Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: retrospective cohort study

Surgical outcomes in surgical oncology patients who participated in a family involvement program

BACKGROUND

There is a lack of evidence regarding the relationship between family involvement and outcomes in gastrointestinal oncology patients after surgery. To evaluate the effect of a family involvement program for patients undergoing oncologic gastrointestinal surgery on unplanned readmissions within 30 days after surgery.

METHODS

A multicenter patient-preference cohort study compared 2 groups: patients who participated in the family involvement program versus usual care. The program comprised involvement of family caregivers in care and training of health care professionals in family-centered care. Multivariable regression analyses were used to evaluate the effect of the FIP on the number of unplanned readmissions up to 30 days after surgery. Secondary outcomes included complications sensitive to fundamental care activities, emergency department visits, intensive care unit admissions, hospital length of stay, and the need for professional home care after discharge.

RESULTS

Of the 301 patients included, 152 chose the family involvement program, and 149 chose usual care. Postoperative readmissions occurred in 25 (16.4%) patients in the family involvement program group, and 15 (10.1%) in the usual care group (P = .11). A significant reduction of 16.2% was observed in the need for professional home care after discharge in the family involvement program group (P < .01). No significant differences were found between the 2 groups in the other secondary outcomes.

CONCLUSION

The family involvement program did not reduce the number of unplanned readmissions, but it led to a substantial reduction in-home care, which suggests an economic benefit from a societal perspective. Implementation of the family involvement program should, therefore, be considered in clinical practice.

Population incidence and associated mortality of urinary tract infection in people living with dementia

OBJECTIVES

Urinary tract infections (UTIs) frequently cause hospitalisation and death in people living with dementia (PLWD). We examine UTI incidence and associated mortality among PLWD relative to matched controls and people with diabetes and investigate whether delayed or withheld treatment further impacts mortality.

METHODS

Data were extracted for n = 2,449,814 people aged ≥ 50 in Wales from 2000-2021, with groups matched by age, sex, and multimorbidity. Poisson regression was used to estimate incidences of UTI and mortality. Cox regression was used to study the effects of treatment timing.

RESULTS

UTIs in dementia (HR=2.18, 95 %CI [1.88-2.53], p < .0) and diabetes (1.21[1.01-1.45], p = .035) were associated with high mortality, with the highest risk in individuals with diabetes and dementia (both) (2.83[2.40-3.34], p < .0) compared to matched individuals with neither dementia nor diabetes. 5.4 % of untreated PLWD died within 60 days of GP diagnosis-increasing to 5.9 % in PLWD with diabetes.

CONCLUSIONS

Incidences of UTI and associated mortality are high in PLWD, especially in those with diabetes and dementia. Delayed treatment for UTI is further associated with high mortality.

The effect of family-centered care on unplanned emergency room visits, hospital readmissions and intensive care admissions after surgery: a root cause analysis from a prospective multicenter study in the Netherlands

BACKGROUND

Optimizing transitional care by practicing family-centered care might reduce unplanned events for patients who undergo major abdominal cancer surgery. However, it remains unknown whether involving family caregivers in patients' healthcare also has negative consequences for patient safety. This study assessed the safety of family involvement in patients' healthcare by examining the cause of unplanned events in patients who participated in a family involvement program (FIP) after major abdominal cancer surgery.

METHODS

This is a secondary analysis focusing on the intervention group of a prospective cohort study conducted in the Netherlands. Data were collected from April 2019 to May 2022. Participants in the intervention group were patients who engaged in a FIP. Unplanned events were analyzed, and root causes were identified using the medical version of a prevention- and recovery-information system for monitoring and analysis (PRISMA) that analyses unintended events in healthcare. Unplanned events were compared between patients who received care from family caregivers and patients who received professional at-home care after discharge. A Mann-Whitney U test was used to analyze data.

RESULTS

Of the 152 FIP participants, 68 experienced an unplanned event and were included. 112 unplanned events occurred with 145 root causes since some unplanned events had several root causes. Most root causes of unplanned events were patient-related factors (n = 109, 75%), such as patient characteristics and disease-related factors. No root causes due to inadequate healthcare from the family caregiver were identified. Unplanned events did not differ statistically (interquartile range 1-2) (p = 0.35) between patients who received care from trained family caregivers and those who received professional at-home care after discharge.

CONCLUSION

Based on the insights from the root-cause analysis in this prospective multicenter study, it appears that unplanned emergency room visits and hospital readmissions are not related to the active involvement of family caregivers in surgical follow-up care. Moreover, surgical follow-up care by trained family caregivers during hospitalization was not associated with increased rates of unplanned adverse events. Hence, the concept of active family involvement by proficiently trained family caregivers in postoperative care appears safe and feasible for patients undergoing major abdominal surgery.

Variation in care and outcomes for people after hip fracture with and without cognitive impairment; results from the Australian and New Zealand Hip Fracture Registry

BACKGROUND

People with dementia have poorer outcomes after hip fracture and this may be due in part to variation in care. We aimed to compare care and outcomes for people with and without cognitive impairment after hip fracture.

METHODS

Retrospective cohort study using Australian and New Zealand Hip Fracture Registry data for people ≥50 years of age who underwent hip fracture surgery (n = 49,063). Cognitive impairment or known dementia and cognitively healthy groups were defined using preadmission cognitive status. Descriptive statistics and multivariable mixed effects models were used to compare groups.

RESULTS

In general, cognitively impaired people had worse care and outcomes compared to cognitively healthy older people. A lower proportion of the cognitively impaired group had timely pain assessment (≤30 min of presentation: 61% vs 68%; p < 0.0001), were given the opportunity to mobilise (89% vs 93%; p < 0.0001) and achieved day-1 mobility (34% vs 58%; p < 0.0001) than the cognitively healthy group. A higher proportion of the cognitively impaired group had delayed pain management (>30 mins of presentation: 26% vs 20%; p < 0.0001), were malnourished (27% vs 15%; p < 0.0001), had delirium (44% vs 13%; p < 0.0001) and developed a new pressure injury (4% vs 3%; p < 0.0001) than the cognitively healthy group. Fewer of the cognitively impaired group received rehabilitation (35% vs 64%; p < 0.0001), particularly patients from RACFs (16% vs 39%; p < 0.0001) and were prescribed bone protection medication on discharge (24% vs 27%; p < 0.0001). Significantly more of the cognitively impaired group had a new transfer to residential care (46% vs 11% from private residence; p < 0.0001) and died at 30-days (7% vs 3% from private residence; 15% vs 10% from RACF; both p < 0.0001). In multivariable models adjusting for covariates with facility as the random effect, the cognitively impaired group had a greater odds of being malnourished, not achieving day-1 walking, having delirium in the week after surgery, dying within 30 days, and in those from private residences, having a new transfer to a residential care facility than the cognitively healthy group.

CONCLUSIONS

We have identified several aspects of care that could be improved for patients with cognitive impairment - management of pain, mobility, nutrition and bone health, as well as delirium assessment, prevention and management strategies and access to rehabilitation. Further research is needed to determine whether improvements in care will reduce hospital complications and improve outcomes for people with dementia after hip fracture.

Impact of Dementia on Incidence and Severity of Postoperative Pulmonary Complications Following Hip Fracture Surgery Among Older Patients

Postoperative pulmonary complications (PPCs) are the leading cause of death following hip fracture surgery. Dementia has been identified as a PPC risk factor that complicates the clinical course. By leveraging electronic health records, this retrospective observational study evaluated the impact of dementia on the incidence and severity of PPCs, hospital length of stay, and postoperative 30-day mortality among 875 older patients (≥65 years) who underwent hip fracture surgery between October 1, 2015 and December 31, 2018 at a health system in the southeastern United States. Inverse probability of treatment weighting using propensity scores was utilized to balance confounders between patients with and without dementia to isolate the impact of dementia on PPCs. Regression analyses revealed that dementia did not have a statistically significant impact on the incidence and severity of PPCs or postoperative 30-day mortality. However, dementia significantly extended the hospital length of stay by an average of 1.37 days.

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.

