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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