Anne-Marie Burn

Comorbidity and dementia: a scoping review of the literature

BackgroundEvidence suggests that amongst people with dementia there is a high prevalence of comorbid medical conditions and related complaints. The presence of dementia may complicate clinical care for other conditions and undermine a patient’s ability to manage a chronic condition. The aim of this study was to scope the extent, range and nature of research activity around dementia and comorbidity.MethodsWe undertook a scoping review including all types of research relating to the prevalence of comorbidities in people with dementia; current systems, structures and other issues relating to service organisation and delivery; patient and carer experiences; and the experiences and attitudes of service providers. We searched AMED, Cochrane Library, CINAHL, PubMed, NHS Evidence, Scopus, Google Scholar (searched 2012, Pubmed updated 2013), checked reference lists and performed citation searches on PubMed and Google Scholar (ongoing to February 2014).ResultsWe included 54 primary studies, eight reviews and three guidelines. Much of the available literature relates to the prevalence of comorbidities in people with dementia or issues around quality of care. Less is known about service organisation and delivery or the views and experiences of people with dementia and their family carers. There is some evidence that people with dementia did not have the same access to treatment and monitoring for conditions such as visual impairment and diabetes as those with similar comorbidities but without dementia.ConclusionsThe prevalence of comorbid conditions in people with dementia is high. Whilst current evidence suggests that people with dementia may have poorer access to services the reasons for this are not clear. There is a need for more research looking at the ways in which having dementia impacts on clinical care for other conditions and how the process of care and different services are adapting to the needs of people with dementia and comorbidity. People with dementia should be included in the debate about the management of comorbidities in older populations and there needs to be greater consideration given to including them in studies that focus on age-related healthcare issues.

Healthcare organisation and delivery for people with dementia and comorbidity: a qualitative study exploring the views of patients, carers and professionals

Objectives People living with dementia (PLWD) have a high prevalence of comorbidty. The aim of this study was to explore the impact of dementia on access to non-dementia services and identify ways of improving service delivery for this population. Design Qualitative study involving interviews and focus groups. Thematic content analysis was informed by theories of continuity of care and access to care. Setting Primary and secondary care in the South and North East of England. Participants PLWD who had 1 of the following comorbidities—diabetes, stroke, vision impairment, their family carers and healthcare professionals (HCPs) in the 3 conditions. Results We recruited 28 community-dwelling PLWD, 33 family carers and 56 HCPs. Analysis resulted in 3 overarching themes: (1) family carers facilitate access to care and continuity of care, (2) the impact of the severity and presentation of dementia on management of comorbid conditions, (3) communication and collaboration across specialities and services is not dementia aware. We found examples of good practice, but these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Conclusions This study suggests that, in order to improve access and continuity for PLWD and comorbidity, a significant change in the organisation of care is required which involves: coproduction of care where professionals, PLWD and family carers work in partnership; recognition of the way a patients diagnosis of dementia affects the management of other long-term conditions; flexibility in services to ensure they are sensitive to the changing needs of PLWD and their family carers over time; and improved collaboration across specialities and organisations. Research is needed to develop interventions that support partnership working and tailoring of care for PLWD and comorbidity.

Multimorbidity and frailty in people with dementia.

Many people with dementia have other complex health needs, including comorbidity and frailty. Most models of care focus on single diseases and do not take into account the needs of those with comorbidities and dementia. Integration, continuity of care and personalisation are particularly important for this vulnerable group. It is also important to recognise potential barriers to accessing care so that these can be addressed. Issues around providing health care for people with dementia and complex health needs are considered in this article, including management and organisation of care, access to care, models of care, role of the family carer, and prevention of dementia, frailty and long-term conditions.

Dementia case-finding in hospitals: a qualitative study exploring the views of healthcare professionals in English primary care and secondary care

Objectives In 2012–2013, the English National Health Service mandated hospitals to conduct systematic case-finding of people with dementia among older people with unplanned admissions. The method was not defined. The aim of this study was to understand current approaches to dementia case-finding in acute hospitals in England and explore the views of healthcare professionals on perceived benefits and challenges. Design Qualitative study involving interviews, focus groups and thematic content analysis. Setting Primary care and secondary care across six counties in the East of England. Participants Hospital staff involved in dementia case-finding and primary care staff in the catchment areas of those hospitals. Results We recruited 23 hospital staff and 36 primary care staff, including 30 general practitioners (GPs). Analysis resulted in three themes: (1) lack of consistent approaches in case-finding processes, (2) barriers between primary care and secondary care which impact on case-finding outcomes and (3) perceptions of rationale, aims and impacts of case-finding. The study shows that there were variations in how well hospitals recorded and reported outcomes to GPs. Barriers between primary care and secondary care, including GPs’ lack of access to hospital investigations and lack of clarity about roles and responsibilities, impacted case-finding outcomes. Staff in secondary care were more positive about the initiative than primary care staff, and there were conflicting priorities for primary care and secondary care regarding case-finding. Conclusions The study suggests a more evidence-based approach was needed to justify approaches to dementia case-finding. Information communicated to primary care from hospitals needs to be comprehensive, appropriate and consistent before GPs can effectively plan further investigation, treatment or care. Follow-up in primary care further requires access to options for postdiagnostic support. There is a need to evaluate the outcomes for patients and the economic impact on health and care services across settings.

Dementia case-finding in acute hospitals: a qualitative study of perspectives of hospital clinicians and general practitioners

Abstract Background Concerns about hospital care of older people with dementia have led to UK Department of Health targets for acute hospitals to identify patients who could have dementia. Although dementia does not fit screening programme criteria, this requirement for dementia case-finding (DCF) reflects policy drives encouraging earlier diagnosis. Hospitals have set up their own processes to conduct assessments on all people aged 75 years and older with unplanned hospital admissions longer than 72 h and inform general practitioners (GPs). The potentially far-reaching effects are unknown. The Cascade study is exploring how hospitals across the East of England are implementing DCF, how results are communicated to GPs, and the impacts on patients and their subsequent care. We aimed to describe current DCF practice and to understand perspectives of both primary and secondary care clinicians on objectives, challenges, barriers, and perceived benefits of DCF. Methods We conducted topic-guided telephone interviews and focus groups with relevant health-care professionals contacted through multiple strategies. Direct e-mail invitations to hospital staff including Trust dementia leads and nurse specialists and invitations to GPs circulated through clinical and research networks, primary care services, and local GP forum meetings aimed for a purposive sample representing hospitals across the East of England. Anonymised transcripts were analysed with a framework approach. Findings We undertook interviews and focus groups with 23 hospital staff and 36 primary care staff (including 30 GPs). Hospitals differed in their approaches to DCF in terms of how, when, and by whom cognition was assessed and ways in which DCF outcomes were recorded and communicated to GPs. Although hospital IT systems were set up to ensure DCF completion, non-compliance could be a problem, especially within specialties where DCF was not a priority. Overall, staff in secondary care were more positive than were those in primary care about the benefits of DCF, including its awareness-raising, although there were concerns about impacts on resources and workload. GPs raised concerns about duplication of effort, the lack of an evidence-base for DCF, lack of access to information, limited post-diagnostic support services, and the appropriateness of DCF in the hospital setting. Interpretation Preliminary findings re-affirm that policies affecting public health need implementation that allows evaluation to inform the evidence-base. Funding National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care East of England