Time for Teamwork

December 16, 2010

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.

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

• Bureaucracy

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.



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.