The association between acupuncture therapy and the risk of reduced pressure ulcers in dementia patients: A retrospective matched cohort study

Background

The pressure ulcer is a complication developed from dementia. The aim of this study is to study the association between the development of pressure ulcers and the use of acupuncture therapy in patients with dementia.

Methods

We performed a retrospective 1:1 propensity score-matched cohort study to investigate the association between acupuncture therapy and the risk of pressure ulcers in patients with dementia.

Results

A total of 8,994 patients were identified, 237 patients in the acupuncture cohort and 362 patients in the no-acupuncture cohort developed pressure ulcers. A reduced cumulative incidence of pressure ulcers was observed in the acupuncture cohort (P<0.001). The association between acupuncture and reducing the incidence of pressure ulcers was not affected by sex, age, residence, income, or comorbidities. The variables of etiologies to cause dementia did not change the final result. In the subgroups analyses, the patients without medication for dementia control had a significantly lower rate of pressure ulcers development when they had accepted acupuncture therapy (log-rank test, P<0.001).

Conclusion

Our results revealed the association between acupuncture therapy and a reduced incidence of pressure ulcer development in patients with dementia. This finding offers important ideas for further research.

Development and preliminary usability testing of an electronic conversation guide incorporating patient values and prognostic information in preparation for older people's decision-making near the end of life

Initiating end-of-life conversations can be daunting for clinicians and overwhelming for patients and families. This leads to delays in communicating prognosis and preparing for the inevitable in old age, often generating potentially harmful overtreatment and poor-quality deaths. We aimed to develop an electronic resource, called Communicating Health Alternatives Tool (CHAT) that was compatible with hospital medical records software to facilitate preparation for shared decision-making across health settings with older adults deemed to be in the last year of life. The project used mixed methods including: literature review, user-directed specifications, web-based interface development with authentication and authorization; clinician and consumer co-design, iterative consultation for user testing; and ongoing developer integration of user feedback. An internet-based conversation guide to facilitate clinician-led advance care planning was co-developed covering screening for short-term risk of death, patient values and preferences, and treatment choices for chronic kidney disease and dementia. Printed summary of such discussion could be used to begin the process in hospital or community health services. Clinicians, patients, and caregivers agreed with its ease of use and were generally accepting of its contents and format. CHAT is available to health services for implementation in effectiveness trials to determine whether the interaction and documentation leads to formal decision-making, goal-concordant care, and subsequent reduction of unwanted treatments at the end of life.

Association between the mental domain of the comprehensive geriatric assessment and prolonged length of stay in hospitalized older adults with mild to moderate frailty

Introduction

Previous researches have shown the risk factors of prolonged length of stay (PLOS) in hospitalized older adults, but it is unclear what are the risk factors of PLOS in hospitalized older adults with mild to moderate frailty.

Objective

To identify the risk factors of PLOS in hospitalized older adults with mild to moderate frailty.

Methods

We recruited adults aged ≥65 years old with mild to moderate frailty admitted to a tertiary medical center in the southern Taiwan from June 2018 to September 2018. Each individual underwent a structural questionnaire interview within 72 h after admission and 72 h after discharge. The data were collected face-to-face, including demographic characteristics, comorbidities, length of stay (LOS), and multiple domains of the comprehensive geriatric assessment. The main outcome was PLOS.

Results

Individuals who had two or more drugs, were female, did not have cognitive impairment and had a Geriatric Depression Scale score ≥ 1 had a higher risk of PLOS (probability = 0.81), and these individuals accounted for 29% of the overall study population. Among male individuals younger than 87 years old, those with cognitive impairment had a higher risk of PLOS (probability = 0.76), and among male individuals without cognitive impairment, living alone was associated with a higher risk of PLOS (probability = 0.88).

Conclusion

Early detection and management of mood and cognition in older adults, together with comprehensive discharge planning and transition care, may be an important part of reducing LOS in hospitalized older adults with mild to moderate frailty.

Adapting and Testing the Care Partner Hospital Assessment Tool for Use in Dementia Care: Protocol for a 2 Sequential Phase Study

BACKGROUND

Research and policy demonstrate the value of and need for systematically identifying and preparing care partners for their caregiving responsibilities while their family member or friend living with dementia is hospitalized. The Care Partner Hospital Assessment Tool (CHAT) has undergone content and face validation and has been endorsed as appropriate by clinicians to facilitate the timely identification and preparation of care partners of older adult patients during their hospitalization. However, the CHAT has not yet been adapted or prospectively evaluated for use with care partners of hospitalized people living with dementia. Adapting and testing the CHAT via a pilot study will provide the necessary evidence to optimize feasibility and enable future efficacy trials.

OBJECTIVE

The purpose of this paper is to describe the study protocol for the adaptation and testing of the CHAT for use among care partners of hospitalized people living with dementia to better prepare them for their caregiving responsibilities after hospital discharge.

METHODS

Our protocol is based on the National Institutes of Health Stage Model and consists of 2 sequential phases, including formative research and the main trial. In phase 1, we will use a participatory human-centered design process that incorporates people living with dementia and their care partners, health care administrators, and clinicians to adapt the CHAT for dementia care (ie, the Dementia CHAT [D-CHAT]; stage IA). In phase 2, we will partner with a large academic medical system to complete a pilot randomized controlled trial to examine the feasibility and estimate the size of the effect of the D-CHAT on care partners' preparedness for caregiving (stage IB). We anticipate this study to take approximately 60 months to complete, from study start-up procedures to dissemination. The 2 phases will take place between December 1, 2022, and November 30, 2027.

RESULTS

The study protocol will yield (1) a converged-upon, ready-for-feasibility testing D-CHAT; (2) descriptive and feasibility characteristics of delivering the D-CHAT; and (3) effect size estimates of the D-CHAT on care partner preparedness. We anticipate that the resultant D-CHAT will provide clinicians with guidance on how to identify and better prepare care partners for hospitalized people living with dementia. In turn, care partners will feel equipped to fulfill caregiving roles for their family members or friends living with dementia.

CONCLUSIONS

The expected results of this study are to favorably impact hospital-based care processes and outcomes for people living with dementia and their care partners and to elucidate the essential caregiving role that so many care partners of people living with dementia assume.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05592366; https://clinicaltrials.gov/ct2/show/NCT05592366.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/46808.

Care Partner Inclusion of People Hospitalized With Alzheimer Disease and Related Dementias: Protocol for a Mixed Methods Systems Engineering Approach to Designing a Health Care System Toolkit

BACKGROUND

Research and policy demonstrate the value and need for the systematic inclusion of care partners in hospital care delivery of people living with Alzheimer disease and related dementias (ADRD). Support provided to care partners through information and training regarding caregiving responsibilities is important to facilitating their active inclusion and ultimately improving hospital outcomes of people living with ADRD. To promote care partners' active inclusion, a toolkit that guides health systems in the identification, assessment, and training of care partners is needed. User-centered approaches can address this gap in practice by creating toolkits that are practical and responsive to the needs of care partners and their hospitalized family members and friends living with ADRD.

OBJECTIVE

This paper describes the study protocol for the development and refinement of the ADRD Systematic Hospital Inclusion Family Toolkit (A-SHIFT). A-SHIFT will provide health care systems with guidance on how to effectively identify, assess, and train care partners of hospitalized persons living with ADRD.

METHODS

The A-SHIFT study protocol will use a 3-aimed, convergent mixed method approach to iteratively develop and refine the toolkit. In Aim 1, we will use a systems-engineering approach to characterize patterns of care partner inclusion in hospital care for people living with ADRD. In Aim 2, we will partner with stakeholders to identify and prioritize health care system facilitators and barriers to the inclusion for care partners of hospitalized people living with ADRD. In Aim 3, we will work with stakeholders to co-design an adaptable toolkit to be used by health systems to facilitate the identification, assessment, and training of care partners of hospitalized people living with ADRD. Our convergent mixed method approach will facilitate triangulation across all 3 aims to increase the credibility and transferability of results. We anticipate this study to take 24 months between September 1, 2022, and August 31, 2024.

