CLINICAL ISSUES

Acute care management of older people with dementia: a qualitative perspective Wendy Moyle, Sally Borbasi, Marianne Wallis, Rachel Olorenshaw and Natalie Gracia

Aim and objectives. This Australian study explored management for older people with dementia in an acute hospital setting.
Background. As the population ages, increasing numbers of older people with dementia are placed into an acute care hospital to manage a condition other than dementia. These people require special care that takes into account the unique needs of confused older people. Current nursing and medical literature provides some direction in relation to best practice management; however, few studies have examined this management from the perspective of hospital staff.
Design. A descriptive qualitative approach was used.
Method. Data were collected using semi-structured audio-taped interviews with a cross section of thirteen staff that worked in acute medical or surgical wards in a large South East Queensland, Australia Hospital.
Results. Analysis of data revealed five subthemes with the overarching theme being paradoxical care, in that an inconsistent approach to care emphasised safety at the expense of well-being and dignity. A risk management approach was used rather than one that incorporated injury prevention as one facet of an overall strategy.
Conclusion. Using untrained staff to sit and observe people with dementia as a risk management strategy does not encourage an evidence-based approach. Staff education and environmental resources may improve the current situation so that people with dementia receive care that takes into account their individual needs and human dignity.
Relevance to clinical practice. Nurses can assist older people with dementia by encouraging evidence-based care practices to become the part of hospital policy.
Key words: acute care, care management, dementia, nurses, nursing, older people
Accepted for publication: 14 January 2010

The world population is ageing as an increase in the number of older persons is offset by a declining birth rate. Australia is no different, with the percentage of the Australian population over 65 years at approximately 13% in 2004 and expected to rise to 20% by 2024 (AIHW 2007). Growth of the older population, coupled with a longer life expectancy, is likely to result in an increased incidence of chronic illness, use of

hospital services and length of hospital stay (AIHW 2004). A period of hospitalisation is known to have an adverse effect on the health of frail older people and in particular people with dementia (Kurrle 2006).
There are approximately 200,000 Australians (6% of the population aged over 65 years) with a diagnosis of moderate to severe dementia (Access Economics 2005). It is predicted that in future, there will be large gaps in the number of formal and informal carers available for people with dementia

Authors: Wendy Moyle, RN, PhD, Professor, Deputy Director,
RCCCPI, Griffith Health Institute, Griffith University, Nathan
Campus; Sally Borbasi, RN, PhD, Professor of Nursing, School of
Nursing and Midwifery, Griffith University, Logan Campus;
Marianne Wallis, RN, PhD, Professor, RCCCPI, Griffith Health
Institute, Griffith University, Gold Coast Campus and Queensland
Health; Rachel Olorenshaw, RN, BN, Research Assistant, RCCCPI,
Griffith Health Institute, Griffith University, Nathan Campus;

Natalie Gracia, BPS, Research Assistant, RCCCPI, Griffith Health
Institute, Griffith University, Nathan Campus, Brisbane, Queensland,
Australia
Correspondence: Professor Wendy Moyle, Deputy Director,
RCCCPI, Griffith Health Institute, Griffith University, 170 Kessels
Road, Nathan, Brisbane, Queensland, Australia. Telephone:
+61 73735 5526.
E-mail: w.moyle@griffith.edu.au

Introduction

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(Access Economics 2009). This may result in an increase in the number of people with dementia being inappropriately placed in acute settings if they require assessment, are unable to be cared for in the community or while waiting for longterm care placement.

Background
Care of the older person with a confusional state as a consequence of dementia, in an acute hospital setting, presents care staff with special challenges, in particular the need to care for the individual’s personhood as well as management of their disruptive behaviours. Such behaviours add to the challenge of caregiving, can result in the use of physical and chemical restraint (Chrzescijanski et al. 2007,
Nakahira et al. 2008) and frequently influence the care of others. A review of the literature provides some consensus on the management of older people with dementia in the acute setting and highlights the importance of early detection and assessment to rule out delirium; knowledge and attitudes of nursing staff; focused communication; a reduction in stressors; familiarity that includes family and carer involvement; and a multidisciplinary approach (Borbasi et al. 2006, Moyle et al. 2008). However, the prevalence of chronically confused patients in hospital settings is not commonly known and many people go undetected (Maslow & Mezey 2008). The detection of dementia is critical as this has the potential to affect resource allocation, choice of treatment and strategies used to care for and manage these people (Moyle et al. 2008).
There remains some debate about what constitutes an optimal approach to the care of people with dementia in acute care. Available evidence suggests there are a number of principles that acute hospitals would do well to incorporate in an effort to maximise the care of older people with dementia. It remains unclear however whether current care practice is in line with these principles. Furthermore, because of the high use of hospital services and the potential negative impact of hospitalisation on the health of older people, it is important to understand the care management of older people with dementia.

