Category Archives: Dementia & the Environment

Circadian circuit may affect “Sundowning”

News Release
April 9, 2018 | Boston – Beth Israel Deaconess Medical Center

New Discovery May Calm ‘Sundowning’

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BOSTON – Patients with Alzheimer’s disease and other forms of dementia commonly experience the sundown syndrome – a sudden worsening of confusion, agitation and aggression at the end of the day. Its daily pattern suggested that “sundowning,” as the phenomenon is also known, may be governed by the body’s internal biological clock. Synchronized by light and darkness, the circadian clock exerts control over wake/sleep cycles, body temperature, digestion, hormonal cycles and other physiological and behavior patterns. But whether the circadian clock regulated aggressive behavior was unknown.

Now, for the first time, a team of neuroscientists at Beth Israel Deaconess Medical Center (BIDMC) has demonstrated circadian control of aggression in male mice and identified the specific neurons and circuitry regulating the daily pattern. The insight opens the door to potential opportunities for managing the evening-time agitation common in patients with degenerative neurological disorders. The study was published today in Nature Neuroscience.

“Sundowning is often the reason that patients have to be institutionalized, and if clinicians can control this circuit to minimize aggressiveness at the end of the day, patients may be able to live at home longer,” said senior author Clifford B. Saper, MD, Chair of the Department of Neurology at BIDMC. “We examined the biological clock’s brain circuitry and found a connection to a population of neurons known to cause violent attacks when stimulated in male mice. We wanted to know if this represented a propensity for violence at certain times of day.”

Saper and colleagues observed aggressive interactions between male mice – resident mice defending territory against intruders introduced to residents’ cages at different times throughout the day. Counting the intensity and frequency of residents’ attacks on intruders revealed for the first time that aggression in male mice exhibits a daily rhythm.

“The mice were more likely to be aggressive in the early evening around lights out, and least aggressive in the early morning, around lights on,” Saper said. “It looks like aggressiveness builds up in mice during the lights on period, and reaches a peak around the end of the light period.”

Next, the scientists used genetics-based tools to manipulate neurons known to regulate the central circadian clock. When Saper and colleagues inhibited these neurons by disabling their ability to produce a specific neurotransmitter, the mice lost the daily waxing and waning of their aggressive tendencies. These genetically manipulated mice were more aggressive overall, demonstrating a significant increase in total time attacking intruders.

Using optogenetics – a technique that uses light to activate or deactivate targeted brain cells – to map brain circuitry revealed two parallel pathways between the biological clock and a population of neurons in a sub-region of the hypothalamus (called the VMHvl) known to cause violent attacks when stimulated in male mice.

Taken together, the experiments showed that this circadian circuit kept aggressiveness in check in the early morning; stimulating it prevented attack, while inhibiting it promoted attack. Because stimulating the neurons in question cools off aggression, Saper suggests that controlling this circuit could potentially make animals – and perhaps people – less aggressive.

“Our results in mice mimic the patterns of increased aggression seen in patients during sundowning,” Saper said. “This new research suggests this pathway may be compromised in neurodegenerative diseases. Examining changes to this pathway in patients could provide insight into future interventions that could greatly improve the quality of life for patients and caregivers alike.”

In addition to Saper, investigators included co-first authors William D. Todd and Henning Fenselau, Joshua L. Wang, Natalia L. Machado, Anne Venner, Rebecca Broadhurst, Satvinder Kauer, Bradford B. Lowell, and Patrick M. Fuller, of BIDMC and Harvard Medical School; Rong Zhang, of Boston Children’s Hospital and Harvard Medical School; Timothy Lynagh of the University of Copenhagen; and David P. Olsen, of the University of Michigan, Ann Arbor.

This work was supported by the G. Harold and Leila Y. Mathers Foundation and the US National Institutes of Health (NIH) (grants NS072337, NS085477, AG09975, HL095491 NS073613, NS092652, NS103161, DK111401, DK075632, DK096010, DK089044, DK046200, DK057521, NS084582-01A1 and HL00701-15. Additional support came from the Alzheimer’s Association (AARF16-443613), CNPq (National Health Council for Scientific and Technological Development), and CAPES (Coordination for the Improvement of Higher Education Personnel).

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Learning from zoos – how our environment can influence our health

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CoolR/Shutterstock

Emmanuel Tsekleves, Lancaster University

We are told that we are a nation of couch potatoes, lacking the will and the strength to turn around the obesity tanker. We all need a little help in our quest for a healthier life and design can play a crucial part. If we designed our towns, cities, homes and workplaces more like animal experts design zoos, we could be one step nearer to reaching our fitness goals – as long as we can have some fun along the way.

It is reported that British people will be the fattest in Europe by 2025 and that if we want to reverse this we should have a healthier lifestyle by exercising more and eating less. But we are often made to feel guilty for not sticking to theses healthy lifestyle plans. I would suggest that before we start blaming people for adopting sedentary lifestyles, we should be taking a step back to look at the design of the environments, towns and cities in which we live.

The link between the design of the built and natural environment and its role in our health and well-being has been well explored. Now new research, led by Lancaster University, on “design for health” suggests that the environment, including buildings, cities, urban spaces and transport infrastructure, is closely linked to the lifestyles we adopt.

What is abundantly clear is that, as we shape our environment, it is also shaping us. Our psychological, physiological and physical status as well as our interactions with other people and with the natural environment are all affected. A key challenge that governments and policy makers worldwide are facing is how our built environment and infrastructure should be shaped to support healthier behaviours to prevent disease.

First, we should stop focusing on methods that tell people what to (or not to) do and which attempt to change their behaviour simply through media campaigns and punitive measures, such as tax schemes. While seeking to minimise the barriers that prevent healthy behaviours, we should make sure that the design of new environments is taken into account.

Looking to zoos

A good model would be to look at how zoos are designed. Before a zoo is built, it is common practice for zoologists, biologists, animal psychologists, nutritionists, architects, designers and landscape architects to work closely together to create an environment that optimises the living conditions for the animals.

Important environmental elements, such as vegetation, habitat, lighting, materials and each animal’s requirements are taken into account. The ultimate aim is to design an environment that fully supports the animals’ physical, psychological and social well-being. Ironically, we do not seem to make the same demands when a town, neighbourhood or workplace environment for humans is planned and designed.

Another opportunity that has recently emerged is the healthy new town NHS initiative. The aim is to radically rethink how we live and take an ambitious look at improving health through the built environment. Ten demonstrator towns will be built across England with community health and well-being as their main focus. Clinicians, designers and technology experts will reimagine how healthcare can be delivered in these places. Although this is a step in the right direction, what it is currently missing is the more holistic approach we have seen in the design of the zoos.

A crucial element in designing these towns so they are places that people would want to live in, is to include community members in their creation. This strategy would help design-in health-promoting behaviours, such as access to healthy food outlets or green spaces in which people can walk and exercise.

Embracing playfulness

Playful design – the mapping of playful experiences from games and toys to other non-game contexts – can play an important role here in inviting and encouraging people towards healthier alternatives. For example, the piano stairs project in Stockholm, which converts the metro stairs into a giant functioning piano keyboard – much like the piano made famous in the Tom Hanks movie Big (1988) – demonstrates great promise. It encourages commuters to opt for the intriguing new stairway instead of the escalators to enjoy making musical movements as they go up and down.

A project in The Netherlands, meanwhile, illustrates how everyday street furniture, such as lampposts, benches and bollards, can be inexpensively converted into impromptu exercise devices, inviting people to engage in casual activity and socialise with their neighbours. We could therefore envisage several other contexts were playfulness can transform mundane everyday activities into fun ones that encourage people into a more active and social lifestyle.

We could convert building walls into activity walls to encourage stretching of arms and legs through touch; redesign public squares and walkways into interactive dance floors that invite movement and guide you through a city; and transform workplace spaces and public places into “playgrounds” that boost movement and productivity and decrease lethargy.

The Conversation

So there you have it. If we want to be a nation of lean, mean and healthy citizens we need to learn from zoos and the animals that live in them. And we need to embrace playfulness and enjoy the place where we live. That way, we can tackle life with a hop, skip and a jump.

Emmanuel Tsekleves, Senior Lecturer in Design Interactions, Lancaster University

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

Memory Garden in a Belfast Care Home

This care home has opened a ‘magical memory garden’, designed to rekindle the memories of those with dementia (SBS Australia).

Building a better world: can architecture shape behaviour?

