Factors Influencing Emergency Care by Persons With Dementia: Stakeholder Perceptions and Unmet Needs

Patterns of national emergency department utilization by fee-for-service Medicare beneficiaries with dementia

BACKGROUND

Individuals with Alzheimer's disease and related dementias (ADRD) often face high acute care clinical utilization and costs with unclear benefits in survival or quality of life. The emergency department (ED) is frequently the site of pivotal decisions in these acute care episodes. This study uses national Medicare data to explore this population's ED utilization.

METHODS

Retrospective cohort study of persons aged ≥66 years enrolled in traditional Medicare with a Chronic Condition Warehouse diagnosis of dementia. Primary 1-year outcome measures included ED visits with and without hospitalization, ED visits per 100 days alive, and health-care costs. A multivariate random effects regression model (clustered by county of residence), adjusted for sociodemographics and comorbidities, examined how place of care on January 1, 2018, was associated with subsequent ED utilization.

RESULTS

In 2018, 2,680,006 ADRD traditional Medicare patients (mean age 82.9, 64.2% female, 9.4% Black, 6.2% Hispanic) experienced a total of 3,234,767 ED visits. Over half (52.2%) of the cohort experienced one ED visit, 15.5% experienced three or more, and 37.1% of ED visits resulted in hospitalization. Compared with ADRD patients residing at home without services, the marginal difference in ED visits per 100 days alive varied by location of care. Highest differences were observed for those with hospitalizations (0.48 visits per 100 days alive, 95% confidence interval [CI] 0.47-0.49), skilled nursing facility (rehab/skilled nursing facility [SNF]) stays (0.27, 95% CI 0.27-0.28), home health stays (0.25, 95% CI 0.25-0.26), or observation stays (0.82, 95% CI 0.77-0.87). Similar patterns were observed with ED use without hospitalization and health-care costs.

CONCLUSIONS

Persons with ADRD frequently use the ED-particularly those with recent hospitalizations, rehab/SNF stays, or home health use-and may benefit from targeted interventions during or before the ED encounters to reduce avoidable utilization and ensure goal-concordant care.

Perspectives from persons living with dementia and their caregivers on emergency department visits, care transitions, and outpatient follow-up: A qualitative study

BACKGROUND

Persons living with dementia (PLWD) experience frequent and costly emergency department (ED) visits, with poor outcomes attributed to suboptimal care and postdischarge care transitions. Yet, patient-centered data on ED care experiences and postdischarge needs are lacking. The objective of this study was to examine the facilitators and barriers to successful ED care and care transitions after discharge, according to PLWD and their caregivers.

METHODS

We conducted a qualitative study involving ED patients ages 65 and older with confirmed or suspected dementia and their caregivers. The semistructured interview protocol followed the National Quality Forum's ED Transitions of Care Framework and addressed ED care, care transitions, and outpatient follow-up care. Interviews were conducted during an ED visit at an urban, academic ED. Traditional thematic analysis was used to identify themes.

RESULTS

We interviewed 11 patients and 19 caregivers. Caregivers were more forthcoming than patients about facilitators and challenges experienced. Characteristics of the patients' condition (e.g., resistance to care, forgetfulness), the availability of family resources (e.g., caregiver availability, primary care access), and system-level factors (e.g., availability of timely appointments, hospital policies tailored to persons with dementia) served as facilitators and barriers to successful care. Some resources that would ameliorate care transition barriers could be easily provided in the ED, for example, offering clear discharge instructions and care coordination services and improving patient communication regarding disposition timeline. Other interventions would require investment from other parts of the health care system (e.g., respite for caregivers, broader insurance coverage).

CONCLUSIONS

ED care and care transitions for PLWD are suboptimal, and patient-level factors may exacerbate existing system-level deficiencies. Insight from patients and their caregivers may inform the development of ED interventions to design specialized care for this patient population. This qualitative study also demonstrated the feasibility of conducting ED-based studies on PLWD during their ED visit.

Out-of-hospital paramedic interactions with people living with dementia: a scoping review

BACKGROUND

Dementia encompasses neurodegenerative disorders that account for a global estimated healthcare expenditure of 1.3 trillion US dollars. In Australia, one in 12 people aged ≥65 has a diagnosis of dementia and it is the second leading cause of death. Paramedics play a crucial role in person-centred dementia care, particularly in the community. While consensus has been established on paramedicine's integration into interdisciplinary care teams, there remains a lack of clarity regarding the paramedic role in dementia care.

OBJECTIVE

This study aimed to examine and report paramedic interactions with people living with dementia in the out-of-hospital setting.

DESIGN AND SETTING

This was a scoping review study of paramedics and people living with dementia within the out-of-hospital setting.

METHODS

This study was guided by the Joanna Briggs Institute (JBI) scoping review framework. Databases were searched without date limits, up to 4 April 2023. These encompassed OVID Medline, CINAHL, Scopus, APA PsycInfo and OVID Embase. Articles were included if they were primary, peer-reviewed studies in English and reporting on paramedic-specific interactions with people living with dementia in the out-of-hospital setting. Data extraction was performed based on study setting, design, population and key findings.

