2023 HSR&D/QUERI National Conference

1173 — Patterns of emergency department visits for Veterans with and without dementia or cognitive impairment: An opportunity for dementia detection?

Lead/Presenter: Ula Hwang,  James J. Peters VAMC, Bronx, NY
All Authors: Hwang UY (GRECC, James J. Peters VAMC), Runels T (COIN, VA Connecticut Healthcare System), Goulet JL (COIN, VA Connecticut Healthcare System), Augustine MR (GRECC, James J. Peters VAMC), Brandt CA (COIN, VA Connecticut Healthcare System), Hastings SN (COIN, Durham VAMC), Hung WW (GRECC, James J. Peters VAMC), Ragsdale L (Durham VAMC), Sullivan JL (COIN, Providence VAMC), Zhu CW (GRECC, James J. Peters VAMC).

There is growing use of VA emergency departments (EDs) by older Veterans, with many having undiagnosed cognitive impairment (CI). The under-recognition of CI has implications on the ED care and safety of older Veterans. Those with CI have poorer outcomes compared to those cognitively intact. These include developing delirium, poorer comprehension of ED discharge diagnoses and instructions, and returning to the ED within 30 days (double those without CI). Understanding the prevalence of older Veterans with CI presenting to the ED, and incidence of those with undiagnosed CI and Alzheimer’s Disease and Related Dementias (ADRD) can improve recognition and care for this at-risk population. The objective of this study is to evaluate patterns of VA ED visits in older Veterans during the 1 year before and after an initial dementia or mild cognitive impairment (MCI) diagnoses and compare these to Veterans with no CI diagnoses.

We used a retrospective cohort of Veterans 65+ years in age with national VA utilization between 2008-2020. Using ICD 9/10 codes from Centers for Medicare and Medicaid Chronic Conditions Warehouse, we identified Veterans with at least 2 ADRD or MCI diagnoses, flagged the first date of diagnosis, and compared them to Veterans with no ADRD or MCI diagnoses during the entire 12-year period. We reviewed for ED stop codes in the Corporate Data Warehouse to indicate VA ED encounters, and extracted Veteran demographics and ED visit data (dates and times of arrival, presenting ED visit chief complaints). ED complaints were organized into 21 categories. Descriptive analyses were completed comparing those with and without dementia or MCI diagnoses.

From 2008-2020, there were over 2.4 million(M) veterans 65+ years in age: 12% had a dementia or MCI ICD9/10 diagnoses during that period; 74% were White, 7% Black, 4% Hispanic, mean Charlson Index score was 1.2 (sd 1.7). Twenty-four percent of these Veterans (n = 576,123) made over 2.8M ED visits. Those with dementia or MCI made 29% of all ED visits during this period. There was a significant increase in ED visits during the 6-12 months prior to first dementia diagnosis: 9% had their first dementia diagnoses < 6 months after an ED visit, 11% < 12 months after an ED Visit. We found differences in ED chief complaints: those with dementia were more likely to present with complaints related to Fall, Altered Mental Status, and Fatigue. Those without dementia were more likely to present with pain related chief complaints.

Although 1 in 10 older Veterans have dementia or MCI diagnoses, this group disproportionately made more ED visits (1 out of 3 by Veterans with dementia). The ED visit frequency increase occurred in the months prior to first dementia or CI diagnoses. The ED visit presentations were different for patients with dementia versus without dementia or CI.

The increased frequency and different ED chief complaints that older Veterans with undiagnosed dementia or CI present with is an opportunity to improve detection and care for this at-risk group of Veterans.