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Alzheimer's Disease and Related Dementias

1.5 Contact Hours

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This peer reviewed course is applicable for the following professions:

Advanced Practice Registered Nurse (APRN), Certified Nurse Midwife, Certified Nurse Practitioner, Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse Practitioner, Clinical Nurse Specialist (CNS), Licensed Practical Nurse (LPN), Licensed Vocational Nurses (LVN), Midwife (MW), Nursing Student, Occupational Therapist (OT), Occupational Therapist Assistant (OTA), Physical Therapist (PT), Physical Therapist Assistant (PTA), Registered Nurse (RN), Registered Nurse Practitioner

This course will be updated or discontinued on or before Thursday, January 7, 2027

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.

≥ 92% of participants will know more about Alzheimer's disease and related dementias, including the prevalence, symptoms, early diagnosis, treatment, and billing.

It is essential that healthcare workers update and refresh their understanding of Alzheimer's disease and related dementias (ADRD). The state of Kentucky, in their 2024 Legislative Assembly statute KRS 314.073, outlines rapidly changing areas that this course will address.

Knowledge gained about epidemiology, measurements, and treatments has expanded greatly. Our task, as professionals, is to put our best foot forward into expanding treatment options so we can run our best race for the clients who need us most.

After the completion of this course, the participant will be able to:

Recognize warning signs and symptoms of Alzheimer's disease and other forms of dementia.
Summarize the importance of early detection and diagnosis.
Implement appropriate communication techniques for discussing memory concerns with the patient and caregiver.
Distinguish between cognitive care assessments and care planning billing codes.
Determine two tools used to assess a patient's cognition.
Identify current treatments that may be available to the patient.

CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated: 1/7/2025

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Alzheimer's Disease and Related Dementias

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Author: David Tilton (RN, BSN)

Introduction

Alzheimer's disease and related dementias (ADRD) have taken some of our brightest and most celebrated lights from us, from presidents, such as Ronald Reagan, our 40th president credited with ending the Cold War (Berger, 2023), to great entertainers like comedian Robin Williams whose battle with Lewy Body Dementia ended in suicide at age 63 (Vargas, 2024).

Table 1: Diagnosis is Important
Prior to his suicide at age 63, actor and comedian Robin Williams had been misdiagnosed and started on treatment for Parkinson's Disease. It was only after his tragic end that it was determined that what he had been afflicted by was the early symptoms of Lewy body alxdementia- a condition named after abnormal deposits of proteins called Lewy bodies in regions of the brain. For Robin, symptoms included paranoia, confusion, forgetfulness, personality changes, anxiety, and difficulty with movement.
(Vargas, 2024)

Dementia is not a specific disease. Rather, it is a spectrum of conditions that lead to memory problems, the inability to think clearly, and difficulty with problem-solving and decision-making, even during everyday activities. Dementia is not a part of normal aging.

Fear of dementia is real and a greater force than most health providers realize. According to the Centers for Disease Control and Prevention (CDC), recent surveys reveal half of adults over forty believe they personally will develop dementia (CDC, 2024). Some experts go as far as to relate that the dread of dementia is one of the top fears present in our aging population. Anxiety over memory and function loss is bolstered by the press, such as the recent statement from the National Institute on Aging that one-third of our seniors over age 85 already have some form of dementing illness (Senior Consulting Advisors Staff, 2024).

Please be aware that research has shown that health professionals sharing information about Alzheimer's and other dementing illnesses may help to mitigate the fear and dread which currently predominate our aging population. Sharing what is known about the disorders, what treatments are available to prolong healthy thinking, and how each of us can take steps to lower our risk of dementia works to offset predisposing lifestyles and take up healthy avoidance plans (Farina et al., 2023).

Alzheimer's Disease and Related Dementias

A great deal is still unknown about the causes of neurocognitive impairments known as dementia. While each type of dementia has some unique factors that set them apart, the grouping of ADRD shares many common factors. One specific shared feature is the destruction or impairment of function of central nervous system neurons, such as the cells in the brain and nervous system that communicate with each other. For neurons, communication is life. When they cease to communicate with each other, they begin to die (Bradley, 2024). While it is considered normal for neurons to thin or die off as we age, an abnormal rate of neuronal decrease leads to dysfunction of memory, emotions, and sensory/movement abilities.

Shared risk factors across the spectrum of dementias include the following (Bradley, 2024):

Older, over the age of 65.
A family history of one or more types of dementia.
A personal history of contributing conditions such as heart disease, diabetes, hypertension, hearing loss, and depression.
Unhealthy lifestyle patterns such as smoking, alcohol, being physically inactive, and not getting enough sleep.
A history of traumatic brain injury (TBI), injuries to the head, and concussions.
Being of Latino or Black descent.
Social isolation or loneliness.

Alzheimer's disease is the most common type of dementia. Of the estimated 55 million people worldwide currently with dementia, 60% to 70% are experiencing Alzheimer's disease (Mayo Clinic Staff, 2024a). While currently there are no cures for Alzheimer's and many of the dementing conditions, there are treatments that help to slow and even improve symptoms and their progression.

Table 2: Definition Time - Dementia
According to WebMD, "Dementia, also called Major Neurocognitive Disorder, is not a disease. It is a group of symptoms caused by other conditions."
(Ellis et al., 2024)

While Alzheimer's disease is most common, researchers state that there are as many as 50 other known dementing conditions (Ellis et al., 2024). Most of them are uncommon, though several are noteworthy enough that we will be looking at them.

Nothing reflects the status of dementia care better than the conflicting information available from reputable sources on dementing illnesses. For example, according to the Lancet Commission on Dementia, spikes in the incidence of dementia are expected due mainly to the growth in the numbers of our aging population (Livingston et al., 2024), as contrasted by the Journal of Clinical Medicine's report of the decrease in dementia incidence in the United States and Europe (Contador et al., 2024). Do not worry; however, apparent contradictions are smoothed out by collaboration and information sharing. As in this example, the current per capita incidence of dementia diagnosis is offset by the increasing capacity for early diagnosis combined with steady population growth, making conflict into two pieces of a greater epidemiological portrait.

