What Primary Care Physicians Need to Know about Dementia

Executive Summary

Alzheimer’s disease and other dementias affect an estimated 11.5 million people in the U.S., and that number is expected to grow in coming decades as the population continues to age. For many dementia patients and their caregivers, primary care is the first and sometimes only resource available, making the primary care physician (PCP) a vital source of guidance and information when an individual begins to experience cognitive decline. Their role in diagnosis and support for both patients and caregivers can make a critical difference in the quality of life for all involved.

Recommended Actions

• If you suspect cognitive decline in a patient, assess and communicate the diagnosis as early as possible.
• As a first step, review a patient’s medication list for potential causes of cognitive disturbance.
• Assess for and treat reversible causes of cognitive decline such as depression, sleep apnea and normal pressure hydrocephalus.
• Consider that poor medication compliance due to cognitive loss might be to blame for comorbidities such as uncontrolled hypertension.
• Consider a neuropsychological assessment to improve diagnostic accuracy, determine the severity of dementia and inform recommendations and interventions.
• Involve caregivers in interventions and offer them support and resources.

Imagine a future where nearly 13 million Americans grapple with the devastating effects of Alzheimer’s disease — a reality projected to unfold by 2050. Today, nearly 7 million individuals in the United States already face this relentless condition, a number that continues to rise as the population ages. When factoring in other types of dementia, the number of people affected could climb as high as 11.5 million. Those figures, reported by the Alzheimer’s Association and the National Institute on Aging, represent more than statistics: they reflect a profound and growing challenge for families, caregivers and the healthcare system.

In the battle against dementia, primary care physicians (PCPs) are often the first and sometimes only responders for many patients and their caregivers.¹ These trusted professionals serve as the gateway to understanding and managing the cognitive, functional and behavioral changes that accompany dementia. Early detection, thoughtful care planning and ongoing support from PCPs can significantly shape the trajectory of a patient’s journey and the well-being of their loved ones, underscoring the vital role of primary care in addressing this complex and far-reaching condition.

Barriers to Diagnosis

Despite the growing number of diagnoses, dementia remains severely under-detected. More than 50 percent of people with dementia, mostly in the mild range but some with moderate dementia, have never received a diagnosis of dementia from a physician.² Therefore, when a diagnosis of Alzheimer’s disease is made, symptoms have likely been present for two to three years, on average.³

A multitude of reasons have been identified as barriers to diagnosis in the primary care setting. These include fear of stigmatizing the patient, lack of training, diagnostic uncertainty, shortage of specialized diagnostic assessment tools, patient denial of issues and the reluctance of healthcare providers to make a diagnosis when no effective disease-modifying options are available.⁴ Although many PCPs identified concerns about the emotional impact of the diagnosis on the patient and suicide risk, there is little evidence to support a significant overall risk of suicide in dementia.⁵

In truth, primary care providers are ideally suited to detect and manage dementia. Given regular and consistent contact with patients, primary care providers are in the best position to notice changes in functioning and cognition over time. The relationship and trust built between PCPs and their patients also can help facilitate assessment and care management, particularly when additional diagnostic assessments may be with specialists the patient has not seen before nor has yet built a relationship with.⁶  

Importance of Early Diagnosis

Physicians, caregivers and patients alike may question the necessity of an early diagnosis in dementia when treatment options are limited and the progression of the disease cannot be stopped.⁴ Physicians in particular may weigh the potential risks and benefits of an early diagnosis and the potentially negative consequences of a dementia diagnosis.⁷ However, the range of benefits that an early diagnosis can provide to patients can offset potential negative consequences. These benefits include:

• Enabling access to available medication and to early intervention and education that may prevent institutionalization
• Ruling out reversible causes of cognitive decline
• Allowing a patient the chance to participate in research and clinical trials for disease-modifying drugs
• Giving patients and their families time to make legal and financial plans.⁸

The ultimate goal of early detection is to improve the quality of life of the patient during their remaining years while reducing the caregiver and family burden as much as possible.

Elimination of reversible causes of cognitive decline. Early detection in the primary care setting can prompt an evaluation for reversible causes of cognitive loss before referral to a specialist. Reviewing the medication list for potential culprits of cognitive disturbance can be done as a first step. Assessing for other reversible conditions such as depression, sleep apnea and normal pressure hydrocephalus is also crucial in the early stages when interventions can be implemented with greater chances of success.

