Download 1 Care of Patients with Dementia Policy Type: Clinical Guideline

Type: Clinical Guideline
Care of Patients with Dementia Policy
Register No: 10081
Status:
Public
Developed in response to:
Best Practice
National Guidance
1,2,4,5,6,7
Contributes to CQC Outcome
Consulted With
Post/Committee/Group
Date
Clive Gibson
Charlie Hoctor
Sandra Morton-Nance
Lead Nurse Elderly Assessment Team
Professional Development Nurse
Hospital Liaison Nurse Specialist & Learning
Disabilities Lead
Senior Occupational Therapist
Chief Nurse
Clinical Audit and NHSLA Lead
Dietitian
Dr Ahsan, Consultant in Elderly Medicine
24/01/14
24/01/14
24/01/14
Frances Hodby
Cathy Geddes
Helen Clarke
Alex Kralevich
Professionally Approved By
Version Number
Issuing Directorate
Ratified by:
Ratified on:
Trust Executive Sign Off Date
Implementation Date
Next Review Date
Author/Contact for Information
Policy to be followed by (target staff)
Distribution Method
Related Trust Policies (to be read in
conjunction with)
24/01/14
24/01/14
24/01/14
24/01/14
11/02/14
2.2
Medicine & Emergency Care
Document Ratification Group
27th February 2014
March 2014
10th March 2014
February 2017
Julie Green, Dementia Specialist
All Clinical Staff
Intranet & Website
Management of Delirium Policy, Consent Policy, Violence
and Aggression Policy, Adult Safeguarding Policy, Mental
Capacity Act Policy, Deprivation of Liberty Safeguards
Policy, Slips,Trips and Falls Policy, Learning Disability
Policy, Carers Policy, Incident Policy
Document Review History
Review No
1.0
2.0
2.1
2.2
Authored/Reviewed by
Rose Elliot CNS
Julie Green, Dementia Specialist
Julie Green, Dementia Specialist
Julie Green, Dementia Specialist
Date
27th October 2010
27th February 2014
21st November 2014
26th March 2016
1
INDEX
1.
Purpose
2.
Introduction
3.
Scope
4.
Staffing and Training
5.
Dementia Screening
6.
Avoidance of in-patient diagnosis of dementia
7.
Diagnosing Dementia
8.
Care and Treatment of the Patient with Dementia
9.
Decision making
10.
Behavioural and Psychological Symptoms of Dementia
11.
Explore Unmet Needs
12.
Use of Sedation
13.
Dual Diagnosis of Learning Disabilities and Dementia
14.
Incident Reporting
15.
Incident Review
16
Breach Reporting
17.
Audit and Monitoring
18.
Communication
19.
References
APPENDICES
Appendix 1: Dementia Pathway
Appendix 2: Find, Assess, Investigate & Refer Tool
Appendix 3: Non Pharmacological Strategies
Appendix 4: Montreal Cognitive Assessment (MoCA)
Appendix 5: Geriatric Depression Scale (GDS)
Appendix 6: Confusion Assessment Method (CAM)
Appendix 7: Short Confusion Assessment Method (CAM)
Appendix 8: Differential Diagnosis
Appendix 9: ‘This Is Me’
Appendix 10: ‘Abbey’ Pain Assessment Tool
Appendix 11: Nutritional Flowchart for Patients with Dementia
Appendix 12: MEHT Delirium Pathway
Appendix 13: Sedation and Risk Assessment
Appendix 14: Behaviour = Communication Assessment Tool
2
1.0
Purpose
1.1
The purpose of this policy is to provide all clinical staff with guidance, to assist them in
meeting the specific needs of patients with dementia.
1.2
To ensure compliance with national guidance, specifically: the National Dementia
Strategy (NDS), Dementia Action Alliance (DAA), National Audit for Dementia (NAD),
National Institute for Health and Care Excellence (NICE).
2.0
Introduction
2.1
Dementia is a clinical syndrome evidenced through a set of symptoms, which
classically include a decline in memory and thinking, present for six months or more,
and of a degree sufficient to impair functioning in daily living, World Health
Organisation (2012). Dementia is a progressive, life limiting disease.
2.2
One in six people over the age of 80 will have dementia (Alzheimer’s Society, 2012).
Dementia is not a normal symptom of ageing.
2.2
Being in hospital can be an unsettling and disorientating experience for anyone. For a
person with dementia the effects may be much worse. There is growing evidence that
when compared to patients without dementia, patients with dementia in hospital are
more likely to:
•
•
•
•
•
experience poor nutrition and poor hydration
develop delirium
receive inadequate pain control
experience extended hospital stays
move from hospital into long term care
2.3
Approximately 25% of people occupying general hospital beds have dementia (DoH,
2012). People with dementia are usually dependant on staff having the skills and
knowledge to meet their needs effectively and ensure the patient’s experience is less
stressful and no longer than necessary.
3.0
Scope
3.1
This policy applies to all staff who are involved in the care and treatment of adults with
either a suspected or confirmed diagnosis of dementia.
4.0
Staffing & Training
4.1
Patients with dementia must receive care from staff appropriately trained in dementia
care (NDS, DAA, NAD & NICE). In Broomfield Hospital, there are three levels of
training available to all staff. It is the responsibility of each Head of Department to
ensure their staff attend the appropriate level of training and access level 1 training as a
minimum.
4.2
It is also the responsibility of each Head of all Clinical Departments to appoint a
Dementia Champion (who will have accessed Level 3 training) and ensure that all
relevant information and learning is cascaded to all staff within their teams.
3
5.0
Dementia Screening
5.1
It is essential that dementia is diagnosed as early as possible in the disease process to
enable people access to the appropriate care, support and treatment available,
including support to plan for the future i.e. making an advanced decision and appointing
a Lasting Power of Attorney (DAA, NDS, NICE). It is estimated that only 43% of people
with dementia receive a diagnosis (Alzheimer’s Society, 2012).
5.2
As part of the National Dementia CQUIN, the nursing and medical staff are responsible
for ensuring the three step Dementia screening tool (Find, Assess, Investigate & Refer,
Appendix 1) is completed for all patients aged 75 and over, stay three days or more and
are admitted as an emergency patient.
