Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial.
BACKGROUND
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.


METHODS
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.


METHODS
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.


METHODS
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.


BACKGROUND
clinicaltrials.gov Identifier: NCT00246896.
Callahan
Christopher M
CM
Indiana University Center for Aging Research, Regenstrief Institute Inc, Indiana University School of Medicine, Indianapolis 46202, USA. ccallaha@iupui.edu
Boustani
Malaz A
MA
Unverzagt
Frederick W
FW
Austrom
Mary G
MG
Damush
Teresa M
TM
Perkins
Anthony J
AJ
Fultz
Bridget A
BA
Hui
Siu L
SL
Counsell
Steven R
SR
Hendrie
Hugh C
HC