3D Team Care for Cognitively Vulnerable Older Adults

  • STATUS
    Recruiting
  • End date
    Jul 31, 2024
  • participants needed
    576
  • sponsor
    UConn Health
Updated on 8 April 2023
depression
cognitive impairment
dementia
depressed mood

Summary

This study addresses how to achieve better outcomes for cognitively vulnerable community-dwelling older adults and their families. Cognitive vulnerability means living with dementia, depression, and/or a recent episode of delirium (the 3Ds). The investigators will test the effectiveness of a team care model focused on the 3Ds (Home Based Care Team) guided by nurse practitioners with expertise in geriatrics and geriatric psychiatry. Specific aims are to determine Home Based Care Team effects on hospitalization or emergency department use, and other outcomes including depression, disability, and quality of life.

Description

This study addresses how to achieve better outcomes for cognitively vulnerable community-dwelling older adults and their families. Cognitive vulnerability means living with dementia, depression, and/or a recent episode of delirium (the 3Ds). Cognitive vulnerability in older adults is often overlooked by primary care and hospital-based providers, and represents a marker for overall vulnerability or frailty often missed when disease-specific approaches are emphasized in the care for older adults. Such patients often cannot adequately self-manage their comorbidities. Many studies of older adults and their families have demonstrated the great burden of living with cognitive vulnerability. The investigators will test the effectiveness of a team care model focused on the 3Ds (Home Based Care Team) guided by nurse practitioners with geriatrics expertise. Other team member disciplines will include pharmacy, social work, occupational and physical therapy, nutrition, and community health worker. Long-term objectives are to determine whether this care model can become a widely available approach for improving healthcare systems for older adults with cognitive vulnerability and their families, while improving outcomes of importance to these patients and families. A project Steering Committee, including cognitively vulnerable patients and family caregivers, will provide extensive input into many aspects of the research process.

Details
Condition Dementia, Depression, Delirium
Treatment Home Based Care Team, Telephone Based Care Team
Clinical Study IdentifierNCT02945085
SponsorUConn Health
Last Modified on8 April 2023

Eligibility

Yes No Not Sure

Inclusion Criteria

Evidence of dementia, depression, and/or delirium, based on diagnostic codes found in medical claims data and based on screening at time of study screening
Living in the community, including assisted living facility, at time of randomization
Plan to live in geographic area for 12 months
Speak or understand English
Willing to be randomly assigned to intervention or active comparator group

Exclusion Criteria

Diagnosed schizophrenia or bipolar disorder
Bedbound and non-communicative
Life expectancy <12 months
Already enrolled in active comparator program
For individuals with dementia, family caregiver is unavailable or unwilling to enroll in study
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Additional screening procedures may be conducted by the study team before you can be confirmed eligible to participate.

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If you are confirmed eligible after full screening, you will be required to understand and sign the informed consent if you decide to enroll in the study. Once enrolled you may be asked to make scheduled visits over a period of time.

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Complete your scheduled study participation activities and then you are done. You may receive summary of study results if provided by the sponsor.

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