Acute care management of older people with dementia

care management in this setting in relation to the available literature. Methodology
A pragmatic, exploratory qualitative approach situated in the interpretive paradigm (Neuman 2000) was used to answer the research question: What is the current model of care for people with dementia in the acute care setting and how might it be improved?

Participants
Convenience sampling was used whereby senior management asked staff to voluntarily participate in the study if they cared for or treated people with dementia in the assigned hospital. The 13 study participants included four senior staff and nine ward staff on acute medical or surgical wards. Senior staff included a medical doctor (MD) who specialised in gerontology, two acute care nursing directors
(NDs) and a clinical nurse consultant (CNC) who was a specialist in the care of older adults in the acute care sector.
Ward staff included three nursing unit managers (NUMs), two clinical nurses (CNs), one registered nurse (RN) and three assistants in nursing (AINs). All interviews took place in a private room in the hospital. While the aim of the research method employed was not to reach data saturation, nevertheless, the stories demonstrate common themes across participants. Data collection
Data were collected using semi-structured, in-depth, face-toface audio-taped interviews. Researchers trained in qualitative techniques using an interview guide conducted interviews. Participants were asked to describe their role in the care of people with dementia; their perceptions of current practices including the use of restraints; ‘special’ staff; family involvement; and their suggestions for improvement in care practices. A funnelling technique beginning with general questions and narrowing down to specifics was used (Grbich
1999). Interviews lasted between 30–60 minutes.

The study
Ethical considerations
Aim
The aim of this study was to: (1) describe the staff perspectives of current practice in the care of older people with dementia in the acute care setting of a large South East
Queensland Hospital and (2) critically evaluate the current

Approval of the study was gained from the relevant committees in the university and participating hospital. Participants were provided with comprehensive information about the study and were assured that confidentiality would be maintained at all times. Written consent was obtained.

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Data analysis

Everyday challenges

The researchers took an interpretative approach to analyse the data for themes (Grbich 2007). Following verbatim transcription of the interviews, each transcript was read several times by the members of the research team to determine ‘what is going on here’. That is, what meanings, values and intentions were coming through and what competing or alternative perspectives are being put forward?
Emerging issues were discussed, and following consensus the data were then classified into themes and subthemes. Analysis of data revealed five subthemes with the overarching theme being ‘paradoxical care’, in that an inconsistent approach to care emphasised safety at the expense of the person’s wellbeing and dignity. Subthemes identified were (1) defining confusion, (2) everyday challenges, (3) cultural barriers, (4) specialling as care management and (5) optimal care practices.

Participants talked about the challenges they encountered when working closely with older people with dementia who were confused. Those AINs employed to ‘special’ (stay with the patient) expressed that the work was often difficult and unrelenting. In addition, AINs expressed their frustration and concern at needing to manage patients who were aggressive.
They felt there were more important things that they could be doing and they displayed negative attitudes towards people with dementia. As one AIN explained:

Findings
Defining confusion
Participants described three types of confused older patients they came across in the acute setting. These were defined as: 1 Older adults with long-standing dementia that is displayed as confusion and at times agitation and aggression.
These people were considered to be usually managed well at home or in an aged care facility and are admitted to acute care facilities, briefly for the management of a comorbid condition.
2 Older adults, who have mild cognitive impairment. When admitted to hospital, these people become acutely confused, with or without agitation and aggression.
3 Older people with either pre-existing or acute-onset confusion who have come into hospital for the assessment and treatment of a medical condition. It becomes apparent that they will need nursing home placement following hospital discharge.
In spite of these classifications, a number of participants seemed unable to distinguish between acute and chronic confusion. Participants acknowledged that in-hospital care and the discharge aims and processes might be different for each of these categories of patients but the majority of participants were unsure of how to assess or treat dementia and delirium. Senior staff was aware that all categories of patients required their needs to be accurately assessed and managed, safety to be ensured and to receive compassionate care tailored to their needs.

