Patterns of unplanned hospital admissions among people with dementia: from diagnosis to the end of life

Determinants of hospital readmissions in older people with dementia: a narrative review

INTRODUCTION

Over 50% of hospitalised older people with dementia have multimorbidity, and are at an increased risk of hospital readmissions within 30 days of their discharge. Between 20-40% of these readmissions may be preventable. Current research focuses on the physical causes of hospital readmissions. However, older people with dementia have additional psychosocial factors that are likely to increase their risk of readmissions. This narrative review aimed to identify psychosocial determinants of hospital readmissions, within the context of known physical factors.

METHODS

Electronic databases MEDLINE, EMBASE, CINAHL and PsychInfo were searched from inception until July 2022 and followed up in February 2024. Quantitative and qualitative studies in English including adults aged 65 years and over with dementia, their care workers and informal carers were considered if they investigated hospital readmissions. An inductive approach was adopted to map the determinants of readmissions. Identified themes were described as narrative categories.

RESULTS

Seventeen studies including 7,194,878 participants met our inclusion criteria from a total of 6369 articles. Sixteen quantitative studies included observational cohort and randomised controlled trial designs, and one study was qualitative. Ten studies were based in the USA, and one study each from Taiwan, Australia, Canada, Sweden, Japan, Denmark, and The Netherlands. Large hospital and insurance records provided data on over 2 million patients in one American study. Physical determinants included reduced mobility and accumulation of long-term conditions. Psychosocial determinants included inadequate hospital discharge planning, limited interdisciplinary collaboration, socioeconomic inequalities among ethnic minorities, and behavioural and psychological symptoms. Other important psychosocial factors such as loneliness, poverty and mental well-being, were not included in the studies.

CONCLUSION

Poorly defined roles and responsibilities of health and social care professionals and poor communication during care transitions, increase the risk of readmission in older people with dementia. These identified psychosocial determinants are likely to significantly contribute to readmissions. However, future research should focus on the understanding of the interaction between a host of psychosocial and physical determinants, and multidisciplinary interventions across care settings to reduce hospital readmissions.

Identifying longitudinal healthcare pathways and subsequent mortality for people living with dementia in England: an observational group-based trajectory analysis

BACKGROUND

The number of people living with dementia (PLWD) continues to increase, particularly those with severe symptomatology. Severe symptoms and greater ill-health result in more acute care need. Early healthcare interventions can prove beneficial. Healthcare use has not been analysed as a holistic set of interlinked events. This study explores different healthcare pathways among PLWD, social or spatial inequalities in healthcare pathways and subsequent mortality risk.

METHODS

Group-based trajectory models (GBTM) were applied to electronic healthcare records. We generated clusters of PLWD with similar five-year, post-diagnosis trajectories in rates of primary and secondary healthcare use. Potential social and spatial variations in healthcare use clusters were examined. Cox Proportional Hazards used to explore variation in subsequent mortality risk between healthcare use clusters.

RESULTS

Four healthcare use clusters were identified in both early- (n = 3732) and late-onset (n = 6224) dementia populations. Healthcare use variations were noted; consistent or diminishing healthcare use was associated with lower subsequent mortality risk. Increasing healthcare use was associated with increased mortality risk. Descriptive analyses indicated social and spatial variation in healthcare use cluster membership.

CONCLUSION

Healthcare pathways can help indicate changing need and variation in need, with differential patterns in initial healthcare use post-diagnosis, producing similar subsequent mortality risk. Care in dementia needs to be more accessible and appropriate, with care catered to specific and changing needs. Better continuity of care and greater awareness of dementia in primary can enhance prospects for PLWD. Research needs to further illuminate holistic care need for PLWD, including health and social care use, inequalities in care, health and outcomes.

Survival analysis of older adults with dementia: predicting factors after unplanned hospitalization in Maharaj Nakorn Chiang Mai Hospital

BACKGROUND

Hospitalization in individuals with dementia can be associated with negative and unintended outcomes. Research indicates that people with dementia experience more hospital admissions in comparison to individuals without dementia. This study aims to assess the survival time of individuals with dementia who experience unplanned hospitalization and examine the factors that are associated with mortality in this population.

METHODS

This retrospective cohort study was conducted using data from older adults with dementia who survived unplanned hospitalizations at Maharaj Nakorn Chiang Mai Hospital between January 1, 2009, and December 31, 2016. The association between factors and mortality were analyzed using a multivariable Cox proportional hazards model.

