A disturbing study about the care of dementia patients has been summarized in the New York Times. The bottom line is that many people with dementia are hospitalized unnecessarily. Here are excerpts from the article:
Perhaps no group of nursing home residents is more vulnerable than those with advanced dementia: unable to speak for themselves, suffering the physical as well as the cognitive effects of their terminal disease, prone to confusion or fear when subjected to blood tests or trips in screaming ambulances.
Yet dementia patients are often subjected to aggressive treatments and transfers even though studies show little benefit, as researchers at Hebrew Senior Life Institute for Aging Research in Boston keep pointing out.
This time, Dr. Susan Mitchell and her colleagues looked at Medicare spending for more than 300 patients with advanced dementia in Boston-area nursing homes over a period of 18 months. One of the largest expenditures, about 30 percent of the total, was for hospitalizations; skilled nursing care after those hospital stays accounted for another 10 percent. (Hospice was a big factor as well, though only 22 percent of the patients with advanced dementia were receiving hospice care, a dispiriting number in itself.)
So what’s wrong with this picture? “I’d estimate 75 percent of those hospitalizations are avoidable,” Dr. Mitchell told me in an interview. “By and large, research shows they can be treated with equal effectiveness in the nursing home. And it’s less traumatic for a nursing home resident with dementia to remain in place.”
Most of those hospital trips occurred when patients developed respiratory infections, particularly pneumonia, a common and recurring problem when dementia progresses to its final stages.
Ideally, patients’ relatives would be discussing, among one another and with doctors, whether to use aggressive treatments like intravenous antibiotics at this stage of the disease. These elderly patients, most in their 80s, could no longer recognize family members, speak more than a few words, leave their beds or feed themselves. The question of quality of life versus quantity comes into play.
But even when families decide to pursue every possible treatment, or when their ailing relatives have specified that course in advance directives, rushing demented old people to hospitals is unnecessary, Dr. Mitchell cautioned. “Being in an emergency room where people are taking blood and putting in IVs in this crazy, noisy setting — it’s been described as an ‘assault,’ and I concur,” she said. Intravenous antibiotics, if that’s the treatment agreed on, can be administered in nursing homes.
Part of the motive for hospitalization, Dr. Mitchell added, might be “cost-shifting” by nursing homes. Patients returning after a hospital stint will be covered for up to 100 days by Medicare, at higher rates than the Medicaid payments that may have covered them before. The billions of dollars saved by reducing repeated hospitalizations, she suggested, might better be spent improving nursing home care.
But families have a role to play, too. If they understand that dementia is a terminal disease, that treating recurring infections may prolong life but won’t restore health or bring comfort, that such treatments, if desired, can be usually administered in nursing homes themselves — they may be less willing to have the staff dial 911.