25 Jun 2010

For conditions as complex and devastating as Alzheimer disease, one might assume that guideline-based care delivered by multidisciplinary experts with skilled caregiver help would make some difference for patients. However, a study published online June 3 in the British Medical Journal found that after two years, French AD patients on a comprehensive care plan fared no better than study participants receiving standard care at memory clinics. Bruno Vellas of Toulouse University Hospital, France, led the study on behalf of the PLASA (Plan de Soin et d’Aide dans la maladie d’Alzheimer, or “Specific Care and Assistant Plan for Alzheimer’s Disease”) group. Despite its negative findings, the study provides a way to measure feasibility and effectiveness of physician-delivered dementia care and underscores the need to develop care plans that doctors can integrate into their practice.

It goes without saying that caring for dementia patients is demanding and costly, and subpar quality care is sometimes meted out by both caregivers (Chodosh et al., 2007) and physicians (Gifford et al., 1999). A few studies in dementia patients suggest that better care could have an impact, at least for improving behavioral and psychological symptoms (Callahan et al., 2006; Chenoweth et al., 2009). But the current study is the first randomized trial to test, at a nationwide level, whether a specific care plan could slow functional decline compared to usual care at memory clinics.

First author Fati Nourhashemi and colleagues recruited 1,131 mild to moderate AD patients at 50 memory clinics in France. Patients at 24 clinics were randomized to receive the center’s usual care, while participants at the other 26 clinics comprised the intervention group, which got checklist-based evaluations every six months plus additional consultations as needed. The checklist queried patients’ and caregivers’ understanding of the illness, and assessed caregiver health, and patient well-being as determined by a slew of factors including nutritional status, physical fitness, functional capacities, behavioral symptoms, and sleeping patterns. The authors administered the Alzheimer’s Disease Cooperative Study Activities of Daily Living exam (a 23-item caregiver-related questionnaire) at baseline and at one- and two-year follow-ups. This was the study’s primary outcome measure, and unfortunately, revealed no difference between the usual care and intervention groups. Both groups deteriorated by about six points each year, faring comparably to—even a tad better than—placebo groups in recent AD clinical trials of tarenflurbil (e.g., Wilcock et al., 2008) and secretagogue (Sevigny et al., 2008), noted the authors. Patients on the specific care plan also fared just as poorly as did the usual care group on both secondary outcome measures in the current study: rates of institutionalization and death.

The study comes as a disappointment since care plans seemed promising in previous studies (Callahan et al., 2006; Chenoweth et al., 2009). In an accompanying editorial (Schneider, 2010), Lon Schneider of the University of Southern California, Los Angeles, notes that prior studies “focused more on patients’ potentially disruptive behaviors and required additional clinician resources that most doctors, including those at specialty clinics, may not be able to access.” He points out that the study design makes it hard to determine whether the “usual care” received by the control group differs much from the “comprehensive care” received by the intervention group. All participants were treated at memory clinics; there was no general practice comparison group. Nevertheless, the results of the current study “should not deter clinicians from providing care that is consistent with this care plan and with evidence-based guidelines,” he wrote.—Esther Landhuis