Predictors of Time to Discharge in Patients Hospitalized for Behavioral and Psychological Symptoms of Dementia

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DOI: 10.1159/000350028 · Source: PubMed
Abstract
BACKGROUNDAIMS: In Japan, more than 50,000 patients with dementia are housed in psychiatric facilities, a trend precipitated by prolonged hospitalizations. This study aimed to determine predictors for the time to discharge in patients hospitalized for behavioral and psychological symptoms of dementia (BPSD). Medical charts of patients admitted to an acute psychogeriatric ward for treatment of BPSD were reviewed. Cox's proportional hazards model was used to evaluate relationships between active behavioral problems and/or demographics at the time of admission, and the time until favorable discharge (FD), defined as discharge to the patient's own home or a care facility. For the 402 study patients included in this study, median time to FD was 101 days. In addition to family and residential factors, multivariate analysis identified higher Mini-Mental State Examination scores as independent clinical predictors for a shorter hospital stay, whereas male gender and combative behavior as the primary reason for hospital admission were predictors for a longer hospital stay. Clinical characteristics can be predictive of the time to discharge for patients with BPSD. Earlier interventions and enhanced care strategies may be needed for patients with a lower likelihood of FD.

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Original Research Article
Dement Geriatr Cogn Disord Extra 2013;3:8695
Predictors of Time to Discharge in Patients
Hospitalized for Behavioral and Psychological
Symptoms of Dementia
Tatsuru Kitamura Maki Kitamura Shoryoku Hino Koichi Kurata
Department of Neuropsychiatry, Ishikawa Prefectural Takamatsu Hospital, Kahoku City , Japan
Key Words
Dementia · Behavioral disorders · Psychiatric symptoms · Length of hospitalization ·
Predictors · Patient care management
Abstract
Background/Aims: In Japan, more than 50,000 patients with dementia are housed in psychi-
atric facilities, a trend precipitated by prolonged hospitalizations. This study aimed to deter-
mine predictors for the time to discharge in patients hospitalized for behavioral and psycho-
logical symptoms of dementia (BPSD). Methods: Medical charts of patients admitted to an
acute psychogeriatric ward for treatment of BPSD were reviewed. Cox’s proportional hazards
model was used to evaluate relationships between active behavioral problems and/or demo-
graphics at the time of admission, and the time until favorable discharge (FD), defined as dis-
charge to the patient’s own home or a care facility. Results: For the 402 study patients in-
cluded in this study, median time to FD was 101 days. In addition to family and residential
factors, multivariate analysis identified higher Mini-Mental State Examination scores as inde-
pendent clinical predictors for a shorter hospital stay, whereas male gender and combative
behavior as the primary reason for hospital admission were predictors for a longer hospital
stay. Conclusion: Clinical characteristics can be predictive of the time to discharge for patients
with BPSD. Earlier interventions and enhanced care strategies may be needed for patients with
a lower likelihood of FD. Copyright © 2013 S. Karger AG, Basel
Introduction
The Japanese government launched the long-term care insurance strategy in 2000 as a
measure to meet the impending increase in the number of patients with dementia [1, 2] . As
part of this policy, a broad network of in-home care services was established [3–5] in addition
Published online: March 23, 2013
EXTRA
Tatsuru Kitamura, MD, PhD
Department of Neuropsychiatry
Ishikawa Prefectural Takamatsu Hospital, Ya-36
Uchi-Takamatsu, Kahoku City, Ishikawa 929-1293 (Japan)
E-Mail tatsu220
@ mxi.mesh.ne.jp
www.karger.com/dee
DOI: 10.1159/000350028
This is an Open Access article licensed under the terms of the Creative Commons Attribution-
NonCommercial-NoDerivs 3.0 License (www.karger.com/OA-license), applicable to the online
version of the article only. Distribution for non-commercial purposes only.
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to various community-based care facilities to support patients with dementia to live indepen-
dently within the community and outside the hospital system. Despite these service provi-
sions, patients often require hospitalization in a psychiatric facility. The primary reason for
hospital admissions is worsening behavioral and psychological symptoms of dementia
(BPSD), which manifest in 90% of dementia patients [6] .
