Strong interprofessional team helps ensure safe transitions and minimize adverse events, medication errors
Alzheimer disease (AD) is a degenerative brain disease and the most common cause of dementia. It is also the fifth leading cause of death in adults older than 65 years.1 More than 6 million Americans live with AD, which cost the US economy an estimated $321 billion in 2022. The cost is expected to increase to more than $1 trillion by 2050.2
Dementia is a syndrome with a group of symptoms and several causes. The characteristic symptoms of dementia include difficulties with memory, language, problem-solving, and other cognitive skills that affect one's ability to perform everyday activities.1 AD is considered a multifactorial disease, with 2 main hypotheses proposed as causes: cholinergic and amyloid hypotheses. Moreover, several risk factors, such as increasing age, genetic factors, head injuries, vascular diseases, infections, and environmental factors, play a role in the disease.3
Currently, there is no cure for AD. However, there are 2 classes of approved drugs to treat the disease, including inhibitors to cholinesterase enzyme and antagonists to N-methyl d-aspartate (NMDA), which are effective only in treating the symptoms of AD.4,5
Approximately 60% of older adults with AD or other dementias live in the community, and only 25% live alone. As their disease progresses, individuals with AD or other dementias generally receive more care from family members, unpaid caregivers, and community-based and residential care providers. Forty-two percent of residents in assisted living communities have AD or other dementias, and 61% of nursing home residents have moderate or severe cognitive impairment.6,7 Furthermore, by age 80, 75% of individuals with AD-related dementia are admitted to a nursing home, compared with only 4% of the general population.8
Dementia care practice recommendations were developed to define quality care across all care settings and throughout the disease course. These guidelines are intended for professional care providers working with individuals with dementia and their families in residential and community-based care settings.9 With the fundamentals of person-centered care as the foundation, the dementia care practice recommendations elucidate the goals of quality dementia care in several areas, including the following:
Practice recommendations for transitions of care (TOC) are provided by the dementia care practice guidelines, and they are the focus of this article.
Transitions of Care Challenges
Recent literature highlights that TOC are challenging for individuals with AD and often lead to adverse events, low satisfaction with care, and high rehospitalization rates.10 Indeed, older adults with dementia undergo more ToC than other populations of older adults due to impairments in communication and disorientation from being in a foreign environment.11
Educating and preparing individuals with dementia and their caregivers about TOC should be done before, during, and after transitions. Because family caregivers are integral to the care of individuals with dementia, providers must acknowledge their need for information about common transitions; this includes across care settings, such as from home to hospital or skilled nursing facility and from nursing home to emergency department, as well as within care settings.
Careful attention is critical to ensure a safe handoff during these transitions. Open communication (both written and verbal) among providers, across settings, and within organizations is essential to avoid poor outcomes often associated with TOC (eg, rehospitalizations, emergency department visits, and medication errors).12 Creating a strong interprofessional collaborative team to support the person with dementia throughout TOC is imperative. Furthermore, the goal of avoiding hospitalization or rehospitalization in this population can potentially prevent delirium and poor outcomes.
Care transitions are also associated with medication-related issues because patients with AD have complex medication regimens; this poses risks during multiple care transitions, especially as the disease progresses. Research suggests that 2.5% of patients have a medication-related adverse event after hospital discharge.13 Unintentional medication discrepancies, preventable adverse drug events, poor medication selection, lack of discharge summary, and supply problems have been identified in care transitions.13-15 These problems can be detrimental to patient safety and thus may lead to hospital readmissions.
Patients with AD are a vulnerable group, and specific dementia-friendly strategies for medication management are critical to ensure safe, high-quality transfer of care.13-15 A recent study in Australia explored medication processes in acute care episodes and care transitions for patients with dementia and the authors made recommendations to improve practices. The study data confirmed that medication management is suboptimal during care transitions and may compromise safety. The investigators suggested improvements such as increased involvement of pharmacists in care transitions; outreach or transitional health care professionals; modified planning for care transitions for individuals older than 80 years; coordinated electronic records; structured communication; and staff training.16
Pharmacists play key roles in care transitions in various ways, including taking medication history on admission, performing medication reconciliation,17 assisting with medication adherence, counseling upon discharge, and sharing information with community pharmacies. They also conduct postdischarge follow-ups such as telephone calls or visits.17
Older adults with dementia undergo more TOC than other populations of older adults, placing them at risk of adverse events, hospitalization, and rehospitalization. Improving communication across TOC, with a solid interprofessional team to support the person with dementia throughout these transitions, is imperative in mitigating poor outcomes. Medication management for patients with AD has also been shown to be suboptimal, but opportunities exist to improve medication processes in acute care and care transitions for AD.
