Care for older people with frailty in hospitals

A frailty checklist was completed in only a quarter of older people at hospital admission | National Institute for Health Research (NIHR)

Frailsafe is a simple safety checklist offering the opportunity to improve safety and quality of care for frail older people while in hospital. It aims to increase key clinical assessments or practices on things like risk of falls, mobility and delirium, and to facilitate communication between staff.

Frailsafe was introduced in 12 NHS hospitals to help health professionals complete key frailty assessments and ultimately improve patient outcomes. This mixed methods study aimed to evaluate how local teams had implemented Frailsafe across the 12 participating NHS trusts and what they thought about it and its influence on patient safety and quality of care.

The study found that compliance with the items on the checklist for the whole period across the 12 sites was 24% (1,687 completed 7,201 checklists). This means only about 1 in 4 patients had evidence if receiving all the appropriate checks. Most hospitals completed the medication reviews and pressure ulcer risk assessments (around 60 to 100%). There was wide variation in the completion of delirium and dementia assessments (between 3 and 96%).

Full reference: Papoutsi C, Poots A, Clements J, et al. |  Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK | Age and Ageing | 2018

Related: National Institute for Health Research: A frailty checklist was completed in only a quarter of older people at hospital admission

Improving the care of people living with dementia admitted to hospitals

This review seeks to identify primary research and use its findings to develop explanations of what characteristics of dementia-friendly initiatives in hospitals make them work, in what circumstances, and why | BMJ 

Abstract

Objectives To identify features of programmes and approaches to make healthcare delivery in secondary healthcare settings more dementia-friendly, providing a context-relevant understanding of how interventions achieve outcomes for people living with dementia.

Design A realist review conducted in three phases: (1) stakeholder interviews and scoping of the literature to develop an initial programme theory for providing effective dementia care; (2) structured retrieval and extraction of evidence; and (3) analysis and synthesis to build and refine the programme theory.

Data sources PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, NHS Evidence, Scopus and grey literature.

Eligibility criteria Studies reporting interventions and approaches to make hospital environments more dementia-friendly. Studies not reporting patient outcomes or contributing to the programme theory were excluded.

Results Phase 1 combined findings from 15 stakeholder interviews and 22 publications to develop candidate programme theories. Phases 2 and 3 identified and synthesised evidence from 28 publications. Prominent context–mechanism–outcome configurations were identified to explain what supported dementia-friendly healthcare in acute settings. Staff capacity to understand the behaviours of people living with dementia as communication of an unmet need, combined with a recognition and valuing of their role in their care, prompted changes to care practices. Endorsement from senior management gave staff confidence and permission to adapt working practices to provide good dementia care. Key contextual factors were the availability of staff and an alignment of ward priorities to value person-centred care approaches. A preoccupation with risk generated responses that werelikely to restrict patient choice and increase their distress.

Conclusions This review suggests that strategies such as dementia awareness training alone will not improve dementia care or outcomes for patients with dementia. Instead, how staff are supported to implement learning and resources by senior team members with dementia expertise is a key component for improving care practices and patient outcomes.

Full reference: Handley M, Bunn F, Goodman C. | Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals: a realist review | BMJ Open 2017; 7:e015257

See also: Dementia care in hospital: training, leadership and culture change needed | The Mental Elf

Dementia assessment and improvement framework

An evidence-based framework to support and enable directors of nursing and medical directors to achieve ‘outstanding’ care standards for those living with dementia during their stay in hospital | NHS Improvement

This framework has eight standards, and draws on learning from organisations that have achieved an ‘outstanding’ rating from the Care Quality Commission. The document integrates policy guidance and best practice with opinion from patients and carers.

Sustainable, competent, and empathetic support for patients with dementia during an acute hospital stay

Internationally, there has been a focus on the development of acute hospital workforces to support and care for people with dementia | The International Journal of Health Planning and Management

Recommendations and initiatives to improve person-centred care in acute hospitals have included: education and training, dementia-specific roles, clinical leads, and environment changes.

