UCSF

Background and objectives: The National Plan to Address Alzheimer’s Disease has identified enhancing care quality and efficiency for older adults with dementia as a major priority. One way to achieve this goal is to reduce potentially avoidable Emergency Department (ED) visits. Although the majority of older adults with dementia live in the community---not nursing homes—there is limited research on the rates, reasons, and risk factors for ED use by community-dwelling older adults with dementia. Pain, which has been shown to increase risk of ED use in other groups, may be one risk factor. This dissertation examines ED use, pain, and the relationship between pain and ED use in community-dwelling older adults with dementia.

Methods: This dissertation is comprised of three separate studies. The first study is an integrative review of the literature with a focus on rates, reasons, and risk factors for ED use in community-dwelling older adults with dementia. The second study is a cross-sectional analysis of prevalence of and risk factors for pain in community-dwelling older adults with dementia using data from the National Health and Aging Trends Study (NHATS). The third study leverages data from the NHATS mortality follow-back interview linked to Medicare claims data on healthcare use to investigate pain and ED use in the last month of life.

Results: Results from the integrative review indicate that community-dwelling older adults with dementia have higher rates of ED visits compared to those without dementia (adjusted risk or odds ratios 1.3-1.8, p<0.05 in 12 of 13 studies), although differences were attenuated in the last year of life. Increased symptoms, disability, and poor care coordination were associated with increased ED use. More than six out of 10 community-dwelling older adults with dementia reported bothersome pain, and four out of 10 reported pain severe enough to limit activities. Risk factors for pain include arthritis, low energy and other physical symptoms, psychological symptoms, and other comorbidities such as heart and lung disease. The majority (56%) of decedents had an ED visit in the last month of life. Estimates suggest decedents with unmet need for pain management had ED visit rates that were 50% higher than those without unmet need for pain management (Adjusted Incident Rate Ration 1.51, 95% Confidence Interval 1.10-2.07).

Discussion and Conclusion: Community-dwelling older adults with dementia are at high-risk of pain and frequent visits to the ED. Findings suggest that unmet need for pain management increases rates of ED use in the last month of life. Interventions to address pain may lower ED use in this vulnerable group.