Introduction by Croakey: Researchers have made wide-ranging recommendations to improve the care of older Australians living in the community with mild cognitive impairment.
These include raising community awareness about the symptoms of mild cognitive impairment, as well as about how accessing healthcare can help identify reversible causes, such as vitamin deficiencies, infections and abnormal thyroid levels.
The recommendations arise from new research analysing non-hospital medical and pharmaceutical use patterns for older people with undiagnosed mild cognitive impairment and diagnosed dementia, living in the Australian community.
The findings are reported below by Dr Anam Bilgrami, from the Macquarie University Centre for the Health Economy, and University of NSW Sydney academics Scientia Professor Henry Brodaty and Scientia Professor Perminder Sachdev.
Anam Bilgrami, Henry Brodaty and Perminder Sachdev write:
More than half a million Australians will be living with dementia by 2030. Many more will have mild cognitive impairment (MCI) – an intermediate stage between normal ageing and early dementia. This is when older people, or their family members, have concerns about their memory and thinking, that are objectively confirmed on testing.
People with mild cognitive impairment can still manage their daily activities without significant difficulties, but mentally demanding activities may need extra effort or support. They are also at a much higher risk of developing dementia than the general population.
It may be helpful for these individuals to access early and ongoing multidisciplinary care, support, and lifestyle advice to manage and potentially slow progression to dementia.
However, our recent research found that people with mild cognitive impairment were less likely than those with normal cognition to visit a doctor, get blood tests, or have diagnostic imaging. Overall, these people were interacting less with the healthcare system.
Also, diagnosing mild cognitive impairment has been subject to much contention.
One of the reasons for this is the sensitivity of diagnosing mild cognitive impairment to various diagnostic criteria used, and the varying success of these criteria in subsequently predicting dementia.
Many people with mild cognitive impairment remain stable or even revert back to normal cognition, leading to some experts questioning how helpful a diagnosis is, and whether it may cause undue stress.
With increasing numbers of older people with mild cognitive impairment living in the Australian community, more research focus is needed on how healthcare services and the community can better support individuals at risk of progressing to dementia and their quality of life.
Research from other countries has found that accurate diagnosis of mild cognitive impairment in primary care and using outpatient care can save costs across health and social care, and prevent expensive hospital stays down the track.
Hence, more accurate screening and better management of mild cognitive impairment may improve healthcare system efficiency and encourage more cost-effective care.
Interaction with healthcare
We conducted our study to learn how older Australians with mild cognitive impairment – who were unaware of their study diagnosis – used outpatient medical services and medications.
We also wanted to analyse any service gaps for people with cognitive impairment living in the community, as this has been studied in the United States but not in Australia.
To do this, we used previously collected data from around 1,000 older Australians who participated in the Sydney Memory and Ageing Study, which started in 2005.
We linked this sample to Medicare data to track medical and pharmaceutical use over ten years. We compared how older people with normal cognition, mild cognitive impairment or dementia – diagnosed by an expert panel during the study – used these services.
Another key finding from our research was that the pattern of less healthcare use particularly applied to people with mild cognitive impairment who lived alone, experienced non-memory symptoms (‘non-amnestic’ mild cognitive impairment) or lacked support from carers for transport or making medical decisions.
This highlights potential population-level barriers to accessing support that may stem from difficulty in recognising and communicating symptoms (particularly non-memory ones), lower mobility, limited carer support and/or potential stigma.
Our findings align with past US study findings on outpatient service gaps for older people with cognitive impairment living in the community.
Provider-level barriers
There are also current provider-level barriers to supporting people with mild cognitive impairment. While primary care through general practitioners (GPs) is often the first point of contact for accessing specialist and multidisciplinary care, GPs in Australia are facing increasing financial and workload strain.
This is partly due to the ageing population, with GPs seeing older and sicker patients with chronic conditions, resulting in an increased clinical and care coordination workload. Longer appointments required for these patients also attracted lower Medicare rebates per minute, and along with ‘rebate freeze’ over 2014-2020, this increased financial pressure on GP clinics.
In the face of such pressures as well as the inherent instability of mild cognitive impairment diagnoses, GPs may be reluctant to diagnose older patients, and need greater support and information.
While recent reports suggest successful educational interventions for GPs relating to timely dementia diagnosis, there is less information on the handling of patients with probable mild cognitive impairment.
Recommendations for improving care
In light of our study findings and in the face of potential population and provider-level barriers, we offer recommendations for better supporting older Australians with mild cognitive impairment in the community:
- Raising community awareness on symptoms of mild cognitive impairment, including non-memory ones, for example, problems with language, trouble paying attention, finding it harder to make decisions and changes in visual perception.
- Increased information provision to older Australians on lifestyle interventions to slow progression and promote healthy brain health, including healthy diet and exercise.
- Better communication on how accessing healthcare can help identify reversible causes of cognitive impairment such as vitamin deficiencies, infections and abnormal thyroid levels.
- Support and outreach for older Australians with limited carer support or those living alone, potentially through increased tailoring of home care packages and telehealth for ongoing mild cognitive impairment management and follow-up.
- Support for more research on mild cognitive impairment, including better identification of risk factors for progression to dementia, and early interventions, and the use of new technologies such as artificial intelligence to assist accurate diagnoses.
- Developing and disseminating consensus recommendations on approaching, assessing and managing mild cognitive impairment in primary care to empower GPs to handle increasing future cases.
- Reducing GP burden through greater encouragement of multidisciplinary, holistic care including through better linkages to memory and cognition clinics and specialised mild cognitive impairment Counsellors or Community Care Coordinators.
- Increasing the uptake of existing but under-used Medicare Benefits Schedule items by GPs to handle mild cognitive impairment including GP Management Plans and Team Care Arrangements, and newly introduced Level E Consultations lasting 60 minutes or more.
About the authors
Dr Anam Bilgrami (BEc BAppFin MEc MRes PhD) is a Senior Research Fellow at the Macquarie University Centre for the Health Economy, who specialises in causal inference and health policy evaluation. She has over a decade of experience in economics research applied to health and aged care, having worked in both academia and the private sector. She is passionate about applying economics to improve decision making and Australian policy design.
Professor Henry Brodaty AO (MBBS MD DSc FRACP FRANZCP) is Scientia Professor of Ageing and Mental Health and Co-Director of the Centre for Healthy Brain Ageing (CHeBA) at the University of New South Wales (UNSW Sydney). He has published extensively, is a senior psychogeriatrician at Prince of Wales Hospital, Sydney and serves on multiple committees for the New South Wales and Australian governments and WHO.
Professor Perminder Sachdev AM (MBBS MD FRANZCP PhD FAHMS) is Scientia Professor of Neuropsychiatry at UNSW Sydney (UNSW), Co-Director of the Centre for Healthy Brain Ageing (CHeBA), UNSW, and Clinical Director of the Neuropsychiatric Institute (Prince of Wales Hospital, Sydney). His major research areas are drug-induced movement disorders, brain imaging, cognitive ageing and dementia, in which he has published extensively.
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