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Summary points:• Dementia in acute hospitals is common, and associated with poor health outcomes• Dementia in acute hospitals is intricately linked with delirium and should always be considered together when developing future policy • The decline in health and function among people with dementia after hospital may be influenced by discrete disease processes, but also to the hospital environment and care itself• Opportunities for further research into the specific acute hospital management of dementia and its complications are many

Background/Aims: Impairment in executive function is associated with a heightened risk for falls in people with mild cognitive impairment (MCI) and dementia. The purpose of this study was to determine which aspects of executive function are associated with falls risk.Methods: Forty-two participants with a mean age of 81.6 years and a diagnosis of MCI or mild dementia completed five different executive function tests from the computerised CANTAB test battery and a comprehensive falls risk assessment. Results: A hierarchical regression analysis showed that falls risk was significantly associated with spatial memory abilities and inhibition of a pre-potent response. Conclusion:The concept of executive function may be too general to provide meaningful results in a research or clinical context, which should focus on spatial memory and inhibition of a pre-potent response.

Aim: This critical review explores the review material on falls prevention interventions in older adults with a cognitive impairment such as dementia.Method: A critical, systematic, review of review method was used. Five large electronic databases, MEDLINE, EMBASE, AMED, CINAHL, and the Cochrane electronic library, were searched. The search terms ‘falls’, ‘rehabilitation’, ‘falls prevention’, ‘interventions’, ‘cognitive impairment’, ‘dementia’, and ‘Alzheimer’s disease’, were used. All available reviews were marked against predetermined inclusion and exclusion criteria. Results: There were seven reviews which met the inclusion criteria. Only one of the included reviews had a homogenous population of adults with a cognitive impairment. Exercise was the most commonly reported intervention, included in 91 studies and all seven reviews. Multifactorial and multicomponent falls prevention programmes were also frequently reported. Reports of efficacy were inconsistent for all interventions.Conclusion: Evidence for falls prevention interventions for adults with cognitive impairment is varied and inconclusive. When compared to literature for falls interventions in healthy older adults, both primary and synthesis studies in older adults with cognitive impairment are lacking in quality, number and homogeneity of sample population and interventions. Promising results are emerging but clinical recommendations cannot be made at this time.

Data analysis and synthesis process form. This combined data extraction sheet was developed specifically for this realist review.

PRISMA-P (Preferred Reporting Items for Systematic review and Meta-Analysis Protocols) 2015 checklist. Recommended items to address in a systematic review protocol.

BackgroundOne in three hospital acute medical admissions is of an older person with cognitive impairment. Their outcomes are poor and the quality of their care in hospital has been criticised. A specialist unit to care for older people with delirium and dementia (the Medical and Mental Health Unit, MMHU) was developed and then tested in a randomised controlled trial where it delivered significantly higher quality of, and satisfaction with, care, but no significant benefits in terms of health status outcomes at three months.ObjectiveTo examine the cost-effectiveness of the MMHU for older people with delirium and dementia in general hospitals, compared with standard care.MethodsSix hundred participants aged over 65 admitted for acute medical care, identified on admission as cognitively impaired, were randomised to the MMHU or to standard care on acute geriatric or general medical wards. Cost per quality adjusted life year (QALY) gained, at 3-month follow-up, was assessed in trial-based economic evaluation (599/600 participants, intervention: 309). Multiple imputation and complete-case sample analyses were employed to deal with missing QALY data (55%).ResultsThe total adjusted health and social care costs, including direct costs of the intervention, at 3 months was £7714 and £7862 for MMHU and standard care groups, respectively (difference -£149 (95% confidence interval [CI]: -298, 4)). The difference in QALYs gained was 0.001 (95% CI: -0.006, 0.008). The probability that the intervention was dominant was 58%, and the probability that it was cost-saving with QALY loss was 39%. At £20,000/QALY threshold, the probability of cost effectiveness was 94%, falling to 59% when cost-saving QALY loss cases were excluded.ConclusionsThe MMHU was strongly cost-effective using usual criteria, although considerably less so when the less acceptable situation with QALY loss and cost savings were excluded. Nevertheless, this model of care is worthy of further evaluation.

OBJECTIVES: The purpose of the study was to establish falls risk factors for people with mild cognitive impairment and mild dementia.METHODS: Survey of 76 people recruited from Memory Clinics (n=56), Falls Services (n=12), Community Geriatricians (n=4), Cognitive Stimulation Therapy groups (n=2), and a Rehabilitation Unit (n=2). The assessments included falls risk, the Falls Efficacy Scale International (FESi), the Montreal Cognitive Assessment (MoCA) as well as neuropsychological tests.RESULTS: Mean age was 80.9 years (SD 6.5, age range: 67-94 years). The sample included 45% men, 98% had a white ethnic background and 48% lived alone. Mean MoCA score was 20.95 (SD 3.6), and 26 people (34%) had between 1 and 24 falls (mean 3.04; SD 4.65). Regarding any fall participants had in the past, 41% sustained an injury, 36% needed medical attention and 32% had been admitted to hospital as a consequence of a fall. The mean FESi score was 27 (SD 10.6) with 59% scoring >23, which is associated with a high fear of falling. The mean Timed Up and Go score was 16.0 seconds with 44% scoring ?13.5 seconds, which is associated with high risk of falling. The mean Berg Balance score was 46 with 28% scoring ?40, which is associated with a 100% chance of future falls. All assessments were acceptable to the particpants.CONCLUSIONS: The proportion of falls and falls risk factors was quite high in this population, which reflects findings from similar studies. Specialized falls prevention intervention should take these factors into account.

