Hospitalization Patterns Among Older Patients With Cancer With and Without Dementia

ABSTRACT

Objective: Cancer and dementia are prevalent chronic conditions among older adults. Despite the complexities involved in caring for individuals with both conditions, the patterns of hospitalization in this specific group are not well understood. This study aimed to examine the associations between the presence of dementia and hospitalization-related outcomes.

Study Design: A multiyear cross-sectional analysis using 2016-2019 National Inpatient Sample data.

Methods: We examined hospitalization pattern disparities between patients with cancer 65 years and older with and without dementia at high risk of mortality. The influence of dementia on multiple hospitalization-related outcomes (eg, emergency admission, hospital charges) was investigated using a series of multivariable regression models.

Results: The study involved 774,812 hospital discharges of patients with cancer 65 years and older, including 8.7% with comorbid dementia. The prevalence of dementia varied across different cancer types, ranging from 5.5% for pancreatic cancer and esophageal cancer to 18.9% for nonmelanoma skin cancer. Multiple adjusted logistic regression models indicated that patients with cancer and dementia were more likely to be admitted through the emergency department (adjusted OR [AOR], 1.48; 95% CI, 1.44-1.52), to have nonelective admissions (AOR, 1.67; 95% CI, 1.61-1.74), and to be discharged to skilled nursing or related facilities (AOR, 2.16; 95% CI, 2.12-2.19), and they had approximately 6.9% lower hospital charges but a 6.8% longer length of stay compared with those without dementia (all P < .001).

Conclusions: Dementia was prevalent among older patients with cancer, particularly those with nonmelanoma, prostate, and bladder cancers. Comorbid dementia was associated with unplanned or unnecessary hospitalization, highlighting the need to enhance health care management and tailored strategies for this population.

Am J Manag Care. 2025;31(2):e32-e38. https://doi.org/10.37765/ajmc.2025.89681

Takeaway Points

• Preexisting or newly diagnosed dementia in patients with cancer can impact their cancer care. Our study examined the associations between the presence of dementia and various hospitalization-related measures among older patients with cancer.
• Almost 10% of older adults with high-risk cancer mortality have comorbid dementia, with varying prevalence depending on the type of cancer.
• Comorbid dementia among older patients with cancer was linked to unplanned or unnecessary hospitalization, emphasizing the urgent need to enhance health care management for this population.

Cancer and dementia are 2 prevalent chronic conditions among older adults in the US that impose significant health and economic challenges for patients and their caregivers. The overall risk of both cancer and dementia increases with age.^1,2 As of 2023, approximately 6.7 million Americans 65 years and older were living with dementia, and more than 12 million older adults had been diagnosed with cancer.^3,4 A systematic review of studies from diverse countries revealed that the prevalence rates of comorbid cancer and dementia varied between 0.2% (observed in patients with ovarian cancer in Denmark) and 45.6% (in hospice patients in the US) among different populations.⁵ Cancer management is complex, especially when cognitive impairments or behavioral/psychological changes associated with dementia are present.^6,7 Many patients with cancer may also deal with multiple competing health- and aging-related conditions, including preexisting or newly diagnosed dementia, which can impact their cancer care. This may exacerbate the overall disease burden, contribute to increased challenges in disease management, and result in adverse health outcomes.^6,7

Few studies have examined the potential impact of dementia on the treatment options of patients with cancer. In general, the presence of dementia is associated with decreased curative care (eg, chemotherapy, radiation, and surgery) and increased noncurative care (eg, hospice and palliative care).⁶ Notably, a study conducted in the mid-South region of the US examined health care utilization among Medicare beneficiaries with comorbid dementia and cancer.⁸ The study found that patients with cancer who had dementia had higher rates of hospitalizations, hospital readmissions within 30 days, intensive care unit use, and emergency department (ED) visits compared with their counterparts without dementia. Another study examining hospitalization trends among patients with cancer and dementia in New York revealed that admissions for both cancer and dementia diagnoses increased from 7.1% in 2007 to 9.7% in 2017 among all hospital admissions.⁹ Moreover, distinct hospitalization patterns were identified between patients with cancer with and without dementia. Although these studies have offered valuable insights into health care utilization among individuals dealing with both cancer and dementia, it is important to highlight that the majority of these studies involved foreign populations, concentrated on specific regions within the US,^8,9 or were limited to a single hospital system with a relatively small sample size.⁷ Additionally, there is a limited comprehension of the specific intricacies concerning hospital admission routes and primary reasons for hospitalization in this population with elevated health care needs.

