A systematic review of the prevalence, associations and outcomes of dementia in older general hospital inpatients

'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.

Neutrophil-Lymphocytes Ratio as Potential Early Marker for Alzheimer's Disease

Background

Neutrophil-lymphocyte ratio (NLR) is a noninvasive, inexpensive, and easily applicable marker of inflammation. Since immune dysregulation leading to inflammation is regarded as a hallmark of dementia, in particular Alzheimer's disease (AD), we decided to investigate the potentials of NLR as a diagnostic and predictive biomarker in this clinical setting.

Materials and Methods

NLR was measured in the blood of patients with AD (n = 103), amnestic type mild cognitive impairment (aMCI, n = 212), vascular dementia (VAD, n = 34), and cognitively healthy Controls (n = 61). One hundred twelve MCI patients underwent a regular clinical follow-up. Over a 36-months median follow-up, 80 remained stable, while 32 progressed to overt dementia.

Results

NLR was higher in patients with aMCI or dementia compared to Controls; however, the difference was statistically significant only for aMCI (+13%, p=0.04) and AD (+20%, p=0.03). These results were confirmed by multivariate logistic analysis, which showed that high NLR was associated with an increase in the likelihood of receiving a diagnosis of aMCI (odd ratio (OR): 2.58, 95% confidence interval (CI): 1.36-4.89) or AD (OR: 3.13, 95%CI: 1.47-6.70), but not of VAD. NLR did not differ when comparing stable vs. progressing aMCI.

Conclusions

This is the first report showing that NLR is significantly increased in MCI and AD but not in VAD. We also found that NLR was unable to predict the conversion from aMCI to AD. Further research on larger cohorts is warranted to definitely ascertain the application of NLR as a possible marker for aMCI and AD.

Effects of a dementia educational programme using virtual reality on nurses in an acute care hospital: A pre-post comparative study

BACKGROUND

Poor awareness of dementia care by healthcare professionals affects the quality of care for people living with dementia in acute care settings.

OBJECTIVES

This study examined the effectiveness of a virtual reality-based educational programme for dementia for nurses working in acute care hospitals in Japan.

METHODS

A dementia education programme for nurses was designed. The programme comprised short movies, virtual reality videos based on the short movies, a lecture, discussions and role-playing based on the experimental learning model. Virtual reality video content was created to promote empathy for people living with dementia through a first-person experience of dementia. The educational programme involved nurses working in an acute care hospital in the Tokyo Metropolitan area. Before and after the programme, we employed structured questionnaires using validated instruments to assess participants' attitudes towards people living with dementia, their intentions of helping behaviour and their confidence in providing dementia care.

RESULTS

Seventy-six nurses participated in and completed the pre- and post-tests. The mean age was 34.9 ± 9.2 years, and 90.8% of the participants were female. A paired t-test showed significant before-after improvement in the participants' attitudes towards people living with dementia (41.9 ± 5.1 vs. 44.5 ± 4.8), intentions of helping behaviour towards people living with dementia (10.8 ± 2.5 vs. 12.8 ± 2.1) and confidence in providing dementia care (25.9 ± 6.7 vs. 29.2 ± 6.0).

CONCLUSION

The programme effectively improved nurses' attitudes towards people living with dementia and confidence in providing dementia care in acute care settings. Future research is important to explore the long-term effects of this programme and its effects on actual dementia care.

IMPLICATIONS FOR PRACTICE

The dementia education programme may promote person-centred care in acute hospitals. Future studies should consider the provision of more flexible programs so that nurses can more easily participate in them.

Nurses' perspectives on shared decision-making in the daily care of hospitalized patients with dementia: An exploratory qualitative study

AIM

Gain insight into the process of shared decision-making (SDM) in daily hospital care for patients with dementia from nurses' perspectives.

DESIGN

Explorative qualitative design.

METHODS

In-depth digital interviews were conducted with 14 registered nurses between June and November 2022. A phenomenological approach was applied using Colaizzi's seven-step method.

RESULTS

Five themes were identified in the data: (1) SDM in daily care: How shared decision-making is applied; (2) Nurses' perceptions and competence: How nurses perceive and manage SDM; (3) Nurses' roles and advocacy: The evolving roles of nurses and their advocacy efforts, (4) Recognition of dementia and its impact: How nurses recognize and manage dementia; and (5) Interventions to support SDM: Strategies and interventions to facilitate SDM.

CONCLUSION

This study highlights the complexity of SDM in patients with dementia. It demonstrates the importance of the involvement of relatives, omission of patient goals in discussions and perceived deficiencies of nurses. The early identification of dementia, evaluation of nuanced capacity and targeted communication are essential. Further research and enhanced training are required to improve care in this context.

IMPACT

Potential areas for further research on SDM in nurses involving patients with dementia include investigating the effects of integrating goal discussions into SDM training for nurses, overcoming barriers to SDM competence, and challenging the idea that SDM is solely the responsibility of physicians. These findings highlight the need for policies that encourage interdisciplinary collaboration, address misconceptions and recommend training programmes that focus on applying SDM to the daily care of patients with dementia, thereby improving the overall quality of patient care.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used for reporting.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Dementia prevalence among hospitalized older patients: a multicenter study in Iran

Dementia poses a significant societal and health challenge in the 21st century, with many hospitalized patients experiencing dementia without a documented diagnosis.

Objective

To evaluate the prevalence of dementia and its associated risk factors among older patients admitted to hospitals.

Methods

The study included older patients (≥ 60 years) admitted to medical departments of a general hospital in three major Iranian cities. Researchers utilized the Activities of Daily Living-Instrumental Activities of Daily Living (ADL-IADL) scale, the Geriatric Depression Scale (GDS), the Mini-Cog test, the 4 A's test (4AT), and the Abbreviated Mental Test Score (AMTS). Among the 420 recruited older inpatients, 228 (54.3%) were female.

Results

The mean age of participants was 71.39 years (standard deviation ±7.95), with 30.7% diagnosed with major neurocognitive disorder (dementia). The likelihood of dementia exhibited statistically significant correlations with gender, age, number of children, and occupation.

Conclusions

Screening older individuals for cognitive impairment upon hospital admission holds the potential to prevent adverse outcomes and enhance the quality of treatment for patients concurrently dealing with dementia.

Development of clinical items to identify dysphagia in patients with dementia-An e-Delphi study

AIM

To identify clinical observable items that can be used to identify dysphagia while observing a typical eating situation.

DESIGN

A three-round e-Delphi survey.

METHODS

An expert panel consisting of five nurses, eight speech language therapists and five physicians participated in this three-round e-Delphi survey from November 2022 to January 2023. Round 1 presented the results of a literature research conducted in September 2022 and an open question to the participants. The answers were analysed using the content analysis method. In the following rounds, the results were presented back to the participants with a request to rate them for usefulness. Means, standard deviations, ANOVA and Fisher's exact test were used to demonstrate the panel's opinion, level of agreement, demographic characteristics of the participants as well as differences between the professional groups in regard of the rating of the items. Methods and results are reported in accordance with the 'Guidance on Conducting and Reporting Delphi Studies' (CREDES).

RESULTS

The content analysis initially generated 36 items suggested by the expert panel. Seven additional items were incorporated from the literature review. In rounds 2 and 3, a 4-point Likert scale was used to rate each item and to calculate the level of agreement. The predetermined level of agreement exceeded 70% for 23 items.

CONCLUSION

Based on the expert opinions, it is possible for nurses to identify dysphagia in patients with dementia by using the determined 23 items while observing a typical eating situation.

PATIENT OR PUBLIC CONTRIBUTIONS

The expert panel contributed to the creation of this study by participating in the Delphi rounds.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The 23 items determined in this e-Delphi study enable nurses to make dietary adjustments or consult other members of the multidisciplinary team based on available evidence, enabling complications to be avoided.

IMPACT

What problem did the study address? This study provides evidence regarding the identification of dysphagia in patients with dementia by nurses. What were the main findings? Twenty-three items were determined by an expert panel that can be used by nurses to identify dysphagia in patients with dementia while observing a typical eating situation. Where and on whom will the research have an impact? This research will have an impact on patients with dementia and the nurses caring for them.

REPORTING METHOD

Methods and results are reported in accordance with the 'Guidance on Conducting and Reporting Delphi Studies' (CREDES) (Jünger et al., 2017), which promotes consistency and quality in conducting Delphi studies.

Recognition of cognitive dysfunction in hospitalised older patients: a flash mob study

BACKGROUND

It is important that healthcare professionals recognise cognitive dysfunction in hospitalised older patients in order to address associated care needs, such as enhanced involvement of relatives and extra cognitive and functional support. However, studies analysing medical records suggest that healthcare professionals have low awareness of cognitive dysfunction in hospitalised older patients. In this study, we investigated the prevalence of cognitive dysfunction in hospitalised older patients, the percentage of patients in which cognitive dysfunction was recognised by healthcare professionals, and which variables were associated with recognition.

