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Nothelle S, Slade E, Zhou J, Magidson PD, Chotrani T, Prichett L, Amjad H, Szanton S, Boyd CM, Wolff JL. Emergency Department Length of Stay for Older Adults With Dementia. Ann Emerg Med 2024; 83:446-456. [PMID: 38069967 PMCID: PMC11032237 DOI: 10.1016/j.annemergmed.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/11/2023] [Accepted: 09/28/2023] [Indexed: 01/11/2024]
Abstract
STUDY OBJECTIVE The emergency department (ED) poses unique challenges and risks to persons living with dementia. A longer ED length of stay is associated with the risk of death, delirium, and medication errors. We sought to determine whether ED length of stay differed by dementia status and trends in ED length of stay for persons living with dementia from 2014 to 2018 and whether persons living with dementia were at a higher risk for prolonged ED length of stay (defined as a length of stay > 90th percentile). METHODS In this observational study, we used data from the Healthcare Cost and Utilization Project State Emergency Department Database from Massachusetts, Arkansas, Arizona, and Florida. We included ED visits resulting in discharge for adults aged ≥65 years from 2014 to 2018. We used inverse probability weighting to create comparable groups of visits on the basis of dementia status. We used generalized linear models to estimate the mean difference in ED length of stay on the basis of dementia status and logistic regression to determine the odds of prolonged ED length of stay. RESULTS We included 1,039,497 ED visits (mean age: 83.5 years; 64% women; 78% White, 12% Hispanic). Compared with visits by persons without dementia, ED length of stay was 3.1 hours longer (95% confidence interval [CI] 3.0 to 3.3 hours) for persons living with dementia. Among the visits resulting in transfer, ED length of stay was on average 4.1 hours longer (95% CI 3.6 to 4.5 hours) for persons living with dementia. Visits by persons living with dementia were more likely to have a prolonged length of stay (risk difference 4.1%, 95% CI 3.9 to 4.4). CONCLUSION ED visits were more than 3 hours longer for persons living with versus without dementia. Initiatives focused on optimizing ED care for persons living with dementia are needed.
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Affiliation(s)
- Stephanie Nothelle
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Eric Slade
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Junyi Zhou
- Biostatistics Epidemiology and Data Management Core, Johns Hopkins University, Baltimore, Maryland
| | - Phillip D Magidson
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tanya Chotrani
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Laura Prichett
- Biostatistics Epidemiology and Data Management Core, Johns Hopkins University, Baltimore, Maryland
| | - Halima Amjad
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah Szanton
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jennifer L Wolff
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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McHugh MC, Muschong KM, Bradley SM, Lo AX. Perspectives from persons living with dementia and their caregivers on emergency department visits, care transitions, and outpatient follow-up: A qualitative study. Acad Emerg Med 2024. [PMID: 38590030 DOI: 10.1111/acem.14898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024]
Abstract
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.
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Affiliation(s)
- Megan C McHugh
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Kayla M Muschong
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sara M Bradley
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander X Lo
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Draper KD, Angles JS, Turk MA, Lovier MA, Formica MK. Defining pre-existing disability among adults captured by the National Trauma Data Bank: A descriptive assessment of patient characteristics and details of injury. Disabil Health J 2024; 17:101574. [PMID: 38129263 DOI: 10.1016/j.dhjo.2023.101574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 11/07/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND There is limited research on trauma in people with disability (PWD), despite potentially increased risk for trauma and negative outcomes following injury. OBJECTIVE This study describes characteristics of trauma among both narrow and broad subsamples of PWD. METHODS Data from the 2016 National Trauma Data Bank was used to identify two Disability Comparison Groups (DCGs). DCG-1 included adult patients with a functionally dependent health status, and DCG-2 included DCG-1 plus other adult patients with disability-associated diagnoses. Trauma characteristics (e.g., signs of life, intent of injury, mechanism of injury, and injury severity score [ISS]) were compared via logistic regression. RESULTS Among the 782,241 reported trauma events, 39,011 belonged to DCG-1 and 193,513 to DCG-2. Falls caused most instances of trauma across both groups (DCG-1: 88.7 %; DCG-2: 67.3 %). Both DCGs were less likely than patients without disability to arrive at the facility without signs of life (DCG-1:aOR = 0.22, 95%CI 0.15-0.31; DCG-2:aOR = 0.40, 95%CI 0.36-0.45) or to have an ISS greater than 15 (DCG-1:aOR = 0.81, 95%CI 0.79-0.84; DCG-2:aOR = 0.92, 95%CI:0.91-0.94). They were, however, more likely to have an ISS greater than or equal to 8 (DCG-1:aOR = 1.14, 95%CI 1.11-1.16; DCG-2:aOR = 1.06, 95%CI 1.05-1.07). CONCLUSION PWD have greater odds for moderately scored injuries and presenting with signs of life at U.S. trauma centers compared to patients without disability. However, they can be more likely to have certain intents and mechanisms of trauma depending on their functional status and the nature of their impairment. Differences warrant further and continued assessment of trauma experiences among patients with pre-existing disability.
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Affiliation(s)
- Katherine D Draper
- Department of Physical Medicine & Rehabilitation, SUNY Upstate Medical University, Syracuse, NY, 13210, USA.
| | - John S Angles
- Department of Epidemiology and Biostatistics, SUNY at Albany, Rensselaer, NY, 12144, USA
| | - Margaret A Turk
- Department of Physical Medicine & Rehabilitation, SUNY Upstate Medical University, Syracuse, NY, 13210, USA
| | - Margaret A Lovier
- Department of Physical Medicine & Rehabilitation, SUNY Upstate Medical University, Syracuse, NY, 13210, USA
| | - Margaret K Formica
- Departments of Public Health & Preventive Medicine and Urology, SUNY Upstate Medical University, Syracuse, NY, 13210, USA
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Chary A, Hernandez N, Rivera AP, Ramont V, Obi T, Santangelo I, Ritchie C, Singh H, Hayden E, Naik AD, Liu S, Kennedy M. Perceptions of Acute Care Telemedicine Among Caregivers for Persons Living with Dementia: A Qualitative Study. J Appl Gerontol 2024; 43:69-77. [PMID: 37682526 PMCID: PMC10693729 DOI: 10.1177/07334648231198018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
Persons living with dementia (PLWD) have high emergency department (ED) utilization. Little is known about using telemedicine with PLWD and caregivers as an alternative to ED visits for minor acute health problems. This qualitative interview-based study elicited caregivers' perspectives about the acceptability of telemedicine for acute complaints. We performed telephone interviews with 28 caregivers of PLWD from two academic EDs, one in the Northeast and another in the South. Using a combined deductive-inductive approach, we coded interview transcripts and elucidated common themes by consensus. All caregivers reported they would need to participate in the telemedicine visit to help overcome communication and digital literacy challenges. People from racial/ethnic minority groups reported lower comfort with the virtual format. In both sites, participants expressed uncertainty about illness severity that could preclude using telemedicine for acute complaints. Overall, respondents deemed acute care telemedicine acceptable, but caregivers describe specific roles as crucial intermediaries to facilitate virtual care.
