Dementia care

‘The public outdoor world is rarely conceived of as an appropriate setting for a person with dementia’: Critically discuss this statement with reference to your reading and practice or caring experience. Use at least one case study or vignette of up to 350 words taken from your practice or caring experience. This should support your argument and illustrate either the opportunities and/or the challenges of accessing the outdoors.

Assignment to be: 2500 words

People with dementia have the right to a dignified, healthy, safe, and friendly environment where they are treated as equals regardless their increasing age or diminishing capabilities. (Mitchell et el., 2004). They can still maintain their abilities to cope independently throughout the early or mild stages of dementia. They still have the desire to stay independent and have control over their own lives. It is essential for people with dementia to experience regular mental and physical exercise to keep their minds and bodies active and to maintain social contact. If the streets in their neighbourhoods are not designed to meet their needs they will be trapped in their homes, because their previously safe and secure neighbourhood changed into a harmful and dangerous environment. There is an increasing need improve urban design through the Local Planning Authorities, as such urban planners should take in consideration the implication of not only normal ageing but they should enable individuals with various types of cognitive impairments to maintain their independence (Burton & Mitchell, 2006).

Effects and challenges of dementia

Physical, mental, and psychological changes are due to the ageing process, and can encompasses several slight impairments in hearing, vision, ability, mobility, and memory. These affect elder individual’s ability to live in their surroundings with ease. This is even more difficult for individuals with dementia because they have to cope with both the normal ageing effects and the challenges of dementia that cause a threat to their personhood and result in the loss of identity (Burton & Mitchell, 2006, Chaudhury, 2008). Dementia pose a number of behavioural, personality, and cognitive changes for example restlessness, agitation, depression, and anxiety. There is a typical decline in physical and mental abilities. They develop a typical style of mobility in the form of an unsteady shuffling pace with a stooped posture, always looking down and as such they are not aware of their surroundings. Dementia also result in sensory impairment which can include hearing and vision. Colour agnosia is often intensified by dementia, dark colours and combinations thereof is difficult to distinguish. There might also be impaired depth perception, sharp colour contrasts or patterns on the ground will be interpreted as steps or holes, shiny or reflective surfaces looks slippery and wet, buzzy designs or repetitive lines will cause dizziness and that can result in trips or falls. The mental decline in dementia is permanent and incurable, it might progress gradually and result in unpredictable physical deterioration. During the mild to moderate stages their short-term memory is very fragile and their long-term memory remains acute (Burton & Mitchell, 2006).

Negative feelings

The statement, ‘The public outdoor world is rarely conceived of as an appropriate setting for a person with dementia’ said it all. “There are currently over 750,000 people with dementia in the UK and this is predicted to rise to about 870,000 by 2010 and over 1, 8 million by 2050”. (Burton & Mitchell, 2006, p. 27). But people with dementia is disabled and disempowered by the unfriendly and unsafe environment, it does not meet their cognitive impairment needs, which is ignored. Accessibility for these individuals have become a huge problem, there is positive transformations for normal disabilities but not effective enough to take into consideration the different barriers for individuals with dementia and their unique impairments. Burton and Mitchell (2006) found that individuals with dementia experience negative feelings that include fearfulness and anxiety. This is due to the fear associated with their decline in mobility and vision. Burton and Mitchell also indicated the complications and risks presented by existing city environments for instance irregular paving, poor seating, no shelter, steep inclines, a lack of signposting, and bicycles on footpaths. The psychological and social difficulties are also serious obstacles for example, poor bus services, inaccessibility of local shops, insufficiency of toilet services, and the possibility of getting lost. Constant noise of heavy traffic flow disturbs the person with dementia’s hearing and has an influence on their concentration. Unexpected, loud sounds often frighten them. Another ‘no-go’ facility is the moving stairways in any public building, it hinders a person with dementia who suffers vision-impairment to judge the stairways distance and speed. (Blackman et al. 2010)

Vignette

The above findings support the caring experience in my practice in that the public outdoor world is not an appropriate setting for a person with dementia, they do experience obstacles and challenges on a daily basis when accessing the outdoors as proven in my vignette:

One of the residents, Mr X, in my care setting has been experiencing Schizophrenia for many years and he has also diagnosed with Vascular Dementia. He was from the local area and very familiar with the neighbourhood and community and is well known by some of the locals. He had free access in and out of the Care Home for many years but recently we received a phone call from a local shop that informed us that Mr X had lashed out towards one of their staff members who approached him to support and guide him. At one stage Mr X entered a private property without consent. He also developed some injuries on his lower legs and hands and also got on the wrong public transport.

