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• Delirium. Dementia is the leading risk factor for delirium. Patients with dementia are three to five times more likelythan other older adult patients to develop delirium in the hospital,1-4 and two-thirds of delirium in hospitals occursin patients with dementia.5

• Falls. Hospital patients with dementia are 1.6 to 3.6 times more likely than other older patients to fall in the hospi-tal.6, 7 One-third to nearly two-thirds of falls in older patients involve a patient with impaired memory, which isindicative of dementia.6, 8

• New incontinence. Hospital patients with dementia are more likely than other older patients to develop new incon-tinence. A study of 13,729 older patients in 81 hospitals in Italy found that those with dementia were five timesmore likely to develop new urinary incontinence and six times more likely to develop fecal incontinence.7

• Indwelling urinary catheters. Hospital patients with dementia are at greater risk than other older patients forplacement of an indwelling urinary catheter without a specific clinical indication. In one hospital, patients withdementia were almost three times more likely than other older patients to have such a catheter placement.9

• Pressure ulcers. The study of more than 13,000 older patients in 81 Italian hospitals, mentioned above, also foundthat patients with dementia were five times more likely than other older patients to develop new pressure sores.7

• Untreated pain: Hospital patients with dementia are more likely than other older patients to have untreated pain.For example, two studies found that hip fracture patients with dementia received roughly one-quarter to two-fifthsof the amounts of opioid analgesics received by other older hip fracture patients.10, 11

• Agitation and related behavioral symptoms. Behavioral symptoms such as agitation, repetitive verbalizations,yelling, and physical aggression are common in people with dementia, and many aspects of hospitalization canexacerbate these symptoms.12-14 In one community hospital, 95% of the patients with dementia were found to haveat least one agitated behavior, and the number and frequency of these behaviors were strongly associated withnurses’ reported levels of burden.15

• Physical restraints. Hospital patients with dementia are three to six times more likely than other older patients tobe physically restrained.16, 17 One study of hip fracture patients found that 32% of those with severe dementiawere physically restrained, compared with only 2% of those with no dementia.11

• Functional decline. Hospital patients with dementia are more likely than other older patients to experience function-al decline during hospitalization. Studies of large samples of older hospitalized patients show that those withdementia were two to four times more likely than other older patients to lose the ability to perform activities ofdaily living during a hospital stay.18, 19

• New feeding tubes. Hospital patients with dementia are more likely than other hospitalized patients to have newfeeding tubes inserted during hospitalization. One study of patients dying in an acute care hospital found thatthose with dementia were more than twice as likely as those with cancer to receive new feeding tubes.20— KatieMaslow, MSW, and Mathy Mezey, EdD, RN, FAAN

Adverse Health Events in HospitalizedPatients with Dementia

[email protected] AJN t January 2008 t Vol. 108, No. 1

REFERENCES1. Elie M, et al. Delirium risk factors in elderly hospitalized patients. J Gen Intern Med

1998;13(3):204-12. 2. Fick DM, et al. Delirium superimposed on dementia: a systematic review. J Am Geriatr Soc

2002;50(10):1723-32. 3. Morrison RS, et al. Relationship between pain and opioid analgesics on the development

of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58(1):76-81.

4. Pompei P, et al. Delirium in hospitalized older persons: outcomes and predictors. J AmGeriatr Soc 1994;42(8):809-15.

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5. Inouye SK. Delirium in older persons. N Engl J Med 2006;354(11):1157-65. 6. Krauss MJ, et al. A case-control study of patient, medication, and care-related risk factors

for inpatient falls. J Gen Intern Med 2005;20(2):116-22. 7. Mecocci P, et al. Cognitive impairment is the major risk factor for development of geri-

atric syndromes during hospitalization: results from the GIFA study. Dement GeriatrCogn Disord 2005;20(4):262-9.

8. Hitcho EB, et al. Characteristics and circumstances of falls in a hospital setting: aprospective analysis. J Gen Intern Med 2004;19(7):732-9.

9. Holroyd-Leduc JM, et al. The relationship of indwelling urinary catheters to death, lengthof hospital stay, functional decline, and nursing home admission in hospitalized oldermedical patients. J Am Geriatr Soc 2007;55(2):227-33.

10. Feldt KS, et al. Treatment of pain in cognitively impaired compared with cognitivelyintact older patients with hip-fracture. J Am Geriatr Soc 1998;46(9):1079-85.

11. Morrison RS, Siu AL. Survival in end-stage dementia following acute illness. JAMA2000;284(1):47-52.

12. Kovach CR, Wells T. Pacing of activity as a predictor of agitation for persons withdementia in acute care. J Gerontol Nurs 2002;28(1):28-35.

13. Stolley JM. When your patient has Alzheimer’s disease. Am J Nurs 1994;94(8):34-40. 14. McCloskey RM. Caring for patients with dementia in an acute care environment. Geriatr

Nurs 2004;25(3):139-44. 15. Sourial R, et al. Agitation in demented patients in an acute care hospital: prevalence, dis-

ruptiveness, and staff burden. Int Psychogeriatr 2001;13(2):183-97. 16. Sullivan-Marx EM. Achieving restraint-free care of acutely confused older adults. J

Gerontol Nurs 2001;27(4):56-61. 17. Bourbonniere M, et al. Organizational characteristics and restraint use for hospitalized

nursing home residents. J Am Geriatr Soc 2003;51(8):1079-84. 18. Pedone C, et al. Elderly patients with cognitive impairment have a high risk for functional

decline during hospitalization: The GIFA Study. J Gerontol A Biol Sci Med Sci2005;60(12):1576-80.

19. Sands LP, et al. Cognitive screening predicts magnitude of functional recovery fromadmission to 3 months after discharge in hospitalized elders. J Gerontol A Biol Sci MedSci 2003;58(1):37-45.

20. Ahronheim JC, et al. Treatment of the dying in the acute care hospital. Advanced demen-tia and metastatic cancer. Arch Intern Med 1996;156(18):2094-100.

Hospital Initiative Advisory Panel

Member Discipline Title Geography/Location Acute Care Experience

Academic/ Research

Program Curriculum Faculty Alzheimer’s Assn

Marie Boltz PhD, APRN, BC Director of Practice Initiatives – Hartford Institute for Geriatric Nursing,

NYU College of Nursing X X X X

Joan D’Ambrose MA,RN, Nurse/Family

(Former) President Alzheimer’s Association- St. Louis Chapter

X X X X

Carol Ellis RN Manager, Education Services St. Anthony’s – St. Louis X X Della Frazier-Rios RN, MS Senior Vice President Alzheimer’s Association –

NYC Chapter X X

James Galvin M.D. , MPH Associate Professor, Neurology, Psychiatry and Neurobiology , Education Core Leader

Alzheimer’s Disease Research Center, Washington University School of Medicine

X X X X

Roni Haas MSW, LCSW Manager, Mental Health Services

Christian Hospital X

Tina Hartlein

RN C Program Director – Senior Lifestyles

Missouri Delta Medical Center – Sikeston, MO

X

Karen Hendrickson

EdD, RN, CNAA, BC

Chief Nursing Officer Southeast Missouri Hospital X X

Helen Lach

PhD, RN, CS Assistant Professor St. Louis University – School of Nursing

X

Nancy Little

RN, Volunteer /family

Staff Nurse, St. Luke’s Hospital

Alzheimer’s Association – St. Louis

x X

Katie Maslow MSW Associate Director for Quality Care Advocacy

Alzheimer’s Association Ntl Public Policy office

X X

Thomas Meuser Ph.D. Director of Gerontology, Associate Professor of Social Work & Psychology

University of Missouri – St. Louis

X X X X

Jan Palmer Ph.D., RN Assistant Professor, RN-BSN Faculty Coordinator

Saint Louis University School of Nursing

X X X X X

Peter Reed Ph.D. Senior Director of Programs National – Chicago x

Clarissa Rentz MSN, APRN Executive Director Alzheimer’s Association – Greater Cincinnati Chapter