METHODS

A multicentre, nationwide, cross-sectional observational study was conducted on a single day using a flash mob study design in thirteen university and general hospitals in the Netherlands. Cognitive function was assessed in hospitalised patients aged ≥ 65 years old, who were admitted to medical and surgical wards. A Mini-Cog score of < 3 out of 5 indicated cognitive dysfunction. The attending nurses and physicians were asked whether they suspected cognitive dysfunction in their patient. Variables associated with recognition of cognitive dysfunction were assessed using multilevel and multivariable logistic regression analyses.

RESULTS

347 of 757 enrolled patients (46%) showed cognitive dysfunction. Cognitive dysfunction was recognised by attending nurses in 137 of 323 patients (42%) and by physicians in 156 patients (48%). In 135 patients (42%), cognitive dysfunction was not recognised by either the attending nurse or physician. Recognition of cognitive dysfunction was better at a lower Mini-Cog score, with the best recognition in patients with the lowest scores. Patients with a Mini-Cog score < 3 were best recognised in the geriatric department (69% by nurses and 72% by physicians).

CONCLUSION

Cognitive dysfunction is common in hospitalised older patients and is poorly recognised by healthcare professionals. This study highlights the need to improve recognition of cognitive dysfunction in hospitalised older patients, particularly in individuals with less apparent cognitive dysfunction. The high proportion of older patients with cognitive dysfunction suggests that it may be beneficial to provide care tailored to cognitive dysfunction for all hospitalised older patients.

Digital remote monitoring for screening and early detection of urinary tract infections

Urinary Tract Infections (UTIs) are one of the most prevalent bacterial infections in older adults and a significant contributor to unplanned hospital admissions in People Living with Dementia (PLWD), with early detection being crucial due to the predicament of reporting symptoms and limited help-seeking behaviour. The most common diagnostic tool is urine sample analysis, which can be time-consuming and is only employed where UTI clinical suspicion exists. In this method development and proof-of-concept study, participants living with dementia were monitored via low-cost devices in the home that passively measure activity, sleep, and nocturnal physiology. Using 27828 person-days of remote monitoring data (from 117 participants), we engineered features representing symptoms used for diagnosing a UTI. We then evaluate explainable machine learning techniques in passively calculating UTI risk and perform stratification on scores to support clinical translation and allow control over the balance between alert rate and sensitivity and specificity. The proposed UTI algorithm achieves a sensitivity of 65.3% (95% Confidence Interval (CI) = 64.3-66.2) and specificity of 70.9% (68.6-73.1) when predicting UTIs on unseen participants and after risk stratification, a sensitivity of 74.7% (67.9-81.5) and specificity of 87.9% (85.0-90.9). In addition, feature importance methods reveal that the largest contributions to the predictions were bathroom visit statistics, night-time respiratory rate, and the number of previous UTI events, aligning with the literature. Our machine learning method alerts clinicians of UTI risk in subjects, enabling earlier detection and enhanced screening when considering treatment.

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.

Documentation of cognitive impairment screening amongst older hospitalised Australians: a prospective clinical record audit

BACKGROUND

Failure to detect cognitive impairment (CI) in hospitalised older inpatients has serious medical and legal implications, including for the implementation of care planning. This mixed methods study aimed to determine amongst hospital in-patients aged ≥ 65 years: (1) Rates of documentation of screening for CI, including the factors associated with completion of screening; (2) Rates of undocumented CI amongst patients who had not received screening during their admission; (3) Healthcare provider practices and barriers related to CI screening.

METHODS

A mixed methods study incorporating a clinical audit and interviews with healthcare providers was conducted at one Australian public hospital. Patients were eligible for inclusion if they were aged 65 years and older and were admitted to a participating ward for a minimum of 48 h. Patient characteristics, whether CI screening had been documented, were extracted using a template. Patients who had not been screened for CI completed the Montreal Cognitive Assessment (MoCA) to determine cognitive status. Interviews were conducted with healthcare providers to understand practices and barriers to screening for CI.

RESULTS

Of the 165 patients included, 34.5% (n = 57) had screening for CI documented for their current admission. Patients aged > 85 years and those with two or more admissions had greater odds of having CI screening documented. Among patients without CI screening documented, 72% (n = 78) were identified as cognitively impaired. While healthcare providers agreed CI screening was beneficial, they identified lack of time and poor knowledge as barriers to undertaking screening.

CONCLUSIONS

CI is frequently unrecognised in the hospital setting which is a missed opportunity for the provision of appropriate care. Future research should identify feasible and effective strategies to increase implementation of CI screening in hospitals.

Visual identifiers for people with dementia in hospitals: a qualitative study to unravel mechanisms of action for improving quality of care

BACKGROUND

Hospitalised people with dementia (PwD) experience worse care and more patient safety incidents than non-dementia patients. Visual identifiers are commonly used to identify patients who have a diagnosis of dementia, with the aim of promoting more personalised care. However, little is known about how they work in practice, nor about the potential unintended consequences that might arise from their use. We aim to identify the mechanisms through which visual identifiers could support good care for PwD, how and why their use may have negative consequences and the conditions for their effective use.

METHODS

We conducted interviews with 21 dementia leads and healthcare professionals, 19 carers and two PwD, and produced case studies of visual identification systems in four UK acute hospital trusts between 2019 and 2021. Analysis drew on the concept of classification to identify and explore mechanisms of action.

RESULTS

We identified four mechanisms through which visual identifiers could help towards providing good care for PwD: enabling coordination of care at organisational level; signalling eligibility for dementia-specific interventions; informing prioritisation of resources on wards; and acting as a quick reference cue for staff. But identifier effectiveness could be undermined by: lack of standardisation and consistency; a lack of closely coupled information about individual needs; and stigma associated with a dementia diagnosis. Identifier effectiveness was dependent on their implementation being supported through staff training, resources directed and efforts to develop a supportive culture for caring for this patient group.

CONCLUSION

Our research highlights the potential mechanisms of action of visual identifiers and their possible negative consequences. Optimising the use of identifiers requires consensus on the rules of classification and the symbols used, and closely coupled patient information. Organisations need to provide support, offer the right resources and training and engage meaningfully with carers and patients about the use of identifiers.

Practical Application of a Battery of Brief Tools to Evaluate Geriatric Medical Inpatients for the Three Ds

OBJECTIVE

The investigators aimed to identify the clinical characteristics of patients with or without delirium and preexisting depression, dementia, both, or neither by using validated tools easily administered in clinical practice.

METHODS

In this cross-sectional prospective observational study conducted in Medellín, Colombia, 200 geriatric inpatients were evaluated with the Delirium Diagnostic Tool-Provisional (DDT-Pro), Informant Questionnaire on Cognitive Decline in the Elderly, Hachinski Ischemic Scale, Cornell Scale for Depression in Dementia, and Charlson Comorbidity Index-short form. Delirium motor subtype, mortality, and length of hospital stay were assessed.

RESULTS

The study included 134 patients without delirium (67%), 14 with delirium only (7%), 16 with delirium and dementia (8%), 13 with delirium and depression (7%), and 23 with delirium, dementia, and depression (the three Ds) (12%). Prevalence rates of dementia (59%) and depression (55%) among 66 patients with delirium were higher than prevalence rates among patients without delirium (13% and 28%, respectively), suggesting that both conditions are risk factors. Main medical diagnoses, mortality, and dementia type did not differ among groups. Motor subtypes were similar among delirium groups. Patients in the delirium groups, except those in the delirium and depression group, were older than patients without delirium. Medical burden was highest among the patients with delirium and dementia and those with all three conditions. Delirium and dementia were more severe when comorbid with each other. Depression was most severe among patients with delirium and depression. Patients with all three conditions had a longer length of hospital stay than those without delirium.

CONCLUSIONS

Using brief tools to detect dementia and depression in conjunction with the DDT-Pro to assess delirium diagnosis and severity is feasible and enables a more in-depth evaluation of elderly hospitalized patients. Because previous longitudinal research suggests that these comorbid conditions influence prognosis following a delirium episode, better identification of the three Ds offers proactive interventional opportunities. Depression is an underrecognized risk factor for delirium.

Individualized Summary Assessment of Detailed Neuropsychological Testing for the Etiological Diagnosis of Newly Detected Cognitive Impairment in Hospitalized Geriatric Patients

BACKGROUND

Neuropsychological testing (NPT) of geriatric inpatients can be affected by the acute illness and/or the hospitalization.