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Sometimes it can be really difficult to look after a person with dementia because they don’t settle, they just keep on wandering and they almost fall over… they don’t even want to listen to you at all.
They take up so much time… (AIN, P9)

Despite participants recognising that aggressive behaviours frequently occurred when the patient was being restrained, either physically by staff holding the patient or by restraint measures such as lap belts, staff did not seem to change the way they approached or managed people with dementia. It seemed that the person with dementia was to be blamed for their behaviour rather than the management technique employed. For example, one AIN expressed:
I was just sitting down reading a magazine with him, all of a sudden he just…hit me on the side of the cheek… we were trying to restrain him and he had one of the Head Nurses there and he bent her thumb back… (AIN, P7)

A common concern expressed by AINs was their perception that hospital management did not show they cared about staff having to manage aggressive patients. In particular, they expressed disappointment with a lack of follow-up or enquiry following their being in contact with an aggressive patient.
On the other hand, senior staff were more likely to express concern about how the patient’s confusion impeded the delivery of technical aspects of care:
…they can be pulling out their IV stuff…trying to get out of bed…pulling off dressings…pulling off their clothes…they can be wandering through the wards…If they’re in traction they can be perhaps trying to pull that out…twisting themselves around the bed...
(ND, P12)

Cultural barriers
Focus on acute problems
The focus of care in the hospital environment was strongly geared towards acute problems, and patients suffering from dementia were viewed as low-priority cases. There seemed

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little time available for people with dementia in the busy acute environment and the perception that such patients only needed activities of daily living addressed is brought to light in the following:
It is very hard for those poor folk to compete with the acute needs of the next patient. Firstly they’re in an acute environment [where they may or may not necessarily be] an acute person themselves... It means that somebody who needs to be resuscitated will come first
(ND, P10)

Acute care management of older people with dementia
…the safety factor… is foremost in our minds. The safety of the patient and what could happen…. A lot of our thoughts are towards preventative care. We’re very, very concerned to prevent any harm to these folk particularly if they’re able to mobilise. (ND, P10)

Person-centred care and its concern for preserving dignity appeared to be overlooked in the pursuit of safety. An example of this can be seen in the following statement from a NUM in her explanation of the approach she takes when orientating new AINs to the care of the older confused person:

Although nursing staff were seen to have primary responsibility for care management, medical staff also played a part in the seeming lack of priority given to the needs of people with dementia. This was also explained as being related to competing interests:

I’ve always explained to them that it’s safety before dignity… they

Doctors have the skills but they are too busy and these patients are at

Participants spoke of resources being allocated based on the level of risk rather than the level of need. The focus on safety seemed to generate a culture that devalued people with confusion and where staff viewed clients with confusion/ dementia as a nuisance or inconvenience and not suitable for an acute hospital setting. Rather than trying to accommodate the needs of the patient with dementia, the focus was spent on how to move the person to another unit:

the bottom of the list. There are so many patients with competing priorities – patients with dementia are just labelled and deemed not able to be helped… There is no-one to advocate for aged care – no secure wards for these patients to go to and be properly assessed – there is no geriatric evaluation unit – the rehab wards are not seen as appropriate – often delirium is seen as a reason not to be rehabilitated
– they want to treat the acute problems. (CNC, P13)

The physical environment
The acute environment was viewed as a barrier to optimal care delivery. The environment impacted on care delivery and the attitudes and behaviours that developed among staff relating to the care of people with dementia and indeed the model of care adopted by the hospital management. A focus on safety became key for staff at all levels. This led to excessive and unnatural monitoring of patients with little emphasis or value placed on basic nursing care and meaningful interaction that might help to decrease aggressive outbursts. Focus on safety
Staff at all levels identified safety as being their prime concern when caring for confused older patients. Staff recognised that identifying acute delirium was critical to plan appropriate care and yet if the patient was assessed as having confusion of a chronic nature nursing care shifted from providing restorative care that aimed to improve cognitive functioning and well-being, to maintenance care focusing on minimising injury or harm to the person, other patients and staff. This is made clear in the following quotations:
First of all we try to discover if there is anything acute causing their confusion and if not then we just try to keep them in a safe environment. (NUM, P1)

need to be able to observe that patient 24/7. In the toilet, not have them behind closed doors because whilst giving them privacy preserves dignity it might also be giving them an opportunity to self-harm or to fall…pull cannulas out... (NUM, P3)

… they try to fit them into the ‘medical’ or ‘nursing’ model which is… the perfect patient who doesn’t complain, who stays by the bed and does everything they are told to do. My impression is that they’re annoying to the nursing staff or an inconvenience or more trouble than the person next to them. So there’s often shifting that goes on to try and get them off their unit. Instead of saying, ‘Okay this person’s in jeopardy. We need to go and help them’, they say, ‘I don’t want them on my unit… They’re interfering with what we are doing. Get rid of them’. (MD, P11)

Specialling as care management
The most common form of care management provided in the acute setting for people with dementia is called ‘specialling’, a practice whereby one staff member, usually the most junior, is assigned to spend their shift observing the patient. The need to maintain patient safety and a lack of understanding about different management strategies encourages the specialling role. Although a one-on-one care situation offers the opportunity for diversional therapy, assessment and individual care, in this study setting, there appeared to be very limited interaction between staff and the confused patient. Care provision seemed to be limited to that which was task orientated and not at all focused on meeting the psychosocial needs of the person. Interactions were often limited to unnatural observation of the patient. Nurse participants

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reported talking to the patient as part of daily care, but only when the interviewer specifically probed this aspect. This may indicate that conversation and social interaction is not a priority for nurses who are specialling people with dementia.
There seemed to be consistent ideas about the role of the special across all staff who worked at ward level. For example, AINs reported:

The allocation of the special is ideally determined by the needs of the patient, yet in reality the allocation is more often determined by other constraints such as nurse shortages and budget constraints. However, it was clear that whatever the background of the special they generally did not have sufficient skills in how to care for a person with dementia.
A MD expressed this as:

[It’s about] just taking care of the person one to one. I usually have to

So they tend to call for a special, who will be someone who is extra,

stand about a foot away from the client, even though they may be

called in. Not necessarily a group of people who have experience in

aggressive…just making sure that they’re not…causing harm to

aged care…it tends to be the most junior nursing staff with the least

themselves, like pulling out catheters or IV’s. (AIN, P7)

amount of education. (MD, P11)

I have to control them if I’m working as a special…I’m here to…keep them safe and calm…just there to keep tabs on his or her actions and to observe their behaviours. (AIN, P9)

RNs who worked closely with the AINs seemed to have similar perceptions about the role of the special. Senior nurses described the role of the special as that of a ‘babysitter’ and one which allowed the other staff to focus on patients who were not confused and were seen as having greater priority of care:
[It’s] basically to keep an eye on them… they’re actually babysitters really… I mean it’s nice if they interact somehow but essentially to keep that patient safe and other patients safe from the patient, if

Although senior staff all agreed the average AIN when employed as a special did not have the education or background to appropriately manage a person with dementia, the AINs saw it differently and reported they were prepared for this role as they had either worked in a care home or had other skills such as training in self-defence and aggression management. Furthermore, although a manual was available to provide guidance on the role of the special
AINs tended to emphasise the policy component that stated they were not allowed to physically touch the patient and therefore saw their role primarily to observe and report.
A Clinical Nurse reported it as such:
Most of our specials don’t really participate in anything. They will just

they’re aggressive. (RN, P6)

sit there and read a book and hope the patient just shuts up and lays
I think they should… mainly keep an eye on that patient, keep the

there. … if they do get up …they’ll come out to the desk … and say

patient from hurting themselves, from wandering off… hurting other

‘Mr Smith, is wandering around’ …Then they’ll say ‘Should I, should

people and take some of the onus off the…nurses who are doing

we stop them? ….They seem to think that it’s our job is to do that sort

other [things]…looking after more acute patients…more or less in a

of thing and, that their job is just to sit there and watch them. (CN, P4)

babysitting role. (CN, P4)

However, despite the heavy use of the special nurse, RNs and senior staff did not see it as a particularly good care option.
Whilst activities such as supervised walks in the hospital grounds were possible, such activities were dependent on the individual special, many of whom rarely took the opportunity.
It appeared there was little attention given to the actual needs of the patient, as demonstrated in the following excerpt:
We don’t even take them routinely for walks…it is only if the nurse wants to go for a walk they will be taken…Often these specials will sit and read ‘women’s’ magazines the entire shift. The patient may be constipated for days and yet ‘specials’ have not picked it up. (CNC, P13)
My impression is [that] it [specialling] aggravates the patient even more because they’ve now lost their personal space…so the patient then tends to try and get away from them…they misinterpret who that person is next to them… it’s a police or an authority figure…who is going to do them harm. (MD, P11)

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The lack of education and training was compounded by AINs who came from a non-English speaking background, which created communication problems.

Optimal care practices
Participants acknowledged there was a need for better care delivery to people with dementia. There was an underlying sense of dissatisfaction with the current model of care provision. Restraint as care management
Restraints were seen as an option to manage a patient who had reached a point where they were ‘out of control’ – becoming aggressive or violent. Although the limitations of restraint were voiced, it was nevertheless justified as a means for staff safety and patient security. Physical restraint was often managed by security guards, who held onto the person

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until chemical restraint took effect or in the placement of mechanical restraints:
…it comes to that point where you have to call Security and they have to restrain them and … it looks quite violent… but it’s necessary because … we can’t let them hit us or hurt themselves. …I’m not really in favour for medicat[ing] and sedat[ing] them for long because
I think, that would just make it worse. (AIN, P9)

Although a clear restraint policy was in place, senior staff felt that requests for restraint were often targeted at junior doctors who were often not aware of the restraint policy requirements and whose frames of reference were likely to be fairly negative towards older people with dementia:
[Their attitude is] oh it’s just an old person. What do you expect?’
Leave them alone. Tie them up. Give them medication. And not look for the source of the confusion. (MD, P11)

Furthermore, there was the perception among some participants that the hospital culture readily accepted restraint:
There is a bit of a cult thing in this hospital of restraining people which I don’t think is good …sometimes you have to resort to it here at times but it’s not the ideal. (NUM, P1)

In comparison, some senior managers appeared to be out of touch with the extent to which restraints were being used and whether they were being used according to hospital protocols. The following was expressed by a ND:
Rarely used. It’s not our choice. Our choice is to perhaps use our nursing resources so that the person can have some freedom of mobility and be allowed to move around rather than looking at… restraint. (ND, P10)

Family involvement in care
Despite acknowledgement that family involvement would be beneficial in many cases, there seemed to be no evidence of a clear strategy for involving family in care. It seemed their involvement was ad hoc and left to the family to initiate. An example of this is expressed in the following:
Yes it is better to do it [use family]… unfortunately…they’re probably not used as frequently as they might be and that’s for a couple of reasons, one, probably because people don’t think of it. (NM, P12)

The concerns centred on the person with dementia and the burden placed on the acute nurse who is not encouraged to value or focus on the special need requirements of such patients. One senior manager spoke candidly:
No they’re not managed optimally at all. They need special care...I don’t think acute nurses have that focus and therefore don’t cater to the needs of the older person. (NM, P12)

Acute care management of older people with dementia

Several options were proposed to improve practice such as a geriatric management service, improvement in workloads, a secure purpose built unit that would incorporate diversional activities, staff education, improving the perceived status of older people so that working with them became more desirable and a greater focus on quality care services rather than budget constraints.

Discussion
The study findings reveal acute care staff perspectives on the care of older patients with dementia. Despite senior staff acknowledging the need to assess and treat acute confusion, participants often displayed a lack of understanding about the differences between acute and chronic confusion. Other researchers have also found that acute care nurses lack specific knowledge about confusion in older adults (McCarthy
2003, Nolan 2006). There was little emphasis given to the importance of education of staff, with a greater emphasis being placed on moving confused older people out of the acute setting rather than a focus on appropriate assessment and treatment. The attitude and responses of staff to confused older people appeared to mirror the attitude and responses to other groups of patients classified as ‘difficult’ or ‘undesirable’. For example, a previous study found that staff on acute wards sought to move patients infected or colonised with multi-resistant organisms (Zimmermann et al. 2004, p. 30).
The care management reported was superficial and general in that participants expected the care they provided to be suitable for any older person with confusion whether it be chronic or acute. The literature, however, recommends the importance of assessment of confused patients during hospital admission (Fick & Foreman 2000, Voyer et al. 2006), as it will effect decisions regarding treatments and strategies for care. While staff did not demonstrate great insight as to how each diagnosis would be treated, there was certainly a sense of urgency and priority given by senior staff to the management of delirium. In contrast, staff seemed somewhat apathetic towards patients who were thought to be suffering from chronic confusion. This was demonstrated further by reports of staff disinterest in and the lack of concern for the person with dementia. Care provision for people with dementia seemed to be task orientated and often devoid of meaningful interaction and lacking a holistic approach to care. The apathetic approach seemed to be masked by an overwhelming focus on safety issues related to the person with dementia or as they related to other patients and staff.
Several conclusions can be drawn about current practice in the acute care setting. The overarching theme of ‘Paradoxical

