Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

In patients with dementia, what is the effectiveness of psychological treatment (i.e., non-pharmacological; e.g., cognitive or behavioral therapy for individuals with dementia; environmental and behavioral interventions to address behavioral change in individuals with dementia; psychotherapy/ psychoeducation for family caregivers) to treat depression, anxiety, and agitation.

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

1. Cognitive versus behavioral therapy for individuals with mild dementia;
2. Individual versus group psychotherapy for individuals with mild dementia;
3. Behavioral management training for caregivers versus usual care for treating behaviors in individuals with moderate-severe dementia;
4. Non-pharmacological interventions versus psychopharmacology for depression, anxiety, and agitation in dementia;
5. Impact of environmental changes on behavior versus usual care
6. Differential effectiveness across disease course

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Individuals with dementia, typically age 60+ (although earlier onset is possible)

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Mild cognitive impairment to moderate-severe dementia.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

1. Reduction in symptoms of depression and anxiety;
2. Reduction and physically or verbally aggressive behaviors;
3. Improvement in "patient centered" care indices as rated by patients and families;
4. Maintenance and/or improvement in function;
5. Reduction in adverse events, falls, hospitalizations, infection;
6. Improved caregiver coping and stress management

Describe any health-related risks, side effects, or harms that you are concerned about.

1. Weight gain, sedation, mortality associated with off-label use of atypical antipsychotics in dementia; 2. Cognitive slowing associated with use of anti-depressants and anti-anxiety medications in elderly adults.
2. Falls, hospitalizations and excess disability related to absence of behavioral and environmental supports.

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Dementia, including Alzheimer's disease

AHRQ Priority Populations

• Elderly
• Individuals with special health care needs, including individuals with disabilities or who need chronic care or end-of-life health care

Federal Health Care Program

• Medicaid
• Medicare

Importance

Describe why this topic is important.

Dementia is a heterogeneous set of diseases whose prevalence is rapidly increasing. It is often progressive in nature, with ever-changing needs of the individual, caregivers, and service systems supporting individuals with dementia. Associated with dementia, psychological comorbidities (e.g., depression, anxiety) are common, detrimental to quality of life, and amenable to treatment. There is a range of effective psychosocial interventions for comorbid psychiatric syndromes and behavioral dysregulation that can be targeted to individuals with dementia and to family and professional caregivers. Given the complexity of presentation, disease course, and interventional strategies for persons with dementia, a research summary, integrating the diverse literature regarding evidenced based interventions at various disease points, would be tremendously beneficial for psychologists and other mental health specialists.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

A systematic review of non-pharmacological treatments for persons with dementia could support clinical guidelines to inform clinical care, as well as inform the Centers for Medicare and Medicaid Services (CMS) in establishing regulatory and reimbursement practices.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

Clinicians and policy makers may be uncertain about which treatments are most effective at which points in the disease course. Pharmacological treatments, although more efficient, may not be more efficacious. For example, the recent AHQR report Comparison of Characteristics of Nursing Homes and Other Residential Long Term Care Settings for People with Dementia reviews interventions that improve processes of care, ranging from creative storytelling, to sensory stimulation, to person-centered protocols for care – all psychological interventions. More information is needed about the professional competencies necessary to provide effective interventions and/ or teaching of others to provide such interventions, and the relevant range of impairment.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

A review of this topic would be useful for psychologists, social workers, nurses and other psychosocial care providers in selecting treatment modalities for persons with dementia; defining treatment doses (e.g., number of therapy sessions and follow up sessions needed to sustain gain); determining limits of treatment (e.g., when an individual is too impaired to benefit from a specific form of treatment). Also, this information may help to support the engagement of behavioral health providers in non-traditional settings and activities that fall outside traditional reimbursement mechanisms in support of individuals with dementia, e.g. home based care, nursing homes and assisted living communities.

Describe the timeframe in which an answer to your question is needed.

By 2030, 7.7 million adults in the United States over the age of 65 will have dementia; by 2050, over 15 million people will be afflicted. The IOM has highlighted the significant shortage of professionals trained to work with older populations. Information about treating dementia is dispersed across several disciplines; thus, there is an urgent need to integrated the diverse literature regarding evidenced based interventions.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

Age is an important but often overlooked diversity variable. The number and proportion of older adults in our society is expanding dramatically. By 2030, there will be 71 million American older adults accounting for approximately 20% of the U.S. population. The older population is increasingly ethnically and racially diverse, who are more at risk for developing dementia. Numerous studies have documented substantial under-treatment of psychiatric syndromes in older adults, and under-recognition and treatment of dementia.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

A review of this topic would be useful for psychologists, social workers, nurses and other psychosocial care providers in selecting treatment modalities for persons with dementia; defining treatment doses (e.g., number of therapy sessions and follow up sessions needed to sustain gain); determining limits of treatment (e.g., when an individual is too impaired to benefit from a specific form of treatment). Also, this information may help to support the engagement of behavioral health providers in non-traditional settings and activities that fall outside traditional reimbursement mechanisms in support of individuals with dementia, e.g. home based care, nursing homes and assisted living communities.

Are you making a suggestion as an individual or on behalf of an organization?

Organization

Please tell us how you heard about the Effective Health Care Program

From a colleague