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Behavioural and psychiatric symptoms in people with dementia admitted to the acute hospital: prospective cohort study

  • Elizabeth L. Sampson, Nicola White, Baptiste Leurent, Sharon Scott, Kathryn Lord, Jeff Round and Louise Jones...
Abstract
Background

Dementia is common in older people admitted to acute hospitals. There are concerns about the quality of care they receive. Behavioural and psychiatric symptoms of dementia (BPSD) seem to be particularly challenging for hospital staff.

Aims

To define the prevalence of BPSD and explore their clinical associations.

Method

Longitudinal cohort study of 230 people with dementia, aged over 70, admitted to hospital for acute medical illness, and assessed for BPSD at admission and every 4 (±1) days until discharge. Other measures included length of stay, care quality indicators, adverse events and mortality.

Results

Participants were very impaired; 46% at Functional Assessment Staging Scale (FAST) stage 6d or above (doubly incontinent), 75% had BPSD, and 43% had some BPSD that were moderately/severely troubling to staff. Most common were aggression (57%), activity disturbance (44%), sleep disturbance (42%) and anxiety (35%).

Conclusions

We found that BPSD are very common in older people admitted to an acute hospital. Patients and staff would benefit from more specialist psychiatric support.

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Copyright
Corresponding author
Elizabeth L. Sampson, Marie Curie Palliative Care Research Unit, Division of Psychiatry, University College Medical School, 1st Floor, Charles Bell House, 67-73 Riding House Street, London W1W 7EJ, UK. Email: e.sampson@ucl.ac.uk
Footnotes
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This project is funded jointly by the Alzheimer's Society and the BUPA Foundation (Grant reference number: 131). The study funder had no influence on the study design, collection, analysis or interpretation of data, the writing of the report or the decision to submit the paper for publication. E.L.S., B.L., S.S., J.R. and L.J. have received support from Marie Curie Cancer Care.

Declaration of interest

None.

Footnotes
References
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Behavioural and psychiatric symptoms in people with dementia admitted to the acute hospital: prospective cohort study

  • Elizabeth L. Sampson, Nicola White, Baptiste Leurent, Sharon Scott, Kathryn Lord, Jeff Round and Louise Jones...
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Behavioural and psychiatric symptoms in people with dementia admitted to the acute hospital

Elizabeta B. Mukaetova-Ladinska, Senior Lecturer in Old Age Psychiatry
19 December 2014