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US architect Frank Lloyd Wright, who designed Fallingwater, believed that appropriate architecture would save the US from corruption.
Via Tsuji

Jan Golembiewski, University of Sydney

In 1966, a British planner called Maurice Broady came up with a new term for the architectural lexicon: architectural determinism.

This was to describe the practice of groundlessly asserting that design solutions would change behaviour in a predictable and positive way.

It was a new phrase but the belief system behind it – that buildings shape behaviour – had allowed the heroes of architecture to make all kinds of outlandish claims.

A hopeful history

Leon Battista Alberti, an Italian Renaissance-era architect, claimed in the 1400s that balanced classical forms would compel aggressive invaders to put down their arms and become civilians.

Frank Lloyd Wright, the US architect who designed one of the most famous buildings in America, Fallingwater, similarly believed appropriate architecture would save the US from corruption and turn people back to wholesome endeavours.

British author and thinker Ebenezer Howard believed companies would be more efficient if their employees lived in village-like garden communities.

Swiss-born French architect Le Corbusier made claims about how his Villa Savoye building in France would heal the sick – and when it did just the opposite, he only avoided court because of the commencement of the second world war.

It took a long list of failures over the millennia before postmodern theorists took to critiquing architectural fantasy with malevolent vengeance. The high-point of this trend was the delight shared over the demolition of the famously dangerous and dysfunctional Pruitt-Igoe urban housing complex in St Louis in the US.

It was designed by architects George Hellmuth, Minoru Yamasaki and Joseph Leinweber to provide “community gathering spaces and safe, enclosed play yards.” By the 1960s, however, it was seen as a hotspot for crime and poverty and demolished in the 1970s.

The demolition of Pruitt-Igoe in 1972 fuelled resistance to deterministic thinking.
Wikimedia

The loss of faith in architecture’s power has been regrettable. Architects’ well-meant fantasies once routinely provided clients with hope and sometimes even with results.

Without this promise, the profession was left inept before the better structural knowledge of engineers, the cumulative restrictions imposed by generations of planners, the calculations of project-managers and the expediency of a draughtsman’s CAD (computer-aided design) skills in turning a client’s every whim into reality.

Without fiction, architecture has become a soulless thing. But was determinism dismissed too soon? Is there a role for imagined futures without rationalist restrictions?

Restoring the faith

Just think of some of the ways architecture can manipulate your own experience. In his book, Happy City: Transforming Our Lives Through Urban Design, US author Charles Montgomery points out that some environments predictably affect our moods.

The fact is that environments do affect us, regardless of whether by design or by accident. In 2008, researchers in the UK found that a ten-minute walk down a South London main street increased psychotic symptoms significantly.

In my own research, I find that the healthier a person is, the more a good environment will affect them positively and the less a bad one will affect them negatively. Mentally ill patients show about 65 times more negative reactivity to bad environments than controls and all these reactions translate directly into symptoms.

The same patients have about half the positive responsiveness. That’s fewer smiles, less laughter and a reported drop in feeling the “fun of life”.

But that’s not all. The potential for architecture is richer still. The ease with which architecture can embrace sublime aesthetics makes it great for generating awe.

Psychiatrists have found that awe reduces the prevalence and severity of mood disorders. Could sublime architecture even potentially save lives?

The psychological effects of architecture are difficult to prove, but difficulty doesn’t dilute the value of a building that hits the right notes and creates a sense of awe. Each building type has different functions, and for each there’s an imperative to use the building to help create an optimal mood, desire or sense of coherence, security or meaning.

Awe reduces mood disorders: Gaudi’s Sacrada Familia church in Spain.
Wikimedia

Fortunately, there’s a resurgence of belief that buildings can change behaviour, led by a few architectural journals: World Health Design, Environment Behavior and HERD.

Most of these focus on health care design, because that’s where behavioural changes have life and death consequences.

But nobody dares make any promises. As such, research rarely opens the black box of environmental psychology, leaving findings unexplained and prone to failure.

To give architecture back its mojo, a new interest in how architecture changes us must be fostered. Clients have to learn to trust architects again and research funding bodies have to re-gear to encourage research into how buildings affect our mood, health and behaviours.

Finally, architecture schools have to teach students how they might predict psychological, emotional, healing and functional effects.

The ConversationAll innovation, ultimately, is led by the imagination – even if that means taking risks and sometimes getting it wrong.

