acute care

There’s a Catch-22’–The complexities of pain management for people with advanced dementia nearing the end of life: A qualitative exploration of physicians’ perspectives.

De Witt Jansen, B., Brazil, K., Passmore, P., Buchanan, H., Maxwell, D., McIlfatrick, S.J., Morgan, S.M., Watson, M. and Parsons, C.
Palliative medicine
In this study De Witt Jansen et al. (2017) interview physicians from hospice, hospital and general practice.
They explore physician perspectives of the barriers to pain management among people nearing the end of life with dementia and on the impact of these barriers on outcomes and how they overcome these challenges. The most common barrier identified was the difficulty in diagnosing pain. Where a patient is no longer able to communicate verbally, physicians rely on nonverbal and physical signs but are concerned about the potential to misinterpret these cues. The complexities of complex comorbidities, low body mass index and ageing physiology were also identified as barriers. This is further complicated by the fact that many patients in this group are already on other medications, resulting in the choice of suitable analgesics being restricted. Many patients are also unable to take oral medication, and more agitated patients often remove syringe drivers. All respondents believe that input from families and other professionals is essential if they are to provide effective pain management. The findings from this study are being used to develop and pilot an intervention that aims to develop a gold standard in pain management for people with dementia.

Care of Patients with Dementia in an Acute Trauma and Orthopaedics Unit

McCorkell, G., Harkin, D., McCrory, V., Lafferty, M. and Coates, V.
Nursing Standard
This paper by Mc Corkell et al. (2017) reports on a piece of action research that set out to improve awareness of the needs and care of patients with dementia in an acute trauma and orthopaedics unit.
In an audit of patient records the authors found inadequate recording of the type of dementia diagnosed, inadequate pain assessment and administration of pain relief and minimal recording of communication with families. Post audit, ward nurses collaborated to design a dementia toolkit that addressed the issues identified in the review. The toolkit included advice on communicating with people with dementia and family members, use of a cognitive impairment pain assessment tool and information on assessment and management of delirium. On introduction, it became evident that ward staff required more education and training to effectively use the toolkit. This was provided and a further audit, six months later, indicated significant improvement in awareness and care of patients with dementia. For example, post implementation; a cognitive impairment pain assessment tool had been used with 95% of patients. The authors suggest the toolkit is discreet and inexpensive while supporting staff to meet the needs of people with dementia.

The detection, diagnosis, and impact of cognitive impairment among inpatients aged 65 years and over in an Irish general hospital – a prospective observational study

Power, C., Duffy, R., Bates, H., Healy, M., Gleeson, P., Lawlor, B.A. and Greene, E..
International Psychogeriatrics
In a prospective observational study Power et al. (2017) assessed patients admitted to an Irish Hospital over a two week period for delirium and cognition. They found high levels of cognitive impairment (48%) with 27% meeting the DSM-IV criteria for dementia and 21% meeting the criteria for MCI.
The authors discuss the discrepancy evidenced in this study and others between prevalence and recognition of dementia among clinicians. This is particularly significant since poorer outcomes are evidenced for people with dementia who had longer hospital stays and were more likely to be readmitted in the next 12months. The authors conclude that significant investment is required in education and resources and this must take place within a wider cultural change in both institutions and society.

Comparison of cognitive and neuropsychiatric profiles in hospitalised elderly medical patients with delirium, dementia and comorbid delirium– dementia

Leonard, M., McInerney, S., McFarland, J., Condon, C., Awan, F., O’Connor, M., Reynolds, P., Meaney, A.M., Adamis, D., Dunne, C., Cullen, W., Trzepacz, P.T. and Meagher, D.J.
BMJ Open
This study by Leonard et al. (2016) assessed 176 patients in an Irish acute hospital and found 50 of the patients to have delirium without dementia, 62 with delirium and dementia, 32 with dementia without delirium and 32 who were cognitively intact.
The study then compared the neuropsychiatric profile of these groups of patients using three well-validated instruments for delirium and dementia severity, the DRS-R98 (Revised Dementia Rating Scale), CTD (Cognitive Test for Delirium) and NPI-Q (Neuropsychiatric Inventory). It found that delirium, both with and without comorbid dementia, could be distinguished from dementia alone using the former two instruments. It also found that, although both delirium and dementia are characterised by a generalised disturbance of cognitive function, delirium can be distinguished from dementia because of distinct differences in impairment of attention and vigilance. The study argues that the cognitive functions of attention and vigilance should be emphasised in efforts to identify delirium, including in populations where there are high rates of dementia.

