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.

BOX 5-1

Examples of Practice Guidelines for Health Care Professionals Relevant to Cognitive Aging. American Association of Colleges of Nursing Older Adult Care Competencies. This briefly mentions that nursing personnel should be prepared to assess and treat cognition (more...)

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).

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.

BOX 5-2

Examples of Resources Addressing Cognitive Assessment Procedures and Tools for Use by Health Care Providers. Alzheimer's Association Recommendations for Operationalizing the Detection of Cognitive Impairment During the Medicare Annual Wellness Visit in (more...)

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.

BOX 5-3

Examples of Resources for Patient Counseling and Education About Cognitive Aging and Related Concerns. Alzheimer's Association 10 Early Signs and Symptoms of Alzheimer's. This resource compares and contrasts normal age-related changes in cognition with (more...)

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).