Transitions in Care in a Nationally Representative Sample of Older Americans with Dementia

Abstract

Objectives: To describe transitions in care for older adults with dementia identified from a nationally representative cohort and to describe transition rates in those with more-severe levels of cognitive and functional impairment.

Design: Longitudinal cohort study.

Setting: Health and Retirement Study (HRS).

Participants: HRS respondents aged 65 and older whose survey data were linked with Medicare claims from 1999 to 2008 (N = 16,186).

Measurements: Transitions in care between home, home with formal services, hospital, and nursing facility care; cognitive function; activities of daily living; and mortality.

Results: The 3,447 (21.3%) HRS subjects who were ever diagnosed with dementia experienced frequent transitions. Of subjects transitioning from a hospital stay, 52.2% returned home without home care services, and 33.8% transitioned to a nursing facility. Of subjects transitioning from a nursing facility, 59.2% transitioned to the hospital, and 25.3% returned home without services. There were 2,139 transitions to death, and 58.7% of HRS subjects with dementia died at home. Even in persons with moderate to severe dementia, multiple transitions in care were documented, including transitions from the hospital to home and back to the hospital.

Conclusion: In this nationally representative sample of older adults, subjects diagnosed with dementia experience frequent transitions. Persons with dementia who are cared for at home and who transition back to home often have moderate to severe impairments in function and cognition.

Keywords: dementia; elder care; transitions.

Figure 1. Outbound and Inbound Transition Probabilities

Panel A. Each box represents one of four mutually exclusive sites of care. The number within each box represents the total number of transitions out of this site of care. For each site of care there are three lines that lead out of it and into the other three sites of care. The number next to each arrow represents the conditional probability of the transition out of the site of care and into the other site of care. When combined with the conditional probability of a transition out of the site due to death (data not shown), the sum of the three conditional probabilities out of each site of care equals 1. Panel B. Each box represents one of four mutually exclusive sites of care. The number within each box represents the total number of transitions into this site of care. For each site of care there are three lines that lead to it from the other three sites of care. The number next to each arrow represents the conditional probability of the transition into the site of care from the other site of care. The sum of the three conditional probabilities into each site of care equals 1.