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Editorial
Annals of Internal Medicine
Envisioning Better Approaches for Dementia Care
The vast majority of patients with dementia receive their
More work will need to be done before we can know care in primary care settings. Clinicians find it chal- for certain how well these interventions will work in other lenging to provide optimal care for these patients and their settings and how durable their effects will be. For example, often-stressed and over burdened caregivers because cur- the REACH trial intervention seemed to perform slightly rent reimbursement mechanisms do not support the kinds differently in various ethnic groups. Also, longer and larger of practical, time-intensive, team-based processes of care trials are needed to determine whether these interventions that have been associated with improved outcomes in these delay nursing home placement. Despite these uncertainties, settings (1, 2). In this issue, 2 care interventions are de- we shouldn’t let the perfect be the enemy of the good. If scribed demonstrating that the well-being of patients with these interventions were drugs, it is hard to believe that dementia and their caregivers can be improved substan- they would not be on the fast track to approval. The mag- tially (3, 4). However, clinicians may feel frustrated reading nitude of benefit and quality of evidence supporting these about these interventions because few will be able to im- interventions considerably exceed those of currently ap- proved pharmacologic therapies for dementia (5, 6).
Vickrey and colleagues (3) present the results of a Both studies illustrate several principles that should novel disease management program for the primary care of guide how care is delivered to patients with dementia.
dementia. Patients with dementia and their caregivers who First, caregivers need to be a dominant focus of any effec- were seen in randomly selected primary care clinics were tive dementia management strategy. Most patients with assigned a case manager who worked with and trained the dementia who could live in nursing homes stay at home caregiver, assessed and prioritized patient and caregiver because of the efforts of caregivers. The resultant savings to needs, and recommended interventions to health care and stressed Medicaid budgets are massive (7). However, being community service providers. The role of the case manager a caregiver for a loved one can present enormous physical, in integrating care needs within primary care practices and psychological, and emotional difficulties (8, 9). Caregivers across community service agencies was a novel feature of often feel that they are invisible to the health system (10).
the program. Quality of care, as measured by adherence to The REACH study offered a level of caregiver support that guidelines, was dramatically higher in patients who re- few clinicians will be equipped to offer to their patients.
ceived the intervention (64% vs. 33%). Patient quality of But the intensity of support is appropriate to the difficulty life improved, and caregivers reported improved social sup- and importance of the caregiver role.
port, mastery of caregiving, and confidence. This interven- A second principle is that much of the care that pa- tion bears many similarities to an approach described by tients with dementia and their caregivers need cannot be Callahan and colleagues (2) that also dramatically im- delivered in the office setting. The usual fee-for-service ap- proved the processes and outcomes of dementia care.
Also in this issue, Belle and colleagues (4) tested a proach works poorly for dementia care. As shown by Vick- multicomponent intervention to improve quality of life in rey and colleagues (3), these patients need medical care that a multiethnic group of distressed caregivers. This interven- is coordinated among multiple team members and inte- tion focused on 5 domains that are important to caregivers: grated with social and community-based resources. The reducing depression, decreasing burden, improving self- practice workload of managing such an interdisciplinary care, enhancing social support, and managing problem be- team (even if such a team were available) and assisting the haviors. The core intervention was providing the caregivers caregiver has little relationship to the office visit.
with access to a trained interventionist who assessed the Recently, Larson (11) recommended an approach to caregivers’ needs and functioned as a coach. Innovative primary care in which the internist leads a multidisci- features of the intervention included tailoring its compo- plinary team. In this model, the internist is paid for man- nents to the unique needs and concerns of each caregiver aging the care of patients rather than on a per office visit and emphasizing self-empowerment. The protocol was in- basis. Such a model would be far superior to the fee per tensive, including 9 home visits, lasting 90 minutes each office visit– based approach, which invariably leads to frag- and 3 telephone calls. Caregivers seemed to like the inter- mented care that cannot possibly address the needs of the vention: 60% completed all 12 visits, and more than 90% patient and caregiver. A major focus of geriatrics fellowship reported that the intervention made their life easier and training is teaching clinicians to provide this type of care improved their ability to provide care. There were mean- and to manage interdisciplinary teams. However, in typical ingful impacts on a global outcome measure that encom- practice settings, current methods of reimbursement make passed the 5 intervention domains. Rates of caregiver de- it difficult for geriatricians to deliver the model of care they pression were halved. There was an encouraging trend were trained to provide. Those who try are often under- toward lower rates of nursing home placement, although mined by managers whose singular focus on office visit the sample size was not large enough to be definitive.
productivity causes them to question why clinicians fo- 780 21 November 2006 Annals of Internal Medicine Volume 145 • Number 10
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Better Approaches for Dementia Care Editorial cused on care of the frail elderly should be less productive Requests for Single Reprints: Kenneth E. Covinsky, MD, MPH,
in terms of care visit volume than other providers.
