Acute hospital care: how much activity is attributable to caring for patients with dementia?

The association of comorbid dementia with length of stay, cost and mortality among older adults in US acute hospitals: An observational study

BACKGROUND

Although overall health and social care expenditures among persons with dementia are larger than for other diseases, the resource and cost implications of a comorbid diagnosis of dementia in acute hospitals in the U.S. are largely unknown. We estimate the difference in inpatient outcomes between similar hospital admissions for patients with and without comorbid dementia (CD).

METHODS

Inpatient admissions, from the U.S. National Inpatient Sample (2016-2019), were stratified according to hospital characteristics and primary diagnosis (using ICD-10-CM codes), and entropy balanced within strata according to patient and hospital characteristics to create two comparable groups of admissions for patients (aged 65 years or older) with and without CD (a non-primary diagnosis of dementia). Generalized linear regression modeling was then used to estimate differences in length of stay (LOS), cost, absolute mortality risk and number of procedures between these two groups.

RESULTS

The final sample consisted of 8,776,417 admissions, comprised of 1,013,879 admissions with and 7,762,538 without CD. CD was associated with on average 0.25 (95 % CI: 0.24-0.25) days longer LOS, 0.4 percentage points (CI: 0.37-0.42) higher absolute mortality risk, $1187 (CI: -1202 to -1171) lower inpatient costs and 0.21 (CI: -0.214 to -0.210) fewer procedures compared to similar patients without CD.

CONCLUSION

Comorbid dementia is associated with longer LOS and higher mortality in acute hospitals but lower inpatient costs and fewer procedures. This highlights potential communication issues between dementia patients and hospital staff, with patients struggling to express their needs and staff lacking sufficient dementia training to address communication challenges.

Identification and information management of cognitive impairment of patients in acute care hospitals: An integrative review

Objectives

Recognition of the cognitive status of patients is important so that care can be tailored accordingly. The objective of this integrative review was to report on the current practices that acute care hospitals use to identify people with cognitive impairment and how information about cognition is managed within the healthcare record as well as the approaches required and recommended by policies.

Methods

Following Whittemore & Knafl's five-step method, we systematically searched Medline, CINAHL, and Scopus databases and various grey literature sources. Articles relevant to the programs that have been implemented in acute care hospitals regarding the identification of cognitive impairment and management of cognition information were included. The Mixed Methods Appraisal Tool and AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) Checklist were used to evaluate the quality of the studies. Thematic analysis was used to present and synthesise results. This review was pre-registered on PROSPERO ( CRD42022343577).

Results

Twenty-two primary studies and ten government/industry publications were included in the analysis. Findings included gaps between practice and policy. Although identification of cognitive impairment, transparency of cognition information, and interaction with patients, families, and carers (if appropriate) about this condition were highly valued at a policy level, sometimes in practice, cognitive assessments were informal, patient cognition information was not recorded, and interactions with patients, families, and carers were lacking.

Discussion

By incorporating cognitive assessment, developing an integrated information management system using information technology, establishing relevant laws and regulations, providing education and training, and adopting a national approach, significant improvements can be made in the care provided to individuals with cognitive impairment.

Exploring dementia care in acute care settings: Perspectives of nurses and social workers on caring for patients with behavioral and psychological symptoms

This qualitative study compares perspectives of nurses (n = 5) and social workers (n = 12) about their role in caring for patients with dementia with behavioral and psychological problems in an acute care setting. A thematic qualitative analysis was conducted using the Rigorous and Accelerated Data Reduction Technique (RADaR). Three themes emerged: engagement of the patient and coordination with family and professionals, treatment and medical management of behavioral and psychological symptoms of dementia (BPSD) in the hospital, and barriers to care. Barriers to care are identified by both professions, with each having its own care niche. Social workers and nurses work as a team with the understanding that they face care challenges. Person centered care is a successful approach for the care team working with patients with BPSD.

Extended length of stay and related costs associated with dementia in acute care hospitals in Ireland

OBJECTIVE

To estimate the additional impact of dementia on in-patient length of stay (LOS) and related costs in Irish acute hospitals. Both principal and secondary diagnosis effects are estimated and valued.

