Improving care for inpatients with dementia at the Royal Berks Professor David Oliver. Consultant Geriatrician, Royal Berkshire NHS Foundation Trust Dr Luke Solomons. Consultant Psychiatrist, Berkshire Healthcare Trust
Dementia Seminar What is dementia? − “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) 10/10/2012
Dementia Seminar − “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.” www.alzheimer’s.org.uk 10/10/2012
Dementia 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 − “Mood changes” − people with dementia may be withdrawn, sad, frightened or angry about what is happening to them.”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.” 10/10/2012
Dementia Seminar Screening for Dementia e.g. − Six item test of cognitive function (6CIT): − 1. What year is it? − 2. What month is it? − 3. Give the patient an address phrase to remember with 5 components, e.g. John Smith, 42, High St, Bedford − 4. About what time is it (within 1 hour) − 5. Count backwards from 20-1 − 6. Say the months of the year in reverse Repeat address phrase 10/10/2012
Dementia Seminar Diagnosing Dementia 10/10/2012
Dementia Seminar Differential diagnoses − 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 increases the risk of dementia − Other conditions can cause similar symptoms so need to be ruled out or treated – “Delirium” 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 10/10/2012
II: The scale of the challenge And implications for hospitals
Dementia Seminar c. 670,000 with Dementia in England, set to double in 30 years 10/10/2012
Dementia Seminar National Policy and Action − National Dementia Strategy (last government and this) − Dementia Action Alliance and Declaration (over 50 organisations) − RCN Dementia in Hospitals Project − Prime Minister’s Dementia Challenge − NHS Operating Framework − New Health Ministers committed − Dementia CQUIN payment for patients admitted to general hospitals − NICE Dementia Guidelines − Mental Capacity Act − NHS Constitution and Equality Act 10/10/2012
Dementia 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] 10/10/2012
Dementia Seminar Nursing and Residential Homes (BGS Quest for Quality Report 2011) − c. 380,000 residents (England) − Average age 86 − 78% have one form of cognitive impairment − 64 % “confused or forgetful” − 20% “challenging behaviour” − 20% “depressed or anxious” − 27% immobile, confused and incontinent 10/10/2012
Dementia Seminar 10/10/2012
Dementia Seminar ONS Projections (146% increase in over 90s & 85% in over 80s in next 20 years) 10/10/2012 Population 000
Dementia Seminar Over 65s in hospital (England) (DH analysis of HES data) − 60% admissions − 70% bed days − 85% delayed transfers − 65% emergency readmissions − 75% deaths in hospital − 25% bed days are in over 85s 10/10/2012
Dementia 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 10/10/2012
Dementia Seminar 10/10/2012
Dementia Seminar Counting the Cost − 1 in 4 adult beds is occupied by someone with dementia − People with dementia stay longer − 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” 10/10/2012
Dementia Seminar Key Questions for Trust Boards (“Acute Awareness”) 10/10/2012
III: How well are we doing these things in the NHS?
Dementia Seminar General issues in inpatient care of older people (many have dementia) − Numerous reports on undignified care – Ombudsman, CQC, Patients’ Association CARE Campaign, All Parliamentary Enquiry. “Delivering Dignity” commission − Safety – e.g. falls, pressure sores, infections, discharge/readmission, drug errors − Data from major audits – Falls, fractures, hip fracture, nutrition, continence, periop care − Evidence of age-based discrimination – e.g. Centre for policy on ageing reviews − Inefficiency and “unwarranted variation” – e.g. delayed transfers of care, emergency readmission, chance of admission, hospital bed days in over 65s − Francis Report 10/10/2012
Dementia Seminar Counting the Cost Report 10/10/2012
Dementia Seminar “Counting the Cost”, 1,291 carers, 657 nurses, 479 ward managers 10/10/2012
Dementia 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 10/10/2012
Dementia Seminar RCPsych Audit 2010 of acute trusts − Only 30% had system for gathering personal information on person with dementia − 70% had no review process for discharge procedures on people with dementia − 77% of had no training strategy identifying key skills for working with people with dementia − 95% of had no mandatory awareness training − 81% of had no system to ensure ward staff were aware that a person had dementia and that necessary information was imparted to other staff − 90% had some access to liaison psychiatry but 36% patients not seen after 96 hours and only 40% within 48 hours 10/10/2012
Dementia Seminar From RCPysch Audit review of casenotes of 7,934 patients 2010 − 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 10/10/2012
IV: Local response: Our integrated dementia steering group
Dementia Seminar Integrated dementia steering group − Late 2009. D.O. = lead clinician − Driven “bottom up” by local enthusiasts − Didn’t wait to be told from on high − Purpose (always evolving): – One space for all parties with a stake – Networking, social capital, momentum, sharing of resources – Develop education, training and skills – Improve care (both personal/essential and technical/diagnostic) – Involve carers/patients more – Improve environment for care − And renew the previous push for commissioning an older peoples mental health liaison team… (OPMHLT) 10/10/2012
Dementia Seminar PATIENTS CARE EoLC HOMES CCGs GPs & PUBLIC HEALTH Dementia DIST. NURSES ALZ. SOC. Steering AGE UK MEMORY Group RED CROSS CLINIC COMM. INTERMEDIATE MENTAL CARE HEALTH LOCAL THERAPIES AUTHORITY CARERS 10/10/2012
V: Local response: Older Peoples Mental Health Liaison Team
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