Delayed discharge in alcohol-related dementia: consequences and possibilities for improvement

Abstract

Individuals with alcohol-related dementia (ARD) are over-represented among ‘difficult to discharge’ patients. ARD is associated with prolonged hospital stay and high rates of discharge at own risk. Risk factors for delayed discharge in patients with ARD include: a lack of appropriate medical and social support; multiple and complex needs; psychiatric symptoms; challenging behaviours; and an unmet need for appropriate residential care. Integration into present services is problematic and aged care is not an acceptable option for these patients. The present paper identifies three key possibilities to reduce the burden of prolonged hospitalisation of patients with ARD. These are: improved availability of specialised, multidisciplinary care pathways for patients with ARD, many of which could be developed out of existing services; the development of flexible supported-accommodation options, including harm minimisation, for the subset of patients who are not able to live independently; and improved practice in the emergency department (ED) to ensure timely administration of parenteral thiamine to all patients at risk of developing ARD. What is known about the topic? Overuse of acute services contributes to strain in the ED and high healthcare costs. ARD is a relatively common but frequently under-recognised condition that is disproportionately associated with delayed discharge, contributing to hospital ‘bed block’. What does this paper add? This paper provides a review of the relevant literature to identify contributing factors to delayed discharge in ARD, and strategies for improvement. Patients with ARD have several risk factors for delayed discharge, including a complex clinical profile, psychiatric symptoms, challenging behaviours, limited social support and a lack of appropriate accommodation. Negative discharge outcomes in ARD are reduced through improved administration of thiamine in the ED and the use of specialised services and care pathways, which can be developed out of existing services. For the subset of patients with highly complex needs who have undergone repeated cycles of detoxification and relapse, flexible, supported residential care with a harm-minimisation approach is cost effective and improves outcomes. What are the implications for practitioners? Increased awareness of ARD as a causative factor in delayed discharge and discharge at own risk is called for to allow identification of patients at risk. Improved use of thiamine in the ED and the development of clinical pathways and specialised services for patients with ARD are needed to address systematic gaps in service delivery and reduce the burden on acute care.