Transitions in Care for Older Adults with and without Dementia
Open accessAbstract
Objectives: To describe transitions in care of persons with dementia with attention to nursing facility transitions. Design: Prospective cohort. Setting: Public health system. Participants: Four thousand one hundred ninety‐seven community‐dwelling older adults. Measurements: Participants’ electronic medical records were merged with M edicare claims, M edicaid claims, the M inimum Data Set ( MDS ), and the O utcome and A ssessment I nformation S et ( OASIS ) from 2001 to 2008 with a mean follow‐up of 5.2 years from the time of enrollment. Results: Older adults with prevalent (n = 524) or incident (n = 999) dementia had greater M edicare (44.7% vs 44.8% vs 11.4%, P < .001) and Medicaid (21.0% vs 16.8% vs 1.4%, P < .001) nursing facility use, greater hospital (76.2% vs 86.0% vs 51.2%, P < .001) and home health (55.7% vs 65.2% vs 27.3%, P < .001) use, more transitions in care per person‐year of follow‐up (2.6 vs 2.7 vs 1.4, P < .001), and more mean total transitions (11.2 vs 9.2 vs 3.8, P < .001) than those who were never diagnosed (n = 2,674). For the 1,523 participants with dementia, 74.5% of transitions to nursing facilities were transfers from hospitals. For transitions from nursing facilities, the conditional probability was 41.0% for a return home without home health care, 10.7% for home health care, and 39.8% for a hospital transfer. Of participants with dementia with a rehospitalization within 30 days, 45% had been discharged to nursing facilities from the index hospitalization. At time of death, 46% of participants with dementia were at home, 35% were in the hospital, and 19% were in a nursing facility. Conclusion: Individuals with dementia live and frequently die in community settings. Nursing facilities are part of a dynamic network of care characterized by frequent transitions.
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Hospital-to-SNF transitions are especially common among patients with dementia, since many already lived in a SNF and dementia raises the likelihood of discharge to a SNF compared with cognitively intact patients.
“For patients with dementia, transitions into a Skilled Nursing Facility (SNF) after hospitalization are particularly common given many are residing in a SNF prior to hospitalization (more than half of SNF patients have dementia) and compared to cognitively unimpaired persons, patients with dementia are more likely to be discharged to a SNF following hospitalization.3, 4”
From Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies during Hospital to Skilled Nursing Facility Transitions (2021) · cites this paper as [3]
The Results (transition probabilities and compound transitions; page not provided) document frequent hospital-to-nursing-facility transfers among patients with dementia. The Introduction says a majority of nursing-facility residents have dementia, but also says most patients with dementia live in the community. The paper shows greater overall nursing-facility use among patients with dementia, not a direct comparison of post-hospital discharge to a nursing facility with cognitively unimpaired patients; it does not establish that many patients with dementia already lived in a facility before hospitalization. (LLM, conf=0.85)
Experimental — accuracy not yet measuredPeople with dementia have disproportionately high use of acute and post-acute care, including hospitalizations, emergency department visits, 30-day re-hospitalizations, repeat emergency department visits, and post-acute care entry.
“Specifically, people with dementia experience disproportionately higher rates of acute and post-acute care utilization, including hospitalizations, emergency department visits, 30-day re-hospitalization events, repeat emergency department visits, and entry into post-acute care settings.3, 15–20”
From Discharge Communication of Dementia-Related Neuropsychiatric Symptoms and Care Management Strategies during Hospital to Skilled Nursing Facility Transitions (2021) · cites this paper as [3]
The Results sections on aggregate health care use and nursing facility use report more hospitalizations and nursing facility use among older adults with dementia than among those without dementia. The Results also report a 23% 30-day rehospitalization rate for those with dementia, but do not establish that this rate was disproportionately higher than in those without dementia. The passages do not report emergency department visits or repeat emergency department visits. Page numbers were not provided in our copy. (LLM, conf=0.87)
Experimental — accuracy not yet measuredIn the UK, people with dementia occupy one in four hospital beds and face heightened risks as they return home from hospital, often encountering adverse outcomes that compromise safety.
