Brain Health, Cognitive Impairment, and Dementia

A Toolkit for Primary Care Teams

The GSA KAER Toolkit is intended to support primary care teams in implementing a comprehensive approach to initiating conversations about brain health, detecting and diagnosing dementia, and providing individuals with community-based supports. It includes practical approaches, educational resources, and validated clinical tools that teams can integrate into their workflow.

Updates to the Toolkit

July 2023 Updates  

• Noted that care teams may find it useful to reflect on their current practices using the Start, Stop, Continue, Improve Action Plan. See page 4.  
• Added the McKnight Brain Research Foundation's Cognitive Aging Explained to support providers in kickstarting brain health conversations. See page 11. 
• Updated Table K-2. Resources on Brain Health for Patients with additional resources promoting brain health and healthy aging. See page 12.  
• Integrated online resources available to support people with dementia and their families, including tip sheets in a variety of languages. See page 33.

May 2023 Updates 

• Added the recently updated GSA Agitation in Alzheimer’s Disease Decision Tree. See pages 16 and 27.

April 2023 Updates

• Showcased a GSA Momentum Discussion podcast episode, Enhancing Early Detection of Cognitive Impairment, that highlights approaches aimed at early detection of cognitive impairment in the primary care setting and underscores how providers can use tools in the Kickstart section of the Toolkit to enhance their early detection efforts. See page 11.
  
  Highlighted the resource Navigating Pre-Screening Conversations from the BOLD Public Health Center of Excellence for Early Detection of Dementia that offers simple steps to ease difficulties related to conversations about cognition. See page 11.

March 2023 Updates 

• Showcased GSA Momentum Discussion podcast episode, "Reimbursement as a Pathway for Quality Dementia Care." Reminded providers that payment policies from the Centers for Medicare & Medicaid Services (CMS) and other payors change frequently and they should refer to payor-specific guidance to guide their documentation and billing practice. See page 6.
• Added ACT on Alzheimer’s resources aimed at increasing the capacity of dental providers and other professionals to care for older adults living with dementia and to support their care partners. See page 15.
• Showcased GSA Momentum Discussion Podcast episode, "Risk-Based Strategies for Referrals to Community Services for Older Adults with Dementia and their Care Partners." See page 33.

November 2022 Updates

• Updated version language, formatting, and pagination. No content changes made.

October 2022 Updates

• Added that individuals with dementia may experience dementia-related psychosis, agitation, and symptoms of pseudobulbar affect and included links to additional GSA resources regarding these issues. See pages 18 and 29.
• Included links to brief cognitive screening tests available in languages other than English in Table A-1. See page 21.
• Updated resources in Table E-1. Resources for the Public About Early Recognition of Dementia, Table E-4. Resources for Dementia Caused by Alzheimer's Disease, Table E-5. Resources on Dementia Caused by Vascular Conditions. See pages 27 and 31.

August 2022 Updates

• Invited users of the KAER Toolkit to provide feedback. See page 4.
• Showcased GSA’s Commitment to Diversity, Equity, and Inclusion and noted that, in line with this, GSA is committed to adding resources that support primary care teams to address the needs of individuals from diverse and under-served communities to the KAER Toolkit. See page 6.
• Provided information about a comprehensive document from USAgainstAlzheimers detailing primary prevention recommendations to reduce the risk of cognitive decline, including recommended billing codes for primary care providers. See page 9.

June 2022 Updates

• Table K-2. Resources on Brain Health for Patients was updated to include the Global Council on Brain Health’s report, "How to Sustain Brain Healthy Behaviors: Applying Lessons of Public Health and Science to Drive Change." The report addresses actions that individuals, communities, and policymakers can take to promote healthy brain behaviors is also available in Spanish, and there are infographics to promote brain health available in several languages. The report was also added to page 15.

January 2022 Updates

• Under “Raise the topic of brain health and continue the conversation over subsequent visits” – added the USAgainstAlzheimer’s Clinician Guide on Risk Reduction, Primary Prevention Recommendations to Reduce the Risk of Cognitive Decline. See page 15.
• Under “Listen for people’s concerns about memory and cognition” – added the USAgainstAlzheimer’s memory questionnaire, BrainGuide, that may be useful for patients who are concerned about their brain health, that of a loved one, of if they are an Alzheimer’s caregiver, it provides the tools needed to move forward confidentially. See page 16.