Objectives To identify patient and caregiver characteristics associated with caregiver dissatisfaction with hospital care of cognitively impaired elderly adults. Design Secondary analysis of data from a randomized controlled trial. Setting An 1,800-bed general hospital in England providing the only emergency medical services in its area. Participants Cognitively impaired individuals aged 65 and older randomly assigned to a specialist unit or standard geriatric or internal medical wards (N = 600) and related caregivers (N = 488). Measurements Patient and caregiver health status was measured at baseline, including delirium, cognitive impairment, behavioral and psychological symptoms, activities of daily living, and caregiver strain. Caregiver satisfaction with quality of care was ascertained after hospital discharge or death. Results Four hundred sixty-two caregivers completed satisfaction questionnaires. Regardless of assignment, 54% of caregivers were dissatisfied with some aspects of care, but overall 87% were satisfied with care. The main areas of dissatisfaction were communication, discharge planning, and medical management. Dissatisfaction was associated with high levels of patient behavioral and psychological symptoms on admission, caregiver strain and poor psychological well-being at admission, a diagnosis of delirium, and the relationship between the caregiver and the patient. There was less dissatisfaction from caregivers of patients managed on the specialist Medical and Mental Health Unit than those on standard wards, after controlling for multiple factors. Conclusion Dissatisfaction was associated with patient behavioral and psychological symptoms and caregiver strain but was not immutable to efforts to improve care.

Background: Around half of people aged over 70 admitted as an emergency to general hospital have dementia, delirium or both. Dissatisfaction is often expressed about the quality of hospital care. A medical and mental health unit was developed to provide best practice care to cognitively impaired older patients. The Unit was evaluated by randomised controlled trial compared to standard care wards. Part of this evaluation involved structured non-participant observations of a random sub-sample of participants and the recording of field notes. Objectives: The aim of this paper is to compare and contrast the behaviours of staff and patients on the Medical and Mental Health Unit and standard care wards and to provide a narrative account that helps to explain the link between structure, process and reported outcomes. Design: Field notes were analysed using the constant comparison method.Setting: A large hospital within the East Midlands region of the United Kingdom.Participants: Patient participants were aged over 65, and identified by Admissions Unit physicians as being ‘confused’. Most patients had delirium or dementia. Results: Sixty observations (360 hours) were made between March and December 2011. Cognitively impaired older patients had high physical and psychological needs, and were cared for in environments which were crowded, noisy and lacked privacy. Staff mostly prioritised physical over psychological needs. Person-centred care on the Medical and Mental Health Unit was mostly delivered during activity sessions or meal times by activities coordinators. Patients on this unit were able to walk around more freely than on other wards. Mental health needs were addressed more often on the Medical and Mental Health Unit than on standard care wards but most staff time was still taken up delivering physical care. More patients called out repetitively on the Unit and staff were not always able to meet the high needs of these patients.Conclusion: Care provided on the Medical and Mental Health Unit was distinctly different from standard care wards. Improvements were worthwhile, but care remained challenging and consistent good practice was difficult to maintain. Disruptive vocalisation may have been provoked by concentrating cognitively impaired patients on one ward.

Introduction: Physical exercise has a positive effect on cognitive functioning, mobility and activities of daily living in people with dementia (Forbes & al., 2013; Pitkälä & al., 2013). Most exercise studies employ motivational strategies to support adherence to the exercise intervention but it is unclear how effective these strategies are. The purpose of this systematic literature review was to establish the range and effect of motivational strategies used in exercise studies for people with MCI and dementia. Method: Articles were identified from the following databases: CINAHL, EMBASE, MEDLINE, PsychINFO and Web of Science. Independently, a minimum of two authors assessed relevant articles based on in- and exclusion criteria. Studies using quantitative as well as qualitative methods to evaluate the effectiveness of motivational strategies were included. Results: The review analysed 28 articles that were identified to report the use of motivational strategies in exercise studies and partly evaluated their effectiveness. Employed strategies included supervision of sessions by instructors, caregivers or students, group settings, goal setting, exercise diaries, tailoring of programme, telephone calls and music. The effectiveness of strategies was only evaluated in a minority of the studies (use of group setting, goal setting and music). Discussion: Adherence to exercise intervention and continuation of the physical activity after completion of the intervention is an ongoing issue in exercise research. Given the limited evidence regarding the effectiveness of motivational strategies, tried and new strategies should be evaluated for people with MCI and dementia to ensure optimal support of physical exercise in this group.