Table 3: Modifiable Risk Factors in Dementia
Maintaining a low level of education Smoking Arterial hypertension Hearing loss Being overweight Depression Diabetes Physical inactivity Low social contact Excessive alcohol intake Head injury Pollutant levels, e.g., air pollution Inadequate levels of vitamin D
(Contador et al., 2024)

Alzheimer's Disease

Alzheimer's disease is a progressive neurodegenerative condition that accounts for 60-70% of all diagnosed dementias. Typically, the onset of Alzheimer's disease occurs gradually, often with years of insidious progression before a client or their family brings symptoms of the condition as a concern to a health provider. During these early, quiet years, pathological changes occur in the brain. Extracellular amyloid plaques are being produced and clumping into neurofibrillary (tau) tangles, leading to the loss of crucial neurons and synapses in the brain (Mayeux, 2024).

Table 4: Alzheimer's Blood Test
Good news! New blood tests are about to hit the medical market that can detect the presence of Alzheimer's biomarkers, specifically p-tau217, and give a 90% accurate result on the presence of Alzheimer's.
(Hamilton, 2024)

The diagnosis of Alzheimer's disease is dependent on observable symptoms provoking the use of a verbal or written cognitive assessment test, then confirmation by spinal tap looking for evidence of amyloid plaque components and neurofibrillary (tau) tangles. This is followed by brain imaging such as a positronic emission tomography (PET) scan to see what current brain tissue damage is present. Genetic testing for the gene APOE-e4 (apolipoprotein E) can also be helpful as those having it have been found at higher risk for Alzheimer's Disease and more serious symptoms (Mayo Clinic Staff, 2024a).

Alzheimer's disease is usually observed presenting in these stages (Barker & Gatta, 2024a):

Alzheimer's Stage I: Normal Outward Behavior

This can be years to decades. Silent gradual brain changes begin years before observable symptoms are present.

Alzheimer's Stage II: Very Mild Changes

This lasts around twelve years. There are small indicators, such as forgetting a name or word they often utilize and losing objects such as keys or a shoe. Irritating events that happen to all of us occasionally are increasingly frequent.

Alzheimer's Stage III: Mild Decline

It lasts around seven years. There are more noticeable changes, including having increased difficulty making plans or organizing, forgetting something they just read, trouble remembering the names of those they do not see frequently, and forgetting to pay bills on time.

Alzheimer's Stage IV: Moderate Decline

Lingers around two years. This is when the progressive symptoms begin to be noticed and can include the following:

Difficulty remembering the date.
Forgetting what month or season it is.
Trouble cooking or even ordering from a menu.
Unable to easily use a smartphone.
Hard to complete multi-step tasks such as cleaning the house.

Alzheimer's Stage V: Moderately Severe Decline

This is around a year to eighteen months in length and is where daily living tasks are affected enough that help is needed. Symptoms can include:

Trouble remembering where they are and what time it is.
Difficulty with their own address or phone number.
Trouble picking out appropriate clothing to wear.

Alzheimer's Stage VI: Severe Decline

This is around two to two and a half years in duration. Symptoms include the following:

Recognize faces yet not names.
Mistake people for someone else.
May need help going to the bathroom.
Difficulty feeding themselves.
Weight loss.
Trouble walking.
Sleep problems.

Alzheimer's Stage VII: Very Severe Decline

This is the terminal stage of Alzheimer's disease. Many basic abilities, such as walking, eating, swallowing, and sitting up become difficult at this stage. As abilities fade, health assistance grows in importance. Supporting clients and their families is a priority.

Alzheimer's Pneumonia

In Alzheimer's disease, pneumonia is often associated with death. Medical care for both treatment for recovery and symptom control and comfort, up to and including hospice care, becomes the focus for health providers and families.

Alzheimer's Treatment

Currently, there is no cure for Alzheimer's disease; there are, however, medications and therapies that slow the decline in function and thinking. Some ancillary therapies promise to contribute to positive care for Alzheimer's disease (Mayo Clinic Staff, 2024b).

Reducing inflammation – The chronic low-grade inflammation found in Alzheimer's disease is being examined to see if lowering it with medications like sargramostim might stimulate the brain and immune system.
Insulin resistance – Some studies have hinted that insulin may be a factor in the progression of Alzheimer's disease. Trials are ongoing, yet they have not shown any effect in slowing Alzheimer's disease progression.
Heart-head connection – Cardiovascular health appears mirrored in the brain. Medications old and new are in trials to determine if a positive effect can be gained in relation to Alzheimer's disease. Healthy heart lifestyles are also being trialed to improve the lives of clients.
Hormones – Mixed results accompany research into the use of hormone therapy for slowing the progression of Alzheimer's disease. In some clients, the use of estrogen during menopause hints that progression can be slowed. More time is needed to determine the cognitive benefits of hormone replacement.

Alzheimer's Medications

Cholinesterase inhibitors such as donepezil, galantamine, and rivastigmine work to boost cell-to-cell communication by increasing levels of chemical messengers depleted by Alzheimer's disease. They tend to improve symptoms related to behavior, such as depression or agitation. Most clients see mild to moderate improvement in their symptoms.

Memantine works by increasing cellular communication like the cholinesterase inhibitors. It serves to slow symptom progression in moderate to severe Alzheimer's disease.

Lecanemab-irmb is an intravenous (IV) infusion given every two weeks, which helps prevent existing amyloid plaques in the brain from clumping.

Donanemab-azbt works like lecanemab-irmb, slowing plaque aggregation in the brain. It is given by IV every four weeks.

Antidepressants and other neuropsychiatric medications may be given to help suppress specific symptoms.

Lewy Body Dementia

After Alzheimer's, Lewy body dementia, sometimes referred to as dementia with Lewy bodies, is one of the most diagnosed neurocognitive disorders. For the most part, it is seldom seen amongst younger people, being found mostly in those 50 years plus, forming around 5% of dementia cases or 1.4 million persons in the United States (Bernstein & Marks, 2024).

