Improving Acute Care of People with Dementia (IMPACT) Study

Funded by Laurence Geller CBE on behalf of the Geller Commission, the focus of the IMPACT study is to reduce hospitalisation in people with dementia by examining the effect of approaches to reduce hospitalisation in people with dementia. 

We are pleased to share our report, Breaking the cycle of hospital admissions in people with dementia:

Project team

Andrew Sommerlad, Connie Howard, Alba Fernández-Sanlés, Daniel Davis, Claire Goodman, Melanie Handley, Naaheed Mukadam, Kate Walters, Gill Livingston 

Lived experience contributors

Sarah Giles, Sanjiv Gupta, Clair Phillips, Carol Riddington, Karin Webb

Executive Summary

Hospital admission is often both necessary and appropriate for people with dementia, providing essential, effective and safe treatment when community-based options are insufficient. However, people with dementia have 42% higher risk of hospitalisation than those without dementia. People with dementia occupy one in every six hospital beds in the UK and, due to rising numbers of people with dementia and increasing hospital admissions, this is forecast to be one in four by 2040. 

Once admitted to hospital, people with dementia are vulnerable to health complications and experience deterioration in their cognitive and functional abilities. Hospitalisation of people with dementia also has significant negative impacts on family carers. The care of people with dementia in acute hospitals costs £2.8 billion annually in the UK and delayed discharge is responsible for £328 million of this. Given the individual, societal and economic problem of hospitalisation of people with dementia, there is urgent need to find and implement effective strategies to minimise avoidable admissions and reduce prolonged hospital admissions.

Our interdisciplinary team of clinical and academic experts in dementia care and people with lived experience of dementia and hospital care identified and synthesised the academic evidence and case studies of good practice, and have made recommendations for current care and future.

We recommend that clinicians and policymakers should suggest and support these approaches:

• Our first recommendation is that people with dementia are supported by multidisciplinary teams to make advance care plans, as this is strongly linked with lower hospitalisation. Advance care planning allows people to state in advance any circumstances in which they would like to avoid transfer to hospital, so that they can receive appropriate care in their home instead.
• We also found including clinical pharmacists in hospital multidisciplinary teams is likely to reduce re-admission to hospital for medication-related complications. Pharmacists can help patients to use medicines safely and effectively, by optimising use of appropriate medication and spotting errors, side effects and drug interactions.

Additionally, carer interventions, palliative care programmes, education and training for staff and hospital setting interventions have shown promise in reducing hospitalisation in dementia, though the evidence for these approaches is not yet as strong, so recommend further research into these approaches.

Conversely, interventions such as case management and physical activity have high-quality evidence showing they are ineffective in reducing hospitalisation, although there may be other beneficial outcomes for people with dementia.

People with dementia are often excluded from clinical trials and important outcomes such as hospital admission and length of stay are not measured. Future research in these outcomes should prioritise the inclusion of people with dementia, ensuring that interventions are tailored to their needs and address issues with communication, comprehension, and mental capacity. Although hospitalisation is often necessary and appropriate, higher-quality research is needed about interventions to reduce preventable hospitalisation and promote more efficient, sustainable care for people with dementia and their carers.

Review of psychosocial and healthcare interventions

Our report is supported by our umbrella review published in Alzheimer’s and Dementia: The effect of psychosocial and healthcare interventions on reducing hospitalization in people with dementia: an umbrella review.

• Umbrella review of 25 reviews comprising 77 unique papers and 1,483,077 participants.
• Interventions previously thought to be effective, such as case management programs and encouraging exercise, have no effect on hospitalization rates or length of stay.
• There is moderate certainty evidence that including clinical pharmacists in multi-disciplinary teams reduces medication-related hospital admissions of people with dementia.
• There is low-certainty evidence that advance care planning reduces hospitalization.
• There is a lack of evidence for other interventions to accurately gauge their effectiveness.

Our future work

1. Systematic review on advance care planning

Preliminary evidence from our umbrella review suggested that advance care plans (ACP) may reduce hospitalisation in dementia. An ACP allows individuals to define their goals, values, and preferences for future medical treatment and care in collaboration with their family and health-care team. A previous systematic review has suggested that ACP may be associated with reduced hospitalisation in people with dementia, but there were limited studies available at the time meaning further research was required.

Therefore, another aspect of the IMPACT study is our systematic review examining the effect of ACP on hospitalisation in people with dementia, drawing on the latest available evidence. In particular, we are exploring how the creation or use of ACP can impact hospital admissions and length of stay in people with dementia. Identifying the successful aspects of ACP intervention may help to make efficient recommendations for broader ACP implementation. 
 

2. Care home longitudinal study

The cost of nursing home care for people with dementia is expected to reach £4.8 billion, with 30,000 more people with dementia expected to live in nursing homes by 2040. Recent literature has also suggested that individuals with Alzheimer’s dementia or related dementias (ADRD) are at 22% higher odds of having an avoidable nursing home-to-hospital transfer.

The final aspect of the IMPACT study is a longitudinal study on the association between care home characteristics and medications provided in care homes and hospitalisation in people with dementia. Using data from the MARQUE (Managing Agitation and Raising Quality of Life) study and the South London and the Maudsley NHS Foundation Trust’s Clinical Record Interactive Search system, we hope to identify potential modifiable care home factors that can be implemented into interventions to reduce hospitalisation in people with dementia. 

Collaborators

1. Public and patient involvement (PPI) 

We have collaborated with Public and patient involvement (PPI) members throughout the IMPACT study. They have helped with developing a comprehensive search strategy, highlighting key areas for analysis, and integrating lived experience in our interpretation of our findings.

2. Team members

Andrew Sommerlad
Gill Livingston
Alba Fernández-Sanlés
Connie Howard
Rudy Harris