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P22. Acute and hospital care

Detailed programme and abstracts

P22.1. Peri-operative Enhanced Recovery hip FracturE Care of paTiEnts with Dementia (PERFECTED)-cluster randomised control trial results

FOX Chris1, PENHALE Bridget1, POLAND Fiona1, SAHOTA Opinder2, HOWARD Robert3, BALLARD Clive4, MACULLICH Alasdair5, TEALE Elizabeth6, KNAPP Martin7, HENDERSON Cate7, HAMMOND Simon1, SHEPSTONE Lee1, CROSS Jane1

1UEA, Norwich, United Kingdom, 2University of Nottingham, Nottingham, United Kingdom, 3UCL, London, United Kingdom, 4University of Exeter, Exeter, United Kingdom, 5University of Edinburgh, Edinburgh, United Kingdom, 6University of Bradford, Bradford, United Kingdom, 7LSE, London, United Kingdom

Background: Hip fracture in people with dementia and delirium, presents major challenges for older patients, their families/carers and health and social care. The outcomes after surgery for elderly hip fracture patients are often poor and are worse in patients with cognitive impairment (CI). The costs of care are 40% more than in those without CI. Our previous work shows that patients, families, carers and staff repeatedly report the need for more sensitive ways to look after people with CI. Staff have also highlighted the need for staff training to engage them more meaningfully with the needs of this group.

To address this need, we developed a complex intervention called PERFECT-ER made up of: a best practice checklist, a staff training manual, staff time to implement the items on the checklist, staff time to train colleagues and a process to help continuous improvement in care. 

Method: A cluster randomised control trial of the PERFECT-ER programme in 11 hospitals in England and Scotland involving 282 people with hip fracture and CI. 

Results/Evaluation: PERFECT-ER had signals for improving cognition (MMSE) (1-point improvement) and in-patient hospital survival rate (1.5x higher). EQ 5 D proxy was significant at 3 and 6 months follow up. From the process evaluation: despite difficulties in the acute hospital environment with staffing levels, bed pressures and numbers of frail patients, the intervention was utilised in the intervention hospitals.

Conclusions/Perspective: People admitted to hospital with hip and CI are vulnerable. Communication and planning have repeatedly been found to be poor and in hospitals, training for staff is at best limited. PERFECTED is the largest trial to date in acute hospital care in CI and has shown that this intervention can be implemented and has the potential to improve important outcomes. Further larger scale evaluation is required. 

P22.2. The care and support needs of people living with dementia and cancer

KELLEY Rachael1, SURR Claire1, GRIFFITHS Alys1, COLLINSON Michelle2, MASON Ellen2, FARRIN Amanda2, HENNELL June3, ASHLEY Laura1

1Centre for Dementia Research, Leeds Beckett University, Leeds, United Kingdom, 2Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, United Kingdom, 3Expert by Experience, Gloucestershire, United Kingdom

Background: Dementia and cancer are both common among older people, making it likely that many people will have both conditions. People living with dementia and cancer could have complex care needs, making cancer care provision more difficult. However, there is little research in this area to inform practice.

Aim: This study aimed to identify the prevalence, characteristics, cancer treatment and care needs of people living with dementia and cancer.

Methods: We undertook two studies. Study 1 used a large dataset from UK GP records. We identified the numbers of people with cancer and dementia, their characteristics, and what NHS services they used, comparing their data to people with only dementia or cancer. Study 2 used ethnographic methods to explore experiences of cancer care for people living with dementia. We used interviews, conversations and observations of cancer care to include the perspectives of people living with cancer and dementia, their families, and hospital staff.

Results: Study 1 found that 3.1% of people living with cancer also had dementia, and 7.3% of people living with dementia also had cancer. The prevalence of dementia amongst people with the four most common cancers ranged from 2.3% (lung cancer) to 4.1% (prostate cancer). People living with dementia and cancer differed in important ways from people with cancer but not dementia. Study 2 identified a number of cancer care challenges for people living with dementia, including recognition of dementia, and difficulties around decision-making, care processes and care environments. Families played important and difficult to replicate roles in their relative’s care.

