1. Oliva, Nancy PhD, MS, MHA, MPA, RN
  2. Wexler, Betty MS, CNS, ACHPN, RN

Article Content

There are now 79 million baby boomers in the United States experiencing a greater life expectancy, often accompanied by complex chronic health conditions. By 2025, an estimated 6.7 million Americans will have developed dementia, with the number growing to 16 million by 2050 (Alzheimer's Association, 2016). At the same time, more and more older adults desire to age in place and remain in their own homes for as long as possible, preferably until their death. Health care professionals serving geriatric populations already know, and other clinicians are finding out, just how challenging it is to manage older patients with social, psychological, neurocognitive, and psychiatric issues adding to their already complicated health regimens. Adding to these complexities is the care fragmentation, resulting from care delivery across many settings. Care transitions often create challenges to optimal care coordination and care quality for most chronically ill older adults.


Interdisciplinary teams (IDTs) that include health care professionals trained in geriatrics/gerontological nursing can help address the needs of the most patients with complex health care needs in all care delivery settings. Care for complex, high-risk older adults requires effective IDTs from a variety of disciplines with specialized geriatrics training and effective communication skills who are open to revised, collaborative roles (Calkins, 1999). The geriatric IDTs functioning in academic inpatient or ambulatory care settings often include geriatrics, geriatric/clinician trainees, gerontological registered nurses (RNs), including advanced practice RNs (clinical nurse specialist [CNS] or nurse practitioners), social workers, and psychologists, all skilled/experienced in delivering evidence-based care to older adults.


There are common elements to successfully caring for high-risk older adults, including targeting services to those most likely to benefit; utilizing focused, standardized assessments; providing goal-oriented care; contacting and monitoring patients to follow-up on the recommended plan of care; and engaging patients and families in participating in their own care (Calkins, 1999). Professionals are better prepared for the task of promoting engagement in older adults if they understand that the unit of care in geriatrics commonly includes family caregivers or other engaged caregivers. Engaging both the patient and caregiver(s) in individualized chronic care reflecting their values and needs can help ensure that care interventions are carried out more successfully (Wagner, 2013). To demonstrate our IDT experience in the VA Palo Alto Health Care System providing interdisciplinary care to older adult Veterans with a diagnosis of neurocognitive disorders, we offer a case example of how the geriatric IDT manages collaborative decision making to meet the needs older adults with complex needs and their caregivers.


History and Current Issues

Ms. E. was an 82-year-old patient of the IDT, who was represented by a conservator, for her person and finances, and lived in her own home with a 24/7 hired caregiver named Leonard. There were no children or other involved family members. Ms. E. had the following health conditions: moderate dementia (Montreal Cognitive Assessment [MoCA] 17/30) with resistive behaviors. Since the 1970s, she had suffered from chronic depression and anxiety with agoraphobia, Type 2 diabetes mellitus with diabetic retinopathy, lower extremity edema, obesity, gastroesophageal reflux disease, insomnia, a history of falls, atrial fibrillation (requiring daily warfarin for anticoagulation), chronic kidney disease with hypertension, and sleep apnea, for which she refused to utilize a prescribed continuous positive airway pressure device.


The caregiver, Leonard, had been phoning the CNS on the IDT almost daily, mostly to report Ms. E.'s resistive behaviors. She had been refusing to bathe and would not leave her home at all, not even to go to the dentist. Ms. E. had lately had been perseverating about the abuse she suffered as a child, by her parents, and her fears about the family dog getting ill and dying. Ms. E. was also getting up at night to wander around the house and eat food out of the refrigerator. Sometimes the caregiver did not hear her get up, although he used a baby monitor, and was fearful of her falling because she had done so a few times when she forgot to use her walker. Ms. E. demonstrated no insight into her behaviors or health conditions.


Over the last 10 years, the mental health clinic psychiatrist whom Ms. E. now refuses to see and most recently the IDT geriatrician have tried many medications for Ms. E.'s behaviors and mood. These included bupropion (Wellbutrin), which was tried and quickly discontinued as it worsened Ms. E.'s anxiety; citalopram (Celexa), started several years prior to IDT intervention and then stopped by the patient because the caregiver said it did not help and made memory worse; Aricept (donepezil), which was terminated when it failed to improve Ms. E.'s memory; and citalopram (Celexa), which was restarted 2 years prior at 10 mg daily and then increased to 20 mg. Caregiver reported this increased dose made Ms. E's memory worse and she developed orthostatic hypotension, so medication was tapered off.


