Category Archives: Dementia & the Environment

Getting the temperature just right helps people with dementia stay cool

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There are currently no rules to ensure that aged-care facilities provide a comfortable indoor environment.
University of Wollongong, CC BY-SA

Federico Tartarini, University of Wollongong; Paul Cooper, University of Wollongong, and Richard Fleming, University of Wollongong

Everyone knows how bad it feels when the temperature is uncomfortably hot or cold. For most of us it doesn’t last long as we can take simple steps to get comfortable, such as putting on clothes, opening a window, or switching on a heater.

But what happens when you can’t control the temperature where you live? This problem is faced by many residents of aged care facilities, and can be particularly difficult for those living with dementia. To find out how these residents cope we recently carried out a three-year research project on the effects of indoor environment in aged care facilities in south-eastern NSW. This was part of a broader program of University of Wollongong research on the impact of indoor environment on elderly people.




Read more:
Australia’s aged care residents are very sick, yet the government doesn’t prioritise medical care


Dementia and agitation

Dementia is a collection of symptoms that affect people’s behaviour, thinking, and their ability to communicate and perform everyday tasks. Sometimes people with dementia can become agitated or distressed, which can be disturbing for other people around them. This often happens for no clear reason.

This is a big issue for the aged care sector since approximately half of all residents in aged care facilities have dementia.

While current rules governing the accreditation of aged care facilities in Australia do make reference to the need to provide ‘comfortable internal temperatures and ventilation’ there is no specific reference to what temperature ranges are considered comfortable. We set out to find whether this should be remedied and whether there is a relationship between agitation among residents living with dementia and the indoor temperatures to which they are exposed.

Dr Federico Tartarini (right) led the study that found that indoor temperatures in aged care centres have a dramatic impact on the wellbeing of residents, particularly those living with dementia. Photo: University of Wollongong.
Author supplied, CC BY

Tracking the temperature

Firstly we set up a network of sensors in six aged care facilities to monitor indoor environmental conditions, such as air temperature, humidity, air velocity and noise.

In collaboration with the care staff of one particular facility we then assessed the frequency and intensity of a range of agitated behaviours exhibited by residents living with dementia over the course of a year.

The most important finding of this study was that the frequency and intensity of agitated behaviours of residents with dementia significantly increased when they were exposed to uncomfortable air temperatures.

A statistically significant correlation was found between rates of agitation of residents and their cumulative exposure to temperatures outside their comfort zone of between 20°C and 26°C.

More generally, the data collected from the hundreds of temperature sensors across all our case study facilities over a one-year period showed that some facilities were often uncomfortably hot or cold (below 19°C in winter and over 30°C in summer) for significant periods.

Poorly designed buildings

This was attributable to many different factors including poor thermal design of the buildings and poor control of the heating and cooling systems. Interestingly, our analysis showed staff were significantly less tolerant of variations in indoor temperature than residents, probably because they were generally more active than the residents (i.e. moving around and working), and therefore had higher metabolic rates. They may have also had higher thermal comfort expectations than the residents.

Regulations can help

The evidence appears to suggest that maintaining a comfortable temperature
will reduce the behavioural and psychological symptoms of dementia.

There is a clear need for new regulations that ensure aged care facilities provide comfortable indoor environmental conditions, particularly for elderly residents, but also for the staff working in these facilities.

The aged care sector needs good indoor environmental rating tools, built on recent research evidence, to guide the design of their facilities and to audit their operations.

This type of approach has already been successfully applied in the commercial building sector, where mandatory disclosure of the real energy consumption of larger offices, for example, is required of owners wishing to sell or lease their property.




Read more:
Why is it so cold in here? Setting the office thermostat right – for both sexes


The ConversationPublicly available ratings of the actual indoor environment provided to aged care residents and staff would alert architects, managers and staff to the importance of thermal comfort and help elderly people, and their families, make a more informed choice as to the best facility in which to live.