“In the United Kingdom (UK), people with dementia occupy one in four hospital beds and face heightened risks as they return home from hospital, often encountering adverse outcomes that compromise safety [1, 2].”
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 [2]
The Results report 30-day rehospitalizations after discharge home, and the Discussion says each care transition presents a risk of miscommunication or medical error. But the Methods place this cohort in Indianapolis, not the UK; the paper does not support the claim that people with dementia occupy one in four UK hospital beds. It describes safety risks rather than establishing that adverse safety outcomes often occur after discharge home. (LLM, conf=0.88)
Experimental — accuracy not yet measuredPrevious studies examining health service utilisation among persons with dementia have been inconsistent regarding the timing of healthcare utilisation increases, with some finding increases with time following diagnosis and others observing increases near the time of death.
“Previous studies examining health service utilisation among persons with dementia have been inconsistent regarding the timing of healthcare utilisation increases—with some finding that utilisation increases with time following diagnosis2 and others observing increases near the time of death.2 12 13 33”
From Trajectories of health system use and survival for community-dwelling persons with dementia: a cohort study (2020) · cites this paper as [2]
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredIn a longitudinal study of primary care patients with dementia, those discharged from a nursing facility were nearly equally likely to be discharged home (39%) as to a hospital (44%).
“In a longitudinal study of primary care patients with dementia, researchers found that individuals discharged from a nursing facility were nearly equally as likely to be discharged home (39%) as discharged to a hospital (44%).750”
From 2023 Alzheimer's disease facts and figures (2023) · cites this paper as [750]
Our findings are consistent with previous work that has demonstrated persons with dementia experience poorer survival and shorter time to long-term care transition than those without dementia, although the magnitude of the differences we show is not as large as in some previous work.
“Our findings are consistent with previous work that has demonstrated persons with dementia experience poorer survival2 26 and shorter time to long-term care transition than those without dementia,11 however the magnitude of the differences we show is not as large as in some previous work.”
From Trajectories of health system use and survival for community-dwelling persons with dementia: a cohort study (2020) · cites this paper as [2]
In a longitudinal study of primary care patients with dementia, individuals discharged from a nursing facility were nearly equally as likely to be discharged home (39%) as discharged to a hospital (44%).
“In a longitudinal study of primary care patients with dementia, researchers found that individuals discharged from a nursing facility were nearly equally as likely to be discharged home (39%) as discharged to a hospital (44%). 901”
From 2024 Alzheimer's disease facts and figures (2024) · cites this paper as [901]
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- Authors
- Callahan, C. M., Arling, G., Tu, W., Rosenman, M. B., Counsell, S. R., Stump, T. E., & Hendrie, H. C.
- Affiliations
- Regenstrief Institute (US)
- Indiana University Indianapolis (US)
- Corresponding author
- Callahan, Christopher M.
- ORCID
- Venue
- Journal of the American Geriatrics Society
- Publisher
- Wiley
- Published
- 2012-05
- Volume
- 60
- Issue
- 5
- Pages
- 813-820
- ISSN
- 0002-8614 (ISSN-L)
- 1532-5415
- PMC
- PMC3354737
- OpenAlex
- W2102016457
- Cited by
- 253
- References
- 47
- Citations by year
- 2026: 5 · 2025: 14 · 2024: 14 · 2023: 17 · 2022: 17 · 2021: 17 · 2020: 21 · 2019: 22 · 2018: 12 · 2017: 18 · 2016: 25 · 2015: 22 · 2014: 22 · 2013: 20 · 2012: 7
- FWCI
- 40.38
- Type
- journal article
- Language
- en
- Open access
- green
- europepmc.org
- Locations
- Journal of the American Geriatrics Society (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- IUScholarWorks (Indiana University) (submittedVersion)
- Funders
- National Institute on Aging (K24AG024078, R01AG031222)
- Topics
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Psychiatry and Mental health › Dementia and Cognitive Impairment Research
- Keywords
- dementia, care transitions, nursing facilities, older adults, hospital readmission, home health care, community-dwelling older adults, end-of-life care
- MeSH terms
- Aged, Alzheimer Disease, Dementia, Female, Health Services for the Aged, Homes for the Aged, Humans, Male, Nursing Homes, Prospective Studies
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