Blurring the lines between acute and aged care

The impact of an ageing population and rising cases of dementia is being deeply felt in hospital wards across Australia. Kasia Bail and Brian Draper explain.

Acute care nurses may easily overlook the care of people with dementia, focusing more on the physical rather than the mental condition of the patient. Traditionally, hospitals are not designed in ways that promote the care of patients with delirium or dementia, and hospital routines and practices are often at odds with person-focused care.

However, two-thirds of adult patients in a general hospital are 65 or over, and up to a third of them are likely to have dementia. So acute care nurses are, by default, aged care nurses. As the population ages, both these ratios of older patients are expected to increase, as is the prevalence of dementia.

The NHMRC funded Hospital Dementia Services (HDS) Project, a collaboration of the Australian Institute of Health and Welfare, the University of Canberra and the University of NSW, is examining what factors impact on care outcomes for hospital patients with dementia.

Here we will outline some of our findings that are relevant to nurses. These findings are based on field visits to 20 hospitals throughout NSW, and on analysis of hospital episode data for more than 20,000 people with dementia and 232,000 people without dementia aged 50 and over who were discharged from NSW public hospitals in 2006-07.

Most patients with dementia are not admitted to hospital because of their dementia; common primary causes of admission include pneumonia, hip fractures and other fall-related injuries, urinary tract infections and strokes. These conditions may result in a worsening of confusion in the person with dementia – in particular when delirium becomes superimposed on the dementia, a very common complication that often goes unrecognised. Nurses and doctors may attribute the confusion to dementia without consideration that there may be a superimposed delirium. This frequently results in an under-estimation of the severity of the illness that can result in poor outcomes.

For people without dementia, sometimes an acutely confused older person with delirium is misdiagnosed as having dementia. This could have lethal consequences as delirium represents the mental state change of an acute physical disorder that can be life-threatening if the underlying cause is not detected and treated urgently. Delirium care pathways should be helpful in these situations and have recently been developed for use Australia-wide by researchers from the University of Wollongong in a project funded by the Department of Health and Ageing.

Many people with dementia are likely to be cared for in units that specialise in the primary condition for which they were admitted, rather than in specialist aged care wards. These wards are less likely to maintain the age- and dementia-friendly conditions which benefit people with dementia.

Dementia-friendly environments which are increasingly prevalent in aged care units include: access to sunlight and fresh air to benefit circadian rhythms as well as socialisation and distraction; a safe environment for mobilisation, such as a securely gated ward; diversional activities and a home-like environment, including eating meals at a table and use of colour to offer interest and interaction; and orienting stimuli to reduce confusion, including clocks and calendars on walls.

Our research has found that recognition of the importance of these kinds of strategies can contribute to the delivery of dementia-friendly care even in ‘‘unfriendly’’ settings. That is, the absence of dementia-friendly features in the ward design does not thwart nurses who can be creative in their delivery of patient-focussed care even under the most trying conditions.

However, even with creative nursing workarounds, the HDS project has demonstrated that people with dementia have worse outcomes of hospital care than patients without dementia. The three main outcomes were higher mortality rates, longer admissions and an increased risk of being transferred to a nursing home. These outcomes were more pronounced in younger people (those under 65) with dementia.

The first poor outcome of higher mortality of people with dementia is not well understood. Two aspects of the increased incidence of death in people with dementia need to be considered. First, patients with severe dementia are more likely to succumb to acute illnesses. A common example is the person who dies with a recurrent chest infection that was precipitated by progressive swallowing impairment secondary to the severe dementia. Mortality is not necessarily an adverse outcome and the recognition of dementia as a terminal condition raises important considerations for appropriate advanced care planning including multidisciplinary liaison and family involvement in care and decision making to possibly prevent unnecessary hospitalisation or unwanted treatment in such circumstances.

On the other side of the coin, people with dementia are exceptionally vulnerable in busy acute hospital settings, as they may be unable to speak for themselves and not have the cognitive capacity to manage the unfamiliar environment, thus making them more susceptible to nosocomial infection and injury.

People with dementia are also likely to have longer admissions than those without dementia. We found that this was particularly the case in younger people. Although some of this increased length of stay was due to delays in transferring to residential aged care facilities, this was not the only reason. In general it seems that people with dementia take longer to recover from acute illnesses and as they are also more likely to be readmitted within three months of discharge, they seem more prone to relapse. This raises questions about the importance of appropriate discharge planning, community supports, and advanced care planning.

The third identified poor outcome in the HDS project was that people with dementia had a higher incidence of transfer to residential care. This supports other research that finds that people with dementia and without a carer are more likely to be admitted to residential care. However, it is important to recognise that while people with dementia have an increased risk of being transferred to a nursing home, almost half of the people with dementia, even those over 85, return to their homes in the community, rather than to residential care. This emphasises the importance for acute care nurses to maintain mobility and independence of people with dementia while in hospital. It is also a crucial message to abolish the stigma that associates dementia with residential care, when there are large numbers of people with dementia living well in the community.

Nurses can contribute to ensuring that people with dementia maintain their functioning and independence as much as possible. A significant component of this is determining what their pre-hospital level of functioning was; and conversations with current carers and relatives are important in establishing baseline functioning. Recognising that delirium could be superimposed on dementia, but is a recoverable state, is also important for setting appropriate rehabilitation goals.

Nurses can work to reduce the impact of the hospital as an unfamiliar setting. Someone who functions well at home may deteriorate significantly in the noisy, busy, frantic acute hospital environment. Many care interventions nurses can provide are not complicated, however, the acute hospital setting may mean they may not be immediately obvious. Some general examples include not rushing, not talking over the person, and learning their personal preferences from family, friends or from the nurse’s own experience. These should be documented and handed-over to the next shift.

We recognise hospital admissions as trigger episodes that can make or break a person’s independence and health journey. We must do all we can to ensure that nursing care does not negatively contribute to that journey.

These research findings have been recently presented to the International Psychogeriatric Association Congress in The Hague and the National Dementia Research Forum in Sydney in September, and the International Association of Gerontology and Geriatrics in Melbourne in October. The Hospital Dementia Services project is continuing.

Kasia Bail is a PhD nursing student from the University of Canberra and Brian Draper is conjoint professor from the school of psychiatry at the University of NSW.

For more information on the project visit: http://www.aihw.gov.au/hospital-dementia-services-project/

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