Half of all people with dementia have three or more comorbidities, with hypertension, cerebrovascular disease, depression, diabetes, and visual impairment being the most common.

Not only are people with multiple comorbidities more likely to develop dementia, but dementia also makes the conditions harder to manage, explains geriatrician Associate Professor Mark Yates, who holds positions at Grampian Health and Deakin University.

Disease-specific management is doing people with dementia or mild cognitive impairment (MCI) a disservice, Associate Professor Yates argues.

Most chronic condition management plans are disease-based, “and they’re often protocol driven,” he says. “This may not be the best approach in someone with a cognitive issue.”

Self-management challenges

Managing chronic conditions often relies heavily on self-management, hinging on the patient’s ability to manage their symptoms, treatment, physical and psychosocial consequences and lifestyle changes, Associate Professor Yates explains.

That can present many challenges for people with cognitive impairment. For example, someone with apraxia might find it difficult to manage wound care or use their inhaler or other devices, while someone with agnosia might lose their insulin pen amidst clutter in their kitchen.

Previous research has identified that optimal care for people with dementia and comorbidities should be patient-centred and flexible, with good communication between services. Moreover, everyone involved in the person’s care, should be aware of their MCI or dementia, and factor it into care planning.

“Dementia and comorbidities interact in three important ways. Comorbidity is an opportunity for primary prevention in dementia or MCI. Dementia clearly impacts on chronic disease management strategies. And good chronic disease management is good for dementia care,” Associate Professor Yates says.

“Comorbidities are a clear predictor of cognitive decline and mild cognitive impairment.”

He recommends the CogDrisk tool to assess risk factors for dementia.

Modifiable risk factors include hypertension, diabetes, obesity, high LDL cholesterol, lack of physical activity and hearing impairment, among others. Managing these may prevent or delay cognitive impairment.

For those with MCI, there are several evidence-based interventions that can slow progression. These include physical activity, optimal nutrition, social engagement, depression management, alcohol reduction and medication review, among others.

Additionally, when comorbid conditions are well managed, cognition often improves.  For example, poor COPD management can cause nocturnal hypoxia and daytime confusion, while unstable diabetes increases infection and delirium risk, he notes.

“Dementia is a unique chronic condition. It goes across all your other chronic conditions. It’s subtle in its presentation. So it actually might first be identified when one of those other chronic conditions starts to go awry,” Associate Professor Yates says.

Consider how various cognitive domains will impact management

Rather than creating separate dementia care plans, it’s important to think about the various cognitive domains that are required for managing each condition, and integrate that into the management plan, he says.

For example:

• For attention and information processing issues, this means using simple, concrete language, providing pictorial rather than written instructions, and involving carer support early.
• For communication difficulties, recognise that patients may struggle to articulate symptoms and delays in seeking help can lead to crisis presentations.
• For visuospatial and motor planning problems, assess ability to measure medications correctly and use medical devices like glucometers and inhalers, and ensure they understand the management plan
• For executive dysfunction, establish routines, provide prompts, and simplify complex tasks to support self-management.

When a chronic condition becomes unexpectedly unstable, consider targeted cognitive screening alongside traditional investigations.

“If there’s a new instability in a chronic disease, such as diabetes or chronic obstructive airways disease, it may not be just because the disease is getting worse… It could be because there’s an underlying cognitive change,” Associate Professor Yates emphasises.

“And what we do know from the evidence is that dementia increases mortality beyond the effect of the comorbid condition.”

More information

Useful resources for practical support include Facing Dementia Together, Dementia Pathways, and anticholinergic burden calculators.

Listen to Mark Yates recent lecture to hear more on the interplay between chronic conditions and cognitive issues – and how to get the best outcomes for your patients, including case studies to work through.