X X X X

Susan Rothas RN, B.S.N. Manager, Professional Training Institute

Greater Il Chapter, Chicago X X

Nancy Smith-Hunnicutt

B.A. Coordinator of Dementia Responsive Care

Mission Hospitals Asheville, NC

X

Myrna Ward MSN, RN Director of Patient Care Southeast Missouri Hospital X

Key Players

Member Discipline Title Geography/Location Acute Care Experience

Academic/ Research

Program Curriculum Faculty Alzheimer’s Assn

Cindy Kempf OTR/L Director of Clinical Services

RPI Therapy Services X X X X

Patty Iverson MA Education Coordinator

Alzheimer’s Association,

St. Louis Chapter X X

Jan McGillick MA,LNHA Director of Education

Alzheimer’s Association, St. Louis Chapter

X X X X

Maggie Murphy-White MA Hospital Initiative

Coordinator


X X

Charla Shurtleff Occupational Therapy

Asst., Gerontology

COTA St. Anthony’s Medical Center,

St. Louis X X X

Joy Snider MD, PhD Assistant Professor,

Dept of Neurology

Alzheimer’s Disease Research

Center, Washington University

X X X X

Cheryl Wingbermuehle MSW Family Services Director

Alzheimer’s Association,

St. Louis Chapter X X

We attempted to make this chart as accurate as possible. If any of your information

is incomplete or incorrect, please notify us. Thank you.

P:\PUBLIC\Education\AAEI\Hospital project\RRF\Advisory Panel\Hospital Inivitiative Advisory Panel 02-27-08.docx

Hospital Initiative Chronology

2003 John A. Hartford Foundation Institute for Geriatric Nursing at New York University in conjunction with national Alzheimer’s Association publishes and promotes Try This: Best Practices in Nursing Care for Persons with Dementia. Provides easy to access best practice knowledge, encourages use, disseminates assessment tools and provides evidence based information to hospital staff.

2006 Alzheimer’s Association St. Louis Chapter conducts a Focus Group with Washington University’s Alzheimer’s Disease Research Center’s Clinicians Partners Program attended by practitioners from rural, urban and suburban acute care settings.

2006 Silverstein and Maslow publish Improving Hospital Care for Persons with Dementia to bring attention to the issue of hospital care for persons with dementia.

Fall 2006- January 2007

Alzheimer’s Disease Research Center collaborates with chapter to videotape interviews with families and professionals about hospital experiences. Program Services Steering Committee member further affirm need for chapter to devote program and staff resources to this issue which is reflected in FY2008 Annual Plan.

January 2007- October 2007

Due to the Association’s ongoing outreach programs, the Missouri Association of Hospital Auxiliaries names the chapter as focus of its Annual Service projects.

April 2007 ADRC and Alzheimer’s staff plan and implement a training program at Southeast Missouri Hospital attended by 73 interdisciplinary staff with pre – post data collection. Informal Resource manual made available at training. Second Hospital: St. Anthony’s Medical Center (SAMC) in south suburban St. Louis agrees to work collaboratively with Chapter and ADRC on a second “pilot”.

May – October 2007 Collaboration with ADRC to evaluate program and develop business plan and program development.

November 2007 – March 2008

ADRC, SAMC, and Alzheimer’s Association collaborate to revise curriculum based on outcomes from pilot programs.

November 2007 Funding received from the Retirement Research Foundation for an 18-month Hospital Training Initiative to document that dementia care training of hospital professionals can be linked to outcomes related to improved quality of care in the acute care setting.

February 2008 Project Coordinator hired to fulfill the objectives outlined in the grant. The Coordinator will work with the selected hospitals to assess their training needs, procure pilot partnership, implement training programs and identify resources to improve hospital systems in ways that have a positive impact on the quality of care provided to persons with dementia and their families during hospitalization.

March 2008 Advisory Panel established to review and refine training curricula, analyze the results of 2007 pilots and determine appropriate course of educational interventions and outcomes measures for the project.

April 2008 Advisory Panel attends a planning meeting in St. Louis. Discussion focused on curriculum enrichment and outcome measures for the project. Work groups established to continue to examine improvements to the program.

June 2008 Final curriculum revision is completed to incorporate Advisory Panel suggestions. Evaluation tools are improved in order to gather more data as well.

October – November Grand Rounds delivered by Dr. Jim Galvin at Christian Hospital and St. Anthony’s

2008 Medical Center. May 2009 Jan McGillick awarded Practice Change Fellowship. This will allow the Association to

continue the Initiative at two additional hospitals and improve data collection. June 2009 Anheuser Busch Grant – Partially supports training at two additional hospitals. July 2009 Data from four pilot hospitals is analyzed by Alzheimers Disease Research Center. April 2010 The hospital initiative is presented at the National Conference for Nurses Improving

Care for Healthsystems Elders (NICHE). July 2010 5 Alzheimer’s Association Chapters – are trained to begin the Hospital Initiative at

their chapters. On-going support and communication is given to ensure success of their programs.

August 2010 Missouri Hospital Association Webinar: 19 hospitals in Missouri participated and received information related to the initiative.

Hospital Initiative Overview presented to the Practice Improvement Committee at Barnes Jewish Hospital.

September 2010 Dementia Friendly Hospitals: Care Not Crisis© - awarded copyright June 2008 – January 2012

Over 1000 Hospital staff members from 7 area hospitals have received education through the Dementia Friendly Hospital Initiative.

Present Grant Application submitted through HealthCare Interactive to provide on-line version of curriculum. Decision pending. Curriculum revisions to incorporate increased support to reducing re-admissions.

Dementia-Friendly Hospitals: Care Not Crisis – Curriculum Outline

Introduction & Purpose Statement

The purpose of the Dementia-Friendly Acute Care training program is to address the reality that approximately one-third of people with Alzheimer’s disease and other dementias are hospitalized each year for a total of 3.2 million hospital stays, a number that will greatly escalate as the population ages. (Analysis of 2000 Medicare data). Older hospital patients with dementia are at much higher risk for functional decline, delirium, falls, elopement incidents, dehydration, aggressive behaviors and physical restraint. Frequently, functional decline occurs during the hospital stay, which may lengthen stay and complicate discharge.

Based on discussions and focus groups with acute care leaders (2006-08), we know that hospital staff are often undertrained to recognize dementias. They need the skills necessary to deal with the associated problems, communicate effectively with family caregivers, and identify ways to better manage individual patient care needs. This will result in reduced staff burden, less family stress and improved patient outcomes. (Maslow, 2006).

As of October 2008, the Centers for Medicare and Medicaid Services (CMS) no longer reimburse hospitals for certain complications that occur during a patient’s stay. Several of these adverse health events commonly happen to persons with dementia (infection related to the use of indwelling catheters, pressure ulcers, delirium, etc). These CMS changes further fuel the need for education and advocacy for improved outcomes during hospitalization.

Models of dementia-capable acute care delivery and training efforts have been documented and researched, but are not being implemented as standard practice. Responding to concerns voiced by family members, hospital staff and leadership, the Alzheimer’s Association Education Institute (AAEI) St. Louis Chapter, in collaboration with the Washington University Alzheimer’s Disease Research Center, is initiating a training program with four area hospitals: St. Anthony’s Medical Center, Southeast Missouri Hospital, Christian Hospital and “to be determined”.

Goal/Vision of Training

This educational opportunity focuses on impacting changes in the care of cognitively impaired patients through offering practical, interactive and dementia specific training to hospital personnel working with persons with cognitive impairments. Considerable data about the effect of training on hospital systems and individual staff knowledge and behaviors will also be gathered as a result of implementing this training initiative in participating institutions. After a pilot phase is evaluated, the program will be adjusted for broad replication. Staff training on practical care for people with dementia has been demonstrated to:

• Increase detection and treatment of Alzheimer’s disease and related dementias in acute care settings

• Raise awareness and improve knowledge resulting in improved patient care. • Challenge outdated or incorrect attitudes and practices to increase staff competence. • Prevent complications from infection and malnutrition. • Facilitate recovery. • Prevent functional decline. • Reduce high risk behaviors to improve safety for both patient and staff.

Acknowledgements The Alzheimer’s Association Education Institute, St. Louis Chapter would like to thank the following people and organizations for their contributions to the development of this training program. The program was developed in 2007 in partnership with the Alzheimer’s Disease Research Center (ADRC) at Washington University, St. Louis, Missouri. ADRC’s participation and leadership in this initiative has been funded in part by the National Institute on Aging (P50-AG05681).

Many families and caregivers describe challenging experiences when their relative or friend with dementia is hospitalized. The development of this pilot educational program is in response to these serious concerns and advocates for people with dementia in hospitals by providing training for hospital staff. Our gratitude is extended to all of our collaborators listed below.

Alzheimer’s Disease Research Center, Washington University School of Medicine Contributors

• James E. Galvin, MD, MPH, Associate Professor Department of Neurology, Psychiatry and Neurobiology and Director of Memory Diagnostic Center, Education Core Leader, Alzheimer’s Disease Research Center, Washington University, Advisory Panel Member

• Mary Coats, BS, MS, RN, CS, GCNS, Research Assistant Professor in the Department of Neurology • Jessica Germino, BA, Medical Student, Washington University School of Medicine • Ronald Hawley, Video Coordinator and Editor • Barbie Kuntemeier, MA, ADRC Education Core Coordinator, Advisory Panel Member • Stacy Jackson, APRN, BC, Nurse Clinician, Dept. of Neurology & Memory and Aging Project • Janice Palmer, RN, MS, Administrative Director of Washington University Center on Aging

Southeast Missouri Hospital Collaborators

• Mark S. Hahn, DO Family Practice • Karen Hendrickson, EdD, RN,CNAA, Vice President, Chief Nursing Officer • Gwen Thoma, EDD, RN, CAN, BC, Director, Educational Services • LaDonna Willis, BSN, RNC, CAN, Nurse Manager, Generations Family Resource Center

St. Anthony’s Medical Center Collaborators

• Carol Ellis, RN, BSN, Manager of Education Services, Advisory Panel Member • Mary Falcetti, MA, OTR/L, Therapy Manager, Acute OT and Acute Rehab • Barbara Finke, Administrative Assistant, Therapy Services • Amanda Finley, MSN, RN, Nurse Educator • Cindy Kempf, MA, OTR/L, Occupational Therapist • Annette Latham, BSN, BA, RN, Director of Care Management and Social Services • Denise Levick, BS, RPT, Director of Therapy Services • Rev. Barbara Patten, M.Div., B.C.C. Chaplain, Pastoral Care Department • Kay Schulze, MSN, RN, CMSRN, Clinical Nurse Educator/Medical Surgery • Charla Shurtleff, BA, COTA/L, MA Intern & Candidate, Lindenwood University, Advisory Panel Member

Acknowledgements - Continued


• Joan D’Ambrose, RN, BA, MA, President • Mandy Stinnett Adkins, MSW • Lisa Hicks, LPN, Outreach Coordinator • Shannon Kitchen, MSW Outreach Coordinator • Janis McGillick, MA, LNHA, Director of Education • Maggie Murphy-White, MA, Hospital Initiative Coordinator • Cheryl Wingbermuehle, MSW, LCSW, Director Family Services, Advisory Panel Member • Carol White, AAS, Administrative Support Specialist

University of Missouri –St. Louis

• Tom Meuser, PhD, Director of Gerontology, Associate Professor of Social Work and Psychology , University of Missouri–St. Louis, Advisory Panel Member

Advisory Panel

• Marie Boltz, PhD, APRN, BC, Director of Practice Initiatives, NYU College of Nursing • Carol Ellis, RN, BSN, Manager of Education Services, St. Anthony’s Medical Center • Della Frazier-Rios, RN, MS, Senior Vice President, Alzheimer’s Association, NYC Chapter • James Galvin, MD, MPH, Education Core Leader, Alzheimer’s Disease Research Center • Roni Haas, MSW, LCSW, Manager, Mental Health Services, Christian Hospital • Tina Harlein, RN C, Program Director – Senior Lifestyles, Missouri Delta Medical Center • Karen Hendrickson, EdD, RN, CNAA, BC, Chief Nursing Officer, Southeast Missouri Hospital • Helen Lach, PhD, RN, CS, Assistant Professor, Saint Louis University - School of Nursing • Nancy Little, RN, St. Luke’s Hospital, Volunteer/Family Member, Alzheimer’s Association, St. Louis Chapter • Katie Maslow, MSW, Assoc. Director for Quality Care Advocacy, Alzheimer’s Assoc., NTl Public Policy office • Thomas Meuser, Psychologist, Director of Gerontology, University of Missouri – St. Louis • Peter Reed, PhD, Senior Director of Programs, Alzheimer’s Association, National Office • Clarissa Rentz, MSN, APRN, Executive Director, Alzheimer’s Association, Greater Cincinnati Chapter • Susan Rothas, RN, BSN, Mgr, Professional Training Institute, Alzheimer’s Assoc, Greater Illinois Chapter • Nancy Smith-Hunnicutt, Coordinator of Dementia Responsive Care, Mission Hospitals, NC • Myrna Ward, MSN, RN, Director of Patient Care, Southeast Missouri Hospital

Many staff and volunteers contributed to this pilot throughout its development.

Content Summary Overall Goals & Objectives This project focuses on the training of individual hospital personnel to impact changes in the care of cognitively impaired patients. Data collection will be utilized to assess the efficacy of implementing a dementia training initiative at participating hospitals. The anticipated results of this project are to:

• Provide a more fully developed and tested core curriculum for training hospital personnel in dementia care

• Develop an outcome-based process that enables hospital administrators to identify needed internal systems changes

• Incorporate strategies that measure training impact on dementia care and systems change

Summary of Learning Objectives Module 1: Introduction to Training: Hospitals and Dementia Care (Includes Pre-Education Packet Information) Learning Outcomes

1. Know the prevalence and financial/social costs of dementia 2. Understand the impact of hospitalization rates and current outcomes for persons with

dementia (PWDs) 3. Make the case for dementia-friendly acute care

Module 2: Medical Overview Learning Outcomes

1. Define Alzheimer’s Disease (AD) and related dementias 2. Differentiate among delirium, dementia, and depression 3. Describe tools and resources for diagnosis and cognitive assessments 4. Recognize treatment options

a. Nonpharmacological b. Pharmacological

Module 3: Communication & Behavior Learning Outcomes

1. Understand dementia’s impact on the ability to communicate 2. List symptoms of dementia that affect communication 3. Review communication challenges inherent in hospitalization of PWDs 4. Utilize family caregivers knowledge to improve care for the PWD 5. Understand behaviors 6. Learn positive interventions for problem behaviors

Module 4: Dementia Friendly Care Learning Outcomes

1. Review clinical best practices during hospital stay that address: a. Safety b. Pain & Medication Issues c. Self-Care & Activities of Daily Living

Module 5: Connecting the Caregiver Learning Outcomes

1. Understand the importance of starting discharge planning early 2. Identify the red flags for high risk cases 3. Recognize common safety issues and ethical concerns 4. Utilize a multi-disciplinary, best practices approach that includes families 5. Ensure continuity of care/referrals 6. Refer to the Alzheimer’s Association for support for PWDs and their caregivers

Case Studies –utilized throughout the day Learning Outcomes

1. Utilize hospital assessment tool to identify possible dementia triggers 2. Utilize nursing plan of care to identify and appropriately address the special needs of PWDs 3. Utilize interdisciplinary teamwork effectively

Integrate and apply the knowledge and skills acquired in this training

‘‘Dementia-friendly Hospitals: Care not Crisis’’

An Educational Program Designed to Improve the Careof the Hospitalized Patient With Dementia

James E. Galvin, MD, MPH,*w zy Barbara Kuntemeier, MA, MS,*Noor Al-Hammadi, MBChB, MPH,* Jessica Germino, BA,*Maggie Murphy-White, MA,J and Janis McGillick, MSWJ

Background: Approximately 3.2 million hospital stays annuallyinvolve a person with dementia, leading to higher costs, longerlengths of stay, and poorer outcomes. Older adults with dementiaare vulnerable when hospitals are unable to meet their specialneeds.

