NURS FPX4050 Assessment 1

Preliminary Care Coordination Plan


Capella University


Instructor’s Name

October 2023

NURS FPX4050 Assessment 1 in this assessment, we will undertake a comprehensive examination of the critical aspects surrounding the management of cognitive impairment, specifically focusing on Alzheimer’s disease and dementia. 

The assessment seeks to address the multifaceted challenges associated with these conditions and develop a coherent plan for a safe and effective continuum of care within the community setting. 

To achieve this goal, we will analyze the best practices for health improvement, outline specific, realistic, and measurable goals, and identify significant community resources.

 This assessment aims to underscore the importance of a holistic approach that encompasses medical, psychosocial, and community-based interventions, ensuring the well-being of those affected by cognitive impairment while addressing the associated uncertainties and complexities.

Health Concerns and Best Practices for Health Improvement

Cognitive impairment, specifically Alzheimer’s disease and dementia, presents a substantial healthcare challenge, necessitating the identification and implementation of best practices for health improvement. 

Early diagnosis and intervention are pivotal in managing these conditions effectively (Gagnon & Masson, 2019). 

Current evidence suggests that cognitive training and cognitive rehabilitation programs can help improve cognitive function and delay cognitive decline. Such interventions are designed to enhance memory, attention, and problem-solving skills, ultimately improving patients’ quality of life (Gagnon & Masson, 2019). 

However, underlying assumptions include the need for personalized treatment plans and the recognition that the effectiveness of these interventions may vary among individuals due to the heterogeneity of dementia (Gagnon & Masson, 2019). 

Furthermore, uncertainties persist regarding the long-term sustainability of cognitive gains and the optimal timing for initiating these interventions in the disease progression.

Additionally, a multidisciplinary approach involving medical, psychological, and social support is imperative. Medications such as cholinesterase inhibitors and NMDA receptor antagonists have demonstrated symptomatic relief in some individuals with Alzheimer’s disease (Takramah & Asem, 2022). 

Nevertheless, the effectiveness of these pharmacological interventions remains limited, and their long-term impact on the disease’s trajectory remains uncertain. Programs for caregiver support and education are essential for offering families dealing with dementia emotional and practical support (Takramah & Asem, 2022). 

Yet, access to such resources can be constrained, and disparities in access may exist across different populations.

Goals to Address Healthcare Issues

Cognitive Maintenance and Enhancement

To address cognitive impairment effectively, one of the key goals is to improve or maintain cognitive function, thereby enhancing the individual’s daily living skills and overall quality of life. 

This goal involves the development of personalized cognitive training programs that specifically target areas such as memory, attention, and problem-solving skills. 

These programs should be tailored to the individual’s cognitive baseline and adjusted as needed to ensure that they are both attainable and realistic (Regan et al., 2021). To measure progress, standardized assessments should be conducted at regular intervals to track cognitive function over time. 

The timeline for this goal is ongoing, with periodic reassessment and adjustments made to the training programs based on the person’s response to the interventions (Regan et al., 2021).

Medication Management

Another crucial goal in addressing cognitive impairment is optimizing medication regimens to manage symptoms and slow cognitive decline, particularly in conditions like Alzheimer’s disease or dementia (Adeola et al., 2020). 

This goal involves a specific focus on evaluating the potential benefits and risks of medications, such as cholinesterase inhibitors or NMDA receptor antagonists, for each patient. Measuring the effectiveness of these medications requires monitoring cognitive and functional changes over time (Adeola et al., 2020). 

Achieving this goal is attainable through collaboration with a healthcare team, which includes physicians and pharmacists, to make informed decisions on medication adjustments as needed. 

However, it’s essential to remain realistic about medication effects, recognizing that responses may vary among individuals. The timeline for this goal involves periodic medication reviews and adjustments based on clinical assessments.

Caregiver Support and Education

In addressing cognitive impairment, supporting caregivers is of paramount importance. One crucial goal is to provide caregivers with the knowledge and resources necessary to offer effective support while minimizing caregiver burden. 

To accomplish this, caregiver education programs should be offered, covering topics related to dementia care, coping strategies, and self-care (Majid, 2020). Measuring the effectiveness of this goal can be done by assessing caregivers’ knowledge and stress levels through surveys or interviews. 

Making this goal attainable involves ensuring the accessibility of caregiver support services, taking into account cultural sensitivity and individual needs (Majid, 2020). Additionally, it is essential to be realistic about the challenges caregivers face, both emotionally and physically, and aim to provide them with practical tools and emotional support. 

The timeline for this goal includes ongoing availability of caregiver support programs and regular check-ins with caregivers to evaluate their needs and progress in providing care. (Majid, 2020).

Available Community Resources

The first thing to know is that Memory Care Centers are specialized healthcare facilities created to offer complete care for those with cognitive impairment. 

These facilities provide a safe setting with educated professionals who are aware of the particular difficulties associated with dementia care (Gaugler, 2022). 

Memory care facilities can raise the quality of life for dementia patients by offering specialized activities, regimented schedules, and expert medical attention. Support groups for family members can also provide emotional and useful support. 

These organizations foster a sense of belonging, lessen isolation, and disseminate useful knowledge about coping mechanisms and resources. (Gaugler, 2022).

Additionally, for people who choose to age in place, in-home care services are essential. These services include qualified care givers who help with daily tasks, medicine administration, and safety oversight. 

Programs for respite care give temporary relief to family caregivers in order to minimize burnout and maintain care for the person with cognitive impairment (Gaugler, 2022).

 Respite care can reduce caregiver stress and depression, ultimately benefiting the patient. 

Adult Day Care Centers offer a structured environment with social and therapeutic activities for individuals with cognitive impairment, allowing family caregivers to work or attend to personal needs (Gaugler, 2022). 

Lastly, Legal and Financial Planning Services help families navigate the complex legal and financial aspects of long-term care, including estate planning and Medicaid eligibility. 

These services contribute to a smoother transition into long-term care arrangements while ensuring the individual’s financial well-being.


The assessment of cognitive impairment, particularly Alzheimer’s disease and dementia, has revealed the critical importance of a holistic and multifaceted approach to care within the community setting. 

From best practices for health improvement to the formulation of specific, realistic goals and the identification of essential community resources, this assessment has underscored the complexity of addressing cognitive impairment. 

While uncertainties and challenges persist, such as varying individual responses and access disparities, a concerted effort involving healthcare professionals, caregivers, and community support services is paramount. 

By integrating medical, psychosocial, and community-based interventions, we can enhance the quality of life for individuals and provide much-needed support to their families, fostering a safer and more effective continuum of care within the community.


Adeola, M., Fernandez, J., & Sherer, J. (2020). Medication management in older adults with dementia. Dementia and Chronic Disease, 39–51.

Gagnon, G., & Masson, M. (2019). Cognitive intervention for patients with neurocognitive impairments. Primary Care Mental Health in Older People.

Gaugler, J. (2022). Supporting dementia caregivers: the public health center of excellence on dementia caregiving. Innovation in Aging, 6(Supplement_1), 69–69.

Majid, T. (2020). Eliciting care management preferences with engaged caregivers and individuals with mild cognitive impairment. Innovation in Aging, 4(Supplement_1), 728–728.

Regan, B., Wells, Y., & O’Halloran, P. (2021). Maximizing cognition in mild cognitive impairment and early-stage dementia. La Trobe EBooks, 811–826.

Takramah, W. K., & Asem, L. (2022). The efficacy of pharmacological interventions to improve cognitive and behavior symptoms in people with dementia: A systematic review and meta‐analysis. Health Science Reports, 5(6).

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