The study includes a total of 18,713 individuals (5878 PWD and 12,837 PWOD). Figure 1 shows a flow chart of the allocation and case numbers in the disease groups for PWD and PWOD. In each disease group, PWOD make up at least 60% of the persons assigned to it and PWD less than 40%.
Table 1 shows the baseline characteristics of the study population. During the 10-year follow up, the median length of observation was 11.9 quarters for PWD and 15.6 quarters for PWOD. Overall, 63.8% (n = 11,941) of the individuals in both groups were female. PWD were on average two years older than PWOD at 81.7 years. For the distribution of levels of care, both groups showed the highest proportions for care level 1 (65.6%, n = 3854 PWD and 75.7%, n = 9721 PWOD) while 30.0% of PWD (n = 1762) and 21.0% of PWOD (n = 2694) were assigned to care level 2. Both groups included small proportions of individuals without a care level who had been downgraded in the observation period after being classified as initially needing care in 2006. On average, almost equal proportions of individuals in both groups lived alone (43.0% PWD versus 43.4% PWOD). The mean number of cognitive impairments (sum of documented anomalies in orientation, drive/motivation, mood, memory, day-night rhythm, perception and thinking, communication/language, situational adaptation, and participation in social aspects of life) was 4.9 for PWD and 2.3 for PWOD. The mean number of functional impairments was similar in both groups. PWOD were prescribed an average of 7.2 different medications compared with 6.4 different medications for PWD, and the proportion of individuals receiving a medication potentially inappropriate for the elderly was 3.4 percentage points higher for PWOD than for PWD, at 32.9%. Selected chronic disease diagnoses also showed similar distributions between the two groups. Differences of 5% or more are evident for the proportion of individuals with COPD (20.2% PWOD versus 14.7% PWD) and depression (28.9% PWD versus 23.4% PWOD). Additional file 2 shows the distribution of QI measures in the baseline quarter, which predominantly showed similar values for PWD and PWOD.
Table 1
Baseline characteristics, 2007, 1st quarter. Absolute and relative frequencies unless otherwise indicated.
| People with dementia (n = 5876) | People without dementia (n = 12,837) | Total (n = 18,713) |
Time under risk in quarters, mean, (SD) | 11.9 (10.8) | 15.6 (12.7) | 14.4 (12.3) |
Age in years, mean, (SD) | 81.7 (6.9) | 79.6 (7.3) | 80.3 (7.3) |
Female gender | 3762 (64.0) | 8179 (63.7) | 11,941 (63.8) |
Level of care none I II III | 31 (0.5) 3854 (65.6) 1762 (30.0) 229 (3.9) | 110 (0.9) 9721 (75.7) 2694 (21.0) 312 (2.4) | 141 (0.8) 13,575 (72.5) 4456 (23.8) 541 (2.9) |
Social network Living alone | 2524 (43.0) | 5565 (43.4) | 8089 (43.2) |
Number of cognitive impairments, mean (SD) | 4.9 (3.4) | 2.3 (2.9) | 3.2 (3.3) |
Number of functional impairments, mean (SD) | 3.6 (0.8) | 3.5 (0.8) | 3.5 (0.8) |
Number of prescribed medications, mean (SD) | 6.4 (3.5) | 7.2 (3.9) | 6.9 (3.8) |
Individuals with potentially inappropriate medication in the elderly | 1735 (29.5) | 4217 (32.9) | 5952 (31.8) |
Diagnoses Asthma COPD Hypertension Heart failure Coronary heart disease Diabetes mellitus type 2 Osteoarthritis Osteoporosis Depression | 31 (0.5) 864 (14.7) 5271 (89.7) 436 (7.4) 2552 (43.4) 3616 (61.5) 1940 (33.0) 908 (15.5) 1699 (28.9) | 118 (0.9) 2591 (20.2) 11,699 (91.1) 1050 (8.2) 5944 (46.3) 8337 (65.0) 4729 (36.8) 2141 (16.7) 3004 (23.4) | 149 (0.8) 3455 (18.5) 16,970 (90.7) 1486 (7.9) 8496 (45.4) 11,953 (63.9) 6669 (35.6) 3049 (16.3) 4703 (25.1) |
SD Standard Deviation, COPD chronic obstructive pulmonary disease |
During the observation period, a total of 2120 (36.0%) PWD and 3010 (23.4%) PWOD were admitted to a nursing home. The numbers of NHA per disease group as well as the average time in quarters between the onset of care-dependency and the NHA event are shown in Table 2. The highest proportions of NHA among all individuals in the corresponding group occurred for PWD for the disease group hypertension and depression (39.1%, n = 482) and for PWOD for the disease group hypertension, diabetes and depression (28.2%, n = 320). In all disease groups, PWD spent an average of about two years (8 quarters) in their own home after the onset of care-dependency before NHA occurred. PWOD spent between 8.1 quarters (disease group hypertension, diabetes, and heart failure) and 13.5 quarters (disease group hypertension and depression) in their own homes before NHA.
