Contents
Key Points
  • DVA funds a wide range of cognitive, dementia and memory assistive aids
  • Refer your patients with cognitive impairment to an occupational therapist to ascertain the need for assistive aids
  • Where possible, cease medicines that contribute to cognitive impairment

Helping your patients with cognitive impairment to live well at home

The neurocognitive disorders mild cognitive impairment and dementia can affect memory, thinking, behaviour, communication and daily functioning.1, 2 Mild cognitive impairment is a condition where the person experiences a change in cognition, particularly memory, greater than would be expected for someone of a similar age, but without the decline in daily function associated with dementia.2, 3 It is difficult to identify the true prevalence of mild cognitive impairment, but it is estimated to affect between 10% and 38% of people aged 65 years and over.3-6 An estimated 40% of people with mild cognitive impairment progress to dementia.7, 8

Of the estimated 436,400 Australians living with dementia in 2018, 94% were aged over 65 years.9, 10 Most people with dementia live at home, with one in three living alone,11 and two in five living in regional, rural or remote communities where access to services is often more limited.9

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Most patients with cognitive impairment have complex care needs and benefit from early referral to health services and support programs.5, 6 While there is no cure for most cases of mild cognitive impairment or dementia, much can be done to maximise cognition, manage symptoms and support patients to live well at home for longer.1, 2, 6, 13

This therapeutic brief provides information about DVA-funded cognitive, dementia and memory assistive aids, and health services that are available to eligible DVA patients with cognitive impairment living at home. It also provides information about how to reduce the use of medicines that can contribute to cognitive impairment.

Timely identification of cognitive impairment

Cognitive impairment that affects daily functioning should not be dismissed as a normal part of ageing.1 Because of the insidious and varied progression of cognitive impairment, dementia may go undiagnosed in as many as 50% of primary care patients.14, 15 The average time from when symptoms are first noticed to the first consultation with a health professional is approximately two years, and three years for a firm diagnosis.16

Early identification of cognitive impairment can enable initiation of health services and support programs, and treatment for potentially reversible causes including depression, hypothyroidism and medicines that affect cognition.2, 6, 17, 18 If you are assessing your patient’s cognitive impairment, note their medicine use; they may be taking medicines that are causing or worsening symptoms (see Page 3). Where possible, cease these medicines before reassessing your patient.

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Refer early to DVA-funded health services and support programs

