Dementia Care in the Acute Hospital Context

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Dementia Care in the Acute Hospital Context

• Louise Nolan,
• School of Nursing and Midwifery, Trinity College
  Dublin
• 16.09.2007

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Aims of the presentation

• To highlight the issues to be considered when
  caring for people with dementia in an acute care
  setting
• To advance participant understanding of the
  implications of the issues highlighted for
  practice
• To provide suggestions for appropriate caring
  dementia practice in the acute care setting

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Introduction

• When a person with dementia is admitted to an
  acute hospital, he/she may often not fare well
  and is potentially a member of a vulnerable
  patient/client group.
• Providing care for people with dementia in an
  acute context is different from care provision
  for patients who do not have dementia!
• Therefore, we need to consider how the experience
  of the person with dementia, their primary carer
  (if appropriate) and professional carers may be
  improved.
• People with dementia are located in increasing
  numbers across a range of wards and research has
  shown that acute care practitioners often
  perceive the environment, for people with
  dementia, as strange, unsafe and dangerous due to
  its unfamiliarity (Borbasi et al., 2006).

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Prevalence

• Actual prevalence of dementia in hospitals is not
  known, some studies have offered estimates e.g.
  30 (Mezey Maslow, 2004) and 63 (Torian et
  al., 1992) of older inpatients. However, it is
  important to note that dementia is not only found
  in older people and not all older people have
  dementia.
• Difficulties arise with estimates as dementia
  does not normally constitute the main admission
  diagnosis (Torian et al., 1992 Dinkel, 1997).
• A high percentage of older persons admitted to
  acute hospitals could have some degree of
  cognitive impairment but may not have undergone
  assessment or received a diagnosis.

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Possible reasons for admission/readmission

• Admission for acute illness dementia then newly
  diagnosed
• Presence of dementia can predispose the person to
  
• accidental injury,
• poor compliance with medication, nutrition or
  lifestyle advice,
• non-recognition or misinterpretation of illness
  and
• delay in or absence of health seeking behaviours
• (Torian et al., 1997).
• Planned admission for assessment, diagnosis etc
• Unplanned admission for acute social or medical
  reason (as above)

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Outcomes of acute hospitalisation

• Higher cost of acute care e.g.
• treating life-threatening infections,
• multiple interdependent co-morbidities,
• pre-disposition of people with dementia to
  hospital acquired (nosocomial) infections
  complications of treatment
• difficulties with after- care which could
  prolong stay /or delay rehabilitation
• Poorer outcomes
• Longer than average stay
• Functional status (Gill et al., 1999 Sager et
  al., 1999) and discharge location
• Hospital readmission

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How must it be for the PERSON?

• When admitted the person might have been just
  balancing on the edge of being able to cope at
  home
• The person will be exposed to the confusing
  effects of moving from dept. to dept. in the
  hospital
• They may be in pain, feeling ill and bombarded
  with information and sensory overload
• There will be many new faces when they often are
  used to seeing a few people each day
• The person may be stressed and their behaviour
  affected by even small frustrations
• The person may become weepy, withdrawn or
  aggressive.

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Contrast this with the assumptions on which acute
care is often based!

• That PATIENTS will be
• Co-operative
• Able to express a need
• Able to acknowledge the needs of other patients
• Able to move quickly through the system
• Able to be discharged having had needs (often
  physical) met
• Consider the person with dementia in the midst of
  such expectations!

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So consider the following

• The acute care environment makes few allowances
  for persons with dementia despite the recognition
  of the challenges that such persons may face in
  this setting.
• Unique care challenges that encompass the 24 hour
  continuum (Stolley et al., 1991).
• Packer (2001) highlights the following issues of
  particular concern
• Business and general design of the environment
• Political imperatives for high bed turnover
• Poor understanding of the needs of people with
  dementia (including attitudes to older people and
  people with dementia)

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• Barbosi et al. (2006) had similar findings and
  further highlighted the following
• Lack of dementia specific knowledge
• Lack of time and multiple demands on staff
• Lack of resources including staff with dementia
  specific training
• Intensive nature of the work
• Inappropriate use of restraint
• The restraining nature of environmental,
  socio-cultural and economic issues

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Normal ageing and dementia!