RESULTS

The A-SHIFT study protocol will yield (1) optimal points in the hospital workflow for care partner inclusion, (2) a prioritized list of potentially modifiable barriers and facilitators to including care partners in the hospitalization of people living with ADRD, and (3) a converged-upon, ready for feasibility testing of the toolkit to guide the inclusion of care partners of people living with ADRD in hospital care.

CONCLUSIONS

We anticipate that the resultant A-SHIFT will provide health systems with a readiness checklist, implementation plan, and resources for identifying, assessing, and training care partners on how to fulfill their caregiving roles for people living with ADRD after hospital discharge. A-SHIFT has the potential to not only improve care partner preparedness but also help reduce health and service use outcomes for people living with ADRD after hospital discharge.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45274.

The impact of a cognitive impairment support program on patients in an acute care setting: a pre-test post-test intervention study

BACKGROUND

Patients with cognitive impairment are at greater risk of hospital acquired complications, longer hospital stays, and poor health outcomes compared to patients without cognitive impairment. The Cognitive Impairment Support Program is a multi-disciplinary approach to improve screening rates and awareness of patients with cognitive impairment and guide clinician response and communication during their hospitalisation to improve health outcomes.

OBJECTIVE

This study evaluated the impact of implementing the Cognitive Impairment Support Program on patient hospital acquired complications, patient reported quality of life and staff satisfaction in an outer metropolitan hospital.

DESIGN

A pre-test post-test design was used to collect data in two 6-month time periods between March 2020 and November 2021.

PARTICIPANTS

Patients aged ≥ 65 years, admitted to a participating ward for > 24 h.

INTERVENTION

The Cognitive Impairment Support Program consisted of four components: cognitive impairment screening, initiation of a Cognitive Impairment Care Plan, use of a Cognitive Impairment Identifier and associated staff education.

MEASURES

The primary outcome was hospital acquired complications experienced by patients with cognitive impairment identified using clinical coding data. Secondary outcomes were patient quality of life and a staff confidence and perceived organisational support to care for patients with cognitive impairment.

RESULTS

Hospital acquired complication rates did not vary significantly between the two data collection periods for patients experiencing cognitive impairment with a 0.2% (95% confidence interval: -5.7-6.1%) reduction in admissions with at least one hospital acquired complication. Patients in the post intervention period demonstrated statistically significant improvements in many items in two of the Dementia Quality of Life Measure domains: memory and everyday life. The staff survey indicated statistically significant improvement in clinical staff confidence to care for patients with cognitive impairment (p = 0.003), satisfaction with organisational support for patients (p = 0.004) and job satisfaction (p ≤ 0.001).

CONCLUSION

This study provides evidence that a multicomponent Cognitive Impairment Support Program had a positive impact on staff confidence and satisfaction and patient quality of life. Broader implementation with further evaluation of the multicomponent cognitive impairment intervention across a range of settings using varied patient outcomes is recommended.

Residential Aged Care Facilities During the COVID-19 Pandemic: A Staff Survey on Impact and Resources

The current study explored the impact of the coronavirus disease 2019 (COVID-19) pandemic on staff in residential aged care facilities (RACFs). A hardcopy, voluntary, anonymous survey was circulated to local RACFs (June-July 2020), exploring challenges, staffing effects, mood within RACFs, and staff perceptions of supports. Overall, 105 staff members responded, which were mainly nursing personnel (67.6%) and owners/managers (10.5%). Seventy percent believed they were equipped to handle patients with COVID-19. One quarter reported personal protective equipment shortages. Respondents reported pressures to accept patients with COVID-19 from hospitals and/or keep residents in the RACF. One third reported staff "calling in sick" related to COVID-19/quarantine. Common compensatory strategies included increasing part-time workers' hours. Reported mood was largely positive. Most (86.4%) respondents felt supported by general practitioner and local geriatric outreach services. Opportunities to best support RACF staff require further research and dialogue. [Journal of Gerontological Nursing, 49(3), 13-17.].

Trends in Healthcare Resource Use Preceding Diagnosis of Alzheimer's Disease Dementia

Introduction

An Alzheimer's disease (AD) dementia diagnosis is often preceded by an extended period of cognitive decline. Few studies have examined healthcare resource use (HRU) during an extended period before AD dementia diagnosis.

Methods

In a historical claims-based cohort study, propensity score-matched cohorts of patients with and without AD dementia were observed for a 5-year prediagnosis period and a 1-year postdiagnosis period. Demographics, clinical characteristics, and HRU were compared between groups.

Results

Individuals in the AD dementia group displayed a greater level of medical complexity in the year before diagnosis of AD dementia relative to those in the matched cohort. Both all-cause and AD dementia complication-related HRU increased gradually, with a marked spike at the time of initial AD dementia diagnosis. Discussion. Further research into the natural history of patients with AD dementia is necessary to improve identification of early AD and to better understand its broader impact.

Activating Relatives to Get Involved in Care After Surgery: Protocol for a Prospective Cohort Study

BACKGROUND

Postoperative complications and readmissions to hospital are factors known to negatively influence the short- and long-term quality of life of patients with gastrointestinal cancer. Active family involvement in activities, such as fundamental care activities, has the potential to improve the quality of health care. However, there is a lack of evidence regarding the relationship between active family involvement and outcomes in patients with gastrointestinal cancer after surgery.

OBJECTIVE

This protocol aims to evaluate the effect of a family involvement program (FIP) on unplanned readmissions of adult patients undergoing surgery for malignant gastrointestinal tumors. Furthermore, the study aims to evaluate the effect of the FIP on family caregiver (FC) burden and their well-being and the fidelity of the FIP.

METHODS

This cohort study will be conducted in 2 academic hospitals in the Netherlands. The FIP will be offered to adult patients and their FCs. Patients are scheduled for oncological gastrointestinal surgery and have an expected hospital stay of at least 5 days after surgery. FCs must be willing to participate in fundamental care activities during hospitalization and after discharge. Consenting patients and their families will choose to either participate in the FIP or be included in the usual care group. According to the power calculation, we will recruit 150 patients and families in the FIP group and 150 in the usual care group. The intervention group will receive the FIP that consists of information, shared goal setting, task-oriented training, participation in fundamental care, presence of FCs during ward rounds, and rooming-in for at least 8 hours a day. Patients in the comparison group will receive usual postoperative care. The primary outcome measure is the number of unplanned readmissions up to 30 days after surgery. Several secondary outcomes will be collected, that is, total number of complications (sensitive to fundamental care activities) at 30 and 90 days after surgery, emergency department visits, intensive care unit admissions up to 30 and 90 days after surgery, hospital length of stay, patients' quality of life, and the amount of home care needed after discharge. FC outcomes are caregiver burden and well-being up to 90 days after participating in the FIP. To evaluate fidelity, we will check whether the FIP is executed as intended. Univariable regression and multivariable regression analyses will be conducted.

RESULTS

The first participant was enrolled in April 2019. The follow-up period of the last participant ended in May 2022. The study was funded by an unrestricted grant of the University hospital in 2018. We aim to publish the results in 2023.

CONCLUSIONS

This study will provide evidence on outcomes from a FIP and will provide health care professionals practical tools for family involvement in the oncological surgical care setting.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/38028.

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.

Two factors that can increase the length of hospital stay of patients with dementia

OBJECTIVES

Patients with dementia are at greater risk of a long hospital stay and this is associated with adverse outcomes. The aim of this service evaluation was to identify variables most predictive of increased length of hospital stay amongst patients with dementia.

METHODS/DESIGN

We conducted a retrospective analysis on a cross-sectional hospital dataset for the period January-December 2016. Excluding length of stay less than 24h and readmissions, the sample comprised of 1133 patients who had a dementia diagnosis on record.

RESULTS

The highest incidence rate ratio for length of stay in the dementia sample was: (a) discharge to a care home (IRR: 2.443, 95% CI 1.778-3.357), (b) falls without harm (IRR: 2.486, 95% CI 2.029-3.045).

CONCLUSIONS

Based on this dataset, we conclude that improvements made to falls prevention strategies in hospitals and discharge planning procedures can help to reduce the length of stay for patients with dementia.

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.

Prognostic value of PaO2/FiO2, SOFA and D-dimer in elderly patients with sepsis

Objective

To investigate the prognostic value for predicting mortality of partial pressure of oxygen/fraction of inspired oxygen (PaO₂/FiO₂), the Sequential Organ Failure Assessment (SOFA) score and D-dimer in elderly patients with sepsis.

Methods

This retrospective cohort study enrolled elderly patients with sepsis admitted to the intensive care unit (ICU) between January 2019 and October 2020. Patients were divided into a survival group and a non-survival group. Biomarkers, SOFA, Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scale scores were recorded within 24 h after admission to the ICU.

Results

A total of 135 elderly patients with sepsis were enrolled in the study: 89 were in the survival group and 46 were in the non-survival group at 28 days. Univariate and multivariate regression analyses demonstrated that PaO₂/FiO₂, SOFA and D-dimer were independently associated with 28-day mortality. The predictive performance for mortality of the combination of PaO₂/FiO₂, SOFA score and D-dimer (area under the receiver operating characteristic curve of 0.926) was higher than the values for the individual factors (0.761, 0.745 and 0.878, respectively).

Conclusion

The combination of PaO₂/FiO₂, SOFA score and D-dimer represents a promising tool and biomarker for predicting 28-day mortality of the elderly patients with sepsis.

Barriers and Facilitators to Screening for Cognitive Impairment in Australian Rural Health Services: A Pilot Study

Australian National standards recommend routine screening for all adults over 65 years by health organisations that provide care for patients with cognitive impairment. Despite this, screening rates are low and, when implemented, screening is often not done well. This qualitative pilot study investigates barriers and facilitators to cognitive screening for older people in rural and regional Victoria, Australia. Focus groups and interviews were undertaken with staff across two health services. Data were analysed via thematic analysis and contextualized within the i-PARIHS framework. Key facilitators of screening included legislation, staff buy-in, clinical experience, appropriate training, and interorganisational relationships. Collaborative implementation processes, time, and workloads were considerations in a recently accredited tertiary care setting. Lack of specialist services, familiarity with patients, and infrastructural issues may be barriers exacerbated in rural settings. In lieu of rural specialist services, interorganisational relationships should be leveraged to facilitate referring ‘outwards’ rather than ‘upwards’.

Testing the sensitivity of two dementia knowledge instruments in dementia workforce education

BACKGROUND

The importance of dementia education in improving the care and support that people living with dementia is well established. Previous research has shown ceiling effects in pre and post educational intervention measures of dementia knowledge using Knowledge in Dementia Scale (KIDE) on post-registered health and social care staff in Scotland. The aim was to test the sensitivity of two dementia knowledge instruments, namely the (KIDE) and the Dementia Knowledge Assessment Scale (DKAS).

DESIGN

A pre and post evaluation comparison of two dementia knowledge scales.

SETTING

The tenth cohort of Scotland's National Dementia Champions Education Programme, September 2019-March 2020.

PARTICIPANTS

Post-registered Health and Social Care staff (n = 117).

METHODS

Both the DKAS and KIDE scales were administered pre and post programme delivery. Wilcoxon signed-rank tests were performed to examine T1 - T2 differences in dementia knowledge for both validated measures.

RESULTS

Ceiling effects continued to be present for the KIDE scale at T1 and T2. The DKAS responses showed a different score distribution than that achieved by the KIDE. Ceiling effects noted for KIDE at T1 were not present for the DKAS. Further, at T2, only 6% of respondents scored the maximum on the DKAS.

CONCLUSIONS

The DKAS appears to be a more useful instrument for measuring knowledge in post-registered health and social care staff; however, there was some evidence of ceiling effects post-intervention. There is a need for both scales to be tested in more educationally diverse populations, so educators and researchers can make informed decisions about the instrument's target range. Additionally, further research is needed to develop new sets of dementia knowledge items suitable for use in trained health and social care staff.

Family involvement on nursing wards and the role conflicts experienced by surgical nurses: A multicentre cross-sectional study

OBJECTIVE

To examine among surgical nurses whether work-role conflict, work-role ambiguity, respect, distress and trust in collaboration due to interactions with family caregivers in the nursing ward are associated with the quality of contact with patients and their families.

METHODS

A multicentre cross-sectional study was conducted between January and March 2020. Surgical nurses completed a questionnaire recording work-role conflict, work-role ambiguity, sense of respect, distress, trust in collaboration and quality of contact with patients and their families. Data were analysed using correlation analysis, multiple linear regression analysis and mediation regression analysis.

RESULTS

A total of 135 nurses completed the questionnaire. The correlation analysis showed significant correlations between nurses' impaired quality of contact with patients and their families and nurses' work-role conflicts, work-role ambiguity, trust in collaboration and distress (p < 0.05). The multiple regression analyses corroborated that work-role conflict and distress were significantly and positively associated with impaired quality of contact. Furthermore, mediation regression analysis showed that work-role conflict was associated indirectly and significantly with quality of contact through distress.

CONCLUSION

Work-role conflict due to having family caregivers involved in the care of hospitalised patients is significantly associated with nurses' distress and quality of contact with patients and their families.

The co-occurrence of dementia in those with epilepsy is associated with 30-day readmission - A population-based study

OBJECTIVE

Dementia and epilepsy often co-occur and are associated with poor health outcomes and increased healthcare utilization. The literature on the association between readmission and co-occurrence of dementia and epilepsy is scant. Our objective was to determine if dementia in patients with epilepsy >40 years old is associated with 30-day hospital readmission, in-hospital mortality, discharge disposition, and length-of-stay.

METHODS

This retrospective cohort study used the 2014 Nationwide Readmissions Database, containing data from hospital discharges across the US and readmissions. Epilepsy and dementia were identified using previously validated ICD-9-CM codes. Primary outcome was 30-day readmission, analyzed with univariable and multivariable logistic regressions. Secondary outcomes were discharge disposition, in-hospital mortality, and length-of-stay, analyzed with univariable multinomial logistic, univariable logistic, and univariable ordinary least squared regressions, respectively. The top ten causes of readmission in each group were compared as well. All analyses accounted for survey weights, cluster, and stratum.

RESULTS

Patients with epilepsy with dementia (n = 15,588) had longer hospital stays [15% (95%CI 10-20%)], and higher odds of readmission [OR 1.11 (95%CI 1.05-1.17)], transfer to another facility [OR 2.18 (95%CI 1.93-2.46)], and in-hospital mortality [OR 1.50 (95%CI 1.25-1.79)] compared to those without dementia (n = 186,289).The top two causes of readmission were septicemia (dementia: 14.81%; no dementia: 9.45%) and epilepsy/convulsions (dementia: 5.91%; no dementia: 6.25%). Other top 10 causes of readmissions in those with epilepsy and dementia which were not present in those without dementia included delirium (5.21%), urinary tract infections (4.98%), and aspiration pneumonitis (4.29%).

SIGNIFICANCE

Dementia in epilepsy is associated with worse outcomes, including higher in-hospital mortality and higher readmissions. Potentially preventable causes of readmission in those with epilepsy and dementia were identified, including septicemia, delirium, urinary tract infection, and aspiration pneumonitis. Future studies are needed to inform interventions aimed at decreasing premature mortality and reducing potentially preventable readmissions in this vulnerable population.

Assessment of common infections and incident dementia using UK primary and secondary care data: a historical cohort study

BACKGROUND

Common infections have been associated with dementia risk; however, evidence is scarce. We aimed to investigate the association between common infections and dementia in adults (≥65 years) in a UK population-based cohort study.

METHODS

We did a historical cohort study of individuals who were 65 years and older with no history of dementia or cognitive impairment using the Clinical Practice Research Datalink linked to Hospital Episode Statistics between Jan 1, 2004, and Dec 31, 2018. Multivariable Cox proportional hazard regression models were used to estimate the association between time-updated previous common infections (sepsis, pneumonia, other lower respiratory tract infections, urinary tract infections, and skin and soft tissue infections) and incident dementia diagnosis. We also tested for effect modification by diabetes since it is an independent risk factor for dementia and co-occurs with infection.

