Association of incident dementia with hospitalizations

The Impact of Hospitalization on Readmission, Institutionalization, and Mortality of People with Dementia: A Systematic Review and Meta-Analysis

BACKGROUND

People with dementia (PwD) are at a high risk of hospitalization. Hospitals are often not adequately equipped for PwD and discharges often come unexpected. Therefore, PwD are at a risk of adverse outcomes. However, information about those outcomes is rare but crucial for the development of preventive strategies.

OBJECTIVES

To conduct a quantitative systematic review and meta-analyses on the impact of a hospitalization on readmission, institutionalization, and mortality in PwD. To identify factors associated with these outcomes.

METHODS

PubMed, CENTRAL, and ScienceDirect were searched for studies including terms for dementia, hospital, readmission, institutionalization, and mortality. Relevant were assessed by a quality criteria sheet. Results were summarized in a table. Meta-analysis was conducted with Review Manager 5.3.

RESULTS

The search yielded 1,108 studies; 20 fulfilled the inclusion criteria and 10 studies were eligible for meta-analyses. The incidence and relative risk (RR) of mortality (RR 1.74 CI95 % 1.50, 2.05) and institutionalization (RR: 2.16 CI95 % 1.31, 3.56) of PwD was significantly higher when compared to people without dementia. Results according to readmission rate were inconsistent. Factors significantly associated with the examined adverse outcomes were severity of dementia, number of medications, and deficits in daily living activities.

CONCLUSION

Hospitalization of PwD lead to adverse outcomes. An improvement in the identification of and care for PwD in the acute setting as well as in after care in the community setting, especially in the interface between both settings, is required to prevent adverse outcomes in hospitalized PwD.

Hospitalisation rates and predictors in people with dementia: a systematic review and meta-analysis

BACKGROUND

Hospitalisation is often harmful for people with dementia and results in high societal costs, so avoidance of unnecessary admissions is a global priority. However, no intervention has yet reduced admissions of community-dwelling people with dementia. We therefore aimed to examine hospitalisation rates of people with dementia and whether these differ from people without dementia and to identify socio-demographic and clinical predictors of hospitalisation.

METHODS

We searched MEDLINE, Embase, and PsycINFO from inception to 9 May 2019. We included observational studies which (1) examined community-dwelling people with dementia of any age or dementia subtype, (2) diagnosed dementia using validated diagnostic criteria, and (3) examined all-cause general (i.e. non-psychiatric) hospital admissions. Two authors screened abstracts for inclusion and independently extracted data and assessed included studies for risk of bias. Three authors graded evidence strength using Cochrane's GRADE approach, including assessing for evidence of publication bias using Begg's test. We used random effects meta-analysis to pool estimates for hospitalisation risk in people with and without dementia.

RESULTS

We included 34 studies of 277,432 people with dementia: 17 from the USA, 15 from Europe, and 2 from Asia. The pooled relative risk of hospitalisation for people with dementia compared to those without was 1.42 (95% confidence interval 1.21, 1.66) in studies adjusted for age, sex, and physical comorbidity. Hospitalisation rates in people with dementia were between 0.37 and 1.26/person-year in high-quality studies. There was strong evidence that admission is associated with older age, and moderately strong evidence that multimorbidity, polypharmacy, and lower functional ability are associated with admission. There was strong evidence that dementia severity alone is not associated.

CONCLUSIONS

People with dementia are more frequently admitted to hospital than those without dementia, independent of physical comorbidities. Future interventions to reduce unnecessary hospitalisations should target potentially modifiable factors, such as polypharmacy and functional ability, in high-risk populations.

Joint impact of dementia and frailty on healthcare utilisation and outcomes: a retrospective cohort study of long-stay home care recipients

OBJECTIVES

To examine the associations between dementia and 1-year health outcomes (urgent hospitalisation, long-term care (LTC) admission, mortality) among long-stay home care recipients and the extent to which these associations vary by clients' frailty level.

DESIGN

A retrospective cohort study using linked clinical and health administrative databases.

SETTING

Home care in Ontario, Canada.

PARTICIPANTS

Long-stay (≥60 days) care clients (n=153 125) aged ≥50 years assessed between April 2014 and March 2015.

MAIN OUTCOME MEASURES

Dementia was ascertained with a validated administrative data algorithm and frailty with a 66-item frailty index (FI) based on a previously validated FI derived from the clinical assessment. We examined associations between dementia, FI and their interactions, with 1-year outcomes using multivariable Fine-Gray competing risk (urgent hospitalisation and LTC admission) and Cox proportional hazards (mortality) models.

RESULTS

Clients with dementia (vs without) were older (mean±SD, 83.3±7.9 vs 78.9±11.3 years, p<0.001) and more likely to be frail (30.3% vs 24.2%, p<0.001). In models adjusted for FI (as a continuous variable) and other confounders, clients with dementia showed a lower incidence of urgent hospitalisation (adjusted subdistribution HR (sHR)=0.84, 95% CI: 0.83 to 0.86) and mortality rate (adjusted HR=0.87, 95% CI: 0.84 to 0.89) but higher incidence of LTC admission (adjusted sHR=2.60, 95% CI: 2.53 to 2.67). The impact of dementia on LTC admission and mortality was significantly modified by clients' FI (p<0.001 interaction terms), showing a lower magnitude of association (ie, attenuated positive (for LTC admission) and negative (for mortality) association) with increasing frailty.

CONCLUSIONS

The strength of associations between dementia and LTC admission and death (but not urgent hospitalisation) among home care recipients was significantly modified by their frailty status. Understanding the public health impact of dementia requires consideration of frailty levels among older populations, including those with and without dementia and varying degrees of multimorbidity.

Impact of health service interventions on acute hospital use in community-dwelling persons with dementia: A systematic literature review and meta-analysis

Background

Persons with dementia have twice the acute hospital use as older persons without dementia. In addition to straining overburdened healthcare systems, acute hospital use impacts patient and caregiver quality of life and is associated with increased risk of adverse outcomes including death. Reducing avoidable acute hospital use in persons with dementia is thus a global healthcare priority. However, evidence regarding the impact of health service interventions as defined by the Effective Practice and Organization of Care Cochrane Group on acute hospital use is scant and inconclusive. The aim of this systematic review and meta-analysis was to synthesize available evidence on the impact of health service interventions on acute hospital use in community-dwelling persons with dementia compared to usual care.

Methods

Data Sources: MEDLINE, EMBASE, CINAHL and Cochrane CENTRAL (from 01/1995 to 08/2017). Study eligibility criteria: Randomised controlled trials measuring the impact of health service interventions on acute hospital use (proportion and mean number of emergency department visits and hospitalisations, mean number of hospital days, measured at 12 months, and at longest follow-up) in community-dwelling persons with dementia, compared to usual care. Study selection, appraisal and synthesis methods: Reviewers independently identified studies, extracted data, and assessed the risk of bias, with the Cochrane risk of bias tool. Authors of relevant trials were queried about unpublished data. Random effects model was used for meta-analyses. Effect heterogeneity was assessed through prediction intervals, and explored using sub-group analyses.

Findings

Seventeen trials provided data on 4,549 persons. Unpublished data were obtained for 13 trials, representing 65% of synthesized data. Most interventions included a case management or a self-management component. None of the outcome comparisons provided conclusive evidence supporting the hypothesis that these interventions would lead to a decrease in acute hospital use. Furthermore, prediction intervals indicated possible and important increased service use associated with these interventions, such as emergency department visits, hospital admissions, and hospital days. Subgroup analyses did not favour any type of intervention. A limitation of this study is the inclusion of any type of health service intervention, which may have increased the observed heterogeneity.

Conclusion

Despite a comprehensive systematic review and meta-analysis, including predominantly unpublished data, no health service intervention beyond usual care was found to reduce acute hospital use in community-dwelling persons with dementia. An important increase in service use may be associated with these interventions. Further research is urgently needed to identify effective interventions for this vulnerable population to limit rising acute hospital use, associated costs and adverse outcomes. Systematic review registration PROSPERO CRD42016046444.

Anticholinergic burden before and after hospitalization in older adults with dementia: Increase due to antipsychotic medications

OBJECTIVES

To evaluate changes in the use of antipsychotics and medications with anticholinergic activity (MACs) during hospitalization in older adults with dementia and factors associated with antipsychotic prescriptions and increased anticholinergic burden (ACB).