Geriatric Assessment/Care Planning

Medication management was a necessary focus for this patient, particularly because risk and benefits need constant monitoring.


* Most recently, after IDT assessment, the following medications and doses were prescribed on a trial basis: venlafaxine (Effexor) 25 mg twice daily and then increased to 50 mg twice daily after several weeks.


* The IDT was mindful of the fact that lorazepam (Ativan) is typically contraindicated for older patients but concluded that benefits of a low-dose regimen were significant and outweighed risk for Ms. E. and helped her with resistive behaviors. She was given 0.5 mg of lorazepam, just twice a week, before bathing or medical/dental outings due to increased anxiety.


* After several months and despite the medication regimen, the caregiver reported increased agitation and resistance to activities of daily living, especially in the evening. In addition, Ms. E. was sleeping more during the day. Venlafaxine (Effexor) was then increased to 100 mg twice daily to treat anxiety and the social phobia, the patient's refusal to leave her home.


* The caregiver then reported that anxiety had worsened, and the team adjusted the dose back to 50 mg twice daily.


* The caregiver reported increased nervousness in the evening, with Ms. E. being only minimally being active and refusing to go out even for essential appointments; the patient expressed no hallucinations, although her memory appeared worse. Her memory was tested at her next clinic visit, and her MoCA had declined to 12/30/15. The IDT then started to taper her off venlafaxine (Effexor).


* The caregiver subsequently reported that patient's mood was definitely worse and her anxiety significantly increased when she was off venlafaxine (Effexor). Another selective serotonin re-uptake inhibitors, sertraline (approved for anxiety as well as depression), was then started at 25 mg daily.


* The caregiver then reported after 1 week that Ms. E. was sleeping a lot during the day, so her sertraline dose, for the treatment of depressive disorders, was moved to bedtime, with the hope that it would have a secondary benefit of reducing wandering at night and reducing the risk of falls.


* The caregiver then reported after several weeks that Ms. E. was sleeping less during the day but evening anxiety was not reduced and mood was not improved; her sertraline dose was then increased to 50 mg at bedtime.


* After another month, the caregiver reported that Ms. E. was having increased worries and anxiety, with fears of her dog getting ill and dying; she was also focusing on her difficult childhood memories again. The IDT then increased the sertraline dose to 100 mg at bedtime.


* Following the increase in the sertraline bedtime dose, the caregiver reported that nighttime sleep improved but resulted in the patient sitting and staring all day, refusing to do anything. The IDT then tried increasing the sertraline dose 2 days each week to 150 mg at bedtime.


* This change resulted in the caregiver reporting that the higher dose was causing more daytime fatigue and making memory worse, so the IDT decreased the dose to 100 mg again at bedtime. The IDT geriatrician then prescribed a trial of valproate (Depakote) 125 mg twice daily as adjunctive therapy. Unfortunately, the caregiver reported no effect from valproate (Depakote) after 3 weeks; therefore, the medication was then discontinued.


The IDT then met to discuss this patients with complex health care needs. It was clear that Ms. E.'s problems with mood and anxiety had been long-standing and that trials of numerous medications were ineffective or exacerbated anxiety and worsened memory. The team determined that venlafaxine (Effexor), at 50 mg twice daily, seemed to provide the most favorable results for the longest time but then began to decrease in its effectiveness as the patient's dementia worsened. Although there were no hallucinations and no aggressive behaviors, Ms. E., instead, was apathetic, inactive, and fearful.


The IDT geriatrician's review of medication and history along with input and documentation by the IDT CNS, who spoke almost daily with the caregiver, helped the IDT step back and reevaluate the patient's case and course. Upon reevaluation, the geriatrician suggested stopping the valproate (Depakote) and initiating Aricept, specific for the treatment of dementia, again to see whether this medication might help with more patient activation and decrease fears; there are data to support effects of Aricept on an individual's affect. Worsening cognition may also be affecting Ms. E.'s long-term coping mechanisms, causing her to focus on her history of childhood abuse. The IDT also discussed the possibility that no medication will fully improve this patient's mood and anxiety level. Avoiding excessive sedation in this older patient was also taken into account in medication trials and dose modification.



