Collaboration in the Care of Alzheimer's Patients

Summarized by Robert W. Griffith, MD
June 5, 2006

Summary

In managing patients with Alzheimer's, a team effort, incorporating the family physician, the principal caregiver, and a psychosocial expert, will get the best results for both patient and caregiver.

Introduction

Behavioral and psychosocial symptoms are the hardest aspect of treating Alzheimer's disease, yet the burden usually falls on the primary physician (family doctor) and the principal caregiver - often a spouse. Guidelines exist for the effective care of Alzheimer patients. Apart from accurate diagnosis, they cover recommendations for referral to patient and caregiver education programs, community support, active monitoring for depression, psychoses, behavioral disturbances, use of appropriate drugs, and caregiver support. However, the effectiveness of implementing the guidelines had not been evaluated until scientists from Indianapolis completed a controlled study. They compared a collaborative treatment program with 'augmented usual care' over a 12-month period. Their findings are reported in the Journal of the American Medical Association, and summarized here.

What was done

Over 150 confirmed Alzheimer's patients were randomly assigned to receive 1 year of care management by an interdisciplinary team led by their primary care physician and a geriatric nurse practitioner, or so-called 'augmented usual care' (this meant the primary care physician could pursue any evaluation or treatment they considered appropriate).

Randomization was by physician; i.e. there were 37 physicians assigned to give augmented usual care, and 37 to participate in collaborative intervention. The collaborative intervention was comprehensive, using standard protocols for identifying, monitoring, and treating behavioral and psychosocial symptoms, stressing non-medicinal management. Eight protocols were used for this purpose, which addressed personal care, repetitive behavior, mobility, sleep disturbances, depression, agitation, aggression, hallucinations, and the caregiver's physical health.

Several scales were used to measure progress of the disease: the Neuropsychiatric Inventory (NPI), the Cornell Scale for Depression in Dementia, mental functioning tests, activities of daily living, and so on, as well as the severity of the caregivers' depression.

What was found

There were 84 patients in the collaborative intervention group, and 69 who received augmented usual care. They were roughly 43% female, 50% black, 48% married, and average age 77. They had moderate dementia, as shown by the average Mini-Mental State Exam (MMSE) score of 18. Caregivers were the spouse (44%) or a child (36%), 90% female, of average age 61. The two groups were evenly balanced.

Ninety percent of the patients in the collaborative care group had at least one non-drug protocol implemented, and the average number per patient was 4. Collaborative intervention patients were more likely to be given cholinesterase inhibitor drugs (e.g. Aricept^®, Exelon^®) and antidepressants than the usual care group patients; 80% of the intervention group got a cholinesterase inhibitor vs. 55% of the usual care group; the corresponding numbers for antidepressants were 45% vs. 28%.

After 12 months, 83% of the intervention caregivers rated their patient's care as very good or excellent, compared with 56% in the usual care group. Times to death or times to nursing home placement were the same in both groups. However, there was improvement in the NPI scores for the collaborative intervention, while those for the usual care patients deteriorated over the 12-month period. The difference in favor of the collaborative intervention was significant. Although the intervention was discontinued after 12 months, there were still significant improvements in the NPI scores at 18 months. Other measures - depression, mental functioning, activities of daily living - failed to show any differences in favor of collaborative intervention, except for caregiver stress at 12, but not at 18 months.

What these results show

This study shows the effectiveness of the published guidelines for managing Alzheimer's disease as delivered by a collaborative care model. The intervention resulted in significant improvement in the behavioral and psychological symptoms of dementia, as measured by the NPI scores. And the improvements were achieved without increasing antipsychotic or sedative-hypnotic medications. Previous studies of this sort have focused on medications alone or psychosocial measures alone, but the present model has achieved excellent results using the collaborative approach.

It's very unlikely that most caregivers of Alzheimer patients will ever have the chance to work with a collaborative unit in the next few years. In the meantime, they should try to build their own informal group to help with the task of managing their patient. Make sure the family doctor knows about the benefits of specific medicines for Alzheimer's (cholinesterase inhibitors and memantine) and antidepressants, and the drawbacks of antipsychotics and sedatives. Find access to an experienced geriatric nurse, psychologist, and/or a psychiatric social worker. And above all, caregivers must take care of themselves, seeking respite from time to time, and watching out for symptoms of depression, an almost inevitable risk with their job.

Source

• Effectiveness of collaborative care for older adults with Alzheimer's disease in primary care. A randomized controlled trial. CM. Callahan, MA. Boustani , FW. Unverzagt ,  et al., JAMA, 2006, vol. 295, pp. 2148--2157

Related Links
Guidelines for Managing Alzheimer's Disease: Part I
Guidelines for Managing Alzheimer's Disease: Part II
Alzheimer's disease: A Family Affair

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