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Affiliation(s)
- Anita Chary
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Norvin Hernandez
- School of Medicine, Baylor College of Medicine, Houston, TX, USA
| | | | - Vivian Ramont
- University of Texas School of Public Health, UT Health Science Center, Houston, TX, USA
| | - Tracey Obi
- University of Texas School of Public Health, UT Health Science Center, Houston, TX, USA
| | - Ilianna Santangelo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Christine Ritchie
- Division of Palliative Care and Geriatric Medicine, Mongan Institute, Massachusetts General Hospital, Boston, MA, USA
| | - Hardeep Singh
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
| | - Emily Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Aanand D. Naik
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA
- University of Texas School of Public Health, UT Health Science Center, Houston, TX, USA
- Consortium on Aging, University of Texas Health Science Center, Houston, TX, USA
| | - Shan Liu
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Jones A, Watt JA, Maclagan LC, Swayze S, Jaakkimainen L, Schull MJ, Bronskill SE. Factors associated with recurrent emergency department visits among people living with dementia: A retrospective cohort study. J Am Geriatr Soc 2023; 71:3731-3743. [PMID: 37314108 DOI: 10.1111/jgs.18457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/12/2023] [Accepted: 05/14/2023] [Indexed: 06/15/2023]
Abstract
BACKGROUND Research on factors associated with recurrent emergency department (ED) visits and their implications for improving dementia care is lacking. The objective of this study was to examine associations between the individual characteristics of older adults living with dementia and recurrent ED visits. METHODS We used health administrative databases to conduct a population-based retrospective cohort study among older adults with dementia in Ontario, Canada. We included community-dwelling adults 66 years and older who visited the ED between April 1, 2010, and March 31, 2019 and were discharged home. We recorded all ED visits within one year after the baseline visit. We used recurrent event Cox regression to examine associations between repeat ED visits and individual clinical, demographic, and health service use characteristics. We fit conditional inference trees to identify the most important factors and define subgroups of varying risk. RESULTS Our cohort included 175,863 older adults with dementia. ED use in the year prior to baseline had the strongest association with recurrent visits (3+ vs.0 adjusted hazard ratio (aHR): 1.92 (1.89, 1.94), 2vs.0 aHR: 1.45 (1.43, 1.47), 1vs.0 aHR: 1.23 (1.21, 1.24)). The conditional inference tree utilized history of ED visits and comorbidity count to define 12 subgroups with ED revisit rates ranging from 0.79 to 7.27 per year. Older adults in higher risk groups were more likely to live in rural and low-income areas and had higher use of anticonvulsants, antipsychotics, and benzodiazepines. CONCLUSIONS History of ED visits may be a useful measure to identify older adults with dementia who would benefit from additional interventions and supports. A substantial proportion of older adults with dementia have a pattern of recurrent visits and may benefit from dementia-friendly and geriatric-focused EDs. Collaborative medication review in the ED and closer follow-up and engagement with community supports could improve patient care and experience.
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Affiliation(s)
- Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Jennifer A Watt
- ICES, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Liisa Jaakkimainen
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael J Schull
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susan E Bronskill
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Women's College Research Institute, Women's College Hospital, Toronto, Ontario, Canada
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Nasu K, Miyashita M, Hirooka K, Endo T, Fukahori H. Ambulance use and emergency department visits among people with dementia: A cross-sectional survey. Nurs Health Sci 2023; 25:712-720. [PMID: 37987542 DOI: 10.1111/nhs.13066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 09/29/2023] [Accepted: 10/26/2023] [Indexed: 11/22/2023]
Abstract
This study aimed to explore factors associated with ambulance use and emergency department (ED) visits among people with dementia in the month before death. A web-based survey of bereaved family caregivers of people with dementia was conducted in March 2020. Multivariate logistic regression analyses were conducted with ambulance use and ED visits in the month before death as dependent variables. Age and gender of people with dementia and their family caregivers, home care use, decision-makers, comorbidities, degree of independence in daily living, and caregivers' preparedness for death were independent variables. Data were collected from 817 caregivers of people with dementia who had died at hospitals (52.4%), long-term care facilities (25.0%), or own homes (22.4%). Caregivers' lack of preparedness for death was significantly associated with ambulance use in the month before death. Comorbidites and males with dementia were significantly associated with ED visits in the month before death. Better death preparedness of family caregivers may reduce ambulance use for symptoms that can be more effectively addressed by palliative care than acute care for people with dementia.
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Affiliation(s)
- Katsumi Nasu
- Keio Research Institute at SFC, Fujisawa, Japan
- School of Nursing, Yasuda Women's University, Hiroshima, Japan
| | | | - Kayo Hirooka
- Graduate School of Health Care Science, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takuro Endo
- International University of Health and Welfare Narita Hospital, Narita, Japan
| | - Hiroki Fukahori
- Faculty of Nursing and Medical Care, Keio University, Fujisawa, Japan
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Dresden SM. Optimizing the Care of Persons Living with Dementia in the Emergency Department. Clin Geriatr Med 2023; 39:599-617. [PMID: 37798067 DOI: 10.1016/j.cger.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
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.
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Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Center for Healthcare Studies and Outcomes Research, 211 East Ontario Street, Suite 200, Chicago, IL 60611, USA.
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Wang JY, Yang YW, Liu CH, Chang KC, Lin YT, Liu CC. Emergency department visits and associated factors among people with dementia residing in nursing homes in Taiwan: a one-year cohort study. BMC Geriatr 2023; 23:503. [PMID: 37605133 PMCID: PMC10441757 DOI: 10.1186/s12877-023-04221-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 08/07/2023] [Indexed: 08/23/2023] Open
Abstract
BACKGROUND Residing in a nursing home (NH) may increase emergency department (ED) utilization in patients with dementia; however, evidence regarding the status of and predictors for ED utilization of NH residents with dementia remains unclear, especially in Asia. This study aimed to assess the incidence density of ED visits and associated factors for the risk of ED utilization among NH residents with dementia. METHODS This one-year cohort study followed 6595 NH residents with dementia aged ≧ 40 years from Taiwan's National Health Insurance Research Database between 2012 and 2014. The Andersen-Gill extension of Cox regression analysis with death as a competing risk was applied to investigate the association of the risk of all causes and the most common causes of ED utilization with the predisposing, enabling, and need factors as defined by the Andersen model. RESULTS All participants encountered 9254 emergency visits in the 5371.49 person-years observed, representing incidence densities of ED visits of 1722.80 per 1000 person-years. Among them, respiratory disease was the most common cause of ED visits. The significant predictors for the risk of all-cause and respiratory-cause ED visits included: (1) predisposing factors (i.e., age and gender); (2) enabling factors (i.e., regional variables); and (3) need factors (i.e., prolonged ventilator dependence and comorbidity status). CONCLUSIONS Predisposing, enabling, and need factors could influence ED visits among studies patients. NH providers should consider these factors to develop strategies for reducing ED utilization.
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Affiliation(s)
- Jiun-Yi Wang
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, 500, Lioufeng Rd, Wufeng, Taichung, 41354, Taiwan
- Department of Medical Research, China Medical University Hospital, China Medical University, Taichung, Taiwan
| | - Yu-Wan Yang
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
- College of Medicine, China Medical University, Taichung, Taiwan
| | - Chien-Hui Liu
- Institute of Biomedical Informatics, National Yang Ming Chiao Tung University, Hsinchu, Taiwan
- Division of Emergency Medical Service, New Taipei City Fire Department, New Taipei, Taiwan
| | - Kun-Chia Chang
- Jianan Psychiatric Center, Ministry of Health and Welfare, Tainan, Taiwan
- Department of Psychiatry, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yi-Ting Lin
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, 500, Lioufeng Rd, Wufeng, Taichung, 41354, Taiwan
| | - Chih-Ching Liu
- Department of Healthcare Administration, College of Medical and Health Science, Asia University, 500, Lioufeng Rd, Wufeng, Taichung, 41354, Taiwan.
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Gettel CJ, Serina PT, Uzamere I, Hernandez‐Bigos K, Venkatesh AK, Cohen AB, Monin JK, Feder SL, Fried TR, Hwang U. Emergency department care transition barriers: A qualitative study of care partners of older adults with cognitive impairment. ALZHEIMER'S & DEMENTIA (NEW YORK, N. Y.) 2022; 8:e12355. [PMID: 36204349 PMCID: PMC9518973 DOI: 10.1002/trc2.12355] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/11/2022] [Accepted: 08/17/2022] [Indexed: 11/18/2022]
Abstract
INTRODUCTION After emergency department (ED) discharge, persons living with cognitive impairment (PLWCI) and their care partners are particularly at risk for adverse outcomes. We sought to identify the barriers experienced by care partners of PLWCI during ED discharge care transitions. METHODS We conducted a qualitative study of 25 care partners of PLWCI discharged from four EDs. We used the validated 4AT and care partner-completed AD8 screening tools, respectively, to exclude care partners of older adults with concern for delirium and include care partners of older adults with cognitive impairment. We conducted recorded, semi-structured interviews using a standardized guide, and two team members coded and analyzed all professional transcriptions to identify emerging themes and representative quotations. RESULTS Care partners' mean age was 56.7 years, 80% were female, and 24% identified as African American. We identified four major barriers regarding ED discharge care transitions among care partners of PLWCI: (1) unique care considerations while in the ED setting impact the perceived success of the care transition, (2) poor communication and lack of care partner engagement was a commonplace during the ED discharge process, (3) care partners experienced challenges and additional responsibilities when aiding during acute illness and recovery phases, and (4) navigating the health care system after an ED encounter was perceived as difficult by care partners. DISCUSSION Our findings demonstrate critical barriers faced during ED discharge care transitions among care partners of PLWCI. Findings from this work may inform the development of novel care partner-reported outcome measures as well as ED discharge care transition interventions targeting care partners.
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Affiliation(s)
- Cameron J. Gettel
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Center for Outcomes Research and EvaluationYale School of MedicineNew HavenConnecticutUSA
| | - Peter T. Serina
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Ivie Uzamere
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Kizzy Hernandez‐Bigos
- Section of GeriatricsDepartment of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
| | - Arjun K. Venkatesh
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Center for Outcomes Research and EvaluationYale School of MedicineNew HavenConnecticutUSA
| | - Andrew B. Cohen
- Section of GeriatricsDepartment of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | - Joan K. Monin
- Social and Behavioral SciencesYale School of Public HealthNew HavenConnecticutUSA
| | - Shelli L. Feder
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
- Yale University School of NursingOrangeConnecticutUSA
| | - Terri R. Fried
- Section of GeriatricsDepartment of Internal MedicineYale School of MedicineNew HavenConnecticutUSA
- VA Connecticut Healthcare SystemWest HavenConnecticutUSA
| | - Ula Hwang
- Department of Emergency MedicineYale School of MedicineNew HavenConnecticutUSA
- Geriatrics ResearchEducation and Clinical CenterJames J. Peters VA Medical CenterBronxNew YorkUSA
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Beauchet O, Afilalo M, Allali G, Lubov J, Galery K, Launay CP. "Emergency Room Evaluation and Recommendations" and Incident Hospital Admissions in Older People with Major Neurocognitive Disorders Visiting Emergency Department: Results of an Experimental Study. Dement Geriatr Cogn Disord 2022; 51:291-296. [PMID: 35551122 DOI: 10.1159/000524533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 04/02/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Older people with major neurocognitive disorders (MNCDs) visiting the emergency department (ED) are at high risk of hospital admissions. The "Emergency Room Evaluation and Recommendations" (ER2) tool decreases the length of stay (LOS) in the hospital when older people visiting ED are hospitalized after an index ED visit, regardless of their cognitive status. Its effect on hospital admissions has not yet been examined in older people with MNCD visiting ED. This study aimed to examine whether ER2 recommendations were associated with incident hospital admissions and LOS in ED in older people with MNCD visiting ED. METHODS A total of 356 older people with MNCD visiting ED of the Jewish General Hospital (Montreal, Quebec, Canada) were recruited in this non-randomized, pre-post-intervention, single arm, prospective and longitudinal open label trial. ED staff and patients were blinded of the ER2 score, and patients received usual ED care during the observation period, whereas ED staff were informed about the ER2 score, and patients had ER2 tailor-made recommendations in addition to usual care during the intervention period. Hospital admissions and the LOS in ED were the outcomes. RESULTS There were less incident hospital admissions (odds ratio ≤ 0.61 with p ≤ 0.022) and longer LOS in ED (coefficient beta ≥4.28 with p ≤ 0.008) during the intervention period compared to the observation period. DISCUSSION/CONCLUSION ER2 recommendations have mixed effects in people with MNCD visiting ED. They were associated with reduced incident hospital admissions and increased LOS in ED, suggesting that they may have benefits in addition to usual ED care.
