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Section 7 -‐ Secondary Care
Secondary care comprises the health care services provided by medical specialists and other
health professionals who generally do not have first contact with patients, for example,
psychiatrists, cardiologists, geriatricians, urologists and dermatologists.
Secondary care includes acute care, i.e. treatment for a short period of time for a brief but
serious illness, injury or other health condition, such as in a hospital Accident and Emergency
Department. It also includes skilled clinical input during childbirth, intensive care, and
medical imaging services.
The term "secondary care" is sometimes used to mean "hospital care". However, many
secondary care providers do not necessarily work in hospitals, e.g. psychiatrists, clinical
psychologists, occupational therapists or physiotherapists, and some primary care services
are delivered within hospitals. Except for most acute cases, patients in the UK are generally
required to see a primary care provider for a referral before they can access secondary care.
Secondary Care in Bradford and Airedale
Bradford and Airedale is covered by a number of hospitals and secondary care services.
From the perspective of hospital admission, it is largely the ‘acute’ hospitals (i.e. the general
hospitals) that concern us in respect of the issues outlined above, although many of them
can apply to patients who are admitted to a specialist mental health facility. In short, if a
person with dementia becomes unwell, in any number of ways, such as heart problems,
falls, respiratory illness, urinary tract infection etc., an admission, if deemed necessary,
would be to an acute/general hospital such as Bradford Royal Infirmary. Admissions to
specialist mental health facilities are often on a slightly different basis, usually crisis
admissions based on specific mental health need as opposed to acute physical health need.
There are two major acute hospitals in the Bradford area: Bradford Royal Infirmary and St
Luke's Hospital. Both are teaching hospitals and are operated by Bradford Teaching Hospitals
NHS Foundation Trust (BTHNFT). The Airedale part of the district is served by Airedale
General Hospital, part of Airedale NHS Foundation Trust (ANFT).
From a Mental Health perspective the key provider is Bradford District Care Trust which is a
provider of mental health, community health and specialist learning disability services. In-‐
patient services are delivered across two main sites:
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• Airedale Centre for Mental Health, situated on the Airedale Hospital site
• Lynfield Mount Hospital, situated on Heights Lane in Central Bradford, close to
Bradford Royal Infirmary
In the community BDCT provides a number of Adult Services which include District Nurses,
Out of Hours, Case Managers, Community Matrons.
Figure 1 below sets out the geographical location of these services across the district.
Figure 1 Distribution of Mental Health Secondary Care Providers
A = Daisy Bank, BD96RL B = Bradford Royal Infirmary, BD96RJ C = St Luke’s Hospital, BD50NA D = Lynfield Mount, BD96DP E = Airedale Hospital, BD206TD F = Airedale Centre for Mental Health, BD206PD
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Dementia and Admission to Hospital
Dementia is a challenge for hospitals. Surveys and consensus agree that around a quarter of
hospital beds are occupied by somebody with dementia, a figure which increases in older
people and individuals with a superimposed delirium (1). Currently around 40% of patients
over the age of 75 who are admitted to general hospitals have dementia, with only half
having prior diagnosis (2).
People with dementia may be repeatedly admitted to hospital because they are not
otherwise in touch with any statutory services, and their dementia means they are neither
aware of their disability nor able to ask for assistance (3).
Many admissions happen when people with dementia are unwell – but not acutely ill
enough to need the specialist care provided in acute hospitals – this can be because it is
difficult to diagnose and manage their care within A&E target times without any prior
knowledge of the person (3).
Being an inpatient in a general hospital can be detrimental to the well-‐being of a person with
dementia. It is often the case that the presence of a dementia prolongs the length of stay.
This may be because treatment can take longer, partially due to lack of staff expertise in
caring for the person with dementia (3). In addition, the presence of frailty (see Section 9 –
Comorbidities and Frailty) can complicate these admissions, as can the presence of delirium,
where the patient is acutely confused, for example as the result of infection.
Patients with dementia in acute hospitals are older, require more hours of nursing care,
have longer hospital stays, and are more at risk of delayed discharge and functional decline
during admission (4).
Inpatients with dementia are at an increased risk of crisis owing to physical health-‐related
factors, including orthopedic, respiratory, and urologic, than inpatients who do not have
dementia (5). Again, this is frequently complicated by delirium.
