Improving the care of people living with dementia admitted to hospitals

This review seeks to identify primary research and use its findings to develop explanations of what characteristics of dementia-friendly initiatives in hospitals make them work, in what circumstances, and why | BMJ 

Abstract

Objectives To identify features of programmes and approaches to make healthcare delivery in secondary healthcare settings more dementia-friendly, providing a context-relevant understanding of how interventions achieve outcomes for people living with dementia.

Design A realist review conducted in three phases: (1) stakeholder interviews and scoping of the literature to develop an initial programme theory for providing effective dementia care; (2) structured retrieval and extraction of evidence; and (3) analysis and synthesis to build and refine the programme theory.

Data sources PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, NHS Evidence, Scopus and grey literature.

Eligibility criteria Studies reporting interventions and approaches to make hospital environments more dementia-friendly. Studies not reporting patient outcomes or contributing to the programme theory were excluded.

Results Phase 1 combined findings from 15 stakeholder interviews and 22 publications to develop candidate programme theories. Phases 2 and 3 identified and synthesised evidence from 28 publications. Prominent context–mechanism–outcome configurations were identified to explain what supported dementia-friendly healthcare in acute settings. Staff capacity to understand the behaviours of people living with dementia as communication of an unmet need, combined with a recognition and valuing of their role in their care, prompted changes to care practices. Endorsement from senior management gave staff confidence and permission to adapt working practices to provide good dementia care. Key contextual factors were the availability of staff and an alignment of ward priorities to value person-centred care approaches. A preoccupation with risk generated responses that werelikely to restrict patient choice and increase their distress.

Conclusions This review suggests that strategies such as dementia awareness training alone will not improve dementia care or outcomes for patients with dementia. Instead, how staff are supported to implement learning and resources by senior team members with dementia expertise is a key component for improving care practices and patient outcomes.

Full reference: Handley M, Bunn F, Goodman C. | Dementia-friendly interventions to improve the care of people living with dementia admitted to hospitals: a realist review | BMJ Open 2017; 7:e015257

See also: Dementia care in hospital: training, leadership and culture change needed | The Mental Elf

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Dementia assessment and improvement framework

An evidence-based framework to support and enable directors of nursing and medical directors to achieve ‘outstanding’ care standards for those living with dementia during their stay in hospital | NHS Improvement

This framework has eight standards, and draws on learning from organisations that have achieved an ‘outstanding’ rating from the Care Quality Commission. The document integrates policy guidance and best practice with opinion from patients and carers.

An Innovative Approach to Managing Behavioral and Psychological Dementia

The older adult population in long-term care is experiencing significant growth, which includes an increased number of minority admissions. An estimated 48% of long-term care patients are admitted with a diagnosis of dementia | The Journal for Nurse Practitioners

Highlights: 

  • Nurse practitioners are in a key position to provide culturally appropriate care in older adults with BPSD
  • Personalized music is an evidence-based, patient centered intervention to reduce BPSD
  • Regulatory agencies are closely monitoring the management of BPSD in long-term care facilities.
  • Personalized music can be an interdisciplinary approach in the management of BPSD

Patient-centered, culturally appropriate care is critical in the management of dementia and treatment of associated behavior and psychological symptoms of dementia (BPSD). The use of personalized music playlists has shown promise in the interdisciplinary treatment of BPSD. Regulatory agencies are closely monitoring the management of BPSD. Accurate diagnosis and treatment of BPSD is an increasingly important skill for the provider.

Full reference: Long, E.M. (2017) An Innovative Approach to Managing Behavioral and Psychological Dementia. The Journal for Nurse Practitioners. Vol. 13 (Issue 7) pp. 475-481

People with dementia benefit from goal-oriented therapy

Personalised cognitive rehabilitation therapy can help people with early stage dementia significantly improve their ability to engage in important everyday activities and tasks. | via ScienceDaily

A large-scale trial has found that cognitive rehabilitation leads to people seeing satisfying progress in areas that enable them to maintain their functioning and independence.

Cognitive rehabilitation involves a therapist working with the person with dementia and a family carer to identify issues where they would like to see improvements. Together, they set up to three goals, and the therapist helps to develop strategies to achieve these goals.

