Barriers to Implementation of Case Management for Patients With Dementia: A Systematic Mixed Studies Review

Vladimir Khanassov; Isabelle Vedel; Pierre Pluye

doi:10.1370/afm.1677

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Figure 1
PRISMA flowchart.

^a Refers to overall interreviewer reliability κ.

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Table 1

Characteristics of Included Qualitative Case Management Implementation Studies

Author, Year Country	Study Design	Sample	Characteristics of the Intervention
Adams, 1996⁷⁸ United Kingdom	Qualitative descriptive Thematic analysis	14 Case managers	Case management focusing on dementia patients and their caregivers
Black, 2007,⁷⁹ 2008⁸⁰ United States	Qualitative descriptive Thematic analysis	27 Community-based case managers	Case management focused on the diseases of older persons, including dementia Focus on advance care planning skills of case mangers as a part of their functions
Bogardus, 1998⁸¹ United States	Qualitative descriptive Constant comparative method	10 Sets of participants (one set: patient, caregiver, case manager, clinician)	Case management focused on dementia patients and their caregivers
Gibson, 2007⁸² United Kingdom	Qualitative descriptive Thematic analysis	10 Dyads (patient with mild to moderate dementia and caregiver) receiving service either via a hospital-based memory clinic or a community-based nursing service	Comparison of a community-based and clinic-based memory service
Gladman, 2007⁸³ United Kingdom	Qualitative descriptive Thematic analysis with conceptual mapping	6 General practitioners, 1 geriatric psychiatrist, caregivers, patient advocate, the team manager, representatives of the Alzheimer Association	Case management focused on dementia patients and their caregivers
Liebel, 2012⁸⁴ United States	Qualitative descriptive Thematic analysis	19 Patients	Secondary analysis of Medicare primary and consumer-directed care. Demonstration designed for patients with disabilities, including cognitive impairment (68%)
McCrae, 2011⁸⁵ United Kingdom	Convergent design Thematic analysis	33 Health care professionals (nurses, occupational therapist, psychiatrists, psychologist, support workers, team leaders) at 6 months, and 27 at 24 months	Evaluation of “Improving the Quality of Care for Older People in Lambeth” impact from staff perspectives: did it help or hinder in performing their roles
Netting, 1999⁸⁶ United States	Qualitative descriptive Thematic analysis	36 Different participants in case management: physicians, case managers, case assistants, practice managers, office staff	Case management focused on the diseases of older persons, including dementia
Seddon, 2001⁸⁷ United Kingdom	Qualitative descriptive/Latent content analysis	8 Care managers and 64 caregivers	Case management focused on caregiver’s assessment (ability to care and continue care, coping ability, relationship with a care recipient)
Van Eijken, 2008⁸⁸ The Netherlands	Qualitative descriptive Inductive thematic analysis	15 General practitioners, 6 case managers (nurses), 2 geriatricians, 11 patients, and 37 caregivers	Case management focusing on problems in cognition, mood, behavior, functional decline, mobility, nutrition and urinary incontinence
Waugh, 2009⁸⁹ Australia	Qualitative descriptive Thematic analysis	5 Staff workers of the Mercy Community Care agency: 2 managers, 2 case managers, one outreach worker	Case management for dementia patients who live alone
Minkman, 2009⁹⁰ The Netherlands	Multiple case study Thematic analysis	9 Case managers	Case management focused on dementia patients and their caregivers

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Table 2

Outcomes in the Randomized Controlled Trials

Outcome	Randomized Controlled Trial		Effect Size of Positive Outcome^a
Outcome	No. Measuring the Outcome	No. With a Positive Outcome	Effect Size of Positive Outcome^a
Clinical outcomes
Behavioral/psychological symptoms of dementia	10	4	0.15⁴⁸ 0.6¹² 1.25²³ 1.5⁵⁹
Depression	7	2	21 58^b
Cognition	8	0	NA
Functional status (ADL, IADL)	5	1	67^b
Perceived health	1	0	NA
Quality of life	3	1	0.3¹³
Mortality	3	1	0.23⁶⁷
Service use
Hospitalization rate	5	2	0.015²¹ 1.3²³
Nursing home placement	11	3	0.18⁴⁸ 0.2⁶⁷ 64^b
Length of hospital stay	2	2	0.224⁴⁸ 1.9²³
Emergency department visit	3	1	0.17²¹
Outcomes for caregivers
Burden	11	4	0.03¹⁵ 0.29⁴⁸ 1.17²³ 58^b
Depression	10	5	0.04¹⁵ 0.18²¹ 1.0^{29, 65} 1.5⁵⁹
Strain	1	1	0.18²¹
Perceived health	6	2	0.24²⁸ 0.4¹²
Quality of life	6	2	0.28⁴⁸ 0.97²³
Satisfaction
Caregivers	5	1	22^b
Health care professionals	1	0	NA
Cost-effectiveness	5	0	NA
Other outcomes
Medication management	1	1	1.07¹²
Adherence to dementia guidelines	1	1	0.65¹³
Dementia detection rate	1	1	0.47⁵³

ADL = activities of daily living; IADL = instrumental activities of daily living; NA = not applicable.
↵a Effect size: <0.2 = weak effect; 0.2–0.5 = small effect; 0.5–0.8 = intermediate effect; >0.8 = large effect.
↵b Insufficient data to calculate the effect size (eg, number of participants missing in comparison groups, only textual information).

In Brief

Barriers to Implementation of Case Management for Patients With Dementia: A Systematic Mixed Studies Review

Isabelle Vedel , and colleagues

Background The growing number of people with dementia and the burden it places on families makes dementia a global health priority. This study examines barriers to implementation of case management for dementia patients and the relationship between barriers and case management outcomes.

What This Study Found Two key conditions appear to significantly improve case management outcomes: high-intensity case management and effective communication among health care professionals and services caring for dementia patients. Five characteristics of high-intensity case management include: 1) a small caseload, 2) regular meetings with patients and caregivers, 3) education on health conditions, 4) close contact with family physicians, and 5) proactive and timely follow-up. Effective communication relies on an efficient referral system and timely support of family physicians and case managers by specialists in complex cases.

Implications

The authors recommend evaluating case management implementation in health care facilities.
Supplemental Appendixes 1-4, Tables 1-5

Supplemental Appendixes 1-4 and Supplemental Tables 1-5

Files in this Data Supplement:

Supplemental data: Appendixes 1-4, Tables 1-5 - PDF file, 34 pages