There currently is no cure for Lewy body disease, although medications and treatment may slow and ease its progression.

Named after distinctive protein clumps, Lewy bodies, which may build up in brain tissue, affect the function of a brain in the areas of thinking skills, mood, memory, and behavior. Alpha-synuclein protein is the protein that forms the Lewy clumps. These clumps, in addition to choking off neurons and brain cells, interfere with the production of the important neurochemical acetylcholine (memory and learning) and dopamine (mood, sleep, movement) (Bernstein & Marks, 2024). Life expectancy with a diagnosis of Lewy body dementia is between five to seven years, although some cases extend from two to twenty years (Hill, 2024).

It is not known what causes Lewy body disease. While not considered hereditary, the risk of developing this disorder increases when relatives are diagnosed. Also, the presence of certain genetic combinations such as glucosylceramidase beta (GBA), alpha synuclein (SNCA), and apolipoprotein E (APOE) have been associated with a higher risk of Lewy body dementia.

Be aware of two distinct types of Lewy body disease (Salamon, 2024).

Dementia with Lewy bodies – Effecting movement, then memory (in a fashion like Alzheimer's), then patterns of behavior. Paranoia and hallucinations are also common.
Parkinson's disease dementia (NOT Parkinson's disease, which we will discuss later) – Impacting movement primarily, though later in the course of the disease, memory issues manifest.

While symptoms may mimic those of Alzheimer's, memory in the short term is less affected in Lewy body dementia. Also, hallucinations may occur early during Lewy body dementia, adding to the sense of paranoia and distrust that are often exhibited. Violent movements during sleep, known as rapid eye movement (REM) sleep behavior disorder, occur frequently and early. Sleep disturbances are often the first clue that unusual feelings and behaviors are due to Lewy body dementia.

Parkinson's disease with dementia is not Parkinson's disease. While those with Lewy body dementia and Parkinson's disease both experience movement disorders, those with Parkinson's do not typically have memory (dementia) and thinking (cognitive) troubles until quite late in the progression of their disease, if at all. Whereas in Parkinson's disease with dementia, memory and cognitive troubles manifest soon into the course of the disease.

Lewy Body Dementia Diagnosis

There are no tests specific to Lewy Body Disease. Due to the similarity of symptoms with other dementing illnesses, missed diagnoses are much too common. Physical exams, laboratory and imaging studies, and cognitive testing should all be employed to rule out other dementias.

Table 5: Symptoms of Lewy Body Disease
Cognitive (Thinking) Disturbances: Decisions, planning, organizing, remembering difficulties Lack of concentration Staring into space Poor judgment Hallucinations Confusion Language and number difficulty	Movement: Stiff muscles Shuffling slow walk Balance and fall issues Stooped posture Hand tremors Swallowing difficulties Reduced facial expression Weak voice
Sleep: REM behaviors – acting out dreams, including violence and falls from bed Increased daytime sleep Decreased nighttime sleep Restless legs	Mood: Crying and laughing episodes Anxiety, agitation, irritability Depression and loss of interest Delusions Paranoia Restlessness
Other Symptoms: Temperature fluctuations Fainting and dizziness Hot, cold sensitivity Blood pressure fluctuates Urinary incontinence Sexual dysfunction Weakened sense of smell
(Bernstein & Marks, 2024; Hill, 2024)

Key symptoms to watch for (table 5), which assist in differentiating between Lewy body dementia and true Parkinson's disease, include (Salamon, 2024):

Acting out of dreams: REM sleep behavioral disorder, an early symptom arising before other cognitive issues, is distinctive of Lewy body dementia.
Movement change: In Lewy Body dementia, stooped posture and slow movements progress slowly through the course of the disease. Stiffness, then tremors, gait changes, then falls. In Parkinson's, progressive movement issues occur early and are the singularly great initial diagnostic indicator.
The "One Year" rule: In Parkinson's, the movement symptoms are first. Then, about a year later, progressive memory and thinking problems surface. In Lewy body dementia, cognitive and problem-solving symptoms arise. Then, about one year later, movement issues surface, if they arise at all.

Treatment for Lewy Body Dementia

Currently, there is no cure for Lewy body dementia. Medications have been found to control many symptoms and prolong the life of those with the condition (Hill, 2024).

Rivastigmine is currently the only Food and Drug Administration (FDA)-approved medication for the treatment of Lewy body dementia. It is an oral medication that improves cognitive abilities and anecdotally extends life expectancy.

Some clinicians have reported satisfactory results with donepezil and galantamine though caution is advised in the off-label use of any medication.

For Parkinson's-like symptoms during Lewy body dementia, levodopa has been promoted to help decrease tremors. Use with caution as an increase in confusion and hallucinations may accompany its use in some clients.

Antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), have found favor in the treatment of the depression that often accompanies Lewy body dementia.

Physical therapy and speech therapy are helpful in slowing the progression of negative symptoms of Lewy body dementia. Good sleep hygiene and decreasing confusing stimuli have also been found to be helpful.

Parkinson's Disease

Parkinson's disease is a neurodegenerative condition where cells in the central nervous system begin to die much earlier than they would during normal aging. Many of these cells, particularly those located in a brain region found in the basal ganglia known as the substantia nigra, produce the important chemical neurotransmitters dopamine and norepinephrine (Brazier, 2024). When levels of dopamine drop, control of our motor functions becomes haphazard and spastic, and many bodily functions begin to deviate in unfortunate and unwanted manners.

No one can say for certain what causes the development of Parkinson's. In a small number of cases, genetic markers play a role, and histories of brain trauma, such as concussions, may also have a minor role. It is more common over the age of 50 and more prevalent in men. Caucasians and Hispanics are diagnosed more often than other populations, yet again, not to a great extent. The best research has to say for now is that it is out there, and we need to remain observant to catch symptoms early and start reducing symptoms as quickly as possible.

