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An Interdisciplinary Approach for Improved Patient Outcomes in Dementia


Collaborative Care in Dementia: Not an Option, But a Necessity!

“If the current U.S. population trends continue, we can expect to have about 65 million people over the age of 65 by the year 2030,” observed Gary W. Small, MD, Parlow-Solomon Professor on Aging, Professor of Psychiatry and Biobehavioral Sciences, and Director, UCLA Center on Aging, Neuropsychiatric Institute, at ULCA School of Medicine in Los Angeles, California. Increasing age is a major risk factor for Alzheimer’s disease: the prevalence of the disease is 10% for individuals older than 65 years, but increases to 32% in people older than 85 years (Clinical Neuroscience Research Associates, 2000. Available at www.therubins.com). This trend has profound economic consequences as the older population grows, noted Dr. Small.

Economic Costs of Alzheimer’s Disease
In 1995, the estimated costs of dementia care, including indirect costs associated with caregiver time, lost productivity, and increased healthcare needs, were approximately $100 billion (National Advisory Council on Aging Report. 1995). Moreover, a recent retrospective, 2-year analysis of a large Medicare-managed care organization database found that Alzheimer’s disease significantly (P < 0.01) increases the cost of not only managed care services but also of caring for comorbid conditions, such as diabetes or cardiovascular disease (Hill. Neurology. 2002;58:62). These troubling figures highlight the need, Dr. Small believes, for a multidisciplinary, collaborative effort to provide more efficient care for patients with dementia.

The Necessity of the Collaborative Care Approach
The care of community-based patients is often fragmented and poorly coordinated, because coexisting medical conditions in the elderly frequently are managed by different clinicians, Dr. Small reported. Collaborative care promotes early and appropriate diagnosis of the illness, with timely initiation of therapy and persistent treatment. This can eliminate duplicative or ineffective services and the underutilization of local advocacy resources, resulting in improved patient outcomes in cognition, function, and behavior.

A Model for the Collaborative Care Approach
At the center of one model for a collaborative approach are the patients and their families, with the primary care physician acting as the coordinator of care. Geriatric psychiatrists, nurses, pharmacists, specialists, and local advocacy resources are other key elements of this model.

No single model is applicable for all patients, Dr. Small pointed out. The changing healthcare system and differences in the care setting (e.g., urban versus rural, or skilled-nursing facility) can influence the effectiveness of collaborative care. Further, different individuals may serve as care coordinators (e.g., geriatric psychiatrists, family members). Early identification of the care coordinator is critical for effective collaborative care. The main aim of collaborative care, he emphasized, is to improve the communication among the various healthcare providers and with the patients and their families.

Communication among the various physicians, either via telephone or meetings, allows each to benefit from the others’ expertise, particularly in areas of psychopharmacology and medical comorbidity. This communication can assist the care coordinator when difficulties occur with differential diagnoses or with behavioral management issues.

Collaborative Care Is Useful in Dementia With Vascular Risk Factors
Early initiation of therapy as a result of collaborative care has been shown to be beneficial in patients with Alzheimer’s disease, probable vascular dementia, or mixed dementia with vascular risk factors, Dr. Small reported. Galantamine was significantly (P < 0.001) more effective than placebo in improving changes in the Alzheimer’s Disease Assessment Scale-cognitive subscale (ADAS-cog) scores at 6 months (Erkinjuntti. Lancet. 2002;359:1283). This improvement, albeit reduced, remained at 12 months.

Two other multinational studies of patients with probable or possible vascular dementia found that donepezil 5 mg and 10 mg were significantly more effective (P = 0.00621 and P = 0.00037, respectively) than placebo in improving ADAS-cog scores at 24 weeks.

Thus, collaborative care, which promotes early initiation of therapy and effective communication among healthcare providers, can provide more efficient care for patients with various types of dementia.


Primary Care of Patients With Dementia: What Should We Expect?

Primary care physicians are responsible for the care of most (64%) dementia patients, but they may not be using standardized criteria to diagnose dementia, according to Stephen Brunton, MD, Director of Faculty Development at Stamford Hospital/Columbia University Family Practice Residency Program in Stamford, Connecticut. As a result, many patients with mild to moderate dementia are not recognized early enough or may be missed.

This underrecognition of dementia, which can lead to increased rates of hospitalization and mortality, may be reduced with a more collaborative approach to patient care, Dr. Brunton believes. Better communication with the specialists to whom they refer patients can assist primary care physicians with diagnoses and coordination of appropriate therapy.

Early Diagnosis Allows Early Treatment and May Reduce Morbidity
The diagnosis of Alzheimer’s disease (AD) often is delayed because early symptoms are considered to be signs of normal aging and routine screening may not be occurring. The patient’s family also may be in denial and may attribute the symptoms to other medical conditions, such as depression.

With early diagnosis, medical therapy can be initiated earlier, thereby possibly attenuating cognitive and functional decline. This, in turn, can help patients to manage the physical and emotional burdens of the disease and allows them to participate in legal and financial decisions, such as long-term care options and power of attorney. Once the dementia has been diagnosed, it is important to set realistic treatment goals with the patient and caregiver, Dr. Brunton remarked.

Treatment Goals for Dementia
The treatment goals for dementia include decreasing behavioral and neuropsychiatric symptoms and lengthening the patient’s period of self-sufficiency. This reduces the caregiver burden, a key concern in caring for AD patients. Indeed, stress and depression among caregivers are important factors in placing patients in nursing homes.

Early initiation of treatment with the cholinesterase inhibitor donepezil delayed substantially a patient’s placement in a skilled-nursing facility over an 8-year period (Lopez, et al. J Neurol Neurosurg Psych. 2002;72:310). In a retrospective analysis of pivotal trials of donepezil, patients who took the maximum doses of done-pezil with > 80% compliance had a
21-month delay in terms of nursing home placement compared with patients in the placebo group or those who had inadequate therapy–i.e., < 5 mg doses or < 80% compliance (Figure 1) (McRae. Presentation. 14th Annual Meeting Am Assoc Geriatr Psychiatry, 2001).

These encouraging results indicate that early medical treatment “can make a difference,” observed Dr. Brunton. Moreover, providing psychosocial support for caregivers, in conjunction with pharmacotherapy for the patients, also can delay placing a patient in a nursing home (Mittelman. JAMA. 1996;276: 1725). Thus, a multidisciplinary approach, involving several healthcare fields, can significantly improve the quality of life of both the patient and the caregiver.

Communication Between PhysiciansIs Essential for Collaborative Care

Because of their interaction with the patient’s family members, primary care physicians still wish to remain involved in and informed of the patient’s care even after they refer their patients to specialists. Communication among these physicians is essential in achieving the appropriate patient outcomes, Dr. Brunton stated. Specialists can offer advice on when to start pharmacotherapy and primary care physicians can advise on aspects of the patient’s condition (e.g., other illnesses or medications) with which the specialist may not be familiar. This communication between all the involved healthcare providers should be an integral aspect of collaborative care, Dr. Brunton believes.


Patient Outcomes: What Should We Expect Now and in the Future?

When cholinesterase inhibitors, such as donepezil, galantamine, and rivastigmine, were first introduced for the treatment of Alzheimer’s disease (AD), the most important variables considered were cognition and improvement in the patient’s orientation and memory. However, Daniel D. Christensen, MD, Clinical Professor of Psychiatry and Neurology and Adjunct Professor of Pharmacology at the University of Utah Neuropsychiatric Institute in Salt Lake City stated that increasing attention is now being directed at preserving the patient’s activities of daily living and maintaining appropriate behavior.

Dr. Christensen hypothesized that if treatment can be initiated at the pre-Alzheimer’s stage, i.e., when the patient is exhibiting only mild cognitive impairment (MCI), the progression to AD may be delayed and the patient can be self-sufficient for a longer period (Figure 1). This reduces the burden on caregivers and delays placement of the patient in a skilled-nursing facility. To illustrate the impact of early initiation of drug therapy, Dr. Christensen showed 2-year data for a
patient diagnosed with AD.

Use of Donepezil in the Treatment of AD: A Case Report
Esther, an AD patient, was considered by her family to be unable to live independently and had a Mini-Mental State Examination (MMSE) score of 23 at baseline. She received donepezil 5 mg/d for the first month and then 10 mg/d. At 3 months, her MMSE score was 27, but subsequently declined to 26 at 6 months and to 24 at 12 months. Thus, over a year, her condition was remarkably stable, especially considering that most AD patients experience a decline within 6 months and often may lose 2-3 points a year. In addition, Esther’s scores in the cognitive subscale of the Alzheimer’s Disease Assessment Scale (ADAS-cog) were relatively stable (approximately 46). She still lived independently at the end of the first year of drug treatment.

At 2 years, Esther’s MMSE and ADAS-cog scores were 22 and 48, respectively—markedly better than the projected scores for patients who have not received drug treatment. Moreover, Esther was still living independently, whereas patients at this stage of the disease would probably have been placed in a nursing home.

