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.
1. Alzheimer’s Association. 2010 Alzheimer’s Disease Facts and Figures. http://www.alz.org/documents_custom/report_alzfactsfigures2010.pdf. Accessed October 18, 2010.
2. Hebert LE, Scherr PA, Bienias JL, et al. Alzheimer disease in the US population: prevalence estimates using the 2000 census. Arch Neurol. 2003;60:1119-1122.
3. Hebert LE, Beckett LA, Scherr PA,Evans DA. Annual incidence of Alzheimer disease in the United States projected to the years 2000 through 2050. Alzheimer Dis Assoc Disord. 2001;15:169-173.
4. Haupt M, Kurz A, Jänner M. A 2-year follow-up of behavioural and psychological symptoms in Alzheimer’s disease. Dement Geriatr Cogn Disord. 2000;11:147-152.
5. Murman DL, Chen Q, Powell MC, et al. The incremental direct costs associated with behavioral symptoms in AD. Neurology. 2002;59:1721-1729.
6. Collet J, de Vugt ME, Verhey FR, Schols JM. Efficacy of integrated interventions combining psychiatric care and nursing home care for nursing home residents: a review of the literature. Int J Geriatr Psychiatry. 2010;25:3-13.
7. Eriksen W, Tambs K, Knardahl S. Work factors and psychological distress in nurses’ aides: a prospective cohort study. BMC Public Health. 2006;6:290.
8. Evers W, Tomic W, Brouwers A. Aggressive behaviour and burnout among staff of homes for the elderly. Int J Ment Health Nurs. 2002;11:2-9.
9. Hofmarcher MM, Oxley H, Rusticelli E. Improved Health System Performance Through Better Care Coordination. http://www.oecd.org/dataoecd/22/9/39791610.pdf. Accessed October 18, 2010.
10. Oxley H. OECD Health Working Papers No. 42: Policies for Healthy Ageing: An Overview. 2009. http://www.oecd.org/officialdocuments/displaydocumentpdf?cote=DELSA/HEA/WD/HWP(2009)1&doclanguage=en. Accessed October 18, 2010.
11. Bergman H. Meeting the Challenge of Alzheimer’s Disease and Related Disorders. http://www.alzheimermontreal.ca/uploads/events_more_info_0.76641600_1263322137_0.pdf. Accessed October 18, 2010.
12. Callahan CM, Boustani MA, Unverzagt FW, et al. Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial. JAMA. 2006;295:2148-2157.
13. Dettmore D, Kolanowski A, Boustani M. Aggression in persons with dementia: use of nursing theory to guide clinical practice. Geriatr Nurs. 2009;30:8-17.
14. Lindsey PL, Buckwalter KC. Psychotic events in Alzheimer’s disease: application of the PLST model. J Gerontol Nurs. 2009;35:20-27.
15. Smith M, Hall GR, Gerdner L, Buckwalter KC. Application of the Progressively Lowered Stress Threshold Model across the continuum of care. Nurs Clin North Am. 2006;41:57-81.
16. American Psychiatric Association. Practice Guideline and Resources for Treatment of Patients With Alzheimer’s Disease and Other Dementias, Second Edition. 2007. http://www.psychiatryonline.com/pracGuide/pracGuideTopic_3.aspx. Accessed October 18, 2010.
17. Ham C, Glasby J, Parker H, Smith J. Altogether now? Policy options for integrating care. http://www.hsmc.bham.ac.uk/news/pdfs/Altogether_Now_Report.pdf. Accessed October 18, 2010.
18. Kim MJ, Chung HC, Ahn YH. Multidisciplinary practice experience of nursing faculty and their collaborators for primary health care in Korea. Asian Nurs Res. 2008;2:25-31.
19. Zwarenstein M, Goldman J, Reeves S. Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009;(3):CD000072.
20. Kohn R, Surti GM. Management of behavioral problems in dementia. Med Health R I. 2008;91:335-338.
21. Demakis JG, Beauchamp C, Cull WL, et al. Improving residents’ compliance with standards of ambulatory care: results from the VA Cooperative Study on Computerized Reminders. JAMA. 2000;284:1411-1416.
22. Casalino L, Gillies RR, Shortell SM, et al. External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA. 2003;289:434-441.
23. Curley C, McEachern JE, Speroff T. A firm trial of interdisciplinary rounds on the inpatient medical wards: an intervention designed using continuous quality improvement. Med Care. 1998;36(8 suppl):AS4-AS12.
24. Cheater FM, Hearnshaw H, Baker R, Keane M. Can a facilitated programme promote effective multidisciplinary audit in secondary care teams? An exploratory trial. Int J Nurs Stud. 2005;42:779-791.
25. Schmidt I, Claesson CB, Westerholm B, et al. The impact of regular multidisciplinary team interventions on psychotropic prescribing in Swedish nursing homes. J Am Geriatr Soc. 1998;46:77-82.
26. Sink KM, Holden KF, Yaffe K. Pharmacological treatment of neuropsychiatric symptoms of dementia: a review of the evidence. JAMA. 2005;293:596-608.
27. Allen MH, Currier GW, Carpenter D, et al; Expert Consensus Panel for Behavioral Emergencies 2005. The expert consensus guideline series. Treatment of behavioral emergencies 2005. J Psychiatr Pract. 2005;11(suppl 1):5-108.
28. Reisberg B, Borenstein J, Salob SP, et al. Behavioral symptoms in Alzheimer’s disease: phenomenology and treatment. J Clin Psychiatry. 1987;48(suppl):9-15.
29. Opie J, Rosewarne R, O’Connor DW. The efficacy of psychosocial approaches to behaviour disorders in dementia: a systematic literature review. Aust N Z J Psychiatry. 1999;33:789-799.
30. Schneider LS, Tariot PN, Dagerman KS, et al; CATIE-AD Study Group. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s disease. N Engl J Med. 2006;355:1525-1538.
31. Saffel D, Levenson S. Taking the pain out of compliance with F-Tag 329: meeting the chal-lenges through collaboration, Part 1. http://www.annalsoflongtermcare.com/content/taking-pain-out-compliance-with-f-tag-329-meeting-challenges-through-collaboration-part-i. Accessed October 18, 2010.
32. Saffel D, Levenson S. Taking the pain out of compliance with F-Tag 329: meeting the chal-lenges through collaboration, Part 2. http://www.annalsoflongtermcare.com/content/taking-pain-out-compliance-with-f-tag-329-meeting-challenges-through-collaboration-part-ii. Accessed October 18, 2010.
33. American Psychiatric Association. Guidelines for psychiatrists in consultative, supervisory or collaborative relationships with nonphysician clinicians. June 2009. http://www.psych.org/Departments/EDU/Library/APAOfficialDocumentsandRelated/ResourceDocuments/200902.aspx. Accessed October 18, 2010.