FINDINGS

Between Jan 1, 2004, and Dec 31, 2018, our study included 989 800 individuals (median age 68·6 years [IQR 65·0-77·0]; 537 602 [54·3%] women) of whom 402 204 (40·6%) were diagnosed with at least one infection and 56 802 (5·7%) had incident dementia during a median follow-up of 5·2 years (IQR 2·3-9·0). Dementia risk increased in those with any infection (adjusted hazard ratio [HR] 1·53 [95% CI 1·50-1·55]) compared with those without infection. HRs were highest for sepsis (HR 2·08 [1·89-2·29]) and pneumonia (HR 1·88 [1·77-1·99]) and for infections leading to hospital admission (1·99 [1·94-2·04]). HRs were also higher in individuals with diabetes compared with those without diabetes.

INTERPRETATION

Common infections, particularly those resulting in hospitalisation, were associated with an increased risk of dementia persisting over the long term. Whether reducing infections lowers the risk of subsequent dementia warrants evaluation.

FUNDING

Alzheimer's Society, Wellcome Trust, and the Royal Society.

Making clinical care decisions with people living with dementia in hospital: An integrative literature review

BACKGROUND

As our population ages, the percentage of hospitalised patients diagnosed with dementia is expected to rise. However, there is emerging evidence that people living with dementia may experience discrimination and exclusion from decisions about their clinical care. Although dementia affects cognition, many patients living with dementia want to participate in decision-making processes relating to their clinical care in hospital.

OBJECTIVE

Identify the processes associated with making decisions about clinical care with people living with dementia in hospital.

DESIGN

An integrative literature review.

DATA SOURCES

Cumulative Index of Nursing and Allied Health Literature (CINAHL), Scopus, EMBASE (Ovid), MEDLINE (PubMED), PsycINFO and HeinOnline.

REVIEW METHOD

One author conducted the initial screening of titles, and two authors screened in subsequent rounds for abstracts and full text. The process of making clinical decisions was the outcome of interest. Articles about people with cognitive impairment that did not include dementia, or decisions such as discharge planning or end of life care were excluded. An inductive synthesis of the findings was undertaken.

RESULTS

Nine articles were identified for review and included expert opinion or hypothetical discussion (n=5), cross-sectional survey research (n=3), and qualitative research (n=1). Three themes were identified: capacity for decision-making is conceptualised as 'all or nothing'; there are no universal principles for including people living with dementia in decision-making in acute care settings; and autonomy is recognised but superseded by beneficence.

CONCLUSIONS

Contemporary hospital practice is focused on determining capacity for decisions, with an all or nothing attitude to capacity, effectively excluding many people living with dementia from participation in decisions. While there is limited evidence to guide clinicians in this complex and situated process of making clinical decisions, emerging models of supported decision-making require further evaluation in the hospital setting.

Hospital readmissions following infections in dementia: a nationwide and registry-based cohort study

INTRODUCTION

We aimed to investigate readmission risks following infections in dementia, identify the types of infections behind the risks, and highlight the reasons for readmissions.

METHODS

Acute inpatient hospital admissions for infections in Danish residents were included from 1 January 2000, or age 65 years. Primary outcomes were 7-day readmissions risk ratios (RRs; risk following infection index admissions of people with dementia relative to those without dementia), risks by infection site, and reasons for readmission. Secondary outcomes were 30- and 90-day readmission risks. Competing risk of death was estimated.

RESULTS

Seven-day readmission RR was increased in all age groups and was highest in the youngest patients (women RR: 1.37, 95% confidence interval [CI] 1.22-1.53; men RR: 1.23, 95% CI 1.12-1.35). RRs decreased with increasing age and longer follow-up. The most notable common readmissions were for infections and dehydration in dementia.

CONCLUSIONS

We conclude that there is a substantially increased readmission risk in people with dementia than in those without dementia, particularly within 7 days, and for the youngest in the cohort. Readmission risks were higher for infection index admissions than for admissions for causes other than infection, and readmissions were mostly due to infections. Our findings highlight the burden of infections in people with dementia and call for in-depth investigations of determinants related to readmission risks, to inform public policy and identify avenues for interventions that can decrease or prevent potentially avoidable readmissions.

Missed Nursing Care Among Patients With Dementia During Hospitalization: An Observation Study

Patients with dementia (PwD) are characterized as a vulnerable group as they are unable to communicate their needs, putting them at risk for care omissions. The current study aimed to explore care toward PwD and detect if any aspects of care are omitted. An observation study was conducted in three medical-surgical adult wards of an acute general hospital. Data were collected by an observer, through field notes, and were analyzed with content analysis. A face scale was used to assess PwD's mood. Thirteen PwD were observed for 90 hours. Four thematic areas were identified: (a) Unmet Fundamental Patient Needs, (b) Human Right to Dignity and Respect, (c) Communication Deficiencies, and (d) Implementation of Nursing Interventions. Nurse-patient contact lasted from 5 to 7 minutes and numerous care omissions were noted. The face scale assessment revealed that most PwD looked very sad after nursing care. This study enriches insight for the care of PwD during hospitalization and emphasizes the need for health care workers' education and support. [Research in Gerontological Nursing, 14(3), 150-159.].

Sensitivity and specificity of the Bamberg Dementia Screening Test's (BDST) full and short versions: brief screening instruments for geriatric patients that are suitable for infectious environments

BACKGROUND

Currently, many patients suffering from dementia do not have a diagnosis when admitted to geriatric hospitals. This is the case despite an increased risk of complications affecting the length of stay and outcome. Unfortunately, many dementia screening tests cannot be used on geriatric inpatients, who are often bedridden. Therefore, we aimed at evaluating the diagnostic accuracy of a small battery of bedside tasks that require minimal vision and fine motor skills in patients with suspected dementia.

METHODS

In this prospective study, the Bamberg Dementia Screening Test (BDST) was administered to a consecutive series of 1295 patients referred for neuropsychological testing. The diagnosis of dementia was confirmed in 1159 and excluded in 136 patients. Sensitivity and specificity for the first subtest (ultra-short form), the first two subtests (short form), and the total score of the BDST were obtained via receiver operating characteristic curves and compared with the sensitivity and specificity values of the Mini-Mental Status Examination (MMSE).

RESULTS

The overall diagnostic quality of the BDST was superior to the MMSE for mild Alzheimer's dementia (sensitivity and specificity = .94 (95% CI .92 to .96) and .82 (95% CI .75 to .88) vs. .79 (95% CI .76 to .83) and .88 (95% CI .82 to .93)) as well as for other subtypes of mild dementia (sensitivity and specificity = .91 (95% CI .88 to .94) and .82 (95% CI .75 to .88) vs. .72 (95% CI .67 to .76) and .88 (95% CI .82 to .93)). Even the short form of the BDST was comparable to the MMSE regarding sensitivity and specificity. For moderate dementia, it was possible to identify dementia cases with sufficient and excellent diagnostic quality by using the ultra-short and the short form.

CONCLUSIONS

The BDST is able to detect dementia in geriatric hospital settings. If the adaptive algorithm is used, administration time can be reduced to less than 2 min in most cases. Because no test materials have to be exchanged, this test is particularly suitable for infectious environments where contact between the examiner and the person being tested should be minimized.

The association between ward staffing levels, mortality and hospital readmission in older hospitalised adults, according to presence of cognitive impairment: a retrospective cohort study

BACKGROUND

Lower nurse staffing levels are associated with increased hospital mortality. Older patients with cognitive impairments (CI) have higher mortality rates than similar patients without CI and may be additionally vulnerable to low staffing.

OBJECTIVES

To explore associations between registered nurse (RN) and nursing assistant (NA) staffing levels, mortality and readmission in older patients admitted to general medical/surgical wards.

RESEARCH DESIGN

Retrospective cohort.

PARTICIPANTS

All unscheduled admissions to an English hospital of people aged ≥75 with cognitive screening over 14 months.

MEASURES

The exposure was defined as deviation in staffing hours from the ward daily mean, averaged across the patient stay. Outcomes were mortality in hospital/within 30 days of discharge and 30-day re-admission. Analyses were stratified by CI.