Federico Tartarini, Associate research fellow, University of Wollongong; Paul Cooper, Senior Professor and Director of the Sustainable Buildings Research Centre (SBRC), University of Wollongong, and Richard Fleming, Professorial Fellow and Executive Director, Dementia Training Australia, University of Wollongong

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

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Why hospital architects need to talk to nurses

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Hospital building work in East Sussex.
Shutterstock

Jens Roehrich, University of Bath

Many of us pay close attention to how our taxes are spent, and how well governments invest in infrastructure projects such as roads, schools and hospitals. Value for money is key. Yet horror stories of waste, lateness and poor quality are common.

To develop and finance public services and infrastructure, governments around the world (but especially in Europe) have become increasingly keen on private sector involvement. These cross-sector collaborations can help provide value for money for taxpayers – but they are also at risk of wasting it.

In health care, collaborations between public and private partners have a direct impact on society. This is why it is important for health care professionals like doctors and nurses to talk directly to the designers and builders of a new hospital. It ensures that these projects not only deliver economic value for the private companies building the hospital – but also social value for the doctors, nurses and patients who will use the hospital for decades to come.

For instance, in one recently built British hospital, medical staff were able to bring valuable insight to the design process. A visit by some of the hospital’s senior nurses to a children’s hospital in the US led to the replication of a lighting design on the ceiling of a children’s ward so that it mimicked a starry night sky. As one of the nurses explained to me afterwards:

It might sound like a small change, but it provides a much more homely surrounding than the normal NHS lighting. This is important for our young patients [providing a] less scary, hospital experience which positively impacts on the healing process. […] It creates a much nicer environment in which our little patients can recover.

In another hospital, input from senior nurses helped to establish a ward design that most suited their professional needs – right down to the placement of plumbing. This saved large amounts of money that might have been spent on undoing unnecessary building work had the nurses not been consulted.

As one project manager of the construction company told me: “Thanks to [the senior nurses’] input and telling us how they intend to use wards, we changed the ward layout, such as the position of sinks. This may seem to be a minor issue, but may have a huge impact when caring for a patient.”

To see how social value can be best achieved through cross-sector collaborations we looked into the key building blocks that go beyond a mere focus on contracts.

An organisations’ prior experience of cross sector collaboration and a supportive climate is vital in creating social value. It also helps to have had some exposure to previous projects (good and bad). But a major ingredient is the individual employees in both public and private sector organisations.

We need a starry sky ceiling right there.
Shutterstock

Building mutual knowledge and aligning goals between doctors, nurses and design and construction professionals is key, as public and private sector employees often have different objectives for projects (making a profit vs healing patients). A shared understanding can come through listening to and appreciating the other parties’ professional language and the expertise that language expresses.

Joint expertise

Beyond an understanding of the other parties’ expertise, practical matters of shared goals and jointly developed timelines are necessary. Coordinating efforts between the two sectors needs to take priority at the outset – rather than emphasising project speed and completion.

To encourage these positive outcomes, the key people need to meet frequently to exchange information, address problems and discuss plans. Without this kind of coordination and collaboration, it will be impossible to make the most of both sides’ specialist knowledge.

So when it comes to hospitals and clinics, the private company needs to actively seek the involvement of doctors and nurses in the design and construction phases. Similarly, doctors and nurses should not be threatened by private companies, but instead seek to become actively engaged. This will help drive creative design innovations such as the “night sky” ceiling in the children’s ward.

The ConversationIt takes time and resources, but this kind of collaboration and coordination between public and private sectors provides an opportunity to increase value – both economic and social. And that’s something that not only benefits construction companies and health care professionals – but patients and taxpayers, too.

Jens Roehrich, Professor of Supply Chain Innovation, University of Bath

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

What good dementia design looks like – A case study on Dementia Training Australia’s work with Scalabrini Village

DTA and Scalabrini Village case study profiled at Alzheimer’s International Conference in Chicago from Dementia Training Australia on Vimeo.

 

A case study on Dementia Training Australia’s work with Scalabrini Village is featured in the program Every Three Seconds, a collaboration between ADI and ITN Productions which highlights the fact that someone in the world is diagnosed with dementia every three seconds.

Source: https://www.dta.com.au/case-studies-dementia-training-australia/

Caring for elderly Australians in a home-like setting can reduce hospital visits

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Personalised care that lets people feel as though they’re living independently is better.
from http://www.shutterstock.com

Suzanne Dyer, Flinders University and Stephanie Harrison, Flinders University

A new study out today has found residents with dementia in aged-care facilities that provide a home-like model of care have a better quality of life and fewer hospitalisations than those living in more standard facilities. We also found the benefits of a home-like model were provided without an increase in running costs.