• A person with dementia is also subject to normal
  age related changes and potentially multiple
  pathology, which in the presence of dementia can
  complicate care.
• Examples include-
• Communication more difficult with visual and
  hearing changes
• Person may not readily be able to express their
  wishes (be careful however not to assume this is
  always the case!)
• Increased risk of inadequate pain control, falls
  etc.
• People with dementia may be more prone to
  delirium
• Effects of medication e.g. psychotropic drugs,
  tranquilisers and sedatives.
• Altered presentation

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Increased risk of delirium

• Persons with dementia who are admitted to an
  acute hospital are at increased risk for acute
  confusion (delirium).
• Influencing factors could include presence of
  urinary tract infection, certain drugs,
  dehydration, environmental change, iatrogenic
  events, presence of illness, social isolation,
  sensory deprivation or overload etc.
• The occurrence of which will further compromise
  the persons ability to process information, cope
  with a new environment and perform activities of
  living (Evans, 1989).

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Possible reactions to hospitalisation

• Psychological
• Stress
• Fear
• Agitation /or agression
• Vocalisations
• Wandering or excessive walking
• Searching
• Wanting to go home

• Physical
• Disturbance in relation to activities of living
  e.g.
• Sleep patterns
• Nutrition
• Hydration
• Elimination
• Mobility
• Etc

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Possible reactions ctd.

• Delirium
• Decreased functional status
• Increased behaviour which challenge
• Significant cognitive decline
• (Erkinjuntti et al. 1986 Cox and Verdieck,
  1994 Day, Musallam Wells, 1999).

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Examples of possible hospital happenings

• Overmedication or wrong medication
• Falls
• Poor nutrition/dehydration
• Weight loss
• Incontinence
• Pressure sores
• Untreated pain

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• So how can we care for people with dementia in an
  acute care context?
• What particular issues need to be considered?
• How can we ensure person-centred, individualised
  care that upholds the dignity and personhood of
  the person with dementia?

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Suggestions

• The role of life-story
• Use of the nursing process
• Multidisciplinary care approaches
• Incorporating specialist dementia specific
  approaches and knowledge into health care
  practice - use of evidence-based dementia
  friendly care protocols, guidelines, policies,
  care pathways etc
• Consideration of the caring context the acute
  care environment
• Involvement of carers (if appropriate)
• Striving towards a vision of a dementia friendly
  acute care hospital environment

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The Role of Life Story!

• Contributes to the development of a three
  dimensional image of the person with dementia.
• Possible headings
• Family, friends, places, pets, occupation,
  hobbies, skills, likes, dislikes, films, music
• Benefits
• Greater understanding enabling a personal care
  approach
• Explanations
• Can be passed on
• A failure free, fun activity
• Family/caregiver involvement
• (Adapted from Murphy, 1994)

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The nursing process!

• Assessment
• Planning
• Implementation
• Evaluation
• All components are vital need to prevent an
  over-emphasis on one aspect!

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Multidisciplinary care approaches

• Who are the ideal members of such a team?
• Are such people in place in your organisation?
• What is the role of each team member?
• What is the specific role of the nurse in the
  context of multidiscipliary dementia care?

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Dementia specific care approaches and frameworks

• Use of dementia specific approaches and
  frameworks as an adjunct to other caring
  approaches can enhance practitioners knowledge
  and skills.
• In dementia this is important as interventions
  must be individualised.
• The practitioner needs to be aware that something
  that works for one person may not work for
  another and a strategy successful at one time may
  be unsuccessful at another time.

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Dementia specific care approaches and frameworks

• Dementia care approaches and frameworks recognise
  this and provide ways for ongoing dynamic care
  planning.
• Eg Use of framework/model to aid interpretation
  of and actions to address behaviours which
  challenge
• ABC model
• (Antecendent, Behaviour Consequences)
• Need Driven, Dementia Compromised Behaviour Model
  (NDB model)

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The Environment Large, unstructured unfamiliar!

• General design issue examples
• Open entry
• Construction of corridors and floors
• Furniture
• Colour schemes (walls, flooring etc.)
• Access to kitchens, other departments etc .
• Presence of healthcare equipment e.g. infusion
  pumps .
• Environmental hazards etc.