5.3
The nursing and medical staff are also responsible for ensuring all patients under the
age of 75 who are not admitted as an emergency but may meet the criteria (as set out in
Appendix 1) are referred to the local Memory Assessment Support Service on
discharge, via the General Practitioners as per current referral pathway.
5.4
On admission it should be established whether a patient has a known diagnosis and if
so the date the diagnosis was made and the type of dementia must be documented.
5.5
All patients who are admitted with a diagnosis of dementia should be given a ‘MEHT
Dementia Pack’ which includes the Trust Information Leaflet, a ‘This Is Me’ and a
Carers Questionnaire.
6.0
Avoid in-patient diagnosis of dementia
6.1
A diagnosis of dementia should only be made when all other reversible causes of
cognitive impairment have been excluded. This includes delirium which can be caused
by pain, surgery, being in an unfamiliar place, infection, analgesia, constipation.
Symptoms of delirium can persist for weeks following completion of treatment and
therefore a potentially inaccurate diagnosis of dementia can easily be made if patient’s
are not allowed sufficient time to recover from delirium. Therefore extreme caution
should be used.
6.2
In complex cases with poor cognition, strongly consider a referral to Enhanced Liaison
Team (Old Age Psychiatry) for inpatient assessment & guidance. If it is clinically
necessary to make a diagnosis of dementia as an in-patient, the Consultant in charge
and/or team is responsible for ensuring the following referrals (NDS, NAD, DAA, NICE):
•
A referral to the Elderly Assessment Team/Dementia Specialist to ensure that
patients and their relatives receive written and verbal information and support as an
in-patient.
•
A referral on discharge to their local Memory Assessment Service (via General
Practitioners), to ensure the patient is assessed for treatment and the patient and
their relative/carer is provided with on-going support and assessment as well as
information on support options local to their area.
7.0
Diagnosing dementia
7.1
Dementia is a diagnosis by exclusion. It is imperative that all other required and
appropriate assessments are carried out before reaching this diagnosis.
4
7.2
7.3
Comprehensive physical examination must be completed and appropriate investigations
carried out:
•
Complete dementia blood screen (B12, Folate, TSH and other test, if relevant, for
example Syphilis serology)
•
Computed Tomography (CT scan) head
A comprehensive biographical profile must be completed by thorough discussion with
the patient and a relative, carer or someone who knows the patient well confirming a
chronic history of cognitive decline.
•
Complete Montreal Cognitive Assessment (MoCA, Appendix 3)
•
Exclude undiagnosed or untreated depression. Complete Geriatric Depression
Scale, (GDS, Appendix 4) if depression is suspected then consider treatment and
refer to mental health.
•
Exclude undiagnosed, untreated or resolving delirium. Complete Confusion
Assessment Method, (CAM, Appendix 5)
•
A diagnosis of dementia must not be made until depression and delirium have been
treated and resolved. Symptoms of delirium can persist for several weeks after the
onset and completion of treatment. Appendix 6 details the clinical differential
diagnoses of depression, dementia and delirium.
8.0
Care and Treatment of the Patient with Dementia
8.1
It is essential that the following information is collated and assessments completed for
all patients with dementia.
•
Collateral History: To enable effective treatment, care planning and discharge
planning, the multi-disciplinary teams must establish functional and cognitive
baseline prior to admission. In patients with dementia, functional status and
cognition can deteriorate significantly if they experience delirium. This is often
reversible and if the patient has not returned to baseline following treatment, should
be considered strongly for transfer to intermediate care for rehabilitation (NDS
Objective 9).
•
‘This Is Me’: To enable effective care planning and to provide appropriate
occupation and stimulation for people with dementia, it is essential that a life history
is obtained. This should be completed using the ‘This Is Me’ format (Appendix 7).
Ideally, relative/carer involvement should be sought. This will improve patient
experience, support patient centred care and reduce agitation/aggression thus
reducing length of stay. If applicable ‘This Is Me’ documentation should be copied
and accompany the patient when transferring to the Residential or Nursing home on
discharge.
•
Abbey Pain Scale: There is evidence to suggest that patients with dementia may
receive less pain relief in hospital than patients who do not have dementia. Patients
with dementia may express their pain in ways that are different from patients without
dementia. This becomes a greater problem in the more severe stages of dementia,
5
therefore, the complexity and frequent inadequacy of pain assessment often leads to
the under treatment of pain (British Medical Journal, 2005).
Pain should be assessed using the Abbey pain assessment tool (Appendix 8) at
least 4 times daily and more frequently if the pain score is greater than 3. It is often
necessary to prescribe analgesia regularly rather than ‘as required’.
•
Individualised Care Plan: All patients care plans must be individualised to meet
their specific needs and identify aims and goals of care/treatment (NDS, NAD, DAA,
NICE).
•
Nutritional Assessment: As dementia progresses, there may be changes in a
persons eating habits and their ability to eat independently. There may be changes
to taste, the ability to swallow or appetite (increase or decrease). Various factors can
also hinder oral intake including constipation, mouth problems and poor oral
hygiene. Finger foods are good way of prolonging independent eating and can be
used if the patient is unable to sit still for long periods of time.
If there are concerns about a patient’s nutritional intake, please complete the MUST
(Malnutrition Universal Screening Tool) booklet and refer to the Dietetic department,
when indicated in line with the Trust Acute Nutrition policy (11028). The ‘Nutrition
Pathway for Patients with Dementia’ should be followed for all patients who have
dementia and are not eating and drinking adequately.
8.2
Patients with dementia are likely to experience increased disorientation each time they
encounter an unfamiliar environment. Patients with dementia must not be moved within
the ward or between wards unless it is clinically indicated or absolutely necessary.
9.0
Decision making
9.1
All patients with dementia should be presumed to have capacity unless proven
otherwise. All decisions about their care and treatment and consent must be gained
lawfully. All clinicians must adhere to the Consent to Treatment policy (04080).
9.2
If there is sufficient evidence to suggest that the patient may lack capacity to make a
particular decision, clinicians must complete a mental capacity assessment. All
clinicians must understand and adhere to the Mental Capacity Act (2005) and the Trust
Mental Capacity Act policy (11001).
9.3
The patient must remain at the centre of decision making even if it is determined that
he/she does not have the capacity to make a particular decision.
9.4
A referral should be made to the Elderly Assessment Team/Dementia Specialist if a
best interest’s decision is being considered which is against the patient’s wishes.
