Chapter 11
Dementia in the Acute Hospital
Introduction
At any time, a quarter of people in hospital will have dementia, and for over half of these patients, dementia will not have been diagnosed. The demographic change that is occurring in the community is reflected in the admissions to hospital. According to the Dementia Action Alliance 2013, there are currently 800,000 people living with dementia in the UK, and this number is expected to rise to over one million by 2025. The current financial cost of dementia to the UK is over £23 billion a year.
This chapter deals with the experiences of people with dementia in hospital, the challenges they and the hospital services may face, and how this very important area of health care can and must be improved.
Challenges to the person with dementia
Coming into hospital can be a bewildering and distressing time for anyone. These feelings become more intense for a person with impaired ability to remember, understand or communicate. The first 48 hours of an admission may involve several changes of location – from A+E, to an assessment unit to a ward, as well as trips to other departments for tests.
The strict structure of the day with meal times, medication rounds and ward rounds regiment the time, and the environment is unfamiliar, noisy and crowded. It is not surprising that, as a result, a person with dementia may call out for help, ask repeated questions or set off to explore the ward hoping to find their way home. The absence of familiar relatives will add to this searching and need for attachment.
Such behaviour may be seen as ‘difficult’ on a ward, especially if irritation shows itself with angry words or actions. Sedating medication frequently follows, significantly increasing the risk of a fall or chest infection, and further reducing a person’s ability to communicate their needs. Even the simple process of ensuring adequate nutrition and hydration can become challenging, and weight loss is common.
Hospitals are frightening, upsetting and dangerous places for people with dementia. It is hard to keep dignity and there is a very high chance of dying in hospital or never returning home.
Challenges to family
Most people living with dementia in the community rely on a carer to support them and this is usually a member of the immediate family. As a person’s dementia progresses, the carer will spend more time in the company of their relative, providing comfort and support, helping with shopping and other household tasks and also often providing high levels of personal care. This can be a stressful experience but it also leads to a strong bond.
When a person with dementia enters hospital and becomes a patient, he or she enters a world of confidentiality. Hospital staff trained in the need to maintain confidentiality can be reluctant to discuss health matters with a relative. The relative can feel like an unwelcome spectator, confined to visiting times with little engagement around the planning and provision of care within the hospital. Their wisdom of caring for their family member is lost to the hospital. The personal likes and dislikes, the tell-tale signs of pain that a close member of the family will know or the fact that the person won’t admit to not hearing well are missed – facts that would help hospital staff provide good care. Previously expressed wishes about care that may be very familiar and could guide important decision-making are unknown to those wishing to help the patient.
Challenges to the hospital
Hospitals are increasingly the setting of rapid and high-tech assessment and treatment. From gathering a history to gaining consent, to carrying out physical examinations or invasive investigations, the cooperation of patients is essential to help this process work efficiently.
What then of the person who can’t say what is the matter? Are they in pain? How long have they been short of breath for? What about consent or involvement in planning? And how to respond to the man who walks around the ward messing with another patient’s drip, or asking how he will get home to his mother despite being over eighty? When nursing staff are carrying out skilled procedures, who will ensure the patients have eaten their meal?
When the process of investigation and treatment has run its course and it is time for discharge, this can be a much more complex process for a person with dementia and lengths of stay are significantly longer. The person with dementia then starts to be referred to as a ‘bed blocker’.
How do hospitals make themselves unfriendly? See Table 11.1.
Table 11.1 How do hospitals make themselves dementia unfriendly?
| Multiple ward moves |
| Structured timetable for the day |
| Sending patients alone to X-ray/clinics |
| Lack of awareness/identification of dementia |
| Lack of appreciation of pain |
| Sedation and use of anti-psychotics |
| Closed visiting times for carers and relatives |
Better dementia care in hospital
There are three parallel approaches to helping the experiences of people with dementia who need hospital care.
- Admission prevention
- Dementia-friendly hospitals
- Mental health liaison
Admission prevention
If it is so problematic to be in hospital with dementia, then the obvious first point to address is whether the admission was needed in the first place or whether there are alternative ways of providing treatment. Strategies include the following:
- Careful management of chronic conditions to prevent acute episodes;
- ‘Virtual ward’ services in the community to provide intensive and specialised care out of hospital;
- Better social care to avoid carer breakdown and emergency calls;
- Inreach into care homes – specialist teams addressing physical or mental health needs for those in care homes to prevent admission;
- Better advanced planning and palliative care.
Admission avoidance can be a better way of providing care. However, a word of ethical caution is needed. ‘Helping people with dementia stay out of hospital’ is very different from ‘keeping people with dementia out of hospital’. Those with dementia deserve good care like anyone else.
The dementia-friendly hospital
With a lot of imagination and hard work it is possible to change the way a hospital stay is experienced by a person with dementia. Hospitals are beginning to recognise the unaddressed needs of patients with dementia in the acute hospital setting. In order to understand how this can be achieved, the following example in Box 11.1 a ‘dementia-friendly hospital’ will be explored.
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