Late Stage Dementia Care: Are Hospitalizations Necessary?

By on October 26, 2013
late stage dementia are

Late stage dementia care is a time when the dementia patient should be made as comfortable as possible and have very little change  to their present environment. A recent study released by the New England Journal of Medicine reports that one in five  individuals that have late stage dementia living in a nursing home setting  are being transferred to the hospital or other setting in the last 90 days of their life.  Death and end stage dementia is a topic many caregivers need to prepare for and plan ahead.

This study also reports that in the last three days of life, repeated hospitalizations occur for the complications that are expected at the end of life in the late stage of dementia. The treatment often given to the late stage dementia patient, does not extend life or improve the quality of life.

The lead author, a Brown University health economist of this study, Pedro Gozalo finds that this practice may be due to financial reasons. The present Medicare system pays nursing homes a higher rate for a patient that has been admitted to the hospital and had a 3 day stay. When they return to the nursing home, the patient may qualify for skilled nursing services. This means the nursing home will be reimbursed at a higher Medicare rate, instead of the Medicaid rate. The present financial incentives under Medicare and Medicaid  actually encourage a nursing home to send their patients out to the hospital.

There are many problems with this present system that have a negative impact of the patient in the late stage of dementia:there is an increase in medical errors, there is an interruption in the continuity of care, increase in confusion and stress for the patient that already has cognitive issues. From the middle stage through the late stages of dementia, a sudden change in environment and unfamiliar people are known to cause undue stress and confusion.

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“Such patterns of transitions are burdensome, particularly since the overwhelming majority of family members state the main goal of care is comfort,” said study co-author Joan Teno, professor of health policy and practice at the Alpert Medical School of Brown University and a palliative care physician. “These transitions reflect the inefficiency of our health care system. Similar outcomes could be achieved by keeping these patients in the nursing home setting.”.

Of course, this trend varies from state to state due to cultural differences regarding end of life, the current market long term care market conditions and financial incentives.

The co authors of this study, included researchers from Harvard University and Dartmouth College. These researchers found that 19 % nationwide is the overall percentage of late stage dementia patients experiencing at least 1 unnecessary admission to the hospital.

last stage dementia care

Economist Jonathan Skinner from Dartmouth College, a co author of the study, reports that these hospitalizations have a negative impact on the federal treasury. This is believed, by the co authors, to hurry the decreasing of the Medicare trust fund to run out of money.

A state-by-state report of the rate of end of life hospitalizations as part of end of life dementia care is available from Brown University.

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The cultural differences show that Blacks and Hispanics patients with late stage dementia were also more likely than Caucasians  to experience transfers to the hospital at the end of life.

Researchers analyzed federal databases of nursing home and Medicare records between the years of 2000 and 2007.  The study  found that 474,829 residents in the nursing homes who were older than 66 years of age, had late stage dementia. These residents  lived in a nursing home for 120 days or more before their death.

Of these, 90,228 residents with late stage dementia had been admitted to the hospital or transferred to another setting at least once. The study considered: a transfer in the last three days of life, admission to a different nursing home than the one the patient  previously lived in before they went to the hospital, and/or repeat hospitalizations in the last 90 days of life.

The study found that the reasons for the hospitalizations were : pneumonia, urinary tract infection, or dehydration. All of these are conditions that are complications that occur at end of life and could  and should be easily treated in a properly equipped and staffed nursing home. Due to the present long term care environment, all skilled facilities are able to handle these various diagnoses.

The difference in the various states and the rate of transfers to different settings correlates with other indicators of poor end-of-life care, Gozalo noted.

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The study compared patients with late stage dementia living in the long term care markets with the lowest rates of transfers,to  those who lived in the regions with the highest rates of transfers. It was found that those in the highest rates of transfers  were three times more likely to have a feeding tube inserted. These late stage dementia patients were more than twice as likely to be admitted to an intensive care unit in the last 30 days of life. These patients were more than twice as likely to have developed an advanced pressure ulcer, or bed sore. Studies show that those admitted to an intensive care unit die with in 24 hours of admission.

These transfers to other settings, during late stage dementia, are signs of an ineffective health care system.

The goal of late stage dementia care as a patient nears the end of life, is often to maximize comfort. The burdens of hospitalizations place on a person with late stage dementia usually outweigh the benefits.

“Our research calls for efforts to reform health care payment that create incentives to improve advance care planning and care coordination,” Gozalo said. “Current reform efforts like accountable care organizations that bundle both the hospital and post-acute care payments could begin to address some of these perverse incentives. We need financial incentives to make sure that people are getting the right care in the right place at the right time.”.
Another study found that seventy one percent of those patients in late stage dementia care, die within 6 months after admission. Of those patients, only eleven percent are ever referred to hospice care. Palliative care services are not often offered. Instead, aggressive treatments offered for late stage dementia care is not only medically appropriate, it has a low rate of success. These aggressive treatments often lead to a faster decline or death.

Studies show that remaining in a nursing home  on hospice or with quality palliative care until end of life long term outcomes were better than those compared those that were admitted to a hospital.

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