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Affiliation(s)
- Olivier Beauchet
- Departments of Medicine, University of Montreal, Montreal, Québec, Canada.,Research Centre of the Geriatric University Institute of Montreal, Montreal, Québec, Canada.,Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, Québec, Canada.,Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Marc Afilalo
- Emergency Department, Jewish General Hospital, McGill University, Montreal, Québec, Canada
| | - Gilles Allali
- Leenaards Memory Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Joshua Lubov
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, Québec, Canada
| | - Kevin Galery
- Research Centre of the Geriatric University Institute of Montreal, Montreal, Québec, Canada
| | - Cyrille P Launay
- Department of Medicine, Division of Geriatric Medicine, Sir Mortimer B. Davis Jewish General Hospital and Lady Davis Institute for Medical Research, McGill University, Montreal, Québec, Canada
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11
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Dresden SM, Taylor Z, Serina P, Kennedy M, Wescott AB, Hogan T, Shah MN, Hwang U. Optimal Emergency Department Care Practices for Persons Living With Dementia: A Scoping Review. J Am Med Dir Assoc 2022; 23:1314.e1-1314.e29. [PMID: 35940683 DOI: 10.1016/j.jamda.2022.05.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/23/2022] [Accepted: 05/26/2022] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Zachary Taylor
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter Serina
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Maura Kennedy
- Department of Emergency Medicine, Harvard Medical School, Boston, MA, USA
| | - Annie B Wescott
- Galter Library and Learning Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Teresita Hogan
- Section of Emergency Medicine, Department of Medicine, University of Chicago Pritzker School of Medicine, Chicago, IL, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA; Geriatric Research, Education and Clinical Center, James J. Peters VA Medical Center, Bronx, NY, USA
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12
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Carpenter CR, Dresden SM, Shah MN, Hwang U. Adapting Emergency Care for Persons Living With Dementia: Results of the Geriatric Emergency Care Applied Research Network Scoping Review and Consensus Conference. J Am Med Dir Assoc 2022; 23:1286-1287. [PMID: 35940679 DOI: 10.1016/j.jamda.2022.05.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 05/14/2022] [Indexed: 12/16/2022]
Affiliation(s)
- Christopher R Carpenter
- Department of Emergency Medicine, Washington University in St Louis School of Medicine, Emergency Care Research Core, St Louis, MO, USA.
| | - Scott M Dresden
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | - Ula Hwang
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT, USA
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13
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Huang MH, Tsai CF, Cheng CM, Lin YS, Lee WJ, Kuo YS, Chan YLE, Fuh JL. Predictors of emergency department visit among people with dementia in Taiwan. Arch Gerontol Geriatr 2022; 101:104701. [DOI: 10.1016/j.archger.2022.104701] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/02/2022] [Accepted: 04/03/2022] [Indexed: 01/01/2023]
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14
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Green RK, Shah MN, Clark LR, Batt RJ, Chin NA, Patterson BW. Comparing emergency department use among individuals with varying levels of cognitive impairment. BMC Geriatr 2022; 22:382. [PMID: 35501721 PMCID: PMC9059422 DOI: 10.1186/s12877-022-03093-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 04/25/2022] [Indexed: 01/25/2023] Open
Abstract
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.
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Affiliation(s)
- Rebecca K. Green
- grid.14003.360000 0001 2167 3675BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive Suite 310, Madison, WI 53705 USA
| | - Manish N. Shah
- grid.14003.360000 0001 2167 3675BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive Suite 310, Madison, WI 53705 USA ,grid.14003.360000 0001 2167 3675Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin-Madison, Madison, WI USA ,grid.14003.360000 0001 2167 3675Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI USA
| | - Lindsay R. Clark
- grid.14003.360000 0001 2167 3675Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin-Madison, Madison, WI USA ,grid.417123.20000 0004 0420 6882Geriatric Research Education and Clinical Center, William S Middleton Memorial Veterans Hospital, Madison, WI USA
| | - Robert J. Batt
- grid.14003.360000 0001 2167 3675BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive Suite 310, Madison, WI 53705 USA ,grid.14003.360000 0001 2167 3675Wisconsin School of Business, University of Wisconsin - Madison, Madison, WI USA
| | - Nathaniel A. Chin
- grid.14003.360000 0001 2167 3675Department of Medicine, Division of Geriatrics and Gerontology, University of Wisconsin-Madison, Madison, WI USA
| | - Brian W. Patterson
- grid.14003.360000 0001 2167 3675BerbeeWalsh Department of Emergency Medicine, University of Wisconsin-Madison, 800 University Bay Drive Suite 310, Madison, WI 53705 USA ,grid.412637.50000 0004 7434 9029University of Wisconsin Health Innovation Program, Madison, WI USA ,grid.14003.360000 0001 2167 3675Department of Industrial and Systems Engineering, University of Wisconsin-Madison, Madison, WI USA ,grid.14003.360000 0001 2167 3675Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI USA
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15
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Dufour I, Dubuc N, Chouinard MC, Hudon C. Characteristics of frequent users of emergency departments living with major neurocognitive disorders: a cohort study. GERIATRICS, GERONTOLOGY AND AGING 2022. [DOI: 10.53886/gga.e0220040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
Abstract
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.
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Systematic Review of Dementia Support Programs with Multicultural and Multilingual Populations. Geriatrics (Basel) 2021; 7:geriatrics7010008. [PMID: 35076511 PMCID: PMC8788268 DOI: 10.3390/geriatrics7010008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 12/21/2021] [Accepted: 12/24/2021] [Indexed: 11/17/2022] Open
Abstract
Background: Dementia care programs have become more common due to a growing number of persons living with dementia and lack of substantial benefit from pharmacologic therapies. Cultural and language differences may present barriers to access and efficacy of these programs. In this article, we aimed to systematically review the current literature regarding outcomes of dementia care programs that included multicultural and non-English speaking populations. Methods: A systematic review was conducted using four scientific search engines. All studies included in the review are English language, randomized control trials evaluating various care coordination models. The initial search strategy focusing on studies specifically targeting multicultural and non-English speaking populations resulted in too few articles. We expanded our search to articles that included these populations although these populations may not have been the focus of the study. Results: Seven articles met inclusion criteria for final review. Measured outcomes included emergency room use, hospitalizations, provider visits, quality of life indicators, depression scores, and caregiver burden. Conclusions: Dementia care programs demonstrate significant ability to provide support and improve outcomes for those living with dementia and their caregivers. There is limited research in this field and thus opportunity for further study in underserved and safety net populations including more high-quality randomized controlled trials with larger sample sizes.
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17
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Schneider J, Miller J, Teschauer W, Kruse A, Teichmann B. Evaluation and Effectiveness of a Two-Day Dementia Training Program for Hospital Staff Working in an Emergency Department. J Alzheimers Dis 2021; 84:1631-1644. [PMID: 34719490 PMCID: PMC8764588 DOI: 10.3233/jad-210505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Entering the hospital via an Emergency Department (ED) is a pivotal moment in the life of People with Dementia (PwD) and often starts an avoidable downward spiral. Therefore, it is required to further educate ED staff to raise awareness of the needs of PwD. Although there are many studies about existing dementia training programs for the hospital setting, empirical evidence for the ED setting and cross-level training evaluations are lacking. Objective: The study aims to evaluate a two-day dementia training course for ED staff on the outcome levels of learning, individual performance, and organizational performance. Furthermore, the study examines whether the training fulfilled participants’ expectations. Methods: Mixed methods were used to assess data from head nurses, nursing, and administrative staff working in EDs. We conducted semi-structured interviews three weeks before (N = 18) and eight months after (N = 9) the training. Questionnaire data were assessed before the training, three months, and six months after the training (N = 44). A qualitative content analysis was conducted to analyze qualitative data; quantitative data was described descriptively. Results: The intervention seems to be effective on both learning and individual performance levels. However, we did not observe any changes in the organizational performance. The training program met attendees’ expectations only partly. The working environment of EDs needs to be taken more into account. Conclusion: Hospital staffs’ expectations of a dementia training program depend on the work area in which they operate. Results support the implementation of intervention bundles to enable sustainable cross-level changes.
