A systematic review of specialist inpatient dementia care services versus standard inpatient dementia care in acute hospitals

Background Specialist inpatient dementia units (SIDU) have been developed to address adverse outcomes often experienced by people living with dementia admitted to acute hospitals. However, the evidence base of their effectiveness remains limited. Aim To review the current literature to establish the comparative effectiveness of acute hospital SIDU vs. standard ward care (SWC). Methods We did an online search of 12 biomedical databases from inception to 31st October 2017. Studies of inpatients with any form of dementia in acute hospitals, published in English language peer-reviewed journals, using experimental, observational or qualitative study designs, comparing SIDU with SWC and which measured any qualitative or quantitative outcome of the patient or carer experience were included in the search criteria. We used a standardised data extraction and appraisal form. Results Three of 46 full-text studies evaluated were suitable for analysis. Due to study heterogeneity, pooled odds ratios were only possible for mortality [OR 1.06 (CI 1.0–1.4)]. Otherwise, a narrative synthesis was performed. Although quantitative measures of length of stay, mortality and behavioural and psychiatric symptoms of dementia are not significantly lower, SIDU are associated with greater patient and carer satisfaction, reduced readmission rates, more accurate and comprehensive assessment processes, documentation of resuscitation decisions, and increased rates of discharge to the patient’s own home. Conclusions Although SIDU may be associated with improved care outcomes, the current evidence of their effectiveness is markedly limited. Further research and service evaluation of SIDU as a method for providing high-quality dementia care in acute NHS Trusts is needed. PROSPERO: CRD42017078364.


Introduction
Dementia represents a significant and increasing health and social care problem in the context of an ageing population [1,2]. Approximately 850,000 people in the UK live with dementia, costing the UK economy an estimated £26 billion annually [3,4]. Recent data indicate that 86.7% of patients aged over 75 admitted to UK NHS Trusts for longer than 72 h were identified as potentially having dementia [5]. Acute hospital admission for patients living with dementia is associated with adverse outcomes from increased length of stay (LOS), morbidity and mortality [6]. The continued assessment and improvement of NHS dementia care is therefore necessary [7].
Multidisciplinary, specialist inpatient dementia units (SIDU) have been developed within acute Trusts for patients with dementia and concomitant acute medical illness, whose needs are more complex. Their aim is to increase patient dignity and autonomy with person-centred care [8] provided by staff from both psychiatric and geriatric care backgrounds, trained in managing the behavioural and psychological symptoms of dementia (BPSD) and delirium [9]. These symptoms are often difficult to identify and manage for untrained staff, particularly within the pressured environment of acute hospitals [10,11]. If SIDU can reduce LOS by 1 week per patient, the NHS could save up to £80 million yearly [12].
The aim of this systematic review was to determine whether acute hospital SIDU are effective when compared with standard inpatient ward care (SWC) in improving outcomes for patients living with dementia.

Search strategy and selection criteria
We attempted to locate all peer-reviewed published studies meeting the selection criteria: (1) included men and/or women of any age with any form of dementia, (2) presented the results of peer-reviewed English language research using the following study designs: experimental studies (e.g., randomised controlled trials, non-randomised controlled trials, parallel group studies), before and after studies, interrupted time series studies, case note reviews, cohort studies, case-control studies, cross-sectional studies, case studies, case series, or any qualitative design (e.g., in-depth interviews, focus groups); (3) included participants who were inpatients of an acute hospital; (4) compared SIDU with SWC; (5) measured qualitative or quantitative outcome measures of patient and/or carer experience of the hospital stay. PRISMA reporting guidelines were followed [13,14]. PROSPERO registration: CRD42017078364.
General discussion papers, comments, letters, book chapters, single case studies, national reports and published conference abstracts were excluded. As there are no gold diagnostic standards aside from post mortem examination, searches were not restricted to studies that used a validated dementia diagnostic method. If stated, the method of assessing dementia was recorded. As we were focusing on acute Trusts in the UK and Ireland, we did not include non-English language studies. If multiple eligible publications from the same study were identified, the one with the largest sample size was included to minimise duplication.
The search strategy comprised (1)

Search terms
Dementia search terms were adapted from a Cochrane systematic review [15]. These were combined with MESH subject heading terms for dementia and health care services, then limited to acute hospitals or inpatient settings, whichever yielded most results, "Appendix 1: Search terms for replication of review".

Data extraction and quality appraisal
Identified abstracts were downloaded to Endnote© software (Thompson Reuters, Version X7) and assessed against the inclusion criteria. A random selection of 10% of the abstracts was screened independently as a quality check.
Potentially eligible studies were downloaded and evaluated against a standardised inclusion checklist. A standardised data extraction form was then used ("Appendix 2: Checklist and data extraction form"). Excluded references were categorised by the primary reason for exclusion. If necessary, the corresponding authors were contacted for clarification or raw data.
Two reviewers independently methodologically assessed the included studies using a standardised appraisal form with a maximum score of 40, developed by Trevillion et al. using criteria adapted from validated tools [16][17][18] ("Appendix 3: Quality appraisal form"). The overall study quality was reported for all included studies.

Data analysis
Descriptive analyses were conducted to summarise the included studies. Forest plots were generated using primary data extracted from the studies using DistillerSR Forest Plot Generator from Evidence Partners. Studies that scored poorly in domains relating to bias were not included in the meta-analysis. Funnel plots for detecting publication bias, Cochrane's I 2 statistic for quantification of study heterogeneity and meta-analyses were not performed as not enough studies met the inclusion criteria.

Results
The results of the study selection strategy and reasons for exclusion are presented in Fig. 1. Only three studies qualified for inclusion, with little consistency in their outcome measures [19][20][21]. This heterogeneity meant that aside from mortality, the data were not suitable to pool for meta-analysis. A narrative synthesis of the remaining data was performed. The study characteristics are summarised in Table 1. Simplified schematic results for comparison are given in Table 2; excluding the study by Spencer et al. [19] as their qualitative results could not be similarly summarised. The combined result for the critical appraisal is included in Table 1. None of the included studies were excluded for scoring poorly on quality.

Qualitative outcomes
Goldberg et al. [21] found no significant difference at 90 days in patient's quality of life (QOL) using multiple The information is presented here as it is given in the included articles, meaning there are some differences in comparison data, e.g., median vs. mean ages. PICO: patient, intervention, comparison and outcome; we have summarised the PICO questions for each paper for clarity and as part of the critical appraisal process In a subsample of patients, mood and engagement was represented by the proportion of time that a behaviour was observed during the designated period; SIDU patients were significantly more often in a positive mood/engaged (SIDU 79% vs. SWC 68%; CI 2-20, P = 0.03), with trends for being more active (82% SIDU vs. 74% SWC; CI − 2 to 16, P = 0.10) and interacting with others (47% SIDU vs. 39% SWC; CI − 3 to 19; P = 0.06). Spencer et al. [19] performed a qualitative study of 40 carers' views of their experience of the Goldberg et al. [21] SIDU. The themes from semi-structured interviews included activities and boredom, staff knowledge, dementia, dignity and fundamental care, ward environment, communication between carers and staff and carer expectations. Carers of patients on SIDU commented their relatives were more often engaged in activities, whereas the SWC carers more often stated that their relatives had little to do. Staff on the SIDU were described as patient and compassionate with good knowledge of how to care for people with dementia, particularly regarding wandering and BPSD, displaying personalised support. This was the opposite for SWC, where carers felt the staff sometimes had negative attitudes towards dementia care, ignoring or shouting at the patients; particularly if they were showing challenging behaviours. Some carers felt they had to provide their relative one-to-one care as the ward staff were inexperienced.
Both carer groups had some negative comments about dignity and privacy, including inadequate personal hygiene care and lack of privacy when 'toileting'. Both groups were happy with the meals provided and efforts taken to offer alternatives if their relative had reduced appetite. However, neither was completely satisfied with the level of personal assistance given for eating and drinking. Both ward environments were felt to be clean, but the personalised touches on the SIDU were appreciated by the carers. Both SIDU and SWC carers wanted more communication with the ward staff; their main concern being feeling uninformed about their relatives' care and discharge. Both groups had positive experiences of interactions with the staff. However, poor relationships with staff or certain staff members were associated with greater general dissatisfaction with the level of care provided. It was commented that despite some measures being taken to understand patients' personal lives, particularly on the SIDU, the typically short LOS on acute wards made it difficult for staff to get to know their patients.
Overall, there was greater satisfaction with the level of care provided by the SIDU than by SWC. To address unmet expectations, carers were asked to suggest improvements. These included staff introducing themselves, increased stimulation for patients, allowing carers to attend ward rounds, extending visiting hours, using named nurses, daily updates from staff and having a separate bay for patients with more BPSD.

