JAMA, January 11, 2012 Vol 307, No. 2

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1 JAMA, January 11, 2012 Vol 307, No. 2

2 Dementia is associated with increased rates and often poorer outcomes of hospitalization Worsening cognitive status Adequate chronic disease management is more difficult in persons with dementia

3 May lead to hospitalization for acute exacerbation of co-morbid conditions Non-elective hospitalization of older people, particularly those with dementia, is not a trivial event

4 Older persons without dementia, hospitalization for serious illness cognitive decline Frail elders Dementia Increased risk of delirium, functional decline, and iatrogenic complications

5 Identifying precipitate hospitalization Focus clinical priorities on secondary and tertiary prevention Improve health care

6 To determine whether dementia onset is associated higher rates of or different reasons for hospitalization ambulatory care sensitive conditions (ACSCs) Proactive outpatient care might prevent the need for a hospital stay

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8 Adult Changes in Thought (ACT) Begun in 1994, ACT is a population-based, longitudinal study of aging and the incidence of and risk factors for dementia Group Health Cooperative (GHC): large integrated health care delivery system

9 Aged 65 years or older Cognitively intact Not residing in a nursing home Follow up every 2 years Person interview (dementia and health status assessment) Completeness of follow-up index for ACT of more than 95%

10 Biennial examination to identify cases of incident dementia Score less than 86 on the Cognitive Abilities Screening Instrument (CASI) or had Symptoms suggesting possible new onset of cognitive impairment underwent a standardized dementia diagnostic evaluation consisting of a examination by a study physician and detailed neuropsychological testing as described elsewhere

11 Biennial examination to identify cases of incident dementia Score less than 86 on the Cognitive Abilities Screening Instrument (CASI) or had Symptoms suggesting possible new onset of cognitive impairment Study physicians Neuropsychologist Research nurse Interviewers

12 Biennial examination to identify cases of incident dementia Score less than 86 on the Cognitive Abilities Screening Instrument (CASI) or had Symptoms suggesting possible new onset of cognitive impairment Diagnosis : standardized criteria Diagnostic and Statistical Manual of Mental Disorders Neurological and Communicative Disorders Stroke Alzheimer Disease Related Disorders Association criteria

13 Retrospective, longitudinal cohort design Follow-up for each participant began at first enrollment in ACT and ended at death, health plan disenrollment, or end of study follow-up February 1, 1994, to December 31, 2007 Non dementia group is restricted to those who are dementia free through follow-up

14 (1) did not have dementia at the baseline ACT visit (2) completed at least 1 ACT follow-up visit (to assess for incident dementia) (3) were enrolled in GHC at the time of a followup visit

15 Outcome Measures Covariates

16 Outcome Measures Covariates Primary outcome measure was rate of hospitalization measured as mean number of admissions per year of followup

17 Outcome Measures Covariates Secondary outcome Measure was the rate of hospitalization by type Classified by the principal discharge diagnosis [ICD-9] Identified ACSCs

18 ACSCs Angina Asthma Bacterial pneumonia Cellulitis Congestive heart failure (CHF) Chronic obstructive pulmonary disease exacerbation Dehydration, Diabetes Duodenal ulcer, ear/nose/throat infection Gastric ulcer, gastroenteritis Hypertension Hypoglycemia Hypokalemia Influenza Malnutrition peptic ulcer seizure disorder Urinary tract infection (UTI)

19 Outcome Measures Covariates Socio-demographic characteristics Co-morbid conditions Health behaviors Self-rated health Place of residence

20 Socio-demographic characteristics Co-morbid conditions Health behaviors Self-rated health Place of residence race/ethnicity white, black Asian or Pacific Islander, American, Indian or Alaska Native, Hispanic, and other

21 Socio-demographic characteristics Co-morbid conditions Health behaviors Self-rated health Place of residence Estimated using the RxRisk score

22 Socio-demographic characteristics Co-morbid conditions Health behaviors Self-rated health Place of residence Depression was defined as a score of 10

23 Demographic and health-related characteristics compared between who developed dementia and those who did not Using t tests (continuous variables) X2 tests (categorical variables) no single covariate had more than 1.6% missing Primary analyses compared the admission rates in the 2 groups, with dementia handled as a time-varying covariate

24 Rates were computed as the total number of admissions in each group divided by the number of years of follow-up Dementia group, only admissions following the first dementia diagnosis were used in computing admission rates Non dementia group, the rate was computed as the total number admissions among persons while free of dementia divided by the total years of dementia-free follow-up

25 P values and confidence intervals for ratios were computed using empirical standard errors to account for over-dispersion in Poisson regression models only 5% of observations were excluded because of missing baseline or follow-up information Only 65 participants (2.2%) were excluded entirely from the fully adjusted analysis

26 Poisson regression analyses were performed for each outcome: unadjusted, age- and sex Adjusted fully adjusted ; adding nursing home residence at follow-up

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28 Participant Characteristics Rates of and Reasons for Hospitalization Relationship Between Death and Hospitalization

29 Participant Characteristics Rates of and Reasons for Hospitalization Relationship Between Death and Hospitalization

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32 Participant Characteristics Rates of and Reasons for Hospitalization Relationship Between Death and Hospitalization

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36 Participant Characteristics Rates of and Reasons for Hospitalization Relationship Between Death and Hospitalization

37 The association between dementia and admission rates remained significant and was attenuated for all cause but not ACSC admissions Fully adjusted rate ratios, 1.21; ( 95% CI, ; P= 0.03 ) for all-cause hospitalizations Rate ratios = 1.71; ( 95% CI, ; P= 0.001) for ACSC hospitalizations

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