«Faculty for People with Intellectual Disabilities Dementia and People with Intellectual Disabilities Guidance on the assessment, diagnosis, ...»
I Calm and stress free Environments can easily become stressful for someone with dementia. To avoid this and keep the environment calm and allow the person to focus better, many aspects of the environment can be adjusted.
Guidance on their Assessment, Diagnosis, Interventions and Support 57 Noise Noise is one factor which needs to be controlled, although not eliminated. People with dementia may have impaired hearing and in addition because of their cognitive impairments, do not know which sounds to attend to or not to attend to. For example it would be difficult for them to know whether they need to attend to the radio playing in the background or the staff talking to them. This impairment can be very distressing and is why noise levels should be controlled where possible. Two types of noise need to be considered – noise from the outside and noise from within the building.
Noise from outside the building may cause the person to be distracted, or prevents I them hearing conversation. Double glazing and lined curtains can help to reduce the level of external noise.
Within the building, noise levels from competing sources need to be reviewed. Noise I can be from TVs, radios and music systems, conversation or people calling out, telephones ringing.
Staff need to consider the level of noise appropriate for each activity, person, and I time of day.
Music can be very calming but must be used selectively, and not be a constant I background noise. Selecting music that is in the person’s long term-memory can be beneficial, giving the person something that they can relate to.
Distractions from other people – either staff, other residents or visitors – can also I cause problems, especially if they are at times when you want the person to concentrate on a task, activity or interaction. Thinking about possible distractions and taking preventative measures can help, as can simple environmental measures such as moving the position of the telephone.
Predictable and making sense It is important to have an environment that is both predictable for the person and makes sense to them, otherwise the result will be disorientation and confusion.To avoid this, it is important to first recognise two important visual changes within individuals with dementia.
One is that their depth perception is lost and, secondly, that they see the red end of the colour spectrum better than the blue end, and as a result colours such as red, orange and yellow are more easily seen.
With regards to the loss of depth perception, one of the obvious consequences of this I is that stairs become impossible to use as the depth of each step is hard to judge. As a result they should be avoided.
Another consequence of this difficulty is that a change in colour can be perceived as I a change in level. For example the point at which one carpet changes colour to another in a different room may be perceived by a person with dementia as a step, and cause them to be hesitant in doorways, or unwilling to enter a room. Staff may not understand what is causing the person’s distress and may wrongly ascribe it to the person being difficult, stubborn or challenging.
Furthermore, dark areas on light flooring can look like holes so the person with I dementia will be inclined to avoid them by walking around them. Lighting which is not too bright or too dark is recommended to prevent shadow effects on the flooring which can look like holes.
58 Dementia and People with Intellectual Disabilities In addition to this, bathrooms and kitchens typically can be problematic as they I usually have shiny floors which can look like pools of water to someone with dementia. It is recommended to have matt flooring which is the same colour as the flooring in the room that leads to it.
With regards to the change in colour perception, it is recommended that red, orange I and yellow are used to make certain objects or rooms more obvious, for example, painting a toilet door red, having red toilet seats, and using contrasting colours for crockery and table mats.
With regard to colours for decoration and furniture, the most important issue is to I ensure colour contrasts – so that the walls are a different colour from the flooring, which is different again from the furniture. This enables the person with dementia to be more able to distinguish items in their environment and helps to avoid accidents and incidents.
As people get older, they need their environment to have more light. It is important I that the tone of colours makes the environment look lighter and brighter, rather than having colours that make the environments seem darker and ‘suck out the light’.
These issues can cause the person to get very distressed and can also increase the possibility of falls. Risk assessments for the environment need to be reviewed regularly to keep the person safe.
Aside from the issues mentioned, memory impairments mean individuals cannot find I their way around familiar settings. This can be frightening for them so simple changes such as adding good signage to doors (e.g. personalised acrylic boxes with personal/significant items of the person within them) at the right level for older people can make a difference.
Nolan et al. (2002) showed that placing a portrait such as a photograph and personal I memorabilia in a display case outside the room of each person with dementia increased room finding by 45 per cent.
Changes such as using rooms for a single clear function wherever possible; using the I same room consistently for an activity (e.g. always using one particular bathroom for washing).
Using picture rather than verbal cues is vital for people with dementia, e.g. picture I timetables, pictures to indicate where things are, signage, picture menus, etc.
Camouflaging doors that people do not need to use by painting them the same I colour as the rest of the wall or using curtains to make the top half of a fire door look like a window; all can reduce confusion dramatically.
Memory loss means mirrors can become scary to look as they do not recognise I themselves. This is because they see themselves at a younger age, so mirrors may need to be covered up (e.g. at night).
Familiar Due to roll back memory (See Section 9 – Conceptual Understanding of the Dementia Process) people will not recognise things that were not around at the age they are ‘experiencing’ now. For example, someone who is 80 years old but whose reality is now the 1950s will have problems recognising and understanding how to use mixer taps, futuristic looking kettles, lamps, chairs, clocks, etc.
Guidance on their Assessment, Diagnosis, Interventions and Support 59 It is important to use traditional style objects that will be recognisable to the person I from their own past. For example, clocks with hands, traditional style kettles, cookers, lamps, chairs, clocks and curtains rather than blinds, etc. Basically, it is best to avoid modern futuristic styles.
