Dementia Risk Reduction in Geriatric Primary Care: A Needs Assessment

Background: Dementia is a costly disease that profoundly impacts patients, caregivers, and health systems, and increasing disease-related morbidity threatens to overwhelm an already overburdened healthcare infrastructure. Although there is no cure for dementia, it may be possible to delay the onset or even prevent some types of dementia by altering individual risk factors. Local Problem: Unfortunately, although the evidence is significant, both patients and providers lack sufficient understanding and awareness of dementia risk-reduction strategies. Methods: This project sought to establish the need for a dementia-risk-reduction program in the geriatric primary care setting and to propose a program for dementia risk factor screening and intervention. Interventions: Questionnaires assessed patients' and providers' attitudes toward dementia risk reduction, and patients received a single-sheet brain health educational flyer developed for the project. A review of The Tulane Healthy Brain Aging Initiative suggested a workflow and implementation recommendation for potential use in the Madsen Geriatrics clinic. Findings from the questionnaires and program review informed the creation of an executive summary presented for review by key strategic partners within the Madsen clinic's administration. Results: Clinical providers overwhelmingly supported adding a dementia-risk-reduction program to their active health initiatives. Most patients (68%) agreed they worry about developing dementia, but many were less confident in reducing their risk. Most (86%) expressed interest in a brain health and dementia risk reduction program. Clinic administrators were enthusiastic about considering the program but raised valid concerns about reimbursement rates for services that could impact sustainability. Conclusions: Project findings clearly establish the need for a dementia-risk-reduction program at the Madsen Geriatrics clinic. More inquiries regarding outside funding and reimbursement are needed to demonstrate the potential profitability and sustainability of the program.

1 Dementia Risk Reduction in Geriatric Primary Care: A Needs Assessment Rebecca L. Shaw, ElLois W. Bailey, Deborah E. Morgan College of Nursing, The University of Utah NURS 7703: DNP Scholarly Project III April 23, 2023 2 Abstract Background: Dementia is a costly disease that profoundly impacts patients, caregivers, and health systems, and increasing disease-related morbidity threatens to overwhelm an already overburdened healthcare infrastructure. Although there is no cure for dementia, it may be possible to delay the onset or even prevent some types of dementia by altering individual risk factors. Local Problem: Unfortunately, although the evidence is significant, both patients and providers lack sufficient understanding and awareness of dementia risk-reduction strategies. Methods: This project sought to establish the need for a dementia-risk-reduction program in the geriatric primary care setting and to propose a program for dementia risk factor screening and intervention. Interventions: Questionnaires assessed patients' and providers' attitudes toward dementia risk reduction, and patients received a single-sheet brain health educational flyer developed for the project. A review of The Tulane Healthy Brain Aging Initiative suggested a workflow and implementation recommendation for potential use in the Madsen Geriatrics clinic. Findings from the questionnaires and program review informed the creation of an executive summary presented for review by key strategic partners within the Madsen clinic's administration. Results: Clinical providers overwhelmingly supported adding a dementia-risk-reduction program to their active health initiatives. Most patients (68%) agreed they worry about developing dementia, but many were less confident in reducing their risk. Most (86%) expressed interest in a brain health and dementia risk reduction program. Clinic administrators were enthusiastic about considering the program but raised valid concerns about reimbursement rates for services that could impact sustainability. 3 Conclusions: Project findings clearly establish the need for a dementia-risk-reduction program at the Madsen Geriatrics clinic. More inquiries regarding outside funding and reimbursement are needed to demonstrate the potential profitability and sustainability of the program. Keywords: dementia, risk reduction, geriatrics, program, brain health 4 Dementia Risk Reduction in Geriatric Primary Care: A Needs Assessment Problem Description Dementia is an umbrella term for a cluster of neurodegenerative disorders characterized by progressive memory, cognitive, and functional impairments. Disease etiology differentiates between the types of dementias: Alzheimer's disease (AD)—which accounts for 60–80% of all dementia—Lewy body dementia, frontotemporal dementia, vascular dementia, and others (Alzheimer's Association, 2022). These disorders are emotionally, socially, and financially costly and profoundly impact patients, caregivers, and healthcare systems (Chan et al., 2019; Dharmarajan & Gunturu, 2009). Diagnosis of dementia typically occurs in older adulthood, and the number of people impacted—directly and indirectly—is expected to double in the next 30 years as the population ages (Rajan et al., 2021). An estimated 47 million people worldwide live with dementia, and the projected future cases will reach 132 million by 2050 (Chan et al., 2019). In Utah alone, projected cases will increase from 34,000 in 2020 to 42,000 in 2025, according to the Alzheimer's Association (2022). Dementia has no known cure, and with the limited success of current pharmacotherapies, the global discussion on dementia focuses increasingly on prevention (Baumgart et al., 2015; Chan et al., 2019). Dementia is one of the most feared diagnoses of older adulthood (Harris Interactive, 2011). The stigma associated with losing one's memories, independence, and quality of life contributes to the complexity of addressing dementia directly and creates anxiety in patients and caregivers (Devlin et al., 2007). While patients with dementia can maintain a good quality of life (Hoe et al., 2009), fears about these disorders are not wholly unfounded. Families may assume tremendous responsibility in caring for older adults with these diagnoses—often at significant 5 personal cost. In addition, caregivers often face the deterioration of their social connectedness, mental and physical health declines, and financial strain due to their efforts (Brodaty & Donkin, 2009). Dementia carries a heavy price tag. In the United States, an estimated 83% of care for community-dwelling patients with dementia is provided by family and informal caregivers, totaling $271.6 billion in unpaid labor (Alzheimer's Association, 2022). Locally, 97,000 Utahns provided 119 million hours of unpaid care for loved ones with dementia in 2021, a service valued at $1.985 billion (Alzheimer's Association, 2022). In addition, families also navigate heavy out-of-pocket expenses, lost work hours, and early exit from the workplace, which disproportionally affects women and carries substantial social costs (Alzheimer's Association, 2022). Dementia also impacts healthcare systems. A report by the Alzheimer's Association (n.d.) found that patients with dementia cost three times more than patients without dementia and stay in the hospital three times more often. These differences translate to higher costs within the health system and additional