Jan Golembiewski, Researcher in Environmental Determinants of Mental Health, University of Sydney

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

How the brain selectively remembers new places

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Neuroscientists identify a circuit that helps the brain record memories of new locations.

MIT News release – Source: How the brain selectively remembers new places

When you enter a room, your brain is bombarded with sensory information. If the room is a place you know well, most of this information is already stored in long-term memory. However, if the room is unfamiliar to you, your brain creates a new memory of it almost immediately.

MIT neuroscientists have now discovered how this occurs. A small region of the brainstem, known as the locus coeruleus, is activated in response to novel sensory stimuli, and this activity triggers the release of a flood of dopamine into a certain region of the hippocampus to store a memory of the new location.

“We have the remarkable ability to memorize some specific features of an experience in an entirely new environment, and such ability is crucial for our adaptation to the constantly changing world,” says Susumu Tonegawa, the Picower Professor of Biology and Neuroscience and director of the RIKEN-MIT Center for Neural Circuit Genetics at the Picower Institute for Learning and Memory.

“This study opens an exciting avenue of research into the circuit mechanism by which behaviorally relevant stimuli are specifically encoded into long-term memory, ensuring that important stimuli are stored preferentially over incidental ones,” adds Tonegawa, the senior author of the study.

Akiko Wagatsuma, a former MIT research scientist, is the lead author of the study, which appears in the Proceedings of the National Academy of Sciences the week of Dec. 25.

New places

In a study published about 15 years ago, Tonegawa’s lab found that a part of the hippocampus called the CA3 is responsible for forming memories of novel environments. They hypothesized that the CA3 receives a signal from another part of the brain when a novel place is encountered, stimulating memory formation.

They believed this signal to be carried by chemicals known as neuromodulators, which influence neuronal activity. The CA3 receives neuromodulators from both the locus coeruleus (LC) and a region called the ventral tegmental area (VTA), which is a key part of the brain’s reward circuitry. The researchers decided to focus on the LC because it has been shown to project to the CA3 extensively and to respond to novelty, among many other functions.

The LC responds to an array of sensory input, including visual information as well as sound and odor, then sends information on to other brain areas, including the CA3. To uncover the role of LC-CA3 communication, the researchers genetically engineered mice so that they could block the neuronal activity between those regions by shining light on neurons that form the connection.

To test the mice’s ability to form new memories, the researchers placed the mice in a large open space that they had never seen before. The next day, they placed them in the same space again. Mice whose LC-CA3 connections were not disrupted spent much less time exploring the space on the second day, because the environment was already familiar to them. However, when the researchers interfered with the LC-CA3 connection during the first exposure to the space, the mice explored the area on the second day just as much as they had on the first. This suggests that they were unable to form a memory of the new environment.

The LC appears to exert this effect by releasing the neuromodulator dopamine into the CA3 region, which was surprising because the LC is known to be a major source of norepinephrine to the hippocampus. The researchers believe that this influx of dopamine helps to boost CA3’s ability to strengthen synapses and form a memory of the new location.

They found that this mechanism was not required for other types of memory, such as memories of fearful events, but appears to be specific to memory of new environments. The connections between the LC and CA3 are necessary for long-term spatial memories to form in CA3.

“The selectivity of successful memory formation has long been a puzzle,” says Richard Morris, a professor of neuroscience at the University of Edinburgh, who was not involved in the research. “This study goes a long way toward identifying the brain mechanisms of this process. Activity in the pathway between the locus coeruleus and CA3 occurs most strongly during novelty, and it seems that activity fixes the representations of everyday experience, helping to register and retain what’s been happening and where we’ve been.”

Choosing to remember

This mechanism likely evolved as a way to help animals survive, allowing them to remember new environments without wasting brainpower on recording places that are already familiar, the researchers say.

“When we are exposed to sensory information, we unconsciously choose what to memorize. For an animal’s survival, certain things are necessary to be remembered, and other things, familiar things, probably can be forgotten,” Wagatsuma says.

Still unknown is how the LC recognizes that an environment is new. The researchers hypothesize that some part of the brain is able to compare new environments with stored memories or with expectations of the environment, but more studies are needed to explore how this might happen.

“That’s the next big question,” Tonegawa says. “Hopefully new technology will help to resolve that.”

The research was funded by the RIKEN Brain Science Institute, the Howard Hughes Medical Institute, and the JPB Foundation.