The goal of in-patient treatment for BPSD is the prompt remission of symptoms and to
return patients to their communities as soon as possible. Recently, however, there has been
an increase in prolonged hospital stays. Even after remission of BPSD, some patients expe-
rience difficulties being accepted by their communities following their discharge from a
psychiatric hospital. In 2010, the Ministry of Health, Labour and Welfare reported that the
average length of a hospital stay for dementia patients admitted to psychiatric hospitals was
944.3 days [7] . Consequently, the number of patients housed in psychiatric hospitals continues
to rise, and is currently greater than 50,000 across Japan [8] . During the lengthy course of
their hospital stay, some patients die, whereas others are transferred to medical hospitals
because of their deteriorating physical condition. These outcomes are considered to consti -
tute ‘unfavorable discharges’ (UFDs). In this context, a ‘favorable discharge’ (FD) encom-
passes moving patients to their own home or to a community-based care facility.
In addition to family and/or residential circumstances, a patient’s clinical characteristics
likely contribute to the time until discharge. However, to our knowledge, no studies have
investigated the exact factors contributing to time until discharge.
The aim of the present study was to determine the factors predicting the time to FD in
patients hospitalized for the treatment of BPSD. The time until FD was examined in relation
to patient profiles at the time of their admission, with a particular emphasis on possible
clinical predictors.
Methods
The medical records of patients hospitalized in the acute psychogeriatric ward of Ishika -
wa Prefectural Takamatsu Hospital were reviewed. The retrospective analysis was approved
by the institutional review board, which also waived the requirement for written informed
consent.
P a t i e n t s
Consecutive patients admitted to the acute psychogeriatric ward at Ishikawa Prefectural
Takamatsu Hospital for the treatment of BPSD between April 2006 and November 2009 were
enrolled in the study. All patients had severe BPSD such that they could not be cared for in
their own home or care facility, or be treated in an out-patient setting. Patients with severe
physical comorbid diseases were deemed ineligible for hospitalization in the acute psycho-
geriatric ward; instead they could receive prioritized medical treatment for their physical
comorbidities. Patients with a record of past hospitalization in our acute psychogeriatric
ward and who had behavioral symptoms prior to their cognitive decline or psychiatric comor-
bidities were excluded from the study.
M e a s u r e s
In all patients, the following items were evaluated and recorded within 1 week of
admission according to the institutional protocol.
Demographics. Information was obtained for each patient regarding gender, age, living
situation before hospitalization (including the type of residence and family situation), and
relationship with the primary caregiver from patient interviews or responses to question-
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© 2013 S. Karger AG, Basel
naires administered to family members or staff at the care facility/hospital by a psychiatric
social worker. Residency prior to hospitalization was classified as living in his/her own home,
a group home, care facility, or medical hospital. In Japan, group homes are care facilities in
which groups of people spend their daily lives basically on their own, with staff support only
when needed. In the present study, ‘family situation’ referred to the people with whom the
patient had lived prior to hospitalization. The family situation of patients living with family
members other than their partner or with staff in care facilities, group homes, or medical
hospitals was classified as ‘other’. The relationships between the patient and primary care-
giver were categorized as partner, son or daughter, other family member or relative, or staff.
Reasons for Admission. Behavioral problems causing distress for the caregiver, which had
become the primary reason for hospitalization, were recorded on the basis of interviews
conducted with the caregiver. The reasons for hospitalization were classified as combative
behavior, overactivity, or apathy or depression. Combative behavior comprised physically or
verbally aggressive behavior during or between care provisions, such as hitting, kicking,
biting, throwing things, cursing, and screaming. Overactivity included nonaggressive behav -
ior that required constant monitoring, such as aimless wandering, trying to reach a differ -
ent place, restlessness, or repetitive actions/mannerisms. Apathy and depression included
serious apathetic or depressive behavior, such as severe loss of appetite, refusal to eat, refusal
to take medication, or suicidal tendencies.
