BGS Position Statement: Person-centred acute hospital care for people with dementia

People with dementia are usually admitted to acute hospitals for management of a medical illness, or a functional or behavioural crisis, and only rarely, if ever, for diagnosis or management of dementia itself. However, about half of people aged over 70 who are admitted as an emergency have a cognitive disorder. Some have dementia alone, but many have superimposed delirium, which requires elements of both physical and mental healthcare. Admission is disruptive to familiarity and routines, and often results in distress. Delivery of necessary care and treatment may be resisted.

Every effort must be made to provide alternatives to admission, and to expedite discharge as soon as appropriate care can be provided elsewhere. But people with delirium and dementia are frequently found in hospital and, despite enthusiasm for hospital at home, this fact is unlikely to change in the near future. Equality law calls for ‘appropriate adjustments’ to services to make them accessible for people with protected characteristics, including age and disability. We need to make necessary admissions more tolerable.

Geriatricians and other healthcare professionals working with older people use a framework called Comprehensive Geriatric Assessment, which includes a mental health dimension. However, older people with cognitive disorders are frequently cared for in general medical, surgical or other specialty beds, emergency departments and admissions units. Many staff feel undertrained and lack confidence in dealing with cognitive disorders, and associated problems such as distress, agitation and aggression, resistance to care, exit-seeking or calling out. Training in dementia care is not mandatory across NHS organisations, despite being widely recommended, including by Health Education England (HEE).

The philosophy of person-centred care (PCC) aims to promote wellbeing and minimise distress through meeting fundamental physical, psychological and social needs. It can be adapted to acute medical care settings.^1,2

Evidence suggests that when staff deliver PCC, people living with dementia, carers and staff experience better care.³ Components of this include know-how and expertise; skills in prevention, assessment and management of distress and associated behaviours; adapting care processes, decision-making and discharge planning to take account of cognitive disorders; close engagement of family carers; and liaison with community and mental health services.

In acute hospitals, four types of service deliver care for older people with cognitive disorders:

• General provision on specialist older people’s wards.
• Older age liaison psychiatry services.
• Specialist acute cognitive disorders units.
• Older age liaison and outreach services, including orthogeriatrics, surgical liaison, trauma services and Emergency Departments.

Previous guidelines for organisation-wide quality improvement include:

• The RCN SPACE principles (Staff who are skilled and have time to care; Partnership working with carers; Assessment, identification of dementia and support; Care and support plans which are person-centred and individual; Environments that are dementia friendly)⁴
• The Dementia Action Alliance Dementia-Friendly Hospitals Charter⁵
• Reports from the National Audit of Dementia in general hospitals⁶
• An NIHR-commissioned systematic review, which concluded with a synthesis and 12 evidence-based pointers for service change, spelling out the acronym DEMENTIA CARE (Dementia understanding; Education and training; Modelling person-centred care from leadership; Environment; Not being alone (teamwork); Time; Information-sharing; Access to resources; Communication; Ask family; Raise the profile of dementia care; Engaging volunteers).³

Research evidence and front-line practitioners consistently report problems with implementation:

• Unsuitable clinical in-patient environments.
• Lack of priority in organisations, not least because of the absence of easily measurable performance indicators for PCC or targets for compliance.
• Dominance of safety, capacity and access targets in operational performance.
• The lack of prioritisation, validation and role-modelling by clinical leaders, including senior nurses, ward managers and consultants.
• Inability to make PCC routine without a change in hospital culture.

The BGS believes that:

Priority and leadership

• Acute hospital organisations should make specific provision for the care of people with cognitive disorders who use their services.
• Hospital executives and leaders should acknowledge the special needs of older people with cognitive impairment, and ensure that environments, staffing, training and processes support implementation of services that are suitable for people living with dementia.   
• Geriatric medicine clinicians should take ownership and show leadership on this issue within acute hospitals.
• Geriatricians who specialise in cognitive disorders should be recognised and supported.