Obstructive sleep apnea is one disorder in particular where adequate treatment can have profound results. Sleep apnea is associated not only with cognitive decline, but also with structural changes in the brain, including atrophy of the hippocampi, microbleeds and white matter damage.⁹ Sleep apnea has a tendency to present differently in the older adult who may not have obvious risk factors,¹⁰ but screening is crucial as just one year of adequate treatment has been found to lead to improvements in cognition and white matter integrity in the brain.¹¹ This highlights the importance of ruling out potentially reversible causes of cognition.

Improved treatment and medical decisions. Early detection of dementia by primary care physicians can also be critical in effectively treating other comorbidities commonly found in the elderly. Physicians may be confused by uncontrolled hypertension, diabetes, etc., when poor medication compliance due to cognitive loss could be to blame. It may also explain sporadic or nonexistent follow-up.

Awareness of the presence of a dementia and neurodegenerative process may also help inform treatment decisions. For example, dementia is the leading risk factor for delirium, which alters the course of cognitive decline, resulting in more rapid progression and worse long-term outcomes.¹² There are many risk factors for delirium that are potentially avoidable, such as the use of specific medications, severe pain and surgery.¹³

Knowledge of a dementia diagnosis would allow more discussion about whether a patient should proceed with a surgical procedure given the increased likelihood of post-operative delirium and potentially permanent cognitive and functional declines.¹⁴

Proactive advance care planning. Early detection also allows for proactive planning to begin at a milder level of impairment, before a crisis disrupts the patient's life and requires urgent intervention. Furthermore, confirmation of a diagnosis of dementia in the milder stages allows the patient to be involved in his or her care and future planning, including decision-making regarding advance directives, living placements and estate management.¹⁵  

The position of the American Geriatric Society is that advance care planning is a critical tool for helping individuals articulate and document their preferences to ensure that the care they receive matches their wishes, particularly near the end of life. Advance care planning improves care and quality of life, while increasing satisfaction with the healthcare system and reducing stress, anxiety and depression for older adults, family caregivers and other relatives.

Attempting to manage legal affairs once a person has reached a stage of cognitive impairment where they are no longer able to make decisions can be costly, time-consuming and stressful. Earlier identification may also assist families in preventing harm that can come to vulnerable persons, such as mismanaging/scamming financial assets, falling, getting lost or having an accident while driving.

Caregiver education. From a familial perspective, early detection can offer a clinical explanation regarding the changes they are observing in their loved one. This can be especially valuable when personality changes (apathy, withdrawal, irritability, disinhibition) are the earliest symptoms and may be seen as being within the patient’s control. Caregivers may experience the disclosure of the dementia diagnosis as a confirmation of suspicions¹⁶ or even with relief.¹⁷ Interventions for caregivers can have a significant impact in the earlier stages of the disease, including psychoeducation, supportive counseling, support groups and respite care.¹⁸

Importance of Cognitive Testing

Neuropsychological assessment is frequently used in the diagnosis of dementia. The neuropsychological assessment integrates information from clinical interviews, medical history, behavioral observations and performance on standardized and validated cognitive tests. Individual scores are compared to normative reference groups, considering personal characteristics such as age, level of education and estimated premorbid abilities.¹⁹

Inclusion of a neuropsychological assessment in the diagnostic workup may ease some of the aforementioned concerns expressed by physicians and improve diagnostic accuracy, determine the severity of dementia and inform recommendations and interventions.²⁰ Neuropsychology can also play a role in tracking disease progression with the use of serial cognitive assessments.

Improve diagnostic accuracy and define level of impairment. There is an abundance of evidence that shows the neuropsychological evaluation improves diagnostic accuracy in patients with dementia over and above routine clinical evaluation alone.²¹ The evaluation plays a crucial role in the differential diagnosis of cognitive complaints. Neuropsychological assessment has been shown to be highly effective at distinguishing between cognitively normal and cognitively impaired older adults. The results of an evaluation can help distinguish between mild neurocognitive disorder (formerly mild cognitive impairment, MCI) and dementia.²²

Mild neurocognitive disorder is a pre-clinical stage; the presence of this condition has relatively high predictive value for conversion to dementia, specifically Alzheimer’s disease. The exact predictive value and rate of conversion are highly dependent on the cognitive profile elucidated by neuropsychological testing.²³ Individuals who display severe impairments in memory consolidation (amnestic) are at higher risk of conversion to dementia in the future.²⁴ The ability to identify patients at this stage helps determine who is at greatest risk for developing dementia and can inform which patients need closer monitoring and resources.

