The challenge of person-centred acute hospital care for people living with dementia
Rowan H Harwood is a Professor at the University of Nottingham and Consultant Geriatrician at Nottingham University Hospitals NHS Trust. He is also Editor-in-Chief of the BGS journal Age and Ageing, and Tweets at @RowanHarwood.
One of the attractions of working in geriatric medicine is its breadth. ‘Physical, mental and social’, or ‘bio-psycho-social’, have long been cornerstones of the way we see the problems our patients face and the way we work to resolve them. The medical, functional, mental health, social and environmental dimensions of comprehensive geriatric assessment have attention to mental health embedded in the middle. Half of people over 70 admitted to hospital as an emergency have a cognitive disorder, and another quarter have some other mental health condition. We will meet people with mental health problems both in hospital and in community work such as hospital-at-home, intermediate care and in care homes.
Yet geriatricians are physicians. Some feel undertrained or lack confidence in mental health assessment and treatment. We are increasingly supported in hospital by liaison old age psychiatry services, but mental health cannot be wholly outsourced. We are the ones making the initial assessments, managing the crises, giving overall direction, explaining and making decisions with patients and families. Our acute hospital emergency departments, admissions units, wards and out-patient clinics, and the processes we run in them, shape the experience and sometimes the outcomes of the patients we serve. They may be the cause of decompensation, distress, deconditioning, delirium, accidents, sedation, loss of ability, prolonged hospital stay and may contribute to missed opportunities for recovery, discharge home or a good death.
Conversely, good practice can make things better. More than half of hip fracture patients have a cognitive disorder and delirium is an ever-present risk; orthogeriatrics has transformed the way this is managed. Dementia-friendly emergency departments, frailty units, wards and whole hospitals are increasingly common, if not yet universal. Specialist medical-cognitive disorder units can make a real difference.
Over the years, research on the subject has accumulated, and policy responses have been developed. There are helpful statements from the National Institute for Health and Care Excellence (NICE), the Royal College of Nursing and the Dementia Action Alliance. We have increasingly realised that helping people with cognitive disorders requires special attention and special skills. We need to know about cognitive and mental illness, how to assess and how to treat, who can help us and how to prevent delirium and distress. The overwhelming consensus is that person-centred care provides the basis for doing this but adapting and applying this in acute care can be challenging.
One problem is that person-centred care means different things to different people. In 2020, Ruth Gwernan-Jones and colleagues from the University of Exeter undertook a major review of factors that contributed to a good experience of care in hospital for people living with dementia. They concluded with a list of 12 evidence-based pointers for service change spelling out the acronym DEMENTIA CARE. Good care for people living with dementia is not the same as that for people who are cognitively intact, and our services will have to make a special and deliberate effort to make it the best it can be. We might observe, in passing, that the same features will also help other vulnerable patients, including those with intellectual disabilities and those who are dying.
Prompted by this report, the BGS Dementia and Related Disorders Special Interest Group has produced a position statement on person-centred acute hospital care for people with dementia. This covers leadership, training, working with mental health services, environment, processes, family engagement and governance. A key point is that in the acute hospital, it must be geriatricians who take the lead and ownership of this problem, working collaboratively with multidisciplinary colleagues. It is a hospital-wide problem, but, supported by our old age psychiatry colleagues, it is geriatricians who have the interest and expertise. We need the same attention to environment and processes that have successfully driven infection control initiatives in recent years.
The good news is that we have already made great strides. But there is certainly more to do. The specific components that are needed are becoming clearer. They are achievable but competing pressures and priorities will not give way easily. We urge colleagues to read the position statement and work out how the recommendations can best be implemented.