OBJECTIVE

To test individualized interpretation of detailed NPT for the differentiation between primary 'neurodegenerative' etiologies (predominantly Alzheimer's disease) and 'other' etiologies (including cerebrovascular disease) of newly detected cognitive impairment in geriatric inpatients without and with delirium in remission.

METHODS

96 geriatric inpatients (81.9±5.6 years, 64.6% females) with clinically uncertain cognitive impairment were included. 31.3% had delirium in remission that was not considered the primary cause of the cognitive impairment. Categorization of the most likely etiology as 'neurodegenerative' or 'other' was established retrospectively by a study neuropsychologist based on individualized summary assessment of detailed NPT compiled in a standardized vignette. The etiological diagnosis based on FDG-PET served as gold standard (54.2% 'neurodegenerative', 45.8% 'other').

RESULTS

Individualized summary assessment by the study neuropsychologist was correct in 80 patients (83.3%, 8 false positive, 8 false negative). The impact of delirium in remission was not significant (p = 0.237). Individualized summary assessment by an independent neuropsychologist resulted in more false positive cases (n = 22) at the same rate of false negative cases (n = 8). Automatic categorization with a decision tree model based on the most discriminative NPT scores was correct in 68 patients (70.8%, 14 false positive, 14 false negative).

CONCLUSION

Individualized summary assessment of detailed NPT in the context of relevant clinical information might be useful for the etiological diagnosis of newly detected cognitive impairment in hospitalized geriatric patients, also in patients with delirium in remission, but requires task-specific expertise.

The impact of dementia on rehabilitation outcomes following hip fracture

Objective

To compare clinical outcomes between patients for whom their participation in inpatient rehabilitation was and was not impacted by dementia through matching patients reporting dementia (dementia group) with those not reporting dementia (non-dementia group).

Methods

Prospectively collected data held by the Australasian Rehabilitation Outcome Centre (AROC) were analyzed for patients aged 65 years or older receiving inpatient rehabilitation in public hospitals in Australia following a hip fracture and discharged between July 1, 2014, and June 30, 2019. Patients reported as having dementia impacting their rehabilitation program were matched to patients not reporting dementia based on age, admission motor Functional Independence Measure (FIM) score, and accommodation prior to rehabilitation. The matched cohorts were compared in relation to clinical outcomes (motor and cognitive FIM improvement, FIM efficiency, length of stay, and discharge destination) following participation in hospital-based rehabilitation using univariate analysis.

Results

Patients with dementia had significantly lower cognitive FIM scores on commencing rehabilitation (17.6 and 26.9, respectively, P < 0.001) and their median length of stay was 2 days shorter than those without dementia (21 and 23 days, respectively, P < 0.001). Relative change in FIM score and FIM efficiency (per week) were lower in the dementia group [relative FIM score change of dementia vs non-dementia, respectively, 26.2% vs. 44.0% (P < 0.001) and FIM efficiency, 6.5 vs. 8.9 (P < 0.001)]. Discharge destination between the two groups was statistically different, with 35.7% of patients with dementia being discharged to residential aged care facilities (RACFs) compared to 21.7% of those without dementia (P < 0.001). More patients with dementia had carers in their private residence in the post-rehabilitation phase, 82.2% vs. 57.6% (P < 0.001).

Conclusion

Patients with dementia who sustain a fractured hip benefit from inpatient rehabilitation, although their clinical outcomes are not as good as those without dementia. FIM change and FIM efficiency were lower in the dementia group. Length of stay in the hospital for patients with dementia was shorter due to earlier recognition for the need for placement in either an RACF or at home with carer support. The need for placement in an RACF or carer support in a private residence was significantly greater in the dementia group.

Acute effects of different exercise forms on executive function and the mechanism of cerebral hemodynamics in hospitalized T2DM patients: a within-subject study

Objective

This study aimed to investigate the acute effects of aerobic exercise (AE), resistance exercise (RE), and integrated concurrent exercise (ICE; i.e., AE plus RE) on executive function among hospitalized type 2 diabetes mellitus (T2DM) inpatients, and the mechanism of cerebral hemodynamics.

Methods

A within-subject design was applied in 30 hospitalized patients with T2DM aged between 45 and 70 years in the Jiangsu Geriatric Hospital, China. The participants were asked to take AE, RE, and ICE for 3 days at 48-h intervals. Three executive function (EF) tests, namely, Stroop, More-odd shifting, and 2-back tests, were applied at baseline and after each exercise. The functional near-infrared spectroscopy brain function imaging system was used to collect cerebral hemodynamic data. The one-way repeated measurement ANOVA was used to explore training effects on each test indicator.

Results

Compared with the baseline data, the EF indicators have been improved after both ICE and RE (p < 0.05). Compared with the AE group, the ICE and RE groups have demonstrated significant improvements in inhibition (ICE: MD = - 162.92 ms; RE: MD = -106.86 ms) and conversion functions (ICE: MD = -111.79 ms; RE: MD = -86.95 ms). Based on the cerebral hemodynamic data, the beta values of brain activation in executive function related brain regions increased after three kinds of exercise, the EF improvements after the ICE showed synchronous activation of blood flow in the dorsolateral prefrontal cortex (DLPFC), the frontal polar (FPA) and orbitofrontal cortex (OFC), the improvement of inhibitory function after RE displayed synchronous activation of DLPFC and FPA, and AE mainly activates DLPFC. The HbO₂ concentration in the pars triangularis Broca's area increased significantly after AE, but the EF did not improve significantly.

Conclusion

The ICE is preferred for the improvements of executive function in T2DM patients, while AE is more conducive to the improvements of refresh function. Moreover, a synergistic mechanism exists between cognitive function and blood flow activation in specific brain regions.

A narrative review of staff views about dementia care in hospital through the lens of a systems framework

Background

Significant numbers of people with dementia are admitted into acute settings. They are likely to face poor health outcomes during hospitalisation. There is the need to fully understand the care provided to people with dementia through novel methods such as a systems approach (i.e. human interactions, policy, environment and equipment).

Aim

The aim of this literature review is to explore hospital practitioners' views on dementia care and to analyse findings using a systems approach.

Methods

We conducted a narrative review of primary studies that examined dementia care in acute settings. We analysed a total of 33 papers using Thomas and Harden's thematic synthesis guidelines.

Results

Thirty-three papers met the inclusion criteria for the review. The findings were as follows: (1) staff-patient relationships (e.g. coping with difficult behaviour), (2) staff-family relationships (e.g. the benefits of involving families in patient care), (3) staff-staff relationships (e.g. building a robust multidisciplinary team), (4) staff-patient care decisions (e.g. decisions directly related to the patient), (5) the environment (e.g. difficulty in adjusting to the hospital environment), (6) policies (e.g. hospital bureaucratic processes) and (7) equipment (e.g. pain assessment tools).

Conclusion

The paper revealed multidimensional challenges in the provision of dementia care within hospitals. We conclude that training programmes, hospital policies and processes aimed at improving outcomes for patients with dementia should adopt a systems approach which focuses on the relational, environmental, procedural and instrumental aspects of the hospital system.

Predicting Progression to Clinical Alzheimer's Disease Dementia Using the Random Survival Forest

BACKGROUND

Assessing the risk of developing clinical Alzheimer's disease (AD) dementia, by machine learning survival analysis approaches, among participants registered in Alzheimer's Disease Centers is important for AD dementia management.

OBJECTIVE

To construct a prediction model for the onset time of clinical AD dementia using the National Alzheimer Coordinating Center (NACC) and the Alzheimer's Disease Neuroimaging Initiative (ADNI) registered cohorts.

METHODS

A model was constructed using the Random Survival Forest (RSF) approach and internally and externally validated on the NACC cohort and the ADNI cohort. An R package and a Shiny app were provided for accessing the model.

RESULTS

We built a predictive model having the six predictors: delayed logical memory score (story recall), CDR® Dementia Staging Instrument - Sum of Boxes, general orientation in CDR®, ability to remember dates and ability to pay bills in the Functional Activities Questionnaire, and patient age. The C indices of the model were 90.82% (SE = 0.71%) and 86.51% (SE = 0.75%) in NACC and ADNI respectively. The time-dependent AUC and accuracy at 48 months were 92.48% (SE = 1.12%) and 88.66% (SE = 1.00%) respectively in NACC, and 90.16% (SE = 1.12%) and 85.00% (SE = 1.14%) respectively in ADNI.

CONCLUSION

The model showed good prediction performance and the six predictors were easy to obtain, cost-effective, and non-invasive. The model could be used to inform clinicians and patients on the probability of developing clinical AD dementia in 4 years with high accuracy.

