dizziness, cognitive impairment
Normal pressure hydrocephalus Metabolic/endocrine imbalance
Walking difficulties, urinary incontinence, cognitive decline Impaired cognitive function (particularly with thyroid disorders, diabetes)
Nutritional deficiencies (e.g., vitamin B12)
Memory loss, cognitive decline
Alcohol use
Cognitive impairment, memory problems Steady decline in overall mental function
Subdural hematoma
Poisoning/toxic exposure (heavy metals, pesticides)
Cognitive impairment
Anoxia
Cognitive impairment, somnolence
Source: Compiled by Author
Table 3
The American Psychological Association asserts that an interdisciplinary team is most likely to provide all the essential information necessary to make an accurate diagnosis of dementia and develop a comprehensive treatment plan.
DIAGNOSTIC PROCESS The diagnostic process for dementia involves several steps to ensure an accurate and comprehensive assessment. Initially, healthcare providers conduct a thorough medical history review and physical examination to rule out other potential causes of cognitive decline. This is followed by cognitive and neuropsychological testing to evaluate memory, problem- solving abilities, language skills, and other cognitive functions [12]. Imaging studies, such as MRI or CT scans, are often used to detect brain changes associated with dementia, while laboratory tests can help identify underlying conditions that may contribute to cognitive impairment. Table 4 provides more details on tests and examinations that may be used to diagnose Alzheimer disease. Healthcare providers play a crucial role in early detection of dementia. Primary care providers, neurologists, and geriatric specialists often notice early signs during routine check-ups or when patients present with memory concerns. They initiate the diagnostic process, coordinate care, and refer patients to specialists as needed. Additionally, they educate and support patients and families, helping them understand the diagnosis and navigate dementia care complexities [7].
(https://www.apa.org/practice/guidelines/guidelines- dementia-age-related-cognitive-change.pdf. Last accessed August 21, 2024.) Level of Evidence : Expert Opinion/Consensus Statement
ASSESSING COGNITION Assessment Tools
Cognitive assessment tools are crucial for diagnosing and moni- toring Alzheimer disease and other dementias. They evaluate cognitive domains like memory, attention, language, and executive function. Common tools include the Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), and clock drawing test (CDT) [15; 16; 17; 18]. The MMSE assesses orientation, registration, attention, calcu- lation, recall, language, and simple commands, scoring out of 30 points. Scores of 24–30 are normal, 18–23 indicates mild impairment, and 0–17 suggests severe impairment. The MoCA provides a comprehensive assessment, including visuospatial abilities, naming, memory, attention, language, abstraction,
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Alzheimer Disease and Dementias: Early Detection and Care Planning _ ______________________________
TESTS/EXAMINATIONS TYPICALLY USED TO DIAGNOSE ALZHEIMER DISEASE
Test/Examination
Assessment
Montreal Cognitive Assessment (MoCA)
Evaluates short-term memory, visuospatial abilities, attention/ concentration/memory, executive function, language, and orientation to time and place Short test that assesses executive function, information registration, recall, language, ability to follow simple commands, and orientation to time and place
Mini-Mental State Examination (MMSE)
Bloodwork
Complete blood count (CBC) Liver function Glucose Thyroid function HIV Electrolytes Folate test Vitamin B12 concentration
CT scan
Evaluate the severity of brain degeneration
Magnetic resonance imaging (MRI)
Deep insight into brain looking for tumors, nerve damage, and unusual markings
Electroencephalogram (EEG)
Measure and evaluate brain wave activity Identify Alzheimer disease amyloid proteins
Positron emission tomography (PET)
Source: [2]
Table 4
and orientation, with scores less than 26 indicating impair- ment. The CDT evaluates executive function and visuospatial abilities by having patients draw a clock showing a specific time [15; 16; 17; 18]. Administering these tools requires a standardized approach for accuracy. The MMSE and MoCA involve guided tasks and scoring, while the CDT involves drawing a clock. Scores are compared with normative data, considering age, education, and cultural background [15; 16; 17; 18]. Choosing the right tool depends on the patient’s clinical presentation and the cognitive domains needing assessment. Other factors to consider include the patient’s language proficiency, cultural background, and any sensory or motor impairments that may affect their performance on the tests. Healthcare providers should also consider the psychometric properties of the tools, such as their sensitivity, specificity, and reliability, to ensure accurate and meaningful results. The MMSE is good for quick screenings, the MoCA for com- prehensive evaluations, and the CDT for executive function and visuospatial skills. Multiple tools can enhance diagnostic accuracy, with the MoCA being particularly sensitive for early impairment detection [15; 18]. COGNITIVE ASSESSMENT BILLING Billing for cognitive assessment and care planning is essential for ensuring that healthcare providers are reimbursed for the time and resources spent on these critical services. The Centers