In addition, studies have shown that a portion of patients diagnosed with mild neurocognitive disorder actually improve over time.²⁵ This pre-clinical period may also represent a time when interventions to change lifestyle factors and target risk factors, namely cerebrovascular risk factors, are most effective.

Determine specific etiology. Neuropsychological and cognitive testing also helps inform specific etiology among the dementia types. Although AD is the leading cause of dementia in the elderly, it has been known for some time that dementia can arise from a wide variety of etiologically and neuropathologically distinct disorders that give rise to different patterns of cognitive strengths and weaknesses. Distinct patterns of cognitive deficits occur in AD and other neurodegenerative disorders such as Parkinson’s disease, dementia with Lewy bodies (DLB), frontotemporal dementia (FTD) and vascular dementia.²¹

Although a definitive etiology cannot truly be determined until post-mortem, defining the disease and clinical features is important for several reasons. One of the clearest reasons is that different dementias have different courses and prognoses. DLB, for example, has been shown to have a less favorable prognosis than AD and other dementias. There is accelerated cognitive decline, shorter lifespan, increased institutionalization and more significant caregiver burden.²⁶ In addition, these patients tend to have more prominent neuropsychiatric symptoms but are at higher risk of serious adverse reactions to antipsychotic drugs, including potentially life-threatening neuroleptic malignant syndrome.²⁷

Similarly, the course of FTD may be punctuated by severe changes in behavior and/or language and not the traditional decline in memory associated with AD.²⁸ Therefore, differential diagnosis can be crucial in determining appropriate treatment methods and providing accurate education to patients and their families about what to expect as the disease progresses.

Importance of Integrating Caregivers in Dementia Care

Evidence-based interventions for neurodegenerative diseases do exist and have been found to alleviate the burden of disease. Unfortunately, as described by Lathren, Sloane, Hoyle, Zimmerman, and Kaufer,²⁹ many physicians report poor knowledge of available resources, unease with dementia counseling and family education and overall low referral rates to social services. Because of this, community resources are often underutilized.

Involving caregivers in intervention is crucial because they provide the largest proportion of care for people with dementia. According to the latest Alzheimer’s Disease Facts and Figures, a report released by the Alzheimer’s Association, more than 11 million family members and friends provided 18 billion hours of unpaid care to people with dementia in 2023. That care was valued at nearly $347 billion.

Significance of caregiver burden in dementia. Caregiver stress and burden is a nationwide concern. The task of family caregiving for a person living with dementia, although rewarding, is not an easy one. Caregivers face many obstacles as they balance caregiving with other demands, including child rearing, career and relationships. They are at increased risk for the burdens of care, stress, depression and a variety of other health complications.³⁰

Numerous studies have shown that caregivers of people with dementia experience increased stress when compared to caregivers of individuals without dementia.³¹ Dementia caregivers spend significantly more time per week providing care and report greater impacts on employment, mental and physical health, leisure time and family life. In some cases, people living with dementia have drastic changes in mood and behavior, exhibiting symptoms of aggression, paranoia, wandering or apathy³² — all of which have to be navigated, day after day, by their caretakers.

What caregivers want from their primary care physicians. Cohen, Pringle and LeDuc reviewed studies examining how caregivers for dementia patients perceive their interactions with family physicians and what they hope to get from these providers.³³

Most notably, caregivers want recognition for the importance of their caregiver role and the challenges they face. Families of affected individuals want a diagnosis of dementia communicated to them directly and did not want the physician to avoid the issue. They often do not feel they receive adequate information from their family physician. Caregivers express the need for assistance with behavioral problems, referrals to agencies and regularly scheduled visits with the primary physician.

Providing support and resources. Primary care providers can support family caregivers in several ways. Acknowledging caregivers as the “hidden patients” in need of direct or indirect intervention can create a supportive environment in the treatment room.³⁴ Understanding and acknowledging the challenges of caregiving can also create such an environment.