Type of Dementia. A diagnosis of dementia was made by either of the two experienced
geriatric psychiatrists (T.K. and M.K.) according to DSM-IV criteria following interviews with
patients and family members or staff, as well as on the basis of physical and neurological
findings, laboratory data, and brain imaging studies.
Behavioral and Psychiatric Symptoms. The prevalence of behavioral and psychiatric
symptoms was evaluated by two geriatric psychiatrists (T.K. and M.K.) using the Behavioral
Pathology in Alzheimer’s Disease (BEHAVE-AD) rating scale [9] . The presence or absence of
symptoms in each of seven clusters comprising a subscale of BEHAVE-AD was recorded,
including paranoid and delusional ideation, hallucinations, aggressiveness, activity distur-
bances, diurnal rhythm disturbances, affective disturbances, and anxieties or phobias.
Cognitive Function. Cognitive function was evaluated by geriatric psychiatrists in the
acute psychogeriatric ward using the Mini-Mental State Examination (MMSE) [10] .
Functional State of Daily Living. Activities of daily living (ADL) were scored by well-
trained nursing staff according to the Nishimura-style senile ADL (N-ADL) scale [11] , which
is one of the most commonly used scales for the evaluation of ADL in Japan. The N-ADL scale
evaluates five items: walking/sitting, range of activities, dressing/bathing, eating, and
excretion. Each item is scored on a scale of 0–10 points, with the total (maximum score 50)
taken as the N-ADL score. Nursing staff rated the reliability of the scale, when completed, as
good.
I n t e r v e n t i o n s
Patients received pharmacological interventions as indicated clinically. All patients were
treated under the supervision of the two geriatric psychiatrists (T.K. and M.K.) based on their
clinical judgment. There was no limit to the time allowed on the acute psychogeriatric ward.
Statistical Analysis
The primary endpoint of the present study was time to FD, defined as moving the patient
to his/her own home, a group home, or another care facility. UFDs were defined as death
during hospitalization or patient transfer to a medical hospital because of their deteriorating
physical condition [12] .
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© 2013 S. Karger AG, Basel
Data management and statistical calculations were performed using Stata version 11.0
(Statacorp, College Station, Tex., USA). Differences between groups (FD vs. UFD) in terms of
age, MMSE score, N-ADL score, and dose of antipsychotics used during hospitalization were
evaluated using t tests. Differences in frequency were analyzed using the χ
2
test.
Kaplan-Meier analysis was used to calculate estimates of hospital stay probability from
time of admission until FD. UFDs or being hospitalized at the end of the study were treated as
censors. Patients’ demographic and clinical characteristics at the time of hospital admission
were analyzed for their association with time to FD using univariate Cox’s proportional
hazards regression model. To determine independent predictors of time until discharge, we
used a multivariate Cox’s proportional hazards regression model. In this model, backward
elimination was used with a cutoff of p = 0.1.
Classification and regression tree analysis (CART) of the failure time data was performed
with the user-supplied Stata CART procedure by van Putten [13] to search for appropriate
cutoff points to count covariates and assess the possibility of interactions among covariates.
To develop a simple prediction tree, we used variables that were found to be significant in the
multivariate Cox’s proportional hazards regression model.
Two-tailed p < 0.05 was considered significant. For multiple comparisons, p values were
adjusted using Bonferroni correction.
Results
Table 1 lists the demographic characteristics of the 402 patients identified as eligible for
inclusion in the present study. Of these, 291 patients (72%) were identified as having an FD
(107 were discharged to their own home, 61 were discharged to a group home, and 123 were
discharged to other care facilities), 108 patients (27%) were identified as having a UFD (93
were transferred to another hospital and 15 died during hospitalization), and 3 patients
remained in the acute psychogeriatric ward when the study ended. Analysis of the demo-
graphic characteristics revealed there were fewer men in the FD compared with UFD group,
and that Alzheimer’s disease was more frequent in the FD group. Furthermore, in the FD
group, patients were more likely to have resided in their own homes and less likely to have
resided in a medical hospital. Both MMSE and N-ADL scores were higher in patients in the FD
group. Finally, the BPSD symptoms at admission in the FD group were less likely to be aggres-
siveness and diurnal rhythm disturbance.