Table 2
Number of NHA and average duration until NHA by disease group.
Disease group | People with dementia | People without dementia | Total |
Hypertension and diabetes |
Number of participants in group | 2732 | 6.314 | 9.046 |
Number of NHAs (% of individuals in the group) | 1018 (37.3%) | 1507 (23.9%) | 2525 (27.9%) |
Quarters until NHA, mean (SD) | 8.0 (7.4) | 11.6 (9.3) | 10.1 (8.8) |
Hypertension and depression |
Number of participants in group | 1231 | 2006 | 3237 |
Number of NHAs (% of individuals in the group) | 482 (39.1%) | 556 (27.7%) | 1038 (32.1%) |
Quarters until NHA, mean (SD) | 8.9 (8.7) | 13.5 (11.1) | 11.4 (10.3) |
Hypertension and COPD |
Number of participants in group | 586 | 1656 | 2242 |
Number of NHAs (% of individuals in the group) | 175 (29.9%) | 319 (19.3%) | 494 (22.0%) |
Quarters until NHA, mean (SD) | 8.1 (7.9) | 11.8 (10.3) | 10.5 (9.7) |
Hypertension and diabetes and depression |
Number of participants in group | 734 | 1136 | 1870 |
Number of NHAs (% of individuals in the group) | 277 (37.7%) | 320 (28.2%) | 597 (31.9%) |
Quarters until NHA, mean (SD) | 8.2 (8.3) | 11.9 (10.0) | 10.2 (9.4) |
Hypertension and diabetes and COPD |
Number of participants in group | 348 | 1098 | 1446 |
Number of NHAs (% of individuals in the group) | 96 (27.6%) | 184 (16.8%) | 280 (19.4%) |
Quarters until NHA, mean (SD) | 7.9 (6.5) | 10.5 (9.0) | 9.6 (8.3) |
Hypertension and diabetes and heart failure |
Number of participants in group | 245 | 627 | 872 |
Number of NHAs (% of individuals in the group) | 72 (29.4%) | 124 (19.8%) | 196 (22.5%) |
Quarters until NHA, mean (SD) | 8.3 (7.4) | 9.6 (8.1) | 9.1 (7.8) |
NHA Nursing home admission, SD Standard Deviation, COPD Chronic obstructive pulmonary disease, Diabetes Diabetes mellitus type 2 |
Table 3 shows the HRs as well as the confidence intervals of the multivariate analyses of the influence of individual quality of care on the event of NHA, stratified by disease group for PWD and PWOD.
Table 3
Results of the time to event analysis among PWD and PWOD with NHA receiving care for chronic conditions.
| PWD | PWOD |
Disease group | Adjusted HR a) | Lower 95% CI | Upper 95% CI | Adjusted HR a) | Lower 95% CI | Upper 95% CI |
Hypertension and diabetes |
Medication for hypertension | 1.26 | 0.97 | 1.63 | 1.00 | 0.82 | 1.21 |
Check of HbA1c | 0.62* | 0.54 | 0.72 | 0.54* | 0.48 | 0.61 |
Ophthalmological examination | 0.60* | 0.48 | 0.75 | 0.59* | 0.50 | 0.69 |
Fundus examination | 0.53* | 0.38 | 0.75 | 0.45* | 0.35 | 0.58 |
Acute inpatient treatment of Diabetes | 2.67* | 1.99 | 3.60 | 2.81* | 2.28 | 3.47 |
Check of triglycerides and cholesterol | 0.70* | 0.54 | 0.90 | 0.70* | 0.58 | 0.84 |
Check of serum-creatinine | 0.72* | 0.63 | 0.83 | 0.69* | 0.62 | 0.77 |
Lower-limb amputation | 3.10* | 1.78 | 5.55 | 2.81* | 1.94 | 4.08 |
Hypertension and depression |
Medication for hypertension | 1.00 | 0.57 | 1.74 | 0.81 | 0.50 | 1.31 |
Antidepressive medication | 0.98 | 0.80 | 1.21 | 1.37* | 1.15 | 1.63 |
Hypertension and COPD |
Medication for hypertension | 0.46 | 0.11 | 1.94 | 0.42 | 0.16 | 1.14 |
Inhaled medication | 0.54* | 0.35 | 0.84 | 0.79 | 0.61 | 1.02 |
Non-useful inhaled medication | --b | --b | --b | --b | --b | --b |
Acute inpatient treatment of COPD | 4.21* | 2.20 | 8.10 | 2.54* | 1.64 | 3.93 |
Respiratory therapy | 0.86 | 0.43 | 1.72 | 1.15 | 0.79 | 1.68 |
Influenza vaccination | 0.64 | 0.33 | 1.27 | 0.79 | 0.50 | 1.26 |
Specific beta-blocker therapy | 0.89 | 0.62 | 1.29 | 0.78 | 0.60 | 1.01 |
Specific anticholinergic therapy | 0.62 | 0.34 | 1.12 | 1.17 | 0.88 | 1.56 |
Oral corticosteroids | 1.40 | 0.82 | 2.35 | 0.86 | 0.58 | 1.26 |
