The care of older people with dementia in acute hospitals

cowdell f. (2010) The care of older people with dementia in acute hospitals. International Journal of Older People Nursing 5 , 83–92. Aim. To explore the experiences of patients and nursing staff of the care received by older people with dementia in acute hospitals. Background. The prevalence of dementia is steadily increasing as is the number of people with the condition requiring acute hospital care. Significant concerns about the quality of this care have been raised. There is a paucity of knowledge about the views of such care from the perspectives of people with dementia and nurses. Method. An ethnographic approach was used and data were collected thorough observation and interviews in one acute hospital in the United Kingdom. Findings. Findings suggest that care for older people with dementia in acute hospitals is not always optimum although there are clear exceptions. Generally, people with dementia found the delivery of care and the experience of being in hospital distressing as they did not know what was happening and they were often ignored. Nurses strive to give good care but do not always achieve this. Conclusion. Bourdieu’s Model of Practice assists in explaining why care is as it is. There is a clear need to improve current practice. Relevance to clinical practice. It is imperative that innovative methods of developing practice are implemented and evaluated. Education alone will not lead to sustained changes in practice. Further research into this subject needs to be undertaken.     

Caring for people with dementia in the acute setting: a study of nurses' views

Caring for people with dementia in an acute hospital setting presents a number of challenges. This article reports the findings of a study which explored nurses' experiences of caring for older people with dementia in a unit caring for older people within an acute hospital. The study used a thematic approach to produce an interpretation of the care experience and a purposive sample of seven nurses was interviewed regarding the research aims. The findings revealed the structural inadequacies of the acute hospital as a dementia care environment and the resultant challenges and complexities of the care experience. Despite the identified challenges, nurses considered the specific needs of people with dementia and the environmental effects of the acute setting on their ability to meet identified needs.     

A new strategy for patients with dementia

There are 800,000 people with dementia in the UK, of whom about 82,000 live in Scotland. The general population is ageing, and because the risk of developing dementia increases with age, the number of people with dementia in Scotland is expected to double over the next 25 years (Alzheimer Scotland 2011). A sharp increase in the number of people with dementia who present to emergency departments (EDs) and acute care settings. Up to one in four of all general hospital beds in the UK are occupied by people aged over 65 years who have dementia (Alzheimer's Society 2009), yet their specific needs are often poorly understood by healthcare staff (Alzheimer's Society 2009, Mental Welfare Commission 2010). This article describes the development of an online resource for ED staff in Scotland, and of the associated infrastructure, to improve the care experience for people with dementia, their families and carers.     

How family carers of people with dementia experienced their stay on an acute care facility and their own collaboration with professionals: a qualitative study

About one third of geriatric patients admitted to an acute care setting suffer from dementia as second diagnosis. For those patients, a hospital stay can negatively influence health outcomes and cause additional burden for families, because structure and organisation of acute care settings are often not adapted to dementia care. The purpose of this qualitative study was to explore the experiences of family members of people with dementia who were admitted to an acute geriatric care facility. Data were collected through interviews with 12 family members and a qualitative content analysis was carried out. Findings showed that, regardless of patients' signs of dementia, family members worried: Will she manage? Will her needs be met? Family members felt a special responsibility. They appreciated the rehabilitative and nursing care; most could subsequently relinquish responsibility and felt temporary relief. Collaboration with professionals was experienced in different ways: Family members were relieved and appreciative when involved, but disillusioned or disappointed when they thought that they were not understood and neglected. For some family members, quality of care and collaboration was related to the practice of individual professionals. It is recommended to reinforce interventions that are experienced positively by family members and to develop a team culture of active relationship building and collaboration with the families of patients with dementia.     