Retrospective study of more than 5 million emergency admissions to hospitals in England: Epidemiology and outcomes for people with dementia

INTRODUCTION

People living with dementia (PwD) admitted in emergency to an acute hospital may be at higher risk of inappropriate care and poorer outcomes including longer hospitalisations and higher risk of emergency re-admission or death. Since 2009 numerous national and local initiatives in England have sought to improve hospital care for PwD. We compared outcomes of emergency admissions for cohorts of patients aged 65+ with and without dementia at three points in time.

METHODS

We analysed emergency admissions (EAs) from the Hospital Episodes Statistics datasets for England 2010/11, 2012/13 and 2016/17. Dementia upon admission was based on a diagnosis in the patient's hospital records within the last five years. Outcomes were length of hospital stays (LoS), long stays (> = 15 days), emergency re-admissions (ERAs) and death in hospital or within 30 days post-discharge. A wide range of covariates were taken into account, including patient demographics, pre-existing health and reasons for admission. Hierarchical multivariable regression analysis, applied separately for males and females, estimated group differences adjusted for covariates.

RESULTS

We included 178 acute hospitals and 5,580,106 EAs, of which 356,992 (13.9%) were male PwD and 561,349 (18.6%) female PwD. Uncontrolled differences in outcomes between the patient groups were substantial but were considerably reduced after control for covariates. Covariate-adjusted differences in LoS were similar at all time-points and in 2016/17 were 17% (95%CI 15%-18%) and 12% (10%-14%) longer for male and female PwD respectively compared to patients without dementia. Adjusted excess risk of an ERA for PwD reduced over time to 17% (15%-18%) for males and 17% (16%-19%) for females, but principally due to increased ERA rates amongst patients without dementia. Adjusted overall mortality was 30% to 40% higher for PwD of both sexes throughout the time-period; however, adjusted in-hospital rates of mortality differed only slightly between the patient groups, whereas PwD had around double the risk of dying within 30 days of being discharged.

CONCLUSION

Over the six-year period, covariate-adjusted hospital LoS, ERA rates and in-hospital mortality rates for PwD were only slightly elevated compared to similar patients without dementia and remaining differences potentially reflect uncontrolled confounding. PwD however, were around twice as likely to die shortly after discharge, the reasons for which require further investigation. Despite being widely used for service evaluation, LoS, ERA and mortality may lack sensitivity to changes in hospital care and support to PwD.

The Prevalence of Psychiatric Disorders in General Hospital Inpatients: A Systematic Umbrella Review

BACKGROUND

To inform the future development of consultation-liaison psychiatry services, we need accurate information on the prevalence of psychiatric disorders in the general hospital inpatient setting. Systematic reviews have summarized the literature on specific aspects of this broad topic, but there has been no high-level overview that aggregates their findings and identifies gaps in the relevant literature.

OBJECTIVE

We aimed to produce a comprehensive overview of the field, summarizing the research literature on the prevalence of psychiatric disorders (i.e., interview-based psychiatric diagnoses) in general hospital inpatients. We did this using a systematic umbrella review (systematic review of systematic reviews), which is the best and most efficient method for summarizing a broad area of research.

METHODS

We searched Ovid Medline, Ovid Embase, Ovid PsycINFO, EBSCO CINAHL, and Scopus from database inception to September 2021 for systematic reviews that provided a pooled prevalence estimate, or prevalence range, for interview-diagnosed psychiatric disorders in general hospital inpatients. Two reviewers independently assessed articles and extracted data. The review is registered with PROSPERO, number CRD42019125574.

RESULTS

We screened 11,728 articles and included 10 systematic reviews in our umbrella review. We were able to extract pooled prevalence estimates from these as follows: major depression 12% to 20%, any anxiety disorder 8%, generalized anxiety disorder 5%, panic disorder 3%, delirium 15%. We were only able to extract a prevalence range for dementia, which was 3% to 63%. We found no systematic reviews from which we could extract prevalence data for the other psychiatric disorders that we included in our searches, indicating important gaps. From these data, we estimated that approximately one-third of inpatients have a psychiatric disorder.

CONCLUSIONS

Psychiatric disorders are very common in general hospital inpatients. While the planning of consultation-liaison psychiatry services will benefit from more research on the prevalence of each of the full range of disorders encountered in the inpatient setting, our findings indicate that we already know enough to justify increased and more population-based service provision.

Is hospitalization a risk factor for cognitive decline in older age adults?

OBJECTIVES

Many studies document cognitive decline following specific types of acute illness hospitalizations (AIH) such as surgery, critical care, or those complicated by delirium. However, cognitive decline may be a complication following all types of AIH. This systematic review will summarize longitudinal observational studies documenting cognitive changes following AIH in the majority admitted population and conduct meta-analysis (MA) to assess the quantitative effect of AIH on post-hospitalization cognitive decline (PHCD).

METHODS

We followed Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Selection criteria were defined to identify studies of older age adults exposed to AIH with cognitive measures. 6566 titles were screened. 46 reports were reviewed qualitatively, of which seven contributed data to the MA. Risk of bias was assessed using the Newcastle-Ottawa Scale.

RESULTS

The qualitative review suggested increased cognitive decline following AIH, but several reports were particularly vulnerable to bias. Domain-specific outcomes following AIH included declines in memory and processing speed. Increasing age and the severity of illness were the most consistent risk factors for PHCD. PHCD was supported by MA of seven eligible studies with 41,453 participants (Cohen's d = -0.25, 95% CI [-0.02, -0.49] I² 35%).

CONCLUSIONS

There is preliminary evidence that AIH exposure accelerates or triggers cognitive decline in the elderly patient. PHCD reported in specific contexts could be subsets of a larger phenomenon and caused by overlapping mechanisms. Future research must clarify the trajectory, clinical significance, and etiology of PHCD: a priority in the face of an aging population with increasing rates of both cognitive impairment and hospitalization.

Visual identifier systems for patients with cognitive impairment in healthcare settings: A survey of practice in UK hospitals

BACKGROUND

People with dementia and other forms of cognitive impairment form a substantial proportion of patients admitted to hospitals, but problems in their care are persistent. One widely proposed improvement approach involves the use of systems using visual identifiers to help staff quickly recognise people with suspected dementia, with the goal of supporting more personalised care. The aim of this paper is to identify the identifier systems in use and staff perceptions of their strengths and weaknesses.

METHODS

We undertook an online survey of staff providing care for people with dementia in acute and mental health hospitals across the United Kingdom. The questionnaire covered different types of visual identifier systems for dementia. It used categorical and open-response questions to access staff views of their use in practice. Responses were analysed using descriptive statistics, and the Framework approach for free-text answers.

RESULTS

162 responses were received from staff in at least 48 hospitals. Of these, 128 had direct experience of using visual identifier systems. They reported that multiple identifier systems are in use, including schemes with national scope and locally developed approaches. Most respondents reported that more than one system is in use in their hospital. Different types of identifier were seen to have different strengths and weaknesses. Respondents had a broadly positive view of identifiers, but highlighted risks including lack of reliable and consistent use (linked to competing pressures on staff time), lack of staff training, uncertainty about patient and family views, and unclear consent processes.

CONCLUSIONS

Our study suggests that a wide range of identifier systems is in use in UK hospitals, with many hospitals using more than one. Further consideration should be given to ensuring that multiple perspectives-including those of patients and carers-are drawn on in optimising their design, resolving ethical issues and supporting implementation.

Lean mass, grip strength, and hospital-associated disability among older adults in Health ABC

INTRODUCTION

Older adults with cognitive impairment, including those with Alzheimer's disease and related dementias, are particularly at risk for hospitalization and hospital-associated disability. Understanding of key risk factors for hospital-associated disability is limited. Sarcopenia, age-related declines in muscle mass and strength, is common in older adults with cognitive impairment and may be an important risk factor for hospital-associated disability.

METHODS

Using data from the Health ABC Study, we examined associations of pre-hospitalization appendicular lean mass (ALM) and grip strength with the development of a new activity of daily living (ADL) disability at the next annual assessment after hospitalization.

RESULTS

Grip strength, but not ALM, was negatively associated with increased risk of hospital-associated ADL disability, and this association was greater among those with cognitive impairment compared to those without.

DISCUSSION

Lower grip strength may be an important risk factor for hospital-associated ADL disability in older adults, particularly those with cognitive impairment.

Preserving independence among under-resourced older adults in the Southeastern United States: existing barriers and potential strategies for research

Disability prevention and preservation of independence is crucial for successful aging of older adults. To date, relatively little is known regarding disparities in independent aging in a disadvantaged older adult population despite widely recognized health disparities reported in other populations and disciplines. In the U.S., the Southeastern region also known as “the Deep South”, is an economically and culturally unique region ravaged by pervasive health disparities – thus it is critical to evaluate barriers to independent aging in this region along with strategies to overcome these barriers. The objective of this narrative review is to highlight unique barriers to independent aging in the Deep South and to acknowledge gaps and potential strategies and opportunities to fill these gaps. We have synthesized findings of literature retrieved from searches of computerized databases and authoritative texts. Ultimately, this review aims to facilitate discussion and future research that will help to address the unique challenges to the preservation of independence among older adults in the Deep South region.

Predictors of falls and hospital admissions in people with cognitive impairment in day-care: role of multimorbidity, polypharmacy, and potentially inappropriate medication

BACKGROUND

Multimorbidity, polypharmacy, and potentially inappropriate medication (PIM) pose challenges for the care of people with cognitive impairment. The aim of the present study is to explore whether multimorbidity, polypharmacy, and PIM predict falls and hospital admissions in a sample of people with cognitive impairment in day-care centers in Germany.

METHODS

We used data from the German day-care study (multicenter longitudinal study, n = 433). Multimorbidity was defined as ≥ 2 chronic diseases. Polypharmacy was defined as prescriptions to ≥ 5 drugs. Potentially inappropriate medication was defined as scoring on the PRISCUS list. Binary logistic regression analyses were computed to determine whether multimorbidity, polypharmacy, and potentially inappropriate medication at t0 predicted falls and hospital admissions as outcomes at t1 (six months later).

RESULTS

The rate of multimorbidity and polypharmacy was 87.8% and 60.3%, respectively. 15.9% of the people with cognitive impairment received PIM / PRISCUS-listed drugs, 43.6% ACB-listed drugs, and 52.7% CNS depressant drugs. Falls and hospital admissions during follow-up were prevalent in 19.4% and 24.7% of the people with cognitive impairment. Both were significantly predicted by the total number of drugs (falls: OR = 1.152, p = 0.001, overall model: p < 0.001; hospital admissions: OR = 1.103, p = 0.020, overall model: p = 0.001), even if regression analyses were controlled for the number of comorbidities.

CONCLUSIONS

Polypharmacy and potentially inappropriate medication are highly prevalent in people with cognitive impairment in German day-care centers. The number of drugs and appropriateness of medication seem to be crucial for the risk of falls and hospital admissions. Polypharmacy and PIM should be critically reviewed by healthcare providers and avoided as much as and whenever possible.

TRIAL REGISTRATION

ISRCTN16412551, 30 July 2014, registered partly retrospectively.

Healthcare-Associated Adverse Events in Alternate Level of Care Patients Awaiting Long-Term Care in Hospital

INTRODUCTION

A growing number of Canadian older adults are designated alternate level of care (ALC) and await placement into long-term care (LTC) while admitted to hospital. This creates infrastructural challenges by using resources allocated for acute care during disproportionately long hospital stays. For ALC patients, hospital environments maladapted to their needs impart risk of healthcare-associated adverse events.

METHODS

In this retrospective descriptive study, we examined healthcare-associated adverse events in 156 ALC patients, 65 years old and older, awaiting long-term care while admitted to two hospitals in London, Ontario in 2015-2018. We recorded incidence of infections and antimicrobial days prescribed. We recorded incidence of non-infectious adverse events including delirium, falls, venothrombotic events, and pressure ulcers. We used a restricted cubic spline model to characterize adverse events as a function of length of stay.

RESULTS

Patients waited an average of 56 ALC days (ranging from 6 to 333 days) before LTC placement, with seven deaths occurring prior to placement. We recorded 362 total adverse events accrued over 8668 ALC days: 94 infections and 268 non-infectious adverse events. The most common hospital-acquired infections were urinary-tract infections and respiratory infections. The most common non-infectious adverse events were delirium and falls. A total of 620 antimicrobial days were prescribed for infections.

CONCLUSIONS

ALC patients incur a meaningful and predictable number of adverse events during their stay in acute care. The incidence of these adverse events should be used to educate stakeholders on risks of ALC stay and to advocate for strategies to minimize ALC days.

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.

Dementia and Related Comorbidity: Analysis of 2 Years of Admissions to Italian Hospitals

BACKGROUND

The aim of the present study was to examine the prevalence of dementia, related comorbidities, and mortality rates in hospitalized elderly patients in Italy.

METHODS

Data were obtained from the Italian Ministry of Health and included all discharge records from Italian hospitals concerning subjects aged 65 years or above admitted to acute Internal Medicine during 2 years (n=3,695,278 admissions). Discharge diagnoses were re-classified into 24 clusters, each including homogeneous diseases by the ICD-9-CM code classification. Dementia was identified by the presence of ICD-9-CM codes 290, 294, or 331 series.

RESULTS

Patients with dementia represented 7.5% of the sample; compared with those without dementia, they were older and more often female, had a greater length of hospital stay and higher mortality rate. Besides delirium [odds ratio (OR): 54.20], enthesopaties (OR: 2.19), diseases of fluids and electrolytes (OR:1.96), diseases of arteries (OR: 1.69), skin diseases (OR: 1.64), and pneumonia and pleurisy (OR: 1.53) were the diseases more strongly associated with the diagnosis of dementia, independent of other clusters, age, sex, and length of stay.

CONCLUSIONS

Some comorbidities are specifically associated with the diagnosis of dementia among hospitalized elderly patients. Overall, these comorbidities describe the typical clinical profile of the patient with advanced dementia and could be treated in the context of the primary care, since they do not require specific skills belonging to hospital settings.

Psychobiological Evaluation of Day Clinic Treatment for People Living With Dementia – Feasibility and Pilot Analyses

Background

Hospitalization is often stressful and burdensome for people living with dementia (PwD) and their informal caregivers (ICs). Day clinic treatment may provide a suitable alternative, but is often precluded by a diagnosis of dementia. Furthermore, it is often caregiver-based ratings that measure treatment success as the validity of self-reports in PwD is critically discussed. We therefore set out to examine the feasibility of psychobiological stress measures in PwD and ICs and to evaluate treatment trajectories considering both the day clinic context and the daily life of the dyads.

Method

A total of 40 dyads of PwD (mean age: 78.15 ± 6.80) and their ICs (mean age: 63.85 ± 13.09) completed paper-and-pencil questionnaires (covering stress, depressive symptoms, and caregiver burden among others) in addition to the measurement of hair cortisol concentrations (HCC) at admission, discharge, and follow-up 6 months after day clinic treatment. As part of an ambulatory assessment, for 2 days at the beginning and 2 days at the end of the day clinic treatment, PwD and ICs collected six saliva samples per day for the analysis of salivary cortisol (sCort) and alpha-amylase (sAA).

Results

Paper-and-pencil questionnaires and HCC assessments were more feasible than the ambulatory assessment. We found discrepancies between subjective and physiological markers of stress in PwD. Whereas HCC decreased over time, self-reported stress increased. Child–parent dyads reported decreases in neuropsychiatric symptoms, associated burden, and self-reported stress from admission to follow-up. In daily life, both PwD and ICs showed characteristic diurnal profiles of sAA and sCort, however, we found no differences in summary indicators of salivary stress markers over time.

Discussion

The psychobiological evaluation was feasible and added informative value, underlining the potential of physiological stress markers to complement self-reports on stress in PwD and to objectively evaluate treatment trajectories. In this sample, HCC was more feasible and acceptable as biological marker of stress compared to saliva samples. Concerning treatment trajectories, differential effects on the dyads were found, with child–parent dyads benefiting more from day clinic treatment compared to spousal dyads.

Dementia-friendly intervention for hospitalized older adults with cognitive impairments: results of the Italian Dementia-Friendly Hospital Trial (IDENTITÀ)

Objective: To evaluate whether a short training focused on improving dementia care practices of the hospital staff was able to counteract functional loss and to decrease negative outcomes at discharge among hospitalized older adults with cognitive impairment.Method: Sixty-eight hospitalized participants aged 65 and over with cognitive impairment were included in the study, allocated in the control group (n = 34) and intervention group (n = 34). The intervention consisted of a short training of the hospital staff aimed at improving the management of patients with cognitive impairment. Participants were evaluated within 48 h of hospital admission and at discharge using a battery of tests including Barthel Index, Mini-Mental State Examination, and Hospital Anxiety and Depression Scale.Results: The intervention group demonstrated shorter hospital length of stay and a maintenance of the functional status at discharge compared to the control group. We observed no differences in cognitive ability between the two groups, and a trend towards a decrease of anxious symptoms in the intervention group compared to the control group.Conclusion: The results suggest that an intervention, focused on improving dementia care practices in healthcare staff, has the potential to improve the outcomes for hospitalized older adults with cognitive impairment.