Our study compared home-like models (which have up to 15 residents per unit and free access to outdoor areas) to more standard residential care, where a large number of people are housed in one building. In 2011, around half of all facilities in Australia had places for more than 60 residents, and the average size is growing.

The World Health Organisation has stated smaller home-like residential care settings “hold promise for older people, family members and volunteers who provide care and support”. But Australia is lagging behind other countries in offering alternative models of residential aged care.




Read more:
There’s no need to lock older people into nursing homes ‘for their own safety’


What is a home-like model of care?

Most older people with dementia want to stay at home as long as they can. When this is no longer possible, they move into residential aged-care facilities, which become their homes.

These residential facilities, or nursing homes, frequently adopt a model of care that emphasises individuality. This is known as person-centred care. But delivering this model may require more staff or a different mix of staff, which may be difficult to deliver with current funding.

So standard aged-care facilities in Australia often have some similarities to health facilities, with designated staff areas and centralised kitchens. Access to outdoor areas, particularly for people with dementia, may depend on the availability of staff. Despite adhering to philosophies such as person-centred care, the scheduling of this care and of meals often lacks flexibility.

The problems are compounded when residential care is used for multiple purposes ranging from palliative care to providing care for people with dementia. The needs of these two groups are quite different and the lack of focus makes delivering quality care a challenge.

Evidence shows the physical design of the residential aged-care environment may play an important role in the well-being of residents, particularly those living with dementia. Internationally, there is a move towards providing care in facilities that feel more like a home and promote independence.

Such models of residential aged care generally have:

  • flexibility in daily routines – for example, the time people get dressed and eat
  • opportunity for residents to participate in domestic activities such as meal preparation
  • access to outdoor spaces
  • clusters of smaller living units (up to, say, 15 residents in each)
  • care staff assigned to living units for continuity of care and development of relationships between staff and residents.



Read more:
God’s waiting room? Life needs to be valued in nursing homes


Being involved in simple tasks such as food preparation can improve quality of life.
from http://www.shutterstock.com

What we found

Our study was specifically designed to include people with dementia and their family members. People with dementia are not often included in research studies.

It included 541 participants from 17 not-for-profit residential aged-care facilities in four different states in Australia. They had been residents for a year or longer.

These facilities were all considered high quality. This means they had lower hospitalisation rates for potentially avoidable conditions than the national performance target. And more than 80% of residents in the standard care facilities indicated they felt as safe as they wanted and that their environment was as clean and comfortable as they wanted.

Around one-quarter of people in the study lived in a facility with a home-like model of care. All of them were living with dementia.

The study found residents in home-like models of care had a better quality of life, as rated by the residents themselves or their family members. They also had a 68% lower rate of being admitted to hospital and 73% lower rate of having an emergency department presentation.

We have previously shown residents who lived in a home-like model were 52% less likely to be exposed to potentially inappropriate medications. These are medications where the potential harms may outweigh the benefit, such as antipsychotics or relaxants, but are still often prescribed to older people in residential care.

The benefits for residents were provided with similar running costs for the home-like and the standard models of care. However, the costs excluded differences in the build of the facilities. Initial establishment costs are likely to be higher, due to the requirement for more space per resident.




Read more:
There is extra funding for aged care in the budget, but not enough to meet demand


Rethinking models of care

Funding arrangements don’t incentivise Australian aged-care providers to offer variety in terms of models of care. Government funding is provided based on the assessed care needs of the residents, rather than the preferred model of care or resident outcomes.

Funding supplements are available to care providers for reasons such as residents’ financial hardship or risk of homelessness and to small, rural aged-care service providers, but none are available for offering an alternative model of care.

The ConversationThe Australian government plans to improve the aged-care system to offer “choice and flexibility”. This is crucial, but we also need to improve choice and variety in residential aged-care models.

Suzanne Dyer, Senior Research Fellow, Flinders University and Stephanie Harrison, Postdoctoral research fellow, Flinders University

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

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).

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).