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

Outline

Background

Methods Geriatric Evaluation and Management Unit

(GEMU)

Results

Conclusion

2

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

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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

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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

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Persistent low function

Quality of life is better than cure.

Typical illness trajectories for

people with dementia

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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

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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.

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METHODS

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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

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Methods

Study design

Cross-sectional, chart review study

Study groups

Intervention: GEMU

Comparison: Medical wards

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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

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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.

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Interdisciplinary Team Geriatrician Neurologist Psychiatrist Physiatrist

Nurses

Social workers Case managers

Family members Dietitian

Clinical Pharmacist

PT, OT

On the same page

Sharing information

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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)

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GEMU Facilities in Taipei VGH

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Acute Wards, 35 beds

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Special designs for people with dementia

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Reminiscence therapy

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Delirium room & Light therapy room

# For safety # Group activities # Non-pharmacological approach

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Lounge

Family activities

Medical consultation

Light therapy

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Rehabilitation: PT& OT

rooms(1F)

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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

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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

27

older

male

28

29

30

Longer

Lower

31

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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.

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Results

Low rate of discussing advance directives in dementia patient who received acute medical care.

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CONCLUSION

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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

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