Some clinicians opt to conceptualize the dyad (patient and caregiver) as one treatment unit, understanding that the wellness of the patient is dependent on the wellness of the caregiver. They may ask how the caregivers are engaging in self-care and encourage them to routinely follow up with their own medical appointments. Some clinicians adhere to the principles of the patient-centered medical home and conceptualize the caregiver as part of the treatment team,³⁵ tasked with carrying out complex aftercare plans, sometimes in the face of adversity. In these cases, clinicians provide the caregiver with education about the disease process and give clear instruction on how best to manage symptoms at home.

If you do not already do so, reframing how you view patient and caregiver can affect the way you communicate, validate and address caregiving concerns. If you wish to formalize this practice as a routine part of usual care, several validated tools exist, such as the Zarit Caregiver Burden Scale, which can screen and track caregiver stress.

Helping families navigate the health and social-care systems is an important aspect of holistic care. However, due to time constraints and staffing, it can be challenging to provide a personalized care plan complete with community resources. Physicians should be aware that while Medicare did not traditionally reimburse these services, they are now covered since the implementation of CPT code 99483 in January 2019. This code covers “assessment of and care planning for a patient with cognitive impairment, requiring an independent historian, in the office or other outpatient, home or domiciliary or rest home.”³⁶

In addition, providing information about key agencies can point families in the direction of those who might be able to help them. Resources exist to help patients and caregivers find their way through the often confusing maze of the healthcare system after a diagnosis of Alzheimer’s or other dementia. But none can be of any help if those in need do not know what is available to them. That is why the primary care physician is such a vital source of guidance and information when an individual begins to experience cognitive, functional or behavioral changes.

One primary source of information for both physicians and caregivers is the Alzheimer’s Association:

• Alzheimer’s Association – Resources for Healthcare Professionals. This website provides “resources and information to enhance your Alzheimer's and dementia patient care and professional development.” A PocketCard App is also available for download.
• Alzheimer’s Association – Information and Resources on CPT Code 99843 - Cognitive assessment and care plan services
• Alzheimer’s Association 24-hour helpline 1-800-272-3900

The Unique Role of PCPs

Alzheimer’s disease and other dementias present profound challenges not only for those diagnosed, but also for their families and caregivers. The role of the primary care physician is undeniably crucial in this landscape, serving as the first line of defense in early detection, accurate diagnosis and comprehensive care planning. With the number of dementia cases projected to rise dramatically in coming decades, the need for timely intervention, proactive management and caregiver and patient support has never been more urgent. Primary care providers are uniquely positioned to make a transformative difference in this journey, leveraging their trusted relationships with patients to foster understanding, provide holistic care, and coordinate community resources.

Nicole Sestito, PhD, ABPP/CN, is a clinical neuropsychologist and licensed psychologist practicing at Brandywine Neuropsychology Associates.

Lisa Bodenheimer, LCSW, MSW, is a clinical social worker and assistant professor at Rowan University SOM, Department of Geriatrics and Gerontology and NJISA.

Christian P. White, DO, is a geriatric psychiatrist and Assistant Professor at Rowan University SOM, Department of Geriatrics and Gerontology and NJISA.

1 Boustani, M., Callahan, C. M., Unverzagt, F. W., Austrom, M. G., Perkins, A. J., Fultz, B. A., Hui, S.L., Hendrie, H. C. (2005). Implementing a screening and diagnosis program for dementia in primary care. Journal of General Internal Medicine, 20, 572–577; Callahan, C. M., Boustani, M. A., Unverzagt, F. W., Austrom, M. G., Damush, T. M., Perkins, A. J., … Hendrie H. C. (2006). Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: A randomized controlled trial. Journal of the American Medical Association, 295 (18), 2148–2157.

2 Boustani, M., Peterson, B., Hanson, L., Harris, R., & Lohr, K. N. (2003). Screening for dementia in primary care: A summary of the evidence for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 130 (11), 927–937

3 Agronin, M. E., & Maletta, G. J. (2011). Geriatric Psychiatry (2nd Edition). Philadelphia, PA: Lippincott Williams & Wilkins.