Table 2 shows the psychotropic medications used during hospitalization. The daily dose
of antipsychotics was higher in the UFD group, while a cholinesterase inhibitor was more
frequently used in the FD group. The Kaplan-Meier survival curve ( fig. 1 ) revealed that the
median length of the hospital stay was 101 days (interquartile range 52–252).
Univariate analyses revealed that patients residing in their own home prior to hospital-
ization, higher N-ADL and MMSE scores at the time of admission, and apathy/depression as
the reason for admission were significant predictors of a shorter hospital stay, whereas male
gender, residing in a medical hospital prior to hospitalization, staff being the primary care-
givers, combative behavior as the reason for admission, and BPSD symptoms of aggres-
siveness and diurnal rhythm disturbances at the time of admission were significant predic -
tors of a longer hospital stay ( table 3 ).
Multivariate analyses revealed that patients residing in their own home prior to hospital-
ization and higher MMSE scores were independent significant predictors of a shorter hospital
stay, whereas male gender, living alone, having a son or daughter as the primary caregiver, and
combative behavior as the reason for hospitalization were predictors of a longer hospital stay
( table 4 ). There was a trend for older age to predict a shorter hospital stay.
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Kitamura et al.: Predictors of Time to Discharge in Patients Hospitalized for Behavioral
and Psychological Symptoms of Dementia
www.karger.com/dee
© 2013 S. Karger AG, Basel
Table 1. Patient demographic characteristics
All patients
(n = 402)
Discharged patients
F D (n = 291) UFD (n = 108) p value
1
Men 167 (42) 102 (35) 64 (59) 0.000
Age, years 81.0
± 7.1 81.0 ± 7.0 81.0 ± 7.4 0.927
Type of dementia 0.027
AD 246 (61) 190 (65) 56 (52)*
VaD 59 (15) 36 (13) 23 (21)
Other 97 (24) 65 (22) 29 (27)
Residency before hospitalization 0.000
Own home 232 (58) 183 (63) 48 (44)**
Group home 48 (12) 34 (12) 13 (12)
Care facility 42 (10) 34 (12) 8 (7)
Medical hospital 80 (20) 40 (13) 39 (37)***
Patient living 0.701
Alone 83 (21) 59 (20) 23 (21)
With partner only 72 (18) 50 (17) 22 (20)
With others 247 (61) 182 (63) 63 (59)
Caregiver relationship 0.093
Partner 107 (27) 73 (25) 34 (31)
Son or daughter 139 (33) 104 (35) 33 (31)
Other family member/relative 47 (14) 40 (14) 7 (7)
Staff 109 (27) 74 (26) 34 (31)
MMSE score 9.4
± 7.9 10.4 ± 7.9 6.5 ± 7.2 0.000
N-ADL score 26.1
± 12.8 28.8 ± 12.0 18.7 ± 12.2 0.000
Reason for admission 0.189
Combative behavior 151 (38) 101 (35) 48 (44)
Overactivity 181 (45) 138 (47) 42 (39)
Apathy or depression 70 (17) 52 (18) 18 (17)
BPSD
Paranoid and delusional ideation 120 (30) 94 (32) 25 (23) 0.076
Hallucination 82 (20) 65 (22) 17 (16) 0.143
Aggressiveness 240 (60) 162 (56) 75 (69) 0.013
Activity disturbances 371 (92) 269 (92) 99 (92) 0.798
Diurnal rhythm disturbances 326 (81) 228 (78) 96 (89) 0.017
Affective disturbances 165 (41) 124 (43) 40 (37) 0.315
Anxieties and phobias 128 (32) 99 (34) 28 (26) 0.123
Data are given as means ± SD or as the number of patients in each group with percentages in parentheses,
as appropriate. * p < 0.05, ** p < 0.01, *** p < 0.001 compared with patients with an FD. AD = Alzheimer’s
disease; VaD = vascular dementia.