9.5
The Elderly Assessment Team/Dementia Specialist are available to provide support and
advice regarding all best interests decisions made on behalf of patients with dementia if
required.
6
10.0
Behavioural and Psychological Symptoms of Dementia
10.1
More than 90 per cent of people with dementia will experience behavioural and
psychological symptoms of dementia. These symptoms, which include aggression,
agitation and psychosis (delusions and hallucinations), can be distressing as well as
presenting a challenge for treatment.
10.2
In many cases behavioural and psychological symptoms can be prevented and
managed without resorting to antipsychotic drugs. The key to achieving this is to follow
the principles of good person-centred care.
10.3
Person-centred care involves tailoring a person's care to their interests, abilities, history
and personality. This helps them to take part in the things they enjoy and are meaningful
to them and can be an effective way of preventing and managing behavioural and
psychological symptoms of dementia.
10.4
The key points of person-centred care are:
•
•
•
•
•
treating the person with dignity and respect
understanding their history, lifestyle, culture and preferences, including their likes,
dislikes, hobbies and interests
looking at situations from the point of view of the person with dementia
providing opportunities for the person to have conversations and relationships with
other people
ensuring the person has the chance to try new things or take part in activities they
enjoy
10.5
Family, carers and the person with dementia (where possible) should always be
involved in developing a care plan based on person-centred care. Families should be
considered for open visiting or extended visiting times. Their knowledge and
understanding of the person is extremely valuable to make sure the care plan is right for
them (Alzheimer’s Society, 2014).
10.6
It is essential that all behaviour is documented on the ‘ABC’ Chart. The purpose of this
is so themes can be examined and ‘triggers’ which might precipitate behaviour and
effective strategies can be identified.
10.7
Patients with dementia who experience distress, or who present with behaviour that is
perceived to be challenging, should be referred to the Elderly Assessment
Team/Dementia Specialist (NDS, DAA, NAD, NICE). A mental health opinion should
be sought where appropriate.
10.8
Refer to the Management of Delirium in Older Adults policy (10082) and delirium
pathway (Appendix 10) if it is suspected that a person may have a delirium superimposed on dementia.
11.0
Explore unmet needs
11.1
The Alzheimer’s Society report that the prescription of antipsychotic drugs to people
with dementia was often the result of factors other than the symptoms of dementia. In
particular, a lack of training in dementia care for staff means that professionals are often
not aware that symptoms such as restlessness and shouting out can be the expression
of unmet needs. This could be because of unidentified pain or boredom due to a lack of
7
social activity being available. The report showed that two thirds of prescriptions for
antipsychotic drugs are unnecessary or inappropriate (Alzheimer’s Society, 2014)
11.2
People with dementia have the same needs as everyone else, including comfort, social
interaction, stimulation, emotional wellbeing and being free from pain. However, people
with dementia may be unable to recognise their needs, know how to meet them, or
communicate what they need to others.
11.3
It is therefore important that staff ensure the patient is not experiencing any of the
following;
•
•
•
•
•
•
•
•
•
Pain
Thirst
Hunger
Dry/sore mouth
Constipation
Boredom
Lack of exercise
Too hot/cold
Over-stimulation
11.3
Ensure the patient is supported to communicate his/her feelings. It is common for all
people to become frustrated and sometimes aggressive if they feel ignored. See
Appendix 8 for communication advice.
12.0
Use of Sedation
12.1
The use of sedatives must only be considered when non-pharmacological interventions
have been attempted.
12.2
The side-effects of antipsychotics can be very harmful and can diminish quality of life.
Side effects include excessive sedation, dizziness and unsteadiness, which can lead to
increased falls and injuries, as well as parkinsonism (tremors and rigidity), body
restlessness, reduced well-being, social withdrawal and accelerated cognitive decline.
12.3
The Delirium Pathway (Appendix 10) must be referred to when prescribing sedation.
12.4
The Alzheimer's Society is working with Department of Health, Dementia Action Alliance
and the Royal College of General Practitioners to support health and social care
professionals in continuing to reduce the use of antipsychotic drugs in people with
dementia.
12.5
Medication may be indicated in the following situations:
•
•
•
•
In order to carry out essential investigations/treatment or prevent removal of life
saving equipment
To calm patients who are exhibiting extreme problem behaviour which is likely to
endanger themselves and others e.g. physical assault of other patients or staff
To relieve distress in a highly agitated or hallucinating patient
Only when all other remedies have been attempted and as a last resort
8
12.6
It is essential to be aware that people with Vascular Dementia, Alzheimer’s disease or
mixed Dementia have an increased risk of cerebrovascular adverse events and death
when given anti-psychotic medication.
12.7
Anti-psychotics are contra-indicated for people with Lewy Body dementia; they have a
particular sensitivity to anti -psychotic medication which can lead to profound adverse
events and death. This knowledge must be evaluated and considered as part of a risk
assessment both when prescribing and administering rapid tranquillisers.
12.8 The clinical rationale for using sedation/antipsychotic medication must be documented in
the medical notes. If the patient is unable to consent to medication a mental capacity
assessment should be completed (Mental Capacity Act, 2005).
12.9 Consider the following when prescribing medication:
•
•
•
•
•
•
Monotherapy
Prescribe initial ‘stat’ dose and then reassess
Prescribe regularly
Start with a low dose and titrate
Avoid ‘PRN’ (as required) prescriptions
Review regularly and discontinue as soon as possible
12.10 The Delirium Pathway (Appendix 10) must be adhered to and it must be evidenced that
a risk assessment has taken place (Appendix 11).
12.11 Where a patient repeatedly expresses a wish to leave the clinical areas, either verbally
or by physically trying to leave the clinical area, or sedation is being used to prevent
this, these actions would amount to deprivation of liberty. Clinicians should refer to
Deprivation of Liberty Safeguards policy (11002).
12.12 All those involved in prescribing and administering sedation to a patient with dementia
must be familiar with the following:
• Mental Health Act 1983
• Requirements of the relevant articles of the European Convention on Human Rights
• Mental Capacity Act (2005) and Deprivation of Liberty Safeguards (2009)
• Consent to Treatment Policy
• Violence and Aggression Policy
• Advocacy services
12.13 An ABC (antecedent, behaviour, consequences, Appendix 12) chart must be used to
review all patients who are presenting with behaviour which could be perceived as
challenging or patients who are becoming very withdrawn and disengaging. This will
enable staff to review:
• Trigger factors
• What happened during the incident
• Staff response to the incident
• What happened to the patient / what did they do
• Root cause analysis to be completed if the incident has an unfavourable outcome.
