Table 2 Subgroup B: Intervention studies

Aizen et al. 2001, Israel [37]

To assess the clinical effectiveness of a hospitalization pilot project

Hospitalization with direct admittance to an acute-care geriatric unit versus through the emergency room

Retrospective comparison design using follow-up data from medical records during a 2-year period

IG: 126 nursing home residents

CG: 80 nursing home residents

Length of stay, discharge disposition, mortality, cause of hospitalization, chronic medical condition, cognitive state, change of functional status during the hospital stays

No significant differences were found between groups in length of stay, mortality, or discharge disposition

Treatment of selected nursing home residents in an acute-care geriatric unit is feasible, medically effective, results in a safe discharge, and provides an alternative to transfer to an emergency room.

Brooke et al. 2017 UK [38]

To understand the impact of dementia-friendly ward environments on nurses’ experiences of caring for patients with dementia

Themed bays with names and colours

Qualitative design using focus groups

Junior qualified nurses (n = 17) and health care assistants (n = 21) from three wards

Perceptions and experiences of nurses working in a dementia-friendly ward environment

Four themes:

‘It doesn’t look like a hospital’- changed environment;

‘More options to provide person-centred care’- no one size fits all;

‘Before you could not see the patients’- a constant nurse presence;

‘The ward remains the same’ - resistance to change.

Facilities creating a space for social dining and activities is useful.

Bay nursing supports nurses to remain present with patients.

Training and education to support and engage with patients beyond the implementation of care is needed.

Elvish et al. 2018, England [39]

To evaluate a dementia care training programme for general hospital staff

Training for trainers and staff using manual for trainer, booklet for staff, communication skills mini guide, a card designed to stand by the hospital bedside, a PowerPoint presentation, and interview clips with people with dementia/relative

Pre–post design, cluster trial

Data from 480 staff participants for pre–post analysis

Confidence in Dementia Scale,

Knowledge in Dementia Scale, Controllability beliefs scale

Significant change between pre–post training on all outcome measures

Staff knowledge in dementia and confidence in working with people with dementia significantly increased following attendance at the training sessions.

Goldberg et al. 2013, UK [40]

To develop and evaluate a best-practice model of general hospital acute medical care for older people with cognitive impairment

A specialist unit designed to deliver best-practice care for people with delirium or dementia staffed with medical and mental health professionals, enhanced staff training in delirium, dementia, and person-centred dementia care. Provision of organised purposeful activity and environmental modification to meet the needs of those with cognitive impairment.

Randomised controlled trial using regular unit as control condition

600 patients aged over 65 admitted for acute medical care, identified as ‘confused’ on admission

Number of days spent at home over the 90 days after randomisation. Structured non-participant observations to ascertain patients’ experiences; satisfaction of family carers with hospital care.

There was no significant difference in days spent at home between the specialist unit and standard care groups.

Patients on the specialist unit spent significantly more time with positive mood and engagement and experienced more staff interactions that met emotional and psychological needs. More family carers were satisfied with care, and severe dissatisfaction was reduced.

Conclusions:

Specialist care for people with delirium and dementia improved the experience of patients and satisfaction of carers, but there were no convincing benefits in health status or service use.

Goldberg et al. 2014, UK [41]

To compare the behaviours of staff and patients on the Medical and Mental Health

Unit (MMHU) and standard care wards and provide a narrative account that helps to explain the link between structure, process, and reported outcomes.

A specialist medical and mental health unit, as described in Goldberg et al. 2013

Qualitative study design using field notes and non-participating observations (Dementia Care Mapping, DCM)

Patients aged over 65 with delirium or dementia.

Median age 86, half were female.

Field notes recorded the events being observed: the behaviour and actions of the patient, the staff member, and visitors interacting with them.

DCM observations of engagement, activity, and staff interactions

Cognitively impaired older patients were cared for in environments that were crowded, noisy, and lacked privacy. Staff mostly prioritised physical over psychological needs.

Person-centred care was mostly delivered during activity sessions or mealtimes by activities coordinators.

Mental health needs were addressed more often on MMHU than on standard care wards, but most staff time was still taken up delivering physical care.

Care provided on the MMHU was distinctly different from standard care wards. Improvements were worthwhile, but care remained challenging, and consistently good practice was difficult to maintain.

Naughton et al. 2005, USA [42]

To improve outcomes for cognitively impaired and delirious older adults

Multifactorial intervention.

Selectively admit cognitively impaired and delirious older adults from the emergency department to an acute geriatric unit.

Implement new assessment and management protocols to improve recognition and pharmacological management of cognitive impairment and delirium.

