Preliminary Data from an Advanced Dementia Consult Service: Integrating Research, Education, and Clinical Expertise

Abstract

Hospitalized patients with advanced dementia often receive care that is of limited clinical benefit and inconsistent with preferences. We designed an Advanced Dementia Consult Service and conducted a pre and post pilot study to evaluate it in a Boston hospital. Consults were conducted by geriatricians and palliative care nurse practitioner. They consisted of structured consultation, counseling and provision of an information booklet to the family, and post-discharge follow-up with the family and primary care providers. Patients > 65 admitted with advanced dementia were identified and consults were solicited using pop-ups programmed into the computerized provider order entry (POE) system. In the initial 3-month period, patients received usual care (N=24). In the subsequent 3-month period, consults were provided to patients for whom it was requested (N=5). Data were obtained from the electronic medical record and proxies interviews (admission, 1-month post-discharge). The patients’ mean age in the combined sample (N=29) was 85.4, 58.6% were from nursing homes, and 86.2% of their proxies stated comfort was the goal of care. Nonetheless, their hospitalizations were characterized by high rates of intravenous antibiotics (86.2%), > 5 venipunctures (44.8%), and radiological exams (96.6%). Acknowledging the small sample size, there were trends towards better outcomes in the intervention group including: higher proxy knowledge of the disease, greater communication between proxies and providers, more advance care planning, lower re-hospitalization rates, and fewer feeding tube insertions after discharge. Targeted consultation for advanced dementia is feasible and may promote greater engagement of proxies and goal-directed care for patients after discharge.

Hospital Palliative Care Teams and Post-Acute Care in Nursing Facilities: An Integrative Review

“…In the months following palliative care consults, patients and family caregivers reported that they continued to require information about advanced illness. In contrast, other researchers found that engaging patients and family caregivers in ongoing communication, education, and advance-care planning during and after discharge may result in clearer expectations and care aligned with preferences (Catic et al, 2013; Gerrard et al, 2011). …”

“…Methodological approaches varied, though most studies were pilot work or descriptive (Benzar, Hansen, Kneitel, & Fromme, 2011; Blackford & Street, 2001; Catic et al, 2013; Thon Aamodt, Lie, & Helleso, 2013). Three studies were longitudinal over a one- to two-year period (Fromme et al, 2006; Kötzsch, Stiel, Heckel, Ostgathe, & Klein, 2014), including one ethnography (Tallman, Greenwald, Reidenouer, & Pantel, 2012).…”

“…A pilot study in the United States that targeted communication, education, and follow-up with family caregivers/proxy decision makers of people with dementia resulted in greater reported communication and advance-care planning discussions at one month postdischarge (Catic et al, 2013). A key component of this intervention provided specific follow-up with the family caregiver/proxy decision maker two weeks after discharge to review health status, goals and decision making, and need for information.…”

“…researchers found a lower hospital readmission rate at one month after discharge with a palliative care education and support intervention for family caregivers of people with dementia, the majority of whom lived in nursing homes (Catic et al, 2013). A key part of the intervention included postdischarge support and contact with the primary care provider.…”

“…Overall, survival in the nursing home after palliative care during hospitalization is poor. Researchers in Germany and the United States were unique in that they reported survival with different models of palliative care services available in the nursing facility (Catic et al, 2013; Kötzsch et al, 2014). The researchers of the other five articles only reported survival after hospital discharge; it is unknown if and how palliative care was delivered to those patients in nursing homes.…”