Methods: We developed, implemented, and evaluated a trainingprogram for 540 individuals at 4 community hospitals. Pretest,posttest, and a 120-day delayed posttest were performed to assessknowledge, confidence, and practice parameters.

Results: The mean age of the sample was 46 years; 83% wereWhite, 90% were female, and 60% were nurses. Upon completion,there were significant gains (P’s <0.001) in knowledge andconfidence in recognizing, assessing, and managing dementia.Attendees reported gains in communication skills and strategiesto improve the hospital environment, patient safety, and behavioralmanagement. At 120 days, 3 of 4 hospitals demonstratedmaintenance of confidence. In the hospital that demonstratedlower knowledge and confidence scores, the sample was older andhad more nurses and more years in practice.

Conclusions: We demonstrate the feasibility of training hospitalstaff about dementia and its impact on patient outcomes. Atbaseline, there was low knowledge and confidence in the ability tocare for dementia patients. Training had an immediate impact onknowledge, confidence, and attitudes with lasting impact in 3 of 4hospitals. We identified targets for intervention and the need forongoing training and administrative reinforcement to sustainbehavioral change. Community resources, such as local chaptersof the Alzheimer Association, may be key community partners inimproving care outcomes for hospitalized persons with dementia.

Key Words: dementia, hospital care, education

(Alzheimer Dis Assoc Disord 2010;24:372–379)

Alzheimer disease (AD), the most common cause ofdementia affects over 5 million Americans.1 In addition

to cognitive and functional decline, AD and relateddementias triple healthcare costs for individuals over65 years of age2,3 and leading to increased morbidity andhigher mortality.3 Studies suggest between 19% and 76%of patients with dementia are hospitalized 1.5 to 2 timesper year.4 Using Medicare data, it is estimated that 3.2million hospital stays involved a person with dementia in2000, suggesting that up to a quarter of hospital stays ofelderly persons were patients with dementia.4 In 2000, 9%of Medicare beneficiaries had at least one claim with adiagnostic code for AD (ICD-9: 331.0) or some other formof dementia, and these same individuals had 3 times morehospital stays than the average stays for all Medicarebeneficiaries.5

The prevalence of dementia among persons dischargedfrom acute care hospitals ranges from 4% to 27%.6 Currentevidence reveals higher rates of hospitalization7 and levelsof comorbidity among patients with dementia than amongcognitively intact patients,8–12 with falls and behavioralproblems being frequent causes of admission.13 AD andrelated disorders may be poorly recognized in communitysettings and if unrecognized may serve as a trigger fora host of undesirable adverse events upon hospitalization,including falls, unintended injuries, deconditioning, mal-nutrition, incontinence, nosocomial infections, over orunder medication, and adverse responses to medications,leading to poorer outcomes.6,14–17 Management of symp-toms, particularly pain,18 is compromised and disruptive,unsafe behaviors are common and often untreated.19 Thus,dementia seems to be associated with significant increases infunctional disability, number of hospitalizations, lengths ofhospital stay, rates of nursing home admission, death andhealth care costs.6

Given the aging population and the risks of dementiawith increasing age, hospital staff can expect that thenumber of elderly persons presenting with memoryproblems in addition to medical and/or surgical problemswhen hospitalized will also increase. Dementia increasesthe burden of acute care systems and is associated withexcessive use of nursing resources, higher complicationrates, and longer stays.20 Older adults, as well as theirfamilies and caregivers, are thus particularly vulnerable tosystems of care that either do not recognize or are unable tomeet their special needs.

Here we present the development, implementation,and evaluation of a program entitled ‘‘Dementia-friendlyCopyright r 2010 by Lippincott Williams & Wilkins

Received for publication November 18, 2009; accepted May 6, 2010.From the *Alzheimer Disease Research Center; Departments of

wNeurology; zPsychiatry; yNeurobiology, Washington UniversitySchool of Medicine; and JAlzheimer Association, St Louis Chapter,St Louis, MO.

Supported by grants from the National Institutes of Health P50AG05681, the Retirement Research Foundation, and the AlzheimerAssociation.

James E. Galvin is now located at New York University LangoneSchool of Medicine.

Statistical Analysis was conducted by Noor Al-Hammadi, MBChB,MPH and James E. Galvin, MD, MPH, Washington UniversitySchool of Medicine.

Reprints: James E. Galvin, MD, MPH, Center of Excellence on BrainAging, New York University Langone School of Medicine, 145East 32nd Street, 2nd Floor, New York, NY 10016 (e-mail:[email protected]).

ORIGINAL ARTICLE

372 | www.alzheimerjournal.com Alzheimer Dis Assoc Disord � Volume 24, Number 4, October–December 2010

Hospitals: Care Not Crisis.’’ This program targeted nursesand other direct-care staff (social workers, pastoral care,discharge planners, physical therapists) working in hospitalsettings to provide them with information and resources toallow them to better care for patients with dementia fromadmission to discharge planning. The impetus for thisprogram came out of the recognition that many of theHelpline calls received at the Alzheimer’s AssociationSt Louis Chapter dealt with the poor outcomes of hospitalvisits for patients with dementia.

METHODS

Study ParticipantsFive hundred forty staff members attended the 2 pilot

and 8 training sessions. Two hospitals (Hospitals A and B)were recruited via ongoing relationships with the AlzheimerAssociation to participate in the pilot program with 143attendees. After the pilot, 397 participants comprised ofnurses, therapists, social workers, nurses’ assistants, pas-toral care, and administrators signed consent to participatein research and attended 1 of 2 sessions held at 4community hospitals in Missouri: Hospital A (N=68)located in suburban south St Louis, Hospital B (N=66)located in southeast rural Missouri, Hospital C (N=97) inurban north St Louis, and Hospital D (N=166) located insuburban St Louis county. Each hospital was responsiblefor advertisement and registration via an online system.The Washington University Human Research ProtectionOffice approved all procedures.

Program and Curriculum DevelopmentThe initial program content ideas was developed from

the John A. Hartford Institute for Geriatric Nursingand the National Alzheimer Association publications‘‘Try This: Best Practices in Nursing Care for Persons withDementia’’ (www.hartfordign.org/trythis). In 2006, theAlzheimer Association St Louis Chapter and the Washing-ton University Alzheimer Disease Research Center colla-borated to conduct focus groups attended by staff fromrural, urban, and suburban acute care settings. Barriers to‘‘dementia-friendly’’ hospital stays, staffing, and trainingissues and unmet needs such as proactive training andhospital-wide system modifications were discussed. Thefocus group also made suggestions for better practices andimproved outcomes. In 2007, the St Louis Chapter of theAlzheimer’s Association and the Washington UniversityAlzheimer Disease Research Center developed a pilotprogram for Hospitals A (suburban) and B (rural). Indeveloping this program, it was important to establishrelevance and validity of the program to urban and ruralareas. Using feedback from these pilot programs, thecurriculum was revised to incorporate group learning.Upon completion of these pilot programs, a nationaladvisory panel was constituted to assist with curriculumdevelopment and program evaluation tools.

