Appropriately designed surroundings can reduce confusion and distress in people with dementia and encourage positive staff interventions
In this article…
- Why identifying dementia on hospital admission is important
- Adaptations to improve the ward for this client group
June Andrews is director, Dementia Services Development Centre at University of Stirling.
Andrews J (2013) A guide to creating a dementia-friendly ward. Nursing Times; 109: 8, 20-21.
Admission to hospital can be distressing for people with dementia, but appropriately designed surroundings can reduce this. This article explains how simple adaptations to the ward environment can improve the quality of care they receive.
- This article has been double-blind peer reviewed
- Figures and tables can be seen in the attached print-friendly PDF file of the complete article in the ‘Files’ section of this page
5 key points
- Admission to hospital may cause avoidable harm to people with undiagnosed dementia
- Good hospital design can help reduce the “care burden” of dementia
- Monitoring technology can reduce the need to observe patients
- All toilet doors should be a consistent, bright, contrasting colour
- Some people eat better if the setting is like a cafe or dining room
Admission to hospital offers an opportunity to identify undiagnosed dementia. Without a diagnosis, patients not only miss out on vital support but can also walk unprotected into dangers when going about normal life - especially as an inpatient, or when attending an outpatient appointment or an accident and emergency department. The hospital may cause them avoidable harm.
Failing to carry out a brief cognitive assessment on admission to detect conditions such as dementia, depression or delirium can make patients vulnerable to distress, injuries and complications.
After an acute hospital admission, people with dementia may not return to their previous level of functioning. This may be in part owing to the design of the hospital and its systems, including the behaviour of staff. Identifying these patients as early as possible is crucial if they are to receive effective care.
Benefits of good hospital design
Any environment, however well designed, can be undermined by bad organisation and poor staff knowledge, while excellent care can be given in places where the design is inappropriate. However, good design can reduce the “carer burden”. It is exhausting for staff to have to undertake repeated unnecessary work because of building design faults.
While the growing numbers of people being admitted to hospital with undiagnosed dementia means it is impossible to make individualised provision for them, basic dementia-friendly changes recommended by Dementia Services Dementia Centre (DSDC) (www.dementia.stir.ac.uk) will offer them some protection without harming others.
Using monitoring technology
Dementia-friendly building design can be supported by technology. Assistive technology is a collective term for devices designed for personal use to enhance the physical, sensory and cognitive abilities of people with disabilities to help them function more independently (Kerr et al, 2010).
In the past, the need to monitor patients dictated the room layout and the position of patients on the ward, but reliable electronic monitoring equipment is now available to suit any setting. A free DSDC guide on the use of assistive technology can be download from www.dementiashop.co.uk/node/287.
Responsibility for specific hazards, such as fire, infection control and food hygiene, rest with different parts of the hospital system. This makes it difficult to balance general risks with those specific to people with dementia.
For example, fire guidance may suggest fire exits are highly visible and clearly labelled “Exit”. This may lead to a patient with dementia obeying what looks to them like an instruction to exit, causing a persistent problem for staff and danger to the patient. Dementia design might suggest partially concealing the fire door, to mitigate the more likely risks.
Many suggestions for dementia-friendly environments are not contrary to UK regulations, just not required by them. To make change happen, you need people in your team who are trained in dementia audit and informed by research evidence. The following general advice is available in greater detail from the DSDC .
A dementia-friendly environment
Floors should be one colour without changes that could be mistaken for a step. Shiny floors can be perceived as slippery. Sound absorption is important.
Skirting and walls must show clearly where the floor and wall join. If the floor covering is bent up against the wall, this must be as low as possible and in a contrasting colour.
Handrails should contrast with the wall and have indicators where they end, such as a knob, or turn into the wall.
Ceilings offer the best opportunity for sound absorption given the difficulties associated with using carpets and fabrics in hospitals. Sound-absorbent tiles can reduce the reverberation of noise around the room. Ceilings should also be light coloured to reflect light.
Doors are crucial for way-finding. All staff-only doors should be the same colour as the wall, while doors that the patient is expected to find and use should contrast with walls. Sliding doors are difficult to understand. Panes of glass let people see what is through the door (bedroom doors are an exception because of sleep and privacy issues). If doors are identical, add striking signs, kick plates or panels. All toilet doors should be a consistent, bright, contrasting colour.
Signs should be consistent throughout, mounted no more than 1.2m high, clearly contrast with the wall or door, using capital and lower case letters and include a graphic.