Worldwide, around ten million persons live with a diagnosis of Parkinson's disease, one million of them in the United States (Siuly et al., 2024). While there is currently no cure for Parkinson's disease, symptoms can be lessened with treatment, and current therapies have made it so that sufferers can have a slow progression while maintaining a good quality of life (Bottaro, 2024).

Parkinson's Disease Diagnosis

Early symptoms are the clue leading to a diagnosis of Parkinson's disease. For diagnosis, four key symptoms are watched for and include the following (Gurarie, 2024):

Bradykinesia. 80% of cases present with slow and/or interrupted movements, often accompanied by a lack of coordination, weakness, and a growing inability to control movements.
Tremor. Shaking or tremors is a common feature of Parkinson's disease, particularly trembling at rest, which tends to worsen over time.
Postural Instability. A growing lack of the ability to hold a normal, erect posture. It is frequently accompanied by feelings of imbalance and an increased risk of falls.
Rigidity. Characterized by stiffness and tension leading to pain and discomfort. Found in 75% to 90% of clients, it is often more pronounced on one side of the body.

Table 6: Parkinson's Symptoms
Non-Motor Symptoms: Autonomic related – constipation, urination issues, dizziness, balance, erectile dysfunction Skin disorders, dermatitis Fatigue, daytime sleepiness Cognitive issues – concentration, memory, dementia Mood fluctuations – anxiety, depression Loss of taste, loss of smell Pain Sleep troubles Weight changes Restless leg syndrome	Motor Symptoms: Shuffling gait Bradykinesia- a generalized slowness of movement Stooped or bent over posture Resting hand tremors are sometimes referred to as "pill-rolling" Drooling Blurred vision Difficulty moving eyes, particularly looking upward Dysphagia Difficulty articulating words Speeding up when making repetitive movements (festination) Sudden stops during repetitive movements (freezing)
(Gurarie, 2024; Sadick, 2024)

Parkinson's Disease Testing

A good general exam followed by a neurological assessment will help rule out other disorders. The neurologic exam should include motor control aspects such as gait assessment, repetitive movement tests, pull tests, rigidity assessments, assay of spontaneous movements, and tremor assessments (Gurarie, 2024).

Advanced testing should include items such as:

Cognitive testing: Psychological testing by a trained professional.
DaTScan: A radioactive imaging study is used to assess metabolic features of the nervous system.
Magnetic resonance imaging (MRI): Imaging study of the brain and supportive structures.
Positron Emission Tomography (PET) scan is an imaging study that is able to track dopamine levels within the brain.

Skin biopsy/ spinal fluid test. Recent developments examining biomarkers have led to some new studies that reveal abnormal levels of the protein phosphorylated alpha-synuclein (P-SYN), a protein found in abnormal levels in Parkinson's and related neurodegenerative conditions (Beth Isreal Deaconess Communications, 2024). Testing protocols and standards are in development and show exciting potential for a new standardized testing regimen for Parkinson's disease.

Parkinson's Disease Treatment

Medicating the symptoms of Parkinson's disease is the current standard of treatment (Gupta, 2024).

Levodopa serves to replace the essential dopamine supply cut off as Parkinson's disease progresses.
Dopamine agonists are medications whose presence mimics the effects of dopamine and, in some clients, provide a better replacement than levodopa. Individual drug names are apomorphine, pramipexole, ropinirole, and rotigotine.
Catechol-O-methyltransferase (COMT) and monoamine oxidase-B (MAO-B) inhibitors block the breakdown of circulating dopamine in the brain. COMT inhibitors include tolcapone, entacapone, and opicapone. MAO-B inhibitors include selegiline, rasagiline, and safinamide.
Anticholinergics aid in minimizing muscle rigidity and tremors. Medications include benztropine and trihexyphenidyl.
Amantadine is an antiviral medication that has been found to help with the side effects of levodopa, as well as some of the symptoms of Parkinson's disease.

To a limited extent, surgical interventions may aid in easing some of the symptoms of Parkinson's disease (Sadick, 2024).

Deep brain stimulation has been approved by the FDA as a painless means of stimulating the brain with minuscule electric pulses and blocking or disrupting some of the irritating motor symptoms of Parkinson's disease.
Thalamotomy or pallidotomy selectively destroys small areas of the brain involved with motor symptoms such as rigidity and tremors.
Focused ultrasound beams are highly focused, high-intensity sound waves that go into a client's brain, pinpointing areas of motor symptoms.

Certain therapies have shown benefits in slowing or easing symptoms of Parkinson's disease (Bottaro, 2024).

Exercise releases brain chemicals that are found to slow the progression of Parkinson's disease.
Remaining socially active has shown slowing of disease progression.
Sleep hygiene for better, fuller sleep aids resiliency needed by the body to offset the demands placed on it by the condition.

Vascular Dementia

Around 10% to 20% of all diagnosed dementia cases are vascular in origin (Cimons, 2024; Nyembwe, 2024). Several etiologies can form the causative lack of blood flow to the brain, robbing it of oxygen and nutrients. When this occurs, neurons in the affected areas of the brain begin to die, resulting in an overall shrinkage of the brain. The causes of circulatory starvation include strokes, mini-strokes, transient ischemic attacks, chronic high blood pressure, diabetes, and high cholesterol blood vessel blockages.

Subtle changes occur, which become more noticeable over time.

Table 7: Vascular Dementia Symptoms
Early Symptoms: Familiar tasks cause increasing challenges Getting lost along familiar routes Difficulty finding the right words Feeling less emotional Lose interest in favored activities Misplacing things Changes in behavior, personality, and social skills	Late Symptoms: Sleep pattern changes Difficulty with basic tasks, e.g., cooking, driving Recent memory loss Delusions, depression, restlessness Reading and writing difficulties Poor judgment Avoiding social interactions
(Nyembwe, 2024)

The most common situation leading to vascular dementia is a phenomenon referred to as multi-infarct dementia (MID), otherwise known as mini-strokes. These small vascular insults, also known as transient ischemic attacks (TIAs), are partial constrictions of blood supply. These transient blood flow deficits are relatively symptom-free. At times, there is brief dizziness or blurring of vision. The accumulation of ischemic cellular damage, however, is the buildup to vascular dementia.

Vascular Dementia Diagnosis

A neurologist will typically assess the client with laboratory essays, cognitive testing, and brain imaging studies to rule out other forms or causes of dementia. A definitive diagnosis of vascular dementia is challenging to obtain due to the number of conditions that present with similar symptoms (Nyembwe, 2024).

A solid diagnostic indicator is a history of past vascular injuries or events. Factors such as high blood pressure often prelude vascular dementia, enough so that it is uncommon to find vascular dementia in the absence of standing hypertension (Barker & Gatta, 2024b). Heart disease in the presence of diabetes, chronic alcohol use, and/or smoking tend also to have a higher rate of vascular dementia.

Cognitive testing is the key to a definitive diagnosis, backed by confirmation of central nervous system changes secondary to vascular issues identified by CT scan or MRI.

Vascular Dementia Treatment

There is no current cure for vascular dementia. The prognosis of death is around five years from diagnosis; treatment will ease symptoms and lengthen life expectancy. Untreated vascular dementia typically ends in death from heart disease, stroke, or infection.

Frontotemporal Dementia

Affecting the front (frontal lobes) and the sides (temporal lobes) of the brain, frontotemporal dementia (FTD), also known as Pick's disease, is a syndrome affecting primarily the personality and behaviors of younger people, typically between ages 45 and 60 (Painter, 2024).

A group of symptoms manifests in FTD. The behaviors manifested tend to revolve around atypical rudeness, impulsiveness, and unusual behaviors for that person. Around 40% of those with FTD will have someone in their family who has manifested the symptoms.

Under the diagnostics of FTD are a few niche dementias that fit the overall criteria for FTD.

Amyotrophic lateral sclerosis is also called Lou Gehrig's disease. It is infamous for its lack of muscle control, twitching, and limb weakness. Slurred speech is often its first sign.

Corticobasal syndrome results in poor coordination and stiffness in the arms or legs (often worse on one side of the body), difficulty thinking, and trouble with speech and language.

Progressive supranuclear palsy is known for problems with walking, balance, eye movements, and swallowing.

Table 8: Frontotemporal Dementia Symptoms
Behavior. Loss of empathy Loss of inhibition Apathy Compulsive acts Changes in eating habits Ingesting nonfood items Decline of personal hygiene	Movement. Tremors, twitches, spasms Stiffness Trouble moving the eyes Difficulty swallowing Slurred speech Weakness, falling, trouble walking
Speech/Language. Primary progressive aphasia Increasing difficulty using and understanding both written and spoken language Difficulty finding the correct word when speaking Forgetting the meaning of words Saying things that do not make sense Shifting to shorter, simpler sentences	Posture. In one version of FTD posture, standing shifts to an upright stance with an arched back. This unstable posture, combined with typical eye movement stiffness, explains why many of those with FTD fall backward, typically causing head injuries.
(Painter, 2024; Ravn, 2024)

Frontotemporal Dementia Diagnosis

Early symptom recognition, followed by neurocognitive testing, is key to diagnosing FTD. Brain imaging looking for the signature shrinkage of the brain, particularly around the frontal lobes, can provide a definitive diagnosis.

Frontotemporal Dementia Treatment

No cure is currently available for FTD. Antidepressants may aid in tempering some of the behavioral symptoms. However, therapy generally revolves around non-medication strategies such as avoidance of behavioral triggers, promoting a calm environment, a structured setting, and routine distraction with redirection of attention from problem behaviors (Lindquist, 2024).

Mixed Dementia

As if recognizing and caring for dementia was not difficult enough, one in every ten clients possessing symptoms of a dementing illness has more than one form of dementia simultaneously (Ford-Martin & Booth, 2024). The most common form of comingled condition is Alzheimer's with vascular dementia (Cherney, 2024). Findings of mixed dementias are based on atypical symptoms followed by neurocognitive testing indicating an unusual mix of neurological deficits. Often, imaging studies will confirm two distinct pathologies that are taking place. Such as the presence of tau plaques as in Alzheimer's, concurrent with ischemic cerebral change from repetitive strokes common in vascular dementia, or the presence of Lewy bodies indicative of Lewy Body dementia.

Mixed Dementia Treatment

No cure for mixed dementia is currently available. Treatment must focus on the most problematic symptoms to the client, and individualized care is necessary.

Table 9: Life Expectancy for Dementia Types
Dementia	Life Expectancy
Alzheimer's disease	Around 8–10 years, depending on the age of diagnosis
Vascular dementia	Around five years, with an increase in the risk of stroke or heart attack
Parkinson's Disease	Around 14 years. With early treatment, a client's life expectancy may be near what it would be without the disease
Lewy body dementia	Around six years, with an increase in the risk of falls and infections
Frontotemporal dementia	Around 6-8 years
Mixed dementia	Less than five years
(Cherney, 2024; Effa, 2024; Jones, 2024)

Diagnosing Dementia

ADRD are progressive conditions whose symptoms take years to build up to clinical onset (Contador et al., 2024). Be aware that individuals will each have a slightly different presentation and progression due to each person's unique factors, such as heritage and environment. Also, the base condition leading toward the manifestation of dementia will contribute to how the condition is expressed and, therefore, the end diagnosis.

In general, early signs of dementia will include (Ellis et al., 2024).

Problems with short-term memory.
Increasing confusion and disorientation.
Growing difficulties with communication and sharing.
Increasing trouble completing familiar tasks.
Inappropriate behaviors.
Personality changes (agitation, paranoia, depression, mood swings).
Difficulty adapting to changes in the environment.
Sleep issues.
Onset of delusions (belief in things that are not true).
Onset of hallucinations (hearing, seeing, tasting things that are not present).