The curriculum consisted of 5 learning modules(Introduction, Medical Overview, Approaches to Commu-nication and Behavior, Dementia Friendly Care, andConnecting the Caregiver). The curriculum contained bothdidactic information and incorporated group learning byasking groups to review case studies and generate care plansand discharge plans using forms specific to each institution.The Introduction module reviewed facts and figuresassociated with AD and introduced each of the accom-

panying modules. The Medical Overview module reviewedsigns and symptoms of dementia, differential diagnosis, anddistinctions between dementia, delirium, and depression.The module reviewed brief screening tools for assessingpatients, both informant based such as the AD8,21 andperformance measures such as the Mini-Cog.22 TheCommunication module reviewed language and compre-hension difficulties associated with cognitive impairmentand behavioral changes that accompany the different stagesof dementia.23 The Dementia Friendly Care modulereviewed topical issues such as safety interventions, falls,pain assessment, nutrition, use of restraints, wandering,agitation, and diversion activities. The Connecting theCaregiver module reviewed the importance of earlyinitiation of interdisciplinary discharge planning andreferral to services such as those provided by the AlzheimerAssociation.

The program lasted 7 hours and included amplebreaks and lunch. Each module was delivered by a differentspecialist in that particular area; for example, a physiciandelivered the Medical Overview module, whereas a socialworker from the Alzheimer Association delivered theConnecting the Caregiver module. In addition, an asso-ciated Medical Grand Rounds at each hospital was offeredto make physicians aware of the training made available tothe staff.

Outcome MeasurementsParticipants completed the following evaluation

materials: (1) a pretest evaluating demographics, clinicalpractice characteristics, medical knowledge about demen-tia, confidence in providing care, and various practicebehaviors; (2) a standard program quality rating formcompleted immediately after training; (3) an immediateposttest questionnaire similar to the pretest to assessimmediate gains in knowledge and confidence; and (4) adelayed posttest at 120 days to test maintenance ofknowledge and confidence. Questions were investigatorgenerated after input from focus groups, a review of theliterature and comments from the advisory panel.

All participants were asked 6 questions regardingcurrent practices and attitudes when caring for hospitalizedpatients with dementia on a 1-5 Likert scale with anchors‘‘Strongly Disagree’’ and ‘‘Strongly Agree.’’ Contentincluded frequency of encountering and difficulty workingwith demented patients, time to provide comprehensivecare, value of family member input, previous training, andopinion on admission procedures. Five questions addressedrespondents’ confidence in assessing and recognizingdementia, managing demented patients, differentiatingdelirium from dementia, communication skills, and dis-charge planning on a 1-5 Likert scale with anchors ‘‘Notat all’’ and ‘‘Extremely.’’ A 9-item multiple choice test wasadministered testing knowledge of basic facts aboutdementia prevalence, risk factors, signs and symptoms, riskof elopement, and use of restraints.

In addition to quantitative data, a series of qualitativequestions were asked. On the pretest, respondents wereasked to list challenges they face when working withdemented patients and skills or resources that would enablethem to provide better care. The posttest asked for changesattendees would make in assessment, care, or managementof dementia patients. The 120-day posttest queried whetherattendees were involved in the care of dementia patients,use of referral to the Alzheimer Association, changes in

Alzheimer Dis Assoc Disord � Volume 24, Number 4, October–December 2010 Dementia-friendly Hospitals

r 2010 Lippincott Williams & Wilkins www.alzheimerjournal.com | 373

clinical care, and remaining barriers faced when workingwith patients with dementia.

Statistical AnalysisAnalyses were performed using SPSS version 15 (SPSS

Inc, Chicago, IL). Descriptive statistics were used tocharacterize and compare groups. An outcome variablefor knowledge was created on a continuous scale rangingfrom 0 to 14 by adding up the number of correct answers.Another composite variable was calculated to assessparticipants’ confidence in dealing with dementia issuesand care on a 0 to 5 continuous scale with very much orextremely=1 and all other answers=0.

Three points of time were used to assess the benefitsthe participants gained from the workshop in terms ofimproving their knowledge, confidence, practices, andattitudes in dealing with a dementia patient: a pretestbefore the program, a posttest at its conclusion and adelayed posttest at 120 days. Paired sample t tests, w2 tests,and 1-way analysis of variance were used to assess thesuccess of the program in achieving its goals and objectives.Stepwise linear regression was performed to assess pre-dictors of knowledge and confidence gain among theparticipants at the end of the program.

There was a preplanned analysis of hospital dataregarding falls, use of restraints, and antipsychotic medica-tions, length of stay, and readmission rates before and afterthe program to evaluate whether gain in knowledgeand confidence or change in attitudes and practice alteredpatient care outcomes. Unfortunately, the participatinghospitals declined to provide this data to the investigators.

RESULTS

Sample CharacteristicsTable 1 depicts the characteristics of the study

participants from each of the 4 medical centers: HospitalD (41.8%), Hospital C (24.4%), Hospital A (17.1%), andHospital B (16.6%). The mean age of the study populationwas 46 years and most were females (90.4%). Participants’reported ethnicity was 83% White, 10% African-American,3% Asian, and 2% Hispanic, whereas 2% did not respond.The participants were mainly nurses (60%). Most partici-pants worked the day shift (73.3%), and 35% reportedworking on a medical-surgical ward. Participants reportedthat 68% of their patients were 65 years of age and olderand that 29% of them had some form of dementia. Mostparticipants (78.6%) had received 3 hours or less of trainingon dementia-related issues and care within the last 2 years.

Immediate Benefits on Knowledgeand Confidence

On a test of knowledge about dementia, the partici-pants’ scores significantly improved at the end of theprogram (Table 2). Participants were asked to rate theirlevel of confidence in dealing with the hospitalized patientwith dementia before and after the program. Participantsreported a significant improvement in their overall con-fidence (Table 2) as well as in each individual variable:assessment and recognition of dementia, managing demen-tia care, differentiating dementia from delirium, commu-nicating with the patient and family, and dischargeplanning.

TABLE 1. Descriptive Statistics of Study Participants

Original Sample

Delayed Posttest

Sample

Variable Mean SD Mean SD P

Age (y) 45.7 12.7 48.3 11.5 NS

Years of practice 17.6 12.3 18.3 13.4 NS

% Patients >65 y 66.9 25.5 65.9 25.9 NS

% Patient with

dementia

32.4 25.1 29.2 26.1 NS

N % N % P

Hospital <0.001

Hospital A

(suburban)

68 17.1 13 38.2

Hospital B (rural) 66 16.6 5 14.7

Hospital C (urban) 97 24.4 7 20.6

Hospital D

(suburban)

166 41.8 9 26.5

Sex 0.002

Male 27 6.8 2 5.9

Female 359 90.4 32 94.1

Race/Ethnicity 0.03

Whites 329 82.9 33 91.1

Other 56 14.6 1 8.8

Profession <0.001

Nurse 238 61.6 19 55.9

OT/PT (any therapy) 57 14.8 9 26.5

Other 91 23.6 6 17.6

Schedule <0.001

Day shift 291 79.7 29 87.8

Evening and night

shift

74 20.3 4 12.1

Training on dementia-

related

care in the last 2 y

<0.001

None 176 44.3 16 47.1

<=3h 136 34.3 12 35.3

>3h 58 14.6 4 11.8

NS indicates not significant; OT, occupational therapy; PT, physicaltherapy.

TABLE 2. Knowledge and Confidence Level Among ParticipantsBefore and at the End of the Workshop

Pretest Posttest

Mean SD Mean SD P

Knowledge 9.97 2.9 12.90 1.5 <0.001Level of confidence 0.86 1.4 2.42 1.9 <0.001

N % N %Assess and recognize <0.001Not at all– reasonably 290 73 196 49.4very much–extremely 78 19.6 155 39

Manage care <0.001Not at all—reasonably 284 71.5 182 45.8Very much–extremely 84 21.2 168 42.3

Differentiate from delirium <0.001Not at all—reasonably 326 82.1 199 50.1Very much–extremely 40 10.1 150 37.8

Discharge planning <0.001Not at all—reasonably 315 79.3 194 48.9Very much–extremely 39 9.8 147 37

Communicate with patientand family

<0.001

Not at all—reasonably 278 70 138 34.8Very much–extremely 90 22.7 212 53.4

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Immediate Benefits on Attitude and PracticeParticipants were asked a series of questions regarding

attitudes and practices toward the hospitalized patient withdementia (Table 3) rated as disagree, neutral, or agree.The questions evaluated participants’ perceptions in termsof the difficulties they face working with a dementia patientand providing enough time for comprehensive care, as wellas their opinions about considering family members andcaregivers in their health plans. They were also asked if theyhad received enough training to recognize and take care ofpatients with AD or other dementias, especially in termsof admission procedures. After the program, there was asignificant improvement in attitude with the exception ofthe respondents valuing help from family members andcaregivers.