1
Dichotomous characteristics were compared using the χ
2
test; continuous
characteristics were analyzed using t tests.
Table 2. Psychotropic medications used during hospitalization
Psychotropic medications All patients
(n = 402)
Discharged patients
FD (n = 291) UFD (n = 108) p value
2
Dose of antipsychotics
1
, mg/kg 3.8 ± 4.2 3.5 ± 3.9 4.6 ± 5.0 0.015
Use of cholinesterase inhibitor 166 (41) 134 (47) 29 (27) 0.001
Data are given as means ± SD or as the number of patients in each group with percentages in parentheses,
as appropriate.
1
Daily dose of antipsychotic in chlorpromazine equivalents employed at the maximum
during hospitalization.
2
Dichotomous and continuous characteristics were compared using the χ
2
test and
the t test, respectively.
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When building the CART, data were split into four groups with significantly different
hazard ratios on the basis of MMSE score, combative behavior as the reason for admission,
and male gender ( fig. 2 ). According to the tree and the optimal cutoff point search, MMSE
scores >12 predict the shortest hospital stay, whereas the combination of MMSE scores 12
and combative behavior as the reason for hospitalization predicts the longest hospital stay.
Discussion
To our knowledge, the present study is the first to investigate the factors affecting the
time to discharge among patients hospitalized for the treatment of BPSD. In addition to family
and residential factors, multivariate analysis identified a further three clinical factors inde-
Fig. 1. Cumulative probability of
hospital stay in patients with
BPSD.
Table 3. Univariate Cox’s proportional hazard regression for time to FD
Variable Hazard ratio 95% CI p value
Male gender 0.69 0.55
0.88 0.003
Type of dementia
AD 1.23 0.97
1.57 0.091
Residency before hospitalization
Own home 1.43 1.12
1.81 0.004
Medical hospital 0.69 0.50
0.97 0.032
Caregiver relationship
Staff 0.75 0.58
0.98 0.032
MMSE score 1.03 1.02
1.05 0.000
N-ADL score 1.02 1.00
1.02 0.003
Reason for admission
Combative behavior 0.68 0.53
0.87 0.002
Apathy or depression 1.38 1.02
1.87 0.034
BPSD
Aggressiveness 0.74 0.58
0.93 0.010
Activity disturbance 0.69 0.45
1.07 0.096
Diurnal rhythm disturbance 0.74 0.56
0.98 0.037
Variables with p < 0.10 are listed. AD = Alzheimer’s disease.
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© 2013 S. Karger AG, Basel
pendently associated with time to FD: MMSE score, combative behavior as the primary reason
for admission, and male gender.
Cognitive function is strongly associated with performing instrumental ADL, which
encompasses complex behaviors such as managing finances, handling medications, and
housekeeping [14–16] . The care burden may be greater for patients with lower MMSE scores,
and this could present a major obstacle to discharging patients after remission of BPSD.
Contrary to our expectations, our analyses did not reveal N-ADL scores, which represent the
performance of basic ADL, as independent predictors of time until discharge. In contrast
with instrumental ADL, it has been reported that basic ADL are highly correlated with motor
function and coordination [17, 18] . In Japan’s long-term care insurance system, although
eligibility is ranked according to assessments of both physical and cognitive status, higher
care levels are provided for physical rather than cognitive impairments [19] . However, some
studies [20, 21] have shown that the care burden for severely demented patients with mild
physical disabilities could be considerably greater than that for patients with severe physical
disabilities because demented patients may act without intention, which may necessitate
constant supervision.
Fig. 2. CART analysis for time to
FD. n = Number of observations;
HR = hazard ratio.