RESULTS

One hundred and eighty-one cases were included. The mean age of the study population was 80.07 (SD 7.49) years, and the majority were female (56.91%). The median survival time of the studied cohort was 3.06 years (95% CI 3.14-3.60). The multivariable analysis revealed that older age (aHR = 1.02, 95% CI 1.00-1.05), a diagnosis of mixed-type dementia (aHR = 3.45, 95% CI 1.17-10.14), higher Charlson comorbidity index score (aHR = 1.19, 95% CI 1.04-1.36), higher serum creatinine level (aHR = 1.35, 95% CI 1.10-1.66), insertion of endotracheal tube (aHR = 1.95, 95% CI 1.07-3.54), and readmission within 30 days (aHR = 1.88, 95% CI 1.18-2.98) were associated with an increased risk of mortality.

CONCLUSIONS

We identified several notable predictors of mortality. Healthcare providers can use the findings of this study to identify patients who may be at higher risk of mortality and develop targeted interventions which may improve patient outcomes.

Exploring access to community care and emergency department use among people with dementia: A qualitative interview study with people with dementia, and current and bereaved caregivers

OBJECTIVES

Emergency department (ED) attendance is common among people with dementia and associated with poor health outcomes. Literature suggests a link between access to community care and the ED, but we know little about the mechanisms behind this link. This study aimed to explore experiences of accessing community and emergency care among people affected by dementia.

METHODS

Informed by critical realism, semi-structured online and telephone interviews were conducted with people with dementia and family caregivers, with and without experience of using the ED. Participants were recruited from across the United Kingdom using purposive sampling with maximum variation. A mostly experiential reflexive thematic analysis approach was used, applying the candidacy model of access to deepen interpretation.

RESULTS

Two dyad and 33 individual interviews were conducted with 10 people with dementia, 11 current caregivers and 16 bereaved caregivers (men = 11, 70-89 years = 18, white ethnicity = 32). Three themes are reported: (1) Navigating a 'push system', (2) ED as the 'last resort', and (3) Taking dementia 'seriously'. Themes describe a discrepancy between the configuration of services and the needs of people affected by dementia, who resort to the ED in the absence of accessible alternatives. Underlying this discrepancy is a lack of systemic prioritisation of dementia and wider societal stigma.

CONCLUSION

Although a last resort, ED attendance is frequently the path of least resistance for people with dementia who encounter multiple barriers for timely, responsive access to community health and social care. Greater systemic prioritisation of dementia as a life-limiting condition may help to reduce reliance on the ED through essential development of post-diagnostic care, from diagnosis to the end of life.

A population-based retrospective cohort study of end-of-life emergency department visits by people with dementia: multilevel modelling of individual- and service-level factors using linked data

BACKGROUND

emergency department (ED) visits have inherent risks for people with dementia yet increase towards the end-of-life. Although some individual-level determinants of ED visits have been identified, little is known about service-level determinants.

OBJECTIVE

to examine individual- and service-level factors associated with ED visits by people with dementia in the last year of life.

METHODS

retrospective cohort study using hospital administrative and mortality data at the individual-level, linked to health and social care service data at the area-level across England. The primary outcome was number of ED visits in the last year of life. Subjects were decedents with dementia recorded on the death certificate, with at least one hospital contact in the last 3 years of life.

RESULTS

of 74,486 decedents (60.5% women; mean age 87.1 years (standard deviation: 7.1)), 82.6% had at least one ED visit in their last year of life. Factors associated with more ED visits included: South Asian ethnicity (incidence rate ratio (IRR) 1.07, 95% confidence interval (CI) 1.02-1.13), chronic respiratory disease as the underlying cause of death (IRR 1.17, 95% CI 1.14-1.20) and urban residence (IRR 1.06, 95% CI 1.04-1.08). Higher socioeconomic position (IRR 0.92, 95% CI 0.90-0.94) and areas with higher numbers of nursing home beds (IRR 0.85, 95% CI 0.78-0.93)-but not residential home beds-were associated with fewer ED visits at the end-of-life.

CONCLUSIONS

the value of nursing home care in supporting people dying with dementia to stay in their preferred place of care must be recognised, and investment in nursing home bed capacity prioritised.