Hypertension and diabetes and depression |
Medication for hypertension | 0.96 | 0.54 | 1.70 | 0.61 | 0.32 | 1.15 |
Check of HbA1c | 0.62* | 0.47 | 0.82 | 0.49* | 0.38 | 0.62 |
Ophthalmological examination | 0.53* | 0.34 | 0.81 | 0.57* | 0.41 | 0.80 |
Fundus examination | 0.40* | 0.20 | 0.77 | 0.56* | 0.35 | 0.89 |
Acute inpatient treatment of Diabetes | 2.12* | 1.20 | 3.74 | 2.89* | 1.82 | 4.59 |
Check of triglycerides and cholesterol | 0.80 | 0.52 | 1.23 | 0.56* | 0.36 | 0.85 |
Check of serum-creatinine | 0.82 | 0.63 | 1.07 | 0.62* | 0.49 | 0.79 |
Lower-limb amputation | 2.05 | 0.47 | 8.88 | 2.26 | 0.68 | 7.59 |
Antidepressive medication | 1.28 | 0.99 | 1.66 | 1.30* | 1.02 | 1.64 |
Hypertension and diabetes and COPD |
Medication for hypertension | 1.02 | 0.35 | 2.93 | 0.68 | 0.29 | 1.58 |
Inhaled medication | 0.80 | 0.43 | 1.50 | 0.80 | 0.57 | 1.11 |
Non-useful inhaled medication | --b | --b | --b | --b | --b | --b |
Acute inpatient treatment of COPD | 2.11 | 0.50 | 8.85 | 1.39 | 0.64 | 3.00 |
Respiratory therapy | 1.69 | 0.87 | 3.27 | 1.47 | 0.93 | 2.33 |
Influenza vaccination | 0.83 | 0.37 | 1.84 | 0.92 | 0.53 | 1.60 |
Specific beta-blocker therapy | 0.65 | 0.49 | 1.34 | 0.74 | 0.54 | 1.03 |
Specific anticholinergic therapy | 1.16 | 0.58 | 2.31 | 0.82 | 0.55 | 1.21 |
Oral corticosteroids | 0.47 | 0.11 | 1.96 | 0.99 | 0.61 | 1.60 |
Check of HbA1c | 0.33* | 0.19 | 0.59 | 0.48* | 0.35 | 0.66 |
Ophthalmological examination | 0.18* | 0.06 | 0.59 | 0.64* | 0.42 | 0.99 |
Fundus examination | 0.12* | 0.02 | 0.91 | 0.66 | 0.38 | 1.17 |
Acute inpatient treatment of Diabetes | 0.69 | 0.15 | 3.17 | 2.51* | 1.26 | 5.00 |
Check of triglycerides and cholesterol | 0.37 | 0.13 | 1.0 | 0.87 | 0.55 | 1.37 |
Check of serum-creatinine | 0.56* | 0.34 | 0.91 | 0.68* | 0.50 | 0.92 |
Lower-limb amputation | 2.04 | 0.20 | 20.97 | 0.80 | 0.11 | 5.82 |
Hypertension and diabetes and heart failure |
Medication for hypertension | 0.83 | 0.23 | 3.02 | 0.63 | 0.27 | 1.46 |
Beta-blocker upon heart failure | 1.24 | 0.70 | 2.17 | 1.03 | 0.68 | 1.57 |
ACE-inhibitor upon heart failure | 0.65 | 0.36 | 1.19 | 1.26 | 0.82 | 1.96 |
Short acting calcium channel blockers | --b | --b | --b | 0.00 | 0.00 | 0.00 |
Acute inpatient treatment of heart failure | 1.08 | 0.41 | 2.89 | 1.55 | 0.85 | 2.83 |
Check of HbA1c | 0.54* | 0.30 | 0.96 | 0.52* | 0.35 | 0.76 |
Ophthalmological examination | 0.59 | 0.17 | 1.38 | 0.39* | 0.20 | 0.75 |
Fundus examination | 0.43 | 0.10 | 1.87 | 0.33* | 0.12 | 0.89 |
Acute inpatient treatment of Diabetes | 2.65 | 0.90 | 7.77 | 3.19* | 1.65 | 6.16 |
Check of triglycerides and cholesterol | 0.51 | 0.20 | 1.31 | 0.68 | 0.36 | 1.26 |
Check of serum-creatinine | 0.56 | 0.32 | 1.00 | 0.53* | 0.36 | 0.78 |
Lower-limb amputation | 1.24 | 0.19 | 8.23 | 2.84 | 0.91 | 8.84 |
a) Adjusted for 9 individual-level covariates: age. sex. level of care. direct social network. number of cognitive impairments. number of functional impairments. osteoarthritis. osteoporosis. Charlson comorbidity index. b) no results determined due to small number of participants in the numerator of the indicator. NHA Nursing home admission, PWD People with dementia, POWD People without dementia, HR Hazard ratio. CI Confidence interval. COPD Chronic obstructive pulmonary disease. Diabetes Diabetes mellitus type 2. |
Disease group hypertension and diabetes
