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.


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