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

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

David Oliver

Consultant Physician

Dementia & Elderly Care seminar

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 institutions

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? (www.alzheimer’s.org.uk)

“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.”


www.alzheimer’s.org.uk

“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 themselves.”


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“Mood changes − people with dementia may be withdrawn, sad, frightened or angry about what is happening to them.”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, paranoia)

– 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 “Alzheimer’s” (c55%)

– Also “vascular” (c25%), mixed, and rarer forms (e.g. Lewy Body disease, Huntington’s 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 reversible)

– Depression causing “pseudo-dementia”

– Metabolic problems (e.g. thyroid, thiamine deficiency)

– 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, Bedford

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 caregiver)

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

Alzheimer’s Disease International, 2009

[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]


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


Alzheimer’s 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 patient’s 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…



Four key priorities in new 2010 implementation plan for government to support local delivery of strategy.

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 antipsychotics

“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 appropriate”



Audit Participation

151 eligible Trusts (England and Wales)

238 eligible hospitals

• Provide general acute services on more than one ward

• Admit people over 65

99% Trust participation (1 or more hospitals core audit)

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 dementia

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 patients 41% received standard mental test score while in hospital

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”



RCPsych Audit. What were patient/ carer priorities?

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



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 Hospitals

(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 PEG

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, Alzheimer’s 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 assessment

Older Peoples Mental Health Liason Team…


Thank you Questions.....?

[email protected]

[email protected]

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 >65 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

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 Sheila’s daughter

How dementia overlaps/ complicates physical illness

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 carers


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

PreventionPrevention Acute Acute Rehab Rehab

PreventionPrevention Awareness Awareness Initial Assessment

Initial Assessment

On-going Assessment

On-going Assessment

Transfer of Care Transfer of Care

On-going 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 delirium

Decrease in inappropriate antipsychotic use

Early identification of dementia

Hands on support for frontline staff

Reduction in length of stays – discharge facilitation

Training – families and staff

Improved quality of care for the duration of hospital stay and beyond


Promoting health!

Any questions?

Documents

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