ED Visits on the Rise for People With Dementia

Abstract

Emergency department (ED) visits in the last year of life for people with dementia are common and increasing in the United Kingdom, according to a retrospective cohort study linking clinical and administrative data. The study also found that being a resident in a care home (both residential care homes with personal care only, and care homes with nursing care) was associated with a reduced likelihood of ED attendance, which suggests that care home residence “might ‘protect’ patients against transitions in care setting close to death,” said Katherine E. Sleeman, PhD, of King’s College London, and her associates. The finding that more than three-quarters of patients (78.6%) with dementia had at least one ED visit in their last year of life is similar to data from the United States and Australia, the investigators said, so policy makers should study and consider not only place of death but a broader range of indicators of the quality of end-of-life care. Dying out of the hospital has been a policy focus in the United Kingdom, but “the place of death … doesn’t tell us about the care they received during their last weeks and months,” the investigators reported (Alzheimer’s Dement 2018;14:20–27). The study also found that being a resident in a care home … was associated with a reduced likelihood of ED attendance. Their study linked electronic medical record data from a large mental health care provider covering four boroughs of South London with national mortality and hospital use data, and focused on the last year of life. The closer patients were to death, the more likely they were to visit EDs; approximately one-quarter of all ED visits occurred in the last month of life. Of the 4,867 patients in the cohort, 44.5% had at least one ED visit in the last month of life, and 20.9% had at least one visit in the last week of life. The mean number of ED attendances per patient in the last year of life increased from 1.6 during 2008–2009 to 2.4 during 2012–2013. Almost all ED visits (91%) were by ambulance, and almost half occurred “out of hours,” which suggests that the visits were precipitated by an acute crisis, the authors said. Approximately 75% of the 1,783 care home residents in the cohort had at least one ED visit in the last year of life, compared with 81% of the 3,084 patients who did not live in a care home. Care home residence remained associated with less ED use in a multivariable model of analysis. Factors associated with greater ED use included male gender, higher cognitive function (Mini-Mental State Examination score), diagnosis of vascular dementia, and living in less affluent areas — the latter of which has been shown in prior research to impact access to palliative care/hospice services, the investigators noted. Investigators were limited by the lack of any information regarding patients’ preferences or wishes, the presence or absence of advance directives, or the decision-making process leading to ED attendance. “For people with dementia, high rates of ED attendance near the end-of-life may indicate inadequate availability of community care, a paucity of advance directives, or lack of focus on patients’ quality of life,” the investigators wrote. The most common diagnosis was Alzheimer’s disease (40.4%) followed by vascular dementia (25.4%). Christine Kilgore is a freelance writer in Falls Church, VA.