Lost and confused: improving hospital care for dementia patients

One in four patients in acute hospital beds has dementia. The recent Care Quality Commission report on dignity and care highlighted the experience these elderly patients suffer in some of our hospitals. Patients experience a lack of holistic, person-centred care that meets their physical, mental and social needs.

For the majority of these patients, care is fragmented and aimless. The physical care environment is often bewildering and even poses risks. Early findings from our Enhancing the Healing Environment projects show how simple changes – such as changes to lighting, floor coverings and signposting – can make a big difference, reducing falls, incidents of aggressive behaviour and the use of anti-psychotic medication. However, acute hospitals have not been designed with these patients in mind.

Many commentators recently have been blaming all-graduate nurse training for poor standards of nursing care for these patients. But the problem is more systemic – these patients need proactive care to ensure they are washed, helped to the toilet, fed, hydrated and mobilised. A team approach is needed, where people with the right skills and experience are able to work effectively together to provide co-ordinated care. This will involve care assistants, cleaners and clinical staff working together.

On a recent visit to Leeds, I observed a multidisciplinary team providing old age liaison psychiatry across two sites at the Leeds General Infirmary and St James's University Hospital. The team – made up of old age psychiatrists, nurses, and occupational therapists – are referred older people from across the trust, including people with undiagnosed or uncontrolled dementia and delirium who are admitted for other medical or surgical treatment. They perform a holistic assessment of the patients' mental health and wellbeing, talk to family and carers about the support at home, their circumstances and their history, and review their medications. The review and actions are recorded on an electronic record used by the mental health trust. Their work has shown good results with reduced lengths of stay, but funding is uncertain.

There is a set of new tariffs to pay mental health trusts but these would not cover treatment of patients whose main reason for admission was not related to their mental health. Acute trust tariffs do not fully reflect the costs of delivering mental health care to a patient admitted for a hip fracture or cancer treatment either. If high-quality integrated care for people with mental and physical conditions is the goal, then tariffs and contracts need to be designed to overcome the organisational divisions that get in the way.

The team in Leeds spend a lot of time training and supporting other staff across the trust to raise awareness of how to diagnose, treat and manage mental health problems in the elderly, advising on how to adapt the environment for these patients.

We need to rethink how we care for frail elderly people with mental health problems in hospitals. While some of these patients could be prevented from admission with better community and home care, some have acute needs that require hospital care. It will mean redesigning buildings, services and roles. It will also mean ensuring that basic standards of care are met – poor nutrition and hydration can exacerbate delirium. If we fail to face this challenge, our hospital beds will continue to be filled with patients who feel lost and confused, and there will be many more families who feel let down by the NHS.

For more on patient experience and quality of care, see our Point of Care Programme

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Comments

#571 DAUGHNE TAYLOR
Retired NHS

Dear Anne,I have read with interest your blog on dementia care,I lost my dear father to dementia in Dec and have to say with saddened heart that our NHS but also private care staff do not seem to have grasped the reality of what dementia means to both the sufferer and the relative,my father and the other residents in the care home were frightened,unsure of their wearabouts,confused and at times mostly childlike as their memory had regressed backwards and on the days I visited him i had to work out where dad's mind was before I knew how to converse with him in a meaningfull way,this saddly takes a lot of time and endless patience which is something our care staff do not have but if only they could understand that our older folk just need that little more TLC and understanding, they aren't asking for much and in most cases don't ask for anything, and isn't it their right to be cared for humainly and with dignity after all 'there but for the grace of god go I'.
Thank you for your effforts in trying to put some of this right and if there were any way I can help I would be proud to do so.
Kind Regards,
Daughne

#577 John Adams OBE
General Secretary
VODG

I agree with Daughne Taylor; after all this type of nursing is not exactly 'rocket science,’ some compassion and kindness would go a long way towards addressing the current serious deficits in NHS care for the elderly. (I will no longer allow my 92 year old mother with dementia anywhere near a hospital). Personally I’d swap care and compassion – basic kindness – any day over the built environment. Physical surroundings are important, but not as important as human interaction and, for example, hydration.

But why do things like the new tariffs undermine an integrated team approach to supporting confused elderly people? Who designed the tariffs and why can’t they be changed? Is the King’s Fund raising this concern with the DH?

#40003 debi britton
carer within the dementia area
residential home

i work with dementia everyday and realise the only reason our nurses (and doctors for that matter) have difficulty with the dementia sufferer is lack of training, my colleagues and i work everyday and treat all our residents with dignity, respect, care, compassion and empathy. if the nhs put trained dementia awareness carers in their hospitals they would see a massive difference in how elderly are treated and want to be treated. They dont want to be talked down to or even spoke over, they can answer their own questions it just takes time which the doctors and nurses dont have, i would love the opportunity for myself and my working team to show them how it can be done

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