METHODS

This is a cross-sectional study based on administrative data collected on all public hospital in-patient discharges in Ireland for people aged 65 years and older in 2019. Coarsened exact matching (CEM) was undertaken to account for observed confounders between dementia and non-dementia groups, while generalised linear modelling (GLM) was used to compare differences in LOS.

RESULTS

Patients with a principal diagnosis of dementia spent on average 17.5 (CI: 15.42, 19.56; p < .01) d longer in hospital than similar patients with no principal diagnosis of dementia. LOS was 6.7 (CI: 6.31, 7.14; p < .01) d longer for patients with a secondary diagnosis of dementia compared to similar patients with no secondary diagnosis of dementia. The additional annual cost of care for patients in hospitals with a secondary (principal) diagnosis of dementia was €62.0 million (€13.2 million).

CONCLUSIONS

This study highlights the economic impact of extended LOS for patients with dementia in Irish acute hospitals. Addressing specific dementia-related needs of people in hospital is likely to optimise resource use and decrease health care costs in acute care settings.

Designing Dementia Care Pathways to Transform Non Dementia-Friendly Hospitals: Scoping Review

People with dementia (PwD) occupy around 25% of the hospital beds. Once PwD are admitted to hospitals, their cognitive impairment is not considered in most of the cases. Thus, it causes an impact on the development of the disease becoming a stressful situation as care plans are not adapted to PwD. The aim of this study was to explore the published core elements when designing a dementia care pathway for hospital settings. A scoping review was conducted to provide an overview of the available research evidence and identify the knowledge gaps regarding the topic. This review highlights person-centered care, compassionate care and end-of-life process as some of the key elements that should integrate the framework when designing a dementia care pathway. Architectonical outdoor and indoor hospital elements have also been found to be considered when adapting the healthcare context to PwD. Findings provide information about the key points to focus on to successfully design dementia interventions in hospital environments within available resources, mostly in those contexts in which national dementia plans are in its infancy. Hospitals should transform their patients’ routes and processes considering the increasing demographic changes of people with cognitive impairment.

Developing a dementia inclusive hospital environment using an Integrated Care Pathway design: research protocol

People with dementia occupy 25% of the hospital beds. When they are admitted to hospitals their cognitive impairment is not considered in most of the cases. Some European and North American countries already have experience of implementing national plans about Alzheimer's disease and dementia. However South European countries such as Spain are in the early stages. The aim of this study is to design an Integrated Care Pathway to adapt the hospital environment and processes to the needs of people with dementia and their caregivers, generating a sense of confidence, increasing their satisfaction and protecting them from potential harmful situations. This study uses King's Fund Dementia Tool to assess the hospital environment and develop a continous improvement process. People with dementia, families, caregivers and healthcare staff will evaluate the different settings in order to provide guidance based on patient needs. Person-centred care, prudent healthcare and compassionate care are the conceptual framework of this care pathway. The implementation and evaluation of this research protocol will provide information about how to successfully design dementia interventions in a hospital environment within available resources in those contexts where dementia plans are in its infancy, as only around 15% of all states worldwide have currently designed a concise dementia national plan.

Cognitive Impairment and Length of Stay in Acute Care Hospitals: A Scoping Review of the Literature

Older persons experiencing a longer length of stay (LOS) or delayed discharge (DD) may see a decline in their health and well-being, generating significant costs. This review aimed to identify evidence on the impact of cognitive impairment (CI) on acute care hospital LOS/DD. A scoping review of studies examining the association between CI and LOS/DD was performed. We searched six databases; two reviewers independently screened references until November 2019. A narrative synthesis was used to answer the research question; 58 studies were included of which 33 found a positive association between CI and LOS or DD, 8 studies had mixed results, 3 found an inverse relationship, and 14 showed an indirect link between CI-related syndromes and LOS/DD. Thus, cognitive impairment seemed to be frequently associated with increased LOS/DD. Future research should consider CI together with other risks for LOS/DD and also focus on explaining the association between the two.

Understanding health-care outcomes of older people with cognitive impairment and/or dementia admitted to hospital: a mixed-methods study

Background

Cognitive impairment is common in older people admitted to hospital, but previous research has focused on single conditions.

