Caregiver outcomes of partners in dementia care: effect of a care coordination program for veterans with dementia and their family members and friends. Community based occupational therapy for patients with dementia and their care givers: randomised controlled trial. Community occupational therapy for older patients with dementia and their care givers: cost effectiveness study Dementia care initiative in primary practice – study protocol of a cluster randomized trial on dementia management in a general practice setting Life- and person-centred help in Mecklenburg-Western Pomerania, Germany (DelpHi): study protocol for a randomised controlled trial Effectiveness and Safety of Dementia Care Management in Primary Care: A Randomized Clinical Trial Does an interdisciplinary network improve dementia care? Results from the IDemUck-study A controlled trial of Partners in Dementia Care: veteran outcomes after six and twelve months Efficacy of psychosocial intervention in patients with mild Alzheimer’s disease: the multicentre, rater blinded, randomised Danish Alzheimer Intervention Study (DAISY) Cost-Effectiveness of One Year Dementia Follow-Up Care by Memory Clinics or General Practitioners: Economic Evaluation of a Randomised Controlled Trial A randomized controlled trial of a community-based dementia care coordination intervention: effects of MIND at Home on caregiver outcomes. Efficacy of a geriatrics team intervention for residents in dementia-specific assisted living facilities: effect on unanticipated transitions. Effectiveness of collaborative care for older adults with Alzheimer disease in primary care: a randomized controlled trial. Early psychosocial intervention in Alzheimer's disease: cost utility evaluation alongside the Danish Alzheimer's Intervention Study (DAISY) Study protocol for a randomised controlled trial of internet-based cognitive-behavioural therapy for obsessive-compulsive disorder Effects of general practitioner training and family support services on the care of home-dwelling dementia patients - Results of a controlled cluster-randomized study WHEDA study: Effectiveness of occupational therapy at home for older people with dementia and their caregivers - the design of a pragmatic randomised controlled trial evaluating a Dutch programme in seven German centres Family care as collaboration: effectiveness of a multicomponent support program for elderly couples with dementia. Randomized controlled intervention study. Effects of Self-Management Groups for People with Dementia and Their Spouses--Randomized Controlled Trial. A multidimensional home-based care coordination intervention for elders with memory disorders: the maximizing independence at home (MIND) pilot randomized trial. Survival times in people with dementia: analysis from population based cohort study with 14 year follow-up Reminiscence groups for people with dementia and their family carers: pragmatic eight-centre randomised trial of joint reminiscence and maintenance versus usual treatment: a protocol Psychosocial group intervention to enhance self-management skills of people with dementia and their caregivers: study protocol for a randomized controlled trial Effects of the Finnish Alzheimer disease exercise trial (FINALEX): a randomized controlled trial. Cost-effectiveness of post-diagnosis treatment in dementia coordinated by multidisciplinary memory clinics in comparison to treatment coordinated by general practitioners: An example of a pragmatic trial The Effect of a Disease Management Intervention on Quality and Outcomes of Dementia Care The Danish Alzheimer Intervention Study: Rationale, Study Design and Baseline Characteristics of the Cohort A Break-Even Analysis for Dementia Care Collaboration: Partners in Dementia Care Effectiveness of dementia follow-up care by memory clinics or general practitioners: randomised controlled trial Cost evaluation of a coordinated care management intervention for dementia. REMCARE: Pragmatic Multi-Centre Randomised Trial of Reminiscence Groups for People with Dementia and their Family Carers: Effectiveness and Economic Analysis Costs of care for dementia patients in community setting: an analysis for mild and moderate disease stage. A three-year follow-up on the efficacy of psychosocial interventions for patients with mild dementia and their caregivers: the multicentre, rater-blinded, randomised Danish Alzheimer Intervention Study (DAISY) REMCARE: reminiscence groups for people with dementia and their family caregivers - effectiveness and cost-effectiveness pragmatic multicentre randomised trial. Impact of the care coordination program “Partners in Dementia Care” on veterans' hospital admissions and emergency department visits A multicentre RCT on community occupational therapy in Alzheimer's disease: 10 sessions are not better than one consultation
The objective is to test the effectiveness of Partners in Dementia Care ( PDC ) , a care-coordination program that integrates and improves access to medical and nonmedical services , while strengthening the informal care network and providing information , coaching , and emotional support . PDC was delivered via a partnership between Veterans Affairs ( VA ) Medical Centers ( VAMCs ) and Alzheimer 's Association chapters , for caregivers of veterans with dementia living in the community and receiving primary care from the VA . The initial sample was 486 caregivers of 508 veterans with diagnosed dementia . Outcomes were evaluated for 394 and 324 caregivers who completed 6- and 12- month follow-up , respectively . PDC had a st and ardized protocol that included assessment and re assessment , action planning , and ongoing monitoring . It was delivered by telephone and e-mail for cost efficiency and the ability to h and le caseloads of 100 to 125 . Care coordinators from VAMCs and Alzheimer 's Association chapters worked as a team using a shared computerized record . A variety of caregiver outcomes was measured after 6 and 12 months . Intervention group caregivers had significant improvements in outcomes representing unmet needs , three types of caregiver strains , depression , and two support re sources . Most improvements were evident after 6 months , with more-limited improvements from Months 6 to 12 . Some outcomes improved for all caregivers , whereas some improved for caregivers experiencing more initial difficulties or caring for veterans with more-severe impairments . PDC is a promising model that improves linkages between healthcare services and community services , which is a goal of several new national initiatives such as the National Plan to Address Alzheimer 's Disease and a proposed amendment to the Older Americans Act OBJECTIVE To determine the effectiveness of community based occupational therapy on daily functioning of patients with dementia and the sense of competence of their care givers . DESIGN Single blind r and omised controlled trial . Assessors were blinded for treatment allocation . SETTING Memory clinic and day clinic of a geriatrics department and participants ' homes . PARTICIPANTS 135 patients aged > or = 65 with mild to moderate dementia living in the community and their primary care givers . INTERVENTIONS 10 sessions of occupational therapy over five weeks , including cognitive and behavioural interventions , to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision . MAIN OUTCOME MEASURES Patients ' daily functioning assessed with the assessment of motor and process skills ( AMPS ) and the performance scale of the interview of deterioration in daily activities in dementia ( IDDD ) . Care giver burden assessed with the sense of competence question naire ( SCQ ) . Participants were evaluated at baseline , six weeks , and three months . RESULTS Scores improved significantly relative to baseline in patients and care givers in the intervention group compared with the controls ( differences were 1.5 ( 95 % confidence interval 1.3 to 1.7 ) for the process scale ; -11.7 ( -13.6 to -9.7 ) for the performance scale ; and ( 11.0 ; 9.2 to 12.8 ) for the competence scale ) . This improvement was still significant at three months . The number needed to treat to reach a clinical ly relevant improvement in motor and process skills score was 1.3 ( 1.2 to 1.4 ) at six weeks . Effect sizes were 2.5 , 2.3 , and 1.2 , respectively , at six weeks and 2.7 , 2.4 , and 0.8 , respectively , at 12 weeks . CONCLUSIONS Occupational therapy improved patients '  daily functioning and reduced the burden on the care giver , despite the patients ' limited learning ability . Effects were still present at 12 weeks , which justifies implementation of this intervention . TRIAL REGISTRATION Clinical Trials NCT00295152 [ Clinical Trials.gov ] Objective To assess the cost effectiveness of community based occupational therapy compared with usual care in older patients with dementia and their care givers from a societal viewpoint . Design Cost effectiveness study alongside a single blind r and omised controlled trial . Setting Memory clinic , day clinic of a geriatrics department , and participants ’ homes . Patients 135 patients aged ≥65 with mild to moderate dementia living in the community and their primary care givers . Intervention 10 sessions of occupational therapy over five weeks , including cognitive and behavioural interventions , to train patients in the use of aids to compensate for cognitive decline and care givers in coping behaviours and supervision . Main outcome measures Incremental cost effectiveness ratio expressed as the difference in mean total care costs per successful treatment ( that is , a combined patient and care giver outcome measure of clinical ly relevant improvement on process , performance , and competence scales ) at three months after r and omisation . Bootstrap methods used to determine confidence intervals for these measures . Results The intervention cost € 1183 ( £ 848 , $ 1738 ) ( 95 % confidence interval € 1128 ( £ 808 , $ 1657 ) to € 1239 ( £ 888 , $ 1820 ) ) per patient and primary care giver unit at three months . Visits to general practitioners and hospital doctors cost the same in both groups but total mean costs were € 1748 ( £ 1279 , $ 2621 ) lower in the intervention group , with the main cost savings in informal care . There was a significant difference in proportions of successful treatments of 36 % at three months . The number needed to treat for successful treatment at three months was 2.8 ( 2.7 to 2.9 ) . Conclusions Community occupational therapy intervention for patients with dementia and their care givers is successful and cost effective , especially in terms of informal care giving Background Current guidelines for dementia care recommend the combination of drug therapy with non-pharmaceutical measures like counselling and social support . However , the scientific evidence concerning non-pharmaceutical interventions for dementia patients and their informal caregivers remains inconclusive . Targets of modern comprehensive dementia care are to enable patients to live at home as long and as independent as possible and to reduce the burden of caregivers . The objective of the study is to compare a complex intervention including caregiver support groups and counselling against usual care in terms of time to nursing home placement . In this paper the study protocol is described . Methods / Design The IDA ( Initiative Demenzversorgung in der Allgemeinmedizin ) project is design ed as a three armed cluster-r and omized trial where dementia patients and their informal caregivers are recruited by general practitioners . Patients in the study region of Middle Franconia , Germany , are included if they have mild or moderate dementia , are at least 65 years old , and are members of the German AOK ( Allgemeine Ortskrankenkasse ) sickness fund . In the control group patients receive regular treatment , whereas in the two intervention groups general practitioners participate in a training course in evidence based dementia treatment , recommend support groups and offer counseling to the family caregivers either beginning at baseline or after the 1-year follow-up . The study recruitment and follow-up took place from July 2005 to January 2009 . 