Hospitalizations among Patients with Dementia

Studies have shown that dementia is associated with increased hospitalizations, but empirical data to support these findings are scarce, according to researchers. Among patients without dementia, hospitalization for serious illness is associated with subsequent cognitive decline. For frail elders, including those with dementia, hospitalization poses increased risks for delirium, functional decline, and iatrogenic complications. The researchers hypothesized that identifying conditions that precipitate hospitalization of elderly patients with dementia could “focus clinical priorities on secondary and tertiary prevention in the outpatient setting and improve healthcare for this vulnerable and increasing population.” They recently conducted a retrospective analysis to determine whether dementia onset is associated with higher rates of or different reasons for hospitalization, for which proactive outpatient care might prevent the need for a hospital stay. They reported study results in the Journal of the American Medical Association [2012;307(2):165-172]. The study utilized data from the ACT (Adult Changes in Thought) study to analyze hospitalizations among ACT participants. The ACT study enrolled patients ≥65 years of age enrolled in an integrated healthcare system. None of the patients had dementia at baseline; those who received a diagnosis of dementia during biennial screening contributed to nondementia hospitalizations until diagnosis. The study period was February 1, 1994, to December 31, 2007. The researchers analyzed hospitalization data to assess inpatient admission rates; follow-up for each participant began at initial enrollment in ACT and ended at death, disenrollment from the health plan, or the end of the study period. The primary outcome measure was the rate of hospitalization, measured as mean number of admissions (hospitalization requiring an overnight stay) per year of follow-up. The secondary outcome measure was the rate of hospitalization by type, classified by the principal discharge diagnosis, using International Classification of Diseases, Ninth Revision codes. After applying inclusion and exclusion criteria, 3019 ACT participants were included in the analysis. Of those, 494 developed dementia during follow-up and 2525 did not. Of those who developed dementia, 86% (n=427) were admitted at least once. Of the 2525 who did not develop dementia, 59% (n=1478) were admitted at least once. In the dementia group, the unadjusted all-cause admission rate was 419 admissions per 1000 person-years compared with 200 admissions per 1000 person-years in the nondementia group. Following adjustment for age, sex, and other potential confounders, the ratio of admission rates for all-cause admissions was 1.41 (95% confidence interval [CI], 1.23-1.61; P<.001). For admissions for ambulatory care–sensitive conditions (ACSCs), the adjusted ratio of admission rates was 1.78 (95% CI, 1.38-2.31; P<.001). For most categories, the adjusted admission rates classified by body system were significantly higher in the dementia group compared with the nondementia group. In addition, adjusted admission rates for all types of ACSCs, including bacterial pneumonia, congestive heart failure, dehydration, duodenal ulcer, and urinary tract infection, were significantly higher among participants with dementia. The researchers noted that among people with dementia, 3 ACSCs (pneumonia, congestive heart failure, and urinary tract infection) accounted for two-thirds of all potentially preventable admissions. This knowledge 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 healthcare organizations reduce their rates of ACSC admissions and associated costs.” They summarized study results by noting that their “findings that persons with dementia have higher rates of hospitalizations for most categories of medical illness and for ACSC suggest that there may be an important opportunity for improving care for demented older persons. 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.”