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Older Dementia Patients More Likely to Visit EDs, Incur Greater Costs

INDIANAPOLIS – The information won’t be much of a surprise to emergency physicians, but older adults with dementia are more frequent visitors to emergency departments, returning at higher rates and incurring greater costs than older adults without dementia.

The study, published recently in the journal Alzheimer's Disease and Associated Disorders, is one of the first to explore long-term patterns of healthcare use and mortality rates of elders with cognitive impairment who visit the ED.

Researchers from the Regenstrief Institute and the Indiana University Center for Aging Research also found that older adults with dementia are more likely to be admitted to the hospital and are more likely to die following an ED visit than those without dementia.

The study focused on 32,697 patients 65 and older – with and without dementia – who sought emergency care over an 11-year period at Eskenazi Health, a large, urban, safety-net healthcare system.

In any given year, between one-third and one-half of older adults visited the ED. Five years after their first emergency department visit, only 46% of those with dementia were alive compared to 76% those without dementia.

"As people live longer we will increasingly be faced with a growing number of individuals with cognitive impairment. We now know that survival rates after an ED visit differ significantly by cognitive status," said lead author Michael LaMantia, MD, MPH. "We need to continue to learn how to provide better care to these vulnerable individuals in fast-paced emergency departments and after their visits to the ED.

"Our findings, which were controlled for age, race, gender and health conditions in addition to degree of cognitive impairment, fill in gaps in knowledge about trajectories of care for older adults with dementia and provide an evidence-based starting point for future investigations that we should not defer,” LaMantia added.

Among other findings is that 53% of patients with dementia visiting the ED were discharged rather than being admitted to the hospital. Study authors say that raises the question of the medical necessity of the ED visit and whether care could have been provided in a lower cost setting. On the other hand, they ask, were decisions to discharge flawed, due to missed medical complications, incomplete assessments of the safety of the patient's home environment or other factors?

"Emergency departments are appropriately focused on recognizing and stabilizing acute life-threatening conditions and should not be, but are often used as, a substitute for ongoing comprehensive primary care especially for those, like patients with dementia, whose evaluations and management require more intensive, time-consuming, and multidisciplinary resources," added co-author Frank Messina, MD.