The management of behavioural and psychological symptoms of dementia in the acute general medical hospital: a longitudinal cohort study

Proactive integrated consultation-liaison psychiatry and time spent in hospital by older medical inpatients in England (The HOME Study): a multicentre, parallel-group, randomised controlled trial

BACKGROUND

Older people admitted to hospital in an emergency often have prolonged inpatient stays that worsen their outcomes, increase health-care costs, and reduce bed availability. Growing evidence suggests that the biopsychosocial complexity of their problems, which include cognitive impairment, depression, anxiety, multiple medical illnesses, and care needs resulting from functional dependency, prolongs hospital stays by making medical treatment less efficient and the planning of post-discharge care more difficult. We aimed to assess the effects of enhancing older inpatients' care with Proactive Integrated Consultation-Liaison Psychiatry (PICLP) in The HOME Study. We have previously described the benefits of PICLP reported by patients and clinicians. In this Article, we report the effectiveness and cost-effectiveness of PICLP-enhanced care, compared with usual care alone, in reducing time in hospital.

METHODS

We did a parallel-group, multicentre, randomised controlled trial in 24 medical wards of three English acute general hospitals. Patients were eligible to take part if they were 65 years or older, had been admitted in an emergency, and were expected to remain in hospital for at least 2 days from the time of enrolment. Participants were randomly allocated to PICLP or usual care in a 1:1 ratio by a database software algorithm that used stratification by hospital, sex, and age, and randomly selected block sizes to ensure allocation concealment. PICLP clinicians (consultation-liaison psychiatrists supported by assisting clinicians) made proactive biopsychosocial assessments of patients' problems, then delivered discharge-focused care as integrated members of ward teams. The primary outcome was time spent as an inpatient (during the index admission and any emergency readmissions) in the 30 days post-randomisation. Secondary outcomes were the rate of discharge from hospital for the total length of the index admission; discharge destination; the length of the index admission after random allocation truncated at 30 days; the number of emergency readmissions to hospital, the number of days spent as an inpatient in an acute general hospital, and the rate of death in the year after random allocation; the patient's experience of the hospital stay; their view on the length of the hospital stay; anxiety (Generalized Anxiety Disorder-2); depression (Patient Health Questionnaire-2); cognitive function (Montreal Cognitive Assessment-Telephone version); independent functioning (Barthel Index of Activities of Daily Living); health-related quality of life (five-level EuroQol five-dimension questionnaire); and overall quality of life. Statisticians and data collectors were masked to treatment allocation; participants and ward staff could not be. Analyses were intention-to-treat. The trial had a patient and public involvement panel and was registered with ISRTCN (ISRCTN86120296).

FINDINGS

2744 participants (1399 [51·0%] male and 1345 [49·0%] female) were enrolled between May 2, 2018, and March 5, 2020; 1373 were allocated to PICLP and 1371 to usual care. Participants' mean age was 82·3 years (SD 8·2) and 2565 (93·5%) participants were White. The mean time spent in hospital in the 30 days post-randomisation (analysed for 2710 [98·8%] participants) was 11·37 days (SD 8·74) with PICLP and 11·85 days (SD 9·00) with usual care; adjusted mean difference -0·45 (95% CI -1·11 to 0·21; p=0·18). The only statistically and clinically significant difference in secondary outcomes was the rate of discharge, which was 8.5% higher (rate ratio 1·09 [95% CI 1·00 to 1·17]; p=0·042) with PICLP-a difference most apparent in patients who stayed for more than 2 weeks. Compared with usual care, PICLP was estimated to be modestly cost-saving and cost-effective over 1 and 3, but not 12, months. No intervention-related serious adverse events occurred.

INTERPRETATION

This is the first randomised controlled trial of PICLP. PICLP is experienced by older medical inpatients and ward staff as enhancing medical care. It is also likely to be cost-saving in the short-term. Although the trial does not provide strong evidence that PICLP reduces time in hospital, it does support and inform its future development and evaluation.

FUNDING

UK National Institute for Health and Care Research.

Is elderspeak communication in simulated hospital dementia care congruent to communication in actual patient care? A mixed-methods pilot study

AIMS

Simulation offers a feasible modality to prepare nurses for challenges communicating with patients with dementia. Elderspeak communication is speech that sounds like baby talk and can lead to rejection of care by patients with dementia. However, it is unknown if simulation can be used to capture elderspeak communication in dementia care. The purpose of this mixed-methods study was to determine if simulation accurately captures elderspeak communication by nursing staff in hospital dementia care.

DESIGN

A 3-part mixed-methods design in which (1) three dementia care simulations were designed and validated by a panel of experts, (2) communication by nursing staff completing each simulation was quantitatively compared to communication during actual patient care, and (3) views on the realism were explored using within- and across-case coding.

METHODS

Three simulations using different modalities (manikin, role-play, and standardised patient) were designed and validated with eight experts using the Lynn Method. Ten nursing staff were audio-recorded and their communication was coded for elderspeak communication. Results for each simulation were compared using Wilcoxon signed-rank test to recordings taken during actual dementia care encounters. Debriefings were coded for realism and results were converged.

RESULTS

The average time using elderspeak during naturalistic care was 29.9% (SD = 20.9%) which did not differ from the average amount of elderspeak used across the three simulations modalities which ranged from 29.1% to 30.4%. Qualitative results suggested a lack of realism with the manikin condition and the nursing staff indicated preference for the simulation with the standardised patient.

CONCLUSIONS

Communication elicited in the dementia care simulations was congruent to communication produced in actual dementia care but preference was for the standardised patient.

IMPLICATIONS FOR PATIENT CARE

Elderspeak communication can be accurately produced in the simulated environment which indicates that simulation is a valid method for person-centred communication training in nursing staff.

IMPACT

Simulation offers a feasible modality to prepare nurses for challenges communicating with patients with dementia. Elderspeak communication is speech that sounds like baby talk and can lead to rejection of care by patients with dementia. However, it is unknown if simulation can be used to capture elderspeak communication in dementia care. Elderspeak communication captured in the simulated environment was congruent to communication nursing staff use during actual patient care to hospitalised persons living with dementia. This study empirically identifies that communication is elicited in similar patterns by nursing staff in the simulated environment compared to the naturalistic care environment which demonstrates that simulation can be used as a valid tool for education and research on person-centred communication.

REPORTING METHODS

STROBE.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

'Becoming restrained': Conceptualising restrictive practices in the care of people living with dementia in acute hospital settings

The use of restrictive practices within health and social care has attracted policy and practice attention, predominantly focusing on children and young people with mental health conditions, learning disabilities and autism. However, despite growing appreciation of the need to improve care quality for people living with dementia (PLWD), the potentially routine use of restrictive practices in their care has received little attention. PLWD are at significant risk of experiencing restrictive practices during unscheduled acute hospital admissions. In everyday routine hospital care of PLWD, concerns about subtle and less visible forms of restrictive practices and their impacts remain. This article draws on Deleuze's concepts of 'assemblage' and 'event' to conceptualise restrictive practices as institutional, interconnection social and political attitudes and organisational cultural practices. We argue that this approach illuminates the diverse ways restrictive practices are used, legitimatised and perpetuated in the care of PLWD. We examine restrictive practices in acute care contexts, understanding their use requires examining the wider socio-political, organisational cultures and professional practice contexts in which clinical practices occurs. Whereas 'events' and 'assemblages' have predominantly been used to examine embodied entanglements in diverse health contexts, examining restrictive practices as a structural assemblage extends the application of this theoretical framework.

A Trajectory of Long-Term Antipsychotic Medication Dosage in Inpatients with Severe Behavioral and Psychological Symptoms of Dementia: A Retrospective Study

INTRODUCTION

While antipsychotics are often prescribed for behavioral and psychological symptoms of dementia (BPSD), typically on an off-label basis, these medications have serious adverse effects. This study investigated the long-term use of antipsychotics among inpatients with dementia displaying severe BPSD, focusing on how prescriptions change over time.

METHODS

Medical charts at Kusakabe Memorial Hospital were retrospectively reviewed from October 2012 to September 2021. The study included patients diagnosed with dementia, admitted for BPSD, and were continuing antipsychotics at 3 months of their admission. Antipsychotic dosages were categorized as high (≥300 mg/d), medium (100-300 mg/d), and low (<100 mg/d) based on chlorpromazine equivalents and tracked until 15 months during hospitalization. Binary logistic regression was used to identify factors associated with dosage reductions between months 3 and 6.

RESULTS

This study involved 188 patients, with an average age of 81.2 years, 67% of whom were diagnosed with Alzheimer's dementia. At 3 months, 15.4% were taking high, 44.1% on medium, and 40.4% on low dosages of antipsychotics. The highest average dosage was observed at 3 months, with a subsequent decrease over time. By the 12th month, 20-30% of patients in all dosage categories had stopped their antipsychotic medication. Significant factors for dosage reduction included higher initial doses (OR 1.003, 95%Cl: 1.001-1.006, P=0.01) and male gender (OR 2.481, 95%Cl: 1.251-4.918, P=0.009).

DISCUSSION

A trajectory of antipsychotic dosage in inpatients with severe BPSD has rarely been reported. This research emphasizes the need for personalized strategies in managing long-term pharmacotherapy for this vulnerable group of patients.

PROTOCOL: Factors influencing the implementation of non-pharmacological interventions for behaviours and psychological symptoms of dementia in residential aged care homes: A systematic review and qualitative evidence synthesis

This is a protocol for a Cochrane Review. The objectives are as follows. This paper aims to describe a protocol for a systematic review that will synthesise the qualitative evidence regarding factors influencing the implementation of non-pharmacological interventions (NPIs) for behavioural and psychological symptoms of dementia (BPSD) management in residential aged care homes (RACHs). The planned systematic review aims to answer the research question: 'What are the factors influencing the implementation of NPIs in the management of BPSD at RACHs?'. Additionally, the planned systematic review also aims to generate recommendations to guide stakeholders (e.g., clinicians and aged care staff) and policymakers in the implementation of NPIs for managing BPSD at RACHs.

The impact of a hospital-based special care unit on behavioural and psychological symptoms in older people living with dementia

BACKGROUND

Hospital patients with behavioural and psychological symptoms of dementia (BPSD) are vulnerable to a range of adverse outcomes. Hospital-based Special Care Units (SCUs) are secure dementia-enabling environments providing specialised gerontological care. Due to a scarcity of research, their value remains unconfirmed.

OBJECTIVE

To compare hospital based SCU management of BPSD with standard care.

DESIGN

Single-case multiple baseline design.

SETTING AND PARTICIPANTS

One-hundred admissions to an 8-bed SCU over 2 years in a large Australian public hospital.

METHODS

Repeated measures of BPSD severity were undertaken prospectively by specialist dementia nurses for patients admitted to a general ward (standard care) and transferred to the SCU. Demographic and other clinical data, including diagnoses, medication use, and care-related outcomes were obtained from medical records retrospectively. Analysis used multilevel models to regress BPSD scores onto care-setting outcomes, adjusting for time and other factors.

RESULTS

When receiving standard care, patients' BPSD severity was 6.8 (95% CI 6.04-7.64) points higher for aggression, 15.6 (95% CI 13.90-17.42) points higher for the neuropsychiatric inventory, and 5.8 (95% CI 5.14-6.50) points higher for non-aggressive agitation compared to SCU. Patients receiving standard care also experienced increased odds for patient-to-nurse violence (OR 2.61, 95% CI 1.67-4.09), security callouts (OR 5.39 95% CI 3.40-8.52), physical restraint (OR 17.20, 95% CI 7.94-37.25) and antipsychotic administration (OR 3.41, 95% CI 1.60-7.24).

CONCLUSION

Clinically significant reductions in BPSD and psychotropic administration were associated with SCU care relative to standard ward care. These results suggest more robust investigation of hospital SCUs, and dementia-enabling design are warranted.

Development of a decision-support framework to support professionals and promote comfort among older hospital inpatients living with dementia

BACKGROUND

Acute hospital wards can be difficult places for many people living with dementia. Promoting comfort and wellbeing can be challenging in this environment. There is little evidence-based support for professionals working on acute care wards on how to respond to distress and maximise comfort and wellbeing among patients living with dementia.

OBJECTIVES

Our overall aim was to codesign an evidence-based easy-to-use heuristic decision-support framework, which was acceptable and practical but acknowledges the complex and acute nature of caring for patients with dementia in the hospital. This paper presents the development process and resulting framework.

METHODS

A codesign study was informed by data from (1) a literature review of the care and management of people living with dementia in acute hospitals; (2) a cohort study of comfort and discomfort in people with dementia in acute hospitals; and (3) interviews with family carers and health care professionals. We synthesised evidence from these data sources and presented to key stakeholders through codesign meetings and workshops to produce our decision-support framework.

RESULTS

The framework consists of a series of flowcharts and operates using a three-stage process of: (1) assess comfort/discomfort; (2) consider causes of discomfort; and (3) address patient needs to manage the discomfort.

CONCLUSION

Working with key stakeholders, synthesising diverse quantitative and qualitative evidence to build a clinical framework is a feasible approach to help address the needs of patients living with dementia in an acute hospital setting. The result is a framework which is now ready for evaluation and implementation.

PATIENT AND PUBLIC CONTRIBUTION

We worked closely with people living with dementia and family carers throughout this study, including the development of the study protocol with input on study development and design, through to inclusion in stakeholder workshops and codesign of the decision support framework.

Identification and information management of cognitive impairment of patients in acute care hospitals: An integrative review

Objectives

Recognition of the cognitive status of patients is important so that care can be tailored accordingly. The objective of this integrative review was to report on the current practices that acute care hospitals use to identify people with cognitive impairment and how information about cognition is managed within the healthcare record as well as the approaches required and recommended by policies.

Methods

Following Whittemore & Knafl's five-step method, we systematically searched Medline, CINAHL, and Scopus databases and various grey literature sources. Articles relevant to the programs that have been implemented in acute care hospitals regarding the identification of cognitive impairment and management of cognition information were included. The Mixed Methods Appraisal Tool and AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) Checklist were used to evaluate the quality of the studies. Thematic analysis was used to present and synthesise results. This review was pre-registered on PROSPERO ( CRD42022343577).

Results

Twenty-two primary studies and ten government/industry publications were included in the analysis. Findings included gaps between practice and policy. Although identification of cognitive impairment, transparency of cognition information, and interaction with patients, families, and carers (if appropriate) about this condition were highly valued at a policy level, sometimes in practice, cognitive assessments were informal, patient cognition information was not recorded, and interactions with patients, families, and carers were lacking.

Discussion

By incorporating cognitive assessment, developing an integrated information management system using information technology, establishing relevant laws and regulations, providing education and training, and adopting a national approach, significant improvements can be made in the care provided to individuals with cognitive impairment.

Nonpharmacological tactile activity interventions for reducing behavioural and psychological symptoms of dementia in the acute hospital setting: An integrative review

AIM

To review existing research on nonpharmacological tactile activity interventions for reducing behavioural and psychological symptoms of dementia in the acute hospital setting.

BACKGROUND

When people living with dementia are admitted to hospital, they often experience an exacerbation of behavioural and psychological symptoms of dementia. Pharmacological interventions are often used to manage behavioural and psychological symptoms of dementia despite the low success rate and the heightened risk of morbidity and mortality. Low-cost alternatives that are implementable at the bedside are nonpharmacological interventions such as tactile activity interventions.

