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Older people who develop dementia have higher rates of hospitalizations for medical illnesses than do those without dementia. In addition, those with dementia are at greater risk for several conditions that could be treated in the ambulatory setting, potentially reducing hospitalizations.
A total of 494 patients developed dementia during an average follow-up of 8 years; of those, 427 (86%) were hospitalized. In comparison, 2,525 individuals remained dementia-free during 10 years of follow-up; of those, 1,478 (59%) were hospitalized. Forty percent of those with dementia had at least one admission for an ambulatory care–sensitive condition (ACSC), compared with 17% of the dementia-free group. ASCSs were considered to be preventable with proactive outpatient care.
The findings come from a population-based, longitudinal study of aging and the incidence of and risk factors for dementia, involving more than 3,500 members of a large integrated health care delivery system. The study results were published in the Jan. 11 issue of JAMA (2012;307:165-72).
"Three ACSCs – pneumonia, [congestive heart failure], and [urinary tract infections] – accounted for two-thirds of all potentially preventable admissions among persons with dementia. 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," wrote Dr. Elizabeth A. Phelan and her coinvestigators.
"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," wrote Dr. Phelan of the division of gerontology and geriatric medicine at the University of Washington in Seattle.
Participants were from the Adult Changes in Thought (ACT) cohort, a population-based, longitudinal study of aging and the incidence of and risk factors for dementia that began in 1994. The study involved more than 3,019 members of Group Health Cooperative, a large integrated health care delivery system. Eligible individuals were aged 65 years or older, cognitively intact, and not residing in a nursing home at the time of enrollment in the cohort (mean age at inception was 75 years). Participants have been followed up every 2 years with an in-person interview that includes dementia and health status assessment.
A biennial examination was conducted to identify cases of incident dementia. Participants who scored less than 86 on the Cognitive Abilities Screening Instrument (CASI) or had symptoms suggesting possible new onset of cognitive impairment underwent a standardized dementia diagnostic evaluation consisting of an examination by a study physician and detailed neuropsychological testing.
The results were presented at a consensus conference attended by study physicians, a neuropsychologist, a research nurse, and interviewers, and a consensus diagnosis was recorded based on standardized criteria (Diagnostic and Statistical Manual of Mental Disorders–IV and Neurological and Communicative Disorders and Stroke–Alzheimer’s Disease and Related Disorders Association criteria). Participants with incident dementia underwent one annual follow-up examination for verification of dementia status and dementia type.
The researchers used a retrospective, longitudinal cohort design to assess inpatient admission rates. ACT participants were eligible for these analyses if they did not have dementia at the baseline ACT visit; had completed at least one ACT follow-up visit (to assess for incident dementia); and were enrolled in GHC at the time of a follow-up visit (to ensure availability of hospitalization data).
The primary outcome measure was rate of hospitalization, measured as mean number of admissions per year of follow-up. An admission was defined as a hospitalization requiring an overnight stay. The secondary outcome measure was the rate of hospitalization by type, classified by the principal discharge diagnosis. The researchers identified ACSCs among principal discharge diagnoses to count conditions for which hospitalization might have been prevented with timely, evidence-driven outpatient care. Potential confounders of the association between dementia and hospitalization – sociodemographic characteristics, comorbidities, health behaviors, self-rated health, and place of residence – were ascertained from self-reported data collected at the baseline visit as well as at 2-year follow-up visits.
In terms of baseline differences, those in the group who eventually developed dementia were older at cohort entry by about 3 years and were less likely to have graduated from high school. In addition, larger percentages in this group reported having trouble dressing and reported a diagnosis of depression or Parkinson’s disease.
Probable Alzheimer’s disease (as a single cause) was the most common etiologic diagnosis in the dementia group, followed by vascular dementia alone (16%), and dementia of multiple etiologies (15%). Other etiologies included other medical (7%), substance-related (2%), and other/unknown (2%). The mean age at diagnosis was 84.3 years, with 61% having diagnoses in their 80s. The mean CASI score at time of diagnosis was 76, which is consistent with mild dementia.