strain on the workforce. The report also suggests that primary care providers are not compensated appropriately for the additional time needed for dementia care appointments and that home health services are typically unavailable for preventative monitoring. Caring for patients with dementia is a complex process, and the increasing diseaserelated morbidity threatens to overwhelm an already overburdened healthcare infrastructure (Dharmarajan & Gunturu, 2009). Despite a trend toward global increases, the incidence of new-onset dementia has declined in higher-income countries such as the United States (Livingston et al., 2020), suggesting that lifestyle may play a role. Researchers have repeatedly identified modifiable risk 6 factors for dementia (Erickson et al., 2011; McMaster et al., 2020; Omura et al., 2022; Solch et al., 2022), and yet, too often, patients are not aware that they can take action to reduce their risk of developing these challenging illnesses (Kim et al., 2015). While some academically connected medical centers have taken the initiative and launched programs targeting these risk factors, many geriatric clinics, including the Madsen Geriatrics clinic, have not yet incorporated early screening for dementia risk factors or dementia-specific risk modification programs into regular practice. Reducing the societal burden of dementia will require taking immediate action to incorporate the latest risk reduction and prevention evidence. Available Knowledge Regardless of varying etiologies, the evidence suggests that multidomain interventions— including lifestyle modification—are essential to reducing the risk of dementia, improving cognitive reserve, and ultimately reducing the unsustainable increase of dementia diagnoses (Ngandu et al., 2015). It may be possible to delay the onset or even prevent some types of dementia by altering individual risk factors (Erickson et al., 2011; Livingston et al., 2020; McMaster et al., 2020; Omura et al., 2022; Solch et al., 2022). Multidomain approaches to risk modification have tremendous potential for helping people reduce the risk of these cognitive disorders (Bott et al., 2019). Although the evidence is significant, both patients and providers lack sufficient understanding and awareness of dementia prevention strategies (Cations et al., 2018). Unlike other chronic illnesses, there are no broadly accepted standards for dementia risk factor screening or intervention. For example, dietary patterns are widely understood to impact cardiovascular health but are rarely discussed as essential in preserving long-term brain health (Dominguez et al., 2021). To address this disparity in approach to care, the World Health 7 Organization's Global Action Plan on the Public Health Response to Dementia developed the Global Dementia Prevention Program (GloDePP). This program identified strategic goals for addressing the challenges posed by dementia, specifically developing personalized risk reduction programs and standardizing prevention guidelines (Chan et al., 2019). Unfortunately, these goals have not yet been widely realized. A recent Lancet Commission report concluded that an estimated 40% of dementias are attributable to only 12 modifiable risk factors: lower education levels, hearing loss, traumatic brain injury (TBI), hypertension, excessive alcohol consumption, obesity, smoking, depression, social isolation, physical inactivity, diabetes, and air pollution (Livingston et al., 2020). Dietary habits and sleep may also be essential contributors (Dominguez et al., 2019). It may be helpful to conceptualize these risk factors into three categories: mitigation of hazards, management of medical conditions, and maximization of protective lifestyle factors (3Ms). A review and metaanalyses of available studies, including the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (FINGER), demonstrated that lifestyle modifications might preserve and improve cognitive function, even in older adults (Livingston et al., 2020). Target interventions for multidomain, dementia-risk-reduction programs, like those based on offerings at Tulane University and NorthShore University HealthSystem, strategically address the 3Ms outlined above and are guided by patient needs and readiness for change (Fosnacht et al., 2017). For example, mitigating hazards might include encouraging helmet use to prevent TBI, advocating for alcohol and tobacco reduction or cessation, and addressing unopposed early menopause with hormone therapy. Management of medical conditions involves collaboration with primary care and specialty providers to optimally control diabetes, hypertension, psychiatric conditions, insomnia, and other chronic illness. Maximizing protective lifestyle factors advises 8 adopting the Mediterranean diet, increasing socialization and physical activity, participating in cognitive training, and promoting sleep hygiene. The targeted education and multi-faceted interventions necessary to reduce individual dementia risk may be outside the scope of the typical primary care visit and may not be feasible due to time constraints on primary care providers. As such, additional program offerings are needed to adequately address patient concerns about preserving brain health. Some academically connected medical centers, such as NorthShore and Tulane University, have devoted significant resources to creating comprehensive brain health programs. These programs consist of in-depth screening for risk factors and approach the 3Ms through interprofessional collaboration and ongoing, patient-centered education, goal setting, and support (Fosnacht et al., 2017). The electronic health record (EHR) facilitates the identification of at-risk patients and monitors progress across multiple variables for those who participate in formalized brain health programming (Fosnacht et al., 2017). Utilization of the EHR in brain health interventions is essential for supporting long-term research and demonstrating the program's efficacy. For patients concerned about brain health, a nurse practitioner-led dementia-riskreduction program provides a value-added service as an adjunct to standard primary care. Nurses are trained in motivational interviewing and patient collaboration, making them ideally suited to act as facilitators in lifestyle modification programs (Hope, 2020). Rationale The Health Belief Model provides an excellent framework for this needs assessment project. This model asserts that an individual's understanding of their risk of disease, perception of current health, barriers or advantages to action, and confidence in their ability to impact 9 positive change ultimately influence health behaviors (Glanz, n.d.). The use of this model in prevention and detection projects and lifestyle modification initiatives (Boskey, 2023) makes it uniquely applicable to a project seeking to reduce the risk of dementia by modifying its risk factors. This project seeks to explore providers' current perceptions of dementia risk reduction. It will also evaluate to what extent patients are concerned about dementia and establish their interest in more individualized risk management. Additionally, the project will educate patients and providers on the proven benefits of lifestyle interventions at any age. These objectives will help create a clear picture of the perceived risk of disease and the need for change. They will also illuminate barriers that might prevent this type of education from becoming a standard in the primary care setting. Specific Aims The aim of this needs assessment project was to evaluate