Sharing Transnational Experiences of Psychogeriatric Units Dedicated to the Management of Behavioral and Psychological Symptoms in Demented Patients

Abstract

The occurrence of Behavioral and Psychological Symptoms of Dementia (BPSD) is one of the major problems associated with dementia, affecting not only the patient’s outcomes but also the caregiver’s health status and quality of life. Despite the progress in the knowledge of dementia, the management of BPSD continues to be a challenge for physicians and health workers in their everyday clinical practice. Indeed, nonpharmacological approaches are often insufficient to control the manifestation of BPSD if used alone. Nonetheless, studies demonstrated that the pharmacological treatment of BPSD with antipsychotic drugs is burdened by a high risk of adverse events, including extrapyramidal signs, falls, cerebrovascular events, and deaths, and, in this context, models of care attempting to combine nonpharmacological approaches with a careful use of drugs are obviously needed to improve assistance for people with BPSD. Consistent with this approach, the French Government has recently developed a project, the “Plan Alzheimer” 2008 to 2012, in which newly designed intermediate-term care units, Cognitive and Behavioral Units (CBUs), have been created in addition to the traditional referral units, the so-called Acute Psychogeriatric Units (APUs), for the management of patients with BPSD. In a recent issue of Alzheimer disease and associated disorders, Koskas et al reported the results of a pilot study of CBUs, comparing data with those from APUs. The authors found that, in comparison with APUs, patients from CBUs are significantly more cognitively impaired and have more specific BPSD (ie, nighttime and aberrant motor behavior and agitation), while they are less impaired in nutritional and health status. The authors conclude that the 2 programs serve populations with different clinical needs, and, therefore, the 2 settings (ie, CBU and APU) do not act competitively. Another relevant finding is that, according to the physician’s impression, the majority of patients served by either CBUs or APUs showed a marked improvement in their overall condition at discharge. Despite these positive outcomes, however, the findings of the Koskas’ study should be interpreted with caution. The small sample size and the lack of a control group among nonhospitalized patients with dementia limit their conclusions. Moreover, the authors do not address the crucial question of how CBUs and APUs might coordinate their activities in an integrated network of care for patients with dementia and their caregivers. Indeed, a health care delivery system is most efficient if it is able to fulfill its proper aims using all the available resources at a given condition. Therefore, the principle of efficiency requires that the system’s resources be allocated in a synergistic manner to maximize this capacity. In the case of dementia services, this means that each unit of the network not only take care of patients with different clinical needs, but also that the sources of admission and the destinations at discharge from these units are not the same, but the efforts of the different programs remain coordinated. In fact, if sources of patient’s admission and destination at discharge overlap within the 2 settings, the risk of duplicates significantly increases. An Italian experience with the “Plan Alzheimer” of the Lombardia region (8 million inhabitants) addresses this issue of coordination and efficiency. This program was initiated in March of 1995 with the aim to improve the care of patients with dementia, promoting the creation of both Special Care Units (SCU), and Geriatric Evaluation and Rehabilitation Units for Dementia (GERU-D). In addition, in September 2000, 71 Alzheimer’s Evaluation Units (AEUs) were created in the Lombardia region, as a part of a project financed by the