[Geropsychiatric consultation-liaison services. An answer to the challenges of dementia?]

Why are there so many hospital beds in Germany?

The place of hospitals in health systems is undergoing rapid change worldwide due to the high cost of hospital care and the changing health needs of the population. The Covid-19 pandemic has recently drawn public attention towards hospital capacity and has added new urgency to discussions on the future role of hospitals. In this context, recent experience in Germany provides valuable information for health systems seeking to manage hospital capacity. Despite reform efforts to reduce hospital capacity, Germany has the highest rates of intensive care beds among high-income countries and the highest overall hospital capacity in Europe. The capacity of the German hospital system can be explained in large part by the high number of elderly in-patients. This, in turn, is driven by (1) a fragmented ambulatory care system; (2) physicians admitting and maintaining elderly patients in hospital at a high rate; (3) a hospital market adding incentives to admit patients; and (4) a political commitment to egalitarian access and universal care. Additionally, recent policies to reduce hospital capacity have had limited impact because hospitals have not responded to financial incentives in the expected manner. Countries looking to learn from Germany's hospital capacity must therefore consider systemic features, political commitments, and unintended policy consequences.

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.

[Dementia friendly care services in general hospitals : Representative results of the general hospital study (GHoSt)]

BACKGROUND

Mostly model projects report on special care services and procedures for general hospital patients with cognitive impairment. The objective of this study was to determine the frequency of special care services and procedures in general hospitals on the basis of a representative cross-sectional study.

METHODS

From a list of all general hospitals in southern Germany we randomly selected a specified number of hospitals und somatic wards. The hospitals were visited and all older patients on the selected wards on that day were included in the study. Information about care services and their utilization was collected with standardized instruments.

RESULTS

A total of 33 general hospitals and 172 wards participated in the study. The patient sample included 1469 persons over 65 (mean age 78.6 years) and 40% of the patients showed cognitive impairments. The staff reported that the most frequent measures for patients with cognitive impairments concerned patients with wandering behavior (63.1%), efforts to involve the patients' relatives to help with their daily care (60.1%), conducting nonintrusive interviews to identify cognitive impairments (59.9%), allocation to other rooms (58%) and visual aids for place orientation of patients (50.6%). In accordance with earlier studies our results show that other dementia friendly services implemented in pilot projects were rare. The existing special services for patients with cognitive impairment were rarely used by the patients or their relatives.

DISCUSSION

The results demonstrate the urgent need to improve special care services and routines for identification of elderly patients with cognitive impairment and risk of delirium in general hospitals.

Preventing postoperative delirium

BACKGROUND

Delirium is a common complication in elderly hospitalized patients. It prolongs the length of hospital stay, raises costs, increases the workload of the nursing staff, and may necessitate transfer of the patient to a nursing home. The risk of postoperative delirium is particularly high in elderly patients with pre-existing cognitive deficits.

METHODS

In an open study, we systematically assessed the frequency of postoperative delirium in patients over age 70 on two surgical wards of a general hospital. In a six-month "prevalence phase," from March to August 2011, we counted the number of patients with postoperative delirium, but did not initiate any intervention. Thereafter, in a ten-month "intervention phase" from September 2011 to June 2012, a nurse with special training in the management of delirium carried out an intervention involving component measures of the Hospital Elder Life Program (HELP) on one of the two wards, with the aim of preventing postoperative delirium. The patients on the other ward served as a control group.

RESULTS

In the prevalence phase, 20.2% of all patients developed postoperative delirium (95% confidence interval [CI], 14.6-26.4). In the intervention phase, postoperative delirium arose in 20.8% (95% CI, 11.3-32.1) of the patients on the ward with no specific interventions, but in only 4.9% (95% CI, 0.0-11.5) of those on the ward where the intervention was carried out. The difference was presumably due to the measures initiated by the specially trained nurse, including validation, improvement of sleep, cognitive activation, early mobilization, improved sensory stimulation, and improved nutritional and fluid intake. Important predictors of postoperative delirium included a low score on the Mini-Mental State Examination, advanced age, and preoperative infection.

CONCLUSION

The frequency of postoperative delirium in elderly patients with cognitive deficits can be lowered with nursing measures carried out by a specially trained nurse, close postoperative supervision, and cognitive activation.

[Acute and long-term cognitive consequences of treatment on intensive care units]

BACKGROUND

Following treatment on the intensive care unit (ICU) patients often suffer from acute and long-term cognitive deficits. This is true for patients of all age groups but especially for elderly patients who have undergone surgery and develop postoperative delirium (POD) or postoperative cognitive decline (POCD). Both are associated with severe limitations in the quality of life and long-term outcome.

OBJECTIVE

Which acute and long-term cognitive effects develop in ICU survivors and how do they influence the outcome? How can POD and POCD be differentiated?

METHOD

A selective literature search was carried out.

RESULTS

Following surgery POCD can develop within days to weeks, may persist for weeks or months and can lead to problems in attentiveness even under conditions of inconspicuous consciousness. Remission is possible but may take up to more than 12 months. The POD is a phenomenon characterized by disturbances of consciousness and problems in attention, beginning acutely hours and days postoperatively, can persist for days to weeks and remission can be expected within a few days. While POD often has an organic cause, such as an infection, the pathogenesis of POCD has not been sufficiently elucidated.

DISCUSSION

Both POD and particularly POCD can lead to a deterioration of cognition following ICU treatment. As efficient treatment still has to be developed preventive methods, such as preoperative screening for risk factors, thorough planning of operative and anesthetic techniques and compensation of risk factors as well as providing assistance to patients, e. g. by a trained nurse should be implemented in the clinical routine more often than is presently the case.

[Geriatric psychiatric home counseling for people with dementia and anosognosia : Results of a model project]

BACKGROUND

Lack of awareness of an illness (anosognosia) is a common symptom in dementia and has a significant impact on the course of the disease. It is associated with dysfunctional interaction with caregivers. Due to unawareness patients are not able to accept diagnostic procedures or medical treatment and refuse any kind of support. Thus, they are not integrated into psychosocial networks and medical support. This has a significant impact on patient-centered care in a domestic environment. In this article a model project with home visits to patients with dementia and anosognosia is described.

METHOD

A total of 55 home visits were carried out. The aim of this project was the integration into the existing healthcare services in order to safeguard the domestic environment. These visits focused on advice and information for the patients and their caregivers initiating the visits. Sociodemographic data of the patient cohort and the satisfaction of the caregiving relatives and general practitioners are presented.

RESULTS

Subjects with dementia were found to be in advanced stages of the disease, caring situations were complex and required assistance. Caregivers showed a substantial burden in accordance with previous reports.

CONCLUSION

New strategies are required to cope with anosognosia in patients with dementia and their caregivers. Even single home visits seem to be sufficient to initiate support for subjects with dementia and their relatives.