The aim of this literature review is to understand the elements of a sustainable, competent, and empathetic acute hospital workforce providing person-centred care for patients with dementia.

Emergent themes were as follows: understanding the current workforce, implementation and evaluation of training, and exploration of new and existing roles. An important element was the sustainability of acute hospital workforces competent in dementia care, as studies highlighted an ageing nursing population and a high turnover of staff. Dementia awareness training was sustainable, although there was a lack of consistency in the length, content, and delivery, which had a viable impact on the provision of empathetic and person-centred care. The lack of consistency of training and specialist dementia roles restricts recommendations from a robust evidence base.

Full reference: Brooke, J. & Ojo, O. (2017) Elements of a sustainable, competent, and empathetic workforce to support patients with dementia during an acute hospital stay: A comprehensive literature review. The International Journal of Health Planning and Management. Published online: 24 August 2017

Dementia-Friendly Hospital Design

We report the findings of a knowledge synthesis research project on the topic of dementia-friendly acute care (D-FAC) design | The Gerontologist

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This exploratory project systematically mapped what is known about D-FAC physical design in hospitals. We discuss our challenges in locating reportable evidence and the implications of such design for maximizing independent function while ensuring safety and harm reduction in older people living with dementia.

A total of 28 primary studies plus expert reviewers’ narratives on the impact of design and architectural features on independent function of hospitalized older people with dementia were included and evaluated. Items were mapped to key design elements to describe a D-FAC environment. This scoping review project confirms the limited nature of available acute care design evidence on maximizing function.

Physical design influences the usability and activity undertaken in a health care space and ultimately affects patient outcomes. Achieving safe quality hospital care for older people living with dementia is particularly challenging. Evidence of design principle effectiveness is needed that can be applied to general medical and surgical units where the bulk of older persons with and without dementia are treated.

Full reference: Parke, B. et al. (2017) A Scoping Literature Review of Dementia-Friendly Hospital Design. The Gerontologist. Vol. 57 (No. 4) pp. e62-e74.

Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals

The aim of this study was to identify features of programmes and approaches to make healthcare delivery in secondary healthcare settings more dementia-friendly, providing a context-relevant understanding of how interventions achieve outcomes for people living with dementia | BMJ Open.

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Results: Phase 1 combined findings from 15 stakeholder interviews and 22 publications to develop candidate programme theories. Phases 2 and 3 identified and synthesised evidence from 28 publications. Prominent context–mechanism–outcome configurations were identified to explain what supported dementia-friendly healthcare in acute settings. Staff capacity to understand the behaviours of people living with dementia as communication of an unmet need, combined with a recognition and valuing of their role in their care, prompted changes to care practices. Endorsement from senior management gave staff confidence and permission to adapt working practices to provide good dementia care. Key contextual factors were the availability of staff and an alignment of ward priorities to value person-centred care approaches. A preoccupation with risk generated responses that werelikely to restrict patient choice and increase their distress.

Conclusions: This review suggests that strategies such as dementia awareness training alone will not improve dementia care or outcomes for patients with dementia. Instead, how staff are supported to implement learning and resources by senior team members with dementia expertise is a key component for improving care practices and patient outcomes.

Full reference: Handley, M. et al. (2017) Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals: a realist review. BMJ Open. 7:e015257

Dementia training programmes for staff working in general hospital settings

Although literature describing and evaluating training programmes in hospital settings increased in recent years, there are no reviews that summarise these programmes | Aging & Mental Health 

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Objectives: This review sought to address this, by collecting the current evidence on dementia training programmes directed to staff working in general hospitals.

Results: Fourteen peer-reviewed studies were identified with the majority being pre-test post-test investigations. No randomised controlled trials were found. Methodological quality was variable with selection bias being the major limitation. There was a great variability in the development and mode of delivery although, interdisciplinary ward based, tailor-made, short sessions using experiential and active learning were the most utilised. The majority of the studies mainly evaluated learning, with few studies evaluating changes in staff behaviour/practices and patients’ outcomes.

