Psychiatric referral and admissionprocesses for people with dementia and behaviour that challenges, who live in nursing homes: a socio-ecological model of contextual factors and assumed connections of dementia crises

Background People with dementia are often repeatedly admitted to geriatric psychiatry due to behaviour that challenges. This can have far-reaching consequences and cause stress for those affected, which can have a negative impact on the recovery process and lead to increased vulnerability to new health problems after hospitalisation. In addition to the behaviour that challenges itself, many other contextual factors, especially those that contribute to dementia crises, can lead to hospitalisation. Methods Building on previously published studies (integrative review, problem-centred interviews) and a new expert validation, we followed the first step, ‘Understanding the problem and its causes,’ of Wight et al.’s ‘Six Steps in Quality Intervention Development’ and developed a socio-ecological model of dementia crises and the associated (re)referrals and (re)admissions of people with dementia to geriatric psychiatry, inspired by McLeroy et al. Results The socio-ecological model comprises 20 concepts drawn from contextual factors and outlines assumptions regarding their connections at various levels. The public policy level refers to ‘Financing’, ‘Research’ and ‘Structural regulations’. The institutional level includes ‘Environment’, ‘Staff’, ‘Operating and everyday norms’, ‘Treatment’ and ‘Admission and discharge interface’. The community level deals with ‘Societal attitudes’ and ‘Social norms and values’. The interpersonal level involves ‘Relationships’ and ‘Roles and hierarchies’, ‘Information and communication’ and ‘Interprofessional decision-making’. The individual level relates to ‘Knowledge and skills’, ‘Burden and resilience’, ‘Behaviour’, ‘Health condition’, ‘Life experiences’ and ‘Views and attitudes’. The connections exist both within each level and between the levels. The institutional level appears to influence the individual and interpersonal level. Similarly, the individual level appears to influence the institutional and the interpersonal level; the interpersonal level seems to affect the individual and the institutional level. The institutional and community levels appear to interact. Furthermore, the public policy level seems to have an impact on both the institutional and the individual levels. Conclusion The socio-ecological model highlights the high complexity of the problem of dementia crises and the associated (re)referrals and (re)admissions of people with dementia to geriatric psychiatry at various levels and provides a basis for future research and the development of programme theories and complex interventions that address actual needs.