NIHR Alert: Careful phrasing of requests by hospital staff could help people with dementia accept care

NIHR | December 2020 | Careful phrasing of requests by hospital staff could help people with dementia accept care

“Healthcare professionals in acute hospitals are not generally trained in how to communicate with people with dementia. This has an impact on their job satisfaction and stress levels. People with dementia and their relatives also report dissatisfaction with communication in hospital.”

Rebecca O’Brien, Study Author, Clinical Researcher School of Health Sciences/ Division of Rehab, Ageing and Well-being University of Nottingham
This study intended to provide healthcare professionals with ways to communicate more effectively with people living with dementia (PLWD). The authors analysed video recordings of HCPs and PWDs interactions from three inpatient wards. Their analysis led to a recognition of requests which led to patients agreement or refusal
The experts also recognise that no manner of verbal requesting would guarantee compliance or ultimately override a patient’s right to refuse to comply with a request. They identify several features of requests can be seen to precede acceptance, principally the use of higher entitlement requests, and the lowering of contingencies. This indicates that by varying tone, phrasing and question construction led to a more positive response from patients who were confused or resisting care.

The authors want to equip health professionals with the skills to make requests in different ways. O’Brien also wants “policymakers to understand the importance of the need to train staff in communication skills.” (Source: NIHR and O’Brien et al, 2020)

O’Brien, R., Beeke, s., Pilnick, A. & Harwood, R.H. | 2020| When people living with dementia say ‘no’: Negotiating refusal in the acute hospital setting | Social Science and Medicine | Vol. 263 113188


A quarter of UK acute hospital beds are occupied by people living with dementia (PLWD). Concerns have been raised by both policy makers and carers about the quality of communication between hospital staff and PLWD. PLWD may experience communication impairments such as word finding difficulties, limited ability to construct coherent narratives and difficulties understanding others. Since much healthcare delivery occurs through talk, healthcare professionals (HCPs) and PLWD are likely to experience increased communication barriers. Consistent with this, HCPs report stress and reduced job satisfaction associated with difficulty communicating with PLWD. HCPs face these challenges whilst striving to deliver person-centred care, respecting the autonomy and wishes of the patient before them. However, best practice recommendations in the field tend not to be based on actual interactional evidence. This paper investigates recurring interactional difficulties around HCP requests to carry out health and social care tasks and subsequent reluctance or refusal on the part of PLWD. Using conversation analysis, we examined 41 video recordings of HCP/PLWD interactions collected across three acute inpatient wards. We identify both the nature of the refusals, and any mitigation offered, and explore the requests preceding them in terms of entitlement and contingency. We also explore the nature of HCP requests which precede PLWD agreement with a course of action. We conclude that several features of requests can be seen to precede acceptance, principally the use of higher entitlement requests, and the lowering of contingencies. Our findings underline the importance of examining the contextual interactional detail involved in the negotiation of healthcare, which here leads to an understanding of how design of HCP requests can impact on an important healthcare activity being carried out. They also emphasise the power of conversation analytic methods to identify areas of frequent interactional trouble in dementia care which have not previously been articulated.

Primary paper is available from Social Science & Medicine

NIHR Alert Careful phrasing of requests by hospital staff could help people with dementia accept care

Respite Care for People with Dementia and their Carers

Emma O’Shea et al. | Respite Care for People with Dementia and their Carers: A Qualitative Study with Multiple Stakeholders | Age and Ageing | Volume 48, Issue Supplement 3 | September 2019 | Pages iii17–iii65


Traditional models of respite, particularly those based within residential care settings, may not always be effective, and there is evidence of low acceptability for some people with dementia and carers. The aim of this study was to synthesise multiple stakeholders’ experiences of respite services for dementia and their perspectives on respite service development.


Purposive sampling was employed. Semi-structured interviews were conducted with 35 key stakeholders, including people with dementia (n=6), carers (n=9), front-line staff (n=7), managers (n=8), policy-makers/academics (n=5). Data were interpreted inductively using thematic analysis, with a focus on latent patterns of meaning.


Three salient themes were identified (‘Phases of Transition’, ‘Person-centred Respite Care’; and ‘Recalibrating Respite’). Three distinct phases of respite transitions for people with dementia and carers are discussed. Respite services that actively support transitions through empathic communication regarding clients’ concerns, support needs and preferences are highly valued. Clients described care resembling a ‘person-centred’ approach as their ideal, without using that term, but people with dementia do not always experience this type of care. The majority of providers indicated that they provide ‘person-centred care’, but many demonstrated a poor understanding of the concept; many of these providers have a biomedical view of dementia and the personhood status of people with dementia. Regarding service development, clients would prefer more choice, flexibility and responsiveness, including a shift away from residential provision towards an integrated continuum of personalised, strengths-focused community-based and in-home supports.


Any recalibration of respite towards a home/community focus will require a transformation in how dementia is constructed by society, as well as a significant financial investment. Other implementation considerations include: staffing and staff competency; and the co-ordination, integration and regulation of personalised, home-based care models. Finally, it may be necessary to replace the outdated term ‘respite’ with an alternative nomenclature that is not discordant with person-centred care principles.

Why it’s important to review the care of people with dementia

Why it’s important to review the care of people with dementia | Healthwatch 

This report summarises data and people’s experiences about social care reviews, reassessments and their outcomes for people with dementia. It also includes recommendations.

Over 850,000 people live with dementia in the UK. One widely reported challenge is the impact dementia has on families and friends, and how it can be a constant struggle to get the right support from social care services.

As dementia is a degenerative condition, The Care Act states that people are entitled to regular reviews to ensure care meets their changing needs. However, when we analysed data from 97 local councils, Healthwatch found people were not getting what they were entitled to.

Full report: Why it’s important to review the care of people with dementia

Ten minutes of social interaction improves wellbeing  in dementia care

Alzheimer’s Society | July 2018 | Ten minutes of social interaction improves wellbeing  in dementia care

Spending ten minutes interacting with people with dementia in care homes can benefit their wellbeing. The Wellbeing and Health for people with Dementia (WHELD) programme trained care home staff to increase social interaction from two minutes a day to ten, combined with a programme of personalised care.  Carers were encouraged to discuss the patient’s interests and involve them in decisions about their care.  The Improving Staff Attitudes and Care for People with Dementia e-Learning (tEACH) study, conducted by the University of Exeter Medical School and King’s College London in partnership with the Social Care Institute for Excellence (SCIE), was presented at the recent Alzheimer’s Association International Conference 2018. The study involved 280 residents and care staff in 24 care homes over a nine- month period.

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Carers participated in an e-learning programme, carers who participated via Skype  continued to deliver improved resident wellbeing four months after the trial was completed. Although boh treatment arms improving resident wellbeing and staff attitudes to person-centred care.

Dr Doug Brown, Chief Policy and Research Officer at Alzheimer’s Society, said:

‘It’s unacceptable that people in care homes only get ten minutes of social interaction each day. What we need is a person-centred approach to care, that takes into account each individual’s unique qualities, abilities, interests, preferences and needs.

‘This study supports what we know from our own research – training is crucial in order to provide this type of individualised care, activities and social interactions, which can have a significant impact of the well-being of people living with dementia in care homes (Source: The Alzheimer’s Society).


Press release:

University of Exeter Just ten minutes of social interaction a day improves wellbeing in dementia care

In the news:

Science Daily  Just 10 minutes of social interaction a day improves wellbeing in dementia care

Dementia – the true cost

Dementia – the true cost: fixing the care crisis | Alzheimer’s Society 

This report from Alzheimers Society is based on qualitative research from five listening events with people affected by dementia, social care professionals and dementia lead nurses in Winchester, Newcastle, Birmingham, Cardiff and Belfast. In total, evidence and testimony was gathered from over 70 people to get an in-depth understanding of the challenges they face day-in and day-out to get the care they need.

The report highlights the inadequacies in the care system regarding dementia patients. The number of potentially unnecessary hospital admissions among dementia patients has risen by 73% across 65 hospital trusts, from 31,000 in 2012 to around 55,000 in 2017. Some of this apparent increase may be attributable to better recording over that period  but the report said that this could not account for the full increase.

Full report: Hutchings, R. Carter, D.& Bennett, K. | Dementia – the true cost: fixing the care crisis  | Alzheimer’s Society | May 2018

See also: Dementia patients ‘abandoned’ by system | BBC

Dementia research must study care as well as cure

In this article, Doug Brown, Chief policy and research officer at Azheimers Society explores research investment in dementia.  He finds that there is a strong focus on finding a cure, with less than 5% of funding studying the best possible care for those affected | Story via The Guardian

The need for a cure for dementia is as pressing as ever, but we also need care research to develop practical solutions that can benefit people with the condition and their carers. In this article, Doug Brown argues that Improving knowledge and practices among health and social care professionals, as well as the quality and inclusivity of the wider system, is just as important as developing medical treatments.

A new Alzheimer’s Society report asked researchers, people with dementia, and the professionals who support them to help create a roadmap for the research needed to deliver these improvements. The roadmap offers five key goals:

  • Increase knowledge of risk factors to prevent future cases of dementia
  • Maximise the benefits of seeking and receiving a dementia diagnosis
  •  Improve quality of life for people affected by dementia
  •  Enable the dementia workforce to deliver improved practice
  •  Optimise quality and inclusivity of health and social care systems

These broad research goals are broken down into recommendations and an action plan that will help achieve them.

Full article via The Guardian

Related: Dementia research roadmap for prevention, diagnosis, intervention and care by 2025 | Azheimers Society



Dementia prevention, intervention, and care

Livingston, G. et al. | Dementia prevention, intervention, and care | The Lancet , Volume 390 , Issue 10113 , 2673 – 2734

This article argues that there is a potential for better disease prevention and for care to offer more improvements to the lives of a growing number of people with dementia.

To reduce dementia incidence, article authors recommend active treatment of hypertension for all people over 45 without dementia. Furthermore, they estimate that interventions into such risk factors as childhood education, exercise, maintaining social engagement, reducing smoking, and management of hearing loss, depression, diabetes, and obesity might have the potential to delay or prevent a third of dementia cases.

Full paper available via The Lancet


Post-diagnostic support for adults with an intellectual disability and dementia

Study finds, Post diagnostic support is essential for the general population, and within the intellectual disability field, needs to be individualized and adapted to the person’s needs as dementia progresses.


Objectives: Post diagnostic support (PDS) has varied definitions within mainstream dementia services and different health and social care organizations, encompassing a range of supports that are offered to adults once diagnosed with dementia until death.

Method: An international summit on intellectual disability and dementia held in Glasgow, Scotland in 2016 identified how PDS applies to adults with an intellectual disability and dementia. The Summit proposed a model that encompassed seven focal areas: post-diagnostic counseling; psychological and medical surveillance; periodic reviews and adjustments to the dementia care plan; early identification of behaviour and psychological symptoms; reviews of care practices and supports for advanced dementia and end of life; supports to carers/ support staff; and evaluation of quality of life. It also explored current practices in providing PDS in intellectual disability services.

Results: The Summit concluded that although there is limited research evidence for pharmacological or non-pharmacological interventions for people with intellectual disability and dementia, viable resources and guidelines describe practical approaches drawn from clinical practice. Post diagnostic support is essential, and the model components in place for the general population, and proposed here for use within the intellectual disability field, need to be individualized and adapted to the person’s needs as dementia progresses.

Conclusions: Recommendations for future research include examining the prevalence and nature of behavioral and psychological symptoms (BPSD) in adults with an intellectual disability who develop dementia, the effectiveness of different non-pharmacological interventions, the interaction between pharmacological and non-pharmacological interventions, and the utility of different models of support.

Full reference:  Dodd, K et al. | Consensus statement of the international summit on intellectual disability and Dementia related to post-diagnostic support. | Aging & Mental Health | Published online: 07 Sep 2017


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

Care in hospitalized patients with dementia

Patira, R. et al. Aging & Mental Health | Published online: 22 March 2017


Background: Hospitalization is an opportunity to address various aspects related to management of dementia, including the goals of care to avoid futile care. We studied the prevalence of these factors when patients with dementia are hospitalized.

Results: In patients with dementia, co-morbidities and vascular disease burden were frequent. When these patients were hospitalized, use of psychotropic medications, invasive procedures, and multi-specialty consultations was common. Tests of mental status, screening for reversible causes, and use of FDA-approved medications for dementia is less common. Despite the lack of advance directives, goals of care were infrequently discussed. When goals of care were discussed, proxy decision-maker preferred palliative care and long-term institutionalization on discharge.

Conclusion: Goals of care and other aspects of management are not fully addressed in hospitalized patients with dementia.

Read the full abstract here