Objective

This project sits in phase 0/1 of the Medical Research Council Framework for the Development and Evaluation of Complex Interventions. It aims to develop an understanding of current health-care outcomes. This will be used in the future development of a multidomain intervention for people with confusion (dementia and cognitive impairment) in general hospitals. The research was conducted from January 2015 to June 2018 and used data from people admitted between 2012 and 2013.

Design

For the review of outcomes, the systematic review identified peer-reviewed quantitative epidemiology measuring prevalence and associations with outcomes. Screening for duplication and relevance was followed by full-text review, quality assessment and a narrative review (141 papers). A survey sought opinion on the key outcomes for people with dementia and/or confusion and their carers in the acute hospital (n = 78). For the analysis of outcomes including cost, the prospective cohort study was in a medical admissions unit in an acute hospital in one Scottish health board covering 10% of the Scottish population. The participants (n = 6724) were older people (aged ≥ 65 years) with or without a cognitive spectrum disorder who were admitted as medical emergencies between January 2012 and December 2013 and who underwent a structured nurse assessment. ‘Cognitive spectrum disorder’ was defined as any combination of delirium, known dementia or an Abbreviated Mental Test score of < 8 out of 10 points. The main outcome measures were living at home 30 days after discharge, mortality within 2 years of admission, length of stay, re-admission within 2 years of admission and cost.

Data sources

Scottish Morbidity Records 01 was linked to the Older Persons Routine Acute Assessment data set.

Results

In the systematic review, methodological heterogeneity, especially concerning diagnostic criteria, means that there is significant overlap in conditions of patients presenting to general hospitals with confusion. Patients and their families expect that patients are discharged in the same or a better condition than they were in on admission or, failing that, that they have a satisfactory experience of their admission. Cognitive spectrum disorders were present in more than one-third of patients aged ≥ 65 years, and in over half of those aged ≥ 85 years. Outcomes were worse in those patients with cognitive spectrum disorders than in those without: length of stay 25.0 vs. 11.8 days, 30-day mortality 13.6% vs. 9.0%, 1-year mortality 40.0% vs. 26.0%, 1-year mortality or re-admission 62.4% vs. 51.5%, respectively (all p < 0.01). There was relatively little difference by cognitive spectrum disorder type; for example, the presence of any cognitive spectrum disorder was associated with an increased mortality over the entire period of follow-up, but with different temporal patterns depending on the type of cognitive spectrum disorder. The cost of admission was higher for those with cognitive spectrum disorders, but the average daily cost was lower.

Limitations

A lack of diagnosis and/or standardisation of diagnosis for dementia and/or delirium was a limitation for the systematic review, the quantitative study and the economic study. The economic study was limited to in-hospital costs as data for social or informal care costs were unavailable. The survey was conducted online, limiting its reach to older carers and those people with cognitive spectrum disorders.

Conclusions

Cognitive spectrum disorders are common in older inpatients and are associated with considerably worse health-care outcomes, with significant overlap between individual cognitive spectrum disorders. This suggests the need for health-care systems to systematically identify and develop care pathways for older people with cognitive spectrum disorders, and avoid focusing on only condition-specific pathways.

Future work

Development and evaluation of a multidomain intervention for the management of patients with cognitive spectrum disorders in hospital.

Study registration

This study is registered as PROSPERO CRD42015024492.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 8. See the NIHR Journals Library website for further project information.

Time of referral to older adult liaison psychiatry service and other factors affecting length of stay in the general hospital

OBJECTIVES

To explore the relationship between social and clinical factors with (1) Time to referral to an older adult liaison psychiatry service, and (2) Length of stay (LOS), in a sample of older adults admitted to an acute general medical hospital receiving liaison psychiatry intervention, in London, United Kingdom, over a 3-year period.

METHODS

Information on patients referred to liaison psychiatry for older adults between January 2013 and December 2015 was collected using structured forms, with clinical diagnoses determined according to International Classification of Mental Disorders-10. The association of social and clinical factors with the time taken to refer to liaison psychiatry and LOS was assessed using Cox proportional hazards regression and zero-truncated Poisson regression, respectively.

