staff members frequently were the
first ones to be called (at times for issues unrelated to dementia).
Unfortunately, DEMO was
underresourced to provide either
real-time feedback true or first
responder services. Misunderstandings concerning this were an early
challenge to PCP acceptance. However, the longitudinal presence and
close working relationships of the
DEMO teamlet in each CBOC allowed their use as an adjunct to
primary care, and increased the
efficacy of both.
A number of additional caveats
must be made. First, this study had
a relatively small number of participants, and there was great variability in health care utilization. This
is particularly germane in this population of patients with dementia,
which typically has an asymmetrically high use of health care resources. Additionally, the relatively
limited follow-up period may have
blunted the programs true effect(s).
Further, although veterans in the
nonconsented group were not officially enrolled in the program, there
was likely spillover of the effects of
the program on practice patterns,
leading to an underestimation of the
With minimal resources, DEMO
successfully brought expert evalu-
ation (usually tertiary referral) ser-
vices, and provided specialized case
management in coordination with
existing primary care to remote pa-
tients. Although there were a num-
ber of features rather unique to this
setting (eg, infrastructural support;
close working interdisciplinary and
interprofessional relationships, buy-
in at all levels, relative geographic
ity of participants), specialized case
management is increasingly being
adopted throughout the VA (and
elsewhere). Although the value of
collaborative, interdisciplinary in-
terventions has been shown in a
variety of settings and conditions—
nursing homes, 9 chronic low back
pain, 10 safety among hospital in-
patients11—its utility for dementia
care is relatively underexplored.
Yet the effectiveness of team-based care for individuals has been
demonstrated in a number of settings, including Alzheimer disease. 12, 13 In addition to involving a
number of disciplines, collaborative care is marked by coordination.
A number of recent systematic reviews have found that behavioral
and multicomponent interventions directed towards the caregiver
as well as case management were
beneficial in improving some outcomes, although there is considerable heterogeneity in the effects. 14, 15
Future work will focus on examining methods to focus/optimize
interventions based on individual
Given the epidemiologic trends,
care for patients with dementia is
expected to grow. Novel interven-
tions, like DEMO, are a particularly
promising option to meet this chal-
lenge. In fact, just such a collabora-
tive practice-ready workforce has
been identified by the World Health
Organization as crucial to meeting
the challenges of the health needs in
the 21st century. 16 With the feasibil-
ity of such an approach in this pop-
ulation now evident, further studies
(including larger sample sizes,
across greater geographic regions, as
well as among more diverse popula-
tions) should be undertaken. These
results, if replicated, suggest a novel
approach to the particularly vexing
problem of caring for patients with
dementia with potentially far-reach-
ing public health implications. l
Supported with T21 funds from VA to
expand noninstitutional alternatives
to institutional extended care for veterans, as well as the Geriatrics Research and Clinical Center (GRECC)
at the Baltimore VAMC.
Dr. Brandt is subcontractor to Econo-metrica, Health Resources & Service
Administration (HRSA), a consultant
to the Center for Medicare and Medicaid Services and CVS Health Omnicare, and serves on the pharmacy
and therapeutic committee advisory
boards for Omnicare and Remidi Se-niorCare. No other authors have conflicts of interest to report.
The opinions expressed herein are
those of the authors and do not
necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S.
Government, or any of its agencies.
This article may discuss unlabeled or
investigational use of certain drugs.
Please review the complete prescribing information for specific drugs or
drug combinations—including indications, contraindications, warnings,
and adverse effects—before administering pharmacologic therapy to
1. National Committee for Quality Assurance. 2011
HEDIS List. http://www.ncqa.org/tabid/1274
/ Default.aspx. Accessed December 16, 2016.
2. Russ TC, Batty GD, Hearnshaw GF, Fenton C,
Starr JM. Geographical variation in dementia: systemic review with meta-analysis. Int J Epidemiol.
2012; 41( 4):1012-1032.
3. Wolfs CA, Kessels A, Dirksen CD, Severens JL,
Verhey FR. Integrated multidisciplinary diagnostic
approach for dementia care: randomized controlled
trial. Br J Psychiatry. 2008;192( 4):300-305.