  • Many DVA-funded health services, including occupational therapists, exercise physiologists, physiotherapists, dietitians and psychologists are underused for DVA patients with cognitive impairment living at home.12 Healthdirect is a directory to help you find health services in your local area: www.healthdirect.gov.au/australian-health-services
  • Individualise interventions to support your patient’s needs, including advice about stopping smoking, eating a healthy diet, engaging in physical exercise, cognitive stimulation and training, and maintaining social connections.3, 5, 17, 19-22
DVA-funded health services and patient eligibility
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Support independence in daily activities
  • Refer early to an occupational therapist to support your patients to live more safely and comfortably at home, and to stay socially connected and physically active.1, 23 To find an occupational therapist in your area, go to Occupational Therapy Australia at: www.otaus.com.au/find-an-occupational-therapist
  • To find out more about the role of allied health professionals in supporting your patients with cognitive impairment, see ‘Better health for people living with dementia: a guide on the role of allied health professionals' at: www.aci.health.nsw.gov.au/resources/aged-health/allied-health/allies-in-dementia
  • Your practice nurse can also discuss appropriate services and support programs with your patient and their carer as part of a GP Management Plan (item numbers 721, 723, 729 and 732) or health assessment for people aged 75 years and older (item numbers 701, 703, 705, 707).24, 25
  • In consultation with an occupational therapist, refer eligible DVA patients for cognitive, dementia and memory assistive aids to support daily functioning available through the ‘Rehabilitation Appliances Program (RAP) National Schedule of Equipment’. For rural and remote areas, ring 1800 550 457 to discuss your patient’s needs for RAP items. For a full list of items go to: www.dva.gov.au/sites/default/files/files/providers/rehabilitation/rap_schedule.pdf
  • Items include:
    • Prompts, reminders and orientation aids, for example clocks and calendars, coloured toilet seats, locator devices, and verbal reminder alarms.
    • Safety and independence aids, for example sound and movement monitors, safety home bracelets, locks, plugs to prevent the bath or sink overflowing, power point safety covers and stove guards.
    • Telecare support, for example a tracking device that uses satellite technology to locate a person who wanders from home.
    • A personal alarm pendant that is monitored 24 hours a day by an emergency response service.
  • Regardless of age, eligible DVA patients with cognitive impairment may benefit from DVA-funded programs. For further information call 1800 555 254. This includes:
    • The Veterans’ Home Care (VHC) Program, which provides domestic assistance, personal care, safety related home and garden maintenance and provision of respite care.
    • The Community Nursing Program, which provides medicines management, wound care and help with hygiene.
  • Many patients with cognitive impairment and their families value discussions about potential outcomes of their illness which can help them to make legal, financial and personal decisions about their future.2, 5, 13 Consider referring your patient and their family early to a social worker. To find a social worker in your area, go to Australian Association of Social Workers at: www.aasw.asn.au/find-a-social-worker/search
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Encourage your patient to stay active and socially connected
  • Keeping physically active, particularly in group programs, has been shown to have significant social and health benefits for patients with cognitive impairment.22, 23 To find out more, refer to the ‘Physical activity guidelines for older Australians with mild cognitive impairment or subjective cognitive decline’ at: https://medicine.unimelb.edu.au/__data/assets/pdf_file/0008/2672846/PAG.pdf
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Support good nutrition
  • If your patient is not eating well or is underweight, consider referring them to a dietitian or speech pathologist. To find a dietitian in your area, go to Dietitians Association of Australia at: https://daa.asn.au/find-an-apd/ or to find a speech pathologist, go to Speech Pathology Australia at: www.speechpathologyaustralia.org.au/find
  • If your patient has poor oral health, poorly fitting dentures or has not had a dental check-up in the last year, refer them to a dentist.1 To find a dentist in your area, go to Australian Dental Association at: www.ada.org.au/Find-a-dentist
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Assess for and treat behavioural and neuropsychiatric symptoms
  • Early interventions can reduce future depression, communication challenges and caregiver burden.6, 26
    • Psychological therapies including relaxation exercises, orientation and memory strategies, and cognitive behavioural therapy can improve well-being, quality of life, communication skills and keep your patient socially connected.6, 27, 28
    • To find a psychologist in your area call 1800 333 497 or go to Australian Psychological Society at: www.psychology.org.au/FindAPsychologist/
    • To find out about the most effective ways to manage behavioural problems associated with dementia, go to a previous MATES topic, Dementia and changes in behaviour at: www.veteransmates.net.au/topic-44-therapeutic-brief
    • The inability to communicate with others can be very distressing and may be exhibited as a behavioural symptom.23 Consider referring your patient to a speech pathologist.
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Reduce the number of medicines that can contribute to cognitive impairment

