Time for Teamwork
Time for Teamwork
As the population of the United States ages, dementia and all its sequelae are becoming an ever-growing challenge for health care systems. In the United States, 5.3 million people have dementia, and by 2050 it is estimated that 14 million people will be afflicted.1-3 Unfortunately, in 90% of those patients with dementia, behavioral problems will develop that will need to be addressed.4 Because of the complexity of the care and the disability caused by the dementia itself, a team effort is required on the part of all caregivers.
Behavioral problems in patients with dementia wreak havoc on their ability to care for themselves and decrease their quality of life; consequently, the time and cost of medical care for treating behavioral symptoms in patients with dementia are increased.5 The demands of caring for these patients, sometimes described as “double-care–demanding patients,” can have a negative impact on caregivers and professionals.6-8
The international community also recognizes the global problem of addressing the increasing population of elderly persons and has specifically addressed behavioral problems associated with dementia as a collaborative target for resources.9-11 Meeting the needs of the aging population (eg, medical, psychiatric, ethical, housing, financial, social, spiritual) is a herculean effort. Although a daunting task, collaboration is necessary to ensure quality coordinated medical care.
The focus of this article is to bring attention to the collaborative management of behavioral issues and how outcomes can be improved in patients with behavioral symptoms of dementia. The discussion covers the benefits of the collaborative model, useful conceptual models, practical interventions to create a collaborative approach, and a review of the role of the psychiatrist.
The benefits of collaborative care
The need for collaboration is obvious, and there are studies to support its efficacy. Collet and collegues6 performed a systematic literature search for studies that investigated a collaborative approach between caregivers and psychiatrists for nursing home residents 55 years or older with severe psychiatric or behavioral problems. Their critical review yielded 8 studies, 7 of which showed significant improvement in agitation and aggression when multidisciplinary evaluations and individualized treatment plans incorporated education, medications, and nonpharmacological therapy. The eighth study showed significant changes in behavior in the active-intervention group compared with baseline; however, the changes were not significantly different from those of the control group.
Callahan and colleagues12 undertook a randomized controlled study of 152 patients with Alzheimer disease. The investigators compared a structured collaborative approach with usual standard care for patients with behavioral problems in a primary care setting. The experimental intervention group was made up of a primary care physician, a geriatrician, a geriatric psychiatrist, a psychologist, and a care manager (an advanced-care nurse).
The study implemented a Web-based system to track patient progress, coordinate treatment, and allow direct but centralized communication among all providers. The study lasted 2 years, and results showed that with an integrated model, there was a significant reduction in behavioral and psychological symptoms as well as caregiver stress.
? Significant improvements were seen in symptoms of agitation and aggression in older nursing home patients who had severe psychiatric or behavioral problems when a collaborative approach between caregivers and psychiatrists was used.
? The 2 widely recognized models that can help create a cohesive, collaborative plan are the Need-Driven Dementia-Compromised Behavior model and the Progressively Lowered Stress Threshold model.
? The lack of clinical and administrative information, poor financial incentive, and poor or absent behavior management education and training are specific challenges to collaborative implementation.
Strategies for involving other professionals
There are several conceptual models for creating a cohesive, collaborative plan for nurses, nurses’ aides, administrators, physicians, pharmacists, and personal caregivers of Alzheimer patients. The 2 widely recognized models are the Need-Driven Dementia-Compromised Behavior (NDB)13 model and the Progressively Lowered Stress Threshold (PLST) model.14,15 These models advocate assessing personal and environmental stressors that create behavioral symptoms of dementia and encouraging nonpharmacological interventions before the use of medications.
The NDB model, originally developed for nursing home residents, views behavioral problems as the patient’s expression of unmet needs, because the patient with dementia is cognitively impaired and may be unable to effectively communicate. The NDB model assesses the patient’s personal preferences and disabilities (cognitive deficits, heat preferences, taste, comfort, pain, etc) in an effort to mitigate those factors that may account for the patient’s behavior. The NDB model encourages the use of behavior logs to assess for temporal relationship of behavioral problems (eg, sundowning, preprandial/postprandial) for the purposes of anticipating future behaviors or uncovering root causes.
The model is structured to address delirium and any physiological or medical conditions that may be contributing to the patient’s behavior. The NDB model takes into account safety to determine which interventions will be the most effective for the patient’s behavior while taking into account the safety of other patients and staff. The model promotes investigating social and environmental factors that can be addressed with nonpharmacological interventions as first-line therapy (eg, music therapy, light therapy, recreational therapy).16
The PLST model is based on the concept that as a person ages, he or she is less able to accommodate various kinds of stress. When the stress exceeds the ability to manage the stress, behavioral problems ensue. The PLST model uses all staff members to incorporate the following 6 tenets14,15:
• Maximize safe function by supporting all real and perceived losses by providing care in a calm and consistent manner for the patient
• Provide unconditional positive regard
• Use behaviors to gauge activity and stimulation levels
• Teach caregivers to interpret behaviors
• Modify the environment to support losses and enhance safety
• Provide ongoing assistance, education, and training to all caregivers
The NDB and PLST models provide a framework for goals from which interdisciplinary team members can identify and address areas of improvement that transcends their specific health care niche.