Discussion
The SIDU model of care has been developed within acute Trusts as a means to improve the quality of care delivered and optimise flow through the hospital for people with dementia. However, due to the limited number of eligible studies, this review found no significant differences in rates of BPSD, mortality and LOS between SIDU or SWC from either study measuring quantitative outcomes [20,21]. As no other measure was used consistently across the eligible studies, the results of other quality and flow outcomes are from individual studies. This review cannot be used to draw firm conclusions about SIDU care and whether they should be established more widely. Nevertheless, it appears that more patients are being discharged to their own homes from SIDU, fewer to care home placements and that SIDU are associated with lower rates of readmission to hospital. This clearly has benefits to the acute trust as well as to the health economy. The SIDU model is associated with better recorded plans for discharge and recording of drug, medical and collateral histories and of resuscitation decisions. The higher incidence of delirium and of new antipsychotic prescriptions on SIDU found by Briggs et al. [20] may reflect more accurate recognition and treatment of delirium on SIDU compared with SWC, possibly be due to differences in staff expertise. Goldberg et al. [21] found that patients on the SIDU were more often in a positive mood, active and interacting with others than SWC patients. Overall carers were more satisfied with the care received on the SIDU, although both SIDU and SWC groups generated areas for improvement, and neither showed quantitative difference in measures of long-term patient QOL or carer strain and psychological well-being [19].

Critical appraisal
All three original studies were limited by omitting the definition of dementia used to classify their participants. Briggs et al. [20] did not record the severity of dementia which may have confounded their results. They studied patients admitted from home rather than care homes, and used the prevalence of BPSD as a proxy measure for dementia severity, stating that as there was no significant baseline difference between groups, any confounders would be equally distributed and therefore not affect the analysis.
Briggs et al. [20] used retrospective data. This is reliant on accurate and thorough documentation of the care given throughout a patient's admission, which is often not completed. The authors argue that this is likely to be an issue for any similarly designed study and will have affected both SIDU and SWC equally, being therefore unlikely to significantly skew their results.
Goldberg et al. [21] and Spencer et al. [19] studies are generated from the same randomised controlled trial; the former presenting quantitative and qualitative outcomes from their entire study, the latter presenting the results of a smaller, more in-depth qualitative arm. Both studies were limited by differences between the groups at baseline due to pragmatically having to recruit participants after randomisation because of pressures on acute unit beds. This was adjusted for in the analysis, but may have introduced confounders.
Following up people with dementia is difficult as they are often frail and may move frequently between their home, healthcare systems and care placements. There are also ethical concerns relating to fluctuating capacity to consent to inclusion in a prolonged trial [21,23,24]. Goldberg et al. [21] used statistical imputation to address their missing follow-up data, a model which replaces the missing value(s) with an estimate based on known results [25]. Although this is an established method of minimising bias introduced by missing data, it would have been preferable to have the complete data set to increase the likelihood of statistically significant results [26].
As Briggs et al. [20] used data from a multi-centre systematic audit in Northern Ireland and Ireland, it is likely that their results are externally valid. However, the other two Fig. 2 Forest plot odds estimates for mortality comparing SIDU with SWC. No significant difference was found by either in mortality between the SIDU and SWC; Briggs et al. [20] (SIDU 9% vs. SWC 8%, OR 1.21; CI 0.65-2.22; P = 0.55); Goldberg et al. [21] (22% SIDU vs. 25% for SWC; OR 0.87; CI 0.60-1.23; P = 0.46). The pooled odds ratio for mortality was 1.06 (CI 1.0-1.4) studies are from the same single hospital in the UK and so their results may not be generalisable.

Strengths and limitations of this review
This review expands on previous research assessing the efficacy and cost-effectiveness of SIDU. To our knowledge it is unique in being a systematic analysis and appraisal of this literature. The protocol was published on PROSPERO for transparency and replication, and PRISMA reporting guidelines were followed [13,14]. The searches and quality appraisal were checked and performed by an independent reviewer to generate a more rigorous result. The data extraction and critical appraisal tools used are standardised and have been piloted previously, with good reliability [27]. Direct correspondence with experts ensured we had not missed unpublished, potentially eligible studies.
Publication and reporting bias may have affected our results as we did not include non-English language studies, and due to the general preferential publication of studies with positive results [28]. This review is limited by the lack of studies eligible for inclusion, meaning we are not able to infer direction of causality between SIDU and outcomes, or make definitive conclusions about the relative advantages or disadvantages of SIDU.

