1/9/13

www.medscape.com/viewarticle/775540_print

www.medscape.com

Multisite Qualitative Study of Primary Care Physicians' and Midlevel Providers' Self-Reported Practices and Perceptions About Maintaining Cognitive Health
AngelaK.Hochhalter,PhD,LucindaL.Bryant,PhD,RebeccaHunter,MEd,RuiLiu,PhD, DanielaB.Friedman,PhD,AnnaE.Price,PhD,JosephSharkey,PhD,MPH,RD,SwarnaReddy,MA,MS,AnthonyJ.Caprio, MD,SindyMcCrystle,MSN PrevChronicDis.20129

AbstractandIntroduction
Abstract

IntroductionTofacilitatenationaleffortstomaintaincognitivehealththroughpublichealthpractice,theHealthy BrainInitiativerecommendedexaminingdiversegroupstoidentifystakeholderperspectivesoncognitivehealth.In response,theHealthyAgingResearchNetwork(HAN),fundedbytheCentersforDiseaseControlandPrevention (CDC),coordinatedprojectstodocumenttheperspectivesofolderadults,caregiversofpeoplewithdementia,and primarycareproviders(PCPs)onmaintainingcognitivehealth.OurobjectivewastodescribePCPs'perceptionsand practicesregardingcognitivehealth. MethodsHANresearchersconducted10focusgroupsand3interviewswithphysicians(N=28)andadvanced practiceproviders(N=21)inColorado,Texas,andNorthCarolinafromJune2007toNovember2008.Datawere transcribedandcodedaxially. ResultsPCPsreportedaddressingcognitivehealthwithpatientsonlyindirectlyinthecontextofphysicalhealthorin responsetoobservedfunctionalchangesandpatientorfamilyrequests.Someprovidersfeltevidenceonthe efficacyofpreventivestrategiesforcognitivehealthwasinsufficient,butmanyreportedsuggestingactivitiessuchas gamesandsocialinteractionwhenqueriedbypatients.PCPsidentifiedbarrierstotalkingwithpatientsabout cognitivehealthsuchaslackoftimeandpatientreactionstorecommendations. ConclusionCommunicatingnewevidenceoncognitivehealthandengagingolderadultsinmakinglastinglifestyle changesrecommendedbyPCPsandothersmaybepracticalwaysinwhichpublichealthpractitionerscanpartner withPCPstoaddresscognitivehealthinhealthcaresettings.
Introduction

In2007aspartoftheHealthyBrainInitiative,theCentersforDiseaseControlandPrevention(CDC)andthe Alzheimer'sAssociationreleaseda"roadmap"forcognitivehealth,whichincludesrecommendationsfor incorporatingcognitivehealthintonationalpublichealthpractice.[1]TheCDCfundedHealthyAgingResearch Network(HAN)initiatedprojectsaddressingtheroadmaprecommendationtodescribehowdiversegroupsperceive cognitivehealthandtheassociationstheymakebetweencognitivehealthandlifestyle. InthefirstHANproject,focusgroupswitholderadultsandcaregiversofpeoplewithcognitiveimpairment documentedperceptionsofcognitivehealthinrelationtoagingwell.Acrossracialandethnicgroups,olderadultsand theircaregiversdefinedsuccessfulcognitiveagingasabsenceofcognitiveimpairment,staying"sharp"and"clear minded,"havingagoodmemory,andstayinginvolvedinstimulatingactivitieslikegames.[2,3]Theybelievedhealth behaviorsandphysicalhealtharetiedtocognitivehealth.[4]Inthesecondproject,Dayandcolleagues[5]developed