To further reveal the intricate relationships between cancer and dementia with health care–related outcomes in the US population, our study utilized nationally representative data from US hospital discharge records to estimate the national prevalence of dementia among patients with cancer and to examine the associations between the presence of dementia and various hospitalization-related outcomes, including hospital admission routes, reasons for hospitalization, hospital dispositions, hospital length of stay (LOS), and hospital charges among US adults 65 years and older. The findings of this study have the potential to offer valuable insights for enhancing care and support for patients with cancer and dementia. This, in turn, could contribute to more informed decision-making, improved disease management, and better overall patient outcomes.

METHODS

Data and Study Population

We conducted a multiyear cross-sectional analysis using 2016-2019 National Inpatient Sample (NIS) data. The NIS is a comprehensive cross-sectional sample of discharges encompassing hospitalization records across various payer groups in the US.¹⁰ The data set included information on patient demographics and hospital attributes related to inpatient admissions.¹⁰ Managed by the Agency for Healthcare Research and Quality (AHRQ) as part of the Healthcare Cost and Utilization Project (HCUP), the NIS was curated to provide valuable insights. Access to the HCUP database is facilitated by the HCUP Central Distributor. After establishing a data user agreement with AHRQ, 2 authors (Z.X. and Y.R.H.) concluded the agreement and obtained full access to the deidentified NIS data used in this study for analysis.

Because one of the study’s objectives was to determine the national prevalence of dementia among patients with cancer and reaffirm the variation in dementia burden based on cancer type, from the pooled data of the 2016-2019 NIS (N = 28,484,087), we initially identified patient admissions linked with individuals 65 years and older with a diagnosis code indicating any cancer using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) provided by the CMS Chronic Conditions Data Warehouse (n = 1,282,221); we then assigned the dementia status to each case using the same ICD-10-CM approach.¹¹ Because the data set lacked information regarding the stage of cancer or dementia and the time of the first diagnosis for both conditions and to mitigate potential biases stemming from varying mortality risks among different cancer types or stages of the same cancer type, we narrowed our focus to those with high-risk mortality (HRM), defined by an All Patient Refined Diagnosis Related Group (APR-DRG) Risk of Mortality rating of 3 to 4 (n = 782,066). The APR-DRG rating calculates disease-specific mortality risk by incorporating the principal diagnosis and other secondary comorbid conditions. This approach ensured homogeneity in terms of mortality risk and comorbidities in the study sample, and it has been used in previous cancer-related studies.^12,13 Additionally, we excluded cases with missing information on key dependent variables (n = 7254), resulting in a final sample of 774,812 (weighted n = 3,874,059) hospital discharges.

Dependent Variables: Hospitalization-Related Outcomes

We incorporated a set of measures related to hospital admission and discharge as the dependent variables, encompassing the following: (1) transfer to the hospital (not transferred, transferred from an acute care hospital, or transferred from another type of health facility [eg, skilled nursing facility]); (2) admission to the hospital through the ED (yes or no); (3) elective admission (yes or no); (4) weekend admission (yes or no); (5) primary reason for hospital admission (ambulatory care–sensitive conditions [ACSCs],¹⁴ injury, or other); (6) discharge disposition (routine, short-term hospital, other types of health facility, home health care, against medical advice, died, or destination unknown); (7) total hospital charges, with adjustments for the annual inflation rate following US Bureau of Labor Statistics estimates (2019 US$)¹⁵; and (8) LOS, calculated by the NIS as the difference between the admission date and the discharge date (excluding leave days), with same-day stays treated as zero.¹⁰