The Revised Medical Care Act is associated with a decrease in hospital death for the total Japanese older adult population regardless of dementia status: An interrupted time series analysis

Background

In 2006, Japan introduced the Revised Medical Care Act aimed to shift end-of-life care from hospitals to communities. For patients and families, dying in hospital can be highly distressing. Persons with dementia are especially susceptible to negative hospital-related outcomes. This study aims to evaluate whether the Revised Medical Care Act is associated with a decrease in the proportion of hospital deaths for older adults and persons with dementia over a 20-year period covering the reform.

Methods and findings

This is a population-level, repeated cross-sectional study using mortality data from Vital Statistics Japan. Participants were Japanese older adults 65 years or older with and without dementia who died between 1996 and 2016. The policy intervention was the 2006 Revised Medical Care Act that increased community care infrastructure. The primary outcome was location of death in hospital, nursing home, home, or elsewhere. The trend in the proportion of location of death, before and after the reforms was estimated using an interrupted time-series analysis. All analyses were adjusted for sex and seasonality. Of the 19,307,104 older adult decedents, 216,442 had dementia identified on their death certificate. Death in nursing home (1.10, 95% CI 1.10–1.10), home (1.08, 95% CI 1.08–1.08), and elsewhere (1.07, 95% CI 1.07–1.07) increased over time compared to hospital deaths for the total population after reform implementation. Nursing home (1.04, 95% CI 1.03–1.05) and home death (1.11, 95% CI 1.10–1.12) increased after reform implementation for persons with dementia.

Conclusion

This study provides evidence that the 2006 Revised Medical Care Act was associated with decreased older adults dying in hospital regardless of dementia status; however, hospital continues as the primary location of death.

Acute care utilization risk among older adults living undiagnosed or unaware of dementia

BACKGROUND

Dementia is associated with increased risk of hospitalization and emergency department (ED) visits. Many persons with dementia are undiagnosed or unaware of their diagnosis, however. Our objective was to determine whether undiagnosed dementia or unawareness affects risk of hospitalization or ED visits.

METHODS

Retrospective longitudinal cohort study of 3537 community-living adults age ≥65 enrolled in the 2011-2017 National Health and Aging Trends Study with linked fee-for-service Medicare claims. Using self or proxy reported diagnosis, proxy dementia screening questionnaire, cognitive testing, and Medicare claims diagnosis, participants were classified as having (1) no dementia or dementia, for which they were classified as (2) undiagnosed, (3) diagnosed but unaware, or (4) diagnosed and aware. Proportional hazards models evaluated all-cause and potentially preventable hospitalization and ED visit risk by time-varying dementia status, adjusting for older adult characteristics.

RESULTS

Most participants (n = 2879) had no dementia at baseline. Among participants with dementia at baseline (n = 658), 187 were undiagnosed, 300 diagnosed but unaware, and 171 diagnosed and aware. In multivariable adjusted proportional hazards models, persons with undiagnosed dementia had lower risk of hospitalization and ED visits compared to persons diagnosed and aware (all-cause hospitalization aHR 0.59 [0.44, 0.79] and ED visit aHR 0.63 [0.47, 0.85]) and similar risks of these outcomes compared to persons without dementia. Individuals diagnosed but unaware had greater risk compared to those without dementia: aHR 1.37 (1.18, 1.59) for all-cause hospitalization and 1.48 (1.28, 1.71) for ED visits; they experienced risk comparable to individuals diagnosed and aware.

CONCLUSION

Older adults with undiagnosed dementia are not at increased risk of acute care utilization after accounting for differences in other characteristics. Individuals unaware of diagnosed dementia demonstrate risk similar to individuals aware of the diagnosis. Increasing diagnosis alone may not affect acute care utilization. The role of awareness warrants further investigation.

Performing One-Session Cognitive Stimulation to Interact with Patients with Dementia in a Hospital for Mood Improvement: A Retrospective Single-Arm Cohort Study

Developing support and an environment for patients with dementia in hospitals is important. This study aims to assess the immediate effect of one-session cognitive stimulation intervention on the mood of patients with dementia in a hospital as preliminary evidence. This study included 33 female patients. The cognitive stimulation intervention was conducted in the day room of the hospital ward by two occupational therapists. The patients participated in one or more sessions. The cognitive stimulation intervention was designed to discuss current affairs that implicitly stimulate memory, executive function, and language skills, according to the cognitive stimulation definition. Outcomes were evaluated using a two-dimensional mood scale. The primary outcome was pleasure. The before and after session scores for the first session and the average score before and after each session at multiple times were compared. The patients' pleasure showed significant improvements in both analyses. These results may indicate that one-session Cognitive stimulation intervention in a hospital effectively improves a mood of pleasure immediately. This study is the first report to provide preliminary evidence on the beneficial alterations of mood after one-session cognitive stimulation intervention for patients with dementia in hospitals. Cognitive stimulation intervention may be an effective non-pharmacotherapy for these patients.

Characteristics and Outcome Determinants of Hospitalized Older Patients with Cognitive Dysfunction

Cognitive dysfunction commonly occurs among older patients during admission and is associated with adverse prognosis. This study evaluated clinical characteristics and outcome determinants in hospitalized older patients with cognitive disorders. The main outcomes were length of stay, readmission within 30 days, Barthel index (BI) score at discharge, BI score change (discharge BI score minus BI score), and proportion of positive BI score change to indicate change of activities of daily living (ADL) change during hospitalization. A total of 642 inpatients with a mean age of 79.47 years (76–103 years) were categorized into three groups according to the medical history of dementia, and Mini-Mental State Examination (MMSE) scores at admission. Among them, 74 had dementia diagnosis (DD), 310 had cognitive impairment (CI), and 258 had normal MMSE scores. Patients with DD and CI generally had a higher risk of many geriatric syndromes, such as multimorbidities, polypharmacy, delirium, incontinence, visual and auditory impairment, fall history, physical frailty. They had less BI score, BI score change, and proportion of positive BI score change ADL at discharge. (DD 70.0%, CI 79.0%), suggesting less ADL change during hospitalization compared with those with normal MMSE scores (92.9%; p < 0.001). Using multiple regression analysis, we found that among patients with DD and CI, age (p = 0.008) and walking speed (p = 0.023) were predictors of discharge BI score. In addition, age (p = 0.047) and education level were associated with dichotomized BI score change (positive vs. non-positive) during hospitalization. Furthermore, the number and severity of comorbidities predicted LOS (p < 0.001) and readmission (p = 0.001) in patients with cognitive disorders. It is suggested that appropriate strategies are required to improve clinical outcomes in these patients.

An Inpatient Geriatrics Program with a Focus on Any Type of Cognitive Impairment Reduces Mortality

BACKGROUND

No matter what type of cognitive impairment an older hospitalized patient has, the risk of mortality is increased.

OBJECTIVES

To describe a hospital-based geriatrics program with a focus on any type of cognitive impairment and to determine whether this program was associated with reduced mortality over time.

DESIGN, PARTICIPANTS AND SETTING

Retrospective chart review of all patients age 70+ admitted during a 3-year period (2017-2019, N=20,401), to a 500-bed community-based hospital (Level 1 Trauma Center and Stroke Center).

INTERVENTION

A multicomponent geriatrics program was developed and implemented throughout 2018 and included: geriatric consultation, data collection, review of the data with hospital leaders, a geriatrics task force, clinician education and a Delirium Unit.

MAIN OUTCOMES AND MEASURES

Monthly mortality rates for patients with and without cognitive impairment over the 3-year period. To control for other variables associated with mortality, pre-post implementation analyses were performed (2017 versus 2019).

RESULTS

A linear regression analysis showed a significant downward trend in mortality over time for patients with cognitive impairment [R2=0.4, P<.0001, (correlation coefficient -0.6, 95% CI, -0.8 to -0.4)] but not among patients without cognitive impairment [R2=0.0, P=0.829, (correlation coefficient 0.0, 95% CI, -0.3 to 0.3)]. When controlling for other variables, there was still a decrease in mortality risk among patients with cognitive impairment.

CONCLUSION

Although there are limitations to this study, a multicomponent geriatrics program with an emphasis on any type of cognitive impairment, may be associated with improved mortality.

Dementia diagnosis and utilization patterns in a racially diverse population within an integrated health care delivery system

Introduction

In an effort to identify improvement opportunities for earlier dementia detection and care within a large, integrated health care system serving diverse Medicare Advantage (MA) beneficiaries, we examined where, when, and by whom Alzheimer's disease and related dementias (ADRD) diagnoses are recorded as well as downstream health care utilization and life care planning.