9
13.0 Dual Diagnosis of Learning Disabilities and Dementia
13.1
If a patient has a dual diagnosis of learning disabilities and dementia a referral should
be made to the Hospital Liaison Nurse Specialist & Learning Disabilities Lead. It is also
important to consider the following:
•
•
•
•
•
Pain & Distress - usual assessment tools like Abbey Pain Scale and MoCA will not
be effective with this group of patients and alternative tools should be used (refer to
Learning Disability Policy).
Staff will need to refer to the patient’s own "Hospital Passport" instead of "This is Me"
document.
Communication: use of alternative methods and easy read/accessible information.
Refer to the "Communication Resource Folder" which is available on each ward
Make reasonable adjustments which may include: additional support from familiar
carers/flexi visiting or 1:1 support and environment - side room - changes in usual
protocols/processes may be necessary
Consent – if there is concern that the patient may not be able to consent to treatment
please refer to Hospital Liaison Nurse Specialist & Learning Disabilities to assist with
assessment of capacity.
14.0
Incident Reporting
14.1
All disturbed/violent incidents should be reported on the Trust Risk Event Form (Datix)
in line with the Trust Incident Reporting Policy. A member of the Elderly Assessment
Team must be notified at the earliest opportunity to facilitate an assessment of the
patient’s needs.
14.2
A Trust Risk Event Form (Datix) must also be completed if there is any evidence that
the patient has come to emotional or physical harm in hospital or if there is evidence
that the patient has been administered inappropriate sedation
15.0
Incident Review
15.1
The aim of a post incident review should seek to learn lessons, support staff and the
patient and encourage a relationship between staff, patient and relatives or carers.
The review should be conducted as soon as possible after the incident and by
someone independent of the incident for example a member of the Elderly
Assessment Team.
16.0
Breach Reporting
16.1
A risk event form (Datix) must be completed when this policy has not been followed and
a patient has experienced harm or disadvantage as a result. This may require a
safeguarding alert (please refer to Adult Safeguarding policy).
17.0
Audit and Monitoring
17.1
Compliance with completion of the FAIR assessment is reported on a monthly basis
internally and externally with performance reviewed at the Dementia MDT.
17.2
Carers of patients with dementia are invited to complete a satisfaction survey and
findings are fed back to ward sisters and collated monthly for the Dementia MDT.
10
17.3
The Trust participates in the National Audit of Dementia and the Dementia MDT will
develop actions to address any deficiencies highlighted within the published report.
Where indicated more frequent audit will be undertaken to drive improvement.
17.4
The Dementia Specialist/Elderly Assessment Team should be informed of all relevant
risk event forms who will raise concerns to the Trust Dementia MDT which meets
fortnightly. The Dementia MDT reports quarterly to the Patient, Safety Group.
18.0
Communication
18.1
The policy will be made available on the Trust’s intranet & website by Governance. The
Dementia Clinical Nurse Specialist will be responsible for issuing copies to all senior
managers, general managers and ward sisters for dissemination within their
departments.
18.2
The approved policy will be notified in the Trust’s Staff Focus
19.0
References
Alzheimer’s Society (2012) Statistics. Available from:
http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=341 [Accessed on
07/01/2014]
Alzheimer’s Society (2014) Reducing the use of antipsychotic drugs: A guide to the treatment
and care of behavioural and psychological symptoms of dementia. Available from:
http://www.alzheimers.org.uk/site/scripts/download_info.php?downloadID=610 [Accessed
05/02/2014]
Dementia Action Alliance (2014) National Dementia Declaration. Available from:
http://www.dementiaaction.org.uk/nationaldementiadeclaration [Accessed on 09/01/2014]
Department of Health (2009) Living Well with Dementia: a national dementia strategy.
Available from: https://www.gov.uk/government/publications/living-well-with-dementia-anational-dementia-strategy [Accessed on 05/01/2014]
Department of Health (2013) Improving care for people with dementia. Available from:
https://www.gov.uk/government/policies/improving-care-for-people-with-dementia [Accessed
on 05/01/2014]
Ministry of Justice (2005) Mental Capacity Act 2005. Available from:
http://www.legislation.gov.uk/ukpga/2005/9/contents [Accessed on 09/01/2014]
National Audit Office (2010) Improving dementia services in England – an interim report.
Available from: http://www.nao.org.uk/report/improving-dementia-services-in-england-aninterim-report/ [Accessed on 09/01/2014]
National Institute for Health and Social Care Excellence (2013) Dementia: Supporting people
with dementia and their carers in health and social care. Available from:
http://www.nice.org.uk/CG42 [Accessed on 05/01/2014]
Scherder, E et al (2005) Recent developments in pain in dementia.
British Medical Journal. [online] 330 (7489). p. 461–464. Available from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC549660/ [Accessed 05/02/2014]
World Health Organisation (2012) Dementia Fact Sheet. Available from:
http://www.who.int/mediacentre/factsheets/fs362/en/ [Accessed on 07/01/2014]
11
Appendix 1 - DEMENTIA PATHWAY:
Part A: Admission
Decision made by medical/surgical team to admit
patient into hospital
Patient consent obtained to be admitted into hospital or admission evidenced to be
in the best interests if the patient lacks capacity and is resisting admission or
Bed allocated on EAU or relevant speciality
ward
Admit to Ward
(Level 1 Bed)
Identify type of
dementia and date
of formal diagnosis
Complete Stage 1 of
FAIR Assessment and
give patient and their
relative the ‘MEHT
Dementia Pack’
Consider if patient is
reaching the end stages
of dementia (NB –
Delirium and depression
must be excluded
before this decision can
be arrived at)
Admission assessments
Assess Environment
Cognition – Consider
Delirium Pathway
Pain – Always assess
using Abbey Pain
Assessment Scale
Nutrition – Consider
use of the ‘Nutrition
Pathway’
Spiritual/emotional
needs
12
Part B: Inpatient Stay
UNMET
NEEDS
Spiritual needs
Overstimulation
Constipation
Nutritional
Pathway
COGNITION
ABC
Behaviour
chart
Nausea
Medication
Lack of
exercise
Environment
Communication
Requires
Requiresinpatient
inpatient
Requires
inpatient
treatment
treatment
treatment
Oral
hygiene
Medical/
Medical/surgical
surgical
treatment
treatment
MCA /
DOLs
Visiting
Medical/ surgical
Medically/surgically
treatment
stable for discharge
Medically/surgically
stable for discharge
Delirium
pathway
Mealtimes
Too
hot /
cold
Meaningful
activities
Mental
Health
review
Medically/surgically
stable for discharge
Boredom
Pain
‘This is
me’
Assess
delirium and
depression
Avoid bed
moves where
possible
Hunger /
thirst
Positioning
Dentures,
hearing
aids,
glasses
Fear &
anxiety
13
• Inform family that options that include alternatives to return to permanent address will not be
considered until all assessments are complete.