www.medscape.com/viewarticle/775540_print

1/9

1/9/13

www.medscape.com/viewarticle/775540_print

anddeployeda5itemmoduleoncognitiveimpairmentanddementiainthe2008PorterNovelliDocStylessurveyof primarycarephysiciansspecializinginfamilyorinternalmedicinewhohadbeenpracticingforatleast3years. Approximately40%ofphysiciansreporteddiscussingcognitionwithpatientsnotdisplayingcognitiveimpairment either"often"or"veryoften."Physiciansmostcommonlyreportedadvisingpatientstoengageinphysicalactivityto preventcognitivedeclineanddementia,regardlessofperceivedstrengthofevidenceforstrategiestoprevent cognitiveimpairment.Lackoftimeandlackofreimbursementwerethemostcommonlycitedbarrierstodiscussing preventionofcognitivedeclineordementiawithprimarycarepatients. Weconductedaqualitativestudytobuildonthefirstprojectconductedwitholderadultsandcaregiverstoprovide primarycareproviders'(PCPs')perspectivesonsimilarissuesandtoadddepthandcontextforfindingsfromPCPs reportedbyDayetal.[5]Thestudyaddressed4questions:1)DoPCPstalkaboutcognitivehealthwithpatientswho havephysicalcomplaintsandalsoareatriskforcognitiveimpairment?2)WhatrecommendationsdoPCPsbelieve theycanmaketohelppatientsmaintaincognitivehealth,anddotheymaketheserecommendationsintheir practices?3)WhatpromptsPCPstoinitiatediscussionsaboutcognitivehealth?and4)Whatarethebarriersto PCPsdiscussingcognitivehealthwithpatients?TheobjectiveofthisstudywastodescribePCPs'perceptionsand practicesrelatedtocognitivehealth.

Methods
Participantswereapurposivesampleoffamilypracticeandinternalmedicinephysicians,nursepractitioners,and physicianassistantsinColorado,Texas,andNorthCarolinarecruitedthroughHANinvestigatorsattheColorado SchoolofPublicHealth,TexasA&MHealthScienceCenter,andUniversityofNorthCarolinaatChapelHillin partnershipwithUniversityofSouthCarolina.Thesamplingframeincludedprovidersactivelyengagedincommunity basedpatientcareinurbanandruralsettingsandwhowerediverseintermsofage,race/ethnicity,andyearsof practice. AreaHealthEducationCenter(AHEC)partnersassistedwithrecruitmentatColoradoandNorthCarolinasites.The partnerAHECinColoradosentemailinvitationstoitslocalprovidercontactlist(approximately40people).The partnerAHECinNorthCarolinaemailedproviderswhowereregisteredforprofessionalconferenceswherefocus groupswerescheduledtooccur.InTexas,invitationstoparticipateweredistributedbyemailorpersonallyfroman investigatoraffiliatedwithahealthcaresystemandbyphysicianchampions.InvitedphysiciansinTexaspracticed at2clinics(estimated50physiciansinvited)orwereaffiliatedwithalocalphysicianorganization(numberinvitedis unknown).Physicianassistantsandnursepractitioners(advancedpracticeproviders[APPs])inTexaswereinvited throughabriefgroupannouncementataprofessionalconference(approximately100APPsinvited).Potential participantsreceivedinvitationstotakepartinfocusgroupsaboutbrainhealthaspartoftheHealthyBrainStudy. [6,7]Allinterestedproviderswereeitherincludedinfocusgroupsorinterviewed. FocusgroupsandinpersoninterviewswereconductedfromJune2007toNovember2008inclinicsandat professionalconferences5focusgroupsand3inpersoninterviewswereconductedwith28physicians,and5focus groupswereconductedwith21APPs.Interviewswereconductedwith1facilitator,1notetaker,and1interviewee. Aninterviewer(A.K.H.,J.S.,L.L.B.,R.H.,S.M.)andanotetaker(A.K.H.,J.S.,L.L.B.,S.R.)fromthestudyteam attendedallfocusgroupsandinterviews.Interviewsoccurredwhenonly1participanteithercametoascheduled focusgroupsessionorindicatedinterestinthestudy.Interviewsdifferedfromfocusgroupsonlyinthenumberof participantsandwerearrangedattheconvenienceofparticipants. ExperiencedmoderatorsfacilitatedfocusgroupsandinterviewsinEnglishbyusingadiscussionguidedevelopedby themultisiteteam.Sessionslasted40to60minutesandwereaudiorecorded.Moderatorsusedprobestoobtainand clarifyparticipantresponses.[8]Researchprotocolswereapprovedbyappropriateinstitutionalreviewboards.

