The Cascade study (Dementia case finding)
Type of research:
What is this study about?
When someone aged 75 or older goes into hospital unexpectedly it is government policy that, amongst the many tests they have done, there should also be an assessment of their memory. This research project looked at what impacts these assessments had on patients and the care they receive.
Dementia touches many people’s lives and is becoming recognised as an important issue for the health service, for social care services and for society as a whole, not just the individuals and families affected. The importance of good care for all older people when they go into hospital has also had a lot of media attention lately, and it is known that older people with dementia are likely to have a particularly difficult time in hospital, often ending up staying in longer than others the same age but without dementia. A particular concern is that sometimes hospital staff are not even aware that a patient has dementia. It can be difficult to know, for example, whether somebody is delirious because of illness or whether they have had cognitive problems for some time affecting their reasoning, behaviour and how they manage day-to-day.
Increasing awareness of dementia has sparked recent policy initiatives to improve rates of diagnosis across health-care settings. The rationale is that earlier recognition may lead to timely treatment and enable better planning of appropriate current and future care. It is now government policy to encourage hospitals to identify which patients have dementia – to “Find Assess Investigate Refer” (the “FAIR” CQUIN, as these Commissioning for Quality and Innovation targets are known). Along with many other assessments routinely done when someone goes into hospital, all acute hospitals in England now include cognitive assessments for everyone aged 75-years-old or older taken into hospital (unless for a planned admission or for less than 72 hours). To do this hospitals across the country have set up new processes so that those identified as potentially having dementia are appropriately assessed or referred and have put in place different ways of letting GPs know the results. This ‘dementia case-finding’ may have far-reaching effects.
The Cascade study aimed to find out how ‘dementia case-finding’ works in our region and what the impacts are. The study aimed to answer:
What does ‘case-finding for dementia’ mean in practice for hospitals and GPs?
- How are hospitals in the East of England region carrying out this case-finding for dementia?
- How are they informing GPs about what the case-finding assessments found?
- What benefits do hospital staff and GPs think this can achieve? What are the challenges?
What does this mean for older people admitted to hospital, especially after they come home?
- What has been the experience of this for patients?
- Were they aware of having these assessments while in hospital or what the GP was told?
- Did a letter from the hospital prompt a GP to re-assess or refer them to another specialist, or to arrange for any new support at home since coming home from hospital?
- What are patients’ views on how this process affected them?
- For patients with families or others closely involved, what has been their experience? And views?
- Have patients and families found this helpful? or did case-finding raise worries but not provide help?
What does ‘dementia case-finding’ mean for other services?
- Has case-finding in hospitals had any impacts on other parts of the NHS or on other services? e.g.
referrals to memory clinics, social workers, Alzheimer’s Society advisors, respite/day care, etc
This mixed methods study was undertaken in three phases, and used quantitative, health economics and qualitative approaches to investigate the research questions above, exploring current practice in hospital dementia case-finding and its impacts on patients and their subsequent care.
- Service mapping and quantifying
interviews with hospital staff and GPs
- Interviews with patients and family carers
constructing case studies of referrals for assessment/services
- Estimating service use costs using case study scenarios
consultations, prescriptions, referrals for further investigation or other services
(please click on image to enlarge)
Our advisory groups and collaborators included:
Volunteer lay ‘patient and public involvement’ members from:
- University of Hertfordshire’s Patients in Research Group
- University of Cambridge’s Public Involvement in Research into Ageing and Dementia group
- Addenbrooke’s Hospital
- The Lister Hospital
- Cambridgeshire & Peterborough Foundation Trust
Clinical researchers from:
- University of Hertfordshire
- University of East Anglia
- University of Cambridge
Key findings and outputs:
Results: The study recruited 23 hospital staff and 36 primary care staff, including 30 general practitioners GPs). Analysis resulted in three themes:
- lack of consistent approaches in case-finding processes
- barriers between primary care and secondary care which impact on case-finding outcomes and
- perceptions of rationale, aims and impacts of case-finding.
The study shows that there were variations in how well hospitals recorded and reported outcomes to GPs. Barriers between primary care and secondary care, including GPs’ lack of access to hospital investigations and lack of clarity about roles and responsibilities, impacted case-finding outcomes. Staff in secondary care were more positive about the initiative than primary care staff, and there were conflicting priorities for primary care and secondary care regarding case-finding.
Conclusions: The study suggests a more evidence-based approach was needed to justify approaches to dementia case-finding. Information communicated to primary care from hospitals needs to be comprehensive, appropriate and consistent before GPs can effectively plan further investigation, treatment or care. Follow-up in primary care further requires access to options for postdiagnostic support. There is a need to evaluate the outcomes for
patients and the economic impact on health and care services across settings.
Publications: Burn AM., Fleming F., Brayne C. and Fox C. Dementia case-finding in hospitals: a qualitative study exploring the views of healthcare professionals in English primary care and secondary care. BMJ Open. 2018;8:e020521. doi:10.1136/bmjopen-2017-020521
News story in the Daily Mail 15th December 2017:
- “NHS dementia tests ‘futile and failing patients’: Warning symptoms in up to 40% of patients are being missed in routine checks”
- DailyMail YouTube – NHS dementia tests futile and failing patients