Integrated Care Pathways and Care Bundles for Dementia in Acute Care: Concept Versus Evidence

Sullivan, D.O., Mannix, M. and Timmons, S.
American Journal of Alzheimer’s Disease and Other Dementias
This paper by O’Sullivan et al. (2017) presents the results of a literature review to identify evidence on the effectiveness of integrated care pathways (ICPs) and/or care bundles for dementia care in the acute hospital sector.
While ICPs for dementia care were identified, none that focusd on dementia care in an acute hospital setting were found. The authors also found limited research on the effectiveness and economic evaluation of ICPs generally.

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

Briggs, R., Coary, R., Collins, R., Coughlan, T., O'neill, D. and Kennelly, S.P.
QJM: An International Journal of Medicine
Briggs et al. (2015) reviewed hospital activity in a 600 bed university hospital where between 2010 and 2012, 929 patients were admitted with a diagnosis of dementia – 2% of all in patient episodes, reflecting a 21% increase in admissions of this patient group.
Overall hospital activity related to people with dementia was equal to 10% of total bed days and 5% of total hospital case mix budget, a cost almost 3 times higher than for those without dementia. On average patients with dementia had a 25.6 day length of stay compared to 11.2 days among those without dementia. The authors highlight the likelihood that the data under represents the true impact of dementia as many people presenting to hospital do not have a diagnosis and cognitive impairment is not recognised. They point to the need for better community services, better cognitive screening and perhaps a dementia specific service for this cohort.

Patterns of psychotropic prescribing and polypharmacy in older hospitalized patients in Ireland: the influence of dementia on prescribing.

Walsh, K.A., O'Regan, N.A., Byrne, S., Browne, J., Meagher, D.J. and Timmons, S.
International Psychogeriatrics
This is a retrospective study; a cross sectional analysis of the original Cork Dementia Study medication data.
The authors set out to describe use of psychotropic, anti-cholinergic and deliriogenic medication among older hospitalised patients, both with and without dementia and to identify the prevalence of polypharmacy (5 or more medications) and psychotropic polypharmacy (2 or more psychotropic agents). They found that over two thirds of older people in hospital experience polypharmacy with a quarter experiencing major polypharmacy. In line with other studies they found high levels of psychotropic medication use with significantly higher levels of these being prescribed to people with dementia. Patients admitted from nursing homes were 5 times more likely to be prescribed an anti-psychotic medication. No significant differences were found between the two groups when it came to anti-cholinergic, deliriogenic or cardiovascular agents. The authors conclude that dementia is under diagnosed among this population and there is a high prevalence of polypharmacy and psychotropic drug use.

Acute Hospital dementia care: Results from a National Audit.

Timmons, S., O’Shea, E., O’Neill, D., Gallagher, P., de Siún, A., McArdle, D., Gibbons, P. and Kennelly, S
BMC geriatrics
This paper reports on the findings of a national audit of dementia care in acute hospitals. Thirty five hospitals, 660 charts, senior and ward management interviews inform the audit.
Levels of physical assessment ranged from high (80% of patients) in mobility, continence and pressure scores to low (less than 40%) in functioning and BMI, while no pain assessment was carried out for almost 25% of the sample. When it came to mental assessment, less than half of patients were assessed for cognition, delirium, behavioural, psychological symptoms of dementia, and mood. Dementia awareness training was found to be low, with a lack of mentorship and supervision. Most wards were running with less than a full complement of staff,. Discharge planning for people with dementia was found to be poor and high numbers of people admitted from home were discharged to long term care.

Living With Dementia’: Implications for the National Dementia Strategy: Summary of Roundtable Discussions Submitted to the National Dementia Strategy Working Group

Alzheimer’s Society
Alzheimer Society of Ireland

The fourth Alzheimer Society of Ireland publication reports on two roundtable discussions organised by the Alzheimer Society of Ireland, which provided an opportunity for the National Dementia Strategy Working Group and Department of Health officials to meet with people with dementia and carers a

nd get their input on priority areas earmarked for inclusion in the strategy. The roundtables were structured around three themes: the role of the GP; community services; and dementia awareness and education. The report summarises the discussions points and key messages under each heading. 

Multidisciplinary Clinicians Roundtable on the National Dementia Strategy

Alzheimer’s Society
Alzheimer Society of Ireland

The third Alzheimer Society of Ireland publication is a report summarising a roundtable discussion involving healthcare professionals from multidisciplinary backgrounds including occupational therapy, social work, physiotherapy, speech and language therapy and nursing.

The themes used to structure the roundtable discussion were grounded in each of the five disciplinary areas: non-pharmacological interventions and behaviours that challenge (occupational therapy); improving Communication (speech and language therapy); physical activity for health and wellbeing (physiotherapy); A Social Work Perspective (social work); and the registered nurse’s contribution to person centred care (nursing).  As with the previous roundtable discussion, the report concludes with a set of suggestions as to how multidisciplinary clinicians can influence the development of the Irish National Dementia Strategy.  


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