Pre-test - post-test study design

A total of 374 patients 75 years and older

Prevalence of delirium, admission to AGU, psychotropic medication use, hospital length of stay

Confusion Assessment Methods Cumulative Illness Rating scale

Prevalence pf delirium was reduced at 4 months and at 9 months compared to baseline. Each case of delirium prevented saved a mean of 3.42 hospital days.

A multi-factorial intervention designed to reduce delirium in older adults was associated with less delirium and hospital savings.

Naughton et al. 2018, UK [43]

To measure the impact of dementia communication training plus older adult unit (OAU) placement in students’ ability to recognise opportunities for person-centred communication compared to OAU placement alone

Dementia communication training using VERA (Validation, Emotion, Reassurance, Activity) framework with follow-up reflective discussions during OAU placement

Mixed method controlled pre-post-study design using electronic survey and focus group interviews

52 students completed surveys (IG:38 and CG:14)

Focus group interviews: 19 students

Students’ ability to identify person-centred responses and application of the VERA principles which was tested using case vignettes

IG: participants were significantly more likely to identify person-centred responses compared with the control group.

Focus group findings:

VERA was described as a flexible approach that added t participants’ communication toolkit.

The VERA framework has potential as a foundation-level dementia communication training intervention, but it requires more rigorous testing.

Sampson et al. 2017, UK [44]

To evaluate the impact of a systemwide training programme in dementia care for acute hospital staff

Train-the-trainer model focusing on the basic, essential competencies relevant to all sections of workforce and society.

Classroom teaching, on-the-ward training, or one-to-one coaching in practice.

Mixed methods design collecting date on four levels: individual, ward, organisation, and system

1700 staff from eight acute hospital trusts

Numbers and types of staff trained,

Changes in dementia care practice,

Staffs’ sense of competency in dementia care (SCID).

The number of staff trained per trust ranged from 67 to 650 (total 2020).

Mean SCID score increased from baseline to follow-up.

Organisational level data suggested increased use of carer’s passport, delirium screening scales, and pathways. Observations demonstrated improved staff–patient interactions but little change in hospital environments.

There was a significant improvement in staffs’ sense of competence in dementia care and the quality of interactions with patients.

Schindel et al. 2016, Canada [45]

To investigate the impact of the education programme on acute care staff’s self-efficacy in delivering person-centred dementia care

Intervention group (IG): The Gentle Persuasive Approaches (GPA) programme focusing on person-centred care (PCC), brain changes in dementia and delirium, communication, team/patient/family debriefing, and reassurance techniques was delivered by clinician educators.

Control group (CG): Waiting list group

Mixed method, nonrandomized controlled, quasi-experimental repeated measures design and focus groups

IG: 468

staff employed on 7 clinical areas at site A

CG:

277 staff employed across 5 clinical areas at site B

Quantitative: scores on short version of the Self-Perceived Behavioural Management Self-Efficacy Profile descriptive statistics

Qualitative:

opinions, beliefs, and practices regarding dementia care and the intervention

The IG demonstrated significant improvement in self-efficacy scores from baseline to immediately postintervention, sustained at 8 weeks.

No changes from baseline to 8 weeks postintervention evident in the wait-listed group.

Participants described positive impacts including implementation of person-centred care approaches.

This study determined that GPA addressed the concerns expressed by staff and provided the needed knowledge and skills to manage NDB in a person-centered fashion.

Sinvani et al., 2018, USA [46]

To determine whether a multicomponent intervention improves care in hospitalized older adults with cognitive impairment

Multicomponent intervention including geographic unit cohorting, multidisciplinary approach, patient engagement specialists and staff education

Non-randomized controlled study using retrospective chart review with propensity score matching

952 visits (IG: 476 and CG: 476) of older adults with cognitive impairment aged > 65

In hospital mortality, LOS, discharge disposition, readmission, medication, delirium, use of restraints from medical records

Patients in the intervention group had lower in-hospital mortality, shorter stays, were less likely to have an order of constant og enhanced observation, to be taking benzodiazepines og antipsychotic medication or to have restraints compared to controls

A multicomponent intervention may offer a new paradigm in the management of older adults with cognitive impairment in hospital care

Spencer et al.2013, UK [47]

To examine in depth carers’ views and experiences of the delivery of patient care for people with dementia or delirium in an acute general hospital in order to evaluate a specialist Medical and Mental Health Unit (MMHU) compared with standard hospital wards

The intervention ward enhanced five aspects of care:

Additional specialist staff;

Staff received enhanced training in dementia, delirium, and PCC;

A programme of purposeful activities were introduced;

The ward environment was optimised to improve patient orientation and independence;

A proactive and inclusive approach to family carers.