Clocks should be large, clear, accurate analogue clocks visible from every bed. There is evidence that clocks can help with delirium (National Institute for Health and Clinical Excellence, 2010).
Lighting levels should be high. By the time people are about 75 years old they need twice as much light as normal lighting standards recommend, and nearly four times as much as a 20-year-old, to see satisfactorily. The implications for care environments are that twice the usual light is required, so the lighting level should be set by an older person (dementia.stir.ac.uk/node/2028). As much daylight as possible should be able to get in. Over-bed and chair task lighting is vital to avoid glare. Good lighting over food and drink helps patients to recognise and consume it.
Staff need adequate lighting to observe patients but making rooms completely dark at night is desirable to encourage sleep. Lighting that is activated by movement needs to stay on for long enough so people who move slowly can do so safely. Light switches should be easy to understand and made visible through contrasting colours.
Sound, including that from buzzers, phones and noisy chatter, should be kept to the minimum. Washable acoustic panels should be fitted on walls and ceilings.
Furniture such as chair seats should contrast in colour from the floor. Beds should go right down to the floor and bedrails be avoided. Table coverings and place mats should contrast in colour with plates to help people see their food.
Mirrors can cause problems for patients who no longer recognise their own image. They may wonder, “Who is the strange person looking puzzled at me through this window?” Provide covers or doors for mirrors.
Nurse call systems can cause alarm because people with dementia may not understand where the noise is coming from or what it means. Passive alarms can be more effective for people with dementia; the signal should be a vibrating pager carried by staff, rather than a sonic or flashing light alarm. Call buttons should be clearly labelled.
Nurses’ stations can be a hub of noise and activity, which makes them attractive to people with dementia. Having several smaller reception desks, ideally with a seating area for patients, providing space where notes can be written close to patients, is desirable. This means that staff can work individually and quietly on notes, rather than gathering together and being tempted into conversation. If there is a chair for a patient, the nurse and patient can provide each other with quiet companionship, allowing the nurse to complete administrative tasks while observing the patient.
Relatives are better able to offer support if patients with dementia are cared for in single rooms with a comfortable reclining chair, foldaway bed or couch for overnight stays. A reassuring, familiar voice can make a huge difference if patients wake in the night and feel disoriented. When patients with dementia are being cared for in bays, a nearby room for relatives is the next best thing. Ward routines must be flexible enough to allow relatives to support care.
Noticeboards and leaflet racks can lead to confusion, and should be kept up to date and free of clutter.
Toilet seats and handrails should contrast with walls and floor. Any raised-level toilet seat should also contrast. Flush controls, taps, soap dispensers, toilet paper dispensers and hand drying arrangements should be classic in design so they are easily recognised. The aim is for domestic ambience.
Bathrooms/shower rooms should have contrasting colours, and familiar fittings. Showers can be frightening if the water lands directly on the person from above; height-adjustable, detachable showerheads allow gradual exposure to water.
Physiotherapy and occupational therapy rooms can contain large amounts of unused equipment.
Kitchens for daily activity assessment should be dementia friendly and all previous guidance on floors, walls, light and sound apply.
A day room for additional activities is a great asset. It can be used for sitting, eating and speaking to relatives. Some people eat better if the setting is like a cafe or dining room. Activities can relieve boredom and the room is good for one-to-one work with people who have communication difficulties in addition to dementia.
Outside views, together with access to sunshine or direct daylight, have been shown to benefit patients’ recovery. The orientation and aspect of inpatient accommodation must be prioritised when developing a hospital master plan. Research suggests that easy access to outside reduces aggressive behaviour (Alzheimer’s Society, 2010).
Doors should be easily visible and easy to use. Internal and external floors should not have too strong a contrast. A seat easily visible from the door is good, and the lobby needs a water-absorbent mat. Outside spaces need a concealed and secure perimeter, non-slip paving, raised garden beds, robust seating, objects of interest to look at and protection from wind/rain/sun in some areas.
The advice in this article outlines the basic principles of dementia-friendly design, but nurses will think of many more ideas in the future. It is important we share ideas and focus our energy on the challenges of implementation so we can make admission to hospital safe for these patients.
Alzheimer’s Society (2010) Keeping Active and Staying Involved.
Kerr E et al (2010) Telecare and Dementia: Using Telecare Effectively in the Support of People with Dementia. Stirling: Stirling University Dementia Services Development Centre.
National Institute for Health and Clinical Excellence (2010) Delirium: Diagnosis, Prevention and Management. London: NICE.