RESULTS

Twenty-nine articles were included in the thematic analysis. Four themes emerged: need for training, patterns of attendances, patterns of documentation and the integrative potential of paramedicine. Paramedics reported feeling ill-equipped and unprepared in caring for patients living with dementia due to challenges in assessment and management of caregiver tensions. They were often called as a last resort due to poor service integration and a lack of alternative care pathways. Despite high conveyance rates, there was low incidence of paramedic interventions initiated. Underdocumentation of dementia and pain was found.

CONCLUSION

Emergency ambulance conveyance of people living with dementia is a surface reaction compounded by a lack of direction for paramedics in the provision of out-of-hospital care. There is a pressing need for establishment of research and educational priorities to improve paramedic training in dementia-specific skillsets.

Emergency department communication with diverse caregivers and persons living with dementia: A qualitative study

BACKGROUND

Research to date has detailed numerous challenges in emergency department (ED) communication with persons living with dementia (PLWD) and their caregivers. However, little is known about communication experiences of individuals belonging to minoritized racial and ethnic groups, who are disproportionately impacted by dementia and less likely to be included in dementia research.

METHODS

We conducted semi-structured interviews with 29 caregivers of PLWD from two urban academic hospital EDs with distinct patient populations. The first site is an ED in the Northeast serving a majority White, English-speaking, and insured population. The second site is an ED in the South serving a majority Black and/or Hispanic, Spanish-speaking, and underinsured population. Interviews lasted an average of 25 min and were digitally recorded and transcribed. We used an inductive approach to analyze interview transcripts for dominant themes and compared themes between sites.

RESULTS

Our sample included caregivers of diverse racial and ethnic backgrounds. Caregivers cared for PLWD who spoke English, Spanish, Arabic, Chinese, and Vietnamese. We identified three themes. First, caregiver advocacy was central to experiences of ED communication, particularly when PLWD primarily spoke a non-English language. Second, routine care plans did not address what mattered most to participants and PLWD. Participants felt that care arose from protocols and did not address what mattered most to them. Third, White English-speaking caregivers in Site 1 more commonly expected ED staff to engage them in care decision-making than Black, Hispanic, Asian, and Middle Eastern caregivers in Site 2.

CONCLUSION

Language barriers amplify the higher intensity care needed by PLWD in the ED. Strategies should be developed for communicating with PLWD and caregivers about what matters most in their ED care.

Preventable Emergency Department Visits of Patients with Alzheimer's Disease and Related Dementias During the COVID-19 Pandemic by Hospital-Based Health Information Exchange

Background: This study examined the relationship between hospital-based electronic health information exchange (HIE) and the likelihood of having a preventable emergency department (ED) visit during the COVID-19 pandemic for US patients with Alzheimer's Disease and Related Dementias (ADRD). Methods: We used multi-level data from six states. The linked data sets included the 2020 State Emergency Department Databases (SEDD), the Area Health Resources File, the American Hospital Association (AHA) Annual Survey, and the AHA Information Technology Supplement to study 85,261 hospital discharges from patients with ADRD. Logistic regression models were produced to determine the odds of having a preventable ED visit among patients with ADRD. Results: Our final sample included 85,261 hospital discharges from patients with ADRD. Patients treated in hospitals that received more types of clinical information for treating patients with COVID-19 from outside providers (OR = 0.961, p < .05) and/or hospitals that received COVID-19 test results from more outside entities were significantly less likely to encounter preventable EDs (OR = 0.964, p < .05), especially among patients who also had multiple chronic conditions (MCC) (OR = 0.89, p = .001; OR = 0.856, p < .001). Conclusion: Our results suggest that electronic HIE may be useful for reducing preventable ED visits during the COVID-19 pandemic for people with ADRD and ADRD alongside MCC.

Caring for persons with Dementia: a qualitative study of the needs of carers following care recipient discharge from hospital

BACKGROUND

A randomised clinical trial titled the Carer End of Life Planning Intervention (CELPI) in people dying with dementia evaluated the effect of carer education and support about palliative care on care recipient outcomes. We present a pre-planned qualitative analysis of data collected during the CELPI trial in which needs of carers randomised to the study intervention group were assessed using a novel instrument (Carer Needs Directed Assessment in Dementia (CANDID). This tool aimed to identify carers' perceptions of their own and their care-recipients' needs and is an important step in identifying support provision for dementia-specific, palliative cares services upon hospital discharge.

METHODS

The CANDID tool was designed to identify the needs and experiences of primary carers and of their care recipients during the last twelve months of the care recipient's life. The tool consisted of 33 open-ended questions evaluating: symptom management, emergency contacts, advance care planning, carer's perception of the care recipient's future needs, carer's current needs, and a proposed current and future care plan. The researcher's philosophical assumption of interpretative phenomenology informed the study and approach to data collection and analysis. Qualitative data collected during interviews using this tool were thematically analysed in five steps: compiling, disassembling, reassembling, interpreting and concluding. An interpretation of participants' reality emerged from their common experiences and the subjective meanings assigned to actions attached to the phenomena studied.

