'Not orientated to time or place'...'confused'...'known dementia'...Seeing these phrases on a clerking sheet may well make a hospital doctor's heart sink. They often signify a long list of upcoming difficulties - the patient will probably be unable to give a history or describe their symptoms, may be unwilling to be examined and could even be aggressive. Cognitive impairment has a significant prevalence (1) in a hospital setting can pose problems for patients, relatives and hospital staff. The unfamiliar, noisy environment of a busy ward adds to the distress and agitation of people with dementia or delirium, increasing their risk of accidents such as falls and sometimes leading to challenging behaviour such as wandering and shouting, which can disturb other patients and upset patients' relatives and friends.
Health care professionals are often unsure how to deal with these patients. Sometimes staff don't make any attempt to communicate with them, assuming they won't be able to impart any clinically useful information at all. Doctors often resort to using sedating medication, such as benzodiazepines, neuroleptics and Z-drugs, to keep patients quiet. This approach has multiple disadvantages for patients - sedative drugs can have very unpleasant side effects (2,3) and have been shown to increase the risk of death.
In reality, challenging behaviour can often be improved by simple measures which address the cause of the patient's agitation. As cognitively impaired patients are often unable to communicate their symptoms, they are less likely to receive simple but important treatments such as pain relief. There is evidence that paracetamol can be just as effective as antipsychotic medication at dealing with challenging behaviour, indicating that much of the agitation exhibited by confused patients arises from untreated pain.(4) Simple measures can vastly improve a patient's quality of life - these could be prescribing paracetamol even if the patient has not stated they are in pain, ensuring regular nutrition and hydration is given, checking that bowel charts are regular and making the environment as calm as possible and free from obstacles which could cause the patient to fall. Liaising with families and carers is paramount - the people who know the patient best possess vast amounts of crucial information about how the patient usually behaves, their likes and dislikes and effective ways to calm them.
But what is the best way to ensure that patients with cognitive impairment get the optimum standard of care that any of us would expect for ourselves during a hospital admission? Hospitals in Nottingham5 and Wolverhampton (6) have introduced specialised wards for patients with delirium and dementia. Features of these units include trained mental health staff, environmental modifications such as clear signposting to the bathroom, a proactive attitude to the inclusion of carers and relatives and a higher nurse to patient ratio than that of general medical wards. Other methods for improving the care of patients with cognitive impairment include training days for hospital staff and the use of a care bundle (a set of interventions which, when used together, have been shown to improve outcomes for patients with a particular condition (7)) to guide the management of patients with dementia.(8)
The idea of having special wards for patients with a particular type of clinical problem is in line with the evidence that stroke patients have better long term outcomes if they are treated in specialist stroke units.(9,10) A randomised controlled trial comparing patients treated on the specialist dementia and delirium unit with cognitively impaired patients receiving standard care on general medical wards was recently carried out in Nottingham, to see whether the specialist unit had achieved comparable benefits. The study did not find any significant differences between the two groups in terms of mortality or readmission rates, but the results came down in favour of the specialist ward in terms of patients' moods and levels of engagement and family carer satisfaction. The authors argue that these factors are just as important as conventional health indicators in the study population, who are usually very frail and often nearing the end of life.(11) Management of these patients can be fraught with difficult decisions, and input from those who know them best is crucial to help staff obtain as much information as possible and ensure that those who will have to deal with the outcomes are involved in the decision making. With this in mind, the improved levels of family satisfaction are encouraging, and the patients' improved moods suggest they had a better quality of life on the specialist ward than they would have done on a general ward.
Specialist delirium and dementia wards are still a new initiative and there is much more research still to be carried out in terms of their effectiveness. However, even if every hospital establishes a specialist ward, it can never be guaranteed that every confused patient can be allocated a bed on the ward, and therefore this can only be part of the solution. In order to reduce challenging behaviour and improve the hospital experiences of cognitively impaired patients and their neighbours on the ward, all health care professionals must be aware of the most effective ways to manage patients with delirium and dementia.
