Research in hospital discharge procedures addresses gaps in care continuity in the community, but leaves gaping holes for people with dementia: A review of the literature: Deficient dementia patient discharge
Abstract
AIM: To examine the literature on the impact of the discharge experience of patients with dementia and their continuity of care. METHODS: Peer-reviewed and grey literature published in the English language between 1995 and 2014 were systematically searched using Medline, CINAHL, PubMed, PsycINFO and Cochrane library databases, using a combination of the search terms Dementia, Caregivers, Integrated Health Care Systems, Managed Care, Patient Discharge. Also reviewed were Department of Health and Ageing and Alzheimer's Australia research reports between 2000 and 2014. RESULTS: The review found a wide range of studies that raise concerns in relation to the quality of care provided to people with dementia during hospital discharge and in transitional care. CONCLUSION: Discharge planning and transitional care for patients with dementia are not adequate and are likely to lead to readmission and other poor health outcomes.
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Healthcare professionals responsible for discharge planning are more likely to learn 'on the job' and training programmes often lack follow-up over time, limiting sustained improvements.
“Research has also found that HCPs responsible for discharge planning are more likely to learn ‘on the job’ and training programmes often lack follow-up over time, limiting sustained improvements [102, 107, 108].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [102]
Hospital discharge procedures do not support the higher levels of coordination, communication and consultation required in complex discharge planning, leaving service gaps for those with dementia.
“This has been reflected in the wider research, which suggests that hospital discharge procedures do not support the higher levels of coordination, communication and consultation required in complex discharge planning, leaving service gaps for those with dementia [102].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [102]
Hospital discharge is a vulnerable stage in the patient pathway.
“Hospital discharge has been reported to be a vulnerable stage in the patient pathway”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [32]
Communication failures across transitions of care contribute to preventable medication-related problems.
“communication failures across transitions of care contribute to preventable medication-related problems. 25,30 -32”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [32]
Caregivers experience significant burden in medication management at transition from the hospital to the home.
“Caregivers are reported to experience significant burden in medication management at transition from the hospital to the home. 32,41”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [32]
Caregivers of people living with dementia receive limited information at discharge to support them in their medication management roles.
“studies report caregivers of people living with dementia receive limited information at discharge to support them in their medication management roles. 32,39”
From Interventions at Hospital Discharge to Guide Caregivers in Medication Management for People Living with Dementia: a Systematic Review (2021) · cites this paper as [32]
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Evidence-Based Interventions for Transitions in Care for Individuals Living With Dementia
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“Caregivers are reported to experience significant burden in medication management at transition from the hospital to the home.(32,41) There is a need for future studies to select appropriate and clinically meaningful measures reporting on medication management measures and patient and caregiver health outcomes.”
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“This has been reflected in the wider research, which suggests that hospital discharge procedures do not support the higher levels of coordination, communication and consultation required in complex discharge planning, leaving service gaps for those with dementia [102].”
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- Authors
- Chenoweth, L., Kable, A., & Pond, D.
- Affiliations
- University of Technology Sydney (AU)
- University of Newcastle Australia (AU)
- Corresponding author
- Chenoweth, Lynn
- Venue
- Australasian Journal on Ageing
- Publisher
- Wiley
- Published
- 2015-03
- Volume
- 34
- Issue
- 1
- Pages
- 9-14
- ISSN
- 0726-4240 (ISSN-L)
- 1440-6381
- OpenAlex
- W1797004534
- Cited by
- 53
- References
- 45
- Citations by year
- 2026: 1 · 2025: 7 · 2024: 2 · 2023: 3 · 2021: 11 · 2020: 6 · 2019: 7 · 2018: 7 · 2017: 7 · 2016: 1 · 2015: 1
- FWCI
- 1.25
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Australian Journal on Ageing (publishedVersion)
- PubMed (publishedVersion)
- NOVA (University of Newcastle Australia) (acceptedVersion)
- Funders
- Dementia Collaborative Research Centre ABC
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Keywords
- dementia, hospital discharge, care transitions, continuity of care, discharge planning, hospital readmission, quality of care, caregivers, integrated health system, managed care
- MeSH terms
- Transitional Care, Age Factors, Aged, Aged, 80 and over, Aging, Community Health Services, Dementia, Health Services for the Aged, Humans, Patient Discharge, Patient Readmission, Risk Factors, Delivery of Health Care, Integrated, Quality Indicators, Health Care
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