Quality of Acute Care for Older Persons with Dementia A Hospital-Based Pilot Study Chien-Liang Liu Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taiwan 2013/04/20
Outline Background Methods Geriatric Evaluation and Management Unit (GEMU) Results Conclusion 2
Background 40% of acute general medical admissions over the age of 70 have dementia. Sampson EL, et al. Brit J Psych. 2009 Hospital presentations also include sudden worsening of confusion or dependency, or functional crisis such as falls. 3
Background Family members and carers of people with dementia are frequently dissatisfied with their experience of hospital care staff not recognizing or understanding dementia lack of activity and social interaction inadequate involvement in decision making perceived lack of dignity and respect London: Alzheimer s Society. 2009 4
Background Hospital stay for people with dementia is longer than for those with similar primary diagnoses but without co-morbid dementia. Sampson EL, et al. Brit J Psych. 2009 Admission can be very prolonged: in England 10% of people with dementia stay in hospital for more than 50 days. Royal College of Psychiatrists. London: RCPsych. 2011 5
Background The comprehensive geriatric assessment (CGA) is the validated and recommended instrument to a correct evaluation and decision making in elderly patients. Riccio D, et al. Arch Gerontol Geriatr. 2007 In-patient CGA may reduce short-term mortality, increase the chances of living at home at one year, and improve physical and cognitive function. However, CGA dose not reduce long-term mortality. Ellis G, Langhorne P. Br Med Bull 2005 6
Typical illness trajectories for people with dementia Persistent low function Quality of life is better than cure. Scott A M, et al. BMJ. 2005 7
Background Dementia in the acute hospital is different. The problems of people with dementia take longer to solve and need more assessment to figure out the current mental and physical status. Rowan H Harwood. Clinical medicine. 2012 8
Objectives We try to design a new acute care model for older people with dementia and performed a pilot study to show the preliminary results. 9
METHODS 10
Methods Participants Inclusion criteria People with dementia Aged 65 years and over Admitted to GEMU or medical wards Exclusion criteria Elective admission Transferred to surgical ward in the target admission 11
Methods Study design Cross-sectional, chart review study Study groups Intervention: GEMU Comparison: Medical wards 12
Acute care model for dementia in Taipei VGH GEMU in Taipei VGH 35-bed acute care unit Diagnosis of dementia: 27% CGA based services Chang-Cieng Building 13
CGA based acute care model for people with dementia Acute illness Home Outpatient Quick assessment Functional recovery (rehabilitation) No restrain (physical or chemical) Medical and care consultation Cognition, delirium Functional assessment Comprehensive geriatric assessment(cga) 1. Screening 2. Diagnosis 3. Treatment 4. Evaluate the treatment outcome Decline or not Yes No Admitted Out-patient services 14
Comprehensive Geriatric assessment like interventions Setting Most intensive CGA, GEM, and rehabilitation units CGA consultation impatient or outpatient Least intensive Community-based and in-home outreach programs Targeting Most restrictive Least restrictive Process Large team, extensive evaluations Screening and referral Cost Very expensive Relatively inexpensive CGA, comprehensive geriatric assessment; GEM, geriatric evaluation and management Hazzard's Geriatric Medicine & Gerontology, 6th Ed. 15
Interdisciplinary Team Geriatrician Neurologist Psychiatrist Physiatrist PT, OT Nurses Clinical Pharmacist Sharing information On the same page Social workers Case managers Dietitian Family members 16
CGA in Taipei VGH Cognitive assessment(mmse, CASI, CDR) Mobility assessment(fall risk) Delirium(Confusion Assessment Method, CAM) Depression(Geriatric Depression Scale, GDS 5) Nutritional assessment ADL, IADL Medication review(antipsychotics, anticholonergics) 17
GEMU Facilities in Taipei VGH 18
Acute Wards, 35 beds 19
Special designs for people with dementia 20
Reminiscence therapy 21
Delirium room & Light therapy room # For safety # Group activities # Non-pharmacological approach 22 22
Lounge Family activities Medical consultation Light therapy 23
Rehabilitation: PT& OT rooms(1f) 24
Methods Interesting variables Basic demographic data Cognitive function: MMSE Reason of admission Quality indicators Acute Care for Vulnerable Elders (ACOVE) NICE guideline Focus on current situation in Taiwan 25
Methods Quality indicators of acute care for older persons with dementia Regular cognitive assessment Mobility assessment Delirium screening Depression screening Nutritional assessment Caregiver support Advanced care plan Medication review Antipsychotics, anticholinergics Symptomatic treatment: Cholinesterase inhibitor, NMDA antagonist 26
RESULTS 27
older male 28
29
30
Longer Lower 31
32
Results Infection(pneumonia and UTI) and geriatric syndrome were the major causes of admissions to hospital. In GEMU services, older patient, longer stay, lower prescribing rate of antipsychotics. Higher rate of screening for cognitive function, delirium, depression, nutritional status under the CGA based services. 33
Results Low rate of discussing advance directives in dementia patient who received acute medical care. 34
CONCLUSION 35
Conclusion CGA based GEMU services can improve the quality of acute care for people with dementia. How to implant the concept of palliative care in acute care services is challenging in Taiwan. 36
References Sampson EL, Blanchard MR, Jones L, Tookman A, King M. Dementia in the acute hospital: prospective cohort study of prevalence and mortality. Brit J Psych 2009;195:61 6. Alzheimer s Society. Counting the cost. London: Alzheimer s Society, 2009. Royal College of Psychiatrists. National audit of dementia in general hospitals. Interim report. London: RCPsych, 2011. Riccio, D., et al., Comprehensive geriatric assessment in female elderly patients with Alzheimer disease and other types of dementia. Arch Gerontol Geriatr, 2007. 44 Suppl 1: p. 343-53. Ellis, G. and P. Langhorne, Comprehensive geriatric assessment for older hospital patients. Br Med Bull, 2004. 71: p. 45-59 Murray, S.A., et al., Illness trajectories and palliative care. BMJ, 2005. 330(7498): p. 1007-11. Rowan H Harwood. Clinical medicine 2012; 12: 35-9 37