DESIGN

An integrative review of the literature.

METHODS

Four databases were searched using the PRISMA framework to guide the search and screening. Eligible studies were identified and the quality of each was evaluated using the Mixed Method Appraisal Tool. Thematic analysis was conducted to identify and analyse key themes across all articles. The PRISMA checklist was used to evaluate the current study.

RESULTS

Seven studies examined the use of tactile activity interventions to reduce the behavioural and psychological symptoms of dementia and the barriers and facilitators to implementation.

CONCLUSION

There is limited evidence exploring tactile activity interventions for reducing behavioural and psychological symptoms of dementia in acute hospital settings. Individualised approaches in combination with staffing expertise appear central to implementation.

RELEVANCE TO CLINICAL PRACTICE

Acute hospital settings can result in increased behavioural and psychological symptoms of dementia which can be distressing for patients and family and challenging for nursing staff. Tactile activity interventions may offer a low resource bedside option to support people with dementia in acute health settings.

PATIENT OR PUBLIC CONTRIBUTION

No direct patient or public contribution to the review.

The use of constant observation with people with dementia in hospitals: a mixed-methods systematic review

OBJECTIVES

Constant observation is used in hospitals with people with dementia to manage their safety. However, opportunities for proactive care are not consistently recognised or utilised. A systematic review of constant observation was conducted to understand measures of effectiveness and facilitators for person-centred approaches.

METHOD

Electronic databases were searched between 2010 and 2022. Four reviewers completed screening, quality assessments and data extraction with 20% checked for consistency. Findings were presented through narrative synthesis (PROSPERO registration CRD42020221078).

FINDINGS

Twenty-four studies were included. Non-registered staff without specific training were the main providers of constant observation. Assessments and processes clarifying the level of observation encouraged reviews that linked initiation and discontinuation to a patient's changing needs. Examples of person-centred care, derived from studies of volunteers or staff employed to provide activities, demonstrated meaningful engagement could reassure a person and improve their mood. Proactive approaches that anticipated distress were thought to reduce behaviours that carried a risk of harm but supporting evidence was lacking.

CONCLUSION

Non-registered staff are limited by organisational efforts to reduce risk, leading to a focus on containment. Trained staff who are supported during constant observation can connect with patients, provide comfort and potentially reduce behaviours that carry a risk of harm.

Offering Outworld Experiences to In-Patients With Dementia Through Virtual Reality: Mixed Methods Study

Background

Research has suggested that institutionalization can increase the behavioral and psychological symptoms of dementia. To date, recent studies have reported a growing number of successful deployments of virtual reality for people with dementia to alleviate behavioral and psychological symptoms of dementia and improve quality of life. However, virtual reality has yet to be rigorously evaluated, since the findings are still in their infancy, with nonstatistically significant and inconclusive results.

Objective

Unlike prior works, to overcome limitations in the current literature, our virtual reality system was co-designed with people with dementia and experts in dementia care and was evaluated with a larger population of patients with mild to severe cases of dementia.

Methods

Working with 44 patients with dementia and 51 medical experts, we co-designed a virtual reality system to enhance the symptom management of in-patients with dementia residing in long-term care. We evaluated the system with 16 medical experts and 20 people with dementia.

Results

This paper explains the screening process and analysis we used to identify which environments patients would like to receive as an intervention. We also present the system's evaluation results by discussing their impact in depth. According to our findings, virtual reality contributes significantly to the reduction of behavioral and psychological symptoms of dementia, especially for aggressive, agitated, anxious, apathetic, depressive, and fearful behaviors.

Conclusions

Ultimately, we hope that the results from this study will offer insight into how virtual reality technology can be designed, deployed, and used in dementia care.

The association between loneliness and life satisfaction: examining spirituality, religiosity, and religious participation as moderators

BACKGROUND

Future cohort of older adults may have to rely on non-family sources and forms of support, religion being one of them. This may be especially so, considering the recent longitudinal evidence that individuals are inclined to become more religious with increasing age. Thus, the purpose of the present study was to assess the association between loneliness and life satisfaction among older adults in India, and the extent to which the association between loneliness and life satisfaction is moderated by spirituality, religiosity, and religious participation.

METHODS

Data come from the Longitudinal Ageing Study in India, with a sample of 31,464 individuals aged 60 years and above. Multivariable logistic regression models were employed to examine the independent association of loneliness and life satisfaction. Further, an interaction analysis was conducted to examine the extent to which the association between perceived loneliness and life satisfaction is moderated by spirituality, religiosity and religious participation among older Indians.

RESULTS

The prevalence of low life satisfaction (LLS) was 30.84%; a total of 37.25% of participants reported feeling lonely, 12.54% reported a lack of spiritual experience, 21.24% reported not being religious, and 19.31% reported not participating in religious activities. Older adults who felt lonely had higher odds of LLS relative to peers who were not lonely. Further, the adverse impact of loneliness on LLS among older Indians is moderated by their spirituality, religiosity, and religious participation. Specifically, the adverse impact of loneliness on LLS was less negatively pronounced among older adults who were spiritual, religious, and engaged in religious activities.

CONCLUSIONS

The study found an independent association between loneliness and lower life satisfaction among older adults in India. It also revealed that religiosity, spirituality and religious participation moderate the association between loneliness and lower life satisfaction. These findings, which underscore the health promoting benefits of religiosity and religious engagement, may be used to build on the interaction between religious and faith-based groups and public health professionals.

Neuropsychiatric Symptoms as Indicators of Fall Risk in Geriatric Inpatients

Background and Objectives: It is well established that patients with cognitive impairment are at a higher risk of falls. However, the impact of coexisting neuropsychiatric symptoms on the overall risk of falls in hospitalized geriatric individuals with and without dementia has not been extensively studied. This cross-sectional study will assess the association between neuropsychiatric symptoms and fall risk in geriatric individuals analyzed by sex. Materials and Methods: A total of 234 patients, both with and without dementia, admitted to the geriatric ward at Leszek Giec Upper-Silesian Medical Centre of the Silesian Medical University in Katowice, Poland, between January 2019 and January 2020 were included in this study. The Neuropsychiatric Inventory-Questionnaire was used to assess the presence of neuropsychiatric symptoms. Increased fall risk was defined by Berg scores of ≤40. Results: The mean age of the study group was 80.7 ± 6.6, and women accounted for 62.8% of the study population. Apathy was the most common neuropsychiatric symptom, affecting 58.1% of patients, and it was the most common symptom among people with dementia, affecting 67.80% of patients. The receiver operating characteristics curve analysis revealed that a high fall risk was significantly associated with the total number of neuropsychiatric symptoms (≥4) and the total intensity of these symptoms (≥6). For women, high fall risk was associated with three or more neuropsychiatric symptoms and a total neuropsychiatric symptom intensity score of at least 6. For men, the association of high fall risk with the total number of NPS was not significant; a total NPS intensity score of 10 or more was associated with high fall risk. Multivariate logistic regression analysis identified associations with fall risk for hallucinations. Conclusions: Our results suggest that the presence of neuropsychiatric symptoms, particularly hallucinations is associated with an increased risk of falls in geriatric inpatients. In addition, the cumulative total of NPS and their cumulative intensity are both independently associated with an increased risk of falls. These results suggest that fall prevention strategies should include the management of neuropsychiatric symptoms in hospitalized geriatric individuals.

Dementia-related agitation: a 6-year nationwide characterization and analysis of hospitalization outcomes

OBJECTIVES

To characterize all hospitalizations held in mainland Portugal (2010-2015) with dementia-related agitation based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding, and to investigate whether there is a relationship between agitation and hospitalization outcomes.

METHODS

A retrospective observational study was conducted using an administrative dataset containing data from all mainland Portuguese public hospitals. Only hospitalization episodes for patients aged over 65 years who have received a dementia diagnosis ascertained by an ICD-9-CM code of dementia with behavioral disturbance (294.11 and 294.21) and dementia without behavioral disturbance (294.10 and 294.20) were selected. Episodes were further grouped according to the presence of an agitation code. For each episode, demographic data and hospitalization outcomes, including length of stay (LoS), in-hospital mortality, discharge destination and all-cause hospital readmissions, were sourced from the dataset. Comparative analyses were performed and multivariable logistic methods were used to estimate the adjusted associations between agitation (exposure) and outcomes.

RESULTS

Overall, 53,156 episodes were selected, of which 6,586 had an agitation code. These were mostly related to male, younger inpatients (mean 81.19 vs. 83.29 years, p < 0.001), had a higher comorbidity burden, stayed longer at the hospital (median 9.00 vs. 8.00 days, p < 0.001) and frequently ended being transferred to another facility with inpatient care. Agitation was shown to independently increase LoS (aOR = 1.385; 95%CI:1.314-1.461), but not the risk of a fatal outcome (aOR = 0.648; 95%CI:0.600-0.700).

CONCLUSION

These results support the importance of detecting and managing agitation early on admission, since its prompt management may prevent lengthy disruptive hospitalizations.

Reducing Behavioral and Psychological Symptoms of Dementia in Acutely Ill Patients via Patient Engagement Specialists: A Pilot Feasibility Study

Behavioral and psychological symptoms of dementia (BPSD) are common in hospitalized persons living with dementia (PLWD). This pilot aimed to test the feasibility of an innovative model of care, PES-4-BPSD (a dementia unit staffed with Patient Engagement Specialists, PES). Non-randomized pilot feasibility trial was conducted, enrolling N = 158 patients to the intervention unit (n = 79, a 10-bed dementia unit, staffed with nursing assistants, NAs, with mental health backgrounds, PES) and an enhanced control unit (n = 79, 40-bed medicine unit, staffed with NAs). All NAs/PES (N = 63) received dementia training, with completion rate of 82.5%. Overall, patients had ~1 NPI-Q (Neuropsychiatric Inventory Questionnaire) assessment/48 hr. 97% (n = 153) of PLWD exhibited at least one behavior. Average NPI-Q scores did not differ across intervention (5.36) and control (3.87) units (p = .23). Patients on the intervention unit had 88% (p = .002) shorter duration of constant observation. A dementia care unit staffed by PES is an innovative model requiring further research.

Pad cultures: An ethnography of continence care and its consequences for people living with dementia during a hospital admission

BACKGROUND

There is little research examining how continence care is organised and delivered to people living with dementia across an acute hospital admission, despite the prevalence of this patient population and their vulnerability within these settings.

OBJECTIVE

To explore how continence care is delivered to people living with dementia during an acute hospital admission.

DESIGN

Ethnographic.

SETTING(S)

Acute medical units and wards within three hospitals across England and Wales.

PARTICIPANTS

People living with dementia and ward staff (registered nurses and care assistants) on participating wards.

METHODS

Ethnographic fieldwork collected over a period of 12 months (180 days of non-participant observation) focussing on the organisation and delivery of continence care to people living with dementia. Observations were supported with in situ ethnographic interviews (n = 562) with patients, visitors and staff within the six observed wards. Data collection and analysis drew on the theoretical sampling and constant comparison techniques of grounded theory.

RESULTS

The findings comprised of five overall themes: (1) visibility of continence; (2) rationales of continence care; (3) containment and contagion; (4) consequences of continence care and (5) supporting continence.

CONCLUSIONS

We introduce the term 'pad cultures' to refer to the established routine use of continence pads in the care of a wider group of people living with dementia (regardless of continence status and independence), with the rationale to provide safeguards, ensure containment and prevent 'accidents' or incontinent episodes. There was an expectation within acute wards that people living with dementia not only wear continence pads but that they also use them.

Hospital practices and clinical outcomes associated with behavioral symptoms in persons with dementia

BACKGROUND

Hospitalized persons living with dementia (PLWD) often experience behavioral symptoms that challenge medical care.

OBJECTIVE

This study aimed to identify clinical practices and outcomes associated with behavioral symptoms in hospitalized PLWD.

DESIGN

A retrospective cross-sectional study.

SETTINGS AND PARTICIPANTS

The study included PLWD (65+) admitted to one of severe health system hospitals in 2019.

INTERVENTION

Behavioral symptoms were defined as the presence of (1) a psychoactive medication for behavioral symptoms; (2) an order for physical restraints or constant observation; and/or (3) physician documentation of delirium, encephalopathy, or behavioral symptoms.

MAIN OUTCOME AND MEASURES

Associations between behavioral symptoms and patient characteristics and hospital practices (e.g., bladder catheter) were examined. Multivariable logistic/linear regression was used to evaluate the association between behavioral symptoms and clinical outcomes (e.g., mortality).

RESULTS

Of hospitalized PLWD (N = 8637), the average age was 84.5 years (IQR = 79-90), 61.7% were female, 60.1% were white, and 9.4% (n = 833) were Hispanic. Behavioral symptoms were identified in 40.6% (N = 3606) of individuals. Behavioral symptoms were significantly associated with male gender (40.3% vs. 36.9%, p = .001), white race (62.7% vs. 58.3%, p < .001), and residence in a facility prior to admission (26.6% vs. 23.7%, p < .001). Regarding hospital practices, indwelling bladder catheters (11.2% vs. 6.0%, p < .001) and dietary restriction (41.9% vs. 33.8%, p < .001) were associated with behavioral symptoms. In multivariable models, behavioral symptoms were associated with increased hospital mortality (odds ratio [OR]: 1.90, CI95%: 1.57-2.29), length of stay (parameter estimate: 2.10, p < .001), 30-day readmissions (OR: 1.14, CI95%: 1.014-1.289), and decreased discharge home (OR: 0.59, CI95%: 0.53-0.65, p < .001).

CONCLUSIONS

Given the association between behavioral symptoms and poor clinical outcomes, there is an urgent need to improve the provision of care for hospitalized PLWD.

Barriers and facilitators to the use of personal information documents in health and social care settings for people living with dementia: A thematic synthesis and mapping to the COM-B framework

INTRODUCTION

People living with dementia experience communication difficulties. Personal information documents, or healthcare passports, enable communication of information essential for the care of a person with dementia. Despite the potential for providing person-centred care, personal information documents are not ubiquitously used. The Capability Opportunity Motivation-Behaviour (COM-B) model can be used to understand factors determining individuals' behaviours.

OBJECTIVES

This study aimed to identify the barriers to and facilitators of the use of healthcare passports for people living with dementia through a systematic review methodology.

METHODS

A systematic search of six electronic databases was undertaken. Grey literature was searched using three databases. All study types reporting barriers to or facilitators of the use of personal information documents in the care of adults living with dementia in high-income countries were included. Study quality was assessed using the NICE Quality Appraisal Checklist. Thematic synthesis was used to develop descriptive themes, which were subsequently mapped to the COM-B framework.

RESULTS

Nineteen papers were included. Themes included training, awareness, embedding the process in norms and appreciating the value of the personal information documents. A broad range of barriers and facilitators was identified within each COM-B domain.

CONCLUSION

This framework provides a starting point for evidence-informed initiatives to improve the use of personal information documents in the care of people with dementia.

PATIENT AND PUBLIC CONTRIBUTION

This is a review of studies and did not involve patients or the public. Review results will guide evaluation of a local personal information document, which will be designed with input from the Dementia Champions Network (includes carers and other stakeholders).

Reliability and Validity of the Neuropsychiatric Inventory-Questionnaire Using a Rasch Analysis

BACKGROUND AND PURPOSE

The purpose of this study was to expand on the limited psychometric testing of the NPI-Q, and extend testing to include hospitalized older adults.

METHOD

This was a descriptive study using data from 318 dyads in an ongoing cluster randomized clinical trial. Rasch analysis and hypothesis testing were done.

RESULTS

The majority of the participants were female (62%), non-Hispanic (98%), and black (50%) with a mean age of 81.62 (SD = 8.43). There was evidence of internal consistency and invariance across race and gender. The items fit with each subscale. Hypothesis testing was supported with a significant association between the NPI-Q and dementia and caregiver distress.

CONCLUSIONS

The NPI-Q is short, easy to complete, and reliable and valid when used with hospitalized older adults.

Hospital nurses' management of agitation in older cognitively impaired patients: do they recognise pain-related agitation?

BACKGROUND

cognitively impaired hospital patients often experience agitation and aggression due to pain. Agitation complicates care, increasing the risk of adverse outcomes and patient-to-nurse violence. Managing agitation is challenging for nurses. Literature suggests they may rely on antipsychotics while missing other more appropriately targeted treatments. However, nurses' management of agitation remains unclear and under-researched.

OBJECTIVE

the aim of this study was to investigate hospital nurses' management of agitation in older cognitively impaired patients with pain.

DESIGN

this was a descriptive correlational study using virtual simulation.

SETTING AND PARTICIPANTS

a total of 274 registered medical and surgical nurses from 10 public hospitals in Queensland, Australia participated in the study.

METHODS

nurses undertook a virtual simulation requiring them to manage agitation in a patient with dementia and an injury. Nurses also completed a post-simulation questionnaire. Their simulation performances were correlated with demographics such as seniority, workplace, training, experience and gerontology-specific knowledge. Constructed from an original, validated vignette, the simulation included branching pathways, video scenarios and an avatar that could converse with participants.

RESULTS

thirteen nurses (4.7%) recognised and treated the virtual patient's agitation as pain-related. Most nurses (89%) gave antipsychotics of which 207 (78%) gave these first-line and 102 (38%) used them twice. Independent of other variables, nurses most likely to diagnose pain were dementia-unit nurses (OR = 8.7), surgical-unit nurses (OR = 7.3) and senior nurses (OR = 5).

CONCLUSIONS

hospital nurses predominately managed agitation with antipsychotics, a decision that most made after undertaking inadequate patient assessments. This confirmed a common gap in practice that may lead to the missing of pain in the clinical care of agitated patients with dementia and/or delirium.

Exploring dementia care in acute care settings: Perspectives of nurses and social workers on caring for patients with behavioral and psychological symptoms

This qualitative study compares perspectives of nurses (n = 5) and social workers (n = 12) about their role in caring for patients with dementia with behavioral and psychological problems in an acute care setting. A thematic qualitative analysis was conducted using the Rigorous and Accelerated Data Reduction Technique (RADaR). Three themes emerged: engagement of the patient and coordination with family and professionals, treatment and medical management of behavioral and psychological symptoms of dementia (BPSD) in the hospital, and barriers to care. Barriers to care are identified by both professions, with each having its own care niche. Social workers and nurses work as a team with the understanding that they face care challenges. Person centered care is a successful approach for the care team working with patients with BPSD.

Nursing interventions to improve care of people with dementia in hospital: a mixed methods systematic review protocol

OBJECTIVE

This review will focus on the effectiveness of, and experience with, nursing interventions to improve the care of people with dementia in hospital.

INTRODUCTION

Acute care for people with dementia has been identified as an area for improvement. Admission to hospital can be upsetting and difficult for people with dementia and can be associated with negative outcomes. Nurses play a significant role in shaping the experience of hospitalization and are the focus of many related interventions.

INCLUSION CRITERIA

This mixed methods review will examine literature on improving acute care for people with dementia. The quantitative component will consider studies that evaluate nursing interventions to improve care of people with dementia, comparing the intervention with usual care, other therapies, or no comparator. Outcomes will include behavioral, health, and health system indicators. The qualitative component will consider studies that explore the experience of nursing interventions from the perspective of people with dementia, their family- or friend-caregivers, and nurses.

METHODS

This review will be conducted in accordance with JBI methodology for mixed methods systematic reviews. Twelve databases and gray literature sources will be searched for published and unpublished studies. Titles, abstracts, and full-text selections will be screened by two or more independent reviewers and assessed for methodological validity using the standard JBI critical assessment tools. This review will follow a convergent segregated approach to data synthesis and integration.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42021230951.

Physical restraint of dementia patients in acute care hospitals during the COVID-19 pandemic: A cohort analysis in Japan

Introduction

The coronavirus disease (COVID-19) pandemic has caused unprecedented challenges for the medical staff worldwide, especially for those in hospitals where COVID-19-positive patients are hospitalized. The announcement of COVID-19 hospital restrictions by the Japanese government has led to several limitations in hospital care, including an increased use of physical restraints, which could affect the care of elderly dementia patients. However, few studies have empirically validated the impact of physical restraint use during the COVID-19 pandemic. We aimed to evaluate the impact of regulatory changes, consequent to the pandemic, on physical restraint use among elderly dementia patients in acute care hospitals.

Methods

In this retrospective study, we extracted the data of elderly patients (aged > 64 years) who received dementia care in acute care hospitals between January 6, 2019, and July 4, 2020. We divided patients into two groups depending on whether they were admitted to hospitals that received COVID-19-positive patients. We calculated descriptive statistics to compare the trend in 2-week intervals and conducted an interrupted time-series analysis to validate the changes in the use of physical restraint.

Results

In hospitals that received COVID-19-positive patients, the number of patients who were physically restrained per 1,000 hospital admissions increased after the government’s announcement, with a maximum incidence of 501.4 per 1,000 hospital admissions between the 73rd and 74th week after the announcement. Additionally, a significant increase in the use of physical restraints for elderly dementia patients was noted (p = 0.004) in hospitals that received COVID-19-positive patients. Elderly dementia patients who required personal care experienced a significant increase in the use of physical restraints during the COVID-19 pandemic.

Conclusion

Understanding the causes and mechanisms underlying an increased use of physical restraints for dementia patients can help design more effective care protocols for similar future situations.

Antipsychotic prescribing in people admitted to hospital with dementia or delirium

OBJECTIVE

To evaluate antipsychotic prescribing in people with dementia or delirium admitted to a large regional Queensland hospital.

METHODS

A retrospective observational study analysing medical records of patients prescribed antipsychotics over 6 months.

RESULTS

We audited a sample of 141 patients, 65 years or over (over 45 years for indigenous peoples) with dementia or delirium, without severe mental illness, prescribed antipsychotics. Over a third (35%) were prescribed antipsychotics prior to admission, with 73% prescribed a new antipsychotic in hospital. Only 23% received documented review of antipsychotic therapy. Under half (48%) had evidence of non-pharmacological interventions as first-line management. Sixty-eight patients (48%) were discharged with antipsychotics; however, only 4% were provided an antipsychotic management plan.

CONCLUSION

Initiation and continuation of antipsychotics in patients with dementia or delirium in hospital is common, with infrequent review. There is significant potential to reduce prescribing antipsychotics in people admitted to hospital with dementia or delirium.

Risk of hospitalization and hip fracture associated with psychotropic polypharmacy in patients with dementia: A nationwide register-based study

OBJECTIVE

To investigate the association of benzodiazepines and antidepressants on the risk of hospitalization and hip fracture in patients with dementia initiating antipsychotic drug treatment.

METHODS

A register-based retrospective cohort study using data on all incident dementia cases (≥65 years) initiating antipsychotic treatment as monotherapy or in combination with benzodiazepines and/or antidepressants in Denmark from 2000 to 2015. The outcomes of interest were all-cause hospitalization and hip fracture. Cox proportional hazards models with adjustment for multiple variables were used to investigate risk of hospitalization and hip fracture within 180 days.

RESULTS

The risk of all-cause hospitalization during 180-days follow-up was significantly increased by 55% (adjusted HR: 1.55, 95% CI: 1.29-1.86, p < 0.0001), when antipsychotic use was combined with benzodiazepines, when compared to antipsychotic monotherapy. The association between the combination of antipsychotics and benzodiazepines with the risk of hip fracture did not reach statistical significance (adjusted HR: 1.50, 95% CI: 0.99-2.26, p = 0.0534).

CONCLUSIONS

The observed increased risk of all-cause hospitalization and hip fracture may indicate increased drug-related adverse events. Thus, careful and regular monitoring is needed to assess response to treatment and decrease the risk of adverse events, when antipsychotics are combined with BZDs, albeit confounding cannot be fully excluded within the current design.

Trauma-informed care in geriatric inpatient units to improve staff skills and reduce patient distress: a co-designed study protocol

Background

Geriatric hospital wards are highly medicalised environments with limited opportunities for choice and control, and can be distressing for older survivors of psychological trauma. While trauma-informed models of care (TIC) are effectively applied across mental health and other settings, the utility of these models in aged care settings has not been assessed. The objective of this study was to examine whether TIC can reduce responsive behaviour, chemical restraint, and improve staff skills and patient experiences in inpatient geriatric settings.

Methods

Four wards participated in this type I hybrid implementation-effectiveness study across southern Adelaide, Australia, including 79 beds. Using a co-design method, the principles of TIC were transformed into an implementation strategy including staff training, establishment of highly trained ‘champions’ on each ward, screening for trauma-related needs, and amending ward policies and procedures. Primary outcomes will be examined using an interrupted time-series design and are monthly incidence of responsive behaviour incidents and use of chemical restraint. Process evaluation will be used to examine secondary, implementation outcomes including the acceptability, feasibility, and fidelity to the implementation strategy.

Discussion

Trauma-informed care has potential to improve the safety and accessibility of hospital wards for older people who have survived psychologically traumatic events and has an extensive evidence base supporting its effectiveness in other settings. Identifying trauma-related needs and amending care to reduce the risk of re-traumatisation and distress may also reduce the incidence of responsive behaviour change, which has a significant impact on the quality of life of hospital patients and staff and is very costly. The inclusion of a process evaluation will allow us to identify and report changes made on each ward and make recommendations for future implementation efforts.

Acupuncture for Behavioral and Psychological Symptoms of Dementia: A Systematic Review and Meta-Analysis

Dementia is an important health issue worldwide, and non-pharmacological strategies for the management of behavioral and psychological symptoms of dementia (BPSD) are considered to be important. This review analyzes the effectiveness and safety of acupuncture for BPSD. Thirteen electronic databases were comprehensively searched to find clinical studies using acupuncture on BPSD, published up to December 2020. Five randomized controlled clinical trials and two before-after studies, mainly on Alzheimer’s disease (AD), were included. Meta-analysis suggested that the total effective rate based on BPSD symptoms in the acupuncture combined with psychotropic drugs group was significantly higher than that in the psychotropic drugs group (risk ratio, 1.27; 95% confidence interval, 1.11 to 1.45; I² = 51%). In terms of other outcomes related to BPSD, acupuncture as an adjunctive therapy, but not as monotherapy, was associated with significant benefits in most included studies. However, the included studies did not have optimal methodological quality. Our review highlights the limited evidence proving the effectiveness and safety of acupuncture for BPSD in patients with AD. Although some clinical studies have reported the potential benefits of adjuvant acupuncture in managing BPSD, the evidence is not robust and is based on small studies. Therefore, high-quality research in this field is needed.

Association of recent hospitalisation with antidepressant initiation among community dwellers with Alzheimer's disease

OBJECTIVES

Antidepressant are commonly prescribed to persons with cognitive disorders to treat depressive and other neuropsychiatric symptoms despite the inconclusive evidence on their effectiveness on this indication. We studied whether recent hospitalisation was associated with antidepressant initiation in people with Alzheimer's disease (AD).

METHODS

The register-based Finnish nationwide Medication use and Alzheimer's disease cohort includes community-dwelling persons diagnosed with AD during 2005-2011 in Finland (n = 70,718). This study was restricted to people who initiated antidepressant use after AD diagnosis and had no active cancer treatment and schizophrenia or bipolar disorder diagnoses. We performed a nested case-control study with antidepressant initiators as cases. A matched noninitiator (sex, age and AD duration), was identified for each initiator (15,360 matched pairs). Recent hospitalisation was defined as hospital discharge within the past 14 days of initiation.

RESULTS

Antidepressant initiators were four times more likely (adjusted odds ratio: 4.41, 95% confidence interval: 4.06-4.80) to have been hospitalised within the past 2 weeks before initiation (21.2%, n = 3250) than matched noninitiators (5.4%, n = 831) and the duration of hospital stay was significantly longer among initiators. Dementia was the most common main discharge diagnosis among both initiators (43.8%, n = 1423) and noninitiators (24.8%, n = 206).

CONCLUSION

Recent hospitalisation was strongly associated with antidepressant initiation in persons with AD. Further studies are needed to investigate whether this is due to neuropsychiatric symptoms leading to hospital admission, inpatient care triggering or worsening neuropsychiatric symptoms or other indications. Nonpharmacological treatments for neuropsychiatric symptoms should be prioritised and the threshold for prescribing antidepressants should be high.

The association between an early diagnosis of dementia and secondary health service use

Background

dementia policy suggests diagnosing dementia early can reduce the risk of potentially harmful hospital admissions or emergency department (ED) attendances; however, there is little evidence to support this. A diagnosis of mild cognitive impairment (MCI) before dementia is a helpful proxy to explore early diagnosis. This study investigated the association between an early diagnosis of dementia and subsequent hospitalisations and ED attendances.

Method

a retrospective cohort study of electronic health care records from 15,836 patients from a large secondary care database in South London, UK. Participants were divided into two groups: those with a diagnosis of MCI before dementia, an early diagnosis, and those without. Cox regression models were used to compare the risk of hospitalisation and ED attendance after dementia diagnosis and negative binomial regression models were used to compare the average length of stay and average number of ED attendances.

Results

participants with an early diagnosis were more likely to attend ED after their diagnosis of dementia (HR = 1.09, CI = 1.00–1.18); however, there was no difference in the number of ED attendances (IRR = 1.04, CI = 0.95–1.13). There was no difference in the risk of hospitalisation (HR = 0.99, CI = 0.91–1.08) or length of stay between the groups (IRR = 0.97, CI = 0.85–1.12).

Conclusion

the findings of this study do not support the assumption that an early diagnosis reduces the risk of hospitalisation or ED attendance. The patterns of health service use in this paper could reflect help-seeking behaviour before diagnosis or levels of co-morbidity.

Administering Virtual Reality Therapy to Manage Behavioral and Psychological Symptoms in Patients With Dementia Admitted to an Acute Care Hospital: Results of a Pilot Study

BACKGROUND

As virtual reality (VR) technologies become increasingly accessible and affordable, clinicians are eager to try VR therapy as a novel means to manage behavioral and psychological symptoms of dementia, which are exacerbated during acute care hospitalization, with the goal of reducing the use of antipsychotics, sedatives, and physical restraints associated with negative adverse effects, increased length of stay, and caregiver burden. To date, no evaluations of immersive VR therapy have been reported for patients with dementia in acute care hospitals.

OBJECTIVE

This study aimed to determine the feasibility (acceptance, comfort, and safety) of using immersive VR therapy for people living with dementia (mild, moderate, and advanced) during acute care hospitalization and explore its potential to manage behavioral and psychological symptoms of dementia.

