Category Archives: Dementia & Carers

Green for wellbeing – science tells us how to design urban spaces that heal us

 

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Generic plotting of ‘green space’ on an urban plan does not target mental wellbeing unless it is designed to engage us with the sights, sounds and smells of nature.
Zoe Myers, Author provided

Zoe Myers, University of Western Australia

One in five Australians will suffer from a mental health issue this year and living in a city makes it far more likely. Research shows that city dwellers have a 20% higher chance of suffering anxiety and an almost 40% greater likelihood of developing depression.

Promisingly, however, research has also found that people in urban areas who live closest to the greatest “green space” are significantly less likely to suffer poor mental health.

Urban designers thus have a significant role to play in lowering these rates of mental illness, and the data on how nature affects our brains are central to changing the ways we design. As depression is the world’s biggest cause of disability, we cannot afford to ignore the impact of public environments on mental health.

Multiple stressors associated with city living have been shown to increase activity in the parts of the brain corresponding to the “flight or fight” response.


Further reading: Vanishing Australian backyards leave us vulnerable to the stresses of city life


How does exposure to nature reduce these stresses? There are two enduring theories on how nature affects the brain. Both are based on nature having a restorative effect on cognitive and emotional function.

Hyde Park, Perth, allows for an immersive ‘escape’ from the urban world.
Zoe Myers, Author provided

It is not emptiness or quiet, however, that has the effect. Nature in its messy, wild, loud, diverse, animal-inhabited glory has the most impact on restoring a stressed mind to a calm and alert state. This provides a more complete sense of “escape” from the urban world, however brief.

This idea is not new, nor is it surprising. Many people seek out nature to restore wellbeing, and multiple disciplines have sought to measure these restorative effects.

The result is more than 40 years of research quantifying specific neurological, cognitive, emotional and physiological effects of “nature” elements. These effects include increased calm and rumination, decreased agitation and aggression, and increased cognitive functioning – such as concentration, memory and creative thought.


Further reading: Biophilic urbanism: how rooftop gardening soothes souls


A neglected resource for urban design

This wealth of data has been largely overlooked in driving good urban design.

Much of this can be attributed to the data being siloed into scientific disciplines separate from design. All use different languages and are often hidden behind academic journal paywalls.

Also significant is the complexity of mental health issues. This makes it difficult to draw conclusions on environmental effects. To use this data required first a meta-analysis of these methodologies and outcomes, and my own interpretation of how the data applied specifically to urban design.

There are some notable conclusions.

This pedestrian and bike path in Perth is unlikely to maximise the benefits of green space.
Zoe Myers, Author provided
  1. Different natural elements can induce different benefits. This means generic design plotting of “green space” on an urban plan, however aesthetically pleasing, does not specifically target mental wellbeing.
  2. Time plays a significant role. There is no point having great green spaces if these do not provide good reason or opportunity to linger long enough to experience the restorative benefits.
  3. How you engage with your environment matters. Results differ depending on whether the user is observing, listening, or exercising in the space. Taking these variables into account can produce a vast combination of design scenarios.

For example, despite the many studies on the restorative effects of forests, these are not the most accessible option for most city-dwellers. Urban parks are an alternative, but creative, natural interventions in urban spaces that encourage incidental interaction with green space can also produce much benefit.

Much has been written about how walking or exercising in green spaces seems to amplify the effects on the brain of viewing nature. Indeed, as little as five minutes of “green exercise” can produce these benefits.


Further reading: Higher-density cities need greening to stay healthy and liveable


What’s wrong with existing green spaces?

Many urban parks and green spaces – particularly in residential areas – are unimaginative, repetitive and lack basic elements to evoke these references to nature. Nor do they encourage walking or enjoying the natural elements for any length of time.