Setting up a collaborative model
Establishing a practical cohesive plan from theory is a daunting but achievable task. Kaiser Permanente, the Veterans Administration, and the Group Health Collaborative have established functional models to show that collaborative care can be used in both the public and private sectors.17 Although precedent has been set, the task of establishing a system of collaborative care is not without challenges. The single most important obstacle to efficient and effective care is the designation of a single point of contact responsible for coordinating all care. Other collaborative barriers include the following18:
• Territoriality and self-protective behaviors
• Lack of insight into primary health care
• Undervalued nursing care
Zwarenstein and colleagues19 highlighted the confusion of interprofessional responsibility and differences in the providers’ approach to patient care as hurdles to collaborative success. The article discusses the lack of clinical and administrative information, poor financial incentive, and poor or absent behavior management education and training as specific challenges to collaborative implementation.
Providers in multidisciplinary group practices are able to provide better care than their colleagues in solo private practices. The chasms between outpatient, inpatient, and extended-care facilities frustrate attempts at seamless and safe transfer of care.17 One of the last obstacles to integrated services is payment. Unfortunately, financial payment systems that encourage individual effort perpetuate the difficulty of establishing a team approach. In the United States, the current financial system rewards the individual and creates a piecemeal and fragmented approach to patient care. A prepaid or group payment schedule for collective services has been shown to encourage collaboration and improve quality of care.17
Fortunately, there are promising ways to overcome obstacles to collaborative efforts. First of all, it has been suggested that in order to break rigid territorial lines of responsibility, it may be necessary to teach the theory and practical execution of collaborative models during early clinical training (eg, medical and nursing schools) before territorial attitudes develop.18
Objective measures to quantify the severity of behavioral problems in patients with dementia already exist (Table). The use of these instruments can facilitate better communication among collaborators. These tools help measure the severity of behavioral problems at the onset and provide feedback on the effectiveness of treatment interventions.20
Practical collaborative improvements include computer reminders, use of skilled nonphysician staff, external financial incentives for quality improvement, performance feedback, electronic records, procedural strategies to standardize referral procedures, and joint training opportunities.17,21,22 Partnership with management and clinicians, clinical decision support systems, and performance oversight through public reporting have also been shown to be useful in ensuring quality of care and as a means of improving collaborative systems.17 Interdisciplinary rounds have been shown to cut cost and reduce hospital stays, and external interprofessional audits have improved inpatient care; however, further research is needed to confirm these findings.23,24 Integrated meetings between physicians, pharmacists, nurses, and nursing assistants have been shown to result in a reduction in the use of anxiolytics and hypnotics in a Swedish nursing home population.25
The psychiatrist’s role
The psychiatrist serves to provide comprehensive diagnostic evaluation and coordination of medical treatments. Psychiatrists detect and treat hosts of medical and psychiatric conditions that contribute to changes in behavior in patients with dementia. Psychiatric problems, such as primary sleep disturbances, depression, substance abuse, mania, sexually inappropriate behaviors, and psychosis, can complicate the care of patients with dementia.
The medical literature is rife with information on the causes of behavioral problems and their specific pharmacological and nonpharmacological management.16,26-30 The comprehensive task of evaluating and managing nonpharmacological and particularly pharmacological behavioral interventions is a signature role for the psychiatrist.
The psychiatrist is also responsible for coordinating medication regimens for patients. In doing so, the psychiatrist manages polypharmacy, which can reduce costs, alleviate drug interactions, and reduce or avoid adverse effects that may, in fact, be causing the behavioral events being targeted by treatment teams. In addition, the psychiatrist must be prepared to help all prescribing providers comply with federal law by reducing effective dosing in a timely manner, in accordance with the Unnecessary Drug Surveyor Guidelines (F-TAG 329).31,32
As its Latin origin implies, doctors are teachers. Psychiatrists are key players in training team members on collaborative protocols and providing information on behavior assessment tools, management models, and interventions.6,33 Defining target symptoms is paramount. The psychiatrist helps decipher (and aids others in deciphering) which behaviors are unsafe and bothersome to the patient and which are simply annoying to care providers. As resident experts in neuropsychology, psychiatrists educate all team members about the evolution, slow progression, effects, and nuances of dementia. Furthermore, psychiatrists educate and support family caregivers and implement evidence-based nonpharmacological strategies as first-line intervention, and when appropriate, empathetically broach end of life issues.
Physicians, regardless of specialty, hold a unique position in society. It is important that the respect and influence afforded to all physicians be used to mobilize treatment teams, encourage and model collaboration, foster comradery, strive for clinical excellence, and uphold the ethical standards of our profession.33
The team approach to dementia psychiatry services requires leadership for direction, decision making, and policy changes in order to make the process efficient and beneficial for all involved. Evidence-based practices demonstrate that a collaborative approach improves the quality of care we provide for patients with dementia who have behavioral problems.
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