The earlier diagnosed, the better. A proper diagnostic regimen typically starts with a broad look at the client. Ruling out other conditions with similar presentations provides a stable foundation for diagnosis. Disorders such as delirium, depression, and cerebrovascular conditions such as a stroke need to be looked at and diagnosed.

A physical examination, bloodwork, and review of personal and family history followed by a brain imaging scan, cerebrospinal fluid tests, and genetic screening all have a place in a comprehensive dementia workup. Most specific are dementia-focused mental health evaluations, often administered by a psychiatrist or other mental health professional.

Cognitive Assessment Tests for Dementia

Cognitive testing is foundational for establishing a diagnosis of dementia. There are several well-established tools available. In general, cognitive tests measure a specific set of mental abilities such as (Tee-Melegrito, 2024):

Orientation, awareness of people, time, and place.
Memory, short and long term.
Communication and language.
Attention and concentration.
Ability to follow instructions.
Problem solving.
Simple math skills.
Visual and spatial skills.

Cognitive tools mostly consist of a set series of questions, mostly verbal, although some will be paper and pencil. Answers will be scored by the questioner following a written scoring guide.

Remember, cognitive assessment tools may give excellent insight into what is happening inside our client's head, yet they also provide exhaustive rabbit trails. The bottom line is that no one should rely on one assessment instrument test alone. In particular, using a second confirmatory tool is good clinical practice for initial diagnosis.

Mini-Mental State Examination

The most used cognitive impairment screening tool is the Mini-Mental State Examination (MMSE). With practice, the original version of the MMSE-1, which is free to use and widely available on the internet, a health professional can roll out the 11 questions or tasks within five minutes.

Covering seven cognitive domains, the test taker can receive a score of 30 points. The test giver rates success on each task following the written guide, giving scores for which the grand total indicates levels of cognitive function (Tee-Melegrito, 2024).

25-30: no cognitive impairment.
20–24: mild dementia.
13–20: moderate dementia.
12 and below: severe dementia.

MMSE, both versions (version one- the old tried and true standard, and version two- expanded to 30 questions), show good reliability and consistency. Declining MMSE scores over time can help document and track dementia progression.

MMSE scores have been found to be associated with progression in Alzheimer's, Lewy body dementia, and vascular dementia in particular (NeuroCog News, 2024).

Abbreviated Mental Test Score

A great early screening tool, the Abbreviated Mental Test Score (AMTS), is a quick, 10-minute, 10-item, verbally delivered quiz validated for identifying cognitive impairment, particularly in older clients (Kamalzadeh et al., 2024). AMTS focuses on short-term/long-term memory, orientation, and attention abilities. By not needing to read, write, or draw, the ATMS is helpful for use with clients with limited abilities.

Mini-Cog and Clock Drawing Test

We have all seen or heard about it, and here it is. The famous "drawing a clock" test, the Mini-Cog. The Mini-Cog consists of two tasks: draw a clock and remember three words. And yes, the order in which the tasks are given does matter. Just try to remember 'words,' 'clock,' 'words'.

First, give your client three words and ask them to repeat them to you.

The clock drawing part consists of asking the client to draw the face of a clock (non-digital for all you smart younger folks), put all the numbers on it, and then draw in the hands to indicate a time that you, the test giver, specify.

Table 10: Mini-Cog
Draw clock at 1:30 Normal	Draw clock at 2:15 Mild Cognitive Impairment Early Alzheimer's disease	Draw clock at 3:45 Clear Cognitive Impairment Late Alzheimer's disease

Numbers are sequential Locations appropriate All numbers are present Time hands are accurate	Number of locations spotty Spacing is labored Time hands wrong	No numeric sequencing Some numbers missing Locations random No attempt at time hands

After the clock is drawn, please resist the impulse to correct or critique your client's artistic effort. After all, what they draw reflects the function of the neural pathways in their brain. Go back to the three words and ask the client to tell you what they were.

The Mini-Cog and, to a lesser extent, the drawing-only section of the exam, which is referred to as the Clock Drawing Test (CDT), gives good testing of the brain's executive function, verbal listening and recall abilities, and visuospatial abilities. Use the test guide to score the tool, which has good diagnostic reliability for cognitive impairment and the presence of dementia.

Montreal Cognitive Assessment

A more substantial, 30-point screening tool for cognitive impairment and dementia is the Montreal Cognitive Assessment (MoCA). Due to the multiple cognitive domains assessed, it is recommended that professionals using it have adequate training. The domains it evaluates include executive functioning, attention, visuospatial abilities, conceptual thinking, recall, language, and orientation (Kamalzadeh et al., 2024). The MoCA is recognized for its early ability to identify Parkinson's and other neurodegenerative disorders (Rosenzweig, 2024).

Cognitive Tools for Reading Impaired

Be honest, we all deal with clients who find reading or writing challenging for multiple reasons. There are good cognitive assessment tools with established validity, especially for our older clients with literacy issues. The AMTS, Short Portable Mental Status Questionnaire (SPMSQ), and Brief Interview for Mental Status (BIMS) all allow a quick, 10-to-15-minute window into the cognitive abilities of our vulnerable adults (Kamalzadeh et al., 2024).

BIMS, for example, is a tool used not for initial diagnosis but rather for tracking changes in cognitive ability on a routine, monthly, or quarterly basis. The test is comprised of three conversational sections.

First, an assessment of immediate recall, giving the client three simple words and then asking them to repeat them immediately. Second, an assessment of orientation is done by asking the client what the current year, month, and day of the week are. Third, an assessment of short-term memory by asking what three words they were supposed to remember. Results are given via a numerical score, which can then be documented and compared to previous scores as a reflection of changing cognitive abilities (Heerema, 2024).

Cognitive Care Assessment and Care Planning Billing Codes

So, let us look at one of the more confusing aspects of dementia care: billing and reimbursement. It can be confusing because you need familiarity with not one system of billing codes but several.