Training

• Geriatricians should be competent to carry out a cognitive and mental state assessment, including the diagnosis and management of delirium and dementia, and following the principles of person-centred dementia care.
• Doctors, nurses and Allied Health Professionals who work with older people should have training to achieve skills in line with Tier 2 of the Dementia Training Standards Framework (Skills for Health and Health Education England). Those who regularly work with older people with cognitive disorders should achieve skills in line with Tier 3.

Working with mental health professionals

• Older People’s liaison psychiatry services should be commissioned, accommodated and integrated with general hospital practice.
• Specialist cognitive disorders units should employ Registered Mental Health Nurses alongside general nursing colleagues.
• Commonalities with provision for adults with Intellectual/Learning disabilities, and other vulnerable adults, should be recognised, and opportunities explored for common training and processes.
• Provision should be made for medical assessment and treatment of older in-patients on mental health wards who have physical conditions.

Environment

• Hospital environments accommodating older people with cognitive disorders should be made appropriate to support their needs for orientation, safety, activity, night-time sleep, and avoiding overstimulation:
  
  • This includes signage and orientation cues, clocks and orientation boards, appropriate furniture, toilet and bathing facilities, space for activities and communal eating (such as a day room), ambient noise reduction, decoration and points of visual interest, provision for displaying and keeping safe items of personal interest and attachment (such as photographs), and access to outdoor spaces.
  • New development and refurbishments should be reviewed against published environmental standards (such as Kings Fund⁷ or University of Stirling⁸), and approved by a multi-professional group with expertise in cognitive disorders.
• Patient ward moves that are not specifically beneficial for the individual should not occur. Ward moves should be avoided at all costs between 8pm and 8am.

Families and other carers

• Family and other carers of people with dementia require special attention and inclusion, to enable gathering of medical and other information, to inform about problems and progress, to assist in decision-making and discharge planning, and to help with ‘hands-on’ occupation, feeding assistance and personal care, where they are able and willing.
• Visiting times should not be restricted, and provision should be made for overnight stays, within practical and safety limits.
• Hospitals should follow the John’s Campaign principles of inclusion for family carers.

Care processes

• Information about a patient living with dementia, including personal profiles, should be accessible.
• Routine care, including physiological observations, pressure area care, continence care, and freedom to walk should be individualised.
• Additional observations should include delirium screening, distress, evidence of psychopathology, behaviour, and sleep.
• Nursing staff need authority to adapt and respond to an unmet need, including taking opportunities to spend time talking or walking with patients.
• Provision is required for meaningful occupational, therapeutic and diversional activities, for those who are well enough and willing, tailored to enable successful achievement across a range of abilities.
• A risk enablement (positive risk-taking) approach to activity and discharge should be adopted.
• The involvement of volunteers to provide additional support and activity should be encouraged.
• End of life care planning should be undertaken.
• Information systems should enable sharing across the health and social care system.

Governance

• The absence of measurable performance metrics is recognised and accepted. Alternative mechanisms for quality assurance and improvement should be identified and used, including National Audit of Dementia outcome data.
• An executive and non-executive director should be identified as champions and scrutineers of the quality of dementia care.

References

1. Harwood RH. Dementia for the hospital physician. Clinical Medicine 2012;12(1):35–9. 
2. Goldberg SE, et al. Comparison of a specialist Medical and Mental Health Unit with standard care for older people with cognitive impairment admitted to a general hospital. doi: 10.1136/bmj.f4132
3. Gwernan-Jones R, et al. Understanding and improving experiences of care in hospital for people living with dementia, their carers and staff: three systematic reviews. Chapter 4. 
4. RCN. Commitment to Care of People living with Dementia ‘SPACE principles’.
5. Dementia-Friendly Hospitals Charter.
6. Royal College of Psychiatrists. National Audit of Dementia care in general hospitals 2018–19: Round Four audit report. London: Royal College of Psychiatrists, 2019
7. King's Fund. Developing supportive design for people with dementia.
8. University of Stirling. The Dementia Centre - Building Accreditation.