Nursing Home Patients: Cognitive Function Linked To Emergency Room Visits

Dr. Caroline E Stephens PhD Department of Community Health Systems University of California, San FranciscoMedicalResearch.com Interview with:
Dr. Caroline E Stephens PhD
Department of Community Health Systems
University of California, San Francisco

Medical Research: What are the main findings of the study?

Dr. Stephens: In our national random sample of nursing home residents, we found that mild cognitive impairment (CI) predicted higher rates of ED visits compared to no CI, but interestingly, ED visit rates decreased as severity of cognitive impairment increased.  However, after nursing home residents were evaluated in the ED, severity of CI was not significantly associated with higher odds of hospitalization.

Another important finding was that the proportion of nursing home residents using feeding tubes more than tripled in advanced or end-stage dementia, from 9.9% to 33.8%.  Moreover, tube-fed nursing home residents had 73% higher rates of total ED visits, but once evaluated in the ED, they were no more likely to be hospitalized than those without feeding tubes.  This finding is particularly striking given the numerous existing studies that have questioned the utility and appropriateness of using feeding tubes in people with advanced dementia.


Medical Research: Were any of the findings unexpected?

Dr. Stephens: Our study findings were unexpected for a couple of reasons:

First, most prior studies that have examined nursing home residents’ utilization of acute care services have used cognitive impairment as a dichotomous predictor and generally found a decreased risk of hospitalization among cognitively impaired residents.  This is the first study to examine severity of cognitive impairment as a continuous primary predictor and we also differentiated between evaluation in the ED and subsequent odds of hospitalization.  Our finding of higher rates of ED visits among nursing home residents with mild cognitive impairment may suggest that MCI plays a unique role in the presentation of acute illness and warrants further investigation.  Such frequent transfers to and from the emergency department may potentially set off a cascade of excess disability, decreased quality of life, and higher health care costs.

Second, this is the first study to find that tube-fed nursing home residents have higher rates of total ED visits, but no higher odds of being hospitalized once evaluated in the ED.  Our current hypothesis is that this pattern of ED visits may be related to feeding tube complications, such as dislodgements or clogs, which do not require hospitalization.  Nevertheless, such frequent visits to the ED are costly and may also represent a substantial burden to this already frail and vulnerable population.

Medical Research: What should clinicians and patients take away from your report?

Dr. Stephens: This study has 3 main take away points for clinicians, patients and families:

1)     Earlier recognition of MCI and attention to the unique needs of this high-risk population may result in more appropriate use of the ED and hospital services and improved health outcomes.

2)     The ED is playing an increasingly vital role in how hospitals and health systems are responding to healthcare reform in order to avoid CMS readmission penalties.  Efforts should be made to improve the quality and nature of communication, as well as care coordination between the nursing home and ED, and to implement early palliative care interventions.

3)     Providers should look for ways to improve communication and shared decision making with nursing home residents and their families about goals of care, particularly as it relates to feeding tube use in persons with advanced dementia.  The American Geriatrics Society recently published an updated position statement on the use of feeding tubes in patients with advanced dementia: http://www.americangeriatrics.org/press/id:5050

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Stephens: Future research should examine which unique clinical features of patients with MCI contribute to greater ED use and how behavioral symptoms of dementia, particularly in the early stages, affects decision making about ED transfers among nursing home caregivers.

Citation:

Alzheimers Dement. 2014 Jul 12. pii: S1552-5260(14)00116-2. doi: 10.1016/j.jalz.2014.03.010. [Epub ahead of print]

The effects of cognitive impairment on nursing home residents’ emergency department visits and hospitalizations.

Stephens CE1, Newcomer R2, Blegen M3, Miller B4, Harrington C2.

 

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