Table 11: Medical Billing Coding Systems
Coding system	Description
International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM)	CDC-70,000 codes. Used globally for diagnosis and procedure coding.
International Classification of Diseases, 10th revision, Procedure Coding System (ICD-10-PCS)	Centers for Medicare & Medicaid Services (CMS)-87,000 codes. Used globally for inpatient procedure coding, diagnosis, and cause of death.
Current Procedural Terminology (CPT)	American Medical Association (AMA)-10,000 codes. Standardized coding system for billing and reporting medical services and procedures performed by healthcare providers.
Healthcare Common Procedure Coding System (HCPCS)	CMS-7,000 level 2 HCPCS codes. Standardized coding system based on CPT codes. Level 1 HCPCS codes are CPT codes, while level 2 HCPCS codes are alphanumeric codes used to report products, supplies, and services not included in CPT codes, i.e., ambulance services, durable medical equipment, prosthetics, etc.
Diagnostic-related Group (DRG)	CMS-700 DRG codes. Used to classify hospital cases into groups for the purpose of payment. DRGs are based on diagnoses, procedures, age, sex, and the presence of complications or comorbidities under the Medicare Inpatient Prospective Payment System (IPPS).
(Khan, 2024)

For payment with clients where dementing conditions are anticipated or already diagnosed, our most used category is known as CPT codes. The AMA created and maintained these medical codes. Physicians use them, as well as allied health professionals, hospitals, nonphysician practitioners, laboratories, and outpatient facilities, to represent care and services rendered. No health service provider gets paid without providing a proper CPT code. So, be kind to your billing and documentation staff.

Base CPT codes are five-digit numbers. The total CPT code may have three parts: the numeric base code, any modifiers, and a description. The numeric base code represents a unique medical procedure or service. The modifier, an extra one or two digits, provides additional information regarding the service if needed. The description is just that, a summary of the object being billed.

Common CPT Codes for Dementia

CPT code 99483 is specific for evaluating and treating dementia. It provides reimbursement for a cognitive assessment with a duration of 50 minutes on the condition that a written care plan is produced. Physicians, clinical nurse specialists, physician assistants, and nurse practitioners can use this code once every 180 days to receive around $260 from Medicare (Creyos, 2024).

Should client care go beyond 50 minutes, CPT code 99354 can be submitted separately for up to an additional 99-minute span. For longer times, CPT 99355 can be added for each 30 minutes further.

Other common CPT codes include the following (Creyos, 2024; Montemayor, 2024; RCM Matter, 2024):

90785: Psychological complex interactive
90791: Psychological diagnostic evaluation
90792: Psychological diagnostic evaluation with medical services
90837: Psychotherapy
90899: Unlisted psychiatric service or procedure
96103: Psychological testing by an administrator
96116: Neurobehavioral status examination prior to neuropsychological testing, first hour
96118: Evaluation of neuropsychological functioning, use this code for computerized neuropsychological testing
96120: Neuropsychological testing by an administrator
96121: Evaluation services beyond the first hour
96125: Standardized cognitive performance testing, first hour
96127: Brief emotional/behavioral assessment
96132: Complex neuropsychological evaluation, first hour
96133: Additional time, add-on to 96132 for 31-60 minutes
96136: Psych or neuropsychological testing by a qualified professional, two or more tests, from 16-30 minutes
96137: Additional time, add-on to 96136 for 31-60 minutes
96138: Psych or neuropsychological testing and/or scoring for two or more tests 16-30 minutes
96139: Additional time, add-on for 96138 for 31-60 minutes
96146: Computer administered and scored neuropsychological test
99201–99215: Office outpatient visits and outpatient procedures
99202: Office or outpatient new patient visit with history and/or simple exam 15-31 minutes
99241-99245: Consultations
99304-99310: Visits to nursing facilities
99324–99337: Home visits with new patients
99341–99350: Home visits
99366–99368: Medical team conference
99483: Cognitive assessment resulting in a written care plan
99497: Advanced care plan, first 30 minutes
99498: Advanced care plan, additional 30 minutes

Do not forget the most common CPT modifiers used in this client base.

28: Another service provided simultaneously
59: Used to identify procedures/services, other than emergency medical services, which are generally not reported together but are appropriate under the circumstances

Case Study One
Family concerns for 51-year-old George brought him into the outpatient clinic this afternoon. You hear raised voices in the waiting area and step in to find George standing over his 73-year-old mother with clenched fists, yelling about being made to wait. Making the pre-planned hand sign to the reception that calls security, you step forward and redirect George's attention to you, introducing yourself and inviting him to sit with you at a table on one side of the area, sitting across the table from him. With plenty of room to retreat if needed, you listen to his concerns, providing empathy while conveying the need for structure. Security arrives and, at your gesture, hovers in the background as if it is an observable presence, yet taking no threatening actions.
Dialoging interactively with George, you find out history, frustrations, and fears. With some effort, you get him to agree to be consistent with the medication regimen prescribed by his primary care physician and come back for cognitive testing. The encounter ends peacefully with George holding the door open for his mother, who mouths profuse thanks.
A reasonable outcome to an edgy situation is brought crashing as the receptionist clears her throat and says, "Okay, so, how do you want to bill this?"
Remember, it is a CPT billing code, followed by any modifiers and a brief description. CPT 96127-28-Emotional aggressive assessment with care interaction with new pt, 35 minutes. CPT 90785-28-Complex psychological care interaction while assessing behaviors, new patient, 35 minutes. CPT 99202-59-Outpt new patient history, simple exam with behavior assessment, and complex psychological care, 35 minutes.

To meet documentation and compliance requirements, be sure to include the following (if applicable) in the description: Duration of service (testing, meeting, etc.), specific tests administered, and differentiation of whether a standardized tool (test, exam) was used, an adaptation of a standardized tool, or some other type of assessment or screening tool.

