On an acute ward, low-cost solutions stimulated patients with dementia, reduced their confusion and disruption to other patients, and enabled staff to individualise care
Busy acute wards can be confusing and frightening to people with dementia, and can lead to challenging behaviour. Staff often lack training in dementia care, can see these patients as disruptive and may find it difficult to care for them. This article reports on an initiative to improve care for people with dementia on an acute medical and orthopaedic ward at minimal cost.
Citation: Beavan M (2014) Low-cost strategies to improve dementia care. Nursing Times; 110: online issue.
Author: Michelle Beavan is staff nurse and dementia champion, Warrington and Halton Hospitals Foundation Trust.
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A rising numbers of people with dementia are being admitted to hospital with problems unrelated to their condition (Sheehan et al, 2009). Their physical symptoms, treatment and interventions - as well as being in an unfamiliar setting - can exacerbate confusion, even in those with mild dementia. This can cause them distress and lead to disruptive behaviour that disturbs other patients. Such behaviour can be difficult for staff to address, particularly if they have no training in dementia care (Clissett et al, 2014).
When my mother, who had dementia, had two periods of time in hospital I gained more insight into this issue. Her first admission was due to a fractured neck of femur, and the treatment she received on the orthopaedic ward was satisfactory; however, when she was readmitted to a medical ward in the same hospital with atrial fibrillation and recurrent urinary tract infections eight months later, her treatment was completely different. Her dementia had worsened and she was frightened and confused by being in a strange place.
Neither the consultant in charge of her care nor the ward nurses spoke to me or my sister about our mother’s treatment plan, even though we were documented as her next of kin. She was sedated because she would wander at night time, which rendered her incapable of holding a conversation, and nobody appeared to take time to understand her needs. My mother’s experience drove me to improve the care and treatment of patients with dementia on the trauma and orthopaedic ward where I work; we have at least two such patients at any time, and there have been as many as 12. This article describes how the ward environments and patient care have changed. Box 1 gives case studies detailing how the patients have benefitted.
Box 1. Case studies
Stimulation and employment
Margaret Green* was admitted to hospital with a lower-leg fracture after a road traffic accident. After surgery she became very confused and began to wander, sometimes managing to leave the ward. A rummage box was created for her, containing a handbag, purse, keys, money, magazines, hat, scarf, gloves, necklaces, crayons and pictures to colour.
Initially Ms Green refused to take the box and said it did not belong to her, but it was left with her and gradually she started looking in it. Once she accepted the box, it kept her occupied and she would carry it around with her. Every morning when she was given the box she would have renewed interest because she could not remember seeing it before. She became more settled and less prone to wandering.
Mrs Green had been employed for many years as a school secretary. We also found that if we sat with her at the nursing station she believed she was back at work. She would often answer the telephone, ask the caller to hold the line and pass it to a staff member and was also happy to file non-confidential papers. This helped to settle her and enabled staff to keep an eye on her.
John Burke* had a tracheotomy, which he constantly tried to remove; a twiddle muff proved an effective distraction. The muff had a pocket sewn into it and contained a small handmade mouse. Mr Burke enjoyed the mouse and handing it to whoever was beside him; they would place it back in the pocket and he would remove it again. He would happily continue doing this all day if someone sat with him.
* Patients’ names have been changed.
Making the ward dementia friendly
After picking up ideas and advice from conferences, in-house training and other nurses, and patients’ family members telling of similar experiences to my mother’s, I became the dementia link nurse for the ward on which I work. After a four-day training course I am now a dementia champion. This role involves nurturing a positive culture of dementia care by raising awareness, knowledge and understanding of dementia in my department and across the trust. My responsibilities include:
- Supporting improvements in the care and treatment of people with dementia in the hospital;
- Identifying areas for improvement and initiating change to enhance the experience, care, treatment and outcomes of people with dementia, their families and carers;
- Providing support and information to staff in my department;
- Attending meetings of the dementia champions group to contribute to the continued development of the trust’s dementia strategy - in addition to nurses, members of the group include staff from a range of allied health professions;
- Providing supplementary in-house training to staff;
- Working and liaising with other dementia champions for mutual support and to share ideas;
- Cascading information from the dementia group to the staff in my own area.
Since I became a dementia champion the culture of the ward has changed. With my manager’s support I have suggested in-house study days for ward staff and identified suitable further education for those showing an interest in learning more.
Staff have been encouraged to critically analyse their attitudes towards patients with dementia, along with their working practices, which has improved their understanding of dementia and patients’ needs. They are now better able to recognise why a patient becomes agitated or distressed - for example, this may be due to them being placed on a bed pan when they would prefer to be taken to the toilet, or given a cup rather than a beaker with a spout.
Staff are kept up to date with new ideas or strategies for caring for patients with dementia, and are encouraged to initiate conversations with relatives rather than waiting for the relatives to approach them.
This is Me leaflet
My first change as dementia champion was to increase the use of This is Me, a leaflet-format tool distributed by the Alzheimer’s Society that enables patients with dementia to tell staff about their needs, preferences, likes, dislikes and interests (www.alzheimers.org.uk/thisisme). The leaflet helps staff to see patients as individuals and enables them to deliver person-centred care that is tailored specifically to patients’ needs. This helps to reduce distress for both patients and relatives, and can also help to prevent problems with communication, or more serious issues such as malnutrition and dehydration.
I gave this leaflet to relatives on admission and took time to speak to them about their relative so I could understand their needs; other staff now also routinely use the tool. Each completed leaflet is kept at the end of the patient’s bed with other documentation such as observation and fluid charts, where anyone can access it and learn about the patient.