People with dementia in general hospitals have worse outcomes in terms of length of stay,
mortality and institutionalisation (6)
There are many factors contributing to any older person’s admission to hospital. The drivers
of variation are complex, and their relative strength varies. They include (7):
o Patient attributes
o Availability of community services
o Access to hospital services
o The way in which hospital services are managed
o Most importantly -‐ the way in which services and staff relate to each other.
4
Analysis confirms other evidence that age, deprivation and geographical access are also
major drivers of emergency bed use.
Figure 2 below, taken from a large American study, demonstrates the effect of dementia on
hospital admission graphically. The vertical red line indicates where there is no increase
effect, with blue marks to the right indicating an increased risk of admission. Where the
horizontal lines passing through the blue boxes cross the red line the effect was not
statistically significant. It is clear to see the stark effect of dementia on risk of admission to
hospital in community residents, with all subgroups showing a marked, statistically
significant effect. Although a smaller effect is seen in nursing home residents, none were
statistically significant (8).
Figure 2 Effects Of Dementia On Hospitalization And Emergency Department Use
Source: Feng, Health Affairs April 2014
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Hospital Admissions for Dementia Patients in Bradford and Airedale
Admissions by CCG
Table 1 and Figure 3 below show the numbers of patients with dementia who are admitted
to hospital every year (primary and secondary diagnoses) from 2009 to 2013, broken down
by the CCG with which they are registered. Bradford Districts CCG shows a slight rise from
2009 to 2012 but then a downward tail off in 2013. AWCCG shows a notable rise between
2011 and 2012 which levels off as it reaches 2013. The apparent year on year increase in the
proportion of patients from Craven within AWCCCG has the appearance of statistical
artefact and is likely due to changes in coding practice. Bradford City CCG slows a steady
yearly number which is significantly lower than the other two CCGs. The overall picture
across the District is of a rising trend up to 2012 which tails off into 2013. Clearly the most
important characteristics of these figures are the rising numbers observed in BDCCG and
AWCCG, although the tail off in 2013 is encouraging.
Table 1 Patients with Dementia admitted to Hospital, by CCG, 2009-‐2013
CCG 31/03/2009 31/03/2010 31/03/2011 31/03/2012 31/03/2013 Grand Total
AWCCCG 385 412 512 840 908 3057
AWCCG 382 395 491 570 600 2438
BCCCG 304 288 299 307 302 1500
BDCCG 1523 1686 1722 1930 1868 8729
Grand Total 2212 2386 2533 3077 3078 13286
YEAR
Figure 3 Patients with Dementia admitted to Hospital, by CCG, 2009-‐2013
0
500
1000
1500
2000
2500
3000
3500
2009 2010 2011 2012 2013
Adm
issi
ons
Year
AWCCCG
AWCCG
BCCCG
BDCCG
Grand Total
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Admissions by Hospital Trust
Table 2 and Figure 4 below show the numbers of patients with dementia who are admitted
to hospital every year (primary and secondary diagnoses) from 2009 to 2013, broken down
by the hospital to which they are admitted. Both acute trusts show a general upward trend,
although again there is a clear tailing off over 2012-‐2013, particularly at BTHFT, this being
reflected in the total figures for the district. The numbers admitted to BDCT remain steady
and low, which is to be expected given the nature of these admissions as explained above.
Table 2 Patients with Dementia admitted to Hospital, by Trust, 2009-‐2013
2009 2010 2011 2012 2013 TOTAL
ANFT 439 475 595 890 968 3367
BDCT 43 70 37 79 86 315
BTHFT 1730 1842 1901 2106 2026 9605
Total 2212 2387 2533 3075 3080 13287
Figure 4 Patients with Dementia admitted to Hospital, by Trust, 2009-‐2013
0
500
1000
1500
2000
2500
3000
3500
2009 2010 2011 2012 2013
Year
Admissions
ANFT
BDCT
BTHFT
Total
Admissions by Gender
The general larger prevalence of dementia in females (see Section 2 – Epidemiology) would
lead us to expect larger numbers of admissions in females and this is reflected in table 3 and
figure 5 below, which show the numbers of patients with dementia who are admitted to
hospital every year from 2009 to 2013, broken down by gender. There is no discernible
7
difference in pattern of change in numbers over the time period, suggesting that there is no
gender effect influencing admissions.
