The University of Nottingham

A new report by The University of Nottingham says there has to be nothing less than a culture shift to improve the hospital care of older people admitted with delirium and dementia. Failure to do so, the report says, will lead to poor outcomes and negative experiences of hospital care for patients and carers, delivered by a de-motivated workforce with inadequate skills for the job.

The report entitled: Better Mental Health: Care for Older People with Cognitive Impairment in General Hospitals was commissioned by the National Institute for Health Research Health Service and Delivery Research (NIHR HS&DR) Programme.

John Gladman, Professor of the Medicine of Older People, said: “Providing care for older people with cognitive impairment is complex, difficult, time consuming and emotionally draining. Staff need to be trained appropriately and wards resourced accordingly. A cultural shift is necessary to recognise that care of older people with mental health problems is core business of general hospitals. Understanding what the patients, their carers and the staff experience is helpful. Concerted efforts are required to interrupt what may become a vicious spiral of poor care and instead provide a virtuous cycle of high quality patient-centred care, with well-trained staff, good communication, an adapted environment and a proactive organisation at its core.”

In a typical 500 bed general hospital 330 beds will be occupied by older people. Half of these older people have confusion: up to 40 per cent have dementia, nearly 30 per cent have delirium and about 20 per cent have both.

Concerns about the care of older people admitted to hospital with mental conditions are widespread and it is accepted that the quality of care needs to be improved. The study did not evaluate the quality of care but explained what care there was and how it could be made better. This report, funded by the National Institute for Health Research Service health Services and Delivery Research (NIHR HS&DR) Programme, set out to identify potential areas for improvement. The results are published today on the programme website.

The study focused on one typical large UK hospital and sampled a wide range of wards that are typically found in general hospitals. Two teams of researchers working independently of one another set out to gain a greater understanding of staff’s experience of caring for such patients and the effect hospitalisation had on patients, their relatives and fellow patients.

Assessing the impact of hospital care on patients and carers

Admission to hospital for these vulnerable people can be seen as a disruption to their familiar routines causing distress behaviours. It can also affect patients sharing the same ward. Patients sharing rooms with elderly patients with mental health problems were at times adversely affected making them feel insecure and less able to rest.

Patients, carers, and staff could all be seen as trying to cope with the disruption by gaining or giving some level of control over the situation. Some attempts to gain or give control were associated with good outcomes such as comforting the patient and promoting their recovery, but some were associated with poor outcomes such as increasing patient’s frustration or further stressing their family carers.

The researchers spent time watching how the elderly with cognitive impairment were cared for. A total of 72 hours of non-participant observations of care took place on the 11 study wards. Interviews were conducted with 34 patients with mental health problems and their carers. Four fellow patients, without mental health problems who had shared a ward with the study patients were also interviewed after being discharged from hospital.

Staff as well as patients want improvements

Sixty staff — doctors, nurses and others — were interviewed in confidence. Two key findings emerged from this element of the study. Staff felt they lacked education and practical training to recognise and manage complex older patients with cognitive impairment. They felt that the system was inflexible and imposed unrealistic targets detracting from their time and ability to provide appropriate care, risking high levels of frustration and stress.

Staff told researchers they are often frustrated by their inability to provide good care for older people who are admitted with conditions such as dementia and delirium, partly because of inadequate training, partly lack of confidence, but also due to organisational factors and insufficient staff numbers.

Professor Amanda Griffiths, from The University of Nottingham’s Institute of Work, Health and Organisations, said: “Staff do care about this issue very much. It is rare to see such a large proportion of any professional group feel so poorly prepared to take on the task in hand. Both initial education and on-the-job training relevant to the care of elderly and confused patients was felt to be seriously inadequate. There were many requests for mandatory training at all levels. Staff who reported feeling confident in their own competence to deal with confused older patients were invariably those who by chance had relevant experience outside of hospital settings, either within their own families or in care homes.”

The benefits of change

Professor Gladman said: “Possible beneficial changes arising from this work include: better staff training, education and support; recognition of the patient–carer relationship underpinned by clear communication; better environmental design; a more proactive and facilitative organisation; commissioning of liaison psychiatry services; and development of specialist units. This will require high level organisational leadership and investment in services and in research and development.”

The paper is entitled: Better Mental Health: Care for Older People with Cognitive Impairment in General Hospitals. Final report NIHR Health Services and Delivery Research Programme; 2012. The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the NIHR HS&DR Programme or the Department of Health. Nottingham University Hospitals NHS Trust gave permission and provided access for the study.