Dementia care in General Hospitals
And 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 “Mood changes − people with dementia may be withdrawn, sad,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 manifestations
See 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
[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]
Alzheimer’s Disease International, 2009
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
 Emotional
 Noise
 Recognise individual distress
 Lighting
 Importance of familiar people,
places and objects
 Heat
 Space
 Proximity
 Posture
 Signage
 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
 Antipsychotics
 Multi-professional specialist
liaison
 Nutrition and Hydration
 Environment and Orientation
 More person centred care
 Including involvement of carers
 Communication
 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, NonExec, 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.....?
 David.Oliver@royalberkshire.nhs.uk
 David.Oliver@dh.gsi.gov.uk
 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
Prevention
Prevention
Awareness
Acute
Initial
On-going
Assessment Assessment
Rehab
Transfer
of 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?