patients' and providers' attitudes related to dementia risk reduction and to propose a program for dementia risk factor screening and intervention in a geriatric primary care setting. Methods Context This dementia risk reduction needs assessment was conducted at the University of Utah Health's Geriatric Patient-Centered Medical Home at the Madsen Health Center, more commonly known as Madsen Geriatrics. The clinic is near the University of Utah campus in metropolitan Salt Lake City. It provides care for adults over 65 but specializes in comprehensive and coordinated care for patients with cognitive or functional impairments and those with multiple comorbid medical conditions (University of Utah Health, 2022). Madsen Geriatrics employs many healthcare providers, including medical doctors (MDs), doctors of osteopathy 10 (DOs), primary care nurse practitioners (NPs), a psychiatric mental health nurse practitioner (PMHNP), and licensed clinical social workers (LCSWs). Additional clinic staff includes registered nurses (RNs) and medical assistants (MAs). This clinic serves a population of both community and facility-dwelling older adults. In addition to primary care, Madsen Geriatrics' Aging Brain Care Program offers diagnostic services, medical and psychiatric support, and long-term management for patients with cognitive disorders. The clinic recently introduced a Dementia Continuing Care (DCC) program, which provides an additional layer of collaborative care for patients and families impacted by dementia. Madsen Geriatrics also explored a brain-healthy lifestyle support group for patients diagnosed with mild cognitive decline and ran the group concurrently with this needs assessment project. As such, exploring the need for a multidomain, dementia-risk-reduction program for cognitively healthy patients was aligned with the clinic's vision and values. Intervention(s) The interventions for this needs assessment took place in four distinct phases. Phase one of the project involved assessing current providers' perceptions of the following: patients' awareness of and interest in dementia risk factors and risk reduction, providers' awareness of dementia risk factors and risk reduction, providers' need for additional support in identifying high-risk patients, providers' desire and ability to offer appropriate risk modification education, and providers' viewpoint of the potential of a dementia-risk-reduction program to benefit patients. Madsen Geriatrics clinicians provided data on these current perceptions in a brief questionnaire (Appendix A) distributed via email. The information gathered established internal support for incorporating a dementia-risk-reduction program into the Aging Brain Care offerings. 11 Phase two of the assessment explored patient interest in participating in a dementia-riskreduction and lifestyle program. Patients deemed eligible for participation were medically stable adults aged 60 to 100 without a current diagnosis of mild cognitive impairment or dementia. Patient data came from qualified participants identified through the electronic health record in the clinic on one of five data collection days. Participants completed a 5-item questionnaire (Appendix B) administered in person during a previously scheduled appointment with their provider. In addition, all participants received a single-sheet brain health educational resource (Appendix C). In phase three, patient and provider questionnaire data informed the creation of an executive summary report (Appendix D) and presentation (Appendix E), including a program workflow summary and a recommendation for implementation based on an existing offering at the Tulane Healthy Brain Aging Initiative. The recommendation also included a sampling of potential patient resources created as part of this project for use at the Madsen Geriatrics clinic (Appendix F). In the final phase of this needs assessment project, key strategic partners within the Madsen Geriatric administration attended (or received) a presentation of the executive summary of project findings and accompanying program proposal so they could review the material and consider adding a dementia risk reduction program to the Aging Brain Care Program permanently. In addition, they had the opportunity to provide feedback, including recommendations for program changes and potential barriers to its implementation. Study of the Intervention(s) While implementing a dementia-risk-reduction program was outside this project's scope, the needs assessment's success was evaluated based on clearly establishing whether the clinic's 12 patients and providers would support such a program. The data collected provided a broad view of participants' awareness of dementia-risk-reduction factors and measured interest levels in additional education and support related to preserving brain health. The abovementioned interventions provide critical information for evaluating the proposed program's feasibility and potential sustainability within the clinic. Measures Measures for this needs assessment project included two questionnaires corresponding with phases one and two of the interventions and feedback from clinic administration corresponding with phases three and four. Initial Provider Questionnaire The provider questionnaire contained two demographic questions, including the provider's discipline and years in geriatric practice (Appendix A). The body of the questionnaire included 22 additional questions that utilized a 4-point Likert scale and an option for those who preferred not to answer. Questions 1 through 6 assessed providers' perceptions of their patients' understanding of dementia risk modification. Questions 7 through 10 assessed providers' awareness of the current body of research related to dementia risk reduction. Questions 11 through 14 evaluated the perceived adequacy of the status quo for supporting patients' brain health. Questions 15 through 18 assessed the perceived value of additional lifestyle support programming. Finally, questions 19 through 22 evaluated providers' willingness to support adding a dementia-risk-modification program to current patient offerings. Patient Questionnaire The patient questionnaire contained two demographic questions identifying the age and gender of the participant and five additional 4-point Likert scale questions with an option for 13 those who preferred not to answer (Appendix B). Questions assessed patients' level of concern about memory loss, their awareness of risk-reducing lifestyle factors, and their interest in participating in a program to preserve brain health. Responses to the patient questionnaire determined the need for and interest in the proposed program. Clinic Administration Feedback The final measure included qualitative feedback from clinic administration and established the appropriateness of the proposed program for the Madsen Geriatrics clinic. Key strategic partners reviewed the executive summary of findings and the program recommendation and then offered feedback regarding the potential adoption of the program. Following a presentation of the above material, this qualitative data was gathered verbally from administrators during a question-and-answer session. Administrative feedback provided insight into the feasibility, usability, and sustainability of the proposed dementia-risk-reduction program at Madsen Geriatrics. Analysis An analysis of patient and provider questionnaire responses included descriptive statistics, frequency, and percentage data to broadly identify provider perceptions and patient interest in dementia risk reduction. This data was interpreted and presented to key strategic partners within the executive summary. In addition, feedback from administrators and key strategic partners was collected verbally and via email. Responses were compiled and summarized to identify common themes. Ethical Considerations This project was quality improvement in nature and not subject to University of Utah institutional review board oversight. There were no conflicts of interest concerning this study. 