CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

Office of the Chief Medical Officer 
Clinical Operations 


Treatment for Co-Occurring Cognitive Impairment with Mental Health 

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Category: Special Considerations
Published Date: June 2019
  1. INTRODUCTION
    1. Treatment should be individualized based on level of cognitive impairment and its etiology, likely clinical course of impairment, nature of co-morbid conditions, stage of dementia or other cognitive disorder, functional assessment, safety concerns, and quality and intensity of social support.
       
  2. EVALUATION AND REFERRAL
    1. Individuals should be screened and or evaluated and referred to a qualified outside provider in instances where such assessment indicates a need for further general medical or neurological evaluation and treatment (i.e. medication for dementia).
    2. Individuals should be assessed for comorbid general medical conditions and referred to appropriate health providers for care.
    3. See Parameter 2.7 Parameters for Assessment of Individuals with Co-Occurring Mental Health and Cognitive Impairment for additional Screening and assessment guidelines.
       
  3. TREATMENT CONSIDERATIONS
    1. Comorbid mental disorders should be fully described, with specific treatment goals and recommended interventions.
    2. Clinicians should consider therapies and interventions known to be effective for cognitive impairment and consistent with the type of behavior, degree of cognitive impairment and level of individual social support. These include behavioral approaches, CBT, PST, other behavioral and cognitive oriented therapies. Other modalities may be available through referral such as stimulation oriented approaches, reminiscent therapies, cognition oriented therapies, skills training, Adult Day Health etc.
    3. Prescribers should closely monitor individuals with cognitive impairment, particularly older adults, for untoward medication effects and drug interactions that may be exacerbated by pharmacokinetic and physiologic factors related to aging and pathologies that impair cognition (e.g. metabolic, etc).
    4. Clinicians should document their analysis of the risks and benefits when prescribing antipsychotic medication in older adults with dementia, specifically referencing the FDA “Blackbox” warning related to the association of such usage with increased mortality, and the uncertain effectiveness of such treatment. E. Clinicians document their assessments for untoward effects and drug interactions presented by concomitant use of complementary and over-the-counter medication, including their potential effects on CCI and physical health.
       
  4. PSYCHOSOCIAL CONSIDERATIONS
    1. Individuals should be referred to early-stage support and or therapy groups and adult day services as appropriate.
    2. Individuals should receive mental health treatment consistent with their wishes regarding end-of-life care and their written advanced directives.
    3. Clinicians should monitor the family and caregiver for signs of stress, self-care maintenance, substance abuse or other maladaptive coping methods.
    4. Clinicians should, counsel and educate family and caregivers regarding course of cognitive impairment expectations at various stages of illness behavioral techniques throughout treatment.
       
  5. REPORTING AND LEGAL CONSIDERATION
    1. Clinicians should complete forms for declaration capacity, as required.
    2. Clinicians should report elder and dependent adult abuse when detected in accordance with legal requirements.
    3. Clinicians should report suspicion of driving impairment as a result of cognitive impairment.
       
  6. SAFETY AND LEVEL OF CARE
    1. Clinicians should regularly assess and provide appropriate recommendations for safety.
    2. Clinicians should recommend referral for appropriate conservatorships (including but not limited to probate with dementia powers).
    3. Clinician should recommend the appropriate level of care for each individual based on level of dementia or other cognitive impairment, functional assessment, physical health status, safety, social support and funding.
    4. Clinician should regularly reassess the ability to self-care and self administer medication and make appropriate recommendations.
       
  7. RESOURCES