Architecture And Design Help the Brain to Recover

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How does the hospital environment affect our rehabilitation? New research from the University of Gothenburg, Sweden, into how the space around us affects the brain reveals that well-planned architecture, design and sensory stimulation increase patients’ ability to recover both physically and mentally. Digital textiles and multisensory spaces can make rehabilitation more effective and reduce the amount of time spent in care.

In an interdisciplinary research project, Kristina Sahlqvist has used research into the recovery of the brain to examine how hospitals can create better environments for rehabilitation.

“We want to help patients to get involved in their rehabilitation, a side effect of which can be an improvement in self-confidence,” says Sahlqvist, interior architect and researcher at the University of Gothenburg’s School of Design and Crafts (HDK).

The project drew on all the expertise used on a ward, with input from neurologists, rehabilitation doctors, nurses, psychologists, occupational therapists and physiotherapists. The result is a conceptual solution for an optimal rehabilitation ward.

“Our concept gives the ward a spatial heart, for example, where patients and their families can prepare food and eat together, which allows for a more normal way of spending time together in a hospital environment,” says Sahlqvist.

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In tandem with her research work, she has teamed up with a designer and researcher at the Swedish School of Textiles in Borås on an artistic development project where they redesigned furniture, developed easy-grip cups and cutlery and used smart textiles, in other words textiles with technology embedded in them. The concept includes a table and chairs, a rug and a muff with integral heating, a cardigan with speakers and a soft bracelet that is also a remote control.

In order to measure and test the research theories Sahlgrenska University Hospital will be developing an intensive care room featuring multimodal stimulation, where all the senses are affected. The work involves an architect, doctors, hospital staff, musicians, a designer, an acoustician and a cognition specialist. In a bid to see what kind of results the environment can produce in practice, the researchers will take account of the entire social situation of patients, family and staff.

There are other interesting tricks in the field of neuroarchitecture, where it is possible, for example, to use spatial expressions to improve learning. Although these are currently used predominantly in schools, they could also have potential for the elderly.

“It’s worth wondering why there are so many educational models for preschool children but so few for the elderly. Many old people need a far more stimulating environment than they have at the moment,” says Sahlqvist.

Date: November 3, 2011
Source: University of Gothenburg
Release from University of Gothenburg

建筑和设计帮助大脑恢复

发布日期:2011年11月2日。
哥德堡大学发布 

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医院环境如何影响我们的康复? 瑞典哥德堡大学的最新研究发现,我们周围的空间如何影响大脑,显示出精心策划的建筑,设计和感官刺激可以提高患者身心恢复的能力。 数字纺织品和多感官空间可以使康复更有效,并减少花费在护理上的时间。

在一个跨学科研究项目中,Kristina Sahlqvist利用大脑恢复研究来研究医院如何创造更好的康复环境。

哥德堡大学设计与工艺学院(HDK)室内设计师兼研究员Sahlqvist说:“我们希望帮助患者参与康复治疗,其副作用可以提高自信心。

该项目利用了病房的所有专业知识,由神经科医生,康复医生,护士,心理学家,职业治疗师和物理治疗师提供投入。 结果是最佳康复病房的概念性解决方案。

Sahlqvist说:“我们的理念给病房提供了一个空间的心脏,例如,病人和他们的家人可以一起准备食物和一起吃饭,这样可以在医院环境中更加正常地花时间在一起。

在她的研究工作的同时,她与布罗斯的瑞典纺织学院的一位设计师和研究员合作开展了一个艺术发展项目,重新设计了家具,开发了易握杯子和餐具,并使用了智能纺织品,换句话说纺织品其中嵌入了技术。 这个概念包括一张桌子和椅子,一个地毯和一个带有整体加热装置的手套,一个带扬声器的开襟衫和一个也是遥控器的软手镯。

为了衡量和测试研究理论,萨尔格林斯卡大学医院将开发一个以多模式刺激为特征的重症监护室,所有感官都受到影响。 这项工作涉及建筑师,医生,医院工作人员,音乐家,设计师,声学家和认知专家。 为了研究环境在实践中能产生怎样的结果,研究人员将考虑患者,家属和工作人员的整个社会状况。

在神经体系结构领域还有其他一些有趣的技巧,例如使用空间表达来改善学习。 虽然这些目前主要用于学校,但也可能对老年人有潜力。

Sahlqvist表示:“值得一提的是,为什么学龄前儿童的教育模式如此之多,而老年人的教育模式却很少。许多老年人需要的环境比现在更为刺激。

Alarming amounts of noise demand ways to silence noisy hospital environments

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Spending a night in the hospital is not only stressful, but also loud. The constant beeps, whirrs and alarms ascend to a cacophony that produces anything but a relaxing, restful environment. Researchers will summarize the limited number of studies available on hospital noise and discuss the different approaches health care facilities are taking to bring restful repose to patients across the country during the 174th ASA Meeting, Dec. 4-8, 2017, in New Orleans, La.

