Cognitive Care Plan

The purpose of this cognitive care plan is to assist clinicians in documenting and managing symptoms associated with their patients’ cognitive decline. It is not a stand-alone diagnostic tool. Any conclusions drawn in this plan should be based upon clinical interviews and observations, cognitive assessment results, mental health examinations, and other evaluations of the patient and/or the patient’s family history.

This is a Summary of your Visit today. Education is provided after the Summary.

DIAGNOSIS: 

• Major Neurocognitive Disorder  
• Mild Cognitive Impairment

NEEDS ASSESSMENT AND PLAN: During this visit, interventions were prescribed to assist with:

• Memory:
• Treatment / Intervention:
  • Medication prescribed
    • Behavior modification recommended
• Goal: to improve need via the above intervention, reviewed with patient &/or caregiver – understood and agreed to
• Caregiver &/or patient role: will implement plan and monitor goals and report back in 3 months
• Behavior
• Treatment / Intervention:
  • Medication prescribed
    • Behavior modification recommended
• Goal: to improve need via the above intervention, reviewed with patient &/or caregiver – understood and agreed to
• Caregiver &/or patient role: will implement plan and monitor goals and report back in 3 months
• Sleep intervention
• Treatment / Intervention:
  • Medication prescribed
    • Behavior modification recommended
• Goal: to improve need via the above intervention, reviewed with patient &/or caregiver – understood and agreed to
• Caregiver &/or patient role: will implement plan and monitor goals and report back in 3 months
• Safety
• Treatment / Intervention:
  • Behavior modification recommended
• Goal: to improve need via the above intervention, reviewed with patient &/or caregiver – understood and agreed to
• Caregiver &/or patient role: will implement plan and monitor goals and report back in 3 months

• End-of-life care intervention
• Treatment / Intervention:
  • Family planning intervention recommended
• Goal: to improve need via the above intervention, reviewed with patient &/or caregiver – understood and agreed to
• Caregiver &/or patient role: will implement plan and monitor goals and report back in 3 months

Diagnosis, Staging, and Treatment Summary

There are two types of neurocognitive impairment – Mild and Major. In most cases, Mild impairment will improve, as with concussion or Brain Fog; however, in some people, there may be longer-lasting problems. Mild is defined as cognitive problems that do not interfere with the ability to lead an independent lifestyle and perform complex daily activities such as managing finances or driving a car.

Major Neurocognitive Impairment is diagnosed when there are objective problems with memory, reasoning and handling complex tasks, visuospatial abilities, language functions, personality and behavior. These impairments lead to a decline in normal functioning.  Conditions that cause Major Neurocognitive Impairment are called Dementia. Different diseases that affect the brain can cause dementia. Around 19 out of 20 people with dementia have one of four main types.

The two most common of these are:

• Alzheimer’s disease – this is the most common type of dementia. It is caused when proteins that are not formed properly build up inside the brain. These proteins join together into structures called ‘plaques’ and ‘tangles,’ which stop the brain from working properly.
• Vascular dementia – this is the second most common type of dementia. It’s the result of the brain not receiving enough blood.

A smaller proportion of people with dementia have one of the following types:

• Dementia with Lewy bodies (DLB) – Lewy bodies are tiny clumps of protein that develop in the brain and stop it working properly. Someone in the early stages of DLB may find it hard to stay alert or have problems with how they see things. This includes seeing things that are not there (hallucinations), mistaking patterns or reflections for other objects, and having problems judging distances.
• Frontotemporal dementia (FTD) – damage from proteins that are not formed properly stops the front and side parts of the brain from working as they should. This leads to symptoms that can include changes in personality, such as becoming withdrawn or inappropriate. Or the person may lose the meaning of words or have difficulty or become slower at getting words out.
• Dementia related to other causes such as Parkinson’s Disease

Dementias are typically progressive, and there are stages:

• Early Stage – The person may experience mild cognitive impairment and their daily routine may be disrupted
• Intermediate Stage – moderate cognitive decline, some loss of independent function.
• Late Stage – The person may experience severe cognitive decline, and their ability to manage their own may be impacted
  

For general brain health to maintain cognitive functioning:

Physical health:

• Regular exercise: Aerobic activities like walking, swimming, or biking are particularly beneficial.
• Healthy diet: Focus on fruits, vegetables, whole grains, and healthy fats.
• Sleep hygiene: Adequate sleep is crucial for cognitive function.
• Manage chronic conditions: Control conditions like diabetes and high blood pressure.