for Medicare & Medicaid Services (CMS) have established specific billing codes for cognitive assessment and care plan- ning services. These codes allow healthcare providers to bill for the time spent on comprehensive cognitive assessments and care planning for patients with cognitive impairment, including Alzheimer disease and other dementias [4]. The primary codes include [19]: • CPT code 99483: Used for a comprehensive cognitive assessment and care planning for patients with cogni- tive impairment, including Alzheimer disease and other dementias. It covers services such as evaluating cogni- tion, functional status, medication review, and the development of a care plan. Clinicians allowed to bill under this code include physicians, physician assistants, nurse practitioners, clinical nurse specialists, and certi- fied nurse midwives. This code can be used once per 180 days (about every 6 months). • CPT code 99484: Used for standardized cognitive performance testing, which includes the administration and scoring of tests to assess cognitive function The code HCPCS code G0505 was previously used for cogni- tive and functional assessment and care planning for patients with cognitive impairment, including Alzheimer disease and other dementias. It has been replaced by CPT Code 99483 [20]. Table 5 lists other diagnostic codes commonly used in the care of cognitive impairment or dementia.
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_______________________________ Alzheimer Disease and Dementias: Early Detection and Care Planning
COMMONLY USED DIAGNOSTIC CODES
Code
Description
G31.09 G31.83 G31.84 G30.0 G30.1 G30.9 F03.90 F03.91 F01.50 F01.51 F02.80 F02.81 F03.91
Frontotemporal Dementia Dementia with Lewy Bodies Mild Cognitive Impairment
Alzheimer’s Disease with Early Onset Alzheimer’s Disease with Late Onset Alzheimer’s Disease Unspecified
Unspecified Dementia without Behavioral Disturbance Unspecified Dementia with Behavioral Disturbance Vascular Dementia without Behavioral Disturbances Vascular Dementia with Behavioral Disturbances
Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbances Dementia in Other Diseases Classified Elsewhere with Behavioral Disturbances
Unspecified Dementia with Behavioral Disturbances
Source: Compiled by Author
Table 5
More information can be found on billing codes specific to cognitive impairment by the Alzheimer’s Association in their Cognitive Impairment Care Planning Toolkit found at https:// www.alz.org/media/Documents/Cognitive-Impairment-Care- Planning-Toolkit_1.pdf. DOCUMENTATION Proper documentation is crucial for billing cognitive assess- ments accurately. It is also important to note that the total time spent on the assessment and care planning must meet the minimum requirements for the chosen billing code (typically 50 minutes for CPT code 99483). When using CPT Code 99483, healthcare providers should conduct a detailed assess- ment and document the assessment findings to include test scores and interpretations, clinical observations, and patient and caregiver reports. The detailed assessment should include: • Cognitive assessment using standardized tools (e.g., MMSE, Montreal Cognitive Assessment): Detailed evaluation of the patient’s cognitive function, including memory, attention, language, and executive function • Functional assessment: Evaluation of the patient’s ability to perform activities of daily living (ADLs) and instrumental activities of daily living (IADLs) • Medication review: Comprehensive review of all medi- cations the patient is taking, including prescription drugs, over-the-counter medications, and supplements • Safety evaluation: Assessment of the patient’s safety, including risks of falls, wandering, and other hazards • Caregiver assessment: Evaluation of the caregiver’s needs and the impact of caregiving on their health and well-being