METHODS AND DESIGN

This retrospective cohort study included all patients aged 65 years or older with a discharge diagnosis of dementia hospitalized at the university hospital of Udine, Italy, from 2012 to 2014. Medications dispensed within 3 months before and after hospitalization were identified in community-pharmacy dispensations while those prescribed at discharge were collected from Hospital Electronic Medical Records (EMR). ACB was assessed using the Anticholinergic Cognitive Burden score.

RESULTS

Among 1908 patients included, at discharge, 37.0% used one or more antipsychotic (9.4% before and 12.6% after hospitalization), 68.6% used one or more MAC (49.1% and 45.7%, respectively), and ACB of 38.4% of patients increased at discharge mainly because of a higher use of antipsychotics with anticholinergic activity (33% at discharge vs 12% before hospitalization). Prescription of antipsychotics at discharge was associated with prior treatment with antipsychotics (adjusted odds ratio [aOR] 4.85; 95%CI, 3.37-6.97), psychiatric conditions, (4.39; 3.47-5.54) and discharge from surgical department (2.17; 1.32-3.55). An increased ACB was associated with psychiatric conditions (1.91; 1.52-2.39), discharge from surgical (1.75; 1.09-2.80) or medical department (1.50; 1.04-2.17), and with cardiac insufficiency (1.41; 1.00-1.99).

CONCLUSIONS

ACB was higher at discharge, and antipsychotics were the main drivers of this increase. Clinicians treating older adults with dementia should be aware of the risks associated with antipsychotics and that some of these medications may increase the risk of anticholinergic effects.

Hospitalisation of people with dementia: evidence from English electronic health records from 2008 to 2016

Hospitalisation of people with dementia is associated with adverse outcomes and high costs. We aimed to examine general, i.e. non-psychiatric, hospitalisation rates, changes since 2008 and factors associated with admission. We also aimed to compare admission rates of people with dementia with age-matched people without dementia. We conducted a cohort study of adults ≥ 65 years, with dementia diagnosed during the 2008-2016 study window, derived from a large secondary mental healthcare database in South London, UK. We used national general hospital records to identify emergency and elective hospitalisations. We calculated the cumulative incidence and rate of hospitalisation and examined predictors of hospitalisation using negative binomial regression, with multiple imputation for missing covariate data. We calculated age-standardised admission ratio for people with dementia compared to those without. Of 10,137 people, 50.6% were admitted to hospital in the year following dementia diagnosis and 75.9% were admitted during median 2.5 years follow-up. Annual admission rate was 1.26/person-year of which 0.90/person-year were in emergency. Emergency hospitalisation rate increased throughout the study period. Compared to controls without diagnosed dementia in the catchment area, the age-standardised emergency admission ratio for people with dementia was 2.06 (95% CI 1.95, 2.18). Male, older, white and socio-economically deprived people and those with clinically significant comorbid physical illness, depressed mood, activity of daily living or living condition problems had more hospitalisations. Emergency hospitalisations of people with dementia are higher than those without, and increasing. Many factors associated with admission are social and psychological, and may be targets for future interventions that aim to reduce avoidable admissions.

Constant Observation Practices for Hospitalized Persons With Dementia: A Survey Study

Despite substantial staffing and cost implications, the use of constant observation (CO) has been poorly described in the acute care setting. The purpose of this cross-sectional, multicenter, survey study was to assess hospital provider practices regarding the use of CO. Of the 543 surveys distributed, 231 were completed across 5 sites. Most respondents worked on medical units (67.5%), as nurses (49.1%); 44.8% were white; and 75.6% were female. The majority (84.2%) reported at least 1 patient/wk requiring CO. Most frequent indication for CO was dementia with agitation (60.7%), in patients older than 70 (62.3%) and predominantly by nurse assistants (93.9%). Almost half (47.3%) stated they felt pressured to discontinue CO, despite a strong perceived benefit (76%). Enhanced observation (92.6%) was most frequently used to decrease CO. Finally, 77.9% perceived that those performing CO lacked training. Our study highlights the widespread use of CO for hospitalized older adults with dementia.

The relationship between frailty, functional dependence, and healthcare needs among community-dwelling people with moderate to severe dementia

This paper examines the healthcare needs of community-dwelling older people living in Porto, Portugal, diagnosed with moderate or severe dementia, linked to functional dependency, cognitive decline, limitations in the activities of daily life, and frailty levels. A sample of 83 participants was recruited. Data were collected between 2013 and 2017. A sociodemographic questionnaire, the Clinical Dementia Rating (CDR), the Barthel Index (BI), the Lawton and Brody Instrumental Activities of Daily Living (IADL) Scale, and the Edmonton Frail Scale (EFS) were used. A set of 26 healthcare needs was defined to support the assessment. The Pearson chi-square or Fisher's exact test (as appropriate) was used to examine the association of the needs (unmet and met) with the levels of dementia and frailty. Participants were diagnosed previously with moderate or severe dementia and benefited from a structured home-care program. There was a high number rated as "severe dementia," "fully dependent," "severely or fully dependent in the activities of daily living (ADL)," and "severe frailty." There were statistically significant differences among needs identified in people with moderate or severe dementia and moderate or severe frailty. The most prevalent healthcare needs in the sample were food preparation, medication/taking pills, looking after their home, toilet use, sensory problems, communication/interaction, bladder, bowels, eating and drinking, memory, sleeping, and falls prevention. In particular, the study identifies a set of needs that are present simultaneously in both frailty and dementia stages. This study underlines that despite well-structured home-care programs for people with dementia, unmet health needs remain. Timely healthcare needs assessment may help professionals to avoid fragmented care and to tailor quality-integrated interventions, including the emotional and psychological balance of the caregiver.

Training interventions to improve general hospital care for older people with cognitive impairment: systematic review

BACKGROUND

In response to increasing numbers of older people in general hospitals who have cognitive impairment such as dementia and delirium, many hospitals have developed education and training programmes to prepare staff for this area of clinical practice.AimsTo review the evidence on educational interventions on hospital care for older people with cognitive impairment.

METHOD

A mixed methods systematic review and narrative synthesis was undertaken. The following electronic databases were searched: Medline, Embase, CINAHL, PsycINFO, EBM Reviews, ASSIA and Scopus, as well as Health Management Information Consortium (HMIC), ProQuest, PubMed and SCIE: Social Care Online. Initial searches were run in August 2014 (update search September 2016). Titles and abstracts of studies retrieved were screened independently. The full text of eligible studies were then independently assessed by two review team members. All included studies were assessed using a standard quality appraisal tool.

RESULTS

Eight studies relating to delirium, six on dementia and two on delirium and dementia were included, each testing the use of a different educational intervention. Overall, the quality of the studies was low. In relation to delirium, all studies reported a significant increase in participants' knowledge immediately post-intervention. Two of the dementia studies reported an increase in dementia knowledge and dementia confidence immediately post-intervention.

CONCLUSIONS

The variety of outcomes measured makes it difficult to summarise the findings. Although studies found increases in staff knowledge, there is insufficient evidence to conclude that educational interventions for staff lead to improved patient outcomes.Declaration of interestNone.

Medicare expenditures attributable to dementia

OBJECTIVE

To estimate dementia's incremental cost to the traditional Medicare program.

DATA SOURCES

Health and Retirement Study (HRS) survey-linked Medicare part A and B claims from 1991 to 2012.

STUDY DESIGN

We compared Medicare expenditures for 60 months following a claims-based dementia diagnosis to those for a randomly selected, matched comparison group.

DATA COLLECTION/EXTRACTION METHODS

We used a cost estimator that accounts for differential survival between individuals with and without dementia and decomposes incremental costs into survival and cost intensity components.

PRINCIPAL FINDINGS

Dementia's five-year incremental cost to the traditional Medicare program is approximately $15 700 per patient, nearly half of which is incurred in the first year after diagnosis. Shorter survival with dementia mitigates the incremental cost by about $2650. Increased costs for individuals with dementia were driven by more intensive use of Medicare part A covered services. The incremental cost of dementia was about $7850 higher for females than for males because of sex-specific differential mortality associated with dementia.

CONCLUSIONS

Dementia's cost to the traditional Medicare program is significant. Interventions that target early identification of dementia and preventable inpatient and post-acute care services could produce substantial savings.

