Dementia care in General Hospitals And what we are doing to improve it at the Royal Berks

1. Dementia care in General HospitalsAnd what we are doing to improve it at the Royal Berks David Oliver Consultant Physician

2. 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

3. I.What is dementia and how does it affect people?

4. 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.”

5. 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.”

6. 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 • “Mood changes − people with dementia may be withdrawn, sad, frightened or angry about what is happening to them.”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.”

7. To recap: The 3 main manifestationsSee 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…

8. 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 symptomsso 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

9. 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

10. Diagnosing Dementiae.g. MMSE

11. 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)

12. II. How common is dementia in society and in general hospitals like the Royal Berks?

13. 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

14. From NHS Information (People over 65 account for 60% admissions and 70% bed days to hospital)

15. “Who cares wins” 2005c 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

16. Alzheimer’s Society “Counting the Cost” 2009

17. 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, yetimproving care has the potential not only to enhance quality of experience but also to reduce length of stay and cost”

18. III. The national response to these issues. Policies, guidelines, audits, strategies etc A time of great momentum and interest…

20. 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

21. 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.”

22. 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”

23. 2009 NHS Confederation

24. Counting the Cost Report

25. “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”

27. 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

28. Survey of 206 Hospitals – organisational level(RCPsychAudit) Only 30% have formal system for gathering personal informationto 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 procedureson people with dementia

29. 70% of hospitals were unable to identify people with dementia within reported information on hospital falls • 77% of trusts had no training strategyidentifying 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 awarethat 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

30. 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

31. 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?

32. From “Acute Awareness”

33. Ann Reid..”Acute Awareness”

35. 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

36. “Counting the cost” 2009 1,291 carers, 657 nurses, 479 ward managers

37. Physical Noise Lighting Heat Space Proximity Posture Signage Emotional Recognise individual distress Importance of familiar people, places and objects Reminiscence individually or with family Activity Causes of distress

39. 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”)

40. What the guide covers in detail.. Whole Hospital Approaches Multi-professional specialist liaison Environment and Orientation More person centred care Including involvement of carers Communication Antipsychotics Nutrition and Hydration Pain Relief Challenging Behaviour Walking and Wandering Withdrawn and unresponsive Preventing Delirium Recognising and Managing Delirium Preserving function and rehabilitation Discharge Planning

41. 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

42. 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

43. Key Questions for Trust Boards (“Acute Awareness”)

44. 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, Non-Exec, Pharmacy, Therapies, Dietetics etc In House training programme with some external places to “train the trainers” “This is Me” Leaflet

45. 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…

46. Thank you Questions.....? David.Oliver@royalberkshire.nhs.uk David.Oliver@dh.gsi.gov.uk Over to Luke and Mental Health Liaison Team

47. Older Persons Mental Health Liaison Team – Royal Berkshire Hospital Dr. Luke Solomons Consultant Liaison Psychiatrist

48. 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

49. 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

50. 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