RESULTS

Compared with people who were diagnosed with depression, older adults with psychotic and alcohol use disorders had higher rates of referral to liaison psychiatry (adjusted hazard ratios [aHRs] 1.83 [95% CI: 1.30, 2.59] and aHR 1.69 [95% CI: 1.01, 2.83]) respectively. In adjusted models, LOS was increased in older adults with delusional disorders and shorter in people with alcohol use disorders, personality disorders and learning disabilities, compared to people with depressive diagnoses. Within this cohort, a new definite dementia diagnosis and longer time to refer to liaison psychiatry were both associated with a longer length of general hospital in-patient stay.

CONCLUSIONS

In older adults admitted to general medical hospitals, and needing liaison psychiatry input, timely referral may be associated with a shorter LOS.

Acute care delivery to persons with cognitive impairment: a mixed method study of health professionals' care provision and associated challenges

Objectives: Cognitive impairment is common among older persons admitted to hospital and associated with adverse outcomes. Inadequate care has been widely reported, with health professionals tending to be ill-equipped to meet the specific needs of this patient group. This study aimed to investigate health professionals' care provision to persons with cognitive impairment and associated challenges.Design and Setting: A concurrent, cross-sectional mixed method study was conducted at two university-affiliated hospitals.Participants: A total of 339 health professionals participated in the study.Measurements: An online survey (n = 312) determined the extent to which health professionals perceived their care provision to be person-centered and evidence-based (POPAC-R), and experience distress in looking after this patient group (NPI-D). Four focus group interviews (n = 27) explored health professionals' experience of care provision.Results: More than half of the health professionals reported to act always or very frequently in person-centered and evidence-based ways, and two third experienced challenging behaviors as moderately to very distressing. Health professionals working in acute geriatric wards demonstrated statistically significant higher levels of person-centered and evidence-based care provision, and lower distress. Their caring practices pertained to building a relationship, addressing specific needs, involving family members, and working collaboratively.Conclusions: Findings suggest that geriatric models of care delivery support staff in meeting the needs of persons with cognitive impairment. Health professionals require an acute care culture that values relational, collaborative and coordinated care as essential to patient safety and quality of care, and supports the consistent implementation of evidence-based practices for this patient group.

Drug related problems in older adults living with dementia

BACKGROUND

Compared with those without dementia, older patients with dementia admitted to acute care settings are at higher risk for triad combination of polypharmacy (PP), potentially inappropriate medication (PIM), and drug-drug interaction (DDI), which may consequently result in detrimental health. The aims of this research were to assess risk factors associated with triad combination of PP, PIM and DDI among hospitalized older patients with dementia, and to assess prevalence and characteristics of PP, PIM and DDI in this population.

METHODS

In this retrospective cross-sectional study, 416 older inpatients diagnosed with dementia and referred for specialist geriatric consultation at a tertiary hospital in Brisbane, Australia during 2006-2016 were enrolled. Patients were categorized into two groups according to their exposure to the combination of PP, PIM and DDI: 'triad combination' and 'non-triad combination'. Data were collected using the interRAI Acute Care (AC) assessment instrument. Independent risk factors of exposure to the triad combination were evaluated using bivariate and multivariate logistic regression analyses.

RESULTS

Overall, 181 (43.5%) were classified as triad combination group. The majority of the population took at least 1 PIM (56%) or experienced at least one potential DDI (76%). Over 75% of the participants were exposed to polypharmacy. The most common prescribed PIMs were antipsychotics, followed by benzodiazepines. The independent risk factors of the triad combination were the presence of atrial fibrillation diagnosis and higher medications use in cardiac therapy, psycholeptics and psychoanaleptics.

CONCLUSIONS

The exposure to triad combination of PP, PIM and DDI are common among people with dementia as a result of their vulnerable conditions and the greater risks of adverse events from medications use. This study identified the use of cardiac therapy, psycholeptics and psychoanaleptics as predictors of exposure to PP, PIM and DDI. Therefore, use of these medications should be carefully considered and closely monitored. Furthermore, comprehensive medication reviews to optimize medication prescribing should be initiated and continually implemented for this vulnerable population.