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Affiliation(s)
- Julia Schneider
- Network Aging Research, Heidelberg University, Heidelberg, Germany.,Institute of Gerontology, Heidelberg University, Heidelberg, Germany
| | - Jennifer Miller
- Network Aging Research, Heidelberg University, Heidelberg, Germany
| | - Winfried Teschauer
- German Alzheimer's Association, Bavaria, Nuremberg.,Institute of Health, Bavarian Health and Food Safety Authority, Nuremberg, Germany
| | - Andreas Kruse
- Institute of Gerontology, Heidelberg University, Heidelberg, Germany
| | - Birgit Teichmann
- Network Aging Research, Heidelberg University, Heidelberg, Germany
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18
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Pereira C, LaRoche A, Arredondo B, Pugh E, Disbrow E, Reekes TH, Brickell E, Boettcher A, Sawyer RJ. Evaluating racial disparities in healthcare system utilization and caregiver burden among older adults with dementia. Clin Neuropsychol 2021; 36:353-366. [PMID: 34338590 DOI: 10.1080/13854046.2021.1951844] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To evaluate racial differences in healthcare utilization and caregiver burden in a culturally diverse population of older adults with dementia. METHOD One hundred and thirty-three dyads (person with dementia, PWD and caregiver, CG), with at least one emergency department (ED) visit or hospitalization 12 months prior, were enrolled. Independent sample t-tests and chi-squared analyses were performed to compare racial groups on healthcare utilization and CG burden. Mann-Whitney U test was used for item-level analyses, principal component analysis was used to examine relationships among outcomes, and regressions were used to identify the relationship between race and potential covariates. RESULTS PWD sample mean age was 79 years, predominantly female, and with high school education. Racial distribution was 65% White and 35% Black. CG sample mean age was 64 years, predominantly female, with more than 12 years of education. No differences were found for age or dementia severity across racial groups. Black PWD experienced more ED and ambulance utilization when compared to White counterparts. Non-emergency hospitalization rates were higher for White PWD. No significant differences were found by race for CG burden total score; however, item-level analysis suggested more anger, reduced social life, uncertainty, and inadequacy in White CGs. Regressions demonstrated a positive relationship between Black race and adult-child CGs with increased ED visits, while dyad educational attainment was associated with hospitalizations independent of race. CONCLUSIONS Healthcare utilization disparities extend to older adults with dementia diagnoses. Our findings suggest that culturally tailored interventions may be appropriate. Future research is encouraged to explore the effect of other covariates.
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Affiliation(s)
| | - Ashley LaRoche
- Neurology Department, Ochsner Health, New Orleans, LA, USA
| | - Beth Arredondo
- Neurology Department, Ochsner Health, New Orleans, LA, USA
| | - Erika Pugh
- Psychology Department, Louisiana State University, Baton Rouge, LA, USA
| | - Elizabeth Disbrow
- Center for Brain Health, LSU Health, Shreveport, LA, USA.,Department of Neurology, LSU Health, Shreveport, LA, USA.,Department of Pharmacology, Toxicology and Neuroscience, Shreveport, LA, USA
| | - Tyler H Reekes
- Center for Brain Health, LSU Health, Shreveport, LA, USA.,Department of Pharmacology, Toxicology and Neuroscience, Shreveport, LA, USA
| | - Emily Brickell
- Neurology Department, Ochsner Health, New Orleans, LA, USA
| | | | - R John Sawyer
- Neurology Department, Ochsner Health, New Orleans, LA, USA
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19
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Bosetti A, Gayot C, Preux PM, Tchalla A. Effectiveness of a Geriatric Emergency Medicine Unit for the Management of Neurocognitive Disorders in Older Patients: Results of the MUPACog Study. Dement Geriatr Cogn Disord 2021; 49:394-400. [PMID: 33333527 DOI: 10.1159/000510054] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 07/09/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The prevalence of neurocognitive disorders (NCDs) increases with age and is associated with cognitive impairment. Older patients with NCD admitted to the emergency department (ED) are readmitted after discharge to home more often than those without NCD. Comprehensive geriatric assessment (CGA) is effective for improving clinical outcomes in older patients; however, the usefulness of CGA for older patients with NCD admitted to the ED has not been investigated. The main objective of our study is to assess the effectiveness of a geriatric emergency medicine unit (GEMU) for elderly patients with NCD admitted to the ED. METHODS This historical cohort study included patients aged 75 years and older with NCD admitted to the ED of Limoges University Hospital in France over a 4-year period. We compared patients treated in our hospital's GEMU, the MUPA unit (exposed group), and patients who received standard care by emergency physicians (control group). The primary end point was the incidence of 30-day readmissions. RESULTS The study included 801 patients admitted to the ED between January 1, 2015, and December 31, 2018 (400 in the exposed group). Of those, 72.5% were female, and the mean age was 87 ± 5 years. After adjusting for confounding factors, the 30-day readmission rate was significantly associated with the MUPA unit intervention. CONCLUSION CGA in a GEMU improved health outcomes in elderly patients with NCD in the ED. We recommend that all EDs include a geriatric team, such as the MUPA unit, to treat all patients with NCD admitted to the ED.
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Affiliation(s)
- Anaïs Bosetti
- EA 6310 HAVAE Handicap Activité Vieillissement Autonomie Environnement, Université de Limoges, Limoges, France, .,CHU de Limoges, Pôle HU Gérontologie Clinique, Limoges, France, .,Centre de Mémoire de Ressources et de Recherche (CMRR) du Limousin, CHU de Limoges, Limoges, France,
| | - Caroline Gayot
- Centre de Mémoire de Ressources et de Recherche (CMRR) du Limousin, CHU de Limoges, Limoges, France.,Unité de Recherche Clinique et d'Innovation (URCI) de Gérontologie, CHU de Limoges, Pôle HU Gérontologie Clinique, Limoges, France
| | - Pierre-Marie Preux
- INSERM, CHU Limoges, IRD, U1094 Tropical Neuroepidemiology, Institute of Epidemiology and Tropical Neurology, Univ. Limoges, GEIST, Limoges, France
| | - Achille Tchalla
- EA 6310 HAVAE Handicap Activité Vieillissement Autonomie Environnement, Université de Limoges, Limoges, France.,CHU de Limoges, Pôle HU Gérontologie Clinique, Limoges, France.,Centre de Mémoire de Ressources et de Recherche (CMRR) du Limousin, CHU de Limoges, Limoges, France.,Unité de Recherche Clinique et d'Innovation (URCI) de Gérontologie, CHU de Limoges, Pôle HU Gérontologie Clinique, Limoges, France
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20
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Werner P, Tur-Sinai A, AboJabel H. Examining Dementia Family Caregivers' Forgone Care for General Practitioners and Medical Specialists during a COVID-19 Lockdown. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:3688. [PMID: 33916152 PMCID: PMC8036927 DOI: 10.3390/ijerph18073688] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/30/2021] [Accepted: 03/31/2021] [Indexed: 12/16/2022]
Abstract
The present study aimed to assess dementia caregivers' reports of the prevalence and correlates of forgone care regarding visits to a general practitioner (GP) and to a specialist during the COVID-19 lockdown in Israel, using Andersen's Behavioral Model of Healthcare Utilization. A cross-sectional study using an online survey was conducted with 73 Israeli family caregivers of persons with dementia residing in the community (81% Jews, 86% female, mean age = 54). Overall, one out of two participants reported having to delay seeking needed help from a GP or a specialist for themselves, as well as for their relatives with dementia, during the COVID-19 lockdown period. Among the predisposing factor, education was associated with caregivers' reports regarding forgone care for themselves as well as for their loved ones. Living with the care-receiver and income level were the enabling factors associated with forgone care for caregivers. Finally, feelings of burden were associated with caregivers' forgone care and feelings of loneliness and perceptions of the care-receiver's cognitive functioning were associated with care-receivers' forgone care. Our findings show that it is essential that this population receive appropriate practical and emotional support at times of distress and crisis to enable them to continue with their caregiving role.
