Predictors of Transition to Hospice Care Among Hospitalized Older Adults With a Diagnosis of Dementia in Texas: A Population-Based Study

Abstract

BackgroundDecedent older adults with dementia are increasingly less likely to die in a hospital, though escalation of care to a hospital setting, often including critical care, remains common. Although hospice is increasingly reported as the site of death in these patients, the factors associated with transition to hospice care during end-of-life (EOL) hospitalizations of older adults with dementia and the extent of preceding escalation of care to an intensive care unit (ICU) setting among those discharged to hospice have not been examined.MethodsWe identified hospitalizations aged ≥ 65 years with a diagnosis of dementia in Texas between 2001 and 2010. Potential factors associated with discharge to hospice were evaluated using multivariate logistic regression modeling, and occurrence of hospice discharge preceded by ICU admission was examined.ResultsThere were 889,008 elderly hospitalizations with a diagnosis of dementia during study period, with 40,669 (4.6%) discharged to hospice. Discharges to hospice increased from 908 (1.5%) to 7,398 (6.3%) between 2001 and 2010 and involved prior admission to ICU in 45.2% by 2010. Non-dementia comorbidities were generally associated with increased odds of hospice discharge, as were development of organ failure, the number of failing organs, or use of mechanical ventilation. However, discharge to hospice was less likely among non-white minorities (lowest among blacks: adjusted odds ratio (aOR): 0.67; 95% confidence interval (CI): 0.65 - 0.70) and those with non-commercial primary insurance or the uninsured (lowest among those with Medicaid: aOR (95% CI): 0.41 (0.37 - 0.46)).ConclusionsThis study identified potentially modifiable factors associated with disparities in transition to hospice care during EOL hospitalizations of older adults with dementia, which persisted across comorbidity and severity of illness measures. The prevalent discharge to hospice involving prior critical care suggests that key discussions about goals-of-care likely took place following further escalation of care to ICU. Together these findings can inform system- and clinician-level interventions to facilitate timely and consistent use of hospice to meet patients’ goals of care.

A retrospective study examining the properties and characteristics of dementia patients in a palliative care center

“…In a study carried out in a nursing home on the clinical course of DPs, among distressing symptoms, dyspnea at 46% was the most frequent symptom, and the second was pain at 39% (13). Similar to the findings in the literature, in this study comorbidities such as CHF and CVE were observed in 24.6% and 15.7% of DPs, respectively (14).…”

Association between palliative care and life-sustaining treatments for patients with dementia: A nationwide 5-year cohort study

“…Cancer, renal failure, respiratory failure and mechanical ventilation have been found to be strong predictors of hospice referral in hospitalised patients with dementia. 33 Taiwanese patients with dementia were often considered for hospital-based palliative care if they had initially undergone a series of life-sustaining treatments to reverse an acute illness or critical condition and then encountered the dilemma of withdrawing or withholding the interventions because of a poor prognosis. 34,35 For the selected life-sustaining treatments in this study, families, as well some medical professionals, in Taiwan often consider enteral feeding, blood transfusions, non-invasive ventilators and haemodialysis as less uncomfortable than other invasive respiratory therapies and CPR.…”

Palliative care for nursing home patients with dementia: service evaluation and risk factors of mortality

“…Studies have previously identified potential prognostic factors and mortality risk factors among dementia patients. For instance, a study in the United States [36] reported cancer, diabetes, the onset of organ failure, and mechanical ventilation as prognostic factors of hospice referral among dementia patients. Moreover, the U.S. National Hospice and Palliative Care Organization developed prognostic criteria for survival in dementia and as a tool to determine Medicare benefits for hospice care; according to their criteria, patients at advanced stages of the disorder (FAST stage 7c) with one or more nutritional (i.e., > 10% weight loss) or medical complications (i.e., recurrent sepsis, pressure sore) are more susceptible to death within 6 months [10].…”