What is the current state of care for older people with dementia in general hospitals? A literature review

Whole Person, Whole Journey: Developing a Person-Centred Regional Dementia Strategy

We present the development of a regional dementia strategy in Southwestern Ontario, Canada. We worked with stakeholders in a regional health authority to develop a dementia strategy. We conducted interviews with persons with dementia and their care partners (n = 26) and health care administrators and policy makers (n = 33); and administered a priority-setting survey (n = 64). Both participant groups identified provider compassion, professionalism, and care in the early stages of dementia as system strengths. Both groups also highlighted a need for more integration and coordination, a need for more person-centred care, support for care partners, and more flexibility in the provision and receipt of services. The highest-ranked priorities were improving care partner support, improving access to care, and improving system-wide quality. We integrate these strengths, needs, and priorities in a strategic framework, “Whole Person, Whole Journey”. Organizations developing a dementia strategy may use this framework as a springboard for their own work.

Cognitive impairment assessment and interventions to optimize surgical patient outcomes

For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.

'Socialised care futility' in the care of older people in hospital who call out repetitively: An ethnographic study

BACKGROUND

People living with dementia may call out repetitively, sometimes called disruptive vocalisation, or verbal agitation. In literature and policy, patients who call out repetitively are assumed to be expressing an unmet need, which should be met. Yet there has been little systematic study of this patient group in an acute hospital setting.

OBJECTIVES

To better understand patients who call out repetitively and to identify what care looks like in an acute hospital setting.

DESIGN

Ethnography.

SETTINGS

Ten acute geriatric medical wards in two hospitals.

PARTICIPANTS

30 cognitively impaired patients who were calling out repetitively, and 15 members of hospital staff.

METHODS

Semi-structured interviews with hospital staff, 150 h of ward observations and informal conversations with staff, scrutiny of medical and nursing documentation, and measures of patient health status.

RESULTS

Patients who called out were moderately or severely cognitively impaired, often had delirium, were very physically disabled, and many were approaching the end of life. Most hospital staff were found to hold contradictory views: that calling out represents distress or unmet need, but that nothing can be done to alleviate the calling out. During informal conversations, most staff also tended to say that they intuitively recognised when intervening was likely to alleviate calling out. During observations, many staff appeared to and spoke of the ability to 'block' calling out. As a result we argue that social, emotional and physical needs may get overlooked. We argue that some calling out is due to a need that is unmeetable. We also found that while staff would talk about strategies for identifying need, observations and hospital documentation did not support evidence of systematic attempts to identify potential need.

CONCLUSION

Calling out repetitively within a hospital setting is difficult for staff to understand and to respond to. This is because many of these patients are severely cognitively impaired, often immobile and dependent on their professional carers. We argue that a form of socialised care futility is communicated between staff and is used to rationalise becoming unresponsive to calling-out. We explain this phenomenon as resulting from two protective mechanisms: defence of staff's professional identity as competent practitioners; and defence of staff as having personal morality. Socialised care futility risks good quality care, therefore systematic strategies to assess and manage possible need should be developed, even if calling out remains irresolvable in some cases.

Reducing time in acute hospitals: A stepped-wedge randomised control trial of a specialist palliative care intervention in residential care homes

BACKGROUND

Care home residents are frequently transferred to hospital, rather than provided with appropriate and timely specialist care in the care home.

AIM

To determine whether a model of care providing specialist palliative care in care homes, called Specialist Palliative Care Needs Rounds, could reduce length of stay in hospital.

DESIGN

Stepped-wedge randomised control trial. The primary outcome was length of stay in acute care (over 24-h duration), with secondary outcomes being the number and cost of hospitalisations. Care homes were randomly assigned to cross over from control to intervention using a random number generator; masking was not possible due to the nature of the intervention. Analyses were by intention to treat. The trial was registered with ANZCTR: ACTRN12617000080325. Data were collected between 1 February 2017 and 30 June 2018.

SETTING/PARTICIPANTS

1700 residents in 12 Australian care homes for older people.

RESULTS

Specialist Palliative Care Needs Rounds led to reduced length of stay in hospital (unadjusted difference: 0.5 days; adjusted difference: 0.22 days with 95% confidence interval: -0.44, -0.01 and p = 0.038). The intervention also provided a clinically significant reduction in the number of hospitalisations by 23%, from 5.6 to 4.3 per facility-month. A conservative estimate of annual net cost-saving from reduced admissions was A$1,759,011 (US$1.3 m; UK£0.98 m).

CONCLUSION

The model of care significantly reduces hospitalisations through provision of outreach by specialist palliative care clinicians. The data offer substantial evidence for Specialist Palliative Care Needs Rounds to reduce hospitalisations in older people approaching end of life, living in care homes.

Use of Direct In-Person Observation in the Care of Hospitalized Older Adults with Cognitive Impairment: A Systematic Review

Hospitalized older adults with cognitive impairment (CI) due to dementia and/or delirium may require individualized care strategies such as direct observation to mitigate safety concerns and manage behavioral symptoms. Despite common use of direct observation as a strategy, little is known about its practice and outcomes. A systematic review was conducted to identify, appraise, and synthesize literature on direct observation among hospitalized older adults with CI. The search yielded 16 eligible studies, with four describing current practices, nine reporting quality improvement efforts to broaden direct observation, and three focusing on direct observation reduction. Strength of evidence across studies was weak, limited in scope, and lacking clarity in definitions, indications for use and discontinuation, and documentation. Overall, findings highlight differing views on direct observation and the need for future, rigorous evaluation of approaches (e.g., nursing autonomy in initiating and discontinuing observation) to better align direct observation with patient needs. [Journal of Gerontological Nursing, 46(5), 23-30.].

Non-contact monitoring of agitation and use of a sheltering device in patients with dementia in emergency departments: a feasibility study

BACKGROUND

Agitation is common in geriatric patients with cognitive impairment, e.g. in persons with dementia (PWD), who are admitted to an emergency department (ED). It might be a first sign of upcoming delirium and is associated with a higher risk of an unfavorable clinical course. Hence, monitoring of vital signs and enhanced movement as indicators of upcoming agitation is essential in these patients during their stay in the ED. Since PWD rarely tolerate fixed monitoring devices, a novel developed non-contact monitoring system (NCMSys) might represent an appropriate alternative. Aim of this feasibility study was to test the validity of a NCMSys and of the tent-like "Charité Dome" (ChD), aimed to shelter PWD from the busy ED environment. Furthermore, effects of the ChD on wellbeing and agitation of PWD were investigated.

METHODS

Both devices were attached to patient's bed. Tests on technical validity and safety issues of NCMSys and ChD were performed at the iDoc institute with six healthy volunteers. A feasibility study evaluating the reliability of the NCMSys with and without the ChD was performed in the real-life setting of an ED and on a geriatric-gerontopsychiatric ward. 19 patients were included, ten males and nine females; mean age: 77.4 (55-93) years of which 14 were PWD. PWD inclusion criteria were age ≥ 55 years, a dementia diagnosis and a written consent (by patients or by a custodian). Exclusion criteria were acute life-threatening situations and a missing consent.

RESULTS

Measurements of heart rate, changes in movement and sound emissions by the NCMSys were valid, whereas patient movements affected respiratory rate measurements. The ChD did not impact patients' vital signs or movements in our study setting. However, 53% of the PWD (7/13) and most of the patients without dementia (4/5) benefited from its use regarding their agitation and overall wellbeing.