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Affiliation(s)
- Perla Werner
- Department of Community Mental Health, University of Haifa, Mt. Carmel, Haifa 3498838, Israel;
| | - Aviad Tur-Sinai
- Department of Health Systems Management, The Max Stern Yezreel Valley College, Yezreel Valley 1930600, Israel;
- School of Nursing, University of Rochester Medical Center, Rochester, NY 14627-0446, USA
| | - Hanan AboJabel
- Department of Community Mental Health, University of Haifa, Mt. Carmel, Haifa 3498838, Israel;
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21
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Impact of Dementia on Health Service Use in the Last 2 Years of Life for Women with Other Chronic Conditions. J Am Med Dir Assoc 2020; 21:1651-1657.e1. [DOI: 10.1016/j.jamda.2020.02.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 02/21/2020] [Accepted: 02/21/2020] [Indexed: 01/17/2023]
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22
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Unroe KT, Caterino JM, Stump TE, Tu W, Carnahan JL, Vest JR, Sachs GA, Hickman SE. Long‐Stay Nursing Facility Resident Transfers: Who Gets Admitted to the Hospital? J Am Geriatr Soc 2020; 68:2082-2089. [DOI: 10.1111/jgs.16633] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 05/06/2020] [Accepted: 05/09/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Kathleen T. Unroe
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Jeffrey M. Caterino
- Department of Emergency Medicine and Internal Medicine The Ohio State University School of Medicine Columbus Ohio USA
| | - Timothy E. Stump
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
| | - Wanzhu Tu
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Jennifer L. Carnahan
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Joshua R. Vest
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
- Department of Health Policy and Management Indiana University Richard M. Fairbanks School of Public Health at Indiana University ‐ Purdue University Indianapolis Indianapolis Indiana USA
| | - Greg A. Sachs
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
| | - Susan E. Hickman
- Division of General Internal Medicine and Geriatrics Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Center for Aging Research Regenstrief Institute Indianapolis Indiana USA
- Department of Community and Health Systems Indiana University School of Nursing Indianapolis Indiana USA
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23
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Improving care for older adults in the Emergency Department warrants greater investment in geriatric nursing-Stat! Geriatr Nurs 2020; 41:345-346. [PMID: 32307221 PMCID: PMC7152902 DOI: 10.1016/j.gerinurse.2020.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Older adults use the Emergency Department (ED) more than any other age group besides infants. Despite high utilization, both the physical environment and care processes in the traditional ED are poorly suited to address the complex needs of older adults. As a result, older adults often experience poor outcomes in the ED. Geriatric nursing has been at the forefront of efforts to develop Geriatric Emergency Department Interventions (GEDI's) to try to address these deficits and improve care. As frontline providers with frequent patient contact, nursing brings critical viewpoints to these issues. This article provides some resources and other ideas for how frontline nurses can improve care for older adults in the ED. Ultimately, to have meaningful impacts on care of older adults in the ED, there is a dire need for greater financial investment specific to geriatric nursing education, training, and research in the ED.
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24
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Higgs L, Atkinson D, Brown NJ, Schnitker L, Lock C, Merlo G, Kramer D, Bennett L, Hughes JA. The effects of therapeutic activity kits in emergency department patients with dementia: Study protocol for a pragmatic randomized control trial. J Adv Nurs 2020; 76:1449-1457. [DOI: 10.1111/jan.14350] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 01/14/2020] [Accepted: 03/06/2020] [Indexed: 01/08/2023]
Affiliation(s)
- Leonie Higgs
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Qld Australia
| | - Diane Atkinson
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Qld Australia
| | - Nathan J. Brown
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Qld Australia
- Faculty of Medicine University of Queensland Brisbane Qld Australia
| | - Linda Schnitker
- School of Nursing Queensland University of Technology Kelvin Grove Qld Australia
| | - Caitlin Lock
- Healthcare Improvement UnitClinical Excellence Queensland Brisbane Qld Australia
| | - Gregory Merlo
- Primary Care Clinical Unit University of Queensland Brisbane Qld Australia
| | - David Kramer
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Qld Australia
| | - Leanne Bennett
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Qld Australia
| | - James A. Hughes
- Emergency and Trauma Centre Royal Brisbane and Women's Hospital Brisbane Qld Australia
- School of Nursing Queensland University of Technology Kelvin Grove Qld Australia
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25
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Beck AP, Jacobsohn GC, Hollander M, Gilmore-Bykovskyi A, Werner N, Shah MN. Features of primary care practice influence emergency care-seeking behaviors by caregivers of persons with dementia: A multiple-perspective qualitative study. DEMENTIA 2020; 20:613-632. [PMID: 32050779 DOI: 10.1177/1471301220905233] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
| | | | - Matthew Hollander
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA
| | | | - Nicole Werner
- College of Engineering, University of Wisconsin-Madison, Madison, WI, USA
| | - Manish N Shah
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, WI, USA; Department of Medicine (Geriatrics and Gerontology), University of Wisconsin-Madison, Madison, WI, USA.,Department of Population Health Sciences, University of Wisconsin-Madison, Madison, WI, USA
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26
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Dufour I, Chiu Y, Courteau J, Chouinard MC, Dubuc N, Hudon C. Frequent emergency department use by older adults with ambulatory care sensitive conditions: A population-based cohort study. Geriatr Gerontol Int 2020; 20:317-323. [PMID: 32017348 PMCID: PMC7187263 DOI: 10.1111/ggi.13875] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/13/2020] [Indexed: 01/18/2023]
Abstract
Aim To identify factors associated with frequent emergency department (ED) use among older adults with ambulatory care sensitive conditions. Methods This was a retrospective cohort study using databases from the Régie de l'assurance maladie du Québec. We included community‐dwelling individuals aged ≥65 years in the Province of Quebec (Canada), who consulted in ED at least once between 2012 and 2013 (index period), and were diagnosed with at least one ambulatory care sensitive condition in the 2 years preceding and including the index date (n = 264 473). We used a multivariate logistic regression model to evaluate the association between independent variables and being a frequent geriatric ED user, defined as four or more visits during the year after the index date. Results Out of the total study population, 17 332 (6.6%) individuals were considered frequent ED users in the year after the index date, accounting for 38% of ED uses for this period. The main variables associated with frequent geriatric ED use were older age, presence of chronic obstructive pulmonary disorder or diabetes, higher comorbidity index, common mental health disorders, polypharmacy, higher number of past ED and specialist visits, rural residence, and higher material and social deprivation. Dementia was inversely associated with frequent ED use. Conclusions Frequent geriatric ED users constitute a complex population whose characteristics need to be managed thoroughly in order to enhance the quality and efficiency of their care. Further studies should address their description in administrative databases so as to combine self‐perceived and professionally evaluated variables. Geriatr Gerontol Int 2020; 20: 317–323.