Conclusions: This study provides the best available UK estimates of the size, characteristics and cancer care needs of people living with dementia. It highlights how hospitals and their staff can improve cancer treatment and care experiences for people living with dementia, and areas for further research.

P22.3. Are hospital outcomes worse for people living with dementia? An analysis of hospital episode statistics

REILLY Siobhan2, REEVES David1, HOLLAND Fiona1, HANN Mark1, AHMED Faraz2, MORBEY Hazel2, KEADY John3

1University of Manchester, Manchester, United Kingdom, 2Lancaster University, Lancaster, United Kingdom, 3University of Manchester, Lancaster, United Kingdom

Concern over the quality of care provided to people living with dementia during hospital stays has led to a wide range of initiatives to improve care. A key indicator frequently referenced as evidence of poorer care is that people living with dementia have longer mean stays in hospital compared to other patients. However, previous analyses of hospital spell data have only weakly controlled for demographic, health and other differences between the groups. Using routine data (Hospital Episode Statistics) for hospital admissions in 2016/17 for ~400,000 people living with dementia and ~2million people without across 187 large acute hospitals, we constructed a range of patient and hospital spell-level variables including demographics (age, sex, ethnicity, residential and income deprivation); spell characteristics (type of admission, time of year and day of week, discharge destination and delay); pre-existing health (comorbidities, previous admissions); and reason for admission and treatment burden.

People living with dementia accounted for 15% of all hospital admissions. They were on average older (75% aged 80 or older versus 40%), more likely to be female (58% versus 51%), to be admitted as an emergency (96% versus 78%), be discharged to a care home (8% versus 2%), and have different conditions for admission but similar overall numbers of comorbidities.  Overall, people with dementia spent on average 3.6 days longer in hospital (mean length of stay 9.5 days compared to 5.9), but after controlling for confounding factors this reduced to 0.5 days, with the remaining difference possibly accounted for by residual confounding.

Longer hospital stays reported for people living with dementia can be mostly or fully accounted for by pre-admission differences in patient characteristics and health, rather than differences in the hospital care received. The analysis is currently being extended to examine other patient outcomes including hospital mortality, emergency re-admissions and hospital-acquired conditions.

P22.4. Acute hospital care experiences of patients with Alzheimer’s disease

JENSEN Anders Møller1, HOUNSGAARD Lise2, PEDERSEN Birthe2, WILSON Rhonda2, OLSEN Rolf3

1VIA University College, Holstebro, Denmark, 2University of Southern Denmark, Odense, Denmark, 3-, Odense, Denmark

Patients with Alzheimer’s as a co-morbidity find hospital stays challenging, because the focus is primarily on the somatic cause for the admission. This results in poorer holistic care, compared to patients without dementia, and an increased cost for the healthcare sector and, society as a whole.

This study conducted participant observation research strategies to follow patient journeys with Alzheimer’s disease admitted to orthopaedic wards, to learn about their experiences as patients. Longitudinal data were gathered by following one patient at a time, in both day and evening shifts, commencing at patient admission and concluding at time of discharge. 257 hours was spent observing, covering 37 shifts and involving three patients. The mean observation time, for the full days the patients were in hospital, was 14 hours and 36 minutes.  This to ensure unique data on the patient’s admission experiences.

The data were interpreted from a phenomenological-hermeneutic perspective, inspired by Ricoeur’s interpretation theory, and incorporates Person-Centred Care and Interactional Nursing Practise Theory, in the analysis.

The study revealed a communication style among nurses who failed to take into account the comprehensive needs of patients with dementia, in terms of timely information exchange and clinical relevance. Patients expressed the desire to be more fully engaged in the care decision-making, together with indicating their appreciation of the work of the health professionals who cared for them. The data revealed that the process of getting to know the patient at the beginning of every shift left little room to alleviate patients’ experienced distress, caused by being in hospital. This resulted in patients who were less involved in the caring situation, or, if a patient took the initiative to act, intentions ended up being misinterpreted as disruptive behaviour.

The findings have relevance for staff and ward management who are interested in becoming a dementia-friendly hospital.

