Dementia Evaluation, Management, and Outreach

Limitations

A number of additional caveats must be made. First, this study had a relatively small number of participants, and there was great variability in health care utilization. This is particularly germane in this population of patients with dementia, which typically has an asymmetrically high use of health care resources. Additionally, the relatively limited follow-up period may have blunted the programs true effect(s). Further, although veterans in the nonconsented group were not officially enrolled in the program, there was likely spillover of the effects of the program on practice patterns, leading to an underestimation of the program’s impact.

Conclusion

With minimal resources, DEMO successfully brought expert evaluation (usually tertiary referral) services, and provided specialized case management in coordination with existing primary care to remote patients. Although there were a number of features rather unique to this setting (eg, infrastructural support; close working interdisciplinary and interprofessional relationships, buy-in at all levels, relative geographic density/demographic homogeneity of participants), specialized case management is increasingly being adopted throughout the VA (and elsewhere). Although the value of collaborative, interdisciplinary interventions has been shown in a variety of settings and conditions—nursing homes,⁹ chronic low back pain,¹⁰ safety among hospital inpatients¹¹—its utility for dementia care is relatively underexplored.

Yet the effectiveness of team-based care for individuals has been demonstrated in a number of settings, including Alzheimer disease.^12,13 In addition to involving a number of disciplines, collaborative care is marked by coordination. A number of recent systematic reviews have found that behavioral and multicomponent interventions directed towards the caregiver as well as case management were beneficial in improving some outcomes, although there is considerable heterogeneity in the effects.^14,15 Future work will focus on examining methods to focus/optimize interventions based on individual patient characteristics.

Given the epidemiologic trends, care for patients with dementia is expected to grow. Novel interventions, like DEMO, are a particularly promising option to meet this challenge. In fact, just such a collaborative practice-ready workforce has been identified by the World Health Organization as crucial to meeting the challenges of the health needs in the 21st century.¹⁶ With the feasibility of such an approach in this population now evident, further studies (including larger sample sizes, across greater geographic regions, as well as among more diverse populations) should be undertaken. These results, if replicated, suggest a novel approach to the particularly vexing problem of caring for patients with dementia with potentially far-reaching public health implications.

Acknowledgments
Supported with T21 funds from VA to expand noninstitutional alternatives to institutional extended care for veterans, as well as the Geriatrics Research and Clinical Center (GRECC) at the Baltimore VAMC.