Methods

Patients 65 years and older, continuously enrolled in the Kaiser Foundation health plan for at least 2 years, and with a first ADRD diagnosis between January 1, 2015, and December 31, 2018, comprised the incident cohort. Electronic health record data were used to identify site and source of the initial diagnosis (clinic vs hospital‐based, provider type), health care utilization in the year before and after diagnosis, and end‐of‐life care.

Results

ADRD prevalence was 5.5%. A total of 25,278 individuals had an incident ADRD code (rate: 1.2%) over the study period—nearly half during a hospital‐based encounter. Hospital‐diagnosed patients had higher comorbidities, acute care use before and after diagnosis, and 1‐year mortality than clinic‐diagnosed individuals (36% vs 11%). Many decedents (58%‐72%) received palliative care or hospice. Of the 55% diagnosed as outpatients, nearly two‐thirds were diagnosed by dementia specialists; when used, standardized cognitive assessments indicated moderate stage ADRD. Despite increases in advance care planning and visits to dementia specialists in the year after diagnosis, acute care use also increased for both clinic‐ and hospital‐diagnosed cohorts.

Discussion

Similar to other MA plans, ADRD is under‐diagnosed in this health system, compared to traditional Medicare, and diagnosed well beyond the early stages, when opportunities to improve overall outcomes are presumed to be better. Dementia specialists function primarily as consultants whose care does not appear to mitigate acute care use. Strategic targets for ADRD care improvement could focus on generating pragmatic evidence on the value of proactive detection and tracking, care planning, and the role of specialists in chronic care management.

Managing a Dual Diagnosis of Cancer and Dementia in an Acute Setting: Considerations, Implications, and Future Recommendations

OBJECTIVES

To present an overview of the issues related to the well-being of people affected by cancer and dementia. To highlight the evidence from dementia care that can help improve the care experiences of people with dementia and cancer.

DATA SOURCES

Electronic databases such as PubMed and CINAHL were used to retrieve relevant literature published between 2010 and 2020.

CONCLUSION

Having a dual diagnosis of dementia and cancer poses several challenges across the cancer care pathway. Communication, treatment decision-making, environment ,and time-related issues were all identified. The literature suggests the need for evidence-based guidelines taking into consideration the person and the environment to support this population.

IMPLICATIONS FOR NURSING PRACTICE

To address these challenges and offer an optimal care experience for this group and their families, solutions need to focus both on the workforce and the environment. Offering dementia education for professionals working in acute cancer care, as well as adapting local environments that facilitate people navigate the space can be a starting point to offer person-centered, rights-based dementia sensitive care.

Factors associated with shorter length of admission among people with dementia in England and Wales: retrospective cohort study

OBJECTIVES

To identify aspects of the organisation and delivery of acute inpatient services for people with dementia that are associated with shorter length of hospital stay.

DESIGN AND SETTING

Retrospective cohort study of patients admitted to 200 general hospitals in England and Wales.

PARTICIPANTS

10 106 people with dementia who took part in the third round of National Audit of Dementia.

MAIN OUTCOME MEASURE

Length of admission to hospital.

RESULTS

The median length of stay was 12 days (IQR=6-23 days). People with dementia spent less time in hospital when discharge planning was initiated within 24 hours of admission (estimated effect -0.24, 95% CI: -0.29 to -0.18, p<0.001). People from ethnic minorities had shorter length of stay (difference -0.066, 95% CI: -0.13 to -0.002, p=0.043). Patients with documented evidence of discussions having taken place between their carers and medical staff spent longer in hospital (difference 0.26, 95% CI: 0.21 to 0.32, p<0.001). These associations held true in a subsample of 669 patients admitted with hip fracture and data from 74 hospitals with above average carer-rated quality of care.

CONCLUSIONS

The way that services for inpatients with dementia are delivered can influence how long they spend in hospital. Initiating discharge planning within the first 24 hours of admission may help reduce the amount of time that people with dementia spend in hospital.

Improvement in Activities of Daily Living after Cataract Surgery in the Very Old

BACKGROUND

The benefits of cataract surgery for patients aged ≥90 years in terms of improvements in activities of daily living (ADL) have been poorly evaluated using only limited data. Using a large nationwide administrative database of hospitalized patients, we investigated the improvement of ADL after cataract surgery in the very old (age of ≥90 years).

METHODS

We identified 84,747 patients with cataracts aged 80 to 89 years and 7,253 patients with cataracts aged ≥90 years who underwent cataract surgery in both eyes during hospitalization from April 2014 to March 2015. A retrospective matched-pair cohort study was performed to compare the proportion of patients with improved ADL after cataract surgery. We also compared the length of hospital stay between the two groups.

RESULTS

Patients aged ≥90 years were more likely to be female and have a lower ADL score at admission. In the 1:4 matched-pair analysis with 7,253 versus 29,012 pairs, a lower proportion of patients aged ≥90 years had an improved ADL score (odds ratio, 0.33; 95% confidence interval, 0.29-0.36; P < 0.001) even after adjusting for other variables. Patients aged ≥90 years had a slightly shorter length of hospital stay than those aged 80 to 89 years (7.5 vs. 8.2 days, respectively; P < 0.001).

CONCLUSIONS

In this large nationwide cohort of patients with cataracts, those aged ≥90 years showed significantly poorer improvement of ADL than did patients aged 80 to 89 years. Cataract surgery before the age of 90 years may be recommended for patients with cataracts.

The relationship between common cognitive screening tests (Standardised Mini-Mental State Examination and Rowland Universal Dementia Assessment Scale) and the Cognitive Functional Independence Measure

OBJECTIVES

To assess whether the Cognitive Functional Independence Measure (Cog-FIM) is correlated with the Standardised Mini-Mental State Examination (SMMSE) and Rowland Universal Dementia Assessment Scale (RUDAS) and whether there is agreement between the Cog-FIM and these two tests.

METHODS

Functional Independence Measure assessments were undertaken on 98 subacute patients. Forty-eight (48) patients were administered the SMMSE, and 50 were administered the RUDAS. Agreement was examined using the Bland-Altman plot.

RESULTS

Correlation was observed between the Cog-FIM and both the SMMSE and the RUDAS. The Bland-Altman analysis demonstrated agreement between the Cog-FIM and RUDAS, but not the Cog-FIM and SMMSE. The limits of agreement between the Cog-FIM and RUDAS were -13 to 13.

CONCLUSION

The Cog-FIM is correlated with the RUDAS, but the agreement is unclear. Despite agreement of the means, the limits of agreement are large, which may suggest a clinically meaningful difference. The study should be repeated with a larger sample size.

Evaluation and Effectiveness of Dementia Staff Training Programs in General Hospital Settings: A Narrative Synthesis with Holton's Three-Level Model Applied

Background:

People with Dementia (PwD) are frequently admitted to hospital settings. The lack of proper dementia knowledge, poor communication skills, negative attitudes toward dementia, and lack of confidence affects the quality of care, thus development of dementia trainings has increased. Nevertheless, literature regarding the effectiveness of training implementation is limited.

Objective:

The aim of this narrative synthesis is to 1) identify the characteristics of training programs and 2) explore the effectiveness of these training programs in everyday clinical practice.

Methods:

A systematic search in PubMed, PsycINFO, CINAHL, and Cochrane was conducted, including qualitative and quantitative peer-reviewed studies. Holton’s evaluation model with its three outcome levels (learning, individual performance, and organizational results) was adopted. 14 studies were included.

Results:

The synthesis of the results was divided into two parts: 1) to describe the characteristics and content of trainings 2) to evaluate the effectiveness of training programs according to the three outcome levels of Holton’s model, taking into consideration its construct domains: ability, motivation, and environment. Learning outcomes were assessed in all selected studies: 13 studies observed changes in individual performance, four studies reported changes within the organizational level, and only five showed sustainable changes over time.

Conclusion:

Person-centered care (PCC) approaches, interactive and varied teaching methods, supporting conditions like champions, action plans, and setting care policies, are all characteristics of effective trainings. Successful programs should be sustainable over time, demonstrating positive outcomes across the organization. Based on current findings, there is a lack of adequate evaluation with regard to training programs on the organizational level.

Improving Sleep Disturbance in Hospitalized Dementia Patients

PROBLEM

Sleep disturbance is common in hospitalized dementia patients. Consequences include adverse health outcomes and heavy social and economic costs. Education programs have improved dementia care and outcomes.

AIMS

A quality improvement project designed to improve sleep disturbance in hospitalized dementia patients was piloted on a medical-surgical unit of an urban, Midwestern hospital.

METHODS

Nurses and nursing assistants received education on evidence-based interventions to improve sleep disturbance in dementia patients. Pre-/posttests measured changes in staff knowledge. Sleep logs measured changes in hours of patient sleep.

RESULTS

Mean test scores increased for nurses from pre- to posttest. Sleep-wake tracking showed increased hours of sleep over time, but small sample sizes precluded pre- and posteducation statistical comparisons.

