The initial search yielded 5957 records after duplicates were removed. We retrieved 60 for the full-text review. In total, 19 articles met the inclusion criteria (see the flow chart in Figure 1). Most of the interventional studies had a before-after design [20–28] (n = 9). One was a cluster-randomised controlled trial [29], one used a repeated measures design [30] and three were controlled clinical trials [31–33]. Five of the studies were systematic reviews [14, 15, 34–36]. The systematic reviews were published in 2015 [35] (n = 1), 2017 [34, 36] (n = 2) and 2019 [14, 15] (n = 2). The interventional studies were published between 2011 and 2019, and only three studies were published before 2015 [20, 27, 29].
Of the interventional studies, five studies were conducted in Australia [22, 23, 28, 32, 33], four in the United States [20, 24, 29, 30], two in the United Kingdom [21, 26] and one each in Canada [31], Germany [27] and Switzerland [25]. All five systematic reviews were carried out in the UK [14, 15, 34–36]. The included interventional studies presented a range of interventions for people with dementia in the acute hospital setting, including educational interventions for healthcare staff [21, 24, 26, 28, 31] (n = 5) or for volunteers working with people with dementia in hospital [27] (n = 1). Three studies focused on family-/person-centred programmes [22, 23, 30], and two studies were on specially trained nurses [29, 32]. Further studies investigated a volunteer programme [33] (n = 1), a delirium management programme for people with cognitive impairment [25] (n = 1) and a special non-pharmacological intervention [20] (n = 1). The systematic reviews were on educational interventions [14, 34] (n = 2), special care units for people with dementia [15] (n = 1), inpatient rehabilitation intervention for people with dementia after hip fracture on surgical units [35] (n = 1) and music therapy [36] (n = 1). Table 1 provides information about the characteristics of the included studies.
Risk of bias of included studies
The main weakness of the non-randomized interventional studies was in the selection of participants because most studies did not use a control group or used a historic control group. The blinding of outcome assessments was not fulfilled in nine of the studies, and the risk for selective outcome reporting was rated as high or unclear in all the non-randomized studies. Furthermore, we rated the overall risk of bias for the randomized controlled trial as high. One systematic review showed very good quality in nearly all domains [35], and the others showed good overall quality with concerns regarding some domains. A detailed description and risk of bias table is provided in Additional file 2.
Educational programmes
Intervention characteristics
Three of the educational interventions for healthcare staff were aimed at different hospital professions (nurses, doctors, allied health professionals, occupational/physiotherapists) [21, 26, 31]. Two focused on communication skills and used experiential and interactive strategies [21, 26]. One focused on person-centred care, communication, self-protection and team/patient/family debriefing [31]. One was targeted to prepare nurses and change leader nurses for the implementation of a systematic nurse-caregiver conversation [28]. One educational intervention was an online training programme for nursing assistants and allied healthcare workers and contained information on dementia-friendly principles, communication and wandering and falls [24]. The volunteer educational programme studied by Eggenberger et al. [27] included contents, such as the life situations of older people, communication, dying in hospital, activities with people with dementia and the role and identity of volunteers. The two systematic reviews about educational interventions included interventions targeted at healthcare staff from different professions, with nurses representing the largest group [14, 34]. Details about intervention characteristics can be found in Table 1.
Reported outcomes and effects
The following outcomes were assessed in the studies about educational interventions: knowledge, self-efficacy and confidence of staff, beliefs and attitudes of staff, burnout, satisfaction with the care of people with dementia, the number of palliative care consultations and the change in aggressive behaviour incidents.
Four interventional studies identified a significant effect regarding knowledge of healthcare staff [24, 26, 28] or volunteers [27]. There was a significant increase in knowledge after the end of a two-day communication training course for nurses, doctors and allied health professionals [26] and after an online training tool for nursing assistants and allied health workers [24]. The systematic reviews of Abley et al. [14] and Scerri et al. [34] showed mixed results, though most included studies showed significant improvement in knowledge. Furthermore, self-rated evaluations of sense of competence, confidence and self-efficacy significantly improved in three interventional studies describing training programmes for healthcare professionals [21, 26, 31]. In the systematic review of Scerri et al. [34], confidence of staff was significantly improved in five included studies, and self-efficacy significantly improved in two studies. In both studies that measured dementia confidence in the review of Abley et al. [14], a significant increase in confidence immediately post-intervention was measured; however, at 120 days post-intervention, confidence levels declined significantly in one study.