METHODS

A prospective, longitudinal pilot study was conducted at a community teaching hospital in Toronto. The study was nonrandomized and unblinded. A total of 10 patients aged >65 years (mean 86.5, SD 5.7) diagnosed with dementia participated in one or more research coordinator-facilitated sessions of viewing immersive 360° VR footage of nature scenes displayed on a Samsung Gear VR head-mounted display. This mixed-methods study included review of patient charts, standardized observations during the intervention, and pre- and postintervention semistructured interviews about the VR experience.

RESULTS

All recruited participants (N=10) completed the study. Of the 10 participants, 7 (70%) displayed enjoyment or relaxation during the VR session, which averaged 6 minutes per view, and 1 (10%) experienced dizziness. No interference between the VR equipment and hearing aids or medical devices was reported.

CONCLUSIONS

It is feasible to expose older people with dementia of various degrees admitted to an acute care hospital to immersive VR therapy. VR therapy was found to be acceptable to and comfortable by most participants. This pilot study provides the basis for conducting the first randomized controlled trial to evaluate the impact of VR therapy on managing behavioral and psychological symptoms of dementia in acute care hospitals.

Are patients with cognitive impairment fit to fly? Current evidence and practical recommendations

BACKGROUND

The worldwide prevalence of dementia is increasing and represents a major public health concern. In the last decades, air travel services have undergone an impressive expansion and one of ten passengers is aged 65 years and older. While air travel can be stressful at all ages and health conditions, older individuals with cognitive impairment carry a greater risk for air-travel-related complications. Consequently, demands to general practitioners for assessing their older patient's fitness to fly are increasing.

METHODS

We conducted a search of the literature in PubMed on the impact of in-flight environmental changes on passengers with cognitive impairment and possible resulting complications. This set the base for a discussion on pharmacological and non-pharmacological interventions aimed at preventing in-flight complications in this vulnerable population.

RESULTS

While our research strategy identified a total of 11 articles related to older age and air travel, only three focused on passengers with cognitive impairment. Our literature review showed that the airplane environment may lead to a large spectrum of symptoms in passengers of all age groups. However, passengers with cognitive impairment due to neurodegenerative diseases are at increased risk for experiencing the most extreme symptoms such as acute confusional state. Non-pharmacological and pharmacological interventions at different stages of the travel process (before, during and after) can help prevent complications in this vulnerable population.

CONCLUSION

The decision to let a patient with cognitive impairment fly requires a solid understanding of the in-flight environmental changes and their impact on older patients with cognitive impairment. Moreover, a sound weighing of the risks and benefits while considering different aspects of the patient's history is demanded. In this regard, the role of the treating physicians and caregivers is essential along with the support of the medical department of the airline.

Disparities in Physical and Psychological Symptoms in Hospitalized African American and White Persons with Dementia

Objectives: This study examined differences in physical function, delirium, depressive symptoms, and behavioral and psychological symptoms of dementia (BPSD) in hospitalized African American and white older adults with dementia. Methods: This secondary data analysis using baseline data from an ongoing trial testing family-centered function-focused care included African American (n = 159) and white persons (n =135) with dementia. Results: A multivariate analysis of covariance showed that controlling for relevant demographic and health characteristics, African Americans with dementia had lower physical function, more delirium, and more depressive symptoms upon admission than white participants. There were no significant differences in BPSD between African American and white persons. Discussion: To our knowledge, this is the first study to examine racial differences in admission symptoms of hospitalized persons with dementia. While the findings are preliminary, they can be used to inform the design of future research, including identifying the causes of disparities.

Benzodiazepine exposure in subjects with incident Alzheimer's disease and related syndromes in France: a longitudinal study 2011-2017

Benzodiazepines are commonly used for behavioral and psychiatric symptoms of dementia, despite their numerous adverse effects and the lack of evidence regarding their efficacy in this context. We studied longitudinal benzodiazepines exposure in incident cases of Alzheimer's disease and related syndromes (ADRS) in France. We used a cohort of incident ADRS patients identified in 2012 within the national health data system. Benzodiazepines exposure was measured 1 year before, to 5 years after ADRS identification. Quarterly benzodiazepines prevalence and incidence were computed. We identified factors associated with long half-life benzodiazepines initiation. A total of 106 508 subjects were included. Quarterly benzodiazepines prevalence was stable (around 25%) but we saw an important decrease in long half-life benzodiazepines compensated by an increase in short half-life benzodiazepines. In most benzodiazepine initiations, the first episode lasted less than 3 months. Factors associated with initiating a long half-life benzodiazepine were young age, male gender, no registration with ADRS as a long-term disease, having consulted an ADRS specialist, antipsychotic reimbursement before the index date, no admission in nursing home. Prevalence of benzodiazepines use remains high in subjects with ADRS despite guidelines for their avoidance. However, indicators regarding benzodiazepine initiations (duration, benzodiazepine type) suggest some caution in their use.

Exploring the barriers and gateways to intersubjectivity in dementia care: A meta-ethnography

BACKGROUND

Behaviours that challenge in dementia, often described and diagnosed as behavioural psychological symptoms of dementia, are experienced by 75% of people living with dementia in care homes or hospital environments, with 43% of nurses and care providers reporting these behaviours as moderately or severely distressing to them. During behaviours that challenge moments in dementia, there is the potential for an intersubjective relationship to take place between the people living with dementia and the nurse.

AIMS

This review explores and synthesises literature to consider the presence of intersubjectivity in people living with dementia. If the ability to be intersubjective remains present for people living with dementia, it will consider how its presence can be nurtured to offer a positive intersubjective communication between the person living with dementia and their carer/nurse.

METHODS

The review used meta-ethnography methodology to develop concepts that help us to understand the implications of existing research on the presence of intersubjectivity in people living with dementia, and its relationship to those providing their care. Sixteen electronic databases (including MEDLINE/PubMed, Wiley Online Library and Sage publications) and grey literature such as Alzheimer's Society and Department of Health across journals dating from 2000-2020 were searched. Eight studies were selected and reviewed for quality and relevance for a meta-ethnographic literature synthesis of intersubjectivity in dementia.

CONCLUSION

The meta-ethnography concluded that people living with dementia continue to have the capacity to be intersubjective on an emotional level. Nurses and other care providers need to acknowledge the presence of "personhood" and "personness" in people living with dementia to nurture positive intersubjective care relationships. The meta-ethnography has also been reviewed for reporting clarity against the EQUATOR checklist in the form of the eMERGe guideline (France et al., 2019).

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.].

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.

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.

Occupational status and hospitalisation for mental disorders: findings from Friuli Venezia Giulia region, Italy, 2008-2017

Purpose: To investigate to which extent occupational status, and job titles, were associated with types of hospitalisations and psychiatric diagnoses among inpatients of Friuli Venezia Giulia Region, Italy.Methods: Cross-sectional study based on 10 years register data (2008-2017) on 2929 subjects hospitalised in General Hospital Psychiatric Units. Odds ratios (OR) of hospitalisations and psychiatric diagnoses for occupational status and job titles were calculated by logistic regression analysis.Results: Employed were at lower risk of urgent and involuntary hospitalisation. The risk of urgent hospitalisation was higher for affective, organic or other disorders, while all psychiatric diagnoses were at lower risk of involuntary hospitalisation than psychosis. Using white collars as reference category, army showed a higher risk for urgent hospitalisation (OR = 2.3) and affective disorders (OR = 1.9). A higher risk for affective disorders was found in managers (OR = 2.0). Blue collars were at higher risk for alcohol and substance abuse (OR = 1.7).Conclusions: Employment was protective for urgent and involuntary hospitalisations and severe diagnoses. Hospitalisation for affective disorders was more likely in managers, army, and for substances abuse in blue collars. More research is needed to assess the association between specific occupational groups and involuntary hospitalisation.KeypointsEmployment was shown to be a protective factor for both urgent and involuntary hospitalisations and diagnosis of severe mental disorder.Managers, police and military forces were at higher risk of being hospitalised for affective disorders, while blue collars were at higher risk of hospitalisation for alcohol and substances abuse.Future research would benefit from a better analysis on the association between more specific occupational groups and hospitalisation for psychiatric disorders, with a particular focus on involuntary treatment.Further research is needed to compare the risk of hospitalisation for mental disorders in temporary or permanent position, according to recent international changes in labour market and its impact on mental health.

Hospitalisation rates and predictors in people with dementia: a systematic review and meta-analysis

BACKGROUND

Hospitalisation is often harmful for people with dementia and results in high societal costs, so avoidance of unnecessary admissions is a global priority. However, no intervention has yet reduced admissions of community-dwelling people with dementia. We therefore aimed to examine hospitalisation rates of people with dementia and whether these differ from people without dementia and to identify socio-demographic and clinical predictors of hospitalisation.

METHODS

We searched MEDLINE, Embase, and PsycINFO from inception to 9 May 2019. We included observational studies which (1) examined community-dwelling people with dementia of any age or dementia subtype, (2) diagnosed dementia using validated diagnostic criteria, and (3) examined all-cause general (i.e. non-psychiatric) hospital admissions. Two authors screened abstracts for inclusion and independently extracted data and assessed included studies for risk of bias. Three authors graded evidence strength using Cochrane's GRADE approach, including assessing for evidence of publication bias using Begg's test. We used random effects meta-analysis to pool estimates for hospitalisation risk in people with and without dementia.

RESULTS

We included 34 studies of 277,432 people with dementia: 17 from the USA, 15 from Europe, and 2 from Asia. The pooled relative risk of hospitalisation for people with dementia compared to those without was 1.42 (95% confidence interval 1.21, 1.66) in studies adjusted for age, sex, and physical comorbidity. Hospitalisation rates in people with dementia were between 0.37 and 1.26/person-year in high-quality studies. There was strong evidence that admission is associated with older age, and moderately strong evidence that multimorbidity, polypharmacy, and lower functional ability are associated with admission. There was strong evidence that dementia severity alone is not associated.

CONCLUSIONS

People with dementia are more frequently admitted to hospital than those without dementia, independent of physical comorbidities. Future interventions to reduce unnecessary hospitalisations should target potentially modifiable factors, such as polypharmacy and functional ability, in high-risk populations.

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.

Hospitalisation of people with dementia: evidence from English electronic health records from 2008 to 2016

Hospitalisation of people with dementia is associated with adverse outcomes and high costs. We aimed to examine general, i.e. non-psychiatric, hospitalisation rates, changes since 2008 and factors associated with admission. We also aimed to compare admission rates of people with dementia with age-matched people without dementia. We conducted a cohort study of adults ≥ 65 years, with dementia diagnosed during the 2008-2016 study window, derived from a large secondary mental healthcare database in South London, UK. We used national general hospital records to identify emergency and elective hospitalisations. We calculated the cumulative incidence and rate of hospitalisation and examined predictors of hospitalisation using negative binomial regression, with multiple imputation for missing covariate data. We calculated age-standardised admission ratio for people with dementia compared to those without. Of 10,137 people, 50.6% were admitted to hospital in the year following dementia diagnosis and 75.9% were admitted during median 2.5 years follow-up. Annual admission rate was 1.26/person-year of which 0.90/person-year were in emergency. Emergency hospitalisation rate increased throughout the study period. Compared to controls without diagnosed dementia in the catchment area, the age-standardised emergency admission ratio for people with dementia was 2.06 (95% CI 1.95, 2.18). Male, older, white and socio-economically deprived people and those with clinically significant comorbid physical illness, depressed mood, activity of daily living or living condition problems had more hospitalisations. Emergency hospitalisations of people with dementia are higher than those without, and increasing. Many factors associated with admission are social and psychological, and may be targets for future interventions that aim to reduce avoidable admissions.

Constant Observation Practices for Hospitalized Persons With Dementia: A Survey Study

Despite substantial staffing and cost implications, the use of constant observation (CO) has been poorly described in the acute care setting. The purpose of this cross-sectional, multicenter, survey study was to assess hospital provider practices regarding the use of CO. Of the 543 surveys distributed, 231 were completed across 5 sites. Most respondents worked on medical units (67.5%), as nurses (49.1%); 44.8% were white; and 75.6% were female. The majority (84.2%) reported at least 1 patient/wk requiring CO. Most frequent indication for CO was dementia with agitation (60.7%), in patients older than 70 (62.3%) and predominantly by nurse assistants (93.9%). Almost half (47.3%) stated they felt pressured to discontinue CO, despite a strong perceived benefit (76%). Enhanced observation (92.6%) was most frequently used to decrease CO. Finally, 77.9% perceived that those performing CO lacked training. Our study highlights the widespread use of CO for hospitalized older adults with dementia.

Co-development of "BRAIN-TRK": Qualitative examination of acceptability, usability and feasibility of an App to support nurses' care for patients with behavioural and psychological symptoms of neurocognitive disorders in hospital

AIMS AND OBJECTIVES

(a) Describe the co-development of a point-of-care App to promote uptake of best practice recommendations and consolidate nurses' knowledge for managing symptoms of neurocognitive disorders. (b) Report acceptability, usability and feasibility of the App to nurses for patient care in hospital.

BACKGROUND

Strategies used in hospitals to reduce symptoms, risk of harm, or complications of behavioural and psychological symptoms associated with neurocognitive disorders are frequently inconsistent with best practice recommendations.

DESIGN

Three-stage, mixed-methods, process and outcome evaluation.

METHODS

The App was co-developed with experts, nurse end-users and a consumer. Evaluation data were collected from a convenience sample of nurses observed during delivery of 80.5 hr of care to 38 patients; the App (n = 32 patients); and individual and focus group interviews with nurses (n = 25). Reporting adhered to an adapted STROBE checklist.

RESULTS

The App included three components: cognition and risk assessment; tailored evidence-based strategies; and monitoring and evaluation of effectiveness. Observation data captured nurses using the App with 44.7% (n = 17) of eligible inpatients. Cognitive screening was completed at least once for each patient, with 146 risk assessments recorded. Interview data indicated the App's acceptability was enhanced by familiarity and perceived benefits, but hindered by perceived increases in workload, inconsistent use, pressure to use the App and resistance to change. Feasibility and usability were enhanced by easy navigation, and clear and useful content, but hindered by unclear expectations, unfamiliarity and device-related factors.

CONCLUSIONS

The App provided an evidence-based tool that was, overall, considered feasible and acceptable to support best practice. Findings provide guidance to enhance usability for future implementation.

RELEVANCE TO CLINICAL PRACTICE

Co-development using best evidence and key stakeholders enabled creation of a novel, feasible and acceptable technology. Real-time access to assessment tools and tailored knowledge supported nurses' clinical decision-making; workload and unfamiliarity were barriers to use.

Delirium and Antipsychotic Medications at Hospital Intake: Screening to Decrease Likelihood of Aggression in Inpatient Settings Among Unknown Patients With Dementia

For individuals with dementia, disorientation and both external and internal stimuli may trigger behaviors that are difficult to manage or dangerous to health-care providers. Identification of correlational risk factors to aggressive behavior in patients who are unknown to the hospital can allow providers to adapt patient care quickly. Records for patients aged 60+ who spent at least 24 hours at the hospital other than in the psychiatric unit were used (N = 14 080). The first 4000 records and every 10th person who met criteria (N = 5008) were searched for documentation of dementia (n = 505). Logistic regressions and χ2 tests were used to examine relationships between variables. Recognition of delirium (P = .014, Exp(B) = 2.53), coupled with an existing prescription for antipsychotic medication at intake (P < .001, Exp(B) < 4.37), may be a reliable means of screening for risk and intervening at the earliest possible contact, improving quality of care and safety in acute care for individuals with dementia.