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Dementia care in General Hospitals And what we are doing to improve it at the Royal Berks


Dementia care in General Hospitals And what we are doing to improve it at the Royal Berks David Oliver Consultant Physician What I will cover 1. What is dementia, how ... – PowerPoint PPT presentation

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Title: Dementia care in General Hospitals And what we are doing to improve it at the Royal Berks

Dementia care in General HospitalsAnd what we
are doing to improve it at the Royal Berks
  • David Oliver
  • Consultant Physician

What I will cover
  • 1. What is dementia, how is it diagnosed and how
    does it affect people
  • 2. How common is it (population and in general
    hospitals) and what does it mean for systems and
  • 3. National Policies, Guidelines and Audits
    (great momentum just now)
  • 4. Some of the issues for people with dementia
    and their carers in general hospital settings
  • 5. What we are doing at the Royal Berks to tackle
    care gaps and improve care
  • A copy of this presentation will be available on
    the Trust Members website, the documents are also
    available on the internet

I. What is dementia and how does it affect people?
What is dementia? (
  • The term 'dementia' describes a set of symptoms
    which include loss of memory, mood changes, and
    problems with communication and reasoning. These
    symptoms occur when the brain is damaged by
    certain diseases, including Alzheimer's disease
    and damage caused by a series of small strokes.

  • Dementia is progressive, which means the
    symptoms will gradually get worse. How fast
    dementia progresses will depend on the individual
    person and what type of dementia they have. Each
    person is unique and will experience dementia in
    their own way. It is often the case that the
    person's family and friends are more concerned
    about the symptoms than the person may be

How does dementia affect people?
  • Loss of memory - this particularly affects
    short-term memory, for example forgetting what
    happened earlier in the day, not being able to
    recall conversations, being repetitive or
    forgetting the way home from the shops. Long-term
    memory is usually still quite good.
  • Mood changes - people with dementia may be
    withdrawn, sad, frightened or angry about what is
    happening to them.
  • Communication problems - including problems
    finding the right words for things, for example
    describing the function of an item instead of
    naming it.
  • In the later stages of dementia, the person
    affected will have problems carrying out everyday
    tasks and will become increasingly dependent on
    other people.

To recap The 3 main manifestationsSee Burns A
and Iliffe S. BMJ Jan/Feb 2009. 2 Clinical Reviews
  • Neuro-psychological
  • Problems with memory or language
  • Neuro-psychiatric
  • Personality changes
  • Psychiatric symptoms (e.g. anxiety, depression,
  • Challenging behaviours/restless wandering
  • Impaired executive function
  • Leading to difficulty with common Activities of
    Daily Living e.g. washing, dressing, feeding,
    grooming, walking etc
  • We can imagine what effect these symptoms can
    have for family care givers and what problems
    they could pose for professional carers

Other clinical considerations
  • Not all dementia is Alzheimers (c55)
  • Also vascular (c25), mixed, and rarer forms
    (e.g. Lewy Body disease, Huntingtons etc)
  • Many older people with memory problems only have
    mild cognitive impairment this increase risk
    of dementia
  • Other conditions can cause similar symptoms so
    need to be ruled out or treated
  • Delirum or acute confusion (very common in
    older people admitted to hospital and often
  • Depression causing pseudo-dementia
  • Metabolic problems (e.g. thyroid, thiamine
  • Brain tumours or bleeding

Screening for Dementia e.g.
  • Six item test of cognitive function (6CIT)
  • 1. What year is it?

  • 2. What month is it?

  • Give the patient an address phrase to remember
    with 5 components,eg John Smith, 42, High St,

  • 3. About what time is it (within 1 hour)

  • 4. Count backwards from 20-1

  • 5. Say the months of the year in reverse

  • 6. Repeat address phrase

Diagnosing Dementia e.g. MMSE
What this can mean for people.e.g..
  • Shock or Anxiety at being diagnosed
  • Satisfaction that the problem has been diagnosed
    and something is being done
  • A need for more information. What can we expect
    next? What treatment is there? What support? etc
  • Worry or uncertainty about the future (including
    care costs, dependency, role for family
  • Issues about being able to maintain personal
    safety and wellbeing
  • Concerns around dignity in care
  • Stress and anxiety for family care givers
  • Satisfaction from delivering the best possible
    care and quality of life
  • Need for advanced decisions (around medical
    interventions, finances etc)

