Optimizing Dementia Care Through Collaborative Recovery Interventions

 说明： 在65岁及以上的退伍军人中，超过7%的人患有痴呆症，这些退伍军人通过退伍军人健康管理局(VHA)寻求治疗，在一些退伍军人中，每11名退伍军人中就有一名患有痴呆症。与阿尔茨海默氏症或相关痴呆症(ADRD)相关的独特的功能和行为障碍极大地导致了家庭照顾者的心理和身体发病率以及疗养院的高安置，60%的ADRD照顾者将照看的情绪压力评为“高度或非常高”，超过三分之一的人报告了抑郁症状。尽管已经开发了许多循证干预措施来减轻照顾者的负担，并改善痴呆症患者的心理健康和功能结果，但最近的一项系统审查指出，这些干预措施几乎没有一项可以在临床环境中随时获得。 护理会诊(CC)已成为一个罕见的例外。CC是一种基于证据的电话干预，在安全、心理和行为健康支持等不同领域提供心理教育、护理协调和资源转介。然而，CC对教练和支持的关注不足以应对经历高度痛苦的二人组。分步干预的方法将满足退伍军人管理局的效率需求，同时允许灵活地在现有的CC框架之外提供更多资源密集型的额外咨询，当出现高度二元痛苦时。CDA-2提案将推动这种二元干预。目标：1)将护理、咨询和咨询组成部分(即CC+C干预)整合起来。CC+C以基于康复的概念模型为指导，使用以患者为中心的方法解决最常见的高苦恼目标(例如，关系苦恼、退伍军人或照顾者抑郁、焦虑或疼痛)。2)评估CC+C干预的初步有效性和可行性，以比较：a)已建立的CC干预，b)CC+C干预对退伍军人和照顾者预后的影响。3)对6个月和12个月的退伍军人长期护理安置CC+C干预进行探索性分析，考察可能影响干预参与度和治疗反应的两个关键治疗调节变量(行为症状和配偶关系状况)。 方法：研究小组在CDA-1期间开发的十个模块结合了现有手动治疗和练习的成功要素，将与CC整合到CC+C干预手册草案中。手册最终定稿时将考虑到指导小组和专家咨询小组对完整性、可行性以及安全和风险方面的考虑。接下来，68名患有痴呆症的苦恼退伍军人及其家庭照顾者将被招募并随机分为CC+C干预组或CC对照组。患者、照顾者和关系结果(例如，负担、抑郁症状、焦虑、生活质量、关系困扰)将在基线、6个月和12个月时进行测量。将收集治疗实施情况和可行性数据。预期影响：这项职业发展提案的目标是获得必要的知识、技能和经验，以成功竞争RR&D功绩评审奖，评估一项旨在建立CC+C干预有效性和测试有效性的随机对照试验。以康复为重点的干预措施，最大限度地发挥功能，对于未来成功的非机构VA痴呆症护理至关重要。在CDA-2期间完成的工作将成为致力于实现这一目标的职业生涯的基础。这项工作的影响将在一种有效和高度可获得的康复干预措施，如正在试点的基于电话的二元干预措施为老年退伍军人及其家人提供时才能实现。

 DESCRIPTION: Dementia affects over 7% of veterans age 65 and above seeking care through the Veteran's Health Administration (VHA), amounting to one out of every eleven veterans in some VISNs. The unique functional and behavioral impairments associated with Alzheimer's or a related dementia (ADRD) contribute substantially to psychological and physical morbidity of family caregivers and high rates of nursing home placement, with 60% of ADRD caregivers rating the emotional stress of caregiving as "high or very high," and over one third reporting depressive symptoms. Although numerous evidence-based interventions have been developed to reduce caregiver burden and improve mental health and functional outcomes of the person with dementia, a recent systematic review noted almost none of these interventions "make it off of the shelf" to be readily available in clinical settings. Care Consultation (CC) has emerged as a rare exception. CC is an evidence-based telephone intervention delivering psychoeducation, care coordination, and resource referrals in diverse areas such as safety and mental and behavioral health support. Yet CC's focus on coaching and support is inadequate for dyads experiencing high levels of distress. A stepped- intervention approach would address the VA's efficiency needs while allowing the flexibility for more resource-intensive additional counseling beyond the established CC framework when warranted by high dyad distress. This CDA-2 proposal would move such a dyadic intervention forward. Objectives: 1) Manualize the integration of care consultation and counseling components (i.e., the CC+C intervention). CC+C is guided by a rehabilitation recovery-based conceptual model to address the most common high distress targets (e.g., relationship distress, veteran or caregiver depression, anxiety, or pain) using patient-centered approaches. 2) Evaluate preliminary effectiveness and feasibility of the CC+C Intervention in a randomized controlled pilot study of distressed dyads to compare: a) the established CC intervention, to b) the CC+C intervention on veteran and caregiver outcomes. 3) Conduct exploratory analyses of the CC+C intervention on veteran long-term care placement at six and 12 months and examine two key treatment moderators (behavioral symptoms and spousal relationship status) that may impact intervention engagement and response to treatment. Methods: Ten modules combining successful elements from existing manualized therapies and exercises developed by the investigative team during the CDA-1 period will be integrated with CC into a draft CC+C intervention manual. The manual will be finalized with input from the mentoring team and an Expert Advisory Panel for completeness, feasibility, and safety and risk considerations. Next 68 distressed veterans with dementia and their family caregivers will be recruited and randomized to either the CC+C intervention group or the CC comparison group. Patient, caregiver, and relationship outcomes (e.g., burden, depressive symptoms, anxiety, quality of life, relationship distress) will be measured at baseline, 6 months, and 12 months. Treatment implementation and feasibility data will be collected. Anticipated Impacts: The goal of this career development proposal is to acquire the knowledge, skills and experience necessary to successfully compete for an RR&D Merit Review Award evaluating a randomized controlled trial powered to establish efficacy and test effectiveness of the CC+C intervention. Rehabilitation- focused interventions that maximize functioning are essential for successful non-institutional VA dementia care in the future. Work completed during the CDA-2 period will serve as a foundation for a career committed to this goal. The impact of this work will be realized when an efficacious and highly-accessible rehabilitation intervention, such as the telephone-based dyadic intervention being piloted, becomes available for aging veterans and their families.