Could nursing home care be key to reducing avoidable emergency department visits among people dying with dementia?

Dr Lesley Williamson is a PhD Clinical Training Fellow at the Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King’s College London. She tweets @LEWilliamson19.

There are almost one million people living with dementia in the UK and most will visit the emergency department (ED) at least once in their last year of life. Most of you will be aware of the distress ED attendance can cause a person with dementia, and the associated risks. Fewer will know that the number of attendances increase with proximity to death for people with dementia, with a quarter of all ED attendances in the last year of life taking place in the last month of life.

There is high-strength evidence that living in a care home has a recognised ‘protective’ influence over ED visits in this population. New research published in Age and Ageing suggests that it may be the clinical continuity afforded by nursing support within care homes that offers greatest protection.

The study examined the health records of 74,486 people who died with dementia in England between 2018 and 2019, using Hospital Episode Statistics and Office of National Statistics civil registration of deaths data. It explored individual- and service-level factors associated with number of ED visits in the last year of life. The study found that living in a local authority with more nursing home beds was associated with fewer ED visits among people with dementia in their last year of life. In contrast, there was no association found between ED visits and the number of residential home beds. Although this may reflect area-level differences such as local funding and demographics, this new finding indicates the importance of community-based clinical continuity for people dying with dementia.

The study also found that higher socioeconomic position was also associated with fewer ED visits, while being of South Asian ethnicity and having chronic respiratory disease as the underlying cause of death were associated with more ED visits in the last year of life. These findings offer valuable insights for developing community models of care, with emphasis on meeting the social, cultural, and clinical needs of individuals with dementia.

Based on the findings of this new research, greater investment in nursing home bed capacity and enhanced community models of care could help to reduce the distress and detriment of visiting the ED for people dying with dementia, as well as helping to ease pressures in the emergency department.

The research team included Dr Lesley Williamson, Dr Javiera Leniz, Dr Emeka Chukwusa, Professor Catherine Evans and Professor Katherine Sleeman from the Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London. It was funded by the Alzheimer’s Society, Cicely Saunders International, The Atlantic Philanthropies and NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust.

Read the Age and Ageing paper 'A population-based retrospective cohort study of end-of-life emergency department visits by people with dementia: multilevel modelling of individual- and service-level factors using linked data'.