Mental stimulation:

• Brain training games: Engaging in activities that challenge memory, problem-solving, and reasoning skills.
• Learning new things: Take up a new hobby or language
• Reading regularly
• Complex puzzles and board games

Stress management:

• Mindfulness meditation: Can improve focus and reduce stress
• Relaxation techniques like deep breathing

Social engagement:

• Maintaining social connections
• Participating in group activities

For those with mild cognitive impairment or those dealing with cognitive problems:

Time management:

• Setting regular schedules and routines
• Using a calendar or planner to track appointments an tasks
• Breaking down large tasks into smaller, manageable steps
• Memory support:
  • Writing down important information to refer back to
  • Using reminder apps or alarms on phones
  • Placing visual cues around the home to trigger memory
• Attention management:
  • Creating a dedicated workspace with minimal distractions
  • Using noise-canceling headphones
  • Taking frequent breaks to maintain focus
• Organization skills:
  • Making checklists for tasks
  • Color-coding items to categorize information
  • Establishing designated storage areas for frequently used items
• Communication support:
  • Asking for clarification or repeating information to ensure understanding
  • Using visual aids like pictures or diagrams
  • Requesting extra time to process information

KEY ASPECTS OF CARE PLANNING FOR MAJOR NEUROCOGNITIVE DISORDERS

• Cognitive stimulation: Engaging in activities that challenge cognitive abilities, like puzzles, memory games, discussion groups, and art therapy, to help maintain cognitive function as much as possible.
• Environmental modifications: Adapting the living space to promote safety and independence by using clear signage, well-lit areas, familiar routines, and removing potential hazards.
• Communication strategies: Using simple language, clear visual cues, and non-verbal communication techniques like gestures to facilitate understanding and interaction.
• Behavioral management involves identifying triggers for challenging behaviors like agitation or aggression and using techniques such as redirection, validation therapy, calming activities, and relaxation techniques to manage them.
• Structured routines: Establishing predictable daily schedules with regular mealtimes, activity periods, and bedtime routines to provide a sense of security and stability.
• Medication management: Properly administering prescribed medications for dementia symptoms, including monitoring for side effects and potential interactions. See Review of Medications.
• Caregiver support: Providing education, training, and emotional support to caregivers to help them cope with the challenges of dementia care.

SPECIFIC INTERVENTIONS DEPENDING ON THE STAGE OF THE MAJOR NEUROCOGNITIVE DISORDER

Early stage

Mild cognitive exercises: Brain training programs designed to improve specific cognitive domains.

Advance care planning: Discussing future care wishes and making legal documents while the person still has capacity.

Education:

• In the early stage of Alzheimer’s, a person may function independently. He or she may still drive, work, and participate in social activities. Despite this, the person may feel as if he or she is having memory lapses, such as forgetting familiar words or the location of everyday objects.
• Symptoms may not be widely apparent at this stage, but family and close friends may take notice, and a doctor would be able to identify symptoms using certain diagnostic tools.
  • Coming up with the right word or name
  • Remembering names when introduced to new people.
  • Having difficulty performing tasks in social or work settings.
  • Forgetting material that was just read.
  • Losing or misplacing a valuable object.
  • Experiencing increased trouble with planning or organizing

Moderate stage

Review of safety issues: home safety, operating motor vehicles, childcare capabilities, etc.

Sensory stimulation: Using sights, sounds, smells, and textures to engage the senses and promote relaxation.

Music therapy: Using music to evoke positive emotions and memories

Personalized activities: Tailoring activities to individual interests and abilities

Education:

• Middle-stage Alzheimer’s is typically the longest stage and can last for many years. As the disease progresses, the person with Alzheimer’s will require a greater level of care.
• Symptoms, which vary from person to person, may include:
• Being forgetful of events or personal history.
• Feeling moody or withdrawn, especially in socially or mentally challenging situations.
• Being unable to recall information about themselves like their address or telephone number, and the high school or college they attended.
• Experiencing confusion about where they are or what day it is.
• Requiring help choosing proper clothing for the season or the occasion.
• Having trouble controlling their bladder and bowels.
• Experiencing changes in sleep patterns, such as sleeping during the day and becoming restless at night.
• Showing an increased tendency to wander and become lost.
• Demonstrating personality and behavioral changes, including suspiciousness and delusions or compulsive, repetitive behavior like handwringing or tissue shredding.
• In the middle stage, the person living with Alzheimer’s can still participate in daily activities with assistance. It’s important to find out what the person can still do or find ways to simplify tasks. As the need for more intensive care increases, caregivers may want to consider respite care or an adult day center so they can have a temporary break from caregiving while the person living with Alzheimer’s continues to receive care in a safe environment.

