Title: Dementia Care in the Acute Hospital Context
1Dementia Care in the Acute Hospital Context
- Louise Nolan,
- School of Nursing and Midwifery, Trinity College
Dublin - 16.09.2007
2Aims of the presentation
- To highlight the issues to be considered when
caring for people with dementia in an acute care
setting - To advance participant understanding of the
implications of the issues highlighted for
practice - To provide suggestions for appropriate caring
dementia practice in the acute care setting
3Introduction
- When a person with dementia is admitted to an
acute hospital, he/she may often not fare well
and is potentially a member of a vulnerable
patient/client group. - Providing care for people with dementia in an
acute context is different from care provision
for patients who do not have dementia! - Therefore, we need to consider how the experience
of the person with dementia, their primary carer
(if appropriate) and professional carers may be
improved. - People with dementia are located in increasing
numbers across a range of wards and research has
shown that acute care practitioners often
perceive the environment, for people with
dementia, as strange, unsafe and dangerous due to
its unfamiliarity (Borbasi et al., 2006).
4Prevalence
- Actual prevalence of dementia in hospitals is not
known, some studies have offered estimates e.g.
30 (Mezey Maslow, 2004) and 63 (Torian et
al., 1992) of older inpatients. However, it is
important to note that dementia is not only found
in older people and not all older people have
dementia. - Difficulties arise with estimates as dementia
does not normally constitute the main admission
diagnosis (Torian et al., 1992 Dinkel, 1997). - A high percentage of older persons admitted to
acute hospitals could have some degree of
cognitive impairment but may not have undergone
assessment or received a diagnosis.
5Possible reasons for admission/readmission
- Admission for acute illness dementia then newly
diagnosed - Presence of dementia can predispose the person to
- accidental injury,
- poor compliance with medication, nutrition or
lifestyle advice, - non-recognition or misinterpretation of illness
and - delay in or absence of health seeking behaviours
- (Torian et al., 1997).
- Planned admission for assessment, diagnosis etc
- Unplanned admission for acute social or medical
reason (as above)
6Outcomes of acute hospitalisation
- Higher cost of acute care e.g.
- treating life-threatening infections,
- multiple interdependent co-morbidities,
- pre-disposition of people with dementia to
hospital acquired (nosocomial) infections
complications of treatment - difficulties with after- care which could
prolong stay /or delay rehabilitation - Poorer outcomes
- Longer than average stay
- Functional status (Gill et al., 1999 Sager et
al., 1999) and discharge location - Hospital readmission
7How must it be for the PERSON?
- When admitted the person might have been just
balancing on the edge of being able to cope at
home - The person will be exposed to the confusing
effects of moving from dept. to dept. in the
hospital - They may be in pain, feeling ill and bombarded
with information and sensory overload - There will be many new faces when they often are
used to seeing a few people each day - The person may be stressed and their behaviour
affected by even small frustrations - The person may become weepy, withdrawn or
aggressive.
8Contrast this with the assumptions on which acute
care is often based!
- That PATIENTS will be
- Co-operative
- Able to express a need
- Able to acknowledge the needs of other patients
- Able to move quickly through the system
- Able to be discharged having had needs (often
physical) met - Consider the person with dementia in the midst of
such expectations!
9So consider the following
- The acute care environment makes few allowances
for persons with dementia despite the recognition
of the challenges that such persons may face in
this setting. - Unique care challenges that encompass the 24 hour
continuum (Stolley et al., 1991). - Packer (2001) highlights the following issues of
particular concern - Business and general design of the environment
- Political imperatives for high bed turnover
- Poor understanding of the needs of people with
dementia (including attitudes to older people and
people with dementia)
10- Barbosi et al. (2006) had similar findings and
further highlighted the following - Lack of dementia specific knowledge
- Lack of time and multiple demands on staff
- Lack of resources including staff with dementia
specific training - Intensive nature of the work
- Inappropriate use of restraint
- The restraining nature of environmental,
socio-cultural and economic issues
11Normal ageing and dementia!