RESULTS

12,544 admissions were included. Patients with CI (33.2%) were exposed to similar levels of staffing as those without. An additional 0.5 RN hours per day was associated with 10% reduction in the odds of death overall (odds ratio 0.90 [95% CI 0.84-0.97]): 15% in patients with CI (OR 0.85 [0.74-0.98]) and 7% in patients without (OR 0.93 [0.85-1.02]). An additional 0.5 NA hours per day was associated with a 15% increase in mortality in patients with no impairment. Readmissions decreased by 6% for an additional 0.5 RN hours in patients with CI.

CONCLUSIONS

Although exposure to low staffing was similar, the impact on mortality and readmission for patients with CI was greater. Increased mortality with higher NA staffing in patients without CI needs exploration.

Emergency department and hospital admissions among people with dementia living at home or in nursing homes: results of the European RightTimePlaceCare project on their frequency, associated factors and costs

Background

Evidence is lacking on the differences between hospitalisation of people with dementia living in nursing homes and those living in the community. The objectives of this study were: 1) to describe the frequency of hospital admission among people with dementia in eight European countries living in nursing homes or in the community, 2) to examine the factors associated with hospitalisation in each setting, and 3) to evaluate the costs associated with it.

Methods

The present study is a secondary data analysis of the RightTimePlaceCare European project. A cross-sectional survey was conducted with data collected from people with dementia living at home or who had been admitted to a nursing home in the last 3 months, as well as from their caregivers. Data on hospital admissions at 3 months, cognitive and functional status, neuropsychiatric symptoms, comorbidity, polypharmacy, caregiver burden, nutritional status, and falls were assessed using validated instruments. Multivariate regression models were used to investigate the factors associated with hospital admission for each setting. Costs were estimated by multiplying quantities of resources used with the unit cost of each resource and inflated to the year 2019.

Results

The study sample comprised 1700 people with dementia living in the community and nursing homes. Within 3 months, 13.8 and 18.5% of people living in nursing homes and home care, respectively, experienced ≥1 hospital admission. In the nursing home setting, only polypharmacy was associated with a higher chance of hospital admission, while in the home care setting, unintentional weight loss, polypharmacy, falls, and more severe caregiver burden were associated with hospital admission. Overall, the estimated average costs per person with dementia/year among participants living in a nursing home were lower than those receiving home care.

Conclusion

Admission to hospital is frequent among people with dementia, especially among those living in the community, and seems to impose a remarkable economic burden. The identification and establishment of an individualised care plan for those people with dementia with polypharmacy in nursing homes, and those with involuntary weight loss, accidental falls, polypharmacy and higher caregiver burden in the home care setting, might help preventing unnecessary hospital admissions.

The experiences of family caregivers who participated in a family involvement program after cancer surgery: A qualitative study

PURPOSE

As recovery time after oncological surgery can be long, family caregivers often play an important role in the delivery of care after patients' discharge. To prepare carers for this role, we developed a family involvement program (FIP) to enhance their active involvement in post-surgical oncology care during hospitalization. The purpose of this qualitative study was to explore family caregivers experience of participating in a FIP.

METHODS

We conducted semi-structured interviews with 12 family caregivers who participated in the family involvement program. The program is comprised of two main components (1) training and coaching of physicians and nurses; (2) active involvement of family caregivers in fundamental care activities. This active involvement included six activities. Data were analyzed using interpretative phenomenological analysis.

RESULTS

Family caregivers positively valued the program. Active participation in post-surgical care was experienced as an acceptable burden. The program gave participants the ability to simply be present ('being there') which was considered as essential and improved their understanding of care, although family caregivers sometimes experienced emotional moments. Active involvement strengthened existent relationship between the family caregiver and the patient. Participants thought clinical supervision. by nurses is important.

CONCLUSIONS

Physical proximity appeared as an essential part of the family involvement program. It helped carers to feel they made a meaningful contribution to their loved ones' wellbeing. Asking families to participate in fundamental care activities in post-surgical oncology care was acceptable, and not over-demanding for caregivers.

Missed nursing care: An overview of reviews

Missed nursing care is care that is delayed, partially completed, or not completed at all. The aim of this overview of reviews was to identify the nursing care that is missed, the factors that influence missed nursing care and the outcomes from it. To be included, reviews had to use the systematic review process and focus on hospital care. Databases were searched from inception until August sixth, 2020. One author screened the papers and extracted data on included reviews and a second checked this. Two authors independently assessed the quality of the reviews. Seven reviews were included in this overview. Categories of care missed included: (a) communication and information sharing; (b) self-management, autonomy, and education including care planning, discharge planning and decision; (c) fundamental physical care; and (d) emotional and psychological care including spiritual support. Factors associated with missed care were related to staffing levels and/or labor resources skill mix, material resources not being available, patient acuity and teamwork/communication. Outcomes of missed nursing care included: less/poorer quality of patient care, patient satisfaction, and nurses' job satisfaction, increased patient adverse events, and the organizational outcomes of increasing hospital length of stay and hospital readmission. In-depth qualitative and mixed methods research is needed to better understand how nurses prioritize care and why care is missed. Longitudinal and experimental research is required to better clarify if these relationships between missed care and negative patient outcomes are likely cause and effect.

Acute hospital staff's attitudes towards dementia and perceived dementia knowledge: a cross-sectional survey in Ireland

Background

Little is known about staff’s attitudes in Irish acute hospital settings towards people living with dementia and their perceived dementia knowledge. The aim of this study was to understand the general level of dementia knowledge and attitudes towards dementia in different types of hospital staff, as well as to explore the potential influence of previous dementia training and experience (having a family member with dementia) and the potential moderating effects of personal characteristics. This data was required to plan and deliver general and targeted educational interventions to raise awareness of dementia throughout the acute services.

Methods

A cross-sectional survey was carried out among a diverse range of hospital staff (n = 1795) in three urban acute general hospitals in Ireland, including doctors, nurses, healthcare attendants, allied professionals, and general support staff. Participants’ perceived dementia knowledge and attitudes were assessed as well as their previous dementia training and experience. To measure participant’s attitude towards dementia, the validated Approaches to Dementia Questionnaire (ADQ) was used.

Results

Hospital staff demonstrated positive attitudes towards people living with dementia, and believed they had a fair to moderate understanding of dementia. Both ‘having previous dementia training’ and ‘having a relative living with dementia’ predicted attitude towards dementia and perceived dementia knowledge. Interestingly, certain personal staff characteristics did impact dementia training in predicting attitude towards dementia and perceived dementia knowledge.

Conclusion

This study provides a baseline of data regarding the attitudes towards dementia and perceived dementia knowledge for hospital staff in Irish acute hospitals. The results can inform educational initiatives that target different hospital staff, in order to increase awareness and knowledge to improve quality of dementia care in Irish hospitals.

Drug related problems in older adults living with dementia

BACKGROUND

Compared with those without dementia, older patients with dementia admitted to acute care settings are at higher risk for triad combination of polypharmacy (PP), potentially inappropriate medication (PIM), and drug-drug interaction (DDI), which may consequently result in detrimental health. The aims of this research were to assess risk factors associated with triad combination of PP, PIM and DDI among hospitalized older patients with dementia, and to assess prevalence and characteristics of PP, PIM and DDI in this population.

METHODS

In this retrospective cross-sectional study, 416 older inpatients diagnosed with dementia and referred for specialist geriatric consultation at a tertiary hospital in Brisbane, Australia during 2006-2016 were enrolled. Patients were categorized into two groups according to their exposure to the combination of PP, PIM and DDI: 'triad combination' and 'non-triad combination'. Data were collected using the interRAI Acute Care (AC) assessment instrument. Independent risk factors of exposure to the triad combination were evaluated using bivariate and multivariate logistic regression analyses.

RESULTS

Overall, 181 (43.5%) were classified as triad combination group. The majority of the population took at least 1 PIM (56%) or experienced at least one potential DDI (76%). Over 75% of the participants were exposed to polypharmacy. The most common prescribed PIMs were antipsychotics, followed by benzodiazepines. The independent risk factors of the triad combination were the presence of atrial fibrillation diagnosis and higher medications use in cardiac therapy, psycholeptics and psychoanaleptics.