14 Results Provider Questionnaire The provider questionnaire contained five general sections. All but the first section consists of 4-point Likert response options: agree, somewhat agree, somewhat disagree, and disagree. Section one focused on demographics and contained two questions related to respondents' discipline and years in geriatric practice (Table 1). Eight (N = 8) providers within the Madsen Geriatrics clinic responded, including three medical doctors (MDs), two doctors of osteopathy (DOs), an advanced practice registered nurse (NP), a licensed clinical social worker (LCSW), and a registered nurse (RN). Of the eight respondents, five reported working in geriatric practice for more than 10 years, one 6–10 years, and two individuals 3–5 years. Section two of the questionnaire contained six questions about the providers' perceptions of their patients' attitudes toward dementia and dementia prevention (Figure 1). All respondents agreed or somewhat agreed that patients are concerned about developing dementia and are interested in prevention strategies. A majority (75%, n = 6) also agree or somewhat agree that patients understand that lifestyle factors may increase their risk for dementia. However, 75% (n = 6) of provider respondents disagree or strongly disagree that patients understand how to reduce their risk of developing dementia, and only 32.5% (n = 3) of respondents somewhat agree that patients know they can reduce their risk. Section three of the provider questionnaire included four questions assessing providers' attitudes and awareness of dementia risk reduction (Figure 2). Seven respondents (87.5%, n = 7) agreed they were concerned about their patients developing dementia; the remaining respondent (12.5%, n = 1) somewhat agreed. All providers agreed (87.5%, n = 7) or somewhat agreed (12.5%, n = 1) that dementia risk factors are modifiable and that modifications can still reduce risk in patients over age sixty. While most respondents agreed or somewhat agreed with the 15 statement, "I am aware that twelve modifiable risk factors may be responsible for 40% of dementia," three providers (37.5%) somewhat disagreed. Section four contained four questions regarding current practices, including screening for risk factors and patient education (Figure 3). Responses in this section indicated that 25% (n = 2) of the providers did not have a system for screening patients for increased dementia risk. An additional 37.5% (n = 3) only somewhat agreed that they had a system for screening. While 87.5% (n = 7) of respondents agreed or somewhat agreed that they regularly discuss risk reduction with their patients, 37% (n = 3) disagreed or somewhat disagreed that they had ample time to educate patients on this topic. In addition, 25% (n = 2) of respondents somewhat disagreed that they had the necessary information to discuss risk reduction with patients. Section five questions explored the perceived benefit of incorporating a dementia-riskreduction program into the available patient programming at Madsen Geriatrics (Figure 4). All respondents (n = 8) agreed that their patients would benefit from an individualized, brain-healthy lifestyle program. All providers agreed (37.5%, n = 3) or somewhat agreed (62.5%, n = 5) that patients would be interested in such an offering if providers recommended it. All providers also agreed (37.5%, n = 3) or somewhat agreed (62.5%, n = 5) that patients need more support in making healthy lifestyle changes. Respondents divided their responses between agree and disagree regarding whether patients already have the information needed to adopt a brain-healthy lifestyle. The final section of the provider questionnaire inquired whether providers at Madsen Geriatrics would support adding a dementia-risk-reduction program to the current clinic offerings (Figure 5). All respondents (100%, n = 8) indicated that they are interested in new opportunities for brain-healthy lifestyle education for patients and would support the 16 development of a risk reduction program. All respondents (100%, n = 8) also agreed they would refer high-risk patients to a program facilitated by a nurse practitioner. Patient Questionnaire The patient questionnaire contained two demographic questions and five additional questions evaluated on a 4-point Likert scale with an option for those who preferred not to provide an answer (Figure 6). In total, fifty-three patients completed the questionnaire across five clinic days. The demographics section asked patients to identify their gender and age range (Table 2). Of the fifty-three (N = 53) respondents, approximately 70% were female (n = 37). Nearly half of the respondents (49%, n = 26) were 75–84 years old, and 36% (n = 19) were 65– 74 years old. The remaining items in the patient questionnaire inquired about patient attitudes and perceptions regarding dementia and dementia risk reduction. Most patients indicated that they agreed (38%, n = 20) or somewhat agreed (30%, n = 16) that they worry about developing dementia in the future. Patients overwhelmingly indicated that they agreed (51%, n = 27) or somewhat agreed (30%, n = 16) that some lifestyle factors might increase their risk and also agreed (47%, n = 25) or somewhat agreed (36%, n=19) that it is never too late to reduce their risk. Responses to the question, "I know how to reduce my risk for memory loss and dementia," were the most varied. Only 17% (n = 9) agreed, 45% (n = 24) somewhat agreed, 8% (n = 4) somewhat disagreed, and 30% (n = 16) disagreed. When asked whether they would be interested in a brain health and dementia risk reduction program, 56% (n = 30) agreed that they would be interested, and an additional 30% (n = 16) somewhat agreed. Of note, the third non-demographic question of the patient questionnaire, "I know how to reduce my risk for memory loss and dementia," may have been poorly constructed. The question 17 aimed to determine whether the patients understood the actionable steps they could take to reduce their risk. Patients frequently referenced working on crosswords, exercising, and healthy eating as risk reduction strategies. While all these interventions have evidence-based merit, it was unclear whether patients understood how to implement them in a way that would realistically reduce their risk. Key Strategic Partner Feedback Three strategic partners (N = 3) within Madsen Geriatrics reviewed the executive summary and proposed program and offered feedback. All respondents expressed a high level of enthusiasm for the content and usefulness of the proposed program. All respondents also reported interest in incorporating a dementia-risk-reduction program into current offerings within the clinic. Each respondent also endorsed high satisfaction with the information gathered from patients and providers and with the materials presented within the program proposal. One partner raised valid concerns about provider reimbursement for preventative programming. Medicare reimbursement rates for preventative programming may be suboptimal and present a significant barrier due to the Madsen Geriatrics payer profile. The partner inquired whether some portion of the proposed program could be incorporated into annual Medicare wellness exams. The partner also requested additional information regarding the purpose of select laboratory values recommended within the Tulane program. Two respondents suggested that outside funding may be available from community, state, and national partners who have a vested interest in healthy aging. In addition, they recommended exploring a dementia-risk-reduction program for a younger population, which may mitigate the concerns related to reimbursement rates. Finally, these respondents also requested information related to medical billing codes and reimbursement. 