Collaborative Care Best for Alzheimer's

Improvements noted in patients and their caregivers, study says

TUESDAY, May 9, 2006 (HealthDay News) -- Alzheimer's patients who were treated with a so-called guided team approach, with an advanced practice nurse coordinating care, had fewer behavioral and psychological symptoms of dementia, a new study found.

At the same time, their caregivers had greatly reduced levels of stress and depression.

Such a collaborative approach is already used to treat diseases such as diabetes and congestive heart failure.

"It really is quite effective and the collaborative care model is what I would argue is the future of chronic-care management," said Dr. Gary J. Kennedy, director of geriatric psychiatry at Montefiore Medical Center in New York City.

Kennedy was not involved in the study, which appears in the May 10 issue of the Journal of the American Medical Association.

Most older adults with Alzheimer's and other forms of dementia receive the bulk of their care from a primary-care physician, not a specialist. But this may not be the best setting.

"Generalists are the most likely to take care of older adults with Alzheimer's; there aren't enough specialists," said Dr. Christopher M. Callahan, lead author of the study and director of the Indiana University Center for Aging Research. "Primary care doesn't have the resources to apply state-of-the-art recommendations."

According to the study authors, more than 90 percent of patients with dementia will have behavioral and psychological symptoms at some point.

The guided team approach guidelines for dementia treatment include easy communication among doctors within the health-care system and the community; active surveillance of patient results with feedback to the health-care team managing the patient; treatment for depression, psychoses and behavioral disturbances; and active monitoring and support of the caregiver's emotional and physical health.

The effectiveness of these recommendations had not yet been tested, Callahan said. "We decided to put it all together and see what happened if you did apply these the way the experts suggest," he said.

So, 153 older adults with mild to moderate Alzheimer's and their caregivers were randomly picked to receive either collaborative-care management or "augmented usual care" at primary-care practices.

The collaborative-care approach involved one year of care from an interdisciplinary team headed by an advanced practice nurse who was located at a primary-care practice.

"The care manager is the quarterback for the management of the patient with Alzheimer's and the caregiver," Callahan explained. "She's acting as an ombudsman, not only for facilitating the knowledge that she has, but also facilitating access to the rest of the health-care system. The primary-care doctor is still quarterbacking everything else."

Caregivers and patients in the augmented usual-care group received counseling from a geriatric nurse practitioner and were also given information about local community resources.

Eighty percent of patients in the collaborative care arm and 55 percent of patients in the control group received cholinesterase inhibitors, an FDA-approved drug treatment for Alzheimer's; and 45 percent in the collaborative arm took antidepressants, compared with 27.5 percent in the control group.

Patients receiving collaborative care had significantly fewer behavioral and psychological symptoms of dementia at one year and at 18 months after the study began. Caregivers also reported improvements in their levels of stress at 12 months and in depression at 18 months.

"The intervention worked even though we were comparing this intervention to another intervention," Callahan said. "It worked on the symptoms that older adults and their families find the most distressing, these behavioral factors."

There was no evidence that the collaborative team approach had any effect on cognition, activities of daily living, or rates of nursing-home placement for the Alzheimer's patients.

Given time, however, some of these results might also change.

"The sample is a little small and the period of observation a little brief to be able to detect differences in hospitalization, mortality or nursing-home placements," Kennedy said. "If it's in a larger sample size and extended over two to three years, you might start to see differences in the more dramatic outcomes."

Callahan and his researchers now plan to look at the cost-effectiveness of the team approach and to see if such collaboration can delay the need for nursing-home care for Alzheimer's patients.

More information

Learn more at the Alzheimer's Association.

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