Projecting the future of inpatient dementia

It'd be hard to walk into a hospital today, let alone practice in one, without noticing that a large number of inpatients are over age 85 and have dementia. To be precise, there were 1.2 million hospitalizations of such patients in 2008.

If that sounds like a lot, just wait. A recent analysis concluded that by 2050, the annual number of dementia-associated hospitalizations of patients older than 85 could surpass seven million. Even by the researchers' most conservative estimates, which took year 2000 statistics and increased them only for population growth, the number would be more than three million.

Photo courtesy of Dr Zilberberg
Photo courtesy of Dr. Zilberberg.

The researchers, who published these calculations in the Nov. 14, 2011 Archives of Internal Medicine, described the numbers as “alarming” and noted that “without planning, the growth in hospitalizations may well overwhelm a health care system already under strain.” For further analysis, and a perspective on how hospitalists fit into this picture, ACP Hospitalist recently spoke to lead author Marya D. Zilberberg, MD, MPH, a critical care specialist and CEO of EviMed Research Group.

Q: What motivated this research?

A: I spend my time as a health services researcher. One of my interests is the growing volume of patients on mechanical ventilation in the intensive care unit. What we've shown over the last five years or so is that there's been an unsustainable growth in these patients. How do we limit care that may be seen as futile or unnecessary or suboptimal? Particularly in the intensive care unit, how do we quantify that? How do we express that? How do we communicate it? This project really came out of that. It was a preliminary, very crude look at what is happening with dementia hospitalizations. We know that patients with terminal dementia do not benefit from being hospitalized. In fact, there is plenty of work that indicates that a lot of it is not only futile, but may actually be hurtful to the patient and the family—uncomfortable, inconvenient, etc.

Q: What did you think of the results you found?

A: To me, the results are shocking, just based on the large number. But really, they are not surprising if you understand the population dynamics and disease dynamics in our society. Do I think that the seven million that we predicted potentially for 2050 is sustainable? Absolutely not. Something needs to change. That's why we do these estimates. We try to call out saying, ‘OK, the older population is growing. These are the diseases that we're going to be seeing. How do we provide for this for the future?’

Q: Do you think hospitals are preparing for this future need?

A: My impression, just from reading the literature and understanding some of the concerns that hospitals experience these days, is they are very much focused on the present situation. There's so much happening in hospitals with increased scrutiny on quote/unquote “quality” (whatever that means), the health IT infrastructure, the reduced reimbursement rates. I think that they have a lot of present-day concerns that aren't necessarily leaving enough bandwidth to address what's happening in the future.

Honestly, I'm not sure that hospitals are the only ones that need to be worrying about this. It's really the broader policymaker community that needs to hear these numbers and really start thinking about it.

Q: What should they be thinking about doing?

A: There are a few things that need to be done. First of all, I think we need better numbers. These are very crude estimates. What we need are really better estimates of a) where we can trim back on what might be considered futile care and b) where care is not futile, how can we deliver care more efficiently? Perhaps [the answer is] not in an acute hospital environment. Perhaps there are other structures that we need to explore—some intermediate care facilities, etc.

Q: What's the role of hospitalists in all this?

A: By the time the patient comes into the hospital and the hospitalist assumes the care of the patient, the horse is a little bit out of the barn. We know that discussions about advance directives don't happen very much in the community. Again, there is plenty of literature to suggest this specifically in dementia. Families, when they understand the implication of a prognosis, are much more likely to drive the decision process in a more sensible way. A lot of our problems arise just from the lack of communication, and I think that's where hospitalists can do a lot of good. Talk to the patients. Talk to the family. Opening the communication is by far the most important thing.