A typical reserve in Perth, Australia.
Zoe Myers, Author provided
A residential footpath and verge in Perth, Australia.
Zoe Myers, Author provided

For example, paths without shade or protection do not encourage walks long enough to achieve benefits. A lack of landscape diversity does little to activate fascination or interest, and fails to offer incentive to visit them, especially given the ways in which parks can be separated from their surroundings.

In an attempt to create spaces to serve function, such as ensuring enough turf for a game of football, much biodiversity has been removed, thus also removing the sights, sounds and smells needed for an immersive, multi-sensory experience. This applies equally to many suburban footpaths and residential streets.

A suburban residential street in Perth, Australia.
Zoe Myers, Author provided

When urban design gets it right

Septuagesimo Uno Pocket Park, Manhattan.
‘Jim Henderson, Atlas Obscura’

Compare this to urban areas that employ creative uses of incidental nature to capture attention and offer genuine interaction.

Successful parks and urban green spaces encourage us to linger, to rest, to walk for longer. That, in turn, provides the time to maximise restorative mental benefits.

Urban design’s role in shaping our cities is becoming less about the design of physical spaces and more about extracting principles that can be applied to urban spaces in ways specifically tailored to context, site, region and climate.

This means urban design can have a real impact on mental wellbeing, but we need to look outside our discipline for data to make it effective.

A Tokyo road reserve.
from Tokyo DIY Gardening

The ConversationFurther reading: Greening cities makes for safer neighbourhoods

Zoe Myers, Research Associate, Australian Urban Design Research Centre, University of Western Australia

This article was originally published on The Conversation. Read the original article.

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Chemical restraint in aged-care homes linked to early death

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Up to 60% of nursing home residents are on psychiatric drugs and around 30% are on powerful anti-psychotics.
Ulrich Joho

Juanita Westbury, University of Tasmania

Last night ABC’s Lateline discussed the case of 63-year-old John Burns, who died within 12 days of going into residential aged care. Burns was put into care after he started to display disinhibited sexual behaviour, and was prescribed anti-psychotics soon after.

The show reported that up to 60% of nursing home residents are on psychiatric drugs with as many as 30% on powerful anti-psychotics. It yet again draws attention to a problem that’s been recognised for over 20 years: the overuse of sedative medication in nursing homes.

And despite strong evidence that many of these drugs are not only often ineffective but may also cause substantial harm (in the worst case, strokes, pneumonia and death), their use appears to be increasing in Australia.

A case study

Lilian moved into the aged care home several weeks ago. She is 84 years old, recently widowed and, two years ago, she was diagnosed with Alzheimer’s disease. Lilian displays certain behaviours that are annoying other residents and some of the nursing staff. The main issue is that she goes into neighbouring rooms and sorts through cupboards, taking out other resident’s toiletries and underwear.

This is a real case that was described to me by nurses who were interviewed for a study looking at sedative medication use in aged care. To address Lilian’s behaviour, a nurse contacted her doctor to discuss the issue and they decided to give her a small dose of diazepam to see if it would help.

Diazepam, better known by its trade name of Valium®, is a long-acting benzodiazepine prescribed mainly for anxiety. There’s limited evidence that it’s effective for managing behaviours associated with dementia. So was it appropriate to prescribe this medication to manage Lilian’s behaviour, or is she being chemically restrained?

Chemical restraint

Medications such as anti-psychotics are often inappropriately prescribed to manage behavioural symptoms of dementia.
Ashley Rose

A variety of medications are prescribed in aged-care homes for their sedative properties. Some are used to manage the behavioural symptoms of dementia, and include anti-psychotics and benzodiazepines. And the use of these agents appears to be increasing. A recent study conducted in 44 Sydney aged-care homes found that over 28% of residents were taking anti-psychotic medications. The researchers noted that six years earlier, drug use in the same group was 24%.

So what exactly does the term “chemical restraint” mean? The definition used by the Federal Government is the “intentional use of medication to control a resident’s behaviour when no medically identified condition is being treated, where the treatment is not necessary for the condition or amounts to over-treatment of the condition.”