The goals participants chose were varied, as dementia affects people in a wide range of ways. Some participants wanted to find ways of staying independent, for example by learning or re-learning how to use household appliances or mobile phones. Some wanted to manage daily tasks better, and worked with therapists on developing strategies to prevent them burning their food when cooking meals. Others wanted to stay socially connected, and focussed on being able to remember details like the names of relatives or neighbours, or improving their ability to engage in conversation. Sometimes staying safe was important, so strategies focused on things like remembering to lock the door at home or withdrawing money safely from a cashpoint.

The Goal-oriented Cognitive Rehabilitation in Early-stage Alzheimer’s and Related Dementias: Multi-centre Single-blind Randomised Controlled Trial (GREAT) trial involved 475 people across eight sites in England and Wales. Half of them received ten cognitive rehabilitation sessions over three months, and the other half did not. The group receiving the therapy then took part in four “top-up” sessions over six months.

The researchers found that those who took part in the therapy showed significant improvement in the areas they had identified, after both the ten week and “top-up” sessions. Family carers agreed that their performance had improved. Both participants and carers were happier with the participants’ abilities in the areas identified.

Full story: University of Exeter. “People with dementia benefit from goal-oriented therapy: Personalized cognitive rehabilitation therapy can help people with early stage dementia significantly improve their ability to engage in important everyday activities and tasks.” ScienceDaily. | 18 July 2017.

Exploring the perspectives of patients with dementia about the hospital environment

Hung, L. et al. International Journal of Older People Nursing. Published online: 18 April 2017

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Background: Recognising demographic changes and importance of the environment in influencing the care experience of patients with dementia, there is a need for developing the knowledge base to improve hospital environments. Involving patients in the development of the hospital environment can be a way to create more responsive services. To date, few studies have involved the direct voice of patients with dementia about their experiences of the hospital environment.

Conclusions: Patient participants persuasively articulated the supportive and unsupportive elements in the environment that affected their well-being and care experiences. They provided useful insights and pointed out practical solutions for improvement. Action research offers patients not only opportunities to voice their opinion, but also possibilities to contribute to hospital service development.

Read the full article here

Dementia: Best practice repository for clinical commissioning

NHS England has developed a repository of examples and case studies of best practice, which is available via the online Learning Environment.

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In March 2016, NHS England introduced a new CCG Improvement and Assessment Framework (CCG IAF). This framework brings together a range of key indicators, enabling NHS England and CCGs to work together to drive improvement for patients.
The CCG IAF framework has indicators for six national clinical priority areas, including dementia. The dementia indicators are:

  • Estimated diagnosis rate for people with dementia.
  • Dementia care planning and post-diagnostic support.

NHS England recognises that CCGs will have varying levels of need for support based on their performance against the indicators, and in October 2016 published a support offer to help with this.

To substantiate the support offer, the NHS England Dementia Team has developed the Best Practice Repository on the NHS England Learning Environment website. This repository is currently being developed and case studies will be added to the NHS England Learning Environment website along with links to other resources.

View an overview of the resource here

Search for case studies here

Best practice in Memory Services: Learning from across England

This report summarises the findings from a series of visits carried out by NHS England’s National Clinical Director for Dementia

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The visits were to a number of memory services which were experiencing longer waiting times from referral to assessment. The audit found that there had been significant successes in a number of clinics in improving access times over the past year, often in challenging circumstances.

Common features of the services which were reducing waiting times were:

  • Reviewing the assessment pathway and reconfiguring workforce to match demand. Some achieved this through upskilling existing staff, using vacancy funding creatively or investing in new staff.
  • Developing joint clinical protocols for referral and diagnosis, follow-up care, access to and reporting of scans and care home management
  • Supporting memory services in primary care 3,4.

Based on the findings the top ten tips to service improvement are:

  1. Involve service users and carers at every step
  2. Understand current and future demand and map against available capacity
  3. Review referral protocols
  4. Review brain scan (CT/MRI) protocols
  5. Examine DNA rates
  6. Ensure correspondence clearly states diagnosis and accompanying ‘Read Codes’
  7. Identify education and training opportunities
  8. Consider protocol for diagnosis in primary care including care homes
  9. Review with commissioners the role of specialist nurses
  10. Become MSNAP accredited and share best practice examples

Read the full report here