Conclusion and future research
Although there is little consistent evidence that SIDU are superior to SWC, this more person-focused form of clinical care for people with dementia appears to be associated with greater patient and carer satisfaction, possible reduced readmission rates, more accurate history taking and documentation of resuscitation decisions and increased rates of discharge to the patients' own home. Although mortality data was comparable, SIDU may represent a higher quality model of care for patients living with dementia.
Acute Trusts need to develop and demonstrate 'gold standard' dementia care models. Whilst quantitative measures such as LOS are important in evaluating service delivery, qualitative assessments are vital in ascertaining broader aspects of clinical care such as maintenance of dignity and autonomy.
The surprising paucity in eligible studies of SIDU directly contradicts the growing number of older people living with dementia admitted acutely. Hospitals nationwide need to develop innovative ways to provide high-quality specialist dementia care in line with NHS and Royal College standards, whilst maintaining flow and avoiding inappropriate readmissions [29]. It is vital to publish more research and service evaluation in this area.

Relevance to key groups
These findings are relevant to any involved in developing dementia services, from healthcare workers to commissioning groups and policy makers.

Summary
• What is known already: -Dementia in acute NHS hospitals is a growing challenge which needs to be addressed to meet the increasing need -SIDU have been developed to tackle the health inequalities experienced by people with dementia during acute admissions • What this review adds: -Despite limited eligible studies, we can infer that some outcomes are improved by SIDU, such as lower rates of admission to a care home, rates of readmission and of failed discharge from hospital • What needs to be further investigated: -There needs to be further investigation of the efficacy and acceptability of these SIDU if they are being offered as a method nationally for improving dementia care in acute NHS Trusts • Our future research aims: -We will conduct a service evaluation of our new SIDU ('Enhanced Dementia Care Ward') as informed by this review, evaluating dementia care by comparing the SIDU with general medicine and geriatric ward care in a busy Tertiary Care Centre in Southampton, UK.
Ethical approval This article does not contain any studies with humanparticipants performed by any of the authors.

Informed consent For this type of study formal consent is not required.
Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

Checklist
Does the paper meet each of the following inclusion criteria?

Inclusion criteria
If yes tick box Study is published in a peer-reviewed journal, report, or is a thesis/dissertation. Study uses an eligible study design (randomised controlled trial, nonrandomised controlled trial, parallel group study, before and after study, interrupted time series, cohort study, case-control study, case review, cross-sectional study, qualitative interview, focus group interviews) Case series will be kept for separate analysis Sample includes participants aged 16 years or older Sample includes participants with dementia Sample includes participants who are inpatients of an acute hospital (including Emergency Department setting, mental healthcare setting (only as part of an acute Trust liaison inpatient setting), acute hospital/medical services, inpatient acute hospital Neurology services, other acute Trust healthcare setting) Study compares specialist dementia services versus standard care in acute hospitals Study results include qualitative or quantitative outcome measures of patient and/or carer experience of the hospital stay.
If the paper does not meet all of the above criteria, please indicate below the reasons why:

Exclusion criteria
If yes tick box Study is published in a book, conference paper, general comment paper, letter, editorial or other non-peer reviewed format. Study uses an ineligible study design (e.g. single case study) Sample is aged 15 or younger (or includes participants aged 15 or younger and does not provide appropriately disaggregated data) Sample does not include participants with a diagnosis of dementia If the paper meets any of the exclusion criteria do not proceed any further.

Study design
Please enter the dates of data collection: Year of start of data collection Year of end of data collection Please select the study design: If specified, please enter any additional information about patient outcome measures provided by this study:

Study
Please enter any notes about these outcomes (e.g., are disaggregated figures available for analysis, were odds ratios adjusted?) Please enter the following raw data: Total number of people included in the analysis Total number of people with dementia in specialist wards/using specialist dementia care Total number of people without dementia in general medical or surgical wards ** Please repeat the outcomes section if you have further estimates for subgroups** Please enter any further comments not covered elsewhere: Please complete part 1 for all study designs and complete the relevant sections for part 2, specific to study design.
Score the answer to each question by ticking 0, 1 or 2: 0-study does not meet criteria/answer question 1-Study partially meets criteria/gives a partially satisfactory answer to the question 2-Study fully meets criteria/gives a fully satisfactory answer to the question Calculate total score (out of a possible total of 40):

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A re the statistical tests used to assess the main outcomes appropriate?