The initial search yielded 7303 records after duplicates were removed. We retrieved 70 records for the full-text review. In total, 20 articles met the inclusion criteria (see flow chart in Figure 1). Most of the interventional studies had a before-after design [22–31] (n = 10). One was a cluster-randomised controlled trial [32], and two were controlled clinical trials [33, 34]. Seven of the studies were systematic reviews [15, 16, 35–39]. The systematic reviews were published in 2015 [36] (n = 1), 2017 [35] (n = 1), 2019 [15, 16, 39] (n = 3) and 2020 [37, 38]. The interventional studies were published between 2011 and 2019. Only three studies were published before 2015 [22, 29, 32].
Of the interventional studies, five studies were conducted in Australia [24, 25, 30, 31, 34], three in the United States [22, 26, 32], two in the United Kingdom [23, 28] and each one in Canada [33], Germany [29] and Switzerland [27]. Four systematic reviews were carried out in the UK [15, 16, 35, 36] and three in Australia [37–39]. The included interventional studies presented a range of interventions for people with dementia in the acute hospital setting, including educational interventions for healthcare staff [23, 26, 28, 30, 33] (n = 5), for healthcare staff and non-clinical staff [31] (n=1) or for volunteers working with people with dementia in the hospital [29] (n = 1). Two studies focused on family-/person-centred programmes [24, 25], and two studies on specially trained nurses [32, 34]. Further studies investigated a delirium management programme for people with cognitive impairment [27] (n = 1) and a special non-pharmacological intervention [22] (n = 1). The systematic reviews focussed on educational interventions [15, 35] (n = 2), on volunteer programmes [38] (n=1), on special care units for people with dementia [16] (n = 1), on palliative care consultation services for people with advanced dementia [39] (n=1), on interventions to improve caregiver readiness [37] (n=1), and on inpatient rehabilitation interventions for people with dementia after hip fracture on surgical units [36] (n = 1). Table 1 provides information about the characteristics of included studies.
Risk of bias of included studies
The main weakness of the non-randomized interventional studies was the selection of participants since most studies did not use a control group [23–26, 28–31]. Confounders were considered in four of the twelve studies [24, 26, 30, 33]. Blinding of outcome assessments was only fulfilled in two studies [22, 28]. The risk for selective outcome reporting was rated as high or unclear in all non-randomized studies. Furthermore, we estimated the overall risk of bias for the randomized controlled trial as high. One systematic review showed very good quality in nearly all domains [36]. The others were of good quality in several domains 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) [23, 28, 33]. One focussed on both clinical and non-clinical staff [31]. Two addressed communication skills and used experiential as well as interactive strategies [21, 26]. One addressed person-centred care, communication, self-protection and team/patient/family debriefing [33]. Another intervention aimed to prepare nurses and change leader nurses for implementing a systematic nurse-caregiver conversation [30]. One intervention introduced key communication strategies and screening for cognitive impairment [31]. Furthermore, a visual cue was placed at the bedside to help staff identifying patients with cognitive impairment [31]. One educational intervention was an online training programme for nursing assistants and allied healthcare workers. It contained information on dementia-friendly principles, communication, wandering and falls [26]. The volunteer educational programme reported by Eggenberger et al. [29] addressed life situations of older people, communication, dying in hospital, activities with people affected by dementia as well as 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 [15, 35]. Details about intervention characteristics are displayed 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, staff comfort, staff beliefs and attitudes, burnout, satisfaction with care for people with dementia, perceived organisational support, perceived equipment of hospital environment, perceived difficulty when caring for patients with dementia and their families, number of palliative care consultations and changes in aggressive incidents.
Four interventional studies identified a significant effect regarding knowledge of healthcare staff [26, 28, 30] or volunteers [29]. There was a significant increase in knowledge after the end of a two-day communication training course for nurses, doctors and allied health professionals [28] and after an online training tool for nursing assistants and allied health workers [26]. The systematic reviews by Abley et al. [15] and Scerri et al. [35] 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 four interventional studies describing training programmes for healthcare professionals [23, 28, 31, 33]. One study with clinical and non-clinical staff reported significantly enhanced staff comfort [31]. In the systematic review by Scerri et al. [35], staff confidence was significantly higher in five included studies, and self-efficacy was significantly elevated in two studies. In the review by Abley et al. [15], both studies measuring dementia confidence reported significant increase in confidence immediately post-intervention. However, at 120 days post-intervention, confidence levels significantly declined.
Self-assessed communication skills did not improve in the volunteer training study [29]. In another study only three of 11 communication behaviours showed significant change [28]. Scerri et al. [35] described improved documentation and risk assessment as well as a reduced use of sedations. One study included in the review by Scerri et al. [35] described less aggressive incidents pre-training compared to post-training.
Table 2 provides an overview of all reported outcomes and effects. Detailed information about findings of included studies and statistical data are included in additional file 3.
Special non-pharmacological interventions
Intervention characteristics
One study focused on “simple pleasures” interventions for hospital patients with late stage dementia. To reduce identified expressions of unmet needs, patients received, for example, balls filled with rice or fleece-covered warm water bottles [22].
Reported outcomes and effects
The study on “simple pleasures” interventions only reported outcomes related to agitation/aggression [22]. Wierman et al. [22] were not able to show a significant effect of “simple pleasures” interventions. However, they reported a trend towards an improvement regarding agitation. Table 2 provides an overview of all reported outcomes and effects.
Delirium management programme
Intervention characteristics
Hasemann et al. [27] investigated a nurse-led interdisciplinary programme to detect and treat 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 benzodiazepine use [27]. 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 as well as geriatrician-led inpatient management [36].