Self- assessed communication skills were not improved in the volunteer training study [27], and another study showed that only three of 11 communication behaviours showed significant change [26]. Scerri et al. [34] described improved documentation and risk assessment, as well as a reduction in the use of sedations. One study included in the review of Scerri et al. [34] described less aggressive incidents pre-training compared to post-training. Table 2 provides an overview of all reported outcomes and effects. Detailed information about the findings of the included studies and statistical data can be found in Additional file 3.
Special non-pharmacological interventions
Intervention characteristics
One study focused on ‘simple pleasures’ interventions for hospital patients with late stage dementia, where items, such as balls filled with rice or fleece-covered warm water bottles, were handed out to patients and specifically targeted to reduce identified expressions of unmet needs [20]. The systematic review about music therapy planned to include interventions for patients with cognitive impairment in hospital conducted by a music therapist, but no studies fulfilled the inclusion criteria [36].
Reported outcomes and effects
The study about the simple pleasures intervention only reported on the outcome of agitation/aggression [20]. Wierman et al. [20] were not able to show a significant effect of the simple pleasures intervention, but reported that there was a trend towards an improvement in agitation. Table 2 provides an overview of all reported outcomes and effects.
Delirium management programme
Intervention characteristics
Hasemann et al. [25] investigated a nurse-led interdisciplinary programme for the detection and treatment of delirium in patients with cognitive impairment. The programme contained an educational package, systematic screening of patients over 70 for cognitive impairment and the implementation of interdisciplinary interventions when delirium occurred.
Reported outcomes and effects
The study reported on outcomes regarding delirium severity/duration and on benzodiazepine use [25]. Delirium severity decreased significantly on the adherent wards. This effect was evident from the first to the second day of delirium and over the complete course of the delirium. Table 2 provides an overview of all reported outcomes and effects.
Inpatient rehabilitation intervention
Intervention characteristics
The systematic review of rehabilitation strategies after hip fracture surgery included patients with any form of dementia. It investigated enhanced interdisciplinary inpatient (and home-based) rehabilitation and care models and geriatrician-led inpatient management [35].
Reported outcomes and effects
Smith et al [35] reported on patient outcomes, such as functional performance and mortality, discharge destination and length of hospital stay. One study included in the systematic review of Smith et al. [35] about enhanced interdisciplinary rehabilitation showed a non-significant trend towards better function performance through the intervention. One study showed a greater proportion of participants in the intervention group regaining pre-fracture walking levels and better ADL performance at 3 and 12 months but not at 24 months [35]. Mortality was not different between the groups in two studies at 3 or 12 months [35].
In two studies comparing enhanced interdisciplinary inpatient and home-based rehabilitation with conventional rehabilitation, a difference between the groups in favour of the intervention was measured regarding discharge destination at 3 months but not at 12 months. There was a significant difference for people with mild or moderate dementia at 3 months but not at 12 months. No difference was shown for those with severe dementia [35]. Table 2 provides an overview of all reported outcomes and effects.
Family-/person-centred programmes
Intervention characteristics
Two of the family-centred programmes were based on the ‘TOP5 strategy’, were staff defines up to five personalised care strategies with the family caregivers to enhance person-centred care [22, 23]. Another study tested the impact of a combination of function-focused care and an educational empowerment intervention for family caregivers, where care pathways were developed together by staff and families [30].
Reported outcomes and effects
The three studies reporting on family- or person-centred programmes reported on a broad range of outcomes, e.g. use of one-to-one nursing care, antipsychotic medication use, staff confidence, ADL performance, walking performance, delirium severity of patients, average length of stay, anxiety, depression or role strain of family caregivers.
One-to-one nursing care, which is used ‘in cases where regular staffing levels are not equipped to provide care, leaving the patient, other patients or staff at risk of negative outcomes’ [23], decreased significantly in two studies [22, 23].