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Environmental considerations for practice!

• Provide a simple, safe, structured environment,
  consistent caregivers (where possible), frequent
  orientation to staff and care-giving activities.
• How?
• Organising work - consistent team membership!
• You can ask anybody because were all involved
  in the care
• (Nichols Heller 2002)
• Plan and maintain a consistent routine (that in
  as much as possible mirrors the persons own
  routine, likes and dislikes)
• Remember to ensure a system of communication so
  that everyone is aware of the persons
  needs,wants, preferred routine etc.

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• Placement in a room which facilitates observation
  but distant enough from the nurses station to
  avoid the associated noise and activity
• Protection from hazards e.g drugs, equipment,
  lines and tubing, monitors, chemical agents
• Safe wandering paths and consideration of exit
  locations
• Maximise safety by modifying the immediate
  environment to compensate for cognitive losses.

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• Use items to help with location identification
  i.e. orientation objects, examples include
• clocks
• signage cueing
• calendars with large print placed at eye level
• mementos from home e.g. pictures, clothing,
  bedding
• adjusting lighting (shadows may be confusing or
  frightening and bright fluorescent lights may
  irritate the eyes over extended time periods) to
  ensure that it is shadow and glare free and low
  lighting should be available for sleep time
• consider the use of mirrors on an individual
  basis

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Sensory stimulation

• There is a risk of being overwhelmed in the
  presence of reduced ability to adapt (multiple
  room mates, loud noises, smells, staff and
  visitors coming and going)
• Stimuli may be interpreted in the context of the
  distant past or the familiar
• Need to balance sufficient environmental stimuli
  with an avoidance of excess stimulation!
• For example
• Controlled sensory input (e.g. is it appropriate
  and/or safe to keep the persons door closed
  during a period of high activity?)
• Location of bed-space noise control
• Social interaction activity

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The importance of activity

• Life exists in the activities of being and
  doing (Hellen, 1992)
• The choice of activity should be based on the
  persons preference, their abilities, maintenance
  of independence and a sensitivity to cultural
  spiritual needs.
• E.G. Use of activity kits focusing on cognitive
  and functional abilities which can reduce
  boredom, agitation and challenging behaviours.

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The CarerCreating care partnerships with carers!

• Care partner and source of knowledge
• Co-operative planning involvement prior to
  admission (if planned!)
• Involvement in care provision unlimited
  visiting
• Caring for carer e.g. -
• identification of needs
• referral for support
• provision of overnight accommodation facilities

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A Vision of a Dementia-Friendly Hospital

• Awareness and support from hospital leadership
  management
• Staff education
• Routine procedures for recognition of dementia
• Effective communication about dementia and
  related care issues
• Consideration of the environment to enhance its
  suitability for persons with dementia
• Discharge planning connecting the person
  family/carer to support services
• (Silverstein Maslow, 2005)

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A Vision of a Dementia-Friendly Hospital

• Awareness and support from hospital leadership
  management
• Staff education
• Routine procedures for recognition of dementia
• Effective communication about dementia and
  related care issues
• Consideration of the environment to enhance its
  suitability for persons with dementia
• Discharge planning connecting the person
  family/carer to support services
• (Silverstein Maslow, 2005)

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In summary

• In the acute care context, emphasis on a
  bio-medical model, cure and rapid treatment and
  throughput, exacerbates the situation for a
  person with dementia, who may not be able to fit
  with this ethos (Archibold, 2002).
• Therefore, healthcare providers must consider how
  the acute care experience of the person and
  his/her family/carers can be improved.

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Our Challenge!

• The challenge when providing acute care for
  adults with dementia
• Treat the acute illness, while preventing
  complications, maintaining function and self-care
  abilities planning for a successful discharge
  to the least restrictive environment (Lehman,
  Tyler Amador, 2005)
• Address ethical, safety and psychosocial issues
• Maximise potential for well-being preservation
  of function and to try to ensure familiarity
  predictability
• Provide dementia specific care while recognising
  the challenges posed by the possibilities of the
  acute context.