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Improving quality of carefor people with dementiain general hospitals

This guide has beensupported by

Written by Hazel Heath, independent nurse consultant for older people; Deborah Sturdy, senior nurse adviser, older people, Department of Health; and Gordon Wilcock, professor of clinical geratology, University of Oxford

3 Going into hospital

4 Whole hospital approach

6 Environment and orientation

7 Caring for individuals and the people close to them

9 Communication

9 Delirium

10 Preventing challenging behaviours

11 Pain and people with a dementia

11 Food and drink

12 Preserving functioning, re-enablement and rehabilitation

13 Leadership, education and training

14 Conclusion

15 References

Contents

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Going into hospital offers an opportunity for people to receive the care they need in crisis situationsand for acute illness to be treated. But when individuals are feeling ill and in pain, or have experiencedan accident or fall, noisy environments, fast pace of work, new faces, intense questioning and movingthrough different hospital settings can be traumatic and confusing. Acute services are gearedtowards fast and effective responses, assessment, diagnosis, intervention, cure, if possible, anddischarge (Cunningham and Archibald 2006). Care is based on an assumption that patients will be able to express their wishes, acknowledge the

needs of other patients, move through the system as required, have their acute needs addressed and bedischarged home or to other services. As Archibald (2002, 2003) identifies, a person with a dementiamay be unable to comply in many of these areas. Small considerations in how care is delivered can helpto create a more positive hospital experience for individuals, such as making the environment as traumafree as possible, trying to preserve continuity with what is familiar to the individual, taking time toreassure, and giving information and support in ways appropriate to the individual.

Going into hospitalPeople with a dementia come into hospital for the same reasons as older people generally. Forexample, acute illness, stroke, fall or fractured hip. There is often a single factor that triggers ahospital stay, and Sampson et al (2009) identified that 43 per cent of people with a dementia wereadmitted with pneumonia and a urinary tract infection. Among unplanned acute hospital admissionsof individuals aged 70 and over, Sampson et al (2009) found that 42 per cent had a dementia, risingto 48 per cent in those aged 80 years and over. Only 21 per cent had received a diagnosis ofdementia before the research. In fact, although it is commonly an incidental condition when peopleare admitted to hospital, dementia is often recognised for the first time in a general hospital (Sheehanet al 2009).For someone who is frail, vulnerable or has a dementia, who may be on the edge of his or her limits of

coping at home in a familiar environment, who is seeing the same people and doing the same thingseach day, the effect of going into hospital can be overwhelming.Cognitive impairment and dementia, whether or not a formal diagnosis has previously been given, are

major issues in general hospitals. In an Alzheimer’s Society (2009) study, 97 per cent of nursing staff andnurse managers reported that they always, or sometimes, care for someone with dementia. The pace inacute hospitals places high demands on staff and, in these environments, their priority is monitoring andmanaging the acute needs of all the patients in the unit. Someone needing additional time and support,whose behaviour can affect ward routines, can be perceived as disruptive or difficult (Cunningham2006). Almost nine out of ten nursing staff respondents in the Alzheimer’s Society (2009) studyidentified that working with people who have dementia is quite or very challenging: particularlymanaging unpredictable behaviour; communicating; wandering; keeping people safe; and not havingenough time to spend with patients and provide one-to-one care. Other studies have shown that,

although nurses strive to provide optimum care,they find that this is not always achievable (Nolan2006, 2007, Cowdell 2010).What happens in general hospitals can have a

profound and permanent effect on individuals witha dementia and their families, not only in terms oftheir inpatient experience, but also their ongoingfunctioning, relationships, wellbeing, quality of lifeand the fundamental decisions that are madeabout their future (Sheehan et al 2009).

