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Adapting the hospital environment to meet the needs of older people with dementia

The Royal College of Psychiatrists (RCP 2011) state that appropriately designed environments for people with dementia have the potential to;

promote independence, reduce the incidence of agitation and challenging behaviour, and the prescription of ant-psychotic medication.

They state that it can also; improve nutrition and dehydration, increase engagement in meaningful activities, encourage greater carer involvement, and improve staff morale, recruitment and retention.

Although there is a dearth of robust research to support environmental adaptations in acute general hospital settings there is a raft of anecdotal evidence and best practice guidelines to support their use. Those available indicate the use of; signage and cues which are applicable to hospital settings; signs should be easy to read in large print if possible, at eye level (of an older person, which is usually lower than for a younger one) and combine words and pictures (Dementia Services Development Centre (DSDC) 2007; NHS Confederation 2010; Design Council 2011; Yates-Bolton et al 2012). For example, a large picture of a toilet on a lavatory door is far more likely to promote continence in elderly confused people, as is being able to see the toilet from the bed (Grealy et al 2005). The use of large print name plates in personal spaces can create points of reference or land-marking; we have all wandered onto the wrong ward or bay in a hospital because they are all so identical; think how much more confusing this would be to a cognitively impaired person,(DSDC 2007; NHS Confederation 2010; Design Council 2011;Yates-Bolton et al 2012).

The opportunity to increase the familiarity of surroundings by bringing in their own belongings has been associated with the maintenance of activities of daily living and reductions in aggression, anxiety and depression (Annerstedt 1997), so service users and relatives should be encouraged to personalise the bed space with mementos from home such as (replaceable) photographs and non-valuable items that are of significance to the individual.Visible clocks and whiteboards with the date and details of the ward can assist with orientation, as can large print name badges for staff (Brooker & Dinshaw 1998) and using different coloured bedding can help stop the person with dementia from climbing in to the wrong bed because it looks identical to their own,(DSDC 2007; NHS Confederation 2010; Design Council 2011;Yates-Bolton et al 2012). Reminiscence resources such as photos and small objects from the past, can also lead to conversations where the older person is the expert, are usually very enjoyable, and have been shown to improve well-being, (Brooker & Duce 2000). The ‘Let’s respect’ boxes are very useful for this, (Let’s Respect Project Team 2006).

The lack of visual cues is a significant factor in general hospitals, the long featureless corridors and identical beds compounding the disorientation of older people, (Smith 2001; Yates-Bolton et al 2012). Some acute general hospitals have incorporated environmental cues, and have used different coloured bays and lino to help distinguish areas for confused patients, (NHS Confederation 2010). There are simple and low cost measures that can help, for example; painting doors like toilets or bathrooms, in a dominant colour such as red so that they are more easily distinguished from the surrounding walls. Whereas to discourage use by cognitively impaired people, (like the doors to the main concourse or fire doors), to paint them the same colour as the surrounding wall so that they are not easily distinguished. Some Trusts have taken these environmental cues further and have used different coloured toilet seats to encourage recognition (Heath et al 2010). Avoiding the use of highly contrasting flooring can also minimise instability and falls, (Perrit et al 2005), as can minimising reflected glare on glossy surfaces, (Bakker 2003), and the use of floor colour to highlight the transition from one area to another can assist in independent walking, (Gutman 2005) . This is of course of great significance in the hospital setting where supervision is often limited. The University of Stirling have developed a virtual ward environment for dementia care which can illustrate some of these points, this can be found at ; http://www.dementia.stir.ac.uk/design/virtual-environments/virtual-hospital
The scanty robust research in this area this does not detract from the usefulness of these approaches in the hospital setting. As (Marshall 1999) puts it, the hospital setting can always be made more comprehensible and dementia friendly even if this is just in the use of pictorial toilet signs.

Other Trusts have gone further, for example in response to John’s Campaign (http://www.johnscampaign.org.uk) in supporting the families and carers of people with dementia to have the same rights as the parents of sick children, and be allowed to remain with them in hospital for as many hours as they are needed, and as they are able to give. Different approaches have been used by the over 100 Trusts and hospitals that have adopted John’s Campaign. Some other examples include: posters on ward doors, permanent display of information at hospital entrances, information packs and Carer’s Passports to distinguish the Carer from other visitors and such examples have formed part of the National Dementia and Delirium CQUIN (Dementia CQUIN Guidance 2015/16).


References

Annerstedt, L (1997) Development and consequences of group living in Sweden: A new mode of care for the demented elderly. Social Science and Medicine, 37, 1529-1538

Bakker, R. (2003). Sensory loss. Dementia and environments. Generations, Spring 46-51

Brooker, D.J.R., & Dinshaw, C.J. (1998). Staff and patient feedback in mental health services for old people. Quality in Health Care, 7, 70-76.

Brooker D.J.R, Duce L. (2000) Well-being and activity in dementia: a comparison of group reminiscence therapy, structured goal-directed group activity and unstructured time. Aging and Mental Health, 4:356-60

Dementia Services Development Centre (2012) Design features to assist patients with dementia in general hospitals. DSDC University of Stirling, UK
Dementia Services Development Centre (2007) Best practice in design for people with dementia. DSDC University of Stirling, UK

Dementia CQUIN guidance - https://www.england.nhs.uk/nhs-standard-contract/15-16

Design Council (2011) Living Well with Dementia. DH, London

Grealy J, McMullen H, and Grealy J (2005). Dementia Care, A Practical Photographic Guide. Oxford. Blackwell

Heath H, Sturdy, D and Wilcock, G (2010) Improving Quality of Care for people with dementia in general hospitals. Nursing Standard supplement Summer 2010 RCN Publishing

Let’s Respect Project Team (2006) Let’s Respect the Mental Health Needs of Older People Vol 20 No 40 RCN Publishing

Marshall M (1999). “They should not really be here”: people with dementia in the acute sector. Keynote Lecture. British Geriatric Society. In Age & Ageing; 28-52; 9-11.

NHS Confederation (2010). Acute awareness: Improving hospital care for people with dementia NHS Confederation London SW1E 5DD

Smith, B. (2001). Dementia on a general ward: the benefits of activities. Journal of Dementia Care Sept/Oct pp 30-31

The Royal College of Psychiatrists (2011). Report of the National Audit of Dementia Care in General Hospitals. Editors: Young J, Hood C, Wooley R, Gandesha A and Souza R. London: Healthcare Quality Improvement Partnership -84629-312-X
Yates Bolton, N., Yates, K., Williamson, T., Newton, R., and Codinhoto, R. (2012) Improving hospital environments for people with dementia. Listening event report, The University of Salford, Salford UK

Author: Bernie Keenan (Senior Lecturer Birmingham City University, Trustee Institute of Ageing & Health – West Midlands).

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