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It was not very pleasant to involve the police to locate Mr X and to guide him back to his own home. After observing Mr X’s change in behaviour we determined that there was a deterioration in his physical and mental functioning, for example he could not remember where a toilet facility was available and used the ally of the local shop. He also entered a private property because that was his previous home. Due to the uneven walkways he also tripped and fell, injuring his legs and hands. Furthermore, Mr X could not read or understand the electronic screen at the bus stop causing him to use the wrong public transport.

We had to involve Mr X’s General Practitioner to review his medical treatment and according to the legislation we had to redo his risk assessments. Out of experience and observation we are aware that a person with dementia experience bad days and good days, and it can be problematic to specify at what stage their dementia has developed. But Mr X still has the capacity to make his own decisions and as such he decided to continue with his daily visits to the local neighbourhood as normal. We understand and support his decision, because this daily routine ‘walk about’ was very vital to maintain his self-respect, independence, and his quality of life. However, Mr X agreed to inform staff when he is leaving the facility and when he can be expected back, following the internal home policy to keep him safe and secure.

Positive transformations

As mentioned above there was positive transformations for normal disabilities, the UK Disability Discrimination Act updated in 2005 affected a change in attitudes towards design for disability in order to meet the needs of anyone with disability. Accessibility has become the most important problem because of the increasing population of older individuals and more positive attitudes towards disability in general.

Recently the mission for dementia friendly communities received an enhancement from the Prime Minister’s Challenge on dementia: a national challenge. In his challenge the Prime Minister highlighted three key areas (see Prime Minister’s Challenge, 2012, p.5)

• Driving improvements in health and care.
• Creating dementia friendly communities that understand how to help.
• Better research.

Mitchell (2012) identified only six projects that have addressed the dementia-friendly design of neighbourhoods. That includes a three year research project, which was sponsored by the Engineering and Physical Sciences Research Council (EPSRC). Individuals with dementia and older people in the community were directly involved, through escorted walks around their own neighbourhoods and in depth interviews. During the research the neighbourhoods were measured, mapped, and evaluated by using a developed checklist of environmental features. This research identified six key design principles that are necessary and required to make the streets and neighbourhoods more dementia friendly. The streets need to be safe, comfortable, accessible, familiar, legible, and distinctive (Burton & Mitchell, 2006).

Familiarity

The roads and outdoor environments and features should be recognisable and easily understandable by older individuals, especially for the person with dementia who experience confusion, spatial disorientation, and memory difficulties. Individuals with dementia do not recognise modernistic unfamiliar designs, they are used to traditional designs with the main entrance facing the street with normal swinging doors and not revolving or sliding doors. They also fail to recognise modern designed street furniture, for example modern bus shelters, telephone boxes, or an automated ‘Superloo’ (Burton & Mitchell, 2006, Mitchell et el., 2004).

To achieve familiarity in the outdoor environment the following can be done. Long-established streets can be maintained, local styles, materials, and forms should be used for new developments, and any changes should be incremental and on a minor-scale (Burton & Mitchell, 2006, Mitchell et el., 2004).

Legibility

Legible roads refers to an easy to recognise network of directions and junctions with simple, obvious signs and noticeable, unmistakeable features. Some individuals with dementia sub-consciously use various techniques to find their way. These include visualising their route through mental maps, route planning by using the same route every time, and they can follow symbols that are realistic and clear. Most individuals with dementia find it difficult to follow or understand the outdoor signs. A cluster of signs is very confusing and difficult to read and understand. People with dementia prefers straightforward, simple signs fixed to the wall. For example the post office sign is familiar and the colour is acceptable for people with colour agnosia. Another technique they tend to use in order to find their way is familiar landmarks and environmental features, such as the letterbox at the corner or a street café. It can happen that individuals with dementia get lost at times, that is due to confusion, disorientation, or distractions like sudden loud noise that causes a break in concentration (Burton & Mitchell, 2006, Mitchell et el., 2004).

To achieve legibility in the outdoor environment, streets should be laid out on an irregular grid pattern, staggered and this will allow the connection of routes that is easy to understand. Forked and T-junctions decrease the amount of routes and offer focus points at the end of the roads (Burton & Mitchell, 2006, Mitchell et el., 2004).

Distinctiveness

Distinctive streets replicate the community’s character through the use of a variety of features, colours, forms and materials that provide the buildings and streets with their own character and identity. It is essential for people with dementia to follow a route with a variety of local styles, shapes, sizes, and colour that will help them maintain concentration. They prefer a visit to the parks that presents them with mix activities such as enough seating, greenery, and public art (Burton & Mitchell, 2006, Mitchell et el., 2004).

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To achieve distinctiveness and to help dementia people find their way in the outdoor environment it is important to provide interesting and understandable places, use landmarks, and environmental features. Firstly, make use of aesthetic features such as water pumps, attractive gardens, hanging baskets, fountains, and trees. Secondly, use practical features for example street furniture that includes familiar letter boxes, red K6 telephone box, bus shelters, and safe public seating (Burton & Mitchell, 2006, Mitchell et el., 2004).

Accessibility

Accessibility states to which degree the local streets empower people with any physical, mental, or sensory impairment to reach, enter, and walk to places they wish to visit. Older people, including people with dementia are no longer able to drive on their own or to use any public transport. Their trips are limited, due to their personal capabilities, to local places within walking distance for their homes. With the decline of their mobility they cannot walk fast or far distances and they struggle to cope in crowded places because they need enough space on the walkways. Level changes also create barriers for frail people, similarly ramps or steps are a challenge for people with mobility problems (Burton & Mitchell, 2006, Mitchell et el., 2004).

To attain accessibility for frail people, they should preferably live no more than 125m from the nearest post box or telephone with 2m wide pathways and no more than 500m from crucial services and facilities. There should also be public seating every 100m to 125m (Burton & Mitchell, 2006, Mitchell et el., 2004).

Comfort

Comfort for older people and people experiencing permanent incapacity can include streets that allow them to visit places of their choice without any mental or physical agitation, it provides them with a welcoming and calm feeling (Burton & Mitchell, 2006, Mitchell et el., 2004).

To achieve a comfortable environment the streets must be designed in a way that it is welcoming, quiet, open, and accessible by providing enough public seating, shelter, and toilets. The seating must preferably be a wooden seat with arm and back rests. Bus stops should provide shelter, with transparent sides and flat seats of non-slippery material that do not conduct cold or heat (Burton & Mitchell, 2006, Mitchell et el., 2004).

Safety

Safety is a critical characteristic of a friendly environment for dementia people, they have to be able to move around without fear of tripping, falling, being run-over, or attacked. Safe streets will be well-lit, wide, plain, level, non-slippery, non-reflected, and smooth footways with isolated bicycle lanes and in front of building entering ways (Blackman et al., 2010, Burton & Mitchell, 2006, Mitchell et el., 2004)

The above principles outline the design guidelines to a more outdoor friendly environment for people with dementia. Burton and Mitchell (2006) also provides 65 recommendations and by using these it will support the design and re-design of an easy to use and welcoming neighbourhood.

To summarise, it is clear that people with dementia, at least during their mild to moderate stages, can still maintain their ability to cope independently and any regular mental and physical exercise is essential to maintain their self-respect, independence, and their quality of life as seen in the vignette.

That is why it is so important to us to ensure that the outdoor environment is accessible, open, and safe for people with all stages of dementia. If this cannot be achieved the environment out there becomes a scary and frightening world for people with dementia.

Although, the neighbourhood environment is not dementia friendly at present there is positive improvements and pressure from Government, through the Prime Minister’s Challenge on dementia. Importantly, the research project identified six principles of a dementia friendly environment that can be used for future planning and implementations. This will ensure that all new developments that take these principals into consideration will be in line with suggested and prescribed rules that cater for a safe and accessible environment for people with dementia.