Whole hospital approach If general hospital settings are to provideeffective care for people with dementia, all staffand services have a role to play (Box 1). TheNational Dementia Strategy for England,Objective 8 (Department of Health (DH) 2009)prioritises the identification of leadership fordementia in general hospitals, defining the carepathway for dementia and the commissioning of

specialist liaison older people’s mental healthteams to work in general hospitals.Health and social care managers should

co-ordinate and integrate the work of agenciesinvolved in the care of people with dementia(National Institute for Health and ClinicalExcellence/Social Care Institute for Excellence(NICE/SCIE) 2006), including:4Jointly agreeing written policies andprocedures.

4Involving service users and carers in jointplanning to help identify local populations.

4Working closely with intermediate care andrehabilitation services.

4Working towards combined care planning thattakes into account the changing needs of theperson with dementia and carers.

Disease-specific pathways of care are not alwaysconducive to meeting the needs of people with adementia (Sturdy 2010) and distinct pathways

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BOX 1

An example of a whole hospital approach

The Royal Bournemouth and Christchurch HospitalsNHS Foundation Trust is improving the careenvironment and supporting increased independencefor people with dementia through a range of measuresincluding improved signage and the removal ofpotential hazards. Wards use colour to highlight certainobjects, making it easier for patients to distinguishthem, for example brightly coloured toilet seats. Clockswith large faces are visible from all beds. Relatives arebeing encouraged to bring in personal items to helppatients to recognise their own bed space. Detailedinformation about dementia is displayed on wards.

Staff have ownership of the changes and areactively encouraged to think about how the trust

can make the ward a better environment forpatients who are confused.

One member of staff has recently suggested thatbright footsteps are painted on the floor from eachward leading to the toilet.

Sue Hazel, lead consultant for implementing theNational Dementia Strategy, said: ‘Hospitals can bechallenging environments for patients with dementia.Small but effective changes can create improvedenvironments to reduce anxiety and confusion.’

Contact: Sue Hazel, lead consultant, NationalDementia Strategy, sue.hazel@rbch.nhs.uk

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for people with a dementia, including pathwaysout of hospital, should be developed inconsultation with local social services and userand carer organisations. Such pathways couldalso specify the arrangements for localleadership and accountability for dementia ingeneral hospitals (DH 2009). NICE/SCIE (2006) recommend that hospitals

review their facilities and service function sothat they promote independence and maintainfunction in people who have a dementia.Consistent, stable staffing, retaining a familiarenvironment and minimising relocations canenhance care for people with dementia. Supportservices should include assistive technology, forexample to enable people to stay in touch withtheir families. NICE/SCIE (2006) also identifythat physical exercise, advice on activities ofliving and skills training from physiotherapistsand occupational therapists, along with

meaningful, enjoyable activity while people are inhospital, can help.A report produced by the NHS Confederation

(2010) includes a list of questions for hospitalmanagers and NHS boards to consider whenreviewing their dementia services. Multiprofessional specialist liaison older people’s

mental health teams can provide valuablespecialist assessment and input into careplanning, including to ongoing care and planningfor discharge from hospital (Box 2). They can alsowork with designated hospital lead clinicians tobuild skills and improve care throughout thehospital (NICE/SCIE 2006, DH 2009). It isimportant to remember, however, that thehospital clinicians retain responsibility andaccountability for the person’s care andtreatment; intervention and support must remainconsistently proactive and not be put ‘on hold’awaiting input from specialist teams.

BOX 2

Specialist hospital mental health team for older people

The Leeds mental health team has been functioningfor ten years and, in 2006, became multidisciplinary.The team offers:4Advice and support to the general hospital ward

teams on mental health diagnosis, managementand discharge planning, which can be provided onan ongoing basis where the admission is prolonged.

4Training and education for all general hospital staffworking with older people.

Service evaluation has been ongoing. Evidence showsthat the team responds rapidly to referrals, with 85 per cent of the past 50 referrals seen within oneworking day. There is also evidence that the team hashad a significant impact on reducing the length of

stay, some figures suggest up to 11 days have beensaved. Referrals to the service have increased by morethan 500 per cent over ten years.