The most common reasons for hospitalization – regardless of dementia status – were circulatory, respiratory, and digestive disorders. Among participants with dementia, the average annual admission rate was 419 admissions per 1,000 persons – more than twice that of those without dementia, who averaged 200 admissions per 1,000 persons each year. After age/sex adjustment, the ratio of admission rates was 1.57 and was 1.41 after adjustment for additional covariates.
In the fully adjusted model, admission rates for five types of disorders (circulatory, genitourinary, infectious, neurologic, and respiratory) were significantly greater among participants with dementia, compared with those without dementia. In contrast, those with dementia had significantly lower admission rates for musculoskeletal disorders.
ACSCs were analyzed separately. The admission rate ratio was 1.78, after full adjustment for covariates. Importantly, three ACSCs – bacterial pneumonia, heart failure, and urinary tract infection – accounted for two-thirds of all potentially preventable admissions; admission rates among those with dementia were significantly greater for all three conditions. Admission rates for dehydration and duodenal ulcer, though low overall, also were significantly greater among those with dementia. Admissions for ACSCs accounted for 28% of all hospitalizations among those with dementia vs. only 19% of all admissions among those who remained dementia free.
The authors speculated about why dementia might lead to more frequent hospitalization. First, underlying conditions that increase the risk of dementia such as stroke, or that develop in the setting of dementia, such as trouble swallowing, which raises the risk of pneumonia, might increase the risk of hospitalization.
"Second, because of its primary deleterious effects on global cognition, executive function, expressive language, symptom perception, and awareness of deficits, dementia impairs the ability to self-manage chronic conditions and to pinpoint symptoms and alert others to their presence, thereby creating substantial diagnostic and treatment challenges for primary care clinicians," the researchers wrote.
Situational factors also might contribute, including a change of living situation, or the temporary or permanent absence of a caregiver who is familiar with the person’s usual habits, behaviors, and ongoing general medical management.
They also cited another potential explanation – the threshold for hospitalizing such persons might be lower because dementia "increases central nervous system vulnerability to the metabolic effects of acute illness, such that for a comparable severity of illness, persons with dementia are in fact sicker."
The authors reported that they have no conflicts of interest. The ACT study is supported by a grant from the National Institute on Aging.
"In the context of earlier literature, the results of this methodologically rigorous study indicate that in the current U.S. health care environment, patients with dementia are much more likely to be hospitalized than age-comparable peers, especially for conditions such as urinary tract infection, congestive heart failure, dehydration, and bacterial pneumonia," Dr. Constantine G. Lyketsos noted in an accompanying editorial (JAMA 2012;307:197-8).
The association between comorbidity and progression is poorly understood but probably 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. Urinary tract infection, upper respiratory tract infections, or brief general anesthesia for routine outpatient procedures, for example, can lead to unforeseen but significant functional declines in patients with dementia, from which it is often difficult for them to recover." Early detection of these conditions "can often lead to effective management in ambulatory settings, thus preventing hospitalizations. Ambulatory care is the optimal setting to both detect dementia early and manage such conditions" Dr. Lyketsos wrote.
He also wrote that early detection of dementia can lead to effective supports that can help manage comorbidities before they lead to acute hospitalizations. "Involvement by physicians of families and caregivers as partners in this process is critically important," he wrote.
"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."
Dr. Lyketsos is chairman of the psychiatry department at Johns Hopkins Bayview Medical Center in Baltimore. He reported that he has significant financial relationships with numerous pharmaceutical companies.
"In the context of earlier literature, the results of this methodologically rigorous study indicate that in the current U.S. health care environment, patients with dementia are much more likely to be hospitalized than age-comparable peers, especially for conditions such as urinary tract infection, congestive heart failure, dehydration, and bacterial pneumonia," Dr. Constantine G. Lyketsos noted in an accompanying editorial (JAMA 2012;307:197-8).
