Evaluating the joint effects of dementia and frailty on burdensome transitions among long-term care residents in Ontario, Canada

Background — Transfers from long-term care (LTC) to hospital near the end of life can be burdensome for LTC residents. Dementia and frailty are common in this population, yet their relationship to burdensome transitions remains unclear. This study examined the joint associations between dementia, frailty, and end-of-life burdensome transitions among LTC residents.

Methods — We conducted a population-based retrospective cohort study using health administrative data, capturing LTC residents aged ≥ 65 who died in Ontario, Canada, January 1, 2015–March 31, 2020. Dementia was identified using a validated algorithm, supplemented with Resident Assessment Instrument—Minimum Dataset 2.0 (RAI-MDS) data. Frailty (non-frail, pre-frail, frail) was assessed using a 72-item frailty index developed for use with the RAI-MDS. Burdensome transitions were defined as 3+ transfers to hospital (≥ 2 if due to pneumonia, urinary tract infection, sepsis, dehydration) in the last 90 days of life (last 180 days as secondary outcome). Poisson regression was used to estimate adjusted relative risks (RRs) and 95% confidence intervals (CIs) for burdensome transitions by dementia and frailty status.

Results — Among 88,507 LTC decedents, most were frail (67.6%) and had dementia (87.5%). Approximately 4.7% of residents experienced a burdensome transition in the last 90 days of life (8.8% in the last 180 days). Dementia was associated with a reduced risk of burdensome transitions in the last 90 days of life across frailty strata (non-frail: RR = 0.77, 95% CI, 0.64–0.92; pre-frail: RR = 0.86, 95% CI, 0.77–0.97; frail: RR = 0.79, 95% CI, 0.71–0.89). Similar findings were observed when examining burdensome transitions in the last 180 days of life.

Conclusion — Dementia and frailty are independently associated with a lower likelihood of burdensome transitions near the end of life in LTC residents. Further research is needed to explore the appropriateness of hospital transfers at the end of life, considering the perspectives of LTC residents, family, and healthcare providers.