www.medscape.com/viewarticle/775540_print

2/9

1/9/13

www.medscape.com/viewarticle/775540_print

Althoughinvitationstoparticipateindicatedthattheprojectwasaboutcognitivehealth,thesessionbeganwitha writtencasestudyaboutacommonpatientcaresituationthatmightsuggestbutdidnotspecifyahigherthan averagelongtermriskforcognitiveimpairment.Itwasdesignedtoelicitresponsesexploringthedegreetowhich cognitivehealthisconsideredduringthecourseofaddressingchronicillnessessuchasdiabetes: Thiscasescenarioinvolvesahealthmaintenancevisit,presumablyatleast30minuteslong. MrHenryY.isa55yearoldmanseentodayforahealthmaintenancevisit.MrY.isobeseandhaspoorly controlledtype2diabetes.Hehasahistoryofreasonablemedicationadherencebutpooradherencetodietand exerciserecommendations.Youalsocareforhismotherwhoisaged76withmoderatecognitiveimpairment andsevereperipheralneuropathy. Inthecontextofthisvisit,whatadvice(recommendations)willyougivehimtohelpmaintainhishealth? Participantsalsodiscussed6additionalquestionsaboutperceptionsofagingwell,messagestheygivetopatients aboutcognitivehealthandpreventionofcognitiveimpairment,perceivedvalueofandbarrierstosuchadvice, perceptionsofstigmaofdementia,andpreferredsourcesofcontinuingeducationaboutcognitivehealth.Thisstudy onlyexaminedresponsestothecasestudyandthefollowing2questions: Isthereanythingthatphysicianscouldtelltheirpatientstodotohelpkeeptheirbrainshealthy,toavoid cognitivedeclineand/ordementia? Werecognizethatphysiciansfaceconstraintsinthetimetheyhavetotalkwithpatients.Withtheseconstraints inmind:Describethingsyouactuallytellyourpatientstodotokeeptheirbrainshealthy. Codinganddatamanagementhavebeendescribedindetailelsewhere.[9]Audiorecordingsweretranscribed verbatimintoMicrosoftWord(MicrosoftCorporation,Redmond,Washington),andtranscriptswerecodedusing ATLAS.tiversion5.0(ATLAS.tiScientificSoftwareDevelopment,Berlin,Germany),aqualitativedatamanagement softwareprogram.Codeddatawerereviewedforaccuracyandexaminedforlinkstoothercodes.This"axialcoding" process[10]connectedcodecategoriesandidentifiedrelationshipsthatcouldreasonablybetakentorepresent commonthemes.Weusedaconstantcomparisonmethod[11]toallowforthediscoveryofsimilaritiesand differencesinthedata.

Results
Physiciansweremostlymale()andhadactivelyengagedinpatientcareforanaverageof16.7yearsasizable percentageoftheirpractices(37%)weremadeupofolderadults.APPsweremostlyfemaleandhadpracticedan averageof26.2years.Almosthalf(46%)oftheirpracticesconsistedofolderadults.
Table.CharacteristicsofPrimaryCareProvidersandTheirPractices,FocusGroupsinColorado,NorthCarolina,and Texas,20072008

Characteristic Malesex Age,y 44 4564

Physician(N= 28)a 78.6

APPs(N= 21)a 19.0

53.6 39.3

9.5 90.5

www.medscape.com/viewarticle/775540_print

3/9

1/9/13

www.medscape.com/viewarticle/775540_print

65 Numberofyearsinpractice,mean(SD) Race/ethnicity White AfricanAmerican Asian/PacificIslander HispanicorLatina/Latino Other Selfdescribedspecialty Familymedicine Internalmedicine Geriatrics Emergencymedicine Publichealth Specialtytraininginpast5years Geriatrics Neurology Practicesetting Mostlyurban Mostlyrural Dementiadiagnosisusuallymadeby Self Specialist(fromreferral) Patientsaged65,mean%(SD) Percentageofpatientsaged65with Alzheimer'sdiseaseorrelateddiagnosis Nonotablememoryimpairmentbutwhoexpressconcernsaboutbrainor cognitivehealth Abbreviation:APPs,advancedpracticeproviders.
aAllvaluesexpressedaspercentagesunlessotherwiseindicated.

