University of California, Davis
Reducing Inappropriate Medication use for Behavioral and Psychological Symptoms of Dementia and Improving Health Outcomes in People Living with Dementia
Health Care Systems
UC Davis Community Physician Network
Dr. Kales is chair of Psychiatry and Behavioral Sciences at University of California, Davis. As a fellowship-trained, board-certified geriatric psychiatrist, Dr. Kale’s research program is directly informed by clinical work and experiences with patients, families, providers, and systems to diminish the barriers to effective and high-quality care for older patients with mental health issues and/or dementia and their care partners. She is a national and international expert in outcomes related to later-life depression, the risks of using antipsychotic and other psychotropic medications in older adults, and in researching ways to improve dementia care. Dr. Kales was named to the standing Lancet Global Commission on Dementia Care in recognition of her work in the field of dementia care.
RATIONALE: Managing behavioral and psychological symptoms of dementia (BPSD) is one of the most challenging aspects of caring for people living with dementia (PLWD). Behavioral and environmental interventions are the preferred first-line treatment approach to reduce excessive and inappropriate medication use to manage BPSD in PLWD. Despite the promise of these evidence-based interventions, there is relatively little translation into real-world clinical management, particularly in the primary care setting.
OBJECTIVE: To embed and test the feasibility and acceptability of delivering the DICE (Decide-Investigate-Create-Evaluate) model into primary care to manage BPSD among PLWD.
SETTING: Four primary care practices in the Primary Care Network at University of California, Davis.
POPULATION: PLWD and care partner dyads with upcoming appointments identified using electronic medical records or by clinic staff.
INTERVENTION: The DICE model is a low-cost, practical, patient- and care partner-centric, evidence-informed approach that systematically guides clinicians and care partners through the assessment and management of BPSD and teaches new problem-solving skills. DICE is comprised of in-person and online module-driven training, including a DICE manual, designed for clinicians and care partners of PLWD. The clinical social worker embedded at each primary care clinic serves as the onsite DICE coordinator and meets with PLWD-care partner dyads in-person or by zoom using the DICE approach to assess and manage BPSD.
OUTCOMES: The primary clinical outcome is the rate of psychotropic medication use at 6 months post intervention. Secondary outcomes include hospitalizations, emergency department visits and nursing home placement. Implementation endpoints include feasibility, time required to deliver DICE, and acceptability to PLWD and care partners.
IMPACT: Embedding the DICE model into primary care has high potential to ensure a systematic approach to provide evidence-based care for managing BPSD and reduce psychotropic medication use. Findings from this pilot study for an embedded pragmatic clinical trial (ePCT) will inform the design of a full-scale ePCT to test the effectiveness of the DICE approach to improve outcomes for PLWD in primary care settings.