RESULTS

Thirty carer participants were included. Analysis identified three major themes: Carers' perceived stressors, systemic barriers to care provision, and future planning. Issues identified included barriers to accessing supports, carer health and division between roles, financial burden, familial conflicts, adquate care in hospital and aged care facilities, concern about future needs, and end-of-life discussions.

CONCLUSION

The CANDID tool enabled an evaluation of carer needs and concerns. Identifying those needs may inform a referral to palliative care services where the level of management required may be benenficial for both the person living with dementia and their primary carer.

TRIAL REGISTRATION

Australian Clinical Trials Registration: (ACTRN12619001187134).

Optimizing the Care of Persons Living with Dementia in the Emergency Department

Emergency department (ED) care for persons living with dementia (PLWD) involves the identification of dementia or cognitive impairment, ED care which is sensitive to the specific needs of PLWD, effective communication with PLWD, their care partners, and outpatient clinicians who the patient and care-partner know and trust, and care-transitions from the emergency department to other health care settings. The recommendations in this article made based on wide-ranging heterogeneous studies of various interventions which have been studied primarily in single-site studies. Future research should work to incorporate promising findings from interventions such as hospital at home, or ED to home Care Transitions Intervention.

Nonspecific Complaints in Older Emergency Department Patients

Nonspecific complaints such as generalized weakness and fatigue are common in older adults presenting to an emergency department. These complaints may be caused by acute or chronic medical problems, or they may be exacerbated or caused by socioeconomic risks factors. Acute causes may be related to serious medical conditions requiring prompt treatment. A thorough history and physical examination in conjunction with an interdisciplinary approach allows emergency departments to identify acute conditions as well as geriatric syndromes and unmet home needs, such as food insecurity and caregiver burden. A whole-health system approach should be used for safe transitions of care.

Exploring access to community care and emergency department use among people with dementia: A qualitative interview study with people with dementia, and current and bereaved caregivers

OBJECTIVES

Emergency department (ED) attendance is common among people with dementia and associated with poor health outcomes. Literature suggests a link between access to community care and the ED, but we know little about the mechanisms behind this link. This study aimed to explore experiences of accessing community and emergency care among people affected by dementia.

METHODS

Informed by critical realism, semi-structured online and telephone interviews were conducted with people with dementia and family caregivers, with and without experience of using the ED. Participants were recruited from across the United Kingdom using purposive sampling with maximum variation. A mostly experiential reflexive thematic analysis approach was used, applying the candidacy model of access to deepen interpretation.

RESULTS

Two dyad and 33 individual interviews were conducted with 10 people with dementia, 11 current caregivers and 16 bereaved caregivers (men = 11, 70-89 years = 18, white ethnicity = 32). Three themes are reported: (1) Navigating a 'push system', (2) ED as the 'last resort', and (3) Taking dementia 'seriously'. Themes describe a discrepancy between the configuration of services and the needs of people affected by dementia, who resort to the ED in the absence of accessible alternatives. Underlying this discrepancy is a lack of systemic prioritisation of dementia and wider societal stigma.

CONCLUSION

Although a last resort, ED attendance is frequently the path of least resistance for people with dementia who encounter multiple barriers for timely, responsive access to community health and social care. Greater systemic prioritisation of dementia as a life-limiting condition may help to reduce reliance on the ED through essential development of post-diagnostic care, from diagnosis to the end of life.

The Experience of Families Accompanying a Senior to the Emergency Department: A Scoping Review

INTRODUCTION

Seniors are often accompanied by a family member to the emergency department. Families advocate for their needs and contribute to the continuity of care. However, they often feel excluded from care. To improve the quality and safety of care for seniors, it is necessary to consider the experience of families in the emergency department. The aim was to identify and synthesize the available scientific literature dealing with the experience of families accompanying a senior to the emergency department. To identify and synthesize the available scientific literature dealing with the experience of families accompanying a senior to the emergency department.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. Six databases were targeted. A description of the identified scientific literature and an inductive content analysis were performed.

RESULTS

Of the 3082 articles retrieved, 19 met the inclusion criteria. Most articles (89%) were published since 2010, were from nursing (63%), and used a qualitative research design (79%). The content analysis identified 4 main categories related to the experience of families accompanying a senior to the emergency department: (1) process leading to the emergency department, families feel uncertainty and ambiguity with the decision to go to the emergency department; (2) staying in the emergency department, families' experiences are influenced by the triage, the ED environment, and the interactions with ED personnel; (3) discharge from the emergency department, families consider that they should be part of the discharge planning; and (4) recommendations and possible solutions, there is a paucity of recommendations specifically focused on families.

DISCUSSION

The experience of families of seniors in the emergency department is multifactorial and part of a trajectory of care and health services.

