Emergency and post‐emergency care of older adults with Alzheimer's disease/Alzheimer's disease related dementias

Abstract

Background The emergency department (ED) is a critical juncture in the care of persons living with dementia (PLwD), as they have a high rate of hospital admission, ED revisits, and subsequent inpatient stays. We examine ED disposition of PLwD compared with older adults with non‐dementia chronic disease as well as healthcare utilization and survival. Methods Medicare claims data were used to identify community‐dwelling older adults 66+ years old from 34 hospitals with either Alzheimer's disease/Alzheimer's disease related dementias (AD/ADRD) or a non‐AD/ADRD chronic condition between January 1, 2014, and December 31, 2018. We compared ED disposition at the index visit, as well as healthcare utilization and mortality in the 12 months following an index ED visit, and adjusted for age, gender, and risk of mortality. Results There were 29,626 patients in the AD/ADRD sample, and 317,046 in the comparison sample. The AD/ADRD sample was older (82.4 years old [SD: 8.2] vs. 76.0 years old [SD: 7.7]) and had more female patients (59.9% vs. 54.7%). The AD/ADRD sample was more likely to experience ED disposition to acute care (OR 1.039, p < 0.001, 95% CI 1.029–1.050), to have an ED revisit (OR 1.077, p < 0.001, 95% CI 1.066–1.087), and an inpatient stay in the subsequent 12 months (OR 1.085, p < 0.001, 95% CI 1.075–1.095). ED disposition to hospice was low in both samples (0.2%). AD/ADRD patients had a higher risk of mortality (OR 1.099, p < 0.001, 95% CI 1.091–1.107) and high short‐term mortality (31.9% within 12 months) than those without AD/ADRD (15.3% within 12 months). Conclusions PLwD who visit the ED have high short‐term mortality. Despite this, disposition to acute care, ED revisits, and inpatient stays, rather than hospice, remain the predominant mode of care delivery. Transition directly from the ED to hospice for PLwD is rare.

Automatable end‐of‐life screening for older adults in the emergency department using electronic health records

“…GEST uses a mixture of demographic, past medical, vital sign, lab, and healthcare utilization data. Among GEST variables, we note the importance of history of delirium or dementia, a finding that mirrors a recent study showing persons living with dementia have a higher risk of one‐year mortality following an ED visit as compared to individuals without dementia 36 . Similarly, though not often used as a prognostic marker in the ED, reticulocyte distribution width is associated with increased inpatient mortality, hospital readmission, and length of stay 37 .…”

2023 Alzheimer's disease facts and figures

“…Emergency department visits for people with Alzheimer's or other dementias per 1,000 Medicare beneficiaries increased 28% between 2008 and 2018 (from 1,265 to 1,545), exceeding the increases in emergency department visits for individuals with cancer, ischemic heart disease and heart failure among others (Figure 14). 726 One group of researchers found that individuals with Alzheimer's or other dementias seen in the emergency department are more likely to be admitted to the hospital or nursing home from the emergency department than Medicare beneficiaries without Alzheimer's or other dementias 728 . Additionally, individuals with Alzheimer's or other dementias are more likely to have at least one hospitalization, have at least one subsequent emergency department visit, and be admitted to hospice in the 12 months following the initial emergency department visit.…”

Aren't you forgetting something? Cognitive screening beyond delirium in the emergency department

“…Without a standard strategy for cognitive screening in the ED, cognitive impairment in the absence of delirium would remain highly undetected, 3,5 as most patients identified as cognitively impaired in the 10‐CS did not have a previous dementia diagnosis or substantial cognitive complaints. Like delirium, cognitive impairment without delirium was associated with increased in‐hospital adverse events, prolonged LoS, and in‐hospital mortality, capturing risks beyond routine ED measures 1–3 . Although barriers exist (e.g., resource‐constrained settings and stressors related to acute illnesses), 9,10 our findings encourage broader cognitive screening for older patients in the ED.…”

“…Like delirium, cognitive impairment without delirium was associated with increased in-hospital adverse events, prolonged LoS, and in-hospital mortality, capturing risks beyond routine ED measures. [1][2][3] Although barriers exist (e.g., resource-constrained settings and stressors related to acute illnesses), 9,10 our findings encourage broader cognitive screening for older patients in the ED.…”

“…Patients with cognitive impairment, particularly those living with dementia, are more likely to be admitted to the hospital and die after an emergency department (ED) visit 1,2 . Nonetheless, cognitive assessments at the ED are scarce and primarily focused on delirium 3,4 .…”