Interventions to optimise transitional care coordination for older people living with dementia and concomitant multimorbidity and their caregivers: A systematic review
Abstract
Background: People living with dementia and multimorbidity are frequent uses of health, amplifying risk of fragmented care when moving between care settings.Objectives: This Systematic review aims to identify interventions to support transitional care for older people living with dementia and multimorbidity, and their caregivers.Methods: A systematic search from January 2000-2018 of academic databases for studies which implemented a transitional care intervention for older people living with dementia and multimorbidity, and their caregivers.Results: Out of 6053 identified citations, 11 studies and 13 papers were included. These studies included 1861 people living with dementia, mean age 80 years and 1503 caregivers, mean age of 69 years. Narrative synthesis identifed six elements of care that optimise outcomes; unmet needs; depression; education and support; physical decline; poor quality of life and; access and knowledge of community services.Conclusion: This review demonstrates the paucity of interventions available to reduce impact and experiences of transitions for this vulnerable population. The need is increasing for further research and development in transitional care.
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Previous synthesis of quantitative evidence identified six elements influencing care transitions for this population: unmet needs, depression, education and support, physical decline, poor quality of health, and limited access to community services.
“Previous synthesis of quantitative evidence identified six elements influencing care transitions for this population: unmet needs, depression, education and support, physical decline, poor quality of health, and limited access to community services [28].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Inconsistencies in the standard of care from admission and during the hospital stay were associated with reduced patient wellbeing and potential inequitable access to care, which increased the risk of readmission.
“Inconsistencies in the standard of care from admission and during the hospital stay (potentially explained in part by a lack of standardised information exchange) were associated with reduced patient wellbeing and potential inequitable access to care, which increased the risk of readmission [28, 39–43].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Key features of discharge planning included developing meaningful care plans, which were communicated to all involved in the transition, informed by the patient's goals of care and provided opportunities for follow-up in the community.
“Key features of discharge planning included developing meaningful care plans, which were communicated to all involved in the transition, informed by the patient’s goals of care and provided opportunities for follow-up in the community [28, 39, 43–61].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Post-discharge follow-up was linked to carers understanding of condition management, and confidence to support the patient's needs.
“Post-discharge follow-up was linked to carers understanding of condition management, and confidence to support the patient’s needs [28, 44, 53–55, 58–60, 62–65].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Patients and carers reported frequent transitions between HCPs and providers as a normal part of care, with limited evidence to suggest this was part of the additional care needs associated with MLTCiD.
“Patients and carers reported frequent transitions between HCPs and providers as a normal part of care [28, 43, 44], with limited evidence to suggest this was part of the additional care needs associated with MLTCiD (dementia care management.”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Substantial cognitive decline and behavioural and psychological symptoms of dementia increased reliance on carers to manage care needs.
“Substantial cognitive decline, behavioural and psychological symptoms of dementia (BPSD) increased reliance on carers to manage care needs [28, 46, 69].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
This education, which also included information on available community services, reduced carer burden due to greater confidence in their ability (CMOC6).
“This education, which also included information on available community services, reduced carer burden due to greater confidence in their ability (CMOC6) [28, 44, 60].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Increasing care needs due to other conditions was linked to exacerbation of dementia symptoms, increasing reliance on others, and subsequently placing more responsibility on carers (CMOC1).
“Increasing care needs due to other conditions was linked to exacerbation of dementia symptoms, increasing reliance on others, and subsequently placing more responsibility on carers (CMOC1) [28, 44, 46–48, 54, 59, 69–74].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Providing tailored and concise education about dementia care and social needs to patients and carers improved transitions by increasing understanding of post-discharge care requirements such as advance care planning.
“Providing tailored and concise education about dementia care and social needs to patients and carers improved transitions by increasing understanding of post-discharge care requirements such as advance care planning [28, 44, 58, 60].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Interventions to support carers were limited.
“Interventions to support carers were limited, though online self-care education showed potential to improve mental health, wellbeing, and self-efficacy, helping carers feel more confident in their roles, and supported higher engagement in patient-focused interventions (CMOC30) [28, 44, 52, 63, 68, 100, 101].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Online self-care education showed potential to improve mental health, wellbeing, and self-efficacy, helping carers feel more confident in their roles, and supported higher engagement in patient-focused interventions.
“Interventions to support carers were limited, though online self-care education showed potential to improve mental health, wellbeing, and self-efficacy, helping carers feel more confident in their roles, and supported higher engagement in patient-focused interventions (CMOC30) [28, 44, 52, 63, 68, 100, 101].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Tailored interventions for older adults with MLTCiD were rarely implemented in the reviewed documents.
“Tailored interventions for older adults with MLTCiD were rarely implemented in the reviewed documents, despite their advantages in reducing hospital readmissions and carer burden [28, 44, 60].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Tailored interventions have advantages in reducing hospital readmissions and carer burden.
“Tailored interventions for older adults with MLTCiD were rarely implemented in the reviewed documents, despite their advantages in reducing hospital readmissions and carer burden [28, 44, 60].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
Existing structures that had been adapted for dementia reported some improvement in preparing carers to support the patient's needs during transitions, but often neglected to provide health and wellbeing support for the carer.
“Existing structures that had been adapted for dementia (e.g., online education programmes) reported some improvement in preparing carers to support the patient’s needs during transitions, but often neglected to provide health and wellbeing support for the carer [28, 44, 52, 63, 68, 100, 101].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
In comparison to previous research that identified key elements influencing transitions from synthesis of quantitative data, this review provides an explanation of the context surrounding these factors among others, to improve understanding of why this population experiences specific outcomes during hospital-to-home transitions.
“In comparison to previous research that identified key elements influencing transitions from synthesis of quantitative data, this review provides an explanation of the context surrounding these factors among others, to improve understanding of why this population experiences specific outcomes during hospital-to-home transitions [28].”
From Do hospital-to-home transitions work for older adults with multiple long-term conditions including dementia? A realist review (2025) · cites this paper as [28]
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- Authors
- Parker, K. J., Hickman, L. D., Phillips, J. L., & Ferguson, C.
- Affiliations
- University of Technology Sydney (AU)
- Western Sydney Local Health District (AU)
- Corresponding author
- Parker, Kirsten J.
- Venue
- Contemporary Nurse
- Publisher
- Informa UK Limited
- Published
- 2020-09-10
- Volume
- 56
- Issue
- 5-6
- Pages
- 505-533
- ISSN
- 1037-6178 (ISSN-L)
- 1839-3535
- OpenAlex
- W3080667900
- Cited by
- 27
- References
- 58
- Citations by year
- 2026: 3 · 2025: 9 · 2024: 6 · 2023: 2 · 2022: 4 · 2021: 3
- FWCI
- 0.54
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Contemporary Nurse (publishedVersion)
- PubMed (publishedVersion)
- Topics
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Epidemiology › Chronic Disease Management Strategies
- Health Sciences › Medicine › Geriatrics and Gerontology › Pharmaceutical Practices and Patient Outcomes
- Keywords
- care transitions, dementia, multimorbidity, older adults, caregivers, care coordination, care fragmentation, unmet needs, depression, physical decline, quality of life
- MeSH terms
- Transitional Care, Multimorbidity, Aged, Aged, 80 and over, Dementia, Humans, Quality of Life, Caregivers
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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