Source: Alarming amounts of noise demand ways to silence noisy hospital environments

Hospital noise is a growing concern for patients, family and staff, but many facilities are looking for new approaches to reduce the din and bring peace back to their environment.

Public Release: ACOUSTICAL SOCIETY OF AMERICA

WASHINGTON, D.C. December 6, 2017– Spending a night in the hospital is not only stressful, but also loud. The constant beeps, whirrs and alarms ascend to a cacophony that produces anything but a relaxing, restful environment. Ilene Busch-Vishniac, of BeoGrin Consulting in Baltimore, Maryland, will summarize the limited number of studies available on hospital noise and discuss the different approaches health care facilities are taking to bring restful repose to patients across the country.

According to the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, noise is the top complaint of patients, staff and visitors. “Nearly everyone has a stay in a hospital at some point,” Busch-Vishniac said. “Noise is a universal problem in hospitals around the world.”

Busch-Vishniac will explore these concepts during the 174th Meeting of the Acoustical Society of America, being held Dec. 4-8, 2017, in New Orleans, Louisiana. Noises emanate from a variety of sources at the bedside. Airflow and the noisy machines controlling it are kept on high to prevent pathogens from lingering near patients, and overhead pages alert staff of needs or announcements. Equipment alarms are the most egregious source, and although they are designed to alert staff of changes in the patient’s medical condition, many also sound when medication needs to be changed or when battery conditions are low.

“Alarms in hospitals are being horribly abused,” Busch-Vishniac said. “Most of the time, they don’t in fact indicate urgent situations.”

Previous studies showed that alarms at a patient’s bedside sound an average 133 times per day. With so many alarms, staff often face alarm fatigue as well.

“Most alarms are being responded to eventually, but not all in a timely fashion,” said Busch-Vishniac. “Staff also may not respond quickly because they recognize that the sound is not critical and the situation will right itself.”

Besides the obvious barrier to rest, high noise levels have been associated with changes in the patient’s heart rate, respiration and blood pressure. These changes increase stress levels and may impair healing. The noise can also impair communication between patients and staff.

With noise levels on the rise, the Centers for Medicare and Medicaid Services (CMS) initiated the HCAHPS survey in 2008 to assess consumer perception of health care providers and systems. Today, more than 5,500 hospitals contribute to the report, which consists of patients’ responses on seven composite measures, including questions focused on room cleanliness and quietness.

The survey has teeth. Hospital value-based purchasing links up to 30 percent of CMS payments to hospitals across the country to the results of the survey.

“Faced with a loss of money, many hospitals are looking for ways to address noise levels in a way that patients can see as an improvement,” said Busch-Vishniac.

Hospitals have been developing and implementing noise control programs that can be broken into two categories: engineering and administrative interventions.

Engineering interventions aim to find ways to quiet the room. The solutions can be as simple as closing the door to a patient’s room or as complex as installing acoustical absorption materials along the walls and ceiling to dampen the noise level. Administrative interventions focus on changing behaviors. Many hospitals have instituted quiet hours when doors are closed and voices are kept low.

One of the big changes during the past 10 years has shifted alarms from solely sounding at the patient’s bedside to also alerting a central monitor at the nursing station. This approach improves the ability of staff to identify and respond to alarms set at a reduced volume.

According to Busch-Vishniac, it may be possible in the future to remove alarms from the bedside. A quiet hospital may not be a pipedream for much longer.

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Presentation 3pIDa: “Hospital noise: how bad is it?” by Ilene Busch-Vishniac is at 1:45-2:05 p.m. CST, Wednesday, Dec. 6, 2017, in Salon E in the New Orleans Marriott. https://asa2017fall.abstractcentral.com/s/u/M8hKSrQu66E