Integrated care program for patients with dementia and behavioural disorders in the home setting.
Authors: Schapira Marcelo , Antolini Yamila , Salvia Mariela González , Perman Gastón , Perazzoli María Verónica , Quintar Eugenia , Restibo Jimena , Abellán Valeria , Patiño Hernán , Trasante Soledad , Outumuro María Belén , Guenzelovich Tami , Saimovici Javier , Terrasa Sergio , Hornstein Lucila , Garfi Leonardo 
Published: January 2024

Introduction: Behavioural symptoms involve suffering and functional worsening of people with dementia, overburden their caregivers and increase emergency department visits, hospitalizations and early institutionalizations.

Objectives And Who It Is For: To evaluate the results of an interdisciplinary intervention to improve the control of behavioural symptoms in elderly people with dementia receiving chronic care at home.

Who We Involved And Engaged With: Representatives of general practitioners, home care specialists, geriatricians, psychiatrists, healthcare managers, and patients and families voice through claims and suggestions. The first pilot was adapted considering patients’ needs and acceptance.

Materials And Methods (What We Did): before-after quasi-experimental study with own individual as control. Inclusion criteria: admission to the Home Medicine section between 06/01/2021 and 09/30/2022, age older than 64 years; and major cognitive impairment with behavioural disorders of complex management for the attending physician; or need for adequacy of psychotropic drugs during the transition of care for having suffered an acute confusional syndrome during hospitalisation. Exclusion criteria: history of psychosis or life expectancy of less than six months.

Intervention: Provision of care by a health care team coordinated by a geriatrician via telemedicine, the home follow-up physician and a health and social care counsellor (comprehensive gerontological assessment). The geriatrician agreed on tailored interventions together with the patient's relatives or caregivers.

The main outcome variable was changes in the score of the behavioural disorders subscale of the NPIq questionnaire administered by the geriatrician. The consumption of psychotropic drugs, standardised by defined daily doses (DDD) according to WHO, was also analysed.

Results: 81 persons were included (72% women), mean age 89.5 years. Seventy percent lived in a private home and the remainder in care homes. At baseline, they had the following mean (SD) symptom intensity scores of: delirium 1.1 (2.7), hallucinations 1.3 (2.6), agitation-aggression 2.6 (4.3), depression 0.9 (2.9), anxiety 1.1 (3.0), euphoria-denial 0.1 (1.0), apathy 0.6 (2.3), disinhibition 0.3 (1.7), irritability 1.0 (2.7), motor disturbances 0.9 (2.7), nocturnal behaviours 2.2 (3.8), appetite-ingestion 0.3 (1.6), total intensity 12.5 (13.7). At baseline, 42.0% were taking benzodiazepines, mean DDD 19.9/100 patients. 

After the intervention there was an average decrease of -7.6 points in the total NPIq scale (95%CI -10.0 to -5.1; p<0.001) and 50% of those taking benzodiazepines had discontinuation or dose decrease. without significant changes in other psychotropic drugs (only an increase in donepezil and memantine).

Learnings: The integrated management program of elderly with dementia and behavioural disorders improved behavioural symptoms with decreased doses of BZD after the intervention.

Next Steps: For scientific purposes, to perform a randomised controlled clinical trial. For local managerial purposes, to scale up the initiative to all eligible persons.