7.1 16.7(12.8)

0 26.2(8.5)

50.0 0 25.0 17.9 7.1

81.0 9.5 0 4.8 4.8

57.1 33.3 0 3.7 3.7

71.4 0 23.8 4.8 0

10.7 7.1

35.0 24.5

64.3 35.7

33.3 66.7

71.4 28.6 36.8(23.1)

40.0 60.0 46.4(29.8)

7.7 19.4

22.6 23.5

Inresponsetothecasestudy,providersemphasizedphysicalhealthrisksandmostfrequentlyrecommendeda healthfuldiet,physicalactivity,andmedicationadherencetoachieveweightlossanddiabetescontrol.Theyalso recommendedotherpreventivecareservices,illnesssurveillance,andexplorationofthepatient'sabilitytofollow

www.medscape.com/viewarticle/775540_print

4/9

1/9/13

www.medscape.com/viewarticle/775540_print

recommendations. Providerssaidtheygenerallytrytogivepatientsarationalefortheirrecommendations,whichmostcommonly focusedonreducingriskforcardiovasculareventsandchronicdiseasemanagement,butthattimeconstraintslimit theirabilitytodoso.Despitethecasestudydescriptionofthepatient'smotherhavingcognitiveimpairmentandhis ownincreasedriskforcognitiveimpairmentgivenhispoorlycontrolleddiabetes,fewproviderstalkedaboutriskof cognitiveimpairmentwhentheydid,itwasinthecontextofthebenefitsofphysicalactivityonvascularrisk,cancer preventionstrategies,orscreeningforriskybehaviorssuchasexcessalcoholconsumption: Vigorousdailyexercisebecauseitimproves,basically,allthevascularriskswhichpeopleinthisagegroup face,especiallysomeonewithdiabetes.Itimprovesriskwithdementia,whichI'msureyou'dbeconcerned about,andactuallyreducescancerriskaswell.(Physician,focusgroupM) IthinkIprobablystartjustreviewingallthiscomplicationofdiabetes.Itsoundslikeyouknowabouthis mother'shealth,soyoucankindofgoonthat.Idon'tmeantoscarepeople,butsometimeswhentheyhave somebodytheycanlookatandtheyhavesomecomplicationsthataresimilartowhattheycanhave,ittends tosinkinmore.(APP,focusgroupJ) Providerswereaskedinconsecutivequestionsaboutwhatadvicetheycouldgivepatientsandwhatadvicethey actuallydogivepatients.Theytendedtoincludetheadvicetheyactuallygiveinresponsetobothquestionsforthat reason,itwasdifficulttodistinguishpossiblefromactualadvice,soresponsestobothquestionswereconsidered togetherforthisanalysis.Providerscitedarangeofrecommendationstomaintaincognitivehealthandavoid cognitivedecline,includingstayingbusy,volunteering,beingsociallyengaged,beingphysicallyactive,eating healthfully,doingpuzzlesorothergames,reading,andlearningnewthingsortryingnewactivities.Providersalso stresseddiseasemanagementincludingcontrollingcholesterol,hypertension,diabetes,andothermedicalconditions. Ifthetimeisavailable,encouragingsocialinteraction,beingoutwithpeopleanddiscussingtopics,encouraging mentalstimulationasmuchaspossibleandreading,thingslikecrosswordsandpuzzlesandthingslikethat. Youknow,tryingtogetpeoplefromjustsittingathomealonewatching[television].(Physician,focusgroupI) Iftheysmoke,that'sariskfactor.Ifthey'realcoholic,thatisatremendousriskfactor.Iftheystartlookingat thesethingsearlyonintheirlate30s/early40s,thentheycanstartdoingsomethingstohelpthatfrom progressing.(APP,focusgroupA) Fromacardiopulmonarystandpoint,nosmoking,improvecardiorespiratoryhealth,improvediabetes,self managementtolessentheendorgandamagethatcanresultfromhyperglycemia.Maintainahealthierstateso thatanincreasedlevelofactivitycancontinueintolaterlife.(Physician,interviewG) SomeprovidersfeltAlzheimer'sdiseaseisnotpreventable: StufflikeAlzheimer's,wecan'tdoanythingabout.Eitheryougetitoryoudon't.Youcan'tpreventit.Youcan't slowitdown,buttheotherriskfactorsfordementia,multiplestrokesrelateddirectlytobloodpressure, diabetes,andobesity,youknow,highcholesterol.Thosewecancontrolstuffwecan't,wecan't.(Physician, focusgroupK). Otherscitedevidenceforthepossibilityofpreventingcognitivedeclineorfelttherewasnoriskinmaking recommendationsbasedonweakevidence: Youknow,thefolkswhohavelovedonesthatmaybehavedementiaandthey'llask"IstheresomewayIcan preventthediseasefromhappeningtome?"AndImustadmit,Ithinkthedataoutthere[are]inconclusiveright nowaboutdoingthosethings,butthere'snoharmindoingthem.(Physician,focusgroupD)