Supporting families of patients with dementia at end-of-life in hospital

IntroductionThere are barriers to implementing person-and family-centred end-of-life care for people with dementia in hospitals. Nursing care for people with dementia is enhanced through family involvement. However, families report unmet needs during admissions contributing to distress and dissatisfaction. Furthermore, little is known about families’ needs during end-of-life care for people with dementia in hospital.AimThis study examined perceptions of interpersonal care during end-of-life for patients with dementia.MethodsThis research used a qualitative approach framed through a social constructionist and complex systems theoretical frameworks. Hospital clinicians (n = 20) and bereaved family members (n = 12) of deceased patients with dementia participated in semi-structured interviews focussing on recent end-of-life care experiences.FindingsAn overarching theme of maintaining connections highlights the need to support patient and family bonds at end-of-life. Although clinicians often presumed families had experienced the social loss of a relative due to dementia, most families described continued bonds. Despite clinicians’ insights into caregiver grief, several families reported unmet bereavement support needs. Clinicians and families sought to personalise end-of-life through affirming signs of patients’ presence, working collaboratively to achieve comfort, personalising basic care interventions and offering gestures of hospitality.ConclusionEnd-of-life care for people with dementia and their families is improved when clinicians personalise patient care interventions using creative and simple strategies. Families feel comforted through humanistic care that acknowledges their unique relationship with the patient. However, it is vital to integrate grief and loss psychoeducation during end-of-life care to address families unmet bereavement needs following patient death.     

Developing champions to enhance the care of people with dementia in general hospitals

In NHS Ayrshire and Arran, almost 5500 people have a dementia diagnosis. This could increase by as much as 60% over the next 20 years (Alzheimer Scotland, 2007). National dementia strategies in the U.K. have identified a need for better training that supports staff in general hospitals. While all clinical settings will admit people with dementia, their specialist care needs are not always being met Better awareness will help ensure these are addressed on both admission and throughout their care journey. This is the second article describing a nurse led initiative to improve approaches towards dementia in a general community hospital. The first article (Crabtree and Mack, 2010) focused on raising awareness of dementia, while this follow-up article describes the development and implementation of a dementia champions programme.     

Palliative care for frail older people: A cross-sectional survey of patients at two hospitals in England

Abstract

Background

The majority of deaths in the UK occur in acute hospitals, and older people have the highest hospital death rates. Improved palliative care for older people has been identified as an international priority, yet little is known about the profile of older patients with palliative care needs in hospitals.

Objective

To describe the profile of older hospital inpatients (≥85 years), and to explore the prevalence and nature of palliative care needs among this group.

Methods

A cross-sectional survey of palliative care need in older people was undertaken in two UK acute hospitals. Hospital case notes were examined for evidence of palliative care need according to Gold Standards Framework (GSF) prognostic indicator criteria. Patients (or consultees) completed assessments of palliative care need.

Subjects

Data were collected for 654 consenting patients/consultees. This paper describes data from 110 patients aged ≥85 years.

Results

Forty per cent of the older patients were identified as having palliative care needs according to GSF criteria. Frailty was the most common indicator of palliative care need (16.7%). The most common reason for admission to hospital was general frailty (25.5%).

Conclusions

While this study is limited by its small sample size, the results suggest that older people with frailty conditions constitute a substantial proportion of hospital inpatients with palliative care needs. However, it is unclear whether a specialist palliative care framework is the most appropriate model for this group. The care provided to older people at the end of life may best be provided by generalists such as geriatricians, as part of a comprehensive generalist-led palliative care framework.     

Healthcare staffs’ experiences and perceptions of caring for people with dementia in the acute setting: Qualitative evidence synthesis