It may seem obvious to readers that, according to this definition, Lilian is being chemically restrained but many health practitioners working at aged-care homes wouldn’t agree. One director of nursing I interviewed said, “We don’t chemically restrain our residents….anyone that is prescribed a sedative medication has a medical condition; be it dementia, anxiety or a problem getting to sleep.”

Others feel that someone is only chemically restrained when the sedative dose is too high. This broad interpretation of what chemical restraint constitutes, or rather, does not constitute, validates the use of sedative medications for a substantial proportion of aged-care residents.

A growing problem

The prevalence of mental health conditions in the residential aged-care is increasing as the population ages and long-term psychiatric beds remain closed.

According to the latest Australian Institute of Health and Welfare (AIHW) report on aged care, over half of aged-care home residents have dementia. The majority of these residents will have symptoms such as aggressive behaviour, calling out and wandering. Over a third will have anxiety disorders and over half will have disturbed sleep. These statistics indicate that the majority of residents are likely to display mental health symptoms.

Among residents with serious mental illness, such as schizophrenia, major depression and severe aggression, the benefits of using sedatives outweigh harms. But for less serious mental health conditions, using such medication is not ideal.

Giving sedatives to older residents can result in significant harm, including confusion, falls, increased rates of pneumonia and even death, especially in the case of antipsychotics.

For less serious mental health conditions, using sedatives is not ideal.
Pedro Ribeiro Simoes/Flickr

Many of these medications only have modest effectiveness in treating difficult behaviours, anxiety and sleep disturbance. And there’s a mounting body of evidence that non-drug strategies can be effective for treating these symptoms. At the very least, non-drug measures should be trialled before sedative medication is prescribed.

Better alternatives

Behavioural symptoms of dementia, anxiety and sleep problems are not always caused by the dementia itself, but can be caused by other underlying medical conditions, such as infections or pain. So it’s important to rule out such causes first before starting treatment. But according to nursing staff, there’s often inadequate assessment of residents.

Non-drug strategies that are effective in managing symptoms include relaxation therapy, personalised music, video tapes of family members, one-on-one time and providing basic counselling and sleep hygiene measures. But many aged-care homes don’t have the staff, training or resources to provide these strategies. As one relative told me, “I just wished that the staff had the time to just be with her and calm her, talk with her and settle her down.”

The ConversationExcessive sedative use in aged-care homes is thought by many to be symptomatic of problems in funding adequate staffing, training and medical services in this sector. Little progress in reducing reliance on sedative use or chemical restraint can be made until this under-resourcing is addressed.

Juanita Westbury, Lecturer in Pharmacy Practice and Research Fellow, University of Tasmania

This article was originally published on The Conversation. Read the original article.

 

Personality changes do not begin in the onset of dementia or MCI

Latest findings from a study of 2,046 participants over 36 years from the Florida State University found that there is no evidence to support preclinical personality changes occur prior to the onset of dementia or even in mild cognitive impairment.

 

Associate Professor Antonio Terracciano, at the College of Medicine stated that “We further found that personality remained stable even within the last few years before the onset of mild cognitive impairment”.

 

Therefore, it is important to note that personality change may not be an early sign or symptom of dementia, however personality changes should not be ignore by caregivers or clinicians. These changes can have a large inpact on the quality of care and life of the person living with dementia and their caregivers.

 

Original article http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2653004

Replacing care staff with robots… is this really the solution?

To be honest, I would not want to stay in a care home like this. I wouldn’t have a robot care for my child, why would I have a robot care for the elderly. Especially when we know that the human elements of social engagement and familiarity are an essential for cognitive function. How confusing would it be for a person living with dementia to be residing in a home fully run by artificial intelligence? Wouldn’t it be like being trapped in a Dr Who episode where the world is run by Cybermen?

Click here to go to source

While he still knows who I am by Kenny Chesney

A beautiful tribute by Kenny Chesney to his Father who was diagnosed with Alzheimer’s disease.