Independent Variables

Our main focus among the independent variables was a dichotomized dementia status, identified using ICD-10-CM.¹¹ Additionally, we incorporated various patient and hospital characteristics into our analysis based on their relevance established in previous research.^8,9 Patient sociodemographic factors encompassed age (65-74, 75-84, or ≥ 85 years), sex (male or female), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, other, or unknown), median household income percentile (0-25th, 26th-50th, 51st-75th, or 76th-100th), health insurance type (any private, any public, or self-pay/no charge), and metropolitan status (metropolitan, micropolitan, or rural). At the hospital level, covariates included hospital region (Northeast, Midwest, South, or West), rural/urban and teaching status (rural, urban teaching, or urban nonteaching), and hospital size (small, medium, or large), which was defined by the HCUP hospital bed size classifications determined by hospital location and teaching status.¹⁶

Statistical Analysis

Initially, we assessed the trend of overall dementia prevalence from 2016 to 2019 and examined the prevalence of dementia across different cancer types within the study sample. Subsequently, we used Rao-Scott χ² tests to compare patient and hospital characteristics based on dementia status. The outcome measure was then estimated between the 2 groups. To explore the influence of dementia on the outcome measures while accounting for age, sex, race/ethnicity, median household income, health insurance type, metropolitan status, hospital region, rural/urban and teaching status, and hospital size, we employed a series of independent multivariable logistic regression models for the nominal outcome variables. Adjusted ORs (AORs) and their corresponding 95% CIs were calculated.

To estimate the associations of dementia status with the LOS and hospital charges, we first tested the distributions of the LOS and hospital charges within the study sample using visual inspection (histogram). Guided by the data distribution, we then used the same approach and constructed multivariable generalized linear regression models (LOS [Poisson distribution] and hospital charges [γ distribution]) due to the skewness of the data. Finally, we carried out subgroup analyses employing the same methodology but limiting the study sample to individuals with a primary cancer diagnosis.

To ensure representation of the entire population of older patients with cancer and HRM, we incorporated the recommended survey sampling weights with PROC SURVEY procedures in all statistical analyses using SAS 9.4 (SAS Institute Inc).¹⁷ The threshold for determining statistical significance was set at a 2-sided adjusted P value using Benjamini-Hochberg correction for multiple comparisons.¹⁸ Lastly, this study received an exemption from review by the institutional review board at the University of North Florida and adhered to the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.¹⁹

RESULTS

The study included 774,812 (weighted n = 3,874,059) hospital discharges of patients with cancer 65 years and older with HRM. Of these patients, 8.7% were diagnosed with dementia. Figure 1 shows the dementia prevalence according to cancer type. The highest rate of dementia was in patients with nonmelanoma skin cancer (18.9%), followed by prostate cancer (14.4%) and bladder cancer (11.4%), and the lowest rate was in patients with pancreatic cancer and esophogeal cancer (both 5.5%). Moreover, when tallying the count of cancer sites irrespective of cancer type, dementia exhibited a higher prevalence among patients with a single cancer site (8.8%) compared with those with multiple cancer sites (2 cancers, 8.4%; ≥ 3 cancers, 7.3%).

Table 1 presents the distribution of the patient and hospital characteristics categorized by dementia status. Compared with patients with cancer without dementia, patients with cancer and dementia were more likely to be older, belong to racial/ethnic minority communities, be female, be covered by public health insurance, reside in a metropolitan area, and receive treatment in a small or medium-sized hospital.Table 2 shows the bivariate association between dementia status and each of the hospitalization-related outcome variables. A higher proportion of patients with cancer and dementia compared with those without dementia were transferred from another health facility (9.5% vs 4.1%, respectively), were admitted to the hospital through the ED (82.4% vs 72.8%), experienced nonelective admissions (93.6% vs 88.3%), were admitted during the weekend (23.7% vs 21.6%), and were primarily admitted with ACSCs (35.2% vs 30.1%) or had injuries (4.7% vs 2.2%). Additionally, a greater percentage of patients with cancer and dementia than those without dementia were discharged to other facilities (48.5% vs 26.6%).