BackgroundDementia is a global issue, with increasing prevalence rates impacting on health services internationally. People with dementia are frequently admitted to hospital, an environment that may not be suited to their needs. While many initiatives have been developed to improve their care in the acute setting, there is a lack of cohesive understanding of how staff experience and perceive the care they give to people with dementia in the acute setting.ObjectivesThe aim of this qualitative synthesis was to explore health care staffs’ experiences and perceptions of caring for people with dementia in the acute setting. Qualitative synthesis can bring together isolated findings in a meaningful way that can inform policy development.SettingsA screening process, using inclusion/exclusion criteria, identified qualitative studies that focused on health care staff caring for people with dementia in acute settings.ParticipantsTwelve reports of nine studies were included for synthesis. Data extraction was conducted on each report by two researchers.MethodsFramework synthesis was employed using VIPS framework, using Values, Individualised, Perspective and Social and psychological as concepts to guide synthesis. The VIPS framework has previously been used for exploring approaches to caring for people with dementia. Quality appraisal was conducted using Critical Appraisal Skills Programme (CASP) and NVivo facilitated sensitivity analysis to ensure confidence in the findings.ResultsKey themes, derived from VIPS, included a number of specific subthemes that examined: infrastructure and care pathways, person-centred approaches to care, how the person interacts with their environment and other patients, and family involvement in care decisions. The synthesis identified barriers to appropriate care for the person with dementia. These include ineffective pathways of care, unsuitable environments, inadequate resources and staffing levels and lack of emphasis on education and training for staff caring for people with dementia.ConclusionsThis review has identified key issues in the care of people with dementia in the acute setting: improving pathways of care, creating suitable environments, addressing resources and staffing levels and placing emphasis on the education for staff caring for people with dementia. Recommendations are made for practice consideration, policy development and future research. Leadership is required to instil the values needed to care for this client group in an effective and personcentred way. Qualitative evidence synthesis can inform policy and in this case, recommends VIPS as a suitable framework for guiding decisions around care for people with dementia in acute settings.     

‘Failure to Maintain’: A theoretical proposition for a new quality indicator of nurse care rationing for complex older people in hospital

Complex older patients represent about half of all acute public hospital admissions in Australia. People with dementia are a classic example of complex older patients, and have been identified to have higher rates of hospital-acquired complications. Complications contribute to poorer patient outcomes, and increase length of stay and cost to hospitals. The care for older people with dementia is complex, and this has been attributed to: their cognitive response to being hospitalised; their limited ability to self-care; and lack of nursing engagement with the family caregiver. Registered nurses can offer simultaneous assessment and intervention to prevent or mitigate hospital-acquired complications. However, it is known that when demand for nursing care exceeds supply, care is prioritised according to acute medical need. Consequently some basic but essential nursing care activities such as patient mobility, communication, skin care, hydration and nutrition are implicitly rationed.This paper offers a theoretical proposition of ‘Failure to Maintain’ as a conceptual framework to indicate implicit care rationing by nurses. Care rationing contributes to functional and cognitive decline of complex older patients, which then contributes to higher rates of hospital acquired complications. Four key hospital acquired complications: pressure injuries, pneumonia, urinary tract infections and delirium are proposed as measurable indicators of ‘Failure to Maintain’.Hospital focus on throughput constrains nurses to privilege predictable, solvable and medically-related procedures and processes that will lead to efficient discharge over patient mobility, communication, skin care, hydration and nutrition. This privileging, also known as implicit rationing, is theoretically and physiologically associated with a rise in the incidence of complications such as pressure injuries, pneumonia, urinary tract infection, and delirium. Complex older patients, including those with dementia, are at higher risk of the complications, therefore should have higher delivery of prophylactic intervention (ie have higher care needs). ‘Failure to Maintain’ offers a conceptual framework that is inclusive of, and sensitive to, this vulnerable population.Implicit rationing is occurring and it likely contributes to functional and cognitive decline in complex older patients and hospital-acquired complications. However, the lack of patient functional ability data at admission and discharge for hospitalised patients, and lack of usable ward and hospital level nurse staffing and workload data makes it difficult to monitor, understand and improve quality of care. Current research in the fields of acute geriatrics and nursing work environments show promise through enabling multidisciplinary team communication, and facilitating clinical autonomy to provide patient focussed care, and avoid ‘Failing to Maintain’.The research field of acute geriatrics can understand and act on the risk modification role of nurses, including controlling for nurse staffing and work environment variables in intervention studies. The research field of nurse sensitive outcomes should incorporate the different profile of complex older patients, by including age brackets and functional ability as variables in their studies. Clinically, nursing work environments can be designed to recognise the different profile of complex older patients by adapting practices to privilege mobility, hydration, nutrition, skin care and communication in the midst of acute care interventions.     