The association between comorbidity and progression is poorly understood but probably 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. Urinary tract infection, upper respiratory tract infections, or brief general anesthesia for routine outpatient procedures, for example, can lead to unforeseen but significant functional declines in patients with dementia, from which it is often difficult for them to recover." Early detection of these conditions "can often lead to effective management in ambulatory settings, thus preventing hospitalizations. Ambulatory care is the optimal setting to both detect dementia early and manage such conditions" Dr. Lyketsos wrote.
He also wrote that early detection of dementia can lead to effective supports that can help manage comorbidities before they lead to acute hospitalizations. "Involvement by physicians of families and caregivers as partners in this process is critically important," he wrote.
"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."
Dr. Lyketsos is chairman of the psychiatry department at Johns Hopkins Bayview Medical Center in Baltimore. He reported that he has significant financial relationships with numerous pharmaceutical companies.
"In the context of earlier literature, the results of this methodologically rigorous study indicate that in the current U.S. health care environment, patients with dementia are much more likely to be hospitalized than age-comparable peers, especially for conditions such as urinary tract infection, congestive heart failure, dehydration, and bacterial pneumonia," Dr. Constantine G. Lyketsos noted in an accompanying editorial (JAMA 2012;307:197-8).
The association between comorbidity and progression is poorly understood but probably 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. Urinary tract infection, upper respiratory tract infections, or brief general anesthesia for routine outpatient procedures, for example, can lead to unforeseen but significant functional declines in patients with dementia, from which it is often difficult for them to recover." Early detection of these conditions "can often lead to effective management in ambulatory settings, thus preventing hospitalizations. Ambulatory care is the optimal setting to both detect dementia early and manage such conditions" Dr. Lyketsos wrote.
He also wrote that early detection of dementia can lead to effective supports that can help manage comorbidities before they lead to acute hospitalizations. "Involvement by physicians of families and caregivers as partners in this process is critically important," he wrote.
"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."
Dr. Lyketsos is chairman of the psychiatry department at Johns Hopkins Bayview Medical Center in Baltimore. He reported that he has significant financial relationships with numerous pharmaceutical companies.
Older people who develop dementia have higher rates of hospitalizations for medical illnesses than do those without dementia. In addition, those with dementia are at greater risk for several conditions that could be treated in the ambulatory setting, potentially reducing hospitalizations.
A total of 494 patients developed dementia during an average follow-up of 8 years; of those, 427 (86%) were hospitalized. In comparison, 2,525 individuals remained dementia-free during 10 years of follow-up; of those, 1,478 (59%) were hospitalized. Forty percent of those with dementia had at least one admission for an ambulatory care–sensitive condition (ACSC), compared with 17% of the dementia-free group. ASCSs were considered to be preventable with proactive outpatient care.
The findings come from a population-based, longitudinal study of aging and the incidence of and risk factors for dementia, involving more than 3,500 members of a large integrated health care delivery system. The study results were published in the Jan. 11 issue of JAMA (2012;307:165-72).
"Three ACSCs – pneumonia, [congestive heart failure], and [urinary tract infections] – accounted for two-thirds of all potentially preventable admissions among persons with dementia. 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," wrote Dr. Elizabeth A. Phelan and her coinvestigators.
"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," wrote Dr. Phelan of the division of gerontology and geriatric medicine at the University of Washington in Seattle.
Participants were from the Adult Changes in Thought (ACT) cohort, a population-based, longitudinal study of aging and the incidence of and risk factors for dementia that began in 1994. The study involved more than 3,019 members of Group Health Cooperative, a large integrated health care delivery system. Eligible individuals were aged 65 years or older, cognitively intact, and not residing in a nursing home at the time of enrollment in the cohort (mean age at inception was 75 years). Participants have been followed up every 2 years with an in-person interview that includes dementia and health status assessment.
