Case management approaches to home support for people with dementia

Background: Many people are affected by dementia and the numbers are expected to rise as populations age. Most types of dementia are characterised by loss of memory and impairment in other cognitive functions, accompanied by functional impairment and difficulties in performing activities of daily living. The increasing number of people with dementia means more demand for both informal and formal sources of care. The extent of support provided depends on factors such as living situation, patient's and carer's characteristics, service provision, and availability of social networks. There are also wider financial costs of care, for example carers missing work for appointments or crises, becoming part-time workers, or leaving work altogether. Developing interventions such as case management, which enhances the co-ordination between different agencies involved in community care, might offer the support necessary to cover some of the needs of people with dementia and their carers. How case management is organised and implemented varies widely, and access to this type of care is influenced by long-term care funding policies and cultural variations in different countries. Case management has been tested in people with dementia and in carers in a number of countries and healthcare systems, but it is not clear whether current evidence supports its effectiveness.

Study characteristics: We found 13 randomised controlled trials (RCTs), including 9615 participants with dementia worldwide. Eleven RCTs also included carers. Studies were conducted in different countries, varied in size and healthcare systems and compared various types of case management interventions with usual care or augmented usual care.

Key findings: Some studies examined the benefit of case management in reducing admissions to residential or nursing homes (institutionalisation). We found benefits at six months and 18 months but not at 12 and 24 months. However, when only studies which were clearly focused upon delaying institutionalisation or prolonging the period of community care were included we found a reduction in institutionalisation at 12 months. Some studies examined the benefits of case management in terms of reduced hospital length of stay, and there was evidence to suggest that it might increase at six months. Some studies indicated that case management was more effective at reducing behaviour disturbance at 18 months, reducing carer burden and depression and improving carer well-being at six months and social support at 12 months. Case management increases the use of community services but there was some indication that overall healthcare costs may be reduced in the first year. Some studies reported that case management was no more effective than usual care in improving patient depression, functional abilities or cognition. There was not enough evidence to clearly assess whether case management could increase the length of time until people with dementia were admitted to care homes.

Quality of the evidence: There were some problems regarding the methods of the studies. Similarly, the different ways in which the case management interventions were provided and the differences in outcome measurements made it difficult to draw clear conclusions.