303 general practitioners were r and omized of which 129 recruited a total of 390 patients .  Time to nursing home admission within the two year intervention and follow-up period is the primary endpoint . Secondary endpoints are cognitive status , activities of daily living , burden of care giving as well as healthcare costs . For an economic analysis from the societal perspective , data are collected from caregivers as well as by the use of routine data from statutory health insurance and long-term care insurance . Discussion From a public health perspective , the IDA trial is expected to lead to evidence based results on the community effectiveness of non-pharmaceutical support measures for dementia patients and their caregivers in the primary care sector . For health policy makers it is necessary to make their decisions about financing new services based on strong knowledge about the acceptance of measures in the population and their cost-effectiveness . Trial registration IS RCT Background The provision of appropriate medical and nursing care for people with dementia is a major challenge for the healthcare system in Germany . New models of healthcare provision need to be developed , tested and implemented on the population level . Trials in which collaborative care for dementia in the primary care setting were studied have demonstrated its effectiveness . These studies have been conducted in different healthcare systems , however , so it is unclear whether these results extend to the specific context of the German healthcare system . The objective of this population -based intervention trial in the primary care setting is to test the efficacy and efficiency of implementing a subsidiary support system on a population level for persons with dementia who live at home . Methods and study design The study was design ed to assemble a general physician-based epidemiological cohort of people above the age of 70 who live at home ( DelpHi cohort ) . These people are screened for eligibility to participate in a trial of dementia care management ( DelpHi trial ) . The trial is a cluster-r and omised , controlled intervention trial with two arms ( intervention and control ) design ed to test the efficacy and efficiency of implementing a subsidiary support system for persons with dementia who live at home . This subsidiary support system is initiated and coordinated by a dementia care manager : a nurse with dementia-specific qualifications who delivers the intervention according to a systematic , detailed protocol . The primary outcome is quality of life and healthcare for patients with dementia and their caregivers . This is a multidimensional outcome with a focus on four dimensions : ( 1 ) quality of life , ( 2 ) caregiver burden , ( 3 ) behavioural and psychological symptoms of dementia and ( 4 ) pharmacotherapy with an antidementia drug and prevention or suspension of potentially inappropriate medication . Secondary outcomes include the assessment of dementia syndromes , activities of daily living , social support health status , utilisation of health care re sources and medication . Discussion The results will provide evidence for specific needs in ambulatory care for persons with dementia and will show effective ways to meet those needs . Qualification requirements will be evaluated , and the results will help to modify existing guidelines and treatment paths . Trial registration Importance Dementia care management ( DCM ) can increase the quality of care for people with dementia . Method ologically rigorous clinical trials on DCM are lacking . Objective To test the effectiveness and safety of DCM in the treatment and care of people with dementia living at home and caregiver burden ( when available ) . Design , Setting , and Participants This pragmatic , general practitioner – based , cluster-r and omized intervention trial compared the intervention with care as usual at baseline and at 12-month follow-up . Simple 1:1 r and omization of general practice s in Germany was used . Analyses were intent to treat and per protocol . In total , 6838 patients were screened for dementia ( eligibility : 70 years and older and living at home ) from January 1 , 2012 , to March 31 , 2016 . Overall , 1167 ( 17.1 % ) were diagnosed as having dementia , and 634 ( 9.3 % ) provided written informed consent to participate . Interventions Dementia care management was provided for 6 months at the homes of patients with dementia . Dementia care management is a model of collaborative care , defined as a complex intervention aim ing to provide optimal treatment and care for patients with dementia and support caregivers using a computer-assisted assessment determining a personalized array of intervention modules and subsequent success monitoring . Dementia care management was targeted at the individual patient level and was conducted by 6 study nurses with dementia care – specific qualifications . Main Outcomes and Measures Quality of life , caregiver burden , behavioral and psychological symptoms of dementia , pharmacotherapy with antidementia drugs , and use of potentially inappropriate medication . Results The mean age of 634 patients was 80 years . A total of 407 patients received the intended treatment and were available for primary outcome measurement . Of these patients , 248 ( 60.9 % ) were women , and 204 ( 50.1 % ) lived alone . Dementia care management  significantly decreased behavioral and psychological symptoms of dementia ( b = −7.45 ; 95 % CI , −11.08 to −3.81 ; P < .001 ) and caregiver burden ( b = −0.50 ; 95 % CI , −1.09 to 0.08 ; P = .045 ) compared with care as usual . Patients with dementia receiving DCM had an increased chance of receiving antidementia drug treatment ( DCM , 114 of 291 [ 39.2 % ] vs care as usual , 31 of 116 [ 26.7 % ] ) after 12 months ( odds ratio , 1.97 ; 95 % CI , 0.99 to 3.94 ; P = .03 ) . Dementia care management significantly increased quality of life ( b = 0.08 ; 95 % CI , 0 to 0.17 ; P = .03 ) for patients not living alone but did not increase quality of life overall . There was no effect on potentially inappropriate medication ( odds ratio , 1.86 ; 95 % CI , 0.62 to 3.62 ; P = .97 ) . Conclusions and Relevance Dementia care management provided by specifically trained nurses is an effective collaborative care model that improves relevant patient- and caregiver-related outcomes in dementia . Implementing DCM in different health care systems should become an active area of research . Trial Registration clinical trials.gov Identifier : BACKGROUND Most persons with dementia live at home and are treated in the primary care . However , the ambulatory health care system in Germany contains a lot of " interface problems " and is not optimized for the future challenges . Innovative concepts like regional networks in dementia care exist on a project level and need to be tested for efficacy to encourage implementation . The goal of the study is the scientific evaluation of an already existing regional dementia network . METHODS Prospect i ve r and omized controlled trial of 235 community-living elderly with dementia and their family caregivers of network treatment ( n=117 ) compared to usual care ( n=118 ) in a predominantly rural region . The allocation to intervention or control group was based on network membership of their General Practitioner . Intervention patients received diagnostic evaluation and subsequent treatment according to network guidelines . Main outcome measures were the early contact with a neurologic or psychiatric specialist and dementia-specific medication  as well as quality of life of the patients , and as secondary outcomes caregiver burden and caregiver health-related quality of life . RESULTS Network patients were more likely to receive antidementive drugs ( 50.5 % vs. 35.8 % ; p=0.035 ) and had more often contact to a neurologist ( 18.6 % vs. 2.8 % ; p<0.001 ) . No group differences were found on patient 's quality of life nor overall effects or treatment by time effects . Intervention caregivers reported no significant improvements in health related quality of life measured by SF-36 and EQ-5D . CONCLUSION The management of dementia patients in an interdisciplinary regional network solelyprovides measurable advantages with respect to the provision of dementia-specific medication and utilization of medical treatment i.e. referral rates to specialists . Further evaluation research is needed to identify relevant mechanismsof collaborative processes with respect to their impact on patient and caregiver related outcomes Introduction “ Partners in Dementia Care ” ( PDC ) tested the effectiveness of a care-coordination program integrating healthcare and community services and supporting veterans with dementia and their caregivers . Delivered via partnerships between Veterans Affairs medical centers and Alzheimer ’s Association chapters , PDC targeted both patients and caregivers , distinguishing it from many non-pharmacological interventions . Hypotheses posited PDC would improve five veteran self-reported outcomes : 1 ) unmet need , 2 ) embarrassment about memory problems , 3 ) isolation , 4 ) relationship strain and 5 ) depression . Greater impact was expected for more impaired veterans . A unique feature was self-reported research data collected from veterans with dementia . Methods and Findings Five matched communities were study sites . Two r and omly selected sites received PDC for 12 months ; comparison sites received usual care . Three structured telephone interviews were completed every 6 months with veterans who could participate . Results Of 508 consenting veterans , 333 ( 65.6 % ) completed baseline interviews . Among those who completed baseline interviews , 263 ( 79.0 % ) completed 6-month follow-ups and 194 ( 58.3 % ) completed 12-month follow-ups . Regression analyses showed PDC veterans had significantly less adverse outcomes than those receiving usual care , particularly for more impaired veterans after 6 months , including reduced relationship strain ( B = −0.09 ; p = 0.05 ) , depression ( B = −0.10 ; p = 0.03 ) , and unmet need ( B = −0.28 ; p = 0.02 ; and B = −0.52 ; p = 0.08 ) . PDC veterans also had less embarrassment about memory problems ( B = −0.24 ; p = 0.08 ) . At 12 months , more impaired veterans had further reductions in unmet need ( B = −0.96 ; p < 0.01 ) and embarrassment ( B = −0.05 ; p = 0.02 ) . Limitations included use of matched comparison sites rather than within-site r and omization and lack of consideration for variation within the PDC group in amounts and types of assistance provided . Conclusions Partnerships between community and health organizations have the potential to meet the dementia-related needs and improve the psychosocial functioning of persons with dementia . Trial Objective To assess the efficacy at 12 months of an early psychosocial counselling and support programme for