A biennial examination was conducted to identify cases of incident dementia. Participants who scored less than 86 on the Cognitive Abilities Screening Instrument (CASI) or had symptoms suggesting possible new onset of cognitive impairment underwent a standardized dementia diagnostic evaluation consisting of an examination by a study physician and detailed neuropsychological testing.
The results were presented at a consensus conference attended by study physicians, a neuropsychologist, a research nurse, and interviewers, and a consensus diagnosis was recorded based on standardized criteria (Diagnostic and Statistical Manual of Mental Disorders–IV and Neurological and Communicative Disorders and Stroke–Alzheimer’s Disease and Related Disorders Association criteria). Participants with incident dementia underwent one annual follow-up examination for verification of dementia status and dementia type.
The researchers used a retrospective, longitudinal cohort design to assess inpatient admission rates. ACT participants were eligible for these analyses if they did not have dementia at the baseline ACT visit; had completed at least one ACT follow-up visit (to assess for incident dementia); and were enrolled in GHC at the time of a follow-up visit (to ensure availability of hospitalization data).
The primary outcome measure was rate of hospitalization, measured as mean number of admissions per year of follow-up. An admission was defined as a hospitalization requiring an overnight stay. The secondary outcome measure was the rate of hospitalization by type, classified by the principal discharge diagnosis. The researchers identified ACSCs among principal discharge diagnoses to count conditions for which hospitalization might have been prevented with timely, evidence-driven outpatient care. Potential confounders of the association between dementia and hospitalization – sociodemographic characteristics, comorbidities, health behaviors, self-rated health, and place of residence – were ascertained from self-reported data collected at the baseline visit as well as at 2-year follow-up visits.
In terms of baseline differences, those in the group who eventually developed dementia were older at cohort entry by about 3 years and were less likely to have graduated from high school. In addition, larger percentages in this group reported having trouble dressing and reported a diagnosis of depression or Parkinson’s disease.
Probable Alzheimer’s disease (as a single cause) was the most common etiologic diagnosis in the dementia group, followed by vascular dementia alone (16%), and dementia of multiple etiologies (15%). Other etiologies included other medical (7%), substance-related (2%), and other/unknown (2%). The mean age at diagnosis was 84.3 years, with 61% having diagnoses in their 80s. The mean CASI score at time of diagnosis was 76, which is consistent with mild dementia.
The most common reasons for hospitalization – regardless of dementia status – were circulatory, respiratory, and digestive disorders. Among participants with dementia, the average annual admission rate was 419 admissions per 1,000 persons – more than twice that of those without dementia, who averaged 200 admissions per 1,000 persons each year. After age/sex adjustment, the ratio of admission rates was 1.57 and was 1.41 after adjustment for additional covariates.
In the fully adjusted model, admission rates for five types of disorders (circulatory, genitourinary, infectious, neurologic, and respiratory) were significantly greater among participants with dementia, compared with those without dementia. In contrast, those with dementia had significantly lower admission rates for musculoskeletal disorders.
ACSCs were analyzed separately. The admission rate ratio was 1.78, after full adjustment for covariates. Importantly, three ACSCs – bacterial pneumonia, heart failure, and urinary tract infection – accounted for two-thirds of all potentially preventable admissions; admission rates among those with dementia were significantly greater for all three conditions. Admission rates for dehydration and duodenal ulcer, though low overall, also were significantly greater among those with dementia. Admissions for ACSCs accounted for 28% of all hospitalizations among those with dementia vs. only 19% of all admissions among those who remained dementia free.
The authors speculated about why dementia might lead to more frequent hospitalization. First, underlying conditions that increase the risk of dementia such as stroke, or that develop in the setting of dementia, such as trouble swallowing, which raises the risk of pneumonia, might increase the risk of hospitalization.