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  • Older people with cognitive impairment are particularly susceptible to medicine-related problems.29-32
  • Using five or more medicines is associated with frailty, disability, mortality, falls and cognitive impairment.31
  • Medicines that can contribute to cognitive impairment or worsen confusion, or are associated with sedation and an increased falls risk include:
    • medicines with anticholinergic effects including
      • hypnotics, for example zopiclone
      • bladder antispasmodics, for example oxybutynin and propantheline
      • inhaled medicines, for example aclidinium, ipratropium and tiotropium
      • some antidepressants, for example amitriptyline and doxepin
      • some antipsychotics, for example chlorpromazine and clozapine18
    • older antihypertensives, for example methyldopa, clonidine and moxonidine
    • opioid analgesics, for example oxycodone, fentanyl, morphine
    • barbiturates, for example phenobarbitone
    • anti-migraine medicines, for example pizotifen
    • antipsychotics
    • anxiolytics, hypnotics and sedatives, for example benzodiazepines, zolpidem.12, 18
  • Refer to the insert ‘A guide to deprescribing in polypharmacy’ to find out how to reduce the anticholinergic load, and to taper and cease opioids, antidepressants or antipsychotics.
  • If you are concerned about your patient’s alcohol use, refer them and their carer to DVA's ‘The Right Mix’ website for help in how to reduce their alcohol use, available at: www.therightmix.gov.au
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Review medicines and reduce the anticholinergic and sedative load
  • A Home Medicines Review (HMR) can be used to identify medicines that contribute to cognitive impairment or an increased falls risk.1
  • When arranging an HMR for your patient:
    • In the referral, ask the pharmacist to focus on assessing your patient’s ability to safely manage their medicines at home, especially for those who live alone, and identifying medicines that can contribute to cognitive impairment and sedation.
    • Ask the pharmacist to pay particular attention to medicines not typically thought of as having anticholinergic effects as they can add to the overall anticholinergic load when added to other strong anticholinergic medicines.18
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Use DVA-funded aids or services to improve medicine management
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Consider cardiovascular risk factors as secondary prevention
  • Assess for and treat type 2 diabetes, hypertension, high cholesterol and other lipids, stroke and kidney disease. Refer to Chapter 8, ‘Guidelines for preventive activities in general practice, 9th Edition’ for details.17
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Provide support for family and carers

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At each visit, assess your patient’s carer’s mental and general health, encourage them to access services that provide support, and offer education and training to enable them to develop skills in managing their spouse or family member.23 Some resources for carers include:

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DVA-funded Respite Care and Carer Support provided through the Veterans’ Home Care (VHC) Program. Details are available at: www.dva.gov.au/factsheet-hsv06-respite-care-and-carer-support

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The Carers Booklet provides information about specific services and funding available through DVA. Contact them at: www.dva.gov.au/about-dva/publications/health-publications/carers-booklet#centrelink

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Open Arms - Veterans & Families Counselling (previously known as Veterans and Veterans Families Counselling Service (VVCS)). Contact them 24/7 on 1800 011 046 or at: www.openarms.gov.au

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The National Dementia Helpline run by Dementia Australia, provides free confidential emotional support, education and information about dementia and mild cognitive impairment. The helpline can be accessed during business hours on 1800 100 500 or at: www.dementia.org.au/helpline

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Dementia Support Australia provides 24/7 support for people with dementia and their carers. Contact them on 1800 699 799 or at: www.dementia.com.au

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Carers Australia offers support to carers by working to improve their health, well-being, resilience and financial security. Contact them on 1800 242 636 or at: www.carersaustralia.com.au/about-carers

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Beyond Blue: contact them on 1300 224 636 or at: www.beyondblue.org.au/

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Lifeline: contact them 24/7 on 13 11 14 or at: www.lifeline.org.au

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Ex-service organisations in your state can be contacted at: www.dva.gov.au/contact/ex-service-organisations


A guide to deprescribing in polypharmacy

Where possible, use non-pharmacological treatment options.18 When prescribing medicines:

  • explain options and consider your patient’s preferences and goals
  • review the ongoing need for the medicine before re-prescribing
  • use the lowest effective dose
  • consider your patient’s functional and cognitive abilities, and their capacity to manage their medicines.18

A Home Medicines Review (HMR) is an effective way to review your patient’s medicines. To find out about the HMR process and to determine if your patient might benefit from having an HMR, go to: www.veteransmates.net.au/HMR_Process

A guide to changing or deprescribing medicines34, 35

Step 1. Review all medicines
Review and reconcile medicines with other medicine lists, including those from an HMR, patient medicine list or discharge summary, with your current medicine list in your record. Discuss any differences found with your patient and their carer and update your current medicine list as appropriate.