Practitioners' Views on Enabling People With Dementia to Remain in Their Homes During and After Crisis

One way of supporting people living with dementia is assisting them to live in their homes (as opposed to being admitted to hospital or other facility) and providing them with a specialist service that responds to crises. This makes it important to understand how best to organize such crisis response services. This study examines practitioners' actions to reduce inpatient admissions among this population. Through interviews with healthcare practitioners, we find that practitioners negotiate a complex intersection between (1) what constitutes a crisis in relation to the patient and/or the carer, (2) the demands of building a working relationship with both the patient and their family carers, and (3) ensuring effective communications with social services responsible for long-term community support. Findings suggest that policies aimed at reducing admissions should be based on a model of care that more closely maps practitioners' relational and bio-medical work in these services.

Expansion of a House Calls Program for Patients With Dementia During COVID-19

Homebound older adults with dementia have increased health care use, hospitalization rates, and mortality risk, which are associated with considerable health care costs. A large, unmet need for individuals with dementia is home-based medical care. Although our institution has had a primary care program for homebound patients since 2019, we did not have an analogous program for patients with dementia before the coronavirus disease 2019 (COVID-19) pandemic. However, with increased health risks and challenges associated with the pandemic, we rapidly expanded the program to include facility-based older adults with dementia. We incorporated telemedicine and home-based visits to effectively provide patient-centered care that was aligned with their goals and preferences, and we describe a program example of how we provided care during a COVID-19 outbreak in a large facility. Further research is needed to capture potential cost savings and hospitalization rates for persons with dementia who receive home-based medical care. [Journal of Gerontological Nursing, 48(10), 21-25.].

Optimal Emergency Department Care Practices for Persons Living With Dementia: A Scoping Review

OBJECTIVES

To summarize research on optimal emergency department (ED) care practices for persons living with dementia (PLWDs) and develop research priorities.

DESIGN

Systematic scoping review.

SETTINGS AND PARTICIPANTS

PLWDs in the ED.

METHODS

The following Patient-Intervention-Comparison-Outcome (PICO) questions were developed: PICO 1, What components of emergency department care improve patient-centered outcomes for persons with dementia? PICO 2, How do emergency care needs for persons with dementia differ from other patients in the emergency department? A scoping review was conducted following PRISMA-ScR guidelines and presented to the Geriatric Emergency care Applied Research 2.0 Advancing Dementia Care network to inform research priorities.

RESULTS

From the 6348 publications identified, 23 were abstracted for PICO 1 and 26 were abstracted for PICO 2. Emergency care considerations for PLWDs included functional dependence, behavioral and psychological symptoms of dementia, and identification of and management of pain. Concerns regarding ED care processes, the ED environment, and meeting a PWLD's basic needs were described. A comprehensive geriatric assessment and dedicated ED unit, a home hospital program, and a low-stimulation bed shade and contact-free monitor all showed improvement in patient-centered or health care use outcomes. However, all were single-site studies evaluating different outcomes. These results informed the following research priorities: (1) training and dementia care competencies; (2) patient-centric and care partner-centric evaluation interventions; (3) the impact of community- and identity-based factors on ED care for PLWDs; (4) economic or other implementation science measures to address viability; and (5) environmental, operational, personnel, system, or policy changes to improve ED care for PLWDs.

CONCLUSIONS AND IMPLICATIONS

A wide range of components of both ED care practices and ED care needs for PLWDs have been studied. Although many interventions show positive results, the lack of depth and reproducible results prevent specific recommendations on best practices in ED care for PLWDs.

Emergency Department Communication in Persons Living With Dementia and Care Partners: A Scoping Review

OBJECTIVES

To synthesize published research exploring emergency department (ED) communication strategies and decision-making with persons living with dementia (PLWD) and their care partners as the basis for a multistakeholder consensus conference to prioritize future research.

DESIGN

Systematic scoping review.

SETTINGS AND PARTICIPANTS

PLWD and their care partners in the ED setting.

METHODS

Informed by 2 Patient-Intervention-Comparison-Outcome (PICO) questions, we conducted systematic electronic searches of medical research databases for relevant publications following standardized methodological guidelines. The results were presented to interdisciplinary stakeholders, including dementia researchers, clinicians, PLWD, care partners, and advocacy organizations. The PICO questions included: How does communication differ for PLWD compared with persons without dementia? Are there specific communication strategies that improve the outcomes of ED care? Future research areas were prioritized.

RESULTS

From 5451 studies identified for PICO-1, 21 were abstracted. From 2687 studies identified for PICO-2, 3 were abstracted. None of the included studies directly evaluated communication differences between PLWD and other populations, nor the effectiveness of specific communication strategies. General themes emerging from the scoping review included perceptions by PLWD/care partners of rushed ED communication, often exacerbated by inconsistent messages between providers. Care partners consistently reported limited engagement in medical decision-making. In order, the research priorities identified included: (1) Barriers/facilitators of effective communication; (2) valid outcome measures of effective communication; (3) best practices for care partner engagement; (4) defining how individual-, provider-, and system-level factors influence communication; and (5) understanding how each member of ED team can ensure high-quality communication.

