Fewer referrals to Swedish emergency departments among nursing home patients with dementia, comprehensive cognitive decline and multicomorbidity

Abstract

Objectives:The objective was to describe the extent to which nursing home patients had cognitive impairments and were diagnosed with dementia. Furthermore, to describe and compare multicomorbidity, health status and drug use in the three subgroups; dementia diagnosis/not referred, dementia diagnosis/referred and no dementia diagnosis/not referred to an emergency department (ED) over a one-year period. Methods: A crosssectional follow-up study was carried out in Sweden. RAI/MDS assessments were conducted on 719 patients in 24 nursing homes, of whom 209 were referred to EDs during a one-year period, accounting for 314 visits. This study involved an extensive examination of the population. Results: The 719 patients were reported to suffer from comprehensive cognitive impairments, which not accorded with the dementia diagnoses, they were significantly fewer. Cognitive decline or dementia diagnosis contributed to a significant decrease of referrals to EDs. Patients with dementia diagnosis/not referred had difficulties understanding others, as well as impaired vision and hearing. Patients with dementia diagnosis/referred usually understood messages. Low BMI, daily pain, multicomorbidity and high drug consumption occurred in all groups. Patients with no dementia diagnosis/not referred had significantly less multicomorbidity. Neuroleptica was significantly more prevalent among those with dementia diagnosis. Conclusion: Dementia remains undetected. Patients with cognitive decline and dementia are probably as sick as or even worse than others but may, due to low priority be undertreated or referrals avoided with the objective to provide good care in the setting. Observational studies are needed to identify what is done and could be done in referral situations. Key words:Nursing home, dementia, cognitive impairment, referrals, emergency department. 891The Journal of Nutrition, Health & Aging© Volume 16, Number 10, 2012 Received November 25, 2011 Accepted for publication January 19, 2012 07 MAMHIDIR/p/c_04 LORD_c 04/12/12 10:31 Page891 (17), the mean number of prescribed drugs was 10.3 per patient. The proportion of individuals prescribed psychotropic drugs was 80% in NHs and 85% in special care units for dementia. According to Olsson et al. (17), anticholinergic drugs were prescribed for approximately 20% of all NH patients and a high rate of psychotropic drug use (>=80%) was reported.Dementia is becoming a greater problem in health care globally (18), due to an increase in the number of people affected. In Sweden, the number of people suffering from dementia increased from 133, 000 to 148, 000 between 2000 and 2008 (14). Disorders such as dementia that cause cognitive impairment are common in long term institutional care. Mamhidir et al. (19) found that cognitive impairment was present in 67% of NH patients and Nordberg et al. (20) reported 62%. Such patients often exhibit symptoms that are difficult to interpret. Although they have the same illnesses as younger patients, their symptoms differ as they...

Factors Associated With Emergency Department Visits by People With Dementia Near the End of Life: A Systematic Review

“…12 This review identified only 1 low-quality study that investigated medication type. 46 Given this evidence gap and potential impact of medications on ED attendance, further research is indicated.…”

“…There was high-strength evidence that neuropsychiatric symptoms, including depression, were associated with increased ED attendance. 16,28,46 Although included studies did not specify any other behavioral or psychological concerns, there is complementary evidence of hospitalizations associated with neuropsychiatric symptoms, 11 including depressed mood. 2,7 As well as carer distress, 64 neuropsychiatric symptoms are associated with complications such as falling and treatment noncompliance, 65 which may also precipitate ED attendance.…”

“…Of the 23 studies, 13 were from North America, 28e35,37,39,41,42,45 5 from Europe, 16,38,43,46,49 4 from Australia, 36,44,47,48 and 1 from Asia. 40 There were 18 high-, 1 moderate-, 49 and 2 low-quality studies, 37,46 with moderate risk and some concerns of bias identified in the nonrandomized 48 and randomized 47 controlled trials, respectively.…”

“…There was high-strength evidence that increased likelihood of ED attendance was associated with increasing numbers of comorbidities, 28,31,34,38,46 neuropsychiatric symptoms (measured as depression, 16 psychiatric problems, 28 or diagnoses 46 ), and a history of previous hospital transfers, including prior hospitalization 31,34 and ED attendance. 31,36 All other clinical factors were associated with low-strength evidence, including limitations in activities of daily living, 28,46 dementia subtype, 16,36,39 pain, 41,46 medications, 46 specific comorbidities, 28,36,46 undiagnosed dementia, 43 and severity of cognitive impairment (measured using the Mini-Mental State Examination 16 and the Minimum Data Set Cognitive Performance Scale 34,46 ).…”

Patterns of chronic co-morbid medical conditions in older residents of U.S. nursing homes: Differences between the sexes and across the agespan

“…Investigators have primarily examined characteristics and treatment of single disease states or use of single drug classes in both U.S. (5–9). and European studies of aggregate nursing home data (10–12). The most recent National Nursing Home Survey collected comprehensive medical data including up to sixteen current diagnoses and provides the data necessary to investigate patterns of co-morbid conditions in a nationally representative sample of U.S. nursing home residents (13).…”