Step 2. Assess medicine-related benefits and risk of harm, and discuss options with your patient
Consider the number of medicines used, high-risk medicines, past or current toxicity and the patient’s individual circumstances and preferences. Ask your patient if they are aware of and understand their options, and explain probable outcomes of continuing or discontinuing medicines. Consider your patient’s age, cognitive ability, dexterity problems, comorbidities, other prescribers, and past or current adherence.

Step 3. Assess and consider the ongoing need for each medicine with your patient

Assess-ongoing-need

Step 4. Prioritise medicines to be changed
Discuss, prioritise and plan any changes with your patient; ask them what they want. Decide and agree on specific medicines to change, generally one at a time, slowly over weeks or months, in a stepwise approach.

Step 5. Implement the plan and monitor the patient
In collaboration with your patient and their carer, initiate the changes, and monitor and support them as necessary. Develop a Medication Management Plan with your patient and communicate the plan to the accredited pharmacist, community pharmacy and your patient.

Adapted from Scott I et al. ‘Reducing inappropriate polypharmacy: the process of deprescribing’. JAMA Internal Medicine. 2015.

For specific information about:

References

  1. Guideline Adaptation Committee. Clinical Practice Guidelines and Principles of Care for People with Dementia. Sydney. Guideline Adaptation Committee; 2016.
  2. Dementia Australia. Mild Cognitive Impairment. Available at: www.dementia.org.au/about-dementia-and-memory-loss/about-dementia/memory-loss/mild-cognitive-impairment [Accessed November 2018].
  3. Langa K, Levine D. The diagnosis and management of mild cognitive impairment: a clinical review. JAMA. 2014; 312(23): 2551-61.
  4. Brodaty H et al. Incidence of MCI and dementia over six years in an Australian population sample. Alzheimer's & Dementia. 2016; 12: 581.
  5. Livingston G et al. Dementia prevention, intervention, and care. The Lancet. 2017; 390: 2673-2734.
  6. Petersen R et al. Practice guideline update summary: mild cognitive impairment. Neurology. 2018; 90: 126-135.
  7. Mitchell A, Shiri-Feshki M. Rate of progression of mild cognitive impairment to dementia-meta-analysis of 41 robust inception cohort studies. Acta Psychiatr Scand. 2009; 119: 252-65.
  8. Dementia Australia. Mild cognitive impairment help sheet. 2014. Available at: www.dementia.org.au/files/helpsheets/Helpsheet-OtherInformation01-MildCognitiveImpairment_english.pdf [Accessed September 2018].
  9. Brown L, Hansnata E, La H. Economic Cost of Dementia in Australia 2016-2056. University of Canberra. Canberra, ACT. 2017.
  10. Dementia Australia. Dementia prevalence estimates 2018-2058. Available at: www.dementia.org.au/files/documents/2018-2058%20Prevalence%20CED_AUSTRALIA_alpha.pdf [Accessed November 2018].
  11. Alzheimer's Australia. Living alone with dementia. Available at: www.dementia.org.au/files/20131011-NSW-PUB-LivingAlone_ServiceGuide.pdf [Accessed November 2018].
  12. DVA Health Claims Database, University of South Australia, QUMPRC. [Accessed November 2018].
  13. Pond D. Office-based assessment of cognitive impairment. AJGP. 2018; 47(9): 602-605.
  14. Connolly A, Gaehl E, Martin H, Morris J, Purandare N. Underdiagnosis of dementia in primary care: variations in the observed prevalence and comparisons to the expected prevalence. Aging Ment Health. 2011; 15(8): 978-84.
  15. Iliffe S, et al. Primary care and dementia: 1. diagnosis, screening and disclosure. Int J Geriatr Psychiatry. 2009; 24: 895-901.
  16. Speechly C, Bridges-Webb C, Passmore E. The pathway to dementia diagnosis. MJA. 2008; 189: 487-489.