out patients with mild Alzheimer ’s disease and their primary care givers . Design Multicentre , r and omised , controlled , rater blinded trial . Setting Primary care and memory clinics in five Danish districts . Participants 330 out patients with mild Alzheimer ’s disease and their 330 primary care givers . Interventions Participating dyads ( patient and primary care giver ) were r and omised to control support during follow-up or to control support plus DAISY intervention ( multifaceted and semi-tailored counselling , education , and support ) . Main outcome measures Primary outcomes at 12 months for patients were change from baseline in mini mental state examination ( MMSE ) score , Cornell depression scale score , and proxy rated European quality of life visual analogue scale ( EQ-VAS ) score . For care givers , outcomes were change from baseline in geriatric depression scale ( GDS 30 items ) score and EQ-VAS score . Results Because of multiple testing , statistical significance was set at an adjusted P limit of < 0.0005 . At 12 months there were no significant differences between the two allocation groups in changes from baseline in the primary and secondary outcomes . However , although non-significant with the adjusted P limit , a small difference was observed for one of the primary patient outcomes ( Cornell depression scale score ) in patients in favour of the DAISY intervention group before and after adjusting for attrition ( P=0.0146 and P=0.0103 respectively ) . Conclusions The multifaceted , semi-tailored intervention with counselling , education , and support for patients with mild Alzheimer ’s disease and their care givers did not have any significant effect beyond that with well structured follow-up support at 12 months after adjustment for multiple comparisons . The small positive effect found in the unadjusted primary outcome addressing depressive symptoms in patients may call for further research focusing on patients with Alzheimer ’s disease and comorbid depression . Trial registration IS RCT N74848736 Objective To evaluate the cost-effectiveness of  post-diagnosis dementia treatment and coordination of care by memory clinics compared to general practitioners ’ care . Methods A multicentre r and omised trial with 175 community dwelling patients newly diagnosed with mild to moderate dementia , and their informal caregivers , with twelve months ’ follow-up .  Cost-effectiveness was evaluated from a societal point of view and presented as incremental cost per quality adjusted life year . To establish cost-effectiveness , a cost-utility analysis was conducted using utilities based on the EQ-5D . Uncertainty surrounding the incremental cost-effectiveness ratio ( difference in costs divided by difference in effects ) was calculated by bootstrapping from the original data . Results Compared to general practitioners ’ care , treatment by the memory clinics was on average € 1024 ( 95 % CI : −€7723 to € 5674 ) cheaper , and showed a non-significant decrease of 0.025 ( 95 % CI : −0.114 to 0.064 ) quality adjusted life years . The incremental cost-effectiveness point estimate from the bootstrap simulation was € 41 442 per QALY lost if one would use memory clinic care instead of general practitioner care . Conclusion No evidence was found that memory clinics were more cost-effective compared to general practitioners with regard to post-diagnosis treatment and coordination of care of patients with dementia in the first year after diagnosis . Trial Registration Clinical Trials.gov OBJECTIVE To assess whether MIND at Home , a community-based , multicomponent , care coordination intervention , reduces unmet caregiving needs and burden in informal caregivers of persons with memory disorders . METHODS An 18-month r and omized controlled trial of 289 community-living care recipient (CR)-caregiver ( informal caregivers , i.e. , unpaid individuals who regularly assisted the CR ) dyads from 28 postal code areas of Baltimore , Maryl and was conducted . All dyads and the CR 's primary care physician received the written needs assessment results and intervention recommendations . Intervention dyads then received an 18-month care coordination intervention delivered by non clinical community workers to address unmet care needs through individualized care planning , referral and linkage to dementia services , provision of caregiver dementia education and skill-building strategies , and care progress monitoring by an interdisciplinary team . Primary outcome was total percent of unmet caregiver needs at 18 months . Secondary outcomes included objective and subjective caregiver burden measures , quality of life ( QOL ) , and depression . RESULTS Total percent of unmet caregiver needs declined in both groups from baseline to 18 months , with no statistically significant between-group difference . No significant group differences occurred in most caregiver burden measures , depression , or QOL . There was a potentially clinical ly relevant reduction in self-reported number of hours caregivers spent with the CR for MIND participants compared with control subjects . CONCLUSION No statistically significant impacts on caregiver outcomes were found after multiple comparison adjustments . However , MIND at Home appeared to have had a modest and clinical ly meaningful impact on informal caregiver time spent with CRs OBJECTIVES To determine whether a multidisciplinary team intervention minimizes unanticipated transitions from assisted living for persons with dementia . DESIGN R and omized trial . SETTING Two dementia-specific assisted living facilities in Connecticut owned and managed by the same corporation . PARTICIPANTS One hundred older adults with dementia who relocated to assisted living . INTERVENTION Four systematic multidisciplinary assessment s by a geriatrician , geriatrics advanced practice nurse , physical therapist , dietitian , and social worker during the first 9 months of relocation to assisted living . MEASUREMENTS Permanent relocation to a nursing facility , emergency department ( ED ) visits , hospitalization , and death . RESULTS Fifty-five residents experienced any unanticipated transition out of assisted living , on average 84 + /- 74 days after relocation ; falls were the primary reason for transition . The intervention reduced the risk of any unanticipated transitions ( 13 % ) , permanent relocation to a nursing facility ( 11 % ) , ED visits ( 12 % ) , hospitalization ( 45 % ) , and death ( 63 % ) , but the results did not meet statistical significance . In secondary analysis , more men experienced any unanticipated transition ( P<.001 ) , hospitalization ( P<.001 ) , or death ( P<.001 ) than women . CONCLUSION Although an untargeted multidisciplinary intervention did not significantly reduce the risk of transitions for individuals with dementia relocating to assisted living in this small sample , trends for decreasing hospitalization and death were found . The data further suggest that those at risk for falls and men may benefit from targeted clinical interventions to prevent unanticipated transitions , especially during the first 3 months after relocation CONTEXT Most older adults with dementia will be cared for by primary care physicians , but the primary care practice environment presents important challenges to providing quality care . OBJECTIVE To test the effectiveness of a collaborative care model to improve the quality of care for patients with Alzheimer disease . DESIGN , SETTING , AND PATIENTS Controlled clinical trial of 153 older adults with Alzheimer disease and their caregivers who were r and omized by physician to receive collaborative care management ( n = 84 ) or augmented usual care ( n = 69 ) at primary care practice s within 2 US university-affiliated health care systems from January 2002 through August 2004 . Eligible patients ( identified via screening or medical record ) met diagnostic criteria for Alzheimer disease and had a self-identified caregiver . INTERVENTION Intervention patients received 1 year of care management by an interdisciplinary team led by an advanced practice nurse working with the patient 's family caregiver and integrated within primary care . The team used st and ard protocol s to initiate treatment and identify , monitor , and treat behavioral and psychological symptoms of dementia , stressing nonpharmacological management . MAIN OUTCOME MEASURES Neuropsychiatric Inventory ( NPI ) administered at baseline and at 6 , 12 , and 18 months . Secondary outcomes included the Cornell Scale for Depression in Dementia ( CSDD ) , cognition , activities of daily living , re source use , and caregiver 's depression severity . RESULTS Initiated by caregivers ' reports , 89 % of intervention patients triggered at least 1 protocol for behavioral and psychological symptoms of dementia with a mean of 4 per patient from a total of 8 possible protocol s. Intervention patients were more likely to receive  cholinesterase inhibitors  ( 79.8 % vs 55.1 % ; P = .002 ) and  antidepressants  ( 45.2 % vs 27.5 % ; P = .03 ) . Intervention patients had significantly fewer behavioral and psychological symptoms of dementia as measured by the total NPI score at 12 months ( mean difference , -5.6 ; P = .01 ) and at 18 months ( mean difference , -5.4 ; P = .01 ) . Intervention caregivers also reported significant improvements in distress as measured by the caregiver NPI at 12 months ; at 18 months , caregivers showed improvement in depression as measured by the Patient Health Question naire-9 . No group differences were found on the CSDD , cognition , activities of daily living , or on rates of hospitalization , nursing home placement , or death . CONCLUSIONS Collaborative care for the treatment of Alzheimer disease result ed in significant improvement in the quality of care and in behavioral and psychological symptoms of dementia among primary care patients and their caregivers . These improvements were achieved without significantly increasing the use of antipsychotics or sedative-hypnotics . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00246896 Objective To assess the cost utility of early psychosocial intervention for patients with Alzheimer 's disease and their primary caregivers . Design Cost utility evaluation alongside a multicentre , r and omised controlled trial with 3 years of follow-up . Setting Primary care and memory clinics in five Danish districts . Participants 330 community-dwelling patients and their primary caregivers . Intervention Psychosocial counselling and support lasting 8–12 months after diagnosis and follow-up at 3 , 6 , 12 and 36 months in the intervention group or follow-up only in the control group . Main outcome measures The primary outcome measure was the cost of additional quality -adjusted life years ( QALYs ) . Costs were measured from a societal perspective , including the costs of healthcare , social care , informal care and production loss . QALYs were estimated separately for the patient and the caregiver before aggregation for the main analysis . Results None of the observed cost and QALY measures were significantly different between the intervention and control groups , although a tendency was noted for psychosocial care leading to cost increases with informal care that was not outweighed by the tendency for cost savings with formal care . The probability of psychosocial intervention being cost-effective did not exceed 36 % for any threshold value . The alternative scenario analysis showed that the probability of cost-effectiveness increased over the range of threshold values used if the cost perspective was restricted to formal healthcare . Conclusions A multifaceted , psychosocial intervention programme was found unlikely to be cost-effective from a societal perspective . The recommendation for practice in setting s that are similar to the Danish setting is to provide follow-up with referral to available local support programmes when needed , and to restrict large multifaceted intervention programmes to patients and caregivers with special needs until further evidence for cost-effectiveness emerges . Trial registration The study was registered in the Clinical Trial Data base as IS RCT N74848736 Background Obsessive-Compulsive Disorder ( OCD ) is a common chronic psychiatric disorder that constitutes a leading cause of disability . Although Cognitive-Behaviour Therapy ( CBT ) has been shown to be an effective treatment for OCD , this specialised treatment is unavailable to many due to access issues and the social stigma associated with seeing a mental health specialist . Internet-based psychological treatments have shown to provide effective , accessible and affordable treatment for a range of anxiety disorders , and two R and omised Controlled Trials ( RCTs ) have demonstrated the efficacy and acceptability of internet-based CBT ( iCBT ) for OCD , as compared to waitlist or supportive therapy . Although these initial findings are promising , they do not isolate the specific effect of iCBT . This paper details the study protocol for the first r and omised control trial evaluating the efficacy of therapist-assisted iCBT for OCD , as compared to a matched control intervention ; internet-based therapist-assisted progressive relaxation training ( iPRT ) . It will aim to examine whether therapist-assisted iCBT is an acceptable and efficacious treatment , and to examine how effectiveness is influenced by patient characteristics . Method / design A r and omised controlled trial using repeated measures with two arms ( intervention and matched control ) will be used to evaluate the efficacy and acceptability of iCBT for OCD . The RCT will r and omise 212 Australian adults with a primary diagnosis of OCD into either the active intervention or control condition , for 12 weeks duration . Outcomes for participants in both study arms will be assessed at baseline and post-intervention . Participants in iCBT will be further assessed at six month follow-up , while participants in the control condition will be crossed over to receive the iCBT intervention and reassessed at post-intervention and six month follow-up . The primary outcome will be clinical ly significant change in obsessive-compulsive symptom scores . Discussion This will be the first known therapist assisted internet-based trial of a comprehensive CBT treatment for OCD as compared to a matched control intervention . Demonstrating the efficacy of an internet-based treatment for OCD will allow the development of models of care for broad-based access to an evidence -based but complex treatment Background More than 90 % of dementia patients are cared for by their general practitioners , who are decisively involved in the diagnosis , therapy and recommendation of support services . Objective : To test whether special training of general practitioners alters the care of dementia patients through their systematic recommendation of caregiver counseling and support groups . Method 129 general practitioners enrolled 390 dementia patients and their informal caregivers in a prospect i ve , three-arm cluster-r and omized 2-year study . Arm A constituted usual care , in Arm B and C support groups and caregiver counseling ( in Arm B one year after baseline , in Arm C at baseline ) were recommended by the general practitioners . The general practitioners received arm-specific training . Diagnostic and therapeutic behavior of physicians was recorded at baseline . Informal caregivers were question ed in follow-up after 2 years about the utilization of support services . Results The diagnostic behavior of the general practitioners conforms to relevant guidelines . The procedure in newly-diagnosed patients does not differ from previously diagnosed patients with the exception of the rate of referral to a specialist . About one-third of the newly-diagnosed dementia patients are given an anti-dementia drug . The utilization of support groups and counseling  increased five- and fourfold , respectively . Utilization of other support services remained low ( < 10 % ) , with the exception of home nursing and institutional short-term nursing . Conclusion Trained general practitioners usually act in conformity with guidelines with respect to diagnosing dementia , and partly in conformity with the guidelines with respect to recommended drug therapy . Recommendations of support services for informal caregivers by the general practitioner are successful . They result in a marked increase in the utilization rate for the recommended services compared to offers which are not recommended by the general practitioner . Trial registration IS RCT Background A recent Dutch mono-centre r and omised controlled trial has shown that occupational therapy improves daily functioning in dementia . The aim of this present study is to compare the effects of the Dutch community occupational therapy programme with a community occupational therapy consultation on daily functioning in older people with mild or moderate dementia and their primary caregivers in a German multi-centre context . Methods / Design A multi-centre single blind r and omised controlled trial design is being used in seven health care centres ( neurological , psychiatric and for older people ) in urban regions . Patients are 1:1 r and omised to treatment or control group . Assessors are blind to group assignment and perform measurements on both groups at baseline , directly after intervention at 6 weeks and at 16 , 26 and 52 weeks follow-up . A sample of 140 community dwelling older people ( aged > 65 years ) with mild or moderate dementia and their primary caregivers is planned . The experimental intervention consists of an evidence -based community occupational therapy programme including 10 sessions occupational therapy at home . The control intervention consists of one community occupational therapy consultation based on information material of the Alzheimer Society . Providers of both interventions are occupational therapists experienced in treatment of cognitively impaired older people and trained in both programmes . ' Community ' indicates that occupational therapy intervention occurs in the person 's own home . The primary outcome is patients ' daily functioning assessed with the performance scale of the Interview for Deterioration in Daily Living Activities in Dementia and video tapes of daily activities rated by external raters blind to group assignment using the Perceive , Recall , Plan and Perform System of Task Analysis . Secondary outcomes are patients ' and caregivers ' quality of life , mood and satisfaction with treatment ; the caregiver 's sense of competence , caregiver 's diary ( medication , re source utilisation , time of informal care ) ; and the incidence of long-term institutionalisation . Process evaluation is performed by question naires and focus group discussion . Discussion The transfer from the Dutch mono-centre design to the pragmatic multi-site trial in a German context implicates several changes in design issues including differences in recruitment time , training of interventionists and active control group treatment . The study is registered under DRKS00000053 at the German register of clinical trials , which is connected to the International Clinical Trials Registry Platform OBJECTIVES To determine whether community care of people with dementia can be prolonged with a 2-year multicomponent intervention program and to analyze effects of the intervention on total usage and expenses of social and healthcare services . DESIGN R and omized controlled trial . SETTING Community-dwelling couples with one spouse caring for the other spouse with dementia . PARTICIPANTS Couples with dementia ( N=125 ) were allocated at r and om to the intervention ( n=63 ) or control group ( n=62 ) . INTERVENTION Intervention couples were provided with a multicomponent intervention program with a family care coordinator , a geriatrician , support groups for caregivers , and individualized services . MEASUREMENTS Time from enrollment to institutionalization of spouses with dementia and use of services and service expenditure of couples . RESULTS At 1.6 years , a larger proportion in the control group than in the intervention group was in long-term institutional care ( 25.8 % vs 11.1 % , P=.03 ) . At 2 years , the difference was no longer statistically significant . The 2-year adjusted hazard ratio for the intervention group was 0.53 ( 95 % confidence interval (CI)=0.23 - 1.19 , P=.12 ) . Intervention led to reduction in use of community services and expenditures . The difference for the benefit of intervention group was -7,985 Euro ( 95 % CI=-16,081 to -1,499 , P=.03 ) . When the intervention costs were included , the differences between the groups were not significant . CONCLUSION Although the intervention did not result in a significant difference in the need for institutional care after 2 years , individualizing services in collaboration with families may lead to reduction in use of and expenditures on municipal services OBJECTIVES To investigate the effect of self-management group rehabilitation for persons with dementia ( PwD ) and their spouses on their health-related quality of life ( HRQoL ) , the cognition of the PwD , and the costs of health and social services . DESIGN A r and omized controlled trial . SETTING Primary care and memory clinics in the Helsinki metropolitan area , Finl and . PARTICIPANTS PwD ( N = 136 ) and their spouses ( N = 136 ) . INTERVENTION Couples were r and omized to usual care or eight-session self-management groups for PwD and concurrently for their spouses . Sessions aim to enhance self-efficacy and problem-solving skills and to provide peer support . MEASUREMENTS The primary outcome measures were the HRQoL of PwD ( measured using a generic , comprehensive ( 15-dimensional ) , self-administered instrument ( 15D ) ) and spouses ( measured using the R AND -36 ) and the spousal Sense of Competence Question naire ( SCQ ) . Secondary outcome measures were PwD cognition ( Verbal Fluency ( VF ) , Clock Drawing Test ( CDT ) ) and costs of health and social services during 24 months . RESULTS At 3 months , the spouse physical component of the R AND -36 improved ( mean change 1.0 , 95 % confidence interval ( CI ) = -0.5 to 2.4 ) for those undergoing the intervention and worsened for controls ( mean change -2.0 , 95 % CI = -3.5 to -0.4 ) ( P = .006 adjusted for age , sex , baseline value of the physical component of the R AND -36 ) . There were no differences between the groups on the mental component of the R AND -36 , the SCQ , or the 15D . At 9 months , PwD change in VF was -0.38 ( 95 % CI = -1.03 to 0.27 ) in intervention group and -1.60 ( 95 % CI = -2.26 to -0.94 ) for controls ( P = .011 adjusted for age , sex , baseline MMSE score ) . CDT changes were similar to VF changes . Differences in incremental costs between the groups was -436 € per person per year ( 95 % CI = -4,986 to 4,115 ) for PwD ( P = .35 adjusted for age , CDR ) and -896 € per person per year ( 95 % CI = -3,657 to 1,864 ) for spouses ( P = .51 adjusted