Harnessing the Power of Machine Learning in Dementia Informatics Research: Issues, Opportunities, and Challenges

Dementia is a chronic and degenerative condition affecting millions globally. The care of patients with dementia presents an ever-continuing challenge to healthcare systems in the 21st century. Medical and health sciences have generated unprecedented volumes of data related to health and wellbeing for patients with dementia due to advances in information technology, such as genetics, neuroimaging, cognitive assessment, free texts, routine electronic health records, etc. Making the best use of these diverse and strategic resources will lead to high-quality care of patients with dementia. As such, machine learning becomes a crucial factor in achieving this objective. The aim of this paper is to provide a state-of-the-art review of machine learning methods applied to health informatics for dementia care. We collate and review the existing scientific methodologies and identify the relevant issues and challenges when faced with big health data. Machine learning has demonstrated promising applications to neuroimaging data analysis for dementia care, while relatively less effort has been made to make use of integrated heterogeneous data via advanced machine learning approaches. We further indicate future potential and research directions in applying advanced machine learning, such as deep learning, to dementia informatics.

A community health case for psychiatric care: A cross-sectional study of county health rankings

OBJECTIVES

To determine if there is an association between the provision of mental health services and county health rankings in the United States.

METHODS

We used retrospective population-based, 2016 U.S. county level cross-sectional analysis to determine the association of mental health services provision on U.S. counties health rankings. The key dependent variables in this study were the county health factor rankings (CHR). The presence of inpatient, outpatient and other facilities which may provide mental health services are identified for each county. Multilevel mixed effects ordinal logistic regression models were used to account for nesting effects utilizing two levels of data which include hospital- and county-level data.

RESULTS

Better county health rankings were associated with the presence of Outpatient services (OR = 0.69, 95% CI: 0.55-0.85) and Psychiatric hospital (OR = 0.55, 95% CI: 0.40-0.74).

CONCLUSION

These findings suggest a significant association between psychiatric care and community health. Access to psychiatric services is associated with improved population health.

Refusal and resistance to care by people living with dementia being cared for within acute hospital wards: an ethnographic study

Background

The acute hospital setting has become a key site of care for people living with dementia. The Department of Health and Social Care recognises that as many as one in four acute hospital beds in the UK will be occupied by a person living with dementia at any given time. However, people living with dementia are a highly vulnerable group within the hospital setting. Following an acute admission, their functional abilities can deteriorate quickly and significantly. Detailed research is required to understand the role and needs of health-care staff caring for this patient population and to explore what constitutes ‘good care’ for people living with dementia within the acute setting.

Objectives

The focus of this study was a common but poorly understood phenomenon within the acute setting: refusal and resistance to care. Our research questions were ‘How do ward staff respond to resistance to everyday care by people living with dementia being cared for on acute hospital wards?’ and ‘What is the perspective of patients and their carers?’.

Design

This ethnography was informed by the symbolic interactionist research tradition, focusing on understanding how action and meaning are constructed within a setting. In-depth evidence-based analysis of everyday care enabled us to understand how ward staff responded to the care needs of people living with dementia and to follow the consequences of their actions.

Setting

This ethnography was carried out on 155 days (over 18 months) in 10 wards within five hospitals across England and Wales, which were purposefully selected to represent a range of hospital types, geographies and socioeconomic catchments.

Participants

In addition to general observations, 155 participants took part directly in this study, contributing to 436 ethnographic interviews. Ten detailed case studies were also undertaken with people living with dementia.

Results

We identified high levels of resistance to care among people living with dementia within acute hospital wards. Every person living with dementia observed within an acute hospital ward resisted care at some point during their admission.

Limitations

Limitations identified included the potential for the Hawthorne or researcher effect to influence data collection and establishing the generalisability of findings.

Conclusions

Ward staff typically interpreted resistance as a feature of a dementia diagnosis, which overshadowed the person. However, resistance to care was typically a response to ward organisation and delivery of care and was typically rational to that person’s present ontology and perceptions. In response, nurses and health-care assistants used multiple interactional approaches that combined highly repetitive language with a focus on completing essential care on the body, which itself had a focus on the containment and restraint of the person in their bed or at their bedside. These approaches to patient care were a response to resistance but also a trigger for resistance, creating cycles of stress for patients, families and ward staff. The findings have informed the development of simple, no-cost innovations at the interactional and organisational level. A further study is examining continence care for people living with dementia in acute hospital settings.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Optimizing Function and Physical Activity in Hospitalized Older Adults to Prevent Functional Decline and Falls

Physical activity, defined as bodily movement that expends energy including such things as bed mobility, transfers, bathing, dressing, and walking, has a positive impact on physical and psychosocial outcomes among older adults during their hospitalization and the post hospitalization recovery period. Despite benefits, physical activity is not the focus of care in the acute care setting. Further there are many barriers to engaging patients in physical activity and fall prevention activities including patient, family and provider beliefs, environmental challenges and limitations, hospital policies, and medical and nursing interventions. This paper provides an overview of falls and physical activity prevalence among acute care patients, challenges to engaging patients in physical activity and falls prevention activities and innovative approaches to increase physical activity and prevent falls among older hospitalized patients.

Preventable hospitalizations among older patients with cognitive impairments and dementia

ABSTRACTObjectives:Dementia and cognitive impairment are associated with higher rates of complications and mortality during hospitalization in older patients. Moreover, length of hospital stay and costs are increased. In this prospective cohort study, we investigated the frequency of hospitalizations caused by ambulatory care-sensitive conditions (ACSCs), for which proactive ambulatory care might prevent the need for a hospital stay, in older patients with and without cognitive impairments.

DESIGN

Prospective cohort study.

SETTING

Eight hospitals in Germany.

PARTICIPANTS

A total of 1,320 patients aged 70 years and older.

MEASUREMENTS

The Mini-Cog test has been used to assess cognition and to categorize patients in the groups no/moderate cognitive impairments (probably no dementia) and severe cognitive impairments (probable dementia). Moreover, lengths of hospital stay and complication rates have been assessed, using a binary questionnaire (if occurred during hospital stay or not; behavioral symptoms were adapted from the Cohen-Mansfield Agitation Inventory). Data have been acquired by the nursing staff who received a special multi-day training.

RESULTS

Patients with severe cognitive impairments showed higher complication rates (including incontinence, disorientation, irritability/aggression, restlessness/anxiety, necessity of Tranquilizers and psychiatric consults, application of measures limiting freedom, and falls) and longer hospital stays (+1.4 days) than patients with no/moderate cognitive impairments. Both groups showed comparably high ACSC-caused admission rates of around 23%.

CONCLUSIONS

The study indicates that about one-fourth of hospital admissions of cognitively normal and impaired older adults are caused by ACSCs, which are mostly treatable on an ambulatory basis. This implies that an improved ambulatory care might reduce the frequency of hospitalizations, which is of particular importance in cognitively impaired elderly due to increased complication rates.

The impact of dementia on hospital outcomes for elderly patients with sepsis: A population-based study

BACKGROUND

Prior studies have suggested that dementia adversely influences clinical outcomes and increases resource utilization in patients hospitalized for acute diseases. However, there is limited population-data information on the impact of dementia among elderly hospitalized patients with sepsis.

METHODS

From the 2009-2011 National Hospital Discharge Database we identified hospitalizations in adults aged ≥65 years. Using ICD9-CM codes, we selected sepsis cases, divided them into two cohorts (with and without dementia) and compared both groups with respect to organ dysfunction, in-hospital mortality and the use of hospital resources. We estimated the impact of dementia on these primary endpoints through multivariate regression models.

RESULTS

Of the 148 293 episodes of sepsis identified, 16 829 (11.3%) had diagnoses of dementia. Compared to their dementia-free counterparts, they were more predominantly female and older, had a lower burden of comorbidities and were more frequently admitted due to a principal diagnosis of sepsis. The dementia cohort showed a lower risk of organ dysfunction (adjusted OR: 0.84, 95% Confidence Interval [CI]: 0.81, 0.87) but higher in-hospital mortality (adjusted OR: 1.32, 95% [CI]: 1.27, 1.37). The impact of dementia on mortality was higher in the cases of younger age, without comorbidities and without organ dysfunction. The cases with dementia also had a lower length of stay (-3.87 days, 95% [CI]: -4.21, -3.54) and lower mean hospital costs (-3040€, 95% [CI]: -3279, -2800).