While drug therapy for hypertension had no significant effect on the length of time to NHA, significant HRs for QI of diabetes care are consistently shown for individuals with hypertension and diabetes, regardless of the presence of dementia. Thereby, protective effects are shown for QI with desirably high values. The likelihood of NHA reduced with regular control of HbA1c levels, ophthalmologic examination, ocular fundus examination, and control of triglycerides, LDL- and HDL-cholesterol, and serum creatinine. Indicators suggesting complications of care, such as emergency inpatient treatment for diabetes (HR = 2.67, 95% CI 1.99–3.60 for PWD and HR = 2.81, 95% CI 2.28–3.47 for PWOD) or lower-limb amputation (HR = 3.10, 95% CI 1.78–5.55 for PWD, HR = 2.81, 95% CI 1.94–4.08 for PWOD) increased the risk of NHA.
Disease group hypertension and depression
For PWOD, receiving antidepressant pharmacotherapy shortened the time to NHA (HR = 1.37, 95% CI 1.15–1.63), whereas no significant effects were found for PWD. Drug therapy for hypertension showed no significant association with the risk of NHA in either group.
Disease group hypertension and COPD
For individuals with hypertension and COPD, receiving emergency inpatient treatment for COPD increased the risk of NHA (HR = 4.21, 95% CI 2.2–8.10 for PWD, HR = 2.54, 95% CI 1.64–3.93 for PWOD). Receiving inhaled medication showed a protective effect for PWD (HR = 0.54, 95% CI 0.35–0.84), while all other QI showed no significant association for this disease group.
Disease group hypertension, diabetes and depression
For individuals with hypertension, diabetes, and depression, significant effects for the quality of diabetes care were found for PWOD except for lower-limb amputations, following the trend of the association reported above for the disease group hypertension and diabetes. Receiving antidepressant pharmacotherapy significantly increased the likelihood of NHA in PWOD (HR = 1.30, 95% CI 1.02–1.64). In PWD, control of triglycerides, LDL- and HDL-cholesterol, and serum creatinine were no protective factors in this disease group, and the impact of lower-limb amputation was also not significantly associated with the occurrence of NHA. Emergency inpatient treatment for diabetes significantly increased the likelihood of NHA for PWD (HR = 2.12, 95% CI 1.20–3.74).
Disease group hypertension, Diabetes and COPD
The risk-reducing influence of quality of diabetes care, which is significant in other disease groups, is also present in PWD with hypertension and COPD for regular control of the HbA1c-value (HR = 0.33, 95% CI 0.19–0.59), ophthalmologic examination (HR = 0.18, 95% CI 0.06–0.59), ocular fundus examination (HR = 0.12, 95% CI 0.02–0.91), and control of serum creatinine (HR = 0.56, 95% CI 0.34–0.91). In PWOD, significant influences on length of stay in one’s home are shown for control of HbA1c-value (HR = 0.48, 95% CI 0.35–0.66), ophthalmologic examination (HR = 0.64, 95% CI 0.42–0.99), inpatient emergency treatment of diabetes (HR = 2.51, 95% CI 1.26–5.00) and control of serum creatinine (HR = 0.68, 95% CI 0.50–0.92). QI for COPD and hypertension showed no significant associations with the risk of NHA in PWD and PWOD.
Disease group Hypertension, diabetes and heart failure
Only control of the HbA1c-value (HR = 0.54, 95% CI 0.30–0.96) showed a statistically significant association with the event of NHA in PWD in this disease group. For PWOD, on the other hand, the majority of QI for diabetes care proved to be significant, following the trend evident in other diseases groups of an increase in length of stay in the one’s own home for desirable QI and a reduction in the length of stay for emergency inpatient treatment for diabetes (HR = 3.19, 95% CI 1.65–6.16).
Table 3 Results of the time to event analysis among PWD and PWOD with NHA receiving care for chronic conditions.