for PwD age , CDR ) . CONCLUSIONS The intervention had beneficial effects on the HRQoL of spouses and the cognitive function of PwD without increasing total costs . TRIAL REGISTRATION anzctr.org.au Identifier : ACTRN12611001173987 OBJECTIVES To assess whether a dementia care coordination intervention delays time to transition from home and reduces unmet needs in elders with memory disorders . DESIGN 18-month r and omized controlled trial of 303 community-living elders . SETTING 28 postal code areas of Baltimore , MD . PARTICIPANTS Age 70 + years , with a cognitive disorder , community-living , English-speaking , and having a study partner available . INTERVENTION 18-month care coordination intervention to systematic ally identify and address dementia-related care needs through individualized care planning ; referral and linkage to services ; provision of dementia education and skill-building strategies ; and care monitoring by an interdisciplinary team . MEASUREMENTS Primary outcomes were time to transfer from home and total percent of unmet care needs at 18 months . RESULTS Intervention participants had a significant delay in time to all-cause transition from home and the adjusted hazard of leaving the home was decreased by 37 % ( Hazard ratio : 0.63 , 95 % Confidence Interval : 0.42 - 0.94 ) compared with control participants . Although there was no significant group difference in reduction of total percent of unmet needs from baseline to 18 months , the intervention group had significant reductions in the proportion of unmet needs in safety and legal/advance care domains relative to controls . Intervention participants had a significant improvement in self-reported quality of life ( QOL ) relative to control participants . No group differences were found in proxy-rated QOL , neuropsychiatric symptoms , or depression . CONCLUSIONS A home-based dementia care coordination intervention delivered by non- clinical community workers trained and overseen by geriatric clinicians led to delays in transition from home , reduced unmet needs , and improved self-reported QOL Objectives To provide estimates of survival after onset of dementia by age , sex , self reported health , disability , and severity of cognitive impairment . Design Analysis of participants from prospect i ve population based cohort study in 1991 - 2003 , with follow-up of dementia status in all individuals after two and six years ( in one centre ) and 10 years and in sub sample s additionally at six and eight years and mortality until 2005 . Setting Multicentre population based study in Engl and and Wales : two rural and three urban centres . Participants 438 participants who developed dementia from a population based study of 13 004 individuals aged 65 years and over drawn from primary care population registers . Main outcome measures Sociodemographic factors , cognitive function , specific health conditions , and self reported health collected at each interview . Cox ’s proportional hazards regression models were used to identify predictors of mortality from the selected variables in people who received diagnosis of dementia according the study ’s criteria . Results By December 2005 , 356 of the 438 ( 81 % ) participants who developed dementia during the study had died . Estimated median survival time from onset of dementia to death was 4.1 years ( interquartile range 2.5 - 7.6 ) for men and 4.6 years ( 2.9 - 7.0 ) for women . There was a difference of nearly seven years in survival between the younger old and the oldest people with dementia : 10.7 ( 25th centile 5.6 ) for ages 65 - 69 ; 5.4 ( interquartile range 3.4 - 8.3 ) for ages 70 - 79 ; 4.3 ( 2.8 - 7.0 ) for ages 80 - 89 , and 3.8 ( 2.3 - 5.2 ) years for ages ≥90 . Significant factors that predicted mortality in the presence of dementia during the follow-up included sex , age of onset , and disability . Conclusion These analyses give a population based estimated median survival for incident dementia of 4.5 years . Such estimates can be used for prognosis and planning for patients , carers , service providers , and policy makers Background The growing number of people with dementia , and the increasing cost of care , provides a major incentive to develop and test methods of supporting them in the community for longer . Most attention has been given to pharmacological interventions , but there is increasing recognition that psychosocial interventions may be equally effective , even preferable where medication has negative side-effects . Reminiscence groups , run by professionals and volunteers , which use photographs , recordings and other objects to trigger personal memories are probably the most popular therapeutic approach to working with people with dementia , but there is little evidence for their effectiveness and cost-effectiveness . The recent inclusion of family carers in groups with people with dementia , notably in our own pilot studies , has generated informal evidence that this joint approach improves relationships between people with dementia and their carers , and benefits both . Design and methods This multi-centre , pragmatic r and omised controlled trial ( RCT ) to assess the effectiveness and cost-effectiveness of joint reminiscence groups for  people with dementia and their family care-givers has two parallel arms – an intervention group and a control group who receive care as usual . The intervention consists of joint reminiscence groups held weekly for twelve consecutive weeks , followed by monthly maintenance sessions for a further seven months . The primary outcome measures are the quality of life of people with dementia , as assessed by QoL-AD , and their care-givers ' mental health as assessed by the GHQ-28 . Secondary outcomes include : the autobiographical memories of people with dementia ; the quality of the relationship between them and their care-givers ; and the levels of depression and anxiety felt by them and their care-giver . Using a 5 % significance level , comparison of 200 pairs attending joint reminiscence groups with 200 pairs receiving usual treatment will yield 80 % power to detect a st and ardised difference of 0.38 in the QoL-AD rated by the person with dementia and 0.28 in the GHQ-28 or carer-rated QoL-AD . The trial will include a cost-effectiveness analysis from a public sector perspective . Discussion Our Cochrane review ( 2005 ) on reminiscence therapy for people with dementia did not identify any rigorous trials or economic analyses in this field . Trial Registration IS RCT Background After diagnosis of a dementing illness , patients and their spouses have many concerns related to the disease and their future . This often leads to poor psychological well-being and reduced health-related quality of life ( HRQoL ) of the family . Support for self-management skills has been proven to be an effective method to improve prognosis of asthma , heart failure and osteoarthritis . However , self-management interventions have not been studied in dementia . Therefore , our aim was to examine , in an objective -oriented group intervention , the efficacy of self-management support program ( SMP ) on the HRQoL of dementia patients and their spousal caregivers as well as on the sense of competence and psychological well-being of caregivers . Methods During the years 2011 to 12 , 160 dementia patients and their spouses will be recruited from memory clinics and r and omized into two arms : 80 patients for group-based SMP sessions  including topics selected by the participants , 80 patients will serve as controls in usual community care . Sessions may include topics on dementia , community services , active lifestyle and prevention for cognitive decline , spousal relationship , future planning and emotional well-being . The patients and spouses will have their separate group sessions ( ten participants per group ) once a week for eight weeks . Main outcome measures will be patients ’ HRQoL ( 15D ) and spousal caregivers ’ HRQoL ( R AND -36 ) , and sense of competence ( SCQ ) . Secondary measures will be caregivers ’ psychological well-being ( GHQ-12 ) and coping re sources , patients ’ depression , cognition and signs of frailty . Data concerning admissions to institutional care and the use and costs of health and social services will be collected during a two-year follow-up . Discussion This is a ‘ proof-of-concept ’ study to explore the efficacy of group support for self-management skills among dementia families . It will also provide data on cost-effectiveness of the intervention . Trial registration IMPORTANCE Few rigorous clinical trials have investigated the effectiveness of exercise on the physical functioning of patients with Alzheimer disease ( AD ) . OBJECTIVES To investigate the effects of intense and long-term exercise on the physical functioning and mobility of home-dwelling patients with AD and to explore its effects on the use and costs of health and social services . DESIGN A r and omized controlled trial . SETTING AND PARTICIPANTS A total of 210 home-dwelling patients with AD living with their spousal caregiver . INTERVENTIONS The 3 trial arms included ( 1 ) group-based exercise ( GE ; 4-hour sessions with approximately 1-hour training ) and ( 2 ) tailored home-based exercise ( HE ; 1-hour training ) , both twice a week for 1 year , and ( 3 ) a control group ( CG ) receiving the usual community care . MAIN OUTCOME MEASURES The Functional Independence Measure ( FIM ) , the Short Physical Performance Battery , and information on the use and costs of social and health care services . RESULTS All groups deteriorated in functioning during the year after r and omization , but deterioration was significantly faster in the CG than in the HE or GE group at 6 ( P = .003 ) and 12 ( P = .015 ) months . The FIM changes at 12 months were -7.1 ( 95 % CI , -3.7 to -10.5 ) , -10.3 ( 95 % CI , -6.7 to -13.9 ) , and -14.4 ( 95 % CI , -10.9 to -18.0 ) in the HE group , GE group , and CG , respectively . The HE and GE groups had significantly fewer falls than the CG during the follow-up year . The total costs of health and social services for the HE patient-caregiver dyads ( in US dollars per dyad per year ) were $ 25,112 ( 95 % CI , $ 17,642 to $ 32,581 ) ( P = .13 for comparison with the CG ) , $ 22,066 in the GE group ( $ 15,931 to $ 28,199 ; P = .03 vs CG ) , and $ 34,121 ( $ 24,559 to $ 43,681 ) in the CG . CONCLUSIONS AND RELEVANCE An intensive and long-term exercise program had beneficial effects on the physical functioning of patients with AD without increasing the total costs of health and social services or causing any significant adverse effects . TRIAL REGISTRATION anzctr.org.au Identifier : ACTRN12608000037303 Background With the rising number of dementia patients with associated costs and the recognition that there is room for improvement in the provision of dementia care , the question arises on how to efficiently provide high quality dementia care . Objective To describe the design of a study to determine multidisciplinary memory clinics ’ ( MMC ) effectiveness and cost-effectiveness in post-diagnosis treatment and care-coordination of dementia patients and their caregivers compared to the post-diagnosis treatment and care-coordination by general practitioners ( GP ) . Next , this article provides the theoretical background of pragmatic trials , often needed in complex interventions , with the AD- Euro study as an example of such a pragmatic approach in a clinical trial . Method The study is a pragmatic multicentre , r and omised