Table 3 Patients with Dementia admitted to Hospital, by Gender, 2009-‐2013
2009 2010 2011 2012 2013 TOTAL
Male 825 913 981 1203 1233 5155
Female 1387 1474 1552 1872 1847 8132
Total 2212 2387 2533 3075 3080 13287
Figure 5 Patients with Dementia admitted to Hospital, by Trust, 2009-‐2013
0
500
1000
1500
2000
2500
3000
3500
2009 2010 2011 2012 2013
Adm
issi
ons
Year
Male
Female
Total
Admissions by Ethnicity
Section 3 – Ethnicity, outlines several factors which can lead to people from BME groups
having poor access to services and tending to present less and in crisis. These factors might
be expected to lead to both underrepresentation in hospital admission figures (e.g. due to
lack of knowledge of available services) or to overrepresentation due to increasing likelihood
of presenting in crisis.
Table 4 and figure 6 below set out a breakdown of hospital admissions (primary and
secondary diagnoses) for the hospital trusts, by ethnicity. South Asian groups are appended
at the bottom of table 4 for comparison (note -‐ Bangladeshi and any other Asian have been
merged as numbers are very small when disaggregated).
8
Three are three major groups observed:
• British – this group shows a steady rise with a slight tail off at 2013
• Pakistani – this group shows a steady rise sustained through to 2013
• Any Other White Background – this group shows a gradual rise through the five
years, potentially due to rising of numbers of people from Central and Eastern
Europe settling in the district.
Table 4 Ethnicity of Dementia Admissions, BTHFT + ATHNFT + BDCT 2009-‐2013
Ethnic Group 2009 2010 2011 2012 2013
British 1765 1955 2083 2478 2524
Irish 19 22 17 20 17
Any Other White Background 173 169 174 223 219
Pakistani 77 90 76 114 131
Indian 21 28 28 32 25
Bangladeshi + Any other Asian 7 6 5 5 10
White/Black Caribbean/African + Other Black 10 17 15 15 16
Others 9 20 15 24 18
Not Given 29 33 59 86 68
Not Stated 102 47 61 80 52
2212 2387 2533 3077 3080
Pakistani 77 90 76 114 131
Indian 21 28 28 32 25
Bangladeshi + Any other Asian 7 6 5 5 10
Total 105 124 109 151 166
% Total Admissions 4.7% 5.2% 4.3% 4.9% 5.4%
A key observation in light of comments above is that the proportion of admissions from the
South Asian community is consistently well below the district proportion made up of people
from this group, which is ~20%.
Although this is not adjusted for other factors such as age and deprivation status it is clearly
a significant observation and preliminary discussions at the Dementia Strategy Group have
identified this as an area that merits further investigation and that may provide important
information about how dementia is managed within the South Asian community.
9
Length of Stay
People with dementia stay far longer in hospital than other people who go in for the same
procedure. The longer people with dementia are in hospital, the worse the effect on the
symptoms of dementia and the individual’s physical health; discharge to a care home
becomes more likely and antipsychotic drugs are more likely to be used. In addition, as well
as the cost to the person with dementia, increased length of stay is placing financial pressure
on the NHS (9). Again, delirium is often a key factor in prolonging length of stay.
People with dementia having longer lengths of stay in hospital than expected is supported in
the research literature (10,11,12).
The two most common reasons for a person with dementia being admitted to hospital have
been reported as suffering a fall and having a hip-‐related condition (9, 13). These are also the
conditions found to have the longest reported length of stay. (UTI, chest infection and
stroke/TIA were found to be the next most common reasons for admission).
Research based on the perceptions of carer and nurse respondents, also suggests that the
longer people with dementia are in hospital (9):
• The worse the effect on the symptoms of dementia and physical health
• Discharge to a care home becomes more likely
• The more antipsychotics are likely to be used
Care of people with dementia on a hospital ward is more costly than the average cost for
people who are admitted to hospital for a similar medical condition. Reducing length of stay
in hospital is therefore a key issue to address, as this will save costs.
