Many people would like to live at home for as long as possible in older age. A review was undertaken to ascertain whether case management improves outcomes for those living with dementia at home
Citation: Christie J (2015) Using case management to support people with dementia. Nursing Times; 111: 43, 20.
Author: Janice Christie is senior lecturer, nursing, School of Nursing, Midwifery and Social Work, University of Manchester.
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Many people with dementia need support from carers to avoid institutional care. Case (also sometimes called care) management is community-based professional care that offers planned, coordinated support, tailored to individual patients that enables them to live at home. This Cochrane review explored whether case management can help people with dementia live at home for longer than other interventions.
Does case management versus usual forms of community support improve outcomes for people living with dementia at home?
The review included randomised controlled trials with people of any age, with any type of dementia. The studies had to evaluate the effect of case management versus usual community-based care (hospital or residential care was excluded). Primary outcomes for people with dementia were:
- Admissions to nursing home care;
- Time in care or time to admission to nursing home care;
- Hospital admission;
- Quality of life (QoL).
Carer burden/quality of life and short- (<12 months), medium- (12-18 months) and long-term (>18 months) outcomes were also considered.
Thirteen RCTs from Canada, Hong Kong, India, The Netherlands, UK and US (with a low-to-moderate risk of bias) were included. This gave a total of 9,615 participants of whom 8,095 came from one large study from the US.
A meta-analysis found evidence that case management reduced the number of individuals admitted to residential or nursing homes versus other forms of community-based care at six months and 18 months. Nonetheless, no evidence of a statistical difference was found at either >12 months or 24 months. The available data about the impact of case management on the reduction of the number of days in a residential home/hospital unit and care recipient mortality was inconclusive.
Carer quality of life was assessed in five trials over various data collection time points. Single-study data at four and six months did not identify a difference in carer QoL; statistically pooled data at 12 and 18 months was difficult to interpret due to the large impact of two studies aiming to empower carers to organise their own care. When these were removed, there was no evidence of a statistical difference in carer QoL. Data on the impact of case management on carer burden was inconclusive.
No conclusive difference in cognition, behaviour, mood, or function/dependency for patients with dementia was identified. No difference ws indentified in:
- Carer distress;
- Carer depression (except at 18 months based on two studies, n=2,888)
- Carer wellbeing (except one study at six months);
- Social support.
While there is some evidence that case management can improve some outcomes for people with dementia or their carers at some points in time during care, however, this review does not provide conclusive findings. Although 13 studies were included, the current evidence is dominated by one large trial conducted in the US more than 20 years ago. In addition, the reviewed studies defined “case management” differently, offered diverse care components, had dissimilar “usual care” comparisons and measured different outcomes. This is because the research concerned designing case management interventions that were tailored to local needs and evaluated case management against usual local care.
Although the differences between studies (heterogeneity) makes it difficult to draw firm conclusions about practice recommendations, there is now a need to devise research that will find out which elements of case management achieve certain outcomes. Such information would support nurses in helping people with dementia and their carers to make appropriate care decisions.
Reilly S et al (2015) Case management approaches to home support for people with dementia. Cochrane Database of Systematic Reviews; 1: CD008345. DOI: 10.1002/14651858.CD008345.pub2.