CONCLUSIONS

Education programs can increase nurses' knowledge of evidence-based sleep disturbance care for dementia patients. Larger sample sizes are needed to determine whether such programs can significantly improve their sleep.

Association between post-hospital clinic and telephone follow-up provider visits with 30-day readmission risk in an integrated health system

BACKGROUND

Follow-up visits with clinic providers after hospital discharge may not be feasible for some patients due to functional limitations, transportation challenges, need for physical distancing, or fear of exposure especially during the current COVID-19 pandemic.

METHODS

The aim of the study was to determine the effects of post-hospital clinic (POSH) and telephone (TPOSH) follow-up provider visits versus no visit on 30-day readmission. We used a retrospective cohort design based on data from 1/1/2017 to 12/31/2019 on adult patients (n = 213,513) discharged home from 15 Kaiser Permanente Southern California hospitals. Completion of POSH or TPOSH provider visits within 7 days of discharge was the exposure and all-cause 30-day inpatient and observation stay readmission was the primary outcome. We used matching weights to balance the groups and Fine-Gray subdistribution hazard model to assess for readmission risk.

RESULTS

Unweighted all-cause 30-day readmission rate was highest for patients who completed a TPOSH (17.3%) followed by no visit (14.2%), non-POSH (evaluation and management visits that were not focused on the hospitalization: 13.6%) and POSH (12.6%) visits. The matching weighted models showed that the effects of POSH and TPOSH visits varied across patient subgroups. For high risk (LACE 11+) medicine patients, both POSH (HR: 0.77, 95% CI: 0.71, 0.85, P < .001) and TPOSH (HR: 0.91, 95% CI: 0.83, 0.99, P = .03) were associated with 23 and 9% lower risk of 30-day readmission, respectively, compared to no visit. For medium to low risk medicine patients (LACE< 11) and all surgical patients regardless of LACE score or age, there were no significant associations for either visit type with risk of 30-day readmission.

CONCLUSIONS

Post-hospital telephone follow-up provider visits had only modest effects on 30-day readmission in high-risk medicine patients compared to clinic visits. It remains to be determined if greater use and comfort with virtual visits by providers and patients as a result of the pandemic might improve the effectiveness of these encounters.

Factors influencing length of hospital stay in an acute psychogeriatric unit

BACKGROUND

Dementia patients represent a significant volume of hospital admissions and impose a high cost on the health system. There is a significantly higher length of hospital stay (LOHS) for elderly demented patients.

METHODS

This study was carried out in an acute psychogeriatric unit specialising in behavioural and psychological symptoms in dementia. Socio-demographic, cognitive and nutritional variables were taken into account. We first compared the patients returning home (group 1) after hospital discharge with those transferred to the rehabilitation psychogeriatric unit (group 2). We secondarily explored the correlation of LOHS with the variables described above for the two groups.

RESULTS

We retained 92 patients (of 375 admitted) for our study, mean age 83.9 ± 6.6, Mini-Mental State Examination 12.8 ± 9.6, initial weight 61.7 ± 13.2 kg and body mass index 24.8 ± 4.7. We noticed significant differences in cognitive status but not in nutritional variables or in socio-demographic characteristics between the two groups. Only weight in nutritional variables was significantly associated with LOHS in the acute psychogeriatric unit.

CONCLUSIONS

Our main finding underlined the key role of cognitive factors in patient discharge home. And only initial weigh seems have an influence in LOHS instead of cognitive status or socio-demographic characteristics.

In-hospital complications in an acute care geriatric unit

Introduction: In-hospital complications frequently occur in hospitalized people over 65 worsening their clinical outcomes. There are, however, few studies on the factors associated with in-hospital complications in elderly patient care. Objective: To evaluate factors associated with in-hospital complications in a geriatric acute care unit in Bogotá, Colombia. Materials and methods: We conducted an analytical, observational, retrospective study in a cohort of 1,657 patients over 65 years of age who received care in the geriatric unit of a high complexity hospital in Bogotá, Colombia. The dependent variable was in-hospital complications and the independent variables, the degree of functional dependence on admission, dementia, nutritional status, social support, comorbidity, and polypharmacy. We used Poisson’s linear regression model to identify associated variables. Results: The bivariate analysis showed that functional dependence (PR=2.092, p≤0.001) and malnutrition (PR=2.850, p≤0.001) were associated with a higher rate of hospital-acquired infection. In the multivariate analysis, functional dependence (PR=1.931, p=0.003) and malnutrition (PR=2.502, p=0.002) remained independent factors for in-hospital complications. Conclusion: In acute care centers, integral assessment at admission to identify functional dependence and malnutrition predicts in-hospital complications.

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.

Development of a questionnaire to assess clinician perspectives of the usefulness of the functional independence measure and cognitive screening tests

OBJECTIVE

A pilot questionnaire was developed to investigate the cognitive tests that clinicians employ in their clinical practice and whether they perceive the Functional Independence Measure (FIM) to add clinical value.

METHODS

A 10-item pilot questionnaire was created and distributed to 43 health professionals of a single health service in Australia. A snowballing approach to sampling was used.

RESULTS

There were 39 respondents. Less than half of respondents thought the FIM added clinical value, and 15% stated that they would use the FIM to assess cognition on subacute wards. Ninety-seven per cent (97%) of respondents stated that they would rely more heavily on cognitive screening tests than the FIM.

CONCLUSION

Participant responses to this survey of a single health service raise interesting questions about how useful clinicians perceive the FIM to be, beyond a costing and benchmarking role. Clinicians may prefer cognitive screening tests to the FIM, in clinical practice.

Current Challenges in the Recognition and Management of Delirium Superimposed on Dementia

Delirium occurring in a patient with preexisting dementia is referred to as delirium superimposed on dementia (DSD). DSD commonly occurs in older hospitalized patients and is associated with worse outcomes, including higher rates of mortality and institutionalization, compared to inpatients with delirium or dementia alone. This narrative review summarizes the screening, diagnosis, management, and pathophysiology of DSD and concludes by highlighting opportunities for future research. Studies were identified via Medline and PsycINFO keyword search, and handsearching reference lists. Conceptually, DSD could be considered an "acute exacerbation" of dementia precipitated by a noxious insult akin to an acute exacerbation of heart failure or acute on chronic renal failure. However, unlike other organ systems, there are no established biomarkers for delirium, so DSD is diagnosed and monitored clinically. Because cognitive dysfunction is common to both delirium and dementia, the diagnosis of DSD can be challenging. Inattention, altered levels of arousal, and motor dysfunction may help distinguish DSD from dementia alone. An informant history suggestive of an acute change in cognition or alertness should be investigated and managed as delirium until proven otherwise. The key management principles include prevention, identifying and treating the underlying precipitant(s), implementing multicomponent interventions to create an ideal environment for brain recovery, preventing complications, managing distress, and monitoring for resolution. Informing and involving family members or caregivers throughout the patient journey are essential because there is significant prognostic uncertainty, including the risk of persistent cognitive and functional decline following DSD and relapse. Furthermore, informal carers can provide significant assistance in management. Emerging evidence demonstrates that increased exposure to delirium is associated with neuronal injury and worse cognitive outcomes although the mechanisms through which this occurs remain unclear. Given the clinical overlap between delirium and dementia, studying shared pathophysiological pathways may uncover diagnostic tests and is an essential step in therapeutic innovation.

Reversible dementia due to vitamin B12 deficiency in a lung cancer patient: Relevance of preoperative evaluation

OBJECTIVE

Cognitive dysfunction has a negative effect on cancer treatment; however, in a cancer setting, specific treatments can restore cognitive function. Such conditions are known as reversible dementia, with one of these being vitamin B12 (VB12) deficiency. However, there have been no reports of VB12 deficiency identified by preoperative evaluation in cancer patients.

METHOD

We studied a patient who was referred to the Department of Psycho-oncology on suspicion of cognitive decline prior to lung cancer surgery. Preoperative evaluation revealed VB12 deficiency.

RESULTS

The patient was an 82-year-old woman diagnosed with lung cancer. She also presented with cognitive decline and, therefore, was referred to the Department of Psycho-oncology for preoperative evaluation. The patient scored 19 points on a Mini-Mental State Examination (MMSE), which is indicative of cognitive decline. As the onset of symptoms occurred several months previously and they were subacute, the possibility of reversible dementia was considered. Extensive examination revealed VB12 deficiency, and VB12 replacement therapy normalized the MMSE score to 25 points before surgery.

SIGNIFICANCE OF THE RESULTS

When cognitive decline is observed in cancer patients, it is necessary to actively evaluate the serum levels of some B vitamins, including VB12.