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Affiliation(s)
- Isabelle Dufour
- School of Nursing, Department of Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Yohann Chiu
- Department of Family and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Josiane Courteau
- Department of Family and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Nicole Dubuc
- School of Nursing, Department of Health Sciences, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Department of Family and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada.,PRIMUS Research Group, Centre de recherche du Centre hospitalier universitaire de Sherbrooke (CRCHUS)
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27
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Possin KL, Merrilees JJ, Dulaney S, Bonasera SJ, Chiong W, Lee K, Hooper SM, Allen IE, Braley T, Bernstein A, Rosa TD, Harrison K, Begert-Hellings H, Kornak J, Kahn JG, Naasan G, Lanata S, Clark AM, Chodos A, Gearhart R, Ritchie C, Miller BL. Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-being, and Health Care Use: The Care Ecosystem Randomized Clinical Trial. JAMA Intern Med 2019; 179:1658-1667. [PMID: 31566651 PMCID: PMC6777227 DOI: 10.1001/jamainternmed.2019.4101] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
IMPORTANCE Few health systems have adopted effective dementia care management programs. The Care Ecosystem is a model for delivering care from centralized hubs across broad geographic areas to caregivers and persons with dementia (PWDs) independently of their health system affiliations. OBJECTIVE To determine whether the Care Ecosystem is effective in improving outcomes important to PWDs, their caregivers, and payers beyond those achieved with usual care. DESIGN, SETTING, AND PARTICIPANTS A single-blind, randomized clinical trial with a pragmatic design was conducted among PWDs and their caregivers. Each PWD-caregiver dyad was enrolled for 12 months between March 20, 2015, and February 28, 2017. Data were collected until March 5, 2018. Study interventions and assessments were administered over the telephone and internet by clinical and research teams in San Francisco, California, and Omaha, Nebraska. Of 2585 referred or volunteer PWD-caregiver dyads in California, Iowa, or Nebraska, 780 met eligibility criteria and were enrolled. A total of 512 PWD-caregiver dyads were randomized to receive care through the Care Ecosystem and 268 dyads to receive usual care. All eligible PWDs had a dementia diagnosis; were enrolled or eligible for enrollment in Medicare or Medicaid; and spoke English, Spanish, or Cantonese. Analyses were intention-to-treat. INTERVENTION Telephone-based collaborative dementia care was delivered by a trained care team navigator, who provided education, support and care coordination with a team of dementia specialists (advanced practice nurse, social worker, and pharmacist). MAIN OUTCOMES AND MEASURES Primary outcome measure: Quality of Life in Alzheimer's Disease based on caregiver's rating of 13 aspects of PWD's well-being (including physical health, energy level, mood, living situation, memory, relationships, and finances) on a 4-point scale (poor to excellent). Secondary outcomes: frequencies of PWDs' use of emergency department, hospitalization, and ambulance services; caregiver depression (score on 9-Item Patient Health Questionnaire; higher scores indicate more severe depression); and caregiver burden (score on 12-Item Zarit Burden Interview; higher scores indicate more severe caregiver burden). RESULTS The 780 PWDs (56.3% female; mean [SD] age, 78.1 [9.9] years) and 780 caregivers (70.9% female; mean [SD] age, 64.7 [12.0] years) lived in California (n = 452), Nebraska (n = 284), or Iowa (n = 44). Of 780 dyads, 655 were still active at 12 months, and 571 completed the 12-month survey. Compared with usual care, the Care Ecosystem improved PWD quality of life (B, 0.53; 95% CI, 0.25-1.30; P = .04), reduced emergency department visits (B, -0.14; 95% CI, -0.29 to -0.01; P = .04), and decreased caregiver depression (B, -1.14; 95% CI, -2.15 to -0.13; P = .03) and caregiver burden (B, -1.90; 95% CI, -3.89 to -0.08; P = .046). CONCLUSIONS AND RELEVANCE Effective care management for dementia can be delivered from centralized hubs to supplement usual care and mitigate the growing societal and economic burdens of dementia. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT02213458.