18 Discussion Summary Data collected in the patient and provider questionnaires strongly supports the development of a dementia-risk-reduction program at the Madsen Geriatrics clinic. Providers largely agree that dementia risk is a concern for patients and that patients would benefit from additional support with risk reduction and lifestyle interventions. Patients themselves are worried about dementia and believe that their risk is modifiable but are less sure about how to protect their brain health. A significant majority of patients are interested in participating in a brain health program, and providers unanimously indicate they would utilize such an offering for highrisk patients if it were available. In the Health Belief Model context, the data show that patients and providers are appropriately concerned about brain health and believe they can affect positive change to reduce their risk for dementia. However, the data also suggest that patients need additional information and support to do so. These findings clearly establish the need for a dementia-risk-reduction program at Madsen Geriatrics. While interest and need for a dementia-risk-reduction program are high, initiating such a program at this stage within Madsen Geriatrics may not be feasible. Currently, there is no dedicated provider for dementia risk reduction, and time constraints on primary care providers are a significant barrier to incorporating evidence-based risk modification strategies into wellpatient exams. Additionally, Medicare reimbursement rates may impact the sustainability of such an initiative. Therefore, more information about profitable ways to incorporate comprehensive dementia-risk-reduction programming into practice is needed. Interpretation Patient and provider questionnaire findings demonstrated a strong interest in and support for developing a dementia-risk-reduction program within the Madsen Geriatrics clinic. 19 Responses from the questionnaires aligned with current evidence, which suggests that older adults are concerned about developing dementia (Harris Interactive, 2011; Devlin et al., 2007) and that patients may not have adequate information about how to protect their brain health (Kim et al., 2015). In addition, patients overwhelmingly expressed interest in learning more about reducing risk and participating in personalized lifestyle programs. Most providers who participated in this assessment routinely screened and educated patients about risk reduction, but they also unanimously expressed interest in adjunctive programming for at-risk patients. Over half of the provider respondents agreed they had ample time to educate patients about dementia risk modification. This finding was unexpected due to the typical time constraints on primary care visits. One possible explanation for this difference is the unique environment at Madsen Geriatrics. Unlike a typical primary care environment, providers at Madsen typically have 30–60 minutes for appointments rather than the 15 minutes per patient that is standard in most primary care settings. Additionally, providers at Madsen Geriatrics are connected with the Dementia Continuing Care program, so they may be better supported or more familiar with dementia risk factors than primary care providers in other locations. The proposed program has the potential to be delivered via telehealth to reduce care access disparities in rural communities. It may also be widely applied throughout the University of Utah Health system. Its implementation in traditional primary care settings with younger patients might significantly impact patient outcomes. Such an expansion might further contribute to the program's sustainability due to more favorable reimbursement rates for non-Medicare patients. Additionally, the program could be adapted for delivery by registered nurses, which could further reduce the cost of implementation. 20 A critical discussion point and valid concern of the clinic administration is the additional resources required to implement this program. The program recommendation and workflow summary provided clinic administration with a tangible product offering that could be monetized and expanded to increase clinic revenues; however, concerns about Medicare reimbursement and billing pose a significant barrier to the immediate adoption of a dementia-risk-reduction program. Efforts to more clearly define the potential revenue generated by the proposed program were in process but not completed at the project's close. Details related to provider reimbursement and funding assistance must be explored before determination of the feasibility of adding this program to the clinic's current offerings. Within the clinic, at least one nurse practitioner must be added to the current staff to support the initiative. Additionally, resources must be dedicated to developing and approving workflows within the electronic health record to improve efficiency and monitor long-term outcomes from program participation. Grants may be available to cover a portion of this cost; however, identifying potential funding was outside this project's scope. Some initial resource investment might be offset by collaborating with Tulane University to share resources and reduce the time needed for developing implementation protocols, data sets, and other initiative components. This needs assessment project required considerable time, mainly due to the in-person collection of patient questionnaire data. A more practical approach might be incorporating the patient survey into the electronic health record for online completion before the patient's appointment. The project minimally impacted clinic staff. 21 Limitations This project had several limitations. Madsen Geriatrics is a unique clinic with providers specializing in caring for older adults who may be more comfortable addressing cognitive concerns than the typical primary care provider. A bias in favor of dementia care may also exist. Providers at Madsen Geriatrics have a high awareness of dementia risk factors and enthusiasm for additional programming that may not be generalizable to the larger primary care community. Both patient and provider questionnaires contained limitations. While these tools appear to have adequately established the need for a dementia-risk-reduction program, collecting qualitative data regarding the questionnaire items was beyond this project's scope. As a result, we believe there may have been a high degree of variability among respondents with identical answers. For example, the project agent who collected patient survey data noted confusion among patients responding to the prompt, "I know how to reduce my risk for memory loss and dementia." While 45% (n = 24) of patient respondents indicated that they somewhat agreed with the statement, the data collection agent noted that many people remarked that doing crosswords, eating a healthy diet, and exercising would reduce their risk. While these are all brain-healthy behaviors, there is little to suggest that patients know how to implement these evidence-based lifestyle behaviors to reduce their risk of cognitive decline. This question may not adequately assess patient understanding of risk-modifying behaviors. Information collected in the provider questionnaire may also have limitations. While all respondents actively engage in patient care, screening for dementia risk factors and providing patient education regarding risk reduction may fall outside the scope of practice for some respondents. 