Severe stage

Locating services for caregivers

Comfort care: Focusing on managing physical symptoms like pain, discomfort, and nutritional needs

Palliative care: Providing holistic support to the person with dementia and their family during the end of life

Non-verbal communication: Using gestures, touch, and facial expressions to connect with the person

Education:

• In the final stage of the disease, dementia symptoms are severe. Individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement. They may still say words or phrases, but communicating pain becomes difficult. As memory and cognitive skills continue to worsen, significant personality changes may take place and individuals need extensive care.
• Require around-the-clock assistance with daily personal care.
• Lose awareness of recent experiences as well as of their surroundings.
• Experience changes in physical abilities, including walking, sitting and, eventually, swallowing
• Have difficulty communicating.
• Become vulnerable to infections, especially pneumonia
• The person living with Alzheimer’s may not be able to initiate engagement as much during the late stage, but he or she can still benefit from interaction in ways that are appropriate, like listening to relaxing music or receiving reassurance through gentle touch. During this stage, caregivers may want to use support services, such as hospice care, which focus on providing comfort and dignity at the end of life. Hospice can be of great benefit to people in the final stages of Alzheimer’s and other dementias and their families.

Cognitive Care Medications

Cognitive Focused Medications:

1^st Line medications (Acetylcholinesterase inhibitors) include donepezil (Aricept), rivastigmine (Exelon), & galantamine (Razadyne).

• How they work: increase cholinergic transmission by inhibiting cholinesterase at the synaptic cleft and provide modest symptomatic benefit in some patients with dementia. All three have been shown to be effective in double-blind placebo-controlled trials, showing some benefit on cognitive measures including memory and concentration as well as global and functional outcome measures; however, their therapeutic cognitive and functional effects seem to be modest in size and purely symptomatic.
• Side effects: gastrointestinal side effects, more commonly seen during the dose escalation phase of treatment, occur with all three agents. Bradycardia and heart block may occur, especially in patients with underlying cardiac conduction deficits or in those individuals taking medications that cause PR interval prolongation such as beta-blockers. If one agent causes intolerable side effects, another AChEI should be tried.

Other 1^st line medication: memantine (Namenda) is sometimes added.

• How it works: Memantine is aGlutamate Receptor Modulatorsand has low to moderate affinity NMDA receptor antagonist that is used as an add-on to ongoing AChEI therapy, shown to have beneficial effect on cognition, behavior, activities of daily living, and global function. Memantine is approved by the US Food and Drug Administration (FDA) for the moderate to severe AD stages (Mini-Mental State Examination [MMSE] score of 5 to 15) in the United States.
• Side effects: Dizziness is the most common side effect associated with memantine. Confusion and hallucinations are reported to occur at a low frequency, but memantine use seems to increase agitation and delusional behaviors in some patients with AD. Others have reported that worsening of delusions and hallucinations is particularly problematic in patients who have dementia with Lewy bodies (DLB).

Medications for Behavioral Symptoms

Nonpharmacologic techniques – The first line of treatment for behavioral symptoms of AD are nonpharmacologic techniques. A quiet, familiar environment with labels on doors and sufficient lighting in all rooms is important to reduce disorientation. Aggressive behavior should always be addressed with positive and clear language to reassure and distract the patient.

Depressive symptoms are treated with selective serotonin reuptake inhibitors (SSRIs) due to their low propensity to cause anticholinergic effects. SSRIs may also ease anxiety, irritability, or other nonspecific symptoms that may accompany depression. The SSRI citalopram may be useful for agitation.

Agitation or disruptive behavior may require a neuroleptic for optimal therapeutic response.

• The newer “atypical” antipsychotic medications (quetiapine, risperidone, olanzapine) are often used in low doses with careful titration. Typical and atypical antipsychotic agents, however, carry a black box warning label due to an association with increased cardiovascular morbidity and mortality (higher for the typical compared to atypical antipsychotics) and cerebrovascular adverse events in the elderly with dementia-related psychosis. In addition, these medications have additional adverse effects: anticholinergic adverse events and orthostatic and metabolic disturbances.
• Traditional neuroleptics are more likely to produce extrapyramidal symptoms, which may worsen cognitive function. All antipsychotics, typical as well as atypical, when used in older adults with dementia, are associated with risk for death. This risk is quite comparable among atypical and typical antipsychotics. It is a black box warning for all antipsychotics as a class when used in older adults with dementia. Thus, judicious use of antipsychotics with frequent reassessment of the therapeutic need is appropriate.

Medications that worsen cognition:

• Medications that can worsen cognition include anticholinergic drugs (often used for bladder control), benzodiazepines (anti-anxiety medications), certain antidepressants, antipsychotics, opioids (narcotic painkillers), some antihistamines, muscle relaxants, and certain medications for Parkinson’s disease, as they can all have side effects that negatively impact cognitive function, especially in older adults.
  

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