Published: 4 May 2020
It is strongly recommended that the linked articles are read before considering the questions.
Cognitive ageing eventually happens to everyone, despite
this it is a difficult issue to raise with patients; younger
people are frequently disinterested in talking about it and
older people often avoid the subject.
When a person is in their 40s and 50s, talking about
cognitive ageing encourages them to implement strategies
to maintain brain health, e.g. being physically, mentally,
socially and culturally active. Later in life, it also facilitates
an early diagnosis in the minority of people who will
experience a clinically significant cognitive decline, i.e.
mild cognitive impairment or dementia. Older patients
should be encouraged to plan for their future during these
conversations which may cover potential issues with their
home, mobility and transportation, who could provide care
for them and who might make decisions for them if they
were not mentally competent.
Symptoms of cognitive decline should be assessed when first
reported or noticed. The initial consultation should focus on
the clinical history to establish the type of symptoms, their
pattern, duration and impact on the patient. Alternative
explanations for a change in cognitive function should be
considered.
If cognitive impairment is suspected, a brief cognitive screening test should be used, e.g. the Mini-Addenbrooke’s
Cognitive Examination (Mini-ACE).
Referral to secondary
care is generally only necessary if there is complexity, e.g.
severe symptoms or rapidly deteriorating function, or
diagnostic or management uncertainty. Encourage early
engagement with the local branch of Alzheimer’s New
Zealand or Dementia New Zealand.
At some stage on their journey, at least 80% of people
with dementia develop behavioural and psychological
symptoms. Depression and anxiety can be among the first
symptoms, while others such as agitation and aggression
more commonly occur later, especially as the person’s ability
to communicate and influence their environment diminishes.
The first approach to managing BPSD is understanding why
the behaviour is occurring, and, where possible, resolving
the underlying factors, e.g. untreated pain, separation from
family or a lack of privacy. Understanding the patient’s
previous vocation, interests, abilities, social and family roles,
cultural background and spirituality helps to individualise
interventions.
Pharmacological interventions have a limited role in the
management of BPSD as they are associated with a range
of serious adverse effects and the indications for which
they are effective is relatively limited. The increased risk of
stroke, cardiovascular events and death associated with
antipsychotic medicines in people with dementia, is a
significant concern. If an antipsychotic is required, it should
be appropriate for the behaviour requiring modification,
and frequent monitoring of treatment response and adverse
effects should occur. Trial withdrawal of the antipsychotic
within three months, except in patients with long-term
psychiatric illnesses, e.g. bipolar disorder. Antipsychotics
should not be used to sedate patients with dementia
who are difficult to manage or as a routine alternative to
benzodiazepines.
When a patient enters advanced stages of dementia,
palliative care is often appropriate. Managing palliative
care may be complicated by an unclear prognosis, patients
not being able to make their preferences known and by a
significant time period between the initial diagnosis of
dementia and death. Focusing on the person’s goals of care
and quality of life, rather than life expectancy is the best
guide for a palliative approach.
As the end of their journey nears, people with advanced
dementia may have pain, difficulties eating and swallowing,
limited or no speech or mobility, incontinence, BPSD and
infections; 24-hour care is required. Non-pharmacological
approaches are generally first-line, with medicines used
as needed to meet the goals of care. Cultural or spiritual
practices may help to address the patient’s psychosocial
needs. A dementia specific pain tool, e.g. the Abbey Pain
Scale can be used to identify and assess pain. Parenteral
administration of medicines may be necessary for patients
in the terminal phase of dementia who have difficulty
swallowing.
The decision to use life-prolonging interventions in a patient
receiving palliative care should be guided by their care plan
and discussions with their EPOA or welfare guardian and
family and whānau.
Questions to consider:
- Do you find it difficult to initiate or engage people in
discussions about cognitive decline? If so, what strategies
have you found most effective to counteract this
reluctance to discuss brain health? These conversations
can often take a considerable amount of time: how much
of a factor do you feel this is for clinicians and are there
any techniques you use to help with this?
- Distinguishing between normal age-related cognitive
decline, mild cognitive impairment and dementia
can be challenging. In your experience are there any
specific questions, symptoms or signs that can make this
distinction easier?
- There are a number of cognitive assessment tools available. Do you favour a particular tool and if so why? The Montreal Cognitive Assessment (MoCA) has now been replaced as the preferred test in New Zealand by Mini-Addenbrooke’s Cognitive Examination (Mini-ACE – online training is available at https://www.nzdementia.org/mini-ace) due to training and costs associated with MoCA. Were you aware of this change? If you have started using the Mini-ACE, have you found it reliable and practical to use? Who else administers cognitive testing in your practice?
- Clinicians are encouraged to initiate discussion with
older people about setting in place an enduring power
of attorney and advance care planning. Are these things
that you include in your routine care of older people? If
not, why not? Is time often the main constraint here?
- Are you aware of the beneficial role of cognitive
stimulation therapy (CST) for people with mild to
moderate dementia? Is it available in your area? If not,
have you found any good alternative strategies for
helping people with dementia remain mentally active?
- Acetylcholinesterase inhibitors can have modest
benefits for some patients with dementia, however,
it is impossible to predict who will respond to the
medicine. Do you offer these medicines to patients? In
your experience, do you find that the beneficial effects
outweigh the adverse effects or vice versa?
- Do you have concerns about the prescription of
antipsychotics for patients with behavioural and
psychological symptoms of dementia (BPSD)? If you
work in a rest home setting, are they suggested by
staff as an immediate treatment option in preference
to a trial of non-pharmacological interventions? If they
are prescribed, how effective are they and is their use
regularly reviewed?
- There is an increasing need for palliative care for patients
with advanced dementia. How comfortable are you with
caring for these patients? Do you have more confidence
in this area after reading the palliative care articles in our
series?
