Collaborative care that includes medication and behavioral treatment improved psychological symptoms of Alzheimer's disease and reduced caregiver stress, a new study has found.

The intensive management model, which is more often provided in specialty centers, worked well in the primary care setting, said researchers led by Dr. Christopher Callahan, director of the Indiana University Center for Aging Research in Indianapolis.

"Most of these patients with Alzheimer's disease are going to be cared for by primary care physicians ... because there simply aren't enough specialist physicians," Dr. Callahan said.

The study, which appears in today's Journal of the American Medical Association, is the first time the guidelines have been tested in primary care clinics, said Richard Schulz, associate director of the University of Pittsburgh's Institute on Aging. He is not a member of the research team.

"That's important because that's really where all the action is," he said. "That's where most of these patients enter the system and are cared for."

Dr. Schulz added, "This is an example of a treatment approach for elderly individuals that will be the wave of the future."

About 150 Alzheimer's patients were randomly assigned to receive in the primary care clinic either augmented usual care, in which physicians chose evaluation and treatments at their discretion and patients received some disease information, or collaborative care.

The collaborative care patients were treated for a maximum of 12 months by a team led by a physician and a geriatric nurse practitioner, who acted as a care manager.

Collaborative care patients also were given a cholinesterase inhibitor drug, which can improve memory, concentration and attention. They and their caregivers were taught communication and coping skills and given legal and financial advice.

Patients and caregivers were regularly seen by a care manager, who assessed problems and stressors and made recommendations based on established protocols. Care managers had weekly meetings with a geriatrician, geriatric psychiatrist and a psychologist, and used a Web-based system to track appointments, treatment and progress and communicate with the team.

The researchers found that collaborative care patients were more likely than the usual care group to be prescribed cholinesterase inhibitors and antidepressants. They also had fewer behavioral and psychological dementia symptoms, both a year and 18 months after the treatment began.

Also, there was less distress and depression among caregivers, which might eventually lead to a reduction in nursing home placement, Dr. Callahan noted.

For now, most primary care practices cannot afford to provide such intensive, collaborative services because they are not reimbursed, he said.

Still, "this notion of how you structure primary care to deliver these kinds of interventions for frail older adults needs to be debated," Dr. Callahan said. According to the Alzheimer's Association, an estimated 4.5 million Americans have the disease. That number could more than triple by 2050.

There will not be enough specialists or neurologists to meet the need for care, said Dr. David Wolk, a neurologist at the University of Pittsburgh's Alzheimer Disease Research Center.

"Definitely the burden is going to fall on primary care physicians," he said. "So their education and ability to handle these patients is going to be critical in the caring of our aging population."

The Indianapolis team's collaborative model is akin to what might be found in a specialty center, Dr. Wolk said. Higher levels of care tend to be more expensive, and psychiatric symptoms lead to greater use of health care services.

"Caregivers are not going to want to put Mom or Dad in a nursing home if they're forgetting where they placed their keys," he pointed out.

But Alzheimer's patients who are agitated, screaming, depressed or exhibit other burdensome behavioral symptoms might be more than family members can handle.