A hospital mental health team for older people canimprove the understanding and skill base of generalhospital staff and increase access to appropriateservices to best meet the needs of older people withbetter rates of successful discharge home. Animportant role for the team is to challenge thestigmatisation of ageing and mental health.

Contact: Julie Budd, clinical team manager; Ceri Edwards, senior clinical nurseJulie.Budd@leedspft.nhs.uk

Environment and orientation Emergency departments are commonly the firstpoint of contact for patients coming into hospitaland, due to the pace and noise of emergency care,these environments can be among the mostchallenging faced by people with a dementia andtheir carers (Cunningham and McWilliam 2006,James and Hodnett 2009). Poor experiences inthese settings can increase stress, communicationdifficulties and the risk of delirium, which canaffect patients through the remainder of theirhospital journeys (British Geriatrics Society andRoyal College of Physicians (BGS/RCP) 2006). The key to managing the emergency departmentexperience for a person with a dementia lies inunderstanding that person’s needs and respondingto them in a flexible and creative way (Bridges

et al 2009, James and Hodnett 2009) (Box 3).Dementias generally cause progressive changes inhow people interpret what they see, hear, taste,feel and smell. While the changes experienced areuniquely individual, people with a dementiacommonly find it difficult to orientate to anunfamiliar environment and have a reduced stressthreshold to many environmental stimuli(Archibald 2003).Environmental modification requires systematic

planning. The commitment of hospitalmanagement to making changes and staffcontributions are essential (Nolan 2007). Gooddesign with effective use of lighting, colourcontrast, noise-limiting measures and clearorientation cues can considerably affectsomeone’s ability to understand and function

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BOX 3

Improving emergency department care

In St Mary’s Hospital in Paddington, London, adesignated cubicle was identified in a quiet but visiblepart of the department for older people. This wasredecorated using tranquil colours, low level picturesand a large-face clock. Clinical equipment in the roomwas reduced and relaxing music was provided. Toiletsignage was improved. These changes were replicatedin the admissions unit to reduce transfer trauma.

To support the environmental changes, the nurses weregiven training in communication, stress responses,mental capacity and pain recognition. The Abbey paintool (Abbey et al 2004) was implemented to improverecognition of pain and an alternative analgesic ladderwas used specifically to support patients with dementia.Alongside this, the use of anaesthetic gel before

cannulation was introduced to reduce discomfort andagitation. A specialist volunteer was trained to providecompanionship and support to patients and their carers,and leaflets were produced for patients and their carersto explain that the department would try toaccommodate their needs.

These changes were inexpensive and easy toimplement but they sent a message to patients with a dementia and their families – that thoughtful andpatient-centred care can be delivered in the pressuredenvironment of the emergency department.

Contact: Jo James, locum nurse consultant inhealth services for the elderly at the Royal FreeHospital, London jbj459@hotmail.com

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within a hospital environment. Large clear signs,particularly to toilets, and clocks showing thecorrect time can aid orientation. In the absence ofthis, a clock beside a person’s bed can be helpful.Some aspects of hospital environments, includingmirrors, pictures and cluttered notice boards, canbe confusing for people searching for their reality.Quality of light is important for orientation. Some

people may want to be near a window withnatural light. Older people can be sensitive to glareand fluorescent light can reflect from polishedfloors, tables or walls. Bright light can have ameasurable impact on sleep (Dewing 2009).However, older people usually require more lightthan younger people to undertake detailed tasks,such as reading, therefore lights that the patientcan turn on or off and which can be moved to suitthe task are useful.Although hearing acuity tends to deteriorate

with age, older people’s hearing can beparticularly sensitive to some sounds andbackground noise from machines, equipment,telephones, trolleys, televisions and other people’sconversations. Exposed to periods of suchcontinuous noise, people with dementia canexperience less efficient sleep, increasedagitation, reduced tolerance for pain and somedecline in cognitive functioning and memory(Dewing 2009).For someone with a dementia who is new to a