P22.5. The experiences of nurses in the care for hospitalized people with dementia

KEUNING Annette1, FINNEMA Evelyn1, ROODBOL Petrie2

1NHL Stenden University of Applied Science/ University of Groningen, Leeuwarden, Netherlands, 2University of Groningen, Groningen, Netherlands

Introduction: Worldwide, around 50 million people are living with dementia. With the ageing population, also the number of people with dementia will increase. People with dementia are regularly hospitalized because of other diseases. They have a greater risk of complications, longer admission and re-admissions. Internationally, it is estimated that around 25% of the hospital beds are occupied by older patients with dementia. Nurses have an important role in the quality of care during admission.

Aim of the study: The aim of this study is to describe nursing care practices, nurses’ attitudes and perceptions of caring for elder people with dementia in acute care in the Netherlands based on person-centred care.

Methods: A cross-sectional quantitative survey design was used. The questionnaire was based on the Geriatric In-Hospital Nursing Care Questionnaire (Persoon, 2015) supplemented with two parts of the questionnaire of Hynninen (2015) about challenging the behaviour of hospitalized people with dementia. The questionnaire was distributed in six hospitals and via social media.

Results: The preliminary results show that nurses (n=159) overall rate their skills more than sufficient. However, they report that they lack time to give good care and that they have problems coping with challenging behaviour. They experience the care as demanding because they don’t know how to deal with challenging behaviour, experience communications as difficult and time-consuming and think that people with dementia don’t belong in their ward. Finally, they point out that the hospital environment is not suitable and not safe for people with dementia, because of the high pace and the many sensations.

Discussion / conclusion: Nurses experience caring for people with dementia as complex. Despite the high overall self-scores of nurses, there are concrete indications that nursing care for hospitalized people with dementia can be improved.

P22.6. The relationship between dementia training, knowledge, attitudes, staff-strain and culture in hospital staff

AHMED Faraz1, REILLY Siobhan1, MORBEY Hazel1, HARDING Andrew1, REEVES David2, HOLLAND Fiona2, HANN Mark2, KEADY John2

1Lancaster University, Lancaster, United Kingdom, 2University of Manchester, Manchester, United Kingdom

Improving the quality of care in hospitals is a key priority within national dementia strategies. The impact of dementia training on multiple aspects of staff outcomes has seldom been evaluated, especially with regards to understanding the relationship between key interrelated factors within a hospital; e.g. dementia knowledge, staff attitudes, staff strain, organisational culture.

We conducted a staff survey to explore the extent of training, knowledge, attitudes, staff strain, organisational culture and satisfaction in caring for people living with dementia in acute National Health Service (NHS) hospitals. We used a range of validated tools, i.e. Dementia Knowledge Assessment Tool V2, Sense of Competence in Dementia Care Staff scale, Culture of Care Barometer, Maslach Burnout Inventory. We identified and approached 24 randomly selected hospitals, based on low, ‘average’ or high scores in each of the domains of governance, patient-related outcomes and training, derived from 2016 National Audit of dementia organisational checklist data.  We recruited 11 hospitals (46%response rate) and 294 staff (average: 27 staff per hospital). The sample consisted of nurses and midwives (29.9%), health care assistants (26.9%), allied health professionals (16.0%), medical and dental doctors (11.6%), support staff and members of the wider health team (11.2%), general management (4.1%), and other (0.3%).

This presentation covers the complex relationship between staff knowledge, attitudes, staff strain and organisational culture among acute NHS hospital staff, with a focus on dementia training. We will be presenting the results of a mixed effect model, which was adjusted for a range of staff related factors. Our findings indicate that the impact of dementia training on staff’s sense of competence in dementia care is limited, when we take into account staff demographics (including their professional background), and organisational culture. Our findings emphasise the need for broader practice and policy changes to support dementia training for hospital staff.

 

 
 

Last Updated: Monday 22 July 2019

 

 
  • Acknowledgements

    The 29th AE Conference in The Hague received funding under an operating grant from the European Union’s Health Programme (2014-2020). Alzheimer Europe and Alzheimer Nederlands gratefully acknowledge the support of all conference sponsors.
  • European Union
  • Roche
 
 

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