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P17 People with dementia in hospitals

Detailed programme and abstracts

P17.1. Identifying critical success factors which lead to improved outcomes for people with dementia, carers and staff in acute care

FLANNIGAN Lynn, IRVINE-BRINKLOW Lyn

People with dementia are more likely to be admitted to hospital, with people with dementia over 65 occupying an estimated 25% of acute beds. When admitted they tend to have a longer length of stay, have adverse outcomes such as falls, pressure ulcers and infections and are more likely to be discharged to a care home (Alzheimer Society 2009).

In Scotland there has been much recognition of the need to improve outcomes for people with dementia and their carers in acute care, with commitments in our 3 National Dementia Strategies.

As part of this work Focus on Dementia carried out a piece of work between January and March 2017 in 4 wards in NHS Grampian’s Aberdeen Royal Infirmary, who has been recognised as delivering particularly good practice in relation to the 10 Dementia Care Actions.

The aim of our work was to identify and articulate the critical success factors associated with improved Dementia Care Actions, using an appreciate inquiry approach, to help inform future improvement work in acute care. This was achieved with an appreciate inquiry methodology of a multidisciplinary workshop, conversations with staff, stakeholder questionnaires, data collection and thematic analysis using the 10 Dementia Care Actions as a framework.

We identified 36 different critical success factors under the 10 Dementia Care Actions. The main themes we found were;

  • Quality Improvement is everyday and everyone’s business
  • Focus on Dementia specific knowledge and skills/leadership
  • Focus on delivering good person centred care
  • Focus on making best of the care environment

The learning from this piece of work will have relevance to acute wards supporting older people and people with dementia across Scotland and wider. A publication and supporting resources are being produced to share the methodology and findings of this work.

P17.2. Dementia-friendly design of hospital wards

BÜTER Kathrin, MARQUARDT Gesine

Staying active during a hospital stay is crucial for patients with dementia to preserve their functionality and maintain independence. As residents in long-term care facilities can be easily engaged in daily activities such as helping with housework or preparing mealtimes, hospital staff states that their options to mobilize patients and engage them in meaningful activities are limited. Further, a large body of research supports the relationship between the design of the built environment and e.g. functionality, orientation, and behavior among people with dementia. However, dementia-friendly design concepts were hardly introduced to hospitals. The aim of this presentation is to report findings from a research project evaluating design interventions which promote activity among patients with dementia in hospitals.

A Pre and Post Occupancy Evaluation was conducted in a ward for internal medicine in a German general acute care hospital. Baseline data was collected through patient observations (behavioral mapping) and interviews with ward staff and patients. Outcomes were, among others type, frequency, duration, and location of active behavior among patients with dementia. Then, a variety of changes were made to the environment. For example, a centrally located activity zone was created in the hallway close to the nursing station. It consisted of a seating area and was enhanced with a variety of opportunities for activity such as reading material, an aquarium TV, or headphones to listen to music and short stories. Follow up data was collected and compared to baseline data.

Findings show which activity items patients with dementia were attracted by most and the preferred locations for patients’ activities. The results further indicate that the central location of a common room, its visual and spatial connectivity to the nursing station, and the design of the common room as a spatial anchor-point are essential design parameters to promote active behavior and interaction among patients with dementia in hospitals.

P17.3. Exploring the effect of temporality on communication between nursing staff and patients with dementia on acute hospital wards: An ethnographic study

OLIVER Emily, BRIDGES Jackie, BARTLETT Ruth

There has been a recent policy drive to improve the quality of care in hospitals both in NHS hospitals and internationally. In the UK, reports such as the Francis Enquiry (Francis 2010) and Keogh review (Keogh 2013) have highlighted some hospital’s inability to provide a sufficient quality of care and recognising the reasons for this. Other countries such as US, Australia and those in Europe are also providing reports identifying the same failures (Wilson, Harrison et al. 1999, McKee and Healy 2002, Jha, Li et al. 2005). The research states that communication is at the heart of all aspects of quality care and paramount to the nurse-patient relationship (Killick and Allan 2001). The literature suggests that nurses find it difficult to communicate well with patients with dementia and have identified time as being the most significant barrier.

The literature exploring the effect of time on communication between nursing staff and patients has focused solely on the physical paradigm, that is, shift patterns and clock hours. In this context, nurses continuously identify time as the most significant barrier to effective communication and the nurse-patient relationship.  The current evidence base is missing an exploration into sociological temporality and the idea that nursing time is different to that of the patients. Time is an important element in the life of hospital patients and in the work of health professionals; it has its own structure and order; indeed, time is an important element of social life.

The study is taking an ethnographic approach using a mixture of qualitative methods. Observations on the acute ward, interviews with nursing staff, field notes and a reflexive journal will be triangulated to develop an understanding of the effect of sociological temporality on nursing staff’s communication and inevitably, relationship with patients with dementia. Preliminary findings drawn from ongoing PhD work will be presented.