www.medscape.com/viewarticle/775540_print

5/9

1/9/13

www.medscape.com/viewarticle/775540_print

ManyPCPssaidtheydonotroutinelyraisetheissueofcognitionwithpatientsunlessprompted,althoughafewdid takeaproactiveapproachtocognitionsuchasusingbriefcognitiveassessmentstoestablishabaselinefromwhich comparisonscanbemadeovertime: Forhealthmaintenance,it'snotonmychecklistthatItalktothemaboutbrainhealth,youknow.(Physician, focusgroupD) Ihaveneverinitiatedit[conversationaboutcognitivehealthorimpairment]whenthepatientdidnotaskorwhen therewasobviousfamilydementiaorsomethingthatwouldbringitincloser.It'snotsomethingInormally initiateinpartbecauseIdon'tfeelthatwehavethatmuchtoofferforit,asidefromwhatI'mtryingtodowith theirhealthingeneral.(Physician,interviewB) Let'sjustspeculate:lessthan20%thinkaboutthemindandtalkaboutpreventivethingstokeepthemindto remainhealthy.(APP,focusgroupL) Ithinkafteracertainage,whentheycomeinthefirsttime,youincludeinyourbasicworkeitheraminimental statusexamorclockssothat,youknow,baseline,wheretheyare.Sodowntheline,youcanretestthem periodicallytoseeifeitheroneofthoseisgettingskewed.(APP,focusgroupC) WhenPCPswerepromptedtodiscusswhatcuesthemtotalkaboutcognitivehealthwithpatients,theymost commonlytalkedaboutquestionsorconcernsfrompatientsorfamilymembers,familyhistoryofimpairment,risk factorsforimpairment,orapparentimpairmentduringtheofficevisit. Thepatientsthemselvesreportmemoryloss,ortheycan'trememberanything,ortheyarelosingthings. (Physician,focusgroupM) Sometimestheywill,inspeakingtoyou,theirverbalskillshavechanged.SoImaythenhavethemdrawa clockordoaminimentalstatus.I'llhavethemkeepajournalforthenext3monthsandbringthatjournaltome andit'samazingsometimesjustin3monthsthedifferenceyoucanseeinhowtheywrite.(APP,focusgroup A) Timeconstraintswerealmostuniversallyacknowledgedasabarriertodiscussionsaboutcognitivehealth.Short officevisitsmeanthatonlythemosturgentconcernscanbeaddressed.Discontinuityofcareacrosshealthcare settingsandproviderswasseenasabarriertodevelopingrelationshipsneededtodiscusssensitivetopicslike cognitionandtoassesschangeovertime: Theageoldthing,I've[got]10minutes,15minutes,20minutes,andyou'vegottodo5or6thingsandthisis probablynotatthetopofyourlistusually.(APP,focusgroupL) Alotofmypatients,Idon'thaveatrustestablished.I'veneverseenthembeforeandI'llneverseethemagain. (APPfocusgroupF) Providersalsodescribedvariabilityinpatientattitudesandresponsestorecommendationsaboutcognitivehealthas abarriertodiscussingcognitivehealthduringofficevisits: Ifindcompliancewithmyrecommendationsisdirectlyproportionaltothepatient'sperceivedfatalityofthe consequencespresent.(Physician,focusgroupM) Ithinktherecommendations[forpreventingdeclineincognitivefunctioning]aresogenericthatthey'rekindof underwhelmedwiththeinformation.(Physician,focusgroupD)