II. How common is dementia in society and in
general hospitals like the Royal Berks?
Dementia affects c 750,000 People in the UK
expected to double within the next 20 years
Total NHS spend in England 122bn. Total spend
on Dementia in Health and Social Care
8.2bn Total spend on police and prisons 9.4bn
Alzheimers Disease International, 2009
From NHS Information (People over 65 account for
60 admissions and 70 bed days to hospital)
Who cares wins 2005 c 1 in 4 adult beds
occupied by someone with Dementia (usually
admitted for other reasons)
  • Typical 500 bed DGH
  • 5000 admissions over 65 each year
  • 3000 with mental disorder
  • On snapshot
  • 220 beds mental disorder in over 65s
  • 96 depression
  • 102 dementia
  • 66 delirium
  • Sampson et al Br J Psych. 41 of people over 75
    admitted to general hospital had dementia. Half
    not previously diagnosed

Alzheimers Society Counting the Cost 2009
From Acute Awareness (NHS Confederation 2010)
  • as dementia is not generally the prime reason
    for admission to hospital it can often be
    difficult to factor into a patients care
    programme, yet improving care has the potential
    not only to enhance quality of experience but
    also to reduce length of stay and cost

III. The national response to these issues.
Policies, guidelines, audits, strategies etc
  • A time of great momentum and interest

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Four key priorities in new 2010 implementation
plan for government to support local delivery of
  • 1. Good quality diagnosis and early intervention
    for all
  • 2. Improved quality of care in general hospitals
  • 3. Living well with dementia in care homes
  • 4. Reducing antipsychotic medication

The other objectives in Living well with
dementia still stand, but a focus on local
delivery, accountability and empowerment
NICE/SCIE Dementia CG 42
  • Acute and general hospital trusts should plan
    and provide services that address the specific
    personal and social care needs and the mental and
    physical health of people with dementia who use
    acute hospital facilities for any reason.

National Audit Office Report 2010
  • Effective identification of patients with
    dementia on admission and more proactive
    co-ordinated management of their care and
    discharge could produce savings of 64m and 102
    m a year nationally

2009 NHS Confederation
Counting the Cost Report
Counting the Cost
  • 1 in 4 adult beds
  • People with dementia stay longer
  • If they left hospital one week sooner, savings of
    at least 80m pa for just four condition codes
  • The longer they stay in hospital the worse the
    effect on the symptoms of dementia and physical
    health, more likely to lose function, be
    discharged to a care home or be prescribed
  • Much of the large sums of money spent on
    dementia care in general hospitals could be more
    effectively invested in workforce capacity and
    development and in community services outside
    hospitals to drive up the quality of care on the
    wards improve efficiency and ensure that people
    with dementia only access acute care when

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Audit Participation
  • 151 eligible Trusts (England and Wales)
  • 238 eligible hospitals
  • Provide general acute services on more than one
  • Admit people over 65
  • 99 Trust participation (1 or more hospitals core
  • 210 or 88 hospitals (core audit) 55 hospitals
    (145 wards) enhanced

Survey of 206 Hospitals organisational level
(RCPsych Audit)
  • Only 30 have formal system for gathering
    personal information to caring for person with
  • 8 of boards review data on readmissions
  • 20 of boards review data on delayed transfer
  • 70 have no review process for discharge
    procedures on people with dementia

  • 70 of hospitals were unable to identify people
    with dementia within reported information on
    hospital falls
  • 77 of trusts had no training strategy
    identifying key skills for working with people
    with dementia
  • 95 of trusts no mandatory awareness training
  • 81 of trusts had no system to ensure ward staff
    were aware that a person had dementia and how it
    affected them and that necessary information was
    imparted to other staff with whom the person came
    into contact

From RCPysch Audit review of casenotes of 7,934
  • 41 received standard mental test score while in
  • 90 of hospitals had some access to liaison
    psychiatry but only 40 seen in 48 hours and 36
    not seen after 96 hours of referral
  • 26 of hospitals documented assessment of carers
    needs in advance on discharge
  • 30 of patients had no documentation of
    nutritional status

IV. We have heard about systems and services but
what are some of the key issues for people with
dementia in general hospital and for those who
look after them?
From Acute Awareness
Ann Reid..Acute Awareness
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RCPsych Audit. What were patient/ carer
  • Care planning and support in relation to the
    dementia (i.e. not just the acute condition) from
    admission to discharge
  • Care of patients with acute confusion
  • Maintaining dignity in care
  • Maintenance of patient ability
  • Communication and collaboration staff and
    patients/ carers
  • Information exchange
  • End-of-life care
  • Ward environment

Counting the cost 2009 1,291 carers, 657
nurses, 479 ward managers
Causes of distress
  • Physical
  • Noise
  • Lighting
  • Heat
  • Space
  • Proximity
  • Posture
  • Signage
  • Emotional
  • Recognise individual distress
  • Importance of familiar people, places and objects
  • Reminiscence individually or with family
  • Activity

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Better bedside care for individual patients and
their families
  • Key information, guidance and references on each
    aspect of the care pathway
  • Backed by good practice examples from English
  • (As is Acute Awareness)