Program EvaluationAt the end of the education program, an evaluation

was distributed among the participants to assess whether itachieved its objectives; 76.3% reported that the programwas excellent and comprehensive; 92% found the handoutmaterial was useful for future reference. Most participants(83%) agreed that the workshop covered ways to improvecommunication with patients with dementia and theirfamily members or caregivers successfully. Attendeesreported that they had gained useful information regardinghow to adjust the physical environment (eg, light, noise)to suit the needs of a patient with dementia (83%), howto address disruptive behaviors or agitation (71%), andrecognize safety issues to promote safer environments(81%). Participants also reported gains in pain assessmentand medication effects (67%), strategies for providingnutrition and personal care for a patient with dementia(72%), and usefulness of community referrals (ie, Alzhei-mer Association) during discharge planning (81%).

Delayed Posttest ResultsFollow up of the program participants was done

120 days after the date of the workshop to assess the

maintenance and retention of knowledge and level ofconfidence as well as their practices and attitudes towardhospitalized dementia patients. Incomplete contact infor-mation was provided by 142 attendees so that no posttestcould be administered. Between the time of the immediateposttest and delayed posttest 4 months later, 17 participantshad left their institutions (Hospital A=4, Hospital B=4,Hospital C=5, and Hospital D=4) and were lost tofollow-up. Of the 238 participants who completed theimmediate posttest and were still at their institution, 34returned the delayed posttest (14.3% response rate).Characteristics of the delayed posttest sample are shownin Table 1. No differences in age, years of practice, orexperience with geriatric or demented patients were found.Respondents in the delayed posttest sample were morelikely to be female (P=0.002), White (P=0.03), a therapist(P<0.001), and work the day shift (P<0.001). The delayedposttest sample was more likely to report no training in thecare of dementia patients in the past 2 years (P<0.001).When comparing posttest scores, 3 hospitals showed slightdeclines in knowledge at 120 days: Hospitals A, B, and C(Table 4). However, there was a significant loss of bothknowledge and confidence in the participants at Hospital A,whereas confidence in assessing and managing dementiapatients remained stable at the other 3 hospitals.

The largest proportion of respondents to the delayedposttest was from 2 hospitals: Hospitals A and D, whichwere also the hospitals with the highest retention of staffattending one of the training programs. Because of thedifferences between Hospitals D (maintenance of knowl-edge and confidence) and A (loss of knowledge and confi-dence), we compared the characteristics of the original anddelayed posttest samples between the 2 hospitals (Table 5).There were neither differences in the original sample on anyof the demographic variable nor were there any differencesin the immediate posttest scores for knowledge orconfidence. When examining the demographic variables ofthe delayed posttest sample from Hospital A, the groupwho returned the delayed posttest was representative of

TABLE 3. Evaluations of Attitudes and Practices Toward Hospitalized Dementia Patients Before and at the End of the Workshop

Disagree Neutral Agree

N % N % N % P

Is it difficult to work with dementia patients? <0.001Pretest 54 13.6 94 23.7 226 56.9Posttest 106 26.7 82 20.7 174 43.8

I do not have enough time to provide comprehensive care <0.001Pretest 122 30.7 102 25.7 148 37.3Posttest 162 40.8 90 22.7 107 27.0

I believe in help from family members and caregivers NSPretest 10 2.5 8 2.0 358 90.2Posttest 14 3.5 0 0.0 347 87.4

I have received sufficient training to take care of dementia patients 0.02Pretest 170 42.8 113 28.5 91 22.9Posttest 21 5.3 43 10.8 295 74.3

Admission procedures should be no different than for patients without dementia <0.001Pretest 296 74.6 35 8.8 45 11.3Posttest 307 77.3 17 4.3 36 9.1

I rarely see a diagnosis of a dementia disorder upon hospital admission <0.001Pretest 224 56.4 62 15.6 84 21.2Posttest 202 50.9 67 16.9 86 21.7

NS indicates not significant.



the original group of participants in terms of their race,schedule, dementia training, and experience with geriatricand demented patients. However, the delayed posttestsample was older (P=0.02), contained more females(P=0.01), had a higher proportion of nurses (P<0.001),and had more years in practice (P=0.03) when comparedwith the original sample. When examining the demographicvariables of the retention sample from Hospital D, thedelayed posttest sample contained more African-Americans(P<0.001), had a smaller proportion of nurses (P<0.001)and had little to no dementia training in the past 2 years(P<0.001).

Stepwise linear regression was performed to assesspredictors of knowledge and confidence gain among theparticipants at the end of the program. Interestingly, thoserespondents who reported receiving dementia training formore than 3 hours in the past 2 years unexpectedly had a1.3-fold decrease in knowledge after the program. None ofthe available characteristics seemed to be an indicator ofconfidence gain among the participants.

Qualitative ResultsParticipants were asked at the time of pretest to

list challenges they face when working with persons withdementia. The most common challenges include dealingwith patient safety issues, how best to communicate withthe patient, and how well the patient understood theinstructions they received (especially at discharge). Staffalso noted challenges dealing with the lack of time they hadto spend with the patients, family denial of cognitiveproblems, behavioral and mood changes, confusion, and alack of staff education to deal with each of these challenges.Respondents were also asked to list skills, tools, supplies, or

resources they believed would enable them to better care forthe person with dementia. The greatest unmet need wasin-service training to increase the staff’s understanding ofdementia and strategies to improve the hospital environ-ment for the patient with dementia. This included reducingthe patient to staff ratio. Attendees also requested appro-priate supplies and activity items to keep the patientsoccupied and strategies for improving communication skillsand patient safety. Other requests included strategiesto improve communication with families and caregiversand intervention approaches and resources for dischargeplanning.

At the posttest, attendees were asked to list 2 changesthey would make in their assessment, care, and dischargeof the patient with dementia. The greatest behavioralchange was to involve the families to a greater extent andto include a family questionnaire such as the AD821 intheir assessments. The staff also recognized the need forimproved communication skills with the patient, such assitting and talking clearly, using nonverbal clues, andasking permission to touch the patient to improve care.Strategies to improve the hospital environment, such asbetter lighting, activity kits, music, familiar pictures andwarm blankets, were listed, as was the need to refer patientsto the Alzheimer Association and other communityresources at the time of discharge.

Other Unanticipated ResultsIn addition to planned outcome evaluations of knowl-

edge, confidence, and practices, a number of changes inthe culture at the institutions have occurred. Three of thetrained hospitals have instituted activity kits for hospita-lized persons with dementia. Hospital B created ‘‘Chris’

TABLE 4. Evaluations of Knowledge and Confidence Levels at the End of the Program and 120 Days

Knowledge Confidence

Posttest Delayed Posttest Posttest Delayed Posttest

Mean (SD) Mean (SD) P Mean (SD) Mean (SD) P

Hospital A (suburban) 12.9 (1.5) 11.2 (2.2) 0.01 2.9 (1.8) 0.9 (1.4) 0.02Hospital B (rural) 12.8 (1.5) 11.6 (1.5) 0.03 2.8 (1.9) 2.2 (1.8) NSHospital C (urban) 12.4 (1.8) 9.8 (2.4) 0.02 2.6 (1.8) 2.1 (1.9) NSHospital D (suburban) 12.8 (1.4) 12.1 (2.1) ns 2.3 (2.1) 1.6 (2.1) NS

NS indicates not significant.

