The Journal of Quality Research in Dementia Issue 8 (lay version)
Caring for people with dementia in general hospitals
Two thirds of medical beds in general hospitals are occupied by people over the age of 65 and around 30% of them will have dementia. Interestingly it is common for people's dementia to be diagnosed for the first time when they are admitted to hospital, usually for a separate health issue.
It is clear therefore that large numbers of people in hospital in the UK have dementia. The decisions that are made about and for this group of people whilst in hospital can have long-term consequences for their quality of life. This article reviews evidence from research about providing care for people with dementia when they are hospital patients.
No matter what care is offered, people in the later stages of dementia who develop an illness are unlikely to have what is known in medical jargon as a 'good outcome'.
Research shows that once admitted to hospital, people with dementia have a higher risk of needing long term residential care and dying than people without the condition. During their time in hospital they are also at high risk of developing major complications such as pressure sores, falls and incontinence. Statistics also show that half of people with moderate dementia who are admitted to hospital with an acute illness, such as hip fracture or pneumonia, will die within six months.
In 2006 a UK study examined the care received by dying patients with and without dementia on acute medical wards. The aim was to identify any differences between the types of care received. Analysis showed that patients with dementia were less likely to be referred to palliative care and less likely to receive palliative medication (and other specific medical interventions) than people without dementia. It was unlikely that this difference could be explained by differences between the groups, other than by the presence of dementia.
Israeli research into the final year of life of people with dementia in a general hospital has shown that:
- Suffering increases for people with dementia in the last months of life
- Suffering among people with dementia can be identified
- Patients who may benefit from palliative care can be identified.
Research into the effects and benefits of palliative care for people with dementia is at an early stage.
Decisions about discharge
Over half of all new admissions to care homes are of people transferred from general hospitals. We know that the majority of residents in care homes are people with dementia, so it follows that most of these new residents will be people with dementia.
There is good practice guidance to assist with the processes and decisions for patients in this situation, but it's unclear how well this guidance is used. Pressures and concerns that may have an impact on discharge decisions include the wish to minimize risk, the failure to include people with dementia in the decision making process and pressures to discharge patients and free up beds as quickly as possible.
Do medical interventions work?
People with dementia may often be excluded from treatments in general hospital but what do we know about how well treatments work for them when they are made available?
A recent study investigated the effect that having dementia had on how long people stayed in hospital, how likely they were to die and how likely they were to be referred to residential care. The experience of people with dementia was compared to similarly aged people with a range of characteristics (such as multiple medical conditions, poor functional ability and poor nutritional status). The study found that having dementia only had an impact on the likelihood of people being referred to residential care. It seems likely that this happens more for people with dementia than for people without the condition because of behavioural disturbances, despite the fact that these can be treated and managed. Overall the study showed that having multiple medical conditions and poor functional status (such as a physical disability) was more likely to have an impact on the length of stay in hospital, the likelihood of dying in hospital and the need for increased care than dementia alone.
An influential Finnish research project has shown that when people with mild to moderate dementia who had broken their hip were given an intensive rehabilitation programme, they spent fewer days in hospital and were more likely to return to independent living than those who were given care as usual. In this research the intensive rehabilitation was all provided on the hospital ward, it consisted of providing advice, training, drug treatment, physiotherapy, occupational therapy, speech therapy; listening to patients' concerns; and help with use of appliances, equipment, and daily living aids.
The same study found that intensive rehabilitation offered no benefit for patients that did not have dementia, or those that had it severely.
An overview of trials of treatments to prevent falls amongst people with dementia showed that it was possible to provide a range of treatments in general hospital that would reduce falls and that the level of dementia that people had did not have an effect on the outcomes. The range of treatments that were shown to be effective included risk assessments, care planning, changes in the physical environment, education programmes, medication review, providing hip protectors, removing physical restraints and encouraging exercise.
There is very little evidence available to assess the effectiveness of psychiatric treatments for people with dementia on general hospital wards.
A 1997 Dutch study that investigated the effects of a liaison psychiatry team for older people in hospital included people with dementia.
Liaison psychiatry is when psychiatric problems are recognised and managed in a general medical setting, such as a hospital, rather than by specialists in the community or a psychiatric hospital. The research showed that providing such a service to older people improved their physical function, reduced the amount of time they spent in hospital and reduced the number of patients admitted to nursing care. There was no difference in the results between people with or without dementia. Much more research is needed into the cost-effectiveness and potential benefits of such services.
Thoughts and opinions
Studies of what people think about their time in hospital tend to exclude people with dementia.
Research has shown that some people with dementia experience an improvement in mood after being discharged from hospital to a care home. Other research has shown that people with dementia are anxious and uncertain about moving into residential care.
There is a clear need for more research into what people with dementia think about their experience of hospital services. This is in addition to the need for research that will enable hospital staff to understand how best to provide services to people with dementia in a general hospital setting.
Sampson EL, Gould V, Lee D, Blanchard MR (2006) Differences in care received by patients with or without dementia who died during acute hospital admission:a retrospective case note study. Age and Ageing 35:187-189
Aminooff BZ, Adunsky A (2005) Dying dementia patients: too much suffering, too little palliation. The American Journal of hospice and palliative care 22(5):344-8.
Stewart R, Bartlett P, Harwood RH (2005) Mental capacity assessments and discharge decisions. Age and Ageing 34:549-550
Zekry D, Herrmann FR, Grandjean R, Vitale A-M, De Pinho M-F, Michel J-P, Gold G, Krause K-H (2009) Does dementia predict adverse hospitalization outcomes? A prospective study in aged inpatients. International Journal of Geriatric Psychiatry 24:283-291
Huusku TM, Karppi P, Avikainen V, Kautiainen H, Sulvaka R (2000) Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. BMJ 321:1107-1111.
Slaets JPJ, Kauffmann RH, Duivenvoorden HJ, Pelemens W, Schudel WJ (1997) A randomized trial of geriatric liaison intervention in elderly medical inpatients. Psychosomatic Medicine 59:585-591