Dying in hospital among nursing home residents with and without dementia in Germany
Introduction
Although hospitalizations of nursing home residents occur frequently (Grabowski, Stewart, Broderick, & Coots, 2008; Hoffmann & Allers, 2016), they may have unintended consequences (Dwyer, Gabbe, Stoelwinder, & Lowthian, 2014; Pedone et al., 2005) and are often considered inappropriate or avoidable (Ouslander et al., 2010; Renom-Guiteras, Uhrenfeldt, Meyer, & Mann, 2014). This is especially the case during end of life (Cardona-Morrell, Kim, Brabrand, Gallego-Luxan, & Hillman, 2017). Potentially, nursing home residents, who die soon after they have been transferred, may not benefit from hospitalization (Dwyer et al., 2014).
Dementia is commonly found among nursing home residents in many countries (Gordon et al., 2014; Hoffmann et al., 2016; Stewart et al., 2014). These residents differ from those without cognitive impairment. For instance, residents with dementia are typically older (Allers, Dörks, Schmiemann, & Hoffmann, 2017; Li, Zheng, & Temkin-Greener, 2013), need more support in activities of daily living (Li et al., 2013; Mitchell, Kiely, & Hamel, 2004; Sloane, Zimmerman, Williams, & Hanson, 2008), but also have lower mortality (Hedinger, Hämmig, Bopp, & Swiss National Cohort Study Group, 2015; Magaziner et al., 2005) and fewer adverse health events compared to those without dementia (Magaziner et al., 2005). Furthermore, as dementia is often a slowly progressive disease, the required end-of-life care might differ from that for residents dying from other conditions (Sloane et al., 2008). This is likely to be the case for end-of-life hospitalizations, as well. Hospitalizations shortly before death are especially burdensome and of limited benefit in this vulnerable group or even entail adverse consequences (Gozalo et al., 2011). Moreover, residents with dementia could often be treated equally well in the nursing home setting (Givens, Selby, Goldfeld, & Mitchell, 2012; Gozalo et al., 2011).
However, the literature on the comparison of in-hospital deaths of nursing home residents with and without dementia is somewhat inconclusive. Few studies examined the differences between these two groups (Allers & Hoffmann, 2018; Li et al., 2013; Sloane et al., 2008; Temkin-Greener, Zheng, Xing, & Mukamel, 2013). While most of these studies found that nursing home residents with dementia are less likely to be hospitalized shortly before death than those without dementia (Krishnan, Williams, & Maharaj, 2015; Li et al., 2013; Sloane et al., 2008; Temkin-Greener et al., 2013), a study from Germany did not observe any differences in hospitalization rates in the last weeks before death (Allers & Hoffmann, 2018). To the best of our best knowledge, no study has yet examined predictors of in-hospital death in nursing home residents stratifying for dementia.
The aim of this study was to investigate the patterns of in-hospital deaths in nursing home residents with and without dementia in Germany.
Section snippets
Database, study population and outcome
We used administrative data of a large health insurance fund, DAK-Gesundheit, with about 6 million members (7.5% of the German population) from all over Germany. The study population included all people aged 65 years and older who were admitted to a nursing home between January 1, 2010, and December 31, 2014, following a continuous insurance period of at least 365 days without nursing home placement. Of those, all residents who died between January 1, 2010, and December 31, 2014 were studied.
Baseline characteristics
Of 127,227 nursing home residents newly admitted between 2010 and 2014, a total of 67,328 died during that period (52.9%). The decedents were on average 85.3 (SD: 7.4) years old, and more than two thirds were women (69.8%). Almost half of them had care level II at the time of death (46.8%). The mean length of stay in the nursing home was 343.5 days, but this varied widely as the median time was 189 days (Table 1). Of all decedents, 43.1% had suffered from dementia. Residents with dementia were
Comparison with other studies and interpretation of results
In our study of over 67,000 deceased nursing home residents, we found that 29.5% died in hospital with no apparent differences between persons with and without dementia. Lower level of care and male sex were associated with a higher chance of dying in hospital. We found different patterns in the influence of age and length of nursing home stay between residents with and without dementia.
Interestingly, we found no difference in the proportion of in-hospital deaths between nursing home residents
Conclusions
We found a comparably high proportion of in-hospital deaths among nursing home residents with and without dementia, with virtually no differences between these groups. More attention should be paid to recognizing the end of life and initiating less aggressive treatment, especially in persons with dementia. Since some predictors of in-hospital death might differ depending on dementia status, we suggest that further studies on hospitalizations near the end of life should stratify their results by
Conflict of interest
The authors declare that they have no competing interests.
Acknowledgments
There was no funding for this study. We thank the DAK-Gesundheit for providing the data. FH and KA conceptualized the study, conducted the analyses and wrote the paper. Both authors interpreted the data, critically revised the manuscript, and have read and approved the final version.
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