22 Conclusions As the number of community-dwelling people with dementia increases, primary care providers must direct attention and resources to support evidence-based risk reduction. Individualized, multidomain, risk-reduction intervention programs implemented by academically connected medical centers support this initiative. Implementing a dementia-risk-reduction program at the Madsen Geriatrics clinic can potentially improve patient outcomes. Risk reduction programs also have the potential to increase clinic revenues. However, immediate concerns about funding and reimbursement must be addressed before determining the program's feasibility and sustainability. The proposed dementia-risk-reduction program can potentially reduce care disparities for older adults living in rural areas and those with mobility or transportation challenges that put them at increased risk. A comprehensive risk-reduction program, such as the one proposed in this need assessment project, could be rapidly expanded to the University of Utah primary care system beyond geriatrics. This expansion could potentially have an even more significant impact on patient outcomes since early intervention has a greater capacity to reduce the risk of disease morbidity. A committee should be appointed within Madsen Geriatrics to explore funding and reimbursement options with a plan to adopt a dementia risk reduction program. This program would serve as an adjunctive offering for primary care and a sister program to the existing Dementia Continuing Care offering. Additionally, they should identify a qualified nurse practitioner to champion the program within the clinic. 23 Acknowledgments We want to thank Dr. Timothy W. Farrell, MD, AGSF, Dr. Michelle K. Sorweid, DO, MPH, Diane Tadehara, RN, Dr. Mark A. Supiano, MD, and all of Madsen Geriatrics clinical staff and administration for their help, support, and interest in this project. We would also like to extend a special thanks to Dr. Demetrius M. Maraganore, MD, FAAN, Chair of Neurology at Tulane University, and Sereen Askar, FNP-C, Tulane Center for Clinical Neurosciences, for their time and contributions to this project. 24 References Alzheimer's Association. (2022). 2022 Alzheimer's disease facts and figures. Alzheimer's & Dementia: The Journal of the Alzheimer's Association, 18(4), 700–789 https://doi.org/10.1002/alz.12638 Alzheimer's Association. 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S., Heo, S., Alves, H., White, S. M., Wojcicki, T. R., Mailey, E., Vieira, V. J., Martin, S. A., Pence, B. D., Woods, J. A., McAuley, E., & Kramer, A. F. (2011). Exercise training 26 increases size of hippocampus and improves memory. Proceedings of the National Academy of Sciences of the U S A, 108(7), 3017–3022 https://doi.org/10.1073/pnas.1015950108 Fosnacht, A. M., Patel, S., Yucus, C., Pham, A., Rasmussen, E., Frigerio, R., Walters, S., & Maraganore, D. (2017). From brain disease to brain health: Primary prevention of Alzheimer's disease and related disorders in a health system using an electronic medical record-based approach. Journal of Prevention of Alzheimer’s Disease, 4(3), 157–164. https://doi.org/10.14283/jpad.2017.3 Glanz, K. (n.d.). Social and behavioral theories. NIH Office of Behavior and Social Sciences Research, E-source. https://obssr.od.nih.gov/sites/obssr/files/Social-and-BehavioralTheories.pdf Harris Interactive. (2011). What America thinks: MetLife Foundation Alzheimer's survey. MetLife Foundation. https://www.metlife.com/content/dam/microsites/about/corporateprofile/alzheimers-2011.pdf Hoe, J., Hancock, G., Livingston, G., Woods, B., Challis, D., & Orrell, M. (2009). Changes in the quality of life of people with dementia living in care homes. Alzheimer Disease and Associated Disorders, 23(3), 285–290 https://doi.org/10.1097/WAD.0b013e318194fc1e Hope, K. (2020). Role of nurses in addressing modifiable risk factors for early Alzheimer's disease and mild cognitive impairment. British Journal of Nursing, 29(8), 460–469. https://doi.org/10.12968/bjon.2020.29.8.460 Kim, S., Sargent-Cox, K. A., & Anstey, K. J. (2015). A qualitative study of older and middleaged adults’ perception and attitudes towards dementia and dementia risk reduction. Journal of Advanced Nursing, 71(7), 1694–1703. https://doi.org/10.1111/jan.12641 27 Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., Brayne, C., Burns, A., Cohen-Mansfield, J., Cooper, C., Costafreda, S. G., Dias, A., Fox, N., Gitlin, L. N., Howard, R., Kales, H. C., Kivimäki, M., Larson, E. B., Ogunniyi, A., . . . Mukadam, N. (2020). Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet, 396(10248), 413–446. https://doi.org/10.1016/s01406736(20)30367-6 McMaster, M., Kim, S., Clare, L., Torres, S. J., Cherbuin, N., D’Este, C., & Anstey, K. J. (2020). Lifestyle risk factors and cognitive outcomes from the multidomain dementia risk reduction randomized controlled trial, Body Brain Life for Cognitive Decline (BBL-CD). Journal of American Geriatric Society, 68(11), 2629–2637. https://doi.org/10.1111/jgs.16762 Ngandu, T., Lehtisalo, J., Solomon, A., Levalahti, E., Ahtiluoto, S., Antikainen, R., Backman, L., Hanninen, T., Jula, A., Laatikainen, T., Lindstrom, J., Mangialasche, F., Paajanen, T., Pajala, S., Peltonen, M., Rauramaa, R., Stigsdotter-Neely, A., Strandberg, T., Tuomilehto, J., . . . Kivipelto, M. (2015). A 2-year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): A randomised controlled trial. Lancet, 385(9984), 2255–2263. https://doi.org/10.1016/S0140-6736(15)60461-5 Omura, J. D., McGuire, L. C., Patel, R., Baumgart, M., Lamb, R., Jeffers, E. M., Olivari, B. S., Croft, J. B., Thomas, C. W., & Hacker, K. (2022). Modifiable risk factors for Alzheimer disease and related dementias among adults aged >/=45 years—United States, 2019. Morbidity Mortality Weekly Report, 71(20), 680–685. https://doi.org/10.15585/mmwr.mm7120a2 28 Rajan, K. B., Weuve, J., Barnes, L. L., McAninch, E. A., Wilson, R. S., & Evans, D. A. (2021). Population estimate of people with clinical Alzheimer's disease and mild cognitive impairment in the United States (2020–2060). Alzheimer's & Dementia, 17(12), 1966– 1975 https://doi.org/10.1002/alz.12362 Solch, R. J., Aigbogun, J. O., Voyiadjis, A. G., Talkington, G. M., Darensbourg, R. M., O'Connell, S., Pickett, K. M., Perez, S. R., & Maraganore, D. M. (2022). Mediterranean diet adherence, gut microbiota, and Alzheimer's or Parkinson's disease risk: A systematic review. Journal of the Neurological Sciences, 434, 120166. https://doi.org/10.1016/j.jns.2022.120166 University of Utah Health. (2022). Health care home: Geriatric care https://healthcare.utah.edu/geriatrics/ 29 Table 1 Provider Questionnaire: Demographics of Respondents Characteristic n % Medical Doctor (MD) 3 32.5 Doctor of Osteopathy (DO) 2 23.0 Nurse Practitioner (APRN) 1 12.5 Licensed Clinical Social Worker (LCSW) 1 12.5 Registered Nurse (RN) 1 12.5 >10 years 5 62.5 6–10 years 