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Managing Older Patients with Cognitive Impairment

 

People with cognitive impairment may require both drug treatment and other types of support. Ideally, a team approach integrating the services of physicians, nurses, other healthcare professionals, social workers, and community organizations may improve medical and behavioral outcomes for both the patient and caregiver.(1,2)

Develop a Management Plan

  • Review the patient’s prescription and over-the-counter medications. Consider whether any might be contributing to cognitive deficits. In particular, reassess the need for anticholinergics, antihistamines, narcotics, sedatives, and benzodiazepines. Review whether the patient takes medications as prescribed, a pill organizer is being used, and a caregiver oversees medication intake to avoid undertreatment and overdoses.
  • Consider Alzheimer’s disease medications when indicated. Note that drug treatment outcomes are modest and may be associated with adverse side effects. Discuss treatment goals and possible side effects with patients and caregivers before beginning therapy. Adjust therapy if desired effects are not seen within 12 weeks.(3)
  • For most non-Alzheimer’s dementias, there is limited information about the efficacy and safety of drug treatment for cognitive symptoms. The exception is Parkinson’s disease dementia, for which the cholinesterase inhibitor rivastigmine (Exelon®) is approved.
  • Evaluate behavioral problems. Determine whether a more structured environment or other nonpharmacological approaches could replace or delay the need for antipsychotic medications.(4)
  • Use great caution for any off-label use of antipsychotic medications in patients with dementia, with constant monitoring for efficacy and safety. No medications are specifically approved to treat behavioral and psychotic symptoms in older adults with dementia. Patients with Parkinson’s disease dementia or dementia with Lewy bodies are particularly sensitive to classic antipsychotics such as haloperidol (Haldol®).(5)
  • Make an appointment for a follow-up visit within a specific timeframe (e.g., 4 to 6 weeks), especially if new medication is prescribed. Ask the patient to bring to each visit a relative or friend who can serve as a care partner, as diminished self-awareness of cognitive decline is common, and reliable information transfer is more likely with the presence of a care partner.

Communicate with the Patient and Caregiver

  • Discuss the diagnosis and treatment plans. Write down all recommendations. Ensure that treatment plans are understood and feasible for the patient and caregiver.
  • Address potential issues of driving, getting lost, and home safety each time the person is seen. These issues are especially critical for people with dementia who live alone.
  • Ask for permission to contact a close relative or friend who can serve as a care partner. Establish and maintain a dialogue with the care partner to discuss safety concerns and help monitor changes in the patient’s daily routine, mood, behavior, and sleep. Also, use this opportunity to ask the care partner how he or she is doing, and what assistance and resources are needed to deliver care and manage stress.
  • Offer the patient and caregiver a checklist of “next steps and resourcesabout Alzheimer’s disease or other dementias.

For tips on communicating with older patients with cognitive impairment, see Talking with Older Patients About Cognitive Problems. For example, to gain the patient’s attention, sit in front of him or her and maintain eye contact. Present one question, instruction, or statement at a time. Write down important information, especially resources.

Source: National Institutes of Health

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