Preventing emergency department (ED) visits and hospitalisations of older adults with cognitive impairment compared with the general senior population: what do we know about avoidable incidents? Results from a scoping review

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.

Impact of COVID-19 on emergency department visits among palliative home care recipients: a retrospective population-based cohort study in the Piedmont region, Italy

BACKGROUND

Integrated palliative home care (IHPC) is delivered to patients with progressive end-stage diseases. During the COVID-19 pandemic, IHPC needed to provide high-quality home care services for patients who were treated at home, with the goal of avoiding unnecessary care, hospital admissions, and emergency department (ED) visits. This study aimed to compare the ED visits of IHPC recipients in a large Italian region before and during the first two waves of the COVID-19 pandemic and to find sociodemographic or clinical characteristics associated with changes in ED visits during the first two waves of COVID-19 pandemic, compared with the period before.

METHODS

Administrative databases were used to identify sociodemographic and clinical variables of IHPC recipients admitted before and during the pandemic. The obtained data were balanced by applying a propensity score. The average number of ED visits before and during the pandemic was calculated by using the Welch's t test and stratified by all the variables.

RESULTS

Before and during the pandemic, 5155 and 3177 recipients were admitted to IHPC, respectively. These individuals were primarily affected by neoplasms. ED visits of IHPC recipients reduced from 1346 to 467 before and during the pandemic, respectively. A reduced mortality among IHCP patients who had at least one ED visit during the pandemic (8% during the pandemic versus 15% before the pandemic) was found. The average number of ED visits decreased during the pandemic [0.143, confidence interval (CI) = (0.128-0.158) versus 0.264, CI = (0.242-0.286) before the pandemic; p < 0.001] for all ages and IHPC duration classes. The presence of a formal caregiver led to a significant decrease in ED use. Medium and high emergency ED admissions showed no difference, whereas a decrease in low-level emergency ED admissions during the pandemic [1.27, CI = (1.194-1.345) versus 1.439, CI = (1.3-1.579) before the pandemic; p = 0.036] was found.

CONCLUSION

ED visits among IHPC recipients were significantly decreased during the first two waves of the COVID-19 pandemic, especially in those individuals characterized by a low level of emergency. This did not result in an increase in mortality among IHPC recipients. These findings could inform the reorganization of home care services after the pandemic.

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.

Religious attendance and global cognitive function: A fixed-effects cross-lagged panel modeling study of older U.S. adults

OBJECTIVES

Evidence linking religious attendance to better cognitive function is based on flawed study designs. No population representative longitudinal studies on the topic have taken both unobserved confounding and reverse causation into account. Recently developed fixed-effects cross-lagged panel modeling (FE-CLPM) offers simultaneous traction on these issues. It also allows parsing of long-from short-run effects. Using FE-CLPM and ten-year data from the Health and Retirement Study-a national probability sample of U.S. adults over age 50-this study began to fill the gaps above.

METHODS

Gender-specific FE-CLPM models were used to examine bidirectional and within-person linkages of religious attendance with global cognitive function. Granger-Sims "causality" tests further examined short-run effects in both directions. Impulse response analysis was used to explore time patterns in these linkages.

RESULTS

At least among women, religious attendance had negative short-term prospective linkages with global cognitive function. Over successive time points, these associations increased in strength among both genders. Feedback effects-of cognitive status on religious attendance-were found in both women's and men's models, but had a gender-specific pattern.

DISCUSSION

Results contradict a large literature positing cognitive benefits of religiosity. Instead, they lend support to a recent "neural resource depletion" model-especially among women. Overall, findings illustrate the "dark side" of religious engagement, which studies increasingly present as a social determinant with "outcome wide" positive effects on multiple health dimensions.

Predictors and trajectories of ED visits among patients receiving palliative home care services: findings from a time series analysis (2013-2017)

BACKGROUND

Current policies recommend integrating home care and palliative care to enable patients to remain at home and avoid unnecessary hospital admission and emergency department (ED) visits. The Italian health care system had implemented integrated palliative home care (IHPC) services to guarantee a comprehensive, coordinated approach across different actors and to reduce potentially avoidable ED visits. This study aimed to analyze the trajectories of ED visit rates among patients receiving IHPC in the Italian healthcare system, as well as the association between socio-demographic, health supply, and clinical factors.

METHODS

A pooled, cross-sectional, time series analysis was performed in a large Italian region in the period 2013-2017. Data were taken from two databases of the official Italian National Information System: Home Care Services and ED use. A clinical record is opened at the time a patient is enrolled in IHPC and closed after the last service is provided. Every such clinical record was considered as an IHPC event, and only ED visits that occurred during IHPC events were considered.

RESULTS

The 20,611 patients enrolled in IHPC during the study period contributed 23,085 IHPC events; ≥1 ED visit occurred during 6046 of these events. Neoplasms accounted for 89% of IHPC events and for 91% of ED visits. Although there were different variations in ED visit rates during the study period, a slight decline was observed for all diseases, and this decline accelerated over time (b = - 0.18, p = 0.796, 95% confidence interval [CI] = - 1.59;1.22, b-squared = - 1.25, p < 0.001, 95% CI = -1.63;-0.86). There were no significant predictors among the socio-demographic factors (sex, age, presence of a non-family caregiver, cohabitant family members, distance from ED), health supply factors (proponent of IHPC) and clinical factors (prevalent disorder at IHPC entry, clinical symptoms).

CONCLUSION

Our results show that use of ED continues after enrollment in IHPC, but the trend of this use declines over time. As no significant predictive factors were identified, no specific interventions can be recommended on which the avoidable ED visits depend.

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.

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

BACKGROUND/OBJECTIVES

People with dementia (PwD) frequently use emergency care services. To mitigate the disproportionately high rate of emergency care use by PwD, an understanding of contributing factors driving reliance on emergency care services and identification of feasible alternatives are needed. This study aimed to identify clinician, caregiver, and service providers' views and experiences of unmet needs leading to emergency care use among community-dwelling PwD and alternative ways of addressing these needs.

DESIGN

Qualitative, employing semistructured interviews with clinicians, informal caregivers, and aging service providers.

SETTING

Wisconsin, United States.

PARTICIPANTS

Informal caregivers of PwD (n = 4), emergency medicine physicians (n = 4), primary care physicians (n = 5), geriatric healthcare providers (n = 5), aging service providers (n = 6), and community paramedics (n = 3).

MEASUREMENTS

Demographic characteristics of participants and data from semistructured interviews.

FINDINGS

Four major themes were identified from interviews: (1) system fragmentation influences emergency care use by PwD, (2) informational, decision-making, and social support needs influence emergency care use by PwD, (3) emergency departments (EDs) are not designed to optimally address PwD and caregiver needs, and (4) options to prevent and address emergency care needs of PwD.

CONCLUSION

Participants identified numerous system and individual-level unmet needs and offered many recommendations to prevent or improve ED use by PwD. These novel findings, aggregating the perspectives of multiple dementia-care stakeholder groups, serve as the first step to developing interventions that prevent the need for emergency care or deliver tailored emergency care services to this vulnerable population through new approaches. J Am Geriatr Soc 67:711-718, 2019.