CONCLUSIONS AND IMPLICATIONS

Research exploring ED communication with PLWD is sparse and does not directly evaluate specific communication strategies. Defining barriers and facilitators of effective communication was the highest-ranked research priority, followed by validating outcome measures associated with improved information exchange.

Comparing emergency department use among individuals with varying levels of cognitive impairment

INTRODUCTION

As the population ages, Alzheimer's disease and related dementias (ADRD) are becoming increasingly common in patients presenting to the emergency department (ED). This study compares the frequency of ED use among a cohort of individuals with well-defined cognitive performance (cognitively intact, mild cognitive impairment (MCI), and ADRD).

METHODS

We performed a retrospective cohort study of English-speaking, community-dwelling individuals evaluated at four health system-based multidisciplinary memory clinics from 2014-2016. We obtained demographic and clinical data, including neuropsychological testing results, through chart review and linkage to electronic health record data. We characterized the frequency and quantity of ED use within one year (6 months before and after) of cognitive evaluation and compared ED use between the three groups using bivariate and multivariate approaches.

RESULTS

Of the 779 eligible patients, 89 were diagnosed as cognitively intact, 372 as MCI, and 318 as ADRD. The proportion of subjects with any annual ED use did not increase significantly with greater cognitive impairment: cognitively intact (16.9%), MCI (26.1%), and ADRD (28.9%) (p = 0.072). Average number of ED visits increased similarly: cognitively intact (0.27, SD 0.72), MCI (0.41, SD 0.91), and ADRD (0.55, SD 1.25) (p = 0.059). Multivariate logistic regression results showed that patients with MCI (odds ratio (OR) 1.62; CI = 0.87-3.00) and ADRD (OR 1.84; CI = 0.98-3.46) did not significantly differ from cognitively intact adults in any ED use. Multivariate negative binomial regression found patients with MCI (incidence rate ratio (IRR) 1.38; CI = 0.79-2.41) and ADRD (IRR 1.76, CI = 1.00-3.10) had elevated but non-significant risk of an ED visit compared to cognitively intact individuals.

CONCLUSION

Though there was no significant difference in ED use in this small sample from one health system, our estimates are comparable to other published work. Results suggested a trend towards higher utilization among adults with MCI or ADRD compared to those who were cognitively intact. We must confirm our findings in other settings to better understand how to optimize systems of acute illness care for individuals with MCI and ADRD.

Effects of the Participation and Involvement of Medical Professionals in Dementia Cafés on the Attendance of People with Dementia Living at Home and Their Family Caregivers

BACKGROUND

Dementia cafés have been attracting attention as a new approach to dementia care, but the effects of the participation of medical professionals remain unclear.

OBJECTIVE

To clarify the significance of collaboration between medical professionals and dementia cafés.

METHODS

Questionnaires regarding the numbers of staff and guests, whether medical professionals introduced guests, whether cafés announced their activities to medical institutions, and whether people with dementia played a role were sent to dementia cafés throughout Japan. The responding dementia cafés were then divided into two groups according to the presence or involvement of medical professionals and institutions and compared.

RESULTS

Responses were received from 148 dementia cafés, among which, medical professionals participated in 96 (64.9%). Significantly more people with dementia living at home attended cafés run or staffed with medical professionals (p = 0.021 and p = 0.017, respectively), as well as when medical professionals introduced guests to the café or when the café announced their activities to medical institutions (p = 0.001 and p = 0.002, respectively). Significantly more people with dementia played a role in cafés where medical professionals were administrators or staff (p = 0.008 and p = 0.018, respectively). Similar effects were observed for family caregivers.

CONCLUSION

The participation and involvement of medical professionals and institutions in dementia cafés increased the attendance of people with dementia, especially those living at home. These results suggest that dementia cafés are an effective hub for connecting care for dementia with medical care, and thus help avoid fragmentation in dementia care.

Characteristics of frequent users of emergency departments living with major neurocognitive disorders: a cohort study

Objective: This study aimed to describe and compare the characteristics of community-dwelling older adults living with or without major neurocognitive disorders who made frequent use of emergency departments. Methods: This is a retrospective cohort study based on a secondary analysis of provincial health administrative data in Quebec, Canada. We included community-dwelling older adults from Quebec who were considered frequent emergency department users (a minimum of 4 visits in the year following an index emergency department visit chosen randomly between January 1, 2012, and December 31, 2013) and who had been diagnosed with at least one chronic condition. We compared characteristics of frequent users living with or without major neurocognitive disorders using chi-square and Kruskal-Wallis tests. Results: The study cohort consisted of 21 393 frequent emergency department users, of which 3051 (14.26%) were identified as having a major neurocognitive disorder. The results highlight a higher burden of chronic conditions, polypharmacy, antipsychotic use, and past use of healthcare services among these individuals. The results also reveal a higher proportion of conditions associated with geriatric syndromes such as trauma and injury, malnutrition, orthostatic hypertension, and gait disorders. Conclusion: Frequent emergency department users living with major neurocognitive disorders represent a complex population. Our results highlight the importance of systematically addressing their needs in appropriate settings and through customized interventions.

