Acute care and the uncomfortable detour on the dementia pathway

We had the opportunity to pick the brains of Dr Mark Yates, Geriatrician, Director of Clinical Studies Ballarat Clinical School, Deakin University; Associate Professor, Medicine, Deakin University prior to the upcoming 4th Annual National Dementia Congress in Melbourne in February 2013.

What do you see as the main challenges and opportunities of dementia being designated a national health priority? In what ways will this change dementia care?
Opportunities – National ownership of the difficulties faced by people with dementia and their families. Until Dementia became a NHPA there was no unified approach – other chronic disease like diabetes, COAD, OA all had a common medical driving force that put them ahead now governments must show leadership and the various health professional groups will have a common purpose. The challenge will be to get agencies to realize the challenges are not insurmountable and addressing them now is only just soon enough.

What are some of the most exciting research or technological developments in the field at the moment?
Pharmacotherapy has not been the breakthrough we had hoped for. The new discovery is the ability to accurately measure the volume of Amyloid in brains and the challenging realization that this protein thought to be a key cause of AD is accumulating 15-20 years before symptoms present. We ( Geriatricians) may the modern day equivalent of the Victorian era renal physician who diagnosed renal failure by taste and smell just a year or so before death when the kidney had been failing for years beforehand. It is exciting to think that if we were to introduce new treatments to patients with confirmed amyloid accumulation in the pre-symptomatic phase we may be able to delay the conversion to symptomatic AD.

Why is it important for hospitals to provide dementia-specific care to people with dementia?
Dementia and Delirium ( I will call this Cognitive Impairment or CI) is common in hospitals occurring in about 20-30% of inpatients over 65 who occupy over 40% of multiday beds. CI is associated with increased hospital adverse outcomes such as falls. CI like visual and hearing impairment has no visual stigmata to alert staff to provide the additional support required and so care can be compromised. For vision and hearing we have addressed this in hospitals by asking patients about their impairments and providing over bed alerts when significant disability is present. Only a minority of hospitals routinely measure cognitive function (which at most takes 6 minutes) so the disability is missed and even if the staff are alerted by family or the presence of obvious impairment there is no hospital process that ensures all staff both clinical and non-clinical can provide the appropriate re-orientation and communication that can make the hospital experience less anxiety provoking and safer.

It should also be recalled that dementia, like most chronic disease, is rarely the reason for the admission and so is often ignored it the haste to treat the admission problem. It is also known the dementia is a risk factor for delirium which is known to be associated with increased in-hospital death and delirium can be avoided.

What are some of the ways that this can be achieved?
To improve care for people with CI in the acute setting all hospitals:
• should screen for CI in the patient group over 65 and when this is identified have clear hospital process to ensure
– that all staff are aware of the CI and know how to communicate appropriately – the cleaning staff, catering and porters must be included
– that carers are involved and invited to participate in the care team – the key family member is often the cognitive anchor who can provide security to an anxious dis-oriented patient

• should apply the National Quality and Safety Standards from the perspective of the person with CI – how do you avoid medication error or falls in a person with memory impairment if you do not know their memory is poor. The ACHS or equivalent should ensure the appropriate measures are in place as are now in place for appropriate screening for diabetes.

• should introduce nursing leadership roles in dementia/delirium(such as a CNC Cognition) to provide ongoing education and behavioral modeling to in the rapidly changing health workforce to ensure sustainability of any care program. The in-hospital prevalence of Diabetes is 11% and appropriately care is supported by Specialist Diabetic Nurses.

• should be provided with adequate funding to meet the challenge of care for cognitive disability as they are to meet the needs of those with physical disability. This should be a focus of the new National Independent Pricing Authority as current DRG funding does not build in these costs appropriately.

Can you briefly explain what you’ll be presenting at the upcoming Dementia Congress?
In addition to the above I will be presenting data demonstrating that care for people with CI in hospitals can be improved as shown by the Dementia Care in Hospitals Program which has been introduced into 22 hospitals in Victoria and is being re-evaluated in the private sector with the support of a BUPA Foundation Grant. The DCHP is an education and culture change program that aims to improve awareness of and communication with people with CI linked to a unique abstract graphic that is used as an over bedside alert. This program was developed at Ballarat Health Service in conjunction with AAV and people with dementia and their families.

Acute Hospitals know how to support people who are easily frightened and confused in the ward setting and they make sure the family is present to reassure and support care- they do it in pediatrics everyday and pediatric hospitals have unique additional funding to achieve this. We just need to understand a person with dementia will find the hospital environment equally frightening and confusing and meet their needs with the same empathy.

If you’d like more information on the Congress, please visit the official website here.