Through continuous communication with the caregiver and patient's conservator, the IDT also determined that the caregiver was suffering from significant caregiver stress. The IDT included a psychologist who was able to reach out to the caregiver and provide some phone support in dealing with a challenging patient like Ms. E. The CNS helped the family to find a part-time caregiver to relieve Leonard, the full-time caregiver. The ongoing communication with the caregiver combined with clinic visits, every 3 months, kept this patient out of the hospital and the emergency department and allowed her to remain in her own home, which was her primary desire. Ultimately, the caregiver came to understand that no medication could "fix" Ms. E. and she did continue to decline. Clear documentation in the electronic health records, including documentation of telephone communications, provided for a fully informed team discussion and prevented redundancy in the plan of care.



Desired outcomes in dementia care are much the same for all evidence-based geriatric care and include the preservation of individuals' general health, as well as cognitive and functional abilities to support independence, minimization of adverse neuropsychiatric and behavioral symptoms, and promotion of caregiver well-being through guidance and support (Odenheimer, 2013). To achieve these outcomes, as illustrated in our case, a geriatric IDT model of care can provide needed proactive, evidence-based, patient-centered dementia care in collaboration with caregivers. The art involved in geriatric IDT model application is leveraging the diverse perspectives and skills of members of the team to meet the unique, complex, and shifting needs of patients with complex illnesses and their caregivers. The science of the geriatric IDT model application involves the synthesis and integration of current evidence for chronic disease management into practice, supporting the achievement of clear patient-centered goals of care.


Although geriatric IDTs may appear to be a resource-intensive, high-cost option for delivering and coordinating care for older adults, with complex comorbid conditions and frailty, they deliver value in the care of chronically ill older adults. Effective IDTs enhance quality of life, patient satisfaction, and optimal care, all valuable outcomes that diminish the likelihood of costly, fragmented care that often leads to avoidable acute inpatient and/or ED admissions. Further policy research is needed to support adequate reimbursement for effective care delivery models for the most complex community-dwelling patients, such as the rapidly growing number of older American adults with neurocognitive disorders.



Our experience with geriatric IDT referrals reveals that most are predominantly neurocognitive disorders and/or polypharmacy management issues, in the presence of co-occurring functional decline. Quality patient-centered care for older adults with complex diseases requires that the skill sets of multiple disciplines be integrated in a collaborative, interdisciplinary care process model. Our IDT model includes evidence-based practices, modifiable goals of care that are codesigned by care recipients and caregivers, and continuous IDT communication and outcome evaluation. The success of this model demonstrates how patient-centered case management improves outcomes, reduces avoidable admissions and readmissions, and is cost-effective in all aspects in the care of the ever-enlarging geriatric population.



The authors thank their interdisciplinary team colleagues in the VA Palo Alto Healthcare System's Geriatric Research, Education and Clinical Center, with whom they served older adult Veterans, their families, and family caregivers. The authors also appreciate the programmatic support provided by the VA Office of Geriatrics and Extended Care and the VA Office of Rural Health to develop telehealth consultation and care coordination programs for older adults and caregivers. Finally, the authors acknowledge the substantial 24/7 support provided by Veterans' families and other engaged caregivers to our Veterans to enable them to live in comfort, with dignity, and love in their chosen setting.




Alzheimer's Association. (2016, March). 2016 Alzheimer's disease facts and figures. Retrieved from ALZ.ORG:[Context Link]


Calkins E. B. (1999). New ways to care for older people: Building systems based on evidence. New York, NY: Springer. [Context Link]


Odenheimer G. B.-E. (2013). Quality improvement in neurology: Dementia management quality measures. The American Journal of Occupational Therapy, 67(6), 704-710. [Context Link]


Wagner E. A. (2013). Improving illness care: Translating illness into action. Health Affairs, 20(6), 64-78. [Context Link]