www.medscape.com/viewarticle/775540_print

6/9

1/9/13

www.medscape.com/viewarticle/775540_print

Discussion
PCPsreportedaddressingcognitivehealthindirectlyaspartoftheirusualclinicalpractice.Althoughtheyrecognized thepotentialofahealthfuldiet,regularphysicalactivity,andeffectivediseasemanagementtoaffectcognitiveand physicalhealth,theyreportedrarelymentioningcognitivehealthtopatientsunlesspromptedbythepatients,their families,orthePCPs'ownobservationsofsymptomsorriskforcognitiveimpairment.Providers'selfreported practicesarenoteworthy,giventheimportanceolderadultsplaceonmaintainingcognitivehealth.[2,3]Barriersto discussingcognitivehealthincludedsystemlevelissues(eg,lackoftime,nothavingarelationshipwithapatient) andpatientlevelissues(eg,adherencetorecommendationsforbehaviorchange). OurfindingsenhancethosereportedbyDayetal,[5]whichindicatedthatlessthanhalfofrespondents(40%) discussedcognitionwithadultpatientswhowerenotdisplayingcognitiveimpairment"often"or"veryoften." Providersinourqualitativestudyofferedrecommendationsforcognitivehealththatweresimilartothosereportedby Dayetal.[5]Whetherornotprovidersfeelthatevidencefortheserecommendationsissufficient,theymayofferthe recommendationswhenpromptedbecauseofotherhealthbenefitsortheirbeliefthatfollowingtherecommendations woulddonoharm.Providers'perceptionthatevidenceisinsufficienttoconcludethatrecommendationsforspecific activitieswillpositivelyaffectcognitionareconsistentwiththeNationalInstitutesofHealthStateoftheScience ConferenceonPreventingAlzheimer'sDiseaseandCognitiveDecline,whichproducedastatementthatinsufficient evidenceexiststoconcludethatmodificationofanyriskfactorswillpreventAlzheimer'sdiseaseorothercausesof cognitivedecline.[12,13] Ourstudyhaslimitations.Thegeneralizabilityofthesefindingsislimitedbythenatureofthestudysample,a conveniencesampleofselfselectedparticipantsfrom3states.Qualitativeworkinothergeographicsettingsmay indicateregionalvariationsinperceptionsandpracticesrelatedtocognitivehealthinprimarycare.Thisstudywas conductedbeforethepassageofthePatientProtectionandAffordableCareAct(PPACA).[14]ThePPACAinitiated coverageforanannualwellnessvisit(AWV)thatincludesassessmentofcognitiveimpairmentbydirectobservation andconsiderationofpatientandrelevantothers'reports(410.15).Providerpracticesmayhavechangedsincethe introductionofAWVs.However,fewerthan2.3millionbeneficiarieshadanAWVin2011.[15]Studiesoftheeffectof AWVsonperceptionsandpracticeswillbeusefulforunderstandinghowthischangeinpolicyhasaffectedcare relatedtocognitivehealth. PCPsarestakeholdersineffortstoaddresscognitivehealthfromapublichealthperspective.Thisstudyaddstothe literaturebydescribingPCPs'perceptionsandpracticesandhighlightingthechallengesprovidersfacewhen addressingolderadults'concernsaboutcognitivehealth.Nationaleffortstoaddresscognitivehealthwillrequire partnershipsbetweenpublichealthpractitionersandPCPs.Communicatingnewevidenceoncognitivehealthand engagingolderadultsinmakinglastinglifestylechangesrecommendedbyPCPsandothersmaybepracticalways inwhichpublichealthpractitionerscanpartnerwithPCPstoaddresscognitivehealthinhealthcaresettings.
References

1. TheHealthyBrainInitiative:anationalpublichealthroadmaptomaintainingcognitivehealth.Chicago(IL): Alzheimer'sAssociation2007. 2. SharkeyJR,SharfBF,StJohnJA."Unapersonaderechita(stayingrightinthemind)":perceptionsof SpanishspeakingMexicanAmericanolderadultsinSouthTexascolonias.Gerontologist200949Suppl 1:S7985. 3. WilcoxS,SharkeyJR,MathewsAE,LaditkaJN,LaditkaSB,LogsdonRG,etal.Perceptionsandbeliefs abouttheroleofphysicalactivityandnutritiononbrainhealthinolderadults.Gerontologist200949Suppl 1:S6171.