To the Editor, We would like to commend Sampson et al [1] on undertaking the difficult task of identifying and monitoring behavioural and psychological symptoms in people with dementia (BPSD) admitted to acute medical wards. The authors have also done their best to untangle the BPSD syndrome from similar clinical symptomatology seen in delirium, which still remains the ongoing conundrum for many of us working in liaison psychiatry. The study provides not only a wealth of information, but also raises a number of issues about how different BPSD presentation may be in older people when admitted to acute medical setting and how it influences their outcomes. For detecting BPSD, the authors used the BEHAVE-AD, a scale that has been widely implemented in detecting behavioural problems in people with dementia, in particular AD. However this scale has a number of shortcomings, in relation to neglecting important BPSD symptoms of dementia, such as apathy, irritability and/or disinhibition [2] frequentlypresent in dementia. The low medium BPSD scores (2.6-4.4 mean BEHAVE-AD severity), are somewhat surprising, since the majority of the enrolled participants had higher FAST staging, corresponding to more advanced stages of dementia. Such lower BPSD scores are usually associated with mild cognitive impairment [3]. Only 5 subjects coming from 'other' place of residence (continuing NHS care?) had substantially higher BPSD severityscores. Similarly, the severity of the dementia (as measured via the FAST)did not influence the BPSD scores, suggesting that either the medical problems modified the BPSD presentation, or the BPSD symptoms were pharmacologically managed. The only significant impact on BPSD was presence of delirium, thus highlighting the difficulties in routine clinical setting in differentiating between BPSD and clinical symptoms of delirium. Nevertheless, Sampson et al work [1] undoubtedly indicates that hospitals make people with dementia worse, trebling their paranoia and delusional beliefs, causing them hallucinations, making them more aggressive and disturbed with substantial worsening in their moods and anxieties. These findings support the public's widespread beliefs that hospitals are dangerous places, not only filled with sick people and germs, but with a wide potential for something to go amiss in lieu of wrong. And this 'wrong' ranges from having newly acquired diagnosis of dementia when physically unwell or worsening BPSD symptoms [1], further complicating their polypharmacy and making them more frail and with poorer functional outcomes [4], as well as increasing their likelihood to die [1]. Not surprisingly, this also impacts on their formal and informal caregivers. Indeed, there is a striking discord between the severity of the recorded BPSD and the caregiver's distress, arguing that the problems around the escalating in-hospital behavioural changes are much more serious than the physical illness alone. Many of the highlighted BPSD symptoms could be easily regulated with non-pharmacological approaches, including better orientation, information, knowing our patients etc. What is happening to make our hospitals more dementia friendly? A number of hospitals have already introduced dementia-friendly wards that should be fully equipped with the professional expertsin dementia care. However, surprisingly, there is a void of research evidence how the newly introduced dementia-friendly policy in the acute medical setting influences the behaviour of people with dementia. Since most of the people with BPSD come from residential and nursing care [1], one wonders whether there should be another way of introducing dementia friendly management, that of 'in-home health dementia care' approach that would avoid (unnecessary) hospital admissions, and will involve medical care professionals treating people with dementia in their own environment,whenever possible. This would reduce substantially not only the distress that both people with dementia and their caregivers face when in the acutemedical setting, but also reduce hospital admissions, and thus result in substantial cost-savings. The data from a recent study on people with advanced dementia stages ('Hope for Home'; [5]) proves that this can be successfully done, stressing that managing the distress, rather than behaviours that challenge, is central when treating people with dementia. We now need to take these lessons on board and implement them not only within our acute medical wards, but also adapt them to use in the community. References:1. Sampson EL, White N, Leurent B, Scott S, Lord K, Round J, Jones L. Behavioural and psychiatric symptoms in people with dementia admitted to the acute hospital: prospective cohort study. Br J Psychiatry 2014; 205(3):189-96. 2. Robert P, Ferris S, Gauthier S, Ihl R, Winblad B, Tennigkeit F. Review of Alzheimer's disease scales: is there a need for a new multi-domain scale for therapy evaluation in medical practice? Alzheimers Res Ther 2010; 2(4):24. 3. Reisberg B1, Auer SR, Monteiro IM. Behavioral pathology in Alzheimer's disease (BEHAVE-AD) rating scale. Int Psychogeriatr 1996; 8 (Suppl 3):301-8. 4. Runganga M, Peel NM, Hubbard RE. Multiple medication use in older patients in post-acute transitional care: a prospective cohort study. ClinIntervent Aging 2014; 9:1453-62.5. Treloar A, Crugel M, Adamis D. Palliative and end of life care of dementia at home is feasible and rewarding. Results from the 'Hope for Home' study. Dementia 2009; 8(3):335-47. Elizabeta B. Mukaetova-Ladinska, MD, MMedSci, PhD, MRCPsych Senior Lecturer in Old Age Psychiatry, Institute of Neuroscience and Newcastle University Institute for Ageing, Campus for Ageing and Vitality, NewcastleUniversity, Newcastle upon Tyne, UK and Newcastle Liaison Team for Older Adults, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle uponTyne, UK Ann Scully, MRCPsych Consultant in Old Age Psychiatry Newcastle Liaison Team for Older Adults, Northumberland, Tyne and Wear NHS Foundation Trust,Newcastle upon Tyne, UK

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Conflict of interest: None declared

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Behavioural and psychiatric symptoms in people with dementia admitted to acute hospitals

Elizabeta B. Mukaetova-Ladinska, Senior Lecturer in Old Age Psychiatry
07 November 2014

To the Editor,

We would like to commend Sampson et al [1] on undertaking the difficult task of identifying and monitoring behavioural and psychologicalsymptoms in people with dementia (BPSD) admitted to acute medical wards. The authors have also done their best to untangle the BPSD syndrome from similar clinical symptomatology seen in delirium, which still remains the ongoing conundrum for many of us working in liaison psychiatry. The studyprovides not only a wealth of information, but also raises a number of issues about how different BPSD presentation may be in older people when admitted to acute medical setting and how it influences their outcomes.