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Nursing Care’ brings to light an inconsistent approach to care that emphasises patient safety at the expense of well-being and dignity. The approach to managing safety seems to be considered within a risk management framework (Yamano &
Akiyama 2008) that focuses only on reducing the risk for staff and the organisation while ignoring the needs of the confused patient. Risk management generally deals with the probability that a given risk will result in poor outcomes and therefore aimed at reducing the probability (Yamano &
Akiyama 2008). However, an holistic approach, which incorporates injury prevention as one facet of an overall strategy to maintain or improve health and well-being for people with dementia who are confused, would help to reduce the probability. The approach taken seemed to limit quality interactions between staff and the person with dementia and nursing care became task orientated with little emphasis given to compassionate care or to finding ways to overcome the difficulties felt by staff in meeting the complex care needs of people with dementia in this setting. Staff frequently failed to incorporate family into the care of the patient even though they were aware that there were benefits associated with their inclusion. Staff resorted to physical and chemical restraints to manage aggressive outbursts and validated this approach by viewing their decision-making through the context of harm minimisation.
Staff felt constrained by the environment, which was not purpose built or secure for people with dementia who were at risk of absconding. Furthermore, the focus on technological and task-driven care impacted on the development of a culture that devalued people with dementia because of the inconveniences they caused to nurses’ routines. This in turn reinforced the nurses’ approaches to managing safety issues and limited interventions that incorporated meeting the physical, social and emotional needs of person with dementia. Furthermore, it highlights many discrepancies between the model of care described by staff working in this hospital setting and best practice approaches to care revealed in current literature.
The importance of staff education and training is widely acknowledged in the health literature (e.g. Tryssenaar &
Gray 2004, Anderson et al. 2005) and has been shown to improve staff behaviour, attitudes and satisfaction and therefore patient outcomes (e.g. Inouye et al. 2000, Li et al.
2003, Bradley et al. 2005). However, the relationship between such outcomes and education is not clear-cut
(Nolan et al. 2008). Although a greater knowledge of dementia and factors that contribute to cognitive decline during hospitalisation and person-centred strategies to assist people experiencing cognitive impairment in the acute setting are important, the findings from this study also
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support the premise that organisational structures have a role in influencing care of people with dementia in the acute care setting. The research literature argues that education and training must go beyond education of individuals and move to being a facilitator of positive organisational change if changes are to be obtained and sustainable (Lieff & Silver
2007, Rampatige et al. 2009). One way to achieve the goal of evidence-based and person-centred dementia care is to encourage an academic environment and one that integrates clinical care with education and research (Mezey et al.
1997).

Limitations
The small number of participants in this study is a limitation, as is the qualitative nature of the research that does not allow the data to be generalised. However, the richness of the data comes from the willingness of participants to tell their story and the practice examples provided.

Conclusion and relevance to clinical practice
Despite the limitations of this study, the findings have important implications for further research, policy and staff education. It is apparent from this research and other research (e.g. Pritchard & Dewing 2001, Borbasi et al.
2006, Cunningham & Archibald 2006, Jones et al. 2006,
Nolan 2006) that people with dementia are not always provided with care that takes into account their individual needs. We know from the available literature including a recent review that there are a number of potentially useful models of acute care management (Moyle et al. 2008). It is timely, given the ageing of the population, to undertake further intervention research so that the best evidence for dementia care practice and policy in acute settings is available. In addition, investigation into nurses’ competence in the delivery of care to older people with dementia needs further exploration (Mezey et al. 2006) so that management can select and appoint appropriately skilled staff to provide care that is both person centred and dementia specific.
Finally, staff education and training is of prime importance, and in particular it must go beyond education of individuals to facilitate positive organisational change.

Acknowledgements
The research team thank the participants and hospital management for their support for this study, the Research
Centre for Clinical and Community Practice Innovation for financial support and Nerolie Bost for her assistance.

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Acute care management of older people with dementia

Contributions

Conflict of interest

Study design: WM, SB, MW; data collection and analysis:
WM, SB, MW, RO and manuscript preparation: WM, SB,
MW, RO, NG.

The authors declare this study was funded by a RCCCPI research grant (Moyle, Borbasi & Wallis).

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