hospital environment, being able to recognise hisor her own bed and locker can be a lifeline.Personalising a bed with, for example, arecognisable item of clothing, placing photographsor other familiar items on a locker and showing

the person around the surrounding area can behelpful. It is important to consider how someonemight feel on waking in the middle of the night.What would they see and hear, and how wouldthey be able to orientate themselves in the hospitalenvironment to avoid becoming distressed?Environmental audits, including the use of light

and noise meters, can offer evidence on thepotential impact of environments on individuals,and design checks for people with a dementia inhealthcare premises are available (for examplewww.hfs. scot.nhs.uk/online-services/publications/ property). As Dewing (2009) identifies, when environments

support person-centred care, patient wellbeing isenhanced and a therapeutic setting and morepleasant working situation are created.

Caring for individuals and the people close to themDespite the pressures and pace in acute hospitalsettings, knowing and respecting each personremains central to the relationship betweenpatients and healthcare professionals (Nolan2006). It is vital to understand that, while somegeneral statements can be made aboutdementias, each individual will be affecteddifferently. Also, while a dementia fundamentallychanges the way in which a person functions, it isonly one aspect of his or her life. Rather thanseeing ‘someone with a dementia’, it is essentialto seek to understand the individual.The term dementia is used to describe a range

of illnesses that result in an overall impairment ofthe person’s brain function and a decline in

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thinking. People may experience changes inpersonality and behaviour that disrupt theirability to live independently and which mayaffect social relationships. The most commondementia is Alzheimer’s disease, where theretends to be a progressive and gradual declineover time. Another common type is vasculardementia, or ‘small vessel disease’, where smallblood vessels in the brain become damaged andthe circulation is affected (see the Alzheimer’sSociety website for detailed explanations of thedifferent types of dementias).One of the most common features of dementia is

loss of memory, particularly short-term memory,which becomes worse as the disease progresses.As Archibald (2003) describes, the person may

also have difficulty in recognising things, forexample a drink or food – visual agnosia.Individuals may have difficulty carrying outpurposeful actions so they may become muddledwhen getting dressed – dressing apraxia. As theillness progresses a person may lose insight intohis or her actions. People’s physical health will alsoaffect their cognitive functioning, for example ifthey have an infection their memory may becomeworse and they may become more disorientated.While staff working in acute areas would

possibly state that they do not need furtherpaperwork, documents recording aspects of aperson’s biography can be particularly helpful inunderstanding how he or she responds tosituations. Cultural and religious aspects can beparticularly important. This is Me, a guide to anindividual’s needs, preferences, likes, dislikes andinterest – produced by the Alzheimer’s Society(2010) – that people with dementia can bringinto hospital, has been found to be particularly

helpful. A more detailed life story profilingtemplate can be found in May et al (2009).Person-centred care for people with a dementia

encompasses understanding how to supporttheir individual needs most effectively. Forsomeone experiencing difficulties with short-termmemory it can be helpful if nurses wear a largebadge identifying who they are and introducethemselves: ‘Good morning Mrs Stephenson, I am Hazel your nurse.’ For the person to be ableto drink sufficient fluid, it is helpful to put amanageable cup or glass of their favourite drinkinto their hand and gesture the action. Anotherexample is setting out clothes in the order inwhich they are usually put on – underwear, top,trousers and so on.Effective care also acknowledges the needs of

families and/or those individuals who have beensupporting the person with dementia in thehome, usually for some time and often withlimited support. Carers report that they often do not know what role to adopt in hospitalsettings and consequently feel disempowered(Douglas-Dunbar and Gardiner 2007). Carersunderstand the person with dementia and howhe or she functions best in everyday situations. Itis, therefore, important to learn from carers andencourage their contribution to the support ofthe person with dementia in the hospital setting.However, as Douglas-Dunbar and Gardiner(2007) highlight, it is also important to recognisethat carers may themselves feel vulnerable and inneed for many reasons. If carers are to offersupport in communal hospital units, the privacyof other patients also has to be considered.Archibald (2003) recommends that staff speak

with carers to ask how they want to be involved

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and what is possible. For example, asking: ‘Howwould you like to be involved in the person’s care?’‘Would you like to help at mealtimes or offersome personal care?’ ‘Could you bring in things todo or to talk about?’

