Quality of Acute Care for Older
Persons with Dementia
A Hospital-Based Pilot Study
Chien-Liang Liu Center for Geriatrics and Gerontology, Taipei
Veterans General Hospital, Taiwan
2013/04/20
Background
40% of acute general medical admissions over the age of 70 have dementia.
Sampson EL, et al. Brit J Psych. 2009
Hospital presentations also include sudden worsening of confusion or dependency, or functional crisis such as falls.
3
Background
Family members and carers of people with dementia are frequently dissatisfied with their experience of hospital care
staff not recognizing or understanding dementia
lack of activity and social interaction
inadequate involvement in decision making
perceived lack of dignity and respect London: Alzheimer’s Society. 2009
4
Background
Hospital stay for people with dementia is longer than for those with similar primary diagnoses but without co-morbid dementia.
Sampson EL, et al. Brit J Psych. 2009
Admission can be very prolonged: in England 10% of people with dementia stay in hospital for more than 50 days.
Royal College of Psychiatrists. London: RCPsych. 2011
5
Background
The comprehensive geriatric assessment (CGA) is the validated and recommended instrument to a correct evaluation and decision making in elderly patients.
Riccio D, et al. Arch Gerontol Geriatr. 2007
In-patient CGA may reduce short-term mortality, increase the chances of living at home at one year, and improve physical and cognitive function. However, CGA dose not reduce long-term mortality.
Ellis G, Langhorne P. Br Med Bull 2005
6
Persistent low function
Quality of life is better than cure.
Typical illness trajectories for
people with dementia
7
Scott A M, et al. BMJ. 2005
Background
Dementia in the acute hospital is different. The problems of people with dementia take longer to solve and need more assessment to figure out the current mental and physical status.
Rowan H Harwood. Clinical medicine. 2012
8
Objectives
We try to design a new acute care model for older people with dementia and performed a pilot study to show the preliminary results.
9
Methods
Participants
Inclusion criteria
People with dementia
Aged 65 years and over
Admitted to GEMU or medical wards
Exclusion criteria
Elective admission
Transferred to surgical ward in the target admission
11
Methods
Study design
Cross-sectional, chart review study
Study groups
Intervention: GEMU
Comparison: Medical wards
12
Acute care model for dementia in
Taipei VGH
GEMU in Taipei VGH
35-bed acute care unit
Diagnosis of dementia: 27%
CGA based services
Chang-Cieng Building
13
CGA based acute care model
for people with dementia
Home Outpatient
Functional assessment
Ou
t-pa
tien
t serv
ices
Admitted
Acute illness
Quick assessment
Cognition, delirium
Functional recovery (rehabilitation)
No restrain (physical or chemical)
Medical and care consultation
No
Yes
Decline or not
Comprehensive geriatric
assessment(CGA) 1. Screening 2. Diagnosis 3. Treatment
4. Evaluate the treatment outcome
14
Comprehensive Geriatric assessment like interventions
Most intensive Least intensive
Setting CGA, GEM, and rehabilitation units
CGA consultation impatient or outpatient
Community-based and in-home outreach programs
Targeting Most restrictive Least restrictive
Process Large team, extensive evaluations
Screening and referral
Cost Very expensive Relatively inexpensive
CGA, comprehensive geriatric assessment; GEM, geriatric evaluation and management
Hazzard's Geriatric Medicine & Gerontology, 6th Ed.
15
Interdisciplinary Team Geriatrician Neurologist Psychiatrist Physiatrist
Nurses
Social workers Case managers
Family members Dietitian
Clinical Pharmacist
PT, OT
On the same page
Sharing information
16
CGA in Taipei VGH
Cognitive assessment(MMSE, CASI, CDR)
Mobility assessment(fall risk)
Delirium(Confusion Assessment Method, CAM)
Depression(Geriatric Depression Scale, GDS 5)
Nutritional assessment
ADL, IADL
Medication review(antipsychotics, anticholonergics)
17
22
Delirium room & Light therapy room
# For safety # Group activities # Non-pharmacological approach
22
Methods
Interesting variables
Basic demographic data
Cognitive function: MMSE
Reason of admission
Quality indicators
Acute Care for Vulnerable Elders (ACOVE)
NICE guideline
Focus on current situation in Taiwan
25
Methods
Quality indicators of acute care for older persons with dementia Regular cognitive assessment Mobility assessment Delirium screening Depression screening Nutritional assessment Caregiver support Advanced care plan Medication review
Antipsychotics, anticholinergics Symptomatic treatment: Cholinesterase inhibitor, NMDA
antagonist 26
Results
Infection(pneumonia and UTI) and geriatric syndrome were the major causes of admissions to hospital.
In GEMU services, older patient, longer stay, lower prescribing rate of antipsychotics.
Higher rate of screening for cognitive function, delirium, depression, nutritional status under the CGA based services.
33
Results
Low rate of discussing advance directives in dementia patient who received acute medical care.
34
Conclusion
CGA based GEMU services can improve the quality of acute care for people with dementia.
How to implant the concept of palliative care in acute care services is challenging in Taiwan.
36
References
Sampson EL, Blanchard MR, Jones L, Tookman A, King M. Dementia in the acute hospital: prospective cohort study of prevalence and mortality. Brit J Psych 2009;195:61–6.
Alzheimer’s Society. Counting the cost . London: Alzheimer’s Society, 2009.
Royal College of Psychiatrists. National audit of dementia in general hospitals. Interim report. London: RCPsych, 2011.
Riccio, D., et al., Comprehensive geriatric assessment in female elderly patients with Alzheimer disease and other types of dementia. Arch Gerontol Geriatr, 2007. 44 Suppl 1: p. 343-53.
Ellis, G. and P. Langhorne, Comprehensive geriatric assessment for older hospital patients. Br Med Bull, 2004. 71: p. 45-59
Murray, S.A., et al., Illness trajectories and palliative care. BMJ, 2005. 330(7498): p. 1007-11.
Rowan H Harwood. Clinical medicine 2012; 12: 35-9
37