Impact of home care on healthcare use after a first diagnosis of dementia in older adults living with severe mental illness

Context: Older adults with severe mental illness (SMI) who develop dementia are a particularly complex and understudied population with various healthcare needs.

Objective: To describe individual characteristics and healthcare use in older adults with SMI across home care services (HCS) profiles before and after the first dementia diagnosis.

Study Design and Analysis: Retrospective cohort study.

Dataset: Health administrative data from 380,124 Quebecers between 1996 and 2016.

Population Studied: Individuals living in the community aged 65 and older, diagnosed with SMI, who received a first dementia diagnosis between January 2013 and December 2015.

Outcome Measures: We considered demographic characteristics (age and sex) at the index date (date of the first dementia diagnosis) and medical characteristics (place of diagnosis, comorbidity, and continuity of care (COC) indices) two years before the index date. We considered healthcare use (HCS, physician consultations, hospitalizations, and emergency department [ED] visits) eight months prior and two years after the index date, as well as transfer to long-term care facility (LTCF) and death two years after the index date.

Results: A total of 3731 individuals were included, from which 53% received HCS before and after the index date (Group 1), 28% received HCS only after the index date (Group 2), and 19% did not receive any HCS (Group 3). Group 1 consisted of older individuals, mainly diagnosed in the hospital and with poorer COC. Group 2 was mainly diagnosed in primary care, while Group 3 included more men with better COC and more diagnoses in primary care. Healthcare use increased after the diagnosis in all groups, but more strikingly in Group 2, with the highest hospitalizations and duration of stays, ED visits, and specialists’ visits. Group 3 had the lowest proportions of hospitalizations and ED visits. Group 1 showed greater HCS use after the index date, both compared to itself before the diagnosis and to Group 2. Finally, Group 1 and 3 individuals had higher mortality and LTCF transfer rates.

Conclusions: This study highlights the impact of dementia diagnosis on healthcare use in older adults with SMI and suggests potential missed opportunities for intervention. Some individuals may have benefited from earlier or any HCS, as shown by the increase in hospitalizations and ED visits in Group 2 and the LTCF transfer and mortality rate in Group 3. Yet, late diagnoses and faster decline cannot be ruled out.