Meeting the nutritional needs of patients with dementia in hospital

This is the third article in a series of five focusing on the needs of patients with dementia. It emphasises the importance of good nutritional intake for patients with dementia in hospital care. On busy wards, nutrition is often overlooked in favour of other aspects of care. Nurses' increased knowledge about dementia, assessment of nutritional needs, and personal capabilities can improve patients' experiences and outcomes. Excess dependency and emotional aspects of food refusal are also discussed.     

The creation of a Dementia Nurse Specialist role in an acute general hospital

Older people form the largest group occupying acute hospital beds and many of them will have undiagnosed mental health problems. The creation of a Dementia Nurse Specialist role in a district general hospital provided the opportunity to assess the extent of the previously unmet need among patients, carers and nursing staff. Over 30 patients were seen each month, while around 6 to 12 were diagnosed as having dementia. Other activities undertaken as part of the role included providing information and support for carers, and advice on management of behaviours and support for ward staff. The role also involved policy writing, pathway and local strategy planning, care plan development, and formal and informal teaching on dementia. It is argued that this fixed-term post demonstrated that a Dementia Nurse Specialist could provide significant input in an acute hospital setting, by improving the experience of hospitalization for vulnerable older people and their carers.     

A Model of Consequences of Need-Driven, Dementia-Compromised Behavior

PURPOSE: To extend the original need-driven, dementia-compromised behavior (NDB) model by explaining the consequences of behavioral symptoms for the person with dementia. ORGANIZING CONSTRUCT AND METHODS: Literature is reviewed and the consequences of expressing needs through need-driven, dementia-compromised behaviors are posited. The consequences of need-driven, dementia-compromised behavior (C-NDB) theory is proposed as a framework to improve understanding of the person with dementia and the consequences of behavioral symptoms and unmet needs. FINDINGS: Instead of normative verbal communication, people with significant dementia commonly communicate need via non-normative behaviors, making it difficult for caregivers to know that the person has a need and the extent of such need. Not meeting needs of people with dementia affects the person with dementia, care factors, and contextual factors. Cascading effects occur in which not meeting the original need results in new needs and behavioral symptoms. CONCLUSIONS: This framework indicates the consequences of expressing need behaviorally rather than verbally and shows that caregiver actions might moderate the events that lead to many needs being unresolved. Suggestions are made regarding future research questions deduced from the model.     

Knowledge of and attitudes toward assisting patients with dementia during mealtime among nursing staff in acute care settings: A cross-sectional study

BackgroundMealtime difficulties are exacerbated in acute care settings, which further complicate health issues in people with dementia (PWD). Understanding staff knowledge and attitudes is crucial for providing better care for PWD in nursing home settings. However, little is known about the knowledge and attitudes of acute care staff in assisting dementia patients during mealtimes.AimTo explore the knowledge and attitudes of acute care staff in assisting dementia patients during mealtimes.MethodsWe conducted a cross-sectional study between August and December 2020 at three acute care hospitals in Illawarra region, New South Wales, Australia. Surveys were distributed to nursing staff including registered nurses, enrolled nurses, and nurse assistants, who worked in geriatric wards. Medical practitioners and casual staff were excluded from the survey. Demographics, knowledge, attitudes, and intentions toward mealtime assistance of PWD were included in the survey.FindingsA higher level of knowledge in mealtime assistance of PWD was found to be associated with positive attitudes toward mealtime assistance of PWD (r = 0.464, p < 0.001). No differences were found between educational levels and knowledge and attitudes of mealtime assistance for PWD.DiscussionThe need for mealtime assistance training to enhance knowledge of and attitudes toward assisting PWD during mealtimes is highlighted and needs more attention. Future studies could consider including a simulation training program and adopting a mealtime engagement scale to provide training and assess changes in nursing staff knowledge of and attitudes toward mealtime assistance for PWD in acute care settings.ConclusionsThe study findings can inform future research in raising awareness of the need for and developing mealtime assistance training programs for nursing staff in acute care settings.     