Bradford and Airedale context
Table 5 and Figure 6 below set out average length of stay in hospital for people with
dementia, by CCG, from 2009 to 2013. The most striking observation is the steady
downward trend in patients from AWCCG and AWCCCG. BCCCG showed a steady rise up to
2011 and then demonstrates a sharp downward trend to 2012. In 2012 there is a general
merging of length of stay across all CCGs to between 7.5 and 10 days length of stay, with all
three CCGs then showing a rise in the following year.
The total average length of stay across the district shows a steady decline down to 2012, and
then a rise to reflect the CCG figures commented upon above.
10
Table 5 Average Length of Stay in Days, by CCG 2009-‐13, all Providers
AWCCG AWCCG BCCCG BDCCG Total
2009 19.09 19.20 10.57 8.71 10.77
2010 14.56 13.80 12.25 8.79 10.22
2011 11.71 11.30 13.60 7.65 9.21
2012 9.53 9.10 9.92 7.94 8.58
2013 10.88 9.80 12.82 8.73 9.78
2009-2013 12.18 12.64 11.82 8.35 9.63
Figure 6 Average Length of Stay in Days, by CCG 2009-‐13, all Providers
0.00#
5.00#
10.00#
15.00#
20.00#
25.00#
2009# 2010# 2011# 2012# 2013# 2009)2013#
Days%
Year%
AWCCG#
AWCCG#
BCCCG#
BDCCG#
Total#
Table 5 and Figure 6 below set out average length of stay in hospital for people with
dementia, by acute trust, from 2009 to 2013. The striking high length of stay at BDCT
represents the clinical nature of the patients who are admitted there (i.e. more likely to be
crisis admissions for prescribed mental health care as opposed to emergency admissions
with acute physical health problems). Following a peak in 2010, average length of stay at
BDCT has fallen steadily to 55 days. The three acute trusts show a relatively unremarkable
pattern, with little to suggest that there has been any systematic change in average length of
stay, in contrast with the CCG effects observed above.
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Table 6 Average Length of Stay, in Days, by Provider 2009-‐13, all CCGs
AHNFT BDCT BTHFT Total
2009 10.36 58.09 7.65 9.17
2010 11.81 68.53 7.11 9.84
2011 10.08 58.73 7.41 8.79
2012 8.30 55.04 6.50 8.27
2013 10.52 54.81 7.00 9.44
2009-2013 10.02 58.83 7.11 9.07
Figure 7 Average Length of Stay, in Days, by Provider 2009-‐13, all CCGs
0.00#
10.00#
20.00#
30.00#
40.00#
50.00#
60.00#
70.00#
80.00#
2009# 2010# 2011# 2012# 2013#
Average'Length'of'Stay,'by'Provider'200982013,'all'CCGs'
AHNFT#
BDCT#
BTHFT#
Total#
Hospital Discharge
People with dementia can often need further long-‐term help after leaving hospital, and
some may move into a care home. Others need support in their own home or in the home of
a relative or friend. Hospital discharge assessment might also take into account whether the
patient will benefit from intermediate care. Intermediate care could include a stay in a
residential rehabilitation unit to regain confidence or nursing and care services to support
the person when they first go home after a hospital stay. Intermediate care services can be
provided in the person’s home, a care home, or a day centre or day hospital.
An important factor to consider in light of discussion on the impact of increased length of
stay discussed above is that, for people with dementia, discharge from hospital can be
delayed by lack of alternatives (13)
12
In 2009, the Alzheimer’s Society undertook a research survey in conjunction with the Royal
College of Psychiatrists called the DEMHOS survey which looked specifically at people with
dementia in General Hospital wards (9). The DEMHOS research shows that there is an
increased likelihood of being discharged to a care home following a stay in hospital in
dementia patients. The data show that over a third of people who enter hospital from their
own home go into a care home, though as can be seen below, local figures are lower than
this. 60% of people with dementia in the DEMHOS research entered hospital from their own
home and this was reduced to 36%returning to their own home. Table 7 below sets out the
DEMHOS figures.
Table 7 DEMHOS data -‐ Person with dementia’s place of residence before and after
entering hospital as reported by carer respondent
Place&of&residence&before&hospital Place&of&residence&after&hospital
Care&home 33% 42%
Own&home 60% 36%
Other 1% 6%
Not&applicable N/A 9%
Place&of&residence&response&options
Proportion&of&carer&respondents&giving&response
Bradford and Airedale Context
Figure 8 below shows the place of discharge for patients with dementia, across all hospitals,
from 2009-‐13. Clearly the majority of discharges have consistently been to the patient’s
usual place of residence, followed by non-‐NHS care homes and inpatient wards.