clinical trial with an economic evaluation alongside , which aims to recruit 220 independently living patients with a new dementia diagnosis and their informal caregivers . After baseline measurements , patient and caregiver are allocated to the treatment arm MMC or GP and are visited for follow up measurements at 6 and 12 months . Primary outcome measures are Health Related Quality of Life of the patient as rated by the caregiver using the Quality of Life in Alzheimer ’s Disease instrument ( Qol-AD ) and self-perceived caregiving burden of the informal caregiver measured using the Sense of Competence Question naire ( SCQ ) . To establish cost-effectiveness a cost-utility analysis using utilities generated by the EuroQol instrument ( EQ-5D ) will be conducted from a societal perspective . Analyses will be done in an intention-to-treat fashion . Results The inclusion period started in January 2008 and will commence until at least December 2008 . After finalising follow up the results of the study are expected to be available halfway through 2010 . Discussion The study will provide an answer to whether follow-up of dementia patients can best be done in specialised outpatient memory clinics or in primary care setting s with regard to quality and costs . It will enable decision making on how to provide good and efficient health care services in dementia . Trial registration Clinical Trials.gov Identifier Context Dementia is an incurable chronic disease , but assistance to caregivers can reduce the severity of patients ' symptoms and delay institutionalization . Because this assistance requires provision of multiple health care and social services , patients and caregivers might benefit from a coordinated system of care . Contribution The investigators r and omly assigned patients with dementia and their caregivers to usual care or to a coordinated system of care . In the coordinated system , care managers regularly assessed patient and caregiver pairs and coordinated guideline -recommended provision of services by health care providers and community agencies using computerized information systems . The study found that pairs cared for in the coordinated system received higher- quality health care and more needed assistance than those who received usual care . Caution s The study focused on a relatively homogeneous population of white , well-educated , otherwise healthy , noninstitutionalized patients with health insurance . The findings might not apply to other population s. Implication s The quality of care for patients with dementia and their caregivers can be improved with a model of care in which services provided by the health system and community agencies are coordinated by a care manager . The Editors Dementia has enormous health and financial consequences for affected individuals , their family caregivers , and society ( 15 ) . Although most dementia is currently neither preventable nor reversible , existing practice guidelines reflect evidence from r and omized , controlled trials that caregiver assistance and support can delay institutionalization ( 68 ) , and nonpharmacologic management of problem behaviors and depression can reduce symptom severity and improve patient health ( 9 , 10 ) . Yet , adherence to published dementia care guidelines ( 1114 ) is poor ( 15 ) , including inappropriate use of psychoactive medications for initial management of agitation ( 16 ) ; low referral rates to community agencies ( 17 , 18 ) ; and underdetection of elder abuse , for which cognitive impairment is a risk factor ( 19 ) , and of depression ( 20 ) , a common comorbid condition ( 21 ) . There are few controlled trials of improvement interventions for dementia care . An opinion leader intervention improved neurologists ' reported adherence to dementia care guidelines ( 18 ) , and a recent trial using advanced practice nurses within primary care improved care quality ( 22 ) ; other trials reported limited impacts ( 23 , 24 ) . All studies were conducted primarily within or outside of health care delivery systems ; to date , trials of comprehensive , guideline -based dementia care interventions that incorporate all chronic care model components , including substantive collaboration between health systems and community agencies ( 25 , 26 ) , have not been reported . Yet , this would seem to be a well-suited approach because of the multifaceted nature of dementia care management and the need for coordinated efforts across health care delivery systems and community agencies to provide recommended medical , behavioral , and social services and support . To address gaps in care quality for persons with dementia , we design ed and tested a guideline -based , comprehensive dementia care management intervention in a clinic-level , cluster r and omized , controlled trial ( 27 ) . Intervention components were based on the chronic care model and emphasized linkages with community re sources and multiagency coordination ( 25 , 26 , 28 ) . Key components included dementia care managers , formal procedures for communication within and between organizations and agencies , Internet-based care management , collaborative care planning with caregivers , caregiver self-management support , ongoing follow-up , and provider education . We hypothesized that patient and caregiver dyads in intervention clinics would receive care in higher accordance with guidelines ; receive more community re sources and services ; have fewer unmet caregiving assistance needs ; and have better patient and caregiver health and caregiving quality , social support , and perceived care quality than dyads receiving usual care . Methods The institutional review boards of the University of California , Los Angeles , and all participating health care organizations approved the study procedures . All enrolled patient and caregiver dyads provided written informed consent . Three health care organizations ( Kaiser Permanente San Diego , Scripps Clinic , University of California , San Diego , Healthcare ) and 3 community agencies ( Alzheimer 's AssociationSan Diego Chapter , Southern Caregiver Re source Center , Meals on WheelsGreater San Diego ) providing services for persons with dementia and their informal caregivers in the San Diego metropolitan area participated . Private group practice , academic group practice , and health maintenance organization practice types were represented by the 3 health care organizations . Study Participants The study included 18 clinics from the participating health care organizations ( 4 to 8 per organization ) ( Table 1 ) . The inclusion criterion was that these be primary care clinics . Table 1 . Characteristics of Participating Health Care Organizations * Patients with dementia who were age 65 years or older and receiving Medicare were identified by querying health care organization administrative data bases for occurrence during the previous year of a dementia diagnosis code ( 29 ) at an outpatient visit or hospitalization or a cholinesterase inhibitor prescription . Patient lists were grouped by primary provider and were circulated to those providers for confirmation of dementia diagnosis and identification of additional potential participants from his or her practice ( generating < 5 % of the sample ) . Patients had to have an informal caregiver ( age 18 years ) . Patients were recruited by mail with English- and Spanish- language letters from their physician and an opt-out postcard , followed by up to 3 mailings of a patient consent or assent form ( depending on the physician 's design ation of the patient 's ability to provide consent ) , a caregiver consent form ( containing a proxy consent for the patient if he or she was judged unable to provide consent ) , and a baseline caregiver survey . R and omization was conducted at the clinic level , based on the clinic-focused design of the care management intervention . Within each health care organization , we paired clinics by patient volume ; within each pair , we r and omly assigned 1 clinic to the intervention and the other clinic to usual care using a computerized r and om-number generator operated by a study statistician . Participants were unaware of clinic r and omization status at enrollment and at completion of the baseline survey and were not reminded of r and omization status at follow-up . Intervention A steering committee that included a physician from each health care organization , a leader from each community agency , a community caregiver , and investigators used a formal method ( 30 ) to identify 23 existing dementia guideline recommendations as care goals ( 11 , 12 , 14 ) . They also design ed a structured assessment , algorithms linking specific care management actions to assessment results , and interorganization care coordination and referral protocol s. A key intervention element was health care organization and community agencybased dementia care managers ( primarily social workers ) who received formal training and used an Internet-based care management software system for care planning and coordination ( 25 , 26 , 28 ) . Every enrolled patient and caregiver dyad in the intervention group was assigned 1 health care organization care manager , who contacted them to schedule a structured home assessment . Assessment responses were entered into the software system , generating a preliminary problem list and guides to care-plan actions . The care manager collaborated with the caregiver to prioritize problem areas ; teach problem-solving skills ; initiate care plan actions ; and send an assessment summary , a problem list , and selected recommendations to the patient 's primary care physician and other design ated providers . A menu of potential care plan actions ( for example , referral for respite care services ) was documented in a comprehensive care management manual . The care management protocol included ongoing follow-up , usually by telephone , with frequency based on need and a formal in-home re assessment every 6 months to assess the need for major care-plan revisions . The software system had a feature to enable efficient tracking of multiple cases and tasks . Referrals to a particular community agency were guided by flagged problem areas . With patient and caregiver consent , referrals were communicated through the software system to that agency , whose design ated care manager subsequently received system access to the assessment , problem list , and care plan . Each dyad could have 1 or more community agency care managers . Care managers from the health care organizations and community agencies received the same formal education and training program , which was conducted jointly , and met monthly to refine care coordination procedures . Care management began within a month after enrollment of the first dyads and was active throughout the study follow-up unless a case was closed , for example , because a patient moved out of the study area and no longer was enrolled in the health care organization . At each intervention clinic , more than 90 minutes of st and ardized , interactive seminars ( in up to 5 sessions ) on relevant care issues , including  evaluation of acute behavioral changes , depression management  , and determination of decision-making capacity  ( 31 ) , were offered to primary care providers . Selected intervention tools and documents with more detailed descriptions can be accessed at www.adc.ucla.edu/access/access.swf . Patients , caregivers , and providers in the usual care group were not offered study interventions . Outcome Measures Primary Outcome The study 's primary outcome was Background : There is a lack of appropriately design ed trials investigating the efficacy of psychosocial interventions for patients with mild dementia and their family caregivers . This paper reports the rationale and design of the Danish Alzheimer Disease Intervention Study and baseline characteristics of the cohort . Methods : The study was a 1-year multicentre r and omized controlled rater-blinded trial with r and omization to follow-up and a multifaceted semitailored intervention programme or to follow-up only ( with extension of follow-up to 3 years ) . The intervention included a counselling programme , teaching courses , written information and logbooks . The outcomes included clinical efficacy parameters , patient satisfaction and health economic consequences . Results : A total of 330 patients and their 330 caregivers were included during a period of 18 months . The majority ( 65.2 % ) of the caregivers were spouses . At inclusion the mean age of the patients and caregivers was 76.2 and 66.0 years , respectively . Conclusion : The study will explore the added value of a multifaceted intervention programme and contribute to the design of future interventions for patients with mild dementia and their caregivers Background Dementia is a costly disease . People with dementia , their families , and their friends are affected on personal , emotional , and financial levels . Prior work has shown that the “ Partners in Dementia Care ” ( PDC ) intervention addresses unmet needs and improves psychosocial outcomes and satisfaction with care . Objective We examined whether PDC reduced direct Veterans Health Administration ( VHA ) health care costs compared with usual care . Design This study was a cost analysis of the PDC intervention in a 30-month trial involving five VHA medical centers . Participants Study subjects were veterans ( N = 434 ) 50 years of age and older with dementia and their caregivers at two intervention ( N = 269 ) and three comparison sites ( N = 165 ) . Interventions PDC is a telephone-based care coordination and support service for veterans with dementia and their caregivers , delivered through partnerships between VHA medical centers and local Alzheimer ’s Association chapters . Main Measures We tested for differences in total VHA health care costs , including hospital , emergency department , nursing home , outpatient , and pharmacy costs , as well as program costs for intervention participants . Covariates included caregiver reports of veterans ’ cognitive impairment , behavior problems , and personal care dependencies . We used linear mixed model regression to model change in log total cost post-baseline over a 1-year follow-up period . Key Results Intervention participants showed higher VHA costs than usual-care participants both before and after the intervention but did not differ significantly regarding change in log costs from pre- to post-baseline periods . Pre-baseline log cost ( p ≤ 0.001 ) , baseline cognitive impairment ( p ≤ 0.05 ) , number of personal care dependencies ( p ≤ 0.01 ) , and VA service priority ( p ≤ 0.01 ) all predicted change in log total cost . Conclusions These analyses show that PDC meets veterans ’ needs without significantly increasing VHA health care costs . PDC addresses the priority area of care coordination in the National Plan to Address Alzheimer ’s Disease , offering a low-cost , structured , protocol -driven , evidence -based method for effectively delivering care coordination Objective To examine the effectiveness of  post-diagnosis dementia treatment and coordination of care by memory clinics compared with general practitioners . Design Multicentre r and omised controlled trial . Setting Nine memory clinics and 159 general practitioners in the Netherl and s. Participants 175 patients with a new diagnosis of mild to moderate dementia living in the community and their informal caregivers . Interventions Usual care provided by memory clinic or general practitioner . Main outcome measures Caregiver rated quality of life of the patient measured with the quality of life in Alzheimer ’s disease instrument and self perceived burden of the informal caregiver measured with the sense of competence question naire ( intention to treat analysis ) . Results The quality of life of the patients in the memory clinic group was 0.5 ( 95 % confidence interval −0.7 to 1.6 ) points higher than in the general practitioner group . Caregivers ’ burden was 2.4 ( −5.8 to 1.0 ) points lower in the memory clinic group than in the general practitioner group . Conclusion No evidence was found that memory clinics were more effective than general practitioners with regard to post-diagnosis treatment and coordination care for patients with dementia . Without further evidence on the effectiveness of these modalities , other arguments , such as cost minimisation , patients ’ preferences , or regional health service planning , can determine which type of dementia care is offered . Trial registration Clinical trials NCT00554047 OBJECTIVE To calculate intervention costs and the potential cost offset of a care management intervention that substantially improved the quality of dementia care . STUDY DESIGN From both a payer perspective and a social planner perspective , we analyzed data from a cluster r and omized controlled trial ( RCT ) evaluating this intervention versus usual care . The RCT included 408 pairs of older adults with dementia and their caregivers . Caregivers were surveyed at baseline , at 12 months , and at 18 months to assess patient healthcare utilization and out-of-pocket costs . METHODS We calculated fixed and per-patient intervention costs  from RCT records . We combined the monthly per-patient costs of healthcare services , informal caregiving , and out-of-pocket costs , and we conducted multivariate analyses comparing this sum ( potential cost offset ) for intervention versus usual care patients . Covariates included patient age , sex , and baseline costs . We limited the main analysis to patients who survived until the 12-month survey or the 18-month survey . RESULTS The intervention required a start-up cost of $ 70,256 and mean intervention per-patient per month costs of $ 118 . There were no significant differences in the mean monthly cost of healthcare and caregiving services for intervention versus usual care patients using the societal perspective ( difference of -$555 per month , P = .28 ) or the payer perspective ( difference of -$219 per month [ including nursing home costs ] , P = .55 ; difference of -$256 per month [ excluding nursing home costs ] , P = .47 ) . CONCLUSION Although this analysis of a dementia care management intervention did not demonstrate a significant cost offset , the intervention may represent a worthwhile approach to improving the quality of care and health outcomes for patients with dementia and their caregivers Background Joint reminiscence groups , involving people with dementia and family carers together , are popular , but the evidence -base is limited . This study aim ed to assess the effectiveness and cost-effectiveness of joint reminiscence groups as compared to usual care . Methods This multi-centre , pragmatic r and omised controlled trial had two parallel arms : intervention group and usual-care control group . A restricted dynamic method of r and omisation was used , with an overall allocation ratio of 1:1 , restricted to ensure viable sized intervention groups . Assessment s , blind to treatment allocation , were carried out at baseline , three months and ten months ( primary end-point ) , usually in the person 's home . Participants were recruited in eight centres , mainly through NHS Memory Clinics and NHS community mental health teams . Included participants were community resident people with mild to moderate dementia ( DSM-IV ) , who had a relative or other care-giver in regular contact , to act as informant and willing and able to participate in intervention . 71 % carers were spouses . 488 people with dementia ( mean age 77.5)were r and omised : 268 intervention , 220 control ; 350 dyads completed the study ( 206 intervention , 144 control ) . The intervention evaluated was joint reminiscence groups ( with up to 12 dyads ) weekly for twelve weeks ; monthly maintenance sessions for further seven months . Sessions followed a published treatment manual and were held in a variety of community setting s. Two trained facilitators in each centre were supported by volunteers . Primary outcome measures were self-reported quality of life for the person with dementia ( QoL-AD ) , psychological distress for the carer ( General Health Question naire , GHQ-28 ) . Secondary outcome measures included : autobiographical memory and activities of daily living for the person with dementia ; carer stress for the carer ; mood , relationship quality and service use and costs for both . Results The intention to treat analysis ( ANCOVA ) identified no differences in outcome between the intervention and control conditions on primary or secondary outcomes ( self-reported QoL-AD mean difference 0.07 ( -1.21 to 1.35 ) , F = 0.48 , p = 0.53 ) . Carers of people with dementia allocated to the reminiscence intervention reported a significant increase in anxiety on a General Health Question naire-28 sub-scale at the ten month end-point ( mean difference 1.25 ( 0.25 to 2.26 ) , F = 8.28 , p = 0.04 ) . Compliance analyses suggested improved autobiographical memory , quality of life and relationship quality for people with dementia attending more reminiscence sessions , however carers attending more groups showed increased care-giving stress . Economic analyses from a public sector perspective indicated that joint reminiscence groups are unlikely to be cost-effective . There were no significant adverse effects attributed to the intervention . Potential limitations of the study include less than optimal attendance at the group sessions — only 57 % of participants attended at least half of the intervention sessions over the 10 month period , and a higher rate of study withdrawal in the control group . Conclusions This trial does not support the clinical effectiveness or cost-effectiveness of joint reminiscence groups . Possible beneficial effects for people with dementia who attend sessions as planned are offset by raised anxiety and stress in their carers . The reasons for these discrepant outcomes need to be explored further , and may necessitate re appraisal of the movement towards joint interventions . Trial Registration IS RCT N Registry IS RCT OBJECTIVE Rising life expectancy is associated with higher prevalence rates of dementia disorders . When disease progresses the patients ' call on formal health care services and on social support grows which imposes increasing costs of care . The aim of this study was to investigate the costs for patients with mild and moderate dementia in community setting in Germany . METHODS We assessed  total costs of care  and individual cost components for 383 community-living dementia patients alongside a cluster-r and omized trial from societal and health insurance perspective .  