Explaining the significance of these scores, Dr. Christensen noted that a 7-point decrease in ADAS-cog scores is defined as a significant improvement and can be considered to represent an approximate 1-year delay in the patient’s decline. Even a 0-point change in the ADAS-cog score is important, Dr. Christensen observed, because it represents a stabilization of the patient’s condition. Thus, in Esther’s case, early initiation of drug treatment prolonged her period of self-sufficiency.

Other Treatment Options for Dementia
Dr. Christensen reviewed some of the other treatment options for dementia. Currently under development are several drugs that reduce levels of the polypeptide Aß42 in the brain. Aß42 is formed through abnormal cleavage of the amyloid precursor protein by gamma secretase, and accumulation of Aß42 can constitute the molecular basis of AD. In a murine model, the nonsteroidal anti-inflammatory drug flurbiprofen altered the cleavage site of gamma secretase and thereby prevented production of Aß42 (Unpublished data. Todd Golde. Mayo Clinic, Jacksonville, Florida, 2003). Dr. Christensen believes that drugs that reduce Aß42 levels in the brain may produce better outcomes in AD patients and might even prevent the condition.

 


Psychosocial Support and Advocacy by the Alzheimer’s Association: What Should We Expect?

The Alzheimer’s Association firmly endorses a collaborative approach to caring for patients with Alzheimer’s disease (AD), according to Orien Reid, MSW, Immediate Past Chair of the Alzheimer’s Association in Chicago, Illinois. The goal of the Alzheimer’s Association, which comprises a national network of 82 chapters, is to respond to the needs of AD patients, their caregivers, the healthcare community, and the general public. The Association operates the Contact Center, a toll-free service available 24 hours a day, 7 days a week, and connects callers to licensed professionals, such as psychologists, nurses, and social workers. Ms. Reid reviewed some of the programs offered by the Alzheimer’s Association.

Safe Return Program
Between 4% and 26% of patients with dementia in a skilled-nursing facility wander, reported Ms. Reid, as do up to 59% of patients in the larger community. Of those who are not located within 24 hours, 46% will die of hypothermia or dehydration (Koester, et al. Wilderness Environ Med. 1996;6:34). Safe Return is the only nationwide identification, support, and registration program available at the community level for individuals with dementia. More than 80,000 people are registered with this program, and approximately 6,000 have been found and returned safely to their homes.

If a person is reported missing, Safe Return uses a fax alert system to notify law enforcement officials, television
stations, and the local Alzheimer’s Association chapter. In addition, this program provides law enforcement and other emergency officials with information and training on wandering behavior.

Association Clearinghouse and Multicultural Outreach
Each chapter has a clearinghouse, which provides long-distance consultation, specialized home visitations, and respite programs. As part of the Spirituality and Dementia program, the Alzheimer’s Association trains spiritual and lay leaders to assist patients and families with dementia, and has chapter outreach programs that serve various ethnic communities.

Physician-Consumer Partnership Program
According to an AMA-Alzheimer’s Association survey, only 33% of caregivers reported receiving information from their physician about their main concerns, whereas 90% of physicians stated that they were providing this information. These findings led to a program called Working With Your Doctor When You Suspect Memory Problems. The program comprises a 2-hour caregiver workshop and a Train the Trainer program. Booklets on follow-up visits, education and support, and a Doctor Visit Worksheet have been provided to the more than 1,700 participants who have attended the 135 free workshops. More than 30 professionals have been trained to teach the program.

Legislative Priorities for 2003
A major priority of the Association is to increase research funding by the National Institutes of Health. “An investment in research saves billions of dollars in Medicare and Medicaid,” observed Ms. Reid, noting that AD patients are the most expensive to treat in these healthcare programs. The consequences of AD-related expenses for Medicare and Medicaid are particularly grave, given the approximately 14 million baby boomers who potentially may suffer from AD.

Other legislative goals include expansion of the matching grant programs that provide services to underserved urban communities; inclusion of a prescription drug plan and chronic care benefits in Medicare; and continued funding of the Safe Return program.

National Education Conference
The Association’s National Education Conference “is an opportunity for professionals to share information and ideas on caring for people with dementia,” Ms. Reid stated. The annual conference, which includes plenary and poster sessions, symposia, and roundtable discussions, is expected to be attended by more than 1,400 healthcare professionals in 2003.

Ms. Reid concluded her presentation by encouraging more healthcare professionals and caregivers to use the various programs provided by the Alzheimer’s Association to improve the care of individuals with AD.


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