CONCLUSIONS

This nationwide population-based study shows that dementia is present in a substantial proportion of adults ≥65s hospitalized with sepsis, and while the condition does seem to come with a lower risk of organ dysfunction, it exerts a negative influence on in-hospital mortality and acts as an independent mortality predictor. Furthermore, it is significantly associated with shorter length of stay and lower hospital costs.

Hospitalization, surgery, and incident dementia

INTRODUCTION

We evaluated whether hospitalization with or without surgery increases risk for dementia or Alzheimer's disease.

METHODS

A clinical sample (843 clinically diagnosed dementia cases; 1686 matched nondemented individuals) was identified from Swedish Twin Registry studies. A register-based sample (4293 cases; 21,465 matched controls) was identified by linkage of Swedish Twin Registry to Swedish Patient Registry records. Apolipoprotein E (APOE) status and within-pair comparisons of dementia discordant twins indicated genetic susceptibility.

RESULTS

Nonsurgical hospitalization is associated with greater dementia risk than hospitalization with surgical intervention. In the register sample, thoracic, abdominal, and major orthopedic procedures entailed dementia risk; in the clinical sample, orthopedic alone. Within-pair analyses indicate that associations in part reflect genetic susceptibility in common to hospitalization and dementia. Potential gene-environment interactions were indicated by greater risk due to hospitalization among APOE ε4 noncarriers.

DISCUSSION

We confirm hospitalization as a risk factor for dementia, with repeated hospitalizations a more important risk factor than surgery.

Systems Delivery Innovation for Alzheimer Disease

OBJECTIVE

The authors describe a comprehensive care model for Alzheimer disease (AD) that improves value within 1-3 years after implementation by leveraging targeted outpatient chronic care management, cognitively protective acute care, and timely caregiver support.

METHODS

Using current best evidence, expert opinion, and macroeconomic modeling, the authors designed a comprehensive care model for AD that improves the quality of care while reducing total per capita healthcare spending by more than 15%. Cost savings were measured as reduced spending by payers. Cost estimates were derived from medical literature and national databases, including both public and private U.S. payers. All estimates reflect the value in 2015 dollars using a consumer price index inflation calculator. Outcome estimates were determined at year 2, accounting for implementation and steady-state intervention costs.

RESULTS

After accounting for implementation and recurring operating costs of approximately $9.5 billion, estimated net cost savings of between $13 and $41 billion can be accomplished concurrently with improvements in quality and experience of coordinated chronic care ($0.01-$6.8 billion), cognitively protective acute care ($8.7-$26.6 billion), timely caregiver support ($4.3-$7.5 billion), and caregiver efficiency ($4.1-$7.2 billion).

CONCLUSION

A high-value care model for AD may improve the experience of patients with AD while significantly lowering costs.

Health Care Utilization and Cost Outcomes of a Comprehensive Dementia Care Program for Medicare Beneficiaries

IMPORTANCE

An estimated 4 to 5 million Americans have Alzheimer disease or another dementia.

OBJECTIVE

To determine the health care utilization and cost outcomes of a comprehensive dementia care program for Medicare fee-for-service beneficiaries.

DESIGN, SETTING, AND PARTICIPANTS

In this case-control study, we used a quasiexperimental design to compare health care utilization and costs for 1083 Medicare fee-for-service beneficiaries enrolled in the University of California Los Angeles Health System Alzheimer and Dementia Care program between July 1, 2012, and December 31, 2015, with those of 2166 similar patients with dementia not participating in the program. Patients in the comparison cohort were selected using the zip code of residence as a sampling frame and matched with propensity scores, which included demographic characteristics, comorbidities, and prior-year health care utilization. We used Medicare claims data to compare utilization and cost outcomes for the 2 groups.

INTERVENTIONS

Patients in the dementia care program were comanaged by nurse practitioners and physicians, and the program consisted of structured needs assessments of patients and their caregivers, creation and implementation of individualized dementia care plans with input from primary care physicians, monitoring and revising care plans, referral to community organizations for dementia-related services and support, and access to a clinician for assistance and advice 24 hours per day, 7 days per week.

MAIN OUTCOMES AND MEASURES

Admissions to long-term care facilities; average difference-in-differences per quarter over the 3-year intervention period for all-cause hospitalization, emergency department visits, 30-day hospital readmissions, and total Medicare Parts A and B costs of care. Program costs were included in the cost estimates.

RESULTS

Program participants (n = 382 men, n = 701 women; mean [SD] age, 82.10 [7.90] years; age range 54-101 years) were less likely to be admitted to a long-term care facility (hazard ratio, 0.60; 95% CI, 0.59-0.61) than those not participating in the dementia care program (n = 759 men, n = 1407 women; mean [SD] age, 82.42 [8.50] years; age range, 34-103 years). There were no differences between groups in terms of hospitalizations, emergency department visits, or 30-day readmissions. The total cost of care to Medicare, excluding program costs, was $601 less per patient per quarter (95% CI, -$1198 to -$5). After accounting for the estimated program costs of $317 per patient per quarter, the program was cost neutral for Medicare, with an estimated net cost of -$284 (95% CI, -$881 to $312) per program participant per quarter.

CONCLUSIONS AND RELEVANCE

Comprehensive dementia care may reduce the number of admissions to long-term care facilities, and depending on program costs, may be cost neutral or cost saving. Wider implementation of such programs may help people with dementia stay in their communities.

Military-related risk factors in female veterans and risk of dementia

OBJECTIVE

To determine whether diagnoses of traumatic brain injury (TBI), posttraumatic stress disorder (PTSD), and depression, alone or in combination, increase dementia risk among older female veterans.

METHODS

This cohort study included data from 109,140 female veterans ≥55 years of age receiving care from Veterans Health Administration medical centers in the United States between October 2004 and September 2015 with at least 1 follow-up visit. TBI, PTSD, depression, and medical conditions at study baseline and incident dementia were determined according to ICD-9-CM codes. Fine-Gray proportional hazards models were used to determine the association between military-related risk factors and dementia diagnosis, accounting for the competing risk of death.

RESULTS

During follow-up (mean 4.0 years, SD 2.3), 4% of female veterans (n = 4,125) developed dementia. After adjustment for demographics and medical conditions, women with TBI, PTSD, and depression had a significant increase in risk of developing dementia compared to women without these diagnoses (TBI-adjusted subdistribution hazard ratio [adjusted sHR] 1.49, 95% confidence interval [CI] 1.01-2.20; PTSD adjusted sHR 1.78, 95% CI 1.34-2.36; and depression-adjusted sHR 1.67, 95% CI 1.55-1.80), while women with >1 diagnosis had the highest risk for dementia (adjusted sHR 2.15, 95% CI 1.84-2.51).

CONCLUSIONS

We found that women with military-related risk factors had an ≈50% to 80% increase in developing dementia relative to women without these diagnoses, while female veterans with multiple risk factors had a >2-fold risk of developing dementia. These findings highlight the need for increased screening of TBI, PTSD, and depression in older women, especially female veterans.

Dementia-Capable Care Coordination in Duals Demonstration Programs: Workforce Needs, Promising Practices, and Policy

Background and Objectives

This study describes the program requirements, workforce competencies, and barriers for dementia capable care coordination within health plans from seven states participating in the Center for Medicare and Medicaid Services demonstration programs for dually-eligible Medicare and Medicaid beneficiaries.

Research Design and Methods

Data came from contracts, policy documents, and 24 semistructured key informant interviews with national experts and leaders from community-based organizations, advocacy organizations, researchers, federal and state government, and health plans in the seven states.

Results

Contracts included language mandating care coordination practices deemed dementia-capable, including workforce qualifications, training, and experience; dementia screening; involvement of a caregiver in the care planning process; and education, support groups, and referral resources for people with dementia and their caregivers. There was little consistency across states in their dementia capable requirements and informants questioned the dementia capability of the care coordination workforce and practice. However, promising practices and areas for improvement were identified.

Discussion and Implications

The variability of the duals demonstrations made it difficult to compare across states. The three-way contracts were often the starting point of a process to more clearly define policies and practices in each state including workforce requirements. Efforts should be made to further adopt and translate evidence-based practices into health systems and evaluate promising practices.

