Improving care for Alzheimer disease sufferers

Behavioral and psychological symptoms of dementia represent a major challenge in the care of older adults with Alzheimer disease.

In a study published in the Journal of the American Medical Association, researchers from the Indiana University Center for Aging Research and the Regenstrief Institute, Inc. report improved quality and outcomes of care for Alzheimer disease by restructuring the primary care practice environment to emphasize a team approach to care.

More than 90 percent of patients with Alzheimer disease will experience behavioral and psychological symptoms of dementia at some point during the course of the illness. Leaving these symptoms of dementia untreated has been associated with nursing home placement, poor management of other health problems, high health-care costs and caregiver burn out. For these reasons, the team approach to care emphasized management of these important symptoms.

"We wanted to build a treatment infrastructure within primary care, where most people with Alzheimer disease get their health care. We asked, what would happen if we put together an interdisciplinary team led by a primary care physician and an advanced practice nurse who served as the care manager working with the patient and the caregiver giving them access to resources, providing education, and helping them navigate the health-care system," said Christopher Callahan, M.D., the study's principal investigator. Dr. Callahan is director if the IU Center for Aging, a Regenstrief research scientist and Cornelius and Yvonne Pettinga Professor in Aging Research at the IU School of Medicine.

The 153 older adults with Alzheimer's disease and their caregivers were divided into two groups and followed for 18 months. One group of patients and their caregivers received the collaborative care spearheaded by the advanced practice nurse. The control group of Alzheimer disease patients and caregivers were not exposed to the team approach to health care, but did receive educational materials on the disease.

Participants in both the treatment arm and the control group were informed of their Alzheimer's disease diagnosis. Eighty percent of those in the treatment arm and 55 percent in control group received cholinesterase inhibitors to treat cognitive symptoms of their disease. The two groups did not show differences in cognition. Where the two groups did show significant differences was in behavioral and psychological disturbances, symptoms which often lead to caregiver burnout and precipitate nursing home placement.

Decreasing patient agitation in the treatment group participants was directly correlated to lower caregiver stress and also translated into less depressive symptoms in the treatment group patient's caregivers. This result was achieved without the use of anti-psychotics or sedative medications. The FDA has recently raised concerns about the safety of anti-psychotic use to treat agitation in older adults with dementia.

"In a disease like Alzheimer, the pill is just part of the package of care that you have to deliver to this patient to get optimal outcomes," said Dr. Callahan. "If you are a busy practitioner, it's a lot easier to prescribe a pill for behavioral problems and focus on the patient's other health-care problems than to do an educational intervention with the caregiver. Our study shows the importance of access to a health-care team in which the physician is not necessarily the person most important to the patient or the caregiver in terms of the day-to-day management of problems.

"Until this study, we didn't know if a package of care like this would have any impact on the outcomes of Alzheimer's disease patients. The more studies like this that we have that show that these kinds of models work, the more evidence we have to go to the payers and say these are cost effective interventions," he said.

Next Dr. Callahan and colleagues plan a larger, longer study to explore the cost effectiveness of this type of team approach to Alzheimer disease and to see if collaborative care can forestall nursing home placement.

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