Chris Callahan, MDAt the American Geriatrics Society meeting a few weeks ago, I—along with most of the attendees—was spellbound by Dr. Diane Meier's Henderson Award lecture on the issues confronting geriatrics and palliative care and our profound failure to deliver useful care to those with incurable serious illnesses.
One of the pieces of evidence for her arguments that I had somehow missed was a paper by Beeson Scholar alumnus Dr. Chris Callahan and colleagues at Indiana University entitled, "Transitions in Care for Older Adults with and without Dementia."
At this point, most people understand that long-term care services for people with dementia are enormously expensive, including paid caregivers and institutions compounded by the true costs of family caregiving. (Ken Langa at the University of Michigan, another Beeson scholar, recently produced new independent estimates of the costs of family caregiving.)
However, it seems to me that the increased medical services used by older adults with dementia are less well understood and their implications under appreciated. Dr. Callahan and his colleagues showed that cognitively impaired people are more likely to have other chronic diseases and much more likely to wind up in hospitals and bounce around the health care system.
They looked at rates of hospitalization among those with long-standing dementia, newly diagnosed dementia, or no dementia and found annual rates of hospitalization of 76.2 percent, 86.0 percent, and 51.2 percent, respectively. Similarly, people with dementia had more transitions in the setting of their care in a year: 2.6 (prevalent dementia), 2.7 (incident diagnosis), versus 1.4 without dementia. They particularly noted that of those discharged from nursing homes (probably for short-stay, post-acute services), 41 percent returned home without home health care.
Hospitalization may be what these older adults need to treat their other medical conditions. But given the disruption and suffering these trips to the hospital represent for a person with dementia, surely more can be done to help those who truly can't help themselves. The results also reminded me strongly of Elizabeth Phalen's finding published in JAMA last year that showed increased risk of hospitalization with the onset of dementia, controlling for the burden of co-morbid conditions and other variables. Our health care system as it is currently designed is really failing to meet the needs of these vulnerable people and tolerating needless harm and suffering for them and their families.
Fortunately, there does seem to be a better way. I was privileged to moderate a session later in the meeting featuring work at Indiana and UCLA addressing the fragmentation in care of older people with dementia and producing very promising early results. Malaz Boustani, MD, another Beeson scholar from Indiana, described his Aging Brain Care Centers, which provide care coordinators and evidence-based protocols for addressing both dementia and depression. Discussing the UCLA Alzheimer's and Dementia Care Program, which is adapted to the environment of West Los Angeles, were Zaldy Tan, MD, the program’s medical director, and David Reuben, MD, UCLA's division chief of geriatrics and 2012 Henderson Award winner.
These programs are notable in that they are both winners in the first round of the Center for Medicare and Medicaid Innovation's (CMMI) Innovation Challenge grant program. Under that program, grantees were essentially given start-up capital to implement and scale up models with evidence to support the potential for reducing total health care spending in a relatively short period of time. (For more on the first round winners, including a video featuring Dr. Reuben, read the Health AGEnda post Basking in Reflective Glory.)
A second round was just announced last week—including specific interest in innovations for special populations such as those with dementia. The implicit promise of this CMMI work is that if the models do indeed work, the Centers for Medicare and Medicaid Services would be able to create a new Medicare benefit to enable the models to spread nationally.
The paradox of U.S. health care is that, while it does so much incredibly well, when it can't fix or cure someone, it acts as if nothing can be done. Nothing is further from the truth. We can't cure Alzheimer's disease yet, but we already can improve the lives of people with the disease, reduce the burden on their caregivers, and decrease unnecessary spending that can be redirected to other pressing needs.
I can't wait for the next round of results.