Validating a methodology to measure frailty syndromes at hospital level utilising administrative data

BACKGROUND

Identifying older people with clinical frailty, reliably and at scale, is a research priority. We measured frailty in older people using a novel methodology coding frailty syndromes on routinely collected administrative data, developed on a national English secondary care population, and explored its performance of predicting inpatient mortality and long length of stay at a single acute hospital.

METHODOLOGY

We included patient spells from Secondary User Service (SUS) data for those ≥65 years with attendance to the emergency department or admission to West Middlesex University Hospital between 01 July 2016 to 01 July 2017. We created eight groups of frailty syndromes using diagnostic coding groups. We used descriptive statistics and logistic regression to explore performance of diagnostic coding groups for the above outcomes.

RESULTS

We included 17,199 patient episodes in the analysis. There was at least one frailty syndrome present in 7,004 (40.7%) patient episodes. The resultant model had moderate discrimination for inpatient mortality (area under the receiver operating characteristic curve (AUC) 0.74; 95% confidence interval (CI) 0.72-0.76) and upper quartile length of stay (AUC 0.731; 95% CI 0.722-0.741). There was good negative predictive value for inpatient mortality (98.1%).

CONCLUSIONS

Coded frailty syndromes significantly predict outcomes. Model diagnostics suggest the model could be used for screening of elderly patients to optimise their care.

Gender analysis of nurses' attitude towards care of the elderly with dementia in Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Osun State, Nigeria

This study assessed nurses' knowledge and attitudes by gender toward the care of elderly patients with dementia and explored gender differences in attitudes and associated factors in Obafemi Awolowo University Teaching Hospital, Ile-Ife. The study adopted a sequential explanatory mixed method design to obtain data from 100 nurses selected through a multistage sampling technique. Data analysis was done at univariate, bivariate, and multivariate levels with a significance at P < .05. Findings revealed that a majority of the nurses have good knowledge and attitudes toward the care of elderly patients with dementia. Previous experience in a specialized unit (Odd = 2.879, CI = 0.013-8.287, P = .047) was the main predictor for the nurses' attitude.

A systematic review of specialist inpatient dementia care services versus standard inpatient dementia care in acute hospitals

BACKGROUND

Specialist inpatient dementia units (SIDU) have been developed to address adverse outcomes often experienced by people living with dementia admitted to acute hospitals. However, the evidence base of their effectiveness remains limited.

AIM

To review the current literature to establish the comparative effectiveness of acute hospital SIDU vs. standard ward care (SWC).

METHODS

We did an online search of 12 biomedical databases from inception to 31st October 2017. Studies of inpatients with any form of dementia in acute hospitals, published in English language peer-reviewed journals, using experimental, observational or qualitative study designs, comparing SIDU with SWC and which measured any qualitative or quantitative outcome of the patient or carer experience were included in the search criteria. We used a standardised data extraction and appraisal form.

RESULTS

Three of 46 full-text studies evaluated were suitable for analysis. Due to study heterogeneity, pooled odds ratios were only possible for mortality [OR 1.06 (CI 1.0-1.4)]. Otherwise, a narrative synthesis was performed. Although quantitative measures of length of stay, mortality and behavioural and psychiatric symptoms of dementia are not significantly lower, SIDU are associated with greater patient and carer satisfaction, reduced readmission rates, more accurate and comprehensive assessment processes, documentation of resuscitation decisions, and increased rates of discharge to the patient's own home.

CONCLUSIONS

Although SIDU may be associated with improved care outcomes, the current evidence of their effectiveness is markedly limited. Further research and service evaluation of SIDU as a method for providing high-quality dementia care in acute NHS Trusts is needed.

PROSPERO

CRD42017078364.

Length of hospital stay and dementia: A systematic review of observational studies

OBJECTIVE

Hospitalizations of people with dementia (PWD) are often accompanied by complications or functional loss and can lead to adverse outcomes. Unsystematic findings suggest an influence of comorbidities on the extent of differences in the length of hospital stay (LOS). This systematic review aimed to identify and evaluate all studies reporting LOS in PWD as compared to PwoD in general hospitals.