Music therapy can be extremely beneficial for people with dementia; it can help to unlock memories and improve scores on cognitive tests (McDermott et al, 2014). I loaded music from the 1940s and 1950s onto an MP3 player and began to play it after breakfast and after the consultant’s ward round. This is our busiest time of day and patients often sit for long periods while waiting to have their hygiene needs met or waiting for physiotherapy. The MP3 player would be played through a small speaker so all the patients in the bay could hear the music. The response from all patients - not just those with dementia -was positive; many of the staff also enjoyed it, so it is now used regularly.
Patients with dementia who do not understand that they are in hospital often become distressed at mealtimes because they want to pay for their meals but do not have their handbags or wallets. I collected old handbags, purses, wallets and keys, and printed images of money to put into the purses and wallets. If patients are seen to be looking for their handbag or purse they are given one, enabling them to “pay” for their food; this generally reduces agitation and makes them seem happier and more settled.
Patients with dementia often have difficulty seeing the clear plastic water jugs and glasses on the ward, or being able to tell whether they contain any water. Similarly, when milky drinks are given in white cups they cannot tell how full the cup is. With this in mind, I bought coloured glasses and cups with coloured interiors making it easier for the patients to see their drinks.
Patients with dementia often need things to occupy them as they become easily bored and have a limited attention span. I introduced a “rummage box” containing crayons and pencils, pictures to colour, modelling clay and activities such as dot-to-dot, crosswords and Sudoku puzzles. When a patient appears to need stimulation I take a selection of items and encourage them to look inside and find something of interest.
To help stimulate patients’ memories I collected photos of local well-known places, both current and from 20-30 years ago, and put them in photograph albums. Staff or relatives are encouraged to sit with patients as they look through the albums to try and stimulate conversation and talk about their memories.
Patients with dementia are often locked in a specific time in their mind; they may believe they are a child who needs to get home to their parents or a young parent who needs to get back to their children. This can cause them distress because they cannot find a way to get home. I contacted the local bus company and asked if it could donate an old bus stop sign; the company generously gave us two, with the number of the hospital bus on them. I mounted a sign on the wall in a safe area of the ward and placed seats under it, allowing patients to sit and “wait” for the bus. A memory board opposite the seats includes photos of actors, and advertising from the past, as well as items such as ration books, old pictures of toys, and old brochures of cookers and other household appliances. While patients sit waiting for the bus they become distracted by the photos and eventually become more settled.
My husband and I made an activity board with a series of switches, locks and bicycle bells attached to it to keep patients occupied. This proved so popular the trust estates department also made one and has been asked to make more for other wards. Generally a member of staff or a relative sits with a patient and tries to stimulate conversation while encouraging the patient to ring the bells, use the keys to open the locks and press the switches.
We have also invited volunteers to create hand-knitted twiddle muffs that come in a range of textures and colours, and have various attachments such as beads, buttons, ribbons and zips sewn both inside and out. The muffs are particularly useful for occupying patients who fiddle with, and pull at, intravenous lines, catheters and oxygen tubing. The twiddle-muff pattern is available on the trust website (tinyurl.com/nhs-twiddlemuff); volunteers have made enough that we distribute them to patients with dementia across the trust.
The ward environment
The ward’s four bays, each containing six beds, looked identical, which often confused patients trying to find their bed. This has been addressed by colour-coding the bays and identifying them with bold pictures of flowers of the relevant colour. Toilets and showers now have bold, red signs with pictures of a toilet or shower to make it easier for patients to find them.
I also hope to persuade the trust to change the colours on the ward from the current pale blue and magnolia, which can make it difficult for patients to navigate, and to introduce more colour, such as bright red doors for toilets and bold colours on bay doors.
The attitude of ward staff towards patients with dementia has changed significantly. Where previously, if patients stood up, some members would simply tell them to sit down, they now try to find out what the patient wants. The atmosphere and staff morale have improved because most staff members enjoy the music as much as the patients, and relatives are encouraged to spend time with patients, and assist with mealtimes and physiotherapy sessions. Many have given positive feedback and some have even taken time to write to the ward or trust chief executive to say how pleased they were with the ward and the environment we have created for patients with dementia.
In May 2014 the trust opened a specialist dementia unit, the Forget-me-not Unit, using a grant from the King’s Fund. The unit has three bays, each in a different colour, with a clearly identified combined shower room and toilet, and a nursing station. The reception area has comfortable seating and a local artist has painted a mural of a bus stop scene, inspired by the bus stop sign on the ward. A small rest room shows black-and-white film of children on a beach, and the unit has a small seating area with a television and fireplace. A door goes out to a secluded but secure garden with seating and a pergola, where local musicians and choirs are invited in to entertain the patients.
- Hospital admission can be distressing and confusing to people with dementia and lead to challenging behaviour
- Inappropriate ward environments can exacerbate confusion
- Ward staff often lack training in dementia and find it difficult to care for patients with the condition
- Person-centred care can reduce distress, confusion and challenging behaviour
- Low-cost initiatives can improve ward environments and dementia care
Clissett P et al (2014) The responses of healthcare professionals to the admission of people with cognitive impairment to acute hospital settings: an observational and interview study. Journal of Clinical Nursing; 23: 13-14, 1820-1829.
McDermott O et al (2014) The importance of music for people with dementia: the perspectives of people with dementia, family carers, staff and music therapists. Aging and Mental Health; 18: 6, 706-716.
Sheehan B et al (2009) The care of people with dementia in general hospital. The Journal of Quality Research in Dementia; 8, 5.