Conclusion: This review indicates that high quality studies are needed that especially evaluate staff behaviours and patient outcomes and their sustainability over time. It also highlights measures that could be used to develop and deliver training programmes in hospital settings.

Full reference: Scerri, A. et al. (2017) Dementia training programmes for staff working in general hospital settings – a systematic review of the literature. Aging & Mental Health. Vol. 21 (no. 8) pp.783-796

Experiences and Needs of Relatives of People with Dementia in Acute Hospitals

The purpose of this meta-synthesis was to present an in-depth analysis of existing qualitative literature concerning experiences and needs of the relatives of patients with dementia in hospitals | Journal of Clinical Nursing

Background: Relatives are an important resource for the care of patients with dementia in hospitals. They provide necessary information about the patient and can support the patient’s care. Simultaneously, they are themselves vulnerable, having specific needs and experiences. A number of studies have been conducted that focus on the perspectives of the relatives. The synthesis of qualitative studies contributes to a more comprehensive understanding of recent study findings.

Results: Relatives of patients with dementia frequently experience a negative cycle of specific worries, negative feelings and resulting roles and functions in hospital due to negative care experiences.

Conclusions: Experiences of relatives are strongly influenced by the attitudes, expertise and communication that they receive from health professionals working in the hospital. The results clearly show how health professionals have the potential to break through the negative cycle and contribute to a more positive feeling about a patient’s hospital stay.

Relevance to clinical practice: Structured and individually planned involvement of the relatives during the hospital care seems to be a key aspect for improving the experiences for the relatives and the patients with dementia. Collaboration with the relatives needs to be valued and supported by the organisation. Also a professional and defined frame for this area of responsibility needs to be provided.

Full reference: Burgstaller, M. et al. (2017) Experiences and Needs of Relatives of People with Dementia in Acute Hospitals – A Meta-Synthesis of Qualitative Studies. Journal of Clinical Nursing. DOI: 10.1111/jocn.13934

 

Integrated Care Pathways and Care Bundles for Dementia in Acute Care

Caring for people with dementia in acute settings is challenging and confounded by multiple comorbidities and difficulties transitioning between community and acute care | American Journal of Alzheimer’s Disease & Other Dementias

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Recently, there has been an increase in the development and use of integrated care pathways (ICPs) and care bundles for defined illnesses and medical procedures, and these are now being promoted for use in dementia care in acute settings. We present a review of the literature on ICPs and/or care bundles for dementia care in the acute sector. This includes a literature overview including “gray literature” such as relevant websites, reports, and government publications.

Taken together, there is clearly a growing interest in and clinical use of ICPs and care bundles for dementia. However, there is currently insufficient evidence to support the effectiveness of ICPs for dementia care in acute settings and limited evidence for care bundles for dementia in this setting.

Full reference:  Sullivan, D.O. et al. (2017) Integrated Care Pathways and Care Bundles for Dementia in Acute Care: Concept Versus Evidence. American Journal of Alzheimer’s Disease & Other Dementias. 32(4) pp. 189 – 193

Specialist geriatric medicine ward for older patients with dementia

The objective of this study is to clarify if admission to a specialist geriatric medicine ward leads to improvements in aspects of acute medical care for patients with dementia.

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We analysed combined data involving 900 patients from the Irish and Northern Irish audits of dementia care. Data on baseline demographics, admission outcomes, clinical aspects of care, multidisciplinary assessment and discharge planning processes were collected.

Relatively low numbers of patients with dementia received care on a specialist geriatric medicine ward. There appears to be a more streamlined discharge planning process in place on these wards, but they did not perform as well as one would expect in certain areas, such as compliance with multidisciplinary assessment and antipsychotic prescribing

Full reference: Briggs, R. et al. (2017) Does admission to a specialist geriatric medicine ward lead to improvements in aspects of acute medical care for older patients with dementia? International Journal of Geriatric Psychiatry. 32(6) pp. 624–632