Management of long-term conditions and dementia: The role of the Admiral Nurse

As life expectancy increases so people often develop a range of conditions and disabilities in the years before death | British Journal of Community Nursing

Multimorbidity represents the most common ‘disease pattern’ found among the elderly and is characterised by complex interactions of co-existing diseases where a medical approach focused on a single disease does not suffice. People with dementia who also have other comorbidities do not always have their comorbid conditions managed as those without dementia which often lead to a high number of hospital admissions with longer lengths of stay and greater treatment costs. This case study presents the case management approach taken by Admiral Nursing in managing the complexities where there is comorbidity of a long-term condition and a diagnosis of dementia. By empowering the person and their carer with information and choices and through good case management and communication, people can be supported to live well and avoid inappropriate hospital admissions.

Full reference: Knight, C. & Harrison Dening, K. (2017) Management of long-term conditions and dementia: The role of the Admiral Nurse. British Journal of Community Nursing. Vol. 22 (no. 6)

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

Association of comorbidity and health service usage among patients with dementia in the UK

Browne, J. et al. (2017) BMJ Open. 7:e012546

Social Care Photography, DH

Background: The majority of people with dementia have other long-term diseases, the presence of which may affect the progression and management of dementia. This study aimed to identify subgroups with higher healthcare needs, by analysing how primary care consultations, number of prescriptions and hospital admissions by people with dementia varies with having additional long-term diseases (comorbidity).

Discussion: In the UK, people with dementia with higher numbers of comorbidities die earlier and have considerably higher health service usage in terms of primary care consultations, hospital admissions and prescribing. This study provides strong evidence that comorbidity is a key factor that should be considered when allocating resources and planning care for people with dementia.

Read the full article here

Developing dementia-friendly care and support for people with a learning disability

A report from several voluntary sector organisations calls for an improvement in the way that the needs of people with learning disabilities and dementia are addressed | VODG

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Image source: VODG

This paper explores how best to develop support, services and treatments for the growing number of people with a learning disability and dementia. It builds on earlier work, across the voluntary sector strategic partnership which focuses on dementia support within the context of the protected characteristics defined under the Equality Act 2010.

Read the full report here

Healthcare organisation and delivery for people with dementia and comorbidity

Bunn, F. et al. BMJ Open. Published online 18 January 2017

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Objectives: People living with dementia (PLWD) have a high prevalence of comorbidty. The aim of this study was to explore the impact of dementia on access to non-dementia services and identify ways of improving service delivery for this population.

 

Conclusions: This study suggests that, in order to improve access and continuity for PLWD and comorbidity, a significant change in the organisation of care is required which involves: coproduction of care where professionals, PLWD and family carers work in partnership; recognition of the way a patient’s diagnosis of dementia affects the management of other long-term conditions; flexibility in services to ensure they are sensitive to the changing needs of PLWD and their family carers over time; and improved collaboration across specialities and organisations. Research is needed to develop interventions that support partnership working and tailoring of care for PLWD and comorbidity.

Read the full article here

New horizons: the management of hypertension in people with dementia

Harrisson, J.K. et al. (2016) Age Ageing. 45(6). pp. 740-746

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The optimal management of hypertension in people with dementia is uncertain. This review explores if people with dementia experience greater adverse effects from antihypertensive medications, if cognitive function is protected or worsened by controlling blood pressure (BP) and if there are subgroups of people with dementia for whom antihypertensive therapy is more likely to be harmful.

Read the full abstract here

Risk of dementia and death in community-dwelling older men with bipolar disorder

Almeida, O.P. et al. The British Journal of Psychiatry .Aug 2016. 209 (2). pp. 121-126;

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Image source: Susan Lockhart – Wellcome Images // CC BY-NC-ND 4.0

Background: Bipolar disorder has been associated with cognitive decline, but confirmatory evidence from a community-derived sample of older people is lacking.

Aims: To investigate the 13-year risk of dementia and death in older adults with bipolar disorder.

Method: Cohort study of 37 768 men aged 65–85 years. Dementia (primary) and death (secondary), as recorded by electronic record linkage, were the outcomes of interest.

Results: Bipolar disorder was associated with increased adjusted hazard ratio (HR) of dementia (HR = 2.30, 95% CI 1.80–2.94). The risk of dementia was greatest among those with <5 years of history of bipolar disorder or who had had illness onset after 70 years of age. Bipolar disorder was also associated with increased mortality (HR = 1.51, 95% CI 1.28–1.77). Competing risk regression showed that bipolar disorder was associated with increased hazard of death by suicide, accidents, pneumonia or influenza, and diseases of the liver and digestive system.

Conclusions: Bipolar disorder in later life is associated with increased risk of dementia and premature death.

Read the abstract here

Dementia and comorbidities

Dementia Rarely Travels Alone: living with dementia and other conditions | Alzheimers Society

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Image source: http://www.alzheimers.org.uk

A report on the All Party Parliamentary Group on Dementia’s inquiry that was held last year in to dementia and comorbidities. The inquiry has brought to light the scale of difficulty faced by people living with dementia and other health conditions.

Despite significant progress to deliver integrated care services and support, the health and social system frequently treats conditions in isolation so that people with dementia and other health conditions receive disjointed, substandard care and treatment.

The report identifies the changes needed across the healthcare system so that the NHS can meet the challenge of caring for people living with dementia and other conditions, supporting them to live fulfilled lives and makes recommendations as to how this can be achieved.

View the full report: Dementia  Rarely Travels Alone: living with dementia and other conditions

Interface between dementia and mental health

The Mental Health Foundation has published The interface between dementia and mental health: an evidence review.

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Image source: http://www.mentalhealth.org.uk

This review was carried out to explore the extent that people living with dementia have co-existing mental health problems.  The main finding of this review is that comorbidities are underdiagnosed in people living with dementia, not extensively researched and therefore not understood fully.  The review makes a number of recommendations at policy, organisation and programme level.

Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem)

Bunn, F. et al. Health Services and Delivery Research, No. 4.8

Background: Among people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.

Objectives: To explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.

Design: We undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.

Participants:The study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.

Results: The scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.

Conclusions:Significant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.

Read the full article here