After STEMI, most community-dwelling patients with dementia went home and stayed there

Design

Retrospective cohort study using 100% national Medicare fee-for-service claims with multivariable linear regression

Population

117,318 beneficiaries aged 65+ with STEMI undergoing cardiac catheterisation, 2017-2022; 7,348 with dementia, 2,617 admitted from a nursing home

Primary outcome

Adjusted days alive at home in the year following the index emergency department visit

Effect

Community-dwelling: 225.1 days with dementia versus 299.4 without (adjusted difference -37.8, 95% CI -41.1 to -34.5). Nursing home source: -71.9 days (-84.0 to -59.8), 1-year survival 42.4%

Dementia influences whether a patient with ST-elevation myocardial infarction is taken to the catheter laboratory, and the reasoning is usually about what they would gain. This study measures that in a form the reasoning actually needs: days alive at home.

Medicare fee-for-service claims from a 100% national sample identified 117,318 beneficiaries aged 65 and over who presented to an emergency department with STEMI between 2017 and 2022 and underwent cardiac catheterisation. Of these, 7,348 (6.3%) had Alzheimer's disease or a related dementia and 2,617 (2.2%) were admitted from a nursing home. The primary outcome was adjusted days alive at home in the year after the index visit, with models controlling for age, sex and comorbidity.

Among community-dwelling patients, those with dementia had 225.1 adjusted days at home against 299.4 without — an adjusted difference of 37.8 days (95% CI -41.1 to -34.5). That is a meaningful loss. It is also, for more than half of them, over 300 days at home.

Admission source separated the groups far more sharply than the diagnosis did. Among patients admitted from a nursing home, dementia was associated with 71.9 fewer days at home (95% CI -84.0 to -59.8) and one-year survival was 42.4%.

The usable distinction is therefore not dementia or no dementia. It is where the patient was living when the chest pain started.

• Ask where the patient lives before you let a dementia diagnosis shape the decision
• Days alive at home is the outcome to discuss with a family, not survival alone
• More than half of community-dwelling patients with dementia spent over 300 days at home
• Nursing home residence with dementia carried 42.4% one-year survival — a different conversation
• Severity of dementia is not captured in claims data and will matter at the bedside

Why it matters

It replaces an intuition about futility with a number, and the number is better than the intuition assumed.

Don't overread it

Retrospective claims data with no measure of dementia severity or functional status; this describes outcomes in those who were catheterised, not in those who were not.

The statistics, in plain English

'Adjusted days alive at home' counts days not spent dead, admitted or in institutional care, which is why it captures something survival alone misses. The adjustment covered age, sex and comorbidity from claims, which will not capture dementia severity, frailty or functional status — all of which plausibly drive both the treatment decision and the outcome. So the 37.8-day gap is an upper bound on what dementia itself costs; some of it belongs to the things claims could not see.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.