- A person with dementia is also subject to normal
age related changes and potentially multiple
pathology, which in the presence of dementia can
complicate care. - Examples include-
- Communication more difficult with visual and
hearing changes - Person may not readily be able to express their
wishes (be careful however not to assume this is
always the case!) - Increased risk of inadequate pain control, falls
etc. - People with dementia may be more prone to
delirium - Effects of medication e.g. psychotropic drugs,
tranquilisers and sedatives. - Altered presentation
12Increased risk of delirium
- Persons with dementia who are admitted to an
acute hospital are at increased risk for acute
confusion (delirium). - Influencing factors could include presence of
urinary tract infection, certain drugs,
dehydration, environmental change, iatrogenic
events, presence of illness, social isolation,
sensory deprivation or overload etc. - The occurrence of which will further compromise
the persons ability to process information, cope
with a new environment and perform activities of
living (Evans, 1989).
13Possible reactions to hospitalisation
- Psychological
- Stress
- Fear
- Agitation /or agression
- Vocalisations
- Wandering or excessive walking
- Searching
- Wanting to go home
- Physical
- Disturbance in relation to activities of living
e.g. - Sleep patterns
- Nutrition
- Hydration
- Elimination
- Mobility
- Etc
14Possible reactions ctd.
- Delirium
- Decreased functional status
- Increased behaviour which challenge
- Significant cognitive decline
- (Erkinjuntti et al. 1986 Cox and Verdieck,
1994 Day, Musallam Wells, 1999).
15Examples of possible hospital happenings
- Overmedication or wrong medication
- Falls
- Poor nutrition/dehydration
- Weight loss
- Incontinence
- Pressure sores
- Untreated pain
16- So how can we care for people with dementia in an
acute care context? - What particular issues need to be considered?
- How can we ensure person-centred, individualised
care that upholds the dignity and personhood of
the person with dementia?
17Suggestions
- The role of life-story
- Use of the nursing process
- Multidisciplinary care approaches
- Incorporating specialist dementia specific
approaches and knowledge into health care
practice - use of evidence-based dementia
friendly care protocols, guidelines, policies,
care pathways etc - Consideration of the caring context the acute
care environment - Involvement of carers (if appropriate)
- Striving towards a vision of a dementia friendly
acute care hospital environment
18The Role of Life Story!
- Contributes to the development of a three
dimensional image of the person with dementia. - Possible headings
- Family, friends, places, pets, occupation,
hobbies, skills, likes, dislikes, films, music - Benefits
- Greater understanding enabling a personal care
approach - Explanations
- Can be passed on
- A failure free, fun activity
- Family/caregiver involvement
- (Adapted from Murphy, 1994)
19The nursing process!
- Assessment
- Planning
- Implementation
- Evaluation
- All components are vital need to prevent an
over-emphasis on one aspect!
20Multidisciplinary care approaches
- Who are the ideal members of such a team?
- Are such people in place in your organisation?
- What is the role of each team member?
- What is the specific role of the nurse in the
context of multidiscipliary dementia care?
21Dementia specific care approaches and frameworks
- Use of dementia specific approaches and
frameworks as an adjunct to other caring
approaches can enhance practitioners knowledge
and skills. - In dementia this is important as interventions
must be individualised. - The practitioner needs to be aware that something
that works for one person may not work for
another and a strategy successful at one time may
be unsuccessful at another time.
22Dementia specific care approaches and frameworks
- Dementia care approaches and frameworks recognise
this and provide ways for ongoing dynamic care
planning. - Eg Use of framework/model to aid interpretation
of and actions to address behaviours which
challenge - ABC model
- (Antecendent, Behaviour Consequences)
- Need Driven, Dementia Compromised Behaviour Model
(NDB model)
23The Environment Large, unstructured unfamiliar!
- General design issue examples
- Open entry
- Construction of corridors and floors
- Furniture
- Colour schemes (walls, flooring etc.)