• Ensure patient is at the centre of all decision making.
• Ensure patient consents to all stages of discharge plan. If there are reasons to assume a
lack of capacity and patient is not in agreement with plan, complete MCA2 and refer to
EAT/Dementia Specialist. If the patient has capacity their choices must be respected.
• Consider referral onto the Fraility Register (via GP discharge summary)
End of life
diagnosis.
Complete MCA2
Discharge
Part C: Discharge
Surgically/Medically
Y
Is the patient back to cognitive/functional
Y
N
Consider referral
to intermediate
care (IMC),
2hhour
reablement or
Non-weight
bearing pathway,
POP
Discharge home
with increased
care
Is there potential for further improvement?
Y
N
Y
Could the needs be met with increased care
N
Continuing
Healthcare
process DST
Consider Nursing Needs Checklist
Y
N
Following Decision
Support Tool (DST),
has CHC funding been
End of
Life,
Fast
Track
Respect
wishes and
plan discharge
accordingly
Y
Y
Liaise with Social care
N
If concerns re: discharge home remain,
complete risk benefit analysis.
If patient is expressing a wish to return home
or is unlikely to respond well in placement,
consider home visit before any decisions are
made about discharge destination
Has patient got mental capacity to make the
decision about discharge?
N
Plan discharge
according to
best interests’
decision
MCA2 if risks identified at home, if 24hr care indicated or if change of
accommodation refer to EAT/Dementia Specialist for best interests’
14
DEMENTIA PATHWAY: Additional Notes
Part A: Admission
Decision made by medical/surgical team to admit patient into hospital
•
•
•
•
Ensure the hospital admission is clinically indicated
Establish baseline cognition; does this impact on the decision to admit?
Are there any alternatives to hospital? Is treatment available in the community?
Is hospital the right environment?
Patient consent obtained to be admitted into hospital or admission evidenced to be in the
best interests if the patient lacks capacity and is resisting admission or treatment
•
•
•
Explain to the patient the purpose of admission and treatment
Complete MCA2 if indicated
Consider DoLS
Bed allocated on EAU or relevant speciality
ward
•
•
•
•
Avoid sending the patient to a medical outlier bed
Prioritise patient with dementia where possible
Prevent unnecessary bed moves
Minimise likelihood of bed moves later in hospital admission
Admit
• to ward
•
•
•
•
Take measures to welcome patient to the ward, reassure and orientate
Consider patient’s ill-being and well-being and spiritual needs
Consider cognition and mood in order to assess risks for patient health and safety
Consider a bed in a high observation area of the ward and/or close to a toilet
Assess environment
•
•
•
•
Encourage next of kin to bring in home comforts, e.g. blankets, photos, clothes,
toiletries, glasses, teeth, hearing aids etc.
Liaise with patient and next of kin
Encourage open visiting where possible
Orientate the patient to the toilets and consider a picture on the toilet door for clear
communication
15
Admission assessments
•
•
•
•
•
Complete all generic assessments
Liaise with next of kin for collateral history and baseline
Explain and encourage completion of ‘This is Me’ to patient and next of kin
Discuss next of kin concerns and offer support if needed; e.g. Action for Family Carers
(AFFC), counselling
Establish patients feelings and concerns and document
Cognition
•
•
•
•
•
•
•
MOCA/CAM
Consider the delirium pathway if indicated
Discuss cognition with the patient and next of kin
Are there any considerations that the patient may lack mental capacity? Consider MCA1
for day-to-day decisions or MCA2 for all significant decisions.
Consider DOLs (Refer to DOLs flowchart)
Are there concerns with behaviour? Consider behaviour chart to identify cause of
distress/agitation.
Refer to EAT/Dementia Specialist if specialist input is required
Pain
•
•
•
•
•
Commence Abbey Pain Scale assessment tool at least four times a day (QDS). This
should be assessed at rest and on movement.
Does the patient have a risk factor for pain?
Does the patient show signs of challenging behaviour on nurse interaction or
movement? Could this be associated with pain?
Was the patient taking analgesia prior to hospital admission?
Liaise with physiotherapists prior to exercise and nursing staff to consider analgesia
Nutrition
•
•
Refer to the Dementia Nutritional Pathway
Encourage relatives to become involved at mealtimes
Spiritual/emotional needs
•
•
It is important to be aware that many patients with dementia may not be able to
communicate their religious beliefs/needs to you but may display signs of ill-being until
these considerations are met
Ensure the patient has home comforts and items required to fulfil their religious needs,
e.g. a bible, rosary beads, prayer mats etc.
16
Identify type of dementia and date of formal diagnosis
•
This information can be obtained from the GP or the Crystal Centre
Commence Step 1 FAIR assessment and give ‘MEHT Dementia Pack’
•
•
•
Essential for those aged 75 and over but should be considered for anyone who meets
the criteria
Complete Step 1 and if the patient already has a confirmed diagnosis of dementia
Ensure Dementia pack is given appropriately and encourage completion of Carers
Questionnaire
Consider if patient is reaching the end stages of dementia (NB – Delirium and
Depression must be excluded before this decision can be arrived at)
• It is essential that all unmet needs (see below) have been explored and all reversible
conditions (such as delirium and dementia) have been either been excluded or treated
• If patient may lack the capacity to understand decisions regarding treatment a MCA2
must be completed to identify the ‘ceiling of treatment’. A Best Interests Decision must
include the views and opinions of the patient (current and past wishes – i.e. Preferred
Place of Care & Advanced Directive), relatives/carers, Lasting Power of Attorney for
Health and Well-being), Care of the Elderly Consultant/Psychiatrist, Dementia
Specialist/Elderly Assessment Team and other involved members of the multidisciplinary team.