Division of Geriatrics, University of California, San Francisco, San Fran- Although dramatic changes in delivery of primary care cisco Veterans Affairs Medical Center, 4150 Clement (181G), San Fran-cisco, CA 94121; e-mail, ken.covinsky@ucsf.edu.
are a long way off, there are changes that could be imple-mented now that will improve the well-being of patients Current author addresses are available at www.annals.org.
with dementia and their caregivers. First, Medicare andother providers should be required to reimburse an exten- Ann Intern Med. 2006;145:780-781.
sive array of caregiver support services. Caregivers routinelyrisk their financial, emotional, and physical well-being toprovide care to their relatives or members of their commu- References
nity with dementia. It is time for the public to recognize 1. Mittelman MS, Ferris SH, Shulman E, Steinberg G, Ambinder A, Mackell
their part of this social contract (12). The type of services JA, et al. A comprehensive support program: effect on depression in spouse-
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2. Callahan CM, Boustani MA, Unverzagt FW, Austrom MG, Damush TM,
available if insurers are willing to pay for them. Second, it Perkins AJ, et al. Effectiveness of collaborative care for older adults with Alzhei-
is time for Medicare to pay for team-based case manage- mer disease in primary care: a randomized controlled trial. JAMA. 2006;295: ment services for elderly persons with dementia, because 2148-57. [PMID: 16684985]
3. Vickrey BG, Mittman BS, Connor KI, Pearson ML, Della Penna RD,
this approach clearly improves the quality of care. In addi- Ganiats TG, et al. The effect of a disease management intervention on quality
tion, promotion of adequately reimbursed, integrated pro- and outcomes of dementia care: a randomized, controlled trial. Ann Intern Med.
grams based on the successes of models, such as Veterans Affairs Medical Center and PACE (Program of All-Inclu- 4. Belle SH, Burgio L, Burns R, Coon D, Czaja SJ, Gallagher-Thompson D, et
al. Enhancing the quality of life of dementia caregivers from different ethnic or
sive Care for the Elderly), could serve to catalyze imple- racial groups. A randomized, controlled trial. Ann Intern Med. 2006:145:727- mentation of more evidence-based approaches to the care of elderly patients with dementia and those with other 5. Schneider LS, Tariot PN, Dagerman KS, Davis SM, Hsiao JK, Ismail MS,
frailty syndromes (13). The need for these changes is com- et al. Effectiveness of atypical antipsychotic drugs in patients with Alzheimer’s
disease. N Engl J Med 2006;355:1525-38. [PMID: 17035647]
pelling, but they need advocates and champions. Patients 6. Courtney C, Farrell D, Gray R, Hills R, Lynch L, Sellwood E. Long-term
with dementia will probably not be forming a lobby any- donepezil treatment in 565 patients with Alzheimer’s disease (AD2000): random- time soon, and their caregivers are too busy. It is time for ised double-blind trial. Lancet. 2004;363:2105-15. [PMID: 15220031] the medical profession to advocate on their behalf.
7. Yaffe K, Fox P, Newcomer R, Sands L, Lindquist K, Dane K, et al. Patient
and caregiver characteristics and nursing home placement in patients with de-
mentia. JAMA. 2002;287:2090-7. [PMID: 11966383]
8. Covinsky KE, Newcomer R, Fox P, Wood J, Sands L, Dane K, et al. Patient
and caregiver characteristics associated with depression in caregivers of patients University of California, San Francisco, and San Francisco Veterans with dementia. J Gen Intern Med. 2003;18:1006-14. [PMID: 14687259]
9. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the Caregiver
Health Effects Study. JAMA. 1999;282:2215-9. [PMID: 10605972] 10. Levine C. The loneliness of the long-term care giver. N Engl J Med. 1999;
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Disclaimer: The opinions expressed are those of the authors and not
11. Larson EB. Health care system chaos should spur innovation: summary of a
necessarily those of the funders or the Department of Veterans Affairs.
report of the Society of General Internal Medicine Task Force on the Domainof General Internal Medicine. Ann Intern Med. 2004;140:639-43. [PMID:15096335] Grant Support: By the National Institute on Aging Grant R0AG023626
12. Arno PS, Levine C, Memmott MM. The economic value of informal care-
and the Donald W. Reynolds Foundation.
giving. Health Aff (Millwood). 1999;18:182-8. [PMID: 10091447]
13. Eng C, Pedulla J, Eleazer GP, McCann R, Fox N. Program of All-inclusive
Potential Financial Conflicts of Interest: Grants received: K.E. Covin-
Care for the Elderly (PACE): an innovative model of integrated geriatric care and financing. J Am Geriatr Soc. 1997;45:223-32. [PMID: 9033525] www.annals.org
21 November 2006 Annals of Internal Medicine Volume 145 • Number 10 781
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Annals of Internal Medicine
Current Author Addresses: Drs. Covinsky and Johnston: Division of
Geriatrics, University of California, San Francisco, San Francisco Veter-
ans Affairs Medical Center, 4150 Clement (181G), San Francisco, CA
94121.
W-222 21 November 2006 Annals of Internal Medicine Volume 145 • Number 10
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