1. Who Cares Wins - Royal College of Psychiatrists Jan 2005 accessed 10/8/13 at http://www.rcpsych.ac.uk/pdf/whocareswins.pdf
2. Royal College of Psychiatry website accessed 10/8/13 at http://www.rcpsych.ac.uk/expertadvice/treatmentswellbeing/antipsychoticm...
3. Benzodiazepines and Z-drugs - Bupa UK accessedn10/8/13 at http://www.bupa.co.uk/individuals/health-information/directory/b/benzodi....
4. Husebo B, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ 2011;343:d4065.
5. Harwood RH. Improving the care of people with dementia in acute general hospital wards accessed 10/8/13 at http://nottingham.ac.uk/mcop/documents/dementias-2012-harwood.pdf
6. NHS Local website accessed 10/8/13 at http://www.nhslocal.nhs.uk/story/new-cross-hospital-pioneers-care-people....
7. McCarron, Kim MS, CRNP. Understaanding care bundles. Accessed 10/8/13 at http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2011/03000/Un...
8. Brooker D, Leung D, Bowley K, Etches C, Bray J, Smith P et al. The Dementia Care Bundle
Improving the quality and safety of hospital care
for patients with acute physical illness who have
co-existing dementia. Accessed 10/8/13 at http://patientsafety.health.org.uk/sites/default/files/resources/the_dem...
9. Chan DK, Cordato D, O'Rourke F, Chan DL, Pollack M, Middleton S, Levi C. Comprehensive stroke units: a review of comparative evidence and experience. Int J Stroke. 2013 Jun;8(4):260-4
10. Langhorne P. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ 1997;314:1151
11. Harwood RH et al. Care in specialist medical and mental health unit compared with standard care for older peoplee with cognitive impairmentadmitted to general hospital: randomsed controlled trial (NIHR TEAM trial). BMJ 2013;347:f4132 doi: 10.1136/bmj.f4132
Rapid Response:
Re: Frontotemporal dementia
'Not orientated to time or place'...'confused'...'known dementia'...Seeing these phrases on a clerking sheet may well make a hospital doctor's heart sink. They often signify a long list of upcoming difficulties - the patient will probably be unable to give a history or describe their symptoms, may be unwilling to be examined and could even be aggressive. Cognitive impairment has a significant prevalence (1) in a hospital setting can pose problems for patients, relatives and hospital staff. The unfamiliar, noisy environment of a busy ward adds to the distress and agitation of people with dementia or delirium, increasing their risk of accidents such as falls and sometimes leading to challenging behaviour such as wandering and shouting, which can disturb other patients and upset patients' relatives and friends.
Health care professionals are often unsure how to deal with these patients. Sometimes staff don't make any attempt to communicate with them, assuming they won't be able to impart any clinically useful information at all. Doctors often resort to using sedating medication, such as benzodiazepines, neuroleptics and Z-drugs, to keep patients quiet. This approach has multiple disadvantages for patients - sedative drugs can have very unpleasant side effects (2,3) and have been shown to increase the risk of death.
In reality, challenging behaviour can often be improved by simple measures which address the cause of the patient's agitation. As cognitively impaired patients are often unable to communicate their symptoms, they are less likely to receive simple but important treatments such as pain relief. There is evidence that paracetamol can be just as effective as antipsychotic medication at dealing with challenging behaviour, indicating that much of the agitation exhibited by confused patients arises from untreated pain.(4) Simple measures can vastly improve a patient's quality of life - these could be prescribing paracetamol even if the patient has not stated they are in pain, ensuring regular nutrition and hydration is given, checking that bowel charts are regular and making the environment as calm as possible and free from obstacles which could cause the patient to fall. Liaising with families and carers is paramount - the people who know the patient best possess vast amounts of crucial information about how the patient usually behaves, their likes and dislikes and effective ways to calm them.
