EXECUTIVE SUMMARY
Recent research suggests new transitional care interventions are needed to improve physical and mental functioning after discharge for patients with dementia.
- People with dementia are more likely to experience cumulative functional decline after an inpatient stay.
- Physical interventions target orthostatic tolerance, ambulation, and activities of daily living while cognitive interventions target sensory intervention, sleep, and communication.
- Future research involves directly interviewing people with dementia — and their caregivers — to assess need.
Researchers recently began studying transitional care that focuses on people with dementia in rural communities, an understudied research area.
“We really don’t know if the current transitional care model is applicable to older people with dementia in rural communities,” says Mary T. Fox, RN, PhD, associate professor in the School of Nursing at York University Centre for Aging, Research, and Education in Toronto. “Most of the studies [on transitional care] have all been done in urban communities with people without dementia. People with dementia have much higher rates of hospitalization with potential cumulative function decline.”
Patients with dementia can lose their ability to function well when they enter a hospital because they are lying on a stretcher in the emergency department, or in a hospital bed all day.
“They’re not walking around doing their daily chores [as they would be at home],” Fox explains. “When they leave the hospital, they tend to lose some of their functioning. They lose more each time they go back to the hospital.”
Fox and colleagues identified six evidence-based interventions that can help patients with dementia.1
• Orthostatic tolerance. This refers to a person’s tolerance for staying upright.
“The strategy is to promote upright physical activity tolerance after a period of physical inactivity, like lying on a bed in a hospital,” Fox says.
This technique helps the patient progressively stand, walk three times a day, and try to be upright through either sitting up or standing for 3.5 hours a day.
This intervention is based on studies from NASA.2 “NASA couldn’t send everyone to space to see what happens to the body, so they put them on bed rest,” Fox says. “We’ve taken that literature and designed this intervention, showing that you have to be up for at least 3.5 hours a day.”
Case managers can teach patients and their caregivers this intervention to use at home.
• Ambulation. A second step is to promote ambulation after the hospital stay, including supervising the patient walking and ensuring they wear non-skid footwear.
“We know that people, after they have been sick, will fall more, but you can’t keep them non-ambulatory because their health will start to deteriorate,” Fox explains. “We are giving these strategies to family caregivers to keep patients safe while promoting physical activity.”
Case managers teach caregivers how to remove tripping hazards and how to walk with the patient, particularly if the patient is afraid of falling. They also help caregivers incorporate walking into the patient’s daily activity, and ensure the patient is wearing shoes, glasses, or hearing aids.
“We’re teaching families that our senses have a lot to do with how safe we are when we’re walking,” she says. “If your eyesight or hearing is clouded, you could easily trip.”
• Activities of daily living. These techniques promote the patient’s independence in their daily activities.
“This intervention is a bit more focused on families,” Fox says. “We’re telling both the patient and family member what the intervention is about.”
For example, a hospitalized patient could experience some functional declines while admitted, including decreased sleep due to bright lights or impaired cognitive functioning.
“They may not remember how to brush their teeth,” she adds. “We are teaching them how to break down the activity — to put toothpaste on the toothbrush, wet the toothbrush, move it over your teeth.”
Case managers need to teach patients and caregivers how to break down activities for the person with dementia because they might not remember how to perform certain tasks.
“If an activity is too difficult, a family member may take over, and a patient will lose more skills,” Fox says. “[The intervention] sounds easy, but it works.”
• Sensory intervention. While the above three interventions focused on physical functioning, three other interventions involve mental functioning, including this cognitive intervention. Sensory intervention is designed to improve orientation.
For example, caregivers can place a clock and calendar within view of the patient, ensure adequate lighting, and minimize distracting environmental factors (such as noise) that can cause overstimulation, Fox says.
• Sleep. Patients often do not sleep well in the hospital. “People with dementia tend to stay in the hospital almost twice as long, so they can sometimes come home with a new sleep problem, if they didn’t already have one,” Fox explains.
Case managers can teach patients and their caregivers how to promote healthy sleep habits. For example, if the person with dementia is worried, their sleep could be affected.
“We tell them to make a plan to deal with [the thing they are worried about] by writing it down on a piece of paper so they’re not worried about remembering it,” Fox says. “Then, they can deal with it the next day.”
Other tactics include avoiding mental stimulation before bed, as that can increase anxiety or decrease relaxation.
“We teach them to try to not watch a very stimulating movie or scary movie before bed,” she says. “Or, [their caregiver] should not have a conversation about things that might upset the person with dementia.”
For instance, people with dementia should not be told about activities that are going to occur the next day — even something as ordinary as grocery shopping.
“You want to have them put the day to rest and not talk about tomorrow until it arrives,” Fox adds.
• Communication. This technique can help family caregivers promote the patient’s comprehension and memory.
Case managers can teach caregivers how to ask patients simple yes-or-no questions. They teach caregivers to speak in short sentences and to use pictures if the person is struggling with their words.
“If the patient is anxious about forgetting certain information, the caregivers can write down a reminder on a piece of paper and leave it within the patient’s view,” Fox adds.
Fox and colleagues plan to interview people with dementia as they continue their research.
“We will show them user-friendly pictures and have the patient look at the pictures with us, asking them what they think about this strategy, and whether it is something they think would help them,” she says. “Then, we are doing the same kind of interview with the family members, but with a little more depth.”
REFERENCES
- Fox MT, Sidani S, Butler JI, et al. Optimizing hospital-to-home for older persons in rural communities: A participatory, multimethod study protocol. Implement Sci Commun 2021;2:81.
- Fox MT, Sidani S, Brooks D, McCague H. Perceived acceptability and preferences for low-intensity early activity interventions of older hospitalized medical patients exposed to bed rest: A cross sectional study. BMC Geriatr 2018;18:53.
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