This study compared ED use among patients based on cognitive status as defined by rigorous neuropsychological testing in an existing cohort of patients. In both analyses, we did not find increased ED use in adults with worse cognition (cognitively intact to MCI to ADRD), though we were likely underpowered to detect a statistically significant difference. Our findings in this small but well-characterized group of patients support ED utilization estimates published in the literature. In our cohort, we found that the rate of ED use for patients with MCI was 37.1% greater than cognitively intact patients, which is in line with what has been previously reported [19], though few studies have looked at this population in particular. Previous studies comparing the proportion of ED visits among patients with and without ADRD have shown that patients with ADRD use the ED anywhere from 35%-49% more often than patients without ADRD [6, 7, 19, 20] while patients with MCI use the ED approximately 35% [19] more often than cognitively intact patients. Our results are within the range reported by those studies that have looked at patients with and without ADRD, suggesting patients with ADRD use the ED 48.5% more often than patients without ADRD.
Of note, our rates of ED use may have been reduced due to the health system’s participation in an ACO. Participants in ACOs with ADRD have reduced rates of preventable ED visits than those not participating in ACOs, potentially because they have systems in place to avoid ED care [21]. Additionally, it’s possible that these patients were less likely to require ED care than patients identified purely through administrative data because of their access to memory clinic resources. It will be important to replicate this study in other communities and populations with the presence of a truly negative control group, because using solely ICD codes in the health record can have highly variable reliability [9, 22], to further elucidate these trends.
We know that ED visits, many of which are preventable, can place undue burden on patients and their caregivers as well as the health care system. A trip to the ED can be a harbinger for potential problems in patients with ADRD, as this environment can often exacerbate underlying challenges and can be incredibly disorienting for the patient and their family [23,24,25,26]. Yet, older adults have disproportionately more preventable ED visits each year than their younger counterparts [27]. For patients with cognitive impairment, however, this disparity appears to be even larger. Although studies have shown that ED use increases during the last year of life for people with ADRD [28], little is known about ED use earlier in patients’ clinical course. These results suggest that patients with cognitive impairment, especially patients with ADRD, use the ED more frequently than cognitively intact patients, which puts them at risk for poor health outcomes and further decline.
If we are able to understand what brings these patients to the ED, we will be better equipped to develop alternative ways of delivering emergency care to this unique patient population and improving the ED experience for these patients. Within the older adult population, there are several factors that prompt patients and their caregivers to seek emergency care [29]. For those with ADRD in particular, several studies have suggested that both caregivers and primary care providers play an important role in the decision to use the ED [30, 31]. Caregivers of patients with ADRD and primary care providers who treat these patients often feel ill-equipped to properly manage their acute care needs, which could be contributing factors causing these patients to seek emergency care [30,31,32]. The ED, however, is seldom the best place to treat patients with ADRD. If we can better understand the needs of this patient and caregiver population, we can craft treatment mechanisms that address these factors, such as community paramedicine or tailored support from primary care, to help patients avoid the ED and potential poor outcomes associated with it.
When ED visits are unavoidable, care must be taken to tailor emergency care for ADRD patients. It is difficult for patients with cognitive impairment to cope with the noise and pace of care in the ED, which can overwhelm the patient and caregiver, leading to poor health outcomes and dissatisfaction with care [26]. Additionally, we know that general older ED patient adherence to discharge instructions, such as medication changes, is poor, [33] and additional barriers of cognitive impairment likely compound this problem, increasing the likelihood of return visits to the ED [34]. Staff expertise in caring for these patients and environmental factors can directly affect the ED experience for these patients, and modifications in these areas may improve these encounters [26]. It is critical to address these contextual factors to improve ED visits and outcomes for cognitively impaired patients.
Addressing the needs of this population will require additional work. First, examining how the ED workup and outcomes differ between patients with ADRD, MCI, and older adults who are cognitively intact could help identify risk factors or patterns for poor outcomes after an ED visit. Examining the rate of recidivism and care trajectories between groups after they leave the ED will help identify vulnerable points in the patient care timeline at which additional support may be beneficial. Finally, it is crucial to understand caregiver and physician perspectives regarding treatment and management of these patients so that interventions are tailored to the needs of the population.
Limitations
Our single center design may make the results less generalizable to the population as a whole, as our cohort of patients who received memory clinic evaluations is comprised predominantly of white, highly educated patients. Furthermore, we only captured ED use if patients visited an ED in our health system, thus if a patient sought care outside of our health system, we did not have a way of capturing that utilization. This suggests we potentially underestimated overall ED use; however the risk of this introducing bias into our analysis is low as we have no reason to suspect that cognitively intact patients seek care outside the health system at a different rate than patients with ADRD. We were also limited by the disproportionately low number of cognitively intact controls identified and included in this analysis, which greatly reduced the power of this study. Finally, given our retrospective chart review study design, we were unable to capture some potentially informative covariates; for example functional status, a critical issue for older adults and among individuals with ADRD, was not documented in the health record and depression testing results were not consistently documented.