One study showed a significant improvement in staff’s confidence in caring for patients with dementia after introduction of the intervention compared to pre-implementation. This effect lasted between 6 and 12 months [22]. Another study showed no difference in the level of confidence at three time points and no improvement in staff’s comfort in engaging with family carers [23]. With their family- and function-focused care programme, Boltz et al. [30] showed a significant improvement in ADL performance and a significant decrease in the delirium severity of patients who received the intervention compared to function-focused care education alone. Furthermore, the intervention showed a positive effect regarding readmission within 30 days [30]. Outcomes for family caregivers were significantly improved regarding preparedness for caregiving, anxiety [30] and satisfaction regarding communication with the staff [22]. Table 3 provides an overview of all reported outcomes and effects.
Use of specially trained nurses
Intervention characteristics
One study investigated the upskill of registered nurses to so-called ‘cognition champions’ who should develop action plans for practice change [32]. Another study compared a transition programme conducted from advanced practice nurses with the care of ‘resource nurses’ (upskilled registered nurses) and with an augmented standard care programme (research assistants who communicated cognitive screening results to staff) [29].
Reported outcomes and effects
As the programme studied by Naylor et al. [29] included an intervention for the transition from hospital to home, led by an advanced practice nurse, the study focused on outcomes regarding the rehospitalisation of patients with cognitive impairment. Besides patient outcomes, such as agitation or confusion, Travers et al. [32] also reported on staff outcomes, e.g. behaviour of staff and assessment of cognitive impairment.
The ‘cognition champions’ intervention led to a significant increase in the number of patients assessed for cognitive impairment with a standardized tool at the time of hospital admission, whereas the frequency of informal assessment of patients’ cognitive impairment by nurses showed no significant effect [32]. Furthermore, no significant change was observed in nurses’ behaviours on the acute care hospital wards based on five pre-defined behaviours, e.g. the nurse explains an action in easily understandable terms [32]. Regarding patient outcomes, Travers et al. [32] did not observe a significant change in patient activity (number of patients doing nothing vs number of patients engaged in some activity), signs of agitation or pain through the ‘cognition champions’ programme.
Patients receiving a transitional care model intervention led by an advanced practice nurse had a longer time to first rehospitalisation or death than the patients in the augmented standard care or the resource nurse care programme. This difference was statistically significant at 30 and 60 days between augmented standard care and the transitional care model [29]. Table 3 provides an overview of the outcomes and the effects.
Volunteer programme
Intervention characteristics
One study investigated a person-centred volunteer programme, where volunteers were trained on dementia, delirium and their role and received support from implementation staff. Volunteers provided care like that of a family caregiver, including orientation support, interaction with others, engagement in therapeutic activities, promoting the use of visual and hearing aids, assisting with drinking and eating and encouraging regular walking [33].
Reported outcomes and effects
The study about a volunteer programme for people with cognitive impairment in hospitals reported on an organisational outcome—the proportion of patients who required one-to-one supervision. Furthermore, patient outcomes, such as length of stay, readmission rate, falls and medication use, were described [33]. It was shown that a significantly smaller proportion of patients in the intervention group required one-to-one supervision than in the historic control group [33]. Although, hospital stays were longer in the intervention group, 28-day readmission rates were significantly lower for the patients receiving volunteer sessions. There were no significant differences in the proportion of patients who were discharged to a residential care facility for the first time after the hospital stay. Table 3 provides an overview of the outcomes and the effects.
Special care units for people with dementia
Intervention characteristics
The systematic review comparing special care units within general hospitals for patients with dementia to standard care wards included acute care hospital inpatients of any age with any form of dementia [15].
Reported outcomes and effects
Special care units for people with dementia in the acute hospital setting were investigated in one systematic review [15]. Patient outcomes, such as mortality, length of stay, delirium incidence or the use of antipsychotic medications, as well as staff outcomes, such as documentation of treatment decisions, drug history or discharge plans, were reported. Family caregiver outcomes were strain and psychological well-being. No significant differences regarding mortality were found between special care units and standard care wards [15].
Special care units showed non-significant improvements in readmission rates, and patients on the special care units were non-significantly more likely to be discharged to their original home and non-significantly less likely to get discharged to a new care home [15]. Although patients on the special care units were significantly often in a positive mood or engaged, no significant difference was found regarding the rates of behavioural and psychological symptoms of dementia [15]. Incidence of delirium was slightly, but not significantly, greater on the special care units, and new prescriptions of antipsychotic medications were slightly, but not significant, greater [15]. Furthermore, no significant differences were shown for carer strain and carer psychological well-being [15]. Table 3 provides an overview of the outcomes and the effects.