How do people with dementia use the ambulance service? A retrospective study in England: the HOMEWARD project

Abstract

ObjectivesAn increasing number of older people are calling ambulances and presenting to accident and emergency departments. The presence of comorbidities and dementia can make managing these patients more challenging and hospital admission more likely, resulting in poorer outcomes for patients. However, we do not know how many of these patients are conveyed to hospital by ambulance. This study aims to determine: how often ambulances are called to older people; how often comorbidities including dementia are recorded; the reason for the call; provisional diagnosis; the amount of time ambulance clinicians spend on scene; the frequency with which these patients are transported to hospital.MethodsWe conducted a retrospective cross-sectional study of ambulance patient care records (PCRs) from calls to patients aged 65 years and over. Data were collected from two ambulance services in England during 24 or 48 hours periods in January 2017 and July 2017. The records were examined by two researchers using a standard template and the data were extracted from 3037 PCRs using a coding structure.ResultsResults were reported as percentages and means with 95% CIs. Dementia was recorded in 421 (13.9%) of PCRs. Patients with dementia were significantly less likely to be conveyed to hospital following an emergency call than those without dementia. The call cycle times were similar for patients regardless of whether or not they had dementia. Calls to people with dementia were more likely to be due to injury following a fall. In the overall sample, one or more comorbidities were reported on the PCR in over 80% of cases.ConclusionRates of hospital conveyance for older people may be related to comorbidities, frailty and complex needs, rather than dementia. Further research is needed to understand the way in which ambulance clinicians make conveyance decisions at scene.

Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences

“… 21 22 Nine studies reported a statistically significant increase in urgent service use when people with dementia have other medical conditions. 10 20 23–29 However, there was not a consensus; two studies that found no association between comorbidities and accessing urgent care. 30 31 …”

“…Twelve studies compared hospitalisation or emergency department use in dementia with those without dementia. Studies were evenly split between whether having dementia increased 20 32–34 or decreased 10 23 27 32 urgent care use. Zhao et al found that people with dementia were more likely to be hospitalised overall than people without dementia, but they were less likely to be hospitalised for osteoarthritis or heart conditions.…”

“…44 61 They were reported to be in less pain and more likely to be marked as less urgent than those without dementia. 10 27 There was concern among carers that a dementia diagnosis led to exclusion from specialist care services that a diagnosis of cancer might not. 42 45 General practitioners (GPs) were reported to find behavioural symptoms in care homes as the most challenging part of their job, 45 with patients with dementia seen as a burden on time.…”

“…9 However, people with dementia are less likely to be taken to hospital after calling the emergency services. 10 This may indicate that people with dementia are presenting straight to emergency rooms rather than going through ambulatory services. 10 It also suggests that people with dementia may present through the ambulance service with lower-acuity issues that do not convert to needing hospital attendance.…”

A qualitative study on conveyance decision-making during emergency call outs to people with dementia: the HOMEWARD project

“…Evidence suggests that people with a diagnosis of dementia are more likely to be admitted to hospital [11], and once admitted, they have poorer outcomes including: longer length of stay; higher rates of readmission; higher chance of discharge to a care home; higher mortality [12][13][14]. However, EMS attendances to people with dementia are commonly due to a fall [15] and there is also evidence to suggest that not conveying older adults who have fallen can lead to a high rate of subsequent emergency healthcare contacts and an increased risk of death and hospitalisation [16]. Consequently, making appropriate conveyance decisions will improve patient outcomes.…”