August 02, 2017
By Marilynn Larkin
NEW YORK (Reuters Health) – Dementia care management (DCM) by specially trained nurses as part of a multidisciplinary team could reduce symptoms of dementia while decreasing caregiver burden, researchers in Germany say.
“Neuropsychiatric symptoms and caregiver burden are among the most important reasons for people with dementia being institutionalized,” Dr. Jochen Rene Thyrian of the German Center for Neurodegenerative Diseases in Greifswald, Germany told Reuters Health.
“Preventing (institutionalization) is desirable from the person with dementia’s point of view,” he said by email, “as well as the point of view of health economics.”
Dr. Thyrian and colleagues compared DCM with usual care in 634 patients (mean age 80, about 60% female). Participants were recruited by their general practitioners (GPs) and then randomized 1:1 without stratification or matching.
DCM is “a complex intervention . . . using a computer-assisted assessment determining a personalized array of intervention modules and subsequent success monitoring,” according to the authors. It involves the generation of a personalized task list by a nurse trained in dementia care, subsequent discussion with a multidisciplinary team, and general practitioner (GP) communication to enable an individualized treatment plan.
During the first six months of the program, the nurse conducts six home visits lasting about an hour, carrying out specific tasks in cooperation with the caregiver, GP and allied health professionals. During the subsequent six months, the nurse monitors task completion.
As reported online July 26 in JAMA Psychiatry, 407 patients, about half of whom lived alone, received DCM and were available for outcome measurements. These were compared with patients who had usual care.
DCM significantly reduced neuropsychiatric symptoms by eight points (a four-point reduction is considered clinically meaningful), with a larger effect size than in previous studies, according to the authors. DCM reduced caregiver burden with a medium effect size, but larger than in other studies (-0.18 vs. -0.07) and also clinically meaningful.
Patients receiving DCM were more likely to receive anti-dementia drugs after one year than were those receiving usual care (39.2% vs. 26.7%; odds ratio, 1.97).
DCM significantly increased quality of life for patients not living alone, from 0.08 to 0.17, but did not increase quality of life overall.
No significant effect on use of potentially inappropriate medication was found.
Driving factors for the improvement seen in dementia symptoms and caregiver burden, Dr. Thyrian said, include “qualification of nurses, provision of computer supported delivery, cooperation between nurses and physicians, systematic feedback, monitoring of recommendations, including the caregiver and going into the people´s homes.”
“These ingredients are not dependent on the health care system, so we think the collaborative dementia care model can be adapted and implemented in different health care systems, even in different countries,” he noted.
“Further implementation trials in cooperation with health insurers and health providers should be conducted in the future,” he added. “We have already studied the acceptance of the model in general physicians and they (had a positive response).”
“Since we focused on the whole person, we also think our model works not only with people with dementia, but is generalizable to geriatric populations in general,” he concluded.
Dr. D. P. Devanand, Director of Geriatric Psychiatry at Columbia University Medical Center in New York City, said, “Overall, the study is promising and provides useful clinical information but requires confirmation with more rigorous, methodologically objective research.”
“Intensive management by nurses led to improvement in psychiatric symptoms, which was the most prominent effect, and reduction in caregiver burden, but there was no effect on quality of life or use of psychotropic medications,” he told Reuters Health by email. “Interestingly, the use of anti-dementia medications like cholinesterase inhibitors and memantine increased, so it appears that the nurses increased medication compliance.”
“Raters were not blind to which treatment the patient received, and the authors state that the general practitioners were also not blind to the treatment intervention,” he noted. “Further, which component or components of the intervention were effective remains unclear, and the effect sizes of the positive results were small other than the decrease in psychiatric symptoms, which was more robust.”
“Finally,” Dr. Devanand concluded, “the cost-effectiveness of utilizing large numbers of nursing personnel to achieve very small clinical changes remains an open question.”
JAMA Psychiatry 2017.
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