CARE PLANNING Care planning is essential in managing Alzheimer disease and other dementias, addressing multiple aspects of the patient’s health and well-being. A comprehensive care plan should out- line treatment goals, medication management strategies, safety measures (e.g., fall prevention), and methods to manage behav- ioral symptoms. It should also include cognitive stimulation activities, social engagement recommendations, and caregiver support and education. Early advance care planning discus- sions are crucial to ensure the patient’s wishes are respected as the disease progresses. Referrals to specialists and community resources should be included for comprehensive support. Person-centered care is vital, involving both the patient and caregivers in the planning process [22]. Healthcare providers should use clear language when explaining assessments and treatment options, encouraging patients to express their prefer- ences and concerns. Caregivers should be included in discussions about care goals and management strategies, as they often play a primary role in day-to-day care. Education about the disease process, expected progression, and available resources should be provided to both patients and caregivers. The needs of the family evolve as Alzheimer disease progresses, and this should be considered at all phases of patient care ( Table 6 ). The importance of advance directives should be discussed, and their completion encour- aged. Regular reviews and updates of the care plan, with input from both the patient and caregiver, ensure its relevance and effectiveness as the disease progresses. Throughout the process,
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Alzheimer Disease and Dementias: Early Detection and Care Planning _ ______________________________
ALZHEIMER DISEASE STAGE AND FAMILY ISSUES
Disease Stage Issues/Concerns of Family
Steps to Address
Early (Stages 1–3)
Accept and address an uncertain future. Identify potential areas of internal family conflict. Recognize that Alzheimer disease can often unveil past conflict.
Form a cohesive family alliance. Seek professional guidance (elder law attorneys, financial planners, social workers). Identify long-term care needs and desires for the person with Alzheimer disease. Establish an honest, open, and supportive communication method. Acknowledge collective grief and loss as the loved one declines. Family members/caregivers may feel trapped, leading to new or worsened conflicts. There may be a sense of lost freedom due to disease-related limitations. It can be hard to separate the person from the illness, necessitating additional support (e.g., respite care). Managing disease symptoms (wandering, mood swings, sleep changes) can be challenging. Balancing work, caregiving, and personal life may seem impossible as needs increase. Without prior planning, families face tough decisions about living arrangements, finances, and external support. Family members may experience grief, health issues, anger, denial, and exhaustion. Family cohesion may suffer due to concerns about providing safe, proper care (e.g., transferring, feeding, supervision). Long-term planning can ensure the person receives hospice care or allows the family to decide. The person is vulnerable to normal age-related health issues. Family may experience exhaustion and worry about their own well-being and the impact on their children and spouse. Long-term stress and grief can affect family relationships and cohesion, especially without planning. Family members may face physical and mental health challenges requiring additional support and lifestyle changes.
Middle (Stages 4–5)
Caregiving needs become more intense to include financial, home safety, and some life management.
Late (Stages 6–7)
Patient will need full-time support for all activities of daily living. Family members may find themselves dealing with effects of long-term caregiving (e.g., financial and health challenges, inability to work, poor self- care).
Source: [23]
Table 6
healthcare providers should offer opportunities for patients and caregivers to ask questions and voice concerns, fostering a collaborative approach to care management. COMMUNICATION TECHNIQUES Effective communication is crucial when caring for patients who have Alzheimer disease or other dementias. Healthcare providers should use clear, simple language, speak slowly, and maintain eye contact when discussing memory concerns. It is important to approach the topic sensitively, acknowledging the patient’s feelings and concerns [24]. Building trust and rapport involves active listening, showing empathy, and respecting the patient’s dignity. Providers should create a comfortable environment and allow ample time for the patient to process information and respond [22].
Engaging caregivers is equally important. Strategies include educating them about the disease, its progression, and avail- able resources. Caregivers should be encouraged to participate in appointments and care planning discussions. Addressing caregiver concerns involves providing emotional support, offer- ing respite care information, and connecting them with sup- port groups. Healthcare providers should also assess caregiver stress and burnout, offering strategies for self-care and stress management [25]. By fostering open communication with both patients and caregivers, providers can ensure more com- prehensive and effective care for individuals with dementia.
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