INDIANAPOLIS — A new study from the Indiana University Center for Aging Research and the Regenstrief Institute has found that almost half of all long-stay nursing home residents experience at least one transfer to an Emergency Department over the course of a year regardless of their cognitive status. While a high percentage of long-stay nursing home residents were sent to the ED, only about a third of these individuals were subsequently admitted to the hospital.
The study determined that while dementia severity was not associated either with likelihood of transfer to the ED or with having that transfer result in a hospitalization; age, race, two or more chronic diseases, number of hospitalizations in the year prior to study entry, and "Do Not Resuscitate" status all influenced the time to first ED visit.
Participants in the study were 4,491 long-stay (90 or more consecutive days) nursing home residents age 65 and above. Average time from entry into a long-term nursing facility to first ED visit for those with advanced stage dementia was 258 days; 250 days for individuals with early to moderate cognitive impairment and 202 days for those with no dementia.
"Transferring to an ED is stressful for most people, but it is especially difficult for cognitively impaired older adults from nursing homes who may not understand what is happening to them," said IU Center for Aging Research and Regenstrief Institute investigator Michael LaMantia, M.D., MPH, first author of the study. "We — physicians, nursing home staff and all who are concerned with older adults who live in long-term care facilities — should be thinking about why individuals with advanced dementia, for whom comfort-oriented care is often more in line with preferences indicated by family members, have ED utilization patterns similar to those patients with early to moderate dementia and even those with no dementia.”
Among nursing home residents sent to the ED, persons with advanced stage dementia were significantly more likely than persons with early to moderate stage or no dementia to receive a diagnosis of a urinary tract infection, a condition potentially treatable in the nursing home.
"Patterns of Emergency Department Use Among Long-Stay Nursing Home Residents with Differing Levels of Dementia Severity" appears online in advance of print publication in JAMDA, the official journal of the Society for Post-Acute and Long-term Care Medicine.
The researchers encourage nursing home providers to employ the findings of the new study to develop strategies that meet their residents’ care goals and avoids unnecessary transfers from the nursing home to the ED, which in addition to being stressful for the individual are costly to the health care system.
“Identifying unnecessary transfers of nursing home patients to the hospital continues to be a high priority for policymakers, researchers and clinicians," said IU Center for Aging Research and Regenstrief Institute investigator Kathleen Unroe, M.D., MHA, senior author of the study. "We need to deliver patient-centered and directed care in the most appropriate setting. This study describes high rates of transfers to the hospital in a frail population; more work needs to be done to understand which of these transfers can be avoided.”
"As dementia is a progressive illness that affects patients’ cognition, functional abilities, and health care utilization, it is not surprising to find that our subjects with advanced dementia were older, more functionally impaired, and more likely to have visited the ED in the previous year than patients with less severe or no cognitive impairment," the authors write. "The fact that long-stay residents with advanced dementia had less comorbidity [serious medical conditions not directly related to dementia] than subjects with early to moderate stage dementia was unexpected and may suggest that long-stay nursing home residents with advanced dementia are “survivors” who are healthy enough to have lived long enough to develop advanced dementia."
This work was funded by grants from the Regenstrief Institute and the National Institute on Aging (5K23 AG043498 and 5K23 AG048323).
Authors, in addition to Drs. LaMantia and Unroe, are Kathleen A. Lane, M.S., and Frank Messina, M.D., of IU School of Medicine; Wanzhu Tu, Ph.D., and Jennifer L. Carnahan, M.D., MPH, of the Regenstrief Institute, IU Center for Aging Research, and IU School of Medicine.