Hospitalization at the end of life among nursing home residents with dementia

Falk Hoffmann, Anke Strautmann & Katharina Allers | Hospitalization at the end of life among nursing home residents with dementia: a systematic review | BMC Palliative Care | volume 18, Article number: 77 (2019)

Background

Half of nursing home residents (NHR) suffer from dementia. End-of-life hospitalizations are often burdensome in residents with dementia. A systematic review was conducted to study the occurrence of hospitalizations at the end of life in NHR with dementia and to compare these figures to NHR without dementia.

Methods

A systematic literature search in MEDLINE, CINAHL and Scopus was conducted in May 2018. Studies were included if they reported proportions of in-hospital deaths or hospitalizations of NHR with dementia in the last month of life. Two authors independently selected studies, extracted data, and assessed quality of studies.

Results

Nine hundred forty-five citations were retrieved; 13 studies were included. Overall, 7 studies reported data on in-hospital death with proportions ranging between 0% in Canada and 53.3% in the UK. Studies reporting on the last 30 days of life (n = 8) varied between 8.0% in the Netherlands and 51.3% in Germany. Two studies each assessed the influence of age and sex. There seem to be fewer end-of-life hospitalizations in older age groups. The influence of sex is inconclusive. All but one study found that at the end of life residents with dementia were hospitalized less often than those without (n = 6).

Conclusions

We found large variations in end-of-life hospitalizations of NHR with dementia, probably being explained by differences between countries. The influence of sex and age might differ when compared to residents without dementia. More studies should compare NHR with dementia to those without and assess the influence of sex and age.

Full document available from BMC Palliative Care

National Audit of Dementia

National Audit of Dementia: care in general hospitals 2018-2019 – Round 4 audit report | The Healthcare Quality Improvement Partnership

This report presents the Round 4 results of the National Audit of Dementia.   Scores from each hospital are derived from key themes and are shown in comparison to the scores from Round 3.

dementia audit
Image source: http://www.hqip.org.uk

There are several areas where improvement has been made: 96% of hospitals in England and Wales now have a system in place for more flexible family visiting; a large number (88%) of carers (and/or patients) receive a copy of the discharge plan; and more staff report being able to access finger food or snacks for patients with dementia.

Key areas for improvement include striving to ensure that more hospitals assess for delirium and that any member of staff involved in the care of people with dementia must have training relevant to their grade and include identification and management of delirium. This training should be recorded to provide assurance to the public and regulators.

For further detail and to download the report, click here

Dementia patients “suffering in silence”

University College London | September 2018 | Dementia patients “suffering in silence”

A new study from University College London (UCL) reports that one-third of patients with dementia who may also experience delirium (a state of acute confusion) are frequently unable to express that they are in pain.  The study has originality, as it is the first of its kind  in a hospital context. It has been funded by the Alzheimer’s Society and Bupa Foundation, and supported by the terminal illness charity Marie Curie. The research was conducted in two acute hospitals in the UK and followed more than 200 patients over the age of 70 (via UCL).

intravenous-141551_1920.jpg

At the outset the researchers asked patients if they were in pain. If the patient was then unable to communicate, researchers assessed people for signs of pain in their facial expression and body language. They recorded the number of people who were unable to communicate that they were in pain, and measured delirium with a standard confusion assessment method.

The researchers found that almost half (49%)  of the participants experienced pain at rest, while a quarter (25%)  experienced pain during activity. A little over a  third (35%) of participants who were delirious and unable to self-report pain,  of these patients 33%  experienced pain at rest, and 56% experienced pain during activity.

The odds of being delirious were 3.26 times higher in participants experiencing pain at rest.

Senior Author Dr Liz Samson from the Marie Curie Palliative Care Research Department, UCL Psychiatry says, ” In the UK, almost half of people admitted to hospital over the age of 70 will have dementia. We know that they are a high-risk group for delirium and yet delirium is often under treated.”  She elaborated, “It’s deeply troubling to think that this vulnerable group of patients are suffering in silence, unable to tell healthcare professionals that they are in pain.” (Source: UCL)

Read the full story at UCL

The research findings have now been published in the journal  Age and Ageing, where the full article can be read

Dementia friendly patient identification wrist bands

A Senior Healthcare Assistant (HCA) and Dementia Champion within the Royal Preston Hospital Emergency Department developed an adapted patient identification wristband that supported staff to recognise that a patient may have additional needs related to their diagnosis of dementia | NHS England

A discreet adaptation was made to existing wrist bands to notify any member of staff that the patient has dementia and that they needed to utilise their dementia care training when supporting the patient.

forget-me-not-1144695_1920

This was achieved by cutting a forget-me-not flower symbol into the patient’s wristband between a patient’s information and the barcode ensuring visibility of the symbol. Further work was undertaken with staff across the emergency and other departments within the hospital to notify them of the changes to the wristband and what the innovation was aiming to achieve.