"Second, because of its primary deleterious effects on global cognition, executive function, expressive language, symptom perception, and awareness of deficits, dementia impairs the ability to self-manage chronic conditions and to pinpoint symptoms and alert others to their presence, thereby creating substantial diagnostic and treatment challenges for primary care clinicians," the researchers wrote.
Situational factors also might contribute, including a change of living situation, or the temporary or permanent absence of a caregiver who is familiar with the person’s usual habits, behaviors, and ongoing general medical management.
They also cited another potential explanation – the threshold for hospitalizing such persons might be lower because dementia "increases central nervous system vulnerability to the metabolic effects of acute illness, such that for a comparable severity of illness, persons with dementia are in fact sicker."
The authors reported that they have no conflicts of interest. The ACT study is supported by a grant from the National Institute on Aging.
Older people who develop dementia have higher rates of hospitalizations for medical illnesses than do those without dementia. In addition, those with dementia are at greater risk for several conditions that could be treated in the ambulatory setting, potentially reducing hospitalizations.
A total of 494 patients developed dementia during an average follow-up of 8 years; of those, 427 (86%) were hospitalized. In comparison, 2,525 individuals remained dementia-free during 10 years of follow-up; of those, 1,478 (59%) were hospitalized. Forty percent of those with dementia had at least one admission for an ambulatory care–sensitive condition (ACSC), compared with 17% of the dementia-free group. ASCSs were considered to be preventable with proactive outpatient care.
The findings come from a population-based, longitudinal study of aging and the incidence of and risk factors for dementia, involving more than 3,500 members of a large integrated health care delivery system. The study results were published in the Jan. 11 issue of JAMA (2012;307:165-72).
"Three ACSCs – pneumonia, [congestive heart failure], and [urinary tract infections] – accounted for two-thirds of all potentially preventable admissions among persons with dementia. 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," wrote Dr. Elizabeth A. Phelan and her coinvestigators.
"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," wrote Dr. Phelan of the division of gerontology and geriatric medicine at the University of Washington in Seattle.
Participants were from the Adult Changes in Thought (ACT) cohort, a population-based, longitudinal study of aging and the incidence of and risk factors for dementia that began in 1994. The study involved more than 3,019 members of Group Health Cooperative, a large integrated health care delivery system. Eligible individuals were aged 65 years or older, cognitively intact, and not residing in a nursing home at the time of enrollment in the cohort (mean age at inception was 75 years). Participants have been followed up every 2 years with an in-person interview that includes dementia and health status assessment.
A biennial examination was conducted to identify cases of incident dementia. Participants who scored less than 86 on the Cognitive Abilities Screening Instrument (CASI) or had symptoms suggesting possible new onset of cognitive impairment underwent a standardized dementia diagnostic evaluation consisting of an examination by a study physician and detailed neuropsychological testing.
The results were presented at a consensus conference attended by study physicians, a neuropsychologist, a research nurse, and interviewers, and a consensus diagnosis was recorded based on standardized criteria (Diagnostic and Statistical Manual of Mental Disorders–IV and Neurological and Communicative Disorders and Stroke–Alzheimer’s Disease and Related Disorders Association criteria). Participants with incident dementia underwent one annual follow-up examination for verification of dementia status and dementia type.
The researchers used a retrospective, longitudinal cohort design to assess inpatient admission rates. ACT participants were eligible for these analyses if they did not have dementia at the baseline ACT visit; had completed at least one ACT follow-up visit (to assess for incident dementia); and were enrolled in GHC at the time of a follow-up visit (to ensure availability of hospitalization data).
The primary outcome measure was rate of hospitalization, measured as mean number of admissions per year of follow-up. An admission was defined as a hospitalization requiring an overnight stay. The secondary outcome measure was the rate of hospitalization by type, classified by the principal discharge diagnosis. The researchers identified ACSCs among principal discharge diagnoses to count conditions for which hospitalization might have been prevented with timely, evidence-driven outpatient care. Potential confounders of the association between dementia and hospitalization – sociodemographic characteristics, comorbidities, health behaviors, self-rated health, and place of residence – were ascertained from self-reported data collected at the baseline visit as well as at 2-year follow-up visits.
