Older People with Dementia in Acute Care: K ey messages from the NAO report Paul Forte The Balance of Care Group .

Older People with Dementia in Acute

Care:

Key messages from the NAO report

Paul Forte

The Balance of Care Group

www.balanceofcare.com

2

NAO dementia study aims

• Set out the overall impacts of dementia in older people on the economy:– research; national surveys of GPs and CMHTs, – local ‘whole system’ study - Lincolnshire – focus groups and web forum for people with dementia

and their carers

• Recommend improvements to support for people with dementia and their carers to enable them to maintain good physical and mental health

• Recommend ways of reducing cost and duplication

• Provide an overall value for money assessment for Parliament and taxpayers

3

Pre admission

Pre admission Admission Diagnosis Treatment Discharge Re-admission

Social details

alone, carers, residence

Risk factors:

age, drugs, co-morbidities,

psychiatric/

dementia, falls

Preventative care

Disease managementManaged populations

Source of referral

Time

Waiting time

Route

Decision maker

Reason for admission

Alternatives to acute admission setting

Admission diagnosis

Inpatient diagnosis

Delays in diagnosis

Chronic disease

Alternative access for diagnosis

Delays in therapy

Alternative settings for therapy (especially rehab)

Discharge planning

Delays in planning

Delays in execution

Alternative sites for discharge

‘Revolving door’

Avoidable e.g. chronic disease management

Alternative sites for readmission

A whole system perspective

4

The Lincolnshire bed usage survey

• To identify the number and types of inpatients

currently receiving hospital care (acute and non-

acute) who might potentially have:

– been treated elsewhere and avoided admission

– required admission, but could now be treated elsewhere

– particular emphasis on people with dementia

5

The Lincolnshire bed usage survey

• To identify the number and types of inpatients

currently receiving hospital care (acute and non-

acute) who might potentially have:

– been treated elsewhere and avoided admission

– required admission, but could now be treated elsewhere

– particular emphasis on people with dementia

• Point prevalence survey on 29 November 2006

– All medical and orthopaedic inpatients (667)

– All intermediate care inpatients (121)

– All OPMH inpatients (75)

6

Age Distribution of Patients by Type of Bed (N=860)

0

50

100

150

200

250

Under 65 65 to 74 75 to 84 85 & over

No

of

pa

tien

ts

A -acute

B intermediate care

C - OPMH

7

Proportion of Patients with Mental Health or Cognitive Issues (N=863)

Dementia13%

Confusion14%

Anxiety/depression8%

Psychosis2%

Substance Misuse2%

Other1%

No mental health issue60%

8

Location of Patients by Mental/Cognitive Issue (N=344)

0

20

40

60

80

100

120

140

Demen

tia

Confus

ion

Anxiet

y/dep

ress

ion

Psych

osis

Substa

nce

Misu

se

Other

No

of p

atie

nts

OPMH

Intermediate care

Acute

9

Occurrences of comorbidities in dementia patients

0

5

10

15

20

25

30

Heart

failu

reIH

D

COPD

Diabet

es

Parkin

sons

Hyper

tensio

n

Arthrit

is

Cance

r

Cereb

rova

scul

ar

No

of o

ccur

renc

es

OPMH

IC

acute

10

Comorbidities for Patients with Dementia (N=111)

0

5

10

15

20

25

30

35

0 1 2 3 4 5

Number of comorbidities

No

of

pa

tien

ts

OPMH

IC

acute

11

Assessed risk of 'confusion' patients having dementia (N=119)

0

10

20

30

40

50

60

High Medium Low

Assessed risk of dementia

No

of

pa

tien

ts

OPMH

IC

acute

12

Source of Referral for Patients with Dementia - Acute (N=65)

Referral by GP18%

Seen by GP17%

99943%

Self2%

Other Hospital

2%

Other/nk18%

Source of Referral for Patients with Dementia - OPMH (N=40)

Referral by GP32%

Seen by GP5%

Other Hospital

15%

CMHT18%

Crisis Team8%

Other/nk22%

13

Appropriateness Evaluation Protocol

On admission

• Severity of illness eg unconscious, unable to move (fall), acute bleeding

• Intensity of service eg surgery + general anaesthesia, regular monitoring, IV

therapy

On day of care• Medical services

• Nursing services

• Patient conditioneg acute confusion, other acute states, coma, fever

14

Percentage of Acute Inpatients within AEP Criteria(Dementia = 65, all other = 602)

83%

32%

85%

53%

0%

20%

40%

60%

80%

100%

on admission on day of care

% o

f pat

ient

s w

ithin

AE

P c

riter

ia with dementia

all other

15

Preferred Alternatives to Admission for Dementia Patients (N=36)

0

1

2

3

4

5

6

7

8

Home

& Soc

ial C

are

Home

& Gen

eral

Health

Car

e

Home

& Spe

cialis

t Hom

e Car

e

Non A

cute

Bed

Non A

cute

Bed

& T

hera

py

Carer

Res

pite

Home

& MH S

uppo

rt

Psych

OP

Non A

cute

Bed

& M

H The

rapy

EMI C

ont C

are

Bed

No

of p

atie

nts

OPMH

IC

acute

16

Alternatives to Continued Stay for Acute Hospital Patients with Dementia (N=43)

0

2

4

6

8

10

12

Own

Home

Home

& Socia

l Car

e

Home

& Gen

eral

Hea

lth C

are

Home

& Reh

ab S

uppor

t

Home

& Spec

ialis

t Nurs

e

Acces

s to

Out

patie

nts

Non A

cute

Bed

& T

herap

y

Non A

cute

Bed

Home

& Spec

ialis

t Hom

e Car

e

Home

& MH S

uppor

t

Home

& MH R

ehab

Suppo

rt

Non A

cute

Bed

& M

H The

rapy

Acute

MH B

ed

EMI C

ont C

are

Bed

Oth

er

No

of p

atie

nts

Quick discharge

Remaining

17

Alternatives to Continued Stay for OPMH Patients with Dementia (N=34)

0

2

4

6

8

10

12

14

16

Own

Home

Home

& Socia

l Car

e

Home

& Gen

eral

Hea

lth C

are

Home

& Reh

ab S

uppor

t

Home

& Spec

ialis

t Nurs

e

Acces

s to

Out

patie

nts

Non A

cute

Bed

& T

herap

y

Non A

cute

Bed

Home

& Spec

ialis

t Hom

e Car

e

Home

& MH S

uppor

t

Home

& MH R

ehab

Suppo

rt

Non A

cute

Bed

& M

H The

rapy

Acute

MH B

ed

EMI C

ont C

are

Bed

Oth

er

No

of p

atie

nts

Quick discharge

Remaining

18

Some Key Points

• 111 out of 863 patients surveyed (13%) had a recorded dementia diagnosis

• 65 were in acute hospital• There may be substantial under-diagnosis or

under-recording of dementia• Majority of acute hospital patients with dementia

were outside AEP criteria on the day of the survey• Potential alternative care settings cover a wide

range of services; specialist coordination may be needed

• Demand for rehab support for people with dementia