Post-hospital transitions: special considerations for individuals with dementia.

Transitions of care refers to the actions involved in coordinating care for patients as they move through the health care system. The clinical goal during a transition is to communicate the care most-recently received and the needs for aftercare and beyond. Communication across settings and practitioners is paramount, as is the patient’s and family’s understanding of the illnesses and clinical requirements for ongoing management. Several post-hospital transition programs have demonstrated reductions in rehospitalization and lower costs for medical patients. The focus of these programs has been the medical discharge and “hand-off” process; interestingly, most studies have excluded individuals with cognitive impairment. Only recently have tailored aftercare services focused on comprehension of discharge instructions and other vulnerabilities that individuals with cognitive impairment may have following medical hospitalization. The vulnerable population of cognitively impaired individuals has a heightened need for coordinated aftercare. Perhaps most demonstrative is the psychiatric hospitalization for behavioral disturbance in dementia; this situation requires complex aftercare for many reasons: 1) cognitive impairment limits the ability of the patient to participate; 2) dementia-related behaviors may result in active resistance to aspects of the posthospital plan; 3) in-hospital improvement in dementia-related behaviors may be in-part or in-full due to behavioral or environmental interventions rather than pharmacotherapy, and communication of these interventions across settings can be cumbersome; 4) co-morbid medical and psychiatric care needs may require multiple specialty consultants and associated treatments may have cross-specialty effects; 5) federal, state and institutional policies may impose unforeseen barriers regarding access to specific aftercare services; and, 6) family caregivers often lack the resources (time, economic, cognitive or emotional, and additional family members) to triage follow-up tasks and solve new dilemmas. Evidence suggests that individuals with cognitive impairment are at heightened risk for both medical and psychiatric hospitalizations. Psychotic disorders in a large Medicare sample comprise the second-highest rate of 30-day rehospitalization (24.6%), just behind heart failure (26.9%). For elderly psychiatric inpatients, cognitive functioning is predictive of overall functioning; and social factors, including family functioning, are predictive of rehospitalization. One recent report suggests that acute care and critical care medical hospitalization is associated with a future diagnosis of dementia. Additional evidence highlights economic concerns regarding individuals with dementia. Alzheimer’s disease is the fifthleading cause of death for Americans over 65 and its death rate has been rising. An estimated $148 billion annually is attributable to Alzheimer’s disease, not including $94 billion in non-compensated services provided by family caregivers. The top 10% of Medicare beneficiaries with all-cause dementia account for 50% of all dementia-related Medicare costs; and the driving factors in the high-utilization of health care by individuals with dementia are inpatient and emergency treatment. Improving transitional care for patients with cognitive impairment may have benefits beyond the patient and health care system. Family caregivers also suffer risks related to carerecipient hospitalizations. In 1999, Schulz reported a 63% higher mortality risk for stressed spousal caregivers. In other studies, caregivers report worse health than non-caregivers, engage in fewer health-promoting behaviors and have worse medication compliance. Caregiving for a hospitalized patient is an independent risk factor for caregiver death and dementia caregivers have the highest risk, possibly due to poor self-care combined with distress while faced with dementiarelated behavioral problems in care recipients. The process of improving transitional care may be particularly cumbersome when the patient has cognitive impairment. Consensus guidelines (2009) regarding best-practice for medical hospital aftercare, based on input from more than 30 stakeholder representatives at the 2007 Transitions of Care Consensus Conference (TOCCC), recommended, by order of importance: