Understanding which people with dementia are at risk of inappropriate care and avoidable transitions to hospital near the end-of-life: a retrospective cohort study

Abstract

Abstract Background transitions between care settings near the end-of-life for people with dementia can be distressing, lead to physical and cognitive deterioration, and may be avoidable. Objective to investigate determinants of end-of-life hospital transitions, and association with healthcare use, among people with dementia. Design retrospective cohort study. Setting electronic records from a mental health provider in London, linked to national mortality and hospital data. Subjects people with dementia who died in 2007–2016. Methods end-of-life hospital transitions were defined as: multiple admissions in the last 90 days (early), or any admission in the last three days of life (late). Determinants were assessed using logistic regression. Results of 8,880 people, 1,421 (16.0%) had at least one end-of-life transition: 505 (5.7%) had early, 788 (8.9%) late, and 128 (1.5%) both types. Early transitions were associated with male gender (OR 1.33, 95% CI 1.11–1.59), age (>90 vs <75 years OR 0.69, 95% CI 0.49–0.97), physical illness (OR 1.52, 95% CI 1.20–1.94), depressed mood (OR 1.49, 95% CI 1.17–1.90), and deprivation (most vs least affluent quintile OR 0.58, 95% CI 0.37–0.90). Care home residence was associated with fewer early (OR 0.63, 95% CI 0.53 to 0.76) and late (OR 0.80, 95% CI 0.65 to 0.97) transitions. Early transitions were associated with more hospital admissions throughout the last year of life compared to those with late and no transitions (mean 4.56, 1.89, 1.60; P < 0.001). Conclusions in contrast to late transitions, early transitions are associated with higher healthcare use and characteristics that are predictable, indicating potential for prevention.