Jan 11, 2012

Persons With Dementia Go to the Hospital More Often

Among older persons without dementia, hospitalization for serious illness is associated with subsequent cognitive decline, and those with dementia are at increased risk of delirium, functional decline, and complications during an inpatient stay.

Alzheimer's Reading Room

Persons With Dementia Go to the Hospital More Often
The bottom line here, persons with dementia end up in the hospital more often than those without dementia. While I am not a doctor, or a nurse, I can say personally I have refused to take Dotty to the hospital on several occasions.

The last time Dotty was in the hospital, she fainted and I called 911. Subsequently, I took her out of the emergency room and the hospital the same day. In other words, I refused to leave her in the hospital over night for the simple purpose of additional observation.

For caregivers of persons living with dementia it isn't easy. One of the biggest problems we face are urinary tract infections. Since the person living with dementia can't tell you they are sick (most of the time), urinary tract infections often "fester" and result in a trip to the emergency room.

Hospitals, and hospital emergency rooms are busy. I know this. I also know that Dotty can no longer tell me when she is sick, or feels sick. So I decided many years ago to get proactive. To check Dotty's temperature, blood pressure, pulse, etc., every day. I believe in being proactive.

Or, as I say over and over on most issues that Alzheimer's caregivers face, get out in front.

The message I want to deliver here is simple and straightforward. I believe it is better and more effective to check Dotty each day to try and see if anything is starting to go wrong. Get out in front.

I have received some of the most gut wrenching, heart aching, emails from readers that you would ever want to read; emails while they are in the emergency room, or after the patient came home from an emergency stay in the hospital.

You get to decide. Establish a routine to check your loved one each day, or risk that a medical problem escalates.

I know I am not perfect but this does not stop me from trying to head off medical problems. Or, to be diligent and demanding when they do occur.

Alzheimer's patients are vulnerable. We sometimes forget this. They need our help.

People often ask, how do you do it? Well, I am always willing to spend time doing more right now, because I know it I don't I might very well suffer emotionally down the road for it.

As many of you know, I am always proactive when it comes to Dotty. What might not be as apparent, by doing so my life as an Alzheimer's caregiver is also improved. Being diligent not only improves the life of the person living with Alzheimer, it improves the life of the Alzheimer's caregiver.

So even though I don't always feel like taking Dotty's temperature, blood pressure, or pulse rate, I do it because I know the minute I let my guard down I am going to suffer the consequences right along with her.

Like they use to say in elementary school,

"a word to the wise is sufficient".

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Persons With Dementia Have Higher Rate of Hospitalizations

Compared to individuals without dementia, persons who developed dementia subsequently had a significantly higher rate of hospital admissions for all causes and admissions for ambulatory care-sensitive conditions for which proactive care may have prevented hospitalizations, according to a study in the January 11 issue of JAMA.

“Nonelective hospitalization of older people, particularly those with dementia, is not a trivial even. 
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
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.

(JAMA. 2012;307[2]:165-172. Available pre-embargo to the media at www.jamamedia.org)

Bob DeMarco is the Founder of the Alzheimer's Reading Room and an Alzheimer's caregiver. The blog contains more than 3,261 articles with more than 402,100 links on the Internet. Bob lives in Delray Beach, FL.

Original content Bob DeMarco, the Alzheimer's Reading Room