Adverse Health Events in Hospitalized Patients with Dementia

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1 How To try this read it watch it try it Adverse Health Events in Hospitalized Patients with Dementia Delirium. Dementia is the leading risk factor for delirium. Patients with dementia are three to five times more likely than other older adult patients to develop delirium in the hospital, 1-4 and two-thirds of delirium in hospitals occurs in patients with dementia. 5 Falls. Hospital patients with dementia are 1.6 to 3.6 times more likely than other older patients to fall in the hospital. 6, 7 One-third to nearly two-thirds of falls in older patients involve a patient with impaired memory, which is indicative of dementia. 6, 8 New incontinence. Hospital patients with dementia are more likely than other older patients to develop new incontinence. A study of 13,729 older patients in 81 hospitals in Italy found that those with dementia were five times more likely to develop new urinary incontinence and six times more likely to develop fecal incontinence. 7 Indwelling urinary catheters. Hospital patients with dementia are at greater risk than other older patients for placement of an indwelling urinary catheter without a specific clinical indication. In one hospital, patients with dementia were almost three times more likely than other older patients to have such a catheter placement. 9 Pressure ulcers. The study of more than 13,000 older patients in 81 Italian hospitals, mentioned above, also found that patients with dementia were five times more likely than other older patients to develop new pressure sores. 7 Untreated pain: Hospital patients with dementia are more likely than other older patients to have untreated pain. For example, two studies found that hip fracture patients with dementia received roughly one-quarter to two-fifths 10, 11 of the amounts of opioid analgesics received by other older hip fracture patients. Agitation and related behavioral symptoms. Behavioral symptoms such as agitation, repetitive verbalizations, yelling, and physical aggression are common in people with dementia, and many aspects of hospitalization can exacerbate these symptoms In one community hospital, 95% of the patients with dementia were found to have at least one agitated behavior, and the number and frequency of these behaviors were strongly associated with nurses reported levels of burden. 15 Physical restraints. Hospital patients with dementia are three to six times more likely than other older patients to be physically restrained. 16, 17 One study of hip fracture patients found that 32% of those with severe dementia were physically restrained, compared with only 2% of those with no dementia. 11 Functional decline. Hospital patients with dementia are more likely than other older patients to experience functional decline during hospitalization. Studies of large samples of older hospitalized patients show that those with dementia were two to four times more likely than other older patients to lose the ability to perform activities of 18, 19 daily living during a hospital stay. New feeding tubes. Hospital patients with dementia are more likely than other hospitalized patients to have new feeding tubes inserted during hospitalization. One study of patients dying in an acute care hospital found that those with dementia were more than twice as likely as those with cancer to receive new feeding tubes. 20 Katie Maslow, MSW, and Mathy Mezey, EdD, RN, FAAN REFERENCES 1. Elie M, et al. Delirium risk factors in elderly hospitalized patients. J Gen Intern Med 1998;13(3): Fick DM, et al. Delirium superimposed on dementia: a systematic review. J Am Geriatr Soc 2002;50(10): Morrison RS, et al. Relationship between pain and opioid analgesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58(1): Pompei P, et al. Delirium in hospitalized older persons: outcomes and predictors. J Am Geriatr Soc 1994;42(8): ajn@wolterskluwer.com AJN January 2008 Vol. 108, No. 1

2 How To try this 5. Inouye SK. Delirium in older persons. N Engl J Med 2006;354(11): Krauss MJ, et al. A case-control study of patient, medication, and care-related risk factors for inpatient falls. J Gen Intern Med 2005;20(2): Mecocci P, et al. Cognitive impairment is the major risk factor for development of geriatric syndromes during hospitalization: results from the GIFA study. Dement Geriatr Cogn Disord 2005;20(4): Hitcho EB, et al. Characteristics and circumstances of falls in a hospital setting: a prospective analysis. J Gen Intern Med 2004;19(7): Holroyd-Leduc JM, et al. The relationship of indwelling urinary catheters to death, length of hospital stay, functional decline, and nursing home admission in hospitalized older medical patients. J Am Geriatr Soc 2007;55(2): Feldt KS, et al. Treatment of pain in cognitively impaired compared with cognitively intact older patients with hip-fracture. J Am Geriatr Soc 1998;46(9): Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA 2000;284(1): Kovach CR, Wells T. Pacing of activity as a predictor of agitation for persons with dementia in acute care. J Gerontol Nurs 2002;28(1): Stolley JM. When your patient has Alzheimer s disease. Am J Nurs 1994;94(8): McCloskey RM. Caring for patients with dementia in an acute care environment. Geriatr Nurs 2004;25(3): Sourial R, et al. Agitation in demented patients in an acute care hospital: prevalence, disruptiveness, and staff burden. Int Psychogeriatr 2001;13(2): Sullivan-Marx EM. Achieving restraint-free care of acutely confused older adults. J Gerontol Nurs 2001;27(4): Bourbonniere M, et al. Organizational characteristics and restraint use for hospitalized nursing home residents. J Am Geriatr Soc 2003;51(8): Pedone C, et al. Elderly patients with cognitive impairment have a high risk for functional decline during hospitalization: The GIFA Study. J Gerontol A Biol Sci Med Sci 2005;60(12): Sands LP, et al. Cognitive screening predicts magnitude of functional recovery from admission to 3 months after discharge in hospitalized elders. J Gerontol A Biol Sci Med Sci 2003;58(1): Ahronheim JC, et al. Treatment of the dying in the acute care hospital. Advanced dementia and metastatic cancer. Arch Intern Med 1996;156(18): ajn@wolterskluwer.com AJN January 2008 Vol. 108, No. 1

3 Hospital Initiative Advisory Panel Member Discipline Title Geography/Location Acute Care Experience Academic/ Research Program Curriculum Faculty Alzheimer s Assn Marie Boltz PhD, APRN, BC Director of Practice Initiatives Hartford Institute for Geriatric Nursing, NYU College of Nursing Joan D Ambrose MA,RN, Nurse/Family (Former) President Alzheimer s Association- St. Louis Chapter Carol Ellis RN Manager, Education Services St. Anthony s St. Louis Della Frazier-Rios RN, MS Senior Vice President Alzheimer s Association NYC Chapter James Galvin M.D., MPH Associate Professor, Neurology, Psychiatry and Neurobiology, Education Core Leader Roni Haas MSW, LCSW Manager, Mental Health Services Tina Hartlein RN C Program Director Senior Lifestyles Karen Hendrickson EdD, RN, CNAA, BC Alzheimer s Disease Research Center, Washington University School of Medicine Christian Hospital Missouri Delta Medical Center Sikeston, MO Chief Nursing Officer Southeast Missouri Hospital Helen Lach PhD, RN, CS Assistant Professor St. Louis University School of Nursing Nancy Little RN, Volunteer /family Staff Nurse, St. Luke s Hospital Alzheimer s Association St. Louis x Katie Maslow MSW Associate Director for Quality Care Advocacy Alzheimer s Association Ntl Public Policy office Thomas Meuser Ph.D. Director of Gerontology, University of Missouri Associate Professor of Social Work & Psychology St. Louis Jan Palmer Ph.D., RN Assistant Professor, RN-BSN Faculty Coordinator Saint Louis University School of Nursing Peter Reed Ph.D. Senior Director of Programs National Chicago x Clarissa Rentz MSN, APRN Executive Director Alzheimer s Association Greater Cincinnati Chapter Susan Rothas RN, B.S.N. Manager, Professional Training Institute Greater Il Chapter, Chicago Nancy Smith- B.A. Coordinator of Dementia Mission Hospitals Hunnicutt Responsive Care Asheville, NC Myrna Ward MSN, RN Director of Patient Care Southeast Missouri Hospital

4 Key Players Member Discipline Title Geography/Location Acute Care Experience Cindy Kempf OTR/L Director of Clinical Services Academic/ Research Program Curriculum Faculty Alzheimer s Assn RPI Therapy Services Patty Iverson MA Education Coordinator Alzheimer s Association, St. Louis Chapter Jan McGillick MA,LNHA Director of Education Alzheimer s Association, St. Louis Chapter Maggie Murphy-White MA Hospital Initiative Coordinator Alzheimer s Association, St. Louis Chapter Charla Shurtleff Occupational Therapy Asst., Gerontology COTA St. Anthony s Medical Center, St. Louis Joy Snider MD, PhD Assistant Professor, Dept of Neurology Alzheimer s Disease Research Center, Washington University Cheryl Wingbermuehle MSW Family Services Director Alzheimer s Association, St. Louis Chapter We attempted to make this chart as accurate as possible. If any of your information is incomplete or incorrect, please notify us. Thank you. P:\PUBLIC\Education\AAEI\Hospital project\rrf\advisory Panel\Hospital Inivitiative Advisory Panel docx

5 Hospital Initiative Chronology 2003 John A. Hartford Foundation Institute for Geriatric Nursing at New York University in conjunction with national Alzheimer s Association publishes and promotes Try This: Best Practices in Nursing Care for Persons with Dementia. Provides easy to access best practice knowledge, encourages use, disseminates assessment tools and provides evidence based information to hospital staff Alzheimer s Association St. Louis Chapter conducts a Focus Group with Washington University s Alzheimer s Disease Research Center s Clinicians Partners Program attended by practitioners from rural, urban and suburban acute care settings Silverstein and Maslow publish Improving Hospital Care for Persons with Dementia to bring attention to the issue of hospital care for persons with dementia. Fall January 2007 January October 2007 April 2007 May October 2007 November 2007 March 2008 November 2007 February 2008 March 2008 April 2008 June 2008 October November Alzheimer s Disease Research Center collaborates with chapter to videotape interviews with families and professionals about hospital experiences. Program Services Steering Committee member further affirm need for chapter to devote program and staff resources to this issue which is reflected in FY2008 Annual Plan. Due to the Association s ongoing outreach programs, the Missouri Association of Hospital Auxiliaries names the chapter as focus of its Annual Service projects. ADRC and Alzheimer s staff plan and implement a training program at Southeast Missouri Hospital attended by 73 interdisciplinary staff with pre post data collection. Informal Resource manual made available at training. Second Hospital: St. Anthony s Medical Center (SAMC) in south suburban St. Louis agrees to work collaboratively with Chapter and ADRC on a second pilot. Collaboration with ADRC to evaluate program and develop business plan and program development. ADRC, SAMC, and Alzheimer s Association collaborate to revise curriculum based on outcomes from pilot programs. Funding received from the Retirement Research Foundation for an 18-month Hospital Training Initiative to document that dementia care training of hospital professionals can be linked to outcomes related to improved quality of care in the acute care setting. Project Coordinator hired to fulfill the objectives outlined in the grant. The Coordinator will work with the selected hospitals to assess their training needs, procure pilot partnership, implement training programs and identify resources to improve hospital systems in ways that have a positive impact on the quality of care provided to persons with dementia and their families during hospitalization. Advisory Panel established to review and refine training curricula, analyze the results of 2007 pilots and determine appropriate course of educational interventions and outcomes measures for the project. Advisory Panel attends a planning meeting in St. Louis. Discussion focused on curriculum enrichment and outcome measures for the project. Work groups established to continue to examine improvements to the program. Final curriculum revision is completed to incorporate Advisory Panel suggestions. Evaluation tools are improved in order to gather more data as well. Grand Rounds delivered by Dr. Jim Galvin at Christian Hospital and St. Anthony s

6 2008 Medical Center. May 2009 Jan McGillick awarded Practice Change Fellowship. This will allow the Association to continue the Initiative at two additional hospitals and improve data collection. June 2009 Anheuser Busch Grant Partially supports training at two additional hospitals. July 2009 Data from four pilot hospitals is analyzed by Alzheimers Disease Research Center. April 2010 The hospital initiative is presented at the National Conference for Nurses Improving Care for Healthsystems Elders (NICHE). July Alzheimer s Association Chapters are trained to begin the Hospital Initiative at their chapters. On-going support and communication is given to ensure success of their programs. August 2010 Missouri Hospital Association Webinar: 19 hospitals in Missouri participated and received information related to the initiative. Hospital Initiative Overview presented to the Practice Improvement Committee at Barnes Jewish Hospital. September 2010 Dementia Friendly Hospitals: Care Not Crisis - awarded copyright June 2008 January Over 1000 Hospital staff members from 7 area hospitals have received education 2012 through the Dementia Friendly Hospital Initiative. Present Grant Application submitted through HealthCare Interactive to provide on-line version of curriculum. Decision pending. Curriculum revisions to incorporate increased support to reducing re-admissions.

7 Dementia-Friendly Hospitals: Care Not Crisis Curriculum Outline Introduction & Purpose Statement The purpose of the Dementia-Friendly Acute Care training program is to address the reality that approximately one-third of people with Alzheimer s disease and other dementias are hospitalized each year for a total of 3.2 million hospital stays, a number that will greatly escalate as the population ages. (Analysis of 2000 Medicare data). Older hospital patients with dementia are at much higher risk for functional decline, delirium, falls, elopement incidents, dehydration, aggressive behaviors and physical restraint. Frequently, functional decline occurs during the hospital stay, which may lengthen stay and complicate discharge. Based on discussions and focus groups with acute care leaders ( ), we know that hospital staff are often undertrained to recognize dementias. They need the skills necessary to deal with the associated problems, communicate effectively with family caregivers, and identify ways to better manage individual patient care needs. This will result in reduced staff burden, less family stress and improved patient outcomes. (Maslow, 2006). As of October 2008, the Centers for Medicare and Medicaid Services (CMS) no longer reimburse hospitals for certain complications that occur during a patient s stay. Several of these adverse health events commonly happen to persons with dementia (infection related to the use of indwelling catheters, pressure ulcers, delirium, etc). These CMS changes further fuel the need for education and advocacy for improved outcomes during hospitalization. Models of dementia-capable acute care delivery and training efforts have been documented and researched, but are not being implemented as standard practice. Responding to concerns voiced by family members, hospital staff and leadership, the Alzheimer s Association Education Institute (AAEI) St. Louis Chapter, in collaboration with the Washington University Alzheimer s Disease Research Center, is initiating a training program with four area hospitals: St. Anthony s Medical Center, Southeast Missouri Hospital, Christian Hospital and to be determined.

8 Goal/Vision of Training This educational opportunity focuses on impacting changes in the care of cognitively impaired patients through offering practical, interactive and dementia specific training to hospital personnel working with persons with cognitive impairments. Considerable data about the effect of training on hospital systems and individual staff knowledge and behaviors will also be gathered as a result of implementing this training initiative in participating institutions. After a pilot phase is evaluated, the program will be adjusted for broad replication. Staff training on practical care for people with dementia has been demonstrated to: Increase detection and treatment of Alzheimer s disease and related dementias in acute care settings Raise awareness and improve knowledge resulting in improved patient care. Challenge outdated or incorrect attitudes and practices to increase staff competence. Prevent complications from infection and malnutrition. Facilitate recovery. Prevent functional decline. Reduce high risk behaviors to improve safety for both patient and staff.

9 Acknowledgements The Alzheimer s Association Education Institute, St. Louis Chapter would like to thank the following people and organizations for their contributions to the development of this training program. The program was developed in 2007 in partnership with the Alzheimer s Disease Research Center (ADRC) at Washington University, St. Louis, Missouri. ADRC s participation and leadership in this initiative has been funded in part by the National Institute on Aging (P50-AG05681). Many families and caregivers describe challenging experiences when their relative or friend with dementia is hospitalized. The development of this pilot educational program is in response to these serious concerns and advocates for people with dementia in hospitals by providing training for hospital staff. Our gratitude is extended to all of our collaborators listed below. Alzheimer s Disease Research Center, Washington University School of Medicine Contributors James E. Galvin, MD, MPH, Associate Professor Department of Neurology, Psychiatry and Neurobiology and Director of Memory Diagnostic Center, Education Core Leader, Alzheimer s Disease Research Center, Washington University, Advisory Panel Member Mary Coats, BS, MS, RN, CS, GCNS, Research Assistant Professor in the Department of Neurology Jessica Germino, BA, Medical Student, Washington University School of Medicine Ronald Hawley, Video Coordinator and Editor Barbie Kuntemeier, MA, ADRC Education Core Coordinator, Advisory Panel Member Stacy Jackson, APRN, BC, Nurse Clinician, Dept. of Neurology & Memory and Aging Project Janice Palmer, RN, MS, Administrative Director of Washington University Center on Aging Southeast Missouri Hospital Collaborators Mark S. Hahn, DO Family Practice Karen Hendrickson, EdD, RN,CNAA, Vice President, Chief Nursing Officer Gwen Thoma, EDD, RN, CAN, BC, Director, Educational Services LaDonna Willis, BSN, RNC, CAN, Nurse Manager, Generations Family Resource Center St. Anthony s Medical Center Collaborators Carol Ellis, RN, BSN, Manager of Education Services, Advisory Panel Member Mary Falcetti, MA, OTR/L, Therapy Manager, Acute OT and Acute Rehab Barbara Finke, Administrative Assistant, Therapy Services Amanda Finley, MSN, RN, Nurse Educator Cindy Kempf, MA, OTR/L, Occupational Therapist Annette Latham, BSN, BA, RN, Director of Care Management and Social Services Denise Levick, BS, RPT, Director of Therapy Services Rev. Barbara Patten, M.Div., B.C.C. Chaplain, Pastoral Care Department Kay Schulze, MSN, RN, CMSRN, Clinical Nurse Educator/Medical Surgery Charla Shurtleff, BA, COTA/L, MA Intern & Candidate, Lindenwood University, Advisory Panel Member

10 Acknowledgements - Continued Alzheimer s Association, St. Louis Chapter Joan D Ambrose, RN, BA, MA, President Mandy Stinnett Adkins, MSW Lisa Hicks, LPN, Outreach Coordinator Shannon Kitchen, MSW Outreach Coordinator Janis McGillick, MA, LNHA, Director of Education Maggie Murphy-White, MA, Hospital Initiative Coordinator Cheryl Wingbermuehle, MSW, LCSW, Director Family Services, Advisory Panel Member Carol White, AAS, Administrative Support Specialist University of Missouri St. Louis Tom Meuser, PhD, Director of Gerontology, Associate Professor of Social Work and Psychology, University of Missouri St. Louis, Advisory Panel Member Advisory Panel Marie Boltz, PhD, APRN, BC, Director of Practice Initiatives, NYU College of Nursing Carol Ellis, RN, BSN, Manager of Education Services, St. Anthony s Medical Center Della Frazier-Rios, RN, MS, Senior Vice President, Alzheimer s Association, NYC Chapter James Galvin, MD, MPH, Education Core Leader, Alzheimer s Disease Research Center Roni Haas, MSW, LCSW, Manager, Mental Health Services, Christian Hospital Tina Harlein, RN C, Program Director Senior Lifestyles, Missouri Delta Medical Center Karen Hendrickson, EdD, RN, CNAA, BC, Chief Nursing Officer, Southeast Missouri Hospital Helen Lach, PhD, RN, CS, Assistant Professor, Saint Louis University - School of Nursing Nancy Little, RN, St. Luke s Hospital, Volunteer/Family Member, Alzheimer s Association, St. Louis Chapter Katie Maslow, MSW, Assoc. Director for Quality Care Advocacy, Alzheimer s Assoc., NTl Public Policy office Thomas Meuser, Psychologist, Director of Gerontology, University of Missouri St. Louis Peter Reed, PhD, Senior Director of Programs, Alzheimer s Association, National Office Clarissa Rentz, MSN, APRN, Executive Director, Alzheimer s Association, Greater Cincinnati Chapter Susan Rothas, RN, BSN, Mgr, Professional Training Institute, Alzheimer s Assoc, Greater Illinois Chapter Nancy Smith-Hunnicutt, Coordinator of Dementia Responsive Care, Mission Hospitals, NC Myrna Ward, MSN, RN, Director of Patient Care, Southeast Missouri Hospital Many staff and volunteers contributed to this pilot throughout its development.

11 Content Summary Overall Goals & Objectives This project focuses on the training of individual hospital personnel to impact changes in the care of cognitively impaired patients. Data collection will be utilized to assess the efficacy of implementing a dementia training initiative at participating hospitals. The anticipated results of this project are to: Provide a more fully developed and tested core curriculum for training hospital personnel in dementia care Develop an outcome-based process that enables hospital administrators to identify needed internal systems changes Incorporate strategies that measure training impact on dementia care and systems change Summary of Learning Objectives Module 1: Introduction to Training: Hospitals and Dementia Care (Includes Pre-Education Packet Information) Learning Outcomes 1. Know the prevalence and financial/social costs of dementia 2. Understand the impact of hospitalization rates and current outcomes for persons with dementia (PWDs) 3. Make the case for dementia-friendly acute care Module 2: Medical Overview Learning Outcomes 1. Define Alzheimer s Disease (AD) and related dementias 2. Differentiate among delirium, dementia, and depression 3. Describe tools and resources for diagnosis and cognitive assessments 4. Recognize treatment options a. Nonpharmacological b. Pharmacological Module 3: Communication & Behavior Learning Outcomes 1. Understand dementia s impact on the ability to communicate 2. List symptoms of dementia that affect communication 3. Review communication challenges inherent in hospitalization of PWDs 4. Utilize family caregivers knowledge to improve care for the PWD 5. Understand behaviors 6. Learn positive interventions for problem behaviors Module 4: Dementia Friendly Care Learning Outcomes 1. Review clinical best practices during hospital stay that address: a. Safety b. Pain & Medication Issues c. Self-Care & Activities of Daily Living

12 Module 5: Connecting the Caregiver Learning Outcomes 1. Understand the importance of starting discharge planning early 2. Identify the red flags for high risk cases 3. Recognize common safety issues and ethical concerns 4. Utilize a multi-disciplinary, best practices approach that includes families 5. Ensure continuity of care/referrals 6. Refer to the Alzheimer s Association for support for PWDs and their caregivers Case Studies utilized throughout the day Learning Outcomes 1. Utilize hospital assessment tool to identify possible dementia triggers 2. Utilize nursing plan of care to identify and appropriately address the special needs of PWDs 3. Utilize interdisciplinary teamwork effectively Integrate and apply the knowledge and skills acquired in this training

13 ORIGINAL ARTICLE Dementia-friendly Hospitals: Care not Crisis An Educational Program Designed to Improve the Care of the Hospitalized Patient With Dementia James E. Galvin, MD, MPH,*w zy Barbara Kuntemeier, MA, MS,* Noor Al-Hammadi, MBChB, MPH,* Jessica Germino, BA,* Maggie Murphy-White, MA,J and Janis McGillick, MSWJ Background: Approximately 3.2 million hospital stays annually involve a person with dementia, leading to higher costs, longer lengths of stay, and poorer outcomes. Older adults with dementia are vulnerable when hospitals are unable to meet their special needs. Methods: We developed, implemented, and evaluated a training program for 540 individuals at 4 community hospitals. Pretest, posttest, and a 120-day delayed posttest were performed to assess knowledge, confidence, and practice parameters. Results: The mean age of the sample was 46 years; 83% were White, 90% were female, and 60% were nurses. Upon completion, there were significant gains (P s <0.001) in knowledge and confidence in recognizing, assessing, and managing dementia. Attendees reported gains in communication skills and strategies to improve the hospital environment, patient safety, and behavioral management. At 120 days, 3 of 4 hospitals demonstrated maintenance of confidence. In the hospital that demonstrated lower knowledge and confidence scores, the sample was older and had more nurses and more years in practice. Conclusions: We demonstrate the feasibility of training hospital staff about dementia and its impact on patient outcomes. At baseline, there was low knowledge and confidence in the ability to care for dementia patients. Training had an immediate impact on knowledge, confidence, and attitudes with lasting impact in 3 of 4 hospitals. We identified targets for intervention and the need for ongoing training and administrative reinforcement to sustain behavioral change. Community resources, such as local chapters of the Alzheimer Association, may be key community partners in improving care outcomes for hospitalized persons with dementia. Key Words: dementia, hospital care, education (Alzheimer Dis Assoc Disord 2010;24: ) Received for publication November 18, 2009; accepted May 6, From the *Alzheimer Disease Research Center; Departments of wneurology; zpsychiatry; yneurobiology, Washington University School of Medicine; and JAlzheimer Association, St Louis Chapter, St Louis, MO. Supported by grants from the National Institutes of Health P50 AG05681, the Retirement Research Foundation, and the Alzheimer Association. James E. Galvin is now located at New York University Langone School of Medicine. Statistical Analysis was conducted by Noor Al-Hammadi, MBChB, MPH and James E. Galvin, MD, MPH, Washington University School of Medicine. Reprints: James E. Galvin, MD, MPH, Center of Excellence on Brain Aging, New York University Langone School of Medicine, 145 East 32nd Street, 2nd Floor, New York, NY ( James.Galvin@nyumc.org). Copyright r 2010 by Lippincott Williams & Wilkins Alzheimer disease (AD), the most common cause of dementia affects over 5 million Americans. 1 In addition to cognitive and functional decline, AD and related dementias triple healthcare costs for individuals over 65 years of age 2,3 and leading to increased morbidity and higher mortality. 3 Studies suggest between 19% and 76% of patients with dementia are hospitalized 1.5 to 2 times per year. 4 Using Medicare data, it is estimated that 3.2 million hospital stays involved a person with dementia in 2000, suggesting that up to a quarter of hospital stays of elderly persons were patients with dementia. 4 In 2000, 9% of Medicare beneficiaries had at least one claim with a diagnostic code for AD (ICD-9: 331.0) or some other form of dementia, and these same individuals had 3 times more hospital stays than the average stays for all Medicare beneficiaries. 5 The prevalence of dementia among persons discharged from acute care hospitals ranges from 4% to 27%. 6 Current evidence reveals higher rates of hospitalization 7 and levels of comorbidity among patients with dementia than among cognitively intact patients, 8 12 with falls and behavioral problems being frequent causes of admission. 13 AD and related disorders may be poorly recognized in community settings and if unrecognized may serve as a trigger for a host of undesirable adverse events upon hospitalization, including falls, unintended injuries, deconditioning, malnutrition, incontinence, nosocomial infections, over or under medication, and adverse responses to medications, leading to poorer outcomes. 6,14 17 Management of symptoms, particularly pain, 18 is compromised and disruptive, unsafe behaviors are common and often untreated. 19 Thus, dementia seems to be associated with significant increases in functional disability, number of hospitalizations, lengths of hospital stay, rates of nursing home admission, death and health care costs. 6 Given the aging population and the risks of dementia with increasing age, hospital staff can expect that the number of elderly persons presenting with memory problems in addition to medical and/or surgical problems when hospitalized will also increase. Dementia increases the burden of acute care systems and is associated with excessive use of nursing resources, higher complication rates, and longer stays. 20 Older adults, as well as their families and caregivers, are thus particularly vulnerable to systems of care that either do not recognize or are unable to meet their special needs. Here we present the development, implementation, and evaluation of a program entitled Dementia-friendly Alzheimer Dis Assoc Disord Volume 24, Number 4, October December 2010

14 Alzheimer Dis Assoc Disord Volume 24, Number 4, October December 2010 Dementia-friendly Hospitals Hospitals: Care Not Crisis. This program targeted nurses and other direct-care staff (social workers, pastoral care, discharge planners, physical therapists) working in hospital settings to provide them with information and resources to allow them to better care for patients with dementia from admission to discharge planning. The impetus for this program came out of the recognition that many of the Helpline calls received at the Alzheimer s Association St Louis Chapter dealt with the poor outcomes of hospital visits for patients with dementia. METHODS Study Participants Five hundred forty staff members attended the 2 pilot and 8 training sessions. Two hospitals (Hospitals A and B) were recruited via ongoing relationships with the Alzheimer Association to participate in the pilot program with 143 attendees. After the pilot, 397 participants comprised of nurses, therapists, social workers, nurses assistants, pastoral care, and administrators signed consent to participate in research and attended 1 of 2 sessions held at 4 community hospitals in Missouri: Hospital A (N=68) located in suburban south St Louis, Hospital B (N=66) located in southeast rural Missouri, Hospital C (N=97) in urban north St Louis, and Hospital D (N=166) located in suburban St Louis county. Each hospital was responsible for advertisement and registration via an online system. The Washington University Human Research Protection Office approved all procedures. Program and Curriculum Development The initial program content ideas was developed from the John A. Hartford Institute for Geriatric Nursing and the National Alzheimer Association publications Try This: Best Practices in Nursing Care for Persons with Dementia ( In 2006, the Alzheimer Association St Louis Chapter and the Washington University Alzheimer Disease Research Center collaborated to conduct focus groups attended by staff from rural, urban, and suburban acute care settings. Barriers to dementia-friendly hospital stays, staffing, and training issues and unmet needs such as proactive training and hospital-wide system modifications were discussed. The focus group also made suggestions for better practices and improved outcomes. In 2007, the St Louis Chapter of the Alzheimer s Association and the Washington University Alzheimer Disease Research Center developed a pilot program for Hospitals A (suburban) and B (rural). In developing this program, it was important to establish relevance and validity of the program to urban and rural areas. Using feedback from these pilot programs, the curriculum was revised to incorporate group learning. Upon completion of these pilot programs, a national advisory panel was constituted to assist with curriculum development and program evaluation tools. The curriculum consisted of 5 learning modules (Introduction, Medical Overview, Approaches to Communication and Behavior, Dementia Friendly Care, and Connecting the Caregiver). The curriculum contained both didactic information and incorporated group learning by asking groups to review case studies and generate care plans and discharge plans using forms specific to each institution. The Introduction module reviewed facts and figures associated with AD and introduced each of the accompanying modules. The Medical Overview module reviewed signs and symptoms of dementia, differential diagnosis, and distinctions between dementia, delirium, and depression. The module reviewed brief screening tools for assessing patients, both informant based such as the AD8, 21 and performance measures such as the Mini-Cog. 22 The Communication module reviewed language and comprehension difficulties associated with cognitive impairment and behavioral changes that accompany the different stages of dementia. 23 The Dementia Friendly Care module reviewed topical issues such as safety interventions, falls, pain assessment, nutrition, use of restraints, wandering, agitation, and diversion activities. The Connecting the Caregiver module reviewed the importance of early initiation of interdisciplinary discharge planning and referral to services such as those provided by the Alzheimer Association. The program lasted 7 hours and included ample breaks and lunch. Each module was delivered by a different specialist in that particular area; for example, a physician delivered the Medical Overview module, whereas a social worker from the Alzheimer Association delivered the Connecting the Caregiver module. In addition, an associated Medical Grand Rounds at each hospital was offered to make physicians aware of the training made available to the staff. Outcome Measurements Participants completed the following evaluation materials: (1) a pretest evaluating demographics, clinical practice characteristics, medical knowledge about dementia, confidence in providing care, and various practice behaviors; (2) a standard program quality rating form completed immediately after training; (3) an immediate posttest questionnaire similar to the pretest to assess immediate gains in knowledge and confidence; and (4) a delayed posttest at 120 days to test maintenance of knowledge and confidence. Questions were investigator generated after input from focus groups, a review of the literature and comments from the advisory panel. All participants were asked 6 questions regarding current practices and attitudes when caring for hospitalized patients with dementia on a 1-5 Likert scale with anchors Strongly Disagree and Strongly Agree. Content included frequency of encountering and difficulty working with demented patients, time to provide comprehensive care, value of family member input, previous training, and opinion on admission procedures. Five questions addressed respondents confidence in assessing and recognizing dementia, managing demented patients, differentiating delirium from dementia, communication skills, and discharge planning on a 1-5 Likert scale with anchors Not at all and Extremely. A 9-item multiple choice test was administered testing knowledge of basic facts about dementia prevalence, risk factors, signs and symptoms, risk of elopement, and use of restraints. In addition to quantitative data, a series of qualitative questions were asked. On the pretest, respondents were asked to list challenges they face when working with demented patients and skills or resources that would enable them to provide better care. The posttest asked for changes attendees would make in assessment, care, or management of dementia patients. The 120-day posttest queried whether attendees were involved in the care of dementia patients, use of referral to the Alzheimer Association, changes in r 2010 Lippincott Williams & Wilkins 373

15 Galvin et al Alzheimer Dis Assoc Disord Volume 24, Number 4, October December 2010 clinical care, and remaining barriers faced when working with patients with dementia. Statistical Analysis Analyses were performed using SPSS version 15 (SPSS Inc, Chicago, IL). Descriptive statistics were used to characterize and compare groups. An outcome variable for knowledge was created on a continuous scale ranging from 0 to 14 by adding up the number of correct answers. Another composite variable was calculated to assess participants confidence in dealing with dementia issues and care on a 0 to 5 continuous scale with very much or extremely=1 and all other answers=0. Three points of time were used to assess the benefits the participants gained from the workshop in terms of improving their knowledge, confidence, practices, and attitudes in dealing with a dementia patient: a pretest before the program, a posttest at its conclusion and a delayed posttest at 120 days. Paired sample t tests, w 2 tests, and 1-way analysis of variance were used to assess the success of the program in achieving its goals and objectives. Stepwise linear regression was performed to assess predictors of knowledge and confidence gain among the participants at the end of the program. There was a preplanned analysis of hospital data regarding falls, use of restraints, and antipsychotic medications, length of stay, and readmission rates before and after the program to evaluate whether gain in knowledge and confidence or change in attitudes and practice altered patient care outcomes. Unfortunately, the participating hospitals declined to provide this data to the investigators. RESULTS Sample Characteristics Table 1 depicts the characteristics of the study participants from each of the 4 medical centers: Hospital D (41.8%), Hospital C (24.4%), Hospital A (17.1%), and Hospital B (16.6%). The mean age of the study population was 46 years and most were females (90.4%). Participants reported ethnicity was 83% White, 10% African-American, 3% Asian, and 2% Hispanic, whereas 2% did not respond. The participants were mainly nurses (60%). Most participants worked the day shift (73.3%), and 35% reported working on a medical-surgical ward. Participants reported that 68% of their patients were 65 years of age and older and that 29% of them had some form of dementia. Most participants (78.6%) had received 3 hours or less of training on dementia-related issues and care within the last 2 years. Immediate Benefits on Knowledge and Confidence On a test of knowledge about dementia, the participants scores significantly improved at the end of the program (Table 2). Participants were asked to rate their level of confidence in dealing with the hospitalized patient with dementia before and after the program. Participants reported a significant improvement in their overall confidence (Table 2) as well as in each individual variable: assessment and recognition of dementia, managing dementia care, differentiating dementia from delirium, communicating with the patient and family, and discharge planning. TABLE 1. Descriptive Statistics of Study Participants Delayed Posttest Original Sample Sample Variable Mean SD Mean SD P Age (y) NS Years of practice NS % Patients >65 y NS % Patient with NS dementia N % N % P Hospital <0.001 Hospital A (suburban) Hospital B (rural) Hospital C (urban) Hospital D (suburban) Sex Male Female Race/Ethnicity 0.03 Whites Other Profession <0.001 Nurse OT/PT (any therapy) Other Schedule <0.001 Day shift Evening and night shift Training on dementiarelated <0.001 care in the last 2 y None <=3 h >3 h NS indicates not significant; OT, occupational therapy; PT, physical therapy. TABLE 2. Knowledge and Confidence Level Among Participants Before and at the End of the Workshop Pretest Posttest Mean SD Mean SD P Knowledge <0.001 Level of confidence <0.001 N % N % Assess and recognize <0.001 Not at all reasonably very much extremely Manage care <0.001 Not at all reasonably Very much extremely Differentiate from delirium <0.001 Not at all reasonably Very much extremely Discharge planning <0.001 Not at all reasonably Very much extremely Communicate with patient <0.001 and family Not at all reasonably Very much extremely r 2010 Lippincott Williams & Wilkins

16 Alzheimer Dis Assoc Disord Volume 24, Number 4, October December 2010 Dementia-friendly Hospitals TABLE 3. Evaluations of Attitudes and Practices Toward Hospitalized Dementia Patients Before and at the End of the Workshop Disagree Neutral Agree N % N % N % P Is it difficult to work with dementia patients? <0.001 Pretest Posttest I do not have enough time to provide comprehensive care <0.001 Pretest Posttest I believe in help from family members and caregivers NS Pretest Posttest I have received sufficient training to take care of dementia patients 0.02 Pretest Posttest Admission procedures should be no different than for patients without dementia <0.001 Pretest Posttest I rarely see a diagnosis of a dementia disorder upon hospital admission <0.001 Pretest Posttest NS indicates not significant. Immediate Benefits on Attitude and Practice Participants were asked a series of questions regarding attitudes and practices toward the hospitalized patient with dementia (Table 3) rated as disagree, neutral, or agree. The questions evaluated participants perceptions in terms of the difficulties they face working with a dementia patient and providing enough time for comprehensive care, as well as their opinions about considering family members and caregivers in their health plans. They were also asked if they had received enough training to recognize and take care of patients with AD or other dementias, especially in terms of admission procedures. After the program, there was a significant improvement in attitude with the exception of the respondents valuing help from family members and caregivers. Program Evaluation At the end of the education program, an evaluation was distributed among the participants to assess whether it achieved its objectives; 76.3% reported that the program was excellent and comprehensive; 92% found the handout material was useful for future reference. Most participants (83%) agreed that the workshop covered ways to improve communication with patients with dementia and their family members or caregivers successfully. Attendees reported that they had gained useful information regarding how to adjust the physical environment (eg, light, noise) to suit the needs of a patient with dementia (83%), how to address disruptive behaviors or agitation (71%), and recognize safety issues to promote safer environments (81%). Participants also reported gains in pain assessment and medication effects (67%), strategies for providing nutrition and personal care for a patient with dementia (72%), and usefulness of community referrals (ie, Alzheimer Association) during discharge planning (81%). Delayed Posttest Results Follow up of the program participants was done 120 days after the date of the workshop to assess the maintenance and retention of knowledge and level of confidence as well as their practices and attitudes toward hospitalized dementia patients. Incomplete contact information was provided by 142 attendees so that no posttest could be administered. Between the time of the immediate posttest and delayed posttest 4 months later, 17 participants had left their institutions (Hospital A=4, Hospital B=4, Hospital C=5, and Hospital D=4) and were lost to follow-up. Of the 238 participants who completed the immediate posttest and were still at their institution, 34 returned the delayed posttest (14.3% response rate). Characteristics of the delayed posttest sample are shown in Table 1. No differences in age, years of practice, or experience with geriatric or demented patients were found. Respondents in the delayed posttest sample were more likely to be female (P=0.002), White (P=0.03), a therapist (P<0.001), and work the day shift (P<0.001). The delayed posttest sample was more likely to report no training in the care of dementia patients in the past 2 years (P<0.001). When comparing posttest scores, 3 hospitals showed slight declines in knowledge at 120 days: Hospitals A, B, and C (Table 4). However, there was a significant loss of both knowledge and confidence in the participants at Hospital A, whereas confidence in assessing and managing dementia patients remained stable at the other 3 hospitals. The largest proportion of respondents to the delayed posttest was from 2 hospitals: Hospitals A and D, which were also the hospitals with the highest retention of staff attending one of the training programs. Because of the differences between Hospitals D (maintenance of knowledge and confidence) and A (loss of knowledge and confidence), we compared the characteristics of the original and delayed posttest samples between the 2 hospitals (Table 5). There were neither differences in the original sample on any of the demographic variable nor were there any differences in the immediate posttest scores for knowledge or confidence. When examining the demographic variables of the delayed posttest sample from Hospital A, the group who returned the delayed posttest was representative of r 2010 Lippincott Williams & Wilkins 375

17 Galvin et al Alzheimer Dis Assoc Disord Volume 24, Number 4, October December 2010 TABLE 4. Evaluations of Knowledge and Confidence Levels at the End of the Program and 120 Days Knowledge Confidence Posttest Delayed Posttest Posttest Delayed Posttest Mean (SD) Mean (SD) P Mean (SD) Mean (SD) P Hospital A (suburban) 12.9 (1.5) 11.2 (2.2) (1.8) 0.9 (1.4) 0.02 Hospital B (rural) 12.8 (1.5) 11.6 (1.5) (1.9) 2.2 (1.8) NS Hospital C (urban) 12.4 (1.8) 9.8 (2.4) (1.8) 2.1 (1.9) NS Hospital D (suburban) 12.8 (1.4) 12.1 (2.1) ns 2.3 (2.1) 1.6 (2.1) NS NS indicates not significant. the original group of participants in terms of their race, schedule, dementia training, and experience with geriatric and demented patients. However, the delayed posttest sample was older (P=0.02), contained more females (P=0.01), had a higher proportion of nurses (P<0.001), and had more years in practice (P=0.03) when compared with the original sample. When examining the demographic variables of the retention sample from Hospital D, the delayed posttest sample contained more African-Americans (P<0.001), had a smaller proportion of nurses (P<0.001) and had little to no dementia training in the past 2 years (P<0.001). Stepwise linear regression was performed to assess predictors of knowledge and confidence gain among the participants at the end of the program. Interestingly, those respondents who reported receiving dementia training for more than 3 hours in the past 2 years unexpectedly had a 1.3-fold decrease in knowledge after the program. None of the available characteristics seemed to be an indicator of confidence gain among the participants. Qualitative Results Participants were asked at the time of pretest to list challenges they face when working with persons with dementia. The most common challenges include dealing with patient safety issues, how best to communicate with the patient, and how well the patient understood the instructions they received (especially at discharge). Staff also noted challenges dealing with the lack of time they had to spend with the patients, family denial of cognitive problems, behavioral and mood changes, confusion, and a lack of staff education to deal with each of these challenges. Respondents were also asked to list skills, tools, supplies, or resources they believed would enable them to better care for the person with dementia. The greatest unmet need was in-service training to increase the staff s understanding of dementia and strategies to improve the hospital environment for the patient with dementia. This included reducing the patient to staff ratio. Attendees also requested appropriate supplies and activity items to keep the patients occupied and strategies for improving communication skills and patient safety. Other requests included strategies to improve communication with families and caregivers and intervention approaches and resources for discharge planning. At the posttest, attendees were asked to list 2 changes they would make in their assessment, care, and discharge of the patient with dementia. The greatest behavioral change was to involve the families to a greater extent and to include a family questionnaire such as the AD8 21 in their assessments. The staff also recognized the need for improved communication skills with the patient, such as sitting and talking clearly, using nonverbal clues, and asking permission to touch the patient to improve care. Strategies to improve the hospital environment, such as better lighting, activity kits, music, familiar pictures and warm blankets, were listed, as was the need to refer patients to the Alzheimer Association and other community resources at the time of discharge. Other Unanticipated Results In addition to planned outcome evaluations of knowledge, confidence, and practices, a number of changes in the culture at the institutions have occurred. Three of the trained hospitals have instituted activity kits for hospitalized persons with dementia. Hospital B created Chris TABLE 5. Comparison of Characteristics of the Original and Delayed Posttest Sample from 2 Hospitals Hospital A Hospital D Variable Original Delayed Posttest P Original Delayed Posttest P Age (y) 44.4 (13.2) 53.0 (7.3) (11.9) 44.6 (11.8) NS Sex, % female NS Race, % White ns <.001 Profession, % nurses < <.001 Years of practice 17.7 (18.6) 23.9 (13.6) (12.9) 11.3 (13.2) NS Schedule, % days ns NS Patients >65, % ns NS Patients with dementia, % ns NS Dementia training >3 h, % ns <0.001 Pearson w 2 or Fisher Exact test was used to calculate P value for categorical variables and t tests for the continuous variable. NS indicates not significant r 2010 Lippincott Williams & Wilkins

18 Alzheimer Dis Assoc Disord Volume 24, Number 4, October December 2010 Dementia-friendly Hospitals Alzheimer s Recreation Kits named after a donor s husband. Each kit includes: Twiddle muff ( com/), a photo album for the family to fill with pictures, soft books, Tangle Toys, an Alzheimer Association catalog, a copy of The Forgetting: Alzheimer s: Portrait of an Epidemic by David Shenk, and a 4 CD box set of music. The kits are being distributed to patients in the hospital with a dementia diagnosis, patients seen on the mobile van, and through the Lutheran Family Services Alzheimer s group. Hospital A created a team of volunteers (called the A-Team ) especially trained to assist in the care of the hospitalized person with dementia. The A-Team centers its activity on the geriatric unit of the hospital, where volunteers spend weekday afternoons with patients with Alzheimer disease or other forms of cognitive impairment. They provide companionship, alert a nurse if the patient tries to do something unsafe, and provide activities. The A-Team was launched at the end of October 2008 and is a pilot program of specialized care for patients with dementia. In addition, Hospital A instituted a Code Green procedure that placed patients at risk for elopement in green gowns and trained staff on appropriate dementiafriendly responses and precautions. DISCUSSION We were able to successfully train over 500 individuals at 4 area hospitals on dementia-friendly care. Most participants had little to no prior training in dementia care within the last 2 years. After completion of the training program, an improvement in knowledge about and confidence dealing with the hospitalized person with dementia was seen and was associated with a significant change in attitude toward dementia care. We were able to identify the staff s unmet needs and barriers to improving care. The program was well received by the attendees and several unanticipated benefits resulted, including the development of specialized care teams, hospital procedures, and activity kits for dementia patients. Delayed posttests demonstrated maintenance of confidence in assessing and managing dementia patients in 3 of 4 hospitals trained. This was surprising given that the hospital that did not retain knowledge or confidence (Hospital A) was the most proactive of the 4 hospitals, participating in the pilot program and developing ancillary care teams, procedures, and activities for dementia care. It was also interesting that the strongest predictor for the lack of a gain in knowledge was in the 15% of attendees who reported they had had more than 3 hours of dementia training in the past 2 years. This may explain, in part, the loss of maintenance at Hospital A as staff from this institution reported the highest percentage of dementia education before the training programs. Participants who received such training may have relied on previously learned information and had limited uptake of new knowledge from the sessions. Alternatively, the information the staff received during previous training may have been incorrect or misremembered. Cognitive impairment of any cause poses challenges to the healthcare providers in the hospital setting; such challenges include recognizing symptoms, making diagnoses, and dealing with potentially serious sequelae such as adverse effects of medications and procedures. 20,24 28 Dementia in all its various forms, particularly at its earliest stages, may be overlooked by providers, leading to underdiagnosis and undertreatment. 29 Furthermore, symptoms of dementia, especially in the hospital setting, may be attributed to other causes such as delirium, depression, medication, infection, or metabolic derangements. 30 This program originally was designed to evaluate whether educating the hospital staff most directly involved in patient care could improve these outcomes; however, at the completion of the programs, the hospitals decided not to share outcome data. Care of the dementia patient while in the hospital may also be compromised. Dementia-related behavioral phenomenon may interfere with accustomed staff policies, placing more emphasis on individual needs of the dementia patient. 31 Additional challenges include communicating with the demented patient, issues with managing nutrition and rehabilitation, and appropriate disposition at the time of discharge. Knowledge of dementia may not be enough to overcome these challenges 32 ; rather, changes in care practices may alleviate staff burden and improve patient outcomes. Results from this and other studies point to the burgeoning recognition by hospitals and acute care health professionals of poor outcomes and high costs associated with dementia care and the need to develop a solution. There have been attempts to improve care of the hospitalized patient with dementia. One such project was initiated by the Providence Milwaukie Hospital System in Portland, Oregon. Providence Milwaukie Hospital implemented a project to improve delivery of care with 5 goals, including improving recognition of dementia on admission, identifying special needs and risks, emphasizing the use of nonpharmacological interventions for behavior, involving family in discharge planning, and providing dementia information and education. 33 Although staff more frequently expressed awareness of dementia screening tools such as the Mini-mental State Examation, there was little evidence for increased use of such instruments either on admission or in care planning. Diagnosis of dementia increased by 34% and depression by 22%; however, management of such problems led to an 8% increased use of antipsychotics and a 22% increased use of benzodiazepines without any increase in the use of antidepressants. 33 Other attempts at improving patient outcomes through education programs alone have had mixed results. Hospital staff come from a variety of disciplines and have a diverse range of practice patterns and educational needs. 34 Interventions limited in scope to select units may not reach desired impact. For example, programs directed a infection control that have focused on single nursing units did not significantly improve patient outcomes. 35 Organizations with frequent changes in personnel and leadership such as occur in most hospital units may not have the stable infrastructure necessary to attain and sustain change. Instead hospital-wide programs associated with protocols for care and management, national guidelines, and evidence-based practice may be the best approach to improving patient outcomes Our study supports that maintenance of knowledge and practice changes may not be longlasting without continued in-service training and hospitalwide systematic change. The Dementia-friendly hospital program described here is one such example of a hospitalwide program that can lead to hospital wide guidelines, practice change, and improved discharge planning including referral to community resources such as the Alzheimer r 2010 Lippincott Williams & Wilkins 377

19 Galvin et al Alzheimer Dis Assoc Disord Volume 24, Number 4, October December 2010 Association. 37 It remains to be seen if these guidelines ultimately lead to improved outcomes. Our study has limitations. In addition to the posttest results, other planned analyses of outcomes included reviewing data on falls, restraint use, elopement incidences, length of stay, and readmission to determine whether the training had tangible benefits to the hospitals. Unfortunately, the participating institutions were unwilling to share this data. The hospitals and staff appeared to be more committed to the practical issues of training rather than participating in the research component. The 120-day posttest was difficult to collect. No incentives were offered for completing the posttest, which may have lowered the response rate. In several instances, contact information on the pretest was incomplete, illegible or incorrect, making it difficult to reach participants for the delayed posttest. The low response rate (14%) for the 120-day delayed posttest limits generalizability of the findings, especially because nonresponse bias is difficult to assess. 38 Reported response rates for mailed surveys to the general population approach 60%, whereas response rates for health professionals vary from 11% to 90%. 38 An alternative interpretation of the low response rate could be that those who did not respond to the survey had an inherently poor view of research in general or of this particular topic and simply chose not to respond. In addition, given the low response rate, the actual responses may be driven by the demographic characteristics of the respondents rather than the educational program they attended. Although there is no way to test this hypothesis, it is informative to note that those with the least prior training and experience gained knowledge and confidence and maintained it, whereas those with the most prior training and experience did not show maintenance. The greatest value of the program was the demonstration of feasibility of gaining the confidence of the hospital and staff to recognize the unmet need of dementia training and to dedicate time and resources to host an educational program. The greatest weakness of the program was the inability to collect the preplanned outcome. The future of the program will depend on the ability to demonstrate that the educational initiatives translate into tangible patient outcomes. One approach we have taken is to partner with 2 academic institutions traditionally more amenable to research data collection. With these caveats in mind, these data highlight the feasibility and interest at both the hospital and staff level in increasing awareness about dementia and its impact on poorer outcomes and higher costs during hospitalization. The serious need for dementia training among acute care staff was identified in the pretraining survey. This was associated with low confidence in knowledge or ability to care for dementia patients who often present with comorbidities. Training had an immediate impact on knowledge, confidence, and attitudes, and confidence was maintained in 3 of 4 hospitals trained. Unanticipated benefits were the development of specialized care teams and activity kits. We were able to identify potential targets for intervention and the need for ongoing training and the administrative reinforcement necessary to sustain behavioral change. In moving forward with the program, we need to include tangible benefits to the participating hospitals, including aspects of cost-benefit analyses. Community resources, such as local chapters of the Alzheimer Association, may be key community partners in improving care outcomes for hospitalized persons with dementia. Hospital Initiative Advisory Panel Marie Boltz, PhD, APRN, BC, Director of Practice Initiatives Hartford Institute for Geriatric Nursing, New York University, New York, NY; Joan D Ambrose, MA, RN, President, Alzheimer s Association St Louis Chapter, St Louis, MO; Carol Ellis, RN, Manager, Education Services, St Anthony s Medical Center, St Louis, MO; Della Frazier-Rios, RN, MS, Senior Vice President, Alzheimer s Association New York City Chapter, New York, NY; James E Galvin, MD, MPH, Associate Professor, Washington University School of Medicine, St Louis, MO; Roni Haas, MSW, LCSW, Manager, Mental Health Services, Christian Hospital, St Louis, MO; Tina Hartlein RN, Program Director Senior Lifestyles, Missouri Delta Medical Center, Sikeston, MO; Karen Hendrickson, EdD, RN, CNAA, BC, Chief Nursing Officer, Southeast Missouri Hospital, Cape Girardeau, MO; Helen Lach, PhD, RN, CS, Assistant Professor, St Louis University School of Nursing, St Louis, MO; Nancy Little, RN, Staff Nurse, St Luke s Hospital, Chesterfield, MO; Katie Maslow MSW, Associate Director for Quality Care Advocacy, National Alzheimer s Association, Chicago, IL; Thomas Meuser, PhD, Director of Gerontology, University of Missouri St Louis, St Louis, MO; Peter Reed PhD, Senior Director of Programs, National Alzheimer Association, Chicago, IL; Clarissa Rentz, MSN, APRN, Executive Director, Alzheimer s Association Greater Cincinnati Chapter, Cincinnati, OH; Susan Rothas, RN, BSN, Manager, Professional Training Institute, Alzheimer Association Greater Illinois Chapter, Chicago, IL; Nancy Smith-Hunnicutt, BA, Coordinator of Dementia Responsive Care, Mission Hospitals, Asheville, NC; and Myrna Ward, MSN, RN, Director of Patient Care, Southeast Missouri Hospital, Cape Girardeau, MO. REFERENCES 1. Hebert LE, Scherr PA, Bienias JL, et al. Alzheimer disease in the US population: prevalence estimates using the 2000 census. Arch Neurol. 2003;60: Alzheimer Association: Facts and Figures. Accessed from the World Wide Web 9/14/09 Available at: alzheimers_disease_facts_figures.asp 3. Naylor MD, Stephens C, Bowles KH, et al. Cognitively impaired older adults: from hospital to home. Am J Nurs. 2005;105: Maslow K. How many people with dementia are hospitalized? In: Silverstein NM, Maslow K, eds. Improving Hospital Care for Persons With Dementia. New York, NY: Springer Publishing Company; 2006: Silverstein NM. In search of dementia-friendly hospitals. A survey of patient care directors in Massachusetts. In: Silverstein NM, Maslow K, eds. Improving Hospital Care for Persons With Dementia. New York, NY: Springer Publishing Company; 2006: Fick D, Foreman M. Consequences of not recognizing delirium superimposed on dementia in hospitalized elderly individuals. 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20 Alzheimer Dis Assoc Disord Volume 24, Number 4, October December 2010 Dementia-friendly Hospitals 10. Hill JW, Futterman R, Duttagupta S, et al. Alzheimer s disease and related dementias increase costs of comorbidities in managed Medicare. Neurology. 2002;58: McCormick WC, Hardy J, Kukull WA, et al. Healthcare utilization and costs in managed care patients with Alzheimer s disease during the last few years of life. J Am Geriatr Soc. 2001;49: Aguero-Torres H, Fatiglioni L, Winblad B. Natural history of Alzheimer disease and other dementias: review of the literature in light of the findings from the Kungholmen Project. Int J Geriatr Psychiatry. 1998;12: Nourhashémi F, Andrieu S, Sastres N, et al. Descriptive analysis of emergency hospital admissions of patients with Alzheimer disease. Alzheimer Dis Assoc Disord. 2001;15: Neville S, Gilmour J. Differentiating between delirium and dementia. Nurs N Z. 2007;13: Naylor MD, Hirschman KB, Bowles KH, et al. Care coordination for cognitively impaired older adults and their caregivers. Home Health Care Serv Q. 2007;26: Balardy L, Nourashe mi F, Andrieu S, et al. Risk factors for early readmission of Alzheimer patients to an acute care unit. Brain Aging. 2003;3: Inouye SK. Current concepts: delirium in older persons. N Engl J Med. 2006;354: Rothschild JM, Bates DW, Leape LL. Preventative medical injuries in older patients. Arch Intern Med. 2000;160: Burgener SC, Twigg P. Interventions for persons with irreversible dementia. Annu Rev Nurs Res. 2002;20: Andrieu S, Reynish E, Nourhashemi F, et al. Predictive factors of acute hospitalization in 134 patients with Alzheimer s disease: a one year prospective study. Int J Geriatr Psychiatry. 2002;17: GalvinJE,RoeCM,PowlishtaKK,etal.TheAD8:abriefinformant interview to detect dementia. Neurology. 2005;65: Borson S, Scanlan J, Brush M, et al. The mini-cog: a cognitive vital signs measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry. 2000;15: Smith M, Hall GR, Gerdner L, et al. Application of the progressively lowered stress threshold model across the continuum of care. Nurs Clin North Am. 2006;41: Landers J. Evaluating and managing delirium, dementia and depression in older adults hospitalized with otorhinolaryngic conditions. ORL Head Neck Nurs. 2007;25: Knopman DS, Boeve BF, Petersen RC. Essentials of the proper diagnoses of mild cognitive impairment, dementia and major subtypes of dementia. Mayo Clin Proc. 2003;78: Wang SG, Goh WK, Lee BJ, et al. Factors associated with post-operative delerium after major head and neck surgery. Ann Otol Rhinol Laryngol. 2004;113: Blazer DG. Depression in late life: review and commentary. J Gerontol. 2003;58A: Jost BC, Grossberg GT. The evolution of psychiatric symptoms in Alzheimer s disease: a natural history study. J Am Geriatr Soc. 1996;44: Pisani MA, Redlich C, McNicoll L, et al. Underrecognition of preexisting cognitive impairment by physicians in older ICU patients. Chest. 2003;124: Cooper S, Greene JD. The clinical assessment of the patient with early dementia. J Neurol Neurosurg Psychiatry. 2005; 76(suppl V): Burgess L, Page S. Educating nursing staff involved in the provision of dementia care. Nurs Times. 2003;99: Packer T. Pass the hot potato- is this person centered teamwork. J Dem Care. 2000;8: Conedera F, Beckwith J. Changing dementia care in a hospital system. The Providence Milwaukie experience. In: Silverstein NM, Maslow K, eds. Improving Hospital Care for Persons With Dementia. New York, NY: Springer Publishing Company; 2006: Rolley J, Salamonson Y, Dennison CR, et al. Nursing care practices following a percutaneous coronary intervention: results of a survey of Australian and New Zealand cardiovascular nurses. J Cardiovasc Nurs. 2010;25: Kollef MH, Micek ST. Using protocols to improve patient outcomes in the intensive care unit: focus on mechanical ventilation and sepsis. Semin Respir Crit Care Med. 2010;31: Bingham M, Ashley J, De Jong M, et al. Implementing a unit-level intervention to reduce the probability of ventilatorassociated pneumonia. Nurs Res. 2010;59(1 suppl):s40 S Connell CM, Kole SL, Benedict CJ, et al. Increasing coordination of the dementia service delivery network: planning for the Community Outreach Education Program Gerontologist. Gerontologist. 1994;34: Cummings SM, Savitz LA, Konrad TR. Reported response rates to mailed physician questionnaires. Health Serv Res. 2001;35: r 2010 Lippincott Williams & Wilkins 379

21 Dementia Friendly Hospitals Care Not Crisis Alzheimer s Association, St. Louis Chapter Alzheimer s Disease Research Center, Washington University. Abstract Acute care settings are ill-equipped to deal with the special needs of persons with dementia. One-third of all persons with dementia are hospitalized annually, currently totaling 3.2 million hospital stays per year. (Silverstein & Maslow, 2006). Staff are not frequently trained to address dementia care issues adequately. Background Hospital systems are geared for cognitively intact persons. Statistically, 1/4 th of all hospital patients 65+ are people with AD or related dementias, a number projected to increase. These patients are at much higher risk for delirium, falls, fractures, elopement incidents, incontinence, dehydration, untreated pain, aggressive behaviors, physical restraint, functional decline, weight loss and pressure sores. (Silverstein & Maslow, 2006), increasing the likelihood of nonreimbursed hospital care, and expensive re-hospitalization or nursing home placement. At present, best practice, dementia-specific training that prevents or reduces poor outcomes is neither mandated or routinely taking place in hospitals. The Alzheimer s Association Education Institute (AAEI), has unique expertise and resources to assist with needs of affected families. Objectives Project Goal: To document that dementia care training of hospital staff can be linked to practice change outcomes related to improved quality of care in the acute care setting. Review and consolidate currently available international, best practices in hospital dementia care to develop and feasibility test, curriculum appropriate for use in acute care settings. Formalize and convene an expert advisory panel to review and refine training curricula, analyze results of 2007 AAEI pilots and determine appropriate course of educational interventions and outcomes measures for this pilot project. Confirm four hospitals willing to identify internal needs to improve dementia care capability, and commit multidisciplinary staff to participate in pilot AAEI training program and a follow-up process. Evaluate impact of training curriculum, format and modify as needed in preparation for larger scale replication and research in a variety of acute care settings. Method Five hundred forty staff members were recruited to attend the 2 pilot and 8 training sessions. A total of 397 participants comprised of nurses, therapists, social workers, nurses assistants, pastoral care and administrators signed consent to participate in research and attended one of two sessions held at 4 community hospitals in the St. Louis area. The curriculum consisted of 5 learning modules (Introduction, Medical Overview, Approaches to Communication and Behavior, Dementia Friendly Care, and Connecting the Caregiver). The curriculum contained both didactic information and incorporated interactive learning, and group case studies reviews. Learners generated care and discharge plans using forms specific to each institution. Assessment at three points of time measured the benefits participants gained from the workshop in terms of improving their knowledge, confidence, practices and attitudes in dealing with a patient with dementia. Data collection was done through a pre-test prior to the program, a post-test at its conclusion and a delayed post-test at 120 days. Correspondence Alzheimer s Association, St. Louis Chapter (alzstl.org) Funding provided by: Retirement Research Foundation (rrf.org) Practice Change Fellows (practicechangefellows.org) Results Data indicates a mean participant age of 46; a mean of 17.6 years of practice, yet 78.6% of respondents received 3 hours or less of training on dementia related issues in the last 2 years despite rapidly evolving advances in dementia assessment and management. Following completion of the training program, an improvement in knowledge about and confidence dealing with the hospitalized person with dementia was seen and was associated with a significant change in attitude toward dementia care. We were able to identify unmet needs and barriers to improving care for the hospitalized dementia patient. The program was well received by the attendees and several unanticipated benefits resulted, including the development of specialized care teams, hospital procedures and activity kits for dementia patients. Conclusions The serious need for dementia training associated with low confidence in knowledge or ability to care for dementia patients among acute care staff was validated. Training had an immediate impact on knowledge, confidence and attitudes, and confidence was maintained in 3 of 4 hospitals trained. We were able to identify potential targets for intervention and the need for ongoing training and the administrative reinforcement necessary in order to sustain behavioral change. Community resources, such as local chapters of the Alzheimer s Association and ADRC s and Hospital Associations are key community partners in improving care outcomes for hospitalized persons with dementia. To improve care for the hospitalized person with dementia, changes in practice delivery are certainly needed. Such a plan could include the following steps 1) Creation of a team to implement change; 2) Adequate supervision and guidance; 3) A plan for staff development and training; 4) An accreditation process; and 5) Effective quality monitors.