Factors Associated With Emergency Department Visits by People With Dementia Near the End of Life: A Systematic Review

OBJECTIVES

Emergency department (ED) attendance is common among people with dementia and increases toward the end of life. The aim was to systematically review factors associated with ED attendance among people with dementia approaching the end of life.

DESIGN

Systematic search of 6 databases (MEDLINE, EMBASE, ASSIA, CINAHL, PsycINFO, and Web of Science) and gray literature. Quantitative studies of any design were eligible. Newcastle-Ottawa Scales and Cochrane risk-of-bias tools assessed study quality. Extracted data were reported narratively, using a theoretical model. Factors were synthesized based on strength of evidence using vote counting (PROSPERO registration: CRD42020193271).

SETTING AND PARTICIPANTS

Adults with dementia of any subtype and severity, in the last year of life, or in receipt of services indicative of nearness to end of life.

MEASUREMENTS

The primary outcome was ED attendance, defined as attending a medical facility that provides 24-hour access to emergency care, with full resuscitation resources.

RESULTS

After de-duplication, 18,204 titles and abstracts were screened, 367 were selected for full-text review and 23 studies were included. There was high-strength evidence that ethnic minority groups, increasing number of comorbidities, neuropsychiatric symptoms, previous hospital transfers, and rural living were positively associated with ED attendance, whereas higher socioeconomic position, being unmarried, and living in a care home were negatively associated with ED attendance. There was moderate-strength evidence that being a woman and receiving palliative care were negatively associated with ED attendance. There was only low-strength evidence for factors associated with repeat ED attendance.

CONCLUSIONS AND IMPLICATIONS

The review highlights characteristics that could help identify patients at risk of ED attendance near the end of life and potential service-related factors to reduce risks. Better understanding of the mechanisms by which residential facilities and palliative care are associated with reduced ED attendance is needed.

Crisis management for people with dementia at home: Mixed-methods case study research to identify critical factors for successful home treatment

Best practice in dementia care is support in the home. Yet, crisis is common and can often result in hospital admission with adverse consequences. The objective of this mixed-methods case study research was to identify the critical factors for resolving crisis for a person with dementia living at home. The research was an in-depth investigation of what happens during crisis for people with dementia and how it is managed by a Home Treatment Crisis Team to resolution and outcome at 6 weeks and 6 months. The methods were; observation of crisis management for 15 patients with dementia (max three observations per patient, total 41), interviews with patients with dementia (n = 5), carers (n = 13) and professionals (n = 14, range one to six interviews per person, total 29), focus group (nine professionals), and extraction of demographics and medical history from medical records. Analysis focused on the identification of factors important for crisis resolution and avoidance of hospital admission. Critical factors for the Home Treatment Crisis Team to enable successful crisis resolution were: immediate action to reduce risk of harm, expertise in dementia care and carer education, communication skills to establish trust and promote benefits of home treatment, shared decision-making, medication management, addressing the needs of carers independently of the person with dementia and, local availability of respite and other community services. The Home Treatment Crisis Team integrated the seven factors to deploy a biopsychosocial systems approach with embedded respect for personhood. This approach enabled crisis resolution for a person with dementia by creating a system of services, treatments, resources and relationships, 'Safe Dementia Space', in the community with avoidance of hospital admission in more than 80% of referrals. The identified critical factors for crisis resolution are important considerations in the design and delivery of home treatment services for people with dementia.

Chronic Brain Failure

Chronic brain failure, also known as dementia or major neurocognitive disorder, is a syndrome of progressive functional decline characterized by both cognitive and neuropsychiatric symptoms. It can be conceptualized like other organ failure syndromes and its impact on quality of life can be mitigated with proper treatment. Dementia is a risk factor for delirium, and their symptoms can be similar. Patients with dementia can present with agitation that can lead to injury. Logic and reason are rarely successful when attempting to redirect someone with advanced dementia. Interactions that offer a sense of choice are more likely to succeed.

Changes in Health Care Use by Mexican American Medicare Beneficiaries Before and After a Diagnosis of Dementia

BACKGROUND

Evidence from predominantly non-Hispanic White cohorts indicates health care utilization increases before Alzheimer's disease and related dementias (ADRD) is diagnosed. We investigated trends in health care utilization by Mexican American Medicare beneficiaries before and after an incident diagnosis of ADRD.

METHODS

Data came from the Hispanic Established Populations for the Epidemiological Study of the Elderly that has been linked with Medicare claims files from 1999 to 2016 (n = 558 matched cases and controls). Piecewise regression and generalized linear mixed models were used to compare the quarterly trends in any (ie, one or more) hospitalizations, emergency room (ER) admissions, and physician visits for 1 year before and 1 year after ADRD diagnosis.