  17. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice, 9th Edn. East Melbourne, Victoria. 2016.
  18. Australian Medicines Handbook Aged Care Companion. Adelaide. Australian Medicines Handbook Pty Ltd. 2018.
  19. Ngandu T et al. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. The Lancet. 2015; 385: 2255-2263.
  20. Cooper C, Sommerlad A, Lyketsos C, Livingston G. Modifiable predictors of dementia in mild cognitive impairment: a systematic review and meta-analysis. Am J Psychiatry. 2015; 172: 323-34.
  21. Rosenberg A et al. Multidomain lifestyle intervention benefits a large elderly population at risk for cognitive decline and dementia regardless of baseline characteristics: The FINGER trial. Alzheimers and Dementia. 2018; 14: 263-270.
  22. Lautenschlager N et al. Physical Activity Guidelines for Older Australians with Mild Cognitive Impairment or Subjective Cognitive Decline. Melbourne: Dementia Collaborative Research Centres, 2018. Available at: www.dementia.unsw.edu.au/ [Accessed October 2018].
  23. Alzheimer's Australia and NSW Agency for Clinical Innovation (ACI). Better health for people living with dementia: a guide on the role of allied health professionals. Chatswood, NSW. 2016.
  24. Australian Government Department of Health. Chronic Disease Management - Provider Information. Updated 2016. Available at: http://www.health.gov.au/internet/main/publishing.nsf/content/mbsprimarycare-factsheet-chronicdisease.htm [Accessed December 2018].
  25. Strivens E. Managing dementia-related cognitive decline in patients and their caregivers. Australian Family Physician. 2014; 43(4): 170-174.
  26. Australian Centre for Posttraumatic Mental Health. Mental Health Advice Book for treating veterans with common mental health problems. Department of Veterans' Affairs, Canberra. 2012.
  27. Aguirre E, Woods R, Spector A, Orrell M. Cognitive stimulation for dementia: a systematic review of the evidence of effectiveness from randomised controlled trials. Ageing Res Rev. 2013; 12: 253-62.
  28. Elliot R, Goeman D, Beanland C, Koch S. Ability of older people with dementia or cognitive impairment to manage medicine regimens: a narrative review. Current Clinical Pharmacology. 2015; 10: 213-221.
  29. Eshetie T, Nguyen T, Gillam M, Kalisch Ellett L. A narrative review of problems with medicines use in people with dementia. Expert Opin Drug Saf. 2018; 17(8): 825-836.
  30. Gnjidic D et al. Polypharmacy cutoff and outcomes: five or more medicines were used to identify community-dwelling older men at risk of different adverse outcomes. J Clin Epidemiol. 2012; 65: 989-95.
  31. Green A, Reifler L, Boyd C, Weffald L, Bayliss E. Medication profiles of patients with cognitive impairment and high anticholinergic burden. Drugs Aging. 2018; 35: 223-232.
  32. Department of Veterans' Affairs. Dose Administration Aid (DAA) Service. Available at: www.dva.gov.au/providers/provider-programs/dose-administration-aid-daa-service [Accessed December 2018].
  33. Adelman R, Tmanova L, Delgado D, Dion S, Lachs M. Caregiver burden: a clinical review. JAMA. 2014; 311(10): 1052-60.
  34. Scott I et al. Reducing inappropriate polypharmacy. The process of deprescribing. JAMA Intern Med. 2015; 175(5): 827-834.
  35. Le Couteur D, Banks E, Gnijidic D, McLachlan A. Deprescribing. Australian Prescriber. 2011; 34(6): 182-185.

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Key Points
  • DVA funds a wide range of cognitive, dementia and memory assistive aids
  • Refer your patients with cognitive impairment to an occupational therapist to ascertain the need for assistive aids
  • Where possible, cease medicines that contribute to cognitive impairment