Novel Program May Help Depression, Dementia

Fran Lowry

June 19, 2015

A novel program appears promising in helping to alleviate symptoms of depression in seniors and in reducing stress among caregivers of people with dementia, preliminary data show.

"Medicare beneficiaries with dementia or depression are cared for in primary care settings and have complex yet unmet biopsychosocial needs," Michael LaMantia, MD, MPH, from the Regenstrief Institute, Indiana University Center for Aging Research and Eskenazi Health, in Indianapolis, told Medscape Medical News.

"We have been involved in developing an aging brain care program here in Indianapolis that we think is scalable to meet the needs of this growing population of vulnerable older adults with depression and dementia," Dr LaMantia said.

"Our preliminary data show that our program is feasible, and also that it is effective," he said.

The results were published online June 15 in the Journal of the American Geriatrics Society.

Filling a Gap

"Depression and dementia, which typically impact other medical conditions, are difficult for primary care doctors to treat during their limited time with patients. And geriatricians who specialize in the care of the elderly are in very short supply. This is why we felt a need to develop our program," Dr LaMantia said.

The Aging Brain Care Medical Home (ABC MedHome) program consists of a team of care coordinator assistants, "the frontline workers" of the program. These are people with a high school diploma or a 2-year college degree who have been selected for their compatibility for working with older adults.

These assistants are trained in the care of older adults with depression or dementia or, in some cases, both conditions.The assistants attend a 2-week boot camp that includes interaction with simulated patients. They also attend lectures, participate in discussions, observe home visits, and initially work with more experienced members of the care team. In the field, they establish relationships with patients living in the community under the supervision of a nurse and a social worker.

"This is really a nested model," Dr LaMantia explained.

"Instead of having doctors on the front line, we have these other members of our team who are able, because there are more of them, to see more people. They review care plans with the nurses and the social worker, and if needed, they are able to bring higher levels of attention to the patients by figuring out if the patients need to go and see a doctor or a nurse. These care coordinator assistants can escalate the care that is provided to the patient and the family very quickly if needed," he said.

"I use the analogy here of sending these folks out into the field and giving them essentially a flare gun to bring attention to people's cases that need it," Dr LaMantia said.

The ABC MedHome program is funded by the Centers for Medicare and Medicaid Services Innovation Center.

Between October 1, 2012, and March 31, 2014, 1650 individuals with dementia, depression, or both were enrolled in the ABC MedHome Registry. Their mean age was 74.6 years (±8.3); 77.7% were women; and 46.5% were African American.

Patients had a high degree of medical comorbidity, with a mean of 3.3 ± 1.8 conditions.

Patients with a diagnosis of dementia had a mean Mini–Mental State Examination (MMSE) score of 21.2; those with diagnoses of dementia and depression had a mean MMSE score of 21.7.

In its first year of the program, 20 full-time clinical staff were hired, trained, and deployed. In the first 18 months, an average of 13 visits were provided by each assistant.

Of the population served by the program, 30% (n = 378) had a diagnosis of dementia, 77% (n = 1155) had a diagnosis of depression, and 117 patients had a diagnosis of both depression and dementia.

The ABC MedHome program reduced dementia and depression symptoms. In participants with depression, Patient Health Questionnaire (PHQ-9) scores decreased 1.7 points per year.

Of the 59 individuals who met ICD-9 diagnostic criteria for depression and whose an initial PHQ-9 score was 14 or greater, indicating moderately severe depressive symptoms, 66% had at least a 50% reduction in PHQ-9 score within 6 months.

In individuals with dementia, Healthy Aging Brain Care–Monitor (HABC-M) scores decreased 5.8 points per year.

Of the 70 individuals who met ICD-9 diagnostic criteria for dementia and whose baseline HABC-M score was 14 or greater, indicating high levels of symptom burden, 51% had at least a 50% reduction in HABC-M score within 6 months.

Dr Michael LaMantia

"This is a new and exciting model, and our healthcare system here in Indianapolis likes very much what they are seeing," Dr LaMantia said.

"We are coming towards the end of our 3 years with the program, and our healthcare system has agreed to continue to support the program past the life of our funding from CMS, which I think is very good news for us also," he said.

Critical Work

Commenting on this project for Medscape Medical News, Donovan Maust, MD, a geriatrician from the University of Michigan, in Ann Arbor, said, "The medical services that physicians are trained and equipped to provide are often not what older adults with dementia or depression or their caregivers may need most. The work of Dr LaMantia and his colleagues is critical, as they use a variety of nonphysician providers to deliver a range of services to more comprehensively care for these patients and caregivers."

"As the population of older adults grows, this sort of approach that expands care beyond the doctor's office is critical to meet patient need. In addition, it will allow physicians to focus more on the medically complex services that they are trained to deliver," Dr Maust added.

Robert P. Roca, MD, vice president and medical director of the Sheppard Pratt Health System, Towson, Maryland, commented that the program tests the idea that a program found to be successful in an academic research setting can be successful in achieving some of the principal goals of population health in the "real world."

The results of the intervention are "impressive and encouraging" but leave many questions unanswered, Dr Roca said.

"The absence of a control group prevents us from being confident that the improvement was the result of the intervention; it may have occurred anyway for other reasons. There were practical difficulties in reaching everyone identified as at risk, so it's not clear that the encouraging results would have been demonstrated in the entire group. And it's too early to say whether or not the intervention will reduce healthcare costs sufficiently to offset the cost of the program. This is important to its long-term sustainability," he said.

Nonetheless, "this is the kind of work that needs to be happening everywhere and is an example of the creativity encouraged and supported by the Affordable Care Act and the Health Care Innovation Award," Dr Roca said.

"We need to find ways to identify persons at risk of getting sick before they present to emergency rooms in crisis and to provide the treatment and support services they need to stay well and stay home. That's what this program seeks to do. It's better care. And hopefully, we'll find it's less expensive as well."

Dr LaMantia, Dr Maust, and Dr Roca report no relevant financial relationships.

J Am Geriatr Soc. Published online June 15, 2015. Abstract

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