CONCLUSIONS

The exposure to triad combination of PP, PIM and DDI are common among people with dementia as a result of their vulnerable conditions and the greater risks of adverse events from medications use. This study identified the use of cardiac therapy, psycholeptics and psychoanaleptics as predictors of exposure to PP, PIM and DDI. Therefore, use of these medications should be carefully considered and closely monitored. Furthermore, comprehensive medication reviews to optimize medication prescribing should be initiated and continually implemented for this vulnerable population.

Adverse Events, Functional Decline, and Access to Allied Health Therapies for Patients With Dementia During Acute Hospitalization

The number of patients attending acute care hospitals with a diagnosis of dementia is increasing. The impact of hospitalization on function and adverse events is perceived to be greater for patients with dementia than those without. This study compared adverse events (falls, wounds, delirium, medication errors, infections, and incontinence), functional decline, and allied health therapy for patients with and without dementia (n = 240). Patients with dementia experienced significantly more adverse events and constant observation by staff, were more dependent with mobility, hygiene and feeding, more often nil by mouth, confused, and incontinent. Patients with dementia were significantly more likely to receive speech and physiotherapy, although they did not significantly improve in function during their hospital stay. Conversely, patients without dementia significantly improved in mobility and continence. The unique health care needs of patients with dementia need to inform models of care, policy, and practice to support safe health care delivery in this vulnerable population.

Under-coding of dementia and other conditions indicates scope for improved patient management: A longitudinal retrospective study of dementia patients in Australia

BACKGROUND

Under-coding of dementia during hospitalisation results in an inability to identify all patients with dementia using hospital administrative data. Clinical coding can be viewed as a proxy for management; therefore, under-coding indicates dementia was not considered in the patient's management. While under-coding of dementia is well established, there is sparse evidence on whether dementia is coded in subsequent hospitalisations among patients with a known diagnosis.

OBJECTIVE

(a) To describe patterns of dementia coding over 5 years after a first-coded (i.e. index) admission for dementia; (b) to identify factors associated with clinical coding of dementia; and (c) to identify patient subgroups at risk of not being coded to inform future interventions to improve hospital identification and management of dementia.

METHOD

Retrospective study of longitudinal hospital data from 1 July 2006 to 30 June 2015 for 7919 patients hospitalised during the 5 years' post-index admission for dementia in a regional local health district of New South Wales, Australia.

RESULTS

Dementia was coded in 63.9% of admissions in the 12 months following index admission for dementia; this decreased to 53.7% after 5 years. Patients were 20% more likely to have dementia actively managed when it co-occurred with delirium. Under-coding varied across conditions, with dementia more likely to be coded in admissions for falls and pneumonitis, and less likely for heart failure, pneumonia and urinary tract infection (UTI).

CONCLUSION

The frequency with which dementia was not coded highlights opportunities to improve identification and management of dementia through dementia-specific care, enhanced clinical protocols, and interventions focused around heart failure, pneumonia and UTI admissions.

Alzheimer's disease medication and outcomes of hospitalisation among patients with dementia

AIMS

The use of Alzheimer disease medication for the treatment of dementia symptoms has shown significant benefits with regards to functional and cognitive outcomes as well as nursing home placement (NHP) and mortality. Hospitalisations in these patient groups are characterised by extended length of stays (LOS), frequent readmissions, frequent NHP and high-mortality rates. The impact of Alzheimer disease medication on the aforementioned outcomes remains still unknown. This study assessed the association of Alzheimer disease medication with outcomes of hospitalisation among patients with Alzheimer disease and other forms of dementia.

METHODS

A dynamic retrospective cohort study from 2004 to 2015 was conducted which claims data from a German health insurance company. People with dementia (PWD) were identified using ICD-10 codes and diagnostic measures. The main predictor of interest was the use of Alzheimer disease medication. Hospitalisation outcomes included LOS, readmissions, NHP and mortality during and after hospitalisation across four hospitalisations. Confounding was addressed using a propensity score throughout all analyses.

RESULTS

A total of 1380 users of Alzheimer disease medication and 6730 non-users were identified. The use of Alzheimer disease medication was associated with significantly shorter LOS during the first hospitalisations with estimates for the second, third and fourth showed a tendency towards shorter hospital stays. In addition, current users of Alzheimer disease medication had a lower risk of hospital readmission after the first two hospitalisations. These associations were not significant for the third and fourth hospitalisations. Post-hospitalisation NHP and mortality rates also tended to be lower among current users than among non-users but differences did not reach statistical significance.

CONCLUSIONS

Our results indicate that Alzheimer disease medication might contribute to a reduction of the LOS and the number of readmissions in PWD.

The prevalence of delirium in patients in Iran: a systematic review and meta-analysis

Aim: The first systematic review and meta analysis investigating the prevalence of delirium in Iran and the importance of delirium in the health status of patients. Method: This study is a review article to determine the overall prevalence of delirium in patients admitted to the hospitals in Iran, with search time frame to 12 October 2000–12 October 2018. The study examined the prevalence of delirium in general wards and ICUs of Iran according to published article in domestic and foreign journals. The methodological quality of the papers was based on a tool used in previous studies. Data was analyzed using comprehensive meta-analysis (CMA) software. Findings: The findings showed the prevalence of delirium in hospitalized patients in Iran is 21.8% (CI: 17.5–27.5%). The prevalence of delirium in hospitalized patients in Iran based on the hospitalization in ICU is 24.7% (CI: 18.1–32.7%) and in the general ward is 17.5% (CI: 13.6–22.3%). Conclusion: Due to the relatively high prevalence of delirium in patients admitted to hospitals in Iran, prevention is necessary to reduce the incidence of delirium.

Developing an evidence-based and theory informed intervention to involve families in patients care after surgery: A quality improvement project

Objectives

In the post-surgical setting, active involvement of family caregivers has the potential to improve patient outcomes by prevention of surgical complications that are sensitive to fundamental care. This paper describes the development of a theoretically grounded program to enhance the active involvement of family caregivers in fundamental care for post-surgical patients.

Methods

We used a quality improvement project following a multi-phase design. In Phase 1, an iterative method was used to combine evidence from a narrative review and professionals' preferences. In Phase 2, the logic model underlying the program was developed guided by four steps: (1) confirm situation, intervention aim, and target population; (2) documented expected outcomes, and outputs of the intervention; (3) identify and describe assumptions, external factors and inputs; and (4) confirm intervention components.

Results

Phase 1 identified a minimum set of family involvement activities that were both supported by staff and the narrative review. In Phase 2, the logic model was developed and includes (1) the inputs (e.g. educational- and environmental support), (2) the ultimate outcomes (e.g. reduction of postoperative complications), (3) the intermediate outcomes (e.g. behavioural changes), and (4) immediate outcomes (e.g. improved knowledge, skills and attitude).

Conclusions

We demonstrated how we aimed to change our practice to an environment in which family caregivers were stimulated to be actively involved in postoperative care on surgical wards, and how we took different factors into account. The description of this program may provide a solid basis for professionals to implement the family involvement program in their own setting.

Association Between Caregiver Depression and Emergency Department Use Among Patients With Dementia

Importance

Current attempts to gauge the acute care needs of patients with dementia have not effectively addressed the role of caregivers, despite their extensive involvement in decisions about acute care management.

Objective

To determine whether caregiver depression is associated with increased use of the emergency department (ED) among patients with dementia.

Design, Setting, and Participants

This longitudinal cohort study used data from the Care Ecosystem study, a randomized clinical trial examining telephone-based supportive care for patients with dementia and their caregivers. Patients were 45 years or older with any type of dementia. A total of 780 caregiver-patient dyads were enrolled from March 20, 2015, until February 28, 2017, and 663 dyads contributed baseline and 6-month data and were included in the analysis.

Exposures

Caregiver depression (9-item Patient Health Questionnaire score of ≥10). Secondary analyses examined caregiver burden and self-efficacy.

Main Outcomes and Measures

The primary outcome was the number of ED visits in a 6-month period.