Evidence-Based Interventions for Transitions in Care for Individuals Living With Dementia

Background and Objectives

Despite numerous, often predictable, transitions in care, little is known about the core elements of successful transitions in care specifically for persons with dementia. The paper examines available evidence-based interventions to improve the care transitions for persons with dementia and their caregivers.

Research Design and Methods

A state-of-the-art review was conducted for research published on interventions targeting transitions in care for persons living with dementia and their caregivers through January 2017.

Results

Our review revealed seven evidence-based interventions to postpone/prevent or reduce care transitions specific to persons living with dementia. Effective approaches appear to be those that involve the individual and caregiver in establishing goals of care, educate the individual and caregiver about likely transitions in care; provide timely communication of information about the individual, create strong inter professional teams with competencies in dementia care, and implement evidence-based models of practice.

Discussion and Implications

Five essential features for consistent and supported care transitions for persons with dementia and their caregivers are recommended. Findings reinforce the need for additional research and adaptation of evidence-based transitions in care interventions.

How complete is the information on preadmission psychotropic medications in inpatients with dementia? A comparison of hospital medical records with dispensing data

OBJECTIVES

Reliable information on preadmission medications is essential for inpatients with dementia, but its quality has hardly been evaluated. We assessed the completeness of information and factors associated with incomplete recording.

METHODS

We compared preadmission medications recorded in hospital electronic medical records (EMRs) with community-pharmacy dispensations in hospitalizations with discharge code for dementia at the University Hospital of Udine, Italy, 2012-2014. We calculated: (a) prevalence of omissions (dispensed medication not recorded in EMRs), additions (medication recorded in EMRs not dispensed), and discrepancies (any omission or addition); (b) multivariable logistic regression odds ratio, with 95% confidence interval (95% CI), of ≥1 omission.

RESULTS

Among 2,777 hospitalizations, 86.1% had ≥1 discrepancy for any medication (Kappa 0.10) and 33.4% for psychotropics. When psychotropics were recorded in EMR, antipsychotics were added in 71.9% (antidepressants: 29.2%, antidementia agents: 48.2%); when dispensed, antipsychotics were omitted in 54.4% (antidepressants: 52.7%, antidementia agents: 41.5%). Omissions were 92% and twice more likely in patients taking 5 to 9 and ≥10 medications (vs. 0 to 4), 17% in patients with psychiatric disturbances (vs. none), and 41% with emergency admission (vs. planned).

CONCLUSION

Psychotropics, commonly used in dementia, were often incompletely recorded. To enhance information completeness, both EMRs and dispensations should be used.

Is increased carer knowledge of the health care system associated with decreased preventable hospitalizations for people in the community diagnosed with dementia? A systematic review protocol

BACKGROUND

People living with dementia (PLWD) are admitted to hospital twice as often as those without dementia, for ambulatory care sensitive conditions (ACSC) that could have been managed in ambulatory and primary care settings. PLWD are at greater risk of poor outcomes during and following hospital admission. Compared to those without dementia, they are almost twice as likely to die in hospital and two to three times more likely to experience an adverse event. Although some hospitalizations are clinically necessary, there may be a proportion related to ACSC that could be potentially avoided with additional support and education for PLWD and their carers. This study aims to assess the effectiveness of interventions focused on reducing avoidable hospitalization for PLWD by supporting carers to manage the health care needs of the PLWD, via improved awareness and understanding of health and the healthcare system.

METHOD

Scientific and gray literature will be searched using a combination of keywords pertaining to dementia, caregivers, education, and support. Included studies will involve community-dwelling PLWD and caregivers, with interventions aimed at improving carer's understanding of the healthcare system and ability to manage the caregiving role. The primary outcome will be hospitalization related to the PLWD and secondary outcomes will be carer burden, stress, wellbeing, and quality of life. All study designs will be considered. Data from included studies will be analyzed using descriptive statistics and content analysis. If the data permits, we will perform a meta-analysis and subgroup analyses, related to the intervention and participant characteristics.

DISCUSSION

This review will provide a comprehensive picture of the knowledge available on the subject and identify knowledge gaps in existing literature. The findings may highlight the lack of existing interventions for PLWD and their carers who live in the community and will help stakeholders to identify needs and develop programs targeted to carers and care recipients that prevent avoidable hospitalization for PLWD.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO number: 49655 .

Effect of Cognitive Status on the Receipt of Procedures Requiring Anesthesia and Critical Care Admissions in Older Adults

OBJECTIVE

To investigate whether older adults with mild cognitive impairment (MCI) or dementia have higher rates of procedures requiring general anesthesia or intensive care unit (ICU) admissions compared with cognitively normal (CN) patients.

PATIENTS AND METHODS

A population-based cohort, 70 to 89 years old at enrollment, underwent clinical and longitudinal neurocognitive testing to identify those with MCI and dementia. We analyzed the effects of cognitive status (CN, MCI, or dementia) at entry into the study from October 1, 2004, through December 31, 2014, on the risk of receiving procedures requiring surgical anesthesia and ICU admission.

RESULTS

Of 2436 participants, 1977 (81%) were CN, 387 (16%) had MCI, and 72 (3%) had dementia. Cognitively impaired individuals were sicker. Compared with CN individuals, the likelihood of receiving a procedure requiring anesthesia was similar in participants with MCI (adjusted hazard ratio [aHR]=0.98; P=.78). Participants with dementia were less likely to receive these procedures (aHR=0.50; P=.02). Compared with CN participants, the likelihood of ICU admission for any indication was increased for those with MCI (aHR=1.24; P=.03) and dementia (aHR=1.59; P=.04). Admissions to the ICU after procedures were not different in patients with either MCI or dementia (aHR=0.96; P=.83 and aHR=1.01; P=.98, respectively).

CONCLUSION

Patients with MCI or dementia are not more likely to undergo surgery, and neither are they more likely to require ICU admission after procedures. An increased rate of nonsurgical ICU admissions requires vigilance to prevent deterioration of nonsurgical diseases that may lead to ICU admissions.

Trends in Hospital Morbidity From Alzheimer's Disease in the European Union, 2000 to 2014

BACKGROUND

Alzheimer's disease (AD) has become a concerning public health issue. We aimed to analyze the trends of hospital morbidity from AD in the European Union (EU) in the period 2000 to 2014.

METHODS

Data from hospital discharges of men and women over 50 years old hospitalized due to AD in the EU were extracted from Eurostat database. We tested for secular trends computing anual percent change, and identified significant changes in the linear slope of the trend.

RESULTS

Hospital morbidity from AD showed a 0.8% (95% confidence intervals -2.2 to 0.6) slight declining trend in the EU. In men and women, we recorded a -0.5% and -1.0% decrease in hospital morbidity rates, respectively. Several countries showed changing trends during the study period.

CONCLUSION

Alzheimer's disease hospital morbidity has slightly declined in the entire EU in the past years. Eastern European countries showed steadily increasing trends, whereas in western and Mediterranean countries the rates decreased or leveled off.

Measuring caregiver activation to identify coaching and support needs: Extending MYLOH to advanced chronic illness

INTRODUCTION

Family and friends of seriously ill patients are key partners in providing support and health care at home, managing relationships with clinicians, and navigating complex health care systems. Becoming a knowledgeable, confident, and effective caregiver is a developmental process we term 'caregiver activation' and could be facilitated by clinicians equipped with suitable tools. Managing Your Loved One's Health (MYLOH) is a new tool to identify gaps in caregivers' knowledge, skills, and access to clinical and personal support. Created in partnership with caregivers and clinicians, MYLOH items reflect the essential dimensions of caregiving and can be used to tailor caregiver coaching to domains of greatest need. In this study, we extend MYLOH's initial focus on dementia care to caregivers of patients with other chronic life-limiting illnesses.

METHODS

MYLOH was completed by primary caregivers (n = 190) of people with a range of advanced chronic illnesses enrolled in the LifeCourse study, an innovative, whole-person approach to health management. Item relevance and responses were compared by group across MYLOH items and domains using z-tests for equality of proportions.

RESULTS

All MYLOH items were relevant to caregiving for all types of chronic illness; only 13% of caregivers answered "not my responsibility" to any question. MYLOH identified caregiving struggles across patient diagnosis groups with a few, disease-specific 'hotspots'. Overall, 64% of caregivers scored low in activation on at least one healthcare management task, especially getting enough help with caregiving, managing everyday caregiving tasks, understanding/managing medications, and knowing how to respond to rapid changes in care recipients' health status. No difficulty was unique to a specific type of care recipient illness.

