Johns Hopkins geriatrician Stephanie Nothelle recaps her research comparing the emergency department (ED) length of stay among adults age 65 and older with and without dementia. Independent of dementia status, a longer ED length of stay is associated with a higher risk of medication errors, development of delirium, and death. The study of more than 1 million ED visits found that adults 65 and older with dementia had a mean length of stay that was 3.1 hours longer than their counterparts without dementia. These results highlight the need for more attention and investigation regarding care of older adults with dementia in the ED.
Hi, I'm Stephanie Noel. I'm a geriatrician and primary care physician at Johns Hopkins University School of Medicine. And I'm excited to tell you today about a study we recently did. Looking at emergency department length this day for people with dementia, emergency departments are an important care setting for older adults. Many of whom live with cognitive impairment or dementia. One in three people with dementia goes to the ED each year and estimate suggests that up to 40% of older adults in the emergency department have some form of cognitive impairment. The ED is not a great place for people with cognitive impairment. They may develop delirium and disorientation. And studies suggest that clinicians who work in the emergency department often feel ill prepared to take care of this population. Persons with dementia often can't accurately report their symptoms or their medical history. This may mean that taking care of someone with dementia takes a little bit more time than someone who doesn't have dementia or a younger adult. The length of time it takes to care for someone in the ED or the patient's length of stay is important, longer length of stay has been repeatedly associated with higher risk of medication errors, development of delirium and even higher risk of death. But research on length of stay among people with dementia was lacking. So, with this study, we sought to determine whether emergency department length this day differed by dementia status and whether people with dementia were more likely to have a prolonged emergency department length this day, which we defined is greater than the 90th percentile for length of stay, which was about 24 hours. In our study, we use data from the health care costs and utilization project State Emergency Department database from the years 2014 to 2018, from the States of Arizona, Arkansas, Massachusetts and Florida. This database provided us with all the data and all of the emergency department visits that resulted in discharge in those states. From 2014 to 2018. We specifically looked at visits by people over the age of 65. We first identified people who had dementia based on I CD codes and then matched them using a process called propensity score waiting to people without dementia who also had an ed visit in our database propensity score matching uses a complex statistical approach to try to match up study participants who are as similar as possible to try to create equal groups. We then created generalized linear regression models to estimate length of stay in the emergency department by dementia status. We adjusted for a large number of variables in our analysis including patient factors like age, sex, race insurance type visit, factors like time of day or time of year of the visit and diagnosis codes for the visit as well as co occurring conditions. We included over a million visits. In our study included, patients were on average 83 years old, 64% female and 78% white visits had a mean of 10.7 CPT coded procedures. The three most common reasons for visits were injuries, nervous system related diagnoses and symptoms, things like nausea or sympathy. In adjusted analysis, we found that the mean length of stay for people with dementia was 3.1 hours longer than persons without dementia. This meant a person with dementia was in the emergency department for an average of 15 hours while a similar older adult without dementia was in the emergency department for only 12 hours. Additionally, persons with dementia were 27% more likely to be in the emergency department for more than 24 hours than someone without dementia perhaps for clinicians. Listening to this, this difference by dementia diagnosis isn't surprising. As I said earlier, it's really hard to take good care of a person with dementia, especially in an acute care setting like the emergency department. But given what we know about the risks of being in the emergency department for longer periods of time, our results call attention to the need for more investigation and attention to the care of persons with dementia in the emergency department. Thanks very much.
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