Dementia patients face "triple jeopardy

1 November 2011

Nurses need to get dementia care right across all sectors, not just residential aged care, believes Scottish nursing professor June Andrews.

Nursing Review finds out more.

If one old person is being badly looked after, it is a scandal, argues June Andrews. She believes in research-led dementia care and that evidence-based dementia nursing practice should be offered across the spectrum, from routine primary health visits to acute hospital wards.

Her work in promoting quality dementia care recently won her the Robert Tiffany International Award at the Nursing Standard’s 2011 awards. She was in New Zealand recently for the Delivering Excellence in Dementia Care conference and to meet with the Ministry of Health.

Andrews, a former hospital director of nursing and senior health department civil servant, has been director of the University of Stirling’s Dementia Services Development Centre since 2005.

The centre’s purpose is not finding the cause or cure for dementia, but carrying out research, training and consultancy work to improve dementia care and services both in the UK and further afield.

A recent focus has been on acute care, after several horrendous reports of care received by dementia patients in the UK acute hospital sector.

Andrews says people with dementia can face ‘double’ or even ‘triple jeopardy’ when they enter hospital. Firstly, people often don’t know how to care for people with dementia; secondly, hospitals and hospital services aren’t designed to support them; and thirdly, people with dementia are vulnerable to “mishaps” like being given too much sedation or not enough pain relief. The result, says Andrews, can be increased mortality rates or at least longer hospital stays. “So doing dementia care well costs less than doing it badly.” It would also lessen patient suffering. She says residential aged-care staff often tell her that residents admitted to an acute hospital may come back with the underlying disease better but with their general well-being dramatically reduced.

With the predicted rise in the number of people with dementia, she believes everybody in the health system would benefit from a better understanding of research-led dementia care.

For instance, Andrews says research indicates many people with dementia don’t get proper pain relief when admitted to hospital for something like a fractured neck of femur, and this can have far-reaching consequences. “Untreated pain in a person with dementia is almost certain to give rise to delirium… and when people with dementia are delirious then it can shorten their lifespan.”

She says there are quite clear nursing actions to prevent delirium but it was also apparent that these nursing actions were not taking place in acute care hospitals in the UK.

Another example is community nurses being able to spot the first signs of dementia in their regular patients, leading to a quicker diagnosis and earlier access to the support or medication that improves the quality of life for these people and their carers.

Merely having the knowledge of evidence-based practice is not enough, you also have to be able to implement it in your workplace or service. Andrews expresses frustration that research developments in other health services, cancer for example, would quickly see them dropping ‘procedure A’ and adopting ‘procedure B’ if the research showed it was a more effective treatment. “But in dementia care, we have known that person-centred care is really, really important but that doesn’t make it happen.

“I have spent quite a lot of time working with nurses on their personal effectiveness in making change happen.” This includes personal effectiveness tools like how to make “high impact communication”, knowing your staff well, and knowing how decisions are made in your service.

She shared some change tools during her conference presentation and ministry visits to help New Zealand health professionals make change happen for people with dementia. ✚

Exercise, lighting and design: tools in dementia care

It is very important to keep people with dementia active, says June Andrews. But getting exercise into the routine of an acute medical ward is easier said than done. Andrews recalls talking to a junior doctor in such a ward when a patient, a lady with dementia, approached the doctor and asked “Have you got something for me to do?”

The doctor gently replied “No dear, can you go back to your bed?” The lady did as she was told before returning to ask the same question and get the same polite response. Then she came back for the third time and announced “Well, if you haven’t got anything for me to do I will just go home then,” recalls Andrews with a laugh. “Clearly they needed to find her something to do.”

Andrews suggests what the doctor could have done was to give her a job delivering a piece of paper to the nurse at the far end of the ward. She could then have been kept busy ferrying paper back and forth, giving her both exercise and a simple task to divert her from wanting to leave. And the evidence is “incontrovertible” that exercise delays the progress of dementia and reduces behavioural symptoms like stress, agitation and insomnia. “Exercise is just amazing in that it can make a huge difference to a person with dementia, but people don’t always have access to it.”

Exercise is just one area where research has proven dementia care could be improved, along with better pain control, better facility design, more obvious signage, to give a few examples.

Andrews points out that the ageing eye suffers from yellowing of the cornea, which can leave the elderly viewing the world as through “yellow goggles”. So, lighting levels need to be two or three times higher for the elderly than for younger people.

Sunlight exposure is also important, with some studies showing that the age-related reduction in melatonin, instrumental in setting your natural body clock, is more marked in people with dementia.

The elderly night owl disrupting the ward maybe doesn’t need sedation, just better exposure to natural sunlight, preferably in the early morning. A morning stroll could be the answer, says Andrews. Providing sunlight and exercise is a cheaper alternative to drugs.

en helpful hints for carers

A practical guide aimed at carers living with people with dementia has found a ready audience with nurses, says author June Andrews.

She drew on an extensive analysis by the University of Leeds into the web advice available to carers that indicated some advice was wrong, some had no evidence-based backing, and other really good evidence-based practice was not being shared with families or carers.

The result was her own 10 Helpful Hints for Carers, an easy-to-read guide offering simple, practical, evidence-based solutions to everyday issues when caring for a person with dementia. Suggestions cover areas like aggression, ‘wandering’, creating relaxing environments and coping with depression.

“My greatest customers are nurses or other healthcare workers,” says Andrews.

More information about an Australian

version of the booklet can be found at: