Talk by Dr Shibley Rahman 5 - 5.30 pm British Geriatrics Society meeting on the gulf between aspirations and the reality of delivery of dementia care in acute NHS hospitals.

1. Dementia: from rhetoric
to reality
Dr Shibley Rahman
MRCP(UK) PhD LLM MBA
Programme for BGS Joint North Thames Summer Meeting
26 July 2016
Chelsea and Westminster Hospital
Post Graduate Medical Centre

3. Rahman (2014)

5. • “Dementia friendly wards” cannot ever be only
about the décor.
• Some of the rationale is evidence based (e.g.
good signage), some with weak evidence (e.g.
particular colour schemes).
• An emphasis on buildings can detract from the
wider therapeutic environment, e.g. staff
culture.

7. Rahman and Dening (2016)

8. cholinergic system of the brain

10. Oliver D Progress on dementia in hospital. BMJ. 2016 Apr
22;353:i2204. doi: 10.1136/bmj.i2204.
• As many as 40% of hospital patients over 75 have dementia
• “It travels with them, although they’re generally admitted for other primary
reasons.”
• “They’re more likely to die in hospital and to experience decompensation,
depersonalisation, and harms.”
• “Two reports, from the NHS Confederation and the Alzheimer’s Society,9
10 found that people with dementia occupy about a quarter of beds in acute
hospitals. They stay about a week longer on average. Nurses feel untrained,
unskilled, and less confident in assessing or treating them.”
• liaison psychiatry models within acute hospitals / workforce training /
specialist practitioners / RCP ‘Future hospitals’

12. RCP report - September 2012
Hospitals on the edge? The time for action
Overview of challenges facing acute hospitals
• Increasing clinical demand.
• Changing patients, changing needs. Nearly two thirds (65%) of people
admitted to hospital are over 65 years old, and an increasing number are
frail or have a diagnosis of dementia.
• Fractured care. Hospital doctors have reported the lack of continuity of care
as their biggest concern about the current health service. [rota gaps?]
• Out-of-hours care breakdown. Emergency admissions activity at weekends
is around a quarter lower than the rest of the week [NHS 24/7 Jeremy
Hunt]
• Looming workforce crisis in the medical workforce.

13. Porock D, Clissett P, Harwood RH, Gladman JR.
Disruption, control and coping: responses of and to the
person with dementia in hospital. Ageing Soc. 2015
Jan;35(1):37-63.
• family carers are often distressed by their
belief that staff did not understand the
condition.
• poor communication between professionals
and agencies and the family carers
• disputes and upsets between staff and family
carers and failed or problematic discharges

14. OTM

15. Rahman et al. (1999) Brain

16. Timmons S, Manning E, Barrett A, Brady NM, Browne V, O'Shea E, Molloy DW,
O'Regan NA, Trawley S, Cahill S, O'Sullivan K, Woods N, Meagher D, Ni
Chorcorain AM, Linehan JG. Dementia in older people admitted to hospital: a
regional multi-hospital observational study of prevalence, associations and case
recognition. Age Ageing. 2015 Nov;44(6):993-9.
• people with dementia stay longer in hospital than
their peers are more commonly discharged to
long-term care and have higher mortality
• of 598 older patients admitted to acute hospitals,
25% overall had dementia
• delirium was commonly superimposed on
dementia (57%) on admission.

17. Rahman (2015)

19. DAC Beachcroft report
DAC Beachcroft Partner Anne Crofts said that
people should be disabused of the notion that
integration will deliver immediate savings:
“That is not going to materialise in the short term
but there are potentially savings to be made in some
areas. Integration may have implications for the way
we train people and the way that systems organise
themselves – for example regulation and training of
healthcare and social workers is currently siloed.”

20. She also cautioned against too much emphasis on
organisational form.
“I think we will see a move to create more diverse NHS
organisations, bringing together services such as primary
care and mental health with acute and community care,
for example. But the statutory framework is complex
because the current organisational structures in acute,
primary and social care have been created under different
statutory regimes, which is a challenge to bringing
organisations together.”

21. “Our approach to designing the legal and
governance structures in projects such as North
West London Whole Systems Integrated Care is to
start from where the local health economy currently
is in terms of organisations and relationships.”
“We then work with that to build governance
structures and information sharing protocols across
organisational boundaries which are both robust and
flexible enough to accommodate mergers or new
entrants.”

23. Rahman (2015)

24. Barber J. Inclusion of carers when confused relatives are admitted to hospital.
Nurs Older People. 2015 Jun;27(5):23-7. doi: 10.7748/nop.27.5.23.e683.
• many older people have dementia but have never been
investigated or received a formal diagnosis
• if they are admitted to acute hospitals from their own homes
or long-term care settings with confusion and little
background information about their usual condition, it can
be challenging for staff to determine if they have dementia,
delirium, delirium superimposed on pre-existing dementia
or something else
• A careful history and information seeking from carers or
family members about their loved one's pre-admission
baseline can inform nursing and medical assessments

29. McMurdo ME, Witham MD. Unnecessary ward
moves. Age Ageing. 2013 Sep;42(5):555-6.
• NHS hospital services face increasing pressure on bed
availability as hospital bed numbers contract and
emergency admissions rise.
• majority of patients being boarded is frail, elderly and
cognitively impaired partly because such patients are
likely to stay in hospital long enough to fall victim to
boarding.
• frequent moves around a hospital are likely to increase
the risk of infection transmission

32. • @dr_shibley
• @dementiasoc
• legalaware1213@gmail.com