CAROLINE BARTLE provides a comprehensive checklist for identifying areas of the home that could be enhanced to support and improve the quality of daily life for the individual living with dementia.
Over the last few years, we have seen a number of tools developed to support good dementia design; some of the key contributors being The University of Wollongong, Australia and The University of Sterling, United Kingdom.
However, the majority of this is focused around a residential facility; very little research has been undertaken to assess how changes in the physical home environment can enable people living with dementia to remain at home longer.
We need more research on how these changes have prevented admission to a residential care facility. We know that by making the environment the best it can be, we are:
- Improving independence
- Reducing risk, such as falls and impact of loneliness
- Reducing anxiety levels
- Improving orientation and potentially self esteem.
A person living with dementia may experience a number of sensory challenges which affect the way that they are able to find their way round the environment. We use both our sensory skills and our cognitive skills to navigate the environment. If a person has damage to their cognitive skills as a result of dementia it is even more important that they have strong sensory input to assist the analysis of the data in interpreting the environment.
Therefore, we need to make sure that we make things more obvious and that sensory problems are properly supported. Sight naturally deteriorates with old age, we lose our ability to focus at close range from mid-life, and it slowly worsens over a period of time. We also have difficulty as we get older seeing things in a distance, and we are more likely to develop age-related eye diseases as we get older such as cataracts, glaucoma or age-related macular degeneration. The ageing eye also has more difficulty discriminating blue colours. If a person has had a cerebral vascular accident (CVA) they might have a visual field loss which would impact on the way they navigate the environment in very specific ways.
Some of the cognitive challenges a person might experience as a result of their dementia are things like using memory to find their way around, recognising certain objects or being able to see the items that are placed against the same or similar objects (colour contrast). The input of poor sensory information into the brain means that the brain has to work harder to analyse that information.
Making some changes may cost a lot of money and may not be possible in the short term, such as changing the flooring. However, highlighting these as areas of concern will still inform the support plan. There may be other changes that can be made more simply and cost effectively. These changes still have the potential to make big differences in prompting the person to eat more, find their way to the toilet, to reduce the risk of falls or to maintain their personal hygiene.
When making any changes it is important that we keep the environment as familiar as possible and in some cases this may be the overriding factor. For example, if you need to change a chair because it is the same colour as the walls and the floor and the person cannot see it (because of problems with colour contrast), you should try and replace this with a similar style but a different colour to reduce the confusion. Orientation links to self-identity, which in turn impacts on self-esteem. Individuals living with dementia may not function well in unfamiliar environments for this reason.
In New Zealand, most home-based support services (HBSS) support plans are informed by interventions that are task-focused, with many of them meeting basic physical needs such as person care and support with dressing. The focus is on treating the disease, rather than focusing on outcomes of wellbeing, such as independence. Some forward-thinking services aim to also make changes to the social environment. These services recognise that self-identity and self-esteem are closely linked, and that developing the intervention in a person-centred way will lead to enablement and aim to be restorative.
However, we need to now push the scope of our assessment and interventions to new boundaries accommodating an understanding of how we make changes to the physical environment to promote wellbeing. With the wealth of evidence now available to us HBSS needs to be incorporating a level of assessment of the physical environment, including how we can utilise assistive technologies in creative ways. For community based services this is an excellent way to improve the reach of interventions even when you are not physically in a person’s home. For example, meeting the challenges of maintaining good, healthy nutrition is a common denominator in many HBSS referrals. Poor nutrition can predispose a number of health problems, including dementia. Poor nutrition can ultimately lead to an admission to a residential facility. The recently published Dementia and Nutrition report (Alzheimers disease International 2014) highlights evidence demonstrating how the use of appropriate tableware and lighting can be associated with increased calorie consumption and increases in weight. In light of research in this area HBSS needs to catch up with the work that has been undertaken in other parts of the industry.
An assessment of the environment would be naturally integrated into an individual’s support package where an individual has specific physical needs which would possibly be led by occupational therapy. However, we need to take a broader view when working with individuals with dementia who may not have obvious physical difficulties yet are challenged in the physical environment. Where HBSS links to other care pathways such as CREST or START (hospital discharge services), functional assessment within the home environment is likely to be supported. However other HBSS appear to have more limited access to clinical expertise. If this is the case, how do they ensure that the assessment incorporates key questions:
- How an individual’s difficulties impact on the way the person navigates the environment
- How the environment supports or hinders a person’s sense of self
- How the environment poses major risks to the persons well being
- How small changes can be made to different rooms to improve independence
- How assistive technologies could be used for safety, communication and cognitive stimulation.
In addition to developing assessments and interventions in the physical environment HBSS services need to have a good understanding of assistive technologies available on the market. Assistive technologies can now be used to aid communication, to support a level of cognitive stimulation as well as offer leisure engagement. Monitoring technologies can reduce carer stress in many ways, most of all by reducing the travel time. There are now a range of products available such as the Mimo – Family Talk telecare product. With the challenges of limited resources, the increased use of assistive technologies seems the obvious choice to make.
However, a recent review of the research in the effectiveness of assistive technologies with individuals living with dementia (Fleming and Sum 2014) concluded that the evidence base is weak for technologies which aim to improve the safety and security of individuals when they attempt to leave their residence. The best results appear to come when the technology augments face-to-face contact.