METHODS

A systematic review of observational studies using PubMed and ISI Web of Knowledge. Inclusion criteria comprised original studies written in English or German, assessment of diagnosis of dementia, measurement of LOS, and comparison of people with and without dementia.

RESULTS

Fifty-two of 60 studies reported a longer hospitalization time for PWD compared to PwoD. The extent of the difference in LOS varied between and within countries as well as by type of primary morbidity (eg, injuries, cardiovascular diseases). The range of the LOS difference for studies without restriction to a primary morbidity was -2 to +22 days after matching or adjustment for a variable number and selection of potentially relevant covariates. For studies with injuries/fractures/medical procedures and infectious/vascular disease as the primary morbidity, the range was -2.9 to +12.4 and -11.2 to +21.8 days, respectively.

CONCLUSIONS

The majority of studies reported a longer hospitalization of PWD compared to PwoD. Length of hospital stay seems to be influenced by a variety of medical, social, organizational factors, including reasons for hospital admission, whose role should be explored in detail in further research.

Dementia in older people admitted to hospital: An analysis of length of stay and associated costs

OBJECTIVES

Patients with dementia in the acute setting are generally considered to impose higher costs on the health system compared to those without the disease largely due to longer length of stay (LOS). Many studies exploring the economic impact of the disease extrapolate estimates based on the costs of patients diagnosed using routinely collected hospital discharge data only. However, much dementia is undiagnosed, and therefore in limiting the analysis to this cohort, we believe that LOS and the associated costs of dementia may be overestimated. We examined LOS and associated costs in a cohort of patients specifically screened for dementia in the hospital setting.

METHODS

Using primary data collected from a prospective observational study of patients aged ≥70 years, we conducted a comparative analysis of LOS and associated hospital costs for patients with and without a diagnosis of dementia.

RESULTS

There was no significant difference in overall length of stay and total costs between those with (μ = 9.9 days, μ = € 8246) and without (μ = 8.25 days, μ = € 6855) dementia. Categorical data analysis of LOS and costs between the two groups provided mixed results.

CONCLUSIONS

The results challenge the basis for estimating the costs of dementia in the acute setting using LOS data from only those patients with a formal dementia diagnosis identified by routinely collected hospital discharge data. Accurate disease prevalence data, encompassing all stages of disease severity, are required to enable an estimation of the true costs of dementia in the acute setting based on LOS.

Hospital outcomes of older people with cognitive impairment: An integrative review

OBJECTIVES

To summarise existing knowledge of outcomes of older hospital patients with cognitive impairment, including the type and frequency of outcomes reported, and the additional risk experienced by this patient group.

METHODS

Integrative literature review. Health care literature databases, reports, and policy documents on key websites were systematically searched. Papers describing the outcomes of older people with cognitive impairment during hospitalisation and at discharge were analysed and summarised using integrative methods.

RESULTS

One hundred four articles were included. A range of outcomes were identified, including those occurring during hospitalisation and at discharge. Older people with a dementia diagnosis were at higher risk from death in hospital, nursing home admission, long lengths of stay, as well as intermediate outcomes such as delirium, falls, dehydration, reduction in nutritional status, decline in physical and cognitive function, and new infections in hospital. Fewer studies examined the relationship of all-cause cognitive impairment with outcomes. Patient and carer experiences of hospital admission were often poor. Few studies collected data relating to hospital environment, eg, ward type or staffing levels, and acuity of illness was rarely described.

CONCLUSIONS

Older people with cognitive impairment have a higher risk of a variety of negative outcomes in hospital. Prevalent intermediate outcomes suggest that changes in care processes are required to ensure maintenance of fundamental care provision and greater attention to patient safety in this vulnerable group. More research is required to understand the most appropriate ways of doing this and how changes in these care processes are best implemented to improve hospital outcomes.

Quality of acute care for persons with cognitive impairment and their families: A scoping review

BACKGROUND

An increasing number of older persons with cognitive impairment use inpatient services for co-occurring acute illness. Research has demonstrated that persons with cognitive impairment face more adverse health outcomes during hospitalization than their age counterparts without cognitive impairment. As hospitals tend to be ill equipped to meet the complex care needs of this population, various initiatives underscore the need to better utilize existing evidence to improve quality of care.

