Dementia Care in the Last Year of Life: Experiences in a Community Practice and in Skilled Nursing Facilities

Objective: People living with dementia often have high care needs at the end-of-life. We compared care delivery in the last year of life for people living with dementia in the community (home or assisted living facilities [ALFs]) versus those in skilled nursing facilities (SNFs). Methods: A retrospective study was performed of older adults with a dementia diagnosis who died in the community or SNFs from 2013 through 2018. Primary outcomes were numbers of hospitalizations and emergency department visits in the last year of life. Secondary outcomes were completed advance care plans, hospice enrollment, time in hospice, practitioner visits, and intensive care unit admissions. Results: Of 1203 older adults with dementia, 622 (51.7%) lived at home/ALFs; 581 (48.3%) lived in SNFs. At least 1 hospitalization was recorded for 70.7% living at home/ALFs versus 50.8% in SNFs (P <.001), similar to percentages of emergency department visits (80.2% vs 58.0% of the home/ALF and SNF groups, P <.001). SNF residents had more practitioner visits than home/ALF residents: median (IQR), 9.0 (6.0-12.0) versus 5.0 (3.0-9.0; P <.001). No advance care plan was documented for 12.2% (n = 76) of the home/ALF group versus 4.6% (n = 27) of the SNF group (P <.001). Nearly 57% of SNF residents were enrolled in hospice versus 68.3% at home/ALFs (P <.001). The median time in hospice was 26.5 days in SNFs versus 30.0 days at home/ALFs (P =.67). Conclusions: Older adults with dementia frequently receive acute care in their last year of life. Hospice care was more common for home/ALF residents. Time in hospice was short.