Treating Dementia

While there are specific therapies and treatment regimens unique to certain diagnoses, there are also therapies that show promise across the board in dementia care. Non-medication approaches such as mindfulness, cognitive behavioral therapy (CBT), light therapy, music, exercise, and specific diets improve quality of life and show promise for life extension with neurocognitive disorders.

Mindfulness brings a focus on the now, working with things, concentrating on what is happening, and bringing calm into a disorganized mind.

CBT is a form of psychotherapy that works to offset negative thoughts and behaviors. A 2023 meta-analysis has shown that in Alzheimer's clients, CBT significantly reduced depression, enhancing emotional well-being and cognitive function (Pedersen, 2024).

Exercise has shown significant benefits for those who are cognitively impaired, enhancing memory and attention, increasing blood flow, and reducing harmful inflammation.

Diet studies have shown that following the Mediterranean, Dietary Approaches to Stop Hypertension (DASH), or Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND) diets can help reduce cognitive decline and lower Alzheimer's risk.

Mediterranean diet: Rich in fruits, vegetables, whole grains, nuts, and olive oil. Reduces inflammation and supports heart and brain health.
DASH diet: Emphasizes fruits, vegetables, whole grains, and lean proteins, which help manage blood pressure and improve cognitive function.
MIND diet: This diet combines elements of the Mediterranean and DASH diets. Focuses on brain-healthy foods, like leafy greens and berries, to slow cognitive decline.

Light therapy shows promise in mild to moderate dementia. Low-powered transcranial near-infrared (tNIR) light used twice daily for eight weeks brought about better memory and verbal skills (Borsuk et al., 2024).

Discussing Memory Concerns

Face it, we, as health professionals, will not be the ones who first see the subtle symptoms of cognitive and memory problems. Sometimes, it will be the client, yet the family or close friends usually get that gut feeling based on interaction that something serious is off. You need to build your communication relationship with clients and their families early so they will be comfortable when that time comes, bringing you concerns and questions. These are the things that allow for early diagnosis, aggressive treatment, and a happier outcome all around.

Communication is Preparation

Before bringing up the conversation topic of memory loss, preparation is key. Is your goal to share information? Always a good start. Do you want to express concern? Think about what and why. Is your purpose to suggest courses of action? Hmm, strengthening a relationship would be a better first move.

Clear goals will help move things along in a productive manner.

Choose a proper time and place. Office talks are fine, yet resist cramming them into the five minutes allowed for total practitioners with client time enforced by your fiscal authority. Having pamphlets or supplemental materials on hand is helpful, yet remember, they are secondary materials. Have specific events or examples thought out beforehand, and do not be afraid to use your own story to set the tone.

Case Study Two
Julian is a mental health nurse assigned to the Teske family through the holistic clinic where he works. They are a vibrant multigenerational family unit with preteens to great-grandparents. This afternoon, he is meeting with Mr. Teske Junior, a forty-seven-year-old career diplomat, and his wife to discuss the subject of elder care planning, a topic the family has avoided on previous occasions. He has chosen a quiet conference room overlooking the clinic garden and has prepared some informational literature for use only should the conversation turn in that direction. He plans to share with the Teskes his own recent experience with his mother, who had been increasingly forgetful and had just last month become disoriented and lost in the local grocery store. Julian explained that most of the time, everyone needed extra help as they matured. The sooner a plan and a process were worked out, the better the outcome would be, as it would encourage the Teskes to share concerns and questions regarding their aging parents, creating liberty for the exchange of information.
Conclusion: Mixed results. Mr. Teske slammed an emotional wall so quickly that Julian felt it in his teeth. Mrs. Teske was interested and open to learning more, and she showed signs of concern, which were highlighted by frequent glances at her husband when his attention was elsewhere. Ending on a friendly and relationship-building note when it became clear Mr. Teske was finished with the topic. Julian passed handouts to Mrs. Teske quietly as he walked with them to the door.

Communication Regarding Signs and Symptoms

Short-term memory loss tends to be the first cognitive display of encroaching dementia. Coach your clients to be alert for recurrent displays that are the clue toward an early examination and treatment. Do be aware that spouses and close family may not be reliable historians of developing symptoms, as there is hesitancy to name something as an illness in most cultures (Rauf & Phillips, 2024). In the initial stages of dementia, the person with the condition is often aware that something is amiss.

Emphasis on early detection leading to earlier and better treatment should be used with both clients and their close support. A proper diagnosis allows planning for potential care needs during a period when the affected individual can take an active role in determining their plan.

Communication Requires Comfort

Having a dementia talk is not a confrontation or battle to be won. Pick a comfortable setting, a time of day when your loved one tends to be alert and relaxed. Be as low-pressured as possible. Express concern in a gentle manner. Be candid and show love and respect.

"Dad, I was worried when you did not answer your phone on your birthday. It is a special time when we all talk together, even when we cannot talk in person. That does not seem like you, and I was wondering what happened."

Communication Requires Follow-Through

Starting a dialogue with "I think you have Alzheimer's" is bad form. Expressing care and concern will achieve a more desirable outcome. Should your family member or client become angry at the thought of having memory or thinking problems, do not write them off. Circle back around later or include a coworker to make the next approach. After all, healthcare is all about teams working together.

Communication Can Birth a Plan

A plan of care, a recipe for action, is best arrived at in collaboration with the client, family, and health professionals. Conversations and discussions can address future fears and worries concerning diagnosis, treatment, finances, care needs, transportation, and day-to-day care. It all begins with awareness and early intervention.

Conclusion

ADRD are much too common amongst older adults, enough to be a fear for many in our aging population. We see politicians and celebrities fall victim to loss of function and decide what chance we have to avoid these harbingers. Well, statistics aside, there is a lot that health professionals can do. Awareness of general signs and symptoms of neurocognitive conditions allows early suspicions, leading to testing, cognitive evaluation, and treatments. While cures are not yet available, quality care planning can bring about longer, healthier lives. It all begins with early recognition, prompt actions, and taking the initiative and time to have difficult conversations with families, clients, and even our relatives. We are making a difference for better living.

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Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.

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