P17.4. Invisible bodies trapped in a temporary space: the experience of people with dementia admitted to medical assessment units

NORTHCOTT Andy, FEATHERSTONE Katie

A common feature of the admission pathways of people with dementia to UK hospitals is the Medical Assessment Unit (MAU). People with dementia, admitted with co-morbidities, form the largest single patient group on these units, occupying on average one in four beds. This paper draws on the findings of 150 days of ethnographic observation of people with dementia within this setting at five hospitals across England and Wales.

The MAU is an admission point for hospital in-patients. Its primary function is to assess and stabilise patients until they are ready for discharge, or for transfer to an appropriate specialist ward. Each unit is designed for admission of 6-48 hours, with a turnover of up to 60 patients every 24 hours. These units are conceptualised as a temporary space: their performance is measured against patient turnover and admissions are measured by the hour.

People with dementia challenge this conceptualisation. For them an admission to MAU may not be measured in hours but in days or weeks. At an organisational level, people with dementia admitted for days within MAU are invisible, a challenge to the performance target goals of the unit, but are also not a visible group that is seen as needing additional hospital resources. At a staff level, constant shift rotations mean that while staff focus on treating their admitting condition, their underlying diagnosis of dementia is often forgotten, overlooked or misdiagnosed until the next handover. For the person with dementia MAU can be disorientating, confusing or boring. This contributes to high levels of resistance and refusal of care, which can further extend their admission, delay transfer and affect discharge routes, with consequences for health outcomes, family life and place of discharge. This paper explores the impacts of prolonged admissions to these units for people with dementia and ward staff.

P17.5. Lessons learnt from the DemPath Project-the creation of an integrated care pathway (ICP) for people with dementia in the largest teaching hospital in Ireland

COLE Natalie, CRAIG Cecilia, BELL Mary, MCCARROLL Kevin, Mc MAHON Geraldine, LAWLOR Brian

The Irish National Audit of Dementia Care in Acute Hospitals 2013 reported that there are no dementia pathways in place, little dementia training and awareness programs and poor design features for people with dementia.

St James's Hospital, Dublin, a large university teaching hospital with more than 1000 beds and over 3,500 staff undertook a three-year project to improve the experiences of people with dementia within the hospital setting.

As part of the creation of an ICP for people with dementia Depth initial findings were that there was no standardised assessment in ED for cognition/dementia/delirium, only ad hoc assessment for dementia throughout the hospital, no routine use of cognitive assessments, no screening or prevention for delirium, discharge letter provides little or no information on dementia, duplication of information collected by multiple people and multiple referrals for 2nd opinion

With extensive stakeholder engagement DemPath created the “to-be “design of the ICP which includes flagging of individuals over 65 with dementia/cognitive impairment/delirium at presentation to the Emergency Department using the 4AT test, follow-up assessment of cognition and delirium during admission and documentation of same assessments on discharge. The project has been implemented and is now in its final phase of embedding and sustainability. The data generated provides the hospital with information for implementing best practice for the individual during their hospital stay and also a template for other acute hospitals

This paper will discuss findings, challenges and lessons learnt in the creation of an ICP for people with dementia in an acute care setting

P17.6. Improving mealtimes for people with dementia in acute hospital: a mixed method study

GALLANT Naomi

Background: Poor food and fluid intake have been reported in acute hospitals across Europe. Poor intake can lead to increased mortality rates and longer hospital stays.

The process of eating is a complex cognitive activity requiring initiation, attention, concentration, memory and executive function. In addition, sensory, behavioural and physical challenges make the process of eating difficult for people with dementia. The meal time experience is a key component of nutritional care in hospitals and has the potential to influence food and fluid intake in people with dementia. 

Aims: The aim of this study was to understand what influences meal time experiences and the process of eating for people with dementia during hospital admission.

Key objectives were: To measure the well-being of people with dementia during meal times in hospital using the structured observation tool Dementia Care Mapping (DCM). To explore current interventions being used to facilitate people with dementia to eat and drink, recording observations of practice through semi-structured field notes.

Methods: A mixed method approach was applied to the study. DCM includes Behaviour Category Codes and Mood and Engagement scores to describe well-being and experiences of people with dementia during 5-minute time frames. Qualitative field notes supplement this data to add depth and meaning to the quantitative coding.

Two acute NHS hospitals in the UK were involved in the study. Three hour observations were completed at meal times in nine Medicine for Older People wards. Participants had a variety of types and stages of dementia.

Results: To date, 20 patients have been observed at meal times. Initial observations suggest two key themes are emerging:

  • Disempowerment – people with dementia who are unable to verbally communicate their wishes lose autonomy, choice and independence at meal times.
  • Meaningful mealtimes – limited anticipation and preparation of the meal may reduce social and sensory cues which would positively influence engagement in the eating process.

 

 
 

Last Updated: Monday 23 October 2017

 

 
  • Acknowledgements

    The 27th AE Conference in Berlin received funding under an operating grant from the European Union’s Health Programme (2014-2020). Alzheimer Europe and Deutsche Alzheimer Gesellschaft e.V. gratefully acknowledge the support of all conference sponsors.
  • European Union
  • Roche
 
 

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