Figure 9 below this focuses on the most common places of discharge over the time period
2009-‐13. The key observation is the reciprocal relationship between that the proportion of
discharges to usual place of residence and those to non-‐nhs care homes. This suggests that
the majority of discharges depend on the factors and dynamics determining suitability for
one of these two and that the majority of final discharge decisions are made on this basis.
(Note – these data are available by acute trust but for the sake of brevity aggregate figures
are presented here)
13
Figure 8 Place of Discharge for patients with Dementia, all Hospitals, 2009-‐13
0"
500"
1000"
1500"
2000"
2500"
3000"
3500"
2009" 2010" 2011" 2012" 2013"
Num
ber'
Year'
Not"Known"
Non.NHS"Run"Hospital"
LA"Part"3"Residen>al"Accommoda>on"
Ward"For"Pa>ents"Who"Are"Mentally"Ill"
Temporary"Place"Of"Residence"
Non.NHS"Run"Hospice"
Not"Finished"At"Episode"End"
NHS"Run"Nursing"Home"
Ward"For"General"Pa>ents"
Pa>ent"Died"Or"S>llBirth"
Non.NHS"Run"Residen>al"Care"Home"
Usual"Place"Of"Residence"
Discharge"Des>na>on"
Figure 9 Selected Places of Discharge for patients with Dementia, all Hospitals, 2009-‐13
0"
0.1"
0.2"
0.3"
0.4"
0.5"
0.6"
0.7"
0.8"
2009" 2010" 2011" 2012" 2013" Grand"Total"
%"of"T
otal"
Year"
Discharge"Des=na=on"
Usual"Place"Of"Residence"
NonENHS"Run"Residen=al"Care"Home"
Pa=ent"Died"
Ward"For"General"Pa=ents"
NHS"Run"Nursing"Home"
Not"Finished"At"Episode"End"
Dementia Diagnosis in Secondary Care
The Commissioning for Quality and Innovation (CQUIN) is a payment framework that
enables commissioners to reward excellence, by linking a proportion of English healthcare
providers' income to the achievement of local quality improvement goals. They were first
introduced in 2009/10 and last year the national dementia CQUIN was introduced.
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The National Dementia CQUIN aims to help identify patients with dementia and other
causes of cognitive impairment, alongside their other medical conditions and to prompt
appropriate referral and follow up after they leave hospital.
The CQUIN has three main aims:
1. Identifying people with dementia – members of staff will ask members of the family
or friends of a person admitted to hospital if the patient has suffered any problems
with their memory in the last 12 months
2. Assess people with dementia – if there is evidence to suggest a problem with their
memory, that person will be given a dementia risk assessment
3. Refer on for advice – a referral would be made for further support either to a liaison
team, a memory clinic or a GP.
The Dementia CQUIN data is collected by NHS England and reports on the number and
proportion of patients aged 75 and over, who were admitted to hospital as an emergency
for more than 72 hours who have been identified as potentially having dementia, who are
assessed and, where appropriate, referred to specialist services. This report presents the
year-‐to-‐date of data from the NHS England's data collection. All providers of NHS-‐funded
acute care are required to return data, and the collection has been mandatory since April
2013. Both acute trusts in Bradford and Airedale have collected these figures and submitted
them to NHS England. The results are summarised below.
Aim 1. Identifying people with dementia – members of staff will ask members of the family
or friends of a person admitted to hospital if the patient has suffered any problems with
their memory in the last 12 months.
Trust No. cases identified No. of emergency admissions % identified
ANFT 1934 2333 82.90%
BTHNFT 2878 2878 100%
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Aim 2 -‐ Assess people with dementia – if there is evidence to suggest a problem with their
memory, that person will be given a dementia risk assessment
Trust No. of cases with diagnostic assessment
No. of cases with positive case finding question % diagnosed
ANFT 367 503 73%
BTHNFT 47 47 100%
Aim 3 -‐ Refer on for advice – a referral would be made for further support either to a liaison
team, a memory clinic or a GP
Trust No. of cases referred
No. of cases with positive or inconclusive diagnostic
assessment
% of cases referred
ANFT 13 13 100%
BTHNFT 47 47 100%
The key significance of these numbers in terms of planning services is the addition of a
systematic secondary care referral process into memory assessment services. Currently
these figures suggest an additional 60 patients per year. This is not an insignificant number,
given the numerous tests and interventions that may be required in order to formalise
diagnosis and dementia subtype and to initiate appropriate management and follow up.
(Note – the updated 2014/15 CQUIN for dementia includes an assessment for delirium as
part of the tariff).
What does this mean for Bradford and Airedale? This section has raised a number of key questions regarding people with dementia and
secondary care across the district. For example:
• How can the transition to admission to BDCT on mental health grounds be managed
without the need for a crisis with actual aggression to occur?
• Is admission to acute medical care sometimes pursued because the most appropriate
option is hard to access out-‐of-‐hours?
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• The CQUIN process seems to significantly underrepresent the actual prevalence of
dementia in patients admitted to hospital, which raises the issue of whether it is working
effectively for the district and what the impact on MATS services would be if diagnosis
rates were higher
Recommendations
• Commissioners should continue to work with secondary care providers and
hospitals, to ensure that admissions to hospital become short-‐term departures from
community care pathways, rather than pathways in themselves
• Priority should be given to agreeing jointly owned integrated discharge planning
processes and pathways, working with patients, carers and local integrated care
teams
• The Dementia Strategy Group should oversee a short, time limited focused piece of
work on making the CQUIN process work for Bradford rather for the "system" –
maybe we could look at the tool they are using?
• The Dementia Strategy Group should oversee a focused piece of work, in
partnership with Meri Yaadain, to better understand the reasons that determine
when and why South Asian people with dementia are admitted to secondary care
• The School of Dementia Studies at Bradford University should be approached to
discuss analysis of the cohort of patients who are admitted to BDCT, as this may
provide valuable insights into the dynamics of the relationship between community-‐
based mental health care and reasons for admission
• Work should be undertaken with local clinicians to better understand the
relationship between dementia and delirium, particularly its impact on
commissioned services, and the measures that can be taken to both improve quality
of life for people with dementia and their carers, and to reduce costs.
REFERENCES
1. Who Cares Wins -‐ Improving the Outcome for Older People admitted to the General
Hospital. Royal College of Psychiatrists 2005.
2. Commissioning for Quality and Innovation 2013/14. Department of Health. 2012.
3. Living well with dementia: A National Dementia Strategy. Joint Commissioning
Framework. Department of Health 2009.
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4. Mukadam N, Sampson EL. A systematic review of the prevalence, associations and
outcomes of dementia in older general hospital inpatients. Int Psychogeriatr. 2010
Aug 18;23(03):344–55.
5. Toot S, Devine M, Akporobaro A, Orrell M. Causes of Hospital Admission for People
With Dementia: A Systematic Review and Meta-‐Analysis. Journal of the American
Medical Directors Association. 2013 Jul;14(7):463–70.
6. Living well with dementia: A National Dementia Strategy. Department of Health
2009
7. Older people and emergency bed use -‐ Exploring variation King’s Fund 2012.
8. Feng Z, Coots LA, Kaganova Y, Wiener JM. Hospital And ED Use Among Medicare
Beneficiaries With Dementia Varies By Setting And Proximity To Death. Health
Affairs. 2014 Apr;33(4):683–90.
9. Counting The Cost -‐ Caring for people with Dementia on Hospital Wards. Alzheimer’s
Society 2009.
10. Holmes J, House A. Psychiatric illness predicts poor outcome after surgery for hip
fracture: a prospective cohort study. Psychol Med. 2000 Jul;30(4):921–9.]
11. Savaray, S., Kaplowitz, M., Kurek, J. et al (2004). How do delirium and dementia
increase length of stay of elderly general medical patients? Psychosomatics, 45,
235–242.
12. King B, Jones C, Brand C. Relationship between dementia and length of stay of
general medical patients admitted to acute care. Australasian Journal on Ageing.
Wiley Online Library; 2006;25(1):20–3.
13. Improving services and support for people with dementia. Report by the
Comptroller and Auditor General. National Audit Office 2007.