Utilization of formal health care services was based on insurance cl aims data and time dedicated to informal care was assessed within caregiver interviews . We estimated costs using a two-part regression model adjusting for age , gender and cluster-effects . RESULTS Costs of care equal € 47,747 ( Euros ) from societal perspective which is almost the 4.7-fold of health insurance expenditures . Valued informal care covers 80.2 % of societal costs and increases disproportionally when disease progresses . In moderate dementia the corresponding amount exceeds the one in mild dementia by 69.9 % , whereas costs for formal health care services differ by 14.3 % . CONCLUSION Due to valued informal care , costs of care for community-living patients with moderate dementia are significantly higher than for patients with mild dementia . Informal care is a non-cash item saving expenditures for professional care . To relieve social security system and family caregivers as well as to allow dementia patients to stay at home as long as possible , concepts fostering community-based dementia care and support to family caregivers need to be further developed Objectives To examine the long-term efficacy at the 36-month follow-up of an early psychosocial counselling and support programme lasting 8–12 months for community-dwelling patients with mild Alzheimer 's disease and their caregivers . Design Multicentre , r and omised , controlled , rater-blinded trial . Setting Primary care and memory clinics in five Danish districts . Participants 330 home-dwelling patients with mild Alzheimer 's disease and their primary caregivers ( dyads ) . Interventions Dyads were r and omised to receive intervention during the first year after diagnosis . Both intervention and control groups had follow-up visits at 3 , 6 , 12 and 36 months . Main outcome measures Primary outcomes for the patients assessed at 36-month follow-up were changes from baseline in global cognitive function ( Mini-Mental State Examination ) , depressive symptoms ( Cornell Depression Scale ) and proxy-rated EuroQoL quality of life on visual analogue scale . The primary outcomes for the caregivers were changes from baseline in depressive symptoms ( Geriatric Depression Scale ) and self-rated EuroQoL quality of life on a visual analogue scale . The secondary outcome measures for the patient were proxy-rated Quality of Life Scale for Alzheimer 's disease ( QoL-AD ) , Neuropsychiatric Inventory- Question naire , Alzheimer 's disease Cooperative Study Activities of Daily Living Scale , all-cause mortality and nursing home placement . Results At a 36-month follow-up , 2 years after the completion of the Danish Alzheimer Intervention Study ( DAISY ) , the unadjusted positive effects previously detected at the 12-month follow-up in one patient primary outcome ( Cornell depression score ) and one patient secondary outcome ( proxy-rated QoL-AD ) disappeared ( Cornell depression score , p=0.93 ; proxy-rated QoL-AD , p=0.81 ) . No long-term effect of DAISY intervention on any other primary and secondary outcomes was found at the 36-month follow-up . Conclusions For patients with very mild Alzheimer 's disease and their caregivers , an intensive , multi-component , semitailored psychosocial intervention programme with counselling , education and support during the first year after diagnosis did not show any positive long-term effect on primary and secondary outcomes . Trial registration The study was registered in the Clinical Trial Data base ( http://www.controlled-trials.com/IS RCT N74848736 ) OBJECTIVES The aim of the REMiniscence groups for people with dementia and their family CAREgivers ( REMCARE ) study was to assess the effectiveness and cost-effectiveness of joint reminiscence groups for people with dementia and their family caregivers  as compared with usual care . DESIGN A multicentre , pragmatic r and omised controlled trial with two parallel arms - an intervention group and a usual-care control group - was carried out . A restricted dynamic method of r and omisation was used with an overall allocation ratio of 1 : 1 , restricted to ensure intervention groups of a viable size . Assessment s , blind to treatment allocation , were carried out at baseline , 3 months and 10 months ( primary end point ) . SETTING Most participants were recruited through NHS Memory Clinics and Community Mental Health Teams for older people . Assessment s were usually carried out in the person 's home , and treatment groups were held in a variety of community setting s. PARTICIPANTS A total of 488 individuals ( mean age 77.5 years ) with mild to moderate dementia ( meeting Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition criteria ) , who were initially living in the community , and who had a relative or other caregiver maintaining regular contact , who could act as an informant and was willing and able to participate in the intervention , were recruited to the study . Most carers were spouses ( 71 % ) . A total of 350 dyads completed the study . INTERVENTIONS The intervention consisted of joint reminiscence groups held weekly for 12 consecutive weeks , followed by monthly maintenance sessions for a further 7 months . The sessions followed a treatment manual , and were led by two trained facilitators in each centre , supported by a number of volunteers . Up to 12 dyads were invited to attend each group . MAIN OUTCOME MEASURES The primary outcome measures were self-reported quality of life for the person with dementia and psychological distress for the carer [ General Health Question naire-28 item version ( GHQ-28 ) ] . Secondary outcome measures included autobiographical memory and activities of daily living for the person with dementia , carer stress for the carer and mood , relationship quality and service use and costs for both parties . RESULTS The intention-to-treat analysis identified no differences in outcome between the intervention and control conditions on primary or secondary outcomes [ self-reported quality of life in Alzheimer 's disease : mean difference 0.07 , st and ard error ( SE ) 0.65 ; F = 0.48 ; p = 0.53 ] . Carers of people with dementia allocated to the reminiscence intervention reported a significant increase in anxiety on a subscale of the GHQ-28 at the 10-month end point ( mean difference 1.25 , SE 0.5 ; F = 8.28 ; p = 0.04 ) . Compliance analyses suggested some benefits for people with dementia who attended more reminiscence sessions ; however , carers attending more groups showed increased caregiving stress . Use of health- and social-care services was modest , with no significant difference in service use between conditions . Owing to negligible difference in quality -adjusted life-year gains ( derived from European Quality of Life-5 Dimensions ) between the conditions the planned full economic analysis was curtailed . CONCLUSIONS This trial does not provide support for the effectiveness or cost-effectiveness of joint reminiscence groups for people with dementia and their carers . Although there may be some beneficial effects for people with dementia who attend sessions as planned , this must be viewed in the context of raised anxiety and stress in their carers . The reasons for these discrepant outcomes need to be explored further , and may necessitate re appraisal of the movement towards joint interventions . TRIAL REGISTRATION Current Controlled Trials IS RCT N42430123 . FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 16 , No. 48 . See the HTA programme website for further project information Introduction “ Partners in Dementia Care ” ( PDC ) tested a care-coordination program based on partnerships between Veterans Affairs ( VA ) medical centers and Alzheimer 's Association chapters . The hypothesis posited PDC would reduce the likelihood and number of veterans ' hospital admissions and emergency department ( ED ) visits , particularly for those with more cognitive impairment or behavioral symptoms . Methods The sample included 328 veterans with dementia and their primary family or friend caregivers from five matched sites ( two r and omly selected treatment sites ) . Data came from VA records ; supplemented by caregiver research interviews . Regression analyses using the likelihood and number of hospital and ED visits as outcomes tested for overall treatment-comparison group differences and statistical interactions with cognitive impairment and behavioral symptoms . Results Consistent with the hypothesis , three significant interactions showed treatment-group veterans , with more cognitive impairment and behavioral symptoms , had fewer hospital admissions and ED visits than comparison-group veterans . There were no differences in the likelihood of hospital or ED use . Discussion PDC , a low-cost program for veterans and caregivers , was effective in reducing the number , but not the likelihood , of hospital admissions and ED visits . Reductions in service use were greater when caregivers reported more difficulties with veterans ' symptoms , which in the absence of PDC would place veterans at risk of being high-volume , high-cost service users . Clinical Trial Registration : Clinical Trials.gov : NCT00291161 Objective To compare the benefits and harms of a Dutch 10-session Community Occupational Therapy programme for patients with Alzheimer 's disease with the impact of a one session consultation at home in German routine healthcare . Design A seven-centre , parallel group , active controlled r and omised controlled trial . Patients and carers were not masked . Assessors were fully blind for treatment allocation for one of two primary - outcome measurements . Setting Patients ' homes . Participants Patients with mild to moderate Alzheimer 's disease ( Mini-Mental State Examination 14–24 ) , living in the community with primary carer available and without severe depression or behavioural symptoms , were eligible . Interventions Experimental 10 home visits within 5 weeks by an occupational therapist , educating patients in the performance of simplified daily activities and in the use of aids to compensate for cognitive decline ; and educating carers in coping with behaviour of the patient and in giving supervision to the patient . Control one home visit including individual counselling of patient and carer and explanation of a leaflet on coping with dementia in daily life . Outcome measures The primary outcome was the patient 's daily functioning measured with the Interview of Deterioration in Daily activities in Dementia and the Perceive , Recall , Plan and Perform System of Task Analysis . Assessment s were at baseline , 6 , 16 and 26 weeks , with a postal assessment at 52 weeks . Results 141 patients were 1:1 r and omised to the experimental ( N=71 ) and control group ( N=70 ) . Data for 54 and 50 participants were analysed . Patients ' daily functioning did not differ significantly between the experimental and control group at week 6 , 16 , 26 or 52 and remained stable over 26 weeks in both groups . No adverse events were associated with the interventions . Conclusions In German healthcare , a Dutch 10-session community occupational therapy was not better than a one-session consultation for the daily functioning of patients with Alzheimer 's disease . Further research on the transfer of complex psychosocial is needed . International Clinical Trials Registry Platform DRKS00000053 ; Funded by the German Federal Ministry of Health
BACKGROUND People with dementia who are admitted to hospital have worse outcomes than those without dementia .
Identifying interventions that could reduce the risk of hospitalisation in people with dementia has the potential to positively impact on lives of people with dementia .
This review aim ed to investigate whether there are non-pharmacological interventions that successfully reduce hospitalisation risk , length of stay and mortality in people with dementia .