Hospitalization for Nursing Home Residents With Dementia: A Closer Look at the Patient Experience

Hospitalization is a common occurrence for nursing home residents living with Alzheimer’s disease and related dementias (ADRD), yet new research suggests the hospital experience may be far more burdensome than many clinicians realize. A recent study published in the Journal of the American Medical Directors Association offers one of the most comprehensive views to date of what geriatric patients encounter during acute care admissions.

Cleveland Clinic geriatrician and study coauthor Ardeshir Hashmi, MD, AGSF, says the findings point to frequent distressing interventions, limited use of palliative care services and missed opportunities for advance care planning.

“For many individuals with advanced dementia — a progressive and ultimately terminal condition — highly invasive treatments may not align with patient preferences or expected quality-of-life outcomes,” notes Dr. Hashmi, Endowed Chair of Geriatric Innovation and Section Chief for the Center for Geriatric Medicine. “Our findings underscore the tension clinicians face between treating acute illness and preserving comfort and dignity in late-stage disease.”

A high-intensity experience

Cleveland Clinic researchers analyzed more than 10,000 hospitalizations of nursing home residents with dementia across a large integrated health system over a 10-year period. The findings of the retrospective cohort study paint a sobering picture of care intensity for a population already vulnerable to functional decline and adverse events.

Among the 10,195 patients studied, the median age was 84, and most were insured through Medicare. Although their hospital stays were relatively short — a median of five days — they frequently involved interventions that can be physically and psychologically taxing for patients with cognitive impairment.

More than one in five developed delirium during their hospitalization, physical or chemical restraints were used in approximately 6% of cases, and nearly 70% of patients required a sitter for safety monitoring. One-third of patients received Foley urinary catheters, and more than half received at least one neuropsychiatric medication.

Although hospital care is intended to stabilize acute medical conditions, the data suggest that the process itself may introduce additional risks, Dr. Hashmi notes. Falls occurred in more than 4% of hospitalizations, and 4.1% of patients died during admission.

Notable findings

One of the study’s most striking findings was the frequency of intensive care utilization. Nearly 20% of patients were admitted to the ICU, where interventions became even more aggressive.

Among ICU patients, more than half experienced delirium, 62% required catheterization, and 21% underwent mechanical ventilation. Feeding tubes were inserted in 10% of ICU admissions, and mortality rose to 14%.

These patterns raise important questions about goal-concordant care, Dr. Hashmi says.

Despite the intensity of care delivered, relatively few patients had documented advance care planning measures in place. Only 45% had do-not-resuscitate (DNR) orders at the time of hospitalization. Even more notable was the limited involvement of supportive specialties: just 2.4% received geriatric consultations, 5% palliative care consultations, and 1.1% hospice consultations.

This gap represents one of the most actionable findings of the study, he notes.

“Earlier and more consistent conversations about goals of care could help families better understand what hospitalization entails and potentially avoid interventions that provide limited clinical benefit,” Dr. Hashmi says.

The researchers emphasize that advance care planning, including discussions about do-not-hospitalize orders or Physician Orders for Life-Sustaining Treatment (POLST) documentation, remains one of the few modifiable factors shown to reduce unnecessary hospital transfers among nursing home residents with advanced dementia.

The risks of hospitalization

“Hospital environments are inherently disorienting,” Dr. Hashmi explains. “Frequent room changes, sleep disruption, alarms and unfamiliar caregivers can exacerbate cognitive symptoms. It’s important to understand that patients with ADRD are already at higher risk for complications like infections, functional decline and prolonged recovery compared with patients without dementia.”

He adds that hospitals are traditionally designed around acute disease management rather than delirium prevention.

“Without age-friendly infrastructure or workflows, even routine care processes can unintentionally contribute to agitation, delirium and loss of independence,” he says.

The authors suggest that stronger collaboration between hospitals and nursing homes could help reduce unnecessary transfers and improve preparedness when hospitalization is unavoidable.

Implications for clinical practice

Rather than arguing against hospitalization entirely, the study authors encourage clinicians to better prepare patients and families for what hospital care realistically involves. Transparent communication about likely interventions — including monitoring, medication use and potential ICU escalation — may allow more informed decision-making, Dr. Hashmi says.

He notes that the findings also reinforce the growing role of interdisciplinary care models, stressing that integrating geriatrics and palliative care earlier in the disease trajectory may help align treatment decisions with patient goals while reducing burdensome transitions of care.

“Improving outcomes for patients with dementia requires shifting from a reactive model of crisis-driven hospitalization toward proactive planning that prioritizes comfort, clarity and coordination across care settings,” he explains.

Looking ahead

The researchers call for future studies examining how advance directives, proactive emergency planning and earlier specialty consultations influence patient experiences and outcomes during hospitalization. Improved access to advance directive documentation and stronger communication among care teams may also help ensure treatment decisions reflect patient wishes, Dr. Hashmi says.

Ultimately, the study reframes hospitalization not simply as a clinical event but as a complex experience with significant emotional, physical and ethical implications.

“For healthcare professionals caring for nursing home residents with dementia, the message is clear: understanding what hospitalization truly looks like is essential to guiding better conversations — and better care — long before a transfer to the hospital occurs,” Dr. Hashmi adds.