Reported outcomes and effects
Smith et al [36] reported on patient outcomes, such as functional performance and mortality, discharge destination and length of hospital stay. The results demonstrate that enhanced interdisciplinary rehabilitation showed a non-significant trend towards better functional performance due to the intervention. A greater proportion of participants in the intervention group regained pre-fracture walking levels and better ADL performance at 3 and 12 months but not at 24 months [36]. Mortality did not differ between the groups in two studies at 3 or 12 months [36].
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 persons with severe dementia [36]. Table 2 provides an overview of all reported outcomes and effects.
Family-/person-centred programmes
Intervention characteristics
Two interventional studies addressed family-centred programmes based on the ‘TOP5 strategy’. To enhance person-centred care, staff defined up to five personalised care strategies with family caregivers [24, 25]. A systematic review focused on interventions (e.g. nurse education sessions) supporting family caregivers of inpatients with dementia. The aim was to assist caregivers in resuming their role as caregivers after discharge [37].
Reported outcomes and effects
Two interventional studies and one systematic review focussing on family- or person-centred programmes reported on a broad range of outcomes, e.g. use of one-to-one nursing care, antipsychotic medication, staff confidence, average length of stay, anxiety, quality of life or family caregiver burden.
One-to-one nursing care 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” [25], significantly decreased in two studies [24, 25].
One study showed significantly improved staff confidence in caring for patients with dementia after introducing the intervention compared to pre-implementation. This effect lasted between 6 and 12 months [24]. Another study showed no difference in the level of confidence at three time points and no improvement of staff comfort in engaging with family carers [25]. The systematic review focusing on interventions to prepare caregivers for fulfilling their role after hospital discharge showed no significant improvement in quality of life, anxiety, depression or family caregiver burden [37]. The family-centred programme investigated by Luxford et al. improved family caregivers’ satisfaction regarding communication with staff [24]. Table 3 provides an overview of all reported outcomes and effects.
Use of specially trained nurses and consultation services
Intervention characteristics
One study investigated the upskill of registered nurses to so-called “cognition champions” who should develop action plans for practice change [34]. Another study compared a transition programme conducted by advanced practice nurses with the help of ‘resource nurses’ (upskilled registered nurses) and an augmented standard care programme (research assistants communicating cognitive screening results to staff) [32]. One systematic review focused on interventions providing palliative care consultation services by specialised healthcare professionals for people with advanced dementia with the aim to influence advance care planning [39].
Reported outcomes and effects
The programme studied by Naylor et al. [32] included an intervention for the transition from hospital to home, led by an advanced practice nurse. The study focused on outcomes regarding rehospitalisation of patients with cognitive impairment. Besides patient outcomes, such as agitation or confusion, Travers et al. [34] also reported on staff outcomes, e.g. staff behaviour and assessment of cognitive impairment.
The systematic review by Kelly et al. addressed the behaviour of staff and relatives regarding advanced care planning and health system processes like hospital length of stay or emergency visits [39].
The “cognition champions” intervention led to a significant increase in the number of patients assessed for cognitive impairment by means of a standardized tool at the time of hospital admission. The frequency of nurses’ informal assessment of patients’ cognitive impairment showed no significant effect [34]. Furthermore, no significant change was observed in nurses’ behaviours on acute care hospital wards based on five pre-defined behaviours, e.g. explaining an action in easily understandable terms [34]. Regarding patient outcomes, Travers et al. [34] did not observe a significant change in patient activity (number of patients doing nothing versus number of patients engaged in some activity), signs of agitation or pain in the “cognition champions” programme. Concerning the outcomes for relatives of people with dementia, palliative care consultation services resulted in improved satisfaction with end-of-life care and in a change in advanced care planning behaviour [39].
Patients receiving a transitional care model intervention led by an advanced practice nurse experienced a longer time to first rehospitalisation or death than patients in the augmented standard care group or in the resource nurse care programme. This difference was statistically significant at 30 and 60 days between augmented standard care and the transitional care model [32]. With regard to system-related processes (e.g. hospital length of stay, emergency visits or hospice referrals), two studies in the systematic review by Kelly et al. showed an improvement, whereas two studies revealed no improvement [39]. Table 3 provides an overview of the outcomes and the effects.
Volunteer programme
Intervention characteristics
The systematic review addressing volunteer-delivered programmes to support people with dementia and/or delirium in acute hospitals included, for example, support with regard to orientation and interaction, mobilisation, provision of non-pharmacological approaches to manage distress or assisting with hydration and nutrition [38].
Reported outcomes and effects
The systematic review reported staff outcomes (level of hope) and a range of patient outcomes like mortality, length of stay, delirium incidence and delirium severity. Regarding staff outcomes, volunteer programmes showed improved levels of hope in volunteers, whereas staff level of hope did not change. Patient outcomes improved regarding delirium incidence, delirium severity and functional status. Furthermore, patients received more analgesics. No improvement was reported for mortality, length of stay, number of falls and residential aged care placement after hospital discharge [38].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 in general hospitals for patients with dementia to standard care wards included acute care hospital inpatients of any age with any form of dementia [16].
Reported outcomes and effects
Patient outcomes, such as mortality, length of stay, delirium incidence or use of antipsychotic medications, as well as staff outcomes, e.g. 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 [16].
Special care units showed non-significant improvements in readmission rates. Patients on special care units were more likely to be discharged to their own home than to a care home (although this was not statistically significant) [16]. Although patients on 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 [16]. Incidence of delirium was slightly but not significantly higher on the special care units. New prescriptions of antipsychotic medications were moderately but not significantly higher [16]. Furthermore, no significant differences were shown for carer strain and carer psychological well-being [16]. Table 3 provides an overview of the outcomes and the effects.