Co-morbidity and dementia: improving healthcare for people with dementia

Background
Among people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.
Objectives
To explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.
Design
We undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.
Participants
The study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.
Results
The scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.
Conclusions
Significant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.

In the UK people living with dementia (PLWD) have an average of 4.6 long-term medical conditions in addition to their dementia. Despite this, health-care services are generally organised around single conditions rather than caring for the person as a whole. The aim of this study was to explore how having dementia alongside diabetes, stroke or vision impairment affects access to care and to identify ways in which services might be improved for this group.
We undertook (1) a review of the literature, (2) a statistical analysis of differences in service use between people with and people without dementia, (3) interviews and group discussions with 28 PLWD, 33 family carers and 56 health-care professionals (HCPs) and (4) a conference in which HCPs, members of the public
and representatives from the voluntary sector generated priorities for research and practice.
We found that PLWD may have poorer access to health services than those without dementia. Systems are not designed to involve family carers in decision-making and there is a lack of guidance for HCPs when they are making decisions about care, for example when weighing up the risks and benefits of treatment.
Key elements of good care for PLWD and other medical conditions include having the PLWD and family carer at the centre, flexibility around processes and good communication, which ensures that all services are aware when someone has a diagnosis of dementia. Guidance for HCPs needs to take into account the impact of a diagnosis of dementia on pre-existing conditions such as diabetes.