Table 4. Multivariate Cox’s proportional hazard regression for time to FD
Variable Hazard ratio 95% CI p value
Male gender 0.70 0.54
0.92 0.010
Age 1.02 1.00
1.04 0.065
Residency before hospitalization
Own home 1.34 1.04
1.73 0.024
Patient living
Alone 0.64 0.46
0.88 0.006
Caregiver relationship
Son or daughter 0.73 0.54
0.97 0.033
MMSE score 1.03 1.01
1.05 0.000
Reason for admission
Combative behavior 0.75 0.58
0.97 0.026
Variables with p < 0.10 are listed. AD = Alzheimer’s disease.
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© 2013 S. Karger AG, Basel
Combative behavior refers to physically or verbally aggressive behavior. We have clearly
shown in the present study that when aggressive behavior becomes prominent and is the
primary reason for admission, it could prolong hospitalization. Although we did not evaluate
chronological treatment response, our findings indicate that aggressive behavior may be less
likely to respond to interventions, including pharmacotherapy, compared with other types
of behavioral problems. Antipsychotics are currently the mainstay of treatment to control
aggressive behavior; however, the available data regarding the efficacy of antipsychotics are
inconsistent [22, 23] and the doses that can be used are limited because of the risk of consid-
erable side effects [24] or death [25] . Safer alternatives [26, 27] include sedative/hypnotics,
anticonvulsants, serotonergic agents, lithium, β-blockers, and estrogen, but there is insuffi-
cient evidence supporting the efficacy of these drugs.
Even after a patient’s aggressive behavior is under control, there is likely to be an effect
on the patient’s interpersonal relationships [28] , with caregivers likely to express disap-
proval of the patient’s discharge because of the harmful nature of this sort of behavior [29–
31] . In addition to enhanced service provision, recently developed interventions targeting
caregivers [32–35] may be beneficial in decreasing the burden and stress of caregiving. Trials
have indicated that these measures can simultaneously improve the quality of life of both the
patient and caregiver [36, 37] .
In a previous study [12] on hospitalized patients with BPSD, we found that the profile of
men at the time of admission was different to that of women: specifically, men were younger,
more frequently had vascular dementia, were more frequently admitted from medical
hospitals, had lower MMSE and N-ADL scores, were more frequently admitted because of
combative behavior, and exhibited aggressiveness and diurnal rhythm disturbances on the
BEHAVE-AD. These factors have been shown in the present study to be potentially associated
with a longer period of hospitalization. In our previous study we also discussed the possible
effect of inequality between genders in terms of the availability of care services. In Japan, 80%
of residents in care institutions are women [38] and there are relatively few beds specifically
equipped for use by men. Furthermore, the majority of care workers are women [39] , who
often prefer that female residents are accepted into the care home because they are perceived
to be easier to care for.
In the present study, CART analysis revealed that the aforementioned clinical predictors
could be used to divide the data into four groups with different hazard ratios for FD. Patients
with severely impaired cognitive function admitted primarily because of combative behavior
had the lowest likelihood of FD. In patients exhibiting aggressiveness, pharmacological or
nonpharmacological interventions involving both patients and caregivers may be required
from the early stages of dementia before the symptoms become prominent. Factors related
to family and residential circumstances were not used to split the data, and this suggests that
these factors may act equally in each of the four groups to affect the likelihood of FD. The
options following the discharge of patients admitted from care or medical facilities may be
limited because these patients are usually in a worse physical condition and require constant
formal care or supervision. In terms of relationships between caregivers and patients, it has
been reported that children are less strongly committed to the caregiving relationship than
spouses [40] , and stronger support systems are needed for patients living alone. However,
under the current long-term care insurance system in Japan, family composition is not
supposed to be taken into account when deciding on the level of care required. Other social
factors that may have an impact on the time to FD could include economic status or the avail-
ability of care resources.
There are some limitations to the present study that need to be acknowledged and
addressed. As described above, because of the retrospective nature of this study based on a
review of patients’ medical charts, only limited information was available. In particular, we
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and Psychological Symptoms of Dementia
www.karger.com/dee
© 2013 S. Karger AG, Basel
did not evaluate caregiver burden, despite findings indicating its potential association with
time to discharge [41] . Furthermore, although any pharmacotherapy was optimized to
achieve remission of BPSD as soon as possible, our routine practice did not include chrono-
logical treatment response. These issues need to be taken into consideration in future studies,
as well as in clinical practice. Finally, the present study was conducted in a single institution
in a particular region of Japan. Future well-designed prospective and larger-scale studies are
warranted to confirm our results.
