A resource pack for staff

About this resource

This resource supports hospital care of people with dementia. It is designed for easy reference within busy ward environments. Each chapter has important issues and key points highlighted. It forms part of a series of resources on dementia care available from The Dementia Centre. These resources are designed to improve outcomes for people with dementia. A review of the literature in this area undertaken by the Dementia Services Development Centre, the University of Stirling, Scotland (Christie, 2011, publication pending) has identified seven key areas that could be improved in the care of people with dementia in acute settings. These are: 1. Staff knowledge and experience of dementia 2. Accident & Emergency and Assessment Units 3. Screening and assessment 4. Promoting a dementia-friendly hospital environment 5. Promoting person-centred care 6. Considering the impact of our attitudes and approaches to people with dementia 7. Care planning with dementia in mind

Introduction
Key Points
The values that underpin this guide are that: > a person with dementia, although they have cognitive impairment, still remains a person > people with dementia are individuals and as such each has a different pathway through the condition and different care needs > personalised care is required to meet optimal outcomes for the individual, their family, staff and the organisation.
Population ageing is stimulating debate in countries throughout the world as the proportion of people aged 60 and over increases faster than any other age group. In Australia, by the year 2050 the number of people aged 64-85 years will double (from 14 to 23% of the population) and the number of people aged over 85 years will quadruple (Australian Government, 2010). In the UK, the government announced in 2009 that for the first time ever there were more people over state pension age than there were children, in the year 2007 (HM Government, 2009). As life expectancy increases, so does the likelihood of more years spent in ill health, with women having an average 11 years and men 6.7 years of ill health (Parliamentary and Health Services Ombudsman, 2011: 8). This is reflected in the increased use of acute care services by older people. Unfortunately at the same time there has also been increasing concern that hospitals are failing to meet basic standards of care for many older people, especially people who have dementia (Kurrle, 2006; Alzheimer Society, 2009; Royal College of Psychiatrists Centre for Quality Improvement, 2010; PHSO, 2011: Mental Welfare Commission for Scotland, 2011). This includes failure to attend to basic levels of cleanliness, ensuring older people are comfortable and pain free, adequately managing complications relating to falls and infections, adequately managing adverse outcomes due to polypharmacy, adequately meeting the nutritional needs of older people coupled with a failure in providing assistance for people to eat and drink; and the inability to call someone who will respond. High quality effective medical treatment is the core business of the hospital/ health system. This activity has three possible outcomes: to return the patient to health, to assist the patient to live with a long term condition or to provide palliative care. As well as this there are three equally important areas of attention in caring for older people in hospital settings. These are: > Establishing a relationship with the person to ensure needs are heard and responded to. > Care plans that not only take account of the persons acute illness/needs but also their chronic needs and the context of their lives and relationships. > Co-ordinated, well-planned discharge arrangements. (PHSO, 2011) However with the focus on diagnosis and treatment of acute medical and/ or surgical problems, many staff in acute care settings have not been exposed to person-centred and contemporary approaches to caring

Caring for people with dementia in hospital settings

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for people with dementia, or their families and carers. As a result affected patients, their families and carers can also experience significant stress, as can staff. Further, patients with dementia experience increased levels of confusion and functional loss, and are at high risk of suffering preventable adverse events during their hospital admission. A positive approach to dementia begins with the recognition that a person with dementia is still a person. This helps us to focus on the rights, dignity and uniqueness of the individual. However, some models of dementia consider that the essence of the person, or their personhood, gradually diminishes and is eventually lost. It then becomes easy to focus on deficits,

problems and losses (Christie, 2007). This training pack is designed using a person-centred approach to dementia. Dementia does bring change over time; however the person needs to be seen in the context of their whole life experience. The introduction of person-centred approaches to dementia care can have a positive impact on the interaction between the patient and ward staff, offering an opportunity for continuity of care, improved communication and preservation of the dignity of the person with dementia. This in turn can help alleviate some of the symptoms and responses of the person with dementia that hospital staff find difficult.

Setting The Scene

People with dementia and hospital care what are the issues? Key Points
> dementia is an umbrella term for a set of signs and symptoms that indicate that there might be changes in the functioning of the brain > dementia is not a normal part of ageing > people with dementia are not always able to participate in their care > a lack of understanding of the issues can cause frustration and a lack of confidence for the person with dementia and staff > older people are expected to move through the hospital system quickly however people with dementia spend far longer in hospital than other people who go in for the same procedure
Policy trends over the last decade have seen a move towards community care and away from institutional settings. When a hospital admission is required this is for emergency or acute purposes and not for convalescence or long-stay care. There is an expectation that patients have short stays, early discharges and that beds have high utilisation rates. Admission to hospital, even if for an unrelated reason, frequently exacerbates dementia symptoms. The person may be in for an infection, heart failure or a fracture, but the dementia is made worse by the admission. Failure to understand dementia may cause distress not only for the person with dementia, but also for staff called upon to provide acute and often intensive care.

Important to Note
Often acute hospital care for patients is based on the assumption and requirement that patients will: > be able to articulate their needs > acknowledge the needs of other patients > move through the system quickly > be ready to be discharged having had their immediate needs met > return to their pre-admission accommodation with minimal support People with dementia will fail in many of these areas. This can lead to frustration and a lack of confidence for both the person and the staff who are involved in the provision of care. Caring for people with dementia in hospital settings
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> actively co-operate with their care

Dementia is NOT a normal part of ageing.

Dementia does affect older people approximately one person in twenty over the age of 65 years and one person in four over the age of eighty. Because ageing is the biggest risk factor in dementia there is a higher than average risk that a person with dementia will become physically ill and need treatment in a hospital setting.

Why is dementia an issue now for acute hospital staff?

Some of the pressures that acute care staff and management currently face include: > an increasing number of older people in the general population. As people age they become more at risk of developing dementia. Older people are major users of acute hospital services > the system is often organised around the needs of younger people > increasing amounts of aged care service provision (11% since 20052006) in public hospital settings (Australian Institute of Health and Welfare, 2010) > the implications of government policy is that older people, and more specifically people with dementia, are remaining in the community and are often living alone with multiple complex needs > community care is often inadequate for people with dementia > increasingly streamlined acute hospital services require people to move quickly through the system

> often general nurses and other hospital staff are not educated about dementia > competing demands of patients in an increasingly pressured environment make dementia care difficult to offer > people with dementia present disproportionate pressures in the acute system, both on beds and finance. In Australian hospitals, up to 50 percent of all patients admitted have some degree of cognitive impairment. Impaired mental status is the most commonly identified factor in patients who fall while in hospital (Marriott, 2003). Delirium and dementia are associated with an increased length of stay in hospital, increased morbidity and poor prognosis. Average lengths of stay in hospital (Draper, 2010a) include > Person under the age of 65 years 8.6 days > Person with dementia as a secondary diagnosis 19.6 days > Person with dementia as a primary diagnosis 30.1 days. The effect of a hospital stay is often detrimental to a person with dementia and its impact is felt well after discharge.