4 Bradford, A., Kunik, M. E., Schulz, P., Williams, S. P., & Singh, H. (2009). Missed and delayed diagnosis of dementia in primary care: Prevalence and contributing factors. Alzheimer’s Disease and Associated Disorders, 23 (4), 306–314; Dubois, B., Padovani, A., Scheltens, P., Andrea, R., & Dell’Agnella, G. (2016). Timely diagnosis for Alzheimer’s disease: A literature review on benefits and challenges. Journal of Alzheimer's Disease, 49 (3), 617–631; Judge, D., Roberts, J., Khandker, R., Ambegaonkar, B., & Black, C. M. (2019). Physician perceptions about the barriers to prompt diagnosis of mild cognitive impairment and Alzheimer’s disease. International Journal of Alzheimer’s Disease, 2019, (3), 1–8.

5 Draper, B. M. (2015). Suicidal behavior and assisted suicide in dementia. Psychosocial and Ethical Aspects of Dementia, 27 (10), 1601–1611.

6 University of California San Francisco, Memory and Aging Center. (2019). Primary Care Portal. Boustani, M., Peterson, B., Hanson, L., Harris, R., & Lohr, K. N. (2003).

7 Mattsson, N., Brax, D., & Zetterberg, H. (2010). To know or not to know: Ethical issues related to early diagnosis of Alzheimer’s disease. International Journal of Alzheimer’s Disease, 2010, (1), 1–4.

8 Prince, M., Bryce, R., & Ferri, C. (2011). World Alzheimer report. Alzheimer’s Disease International, 1–68.

9 Gale, S. D., & Hopkins, R. O. (2004). Effects of hypoxia on the brain: Neuroimaging and neuropsychological findings following carbon monoxide poisoning and obstructive sleep apnea. Journal of the International Neuropsychological Society, 10, 60–71; Gelber, R. P., Redline, S., Ross, G. W., Petrovitch, H., Sonnen, J. A., Zarow, C., … White L. R. (2014). Associations of brain lesions at autopsy with polysomnography features before death. Neurology, 84 (3), 296–303.

10 Ancoli-Israel, S. (2007). Sleep apnea in older adults: Is it real and should age be the determining factor in the treatment decision matrix? Sleep Medicine Review, 11 (2), 83–85.

11 Castronova, V., Scifo, P., Castellano, A., Aloia, M. S., Iadanza, A., Marelli, S., Cappa, S. F., Ferini Strambi, L., & Falini, A. (2014). White matter integrity in obstructive sleep apnea before and after treatment. Sleep, 37 (9), 1465–1475.

12 Inouye, S. K. (2006). Delirium in older persons. New England Journal of Medicine, 354, 1157–1165.

13 Fong, T. G., Tulebaev, S. R., & Inouye, S. K. (2009). Delirium in elderly adults: Diagnosis, prevention and treatment. Nature Reviews Neurology, 5 (4), 210–220.

14 Bates, A. T. (2014). Understanding and treating delirium. Psychiatric Times, 31 (12), 41–45.

15 Borson, S., Frank, L., Bayley, P. J., Bouston, M., Dean, M., Pei-Jung, L. … Ashford, J. W. (2013). Improving dementia care: The role of screening and detection of cognitive impairment. Alzheimer's & Dementia: The Journal of the Alzheimer’s Association, 9 (2), 151–159.

16 Derksen, E., Vernooij-Dassen, M., Gillissen, F., Olde-Rikkert, M., & Scheltens, P. (2005). The impact of diagnostic disclosure in dementia: A qualitative case analysis. International Psychogeriatrics, 17, 319–326.

17 van Vliet, D., de Vugt, M. E., Bakker, C., Koopmans, R. T., Pijnenburg, Y. A., Vernooij-Dassen, M. J., & Verhey, F. R. (2011). Caregivers’ perspectives on the pre-diagnostic period in early onset dementia: A long and winding road. International Psychogeriatrics, 23 (9), 1393–1404.

18 de Vugt, M. E., & Verhey, F. R. J. (2013). The impact of early dementia diagnosis and intervention on informal caregivers. Progress in Neurobiology, 110, 54–62.

19 Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). Neuropsychological assessment (5th Edition). New York: Oxford University Press.

