“People with dementia experience more than three times the hospitalizations of older adults without cognitive impairment,” Liron Sinvani, MD, explains. “The acute illness, and the unknown and complicated hospital setting, result in behavioral symptoms that concern family members and cause challenges for hospital team members attempting to provide medical care.”

Behavioral and psychological symptoms, which occur in as many as three-quarters of hospitalized patients with dementia, may have different causes, according to Dr. Sinvani.

“Symptoms can result from factors associated with the patient (unmet pain needs, fear, nutrition, toileting), the hospital caregiver (stress, lack of dementia knowledge, communication issues), and the environment (lack of activity and structure),” she says. “In addition to behavioral and psychological symptoms of dementia, behavioral symptoms in hospitalized patients with dementia can develop as the result superimposed delirium. Delirium, an acute confessional state of inattention and global cognitive dysfunction, is a frequent, devastating, and costly syndrome that develops in more than 50% of hospitalized patients with dementia that can result in hyperactive and hypoactive behaviors.”

Dr. Sinvani notes that, regardless of etiology, these symptoms are often treated with physical and/or chemical restraints, which have been associated with more adverse events, or necessitate constant observation, which leads to significant resource utilization. However, while there is a considerable risk for behavioral symptoms in this group, “there is a lack of studies assessing these behaviors,” she says.

For a study published in the Journal of Hospital Medicine, Dr. Sinvani and colleagues examined clinical practices and outcomes associated with behavioral symptoms in 8,637 patients with dementia (average age, 84.5; 61.7% female) who were hospitalized at one of seven hospitals in a 1-year period. They used multivariable logistic/
linear regression to examine the association between behavioral symptoms and clinical outcomes, including mortality.

Behavioral Symptoms Common & Associated With Hospital Practices

“We found that almost half of hospitalized people with dementia, or 40.6%, displayed behavioral symptoms,” Dr. Sinvani notes. “In addition to patient characteristics (eg, male sex and White race), our findings show that hospital practices were significantly associated with behavioral symptoms.”

Specifically, behavioral symptoms occurred more often in patients admitted to the medicine service (vs surgical service), those with indwelling bladder catheters, dietary restrictions, fall risk, bed alarms, chair alarms, do not resuscitate orders, ICU stays, and invasive mechanical ventilation (Table).

“The key takeaways are that common hospital practices that we sometimes think of as protecting the patient (eg, bed alarms) may be associated with behavioral symptoms in hospitalized older adults with dementia,” Dr. Sinvani says. “While associations do not prove causality, it has been established that these practices result in immobility and malnutrition, which are significant risk factors for delirium.”

Addressing Unmet Needs as Number of Elderly Adults Increases

While the findings are “not surprising,” according to Dr. Sinvani, they add to evidence of the contribution of these factors to worse outcomes among people with dementia, as well as the need for better hospital care. “Behavioral symptoms are difficult to cope with, impact patient safety, upset family members, and disturb medical care,” she explains. “We showed that nearly 75% of behavioral symptoms were managed with physical and chemical restraints, as well as the use of constant observation or sitters.”

However, both approaches are linked with adverse outcomes. “The use of antipsychotics to treat behavioral symptoms in dementia has a black box warning for heightened morbidity and mortality, and benzodiazepines have been established as a cause of adverse events in older adults,” she says. “Constant observation, which conventionally was employed for those at risk for harm to self or others, has significantly increased in the management of older adults with behavioral symptoms. In addition to untenable costs, constant observation by staff with no training in dementia care leads to poor patient outcomes. Given the association between behavioral symptoms and poor clinical outcomes, there is an urgent need to identify this and improve the provision of care.”

As the number of older adults continues to rise, so too will the number of people with dementia who are hospitalized and at risk for developing behavioral symptoms, Dr. Sinvani notes.

“Novel models of care, including acute care of elderly units, dementia units, the Hospital Elder Life Program, and the Nurses Improving Care for Health System Elders, as well as focused nonpharmacological strategies (eg, music therapy and diversionary activities) have shown some success, but are underutilized and understudied,” she says. “There exists a critical need to examine innovative strategies to improve the provision of care for this vulnerable population.”