CONCLUSIONS

The results of this feasibility study encourage a future controlled clinical trial in geriatric ED patients, including PWD, to further evaluate if our concept of non-contact measurement of vital signs and movement combined with the "Charité Dome" helps to prevent upcoming agitation in this vulnerable patient group in the ED.

TRIAL REGISTRATION

ICTRP: "Charité-Dome-Study - DRKS00014737" (retrospectively registered).

[Prevalence of cognitive impairments in acute nursing care-Analysis and comparison of routine data]

Hintergrund

Aufgrund des demografischen Wandels ist von einer zunehmenden Prävalenz stationärer Patienten mit kognitiven Beeinträchtigungen auszugehen. Für eine bestmögliche Versorgung gilt es, diese Patientengruppe mit einem routinemäßigen Verfahren frühzeitig zu erkennen.

Methode

Die aktuelle Studie untersuchte die Prävalenzrate von kognitiven Beeinträchtigungen bei stationären Patienten >65 Jahre, die mit dem Mini-Mental-Status-Test (MMST) während der pflegerischen Aufnahme untersucht wurden. Anhand der Screeningquote wurde die Bereitschaft von Pflegekräften, den MMST als Routineinstrument zu verwenden, überprüft. Die Quote wurde zudem mit der Anzahl der kodierten F‑Diagnosen der ICD-10-GM verglichen. Diese retrospektive Studie wurde vom Oktober 2018 bis März 2019 an einer Universitätsklinik durchgeführt.

Ergebnisse

Von 7311 stationären Patienten >65 Jahre wurden 11,7 % gescreent. Die Prävalenz kognitiver Beeinträchtigungen betrug 20,7 % und war höher als die Prävalenzrate von Demenz und Delir aufgrund medizinischer Diagnosen (p < 0,001). Mit 11,7 % ist die Bereitschaft des Pflegepersonals, den MMST zur Einschätzung kognitiver Beeinträchtigungen während der Patientenaufnahmen einzusetzen, gering.

Diskussion

Die höhere Prävalenz bestätigt die Notwendigkeit, Patienten mit kognitiven Störungen zu erkennen. Die geringe Bereitschaft, den MMST anzuwenden, legt jedoch nahe, dass zum einen ein kürzeres Instrument verwendet und zum anderen Pflegenden mehr Informationen zu kognitiv beeinträchtigten Patienten vermittelt werden sollten.

Identifying features associated with higher-quality hospital care and shorter length of admission for people with dementia: a mixed-methods study

Background

Concerns have repeatedly been expressed about the quality of inpatient care that people with dementia receive. Policies and practices have been introduced that aim to improve this, but their impact is unclear.

Aims

To identify which aspects of the organisation and delivery of acute inpatient services for people with dementia are associated with higher-quality care and shorter length of stay.

Design

Mixed-methods study combining a secondary analysis of data from the third National Audit of Dementia (2016/17) and a nested qualitative exploration of the context, mechanism and outcomes of acute care for people with dementia.

Setting

Quantitative data from 200 general hospitals in England and Wales and qualitative data from six general hospitals in England that were purposively selected based on their performance in the audit.

Participants

Quantitative data from clinical records of 10,106 people with dementia who had an admission to hospital lasting ≥ 72 hours and 4688 carers who took part in a cross-sectional survey of carer experience. Qualitative data from interviews with 56 hospital staff and seven carers of people with dementia.

Main outcome measures

Length of stay, quality of assessment and carer-rated experience.

Results

People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission. This is a challenging task when patients have complex needs, and requires named staff to take responsibility for co-ordinating the discharge and effective systems for escalating concerns when obstacles arise. When trust boards review delayed discharges, they can identify recurring problems and work with local stakeholders to try to resolve them. Carers of people with dementia play an important role in helping to ensure that hospital staff are aware of patient needs. When carers are present on the ward, they can reassure patients and help make sure that they eat and drink well, and adhere to treatment and care plans. Clear communication between staff and family carers can help ensure that they have realistic expectations about what the hospital staff can and cannot provide. Dementia-specific training can promote the delivery of person-centred care when it is made available to a wide range of staff and accompanied by ‘hands-on’ support from senior staff.

Limitations

The quantitative component of this research relied on audit data of variable quality. We relied on carers of people with dementia to explore aspects of service quality, rather than directly interviewing people with dementia.

Conclusions

If effective support is provided by senior managers, appropriately trained staff can work with carers of people with dementia to help ensure that patients receive timely and person-centred treatment, and that the amount of time they spend in hospital is minimised.

Future work

Future research could examine new ways to work with carers to co-produce aspects of inpatient care, and to explore the relationship between ethnicity and quality of care in patients with dementia.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 22. See the NIHR Journals Library website for further project information.

Components of impactful dementia training for general hospital staff: a collective case study

Background and objectives: People with dementia occupy around one quarter of general hospital beds, with concerns consistently raised about care quality. Improving workforce knowledge, skills and attitudes is a mechanism for addressing this. However little is known about effective ways of training healthcare staff about dementia. This study aimed to understand models of dementia training most likely to lead to improved practice and better care experiences for people with dementia, and to understand barriers and facilitators to implementation.Method: A collective case study was conducted in three National Health Service Acute Hospital Trusts in England. Multiple data sources were used including interviews with training leads/facilitators, ward managers and staff who had attended training; satisfaction surveys with patients with dementia and/or carers; and observations of care using Dementia Care Mapping.Results: Interactive face-to-face training designed for general hospital staff was valued. Simulation and experiential learning methods were felt to be beneficial by some staff and stressful and distressing by others. Skilled delivery by an experienced and enthusiastic facilitator was identified as important. Staff identified learning and practice changes made following their training. However, observations revealed not all staff had the knowledge, attitudes and skills needed to deliver good care. Patient and carer satisfaction with care was mixed. A major barrier to training implementation was lack of resources. Supportive managers, organisational culture and strong leadership were key facilitators.Conclusion: Dementia training can lead to improved care practices. There are a range of key barriers and facilitators to implementation that must be considered.

A qualitative focus group discussion study on the experiences of Certified Nurses in Dementia Nursing related to effective staff education

Aim

To explore the experiences of Certified Nurses in Dementia Nursing (DCNs) concerning the effective education of staff in acute hospitals.

Background

In Japan, the number of inpatients with dementia who need medical care continues to increase. DCNs play an important role in educating medical staff about dementia care in acute hospitals. However, there is a lack of a clear understanding in this regard.

Design

A qualitative design using a thematic analysis.

Methods

Data were extracted from a focus group discussion conducted with 10 DCNs working in 10 different acute hospitals in central Japan. Participants answered semi-structured, open-ended questions about their experiences related to effective staff education. Categories, subcategories and themes were created. This study complied with the Standards for Reporting Qualitative Research.

Results

The two themes identified were "building a foundation for dementia care education" and "continuous support based on practical processes."

Reconciling economic concepts and person-centred care of the older person with cognitive impairment in the acute care setting

Person-centred care is a relatively new orthodoxy being implemented by modern hospitals across developed nations. Research demonstrating the merits of this style of care for improving patient outcomes, staff morale and organizational efficiency is only just beginning to emerge. In contrast, a significant body of literature exists showing that attainment of person-centred care in the acute care sector particularly, remains largely aspirational, especially for older people with cognitive impairment. In previous articles, we argued that nurses work constantly to reconcile prevailing constructions of time, space, relationships, the body and ethics, to meet expectations that the care they provide is person-centred. In this article, we explore key concepts of neo-liberal thought which forms an important back-story to the articles. Economic concepts, "efficiency" and "freedom" are examined to illustrate how nurses work to reconcile both the repressive and productive effects of economic power. We conclude the article by proposing a new research agenda aimed at building a more nuanced understanding of the messy actualities of nursing practice under the influences of neo-liberalism, that illuminates the compromises and adaptations nurses have had to make in response to economic power.

