Persons with dementia have higher rate of hospitalizations

"Nonelective hospitalization of older people, particularly those with dementia, is not a trivial event. Among older persons without dementia, hospitalization for serious illness is associated with subsequent cognitive decline, and frail elders, including those with dementia are at increased risk of delirium, functional decline, and iatrogenic [induced by a physician's activity, manner, or therapy] complications during an inpatient stay. Identifying conditions that precipitate hospitalization of elderly individuals with dementia could focus clinical priorities on secondary and tertiary prevention in the outpatient setting and improve health care for this vulnerable and increasing population," according to background information in the article.

Elizabeth A. Phelan, M.D., M.S., of the University of Washington, Seattle, and colleagues conducted a study to determine whether dementia onset is associated with higher rates of or different reasons for hospitalization, particularly for ambulatory care-sensitive conditions (ACSCs), for which proactive outpatient care might prevent the need for a hospital stay. The study included an analysis of hospitalizations among 3,019 participants in Adult Changes in Thought (ACT), a study of adults ages 65 years or older enrolled in an integrated health care system. All participants had no dementia at the beginning of the study and those who eventually had a dementia diagnosis as part of dementia screening contributed nondementia hospitalizations until their diagnosis. Automated data were used to identify all hospitalizations of all participants from time of enrollment in ACT until death, disenrollment from the health plan, or end of follow-up, whichever came first. The study period was from February 1994 to December 2007.

During the study period, 494 individuals eventually developed dementia and 427 (86 percent) of these persons were admitted to a hospital at least once; 2,525 remained free of dementia and 1,478 (59 percent) of those were admitted at least once. Admissions totaled 5,328. Among those who developed dementia, there were 689 admissions prior to diagnosis and 714 after dementia diagnosis. Of ACSC admissions for this group, 121 occurred before dementia diagnosis and 198 after. Forty percent (n=196) of the dementia group had at least 1 ACSC admission compared with 17 percent (n = 424) of the dementia-free group.

Among participants with dementia, the average annual admission rate was more than twice that of those without dementia. In the fully adjusted model, admission rates for 5 types of disorders (circulatory, genitourinary, infectious, neurological, and respiratory) were significantly higher among participants with dementia compared with those without dementia.

The crude admission rate for ACSCs was higher among those with dementia. "Three ACSCs, bacterial pneumonia, congestive heart failure, and urinary tract infection, accounted for two-thirds of all potentially preventable admissions, and admission rates among those with dementia were significantly higher for all 3 conditions. Admission rates for dehydration and duodenal ulcer, though low overall, were also significantly higher among those with dementia. Admissions for ACSCs accounted for 28 percent of all hospitalizations among those with dementia vs. only 19 percent of all admissions among those who remained dementia free," the authors write.

"Knowledge of the ACSCs most likely to lead to hospitalization is important, as this information may help clinicians focus their differential diagnostic considerations and thereby permit proactive, early management for these conditions among patients with dementia. Early detection and outpatient management of acute illness when it is still in its early phases might minimize the need for hospitalization for these conditions and help health care organizations reduce their rates of ACSC admissions and associated costs."

"In summary, our findings that persons with dementia have higher rates of hospitalizations for most categories of medical illness and for ACSCs suggest that there may be important opportunities for improving care of demented older persons, including developing better strategies for delivering anticipatory, proactive primary care to this population. The characteristic feature of late-life dementia—cognitive impairment in the face of multiple other comorbidities—presents a special challenge not currently addressed in models of chronic disease care," the researchers conclude.

Constantine G. Lyketsos, M.D., M.H.S., of Johns Hopkins University, Johns Hopkins Bayview, Baltimore, writes in an accompanying editorial that "the challenges posed by dementia are not going away any time soon."

"Medical professionals have an obligation to detect and manage this devastating chronic disease in ways that are known to be effective, albeit not curative. Physicians should participate in this effort by making detection of dementia in its early stages and implementation of dementia care a priority. Major goals are to manage comorbidities and to prevent hospitalizations. Hospital stays are very difficult for patients with dementia as they are more likely to require restraints, develop delirium, or experience falls, thus prolonging stays and increasing costs. Effective ambulatory care that prevents hospitalizations through proactive dementia detection and management is a major and realistic priority in the public health response to dementia."

More information: JAMA. 2012;307[2]:165-172.
JAMA. 2012;307[1]:197-198.

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