Part B: Inpatient stay
Environment
•
•
•
•
•
•
History can be obtained from the patient, family and carers, care home, GP, community
staff.
Encourage family involvement and reduce distractions in the environment
Encourage next of kin to bring in home comforts, e.g. blankets, photos, clothes, toiletries
etc.
Encourage open visiting where possible
Orientate the patient to their surroundings and for example consider a picture on the
toilet door for clear communication
Encourage small meals and drinks, finger foods and snacks frequently
Cognition
17
•
•
•
•
•
•
•
In patients with Dementia, functional status and cognition can deteriorate significantly if
they experience delirium. Ensure that a medical assessment of the symptoms is
performed.
Refer to the delirium pathway
Perform a delirium screen including urinalysis.
Commence and maintain the ABC behaviour chart to explore trigger factors
Refer to the Elderly Assessment Team/Dementia Specialist and if the medical team
decide that the patient is not experiencing delirium, consider a mental health referral.
Avoid prescribing medication as required and consider covert medication
Consider MCA2 and DoLS. A ‘Best Interests’ Decision must include the views and
opinions of the patient (current and past wishes – i.e. Preferred Place of Care &
Advanced Directive), relatives/carers, Lasting Power of Attorney for Health and Wellbeing), Care of the Elderly Consultant/Psychiatrist, Dementia Specialist/Elderly
Assessment Team and other involved members of the multi-disciplinary team.
Unmet needs
•
•
•
•
•
•
•
•
•
Use the ‘This is me’ and discuss the reactions with the patient and next of kin to explore
unmet needs and to ensure that the care is person-centred.
Discuss pain regularly with the patient and if the patient may have difficulty expressing
their needs, the Abbey pain scale should be used at least 4 times a day and more
frequently if the pain score is greater than 3.
Consider prescribing analgesia regularly rather than as required.
The patient may appear comfortable at rest, but consider that the individual might be
experiencing pain or discomfort when repositioned, during personal hygiene or during
therapy sessions. Therefore it may be necessary to give analgesia prior to these times.
Refer to the Nutritional Pathway
Ensure the patient is receiving adequate oral care and is clear from oral infection
Consider constipation, nausea and pain as causes for signs of distress
Ensure the patient has dentures, hearing aids and/or glasses and uses them when
required
Consider referral to Elderly Assessment Team/Dementia Specialist
Part C: Discharge
Is the patient back to cognitive/functional
•
Evidence clinical rationale why patient will not return to previous cognitive and functional
ability
Is there potential for further improvement?
•
Explore patient views and establish goals
18
•
Therapists to establish achievable goals for the individual
Could the needs be met with increased care package?
•
Relevant professionals to reach agreement on level of care required. This must include
agreement between social workers, therapists and nursing staff
Consider Nursing Needs Checklist
•
Liaise with the ward discharge co-ordinator
If concerns re: discharge home remain, complete risk benefit analysis
•
•
•
•
•
•
If patient is expressing a wish to return home or is unlikely to respond well in placement,
consider home visit before any decisions are made about discharge destination
Risk/benefit analysis must include risk of psychological harm as well as physical harm
Explore least restrictive option as a priority and therefore evidence attempts made to
mitigate risks
If fire risk identified refer to Home Fire Safety Manager ([email protected]/ 01376 576226)
Therapists, Dementia Specialist /Elderly Assessment Team and Social Workers to
decide whether a discharge home visit is indicated
Refer to Elderly Assessment Team/Dementia Specialist
MCA2 if risks identified at home, if 24hr care indicated or if change of accommodation
- refer to EAT/Dementia Specialist for best interests’ collaboration
•
Ensure relevant professionals (e.g. GP, community staff), patient and family are
provided with a copy of the MCA2 as indicated
19
Appendix 2: ‘Find, Assess, Investigate, Refer’ Tool
20
Appendix 3: Non Pharmacological Strategies
NON PHARMACOLOGICAL STRATEGIES
•
Treat underlying physical causes
•
Good biographical history to get to know the patient
•
Appropriate lighting
•
Consider single room/small bay/close to nursing station
•
Provide repeated visual and verbal clues to orientate for example clocks
•
Provide reassurance/explanation in short sentences
•
Ensure continuity of care for example one nurse to establish rapport
•
Ensure glasses/hearing aid / false teeth etc are worn and working
•
Avoid inter and intra ward moves
•
Avoid catheters
•
Encourage early mobilisation
•
Ensure adequate pain control –regular pain relief is preferential to “as required”
•
Establish regular sleep pattern-maintain and restore pattern.
•
Ensure good diet and fluid intake
•
Avoid constipation
•
Avoid sedation
•
Eliminate unexpected noises for example pump alarms
•
Encourage visits from family and friends
•
Ensure patient is provided with appropriate occupation and stimulation
•
Consider 1:1 nursing
•
Ascertain message patient might be trying to communicate through their behaviour
•
Explore unmet needs
21
Appendix 4: Montreal Cognitive Assessment (MoCA)
22
Appendix 5 - Geriatric Depression Scale (GDS)
Geriatric Depression Scale (GDS) (15 item version)
Are you basically satisfied with your life?
Yes
/
NO
Have you dropped many of your activities and interests?
YES
/
No
Do you feel that your life is empty?
YES
/
No
Do you often get bored?
YES
/
No
Are you in good spirits most of the time?
Yes
/
NO
Are you afraid something bad is going to happen to you?
YES
/
No
Do you feel happy most of the time?
Yes
/
NO
Do you often feel helpless?
YES
/
No
Do you prefer to stay at home rather than going out and doing new things?
YES
/
No
Do you feel you have more problems with memory than most?
YES
/
No
Do you think it is wonderful to be alive now?
Yes
/
NO
Do you feel pretty worthless the way you are now?
YES
/
No
Do you feel full of energy?
Yes
/
NO
Do you feel that your situation is hopeless?
YES
/
No
Do you think that most people are better off than you are?
