Dementia Care Requires Team Approach

Abstract

Bruce K. Dixon is with the Chicago bureau of Elsevier Global Medical News. The excessive off-label use of neuroleptic medications in nursing homes is largely the fault of the American health care system's emphasis on provider-based, rather than team-based management of dementia, according to Dr. Malaz Boustani, MPH. In his address at the Alzheimer's Association Dementia Care Conference Dr. Boustani said the stressors that cause agitation and other dementia symptoms and lead to overmedication should be alleviated by changing the way dementia is treated. “We shouldn't blame nursing homes, long-term care, home care, or hospitals. We should blame a system that has us in a situation where we don't know how to deal with dementia in these settings, so we use unapproved medicines whose harm can outweigh their benefits,” said Dr. Boustani, assistant professor of medicine at Indiana University (IU) School of Medicine in Indianapolis. “Instead of one doctor or one nurse providing care for a patient, a team of professionals should be responsible for that care, and depending on where the patient is located, the team could consist of a primary care physician, a dementia care provider, a psychologist or psychosocial psychologist, a registered nurse, and formal or informal caregivers,” Dr. Boustani said in an interview. At the Indiana University Center for Aging Research, Dr. Boustani and his colleagues created a cooperative care model that decreased the behavioral symptoms among dementia patients 30% without increasing the use of psychotropic drugs. Led by Dr. Christopher M. Callahan, professor of medicine at IU, the Indianapolis researchers tested the model in a controlled clinical trial whose results were published last year and showed that collaborative care for the treatment of Alzheimer's disease results in “significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers” (JAMA 2006;295:2148–57). In that study, 84 intervention patients received 1 year of care management by an interdisciplinary team led by an advanced-practice nurse working with the patient's family caregiver and integrated within primary care. An additional 69 patients received augmented usual care. The team used standard protocols to initiate treatment and to identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacologic management. Intervention patients and their caregivers received collaborative care management for a maximum of 12 months by a team led by their primary care physician and a geriatric nurse practitioner who served as the care manager. All intervention patients were recommended for treatment with cholinesterase inhibitors (or memantine) unless contraindicated. The minimum intervention that all treatment group caregivers and patients received included education on communications skills, caregiver coping skills, legal and financial advice, patient exercise guidelines with a guidebook and videotape, and a caregiver guide provided by the local chapter of the Alzheimer's Association. All components of this minimum intervention, as well as behavioral interventions, were provided by a geriatric nurse practitioner serving as the care manager. On the basis of caregivers' reports, 89% of intervention patients triggered at least one protocol for behavioral and psychological symptoms of dementia with a mean of four per patient from a total of eight possible protocols. Intervention patients were significantly more likely to receive cholinesterase inhibitors (80% vs. 55% in the usual care group) and antidepressants (45% vs. 27.5%). In addition, intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total neuropsychiatric inventory score at 1 year and at 18 months. Caregivers reported significant improvements in distress at 1 year, and improvements in depression at 18 months. This team approach to dementia care is not necessarily more costly, Dr. Boustani added, but it is more work. First, you set a reasonable goal, then create your team and give them time and space to interact; you get support from the leadership or stakeholder; then you give the team time lines before modifying the results to suit the needs of that facility, he said, stressing that the process must be kept flexible and adaptive.