Year: 2012
Type: article
Abstract: Dementia is a major cause of long-term care use. As a progressive debilitating disease, it is usually seen as having an inexorable downward course. Thus, one might think that, once a person with dementia is admitted to a nursing home, it is a life sentence. The article in this month's issue of the Journal by Callahan et al.1 suggests otherwise. Patients with dementia made numerous transitions. Of 3,987 persons with dementia discharged from an acute hospital, 40% went home with no formal services. Approximately an equal number were admitted to a nursing home, but even approximately 60% of these went home, most without formal services. Because the data analysis was designed to emphasize transitions, it is not clear what proportion of individuals admitted to a nursing home during this period made no transition. Adding together all the cases admitted from various sources shown in Figure 2 in the Callahan article yields 3,709 admission, 2,015 (54%) of whom made transitions out of the nursing home, and some residents may have made more than one transition.1 Even if the actual rates are half those shown, and we can presume that the proportions hold, traffic is still brisk. The high rate of transition points to a need to address transitional care for persons with dementia. At a minimum, dementia complicates a process that is already fraught with problems.2-4 Discharging individuals with dementia from hospitals and nursing homes after a postacute stay, especially with no formal services, places vulnerable older people with cognitive impairment and medical comorbidity at high risk for adverse events. Medication adherence, getting to follow-up appointments, and participating in one's own care are critical factors in reducing hospital readmissions and may be compromised in individuals with dementia who do not have formal support services in place or lack family or friends as caregiver support. Rehospitalizations are common, expensive, and dangerous, whether from the community or the nursing home.5, 6 Reducing hospital complications and hospital admissions is the major goal of the new Department of Health and Human Services Partnership for Patients campaign (http://www.healthcare.gov/news/factsheets/2011/04/partnership04122011a.html). Care transition programs have been shown to specifically address hospital readmissions in individuals discharged to the community and within the nursing home.7 Good resources for understanding these programs are available through the Centers for Medicare and Medicaid Services (CMS) care transitions website, “Integrating Care for Populations and Communities”(http://www.cfmc.org/integratingcare/), the Administration on Aging's Care Transitions Toolkit (http://aoa.gov/AoARoot/AoA_Programs/HCLTC/ADRC_CareTransitions/toolkit/), the National Transitions of Care Coalition (http://www.cfmc.org/integratingcare/), and the Institute for Healthcare Improvement State Action on Avoidable Rehospitalizations program (http://www.ihi.org/offerings/Initiatives/STAAR/Pages/default.aspx). Although robust evidence from randomized clinical trials is lacking to show that these programs have a dramatic effect on hospital readmissions, many have shown promise in achieving this goal.8 Because the causes of hospital readmissions in medically complex older people are multifactorial, it is likely that a combination of critical elements of these care transition interventions will be most effective in improving unnecessary morbidity, mortality, and healthcare expenditures. How can the reality about care transitions in people with dementia be so far from common beliefs? One explanation may lie in the extent of the dementia, as well as comorbid conditions in this population. Presumably the reasons behind most of these hospitalizations were not dementia per se. Rather, a comorbid condition probably precipitated the need for acute hospital care. Persons with dementia have more comorbidities and more serious comorbidity.9-11 In a cross-sectional analysis, 61% had three or more comorbid medical illnesses. Adjusting for age, sex, race, and care setting, there was a strong association between medical comorbidity and dementia severity, and higher medical comorbidity was associated with greater impairment in cognition and in self-care.12 Persons with dementia and cognitive impairment, but not dementia had more-serious medical comorbidity than a control group, and the seriousness of medical comorbidity was significantly associated with worse day-to-day functioning and worse cognition.10 A second explanation may lie in the severity of the dementia—which we do not know in the population studied in this report—but unless clinicians were especially keen to identify early dementia, it is not likely that all of the dementia was mild. Something else must be going on to account for these care transitions. An analysis of Medicare beneficiaries showed a strong association between presence of dementia and greater probability of all-cause hospitalization (adjusted odds ratio = 3.68, 95% confidence interval = 3.62–3.73), and this relationship held at all levels of chronic disease burden and across all disease pairings.13 We also know that, although individuals with Alzheimer's disease (AD) have twice as many hospital admissions as and longer hospital stays than controls, earlier-stage AD is associated with lower costs.14 In another study, as dementia worsened, the probability of hospitalization increased in individuals living at home but decreased in those who were institutionalized. Furthermore, for institutionalized individuals, the number of admissions, length of stay, and cost also decreased significantly, but the stage of dementia had no effect on at-home individuals.15 Although dementia is a risk factor for hospital discharges to nursing homes and a major reason for nursing home admissions from the community, can we safely assume that many persons with dementia recover from their physical problem and can return home? Some assessment of the severity of the dementia would greatly strengthen future studies of dementia transitions. In nursing homes, even the relatively crude measures from the Minimum Data Set could shed valuable light on just what is going on. The large number of persons with dementia who went home with no formal care is especially intriguing. In this study, we do not know anything about the informal care available at home.1 Presumably, family members were available and willing to take on this burden. The rate of rehospitalizations and admissions to the nursing home reflect the scope of this challenge. Informal caregivers bear the large brunt of the burden for dementia care, and that burden can be heavy,16-19 but once a decision to use a nursing home is made, one would expect it to be permanent. Again, the issue may be mild cases of dementia for which the major problem was a transient medical condition. Many caregivers receive no formal assistance. Using data on 1,200 family caregivers from the Resources for Enhancing Alzheimer's Caregiver Health program, one study found that 65.2% of the entire population reported some formal service use over the past month.20 In the Medicare Alzheimer's Disease Demonstration Evaluation Study, caregivers used 7.7 days of adult day services in the 6 months before baseline, and 62.7% did not use adult day care at all.21 This article has played a useful role in stimulating interest in the relationship between dementia and other morbidities and challenging our beliefs about the permanence of nursing home care for persons with dementia. More work needs to be done to understand what is really going on and how we can improve the situation. As healthcare reform and Medicare payment policies evolve over the next several years, geriatric health professionals should become actively involved in the further development, implementation, and evaluation of care transition interventions for this population to meet the national goals articulated by the Partnership for Patients campaign. Several funding opportunities to do so have already been announced through the new CMS Innovation Center, and more are likely to become available. They represent a great opportunity for our field to help support patients and their caregivers and to contribute to achieving the triple aim articulated by the former CMS Administrator Donald Berwick—improving care, improving health, and making care more affordable. Conflict of Interest: None. Author Contributions: Kane: drafted original version and revised. Ouslander: revised original version and edited subsequent versions. Sponsor's Role: No sponsor.
Authors: Robert L. Kane, Joseph G. Ouslander
Institutions: University of Minnesota, Florida Atlantic University
Language: English
Subfield: General Health Professions
Field: Health Professions
Domain: Health Sciences
Open Access status: bronze
OpenAlex ID: W2072820858