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Mayo Clinic Health System Dementia Program

Introduction

The Dementia Care Program is a coordinated, multidiscipline programmatic approach to the dementia patient. The program was started in 1997 with the goal of improving the diagnosis, treatment, and long-term follow-up care of the dementia patient and dementia associated problems that can occur. A computer database is also maintained for data and information collection that will be used to further expand the knowledge about dementia, how it impacts the local community, and what interventions are effective in maintaining the patients at home with a good quality of life. The multidisciplinary team meets to review and discuss the status of Dementia Care Program patients, especially those patients that are at high risk of needing extra assistance or close monitoring. Family support and education are also provided.

 

Participants and Their Roles

Department of Geriatrics:

  • Medical evaluation and diagnosis
  • Long-term follow-up
  • Database
  • Coordination of care
  • Medical care of nursing home patients
  • Dementia education coordination for patients, families, communities, nursing home staffs, etc.
  • Support Groups for individuals with early memory loss, mid-stage memory loss and a group for their families
  • Training for staff
  • Interaction/coordination with the Alzheimer's Association, Greater Wisconsin Chapter

Elder Services:

  • Social service assessments
  • Advanced care planning
  • Community resources
  • Senior housing
  • Emergency response system
  • Senior Helpline
  • Education

Department of Behavioral Health/Neurology:

  • Neuropsychological evaluation
  • Long-term follow-up
  • Education
  • Counseling of patients and caregivers on an as-needed basis

Alzheimer's Association, Greater Wisconsin Chapter:

  • Education for patients, families, community
  • Support groups
  • Program volunteer training and coordination

Patient Evaluation

The initial visit takes approximately one hour. The Geriatrics team will gather a detailed history of the patients symptoms and medical background. We encourage patients to have a family member or friend accompany them to their appointments. At the conclusion of the first visit a treatment plan is developed with the patient and family. The treatment plan varies based on individual needs, but often will include referral for neuropsychiatric testing, and lab work. After completion of testing the patient will return to the department of Geriatrics where the results of their testing will be discussed and further treatment planning will occur. At this time patients and families can receive education, information and referral to community resources, assistance with Advance Directives, etc.

 

Follow-up Protocol

Patients starting or changing medications are seen monthly until stabilized. They are then seen for routine follow-up visits every 6 months. Each year the patient will be tested with a follow-up neuropsychology test and the database is updated. Patients will be seen sooner if needed. Assistance to patients and families is provided on an ongoing basis by connecting them with community services and educational resources. Routine telephone follow-up will also be made.

 

Wisconsin Alzheimer's Institute

The role of the WAI will be to coordinate the database collection for the state-wide system of diagnostic clinics, assist with data analysis for publications and serve as a resource for Alzheimer's and related dementia. If needed, the WAI will also assist with the interactions of the Program with the Alzheimer's Association chapters.

 

Conclusions

Mayo Clinic Health System - La Crosse, Dementia Care Program, in conjunction with the opportunities afforded with participation in the WAI's state-wide system of clinics, will provide state-of the-art diagnostic and treatment planning for dementia patients in the La Crosse area. The Dementia Care Program provides services throughout the rural tri-state regional area of La Crosse, through the Geriatric Medicine outreach service to the regional cinics and nursing homes.

 

For more information, or to make an appointment, please contact:

 

Mayo Clinic Health System Dementia Program
Franciscan Healthcare
Thomas Loepfe, MD, Director
800 West Ave. S.
La Crosse, WI 54601-4700
608-791-9505
www.franciscanskemp.org

 

 

This clinic is a member of the WAI-Affiliated Dementia Diagnostic Clinic Network. Network clinics differ from other memory clinics in that their staff have received training/observation time and/or guidance from the WAI and the UW Health Memory Assessment Clinic. In addition, clinic network staff attend the WAI's annual conference and bi-annual clinic network meetings, which provide up-to-date research and disease management information. Clinics in the network do remain autonomous, but follow a set of guidelines.