OBJECTIVES

To map the extent of knowledge about quality of acute care in inpatient settings, and to synthesize knowledge on strategies to improve quality care for persons with cognitive impairment and their families.

DESIGN

A scoping review using Arksey and O'Malley's methodological framework.

DATA SOURCES

CINAHL and Medline were searched and reference lists of pertinent articles screened to identify publications regarding acute care for persons with cognitive impairment.

REVIEW METHODS

Two reviewers independently screened and identified publications based on eligibility criteria. Publications were included if they targeted acute care issues relating to persons with cognitive impairment 65 years or older, their family members, or health professionals caring for them, and were published after 2000 in English or German. Publications were read and data were extracted using a predefined template. Thematic analysis was conducted by two reviewers.

RESULTS

Of the 1445 identified publications, 66 were included. Quality of acute inpatient services pertained to structural (such as staff capacity and knowledge) and process dimensions (such as forming a caring relationship, assessing and intervening). Strategies identified to improve care quality included interventions at the point of care, such as specific tools and specialist roles to improve patient outcomes, as well as educational and training interventions to enable staff to care for this patient group.

CONCLUSIONS

There is a discrepancy between clearly defined best practice for persons with cognitive impairment utilising inpatient services, and the quality of care actually experienced by patients, family members, and staff. Research reveals a sobering picture of inadequate care and manifold challenges encountered by this patient group, family members and staff alike. Promising strategies to improve care quality target health professionals' knowledge and capacity to work with this group and include specific tools and models of care, such as specialist roles and units. Organisation-wide efforts to ensure quality care for this patient group are needed, as is further research to determine which implementation and intervention strategies achieve the most beneficial outcomes for all involved.

Predicting excess cost for older inpatients with clinical complexity: A retrospective cohort study examining cognition, comorbidities and complications

BACKGROUND

Hospital-acquired complications increase length of stay and contribute to poorer patient outcomes. Older adults are known to be at risk for four key hospital-acquired complications (pressure injuries, pneumonia, urinary tract infections and delirium). These complications have been identified as sensitive to nursing characteristics such as staffing levels and level of education. The cost of these complications compared to the cost of admission severity, dementia, other comorbidities or age has not been established.

METHOD

To investigate costs associated with nurse-sensitive hospital-acquired complications in an older patient population 157,178 overnight public hospital episodes for all patients over age 50 from one Australian state, 2006/07 were examined. A retrospective cohort study design with linear regression analysis provided modelling of length-of-stay costs. Explanatory variables included patient age, sex, comorbidities, admission severity, dementia status, surgical status and four complications. Extra costs were based on above-average length-of-stay for each patient's Diagnosis Related Group from hospital discharge data.

RESULTS

For adults over 50 who have length of stay longer than average for their diagnostic condition, comorbid dementia predicts an extra cost of A$874, (US$1,247); any one of four key complications predicts A$812 (US$1,159); each increase in admission severity score predicts A$295 ($US421); each additional comorbidity predicts A$259 (US$370), and for each year of age above 50 predicts A$20 (US$29) (all estimates significant at p<0.0001).

DISCUSSION

Hospital-acquired complications and dementia cost more than other kinds of inpatient complexity, but admission severity is a better predictor of excess cost. Because complications are potentially preventable and dementia care in hospitals can be improved, risk-reduction strategies for common complications, particularly for patients with dementia could be cost effective.

CONCLUSIONS

Complications and dementia were found to cost more than other kinds of inpatient complexity.

Does admission to a specialist geriatric medicine ward lead to improvements in aspects of acute medical care for older patients with dementia?

OBJECTIVE

The objective of this study is to clarify if admission to a specialist geriatric medicine ward leads to improvements in aspects of acute medical care for patients with dementia.

METHODS

We analysed combined data involving 900 patients from the Irish and Northern Irish audits of dementia care. Data on baseline demographics, admission outcomes, clinical aspects of care, multidisciplinary assessment and discharge planning processes were collected.