YES /
No
Overall Score
Score 1 for answers in Capitals
Score 0 – 5
Not Depressed
Score 6 – 15
Depressed
23
Appendix 6 - The Confusion Assessment Method (CAM)
24
Appendix 7- Short Confusion Assessment Method (CAM)
25
Appendix 8 - Differential Diagnoses
Clinical features of dementia, depression and acute confusional
state
Feature
Dementia
Acute Confusional State
Depression
ONSET
Insidious
Acute
Gradual
DURATION
Months/Years
Hours/days/??weeks
Weeks/months
COURSE
Stable and progressive
MID: usually stepwise
Fluctuates: worse at night
Lucid periods
Usually worse mornings
Improves as day goes
on
ALERTNESS
Usually Normal
Fluctuates
Normal
May be normal: usually
impaired for time/place
Impaired recent and
sometimes remote
memory
Slowed
Reduced interests
Perseverate
? Normal
Hallucinations in 30 – 40%
(often visual)
Always impaired:
Time/Place/Person
Usually Normal
Recent impaired
Recent may be
impaired remote intact
ORIENTATION
MEMORY
THOUGHTS
PERCEPTION
Often paranoid and grandiose
? bizarre ideas and topics
Visual and Auditory
Hallucinations common
Usually slowed,
preoccupied with sad
and hopeless thoughts
Mood congruent
Auditory Hallucinations
in 20%
Flat, unresponsive, or
sad and fearful, may be
imitable
EMOTIONS
Shallow, apathetic, labile,
? irritable, careless
Irritable, aggressive, fearful
SLEEP
Often disturbed
Nocturnal wandering
common
Nocturnal Confusion
Nocturnal Confusion
Early morning wakening
Other physical disease may
not be obvious
? past history of mood
disorder
OTHER
FEATURES
26
Appendix 9: ‘This is me’
27
Appendix 9: ‘This is me’
28
Appendix 9: ‘This is me’
29
Appendix 9: ‘This is me’
30
Appendix 10: Abbey Pain Scale
31
Appendix 11: Flowchart for Patients with Dementia who are not eating and drinking
adequately
32
POINT 1 - COLLATERAL HISTORY AND IDENTIFY BASELINE:
•
Malnutrition Universal Screening Tool (MUST) assessed within 12hours of admission to hospital and completed weekly or more
frequently for those at risk. Eating and Drinking Assessment.
•
Research background nutritional history; e.g. ‘This Is Me’, weight history, dietary habits, likes/dislikes, usual food portions,
assistance required with meals, *religious beliefs/needs? *Consider patient’s ability to communicate.
POINT 2 - IDENTIFY & ADDRESS UNMET NEEDS:
Rule out constipation, impact of Medication, pain, surgery, nausea, oral health, infection, dentures, positioning, minimise distractions,
depression. Treat delirium (refer to Delirium Pathway for Guidance).
POINT 3 - COMMENCE INITIAL INTERVENTIONS:
Monitor food/fluid intake accurately. Monitor amount of weight loss (weekly weights). Offer relatives mealtimes with the patient & open
visiting. Consider food fortification, snacks and finger foods.
Use ‘Red Tray System’. Use coloured cups and plates. Review medication. Encourage to eat meals sitting in chair.
POINT 4 – REFER TO RELEVANT PROFESSIONALS AND COMMENCE SECONDARY INTERVENTIONS:
Consider referrals to Dietitian, Dementia Specialist, Nutrition CNS Consultant Geriatrician with specialist interest in Dementia. Consider
oral nutritional supplements. Consider if there may be a swallowing problem & if so refer to SALT and identify if texture modification is
indicated.
POINT 5 – IF ORAL INTAKE INSUFFICIENT AND THERE IS AN ADDITIONAL ACUTE ILLNESS THAT MAY IMPROVE WITH TREATMENT?
Determine if IVI required. Consider if there is any potential for recovery i.e. does the patient have an illness that may improve with
treatment?
POINT 6 - COMPLETE MCA2 AND DETERMINE IF NON-ORAL FEEDING TRIAL IS APPROPRIATE:
Best Interests decision should include all relevant members of MDT (Drs, Nurses, SALT, Dietitian, Dementia Specialist and Nutrition CNS),
relatives and the patient’s current and previous wishes, spiritual wishes & consider re-feeding syndrome. Please note that a MDT meeting
is not necessary (particularly if this delays decision making) as the decision maker can ascertain the views of others individually. Consider
DoLS if it is anticipated the patient may struggle to tolerate NG feeding. Consider mittens and 1:1 nursing.
POINT 7 - COMPLETE NON-ORAL FEEDING TRIAL AND MONITOR FOR IMPROVEMENT:
Refer to Nutrition CNS (#6555 1710) and Dementia Specialist (#6555 2557). If patient’s condition continues to deteriorate consider MCA2
to withdraw active treatment if no reversible illness.
POINT 8 - CONSIDER LONG TERM NON-ORAL FEEDING IF TRIAL SUCCESSFUL:
Only applicable if the patient consents or if she/he lacks capacity and it can be evidenced this is deemed to be in the patients’ best
interests. Refer to Nutrition CNS #6555 1710
POINT 9 - CONFIRM POOR ORAL INTAKE IS SOLELY RELATED TO DISEASE PROGRESSION:
If it can be evidenced that there are no reversible illnesses and there are concerns regarding mental capacity, complete MCA2 regarding
withdrawal of treatment and inform patient and family of poor prognosis. Consider palliative discharge. Refer to Dementia Specialist
(#6555 2557). Establish and agree new baseline with MDT, patient and family - if there are concerns regarding mental capacity consider
MCA2 regarding ceiling of treatment if inadequate oral intake.
POINT 10 - COMPLETE MCA2 AND DETERMINE IF NON-ORAL FEEDING IS INAPPROPRIATE:
Best Interests decision should include all relevant members of MDT (Drs, Nurses, SALT, Dietitian, Dementia Specialist and Nutrition CNS),
relatives and the patient’s current and previous wishes, spiritual wishes. Ceiling of treatment established.
