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Seniors with dementia more likely to be hospitalized, stay longer in emergency department

Seniors with dementia spend more time in the emergency department, have higher hospitalization rates and are more prone to hospital harm than other Canadians age 65 and older, CIHI analysis shows.

“Health systems don’t plan to fail people with dementia, but rather fail to plan what to do with them when they reach the inevitable crisis of needing more intense resources and sometimes dealing with acute behavioural issues,” said Dr. Barry Campbell, medical director of geriatric psychiatry at St. Boniface Hospital in Winnipeg.

 

2.5

Seniors living with dementia spent 2.5 hours longer in emergency departments than those without dementia

65%

Hospitalization rates are 65% higher for seniors with dementia than for those without

2

Seniors with dementia age 65 to 79 stay in hospital twice as long as seniors without dementia

1.5

More seniors living with dementia experience hospital harm than those without

 

Longer emergency department lengths of stay

Seniors with dementia — especially younger ones — spent more time in Canadian emergency departments in 2015–2016 than those without.

Upon arriving at the emergency department, seniors with dementia waited the same amount of time for their initial physician assessment as seniors without dementia (1.1 hours). However, in total, seniors with dementia spent 2.5 hours longer in emergency departments than those without dementia (6.2 and 3.7 hours, respectively). The difference decreased among older seniors. Seniors with dementia present challenges in being assessed, as they may not be able to provide an accurate history because of their dementia, which may result in a delay in making a diagnosis. They may also require additional tests and follow-up associated with their dementia, such as arranging for geriatric outreach, support services and/or formal home care services.

Seniors living with dementia stay longer in emergency department

Seniors 65 to 79 with dementia spent 2.4 hours longer in the emergency department than those without (5.7 vs. 3.3 hours). The difference decreased among older seniors; those 80+ with dementia spent 2 hours longer than those without (6.4 vs. 4.4 hours).

Median length of stay in emergency department, 2015–2016

Seniors living with dementia stay longer in the emergency department, compared with those who do not have dementia. Seniors age 65 to 79 with dementia spent 2.4 hours longer than those without dementia (5.7 and 3.3 hours, respectively). The difference decreased among older seniors — those 80 and older with dementia spent about 2 hours longer than those without (6.4 and 4.4 hours, respectively).

Source
National Ambulatory Care Reporting System, 2015–2016, Canadian Institute for Health Information.

In 2015, 1 in 4 seniors living with dementia in Ontario and Alberta visited an emergency department at least once. That was less than the 1 in 3 seniors without dementia. This lower proportion could be explained by the fact that about 39% of seniors with dementia reside in long-term care or nursing homes and might have some of their medical needs addressed there.

The emergency department visits were rarely for dementia itself; causes included injury, pneumonia, urinary tract infections, chronic obstructive pulmonary disease (COPD), heart failure and general pain.

82% of seniors with dementia were deemed to be high severity and needed to be seen urgently (they had a Canadian Triage and Acuity Scale score of 1, 2 or 3), compared with 70% of seniors without dementia. As well, 43% of seniors with dementia were admitted to an acute care bed, compared with 21% of those without. Higher acuity and higher hospitalization rates suggest that seniors living with dementia who visited emergency departments had more urgent conditions than seniors without dementia.

 

Higher hospitalization rates

About 90,000 seniors with dementia (or 1 in 5) were hospitalized in 2015–2016. As more than a third (38%) of them were hospitalized more than once, that resulted in about 145,000 hospitalizations.

Hospitalization rates were 65% higher for seniors with dementia: 33 hospitalizations per 100 seniors with dementia compared with 20 hospitalizations per 100 seniors without. The difference decreased and reversed in older age groups.

Higher hospitalization rates among seniors with dementia

The overall hospitalization rate for seniors with dementia vs. without dementia was 33 per 100 vs. 20 per 100. These rates (per 100) varied by age group: 65–69, 38 vs. 13; 70–74, 34 vs. 17; 75–79, 35 vs. 22; 80–84, 35 vs. 29; 85–89, 35 vs. 38; and 90+, 29 vs. 57.

Hospitalization rates for seniors with and without dementia, per 100, 2015–2016

1 in 5 seniors living with dementia was hospitalized in 2015–2016, more than a third of them more than once. Overall, hospitalization rates were 33 per 100 for seniors living with dementia, compared with 20 per 100 for those without; the difference decreased and reversed in older age groups.

Sources
Discharge Abstract Database and Hospital Morbidity Database, 2015–2016, Canadian Institute for Health Information.

Hospitalization rates vary among jurisdictions

The average hospitalization rate for seniors living with dementia in Canada is 33 per 100. Provincial rates (per 100) are 29 in Ont., 31 in both N.S. and B.C., 34 in N.L., 36 in P.E.I., 37 in Alta., 39 in both Man. and Sask., 40 in Que. and 41 in N.B.

Hospitalization rates for seniors with dementia by province, per 100, 2015–2016

There is variation in hospitalization rates for seniors with dementia, from 29 per 100 in Ontario to 41 per 100 in New Brunswick and Quebec.

Sources
Discharge Abstract Database and Hospital Morbidity Database, 2015–2016, Canadian Institute for Health Information.

Seniors living with dementia who were admitted for medical reasons (they didn’t require surgery) were hospitalized for similar reasons as other seniors; dementia was responsible for 12% of all hospitalizations. The majority of patients were admitted for treatment of medical conditions such as pneumonia (7.3%), COPD (5.1%), urinary tract infections (5.1%) and heart failure (4.8%).

Research suggests that while in hospital,Reference1 seniors with dementia suffer more distress due to changes in their daily routines and the variety of treatments and tests they have. Therefore, limiting unnecessary hospitalizations may be beneficial for patients with dementia and their families.Reference2 Even though not all admissions are preventable, careful care planning may improve the quality of life for seniors living with dementia.

We have not provided appropriate alternatives for the urgent care of people with dementia. If families had more information about possible harms of hospitals and alternate resources, there would be fewer emergency room visits and hospitalizations. — Dr. Barry Campbell
 

Longer hospital stays

Seniors living with dementia stayed in hospital much longer than seniors without — their median length of stay was 1.3 to 2 times higher. The difference was more pronounced for younger seniors. Although rare, the proportion of extremely long hospital stays — 6 months or more — was also substantially higher among seniors living with dementia (0.85% versus 0.12%).

Longer stays are associated with more patients being designated alternate level of care (ALC). Hospitals use the term “alternate level of care” to describe patients who occupy a hospital bed after the acute phase of their inpatient stay is complete. Seniors with dementia accumulated about half of all ALC days reported. Seniors with dementia were 3 times more likely to have ALC days — 1 in 5 seniors with dementia had an ALC component to their stay, versus 1 in 15 seniors without. Similar to the total length of stay difference, the difference in ALC stays was more pronounced among younger seniors.

Longer hospital stays for seniors with dementia

Among those age 65 to 69, the median length of stay for seniors living with dementia was 8 days, compared with 4 days for seniors without. The gap decreased among those age 80 and older: 8 days for seniors with dementia and 6 days for seniors without.

Median total length of stay among seniors living with dementia and seniors without dementia admitted for medical reasons, 2015–2016

Seniors with dementia stayed in hospital much longer than those without — their median length of stay was 1.3 to 2 times higher. Among those age 65 to 69, the median length of stay for seniors living with dementia was 8 days, compared with 4 days for seniors without. The gap decreased among those age 80 and older: 8 days for seniors with dementia and 6 days for seniors without.

Sources
Discharge Abstract Database and Hospital Morbidity Database, 2015–2016, Canadian Institute for Health Information.

 

Increased hospital harms

More seniors living with dementia experience hospital harm than those without dementia. Hospital harm is defined as a hospitalization with at least one unintended occurrence of harm that could be potentially prevented by implementing known evidence-informed practices.Reference3Reference4 The leading types of harm were urinary tract infections (3.5%), dehydration (2.6%), pneumonia (2.5%) and delirium (2.3%).

“Hospitals do many tests, so patients are more likely to be diagnosed and have an adverse event from inappropriate treatments. We know there is increased risk of falls and delirium in hospitals,” said Dr. Campbell.

Longer length of stay was the strongest predictor of hospital harm — seniors with dementia who stayed in hospital more than a week had 7 times higher odds of experiencing hospital harm compared with those without dementia (odds ratio = 7.0, 95% confidence interval 6.5 to 7.4).

The findings suggest that the risk of hospital harm may be reduced if unnecessary hospitazliations for seniors with dementia are limited and lengths of stay are shortened.

Seniors with dementia experience more hospital harm

In Canada in 2015–2016, 11.5% of seniors living with dementia experienced hospital harm, compared with 7.9% of seniors without.

Percentage of seniors who experienced hospital harm, 2015–2016

More seniors living with dementia experience hospital harm than those without dementia. In Canada in 2015–2016, 11.5% of seniors living with dementia experienced hospital harm, compared with 7.9% of seniors without.

Source
Discharge Abstract Database, 2015–2016, Canadian Institute for Health Information.

 
 

References

1.
Back to Reference 1 in text
Miller J, et al. Elder care supportive interventions protocol: Reducing discomfort in confused, hospitalized older adults External link, opens in new window. Journal of Gerontological Nursing. 2004.
2.
Back to Reference 2 in text
Donnelly M, McElhaney J, Carr M. Improving BC’s Care for Persons With Dementia in Emergency Departments and Acute Care Hospitals External link, opens in new window. 2011.
3.
Back to Reference 3 in text
Canadian Institute for Health Information, Canadian Patient Safety Institute. Measuring Patient Harm in Canadian Hospitals. With What can be done to improve patient safety? authored by Chan B, Cochrane D. 2016.
4.
Back to Reference 4 in text
Canadian Institute for Health Information. Hospital Harm. Accessed May 17, 2018.