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

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.

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}

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/providers/health-programs-and-services-dva-clients/rehabilitation-appliances-program-rap
• 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 VETERAN (1800 838 372). 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

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
  • To find a physiotherapist in your area, go to Australian Physiotherapist Association at: https://choose.physio/findaphysio or to find an exercise physiologist, go to Exercise and Sports Australia at: www.essa.org.au

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

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.

Reduce the number of medicines that can contribute to cognitive impairment

• 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

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

Use DVA-funded aids or services to improve medicine management

• A Dose Administrative Aid can help your patient with cognitive impairment to better manage their medicines at home.³³ Where possible, conduct a HMR prior to accessing the DAA service. To arrange a DAA through DVA, write an authority prescription. For further information go to: www.dva.gov.au/providers/provider-programmes/dose-administration-aid-daa-service
• For information about a medication timer with alarm settings and storage compartments, go to the ‘Rehabilitation Appliances Program (RAP) National Schedule of Equipment’ at: www.dva.gov.au/health-and-treatment/care-home-or-aged-care/equipment-and-modifications-you-and-your-home
• If your patient is unable to manage their medicines, community nursing services can provide administration of medicines to eligible DVA patients in their home. For further details go to: www.dva.gov.au/providers/health-programs-and-services-dva-clients/community-nursing

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, 9^th Edition’ for details.¹⁷

Provide support for family and carers

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:

DVA-funded Respite Care and Carer Support - DVA provides information on respite care and support for carers in other agencies, at: www.dva.gov.au/health-and-treatment/care-home-or-aged-care/support-carers/carer-support-other-agencies

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

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

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

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

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

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

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 medicines^34, 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

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:

• which medicines have anticholinergic effects and strategies to reduce the anticholinergic load, go to the MATES topic: Thinking clearly about the anticholinergic burden at: www.veteransmates.net.au/topic-39-therapeutic-brief
• how to taper and cease an antidepressant, go to the MATES topic: Achieving best outcomes for depression at: www.veteransmates.net.au/topic-49-therapeutic-brief
• how to taper and cease an opioid, go to the MATES topic: Chronic pain rehabilitation: It’s about improving function and day-to-day life at: www.veteransmates.net.au/topic-48-therapeutic-brief
• how to taper and cease an antipsychotic, go to the MATES topic: Antipsychotic use in BPSD: limited benefits, high risks at: www.veteransmates.net.au/topic-44-therapeutic-brief
• how to manage benzodiazepine dependence, and how to taper and cease, go to: www.nps.org.au/medical-info/clinical-topics/news/managing-benzodiazepine-dependence-in-primary-care

References

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