High Impact Change Area D: Enabling timely identification and assessment in hospital

Setting out the challenge

Data shows that two-thirds of people with dementia receive a formal diagnosis (NHS England, 2024), and about 29 to 76 per cent of people with dementia or probable dementia in primary care are estimated to be undiagnosed (NICE CKS). This can be for a number of reasons, including: the stigma associated with the diagnosis; and later diagnosis in minority ethnic groups, some of whom may not see dementia as a medical condition at all (and can be impacted by a lack of access to culturally appropriate information).

Where a timely diagnosis is made, the person is able to make better choices about their care and outline goals that are focused on what is important to them (and can be conveyed to the professional in the acute hospital who is caring for them).

On presentation at hospital, identification of the acute reason for presentation is important to determine the best intervention, and is more challenging for those without a diagnosis. Identifying a worsening dementia from delirium superimposed on dementia (DSD) can be challenging where symptoms of delirium (for example, inattention, cognitive dysfunction) are also features of dementia. DSD is associated with poorer clinical outcomes than dementia alone, and therefore detecting delirium is important for this population.

Although the assessment approach for people with frailty (including dementia and delirium) is clear, the destination and support following an assessment can vary depending on whether or not a diagnosis is in place. For example, a person without a dementia diagnosis (including those with DSD) may not be able to access a dedicated dementia ward in the hospital if admission is considered the most appropriate option.

Before admitting a person living with dementia to hospital, the value of keeping them in a familiar environment as well as any advance care and support plans should be considered. For people living with severe dementia, it is recommended that an assessment should be carried out that balances the person’s current medical needs with the additional harms they may face in hospital, such as a longer length of stay and increased mortality.

Voices from stakeholders

If a person with dementia changes presentation, it’s not the first thought to check if it is delirium. It’s too often assumed a worsening dementia"

You need time and space to make the full assessment outside of hospital otherwise you will always wonder if you made the right decision."

Staff need the skills, knowledge and understanding to support positive risk taking."

Outcomes

D.1: Identification and assessment of dementia, suspected dementia and delirium (including DSD), aligned to the acute frailty pathway

This requires:

• staff with a dementia and delirium attuned skillset, and the ability to make a decision on the presentation. This should be performed in conjunction the collateral history, maximising input from care partners, and advice from other professionals
• recognition that older patients living with frailty (including dementia) should not be kept on ward trolleys for excessive periods, pathways should be reviewed to avoid long Emergency Department waits e.g. direct access to Acute Medical Unit/Frailty Unit.

This includes:

• National Early Warning Score (NEWS) 2 
• Clinical Frailty Score (CFS) assessment (for patients aged 65+) 
• 4AT (rapid clinical test for delirium) 
• Comprehensive Geriatric Assessment with targeted actions including asking the patient "What matters to you?", and how this assessment can be accessed by wider professionals that support the person (e.g. Primary Care, Community Mental Health Teams). 
• the PINCHME mnemonic could be used to identify and act upon potential causes of delirium: Pain; Infection; Nutrition; Constipation; Hydration; Medication; and Environment. 
• a holistic assessment by a multidisciplinary team (MDT) in order to meet the needs of the patient.

This includes:

• liaising with other key services to support same day discharge, where it is safe and appropriate to do so (e.g. liaison psychiatry, CMHT, social care providers). This will include ensuring a person in inclusion health groups is able to access the right level of support if being discharged. Consideration should be given for any equipment, medication, follow up monitoring, virtual monitoring, point of care testing, and transport with the person and their care partner. 
• fostering close working relationships with other services that support the patient in their usual place of residence. These include but are not limited to: standalone remote monitoring services, Virtual Wards / Hospital at Home services, VCFSE organisations (e.g. Age UK) and social care providers (including to resume care after an admission). 
• having knowledge of and being able to recommend wards within the hospital that would be best suited for people with dementia, and any other support available that would benefit the person whilst they are an inpatient (e.g. CMHT in-reach, liaison psychiatry, carers groups, volunteers, dementia and delirium teams). 

Supporting materials