www.medscape.com/viewarticle/775540_print

7/9

1/9/13

www.medscape.com/viewarticle/775540_print

4. LaditkaSB,CorwinSJ,LaditkaJN,LiuR,TsengW,WuB,etal.Attitudesaboutagingwellamongadiverse groupofolderAmericans:implicationsforpromotingcognitivehealth.Gerontologist200949Suppl1:S309. 5. DayKL,FriedmanDB,LaditkaJN,AndersonLA,HunterR,LaditkaSB,etal.Preventionofcognitive impairment:physicianperceptionsandpractices[publishedonlineaheadofprintMarch15,2011].JAppl Gerontol.http://jag.sagepub.com/content/early/2011/03/15/0733464811401354.AccessedJuly6,2011. 6. LangJE,AndersonL,LoGerfoJ,SharkeyJ,BelanskyE,BryantL,etal.TheHealthyAgingResearch NetworkWritingGroup.ThePreventionResearchCentersHealthyAgingResearchNetwork.PrevChronicDis 20063(1):A17.http://www.cdc.gov/pcd/issues/2006/jan/05_0054.htm.AccessedSeptember12,2012. PubMed 7. LaditkaJN,BeardRL,BryantLL,FettermanD,HunterR,IveyS,etal.Promotingcognitivehealth:a formativeresearchcollaborationoftheHealthyAgingResearchNetwork.Gerontologist200949Suppl1:S12 7. 8. StewartD,ShamdsaniP.Focusgroups:theoryandpractice.ThousandOaks(CA):Sage1990. 9. LaditkaSB,CorwinSJ,LaditkaJN,LiuR,FriedmanDB,MathewsAE,etal.Methodsandmanagementofthe healthybrainstudy:alargemultisitequalitativeresearchproject.Gerontologist200949Suppl1:S1822. 10. StraussA,CorbinJ.Basicsofqualitativeresearch.ThousandOaks(CA):Sage1998. 11. GlaserB,StraussA.Thediscoveryofgroundedtheory:strategiesforqualitativeresearch.Chicago(IL): AldineDeGruyter1967. 12. DaviglusM,BellC,BerrettiniW,BowenP,ConnollyE,CoxN,etal.NIHStateoftheScienceConference Statement:preventingAlzheimer'sdiseaseandcognitivedecline.Washington(DC):USDepartmentofHealth andHumanServices,NationalInstitutesofHealth2010. 13. DaviglusML,PlassmanBL,PirzadaA,BellCC,BowenPE,BurkeJR,etal.Riskfactorsandpreventive interventionsforAlzheimerdisease:stateofthescience.ArchNeurol201168(9):118590.CrossRefPubMed 14. 111thUSCongress.Publiclaw111148:ThePatientProtectionandAffordableCareAct,2010.HR3590. http://www.gpo.gov/fdsys/pkg/PLAW111publ148/pdf/PLAW111publ148.pdf. 15. USDepartmentofHealthandHumanServices.TheAffordableCareAct:strengtheningMedicarein2011. http://www.cms.gov/apps/files/MedicareReport2011.pdf.

Acknowledgments ThisworkwassupportedbycooperativeagreementsfromtheCDCHAN,SpecialInterestProjectnos.1304and8 06,andbycooperativeagreementnos.1U48DP000025,1U48DP000033,1U48DP000045,1U48DP000048, 1U48DP000050,1U48DP000051,1U48DP000052,1U48DP000054,and1U48DP000059.

TheopinionsexpressedbyauthorscontributingtothisjournaldonotnecessarilyreflecttheopinionsoftheU.S. DepartmentofHealthandHumanServices,thePublicHealthService,theCentersforDiseaseControland Prevention,ortheauthors'affiliatedinstitutions. PrevChronicDis.201292012CentersforDiseaseControlandPrevention(CDC)

www.medscape.com/viewarticle/775540_print

8/9

1/9/13

www.medscape.com/viewarticle/775540_print

www.medscape.com/viewarticle/775540_print

9/9