TABLE 5. Comparison of Characteristics of the Original and Delayed Posttest Sample from 2 Hospitals

Hospital A Hospital D

Variable Original Delayed Posttest P Original Delayed Posttest P

Age (y) 44.4 (13.2) 53.0 (7.3) 0.02 45.4 (11.9) 44.6 (11.8) NSSex, % female 92.5 100 0.01 95.1 88.9 NSRace, % White 95.5 76.9 ns 87.9 100 <.001Profession, % nurses 53.7 69.2 <0.001 66.9 30.8 <.001Years of practice 17.7 (18.6) 23.9 (13.6) 0.03 17.7 (12.9) 11.3 (13.2) NSSchedule, % days 77.9 75.0 ns 79.9 88.9 NSPatients >65, % 72.5 71.5 ns 71.7 76.7 NSPatients with dementia, % 34.8 34.1 ns 25.2 29.2 NSDementia training >3h, % 20.9 25.0 ns 12.5 0 <0.001

Pearson w2 or Fisher Exact test was used to calculate P value for categorical variables and t tests for the continuous variable.NS indicates not significant.



Alzheimer’s Recreation Kits’’ named after a donor’shusband. Each kit includes: Twiddle muff (http://beaulily.com/), a photo album for the family to fill with pictures,soft books, Tangle Toys, an Alzheimer Association catalog,a copy of ‘‘The Forgetting: Alzheimer’s: Portrait of anEpidemic’’ by David Shenk, and a 4 CD box set of music.The kits are being distributed to patients in the hospitalwith a dementia diagnosis, patients seen on the mobile van,and through the Lutheran Family Services Alzheimer’sgroup.

Hospital A created a team of volunteers (called the‘‘A-Team’’) especially trained to assist in the care of thehospitalized person with dementia. The A-Team centersits activity on the geriatric unit of the hospital, wherevolunteers spend weekday afternoons with patients withAlzheimer disease or other forms of cognitive impairment.They provide companionship, alert a nurse if the patienttries to do something unsafe, and provide activities. TheA-Team was launched at the end of October 2008 andis a pilot program of specialized care for patients withdementia. In addition, Hospital A instituted a ‘‘CodeGreen’’ procedure that placed patients at risk for elopementin green gowns and trained staff on appropriate dementia-friendly responses and precautions.

DISCUSSIONWe were able to successfully train over 500 individuals

at 4 area hospitals on dementia-friendly care. Mostparticipants had little to no prior training in dementia carewithin the last 2 years. After completion of the trainingprogram, an improvement in knowledge about andconfidence dealing with the hospitalized person withdementia was seen and was associated with a significantchange in attitude toward dementia care. We were able toidentify the staff’s unmet needs and barriers to improvingcare. The program was well received by the attendees andseveral unanticipated benefits resulted, including the devel-opment of specialized care teams, hospital procedures, andactivity kits for dementia patients.

Delayed posttests demonstrated maintenance of con-fidence in assessing and managing dementia patients in 3of 4 hospitals trained. This was surprising given that thehospital that did not retain knowledge or confidence(Hospital A) was the most proactive of the 4 hospitals,participating in the pilot program and developing ancillarycare teams, procedures, and activities for dementia care. Itwas also interesting that the strongest predictor for the lackof a gain in knowledge was in the 15% of attendees whoreported they had had more than 3 hours of dementiatraining in the past 2 years. This may explain, in part, theloss of maintenance at Hospital A as staff from thisinstitution reported the highest percentage of dementiaeducation before the training programs. Participants whoreceived such training may have relied on previouslylearned information and had limited uptake of newknowledge from the sessions. Alternatively, the informationthe staff received during previous training may have beenincorrect or misremembered.

Cognitive impairment of any cause poses challengesto the healthcare providers in the hospital setting; suchchallenges include recognizing symptoms, making diag-noses, and dealing with potentially serious sequelae such asadverse effects of medications and procedures.20,24–28

Dementia in all its various forms, particularly at its earliest

stages, may be overlooked by providers, leading to under-diagnosis and undertreatment.29 Furthermore, symptomsof dementia, especially in the hospital setting, may beattributed to other causes such as delirium, depression,medication, infection, or metabolic derangements.30 Thisprogram originally was designed to evaluate whethereducating the hospital staff most directly involved inpatient care could improve these outcomes; however, atthe completion of the programs, the hospitals decided notto share outcome data.

Care of the dementia patient while in the hospital mayalso be compromised. Dementia-related behavioral phe-nomenon may interfere with accustomed staff policies,placing more emphasis on individual needs of the dementiapatient.31 Additional challenges include communicat-ing with the demented patient, issues with managingnutrition and rehabilitation, and appropriate dispositionat the time of discharge. Knowledge of dementia may notbe enough to overcome these challenges32; rather, changesin care practices may alleviate staff burden and improvepatient outcomes. Results from this and other studies pointto the burgeoning recognition by hospitals and acute carehealth professionals of poor outcomes and high costsassociated with dementia care and the need to develop asolution.

There have been attempts to improve care of thehospitalized patient with dementia. One such project wasinitiated by the Providence Milwaukie Hospital System inPortland, Oregon. Providence Milwaukie Hospital imple-mented a project to improve delivery of care with 5 goals,including improving recognition of dementia on admission,identifying special needs and risks, emphasizing the use ofnonpharmacological interventions for behavior, involvingfamily in discharge planning, and providing dementiainformation and education.33 Although staff more fre-quently expressed awareness of dementia screening toolssuch as the Mini-mental State Examation, there was littleevidence for increased use of such instruments either onadmission or in care planning. Diagnosis of dementiaincreased by 34% and depression by 22%; however,management of such problems led to an 8% increased useof antipsychotics and a 22% increased use of benzodiaze-pines without any increase in the use of antidepressants.33

Other attempts at improving patient outcomesthrough education programs alone have had mixed results.Hospital staff come from a variety of disciplines and have adiverse range of practice patterns and educational needs.34

Interventions limited in scope to select units may not reachdesired impact. For example, programs directed a infectioncontrol that have focused on single nursing units didnot significantly improve patient outcomes.35 Organizationswith frequent changes in personnel and leadership suchas occur in most hospital units may not have the stableinfrastructure necessary to attain and sustain change.Instead hospital-wide programs associated with protocolsfor care and management, national guidelines, and evi-dence-based practice may be the best approach to improv-ing patient outcomes.34–36 Our study supports that mainte-nance of knowledge and practice changes may not be long-lasting without continued in-service training and hospital-wide systematic change. The Dementia-friendly hospitalprogram described here is one such example of a hospital-wide program that can lead to hospital wide guidelines,practice change, and improved discharge planning includ-ing referral to community resources such as the Alzheimer



Association.37 It remains to be seen if these guidelinesultimately lead to improved outcomes.

Our study has limitations. In addition to the posttestresults, other planned analyses of outcomes includedreviewing data on falls, restraint use, elopement incidences,length of stay, and readmission to determine whetherthe training had tangible benefits to the hospitals.Unfortunately, the participating institutions were unwillingto share this data. The hospitals and staff appeared to bemore committed to the practical issues of training ratherthan participating in the research component. The 120-dayposttest was difficult to collect. No incentives were offeredfor completing the posttest, which may have lowered theresponse rate. In several instances, contact information onthe pretest was incomplete, illegible or incorrect, makingit difficult to reach participants for the delayed posttest. Thelow response rate (14%) for the 120-day delayed posttestlimits generalizability of the findings, especially becausenonresponse bias is difficult to assess.38 Reported responserates for mailed surveys to the general population approach60%, whereas response rates for health professionals varyfrom 11% to 90%.38 An alternative interpretation of thelow response rate could be that those who did not respondto the survey had an inherently poor view of research ingeneral or of this particular topic and simply chose not torespond. In addition, given the low response rate, the actualresponses may be driven by the demographic characteristicsof the respondents rather than the educational programthey attended. Although there is no way to test thishypothesis, it is informative to note that those with the leastprior training and experience gained knowledge andconfidence and maintained it, whereas those with the mostprior training and experience did not show maintenance.