KAER Framework

The Toolkit is based on the KAER Framework, which consists of four steps: Kickstart, Assess, Evaluate, and Refer.

While the KAER Framework was originally developed for the primary care setting, it can be valuable to other health care professionals, educators and students.

GSA KAER in the News

July 2021: At the Alzheimer's Association International Conference, Annette L. Fitzpatrick, PhD, presented on an ongoing quality initiative at the University of Washington based on the KAER Toolkit. The aim of the initiative is to increase and improve timely detection of cognitive impairment across primary care in 15 neighborhood clinics in the Pacific Northwest. Her presentation, titled "Evaluating a System to Promote Timely Detection of Cognitive Impairment in Primary Care Practice," described the Cognition in Primary Care Program which is working on implementing an adapted version of the GSA KAER Toolkit to all 16 primary care clinics at UW Medicine.

October 2020: The Center for Disease Control and Prevention has awarded a $500,000, two-year research grant to review, refine, test, and evaluate components of the KAER Model in primary care. The recipient is Dr. Annette Fitzpatrick, Research Professor of Family Medicine at University of Washington and affiliate investigator of UW’s Health Promotion Research Center (a CDC Prevention Research Center). Dr. Fitzpatrick and her team will use the results from this study to provide recommendations for the practical application of the KAER Model and initiate steps for integrating tools into a broader reach of primary care practices within the multi-state UW Medicine network.

Other Relevant Resources

• Download KAER Toolkit 2017 Edition
• The Gerontological Society of America Workgroup on Cognitive Impairment and Earlier Diagnosis: 2015 Report and Recommendations
• "Transforming the Alzheimer’s Disease Journal: The Role of Geriatric Specialists in Early Diagnosis and Patient-Centered Care" (A symposium held in conjunction with the GSA Annual Scientific Meeting)

Inviting User Feedback

Please send us tools or resources that you recommend for inclusion in the kit. We also welcome input on how to enhance the KAER Toolkit from teams who have adapted the KAER Framework and used toolkit resources in their practice. Please send your feedback or suggestions to Jen Pettis at This email address is being protected from spambots. You need JavaScript enabled to view it..

2017 KAER Toolkit: 4-Step Process to Detecting Cognitive Impairment and Earlier Diagnosis of Dementia

Approaches and tools for primary care providers

This comprehensive toolkit is focused on the KAER model developed by the GSA Workgroup on Cognitive Impairment Detection and Earlier Diagnosis. The workgroup identified valuable tools and resources to implement the four steps in the KAER model. The resulting toolkit provides options for each of the steps so that PCPs, health plans and health care systems can select the approaches and tools that fit best with their existing primary care structure, organization, and procedures.

The toolkit is broken down by each section of the KAER model to allow quick and easy access:

• Kickstart the cognition conversation
• Assess for cognitive impairment
• Evaluate for dementia
• Refer for community resources

Each step in the model will help the PCP initiate conversations about brain health, detect and assess cognitive impairment, diagnose dementia, and provide post‐diagnostic referrals for education and supportive community services for persons with dementia and their family caregivers.

There also is a free companion webinar, "How to Use the GSA KAER Toolkit: A 4-step Process to Detecting Cognitive Impairment and Earlier Diagnosis of Dementia."

KAER Toolkit Table of Contents

List of Approaches and Tools Found in the Toolkit

• Two-page summary document of the toolkit's contents

Introduction

• The KAER Model (Page 6)
• Objectives and components of the toolkit (page 8)
• General tips for communications with older adults (page 10)
• Terms and definitions (page 10)
• Appendices — Tools to Use (page 11)

Additional Resources

• The Gerontological Society of America Workgroup on Cognitive Impairment and Earlier Diagnosis: Report and Recommendations
  • The cognitive assessment tools mentioned in this report are accessible from the following two websites: the Alzheimer’s Association and the National Institute on Aging
• December 2017 webinar: "How to Use the GSA KAER Toolkit: A 4-step Process to Detecting Cognitive Impairment and Earlier Diagnosis of Dementia"
  • Webinar slides
• January 2015 webinar: Medicare Annual Wellness Visit as Springboard to Detection of Cognitive Impairment, Diagnosis, and Post-Diagnosis Support
  • Webinar slides
• November 2014 symposium: Medicare Annual Wellness Visit as Springboard to Detection of Cognitive Impairment, Diagnosis, and Post-Diagnosis Support handouts

Workgroup Members

This program is developed by GSA and supported by Eli Lilly and Company.