Person-centered dementia care in acute hospital wards—The influence of staff knowledge and attitudes

Person-centered dementia care practices in acute hospital wards are suboptimal and not commonly measured. Although previous research has indicated that the work environment of staff influences their perceptions of person-centeredness, few studies have examined how their personal attributes, such as their level of dementia knowledge and attitudes, influence their person-centered dementia care practices. A questionnaire was distributed to test the relationship between staff perceptions of person-centered dementia care and their dementia knowledge and attitudes in general medical wards. The results showed that staff with better dementia knowledge were significantly more critical about the extent they were using evidence-based guidelines and external expertise. Staff with better attitudes perceived themselves as using more individualized care practices. The findings demonstrate that to enhance person-centered dementia care in acute hospitals, staff training programs should develop both their intellectual and interpersonal skills to improve their knowledge and attitudes.     

Educating nursing staff involved in the provision of dementia care

Evidence from several studies suggests that general nurses and acute health care staff do not always have an adequate understanding of the needs of people with dementia. This has major implications for the quality of care that is delivered and the well-being of people with dementia and a concurrent medical or surgical condition. This article describes how the creation of the role of nurse educator in dementia care helped to address this problem in one NHS trust.     

Palliative assessment and advance care planning in severe dementia: an exploratory randomized controlled trial of a complex intervention

Patients with advanced dementia often receive poor end-of-life care. We aimed to design and pilot a palliative care and advance care plan (ACP) intervention. Patients had undergone emergency hospital admission and had severe dementia. The intervention consisted of a palliative care patient assessment which informed an ACP discussion with the carer, who was offered the opportunity to write an ACP for the person with dementia. Carer-patient dyads were randomized to 'usual care' or the intervention. Carer-related outcome measures included the Kessler Distress Scale, Decision Satisfaction Inventory, Client Satisfaction Questionnaire and the Euroqol-5D, measured at baseline, six weeks, six months and three months after bereavement. The Satisfaction with End of Life Care in Dementia Scale was completed if the patient died. The 32 patient participants were physically frail and in the advanced stages of dementia: 62% had pressure damage to the skin, all needed feeding assistance and 95% were in pain. Nearly 50% died during the six-month follow-up period. Carers were difficult to recruit during acute admission; 33 patients and carers entered the study (22 intervention arm; 11 control arm). Only seven carers made ACPs. The care planning discussion was well received, but few carers wrote an ACP, despite intensive support from an experienced nurse specialist. Advance care planning is, in theory, a necessary intervention for people with severe dementia; the reluctance of carers to write plans needs to be explored further.     

Rationale and principles of early rehabilitation care after an acute injury or illness

Patients hospitalized for an acute illness or injury are at risk of experiencing a significant loss of functioning as defined by the International Classification of Functioning, Disability and Health (ICF). The risk of a significant loss of functioning is increased in critically ill patients, in patients with complications or long-term intensive care stays, in persons with disabilities or with pre-existing chronic conditions and in the elderly. Early identification of rehabilitation needs and early start of rehabilitation can reduce healthcare costs by reducing dependence and nursing care, length of stay and prevention of disability. Two principles of rehabilitation for acute and early post-acute care can be distinguished. First, the provision of rehabilitation by health professionals who are generally not specialized in rehabilitation in the acute hospital. And second, specialized rehabilitation care provided by an interdisciplinary team. There is large variation how this specialized, typically post-acute rehabilitation care is organized, provided, and reimbursed in different countries, regions, and settings. For instance, it may be provided either in the acute hospital or in a rehabilitation or nursing setting. Most in-patients do not receive specialized rehabilitation at all during their whole stay in the acute hospital. But, it is important to point out that health professionals working in acute hospitals and who are not specialized in rehabilitation need to be able to recognize patients' needs for rehabilitation care and to perform rehabilitation interventions themselves or to assign patients to appropriate rehabilitation care settings. The principles outlined in this paper can serve as a basis for the development of clinical assessment instruments to describe and classify functioning, health and disability of patients receiving acute or early post-acute rehabilitation care.