Summary
Dementia is a progressive and usually irreversible condition that is estimated to affect 850,000 Australians by 2058 (AIHW 2023a). People living with dementia tend to be high users of hospital and residential aged care services, particularly as their condition progresses. Understanding how people living with dementia access and transition between hospitals and residential aged care is needed to inform planning for current and future care needs and assess coordination of care. It is also essential to identify points along the care continuum that need improving.
This study is the first large-scale analysis to examine movements between residential aged care and hospital for Australians living with dementia who were aged 65 or older and hospitalised in 2017. Factors that influenced people’s length of stay and use of health services in the 12-months after discharge from their first hospitalisation for that year were also examined.
This study included nearly 79,000 people living with dementia and 630,000 people without dementia. At the time of their first hospitalisation, 3 in 5 people living with dementia (62%) and 97% of people without dementia were living in the community, with the remainder living in residential aged care.
1 in 4 people with dementia who were living in the community moved into aged care after a hospital stay.
By comparison, 1 in 50 people without dementia who were living in the community moved into residential aged care in the 7-days after being discharged from hospital.
People living with dementia were also more likely to move to residential aged care, and/or to die in the 12-months after a hospitalisation compared with people without dementia who were also hospitalised.
These findings were observed in all age groups (65–74, 75–84 and 85+) for both men and women, indicating that differences in age and sex between people living with dementia and people without dementia are not driving these differences in outcomes.
Greater consideration is needed on the co-ordination of care for people living with dementia, and how care needs will be met during and after hospital visits, particularly for those who are living in the community. Appropriate clinical handover notes to the person’s GP or residential aged care facility are also required. This is in line with Recommendation 66 from the Royal Commission into Aged Care Quality and Safety as well as Recommendation 54 from the Clinical Practice Guidelines and Principles of Care for People with Dementia (Royal Commission 2021, Guideline Adaptation Committee 2016).
See Transitions of care and mortality outcomes for more information.
People living with dementia who had potentially preventable complications in hospital were more likely to move into residential aged care
Community-dwellers living with dementia were more likely to experience potentially preventable complications during their hospital stay compared with aged care residents living with dementia. Complications include delirium, urinary tract infections, pneumonia, pressure injuries and in-hospital falls.
Within 7-days of being discharged from hospital, community-dwellers who experienced complications were more likely to transition into residential aged care, or die, compared with people living with dementia who did not experience a complication.
These findings appear to indicate that community-dwellers living with dementia who require hospital care are particularly vulnerable to complications in the hospital environment. This may be because community-dwellers living with dementia typically had longer hospital stays compared with aged care residents living with dementia. Alternatively, while these conditions were reported to arise during people’s hospitalisation, we cannot rule out the possibility that these conditions were present prior to the hospitalisation and were first identified during a hospital stay.
See Conditions reported during hospitalisation for more information.
People living with dementia who experienced a potentially preventable complication spent two to four weeks longer in hospital compared with people who did not develop a complication – resulting in thousands of additional hospital bed-days. People living with dementia who experienced a urinary tract infection, delirium or pneumonia in hospital had nearly 110,000 additional bed-days compared with people who did not experience these conditions.
Work is needed to make hospitals more dementia-friendly and to reduce the occurrence of potentially preventable complications. This will require a multi-disciplinary approach, including improvements to the environment, involvement of families or carers, education and leadership opportunities for staff, and structural changes to ensure the long-term sustainability of programs (Cahill et al. 2018).
See Effect of conditions reported during hospitalisation and aged-care characteristics on average length of stay for more information.
People who moved into aged care after their hospital stay spent 20-days longer in hospital than other older people
People living with dementia and people without dementia who moved from the community to residential aged care up to 7-days after their hospitalisations had the longest median length of hospital stays (24 days), about 20-days longer than people who returned to their usual residence in the community or in aged care (about 4-days).
See Median length of stay and effect of specific conditions for more information.
People awaiting entry to residential aged care or who moved to a new facility spent more time in hospital
Among people who moved to residential aged care, people who were reported to be ‘eligible and awaiting entry to residential aged care’ typically spent 13-days longer in hospital than people who did not receive this flag.
Aged care residents living with dementia and without dementia typically had the shortest lengths of hospital stay (4 days). Most aged care residents were able to return to the facility they lived in before their hospitalisation, but people who moved to a new residential aged care facility typically spent 30-days longer in hospital and had similar lengths of stay in hospital as people who newly transitioned to living in residential aged care.
Aged care residents who need to or want to move to a new residential aged care facility after a hospitalisation appear to face similar barriers to entering a new facility as people who are moving from the community to a residential aged care facility. These results highlight the need to better understand the hospital and aged care interface to improve the flow of people between these two systems.
See Median length of stay and effect of specific conditions for more information.
Using respite care to enter a new aged care facility reduced time spent in hospital
Among people living with dementia who transitioned to aged care after discharge from hospital, people who entered their new aged care facility as a respite resident spent 11-days less in hospital than people who entered as a permanent resident.
Using residential respite care before entering an aged care facility as a permanent resident is increasingly common (AIHW 2023b). However, many people face barriers to accessing residential respite care. Increasing the number of dementia-specific respite care places, as recommended by Carers Australia, should be considered to improve access to residential respite care by people living with dementia (Carers Australia 2016).
See Effect of conditions reported during hospitalisation and aged-care characteristics on average length of stay for more information.
People with dementia living in residential aged care were less likely to return to hospital than those in the community
In the 12-months after discharge from hospital, people who returned to live in the community after their first hospitalisation were more likely to have a subsequent emergency department presentation or hospitalisation compared with people who moved to residential aged care or who continued to live in residential aged care after their hospitalisation. These findings indicate that people living with dementia in the community may require additional health and personal support to ensure their needs are being met.
See Health services used in the year after first hospitalisation for people living with dementia for more information.
2 in 5 people with dementia did not have a chronic disease plan or review in the year after being discharged from hospital
Community-dwellers and aged care residents living with dementia who survived for 12-months after their first hospitalisation had similar rates of accessing GP consultations (95%) and chronic disease management services (around 55%). However, people who transitioned to live in residential aged care after their hospitalisation were more likely to have a medication management review (51%) compared with people who continued to live in aged care (33%) or the community (16%).
Given dementia is a chronic and progressive condition, people living with dementia would benefit from having medication management reviews and chronic disease management services. However, almost half of people living with dementia did not receive these in the 12-months after being discharged from hospital. Improving the provision and regular review of chronic disease management services and medication management reviews by health professionals is needed to ensure these services are appropriately provided to people living with dementia. This may be through greater education of dementia management among GPs and other health professionals as well as structural changes to ensure health professionals who deliver these services have the required tools and are appropriately funded.
See Health services used in the year after first hospitalisation for people living with dementia for more information.
Community-dwellers were more likely to die in hospital compared with aged care residents
Among people who died in the 12-months after discharge from hospital, most people who were living in the community at the time of their death died in hospital or the emergency department (79%) whereas most people who were aged care residents died in their aged care facility (71%). This was consistent for people living with dementia and people without dementia and for men and women of all age groups studied.
See Where were people living when they died? for more information.