Communication Good communication is essential in supportingthe wellbeing of someone with dementia and inpreventing stressful situations from developing.The full range of communication strategiesshould be used. Through observation andlistening, staff can identify the most effectivemeans of communicating with individuals,including which senses – auditory, visual,kinaesthetic, olfactory – predominate in theperson’s perceptions (Dewing 2003a). Also, whilesome individuals are unable to communicateverbally, staff can enhance communication byrecognising that these individuals often becomeexpert in communicating on an emotional level(Archibald 2003).In common with many older people, individuals

with a dementia may have visual or hearingimpairments, compounded by the organicchanges accompanying the dementia. AsArchibald (2003) describes, it can take someonewith dementia longer to understand what is beingsaid to them. She recommends that staff:4Speak clearly and at a steady pace.4Keep language as uncomplicated as possible.4Approach the person from the front, engageeye contact and speak face to face.

4Show an attitude of warmth and firmness.4Address constantly by name and provideidentifying information.

4Do not use complicated idioms of speech, for

example saying ironically: ‘It is a lovely day’when it is raining.

4Use non-verbal means of communicating suchas facial expression, touch and gesture to giveadditional clues.

While staff may feel frustrated thatconversations are not straightforward or that thesame issues are raised repeatedly, Dewing(2003a) highlights that this offers an excellentopportunity to rehearse responses to identifythose that are most effective for the individual.

Delirium Delirium is defined as a: ‘...disturbance ofconsciousness and a change in cognition thatdevelop over a short period of time and whichcan fluctuate during the course of the day. In addition, there is evidence from the patient’shistory, examination or investigation that thedelirium is a direct consequence of a generalmedical condition, substance intoxication orwithdrawal, use of a medication, toxin exposure,or a combination of these factors’ (AmericanPsychiatric Association 1994).Delirium affects up to 30 per cent of older

hospital patients and people who develop deliriumhave high mortality, high complication rates andlonger hospital stays (BGS/RCP 2006). Peoplewith a dementia have a fivefold risk of developingdelirium (Faculty of Old Age Psychiatry, RoyalCollege of Psychiatrists 2005) and, in someonewith a dementia, precipitating factors for deliriuminclude medications, immobilisation, malnutrition,infection, an indwelling catheter, environment orpsychosocial influences (Schofield and Dewing2001). It is vital that staff remain vigilant in casedelirium should develop.

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Screening for cognitive impairment isrecommended (BGS/RCP 2006) and theConfusion Assessment Method (CAM) (Inouye etal 1990) differentiates delirium from other causesof cognitive impairment. The CAM focuses on:1. Acute onset and fluctuating course.2. Inattention.3. Disorganised thinking.4. Altered level of consciousness.The diagnosis of delirium by CAM requires the

presence of features 1 and 2 and either 3 or 4. (A guide to nursing assessment of cognitivedecline, delirium, depression and dementia isoffered by Insel and Badger 2002.)Delirium may be prevented in up to one third of

older patients (BGS/RCP 2006) througheffective interdisciplinary care, medical diagnosisand treatment of the underlying cause andsupportive nursing care (Schofield 2008).Nursing measures to prevent delirium

encompass those outlined in this guide, andparticularly (Schofield 2002):4Orientation to time and place.4Ensuring that the person has spectacles andhearing aid.

4Keeping the person stimulated and abreast ofdaily events.

4Ensuring uninterrupted sleep at night byminimising noise.

4Ensuring adequate fluid intake.4Promoting movement and mobilisation.4Minimising the use of interventions such ascatheterisation.

Schofield (2008) offers recommendations forinitiating facility-wide strategies aimed atproactive prevention, recognition andtreatment. NICE will soon publish a clinical

guideline on the diagnosis, prevention and management of delirium(http://guidance.nice.org.uk/CG/Wave17/21).

Preventing challenging behavioursIt is not only people with a dementia who havedisturbed behaviour in hospital and not all peoplewith a dementia show disturbed behaviour(Archibald 2003). Due to illness or the stress of hospitalisation,

people with dementia can be pushed beyond theirlimit of coping, become distressed and behave inways that demonstrate they are disturbed.Understanding individuals through personalprofiling and discussions with those closest tothem can help to predict and prevent distress. It is important to understand that disturbedbehaviours are not always due to dementia. Peoplewith dementia show disturbed patterns of behaviour for a reason, but they may be unableto explain this. Check whether they are thirsty,hungry, too hot, too cold, in pain, need the toilet or are constipated. Check how they are feeling –are they anxious? Have they forgotten they are inhospital and are trying to find the way home? Are they feeling unwell? Sometimes disturbedbehaviour is the only sign of an underlying physicalillness such as an infection. It is important to actimmediately if someone is showing any signs ofdistress. As Dewing (2003a) highlights, the bestmanagement of disturbed behaviour is not throughcontainment, but by seeking to respond to theperson’s immediate needs and to understanddeeper unmet psychological needs.Walking about, or wandering as this is often

described, is commonly seen as a problembehaviour. Dewing (2005) describes wandering

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as: ‘A complex, meaningful human activity whichmay take on various forms over time and place inthe same person and between people.’ Dewingalso (2005) emphasises the importance of fullassessment to help identify individuals who arelikely to wander and possible reasons for this,and offers a screening tool for wandering.Structured observation can also be helpful sothat proactive decisions can be made about risk,supervision and helpful interventions to respondto the person’s need to wander.‘Sundowning’ – cognitive and behavioural

changes that take place in the late afternoon orearly evening – occurs for a range of reasons.Such changes can be prompted by hospitalenvironments that affect the person’s cognition,for example changes in lighting levels, oralterations in the person’s routine, such as sleeping in the afternoon. They can beexacerbated by sleeping problems, fatigue, over- or under-stimulation, feelings of illbeing,agitation and concern about separation fromfamily members (Dewing 2003b).Changes in behaviour may be a consequence of

multiple medications.A behaviour seldom reported as ‘challenging’ is

when the person is withdrawn or not veryresponsive, but this can also be a sign of illness, illbeing, depression or delirium, and healthcareprofessionals should be vigilant for this.Comprehensive assessment is essential to

understand the reasons for changes in behaviourand offer appropriate support. Stokes (2000) offersa framework for assessment using ABC:4A – antecedents or triggers, what washappening before the behaviour occurred, whowas present, when and where did it occur?

4B – behaviour. Describe exactly what thebehaviour was, be specific; is this new behaviour,what form did it take, how long did it last?

4C – consequences of the person’s behaviour.

Pain and people with a dementia People with a dementia experience physical andpsychological pain but, particularly if thedementia is advanced, may not express this inconventional ways. It is important to identifyappropriate terminology for individuals. Forexample, do they describe aching or discomfort?It is also important to recognise non-verbal waysin which people might express pain. For example,through grimacing, flinching or guarding thepainful area, restlessness or aggressive behaviouror pulling at tubes. In advanced dementia, Briggs(2002) recommends observing for noisybreathing, negative vocalisation, absence of alook of contentment, looking sad, lookingfrightened, frowning, absence of relaxed bodyposture, looking tense and fidgeting.As Archibald (2003) highlights, often when

people are assessed for pain they are lying orsitting, whereas most pain occurs on movement,particularly with arthritis or surgery. Pain shouldbe assessed systematically when people aremoving as well as still. It is important to giveanalgesia before doing anything that may causepain. Pain assessment tools for use with peoplewho have a dementia are available (Briggs 2001).

Food and drink Nutrition and hydration are vital for health andwellbeing and for recovery from illness, surgery oraccident. Nutrition for older people in hospital hasbeen recognised as a major issue (Age Concern

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2006) and dehydration is estimated to be presentin one quarter of older patients (Archibald 2006a).The needs of each individual are distinct but,

broadly, people with a dementia can experienceparticular challenges in maintaining adequatehydration and nutrition (Archibald 2006a, 2006b):4Memory People can forget how to eat, drink,chew or swallow. Identifying and offeringfavourite drinks and food, reminding people todrink and offering frequent drinks, even if insmall quantities, can help. If a person is unableto chew, Archibald (2006b) suggests that staffmoisten food, offer small bites at a time, rolemodel chewing or try applying light pressureunder the chin.

4Visual agnosia People with a dementia maynot be able to recognise a cup or glass, a plateor food or cutlery. Presenting food that isuncomplicated, along with placing a cup or forkin someone’s hand and gesturing how to drinkor eat, can be helpful.

4Receptive and expressive dysphasia A personwith dementia may be unable to understandwhat staff are saying or to express that he orshe is hungry or thirsty. Learning to understandindividual needs and clear communication,described above, are essential.

People may also be reluctant to eat if they arefeeling anxious or agitated, unwell, tired,constipated, or if other problems, such asinfections, are imminent.People with a dementia can be particularly at risk

of dehydration if ward environments are hot anddry. Adequate nutrition is essential, particularly ifthe person is active, for example walking.Supplemental foods and snacks may be necessary. A range of mealtime schemes has been tried,

including red trays for people who need assistance,protected mealtimes and using volunteers to helppatients to eat. People with dementia shouldreceive nutritional screening to ensure those at riskof undernutrition or dehydration are identified andappropriate care plans implemented. The BritishAssociation for Parenteral and Enteral Nutrition(BAPEN) (2003) offers a nutritional screening tooland Archibald (2006b) provides profiling,observation and alert tools. Dietician advice shouldbe sought when appropriate, and swallowingdifficulties should be referred to a speech andlanguage therapist.

Preserving functioning, re-enablement and rehabilitationTime spent in hospital can result in thedeterioration of daily living skills, confidence andindependence for all patients and, while the effectsof a dementia cannot be ignored, it is vital that themultiple abilities and needs of individuals areacknowledged. To prevent excess disabilitycompounding functioning that is alreadycompromised, care should proactively promote re-enablement and rehabilitation to optimumindividual potential. Each person’s abilities andcoping strengths, along with those of their carers,should be maximised, and rehabilitativeapproaches could incorporate memory skillssupport, the use of memory aids and maintainingskills for everyday living. The ultimate goal is: ‘Theequipping of individuals to live in ways that theyhave previously enjoyed, with or without theassistance of others’ (Dewing 2003a).People with a dementia have commonly been

excluded from access to multiprofessionalrehabilitation services on the mistaken

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assumption that they will be unable to benefitfrom such input (Alzheimer’s Society 2009).Multiprofessional assessment of individuals shoulddetermine which services are offered andimproved systems of care will result in morepeople with dementia accessing rehabilitativesupport and intermediate care (DH 2009).

Leadership, education and training Each hospital should identify a senior clinician totake the lead for quality improvement indementia and for defining the care pathway(Alzheimer’s Society 2009, DH 2009). Dementiachampions have been widely appointed in acutetrusts. It is also vital that all hospital personnel

who encounter people with dementia, includingreception and portering staff as well as healthprofessionals, have the education and skills towork effectively with them (Cunningham andMcWilliam 2006).Trusts need to review their staff capacity for

delivering high quality dementia care and toprioritise workforce developments for dementia(NICE/SCIE 2006). The National DementiaStrategy (DH 2009) suggests that corecompetencies for all staff who have contact withpeople affected by dementia (including patientadvice and liaison services and local involvementnetworks) could be developed, and trainingprovided on these competencies (Box 4).

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BOX 4

An example of leadership, education and training

South Tees Hospitals NHS Foundation Trust has been working to support the Department of Health’sDignity in Care campaign and the National DementiaStrategy. The motivation to improve services cameafter complaints about the levels of care for olderpeople with mental ill health and dementia.Observation and analysis of patient records provided insight into the need for all levels of staff todevelop their knowledge and understanding of mentalill health and dementia.

Two clinical matrons, Julie Suckling (Essence of Care,privacy and dignity lead) and Jeanette Power-Jepson(dementia lead) began their journey after finding a Let’s Respect toolkit* in their office. Their first task wasto gain commitment from senior level managers andpeer group matrons. The matrons worked with thetrust training department and a local college, anddeveloped level 2 and level 4 City & Guilds programmesfor healthcare assistants and nurses, which are nowincluded in mandatory training for new staff.

A further development was to create a trust-wideprivacy and dignity policy which supports the delivery ofcare standards for all patients, relatives, carers andfamilies. The matrons’ forum worked in partnership withprivate finance initiative providers Carillion, who nowinclude privacy and dignity in annual training. Carillionhas developed a ‘don’t walk by’ policy – if a member ofstaff sees anything that compromises patient dignity orsafety, they intervene where appropriate and report itimmediately. As delivery of care is supported by Carillionit was vital to collaborate to ensure that a consistentmessage was delivered across the trust.

Contact: Jeanette Power-Jepson, clinical matronand dementia lead, Jeanette.power-jepson@stees.nhs.uk Tel: 01642 850850

*Information on the Let’s Respect campaign andtoolkit are available at: www.nmhdu.org.uk/ our-work/mhep/later-life/lets-respect

ConclusionPeople with dementia are a major client group ingeneral hospitals (Sampson et al 2006, 2009)and the numbers of people with dementiacoming into acute services will increase with theageing of the population. The needs of theseindividuals could also become more complex asnew populations experience dementia. It is vital that all staff see beyond the label of

‘dementia’ to work with patients and theirfamilies in all the complexity of their individualneeds. There is growing evidence on the measuresthat can be most effective in meeting the needs ofpeople with dementia in acute settings, and thisguide has outlined key aspects such asenvironment, communication, assessment, soundcare practices, rehabilitative and supportiveapproaches and effective multiprofessional teamworking. There is also international evidence thatinterventions such as staff education andstandard care protocols can help to meet the

needs of people with dementia in acute settings(Moyle et al 2008). The National DementiaStrategy (DH 2009) recommends:4The identification of a senior clinician to takethe lead for quality improvement.

4The development of an explicit care pathway.4The gathering and synthesis of existing data onthe nature and impact of specialist liaison olderpeople’s mental health teams.

4Thereafter, the commissioning of specialistliaison older people’s mental health teams towork in general hospitals.

Professor Alistair Burns has been appointed asthe national clinical director for dementia to leadon the strategy. Offering effective care to people with dementia

in general hospitals can reduce the trauma of ahospital admission, the length of the inpatient stayand other healthcare-related complications, andenhance the health, wellbeing and quality of life forindividuals and their families (Box 5).

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BOX 5

A new model of care

The Royal Wolverhampton Hospitals NHS Trust hasbeen sponsored by NHS West Midlands to develop acare bundle for dementia care in the acute hospital andto use this as the basis for raising clinical outcomes andproviding more cost-effective care for people withdementia. This two-year programme will adopt aperson-centred approach to care and the environment.

The proposed model centres on a dedicated ward,opening in August 2010, which will provide a calm andquieter environment than a standard ward. To test theefficacy of the interventions and refine themaccordingly, the staff group will be encouraged to

recognise the importance of approaches sensitive toindividual needs. They will be equipped with knowledgeof dementia and its management.

Transferring patients in the hospital will be minimised toreduce disorientation. An outreach team will be closelylinked to the ward. The team will also be available tosupport and advise other wards and departments inproviding high quality care.

The trust’s lead is Cheryl Etches, director of nursingand quality. For further information contact GraceHampson, project manager: grace.hampson@nhs.net

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