Care 5-1-2014 Results and Lessons Learned from a Nurse Practitioner-Guided Dementia Care Intervention for Primary Care Patients and Their Family Caregivers

Older adults with dementia care needs often visit primary care physicians (PCPs), but PCP dementia care limitations are widely documented. This study tested the value of employing a nurse practitioner (NP) with geropsychiatric expertise to augment PCP care for newly and recently diagnosed patients and family caregivers. Twenty-one dyads received the NP intervention; 10 dyads were controls. Outcomes included patient neuropsychiatric symptom and quality of life changes, and caregiver depression, burden, and self-efficacy changes. Intervention acceptability by patients, caregivers, and PCPs was determined. No outcome differences were found; however, the NP intervention was deemed highly satisfactory by all stakeholders. Patients experienced no Address correspondence to Richard H. Fortinsky, PhD, Professor and Health Net, Inc. Chair in Geriatrics and Gerontology, UConn Center on Aging, University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT 06030-5215; fortinsky@uchc.edu. The authors have disclosed no potential conflicts of interest, financial or otherwise. NIH Public Access Author Manuscript Res Gerontol Nurs. Author manuscript; available in PMC 2014 June 01. Published in final edited form as: Res Gerontol Nurs. 2014 May 1; 7(3): 126–137. doi:10.3928/19404921-20140113-01. N IH -P A A uhor M anscript N IH -P A A uhor M anscript N IH -P A A uhor M anscript significant cognitive decline during their 12-month study period, helping explain why outcomes did not change. Given widespread acceptability, future tests of this PCP-enhancing intervention should include patients with more progressive cognitive decline at study entry. NPs with geropsychiatric expertise are ideal interventionists for this rapidly growing target population. Dementia, an age-associated clinical syndrome characterized by irreversible loss or decline in memory and other cognitive abilities, is a growing health problem due primarily to the steady aging of the population. In 2013, an estimated 5.2 million Americans were diagnosed with Alzheimer’s disease (AD), the most common cause of dementia. This figure is projected to reach 7.1 million Americans 65 and older with AD by 2025, and 13.8 million by 2050 (Alzheimer’s Association, 2013). AD accounts for an estimated 60% to 80% of all dementia; therefore, projected figures for the number of Americans with all types of dementia combined are even higher (Alzheimer’s Association, 2013). Pharmacotherapy is only modestly effective in addressing cognitive and behavioral symptoms of dementia; therefore, active management of dementia involves careful monitoring of symptoms, treatment of comorbidities, medication monitoring, nonpharmacological management strategies, and linkage to community support services (Brodaty & Arasaratnam, 2012; Gitlin, 2012). Moreover, it has long been known that family members caring for individuals with dementia often experience adverse health consequences due to stresses associated with dementia symptoms and uncertainties about how to find information and help to support their care responsibilities (Schulz & Beach, 1999; Schulz, O’Brien, Bookwala, & Fleissner, 1995). Therefore, family members must be included in active management of patients with dementia to maximize health-related outcomes for patients and their family caregivers. Many studies have demonstrated gaps in care provided by primary care physicians (PCPs) to older adults with dementia in the United States and elsewhere (Callahan, Hendrie, & Tierney, 1995; Fortinsky, 1998; Fortinsky, Leighton, & Wasson, 1995; Koch & Iliffe, 2010). Considering the current U.S. health policy climate focused on improving health care quality while reducing costs to Medicare and other health insurers, primary care enhancements that could effectively address PCP gaps in care for patients with dementia hold great potential for significant cost savings and improved health-related outcomes. A limited number of published trials of nonpharmacological interventions to enhance primary care for people with dementia and/or their family caregivers by augmenting the care provided by PCPs have yielded positive results (Bass, Clark, Looman, McCarthy, & Eckert, 2003; Callahan et al., 2006; Fortinsky, Kulldorff, Kleppinger, & Kenyon-Pesce, 2009; Maslow, 2012; Vickrey et al., 2006). However, none have been successfully sustained beyond the study period or replicated in community-based primary care settings. Tested interventions either required unsustainable linkages between PCPs and community organizations, involved multidisciplinary teams whose services are not presently reimbursable by Medicare or other health insurers, or occurred solely at academic health centers where only a fraction of all patients seek primary care. Therefore, models based on evidence-based care protocols still need to be tested in community-based settings where most primary care is delivered in the United States. Fortinsky et al. Page 2 Res Gerontol Nurs. Author manuscript; available in PMC 2014 June 01. N IH -P A A uhor M anscript N IH -P A A uhor M anscript N IH -P A A uhor M anscript Nurse practitioners (NPs) working collaboratively with PCPs successfully implemented dementia care protocols in two published trials based at academic health centers (Callahan et al., 2006; Vickrey et al., 2006). Although the scope of practice of NPs varies across the United States, all NPs can diagnose, treat, and prescribe medications with physician involvement (Iglehart, 2013). NP services provided in primary care settings, or in home settings when approved by PCPs, are reimbursable by Medicare and many private health insurance plans. Using NPs as primary care–based dementia care specialists is a timely innovation given the growing recognition of roles NPs can play to address primary care workforce shortages (Cassidy, 2012; Donelan, DesRoches, Dittus, & Buerhaus, 2013; Iglehart, 2013) and the growing movement within the nursing profession to teach geropsychiatry core competencies to new and established nurses and NPs due to the growing older population living with dementia and other mental health–related challenges (Buckwalter, 2005; Evans, Beck, & Buckwalter, 2012). Employing NPs as dementia care experts in primary care settings is also consistent with many goals and strategies included in the 2013 update to the National Alzheimer’s Project Act of 2011 (U.S. Department of Health and Human Services [USDHHS], 2013) and with collaborative care and comanagement principles that have been successfully tested to treat depression and other geriatric conditions in the primary care setting (Reuben et al., 2013; Unützer, et al, 2002). Accordingly, the current study implemented and evaluated an evidence-based NP-guided dementia care intervention, where the NP received referrals from and worked collaboratively with three community-based PCP group practice sites. Important differences between this intervention and collaborative care models tested elsewhere are the home-based location of NP-guided dementia care and the equal focus on the patient and family caregiver. Targeted groups were individuals with newly or recently diagnosed AD or other dementia (patients) and their family caregivers. This 12-month dementia care intervention, featuring monthly in-home visits by the NP, used medication management and nonpharmacological treatment protocols developed in a published randomized controlled trial that was tested at an academic health center (Callahan et al., 2006). The intervention tested in this study was called Proactive Primary Dementia Care (PPDC). The following two objectives, as well as major hypotheses for Objective 1, formed the scope of this study: • Objective 1: Determine the preliminary efficacy of PPDC on health-related outcomes in patients and their family caregivers. Patient-specific hypotheses: Patients receiving PPDC will show reduced or more stabilized neuropsychiatric symptoms, as well as improved or more stabilized selfreported quality of life, as compared to control group patients. Family caregiver-specific hypotheses: Caregivers receiving PPDC will show reduced or more stabilized depressive symptoms and burden, as well as increased or more stabilized self-efficacy for managing dementia, as compared to control group caregivers. • Objective 2: Determine the acceptability of PPDC based on satisfaction expressed by physicians, patients, and caregivers. Fortinsky et al. Page 3 Res Gerontol Nurs. Author manuscript; available in PMC 2014 June 01. N IH -P A A uhor M anscript N IH -P A A uhor M anscript N IH -P A A uhor M anscript