There has been positive feedback from patients’, their families, friends and carers, as well as health professionals and the general public. The impact of the improvements has been well received by patients, their families and carers as well as staff at the hospital. Qualitative feedback, has shown that they feel patients are treated with dignity and respect by the Emergency Department team.

Full story at NHS England

Assessment of delirium in hospital for people with dementia

This report published by the Royal College of Psychiatrists provides a full breakdown of results from a national audit focusing on the identification and assessment of delirium in general hospitals.  It also includes key findings, recommendations, and a discussion of results. 

Key findings

spotlight
Image source: http://www.rcpsych.ac.uk/

A high proportion of patients with dementia admitted as emergencies to hospital did not receive an initial assessment for delirium, even after adjustment

After taking account of the greater number of initial assessments identified by the additional questions included in the questionnaire, we found that 32% of patients with dementia, admitted to hospital as an emergency, did not have an initial assessment or screen for delirium. At just under one third of the sample, this remains a very high proportion of people at high risk of delirium and requires improvement.

Questions about initial screen or assessment for delirium are inconsistently interpreted

Variation is apparent in the approach hospitals take to carrying out and recording the assessment of delirium, as questions about an initial screen or assessment for delirium are inconsistently interpreted. In 219 (10%) casenotes, auditors reported no screen, but questions about specific assessments found that it had taken place.  Following adjustment allowing for responses for the follow up questions, results for individual hospitals improved by an average of 19% with individual hospitals seeing increases ranging from to 64 percentage points.

Over a quarter of patients have no confusion or cognitive tests recorded

37% of patients received no confusion or cognitive tests at all, as well as no initial screen.  Cognitive assessment is an important part of comprehensive assessment which all patients with dementia admitted acutely should receive.

Delirium not included in discharge correspondence

Only 48% of patients whose casenotes recorded possible delirium at admission or after initial screening had this recorded on their discharge letter or summary.  All patients who have delirium during admission to hospital should have this information communicated to their General Practitioner (and Primary Care team) on discharge.

Full report: Assessment of delirium in hospital for people with dementia. Spotlight audit 2017 – 2018

 

Dementia Assessment and Referral

Information on the Dementia Assessment and Referral data collection for the period April 2017 to March 2018 | NHS England

This data collection reports on the number and proportion of patients aged 75 and over admitted as an emergency for more than 72 hours in England who have been identified as potentially having dementia, who are appropriately assessed and who are referred on to specialist services.

March 2018 Data (Quarter 4 2017-18) (released 6th June 2018)

Hospitals do not recognise dementia in a third of patients admitted with other conditions

Hospitals fail to recognise dementia in a third of patients who have already had the condition diagnosed if they are admitted to hospital for a different reason | Alzheimer’s and Dementia | via BMJ

adult-bed-black-and-white-886464

Researchers reviewed data on 21 387 patients aged over 65 who had been assessed at South London and Maudsley NHS Foundation Trust memory clinics from 2008 to 2006. A total of 8246 people had dementia diagnosed and were then admitted to general hospitals 37 329 times after their diagnosis.

The results, published in Alzheimer’s and Dementia, showed that 6429 patients (78%) had a dementia diagnosis recorded at some point in their hospital records. The proportion of all individual hospital records that included dementia was 50.3% and, among the 26 894 non-elective hospital admissions, the proportion was 63.3%.

Hospitals were more likely to miss dementia in patients who were younger, single, had more physical illness, had better cognitive function and less agitation or activity of daily living impairment, or were from an ethnic minority group.

Full story at BMJ

Full article: Sommerlad A, et al. | Accuracy of general hospital dementia diagnoses in England: sensitivity, specificity, and predictors of diagnostic accuracy 2008-2016 | Alzheimer’s and Dementia | published online 24 April 2018