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Up to the challenge

Speakers at a recent symposium discussed the problems with dementia care in the hospital system – and what’s being done about them. 

Many were relieved when the government’s recent Budget upheld its pre-election promise to commit $200 million over the next five years to those working on ways to prevent or cure dementia.

However, greater attention needs to be placed on improving outcomes for people with dementia entering the hospital system.

Research suggests people with dementia who enter hospital stay there longer and have worse outcomes than people without dementia who stay in hospital. Dementia researchers who recently took part in the Dementia Care in Hospitals symposium highlighted this issue. Nursing Review spoke to four of the event’s key speakers about the challenges the system faces, as well as new tools and methods being implemented throughout Australian hospitals.

To serve them better

Brian Draper, conjoint professor in the school of psychiatry at the University of New South Wales, says in general the hospital system struggles when it comes to meeting the needs of people with dementia.

“The basic hospital system is set up for examining acute medical and surgical problems, and is not well designed to meet the needs of people who have more chronic problems, like people with dementia,” he says. “Simple improvements, including better consultation of families in care decisions and early identification of cognitive impairments in patients, can make a significant impact on the acute care experience for someone with dementia.”

Draper presented the practical implications of the findings from The Hospital Dementia Services Project – a study involving all NSW public hospital admissions over a 12-month period, designed to inform health practitioners, policymakers, planners and consumers about the system outcomes for patients with dementia.

The study showed that nurses outside aged care had limited training, and therefore little confidence, in how they would look after people with dementia particularly when resources weren’t ideal.

“For example, a lot of emergency departments are not well designed for people with dementia. They are very busy places, with a lot going on, with a lot of other people and a lot of crisis happening,” Draper says. “[So], if you have a confused older person who feels anxious about being in that situation, it is often a huge challenge for nursing staff to know how to best help that person in that situation.”

Another aspect, Draper says, is identification of people with dementia in hospitals, which he says is a “huge challenge and is not very well done”.

Many doctors and nurses don’t recognise that a person has dementia, and therefore are unaware that some of the history they have obtained is a tad unreliable.

“They might notice sometimes later that a person is confused but they are not too sure if this is something new or old, so they are not sure if they are dealing with more of a crisis … or whether it is a part of the person’s level of confusion that they have had for a long time.”

As nurses are the ones dealing with the people and their families, day in and day out, Draper says it is also important to get the balance right between getting the carer in to give the information and provide support and help and not overburdening the carer, so it is a difficult challenge.

He believes a “huge amount” of education is needed in this area.

Fall factor

Falls are one of the most common adverse events in hospitals across Australia.

And if we fail to see the crucial link between dementia and the risk of falls, we are missing an opportunity to reduce harm in our hospitals, says professor Jacqueline Close, orthogeriatrician at Prince of Wales Hospital and director of Falls and Injury Prevention Group, Neuroscience Research Australia.

“For many years, we have concentrated on strategies for falls prevention without giving adequate thought to the role cognition plays in falls prevention,” Close says. “I think people are now slowly waking up to the need to ensure our hospital workforce is trained and supported to care for confused, hospitalised older people.”

Close has been involved in the ongoing implementation of a falls prevention program at Prince of Wales Hospital in Sydney, a journey that includes regular monitoring and review of what the hospital has done to prevent falls and serious injury.

Part of the implementation has been the provision of a series of training and education sessions on delirium and dementia, as well as ongoing support from geriatricians and clinical nurse consultants in aged care and dementia/delirium.

“[Through the project], we have been able to reduce our incidence of falls in the hospital and reduce our use of medications associated with an increased risk of falls – a reduction in the use of sleeping tablets is probably the best example of this,” Close said. “We have also been able to demonstrate a significant reduction in our use of antipsychotic medication across the whole hospital.”

The project underscored the important role nurses play in meeting national standards for falls in hospital.

“Nurses are by far the most important group of health professionals in terms of identifying when people are confused and are becoming behaviourally challenging in hospitals, because they have so much exposure to patients,” Close says. “The nurses are often the key people who do the critical interaction with the family and carers, [meaning they are best placed] to understand what the patients’ needs are and what signs and symptoms mean for the individual.”

The project highlights how critical it is to have a workforce that has adequate training in terms of caring for confused, hospitalised older people.

Five-point personalisation

Dr Sian White, manager of Carer Support Unit, Central Coast Local Health District, spoke about TOP5 – a process that allows healthcare staff, mainly nurses, to capture tips and strategies from carers on how to personalise care for dementia patients in the hospital sector.

The Carer Support Unit developed the concept, which was originally crafted to address nursing frustrations with the lack of communication across shifts and disciplines in regards to patients with dementia. It provides the opportunity to gain insight into the patient/client through the eyes of the carer.

“TOP5 has a proven track record of [fostering] confidence and comfort for staff working alongside people with dementia in a hospital setting,” White says. “On the Central Coast, we are now pushing [the program] out of the health setting and into the community and residential aged-care facilities. So now, for our nursing staff, the TOP5 will come from the community.”

It is a single-page medical record, gold in colour, that is “visible, portable, simple and unique to the individual”. It includes the TOP5 strategies to support the patient during hospital admission.

Nurses, allied health and geriatricians use the tool, which allows the professional and carer to incorporate the carer’s expertise and knowing of the patient into the care being provided.

The pilot was run back in 2007, and today the organisation’s work is starting to be mirrored across NSW. Many larger hospitals use the TOP5 system.

“It is a really good visual and portable strategy that delivers the individualised care needed and is easily shared across staff, settings and disciplines,” White confirms. “We have found the TOP5 process helpful for reducing anxiety in people with dementia. They are scared enough as it is in hospital, so a process where we can use the exact words and actions specific to their needs really settles them and makes a difference.”

White says the concept is applicable to any hospital setting and nurses’ feedback shows that TOP5 makes it far easier to communicate with carers, by firstly breaking the ice and secondly helping develop trust.

Talk with Carer/Family

Obtain Information

Personalise Care

5 strategies recorded

Educate for confidence

Delirium and dementia are thought to be present in up to 60 per cent of older people in hospital, according to figures from the Agency for Clinical Innovation.

Anthea Temple, project officer, Aged Health Network NSW Agency for Clinical Innovation, presented to the symposium the results of the Caring for Confused Hospitalised Older Persons (CHOPs) pilot study that ran in 2011–2012.

CHOPs is designed to make sure health professionals are aware that confusion is not normal and if someone is confused they need to find out why.

The study involved the implementation of a range of educational programs across the five sites, aimed at increasing staff knowledge and also communication between hospital and community care staff.

“We were able to target the needs of each site but also build on some existing strengths that the sites had,” Temple says. “One of the big things was having local champions at the sites who were keen, enthusiastic and able to help implement the program and educate.”

Particularly for nurses, results showed a significant increase in their confidence that they could recognise and manage patients with delirium. Many staff didn’t feel as though they had enough training in the area at first.

“It was quite alarming that staff didn’t feel confident that they could recognise patients with delirium or the confidence to manage that person,” Temple says. “Forty per cent of staff surveyed felt they had received training on how to manage confused older people. This rose to 90 per cent following the trial period.”

From the pilot, seven key principles have been identified for the care of confused people in hospitals. They are cognitive screening, delirium risk, assessment, management, communication, staff education and supportive care environments.

The group is continuing to look for different ways health services can implement the program.

The project is now being rolled out over three hospitals, which is expected to reach 14 over the next 12 months. Temple confirmed a state-wide approach would be considered following that.

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