Collaborative Care for Patients With Cognitive Disorders

Neurocognitive disorders such as Alzheimer’s disease have become an enormous challenge for affected families and our health care system. In this month’s column, Ruth Kohen, M.D., an experienced geriatric psychiatrist, shares her experiences with adapting the principles of collaborative care to improve the care of individuals living with these common and disabling conditions.—Jürgen Unützer, M.D., M.P.H.

Neurocognitive disorders, broadly dichotomized into major neurocognitive disorder (dementia) and mild neurocognitive disorder (also known as mild cognitive impairment), rise steeply with age. The boundary between mild and major neurocognitive disorders is somewhat fluid, as the distinction rests on the judgment of family members, friends, or clinicians to what extent cognitive limitations interfere with everyday life. Due to ageism bias or generosity of spirit, less is often expected of the oldest old, hence dementia is frequently underdiagnosed.

By far the most common cause of neurocognitive disorders is Alzheimer’s disease, followed by cerebrovascular disease, or a combination of the two. As about a third of people over age 85 have Alzheimer’s disease, the aging of the U.S. population means a steep increase in the number of patients with dementia.

For primary care providers, this patient group presents a unique set of challenges. The great majority of patients with neurocognitive disorders exhibit comorbid neuropsychiatric symptoms at some point in their illness. Depression, anxiety, apathy, agitation, or delusions are common. Patients acting violently upset, confused, or paranoid often overwhelm the caregiving capacity of friends and family members, prompting urgent calls to the primary care provider, emergency room visits, or hospitalizations. Depression or anxiety increase the risk of further cognitive decline; hence, their detection and treatment are essential not only to enhance quality of life, but also to preserve functional ability as much as possible.

This rising tide of dementia and comorbid neuropsychiatric symptoms is met by a dearth of specialty care. The University of Washington’s Memory and Brain Wellness Clinic employs an interdisciplinary team of neurologists, geriatric psychiatrists, and gerontologists dedicated to diagnosis and long-term care of patients with neurocognitive disorders. The clinic has a three-month waiting list—far too long for the families of agitated, irritated, confused, sad, or fearful patients with memory disorders. There are currently less than 2,000 board certified geriatric psychiatrists in the United States—and 5.4 million Americans with Alzheimer’s disease.

Attempts to increase specialty care for dementia to match the rising need may not only be futile, but also ill advised. Frail older patients tend to accumulate a diverse cast of specialty providers, which can result in poor care coordination, dangerous polypharmacy, increased cost, and burden of travel to the patient. A collaborative care dementia program based in a primary care clinic can help answer the complex biopsychosocial needs of older patients with comorbid medical, neurologic, and psychiatric problems.

Research has shown that collaborative approaches to dementia care can reduce behavioral and psychological symptoms of dementia; reduce disparities; lower caregiver distress and depression; and increase patient, caregiver, and provider satisfaction. More large-scale trials are needed to determine to what extent this approach also reduces costs incurred by paid caregivers, hospitalization, or nursing home placement.

Pending better knowledge about potential cost savings, the greatest barrier to implementing collaborative dementia care in the primary care setting is the up-front expense of hiring a skilled care coordinator. This care coordinator, usually a nurse or social worker, leads the collaborative care team. At minimum, a collaborative care team consists of a care coordinator and primary care physician, yet the scope and effectiveness of interventions is greatly enhanced through the inclusion of additional team members. Including both a nurse and social worker is desirable and will ensure that both medical and psychosocial care needs are met. Successful programs have employed consulting pharmacists to streamline medications and reduce anticholinergic load, and work with patients and their care partners to increase adherence. Partnerships between the clinic and community organizations, for example the local chapter of the Alzheimer’s Association, can facilitate access of patients and their families to additional support services.

As collaborative care team members, geriatric psychiatrists consult on diagnosis and management of neuropsychiatric symptoms for all patients on the team’s roster. They provide face-to face consultation for the most complex and challenging patients, usually less than 10 percent of the total caseload. The broader role of geriatric psychiatrists in collaborative dementia care includes educating other members of the team about evidence-based treatment approaches for neuropsychiatric symptoms and facilitating the implementation of structured behavioral interventions. The benefits of embedding geriatric psychiatrists in primary care clinics cut both ways. For geriatric psychiatrists, working in collaborative care is an opportunity to reach and help a far greater number of patients than a traditional practice would allow. In addition, the opportunity to become a better physician through the exchange of knowledge with other team members has been one of the most rewarding aspects of collaborative care for me. ■