But what is the best way to ensure that patients with cognitive impairment get the optimum standard of care that any of us would expect for ourselves during a hospital admission? Hospitals in Nottingham5 and Wolverhampton (6) have introduced specialised wards for patients with delirium and dementia. Features of these units include trained mental health staff, environmental modifications such as clear signposting to the bathroom, a proactive attitude to the inclusion of carers and relatives and a higher nurse to patient ratio than that of general medical wards. Other methods for improving the care of patients with cognitive impairment include training days for hospital staff and the use of a care bundle (a set of interventions which, when used together, have been shown to improve outcomes for patients with a particular condition (7)) to guide the management of patients with dementia.(8)
The idea of having special wards for patients with a particular type of clinical problem is in line with the evidence that stroke patients have better long term outcomes if they are treated in specialist stroke units.(9,10) A randomised controlled trial comparing patients treated on the specialist dementia and delirium unit with cognitively impaired patients receiving standard care on general medical wards was recently carried out in Nottingham, to see whether the specialist unit had achieved comparable benefits. The study did not find any significant differences between the two groups in terms of mortality or readmission rates, but the results came down in favour of the specialist ward in terms of patients' moods and levels of engagement and family carer satisfaction. The authors argue that these factors are just as important as conventional health indicators in the study population, who are usually very frail and often nearing the end of life.(11) Management of these patients can be fraught with difficult decisions, and input from those who know them best is crucial to help staff obtain as much information as possible and ensure that those who will have to deal with the outcomes are involved in the decision making. With this in mind, the improved levels of family satisfaction are encouraging, and the patients' improved moods suggest they had a better quality of life on the specialist ward than they would have done on a general ward.
Specialist delirium and dementia wards are still a new initiative and there is much more research still to be carried out in terms of their effectiveness. However, even if every hospital establishes a specialist ward, it can never be guaranteed that every confused patient can be allocated a bed on the ward, and therefore this can only be part of the solution. In order to reduce challenging behaviour and improve the hospital experiences of cognitively impaired patients and their neighbours on the ward, all health care professionals must be aware of the most effective ways to manage patients with delirium and dementia.
1. Who Cares Wins - Royal College of Psychiatrists Jan 2005 accessed 10/8/13 at http://www.rcpsych.ac.uk/pdf/whocareswins.pdf
2. Royal College of Psychiatry website accessed 10/8/13 at http://www.rcpsych.ac.uk/expertadvice/treatmentswellbeing/antipsychoticm...
3. Benzodiazepines and Z-drugs - Bupa UK accessedn10/8/13 at http://www.bupa.co.uk/individuals/health-information/directory/b/benzodi....
4. Husebo B, Ballard C, Sandvik R, Nilsen OB, Aarsland D. Efficacy of treating pain to reduce behavioural disturbances in residents of nursing homes with dementia: cluster randomised clinical trial. BMJ 2011;343:d4065.
5. Harwood RH. Improving the care of people with dementia in acute general hospital wards accessed 10/8/13 at http://nottingham.ac.uk/mcop/documents/dementias-2012-harwood.pdf
6. NHS Local website accessed 10/8/13 at http://www.nhslocal.nhs.uk/story/new-cross-hospital-pioneers-care-people....
7. McCarron, Kim MS, CRNP. Understaanding care bundles. Accessed 10/8/13 at
http://journals.lww.com/nursingmadeincrediblyeasy/Fulltext/2011/03000/Un...
8. Brooker D, Leung D, Bowley K, Etches C, Bray J, Smith P et al. The Dementia Care Bundle
Improving the quality and safety of hospital care
for patients with acute physical illness who have
co-existing dementia. Accessed 10/8/13 at http://patientsafety.health.org.uk/sites/default/files/resources/the_dem...
9. Chan DK, Cordato D, O'Rourke F, Chan DL, Pollack M, Middleton S, Levi C. Comprehensive stroke units: a review of comparative evidence and experience. Int J Stroke. 2013 Jun;8(4):260-4
10. Langhorne P. Collaborative systematic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ 1997;314:1151
11. Harwood RH et al. Care in specialist medical and mental health unit compared with standard care for older peoplee with cognitive impairmentadmitted to general hospital: randomsed controlled trial (NIHR TEAM trial). BMJ 2013;347:f4132 doi: 10.1136/bmj.f4132
Competing interests: No competing interests