Distress Associated with Dementia-Related Psychosis and Agitation in Relation to Healthcare Utilization and Costs

https://doi.org/10.1016/j.jagp.2017.02.025Get rights and content

Objectives

Explore the relationship between behavioral and psychological symptoms of dementia (BPSD; specifically, delusions, hallucinations, and agitation/aggression) and associated caregiver distress with emergency department (ED) utilization, inpatient hospitalization, and expenditures for direct medical care.

Design/Setting/Participants

Retrospective cross-sectional cohort of participants with dementia (N = 332) and informants from the Aging, Demographics, and Memory Study, a nationally representative survey of U.S. adults >70 years old.

Measurements

BPSD of interest and associated informant distress (trichotomized as none/low/high) were assessed using the Neuropsychiatric Inventory (NPI). Outcomes were determined from one year of Medicare claims and examined according to presence of BPSD and associated informant distress, adjusting for participant demographics, dementia severity, and comorbidity.

Results

Fifty-eight (15%) participants with dementia had clinically significant delusions, hallucinations, or agitation/aggression. ED visits, inpatient admissions, and costs were not significantly higher among the group with significant BPSD. In fully adjusted models, a high level of informant distress was associated with all outcomes: ED visit incident rate ratio (IRR) 3.03 (95% CI: 1.98–4.63; p < 0.001), hospitalization IRR 2.78 (95% CI: 1.73–4.46; p < 0.001), and relative cost ratio 2.00 (95% CI: 1.12–3.59; p = 0.02).

Conclusions

A high level of informant distress related to participant BPSD, rather than the symptoms themselves, was associated with increased healthcare utilization and costs. Effectively identifying, educating, and supporting distressed caregivers may help reduce excess healthcare utilization for the growing number of older adults with dementia.

Section snippets

Data Sources

The ADAMS sample was drawn from the larger Health and Retirement Study, an ongoing, nationally representative cohort of individuals aged over 50 years that began in 1992. ADAMS was designed to provide nationally representative data on the antecedents, prevalence, outcomes, and costs of dementia and began with a stratified random subsample of 1,770 individuals selected from HRS respondents older than 70 years who completed the 2000 or 2002 HRS wave.19 Of those HRS respondents selected for

Results

Characteristics of ADAMS participants with dementia are presented in Table 1. In the sample, 58 participants (15.0%) had significant BPSD (hereafter, “significant BPSD” will refer specifically to presence of clinically significant symptoms in the NPI domains of psychosis [delusions and/or hallucinations] or agitation). Overall, this group had more impaired cognition and more severe dementia than the group without significant BPSD. The group with significant BPSD had a higher total NPI score

Conclusions

Using the only nationally representative sample of patients with dementia in the U.S., which we have linked with Medicare claims, our main finding is that informant distress related to psychosis or agitation in persons with dementia is associated with increased ED utilization, inpatient hospitalization, and Medicare expenditures. Contrary to our hypothesis, the NPS burden among ADAMS participants was not independently associated with utilization or cost in either unadjusted or adjusted models,

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