Results

Among the 663 caregivers (467 women and 196 men; mean [SD] age, 64.9 [11.8] years), 84 caregivers (12.7%) had depression at baseline. The mean incidence rate of ED visits was 0.9 per person-year. Rates of ED presentation were higher among dyads whose caregiver did vs did not have depression (1.5 vs 0.8 ED visits per person-year). In a Poisson regression model adjusting for patient age, sex, severity of dementia, number of comorbidities, and baseline ED use, as well as caregiver age and sex, caregiver depression continued to be associated with ED use, with a 73% increase in rates of ED use among dyads with caregivers with depression (adjusted incident rate ratio, 1.73; 95% CI, 1.30-2.30). Caregiver burden was associated with higher ED use in the unadjusted model, but this association did not reach statistical significance after adjustment (incident rate ratio, 1.19; 95% CI, 0.93-1.52). Caregiver self-efficacy was inversely proportional to the number of ED visits in the unadjusted and adjusted models (adjusted incident rate ratio, 0.96; 95% CI, 0.92-0.99).

Conclusions and Relevance

Among patients with dementia, caregiver depression appears to be significantly associated with increased ED use, revealing a key caregiver vulnerability, which, if addressed with patient- and caregiver-centered dementia care, could improve health outcomes and lower costs for this high-risk population.

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

BACKGROUND

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PARTICIPANTS

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

METHODS

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

FINDINGS

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

CONCLUSIONS

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

Implementation of a training program to increase knowledge, improve attitudes and reduce nursing care omissions towards patients with dementia in hospital settings: a mixed-method study protocol

INTRODUCTION

There is an evidence showing that when nurses have to allocate their time because of a lack of resources, older patients and especially those with dementia have a secondary care priority. The purpose of this study is to advance the level of knowledge, promote positive attitudes of nurses and reduce care deficits towards people with dementia through the implementation of a training programme. The programme will be enriched by an observational study of the care of patients with dementia to identify areas of missed care.

METHOD AND ANALYSIS

This study will follow a mixed methodology consisting of three stages: (1) evaluation of the level of nurses' knowledge and attitudes towards dementia care through the use of structured questionnaires, (2) observational study to evaluate nursing care in hospital settings, in order to detect any missed care and (3) quasi-experimental study, with a before-and-after design, through the implementation of the training programme in order to increase nurses' knowledge, improve attitudes and consequently to promote care for patients with dementia. The data will be analysed with descriptive and inferential statistics with the use of the SPSS V.24.0 and with content analysis as regard to the observational data.

ETHICS AND DISSEMINATION

The protocol was approved by the National Bioethics committee and other local committees (ΕΕΒΚ: 2018.01.02). The participants will give their informed consent and the anonymity and confidentiality. Also, the protection of data will be respected. The results of the study will be disseminated in peer-reviewed international journals and conferences. If the intervention is successful, the training package will be given to the continuous education unit of the National Professional Association in order to be used on a regular basis.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Active involvement of family members in postoperative care after esophageal or pancreatic resection: A feasibility study

BACKGROUND

Active involvement of relatives has the potential to improve postoperative patient outcomes by prevention of complications sensitive to basic care and unplanned readmissions. The aim of this study was to assess the feasibility of a program in which relatives participated in postoperative care.

METHODS

A pragmatic feasibility trial conducted at the surgical ward of a University hospital in the Netherlands. Patients undergoing esophageal or pancreatic resection with a relative who was willing and able to participate formed the intervention group (n = 20). A control group (n = 20) received usual postoperative care. The program consisted of the following: (1) information; (2) shared goal setting; (3) task-oriented training; (4) participation in basic care, focusing on mobilization, breathing exercises, cognitive activities and oral hygiene; (5) presence of relatives during ward rounds; and (6) rooming-in. Feasibility criteria were adherence to basic care, caregiver burden, and satisfaction of patients, family, and healthcare professionals.

RESULTS

All participants completed the program. Patients in the intervention group mobilized more (estimated difference for walking 170 meters per day, P = .037, and for sitting 109 minutes per day, P < .001), and showed more adherence to breathing exercises (estimated difference per day 1.4, P = .003), oral hygiene (estimated difference 1.52, P = .001), and cognitive activities (estimated difference 2.6, P < .001). Relatives'Care-Related Quality of Life instrument score did not deteriorate over time (P = .64); 96% of relatives would recommend the program and 92% felt better prepared for discharge. Patients in the intervention group were more satisfied with hospital admission. Healthcare professionals valued the program positively.

CONCLUSION

This program is feasible and is positively appreciated by patients, family, and healthcare professionals. Patients following the program showed more adherence to basic care activities.

Feasibility and utility of a cognitive screening for risk stratification in hospitalized older patients

OBJECTIVES

To determine whether the Mini-Cog can be applied by nursing staff to hospitalized elderly patients for cognitive impairment associated risk stratification.

METHODS

This explorative prospective multicenter cohort study was carried out among 2522 patients aged 70 and older, hospitalized due to physical illness in eight hospitals in Rhineland-Palatinate, Germany. All patients were asked to conduct the Mini-Cog at the day of admission and were clustered into low-performance, intermediate-performance, and good-performance categories by trained nursing staff and two experienced geronto-psychiatrists as gold standard. Complications in the course of the treatment were monitored.

RESULTS

The Mini-Cog was conducted in 1398 (54%) out of 2522 eligible patients. Mini-Cog scores assessed by nursing staff differed from the gold standard in 327 cases (23.9%). According to the area under the curve (AUC), nursing staff identified cognitively low-performing patients almost as well as the geronto-psychiatrists (AUC = 0.862; 95% CI, 0.83-0.89; P < 0.001, accuracy 89.6%). Overall, 241 (17.6%) patients were classified as low performing. These patients had a significantly higher probability of suffering from at least one complication (odds ratio [OR] = 3.13; 95% CI, 2.09-4.70; calculated by a logistic regression model, adjusted for age), and they had a higher probability to show behavioral symptoms.

CONCLUSION

Even under naturalistic conditions, nursing staff detected cognitively low-performing inpatients with the Mini-Cog. Using this short screening instrument should enable to predict complications of hospitalized older patients associated with cognitive impairment, a precondition to implement targeted care for this vulnerable patient group.

The impact of dementia on hospital outcomes for elderly patients with sepsis: A population-based study

BACKGROUND

Prior studies have suggested that dementia adversely influences clinical outcomes and increases resource utilization in patients hospitalized for acute diseases. However, there is limited population-data information on the impact of dementia among elderly hospitalized patients with sepsis.

METHODS

From the 2009-2011 National Hospital Discharge Database we identified hospitalizations in adults aged ≥65 years. Using ICD9-CM codes, we selected sepsis cases, divided them into two cohorts (with and without dementia) and compared both groups with respect to organ dysfunction, in-hospital mortality and the use of hospital resources. We estimated the impact of dementia on these primary endpoints through multivariate regression models.

RESULTS

Of the 148 293 episodes of sepsis identified, 16 829 (11.3%) had diagnoses of dementia. Compared to their dementia-free counterparts, they were more predominantly female and older, had a lower burden of comorbidities and were more frequently admitted due to a principal diagnosis of sepsis. The dementia cohort showed a lower risk of organ dysfunction (adjusted OR: 0.84, 95% Confidence Interval [CI]: 0.81, 0.87) but higher in-hospital mortality (adjusted OR: 1.32, 95% [CI]: 1.27, 1.37). The impact of dementia on mortality was higher in the cases of younger age, without comorbidities and without organ dysfunction. The cases with dementia also had a lower length of stay (-3.87 days, 95% [CI]: -4.21, -3.54) and lower mean hospital costs (-3040€, 95% [CI]: -3279, -2800).

CONCLUSIONS

This nationwide population-based study shows that dementia is present in a substantial proportion of adults ≥65s hospitalized with sepsis, and while the condition does seem to come with a lower risk of organ dysfunction, it exerts a negative influence on in-hospital mortality and acts as an independent mortality predictor. Furthermore, it is significantly associated with shorter length of stay and lower hospital costs.