Aside from this issue, other adaptations that could be made to make the environment I more familiar is to use small-scale, domestic, homely furnishings and to use objects/pictures for orientation (eg. picture of a toilet on the toilet door). Cohen and Weisman (1990) stated that familiar objects, activities, and spaces can trigger personal associations and even encourage social interactions and meaningful activity.
Suitably stimulating Although the environment needs to be calm, it is still important that the environment is sufficiently stimulating. There must be a happy balance between over stimulation and under stimulation. The study by Morgan and Stewart (1999) supported this notion and showed a curvilinear relationship between environmental demands and negative behaviour in people with dementia. Thus negative outcomes were associated with both under stimulation and over stimulation.
To achieve this suitably stimulating environment, appropriate levels of noise for that I person, activity and time of day are important.
In addition clear views of the outside world and small quiet areas are important as I they allow individuals suitable stimulation and allow peaceful and calming times.
Safe Safety is of paramount importance and there are a number of issues which need to be considered with people with dementia in a home.
One behaviour which people with dementia may exhibit is wandering, and although I this can lead to some safety problems, it should not be totally discouraged. As a result it is important all exits are monitored and/or alarmed and that fire exits are camouflaged so they are not subject to misuse.
In addition it is important that steps, stairs and uneven flooring are all considered I within the home due to the depth perception problems experienced in early and middle stages of dementia.
It is important the garden is secure and safe for wandering, with safe plants and even I surfaces. Ideally a home and garden should be designed with wandering in mind, thus a circular design is optimal for a home, allowing clients to wander around and return to where they started. This notion of a circular arrangement would also be applicable to the garden in terms of a pathway.
In addition to this, the temperature of water in the kitchen, bathrooms and toilets I need to be controlled and all possible hazardous objects, such as knives, sharp corners, hot kettles, need to be stored away safely.
Assistive technology, e.g. bed alarms, epilepsy monitors, are a useful adjunct to the environment for people with intellectual disabilities and dementia, but should not be used as a replacement for sufficient and competent support.
60 Dementia and People with Intellectual Disabilities Key points Wherever possible, people with intellectual disabilities and dementia should remain I in familiar environments.
If the person has to move, then this should be within an intellectual disabilities I service.
Environments can be adapted to make them dementia-friendly and enable the I person with dementia to make sense of where they are living.
It is important that environments provide stimulation for the person without I putting them under any stress.
Guidance on their Assessment, Diagnosis, Interventions and Support 61 Section 12 – Meeting changing needs/interventions
12.1 Overview of approaches to intervention It is important that the diagnostic process, which can be lengthy, does not preclude the implementation of interventions. Regardless of the eventual outcome of the diagnostic process, support is required to address current areas of need. Interventions need to be tailored to the individual, particularly the person’s existing health, disability and social circumstances. There needs to be an emphasis on enhancing the psychological well-being of the individual, and minimizing the impact of changes being felt by the person’s carers and/or peers.
Most of the interventions likely to be required are ones that are not specific to dementia, and likely to be beneficial regardless of the eventual outcome of the diagnostic process. The interventions will be familiar as core to the work of intellectual disability professionals with emphasis on a person centered approach with interdisciplinary and multiagency working.
For example; the provision of accurate and timely information; formulation; interventions to maximise and maintain independence, skills and health; and at the same time promoting safety comfort, and dignity. Reducing excessive demands and simplifying routines are key, while minimising avoidable changes, especially any exclusion from appropriate services. It is notable that where someone is in a totally unsuitable environment for their needs (e.g.
isolated or bullied) and may be depressed, then a change can be beneficial and aid the diagnostic process. Furthermore, awareness needs to be maintained regarding the person’s changing needs and interventions reviewed at regular intervals.
The use of Person Centred Planning (DH, 2001) and the Care Programme Approach (DH,
2008) provide the same overall framework for individualised planning and care coordination as for anyone else with intellectual disabilities and changing or complex needs. All care planning, of course, has to be in the context of the individual and their family’s religious/cultural context. Consent, capacity and risk management issues need to be considered at all stages, alongside the need for advocacy, advance directives, living wills and other mechanisms to facilitate best interest or complex decision making, according to changing legislative frameworks and ethical practice. Furthermore the Quality Outcome Measure for Individuals with Dementia (Dodd & Bush, 2013) provides guidance in providing quality person centered care for people with Intellectual disabilities and dementia (see Appendix 2).
12.2 Meeting changing needs As the dementia progresses, the emphasis of care changes from enabling the person to maintain their skills with support to increasingly taking on tasks for the person with dignity and respect.
At the early stage of dementia, this will involve reminding the person of the day, time, place; simplifying routines and reducing choices; introducing memory aids such as diaries, timetables and objects of reference; simplifying communication, and using additional cues and prompts.
Guidance on their Assessment, Diagnosis, Interventions and Support 63
12.3 Understanding behaviour in people with intellectual disabilities and dementia By implementing the philosophy of care outlined earlier, for example, Buijssen (2005) psychosocial model of dementia, many of the difficulties that can occur in dementia can be prevented or minimised. However, there will often be times when people present with behaviours that staff or family find difficult to understand and respond to.
Positive behaviour support approaches (PBS) have become established as a preferred approach when working with people with intellectual disabilities who present behaviours
that can be perceived as challenging. This is evidenced in Positive and Proactive Care: