Primary Care Providers Are Challenged by Dementia Care

An excellent article in the Journal of the American Geriatrics Society provides insights into primary care physicians views of dementia care. Since the vast majority of patients with dementia are cared for by primary care providers, improving care makes it very important to understand the perspective of their providers. The paper is authored by Dr. Dorothy Harris of UCLA.

The authors surveyed 164 primary care providers (mostly family physicians and internists). The survey primarily compared the providers’ views of caring for dementia, with that of caring for diabetes and heart disease. The key findings:

• Providers were much more likely to somewhat or strongly agree that dementia is difficult to manage (56%) than heart disease (22%) or diabetes (22%)
• Providers were much less likely to stronlgy agree that they could improve the quality of life for patients with dementia (31%) compared to heart disease (59%) or diabetes (62%)
• Providers were much less likely to strongly agree that their health care organization had the resources to manage dementia (21%) than for heart disease (52%) or diabetes (49%).

On the one hand, it is not surprising that clinicians lacked confidence that they could improve the quality of life for patients with dementia. For heart disease and diabetes, there are effective pharmacologic therapies that significantly alter the natural history of the disease and clearly improve outcomes and quality of life. For dementia, the ability to change the natural history of the disease is very limited, and existing pharmacologic treatments are of marginal benefit.

On the other hand, behavioral and psychosocial interventions are very effective at improving patient and caregiver quality of life and outcomes in dementia. (see Vickrey, Belle, and Callahan studies). However, these interventions take training to administer, and require team based approaches. They are not purely clinic based, but require collaboration with community-based service providers. Further, Medicare and other insurers do not pay for these approaches and support for services aimed at helping family caregivers is woefully inadequate. Bree Johnston and I previously notedthat if these behavioral interventions were drugs, they would be on the fast track to approval.

The difficulty reported by clinicians likely reflects the reality that few health systems have the necessary systems in place to optimally care for patients with dementia. Improving care will require changes at the system level that enable primary care providers to coordinate optimal care. And as noted by Harris:

“The challange lies in instituting cultural changes in primary care practice and training—such as making the caregiver a focal point of care interventions–to elevate this type of care to the same status as practices for treating heart disease, diabetes mellitus, and other common conditions that rely more centrally on prescribing medications.”