CONCLUSIONS

MYLOH has potential as a tool for identifying caregiver coaching and support needs in managing a range of serious chronic illnesses. Caregiving difficulties endorsed by over 20% of caregivers should be core components of chronic illness management programs regardless of disease focus, with disease-specific tailoring as required. MYLOH may be useful in evaluating caregiver interventions and health systems' performance in integrating caregivers into the care management of patients with complex life-limiting illness.

Medicare Expenditures and Health Care Utilization in a Multiethnic Community-based Population With Dementia From Incidence to Death

INTRODUCTION

While individuals live with dementia for many years, utilization and expenditures from disease onset through the end-of-life period have not been examined in ethnically diverse samples.

METHODS

We used a multiethnic, population-based, prospective study of cognitive aging (Washington Heights-Inwood Columbia Aging Project) linked to Medicare claims to examine total Medicare expenditures and health care utilization among individuals with clinically diagnosed incident dementia from disease onset to death.

RESULTS

High-intensity treatment (hospitalizations, life-sustaining procedures) was common and mean Medicare expenditures per year after diagnosis was $69,000. Non-Hispanic blacks exhibited higher spending relative to Hispanics and non-Hispanic whites 1 year after diagnosis. Non-Hispanic blacks had higher total (mean=$205,000) Medicare expenditures from diagnosis to death compared with non-Hispanic whites (mean=$118,000). Hispanics' total expenditures and utilization after diagnosis was similar to non-Hispanic whites despite living longer with dementia.

DISCUSSION

Health care spending for patients with dementia after diagnosis through the end-of-life is high and varies by ethnicity.

Attributable Cost of Dementia: Demonstrating Pitfalls of Ignoring Multiple Health Care System Utilization

OBJECTIVES

To determine dementia prevalence and costs attributable to dementia using Veterans Health Administration (VHA) data with and without Medicare data.

DATA SOURCES

VHA inpatient, outpatient, purchased care and other data and Medicare enrollment, claims, and assessments in fiscal year (FY) 2013.

STUDY DESIGN

Analyses were conducted with VHA data alone and with combined VHA and Medicare data. Dementia was identified from a VHA sanctioned list of ICD-9 diagnoses. Attributable cost of dementia was estimated using recycled predictions.

DATA COLLECTION

Veterans age 65 and older who used VHA and were enrolled in Traditional Medicare in FY 2013 (1.9 million).

PRINCIPAL FINDINGS

VHA records indicated the prevalence of dementia in FY 2013 was 4.8 percent while combined VHA and Medicare data indicated the prevalence was 7.4 percent. Attributable cost of dementia to VHA was, on average, $10,950 per veteran per year (pvpy) using VHA alone and $6,662 pvpy using combined VHA and Medicare data. Combined VHA and Medicare attributable cost of dementia was $11,285 pvpy. Utilization attributed to dementia using VHA data alone was lower for long-term institutionalization and higher for supportive care services than indicated in combined VHA and Medicare data.

CONCLUSIONS

Better planning for clinical and cost-efficient care requires VHA and Medicare to share data for veterans with dementia and likely more generally.

Cognition and Incarceration: Cognitive Impairment and Its Associated Outcomes in Older Adults in Jail

OBJECTIVES

To determine prevalence of, and outcomes associated with, a positive screen for cognitive impairment in older adults in jail.

DESIGN

Combined data from cross-sectional (n=185 participants) and longitudinal (n=125 participants) studies.

SETTING

Urban county jail.

PARTICIPANTS

Individuals in jail aged 55 and older (N = 310; mean age 59, range 55-80). Inclusion of individuals aged 55 and older is justified because the criminal justice system defines "geriatric prisoners" as those aged 55 and older.

MEASUREMENTS

Baseline and follow-up assessments of health, psychosocial factors, and cognitive status (using the Montreal Cognitive Assessment (MoCA)); 6-month acute care use and repeat arrest assessed in those followed longitudinally.

RESULTS

Participants were of low socioeconomic status (85% annual income < $15,000) and predominantly nonwhite (75%). Many (70%) scored less than 25 on the MoCA; those with a low MoCA score were more likely to be nonwhite (81% vs 62%, p<.001) and report fair or poor health (54% vs 41%, p=.04). Over 6 months, a MoCA score of less than 25 was associated with multiple emergency department visits (32% vs 13%, p=.02), hospitalization (35% vs 16%, p=.03), and repeat arrests (45% vs 21%, p=.01).

CONCLUSIONS

Cognitive impairment is prevalent in older adults in jail and is associated with adverse health and criminal justice outcomes. A geriatric approach to jail-based and transitional health care should be developed to assess and address cognitive impairment. Additional research is needed to better assess cognitive impairment and its consequences in this population. J Am Geriatr Soc 66:2065-2071, 2018.

Reducing disability via a family centered intervention for acutely ill persons with Alzheimer's disease and related dementias: protocol of a cluster-randomized controlled trial (Fam-FFC study)

Background

Hospitalized older persons with Alzheimer’s disease and related dementias are at greater risk for functional decline and increased care dependency after discharge due to a combination of intrinsic factors, environmental, policy, and care practices that restrict physical and cognitive activity, lack of family involvement and limited staff knowledge of dementia care. We have developed a theory-based intervention, Family centered Function-focused Care, that incorporates an educational empowerment model for family caregivers (FCGs) provided within a social-ecological framework to promote specialized care to patients with dementia during hospitalization and the 60-day post-acute period. Primary aims are to test the efficacy of the intervention in improving physical and cognitive recovery in hospitalized persons living with Alzheimer’s disease and related dementias (ADRD) and improving FCG preparedness and experiences.

Method

We will implement Family centered Function-focused Care in a cluster-randomized trial of 438 patient/FCG dyads in six hospital units randomized within three hospitals. We hypothesize that patients who receive the intervention will demonstrate better physical function, less delirium occurrence and severity, neuropsychiatric symptoms, and depression compared to those in the control condition (Education-only). We also hypothesize that FCGs enrolled in Family centered Function-focused Care will experience increased preparedness for caregiving, and less strain, burden, and desire to institutionalize, as compared to FCGs the control group. We will also examine the costs and relative cost savings associated with the intervention and will evaluate the cultural appropriateness of Family centered Function-focused Care for families from diverse backgrounds.

Discussion

Our theory-based intervention makes use of real-world applicable approaches in a novel and innovative way to change the paradigm of how we currently look at acute care and post-acute transitions in persons with ADRD.

Trial registration

ClinicalTrials.gov, ID: NCT03046121. Registered on 8 February 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2875-1) contains supplementary material, which is available to authorized users.

Clinical characteristics of patients with dementia in a local emergency clinic in Japan

AIM

The present study aimed to clarify the clinical characteristics of patients with dementia in an emergency clinic.

METHODS

We retrospectively examined patients with dementia who visited the emergency clinic at Kurashiki Heisei Hospital, Okayama, Japan. Among 16 764 patients who visited our emergency clinic in the 3 years from 2014 to 2017, we focused on 2574 (15.4%) patients with dementia.

RESULTS

The mean age of patients with dementia was 84.9 ± 0.1 years, which was much older than the age of the total emergency patients (58.1 ± 0.2 years). The hospitalization rate was 54.9% for patients with dementia, which was more than double that of patients without dementia (23.3%; P <0.01), and was higher than that (44.3%) of patients who were aged ≥75 years without dementia. Infection (42.4%) and falls (20.9%) were the most common causes for emergency visits and hospitalization in the present study. Hospitalized patients with dementia spent a longer time in hospital for stroke (64.0 ± 5.3 days) and falls (51.9 ± 2.1 days) than those with infection, epilepsy, syncope, loss of consciousness, other causes (all P <0.01) or dehydration (P ≤ 0.05).

CONCLUSIONS

Patients with dementia commonly attend our emergency clinic. These patients are older in age, have a higher hospitalization rate and have a longer hospitalization, especially due to stroke and falls, than patients without dementia. Geriatr Gerontol Int 2018; 18: 1383-1387.