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Affiliation(s)
- Katherine L Possin
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco.,Global Brain Health Institute, University of California, San Francisco
| | - Jennifer J Merrilees
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Sarah Dulaney
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Stephen J Bonasera
- Home Instead Center for Successful Aging, Division of Geriatrics, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Winston Chiong
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Kirby Lee
- Department of Clinical Pharmacy, University of California, San Francisco
| | - Sarah M Hooper
- UCSF/UC Consortium on Law, Science & Health Policy, UC Hastings College of the Law, San Francisco
| | - Isabel Elaine Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Tamara Braley
- Home Instead Center for Successful Aging, Division of Geriatrics, Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Alissa Bernstein
- Global Brain Health Institute, University of California, San Francisco.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Talita D Rosa
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco.,Global Brain Health Institute, University of California, San Francisco
| | - Krista Harrison
- Global Brain Health Institute, University of California, San Francisco.,Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco.,Division of Geriatrics, University of California, San Francisco
| | - Hailey Begert-Hellings
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - John Kornak
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - James G Kahn
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Georges Naasan
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Serggio Lanata
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Amy M Clark
- Home Instead Center for Successful Aging, Division of Geriatrics, Department of Internal Medicine, University of Nebraska Medical Center, Omaha.,Department of Social Work, Nebraska Wesleyan University, Lincoln
| | - Anna Chodos
- Division of Geriatrics, University of California, San Francisco
| | - Rosalie Gearhart
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
| | - Christine Ritchie
- Division of Geriatrics, University of California, San Francisco.,Center for Research on Aging, San Francisco Campus for Jewish Living, San Francisco, California
| | - Bruce L Miller
- Memory and Aging Center, Department of Neurology, UCSF Weill Institute for Neurosciences, University of California, San Francisco
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28
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Kent T, Lesser A, Israni J, Hwang U, Carpenter C, Ko KJ. 30-Day Emergency Department Revisit Rates among Older Adults with Documented Dementia. J Am Geriatr Soc 2019; 67:2254-2259. [PMID: 31403717 PMCID: PMC6899685 DOI: 10.1111/jgs.16114] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 06/21/2019] [Accepted: 07/09/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Published literature on national emergency department (ED) revisit rates among older adults with dementia is sparse, despite anecdotal evidence of higher ED utilization. Thus we evaluated the odds ratio (OR) of 30-day ED revisits among older adults with dementia using a nationally representative sample. DESIGN We assessed the frequency of claims associated with a 30-day ED revisit among Medicare beneficiaries with and without a dementia diagnosis before or at index ED visit. We used a logistic regression model controlling for dementia, age, sex, race, region, Medicaid status, transfer to a skilled nursing facility after ED, primary care physician use 12 months before index, and comorbidity. SETTING A nationally representative sample of claims data for Medicare beneficiaries aged 65 and older who maintained continuous fee-for-service enrollment during 2015 and 2016. Only outpatient claims associated with an ED visit between January 2016 and November 2016 were included as a qualifying index encounter. PARTICIPANTS We identified 240 249 patients without dementia and 54 622 patients for whom a dementia code was recorded in the year before the index encounter in 2016. RESULTS Our results indicate a significant difference in unadjusted 30-day ED revisit rates among those with an ED dementia diagnoses (22.0%) compared with those without (13.9%). Our adjusted results indicated that dementia is a significant predictor of 30-day ED revisits (P < .0001). Those with a dementia diagnosis at or before the index ED visit were more likely to have experienced an ED revisit within 30 days (OR = 1.27; 95% confidence interval = 1.24-1.31). CONCLUSION Dementia diagnoses were a significant predictor of 30-day ED revisits. Further research should assess potential reasons why dementia is associated with markedly higher revisit rates, as well as opportunities to manage and transition dementia patients from the ED back to the community more effectively. J Am Geriatr Soc 67:2254-2259, 2019.
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Affiliation(s)
- Tyler Kent
- The Gary and Mary West Health InstituteLa JollaCalifornia
| | - Adriane Lesser
- The Gary and Mary West Health InstituteLa JollaCalifornia
| | - Juhi Israni
- The Gary and Mary West Health InstituteLa JollaCalifornia
| | - Ula Hwang
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew YorkNew York
| | - Christopher Carpenter
- Washington University Division of Emergency MedicineWashington University School of Medicine in St. LouisSt. LouisMissouri
| | - Kelly J. Ko
- The Gary and Mary West Health InstituteLa JollaCalifornia
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Guterman EL, Allen IE, Josephson SA, Merrilees JJ, Dulaney S, Chiong W, Lee K, Bonasera SJ, Miller BL, Possin KL. Association Between Caregiver Depression and Emergency Department Use Among Patients With Dementia. JAMA Neurol 2019; 76:1166-1173. [PMID: 31282955 DOI: 10.1001/jamaneurol.2019.1820] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Current attempts to gauge the acute care needs of patients with dementia have not effectively addressed the role of caregivers, despite their extensive involvement in decisions about acute care management. Objective To determine whether caregiver depression is associated with increased use of the emergency department (ED) among patients with dementia. Design, Setting, and Participants This longitudinal cohort study used data from the Care Ecosystem study, a randomized clinical trial examining telephone-based supportive care for patients with dementia and their caregivers. Patients were 45 years or older with any type of dementia. A total of 780 caregiver-patient dyads were enrolled from March 20, 2015, until February 28, 2017, and 663 dyads contributed baseline and 6-month data and were included in the analysis. Exposures Caregiver depression (9-item Patient Health Questionnaire score of ≥10). Secondary analyses examined caregiver burden and self-efficacy. Main Outcomes and Measures The primary outcome was the number of ED visits in a 6-month period. Results Among the 663 caregivers (467 women and 196 men; mean [SD] age, 64.9 [11.8] years), 84 caregivers (12.7%) had depression at baseline. The mean incidence rate of ED visits was 0.9 per person-year. Rates of ED presentation were higher among dyads whose caregiver did vs did not have depression (1.5 vs 0.8 ED visits per person-year). In a Poisson regression model adjusting for patient age, sex, severity of dementia, number of comorbidities, and baseline ED use, as well as caregiver age and sex, caregiver depression continued to be associated with ED use, with a 73% increase in rates of ED use among dyads with caregivers with depression (adjusted incident rate ratio, 1.73; 95% CI, 1.30-2.30). Caregiver burden was associated with higher ED use in the unadjusted model, but this association did not reach statistical significance after adjustment (incident rate ratio, 1.19; 95% CI, 0.93-1.52). Caregiver self-efficacy was inversely proportional to the number of ED visits in the unadjusted and adjusted models (adjusted incident rate ratio, 0.96; 95% CI, 0.92-0.99). Conclusions and Relevance Among patients with dementia, caregiver depression appears to be significantly associated with increased ED use, revealing a key caregiver vulnerability, which, if addressed with patient- and caregiver-centered dementia care, could improve health outcomes and lower costs for this high-risk population.
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Affiliation(s)
- Elan L Guterman
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - I Elaine Allen
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - S Andrew Josephson
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco.,Editor, JAMA Neurology
| | - Jennifer J Merrilees
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Sarah Dulaney
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Winston Chiong
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Kirby Lee
- Department of Clinical Pharmacy, University of California, San Francisco
| | - Stephen J Bonasera
- Department of Geriatrics, Gerontology, and Palliative Medicine, University of Nebraska Medical Center, Omaha.,Department of Internal Medicine, University of Nebraska Medical Center, Omaha
| | - Bruce L Miller
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
| | - Katherine L Possin
- Department of Neurology, University of California, San Francisco.,Weill Institute for Neurosciences, University of California, San Francisco
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30
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Jacobsohn GC, Hollander M, Beck AP, Gilmore-Bykovskyi A, Werner N, Shah MN. Factors Influencing Emergency Care by Persons With Dementia: Stakeholder Perceptions and Unmet Needs. J Am Geriatr Soc 2019; 67:711-718. [PMID: 30624765 DOI: 10.1111/jgs.15737] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2018] [Revised: 11/30/2018] [Accepted: 12/04/2018] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Gwen Costa Jacobsohn
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Matthew Hollander
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | - Aaron P Beck
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin
| | | | - Nicole Werner
- College of Engineering, University of Wisconsin-Madison, Madison, Wisconsin
| | - Manish N Shah
- Department of Emergency Medicine, University of Wisconsin-Madison, Madison, Wisconsin.,Department of Medicine (Geriatrics and Gerontology), University of Wisconsin-Madison, Madison, Wisconsin.,Department of Population Health Sciences, University of Wisconsin-Madison, Madison, Wisconsin
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