In conclusion, clinical characteristics, such as lower MMSE scores, combative behavior as
the primary reason for hospitalization, and male gender, could be predictors of a lower like-
lihood of FD in patients with BPSD. These findings should be taken into consideration when
managing patients with BPSD to enable implementation of optimal treatment and care strat-
egies to improve in-patient treatment outcomes.
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    • "Auch können längere Rekonvaleszenzzeiten, beispielsweise nach Operationen, sowie höhere Anpassungsschwierigkeiten an die Krankenhausumgebung einen Einfluss haben [11]. Ein weiterer Grund wird den herausfordernden Verhaltensweisen zugesprochen [20], die bei Patienten mit Demenz häufiger auftreten [21]. Herausfordernde Verhaltensweisen, wie Aggression, unruhiges Verhalten, Tag- Nacht-Umkehr oder das Herausziehen von Kathetern, können die Pflege erschweren [22] 19 % je Fall verdeutlichen somit die ökonomische Relevanz der akutstationären Versorgung der Demenz. "
    [Show abstract] [Hide abstract] ABSTRACT: Background The treatment of patients with dementia in acute care hospitals is becoming increasingly more important. The aim of this study was to investigate and demonstrate aspects of the healthcare situation and resource consumption of dementia patients during their hospital stay in a ward for internal medicine. Material and methods Secondary data from a ward of internal medicine were analyzed on a retrospective and case-related basis. For 100 patients a diagnosis of dementia by a general practitioner before hospitalization was identified. The control group was selected by age and sex from the other patients in the ward (n = 100). The costs were calculated on the basis of the German diagnosis-related groups (G-DRG) flat rate case classification. The relationship between dementia, deviation from the average length of stay and costs was investigated under the control of comorbidities using multivariate regression analysis. Results Patients with dementia had poorer health at admission with respect to functionality and orientation and a higher risk of falls and pressure ulcers. During hospitalization patients with dementia fell more frequently than patients without dementia (12 % versus 3 %, p = 0.029). Regarding the average length of stay, according to the G‑DRG catalogue patients with dementia stayed 1.4 days longer in hospital than patients without dementia and caused excess costs of 19 %. Conclusion Patients with dementia are a highly vulnerable patient group with a higher consumption of resources than patients without dementia. The results demonstrate the care-related and economic consequences, which the increasing number of patients with dementia could have in the future.
    Article · Apr 2016
  • [Show abstract] [Hide abstract] ABSTRACT: The Japanese government recently announced the 'Five-Year Plan for Promotion of Measures Against Dementia (Orange Plan)' to promote people with dementia living in their communities. To achieve this, it is imperative that patients hospitalized with behavioural and psychological symptoms of dementia (BPSD) are helped to return to their own homes. The aim of the present study was to identify predictors of home discharge among patients hospitalized for BPSD. A single-centre chart review study was conducted on consecutive patients hospitalized from home between April 2006 and March 2011 for the treatment of BPSD. The frequency of discharge back to home was examined in relation to a patient's active behavioural problems and demographics at the time of admission. Diagnoses of dementia were made on the basis of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, and consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy bodies. In all, 391 patients were enrolled in the study. Of these patients, 163 (42%) returned home. Multiple logistic regression analysis identified high Mini-Mental State Examination and Nishimura-style senile activities of daily living scores as significant independent predictors of home discharge. In contrast, living alone and manifestation of aggressiveness at the time of admission were negatively associated with home discharge. Few patients hospitalized for BPSD are discharged home, and this number is affected by a patient's clinical and demographic characteristics at the time of admission. These findings should be considered in designing and implementing optimal management and care strategies for patients with BPSD. © 2015 The Authors. Psychogeriatrics © 2015 Japanese Psychogeriatric Society.
    Article · Apr 2015