Caring for people with dementia: noise and light

Transcription

1 Caring for people with dementia: noise and light Sensory stimulation can have a significant effect on the wellbeing of people with dementia. Jan Dewing explains how, with some simple modifications, the care environment can be made more therapeutic Summary This article explores how two fundamental aspects of sensory stimulation, noise and light, affect the person with dementia and discusses some of the implications that nurses need to consider to create more therapeutic care environments. Keywords Dementia, environment, sensory stimulation There are environmental challenges when working towards providing person-centred care, regardless of the care setting, for example, acute hospitals, day hospitals/centres and care homes, and whether the setting is new or very old. In most cases, modifications can be made by nurses and nurse leaders such as modern matrons and nurse consultants. These modifications will enhance the wellbeing of the person with dementia, contribute to the creation of a more therapeutic care setting and offer staff a more pleasant working environment. Noise and light are the two most obvious sources of sensory stimulation in the environment, and when ignored or mismanaged, they can become important sources of under or overstimulation for the person with dementia (Bakker 2003). Assessing and modifying light and noise levels in the environment can contribute to providing dignified care for older people with dementia and for other older people with a range of sensory and cognitive impairments. For the most part, staff can have a significant degree of control over levels of light and noise in the care environment and nurses need to set up processes to ensure that they take responsibility for managing them as part of daily patient care. There is an increasing amount of research in different fields to show that the environment is an important but sadly often undervalued and even ignored resource in dementia care (Sloane et al 2002, Nolan 2007). This can be partially explained by historical inadequate resourcing of, and undervaluing of, services for older people. Consequently, the environment has not always been given the priority it deserves. More recently Judd (2008), discussing care homes, proposed that there are tensions around the rigid interpretations of health and safety and infection control regulations and the goal of providing more meaningful and homely environments for people with dementia. Judd (2008) called for creative solutions that address safety concerns from all points of view. In this debate, we should keep central what is best for the person with dementia. The challenge is to ensure that the goal of home is achieved while at the same time having a safe enough working environment. The physical and social environment in all care settings can have a significant effect on caring experiences, day-to-day living, overall wellbeing and quality of life (Day et al 2000, Brush et al 2002). Sensory overload or underload In an environment where there is no education, audit or regular evaluation of noise and light levels, sensory stimulation can become unbalanced. The consequences for the person with dementia can vary from minor to severe, according to the remaining abilities of the person for dealing with the often overwhelming presence or absence of sensory stimuli. At a fundamental level, Alzheimer s disease and related dementias generally result in progressive and significant changes in how people interpret what 34 June 2009 Volume 21 Number 5

2 they see, hear, taste, feel and smell (Price et al 2000, Bakker 2003). The extent of these changes is highly individual and constantly changing according to the person, their impairments and their environment. Additionally, it has been documented that people with dementia have a reduced stress threshold to many environmental stimuli (Hall and Buckwalter 1987). Therefore, environmental stimuli that staff, for example, might consider acceptable, can be too much and reduce the person s remaining capacity to cope with being in the care environment. Thus, in some settings, the way in which a person presents and behaves may be influenced by the environment. This means it must not be assumed that the level of impairment and disability observed is entirely caused by pathological changes. There are many situations, in various care settings, where people with dementia exhibit what are often referred to as behavioural problems, such as anxiety and agitation, that are partially a consequence of being in an environment that is not dementia friendly or enabling (Cohen-Mansfield 2004). At the core of this is often sensory overload or underload from noise and light sources. The best environment can enable the person with dementia to achieve maximum independence and wellbeing. A very poor environment can result in the person with dementia experiencing an unnecessary increase in their disability, ill health, declining care and even agitation or different types of aggressive responses. Noise Hearing loss is prevalent among older people from the general population as a result of age-associated changes (Le May 1999), although Gussekloo et al (2003) found that the majority of older people tended to decline hearing aids. Many older people in healthcare settings will present with a hearing impairment and the consequences of this include difficulty with participating in conversations and altered responses to sounds in the environment. Additionally, people with dementia are adapting to increasing cognitive decline. Most care settings are noisy places. Most older people would not be used to the levels of noise, the continuous noise and noise associated with movement going on around them in their own homes. Having a bed next to or sitting close to work stations, offices and corridors can, for example, mean hearing disjointed parts of conversations. Background noise from telephones and machines, trolleys and other pieces of equipment, the television and radios all increase auditory stimulation. The motion of people coming and going also adds another layer to auditory stimulation. Noise disturbs rest, relaxation and sleep (Cmiel et al 2004). It can increase anxiety and affects family and communication at visiting times. Topf (2000) considers that noise levels in hospital can become a form of environmental pollution. Sudden noises, such as when equipment is dropped or when doors are slammed, cause a startle reflex, which as well as causing various physiological responses in the person with dementia, can also increase the sense of disorientation and insecurity. Missildine (2008), in a small descriptive study in acute care settings, found increased levels of noise and light at night resulted in a sleep efficiency rating of 45 per cent and between five to 38 waking episodes per night. A similar finding regarding noise levels at night was made in a study of care homes by Schnelle et al (1999). Alzheimer s Australia (2004) state that of all stimuli, noise has the most significant and damaging effect on people with dementia. Further, people with dementia exposed to periods of continuous noise can experience increased alterations in memory and other cognitive functions, increased agitation, less tolerance for pain and feelings of isolation. This then affects the person s ability to understand and cope with Lack of illumination may induce a higher risk of accidental falls for people with dementia as well as for other residents David Mitchell New dementia-friendly designs use bold colours because people with dementia find it difficult to distinguish objects or areas where there is a lack of colour contrast June 2009 Volume 21 Number 5 35

3 aspects of care and treatment. Ultimately, it can lead to the person seeming to resist or decline care. Visual stimulation Windows are the obvious source of natural light. Making the most of them is vital. Clear, bright lights that are well positioned can make light bounce off walls and add brightness to a room or space. Poor lighting and lighting that is poorly positioned may cause a glare, especially if it reflects off highly polished floors and table tops, glossy walls and doors (Bakker 2003). Not everyone can be or wants to be by a window. The quality of light in the centre of a room is as important as ensuring that light is able to enter the room or space via a window. Glare can be distracting or even reduce a person s mobility. It has been estimated that older people generally require between two to three times the amount of light as younger individuals (De Lepeleire et al 2007, Pollock et al 2008). Yet, van Someren et al (1996) found that older people with dementia were subjected to reduced amounts of bright light on an ongoing basis. De Lepeleire et al (2007) found that in most care homes (n=8) the amount of light was seldom sufficient to meet the visual needs of older people. The researchers concluded that lack of illumination may induce a higher risk of accidental falls for people with dementia and for other residents. An ongoing lack of natural daylight, along with either low levels of interior lighting or interior lighting of the clear fluorescent type left on for prolonged periods, not only affects people during the day but can also affect sleep patterns (Bliwise 1994). Sloane et al (2007) found that high-intensity ambient light; that is, bright light therapy, in public areas of a psychiatric hospital and in longterm care facilities improved sleeping patterns and the circadian rhythms of 66 people with dementia. Sloane et al (2007) found that night-time sleep increased by approximately 60 minutes in participants exposed to all-day light therapy, with the increase most prominent in participants with severe or very severe dementia. Exposure to morning-time light only produced a 30-minute increase in sleep duration and evening light a 15-minute increase. The researchers concluded that bright light appeared to have a modest but measurable effect Making modifications to the environment can reduce disability and dependency and increase wellbeing on sleep. A number of researchers have found that bright light therapy of between 1,000 and 5,000 lux led to less agitation, reduced sundowning or agitated behaviours towards sunset, improved activity and rest during the day and helped nighttime sleep (Ancoli-Israel et al 1991, Okawa et al 1991, Satlin et al 1992, Mishima et al 1994, Mishima et al 1995, van Someren et al 1996, Okumoto et al 1998, Thorpe et al 2000). However, in a Cochrane review, Montgomery and Dennis (2002) found no trials on which to base any conclusions for the effectiveness of this treatment. The reviewers go on to say that when the possible side effects of the standard treatment (such as hypnotic medication) are considered, there is an argument to be made for the use of non-pharmacological treatments such as bright light therapy with older people. For older people who have visual impairment, the presence of background noise reduces their face-toface and reading abilities (Osborn et al 2000). The colours used in an environment can also give or take away from the effects of lighting. Clear bright colours with planned colour contrasts in appropriate places can be helpful. It has to be kept in mind that colour design that enables older people with dementia to feel more oriented is not necessarily what we would have for ourselves or in our own homes. Wherever there is a lack of visual and colour contrast, people with dementia often have difficulty in seeing clearly. This difficulty is experienced by many older people and not just those with dementia. For example, people with glaucoma and cataracts and those who have had strokes may also experience similar difficulties to people with dementia. Bakker (2003) suggests that people with Alzheimer s disease have a decreased ability to perceive colour contrasts and impaired depth perception. When objects close together or on top of each other are also similar in colour or in colour value, that is, the lightness or darkness on a gray scale, older people find it harder to see the edges of objects within the space (Koss and Gilmore 1998). An example is signs on doors and walls that are a similar colour to the background or tableware that is all matching and placed on a dull coloured table surface. This can unnecessarily increase the person s disability and make them more dependent on others. In care homes, Kerr et al (2008) found that sleep could be further disrupted by unacceptable levels of light and noise. The night-time physical environment was often disabling rather then enabling, especially for people with dementia. Night-time disruption could be doubly confusing for those with dementia who might wake in 36 June 2009 Volume 21 Number 5

4 the night to find strangers in their room, or be disoriented by wall mirrors or poor design features. Objects in a care setting are also a source of visual stimulation and can be a potential source of over or understimulation. For example, a cluttered noticeboard or very loud patterned curtains, a plain single room, mirrored walls or a long corridor where all the walls and doors look the same. Staff generate the most noise in the care environment and this should be taken into account when assessing levels Implications for practice Nurses need to believe that sensory stimulation can have a significant effect on the person with dementia. Developing greater insight and learning more about this area are important preparations for making changes in the environment. Creating a therapeutic environment for people with dementia does not happen by chance (Bakker 2003); it requires systematic intervention (Elmståhl et al 1997, Nolan 2007, Moyle et al 2008). The key to change is to aim to achieve a balance of sensory stimulation for older people with dementia, so that noise and light are neither excessive nor too minimal (Miller 1999). Achieving this balance requires a long-term commitment. Assessment of noise and light levels in the environment is the first step to providing a more person-centred and dementia-friendly environment. Making modifications to the environment can reduce disability and dependency and increase wellbeing. It can also help staff feel more positive about their work with the person with dementia. There are many small but significant interventions that nursing leaders and teams can make. There will be others that require management input and probably that of estates managers as well, especially in acute settings (Nolan 2007). Recognising that most noise in an environment is produced by staff is often the first step to modifying noise levels, although some areas of staff-generated noise are easier to address than others. Investing in a light and noise meter provides the opportunity to measure light and noise levels accurately and produce evidence for audit and evaluation. It is also important to examine the types of surfaces in the care setting in terms of noise absorption (Bakker 2003). If there are many windows, which are a hard surface that bounces noise instead of absorbing it, the use of plain coloured curtains helps absorb some noise. Acoustic panels to walls can also reduce noise levels. Ensuring that regular maintenance and replacement are carried out on equipment can help to reduce noise. In addition to regular maintenance of lighting, modifying other aspects of the visual environment can be enabling for the person and reduce sensory over or underload. These are low cost and high impact modifications. For example, by providing high contrast between doors and walls, between the plate and the table or place setting, the person may become more independent with mobility and meals. In the latter example, some research has shown that this change, along with increased light levels, can be effective in increasing independence and caloric intake (for example, Koss and Gilmore 1998, Brush et al 2002). Brush et al (2002) also found that significant improvements were observed in oral intake and functional abilities at mealtimes following an intervention to improve lighting and colour contrast. When there is an opportunity to redesign, there is emerging evidence about good principles of design in dementia care that need to be incorporated into service planning (Cantley and Wilson 2002). This report stresses that it is vital to address noise and light levels in the care setting. Nurses in leadership and management positions may need to help other people, such as those working in estates, to become more aware of the evidence base underpinning sensory management in the environment and in good design principles and Science Photo Library June 2009 Volume 21 Number 5 37

5 For author guidelines visit the Nursing Older People home page at www. nursingolderpeople.co.uk For related articles visit our online archive and search using the keywords This article has been subject to double-blind review Jan Dewing is an independent nurse consultant, visiting professor of aged care and practice development, University of Wollongong, NSW, Australia (in partnership with Uniting Care Ageing), honorary research fellow, University of Ulster and visiting fellow, University of Northumbria develop collaborative opportunities to make more major modifications to the care setting. However, day-to-day monitoring and ongoing management by all the nursing team can have a significant effect on people with dementia. Conclusion Modifying noise and light in the care environment is everyone s business and nurses are in a good position to co-ordinate this. After observing how noise and light affect sensory stimulation in the care environment, it is possible to find simple and effective interventions. Taking action will help the care setting to feel an easier, more comfortable place for the person with dementia to be in and for nurses to work in too. Enabling the person with dementia to stay below their stress threshold by modifying noise and light levels can mean the person will then be more able to collaborate with caregiving. This will have a reciprocal benefit for nurses. What next? Implications for practice Nurses are ideally placed to co-ordinate modifications to noise and light in different care environments for people with dementia. Action points n Learning more about the effect of sensory stimulation on people with dementia is important preparation for making environmental changes. n Audit the care environment for noise and lighting levels. Further reading Design Checks for People with Dementia in Healthcare Premises (free online access) A report on designing and managing care homes by Cantley C, Wilson R (2002) Put Yourself in My Place. Policy Press, Bristol. References Alzheimer s Australia (2004) Dementia Care and the Built Environment. Position Paper 3. (Last accessed: April ) Ancoli-Israel S, Kripke D, Jones D (1991) Light exposure and sleep in nursing home patients. Journal of Biological Rhythms. 3, 1, Bakker R (2003) Sensory loss, dementia, and environments. Generations: Journal of the American Society on Aging. 27, 1, Bliwise D (1994) Dementia. In Kryger M, Roth T, Dement W (Eds) Principles and Practice of Sleep Medicine. Second edition. Saunders, Philadelphia PA. Brush J, Meehan R, Calkins M (2002) Using the environment to improve intake for people with dementia. 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