POINT 11 - FOR PATIENTS WITH IDENTIFIED SWALLOWING DIFFICULTIES CONSIDER AT RISK EATING AND DRINKING AND IMPLEMENT
PROTOCOL:
Consider safest ‘at risk’ feeding recommendations & optimise intake, e.g. finger foods, food fortification, full fat milk
POINT 12 - AGREE NUTRITIONAL SUPPORT PLAN & DISSEMINATE TO COMMUNITY STAFF:
Ensure all decisions made (including MCA2 if appropriate) are recorded on discharge summary and a copy of MCA 2 is provided to
community SALT, Dietitian, Matron and District Nurse.
Version 4/Dementia Steering Group/February 2016
33
Appendix 12: MEHT Delirium Pathway
34
Appendix 13: Sedation and Risk Assessment
Sedation and Risk Assessment
The following questions must also be considered:
• Will rapid tranquilisation reduce the ability of an individual to communicate and therefore
increase agitation?
• What impact will rapid tranquilisation have on nutritional status? (Update MUST Tool,
consider Dietician referral)
• What impact will rapid tranquilisation have on hydration status? (Monitor fluid balance,
consider Intravenous or subcutaneous fluids)
• How will medication affect levels of cognitive impairment?
• Will rapid tranquilisation increase risk of falls? (Update falls assessment, Bed Rails
assessment)
• Will rapid tranquilisation increase risk of pressure ulcers? (Update Waterlow, provide
necessary pressure relieving equipment)
• Will rapid tranquilisation result in incontinence and impact on dignity?
• How is the risk identified?
• Who is at risk? How are they at risk?
• What is the risk to the individual?
• What is the risk to others i.e. patients, staff?
• Is the risk high, medium or low?
• When is the risk? (Is it current or expected or at a particular time?)
• What other ways of reducing the risk have been explored?
• Is it indeed a risk rather than a ‘nuisance’ or disruption to routines?
All decisions to prescribe and administer sedation to an elderly patient with dementia must be
evidence based and clearly identify specific risks. Details of the risk assessment and other
measures explored and discounted must be clearly documented in medical and nursing notes.
An action plan to prevent recurrence must be formulated at this stage.
35
Appendix 14: Behaviour = Communication Tool
Appendix 14: MEHT Dementia Policy 10081
Behaviour = Communication Assessment Tool
Assessment of ill-being and well-being for patients who have cognitive impairment
Consider any unmet needs (see over)
Summarise evidence of unmet needs, ill-being and well-being that the patient may have been trying to communicate through
their behaviour over the previous 24 hours.
Signature of RN
Date/Time
Description of behaviour and situational triggers
What is the patient is trying to communicate?
Actions Taken, review of care and Outcomes
Care Plan(S) Updated
Date/Time
Signature/Role
Description of behaviour and situational triggers
What is the patient is trying to communicate?
Actions Taken, review of care and Outcomes
Care Plan(S) Updated
Date/Time
Signature/Role
Description of behaviour and situational triggers
What is the patient is trying to communicate?
Actions Taken, review of care and Outcomes
Care Plan(S) Updated
Date/Time
Signature/Role
Description of behaviour and situational triggers
Actions Taken, review of care and Outcomes
Care Plan(S) Updated
What is the patient is trying to communicate?
36
Signature/Role
Appendix 14: MEHT Dementia Policy 10081
Unmet Needs
People with dementia have the same basic needs as everyone else. However, they may be less able to recognise their
needs, know how to meet them, or communicate them.
When a person with dementia behaves differently, this is often mistakenly seen as a direct result of the dementia or simply
as another symptom of the condition. However, this is often not the case. The behaviour may have many causes, including
difficulties relating to dementia (such as memory loss, language or orientation problems), but also physical and mental
health, habits, personality, interactions with others and the environment.
When supporting a person with dementia who is behaving differently, it is important to see beyond the behaviour itself and
think about what may be causing it. Sometimes behaviour can be a result of frustration about how others around the
person are behaving, a sense of being out of control, or a feeling of not being listened to or understood.
Behaviour may be an attempt to meet a need (e.g. removing clothing because they are too hot or walking around because
they are bored or feel they need to be somewhere), or to communicate a need (e.g. shouting out because they need the
toilet).
Types of behaviour and possible unmet needs
Alzheimer’s Society: ‘Changes in Behaviour’ (2015)
Restlessness
Shouting and screaming
Walking
Sleep disturbance and
(fidgeting/ pacing /agitation)
night-time waking
Pain or discomfort
Pain or discomfort
Some people with dementia
Sleep disturbances are
start to walk about more.
common for people with
Communication problems
Communication problems
Some reasons why people may dementia, and often lead to
A feeling, e.g. anxiety or
A response to a hallucination
walk include relieving boredom carers also experiencing
boredom
or anxiety, revisiting a past
problems with their sleep.
A medical reason, e.g.
Under-stimulation or overhabit (e.g. collecting the
A person with dementia
depression, constipation or the
stimulation
children from school or taking
may get up repeatedly
side effects of medication
the dog for a walk) or
during the night and may
A basic need, e.g. hunger, thirst Attempting to communicate a
confusion. The person may also become disorientated
or needing the toilet, being
need, e.g. hunger or thirst
feel that they have somewhere when they wake. They may
prevented from getting out of
to be. Walking may offer the
get dressed or try to leave
bed
person
a
chance
to
be
the house. This may make
The environment - it may be too An expression of distress due to
independent,
give
the
person
the person tired during the
hot or too cold, over-stimulating strong feelings such as
something
to
do
and
day and they may sleep for
embarrassment, frustration
or under-stimulating.
opportunities
for
exercise.
long periods.
A feeling, e.g. anxiety, loneliness
or boredom An unsupportive
environment - e.g. it may be too
hot, too cold or too dark.
SIGNS OF WELL-BEING:
Making wishes known (non-destructively)
Making contact with other people
Warmth and affection
Self-respect
Being helpful
Sense of humour
Bodily relaxation
Creative self-expression
Showing pleasure or enjoyment
Sensitivity to the needs of others
Expressing appropriate emotions
Holding his/her own socially
Alertness, responsiveness
Using remaining abilities /Being purposeful
SIGNS OF ILL-BEING:
Depression or despair
Intense anger or aggression
Anxiety or fear
Agitation
Apathy and withdrawal
Physical discomfort or pain
Unresolved grieving over losses
Bodily tension
Boredom
Distress
Easily walked over by others
Being an outsider / cultural isolation
Bradford Dementia Group (2008)
Version 1.2 AW/JG 11/15
37