Qualitative study design using semi-structured interviews

40 carers of patients with cognitive impairment admitted to hospital, 20 from each of the settings

Patient admission.

Carer relationship with staff.

The ward environment.

Patients’ daily routines.

Care and medical treatment.

Discharge planning.

The themes identified were related to family carers’ expectations and included activities and boredom, staff knowledge, dignity and fundamental care, the ward environment, and communication between staff and carers.

Carers from MMHU appreciated improvements relating to activities, the ward environment, and staff skills, but communication and engagement with family carers were still perceived as insufficient.

Even though neither setting was perceived as wholly good or wholly bad, greater satisfaction and less dissatisfaction with care were experienced by carers from MMHU compared with standard care wards.

Stenvall et.al. 2011, Sweden [48]

To investigate whether a multidisciplinary postoperative intervention programme could reduce postoperative complications and improve functional recovery among people with dementia

Staff trained for individualized care planning and rehabilitation to prevent postoperative delirium.

Geriatric assessment, management, and rehabilitation, including a follow-up at 4 months postoperatively.

Control group: conventional postoperative routines

A randomized controlled trial

64 patients (IG: 28 and CG: 36) with a dementia diagnosis and femoral neck fracture aged > 70 years in orthopaedic acute hospital department

Postoperative complications, living situations, and functional performance during hospitalization and during follow-ups at 4 and 12 months postoperatively.

Katz ADL index,

Mini-Mental State Examination,

The modified Organic Brain Syndrome

Scale,

Geriatric Depression Scale (GDS-15).

There were fewer postoperative complications in the intervention group such as urinary tract infections, nutritional problems, postoperative delirium, and falls. At 4 months a larger proportion of the intervention group had regained their previous independent indoor walking ability. At 12 months a larger proportion in the intervention group had regained

ADL performance level.

Patients with dementia who suffer a hip fracture can benefit from the intervention.

Surr et al. 2016, UK [49]

To evaluate the efficacy of a specialist training programme for acute hospital staff regarding improving attitudes, satisfaction, and feelings of caring efficacy in provision of care to people with dementia

A cascade training programme designed for acute hospital settings focusing on person-centred dementia care and the impact of the physical environment

Repeated measures design

40 acute hospital staff working in clinical roles

Approaches to Dementia Questionnaire (ADQ),

Staff Experiences of Working with Demented Residents questionnaire,

Caring Efficacy Scale

A significant positive change on all three outcome measures following intermediate training compared to baseline

The results suggest that Foundation level training may be adequate for awareness raising and supporting a more positive attitude towards people with dementia. However, the findings indicate that the knowledge offered by the Intermediate level training is needed to have an impact on staff feelings of caring efficacy and satisfaction.

Tay et al. 2018, Singapore [50]

To evaluate the effectiveness of an acute hospital that adopts a person-centred dementia care (PCC) protocol

Intervention group (IG): moderating intrusive interventions and encouraging family members and volunteers to engage in daily activities.

Control group (CG): Patients received standard medical care.

Prospective cohort study intervention versus usual care on pre-post outcomes

IG: 170 patients

CG: 60 patients

Dementia type and stage, comorbidities, well-being, ill-being, functional status, agitation levels, quality of life, Charlson’s Comorbidity Index, Modified Barthel Index, Pittsburgh Agitation Scale, EuroQoL,

IG: greater gains in Modified Barthel Index function and well-being, decreased ill-being and agitation, and greater improvement in EuroQoL index score compared to CG

The findings call for wider adoption of PCC models of enhanced care for PWDs in the acute hospital setting.

Travers et al. 2018, Australia [51]

To evaluate the effectiveness of the collective social education process and its impact on nurses’ knowledge of dementia and screening of at-risk patients for delirium early in their admission

Nomination of a Cognition Champions leader for each ward.

Inclusion of the CogChamps project at regular ward meetings.

Delirium education sessions for nurses.

Quantitative descriptive study design

CogChamps were assessed for demographic characteristics, knowledge, self-rated confidence and stress assessment of nurses’ delirium knowledge pre- and post-education.

Audit of CAM assessments pre-and post-education

34 experienced nurses from 6 hospital wards at a large hospital

The percentage of staff that engaged in the educational sessions, nurses’ performance on knowledge tests for the accurate identification of delirium, and improvements in timely and accurate assessments of at-risk patients for delirium

Post-audit results showed a significant increase in CAM screening rates compared to baseline.

Development or acquisition of resources to support nurses’ learning.

The education process led by CogChamps and supported by educators and clinical experts provides an example of successfully educating nurses about delirium and improving screening rates of patients for delirium.