How do people with dementia use the ambulance service? A retrospective study in England: the HOMEWARD project

OBJECTIVES

An increasing number of older people are calling ambulances and presenting to accident and emergency departments. The presence of comorbidities and dementia can make managing these patients more challenging and hospital admission more likely, resulting in poorer outcomes for patients. However, we do not know how many of these patients are conveyed to hospital by ambulance. This study aims to determine: how often ambulances are called to older people; how often comorbidities including dementia are recorded; the reason for the call; provisional diagnosis; the amount of time ambulance clinicians spend on scene; the frequency with which these patients are transported to hospital.

METHODS

We conducted a retrospective cross-sectional study of ambulance patient care records (PCRs) from calls to patients aged 65 years and over. Data were collected from two ambulance services in England during 24 or 48 hours periods in January 2017 and July 2017. The records were examined by two researchers using a standard template and the data were extracted from 3037 PCRs using a coding structure.

RESULTS

Results were reported as percentages and means with 95% CIs. Dementia was recorded in 421 (13.9%) of PCRs. Patients with dementia were significantly less likely to be conveyed to hospital following an emergency call than those without dementia. The call cycle times were similar for patients regardless of whether or not they had dementia. Calls to people with dementia were more likely to be due to injury following a fall. In the overall sample, one or more comorbidities were reported on the PCR in over 80% of cases.

CONCLUSION

Rates of hospital conveyance for older people may be related to comorbidities, frailty and complex needs, rather than dementia. Further research is needed to understand the way in which ambulance clinicians make conveyance decisions at scene.

Direct health and residential care costs of people living with dementia in Australian residential aged care

OBJECTIVES

This analysis estimates the whole-of-system direct costs for people living with dementia in residential care by using a broad health and social care provision perspective and compares it to people without dementia living in residential care.

METHODS

Data were collected from 541 individuals living permanently in 17 care facilities across Australia. The annual cost of health and residential care was determined by using individual resource use data and reported by the dementia status of the individuals.

RESULTS

The average annual whole-of-system cost for people living with dementia in residential care was approximately AU$88 000 (US$ 67 100) per person in 2016. The cost of residential care constituted 93% of the total costs. The direct health care costs were comprised mainly of hospital admissions (48%), pharmaceuticals (31%) and out-of-hospital attendances (15%). While total costs were not significantly different between those with and without dementia, the cost of residential care was significantly higher and the cost of health care was significantly lower for people living with dementia.

CONCLUSION

This study provides the first estimate of the whole-of-system costs of providing health and residential care for people living with dementia in residential aged care in Australia using individual level health and social care data. This predominantly bottom-up cost estimate indicates the high cost associated with caring for people with dementia living permanently in residential care, which is underestimated when limited cost perspectives or top-down, population costing approaches are taken.

Effectiveness of multidisciplinary consultation for older adults with Alzheimer's disease in response to acute situations

BACKGROUND

To avoid emergency hospitalisation of elderly people with dementia, which often has negative consequences, there are two main approaches: consultation and day care hospitalisation. However, it usually takes some time to arrange a consultation, and geriatric day hospital facilities are over-subscribed and costly. In 2014, we created a "consultation de crise" (CMC) programme in our sector of Paris, with several special features: a short wait for an appointment, a consultation involving an interdisciplinary team, a weekly multi-disciplinary meeting to reassess complex patients, and the possibility of a rapid referral to a social worker.

METHODS

To determine whether the CMC programme is a useful way to minimise hospitalization among elderly community-dwelling populations, and to examine its design criteria. Retrospective review of all CMC requests from April 2014 to January 2017 in comparison with consultation at the Memory Center and geriatric day hospital. CMC patients were followed up at one month after their assessment.

RESULTS

Mini Mental Status and Neuro Psychiatric Inventory vary significantly different between the 3 groups. The CMC group had the lowest score on the MMSE scale and the highest for NPI. After one month, 60% of CMC patients were still at home (33 patients) or in the same nursing home (6 patients) and about 23% were hospitalized during the follow-up period.

CONCLUSION

Our study showed the potential value of a less expensive multidisciplinary consultation, and confirmed that collaborative care resulted in a significant improvement in the quality of care.

Comparison of psychosocial and medical characteristics of patients with dementia and their primary informal caregivers between inpatient and day clinic treatment

Background

Caregiver burden is one of the most common reasons for hospitalization of patients with dementia. However, changes of location are not recommended for patients with dementia and associated with negative outcomes for patients with dementia. As there is yet a lack of outpatient treatment options, this study explores psychiatric day clinic treatment as option for patients with dementia by comparing characteristics of voluntarily treated patients with dementia and their respective informal caregivers between an inpatient and day clinic setting.

Methods

A total of 92 patients with dementia (56 inpatient, 36 day clinic) and their informal caregiver provided information on psychosocial and clinical characteristics (Mini-Mental-Status-Test, Neuropsychiatric Inventory, Bayer Activities of Daily Living, Barthel Index, Geriatric Depression Scale-30, Beck’s Depression Inventory-II, caregiver burden, Short Form Health Survey-36) at the beginning of treatment and at follow-up (n = 48 patient caregiver dyads) six months after discharge.

Results

Patients with dementia did not differ in disease severity, neuropsychiatric symptoms, and depression depending on treatment setting. However, the higher the Bayer activities of daily living score, the more likely treatment in day clinic was. Caregivers from patients with dementia in the inpatient setting were younger and reported more financial burden, whereas caregivers from patients with dementia in the day clinic reported lower physical health and more burden due to practical caring responsibilities. Longitudinal data indicated no differences in characteristics of patients with dementia and caregivers depending on treatment setting, despite caregivers from patients in the day clinic reporting more depressive symptoms after six months.

Conclusion

Day clinic treatment for voluntarily treated patients with dementia might be an alternative to inpatient settings. Patients with dementia do not substantially differ depending on treatment setting, rather characteristics of the caregivers were associated with placement in inpatient or day clinic setting. The needs of caregivers deserve special attention when considering treatment for patients with dementia.

Behavioural and psychological symptoms in general hospital patients with dementia, distress for nursing staff and complications in care: results of the General Hospital Study

AIMS

Little is known about how behavioural and psychological symptoms of dementia (BPSD) manifest in the general hospital. The aim was to examine the frequency of BPSD in general hospitals and their associations with nursing staff distress and complications in care.

METHODS

Cross-sectional representative study with 1469 patients aged ≥65, including 270 patients with dementia, of 33 randomly selected general hospitals in Germany. BPSD and complications were reported by nurses.

RESULTS

Overall frequency of BPSD was higher in patients with dementia (76%) than without (38%). The most frequent symptoms in patients with dementia were nighttime disturbances (38%), depression (29%) and aberrant motor behaviour (28%) and the most distressing symptoms for nursing staff were delusions, aggression and nighttime disturbances. The overall frequency of BPSD increased from 67% in mild dementia, to 76% in moderate dementia and to 88% in severe dementia. The most frequent symptoms in patients without dementia were depression (19%), nighttime disturbances (13%) and irritability (13%). The most distressing symptoms were aggression and delusions, while the same symptoms were consistently rated as less distressing than in patients with dementia. Factor analysis revealed three independent groups of BPSD that explained 45% of the total variance. First, expansive symptoms (aggression, irritability, nighttime disturbances, aberrant motor behaviour and disinhibition) were frequent, distressing for nursing staff and associated with many complications. Second, psychotic symptoms (delusions and hallucinations) were infrequent, distressing and associated with some complications. Third, affective symptoms (apathy, anxiety and depression) were frequent, non-distressing and associated with few complications. The results did not change when cases with delirium were excluded from both groups.

CONCLUSIONS

BPSD are common in older hospital patients with dementia and associated with considerable distress in nursing staff, as well as a wide range of special treatments needs and additional behavioural and medical complications. Management strategies are needed to improve the situation for both patients and hospital staff.

Place of death in patients with dementia and the association with comorbidities: a retrospective population-based observational study in Germany

Background

Due to increasing life expectancy, more and more older people are suffering from dementia and comorbidities. To date, little information is available on place of death for dementia patients in Germany. In addition, the association of place of death and comorbidities is unknown.

Methods

A population-based cross-sectional survey was conducted in Westphalia–Lippe (Germany), based on the analysis of death certificates from 2011. Individuals with dementia ≥ 65 years were identified using the documented cause of death. In this context, all mentioned causes of death were included. In addition, ten selected comorbidities were also analyzed. The results were presented descriptively. Using multivariate logistic regression, place of death was analyzed for any association with comorbidities.

Results

A total of 10,364 death certificates were analyzed. Dementia was recorded in 1646 cases (15.9%; mean age 86.3 ± 6.9 years; 67.3% women). On average, 1.5 ± 1.0 selected comorbidities were present. Places of death were distributed as follows: home (19.9%), hospital (28.7%), palliative care unit (0.4%), nursing home (49.5%), hospice (0.9%), no details (0.7%). The death certificates documented cardiac failure in 43.6% of cases, pneumonia in 25.2%, and malignant tumour in 13.4%. An increased likelihood of dying in hospital compared to home or nursing home, respectively, was found for the following comorbidities (OR [95%-CI]): pneumonia (2.96 [2.01–4.35], p = 0.001); (2.38 [1.75–3.25], p = 0.001); renal failure (1.93 [1.26–2.97], p = 0.003); (1.65 [1.18–2.32], p = 0.003); and sepsis (13.73 [4.88–38.63], p = 0.001); (7.34 [4.21–12.78], p = 0.001).

Conclusion

The most common place of death in patients with dementia is the retirement or nursing home, followed by hospital and home. Specific comorbidities, such as pneumonia or sepsis, correlated with an increased probability of dying in hospital.

Hospital admissions 2000-2014: A retrospective analysis of 288 096 events in patients with dementia

INTRODUCTION

Dementia is a leading cause of disability worldwide. It is associated with an increased risk of hospitalization, imposing a significant burden on healthcare systems. The evidence on the long-term evolution of this issue and broadly on healthcare systems is currently limited. This study aims to describe the hospitalizations of people who received a diagnosis of dementia admitted to public general hospitals in a western European country with universal health coverage, over more than a decade.

METHODS

This retrospective observational study analyzed all inpatient episodes from 2000 to 2014 with a primary or secondary diagnosis of dementia using a national hospitalization database from mainland Portuguese public hospitals.

RESULTS

A total of 288 096 hospital admissions were registered. Hospitalization rates increased 4.7 times throughout the study period. Pneumonia and urinary tract infections were the most frequent main diagnoses, while dementia itself was the cause of admission in a minority (6.8%) of cases. Cerebrovascular disease, diabetes without chronic complications, and congestive heart failure were the most prevalent comorbidities; 5.9% of patients with dementia admitted to hospital underwent a surgical procedure, orthopedic surgeries being the most frequent. The median length of hospital stay was 8.0 days, and in-hospital mortality rate was 16.1%.

CONCLUSIONS

Dementia patients represent a significant amount of hospital admissions. Most leading causes of hospital admissions are preventable if timely diagnosed and could be effectively managed in the outpatient setting. These findings may be useful for healthcare resource planning and allocation. Further research should drive evidence-based reorganization of health care systems.

The canary in the coal mine: Continence care for people with dementia in acute hospital wards as a crisis of dehumanization

Continence is a key moment of care that can tell us about the wider care of people living with dementia within acute hospital wards. The spotlight is currently on the quality of hospital care of older people across the UK, yet concerns persist about their poor treatment, neglect, abuse, and discrimination within this setting. Thus, within hospitals, the care of people living with dementia is both a welfare issue and a human rights issue. The challenge of continence care for people living with dementia can be seen as the 'canary in the coal mine' for the unravelling of dignity within the acute setting. This paper draws on an ethnographic study within five hospitals in England and Wales, selected to represent a range of hospital types, geographies and socio-economic catchments. Observational fieldwork was carried out over 154 days in acute hospitals known to admit large numbers of people living with dementia. This paper starts to fill the gap between theory and data by providing an in-depth ethnographic analysis examining the ways in which treatment as a person is negotiated, achieved or threatened. We examine how the twin assaults on agency of a diagnosis of dementia and of incontinence threaten personhood. The acute threats to this patient group may then act to magnify perils to treatment as a person. Our findings suggest that personal dignity and the social construction of moral personhood are both threatened and maintained in such a setting. We show how empirical ethnographic data can lend weight to, and add detail to, theoretical accounts of moral personhood and dignity.

Incongruent perceptions of the care values of hospitalized persons with dementia: a pilot study of patient-family caregiver dyads

OBJECTIVE

Many difficult decisions are made in the inpatient hospital setting regarding the daily care of persons with dementia (PWDs). Incongruent perceptions of the PWD's care values limit the family caregiver's ability to make surrogate decisions. The objectives of this pilot study were to describe and identify determinants of incongruent perceptions in the hospital setting.

METHODS

Using multilevel modeling (MLM), we examined cross-sectional data collected from 42 PWD-family caregiver dyads.

RESULTS

There was a significant amount of incongruence, on average, for all four subscales representing the PWD's care values: autonomy = -0.33 (p < .001); burden = -.49 (p < .001); safety/quality of care = -.26 (p < .001); and social interactions = -.21 (p = .004). Family caregivers (CG) rated the importance of care values to the PWD as lower than the PWD rated the importance. Determinants of greater incongruence included higher relationship strain and fewer positive dyadic interactions.

CONCLUSION

Our findings reveal significant levels of incongruence in perceptions of the PWD's values among dementia care dyads in the hospital setting. Our analysis suggests a potential impact of relationship variables on incongruence. Further research is needed around this overlooked interpersonal context for supporting the dementia care dyad in the hospital setting.

Falls and Hospitalizations Among Persons With Dementia and Associated Caregiver Emotional Difficulties

Background and Objectives

Falls and hospitalizations are adverse health events commonly experienced by persons with dementia (PWDs). These events often require urgent care from a family caregiver and may increase caregiver stress. We examine falls and hospitalizations among PWDs as predictors of caregivers' reported care-related emotional difficulty, in addition to care-related stressors.

Research Design and Methods

Cross-sectional telephone survey of 652 informal caregivers for PWDs. A multinomial logistic regression examined falls (last month) and hospitalizations (prior year) experienced by PWDs as predictors of caregivers' care-related emotional difficulty, accounting for demographic characteristics and primary and secondary caregiving stressors.

Results

Over 20% of caregivers reported high levels of care-related emotional difficulty. Controlling for demographic characteristics and primary and secondary caregiving stressors, the PWD's prior month fall was significantly associated with greater care-related emotional difficulty; the PWD's hospitalizations were not associated with care-related emotional difficulty.

Discussion and Implications

Approximately 30% of PWDs had experienced a past year hospitalization and prior month fall, and one in five caregivers reported high emotional difficulty related to care. Although secondary strains and resources of caregiving were strong predictors of care-related emotional difficulty, PWDs' falls represent a significant stressor that increases odds of caregiver emotional difficulty over and above other strains. Consequently, a fall experienced by a PWD may represent a key time for clinicians to assess caregiver well-being.

Determinants of hospitalization and length of stay among people with dementia - An analysis of statutory health insurance claims data

OBJECTIVE

Dementia is a crucial challenge in acute care hospitals. Using a retrospective claims data cohort, this paper explores dementia patients' acute hospitalization rates, risk factors, and length of stay.

METHODS

The study used claims data from AOK PLUS, the largest statutory health insurance service (SHI) in Saxony, a federal state of Germany. The analysis included 61,239 people with dementia and 183,477 control subjects, all 65 years and older. Control subjects were age, gender, and regionally matched in a 1:3 ratio. Negative binomial hurdle regression was used to compare differences in hospitalization for the year 2014.

RESULTS

People with dementia had 1.49 times higher adjusted odds of being hospitalized at least once (95% confidence interval [CI], 1.46-1.52). Among those individuals hospitalized at least once, dementia increased the number of readmissions by 18% (95% CI, 1.15-1.20). Dementia patients also had a 1.74 times higher odds for at least one emergency admission compared to individuals without dementia (95% CI, 1.70-1.78). Dementia patients' admission risk factors included having care dependency, being recently diagnosed with dementia and living outside a metropolitan region. The increased length of stay for people with dementia per year was mainly attributable to higher admission rates.

CONCLUSIONS

Dementia patients are at higher risk for hospitalization, especially if they live outside the metropolitan region. Healthcare systems need to respond to the challenges resulting from the predicted demographic developments and increasing burden of dementia in the general population.