Dementia Patients More Likely to Be Hospitalized
Dementia was associated with higher hospitalization rates in patients 65 and older and many of the admissions were preventable with better outpatient care, a longitudinal study found.
All-cause admissions rose 41% with incident dementia compared with other seniors in the same integrated healthcare system after adjustment for other factors (P<0.001), Elizabeth A. Phelan, MD, MS, of the University of Washington in Seattle, and colleagues reported.
Potentially preventable hospitalizations, such as those for urinary tract infections, were 78% more common with dementia (P<0.001) in the fully adjusted results appearing in the January 11 issue of the Journal of the American Medical Association.
These admissions are not trivial events for dementia patients, Phelan emphasized in an interview with MedPage Today.
Complications that develop in the hospital, such as pressure ulcers or delirium, reduce their quality of life and can keep them from being discharged home, she explained.
“If we could avoid hospitalizations for this population subgroup in the first place, patients would be better off,” she said.
Dementia patients are an at-risk group with as many or more comorbidities and more prescriptions than others their age, Constantine G. Lyketsos, MD, MHS, of Johns Hopkins, noted in an accompanying editorial.
Worsening in those comorbidities accelerates functional decline, which “likely reflects the vulnerability of the diseased brain to biologic stresses and to the frequent development of delirium even with mild exacerbations of acute or chronic diseases,” he wrote.
In Phelan’s analysis of the Adult Changes in Thought (ACT) study, the top causes of preventable admissions were all significantly more common with dementia.
Bacterial pneumonia, congestive heart failure, and urinary tract infection accounted for two-thirds of such “ambulatory care-sensitive conditions” in dementia patients.
“Have a high index of suspicion for infections in particular and also exacerbations of conditions like heart failure,” Phelan recommended.
Antihypertensive treatment in elderly patients does not statistically reduce incidence of dementia. This negative finding might have been due to the short follow-up, owing to the early termination of the trial, or the modest effect of treatment. Nevertheless, the HYVET findings, when included in a meta-analysis, might support antihypertensive treatment to reduce incident dementia.
Peters R, Beckett N, Forette F, Tuomilehto J, Clarke R, Ritchie C, Waldman A, Walton I, Poulter R, Ma S, Comsa M, Burch L, Fletcher A, Bulpitt C; HYVET investigators.
Changes in normal daily function, such as level of awareness or frequency of incontinence, can be the tip-off to catch problems early enough to avoid hospitalization, which makes partnering with patients and their caregivers important, she explained.
Her group’s retrospective analysis of the ACT study included 3,091 community-dwelling members of the Group Health Cooperative care system, age 65 or older, who were screened every two years for development of dementia. The ACT study also had a control group from the same community-dwelling elders as the dementia cases.
The 427 seniors with incident dementia during the average eight years of follow up had roughly twice the annual hospitalization rate of other participants (419 versus 200 per 1,000 person-years).
Overall, 86% of seniors with dementia went to the hospital at least once compared with 59% of those without dementia.
Potentially preventable admissions accounted for more of these hospitalizations among the dementia patients (28% versus 19% among controls) with a rate of 116 versus 37 admissions per 1,000 person-years.
The higher mortality rate with dementia didn’t appear to explain these differences as the associations remained significant in a sensitivity analysis excluding hospitalizations around the time when a patient died.
The study design also controlled for access to healthcare, delayed diagnosis, and living situation and analyses controlled for comorbidity, “increasing confidence that the effect on hospitalizations is specific for the presence of dementia,” the researchers noted.
Many factors likely account for the higher hospitalization rates with dementia, such as conditions that underlie dementia (stroke), conditions that develop with dementia (trouble swallowing, leading to pneumonia), and inability to communicate symptoms, they suggested.
The threshold for hospitalizing patients may also be lower in the setting of dementia, the group added.
They acknowledged that the population that agreed to enroll in the study may have been younger and healthier than the general population. Also, the proactive approach of the integrated healthcare system may have reduced potentially preventable hospitalizations compared with fee-for-service settings.
The study could not determine how many of the potentially preventable admissions truly were preventable.
The results do, nevertheless, clearly point to room for improvement in “anticipatory, proactive primary care” for older adults with dementia, they concluded.
“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,” Lyketsos agreed.
ACT is supported by a National Institute on Aging grant.
The study was conducted with funds to Phelan from the National Institute on Aging and a Paul Beeson Physician Faculty Scholars in Aging award.
The researchers reported having no conflicts of interest to disclose.
Primary source: Journal of the American Medical Association
Phelan EA, et al “Association of incident dementia with hospitalizations” JAMA 2012; 307: 165-172.