In terms of baseline differences, those in the group who eventually developed dementia were older at cohort entry by about 3 years and were less likely to have graduated from high school. In addition, larger percentages in this group reported having trouble dressing and reported a diagnosis of depression or Parkinson’s disease.
Probable Alzheimer’s disease (as a single cause) was the most common etiologic diagnosis in the dementia group, followed by vascular dementia alone (16%), and dementia of multiple etiologies (15%). Other etiologies included other medical (7%), substance-related (2%), and other/unknown (2%). The mean age at diagnosis was 84.3 years, with 61% having diagnoses in their 80s. The mean CASI score at time of diagnosis was 76, which is consistent with mild dementia.
The most common reasons for hospitalization – regardless of dementia status – were circulatory, respiratory, and digestive disorders. Among participants with dementia, the average annual admission rate was 419 admissions per 1,000 persons – more than twice that of those without dementia, who averaged 200 admissions per 1,000 persons each year. After age/sex adjustment, the ratio of admission rates was 1.57 and was 1.41 after adjustment for additional covariates.
In the fully adjusted model, admission rates for five types of disorders (circulatory, genitourinary, infectious, neurologic, and respiratory) were significantly greater among participants with dementia, compared with those without dementia. In contrast, those with dementia had significantly lower admission rates for musculoskeletal disorders.
ACSCs were analyzed separately. The admission rate ratio was 1.78, after full adjustment for covariates. Importantly, three ACSCs – bacterial pneumonia, heart failure, and urinary tract infection – accounted for two-thirds of all potentially preventable admissions; admission rates among those with dementia were significantly greater for all three conditions. Admission rates for dehydration and duodenal ulcer, though low overall, also were significantly greater among those with dementia. Admissions for ACSCs accounted for 28% of all hospitalizations among those with dementia vs. only 19% of all admissions among those who remained dementia free.
The authors speculated about why dementia might lead to more frequent hospitalization. First, underlying conditions that increase the risk of dementia such as stroke, or that develop in the setting of dementia, such as trouble swallowing, which raises the risk of pneumonia, might increase the risk of hospitalization.
"Second, because of its primary deleterious effects on global cognition, executive function, expressive language, symptom perception, and awareness of deficits, dementia impairs the ability to self-manage chronic conditions and to pinpoint symptoms and alert others to their presence, thereby creating substantial diagnostic and treatment challenges for primary care clinicians," the researchers wrote.
Situational factors also might contribute, including a change of living situation, or the temporary or permanent absence of a caregiver who is familiar with the person’s usual habits, behaviors, and ongoing general medical management.
They also cited another potential explanation – the threshold for hospitalizing such persons might be lower because dementia "increases central nervous system vulnerability to the metabolic effects of acute illness, such that for a comparable severity of illness, persons with dementia are in fact sicker."
The authors reported that they have no conflicts of interest. The ACT study is supported by a grant from the National Institute on Aging.
FROM JAMA
Major Finding: A total of 494 patients developed dementia during a mean follow-up of 8 years; of these, 427 individuals (86%) were hospitalized. In comparison, 2,525 individuals remained dementia-free during 10 years of follow-up; of these, 1,478 (59%) were hospitalized. Forty percent of those with dementia had at least one admission for an ambulatory care–sensitive condition (ACSC), compared with 17% of those in the dementia-free group. ASCSs were considered to be preventable with proactive outpatient care.
Data Source: A population-based, longitudinal study of aging and the incidence of and risk factors for dementia, involving more than 3,500 members of a large integrated health care delivery system.
Disclosures: The authors reported that they have no conflicts of interest. The ACT study is supported by a grant from the National Institute on Aging.