Effectiveness of collaborative care for older adults with Alzheimer disease in primary care

A randomized controlled trial

Research output: Contribution to journalArticle

473 Citations (Scopus)

Abstract

Context: Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. Objective: To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease. Design, Setting, and Patients: Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were randomized by physician to receive collaborative care management (n=84) or augmented usual care (n=69) at primary care practices within 2 US university-affiliated health care systems from January 2002 through August 2004. Eligible patients (identified via screening or medical record) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver. Intervention: Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient's family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacological management. Main Outcome Measures: Neuropsychiatric Inventory (NPI) administered at baseline and at 6, 12, and 18 months. Secondary outcomes included the Cornell Scale for Depression in Dementia (CSDD), cognition, activities of daily living, resource use, and caregiver's depression severity. Results: Initiated by caregivers' reports, 89% of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocols. Intervention patients were more likely to receive cholinesterase inhibitors (79.8% vs 55.1%; P=.002) and antidepressants (45.2% vs 27.5%; P=.03). Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months (mean difference, -5.6; P=.01) and at 18 months (mean difference, -5.4; P=.01). Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months; at 18 months, caregivers showed improvement in depression as measured by the Patient Health Questionnaire-9. No group differences were found on the CSDD, cognition, activities of daily living, or on rates of hospitalization, nursing home placement, or death. Conclusions: Collaborative care for the treatment of Alzheimer disease resulted in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. Trial Registration: clinicaltrials.gov Identifier: NCT00246896.

Original languageEnglish
Pages (from-to)2148-2157
Number of pages10
JournalJournal of the American Medical Association
Volume295
Issue number18
DOIs
StatePublished - May 10 2006

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Primary Health Care
Alzheimer Disease
Randomized Controlled Trials
Caregivers
Dementia
Behavioral Symptoms
Quality of Health Care
Depression
Psychology
Activities of Daily Living
Equipment and Supplies
Cognition
Cholinesterase Inhibitors
Controlled Clinical Trials
Primary Care Physicians
Nursing Homes
Hypnotics and Sedatives
Antidepressive Agents
Antipsychotic Agents
Medical Records

ASJC Scopus subject areas

  • Medicine(all)

Cite this

@article{5dec1bd222894f3fb750f10b10b5f3c1,
title = "Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: A randomized controlled trial",
abstract = "Context: Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. Objective: To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease. Design, Setting, and Patients: Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were randomized by physician to receive collaborative care management (n=84) or augmented usual care (n=69) at primary care practices within 2 US university-affiliated health care systems from January 2002 through August 2004. Eligible patients (identified via screening or medical record) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver. Intervention: Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient's family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacological management. Main Outcome Measures: Neuropsychiatric Inventory (NPI) administered at baseline and at 6, 12, and 18 months. Secondary outcomes included the Cornell Scale for Depression in Dementia (CSDD), cognition, activities of daily living, resource use, and caregiver's depression severity. Results: Initiated by caregivers' reports, 89{\%} of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocols. Intervention patients were more likely to receive cholinesterase inhibitors (79.8{\%} vs 55.1{\%}; P=.002) and antidepressants (45.2{\%} vs 27.5{\%}; P=.03). Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months (mean difference, -5.6; P=.01) and at 18 months (mean difference, -5.4; P=.01). Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months; at 18 months, caregivers showed improvement in depression as measured by the Patient Health Questionnaire-9. No group differences were found on the CSDD, cognition, activities of daily living, or on rates of hospitalization, nursing home placement, or death. Conclusions: Collaborative care for the treatment of Alzheimer disease resulted in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. Trial Registration: clinicaltrials.gov Identifier: NCT00246896.",
author = "Christopher Callahan and Malaz Boustani and Frederick Unverzagt and Mary Austrom and Teresa Damush and Perkins, {Anthony J.} and Fultz, {Bridget A.} and Siu Hui and Steven Counsell and Hugh Hendrie",
year = "2006",
month = "5",
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doi = "10.1001/jama.295.18.2148",
language = "English",
volume = "295",
pages = "2148--2157",
journal = "JAMA - Journal of the American Medical Association",
issn = "0002-9955",
publisher = "American Medical Association",
number = "18",

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TY - JOUR

T1 - Effectiveness of collaborative care for older adults with Alzheimer disease in primary care

T2 - A randomized controlled trial

AU - Callahan, Christopher

AU - Boustani, Malaz

AU - Unverzagt, Frederick

AU - Austrom, Mary

AU - Damush, Teresa

AU - Perkins, Anthony J.

AU - Fultz, Bridget A.

AU - Hui, Siu

AU - Counsell, Steven

AU - Hendrie, Hugh

PY - 2006/5/10

Y1 - 2006/5/10

N2 - Context: Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. Objective: To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease. Design, Setting, and Patients: Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were randomized by physician to receive collaborative care management (n=84) or augmented usual care (n=69) at primary care practices within 2 US university-affiliated health care systems from January 2002 through August 2004. Eligible patients (identified via screening or medical record) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver. Intervention: Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient's family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacological management. Main Outcome Measures: Neuropsychiatric Inventory (NPI) administered at baseline and at 6, 12, and 18 months. Secondary outcomes included the Cornell Scale for Depression in Dementia (CSDD), cognition, activities of daily living, resource use, and caregiver's depression severity. Results: Initiated by caregivers' reports, 89% of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocols. Intervention patients were more likely to receive cholinesterase inhibitors (79.8% vs 55.1%; P=.002) and antidepressants (45.2% vs 27.5%; P=.03). Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months (mean difference, -5.6; P=.01) and at 18 months (mean difference, -5.4; P=.01). Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months; at 18 months, caregivers showed improvement in depression as measured by the Patient Health Questionnaire-9. No group differences were found on the CSDD, cognition, activities of daily living, or on rates of hospitalization, nursing home placement, or death. Conclusions: Collaborative care for the treatment of Alzheimer disease resulted in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. Trial Registration: clinicaltrials.gov Identifier: NCT00246896.

AB - Context: Most older adults with dementia will be cared for by primary care physicians, but the primary care practice environment presents important challenges to providing quality care. Objective: To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease. Design, Setting, and Patients: Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were randomized by physician to receive collaborative care management (n=84) or augmented usual care (n=69) at primary care practices within 2 US university-affiliated health care systems from January 2002 through August 2004. Eligible patients (identified via screening or medical record) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver. Intervention: Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient's family caregiver and integrated within primary care. The team used standard protocols to initiate treatment and identify, monitor, and treat behavioral and psychological symptoms of dementia, stressing nonpharmacological management. Main Outcome Measures: Neuropsychiatric Inventory (NPI) administered at baseline and at 6, 12, and 18 months. Secondary outcomes included the Cornell Scale for Depression in Dementia (CSDD), cognition, activities of daily living, resource use, and caregiver's depression severity. Results: Initiated by caregivers' reports, 89% of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocols. Intervention patients were more likely to receive cholinesterase inhibitors (79.8% vs 55.1%; P=.002) and antidepressants (45.2% vs 27.5%; P=.03). Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months (mean difference, -5.6; P=.01) and at 18 months (mean difference, -5.4; P=.01). Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months; at 18 months, caregivers showed improvement in depression as measured by the Patient Health Questionnaire-9. No group differences were found on the CSDD, cognition, activities of daily living, or on rates of hospitalization, nursing home placement, or death. Conclusions: Collaborative care for the treatment of Alzheimer disease resulted in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers. These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics. Trial Registration: clinicaltrials.gov Identifier: NCT00246896.

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