What the guide covers in detail..
  • Whole Hospital Approaches
  • Multi-professional specialist liaison
  • Environment and Orientation
  • More person centred care
  • Including involvement of carers
  • Communication
  • Antipsychotics
  • Nutrition and Hydration
  • Pain Relief
  • Challenging Behaviour
  • Walking and Wandering
  • Withdrawn and unresponsive
  • Preventing Delirium
  • Recognising and Managing Delirium
  • Preserving function and rehabilitation
  • Discharge Planning

What else might be useful...
  • Falls and Injuries
  • Safeguarding
  • Deprivation of Liberty
  • Physical Restraint (Bedrails/Alarms)
  • Mental Capacity and IMCAs
  • Testamentary capacity
  • Advance Decisions
  • End of Life Care
  • Including withdrawal of food and fluids/use of
  • Ethical Dilemmas e.g. Persuasion/paternalism/risk

V. What are we doing at the Royal Berks to
address care gaps and improve the quality of care
for people with Dementia?
  • Much of it driven from the bottom by a coalition
    of the willing but now supported from the top

Key Questions for Trust Boards (Acute Awareness)
Initiatives at the Royal Berks
  • Dementia Lead Clinician
  • Trust wide dementia group meets monthly to
    oversee progress/share success/bring in outside
    speakers/report to board. Dementia now an
    organisational priority for 2011-12
  • Geriatricians, Mental Health Trust, Patients
    Panel, Nurses/Matrons, Alzheimers Soc, Age UK,
    Local Authorities, Non-Exec, Pharmacy, Therapies,
    Dietetics etc
  • In House training programme with some external
    places to train the trainers
  • This is Me Leaflet

Initiatives at the Royal Berks
  • Participation in RCPsych Audit
  • Care Bundle for BPSD
  • Antipsychotic audit
  • Falls strategy, care bundle and training
  • Policy on bedrails and restraint
  • Falls alarms and fully low beds
  • Attention to patients admitted on memory
    enhancing drugs
  • Standardised guidance on mental capacity
  • Older Peoples Mental Health Liason Team

Thank you
  • Questions.....?
  • Over to Luke and Mental Health Liaison Team

Older Persons Mental Health Liaison Team Royal
Berkshire Hospital
  • Dr. Luke Solomons
  • Consultant Liaison Psychiatrist

Dementia in West Berkshire
  • 1536 people on GP dementia registers against a
    predicted prevalence of 4900 people (2009)
  • 2/3 NHS inpatients are over 65 years
  • Up to 60 per cent have or develop mental disorder
    - delirium and dementia most common.
  • RBH has 607 beds potentially 300 patients gt65
    with memory/ mental health problems

Most common reasons for admission in patients
with dementia
  • Urinary Tract Infection
  • Pneumonia
  • Fracture of femur
  • Unspecified acute lower respiratory infection
  • Senility
  • Pneumonitis due to solids and liquids
  • Syncope and collapse
  • Open wound of head
  • Cerebral infarction (stroke)
  • Other chronic obstructive pulmonary disease

How does dementia complicate treatment?
  • Current recognition rate 1 in 3
  • Connection between physical illness and memory
  • Problems maybe first noticed during hospital stay
    - why?
  • Decreased brain reserve
  • Effect of medication anticholinergics
  • Unfamiliar environment

Summary of videos
  • Conversation with Sheila and Ken
  • Conversation with Sheilas daughter
  • How dementia overlaps/ complicates physical
  • Admissions to several hospitals over the years
  • Hope for the future?

Video 1
  • Daughter of a lady with dementia describing her
    illness and the overlap with physical health

Video 2
  • Lady with dementia and her husband talking about
    her physical symptoms
  • Pay close attention to her answers to my queries
  • The need for close working with families and

OPMHLT who we are
  • Bridge between acute (RBH) and mental health
    services (memory clinic)
  • Small team 3 senior nurses 1 social worker
    0.5 consultant psychiatrist 0.5 SaLT
  • Concentrate efforts on early recognition,
    training staff and helping with the most
    challenging and complex cases
  • Based in the RBH, and working with the elderly
    care directorate

OPMHLT end to end pathway
Initial Assessment
On-going Assessment
Transfer of Care
On-going Care
Video 3
  • Improving care
  • Joining up the dots RBH, local councils, memory
    clinics, GP surgeries, voluntary sector

Our aims
  • Anticipation and prevention of complications like
  • Decrease in inappropriate antipsychotic use
  • Early identification of dementia
  • Hands on support for frontline staff
  • Reduction in length of stays discharge
  • Training families and staff
  • Improved quality of care for the duration of
    hospital stay and beyond

Promoting health!
Any questions?