Dementia Screening in Primary Care
In 2006, the results of a randomized controlled trial that tested the efficacy of a collaborative care model that delivered best practice dementia care were reported. Over 12 months, intervention participants received care management from an interdisciplinary team led by a nurse practitioner serving as a care coordinator who worked with individuals' family caregivers and integrated within primary care. The team used standard protocols to identify, monitor, and treat behavioral and psychological symptoms of dementia (BPSDs). At 12 and 18 months, intervention participants had fewer BPSDs, and intervention caregivers reported improvements in distress and depression, but there are no data to demonstrate that providing the collaborative dementia care model to screening-detected individuals with dementia leads to better outcomes than providing this model to individuals with recognized dementia in primary care.
In 2009, with support from the National Institutes of Health (NIH), an interdisciplinary implementation team from Indiana University Center for Aging Research and the urban safety net healthcare system in Indianapolis implemented the collaborative dementia care model. The team used the lens of complex adaptive system theory and the tools of the reflective adaptive process to translate the collaborative models into a locally sensitive program, called the Aging Brain Care (ABC) Program. The ABC Program includes a clinical team that has an advanced practice nurse as the care coordinator, a medical assistant as a care coordinator assistant, and a social worker. A medical director supervises these providers, and care coordination support software is used. Serving individuals with recognized dementia, the ABC Program improved access for participants and informal caregivers, improved participant satisfaction with care, enhanced quality of dementia care, and reduced use of acute care.
Although the efficacy of the collaborative dementia care model has been demonstrated, and it was possible to implement it within the safety net healthcare system, the generalizability and sustainability of this model in other healthcare systems has not been tested, and the benefit of this model in screening-detected individuals with dementia has not been demonstrated. Thus, the value, including harms and benefits, of screening populations of asymptomatic older adults for dementia in an attempt to identify the disease at its earliest manifestations remains controversial.
To fill this gap in the literature, funding was received from the NIH to conduct a randomized controlled dementia screening trial to obtain new knowledge to judge the benefits and potential harms of early exposure to the collaborative dementia care model through screening. The trial will randomize 4,000 adults aged 65 and older into a no screening group or a dementia screening, diagnosis, and management group. To fully explore the potential benefits and harms of dementia screening, the trial will provide subjects randomized into the screening arm with the resources of the ABC Program, which will conduct a diagnostic assessment of individuals with positive screening results, deliver the collaborative care model for those with a confirmed dementia diagnosis, and counsel and follow-up those with positive screening results but without evidence of dementia. The primary aims of the trial are to test the effect of dementia screening on the health-related quality of life, mood, and anxiety of the individual at 1, 6, and 12 months. The trial will also estimate the cost effectiveness of dementia screening (Figure 1).
(Enlarge Image)
Figure 1.
The design of randomized dementia screening trial in primary care.
Is There Evidence Supporting the Benefit of Early Implementation of Best-practice Dementia Care in Screening-detected Cases of Dementia?
In 2006, the results of a randomized controlled trial that tested the efficacy of a collaborative care model that delivered best practice dementia care were reported. Over 12 months, intervention participants received care management from an interdisciplinary team led by a nurse practitioner serving as a care coordinator who worked with individuals' family caregivers and integrated within primary care. The team used standard protocols to identify, monitor, and treat behavioral and psychological symptoms of dementia (BPSDs). At 12 and 18 months, intervention participants had fewer BPSDs, and intervention caregivers reported improvements in distress and depression, but there are no data to demonstrate that providing the collaborative dementia care model to screening-detected individuals with dementia leads to better outcomes than providing this model to individuals with recognized dementia in primary care.
In 2009, with support from the National Institutes of Health (NIH), an interdisciplinary implementation team from Indiana University Center for Aging Research and the urban safety net healthcare system in Indianapolis implemented the collaborative dementia care model. The team used the lens of complex adaptive system theory and the tools of the reflective adaptive process to translate the collaborative models into a locally sensitive program, called the Aging Brain Care (ABC) Program. The ABC Program includes a clinical team that has an advanced practice nurse as the care coordinator, a medical assistant as a care coordinator assistant, and a social worker. A medical director supervises these providers, and care coordination support software is used. Serving individuals with recognized dementia, the ABC Program improved access for participants and informal caregivers, improved participant satisfaction with care, enhanced quality of dementia care, and reduced use of acute care.
Although the efficacy of the collaborative dementia care model has been demonstrated, and it was possible to implement it within the safety net healthcare system, the generalizability and sustainability of this model in other healthcare systems has not been tested, and the benefit of this model in screening-detected individuals with dementia has not been demonstrated. Thus, the value, including harms and benefits, of screening populations of asymptomatic older adults for dementia in an attempt to identify the disease at its earliest manifestations remains controversial.
To fill this gap in the literature, funding was received from the NIH to conduct a randomized controlled dementia screening trial to obtain new knowledge to judge the benefits and potential harms of early exposure to the collaborative dementia care model through screening. The trial will randomize 4,000 adults aged 65 and older into a no screening group or a dementia screening, diagnosis, and management group. To fully explore the potential benefits and harms of dementia screening, the trial will provide subjects randomized into the screening arm with the resources of the ABC Program, which will conduct a diagnostic assessment of individuals with positive screening results, deliver the collaborative care model for those with a confirmed dementia diagnosis, and counsel and follow-up those with positive screening results but without evidence of dementia. The primary aims of the trial are to test the effect of dementia screening on the health-related quality of life, mood, and anxiety of the individual at 1, 6, and 12 months. The trial will also estimate the cost effectiveness of dementia screening (Figure 1).
(Enlarge Image)
Figure 1.
The design of randomized dementia screening trial in primary care.
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