Figure 2 illustrates the associations between dementia status and hospitalization outcomes in a series of multiple logistic regression analyses after adjusting for patient and hospital characteristics. Patients with cancer and dementia were more likely to be transferred into the hospital (AOR, 1.56; 95% CI: 1.52-1.60), be admitted to the hospital through the ED (AOR, 1.48; 95% CI, 1.44-1.52), have a weekend admission (AOR, 1.08; 95% CI, 1.06-1.10), and be admitted due to ACSCs (AOR, 1.23; 95% CI, 1.21-1.25), and they were less likely to have elective admission (AOR, 0.60; 95% CI, 0.58-0.62) compared with patients with cancer without dementia. Additionally, patients with cancer and dementia had an increased likelihood of discharge to skilled nursing or related facilities (AOR, 2.16; 95% CI, 2.12-2.19) compared with their counterparts without dementia. The eAppendix Table (eAppendix available at ajmc.com) provides comprehensive results of each regression model. Moreover, the eAppendix Figure illustrates analogous findings when narrowing the study sample to those with a primary cancer diagnosis.

The mean LOS and total hospital charges were 7.19 days (SE, 0.02; median, 4.67) and $82,254 (SE, $690.46; median, $48,616) in the overall study participants. Upon stratifying the study participants by dementia status, patients with cancer and dementia exhibited a mean LOS and total hospital charges of 7.25 days (SE, 0.04; median, 4.83) and $70,285 (SE, $592; median, $44,695). In comparison, patients with cancer without dementia had a mean LOS and total hospital charges of 7.19 days (SE, 0.02; median, 4.66) and $83,400 (SE, $716; median, $49,038). The results from 2 multiple generalized linear regression models (data not shown), adjusting for patient and hospital characteristics, revealed that patients with cancer and dementia had approximately 6.9% lower hospital charges (P < .001) but a 6.8% longer LOS (P < .001) compared with patients with cancer without dementia.

DISCUSSION

We conducted this study to better understand the complex dynamics between patients with cancer with and without dementia in an older population with HRM, revealing distinct hospitalization patterns and outcomes for individuals facing the dual challenge of these prevalent chronic conditions. Our analysis of NIS data found that almost 10% of older adults with high-risk cancer mortality have comorbid dementia, with varying prevalence depending on the type of cancer (from 5.5% in pancreatic cancer and esophageal cancer to 18.9% in nonmelanoma skin cancer). These results align with those of previous studies, which found a high rate of dementia among older adults with cancer compared with their counterparts without cancer.⁶ The higher prevalence of dementia in some types of cancer could be attributed to several factors, including differences in cancer treatment and prognosis, the age distribution of patients with different cancers, and the potential neurotoxic effects of certain cancers.^20-23 This highlights the need for understanding the specific mechanisms through which cancer types, treatments, and patient demographics intersect with cognitive health in both oncology and geriatric medicine.

Our study also found that patients with comorbid cancer and dementia were more likely to be admitted through the ED, have nonelective admissions, and be discharged to skilled nursing or related facilities compared with those without dementia. These results might be attributed to the increased complexity of treating these patients, who require comprehensive care to address both cancer and dementia.²⁴ This may suggest that patients with comorbid cancer and dementia are within a revolving door of needing unplanned hospital visits or readmissions and require skilled nursing care post discharge. With the aging population in the US, the prevalence of patients with these dual comorbidities is expected to rise. To tackle this challenge, implementing improved coordinated care mechanisms such as accountable care organizations may be part of the solutions for these patients with higher health care needs.^25,26

Moreover, the study revealed that patients with cancer and dementia had a higher percentage of admissions for ACSCs and injuries than those without dementia. This finding is consistent with previous research that has shown that patients with dementia often have higher rates of hospitalization for potentially preventable conditions and injuries, suggesting a need for improved outpatient care for these patients.^27,28 This finding emphasizes the vulnerability of this population to preventable hospitalizations, indicating potential gaps in outpatient care and disease management. Considering the widely recognized underinvestment in the primary care system in the US, there is a clear imperative to bolster this primary health care provider network to ensure that patients with complex chronic conditions such as cancer and dementia can have their ACSCs managed effectively within the primary care setting.