Dementia care in acute hospitals-A qualitative study on nurse managers' perceived challenges and solutions

AIM

The aim of this study was to explore the perceived challenges of nurse managers when caring for patients with dementia in acute hospitals and identify possible solutions to address these challenges.

BACKGROUND

Although dementia care in acute hospitals is suboptimal, few solutions have been identified. Multi-level factors need to be considered to promote changes in practice.

METHOD

Two focus groups were held with sixteen nurse managers responsible for eleven acute medical wards in Malta. Deductive qualitative analysis using an adapted version of McKinsey 7-S model was used as an a priori framework to categorize the perceived challenges and solutions.

RESULTS

The nursing managers identified a number of organizational challenges that have a direct impact on the quality of care of patients with dementia. They also suggested a number of solutions such as realigning the hospital strategy, improving training and care coordination, redesigning the ward environment and changing leadership styles.

CONCLUSION

This study highlight the complexity of improving dementia care in hospitals and continues to show that a system-wide approach is needed.

IMPLICATIONS FOR NURSING MANAGEMENT

Understanding the challenges and identifying possible solutions can help hospital staff provide better person-centred dementia care.

Risk of Frequent Emergency Department Use Among an Ambulatory Care Sensitive Condition Population: A Population-based Cohort Study

BACKGROUND

A small fraction of patients use a disproportionately large amount of emergency department (ED) resources. Identifying these patients, especially those with ambulatory care sensitive conditions (ACSC), would allow health care professionals to enhance their outpatient care.

OBJECTIVE

The objectives of the study were to determine predictive factors associated with frequent ED use in a Quebec adult population with ACSCs and to compare several models predicting the risk of becoming an ED frequent user following an ED visit.

RESEARCH DESIGN

This was an observational population-based cohort study extracted from Quebec's administrative data.

SUBJECTS

The cohort included 451,775 adult patients, living in nonremote areas, with an ED visit between January 2012 and December 2013 (index visit), and previously diagnosed with an ACSC but not dementia.

MEASURES

The outcome was frequent ED use (≥4 visits) during the year following the index visit. Predictors included sociodemographics, physical and mental comorbidities, and prior use of health services. We developed several logistic models (with different sets of predictors) on a derivation cohort (2012 cohort) and tested them on a validation cohort (2013 cohort).

RESULTS

Frequent ED users represented 5% of the cohort and accounted for 36% of all ED visits. A simple 2-variable prediction model incorporating history of hospitalization and number of previous ED use accurately predicted future frequent ED use. The full model with all sets of predictors performed only slightly better than the simple model (area under the receiver-operating characteristic curve: 0.786 vs. 0.759, respectively; similar positive predictive value and number needed to evaluate curves).

CONCLUSIONS

The ability to identify frequent ED users based only on previous ED and hospitalization use provides an opportunity to rapidly target this population for appropriate interventions.

Role of nursing associates in addressing the needs of people with dementia in hospital

It is estimated that people with dementia comprise about one quarter of all inpatients in acute hospital wards, although this could be an underestimate. Healthcare assistants often lack the training and skills, and nurses often lack the time, to provide optimal care for these patients. As a result, the needs of hospital inpatients with dementia are often unmet, they may have suboptimal outcomes compared with inpatients who do not have dementia, and they may experience significantly reduced well-being and quality of life. Nursing associates have a hands-on role in patient care, and their training should equip them with the skills required to overcome communication barriers and identify patients' needs. This article explores the potential role of nursing associates in addressing the needs of inpatients with dementia.

"Even Though I Have Dementia, I Prefer That They Are Personable": A Qualitative Focused Ethnography Study in a Danish General Hospital Setting

Patients with dementia often face challenges in hospital settings due to cognitive impairment. The aim of this study is to explore the encounter between patients with dementia and hospital staff, from the patient perspective. Focused ethnography guided the method for data collection and the analytical approach was abductive. The findings, based on 10 observations of patients with dementia and their encounter with hospital staff in a variety of hospital settings, reveal that staff often seem to not see the person beyond the dementia diagnosis. The findings also show, however, that significant moments are constantly negotiated during encounters between patients with dementia and hospital staff, moments which occasionally allow staff to see the patients to be seen as the person they are. A rethinking of the current dementia discourse is discussed, recommending attention to the two-way interaction between patients with dementia and hospital staff, and within this an awareness of a personable approach.

Exploring dementia care competence of nurses working in acute care settings

AIMS AND OBJECTIVES

To examine the current status of dementia care competence of nurses working in acute care settings as well as the relationship between competence and demographic attributes.

BACKGROUND

Most people with dementia are older individuals when they are admitted to unfamiliar acute care settings for treatment, and they are prone to displaying BPSD. If nurses working in acute care settings are not sufficiently competent in dementia care, providing proper patient care is difficult.

DESIGN

The study used a one-sample descriptive-correlation design.

METHODS

This study enrolled nurses at two medical centres in southern Taiwan as the research participants and performed a stratified random sampling according to the units where they served. The Dementia Care Competence Scale was used for data collection. An independent samples t test, ANOVA and Pearson's product-moment correlation were performed for data analysis (See STROBE).

RESULTS

A total of 308 valid questionnaires were collected. The results showed that dementia care competence of nurses working in acute care settings was moderate. In particular, they had insufficient knowledge of the special needs related to dementia and lacked the skills and patience necessary for identifying, preventing and managing BPSD. Additionally, although the nurses tended to have a positive attitude, they seldom communicated with people with dementia. This study also found that dementia care competence was better in nurses who were older, who had more seniority, who had taken care of people with dementia for a longer period of time and who had received training in dementia care.

CONCLUSIONS

Dementia care training topics for nurses working in acute care settings should include palliative care for dementia, skills for managing behavioural and psychological symptoms of dementia and communication techniques for improving person-centred care. Nurses should also be encouraged to maintain a warm, friendly attitude when providing patient care.

RELEVANCE TO CLINICAL PRACTICE

Continuing education in managing behavioural and psychological symptoms of dementia is necessary for currently practicing acute care nursing staff and should be developed according to the staff's educational background and needs.

Healthcare professionals' perceptions of P.I.E.C.E.S. education in supporting care delivery for older adults with responsive behaviours of dementia in acute care

Introduction: In acute care settings persons with dementia often use responsive behaviours such as yelling and hitting as a meaningful mode of communication. Staff dementia care education programs such as P.I.E.C.E.S. may help to address these gaps in care. P.I.E.C.E.S. is a holistic clinical assessment framework that focuses on Physical, Intellectual, and Emotional health, Capabilities of an individual, and the living Environment of a person and the Social being.Aims: The aim of this interpretive descriptive study was to explore the perceptions of healthcare professionals of P.I.E.C.E.S. and recommendations to enhance its uptake.Methods: A total of 15 healthcare professionals from acute medical settings in a hospital in Ontario participated in face-to-face, semi-structured interviews. Experiential thematic and secondary data analyses were performed.Findings: P.I.E.C.E.S. had many positive perceived impacts such as promoting interdisciplinary collaboration. However, participants reported that it was challenging to sustain P.I.E.C.E.S. in practice which led to a tapering off of it approximately one year post-education. A barrier to applying P.I.E.C.E.S. was limited time.Conclusions: Findings indicate the need for educational reinforcements and sustainability strategies for dementia care programs in acute care settings. Organizations should implement regular interdisciplinary meetings to provide opportunities for staff to apply P.I.E.C.E.S.