- Access to kitchens, other departments etc .
- Presence of healthcare equipment e.g. infusion
pumps . - Environmental hazards etc.
24Environmental considerations for practice!
- Provide a simple, safe, structured environment,
consistent caregivers (where possible), frequent
orientation to staff and care-giving activities. - How?
- Organising work - consistent team membership!
- You can ask anybody because were all involved
in the care - (Nichols Heller 2002)
- Plan and maintain a consistent routine (that in
as much as possible mirrors the persons own
routine, likes and dislikes) - Remember to ensure a system of communication so
that everyone is aware of the persons
needs,wants, preferred routine etc.
25- Placement in a room which facilitates observation
but distant enough from the nurses station to
avoid the associated noise and activity - Protection from hazards e.g drugs, equipment,
lines and tubing, monitors, chemical agents - Safe wandering paths and consideration of exit
locations - Maximise safety by modifying the immediate
environment to compensate for cognitive losses.
26- Use items to help with location identification
i.e. orientation objects, examples include - clocks
- signage cueing
- calendars with large print placed at eye level
- mementos from home e.g. pictures, clothing,
bedding - adjusting lighting (shadows may be confusing or
frightening and bright fluorescent lights may
irritate the eyes over extended time periods) to
ensure that it is shadow and glare free and low
lighting should be available for sleep time - consider the use of mirrors on an individual
basis
27Sensory stimulation
- There is a risk of being overwhelmed in the
presence of reduced ability to adapt (multiple
room mates, loud noises, smells, staff and
visitors coming and going) - Stimuli may be interpreted in the context of the
distant past or the familiar - Need to balance sufficient environmental stimuli
with an avoidance of excess stimulation! - For example
- Controlled sensory input (e.g. is it appropriate
and/or safe to keep the persons door closed
during a period of high activity?) - Location of bed-space noise control
- Social interaction activity
28The importance of activity
- Life exists in the activities of being and
doing (Hellen, 1992) - The choice of activity should be based on the
persons preference, their abilities, maintenance
of independence and a sensitivity to cultural
spiritual needs. - E.G. Use of activity kits focusing on cognitive
and functional abilities which can reduce
boredom, agitation and challenging behaviours.
29The CarerCreating care partnerships with carers!
- Care partner and source of knowledge
- Co-operative planning involvement prior to
admission (if planned!) - Involvement in care provision unlimited
visiting - Caring for carer e.g. -
- identification of needs
- referral for support
- provision of overnight accommodation facilities
30A Vision of a Dementia-Friendly Hospital
- Awareness and support from hospital leadership
management - Staff education
- Routine procedures for recognition of dementia
- Effective communication about dementia and
related care issues - Consideration of the environment to enhance its
suitability for persons with dementia - Discharge planning connecting the person
family/carer to support services - (Silverstein Maslow, 2005)
31A Vision of a Dementia-Friendly Hospital
- Awareness and support from hospital leadership
management - Staff education
- Routine procedures for recognition of dementia
- Effective communication about dementia and
related care issues - Consideration of the environment to enhance its
suitability for persons with dementia - Discharge planning connecting the person
family/carer to support services - (Silverstein Maslow, 2005)
32In summary
- In the acute care context, emphasis on a
bio-medical model, cure and rapid treatment and
throughput, exacerbates the situation for a
person with dementia, who may not be able to fit
with this ethos (Archibold, 2002). - Therefore, healthcare providers must consider how
the acute care experience of the person and
his/her family/carers can be improved.
33Our Challenge!
- The challenge when providing acute care for
adults with dementia - Treat the acute illness, while preventing
complications, maintaining function and self-care
abilities planning for a successful discharge
to the least restrictive environment (Lehman,
Tyler Amador, 2005) - Address ethical, safety and psychosocial issues
- Maximise potential for well-being preservation
of function and to try to ensure familiarity
predictability - Provide dementia specific care while recognising
the challenges posed by the possibilities of the
acute context.