For detecting BPSD, the authors used the BEHAVE-AD, a scale that has been widely implemented in detecting behavioural problems in people with dementia, in particular AD. However this scale has a number of shortcomings, in relation to neglecting important BPSD symptoms of dementia, such as apathy, irritability and/or disinhibition [2] frequentlypresent in dementia. The low medium BPSD scores (2.6-4.4 mean BEHAVE-AD severity), are somewhat surprising, since the majority of the enrolled participants had higher FAST staging, corresponding to more advanced stages of dementia. Such lower BPSD scores are usually associated with mild cognitive impairment [3]. Only 5 subjects coming from 'other' place of residence (continuing NHS care?) had substantially higher BPSD severityscores. Similarly, the severity of the dementia (as measured via the FAST)did not influence the BPSD scores, suggesting that either the medical problems modified the BPSD presentation, or the BPSD symptoms were pharmacologically managed. The only significant impact on BPSD was presence of delirium, thus highlighting the difficulties in routine clinical setting in differentiating between BPSD and clinical symptoms of delirium.

Nevertheless, Sampson et al work [1] undoubtedly indicates that hospitals make people with dementia worse, trebling their paranoia and delusional beliefs, causing them hallucinations, making them more aggressive and disturbed with substantial worsening in their moods and anxieties. These findings support the public's widespread beliefs that hospitals are dangerous places, not only filled with sick people and germs, but with a wide potential for something to go amiss in lieu of wrong. And this 'wrong' ranges from having newly acquired diagnosis of dementia when physically unwell or worsening BPSD symptoms [1], further complicating their polypharmacy and making them more frail and with poorerfunctional outcomes [4], as well as increasing their likelihood to die [1]. Not surprisingly, this also impacts on their formal and informal caregivers. Indeed, there is a striking discord between the severity of the recorded BPSD and the caregiver's distress, arguing that the problems around the escalating in-hospital behavioural changes are much more serious than the physical illness alone.

Many of the highlighted BPSD symptoms could be easily regulated with non-pharmacological approaches, including better orientation, information,knowing our patients etc. What is happening to make our hospitals more dementia friendly? A number of hospitals have already introduced dementia-friendly wards that should be fully equipped with the professional expertsin dementia care. However, surprisingly, there is a void of research evidence how the newly introduced dementia-friendly policy in the acute medical setting influences the behaviour of people with dementia. Since most of the people with BPSD come from residential and nursing care [1], one wonders whether there should be another way of introducing dementia friendly management, that of 'in-home health dementia care' approach thatwould avoid (unnecessary) hospital admissions, and will involve medical care professionals treating people with dementia in their own environment,whenever possible. This would reduce substantially not only the distress that both people with dementia and their caregivers face when in the acutemedical setting, but also reduce hospital admissions, and thus result in substantial cost-savings. The data from a recent study on people with advanced dementia stages ('Hope for Home'; [5]) proves that this can be successfully done, stressing that managing the distress, rather than behaviours that challenge, is central when treating people with dementia. We now need to take these lessons on board and implement them not only within our acute medical wards, but also adapt them to use in the community.

References:1. Sampson EL, White N, Leurent B, Scott S, Lord K, Round J, Jones L. Behavioural and psychiatric symptoms in people with dementia admitted to the acute hospital: prospective cohort study. Br J Psychiatry 2014; 205(3):189-96.2. Robert P, Ferris S, Gauthier S, Ihl R, Winblad B, Tennigkeit F. Review of Alzheimer's disease scales: is there a need for a new multi-domain scale for therapy evaluation in medical practice? Alzheimers Res Ther 2010; 2(4):24.3. Reisberg B1, Auer SR, Monteiro IM. Behavioral pathology in Alzheimer's disease (BEHAVE-AD) rating scale. Int Psychogeriatr 1996; 8 (Suppl 3):301-8.4. Runganga M, Peel NM, Hubbard RE. Multiple medication use in older patients in post-acute transitional care: a prospective cohort study. ClinIntervent Aging 2014; 9:1453-62.5. Treloar A, Crugel M, Adamis D. Palliative and end of life care of dementia at home is feasible and rewarding. Results from the 'Hope for Home' study. Dementia 2009; 8(3):335-47.

Elizabeta B. Mukaetova-Ladinska, MD, MMedSci, PhD, MRCPsychSenior Lecturer in Old Age Psychiatry, Institute of Neuroscience and Newcastle University Institute for Ageing, Campus for Ageing and Vitality,Newcastle University, Newcastle upon Tyne, UK and Newcastle Liaison Team for Older Adults, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK

Ann Scully, MRCPsychConsultant in Old Age PsychiatryNewcastle Liaison Team for Older Adults, Northumberland, Tyne and Wear NHSFoundation Trust, Newcastle upon Tyne, UK

Conflict of Interest: None declared

Conflict of Interest:None declared
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