Low investment non-pharmacological approaches implemented for older people experiencing responsive behaviours of dementia

INTRODUCTION

The acute care setting is not ideal for older people with dementia; responsive behaviours may be triggered when care is delivered within a strange environment by staff with limited knowledge of life history and personal preferences. Responsive behaviours (e.g., yelling, hitting, restlessness) are used by older people with dementia to communicate their needs and concerns. It is unknown whether non-pharmacological approaches used by nurses support the development of a meaningful interpersonal relationship between nurses and older people with dementia.

AIMS

The aims of this study were to explore: (a) the types of low investment non-pharmacological approaches (e.g., music, social activities) used by nurses caring for older people experiencing responsive behaviours of dementia in acute medical settings and (b) the factors that influence the decisions of these nurses to implement these approaches.

METHODS

We present a qualitative secondary analysis of data from a primary study using Thorne's interpretive description approach. Interviews were conducted with 11 nurses and four allied health professionals from acute medical settings in Canada. A qualitative secondary data analytic approach was used, specifically analytic expansion, and experiential thematic analysis.

FINDINGS

egardless of the educational preparation of nurses, the decision to use specific types of low investment non-pharmacological approaches were influenced by the perfunctory development of the interpersonal relationships in acute care hospitals. The factors that led nurses to use limited approaches (e.g., turning on the TV and providing a newspaper) were lack of dementia care education and attending to other acutely ill clients.

CONCLUSIONS

This study revealed that nurses in acute medical settings require greater practice growth to deliver relational care which is crucial to supporting older people with dementia. Nurses need education and knowledge translation support to use creative low investment non-pharmacological approaches with the intent on upholding the quality of life older people with dementia.

What are we asking for when requesting "Specialling" for the confused hospitalised older person? A concept analysis

BACKGROUND AND/OR RATIONALE: "Specialling" is a common nursing practice in hospitals which entails the allocation of extra staff to be with an older person who is confused to maintain safety. Despite ongoing use, this practice has little evidence of effectiveness. To facilitate further investigation, a concept analysis of "specialling" was undertaken.

AIMS

The aim of this paper was to report on a concept analysis on the practice of "specialling" pertaining to older people who have cognitive impairment when in hospital.

METHODS

This study used Rodgers evolutionary approach to concept analysis to clarify the attributes, antecedents and consequences of the concept to determine a definition of "specialling." Web of Science (Core Collection and Web of Science Medline), CINAHL and SCOPUS databases were searched to identify relevant literature. Due to the scarcity of papers, the search was broadened to include all sources that could add understanding.

FINDINGS

A total of (n = 43) sources were identified. The attributes were themed to 5 categories: Labels and descriptions; the "Special" role; Patient safety; Patient care; and Communication. The antecedents to 2 themes: Patient characteristics; and Organisational risk. The consequences of "specialling" were diverse with 6 themes: the "Special" role; the Older persons experience; Costly; "Special" use and nursing beliefs; Safety outcomes; and Opportunities.

DISCUSSION

The process of concept analysis provided a means to identify knowledge gaps and practice challenges. The definition determined from this analysis has provided a reflective opportunity for clinicians and researchers to consider when implementing care initiatives to support older people in hospital. Important is the lack of person-centred approaches and the opportunities in developing nurse leadership through empowerment. The findings from this analysis will inform a PhD study.

IMPLICATIONS FOR PRACTICE

Nurses have an opportunity to lead care improvements by ensuring person-centred approaches in the care of older people with cognitive impairment.

[Dementia-specific characteristics of patients with fall-related femur fractures : A case study based on routine hospital data of patients with unspecified dementia]

BACKGROUND

A fall-related femur fracture is one of the most frequent reasons for hospital admission of patients with dementia. The aim of the study was to identify dementia-specific characteristics of patients with fall-related femur fractures and additionally an unspecified dementia in order to gain further knowledge about this particular patient group.

METHODS

A descriptive explorative case study with a single case-embedded design based on routine hospital data from a university hospital was performed. A total number of 34 patient records from 2015 were analyzed. In the embedded unit of analysis I the data of selected items of the nursing assessment AcuteCare (ePA-AC©) were descriptively analyzed for the time of admission and discharge. In the embedded unit of analysis II a summarizing inductive content analysis was conducted.

RESULTS

The results of the embedded unit of analysis I showed that this patient group is characterized by a high need for care, changes of cognition and behavioral symptoms. The status of cognition, behavior and reciprocity as well as the self-care index stagnated or deteriorated in many patients from admission to discharge. The embedded unit of analysis II identified observable (social)behavior, (non)compliance and orientation as central dementia-specific characteristics.

CONCLUSION

The results reflect the complexity of the care situation of patients with unspecified dementia in acute care hospitals. The results showed that a higher awareness for this particular patient group is needed to improve outcomes.

Views of nursing staff on computerized dementia screening : A validation and pilot study in a general hospital

Background

Cognitive disorders such as dementia are common among older adults admitted to general hospitals. They can complicate treatment leading to longer hospitalization and worse outcomes. They often remain underdiagnosed as the busy routine of the hospital does not enable efficient screening and available screening instruments are not suitable for the hospital environment. Computerized cognitive testing (CCT) has been proposed as an efficient screening method as it can be employed by nonspecialists, such as nurses while featuring automatic scoring and interpretation of results.

Objective

This study validated a newly developed questionnaire for measuring the attitudes of Greek nurses towards computerized dementia screening.

Material and methods

The questionnaire was validated in a sample of 212 undergraduate psychology students and subsequently administered to a sample of 19 nurses working in a general hospital. Reliability of the questionnaire was calculated using Cronbach’s alpha (= 0.762). Factor analysis revealed the existence of a single factor (acceptability-feasibility) that accounted for 33.73% of variance with an eigenvalue of 3.036.

Results

The total score of all the items loading on the single factor (acceptability-feasibility) was calculated. Scores ranged between 10 and 40 with the average score for the validation group being 29.33 (SD = 4.89) and the average score for the nurses’ group being 29.50 (SD = 3.20).

Discussion

The questionnaire has acceptable reliability. Results indicate that acceptability-feasibility is high in both groups and there were no statistically significant differences between the two groups.

Electronic supplementary material

The online version of this article (10.1007/s00391-019-01633-0) contains supplementary material, which is available to authorized users.

Care challenges in older general hospital patients : Impact of cognitive impairment and other patient-related factors

BACKGROUND

Older general hospital patients, particularly those with cognitive impairment, frequently experience adverse events and other care complications during their stay. As these findings have so far been based on small and selected patient samples, the aim of the present study was to provide reliable data on a) the prevalence of adverse care issues (summarized under the term care challenges) in older general hospital patients and on b) associated patient-related risk factors (e.g. cognitive impairment).

METHODS

A cross-sectional representative study comprising 1469 patients aged ≥65 years from 33 randomly selected general hospitals in southern Germany (GHoSt). Data collection included the use of different data sources, e.g. structured interviews with responsible nursing staff concerning care challenges and procedures for determining the patients' cognitive status.

RESULTS

Care challenges were statistically significantly (p < 0.001) more often reported for patients with dementia and/or delirium (87.5%) and mild cognitive impairment (47.9%) compared to cognitively unimpaired patients (24.6%). Adjusted odds ratios suggested cognitive impairment, impaired activities of daily living, receiving long-term care and unplanned admission as significant patient-related risk factors for care challenges. Furthermore, the occurrence of such issues was associated with the application of physical restraints, support from relatives, prescription of psycholeptics and specialist consultations.

CONCLUSION

The findings suggest a strong impact of different degrees of cognitive impairment on challenges in care. The results might help to design appropriate training programs for hospital staff and other interventions to prevent or reduce critical situations.

Expectations of nursing personnel and physicians on dementia training : A descriptive survey in general hospitals in Germany and Greece

Background

The number of dementia training programs in hospital settings is steadily increasing. The way training sessions are designed influences the way the learning content is implemented in practice. To develop a successful training it is important to meet the needs of the target group; however, not much is known about staff preferences and expectations relevant to future dementia training programs in hospitals in Germany and Greece.

Objective

The aim of this survey was to explore staff training needs relevant to the topic of dementia, in general hospitals in Germany and Greece. This study analyzed the interests of staff members, preferences and expectations with respect to dementia training.

Material and methods

This was a descriptive survey based on a 54-item questionnaire conducted with 61 nursing staff, head nurses and physicians (Germany: n = 25, Greece: n = 36) recruited from 5 hospitals (Germany: n = 3, Greece: n = 2). Parts of the questionnaire explored participants’ previous education regarding dementia and their expectations towards future dementia programs.

Results

Although staff attendance in educative programs was high in the last 5 years for both countries, participation in dementia training programs was low (Germany 24%, Greece 5.5%). Additionally, the great majority of participants were willing to be trained in future dementia training programs (Germany 96%, Greece 100%). Employees from both countries expect increased clinical skills as a result of participation in such training programs. In Greece, staff members hope for better handling of people with dementia, while in Germany, concrete practical advice is preferred.

Conclusion

There seems to be a strong willingness to participate in further dementia training programs where not only theoretical knowledge is provided but also practical advice.

Electronic supplementary material

The online version of this article (10.1007/s00391-019-01625-0) contains supplementary material, which is available to authorized users.

Facilitators for person-centred care of inpatients with dementia: A meta-synthesis of registered nurses’ experiences

Person-centred care is widely advocated when caring for people with dementia. When a person with dementia is admitted for hospital care, hospital wards are obliged to not only address the cause for admission but also provide dementia-specific care during the hospital stay. Research has shown that the delivery of person-centred care to people with dementia is often inadequate or absent in the hospital setting. Moreover, whilst registered nurses often wish to improve the in-hospital care of patients with dementia, there is evidence of experienced barriers. This study aimed to describe registered nurses’ experiences of facilitators for the delivery of person-centred care to inpatients with dementia. By way of systematic searches in the databases PubMed, CINAHL and PsycINFO, qualitative studies (n = 19) reporting registered nurses experience of caring for inpatients with dementia were identified. Relevant content was analysed using a method of thematic synthesis. Three main categories and nine subcategories were presented, internal facilitators (experience and knowledge; values and beliefs; professional identity; empathy), external facilitators (physical environment; organisational culture and structure) and facilitating actions (forming a holistic picture; establishing trust; adjusting routines and interventions). While facilitators did exist in the hospital setting, the findings indicate that care received by inpatients with dementia is dependent on individual registered nurses knowledge, personal aptitude and ability to compensate for structural flaws. In order to minimise arbitrary outcomes of care for patients with dementia, consistent organisational support in the form of educational interventions and allocation of resources is crucial.

The feasibility of implementing education on older person care to practice on medical units: Nurses' perceptions and the influence of practice context

AIM

As part of a larger primary study on evidence-informed practice with hospitalised older people, we aimed to (a) examine nursing staffs' perceptions of the interactive geriatric educational intervention and to explore how perceptions of their work context may influence their ability to enact the evidence-informed assessment and care approaches discussed during the educational sessions and (b) compare differences in perceptions of context between RNs, LPNs and HCAs.

METHOD

A survey-based evaluation that used both closed and open-ended questions was conducted as part of an interactive educational intervention on cognitive impairment and managing responsive behaviours. Data were gathered on participants' perceptions of the education intervention and organisational context.

RESULTS

Findings from this study suggest when education is tailored to nurses' articulated educational needs, it is well received; however, barriers to implementation exist. Assessment of the context by using a standardised survey tool to get the nursing staffs' perceptions of organisational context revealed strengths in leadership support and day-to-day interactions with other nurses and healthcare professionals, but potential barriers related to lack of facilitation to transfer new knowledge into practice existed.

CONCLUSION

Providing evidence-based education related to care of older patients and evaluating nursing staffs' perceptions of the education and their context has laid the groundwork for a long-term relationship with the managers and nursing staff on the participating medical units. Further investigation about how best to incorporate the facilitator role into the medical units to support evidence-based practices with older patients is warranted.  IMPLICATIONS FOR PRACTICE: While nurses are receptive to new knowledge, the unpredictable workload of acute care creates challenges to implementing this new knowledge. Assessment of contextual factors that influence evidence-informed practice facilitates planning for implementation of new knowledge and support practice change.

Patients with dementia in hospitals: a nation-wide analysis of administrative data 2010-2014

PURPOSE

Considering the limited information available, the aim of the study was to examine the prevalence and characteristics of inpatients with dementia in Belgian general hospitals.

METHODS

All admissions of inpatients aged at least 40 years with or without dementia were retrieved from the nationwide administrative hospital discharges database for the period 2010-2014.

RESULTS

Admissions of inpatients aged 40 years or more with dementia have increased to reach 83,017 out of 1,285,593 admissions (6.46%) in general hospitals in 2014, mostly admitted through the emergency department (79.7%) and for another reason than dementia (85.9%). These patients stayed longer [19.2 days, standard deviation (sd) = 23.6, median = 13] than the average length of stay of patients of the same age (7.9 days, sd = 14.1, median = 17). Considering patients aged 75 years or more falling into the 20 most common pathology groups (of patients with dementia), the group with dementia spent 5 days more than the group without dementia. Patients admitted from home spent more time in hospital when they were discharged to a residential care facility than when they returned home (27.2 days versus 15.8 days). The in-hospital mortality was high in the first days of admission.

CONCLUSIONS

The growing prevalence of patients with dementia in inpatient setting puts a high pressure on the hospital capacity planning and geriatric expertise. Moreover, as patients with dementia should be kept outside hospitals when possible for safety and quality matters, long-term organizational investments are required inside hospital and residential care settings as well as in community care.

Supporting general hospital staff to provide dementia sensitive care: A realist evaluation

BACKGROUND

There are an increasing number of interventions to improve hospital care for patients with dementia. Evidence for their impact on staff actions and patient outcomes is, however, limited and context dependent.

OBJECTIVE

To explain the factors that support hospital staff to provide dementia sensitive care and with what outcomes for patients with dementia.

DESIGN

A realist evaluation using a two-site case study approach.

SETTING

Two hospital trusts in the East of England. Site 1 had a ward for patients with dementia that would address their medical and mental health needs. Site 2 used a team of healthcare assistants, who had support from dementia specialist nurses, to work with patients with dementia across the hospital.

PARTICIPANTS

Hospital staff who had a responsibility for inpatients with dementia (healthcare assistants, nurses, medical staff, allied healthcare professionals and support staff) (n = 36), patients with dementia (n = 28), and family carers of patients with dementia (n = 2).

METHODS

A three stage realist evaluation: 1) building the programme theory of what works and when; 2) testing the programme theory through empirical data (80 h non-participant observation, 42 interviews, 28 patient medical notes, 27 neuropsychiatric inventory, and documentary review); 3) synthesis and verification of findings with key stakeholders.

FINDINGS

The programme theory comprised six interconnected context-mechanism-outcome configurations: 1) knowledge and authority to respond to an unmet need; 2) role relevant training and opportunities for reflection; 3) clinical experts and senior staff promoting practices that are patient-focused; 4) engaging with opportunities to spend time with patients; 5) risk management as an opportunity for person-centred care; 6) valuing dementia care as skilled work. Effective interactions reduced patient distress and supported patient orientation. Training and allocation of staff time were of themselves insufficient to ensure dementia care was prioritised and valued as skilled work. Staff concerns about the consequences of adverse incidents and work pressures on the ward, even with support, took precedence and influenced the quality of their interactions with patients with dementia. A key finding linked to staff retention and developing capacity in the workforce to provide expert dementia care was that despite extra training and organisational endorsement, nursing staff did not regard dementia care as skilled nursing work.

CONCLUSIONS

There is increased awareness and organisational commitment to dementia-friendly healthcare in general hospitals. However, in addition to training and adapting the environment to the patient, further work is needed to make explicit the specialist skills required for effective dementia care.

The dementia-friendly emergency department: An innovation to reducing incompatibilities at the local level

Emergency Departments (EDs) are an integral part of the Canadian healthcare system. Older people living with dementia challenge EDs. They have complex health profiles that pose multiple challenges for staff. The current one-size-fits-all approach that aids efficiency in a technologically dependent hospital setting may not always serve older people living with dementia, their caregivers, or staff well. The premise that older people living with dementia are a problem for Canadian EDs must be reconsidered. Understanding the complexity of the situation is aided by the dementia-friendly ED framework. We propose one way to enhance communication between those living with dementia who receive ED services and those providing the service.

Feasibility of the Namaste Care Programme to enhance care for those with advanced dementia

Many individuals approaching the end of life with advanced dementia will live in a care or residential home. A wide spectrum of care is required and physical and safety needs may be prioritised above all other requirements. The Namaste Care Programme is designed to provide a holistic approach to meeting the needs of those with advanced dementia. This paper will outline the process of introducing this programme into a care home and its impact upon those who were involved. With a small sample of residents (n=9) the programme ran for 4 weeks. Feedback was gathered at baseline and during the programme from family and staff. This service innovation offered useful insights and indicated that it has the potential to improve the experiences of those with dementia, their family members and staff. The learning gained will be valuable when developing this initiative at scale and for future robust evaluation.

The Impact of Hospitalization on Readmission, Institutionalization, and Mortality of People with Dementia: A Systematic Review and Meta-Analysis

BACKGROUND

People with dementia (PwD) are at a high risk of hospitalization. Hospitals are often not adequately equipped for PwD and discharges often come unexpected. Therefore, PwD are at a risk of adverse outcomes. However, information about those outcomes is rare but crucial for the development of preventive strategies.

OBJECTIVES

To conduct a quantitative systematic review and meta-analyses on the impact of a hospitalization on readmission, institutionalization, and mortality in PwD. To identify factors associated with these outcomes.

METHODS

PubMed, CENTRAL, and ScienceDirect were searched for studies including terms for dementia, hospital, readmission, institutionalization, and mortality. Relevant were assessed by a quality criteria sheet. Results were summarized in a table. Meta-analysis was conducted with Review Manager 5.3.

RESULTS

The search yielded 1,108 studies; 20 fulfilled the inclusion criteria and 10 studies were eligible for meta-analyses. The incidence and relative risk (RR) of mortality (RR 1.74 CI95 % 1.50, 2.05) and institutionalization (RR: 2.16 CI95 % 1.31, 3.56) of PwD was significantly higher when compared to people without dementia. Results according to readmission rate were inconsistent. Factors significantly associated with the examined adverse outcomes were severity of dementia, number of medications, and deficits in daily living activities.

CONCLUSION

Hospitalization of PwD lead to adverse outcomes. An improvement in the identification of and care for PwD in the acute setting as well as in after care in the community setting, especially in the interface between both settings, is required to prevent adverse outcomes in hospitalized PwD.

Investigation into attitudes towards older people with dementia in acute hospital using the Approaches to Dementia Questionnaire

Background

Health care professionals have poor recognition of cognitive impairment among older patients and often have difficulties in providing care for people with dementia in acute hospitals. There are also reported high levels of stigma and negative staff attitudes towards people with dementia.

Methodology

A one-time survey of staff working on acute medical and orthopaedic wards of five District Health Boards in New Zealand using the ‘Approaches to Dementia Questionnaire’; a 19-item Questionnaire that aims to capture two attitudinal domains (Hope and Person-Centredness), towards people with dementia. A total of 563 questionnaires were distributed. Data were analysed using R.

Results

Three hundred and four (53.99%) respondents completed the survey. Ninety-four of the respondents (31.1%) were aged 51 years or older, and nearly all (88.4%) were women. One hundred and sixty-four of the respondents (53.9%) were registered nurses, 10 were student nurses (3.3%), 24 (7.9%) were healthcare assistants, 70 (23.0%) were allied health professionals, 27 (8.9%) were doctors and 9 (3%) were pharmacists. The mean total score of 72.7 reflected positive attitudes overall on the part of the respondents. Allied health professionals, student nurses and pharmacists had high scores on both scales whilst healthcare assistants scored lowest on both scales.

Conclusion

Overall, the Approaches to Dementia Questionnaire is a useful measure, but it can be difficult to differentiate between genuine attitudinal differences and confounding influences such as level of knowledge and education amongst such a diverse group of participants. Differences between staff may be considered as a reflection of the high level of direct care that is expected of some staff and not of others. Further, the Approaches to Dementia Questionnaire may not be the most appropriate measure to accurately understand attitudes to dementia care in acute environments; and that it more usefully reveals knowledge about dementia rather than attitudes related to real-time practice.

Practical strategies to help develop dementia-friendly hospital wards

Hospital stays can have significant negative effects for people with dementia. This article explores methods of improving dementia care in general hospital wards. Taking its starting point as the importance of person-centred care, it explores ways of improving the ward environment, meaningful activities, personal history work, involving carers, and identifying and treating delirium. Practical strategies are suggested in each of these areas. The article acknowledges that implementing change can be challenging in NHS settings where wards are understaffed, and time is precious. However, it encourages all nurses working in these settings to recognise the importance of person-centred care for people with dementia and to make even small changes that can have a significant effect.

The experiences and perceptions of care in acute settings for patients living with dementia: A qualitative evidence synthesis

BACKGROUND

Increasing numbers of people with dementia are presenting to acute care facilities for management of medical conditions and co-morbidities. They require an individual approach to care due to the confusion and disorientation which may accompany their illness. Current evidence syntheses on this topic explore how staff, family and carers view their care. This review aims to complement previous work in the area by exploring care from the perspective of the patient living with dementia.

OBJECTIVES

The aim of this qualitative evidence synthesis was to explore the experiences and perceptions of patients living with dementia on the care they receive in acute settings.

DESIGN

Qualitative evidence synthesis systematically draws the findings from individual studies together to create valid, reliable and meaningful evidence for healthcare policy development. Framework synthesis was utilised and guided by the VIPS framework; Values, Individualised, Perspective, and Social and psychological. The VIPS framework has previously been used for exploring staffs' views of care in the acute setting and provides guidance to caring for people with dementia.

REVIEW METHODS

Following screening, data were extracted and appraised using Critical Appraisal Skills Programme. Framework synthesis, incorporating thematic synthesis, was conducted and the confidence in findings was assessed using GRADE CERQual.

DATA SOURCES

Seven qualitative studies that explored care in acute hospitals as experienced or perceived by the person living with dementia.

RESULTS

The VIPS framework helped to capture views of care. Patients often experienced rushed and task- based approaches, poor communication, and exclusion in some cases. The environments were clearly unsuitable, sometimes exacerbating behaviours of concern, thus leading to unnecessary restraint due to an inability to protect this group.

CONCLUSIONS

Further research needs to be conducted in testing existing or developing new interventions to improve the physical environment, the systems of care and to provide more person-centred approaches to care. Organisational structures must ensure patients are cared for in a dementia friendly environment by a dementia trained workforce. At local level, involving support workers, eliminating unnecessary care practices, and facilitating individual choices of patients are recommended.

Importance of personal and professional experience for hospital staff in person-centred dementia care: a cross-sectional interview study using freelisting in a UK hospital ward

OBJECTIVE

To detail how hospital staff with differing personal and professional caregiving experiences approach the care of patients with dementia, in order to make practical recommendations for practice.

DESIGN

Cross-sectional qualitative interviews.

SETTING

A UK hospital ward providing dementia care.

PARTICIPANTS

A complete hospital ward staff team, constituting 47 hospital staff from 10 professions.

METHODS

Hospital staff were asked to list their approaches to emotion-focused care in individual, ethnographic freelisting interviews. Cultural consensus analysis was used to detail variations in approaches to dementia care between staff subgroups.

MAIN OUTCOME MEASURES

The most salient listed descriptions of care emphasised by staff members with personal experience of dementia caregiving when compared with staff members without such experience, and descriptions from staff newer to the profession compared with staff with more years of professional dementia caregiving experience.

RESULTS

Subgroups of hospital staff showed different patterns of responses both in how they noticed the emotional distress of patients with dementia, and in prioritised responses that they deemed to work. Hospital staff with professional experience of dementia caregiving and staff with fewer years of professional experience prioritised mutual communication and getting to know each patient.

CONCLUSIONS

Subgroups of hospital staff with personal caregiving experiences and fewer years of professional care experience were more likely to describe person-centred care as their routine ways of working with patients with dementia. It is recommended that personal experience and the novice curiosity of hospital staff be considered as valuable resources that exist within multidisciplinary staff teams that could enhance staff training to improve the hospital care for patients with dementia.

Nurses' Experiences in Caring for Older Adults With Responsive Behaviors of Dementia in Acute Care

Introduction: Approximately 56,000 individuals with dementia were admitted to Canadian hospitals in 2016, and 75% of them experience responsive behaviors. Responsive behaviors are words or actions used to express one's needs (e.g., wandering, yelling, hitting, and restlessness). Health-care professionals perceive these behaviors to be a challenging aspect in providing care for persons with dementia.

Aims: This study explores the perceptions of nurses about (a) caring for older adults with dementia experiencing responsive behaviors in acute medical settings and (b) recommendations to improve dementia care.

Methods: Thorne's interpretive description approach was used. In-person, semistructured interviews were conducted with 10 nurses and 5 allied health professionals from acute medical settings in an urban hospital in Ontario. Interviews were conducted with allied health professionals to understand their perspectives regarding care delivery for persons with responsive behaviors of dementia. Data were analyzed using Braun and Clarke's experiential thematic analysis.

Findings: Themes related to caring for individuals with responsive behaviors included (a) delivering care is a complex experience, (b) using pharmacological strategies and low investment nonpharmacological strategies to support older adults with responsive behaviors, (c) acute medical settings conflicted with principles of dementia care due to a focus on acute care priorities and limited time, and (d) strong interprofessional collaboration and good continuity of care were facilitators for care.

Conclusions: Findings provide guidance for improved support for nurses who provide care for individuals experiencing responsive behaviors in acute medical settings such as increasing staffing and providing educational reinforcements (e.g., annual review of dementia care education and in-services).

The impacts of family involvement on general hospital care experiences for people living with dementia: An ethnographic study

BACKGROUND

A quarter of people in general hospitals have dementia. Limited existing studies suggest that hospital care experiences of people living with dementia, and the involvement of their families in care, may be suboptimal.

OBJECTIVES

The objectives of this study were to explore how family involvement impacts upon experiences of hospital care for people living with dementia.

DESIGN

A qualitative ethnographic study.

METHODS

Ethnographic data were collected from two care of older people general hospital wards. Data were collected via observations, conversations and interviews with people living with dementia, families and staff. In total, 400 hours of observation and 46 interviews were conducted across two 7-9 month periods.

RESULTS

People living with dementia could experience a lack of connection on multiple levels - from pre-hospital life as well as life on the wards - where they could spend long periods of time without interacting with anyone. There was great variation in the degree to which staff used opportunities to involve families in improving connections and care. When used, the knowledge and expertise of families played a crucial role in facilitating more meaningful interactions, demonstrating how person-centred connections and care are possible in busy hospital settings. Despite such benefits, the involvement of families and their knowledge was not routine. Care was required to ensure that family involvement did not override the needs and wishes of people living with dementia.

CONCLUSIONS

This study demonstrates the benefits of involving families and their knowledge in care, advocating for family involvement, alongside the involvement of people living with dementia, to become a more routine component of hospital care.

Caring for an older person with dementia in the Emergency Department (ED): An Appreciative Inquiry exploring family member and ED nurse experiences

AIMS AND OBJECTIVES

To generate insights about what matters and is valued by family members of older people with dementia in the emergency department. To explore the experiences of emergency nurses looking after older people with dementia in an episode of care.

BACKGROUND

In the emergency department, older people with dementia are at risk of suboptimal care. Little is known of the experiences of family members of being with an older person with dementia in the emergency department or the experiences of emergency nurses looking after older people with dementia in this environment.

DESIGN AND METHODS

Phase 1 Data Analysis of the Discovery Phase of an Appreciative Inquiry study. Study participants were family members of older people with dementia and emergency nurses. Data collection methods included interviews with family members of older people with dementia and 30 hr of participant observation working alongside emergency nurses. This study was guided by the Standards for Reporting Qualitative Research.

RESULTS

Two themes emerged from the analysis: What matters to family members with four subthemes and challenges for family members and nurses in the emergency department with two subthemes.

CONCLUSION

This study demonstrates that some emergency nurses are connecting with family members even in the briefest of clinical encounters. It is feasible for more emergency nurses to do the same more of the time.

RELEVANCE TO CLINICAL PRACTICE

The older person with dementia must be given a triage category of no less than 3 (to be seen by the doctor within the hour) on arrival in the department. Further education is needed to assist emergency nurses to establish rapport and incorporate family member insights as part of care planning and assessment of the needs of the older person with dementia.

Training interventions to improve general hospital care for older people with cognitive impairment: systematic review

BACKGROUND

In response to increasing numbers of older people in general hospitals who have cognitive impairment such as dementia and delirium, many hospitals have developed education and training programmes to prepare staff for this area of clinical practice.AimsTo review the evidence on educational interventions on hospital care for older people with cognitive impairment.

METHOD

A mixed methods systematic review and narrative synthesis was undertaken. The following electronic databases were searched: Medline, Embase, CINAHL, PsycINFO, EBM Reviews, ASSIA and Scopus, as well as Health Management Information Consortium (HMIC), ProQuest, PubMed and SCIE: Social Care Online. Initial searches were run in August 2014 (update search September 2016). Titles and abstracts of studies retrieved were screened independently. The full text of eligible studies were then independently assessed by two review team members. All included studies were assessed using a standard quality appraisal tool.

RESULTS

Eight studies relating to delirium, six on dementia and two on delirium and dementia were included, each testing the use of a different educational intervention. Overall, the quality of the studies was low. In relation to delirium, all studies reported a significant increase in participants' knowledge immediately post-intervention. Two of the dementia studies reported an increase in dementia knowledge and dementia confidence immediately post-intervention.

CONCLUSIONS

The variety of outcomes measured makes it difficult to summarise the findings. Although studies found increases in staff knowledge, there is insufficient evidence to conclude that educational interventions for staff lead to improved patient outcomes.Declaration of interestNone.

The economic cost of dementia: A systematic review

The purpose of this article is to analyse the available literature describing the economic burden of dementia and to compare costs between studies examining cost drivers. To shed light on this field, a systematic review is performed using PubMed, the Cochrane Library and Web of Science. An eight-year retrospective horizon was considered until 25 May 2018. Several papers were obtained from the database search (n = 23), being others (n = 3) identified through other sources (hand-searching) because we did not detect it through the three databases. The cost estimates were compared between three perspectives: state/publicly funded health services, third-party/private sector/not-for-profit organisations and patient and family and/or societal. The estimated total annual cost per person with dementia in Europe is on average €32,506.73 (n = 10), whereas for the United States, it gets €42,898.65 (n = 2). Furthermore, differences are appreciated by type of costs. Besides, differences by severity groups are also considered. Overall, the higher the severity the higher the associated costs. Dementia imposes a huge economic burden. The figures here presented provide a good framework to quantify these costs for both, economic experts and researchers, and policy decision makers.

Refusal and resistance to care by people living with dementia being cared for within acute hospital wards: an ethnographic study

Background

The acute hospital setting has become a key site of care for people living with dementia. The Department of Health and Social Care recognises that as many as one in four acute hospital beds in the UK will be occupied by a person living with dementia at any given time. However, people living with dementia are a highly vulnerable group within the hospital setting. Following an acute admission, their functional abilities can deteriorate quickly and significantly. Detailed research is required to understand the role and needs of health-care staff caring for this patient population and to explore what constitutes ‘good care’ for people living with dementia within the acute setting.

Objectives

The focus of this study was a common but poorly understood phenomenon within the acute setting: refusal and resistance to care. Our research questions were ‘How do ward staff respond to resistance to everyday care by people living with dementia being cared for on acute hospital wards?’ and ‘What is the perspective of patients and their carers?’.

Design

This ethnography was informed by the symbolic interactionist research tradition, focusing on understanding how action and meaning are constructed within a setting. In-depth evidence-based analysis of everyday care enabled us to understand how ward staff responded to the care needs of people living with dementia and to follow the consequences of their actions.

Setting

This ethnography was carried out on 155 days (over 18 months) in 10 wards within five hospitals across England and Wales, which were purposefully selected to represent a range of hospital types, geographies and socioeconomic catchments.

Participants

In addition to general observations, 155 participants took part directly in this study, contributing to 436 ethnographic interviews. Ten detailed case studies were also undertaken with people living with dementia.

Results

We identified high levels of resistance to care among people living with dementia within acute hospital wards. Every person living with dementia observed within an acute hospital ward resisted care at some point during their admission.

Limitations

Limitations identified included the potential for the Hawthorne or researcher effect to influence data collection and establishing the generalisability of findings.

Conclusions

Ward staff typically interpreted resistance as a feature of a dementia diagnosis, which overshadowed the person. However, resistance to care was typically a response to ward organisation and delivery of care and was typically rational to that person’s present ontology and perceptions. In response, nurses and health-care assistants used multiple interactional approaches that combined highly repetitive language with a focus on completing essential care on the body, which itself had a focus on the containment and restraint of the person in their bed or at their bedside. These approaches to patient care were a response to resistance but also a trigger for resistance, creating cycles of stress for patients, families and ward staff. The findings have informed the development of simple, no-cost innovations at the interactional and organisational level. A further study is examining continence care for people living with dementia in acute hospital settings.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Increased mortality and hospital readmission risk in patients with dementia and a history of cardiovascular disease: Results from a nationwide registry linkage study

OBJECTIVE

To evaluate the impact of cardiovascular disease (CVD) on mortality and readmission risk in patients with dementia.

METHODS

Prospective hospital-based cohort of 59 194 patients with dementia admitted to hospital or visiting a day-clinic between 2000 and 2010. Patients were divided in those with and without a history of CVD (ie, previous admission for CVD; coronary heart disease, heart failure, stroke, atrial fibrillation, or other CVD). Absolute mortality risks (ARs), median survival times, and hazard ratios (adjusted for age, sex, and comorbidity) were calculated.

RESULTS

Three-year ARs and HRs were higher, and survival times were shorter among patients visiting a day-clinic with a history of CVD than in those without. The differences were less pronounced for inpatients. Readmission risk was further increased in the presence of CVD in both day clinic and inpatients.

CONCLUSION

Clinicians need to be more aware of worse prognosis of the population with CVD and dementia.

The experience of hospital staff in applying the Gentle Persuasive Approaches to dementia care

WHAT IS KNOWN ON THE SUBJECT?: Although the seminal work of McCormack et al. (International Practice Development Journal, 2015, 5, 1) and Nolan, Davies, Brown, Keady, and Nolan () provides useful conceptual frameworks in person-centred care, research is needed to understand how theoretical concepts can be applied into practice to support dementia care. Also, evidence is needed to demonstrate the impacts of implementing person-centred care and staff experiences. WHAT DOES THIS PAPER ADD TO EXISTING KNOWLEDGE?: This paper adds to the emerging work that is providing a greater understanding of how team education in practice can make a difference in building capacity to improve dementia care. We offer timely evidence and useful insights into how an education programme, Gentle Persuasive Approaches (GPA), was implemented ("what worked" and "how") in a large Canadian hospital to improve knowledge and skills among staff in dementia care. The GPA education helped hospital staff enact person-centred care by cultivating shared values and a learning environment to change attitudes, practices and conditions for continuous practice development. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses in advance practice are well positioned to lead dementia education and advocate for person-centred care in hospitals. Hospital leaders are responsible for providing resources to cultivate a supportive environment for continuous learning to ensure the workforce gains the capacity to meet the changing demands and needs of the ageing population. System support is essential for creating conditions to enable person-centred care. ABSTRACT: Introduction Hospital staff lacks knowledge and skills in dementia care. There is a need to understand how person-centred care theory can be operationalized in staff's practices to improve dementia care. Aims To describe the staff's experiences of learning and applying the Gentle Persuasive Approaches (GPA) to enact person-centred care in a hospital. Methods Mixed methods, including posteducation survey and focus groups, were used. Thematic analysis was conducted to identify themes that describe participants' experiences. Results Three hundred and ten staff and leaders in a hospital participated in the GPA education and completed a posteducation survey (n = 297). After 1 year, two follow-up focus groups were conducted with interdisciplinary staff (n = 24) across medicine and mental health programmes. Our analysis identified three themes to enable person-centred care: (a) changing attitudes, (b) changing practices and (c) changing conditions. Discussion This study contributes to the literature by providing evidence of how an education programme was implemented in a large Canadian hospital to build capacity for dementia care. Joint education for interprofessional staff offers value in enabling person-centred care. Implication Mental health nurses are in position to lead dementia education and advocate for person-centred care in hospitals. Staff need structural support to engage in team learning for practice improvement.