1 12.5 3–5 years 2 25.0 Discipline Years in Geriatric Practice 30 Table 2 Patient Questionnaire: Demographics of Respondents Characteristic n % Male 15 28 Female 37 70 Incomplete 1 2 60–64 1 2 65–74 19 36 75–84 26 49 85–90 5 9 91+ 2 4 Gender Age in years 31 Figure 1 Provider Perceptions of Patient Attitudes About Dementia Provider Perceptions of Patient Attitudes About Dementia 8 Number of Providers 7 6 5 4 3 2 1 0 1. My patients are concerned about developing dementia 2. My patients 3. My patients are 4. My patients 5. My patients are interested in understand that aware that they think that it is too preventing specific lifestyle can reduce their late for lifestyle dementia factors may put risk for dementia changes to them at increased improve their risk for dementia cognition Agree Somewhat agree Somewhat diagree Section 2 Questions Disagree 6. My patients understand how to reduce their risk for dementia 32 Figure 2 Provider Perceptions of Dementia Risk Reduction Strategies Provider Perceptions of Dementia Risk Reduction Strategies 8 Number of Providers 7 6 5 4 3 2 1 0 7. I am concerned about my 8. I am aware that 12 9. I am aware that dementia 10. I am aware that lifestyle patients developing modifiable risk factors may risk factors can be modified, changes can reduce the risk of dementia, even in dementia be responsible for 40% of and doing so may preserve patients who are already dementia brain health over 60 Agree Somewhat agree Somewhat diagree Section 3 Questions Disagree 33 Figure 3 Provider Perceptions of the Need for Dementia Risk Reduction Program 1 Need for Dementia Risk Reduction Program 1 8 Number of Providers 7 6 5 4 3 2 1 0 12. I regularly discuss 11. I have a system for identifying patients who are dementia risk reduction with my patients at increased risk of developing dementia Agree Somewhat agree 13. I have ample time to 14. I have the necessary educate patients about information to talk to my dementia risk modification patients about dementia risk and risk reduction Somewhat diagree Section 4 Questions Disagree 34 Figure 4 Provider Perceptions of the Need for Dementia Risk Reduction Program 2 Need for Dementia Risk Reduction Program 2 8 Number of Providers 7 6 5 4 3 2 1 0 15. My patients would 16. My patients already 17. My patients need more 18. My patients would be benefit from an have the information they support in making lifestyles interested in participating in changes a brain-healthy lifestyle individualized, brain-healthy need to adopt a brainprogram if I recommended lifestyle program healthy lifestyle it Agree Somewhat agree Somewhat diagree Section 5 Questions Disagree 35 Figure 5 Provider Support for a Dementia Prevention Program Provider Support for a Dementia Prevention Program 8 Number of Providers 7 6 5 4 3 2 1 0 19. I am interested in 20. I am interested in new 21. I would support the 22. I would refer high-risk offering my patients more opportunities for brain- development of a dementia patients to an NP-led information about reducing healthy lifestyle support for risk reduction program at dementia risk modification their risk for dementia my patients Madsen Geriatrics program Agree Somewhat agree Somewhat diagree Section 6 Questions Disagree 36 Figure 6 Dementia Risk Reduction Patient Questionnaire Results Dementia Risk Reduction Patient Questionnaire Results 60 50 8 4 Number of Patients 40 3 5 5 0 5 16 8 16 16 30 4 19 16 24 20 30 27 25 20 10 9 0 I worry about losing I am aware that some I know how to reduce It is never too late to my memory or having lifestyle factors might my risk for memory reduce my risk for increase my risk for loss and dementia. dementia in the memory loss and memory loss and future dementia. dementia. Agree Somewhat agree Somewhat diagree Disagree Patient Questions I would be interested in a brain health and dementia risk reduction program if one were available. Prefer not to answer 37 Appendix A 38 39 40 41 42 43 Appendix B 44 Appendix C 45 Appendix D 46 47 48 49 50 51 52 Appendix E DEMENTIA RISK REDUCTION IN PRIMARY CARE A NEEDS ASSESSMENT REBECCA SHAW RN, BSN, DNP STUDENT DR. ELLOIS W. BAILEY, DR. DEBORAH E. MORGAN UNIVERSITY OF UTAH COLLEGE OF NURSING IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DOCTOR OF NUR SING PRACTICE CONFIDENTIAL BACKGROUND • Cognitive disorders are among the most feared diagnoses of older adulthood • Increasing disease -related morbidity threatens to overwhelm healthcare infrastructure • An estimated 40% of dementias are attributed to only 12 modifiable risk factors • It is possible to prevent or delay some types of dementia by altering individual risk factors Harris Interactive, 2011; Dharmarajan & Gunturu , 2009; Livingston et al., 2020; Solch et al., 2022; Omura et al., 2022; Erickson et al., 2011; McMaster et al., 2020; Livingston et al., 2020; Ngandu et al. 2015 CONFIDENTIAL 53 PROBLEM STATEMENT • Patients lack sufficient understanding and awareness of dementia prevention strategies • There is no widely accepted standard for dementia risk screening, risk modification, and prevention education (Kim et al., 2015; Cations et al., 2018) CONFIDENTIAL PURPOSE • Evaluate patient and provider attitudes related to dementia risk reduction • To propose a program for dementia risk factor screening and intervention in a geriatric primary care setting CONFIDENTIAL 54 PROJECT OBJECTIVES Assess current provider knowledge, attitudes, and beliefs regarding dementia risk modification Assess patient attitudes and interest in additional individualized brainhealthy lifestyle education and coaching Project Objectives Propose a process for a dementia risk factor screening and intervention program Present the program to key strategic partners within the healthcare team and evaluate feedback CONFIDENTIAL PROVIDER QUESTIONNAIRE 22-item questionnaire created inRedCAP was distributed to Madsen Geriatrics providers via email in December 2022 • 8 respondents – – – – – 3 MDs 2 DOs 1 APRN 1 LCSW 1 RN • Years in geriatrics – >10 yrs: 5 – 6-10 yrs: 1 – 3-5 yrs: 2 CONFIDENTIAL 55 PROVIDER QUESTIONNAIRE - FINDINGS Provider Perceptions of Patient Attitudes 8 7 6 5 4 • 100% agree/somewhat agree that patients worry about developing dementia and are interested in preventing it 3 2 1 0 1. My patients 2. My patients 3. My patients 4. My patients 5. My patients 6. My patients are concerned understand that are aware that think that it is too are interested in understand how about developing specific lifestyle they can reduce late for lifestyle preventing to reduce their dementia factors may put their risk for changes to dementia risk for dementia them at increased dementia improve their risk for dementia cognition Agree Somewhat agree Somewhat diagree • Only 25% somewhat agree that patients understand how to reduce their risk Disagree CONFIDENTIAL PROVIDER QUESTIONNAIRE - FINDINGS Provider Perceptions of Dementia Risk Reduction 8 7 6 5 • 100% agree/somewhat agree that they are concerned about patients developing dementia 4 3 2 1 0 7. I am concerned 8. I am aware that 12 9. I am aware that 10. I am aware that about my patients modifiable risk factors dementia risk factors lifestyle changes can developing dementia may be responsible for can be modified, and reduce the risk of 40% of dementia doing so may preserve dementia, even in brain health patients who are already over 60 Agree Somewhat agree Somewhat diagree • 100% agree/somewhat agree that risk can be modified Disagree CONFIDENTIAL 56 PROVIDER QUESTIONNAIRE - FINDINGS Need for Dementia Risk Reduction Program 1 • Most providers screen patients for dementia risk factors and discuss risk modification with patients • Based on variation within responses, there may be an opportunity to standardize the approach to risk screening and the provision of patient education 8 7 6 5 4 3 2 1 0 11. I have a system for 12. I regularly discuss 13. I have ample time 14. I have the identifying patients dementia risk to educate patients necessary information who are at increased reduction with my about dementia risk to talk to my patients risk of developing patients modification about dementia risk dementia and risk reduction Agree Somewhat agree Somewhat diagree Disagree CONFIDENTIAL PROVIDER QUESTIONNAIRE - FINDINGS Need for Dementia Risk Reduction Program 2 • 8 7 6 • 5 4 3 2 1 0 15. My patients would 16. My patients 17. My patients need 18. My patients would benefit from an already have the more support in be interested in individualized, brain- information they need making lifestyles participating in a healthy lifestyle to adopt a brainchanges brain-healthy lifestyle program healthy lifestyle program if I recommended it Agree Somewhat agree Somewhat diagree • 100% agree/somewhat agree that patients would benefit from additional support in lifestyle changes 100% agree/somewhat agree that patients would be interested in participating in a brain -healthy lifestyle program Mixed responses regarding whether patients already have the information they need Disagree CONFIDENTIAL 57 PROVIDER QUESTIONNAIRE - FINDINGS Provider Support for a Dementia Prevention Program 8 7 6 5 4 3 2 1 0 19. I am interested in 20. I am interested in 21. I would support 22. I would refer highoffering my patients new opportunities for the development of a risk patients to an NPmore information brain-healthy lifestyle dementia risk led dementia risk about reducing their support for my reduction program at modification program risk for dementia patients Madsen Geriatrics Agree Somewhat agree Somewhat diagree • Respondents unanimously agree that they would support and refer patients to an NP led dementia risk reduction program Disagree CONFIDENTIAL PATIENT QUESTIONNAIRE • 53 respondents – Male: 15 – Female: 37 – Incomplete: 1 • Patient Age – – – – – (in years) 60-64: 2% (1) 65-74: 36% (19) 75-84: 49% (26) 85-90: 9% (5) 91+: 4% (2) CONFIDENTIAL 58 PATIENT QUESTIONNAIRE - FINDINGS Worry 100% Awareness 90% 80% 70% 60% 50% • 68% agree/somewhat agree that they worry about memory loss and dementia in the future 40% 30% 20% 10% 0% I worry about losing my memory or I am aware that some lifestyle having dementia in the future factors might increase my risk for memory loss and dementia. Agree Somewhat agree Disagree Prefer not to answer Somewhat diagree • 81% agree/somewhat agree that lifestyle factors may contribute to increased risk CONFIDENTIAL PATIENT QUESTIONNAIRE - FINDINGS Knowledge 100% Timing 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% I know how to reduce my It is never too late to reduce risk for memory loss and my risk for memory loss and dementia. dementia. Agree Somewhat agree Somewhat diagree Disagree Incomplete • 38% do not know how to reduce their risk • 45% only “somewhat agree” that they know how to reduce their risk • 83% believe that they can still reduce their risk CONFIDENTIAL 59 PATIENT QUESTIONNAIRE - FINDINGS Program Interest 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% I would be interested in a brain health and dementia risk reduction program if one were available. Agree Somewhat agree • 87% agree/somewhat agree that they would be interested in a risk reduction program Disagree Prefer not to answer Incomplete CONFIDENTIAL SUMMARY OF FINDINGS • Madsen Geriatrics providers universally support the development of a dementia risk reduction program • Madsen Geriatrics patients are sufficiently interested in improving brain health and participating in a dementia risk reduction program CONFIDENTIAL 60 RECOMMENDATIONS • Screening – Standardize risk -factor screening process • CAIDE RiskScorethe or Tulane Brain Health Quiz • Utilize EHR to identify high -risk patients • Establish a program development committee – Review and adapt existing programs at Tulane/NorthShore – Explore opportunities for associated research funding – Establish a timeline and scope for implementation CONFIDENTIAL RECOMMENDATIONS • Adopt the Dementia Risk Reduction program as an extension of the Aging Brain Program within Madsen Geriatrics CONFIDENTIAL 61 SPECIAL THANKS • • • • • • • Dr. Mark Supiano Dr. Deborah Morgan Dr. Timothy Farrell Dr. Michelle Sorweid Annamarie Faucher Diane Tadehara Madsen Geriatrics providers and nursing staff CONFIDENTIAL REFERENCES Dharmarajan, T. S., &Gunturu, S. G. (2009). Alzheimer's disease: a healthcare burden of epidemic proportion. Am Health Drug Benefits, 2(1), 39-47. https://www.ncbi.nlm.nih.gov/pubmed/25126271 Erickson, K. I., Voss, M. W., Prakash, R. S.,Basak, C., Szabo, A.,Chaddock, L., Kim, J. S.,Heo, S., Alves, H., White, S. M., Wojcicki, T. R.,Mailey, E., Vieira, V. J., Martin, S. A., Pence, B. D., Woods, J. A., McAuley, E., & Kramer, A. F. (2011). Exercise training increases size of hippocampus and improves memory.Proc Natl Acad Sci U S A, 108(7), 3017-3022. https://doi.org/10.1073/pnas.1015950108 Harris Interactive. (2011).What America thinks: MetLife Foundation Alzheimer’s survey . MetLife Foundation. Kim, S., Sargent-Cox, K. A., & Anstey, K. J. (2015). A qualitative study of older and middle -aged adults' perception and attitudes towards dementia and dementia risk reduction.Journal of Advanced Nursing, 71(7), 1694-1703. https://doi.org/10.1111/jan.12641 Livingston, G., Huntley, J.,Sommerlad, A., Ames, D., Ballard, C., Banerjee, S.,Brayne, C., Burns, A., Cohen-Mansfield, J., Cooper, C.,Costafreda, S. G., Dias, A., Fox, N., Gitlin, L. N., Howard, R., Kales, H. C.,Kivimäki, M., Larson, E. B.,Ogunniyi, A., . . . Mukadam, N. (2020). Dementia prevention, intervention, and care: 2020 report of the Lancet Commission.The Lancet, 396(10248), 413-446. https://doi.org/10.1016/s0140-6736(20)30367-6 McMaster, M., Kim, S., Clare, L., Torres, S. J., Cherbuin, N., D'Este, C., & Anstey, K. J. (2020). Lifestyle Risk Factors and Cognitive Outcomes from the Multidomain Dementia Risk Reduction Randomized Controlled Trial, Body Brain Life for Cognitive Decline (BBL -CD). J Am Geriatr Soc, 68(11), 2629-2637. https://doi.org/10.1111/jgs.16762 Ngandu, T.,Lehtisalo, J., Solomon, A.,Levalahti, E., Ahtiluoto, S., Antikainen, R., Backman, L.,Hanninen, T.,Jula, A., Laatikainen, T., Lindstrom, J.,Mangialasche, F.,Paajanen, T.,Pajala, S., Peltonen, M., Rauramaa, R., Stigsdotter-Neely, A., Strandberg, T.,Tuomilehto, J., . . . Kivipelto, M. (2015). A2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in-risk at elderly people(FINGER): arandomisedcontrolled trial. Lancet, 385(9984), 2255-2263. https://doi.org/10.1016/S0140-6736(15)60461-5 Omura, J. D., McGuire, L. C., Patel, R., Baumgart, M., Lamb, R., Jeffers, E. M., Olivari, B. S., Croft, J. B., Thomas, C. W., & Hacker, K. (2022). Modifiable Risk Factors for Alzheimer Disease and Related Dementias Among Adults Aged >/=45 Years - United States, 2019.MMWR Morb Mortal Wkly Rep, 71(20), 680-685. https://doi.org/10.15585/mmwr.mm7120a2 Solch, R. J., Aigbogun, J. O., Voyiadjis, A. G., Talkington, G. M., Darensbourg, R. M., O'Connell, S., Pickett, K. M., Perez, S. R., &Maraganore, D. M. (2022). Mediterranean diet adherence, gut microbiota, and Alzheimer's or Parkinson's disease risk: A systematic review. Journal of the Neurological Sciences, 434, 120166. https://doi.org/10.1016/j.jns.2022.120166 CONFIDENTIAL 62 Appendix F