Kenny C

Digital life stories spark joy in people with dementia

 

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Creating a ‘digital story’ of their memories using photos, music, text and video, can hep dementia patients open up to their fear and move into optimism.
(Shutterstock)

Elly Park, University of Alberta

I was sitting on the sofa across from Christine in her home. She offered me a cup of coffee. Each time I visited, she sat in the same spot — the place where she felt most comfortable and safe. She had shared stories from the past and decided to talk about the birth of her daughters, grandchildren and great grandchildren.

For Christine, a research participant in a multi-sited study into dementia and digital storytelling, the fear dementia brings is that she won’t be able to be a part of special moments such as the celebration of birth.

As we worked together in Edmonton, creating a multimedia story from her memory, Christina started to remember new things. She became emotional when she talked about her daughters becoming mothers themselves. She pointed out that the project was so much more powerful than looking through a photo album. Like many participants, she said she recalled stories she hadn’t thought about for years.

As a post-doctoral fellow in occupational therapy under the supervision of Dr. Lili Liu, at the University of Alberta I worked with several participants in this study. Funded by the Canadian Consortium on Neurodegeneration in Aging, one of our goals was to investigate quality of life and how technology affects the lived experiences of persons with dementia.

Technology and quality of life

In this research project we defined digital storytelling as using media technology — including photos, sound, music and videos — to create and present a story.

Most previous research on digital storytelling and dementia has focused on the use of digital media for reminiscence therapy, creating memory books, or enhancing conversation. Collaboratively creating personal digital stories with persons with dementia is an innovative approach, with only one similar study found in the United Kingdom.

During this project, I met with seven participants over eight weeks. Our weekly sessions included a preliminary interview to discuss demographics and past experiences with technology. Then we worked on sharing different meaningful stories, selecting one to focus on and building and shaping the story. This included writing a script, selecting music, images and photographs and editing the draft story.

“I was blessed with wonderful parents, and I was a mistake,” begins Myrna Caroline Jacques, 77, a grandmother of five.

Participants worked on a variety of topics. Some told stories about family and relationships, while others talked about a particular activity or event that was important to them. After all participants completed their digital stories, we had a viewing night and presented the stories to family members.

Happiness in the moment

It was an intense process. Eight sessions working one-on-one with persons with dementia required a significant amount of thinking, remembering and communicating for the participants. There were challenges, such as when participants found themselves unable to express their thoughts or remember details.

In this digital story, Christine Nelson talks of her love for her children and her fear of forgetting special moments.

Although many participants were tired after a session, they all felt that it was a beneficial and meaningful activity. Working in their homes on a personally gratifying activity with a tangible outcome seemed to keep them motivated and eager to continue. The process was also enjoyable and gave the participants something to look forward to each week.

There was a sense of happiness in the moment. And the way that participants responded to me, along with their ability to remember who I was and the purpose of our sessions, all indicated a deeper positive connection. The participants all felt a sense of accomplishment and family members were proud to see the end product at the viewing night.

Into the future

I have met with one of the research participants again recently, and she still remembers me. I would like to follow up with the others to get a sense of the long term impact of this digital storytelling project. I am also eager to see how the findings in Edmonton line up with those from the studies in Vancouver and Toronto.

The ConversationFor the participants, talking about memories helped them open up about having dementia. Getting past the fear and looking ahead with optimism was the message I heard, and one that I hope to keep hearing.

Elly Park, Assistant Clinical Lecturer in Occupational Therapy, University of Alberta

This article was originally published on The Conversation. Read the original article.

Japan offers us many lessons in embracing longevity

Japan offers us many lessons in embracing longevity

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With a quarter of the population aged over 65, Japan has had to be innovative in catering for their wants and needs.
Martyn Jones, Author provided

Marco Amati, RMIT University; Marilena Kavoura, RMIT University; Martyn Jones, RMIT University, and Robin Goodman, RMIT University

Japan is famous for the longevity of its citizens. A quarter of its population is older than 65. That is a proportion that Australia is likely to reach only by 2056. Japan’s experience makes it an interesting example to learn from in the area of aged care.

