dementia care in general hospitals and what we are doing to improve it at the royal berks david...
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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?
Dementia & Elderly Care seminar
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.”
Dementia & Elderly Care seminar
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.”
Dementia & Elderly Care seminar
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“Mood changes − people with dementia may be withdrawn, sad, frightened or angry about what is happening to them.”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.”
Dementia & Elderly Care seminar
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…
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
Diagnosing Dementia e.g. MMSE
Dementia & Elderly Care seminar
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 & Elderly Care seminar
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]
Dementia & Elderly Care seminar
From NHS Information (People over 65 account for 60% admissions and 70% bed days to hospital)
Dementia & Elderly Care seminar
“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
Dementia & Elderly Care seminar
Alzheimer’s Society “Counting the Cost” 2009
Dementia & Elderly Care seminar
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…
Dementia & Elderly Care seminar
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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.”
Dementia & Elderly Care seminar
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”
Dementia & Elderly Care seminar
2009 NHS Confederation
Dementia & Elderly Care seminar
Counting the Cost Report
Dementia & Elderly Care seminar
“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”
Dementia & Elderly Care seminar
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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?
Dementia & Elderly Care seminar
From “Acute Awareness”
Dementia & Elderly Care seminar
Ann Reid..”Acute Awareness”
Dementia & Elderly Care seminar
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
“Counting the cost” 2009 1,291 carers, 657 nurses, 479 ward managers
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
Dementia & Elderly Care seminar
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”)
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
Key Questions for Trust Boards (“Acute Awareness”)
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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…
Dementia & Elderly Care seminar
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 & Elderly Care seminar
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
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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?
Dementia & Elderly Care seminar
Video 1
Daughter of a lady with dementia describing her illness and the overlap with physical health
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
Video 3
Improving care
Joining up the dots – RBH, local councils, memory clinics, GP surgeries, voluntary sector
Dementia & Elderly Care seminar
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
Dementia & Elderly Care seminar
Promoting health!
Any questions?