Most older adults, including those with dementia, receive their health care from generalist physicians. Although primary care physicians prescribe most psychoactive medications to older adults, the primary care setting appears to be poorly designed and underresourced to provide comprehensive management approaches for dementia, according to background information in the article. Over the past decade, quality improvement efforts for geriatric syndromes in primary care have focused on decision support, care management, and other systems-level innovations to deliver guideline-level care.
Christopher M. Callahan, M.D., of the Indiana University School of Medicine, Indianapolis, and colleagues conducted a randomized controlled trial to test the effectiveness of collaborative care management for older adults with Alzheimer disease compared with augmented usual care. Physicians caring for patients at primary care practices within 2 university-affiliated health care systems were randomized to administer collaborative care management (received by 84 patients) or augmented usual care (received by 69 patients). The study was conducted from January 2002 through August 2004.
Intervention patients received 1 year of care management by an interdisciplinary team led by a nurse practitioner working with the patient's family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, including protocols for personal care, mobility, sleep disturbances, depression, agitation or aggression, delusions or hallucinations, and the caregiver's personal health. The protocols stressed management without medications. The minimum intervention that all treatment group caregivers and patients received included education on communication skills; caregiver coping skills; legal and financial advice; patient exercise guidelines with a guidebook and videotape; and a caregiver guide. All of the components of this minimum intervention were provided by a geriatric nurse practitioner, who served as the care manager.
Augmented usual care included participants and their caregivers being provided written materials and information describing local community resources and receiving face-to-face counseling by a geriatric nurse practitioner.
The researchers found through various surveys that intervention patients had significantly fewer behavioral and psychological symptoms of dementia at 12 months and at 18 months. Intervention caregivers also reported significant improvements in distress at 12 months; at 18 months, caregivers showed improvement in depression. There was no evidence that the intervention improves or worsens cognition, activities of daily living, or rates of nursing home placement.
"In summary, application of the current treatment guidelines for the care of older primary care patients with Alzheimer disease results in significant improvements in behavioral and psychological symptoms of dementia and significant improvement in caregiver stress. These improvements exceed those previously reported in studies focusing on pharmacological therapy alone. Achieving a guideline-level dose and duration of the intervention required a care manager who supported the patient's caregiver and physician and adhered to recommended treatment protocols. The intervention demonstrates that care for patients with Alzheimer disease can be improved in the primary care setting but not without substantial changes in the system of care," the authors conclude.
(JAMA. 2006;295:2148-2157. Available pre-embargo to the media at www.jamamedia.org)
Editor's Note: This work was supported by a grant from the Agency for Healthcare Research and Quality. Co-author Dr. Boustani reported receiving research support or honoraria from Pfizer, Forest, and Lundbeck.
Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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