20 Geroldi, C., Canu, E., Bruni, A. C., Dal Forno, G., Ferri, R., & Gabelli, C., … Frisoni, G. B. (2008). The added value of neuropsychologic tests and structural imaging for the etiologic diagnosis of dementia in Italian expert centers. Alzheimer’s Disease and Associated Disorders, 22 (4), 309–320; Pinskser, D., Lo, A. H. Y., Haslam, C., Pachana, N. A., & Pinsker, H. (2018). Hit or miss? Diagnostic contributions of neuropsychological assessment in patients with suspected dementia. International Journal of Clinical Neurosciences and Mental Health, 5, 1–8.

21 Salmon, D. P., & Bondi, M. W. (2009). Neuropsychological assessment of dementia. Annual Review of Psychology, 60, 257–282.

22 Sano, M. (2006). Neuropsychological testing in the diagnosis of dementia. Journal of Geriatric Psychiatry and Neurology, 19 (3), 155–159.

23 Tabert, M. H., Manly, J. J., Liu, X., Pelton, G. H., Rosenblum, S., Jacobs, M., … Devanand, D. P. (2006). Neuropsychological prediction of conversion to Alzheimer disease in patients with mild cognitive impairment. Archives of General Psychiatry, 63, 916–924; Sano, M. (2006).

24 Summers, M. J., & Saunders, N. L. (2012). Neuropsychological measures predict decline to Alzheimer's dementia from mild cognitive impairment. Neuropsychology, 26, 498–508.

25 Busse, A., Hensel, A., Guhne, U., Angermeyer, M. C., &. Riedel-Heller, S. G. (2006). Mild cognitive impairment: Long-term course of four clinical subtypes. Neurology, 67, 2176–2185;  García-Herranz, S., Díaz-Mardomingo, M. C., & Peraita, H. (2016). Neuropsychological predictors of conversion to probable Alzheimer disease in elderly with mild cognitive impairment. Journal of Neuropsychology, 10 (2), 239–255.

26 Mueller, C., Ballard, C., Corbett, A., & Aarsland, D. (2017). The prognosis of dementia with Lewy bodies. The Lancet Neurology, 16 (5), 390–398.

27 McKeith, I. G., Dickson, D. W., Lowe, J., Emre, M., O’Brien, J. T., Feldman, H., …Yamada, M. (2005). Diagnosis and management of dementia with Lewy bodies: Third report of the DLB Consortium. Neurology, 65 (12), 1863–1872.

28 Warren, J. D., Rohrer, J. D., & Rossor, M. N. (2013). Frontotemporal dementia. British Medical Journal, 347, 1–9.

29 Lathren, C. R., Sloane, P. D., Hoyle, J. D., Zimmerman, S., & Kaufer, D. I. (2013). Improving dementia diagnosis and management in primary care: A cohort study of the impact of a training and support program on physician competency, practice patterns, and community linkages. BMC Geriatrics, 13, 134.

30 Brodaty, H., & Donkin, M. (2009). Family caregivers of people with dementia. Dialogues in Clinical Neuroscience, 11 (2), 217-228.

31 Schulz, R., & Sherwood, P. R. (2008). Physical and mental health effects of family caregiving. American Journal of Nursing, 108 (9), 23–27; Ory, M. G., Hoffman III, R. R., Yee, J. L., Tennstedt, S., & Schulz, R. (1999). Prevalence and impact of caregiving: A detailed comparison between dementia and nondementia caregivers. Gerontologist, 39 (2), 177–185.

32 Cerejeira, J., Lagarto, L., & Mukaetova-Ladinska, E. B. (2012). Behavioral and psychological symptoms of dementia. Frontiers in Neurology, 3, 73.

33 Cohen, C. A., Pringle, D., & LeDuc, L. (2001). Dementia caregiving: the role of the primary care physician. Canadian Journal of Neurological Sciences, 28 (1), 72–76.

34 Reinhard, S. C., Given, B., Petlick, N. H., & Bemis, A. (2008). Supporting family caregivers in providing care. In R. Hughes (Ed.), Patient safety and quality: An evidence-based handbook for nurses (Chapter 14). Rockville, MD: Agency for Healthcare Research and Quality.

35 Rich, E. C., Lipson, D., Libersky, J., Peikes, D. N., & Parchman, M. L. (2012). Organizing care for complex patients in the patient-centered medical home. Annals of Family Medicine, 10(1), 60–62.

36 Moore, K., & Hays, B. (2018). Coding changes for family medicine in 2018. Family Practice Management, 25 (1), 5–8.