Frail elderly with dementia: there is an alternative

BEFORE COVID-19, it might have sounded ludicrous to say “hospitals are no place for the old and ill”.

Sadly, recent months have been a lesson in debates around whether frail older people, particularly those in residential care, should be admitted to acute care hospitals or cared for in “more familiar” surroundings. The correct practice is that, as for any other age group, admission should be based on clinical need and individual preference. But COVID-19 has shone a light on an older debate – that hospitals are so dangerous for frail older people that admission should be avoided in all but extreme situations. And, when those older patients have dementia, the risks rise and the issue becomes more complex.

If hospital care is considered a dangerous option for older people, there is an alternative to arguing against their admission.

The alternative is to change hospitals to be more suited to older people with multiple health conditions, including those with dementia. Patients with dementia are present in our acute health system, at a rate of 20–25% of those over age 70 years. The vignette of Mr J provides a window into what that experience can be like:

Mr J, an 80-year-old man with dementia, had four hospital admissions in his last year of life. His family described the experience as “one very long nightmare”, and gave the following examples:

• Being given five times the dose of his medication to “quieten him down”, which rendered him unconscious for 5 days.

• Being assigned a “special” nurse who just sat at the end of the bed and watched him – consequently his ability and mobility declined, and his dependence and incontinence increased.

• Having both wrists and ankles tied to the bedrails for 48 hours so he wouldn’t pull his tubes out, during which time a nurse gave him a rolled-up bandage to “play with”.

• Being declared palliative with a month to live and discharged to the care of his family, where he recovered his swallowing reflex, some weight, his skin integrity and his ability to engage with people. He regained some quality of life for the next 6 months.

• During his next and final hospital stay, Mr J developed aspiration pneumonia and died at home a few days later.

Such anecdotes are supported by evidence from large Australian databases. People with dementia are two to three times more likely to experience a complication while in hospital. When age and relevant illnesses are taken into account, patients with dementia still have higher rates than patients without dementia in a range of complications, as well as higher rates of death resulting from such complications. The highest rates and the greatest difference between patients with and without dementia are found in four common hospital complications: urinary tract infections, pressure areas, pneumonia and delirium. These complications cause significant distress for the patient, family and carers and account for some of the highest dollar costs for hospitals.

These complications are potentially preventable.

We already know that more registered nurses by the bedside are associated with lower rates of patient complications (here, here and here). Good nursing care can mitigate and reduce the incidence of the most common hospital complications for people with dementia (Table 1). Nursing interventions involve mobility, hydration, hygiene, patient education and reassurance in a context of nursing surveillance, assessment, early intervention and advocacy. While actions that prevent such complications may seem simple, the skills and leadership required to facilitate these care-giving tasks are not.

Table 1. Complication rates for people with dementia and related nursing care activities

Source: Potentially preventable complications of urinary tract infections, pressure areas, pneumonia, and delirium in hospitalised dementia patients: retrospective cohort study

The family expects that the most educated nurses will pre-empt the urinary tract infection and pressure sores, judge when the patient’s confusion is normal and when it is new, advocate in the best interests of the patient with the medical and allied health teams to diagnose, treat and rehabilitate the patient’s delirium, and expect these university-educated nurses to challenge the status quo, by arguing that the confused person’s need to be mobilised to the courtyard to prevent complications can be as important as medication administration.

And yet, registered nurses are being replaced with other kinds of carers. The “special” nurse mentioned in Mr J’s case was mostly likely an “assistant in nursing”, someone with very limited training, who is nominally supervised by a registered nurse.

AIN, EN, RN — what’s the difference?

• An AIN (assistant in nursing) has 0–1 years of specialist education. The role requires either on-the-job training or a Certificate III from TAFE. They are not registered health workers. Also known as nursing aid or personal care assistant (PCA).
• An EN (enrolled nurse) has 1–2 years of specialist education and will hold either a Certificate IV or Diploma in Nursing from TAFE. ENs may be “endorsed” (EEN) to undertake additional tasks. They are registered health professionals. Also known as division 2 nurse (Victoria) or licensed practical nurse (LPN).
• An RN (registered nurse) has a minimum of 3–4 years university level specialist education, and holds a Bachelors degree. They are registered health professionals. Also known as division 1 nurse (Victoria) or sister.

The impact of these nursing replacements upon patient care has only recently started being investigated. Despite hospitals spending approximately one-third of their budget on ward nursing, hospital administrative datasets have not been designed to capture a great deal of information about nurses, because nursing has traditionally been viewed as a labour cost rather than an intervention that has an effect on patient outcomes. Improved data collection on the staffing levels and conditions of nurses in hospitals (and indeed, in aged care) and on specific nurse-sensitive patient outcomes is an essential but overlooked step in improving patient outcomes and decision making about hospital resource distribution.

What happens to you and your loved ones with dementia while you are in hospital is crucial to understanding, anticipating and planning care for future success of health delivery within finite resources. But as long as units of factory efficiency, such as waiting times and surgical outputs, are used to measure hospital outcomes, then it follows that hospital care will remain structurally aligned to meet the needs of those who have predictable courses of illness, and leave hospital when expected. Neither of which describes older people with multiple health conditions, and particularly not dementia.

Dr Kasia Bail is Associate Professor of Nursing at the University of Canberra, known for her research with older people, health services, nurse sensitive outcomes, and health information systems. Dr Bail maintains casual hospital nursing shifts and shares her scholarly inquiry with nursing students, industry partners and professional groups in order to address structures and processes that enable person-focused care.

Diane Gibson is Distinguished Professor of Health and Ageing at the Health Research Institute, Faculty of Health, University of Canberra.

With acknowledgement to Joan Jackman, Alzheimer’s Australia/Consumer Dementia Research Network Member.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.