The greatest value of the program was the demonstra-tion of feasibility of gaining the confidence of the hospitaland staff to recognize the unmet need of dementia trainingand to dedicate time and resources to host an educationalprogram. The greatest weakness of the program was theinability to collect the preplanned outcome. The future ofthe program will depend on the ability to demonstrate thatthe educational initiatives translate into tangible patientoutcomes. One approach we have taken is to partner with2 academic institutions traditionally more amenable toresearch data collection.

With these caveats in mind, these data highlight thefeasibility and interest at both the hospital and staff level inincreasing awareness about dementia and its impact onpoorer outcomes and higher costs during hospitalization.The serious need for dementia training among acute carestaff was identified in the pretraining survey. This wasassociated with low confidence in knowledge or abilityto care for dementia patients who often present withcomorbidities. Training had an immediate impact onknowledge, confidence, and attitudes, and confidence wasmaintained in 3 of 4 hospitals trained. Unanticipatedbenefits were the development of specialized care teams andactivity kits. We were able to identify potential targets forintervention and the need for ongoing training and theadministrative reinforcement necessary to sustain behav-ioral change. In moving forward with the program, we needto include tangible benefits to the participating hospitals,including aspects of cost-benefit analyses. Communityresources, such as local chapters of the Alzheimer Associa-tion, may be key community partners in improving careoutcomes for hospitalized persons with dementia.

Hospital Initiative Advisory PanelMarie Boltz, PhD, APRN, BC, Director of Practice

Initiatives—Hartford Institute for Geriatric Nursing, NewYork University, New York, NY; Joan D’Ambrose, MA,RN, President, Alzheimer’s Association–St Louis Chapter,St Louis, MO; Carol Ellis, RN, Manager, EducationServices, St Anthony’s Medical Center, St Louis, MO;Della Frazier-Rios, RN, MS, Senior Vice President,Alzheimer’s Association–New York City Chapter, NewYork, NY; James E Galvin, MD, MPH, AssociateProfessor, Washington University School of Medicine,St Louis, MO; Roni Haas, MSW, LCSW, Manager,Mental Health Services, Christian Hospital, St Louis,MO; Tina Hartlein RN, Program Director—Senior Life-styles, Missouri Delta Medical Center, Sikeston, MO;Karen Hendrickson, EdD, RN, CNAA, BC, Chief NursingOfficer, Southeast Missouri Hospital, Cape Girardeau,MO; Helen Lach, PhD, RN, CS, Assistant Professor, StLouis University School of Nursing, St Louis, MO; NancyLittle, RN, Staff Nurse, St Luke’s Hospital, Chesterfield,MO; Katie Maslow MSW, Associate Director for QualityCare Advocacy, National Alzheimer’s Association, Chica-go, IL; Thomas Meuser, PhD, Director of Gerontology,University of Missouri–St Louis, St Louis, MO; Peter ReedPhD, Senior Director of Programs, National AlzheimerAssociation, Chicago, IL; Clarissa Rentz, MSN, APRN,Executive Director, Alzheimer’s Association—Greater Cin-cinnati Chapter, Cincinnati, OH; Susan Rothas, RN, BSN,Manager, Professional Training Institute, Alzheimer Asso-ciation—Greater Illinois Chapter, Chicago, IL; NancySmith-Hunnicutt, BA, Coordinator of Dementia Respon-sive Care, Mission Hospitals, Asheville, NC; and MyrnaWard, MSN, RN, Director of Patient Care, SoutheastMissouri Hospital, Cape Girardeau, MO.

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Acute care settings are ill-equipped to deal with the special needs of persons with dementia. One-third of all persons with dementia are hospitalized annually, currently totaling 3.2 million hospital stays per year. (Silverstein & Maslow, 2006). Staff are not frequently trained to address dementia care issues adequately.

Dementia Friendly Hospitals Care Not Crisis


Alzheimer’s Disease Research Center, Washington University

Hospital systems are geared for cognitively intact persons. Statistically, 1/4th of all hospital patients 65+ are people with AD or related dementias, a number projected to increase. These patients are at much higher risk for delirium, falls, fractures, elopement incidents, incontinence, dehydration, untreated pain, aggressive behaviors, physical restraint, functional decline, weight loss and pressure sores. (Silverstein & Maslow, 2006), increasing the likelihood of non-reimbursed hospital care, and expensive re-hospitalization or nursing home placement. At present, best practice, dementia-specific training that prevents or reduces poor outcomes is neither mandated or routinely taking place in hospitals. The Alzheimer’s Association Education Institute (AAEI), has unique expertise and resources to assist with needs of affected families.

Background

Abstract Objectives

Correspondence

Method

Results

Conclusions

.

Project Goal: To document that dementia care training of hospital staff can be linked to practice change outcomes related to improved quality

of care in the acute care setting.

•Review and consolidate currently available international, “best practices” in hospital dementia care to develop and feasibility test, curriculum appropriate for use in acute care settings. •Formalize and convene an expert advisory panel to review and refine training curricula, analyze results of 2007 AAEI pilots and determine appropriate course of educational interventions and outcomes measures for this pilot project. •Confirm four hospitals willing to identify internal needs to improve dementia care capability, and commit multidisciplinary staff to participate in pilot AAEI training program and a follow-up process. •Evaluate impact of training curriculum, format and modify as needed in preparation for larger scale replication and research in a variety of acute care settings.

Five hundred forty staff members were recruited to attend the 2 pilot and 8 training sessions. A total of 397 participants comprised of nurses, therapists, social workers, nurses’ assistants, pastoral care and administrators signed consent to participate in research and attended one of two sessions held at 4 community hospitals in the St. Louis area.

The curriculum consisted of 5 learning modules (Introduction, Medical Overview, Approaches to Communication and Behavior, Dementia Friendly Care, and Connecting the Caregiver). The curriculum contained both didactic information and incorporated interactive learning, and group case studies reviews. Learners generated care and discharge plans using forms specific to each institution.

Assessment at three points of time measured the benefits participants gained from the workshop in terms of improving their knowledge, confidence, practices and attitudes in dealing with a patient with dementia. Data collection was done through a pre-test prior to the program, a post-test at its conclusion and a delayed post-test at 120 days.

Data indicates a mean participant age of 46; a mean of 17.6 years of practice, yet 78.6% of respondents received 3 hours or less of training on dementia related issues in the last 2 years despite rapidly evolving advances in dementia assessment and management. Following completion of the training program, an improvement in knowledge about and confidence dealing with the hospitalized person with dementia was seen and was associated with a significant change in attitude toward dementia care. We were able to identify unmet needs and barriers to improving care for the hospitalized dementia patient.

The program was well received by the attendees and several unanticipated

benefits resulted, including the development of specialized care teams, hospital procedures and activity kits for dementia patients.

The serious need for dementia training associated with low confidence in knowledge or ability to care for dementia patients among acute care staff was validated. Training had an immediate impact on knowledge, confidence and attitudes, and confidence was maintained in 3 of 4 hospitals trained. We were able to identify potential targets for intervention and the need for ongoing training and the administrative reinforcement necessary in order to sustain behavioral change. Community resources, such as local chapters of the Alzheimer’s Association and ADRC’s and Hospital Associations are key community partners in improving care outcomes for hospitalized persons with dementia.

To improve care for the hospitalized person with dementia, changes in practice delivery are certainly needed. Such a plan could include the following steps 1) Creation of a team to implement change; 2) Adequate supervision and guidance; 3) A plan for staff development and training; 4) An accreditation process; and 5) Effective quality monitors.

Alzheimer’s Association, St. Louis Chapter (alzstl.org) Funding provided by:

Retirement Research Foundation (rrf.org) Practice Change Fellows (practicechangefellows.org)

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