RESULTS

The piecewise regression models showed that the per-quarter odds for any hospitalizations (odds ratio [OR] = 1.62, 95% CI = 1.43-1.84) and any ER admissions (OR = 1.40, 95% CI = 1.27-1.54) increased before ADRD was diagnosed. Compared to participants without ADRD, the percentage of participants with ADRD who experienced any hospitalizations (27.2% vs 14.0%) and any ER admissions (19.0% vs 11.7%) was significantly higher at 1 quarter and 3 quarters before ADRD diagnosis, respectively. The per-quarter odds for any hospitalizations (OR = 0.88, 95% CI = 0.80-0.97) and any ER admissions (OR = 0.89, 95% CI = 0.82-0.97) decreased after ADRD was diagnosed. Trends for any physician visits before or after ADRD diagnosis were not statistically significant.

CONCLUSIONS

Older Mexican Americans show an increase in hospitalizations and ER admissions before ADRD is diagnosed, which is followed by a decrease after ADRD diagnosis. These findings support the importance of a timely diagnosis of ADRD for older Mexican Americans.

Nomenclature Used by Family Caregivers to Describe and Characterize Neuropsychiatric Symptoms

BACKGROUND AND OBJECTIVES

Neuropsychiatric symptoms (NPS) are a core feature of Alzheimer's disease and related dementias that are characterized by a fluctuating course. NPS are challenging to manage and contribute to high rates of burden among family caregivers. Successful information exchange between clinicians and family caregivers is critical for facilitating effective management of NPS. However, this communication is often challenging due to inconsistent terminology and classification of symptoms and limited understanding of how family caregivers recognize and describe symptoms. The objective of this study was to examine the language family caregivers' use to describe and contextualize NPS.

RESEARCH DESIGN AND METHODS

Descriptive qualitative study of 20 family caregivers in a mostly urban county in the Midwestern United States using semistructured interviews. Caregiver descriptions of NPS were analyzed using directed content and text analysis to examine terminology, followed by a thematic analysis approach to examine contextualization of NPS.

RESULTS

Caregivers employed shared terminologies to describe NPS that differed substantially from clinical terminology used to classify symptoms. Caregivers frequently engaged sense-making as a strategy to explain NPS. This sense-making served to contextualize patterns in behavior and was characterized by explanatory, situational, and strategy-oriented frameworks for understanding behavior in terms of its purpose and meaning. Caregivers' descriptions of NPS reflected broad overlap between individual NPS (i.e., agitation and care resistance) that would generally be considered clinically distinct symptoms.

DISCUSSION AND IMPLICATIONS

Nomenclature surrounding NPS may vary considerably between family caregivers and clinicians, and should be evaluated in partnership with people with dementia and their caregivers to ensure supportive interventions and resources are responsive to caregivers' interpretation of symptoms and sense-making.

Urgent care for patients with dementia: a scoping review of associated factors and stakeholder experiences

OBJECTIVES

People with dementia are more vulnerable to complications in urgent health situations due to older age, increased comorbidity, higher dependency on others and cognitive impairment. This review explored the factors associated with urgent care use in dementia and the experiences of people with dementia, informal carers and professionals.

DESIGN

Scoping review. The search strategy and data synthesis were informed by people with dementia and carers.

DATA SOURCES

Searches of CINAHL, Embase, Medline, PsycINFO, PubMed were conducted alongside handsearches of relevant journals and the grey literature through 15 January 2019.

ELIGIBILITY CRITERIA

Empirical studies including all research designs, and other published literature exploring factors associated with urgent care use in prehospital and emergency room settings for people with dementia were included. Two authors independently screened studies for inclusion.

DATA EXTRACTION AND SYNTHESIS

Data were extracted using charting techniques and findings were synthesised according to content and themes.

RESULTS

Of 2967 records identified, 54 studies were included in the review. Specific factors that influenced use of urgent care included: (1) common age-related conditions occurring alongside dementia, (2) dementia as a diagnosis increasing or decreasing urgent care use, (3) informal and professional carers, (4) patient characteristics such as older age or behavioural symptoms and (5) the presence or absence of community support services. Included studies reported three crucial components of urgent care situations: (1) knowledge of the patient and dementia as a condition, (2) inadequate non-emergency health and social care support and (3) informal carer education and stress.

CONCLUSIONS

The scoping review highlighted a wider variety of sometimes competing factors that were associated with urgent care situations. Improved and increased community support for non-urgent situations, such as integrated care, caregiver education and dementia specialists, will both mitigate avoidable urgent care use and improve the experience of those in crisis.

Features of primary care practice influence emergency care-seeking behaviors by caregivers of persons with dementia: A multiple-perspective qualitative study

BACKGROUND

Persons with dementia use emergency department services at rates greater than other older adults. Despite risks associated with emergency department use, persons with dementia and their caregivers often seek emergency services to address needs and symptoms that could be managed within primary care settings. As emergency departments (EDs) are typically sub-optimal environments for addressing dementia-related health issues, facilitating effective primary care provision is critical to reduce the need for, or decision to seek, emergency services. The aim of this study is to explore how features of primary care practice influence care-seeking decisions by community-dwelling persons with dementia and familial caregivers.

