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Association Between Caregiver Depression and Emergency Department Use Among Patients With Dementia

Educational Objective
To investigate whether caregiver depression is associated with emergency department (ED) use among patients with dementia.
1 Credit CME
Key Points

Question  Is caregiver depression associated with emergency department use among patients with dementia?

Findings  This cohort study of patients with dementia and their caregivers included 663 caregiver-patient dyads. A total of 84 caregivers had depression at baseline and the presence of caregiver depression was associated with a 73% increase in the rates of emergency department use among patients with dementia.

Meaning  Caregiver depression appears to be an important risk factor associated with increased health care use among community-dwelling individuals with dementia.

Abstract

Importance  Current attempts to gauge the acute care needs of patients with dementia have not effectively addressed the role of caregivers, despite their extensive involvement in decisions about acute care management.

Objective  To determine whether caregiver depression is associated with increased use of the emergency department (ED) among patients with dementia.

Design, Setting, and Participants  This longitudinal cohort study used data from the Care Ecosystem study, a randomized clinical trial examining telephone-based supportive care for patients with dementia and their caregivers. Patients were 45 years or older with any type of dementia. A total of 780 caregiver-patient dyads were enrolled from March 20, 2015, until February 28, 2017, and 663 dyads contributed baseline and 6-month data and were included in the analysis.

Exposures  Caregiver depression (9-item Patient Health Questionnaire score of ≥10). Secondary analyses examined caregiver burden and self-efficacy.

Main Outcomes and Measures  The primary outcome was the number of ED visits in a 6-month period.

Results  Among the 663 caregivers (467 women and 196 men; mean [SD] age, 64.9 [11.8] years), 84 caregivers (12.7%) had depression at baseline. The mean incidence rate of ED visits was 0.9 per person-year. Rates of ED presentation were higher among dyads whose caregiver did vs did not have depression (1.5 vs 0.8 ED visits per person-year). In a Poisson regression model adjusting for patient age, sex, severity of dementia, number of comorbidities, and baseline ED use, as well as caregiver age and sex, caregiver depression continued to be associated with ED use, with a 73% increase in rates of ED use among dyads with caregivers with depression (adjusted incident rate ratio, 1.73; 95% CI, 1.30-2.30). Caregiver burden was associated with higher ED use in the unadjusted model, but this association did not reach statistical significance after adjustment (incident rate ratio, 1.19; 95% CI, 0.93-1.52). Caregiver self-efficacy was inversely proportional to the number of ED visits in the unadjusted and adjusted models (adjusted incident rate ratio, 0.96; 95% CI, 0.92-0.99).

Conclusions and Relevance  Among patients with dementia, caregiver depression appears to be significantly associated with increased ED use, revealing a key caregiver vulnerability, which, if addressed with patient- and caregiver-centered dementia care, could improve health outcomes and lower costs for this high-risk population.

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Article Information

Accepted for Publication: May 3, 2019.

Corresponding Author: Elan L. Guterman, MD, Department of Neurology, University of California San Francisco, 505 Parnassus Ave, M798 Box 0114, San Francisco, CA 94143 (elan.guterman@ucsf.edu).

Published Online: July 8, 2019. doi:10.1001/jamaneurol.2019.1820

Author Contributions: Dr Guterman had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Guterman, Possin.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Guterman, Possin.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Guterman, Allen, Possin.

Obtained funding: Bonasera, Possin.

Administrative, technical, or material support: Josephson, Merrilees, Dulaney, Lee, Bonasera, Possin.

Supervision: Allen, Josephson, Chiong, Bonasera, Miller, Possin.

Conflict of Interest Disclosures: Drs Allen, Merrilees, Chiong, Lee, Bonasera, and Possin and Ms Dulaney reported receiving grant 1C1CMS331346 from the Department of Health and Human Services Centers for Medicare & Medicaid Services. Drs Allen, Merrilees, Chiong, Bonasera, and Possin and Ms Dulaney reported receiving grant 5R01AG056715 from the National Institute on Aging. Drs Merrilees, Chiong, and Possin reported receiving funding from the Administration for Community Living. Drs Allen, Merrilees, Chiong, and Possin and Ms Dulaney reported receiving funding from the Global Brain Health Institute. Dr Guterman reported receiving grants from the Department of Health and Human Services Centers for Medicare & Medicaid Services, the National Institute on Aging, the Administration for Community Living, and Global Brain Health Institute during the conduct of the study. Dr Josephson reported serving as Associate Editor for Continuum Audio. Dr Merrilees reported receiving grants from the Centers for Medicare & Medicaid Services during the conduct of the study. Dr Chiong reported receiving grants from the Centers for Medicare & Medicaid Services during the conduct of the study. Dr Miller reported receiving grants from the National Institutes of Health/National Institute on Aging outside the submitted work; serving as Medical Director for the John Douglas French Foundation, Scientific Director for the Tau Consortium, Director/Medical Advisory Board of the Larry L. Hillblom Foundation, and Past President of the International Society of Frontotemporal Dementia. Dr Possin reported receiving grants from the Centers for Medicare & Medicaid Innovation and the National Institute on Aging during the conduct of the study; and receiving grants from Cornell University, the Bluefield Project to Cure Frontotemporal Dementia, and the Quest Diagnostics outside the submitted work. No other disclosures were reported.

Funding/Support: This project was funded by grant 1C1CMS331346 from the Department of Health and Human Services Centers for Medicare & Medicaid Services, grant 5R01AG056715 from the National Institute on Aging, the Administration for Community Living, and the Global Brain Health Institute.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimers: Dr Josephson is Editor of JAMA Neurology, but was not involved in the editorial evaluation or decision to accept this article for publication. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the US Department of Health and Human Services or any of its agencies.

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