25 January 2012. While hospital stays are no fun for anyone, such experiences can be particularly traumatic for people with dementia, who easily become anxious and confused in new surroundings. Yet a longitudinal study in the January 11 Journal of the American Medical Association finds that dementia patients get sent to hospitals nearly twice as often as peers who are cognitively healthy—and even more frequently for conditions seen as preventable or treatable in outpatient settings. First author Elizabeth Phelan of the University of Washington led the study with Eric Larson of Group Health Research Institute, both in Seattle. While perhaps not surprising to physicians who care for dementia patients, the findings provide “solid empirical data that demonstrate a major problem with current dementia care in this country,” noted Adam Boxer of the University of California, San Francisco, in an e-mail to ARF. Earlier diagnosis of dementia would enable doctors to identify patients for more tailored management, which should reduce hospitalization rates, experts say.
Getting poked and prodded for routine hospital procedures such as an intravenous line is a nuisance most cognitively healthy folks can tolerate, Phelan said. “But those are much more stressful for people who don’t understand what is happening to them. Dementia patients are more likely to become confused in environments outside of their normal routine, and they have a hard time recovering from that confusional state.” Some research suggests that hospital stays can worsen cognitive decline in dementia patients (ARF related news story on Ehlenbach et al., 2010), and yet previous research hinted that such patients get admitted to emergency rooms more often than those who are mentally intact (Lyketsos et al., 2000; Natalwala et al., 2008). Many of these studies used retrospective claims data to identify dementia patients, yet dementia is frequently detected late in its course, Phelan said, suggesting that prior estimates of their hospitalization rates may have been low.
The current study is more rigorous in that it looked at incipient dementia. The scientists tracked hospitalization rates of nearly 500 seniors who developed the condition, compared to some 2,500 who did not, during a ~13-year period. All were enrolled in the same healthcare delivery system, and were followed up every two years as part of their participation in a Group Health longitudinal study (Adult Changes in Thought).
In their analysis of hospitalizations due to any cause, the researchers found that people who developed dementia were admitted 41 percent more often than those who remained cognitively healthy. And for the subset of hospitalizations for conditions—such as urinary tract infections and bacterial pneumonia—that could have been managed with timely outpatient care, admission rates were 78 percent higher in people with dementia.
Dementia patients may end up at hospitals more frequently because they have trouble managing existing medical conditions, the authors suggest. Their dementia makes it hard for them to take medications on schedule, or to alert caregivers and physicians to new symptoms. In addition, the authors write, “underlying conditions that increase the risk of dementia (e.g., stroke) or that develop in the setting of dementia (e.g., trouble swallowing, which increases risk of pneumonia) may increase the risk of hospitalization.”
“If we want to reduce admissions to hospitals in general, then outpatient care of people with dementia would be a very worthy way to go,” said Ken Kosik, a neurologist at the University of California, Santa Barbara, who directs an integrated Alzheimer’s care facility (see ARF related news story). “This paper brings that message home.”
But improving outpatient care for these patients requires earlier diagnosis of their dementia, which some say can be difficult under current U.S. policies. “There are financial incentives to hospitalize advanced dementia patients, and financial disincentives to take care of these patients,” Boxer noted.
Moreover, some physicians may be hesitant to diagnose someone with a condition for which there are no effective remedies, Phelan said. Yet with global AD rates expected to quadruple to more than 106 million by 2050 (Brookmeyer et al., 2007), “the challenges posed by dementia are not going away anytime soon,” Constantine Lyketsos of Johns Hopkins University in Baltimore, Maryland, wrote in an accompanying editorial.
The current paper “provides strong evidence that doctors need to be aware of a patient’s memory difficulties as soon as possible,” wrote John (Wes) Ashford of Stanford University and the Veterans Affairs Palo Alto Health Care System in an e-mail to ARF. Ashford said memory screens should be essential for seniors (65 years or older) coming into a doctor’s office, and can be done in under three minutes by a physician’s staff. The field is currently grappling with how to screen for cognitive impairment in the primary care setting. No one test has emerged as a gold standard, and patients often don’t follow up for more sophisticated screens that could deliver a more accurate diagnosis (see ARF related news story).—Esther Landhuis.
Phelan EA, Borson S, Grothaus L, Balch S, Larson EB. Association of Incident Dementia with Hospitalizations. JAMA. 11 Jan 2012;307(2):165-172. Abstract
Lyketsos CG. Prevention of Unnecessary Hospitalization for Patients With Dementia: the role of ambulatory care.
JAMA. 11 Jan 2012;307(2):197-198. Abstract