RESULTS

Less than one-fifth of patients received their inpatient care on a specialist geriatric medicine ward. Patients admitted to a geriatric medicine ward were less likely to undergo a formal assessment of mobility compared with those in non-geriatric wards (119/143 (83%) vs 635/708 (90%), odds ratio (OR) = 0.57 (0.35 to 0.94)) and were more likely to receive newly prescribed antipsychotic medication during the admission (27/54 (50%) vs 95/2809 (36%), OR = 1.95 (1.08 to 3.51)). Patients admitted to a geriatric medicine ward were more likely to have certain aspects of discharge planning initiated, including completion of a single plan for discharge (78/118 (66%) vs 275/611 (45%), OR = 2.38 (1.58 to 3.60)). Surgical wards performed more poorly on certain aspects including having a named discharge co-ordinator (32/71, 45%) and documentation of decisions regarding resuscitation status (18/95, 19%).

CONCLUSION

Relatively low numbers of patients with dementia received care on a specialist geriatric medicine ward. There appears to be a more streamlined discharge planning process in place on these wards, but they did not perform as well as one would expect in certain areas, such as compliance with multidisciplinary assessment and antipsychotic prescribing. Copyright © 2016 John Wiley & Sons, Ltd.

'Dementia-friendly communities' and being dementia friendly in healthcare settings

PURPOSE OF REVIEW

This review discusses the concept of 'dementia-friendly communities' and summarizes the latest research and practice around such communities. This review also highlights important topic areas to be considered to promote dementia friendliness in healthcare settings.

RECENT FINDINGS

Definitions of 'dementia-friendly communities' reflect the contemporary thinking of living with dementia (e.g., dementia as a disability, equal human rights, a sense of meaning). Existing research has covered a wide range of topic areas relevant to 'dementia-friendly communities'. However, these studies remain qualitative and exploratory by nature and do not evaluate how dementia-friendly communities impact health and quality of life of people living with dementia and their caregivers. In healthcare settings, being dementia friendly can mean the inclusion of people with dementia in treatment discussion and decision-making, as well as the provision of first, adequate and appropriate service to people with dementia at an equivalent standard of any patient, second, person-centered care, and third, a physical environment following dementia-friendly design guidelines.

SUMMARY

Research incorporating more robust study designs to evaluate dementia-friendly communities is needed. Being dementia-friendly in healthcare settings requires improvement in multiple areas - some may be achieved by environmental modifications while others may be improved by staff education.

Challenges and opportunities in understanding dementia and delirium in the acute hospital

In an Essay, Andrew Jackson and colleagues discuss challenges in the diagnosis and management of older people with dementia and delirium in acute hospitals.

Dementia in the acute hospital: the prevalence and clinical outcomes of acutely unwell patients with dementia

BACKGROUND

Studies have demonstrated that a significant minority of older persons presenting to acute hospital services are cognitively impaired; however, the impact of dementia on long-term outcomes is less clear.

AIM

To evaluate the prevalence of dementia, both formally diagnosed and hitherto unrecognised in a cohort of acutely unwell older adults, as well as its impact on both immediate outcomes (length of stay and in-hospital mortality) and 12-month outcomes including readmission, institutionalisation and death.

DESIGN

Prospective observational study.

METHODS

190 patients aged 70 years and over, presenting to acute hospital services underwent a detailed health assessment including cognitive assessment (standardised Mini Mental State Examination, AD8 and Confusion Assessment Method for the Intensive Care Unit). Patients or informants were contacted directly 12 months later to compile 1-year outcome data. Dementia was defined as a score of 2 or more on the AD8 screening test.

RESULTS

Dementia was present in over one-third of patients (73/190). Of these patients, 36% (26/73) had a prior documented diagnosis of dementia with the remaining undiagnosed before presentation. The composite outcome of death or readmission to hospital within the following 12 months was more likely to occur in patients with dementia (73% (53/73) vs. 58% (68/117), P = 0.043). This finding persisted after controlling for age, gender, frailty status and medical comorbidities, including stroke and heart disease.

CONCLUSION

A diagnosis of dementia confers an increased risk of either death or further admission within the following 12 months, highlighting the need for better cognitive screening in the acute setting, as well as targeted intervention such as comprehensive geriatric assessment.