Although the difference in LOS between patients with cancer with and without dementia was modest, with patients having comorbid cancer and dementia exhibiting a slightly longer LOS, the impact on hospital charges was notable. This can be explained by the fact that patients with cancer and dementia are more likely to be admitted to skilled nursing facilities for additional care as evident in our study results. Other study findings have shown that patients transferred to skilled nursing facilities can be discharged sooner than those leaving for home or in less care-intensive facilities.²⁹ Another possible reason could be that patients with cancer and dementia, in general, usually experience a longer LOS compared with their counterparts without dementia.³⁰ Our adjusted analysis also indicated a significant 6.9% decrease in hospital charges but 6.8% longer LOS for patients with comorbid cancer and dementia. Family caregivers of individuals with dementia typically prioritize enhancing the quality of life for the patients rather than opting for aggressive treatments. Consequently, the reduction in hospital charges may be linked to patients with dementia receiving a greater emphasis on palliative care, which tends to be less costly than curative treatments.^6,31 Furthermore, this contradiction suggests potential complexities in resource utilization and reimbursement mechanisms for this specific patient population.³² These findings underscore the need for better management of patients with comorbid cancer and dementia, including improved coordination of care and targeted interventions to reduce unnecessary hospitalizations and improve health outcomes.

Limitations

Our study has several limitations. First, the identification of cancer and dementia relied on the utilization of ICD-10-CM codes. It is crucial to acknowledge that this coding approach may be susceptible to limitations arising from incomplete or inaccurate administrative coding. Additionally, the presence of duplicated patient records in hospital discharges might not accurately reflect individual-level LOS and hospital charges. Nevertheless, it is important to highlight that this coding methodology has been successfully employed in prior studies utilizing the NIS data set.^8,13 Second, we were unable to include dementia severity in our analysis, which could have different implications for the outcomes of interest. Therefore, additional research focusing on the effects of dementia stages on these outcomes is warranted. Third, due to the nature of dementia, the involvement of informal family caregivers and family structure significantly influences decision-making for patient care. However, we could not incorporate these crucial variables into the analysis. Future studies should delve into exploring the association between caregiver-related factors and hospitalization. Fourth, because this study focused on patients with cancer with HRM and due to data availability limitations, cancer-specific factors such as treatment types were not included in the analyses. Future studies should consider adjusting for these factors or focusing on specific cancer types. Finally, the classifications of outcome measures heavily depended on the availability of data from the NIS. The absence of detailed categories for some outcome variables may obscure the nuances in the relationships between the outcomes of interest and the statuses of cancer and dementia.

CONCLUSIONS

Despite the limitations, we found significant differences in hospitalization-related outcomes among older patients with cancer with HRM in the US based on dementia status. Dementia was more prevalent in older patients with some cancer types. Comorbid dementia among older patients with cancer was associated with unplanned or unnecessary hospitalization, emphasizing the urgent need to enhance health care management for this population. Future research with longitudinal designs to further investigate how comorbid dementia impacts cancer-specific outcomes such as cancer-specific survival and overall survival is warranted. 

Author Affiliations: Department of Public Health (ZX, EB, SP) and Department of Health Administration (HYH), University of North Florida, Jacksonville, FL; Department of Public Health, College of Education, Health, and Human Sciences, The University of Tennessee (BC), Knoxville, TN; Department of Health Services Research, Management, and Policy, College of Public Health and Health Professions, University of Florida (YRH), Gainesville, FL.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (ZX, HYH, EB, SP); acquisition of data (ZX, SP, YRH); analysis and interpretation of data (ZX, BC, YRH); drafting of the manuscript (ZX, HYH, EB, BC, SP); critical revision of the manuscript for important intellectual content (ZX, HYH, EB, BC, SP, YRH); statistical analysis (ZX); administrative, technical, or logistic support (YRH); and supervision (YRH).

Address Correspondence to: Zhigang Xie, PhD, MPA, Department of Public Health, University of North Florida, 1 UNF Dr, Jacksonville, FL 32224. Email: zhigang.xie@unf.edu.

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