About the Author
Deepali Dixit, PharmD, BCPS, BCCCP, FCCM, is a clinical associate professor at Ernest Mario School of Pharmacy at Rutgers, The State University of New Jersey, Piscataway, and a clinical pharmacy specialist in critical care at Robert Wood Johnson University Hospital in New Brunswick, New Jersey.
1. De-Paula VJ, Radanovic M, Diniz BS, Forlenza OV. Alzheimer’s disease. Subcell Biochem. 2012;65:329-352. doi:10.1007/978-94-007-5416-4_14
2. Wong W. Economic burden of Alzheimer disease and managed care considerations. Am J Manag Care. 2020;26(suppl 8):S177-S183. doi:10.37765/ajmc.2020.88482
3. Armstrong RA. Risk factors for Alzheimer’s disease. Folia Neuropathol. 2019;57(2):87-105. doi:10.5114/fn.2019.85929
4. Yiannopoulou KG, Papageorgiou SG. Current and future treatments in Alzheimer disease: an update. J Cent Nerv Syst Dis. 2020;12:1179573520907397. doi:10.1177/1179573520907397
5. Livingston G, Huntley J, Sommerlad A, et al. Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. Lancet. 2020;396(10248):413-446. doi:10.1016/S0140-6736(20)30367-6
6. Caffrey C, Sengupta M, Park-Lee E, Moss A, Rosenoff E, Harris-Kojetin L. NCHS Data Brief, No. 91, April 2012: Residents Living in Residential Care Facilities: United States, 2010. National Center for Health Statistics; 2012:1-8.
7. Zimmerman S, Sloane PD, Reed D. Dementia prevalence and care in assisted living. Health Aff (Millwood). 2014;33(4):658-666. doi:10.1377/hlthaff.2013.1255
8. Arrighi HM, Neumann PJ, Lieberburg IM, Townsend RJ. Lethality of Alzheimer disease and its impact on nursing home placement. Alzheimer Dis Assoc Disord. 2010;24(1):90-95. doi:10.1097/WAD.0b013e31819fe7d1
9. Fazio S, Pace D, Maslow K, Zimmerman S, Kallmyer B. Alzheimer’s Association dementia care practice recommendations. Gerontologist. 2018;58(suppl 1):S1-S9. doi:10.1093/geront/gnx182
10. Naylor M, Keating SA. Transitional care. Am J Nurs. 2008;108(suppl 9):58-63. doi:10.1097/01.NAJ.0000336420.34946.3a
11. Callahan CM, Tu W, Unroe KT, LaMantia MA, Stump TE, Clark DO. Transitions in care in a nationally representative sample of older Americans with dementia. J Am Geriatr Soc. 2015;63(8):1495-1502. doi:10.1111/jgs.13540
12. Deng Y, Bisset J, Lim S, Edwards M. Improving transitions in care for people with dementia: the CARED tool. Community Engaged Learning Final Projects. Western University. December 4, 2017. Accessed February 21, 2023. https://ir.lib.uwo.ca/se-ccel/5
13. Hirschman KB, Hodgson NA. Evidence-based interventions for transitions in care for individuals living with dementia. Gerontologist. 2018;58(suppl 1):S129-S140. doi:10.1093/geront/gnx152
14. Forster AJ, Murff HJ, Peterson JF, Gandhi TK, Bates DW. The incidence and severity of adverse events affecting patients after discharge from the hospital. Ann Intern Med. 2003;138(3):161-167. doi:10.7326/0003-4819-138-3-200302040-00007
15. Duggan C, Feldman R, Hough J, Bates I. Reducing adverse prescribing discrepancies following hospital discharge. Int J Pharm Pract. 1998;6(2):77-82. doi:10.1111/j.2042-7174.1998.tb00920.x
16. Deeks LS, Cooper GM, Draper B, Kurrle S, Gibson DM. Dementia, medication and transitions of care. Res Social Adm Pharm. 2016;12(3):450-460. doi:10.1016/j.sapharm.2015.07.002
17. Crotty M, Rowett D, Spurling L, Giles LC, Phillips PA. Does the addition of a pharmacist transition coordinator improve evidence-based medication management and health outcomes in older adults moving from the hospital to a long-term care facility? results of a randomized, controlled trial. Am J Geriatr Pharmacother. 2004;2(4):257-264. doi:10.1016/j.amjopharm.2005.01.001