METHODS

Semi-structured qualitative interviews were conducted with 27 key dementia-care stakeholders (10 primary care/geriatrics providers, 5 caregivers, 4 emergency medicine physicians, 5 aging service providers, and 3 community paramedics) from multiple health systems. Transcripts from audio recordings were analyzed using a thematic analysis framework to iteratively code and develop emergent themes. Features of primary care were also synthesized into lists of tangible factors leading to emergency care-seeking and those that help prevent (or decrease the need for) ED use.

FINDINGS

Stakeholders identified eight categories of features of primary care encompassing the clinical environment and provision of care. These collapsed into four major themes: (1) clinic and organizational features-including clinic structure and care team staffing; (2) emphasizing proactive approaches to anticipate needs and avoid acute problems-including establishing goals of care, preparing for the future, developing provider-patient/provider-caregiver relationships, and providing caregiver support, education, and resources to help prevent emergencies; (3) health care provider skills and knowledge of dementia-including training and diagnostic capabilities; and (4) engaging appropriate community services/resources to address evolving needs.

CONCLUSIONS

Features of primary care practice influence decisions to seek emergency department care at the system, organizational/clinic, medical, and interpersonal levels, particularly regarding proactive and reactive approaches to addressing dementia-related needs. Interventions for improving primary care for persons with dementia and their caregivers should consider incorporating features that facilitate proactive family-centered dementia care across the four identified themes, and minimize those leading to caregiver decisions to utilize emergency services.

What happens before, during and after crisis for someone with dementia living at home: A systematic review

BACKGROUND

People living with dementia often experience crisis. Home treatment of crisis is an alternative to hospital admission that can have better outcomes. This systematic review is about people with dementia living at home and in crisis. It identifies modifiable factors in the crisis process that may facilitate crisis resolution.

METHODS

The protocol is registered on PROSPERO. A systematic search of MEDLINE, EMBASE, CINAHL, AHMED, PsycINFO, Cochrane Library and references of retrieved publications, identified empirical research in English language and date range January 2000 to February 2019. Two researchers independently screened abstracts, selected publications and extracted data using a framework based on published guidelines. This is a report of the analysis and narrative synthesis.

RESULTS

The search identified 2755 titles and abstracts, 76 were selected for full-text examination and 13 agreed for inclusion. The included studies evidence that: for a person with dementia, crisis is a process that begins with a problem judged to put them or others at risk of harm. It leads to decision and action to treat this risk, thus resolve the crisis. Such crisis can be predicted or unpredicted and progress quickly or slowly. Medical treatment, community resources and psychosocial support of personal resources, decision making, relationships and social networks, are all modifiable factors that can treat the risk of harm during crisis. Carers' and professionals' knowledge and skills in dementia care are likely to play a key role in crisis resolution in the home.

CONCLUSION

There has been limited investigation of the process and management of crisis at home for people living with dementia. The results of this review provide a foundation for future research. There is no consensus on critical components of home treatment to facilitate crisis resolution. However, education in dementia care for carers and professionals is likely to prove essential to successful home treatment.

A qualitative study on conveyance decision-making during emergency call outs to people with dementia: the HOMEWARD project

Background

Paramedics are increasingly required to make complex decisions as to whether they should convey a patient to hospital or manage their condition at the scene. Dementia can be a significant barrier to the assessment process. However, to our knowledge no research has specifically examined the process of decision-making by paramedics in relation to people with dementia. This qualitative study was designed to investigate the factors influencing the decision-making process during Emergency Medical Services (EMS) calls to older people with dementia who did not require immediate clinical treatment.

Methods

This qualitative study used a combination of observation, interview and document analysis to investigate the factors influencing the decision-making process during EMS calls to older people with dementia. A researcher worked alongside paramedics in the capacity of observer and recruited eligible patients to participate in case studies. Data were collected from observation notes of decision-making during the incident, patient care records and post incident interviews with participants, and analysed thematically.

Findings

Four main themes emerged from the data concerning the way that paramedics make conveyance decisions when called to people with dementia: 1) Physical condition; the key factor influencing paramedics’ decision-making was the physical condition of the patient. 2) Cognitive capacity; most of the participants preferred not to remove patients with a diagnosis of dementia from surroundings familiar to them, unless they deemed it absolutely essential. 3) Patient circumstances; this included the patient’s medical history and the support available to them. 4) Professional influences; participants also drew on other perspectives, such as advice from colleagues or information from the patient’s General Practitioner, to inform their decision-making.

Conclusion

The preference for avoiding unnecessary conveyance for patients with dementia, combined with difficulties in obtaining an accurate patient medical history and assessment, mean that decision-making can be particularly problematic for paramedics. Further research is needed to find reliable ways of assessing patients and accessing information to support conveyance decisions for EMS calls to people with dementia.