In an environment where many hospitals are struggling to cope with rising demand and inadequate resources, what are the challenges and opportunities in acute care for people with dementia?
Are our hospitals fit places for people with dementia? The answer too often is no. But many of the problems could be fixed if we could pay attention to a few simple things. For those with dementia to be helped they must be recognised. Hospitals achieve an easy win if they have a system so that staff know that the person has dementia. Secondly, all staff need training in meeting the needs of the person with dementia. This should focus on improving communication and urgently address the under-recognition of pain and delirium. Local leadership and role modelling is needed to challenge assumptions that the person with dementia automatically lacks capacity (which is often not the case) and stress the importance of involving and listening to their loved ones. We should also avoid the building itself becoming part of the problem. Wards are very confusing places, even if you don’t have dementia. Creating dementia-friendly wards has a positive impact and there are now well-proven principles to design them. None of this is rocket science. The best practice is already out there and it is an unkindness to those with dementia, their loved ones and to the staff if it is not more widely disseminated and acted upon.
Amanda Thompsell is consultant old age psychiatrist at the South London and Maudsley NHS Trust
Increasingly, frontline dementia care takes place in acute general hospital wards, where time, staffing and environmental pressures create very challenging circumstances. I believe that the way we train staff needs to adapt to this shifting landscape. Traditionally, we have taken highly educated, senior staff off-site to a lecture hall. We talk at them for a full day and then they go home and we keep our fingers crossed that some of what we have told them will be remembered by the time they are back on shift. Strangely, the staff who spend most face-to-face time with our patients (the cleaners, housekeepers and health care assistants) get the least opportunity for training. The Royal Free CAPER Anchor scheme recruited these junior staff and invested seven weeks in them to make them highly-skilled dementia experts. I think the ward is the best classroom. I don’t show them theoretical, abstract information like cross-sections of brain tissue; they don’t need to know that. What they need to know is how to spot pain and delirium, and how to talk to someone who is agitated and distressed. How to change how care is delivered based on their values and how to reach patients that get failed by our hospitals. At first they all felt low in confidence, but as they have developed they have taught us that you don’t have to be the boss to be a leader.
Danielle Wilde is dementia lead at the Royal Free Hospital in London
One of the biggest problems facing acute hospitals is delirium. Delirium is an acute medical condition associated with an increased need for care, longer length of stay, and mortality. Over the last year, I have realised that managing patients who have a diagnosis of a dementia is not our biggest challenge. Rather, it is those patients who present with delirium on top. We first need to recognise delirium as an acute medical condition and start using the appropriate language to trigger the correct responses to treat delirium appropriately. Studies suggest that one-third of older people have undetected or unresolved symptoms of delirium on discharge which can lead to an increase in adverse events. Delirium deserves its own national campaign to raise awareness and reduce the occurrence, not just in acute hospital settings but in the community. More collaborative work needs to be focused on prevention, targeting the potential causes. I am a lone practitioner like many other dementia specialist nurses and we face a huge challenge in getting not only our individual trusts to realise the problem we face, but our community and neighbouring hospitals. I am a member of the Yorkshire and Humber clinical network acute champions for dementia and I have been fortunate to have their support. Together with other acute champions members, we are tackling this head-on, raising the profile of delirium.
Danielle Woods is lead nurse for dementia at Bradford Teaching Hospitals NHS Foundation Trust
Providing compassionate, effective care for people with dementia in acute care is perhaps the biggest challenge for hospitals today. The media is quick to point out when we get it wrong. What we don’t hear enough of are examples of good practice that happen daily. There is a real commitment to change the way we deliver care, demonstrated by the sign-up by over 400 hospitals to welcome family and carers and implement John’s Campaign for the right to stay with a person with dementia in hospital. NHS acute staff are using a range of learning resources to support them in delivering compassionate care and are working with architects and maintenance staff to make environmental improvements to busy clinical areas, although for some buildings this proves impossible. Protected mealtimes, often with volunteers specifically trained to help someone with dementia eat and drink, are now commonplace in many hospitals. Such initiatives help to avoid delirium and reduce length of stay. Challenges remain, particularly the need for more skilled staff and an understanding across all departments that dementia care is their core business. But dementia leads across the NHS continue to make changes and improve care.
Jane Buswell is an independent nurse consultant and best interest assessor
Speaking to professionals in hospitals, I hear this comment all the time: “We are an acute ward, we should not have to deal with dementia!” I’m often asked why we do not have dementia-specific wards, but the fact is that this would not be viable due to sheer numbers. Nearly 50% of people admitted to hospital have some form of confusion or a dementia. It is also important to remember that most people with dementia who are admitted to hospital actually come in because of co-morbidities. Their medical needs would be harder to meet on a dementia-specific ward. A person with pneumonia, for example, should be on a respiratory ward. The alternative to a dementia ward would be to improve dementia care throughout the hospital. This can be hard work but it is vital. It can be achieved through comprehensive dementia training, having an active dementia support team and adopting better practices that serve the whole hospital. An example of a better practice would be John’s Campaign, which allows carers and family members to stay with their loved one when admitted with dementia. This addresses concerns such as staffing levels and lack of awareness of the specific needs of a person with dementia. Dementia care is core business in health care now and we should treat it as such.
Phil Harper is a senior dementia carer in a Worcestershire care home and is a former dementia care practitioner at Hampshire NHS Foundation Trust