In 2000, following a decade of stagnant growth, mounting public debt and skyrocketing hospitalisation, Japan introduced the Long-Term Care Insurance Scheme (LTCIS). This universal and compulsory scheme provides support to assess and deliver care through institutional or community-based services for all people over 65. It provides sufficient funds to allow everyone to age in place – even those in public housing and with late-onset dementia.

The scheme represents one of the boldest social democratic experiments in aged care policy in the last 30 years. Yet with bold experiments come surprises.

To the chagrin of the scheme’s designers the LTCIS has been too successful. Cheaper to implement than the policy it replaced, it is still oversubscribed and contributing to Japan’s public debt (230% of GDP).

Happy Active Town in Kobe is a public housing estate where more than 50% of residents are older than 65.
Photo: Martyn Jones

The universal acceptance of the scheme contributes to a paradox: while Japan has the largest ageing population in the world, it is difficult to make a business of providing aged care, as the collapse of Watami, the food chain-cum-nursing home provider, demonstrates. So what can this experience teach Australia’s aged care sector?

Care happens within the community

The first set of lessons concerns community-based integrated care. Here, the LTCIS, following 2012 reforms, mobilises support through community general support centres.

Australia is seeking to improve integration of multi-level care. The support centre in “Happy Active Town”, Kobe, provides an example. This public housing estate houses many refugees from the 1995 Great Hanshin Awaji earthquake. Its proportion of residents over 65 is more than 50%.

The LTCIS, with the local government, provides a care hub for volunteers, social workers and health professionals to provide services and respite care free to all residents on and off the estate. Community hubs such as these are designed to support a range of needs from intense support to community and family engagement in care across the life course.

Happy Active Town in Kobe houses many aged survivors of the devastating 1995 earthquake.

Harnessing technological innovation

The second lesson comes from watching and observing the Japanese experience of integrating technology in care provision. Dense, multistorey buildings of small units are typical in Japan. New, so-called “Platinum” housing integrates universal design and new technologies to ensure safe independent living for the elderly.

Retrofitting large areas of public housing to this standard is complex and expensive. A limited number of exemplary regeneration projects where the local municipality, private providers and the LTCIS work together guide the way. One example is Toyoshikidai, a public estate built for young families in the 1950s in Kashiwa to the north of Tokyo.

Alongside these urban changes a generational change is afoot. As the digitally literate generation reaches old age, smart home devices and new security and communication technology assume increasing importance. The business opportunities alone could amount to US$1 trillion by 2035.

The Japanese government supports this shift with its “Silver ICT” agenda. This includes a raft of e-strategies to bridge the digital divide between “active and inactive” elderly populations.

Yet in the nation where the development of robotic assistive technologies enjoys vast sums of research and development support, there is little sign of this in daily life. In Japan, applying technology in aged care is fraught with ethical, personal and logistical challenges. The solution, for now, centres on the involvement of humans.

The ConversationThe Japanese experience of ageing is unique and varied, but presents a foretaste of the future for many post-industrial societies. The “Happy Active Town” of Kobe, 20 years after a major natural disaster, is one example of a place where public policy, housing and technology converge to create solutions for an ageing society. Its mechanisms to support the passion and commitment of the people working and living there can teach Australia how to age with dignity.

Marco Amati, Associate Professor of International Planning, Centre for Urban Research, RMIT University; Marilena Kavoura, Manager Industry Linkage, RMIT University; Martyn Jones, Associate Professor of Social Work, RMIT University, and Robin Goodman, Professor of Urban Planning, Deputy Dean, Sustainability and Urban Planning, RMIT University

This article was originally published on The Conversation. Read the original article.