Dementia Gateway: The environment

Case study: Learning disability, dementia and creating a supportive environment at mealtimes

Adapting the physical and social environment to support positive eating and drinking.

Background

James is a 52-year-old man with Down's syndrome. He lives in a share house with another man with a learning disability whose name is Michael. James was diagnosed with dementia one year ago although staff feel that he was showing symptoms for a year before this. Recently James has become increasingly distressed at mealtimes, refusing to eat and throwing food.

Staff are concerned at how much weight he has lost. In this case study, the staff team make a number of changes to improve James's eating experience, some of which involve altering the care environment.

Promoting a consistent approach in the care and support of people with dementia is essential.

Read the full case study:

Understanding the situation - 1. Research and development findingsOpen

What we know from research in this area is that, while a person with dementia may lose interest in eating or drinking, this is not inevitable (see the section on 'Eating well', and Crawley 2002). Issues such as how staff communicate about food, the availability of food and drink (for example, having snacks and drinks available outside mealtimes) and the atmosphere and design of the room will all contribute towards a positive experience.
Understanding the situation - 2. Views collected from key peopleOpen

Staff initially discussed the situation among themselves: through doing this, they realised that they were assuming that James's loss of appetite and distress at mealtimes was due to him having dementia. They also realised that they were not being consistent in their approach at mealtimes. For example, some staff approached James from behind, and this startled and frustrated him.

The team decided to approach the local community-based learning disability team for input from their speech and language therapist. Out of this, the staff team developed a consistent approach to mealtimes. This included the suggestion from the speech and language therapist that if James had eaten food from only one side of the plate, to turn the plate clockwise half a turn to bring the remaining food into his field of vision.

Staff supporting James also discussed the way in which they spoke to him. His verbal capacity and word finding skills were decreasing, yet staff hadn't realised the importance of changing their approach. After reflection, they agreed to do this by altering their body language, looking for non-verbal cues and reducing the amount of information they gave or requested.

James's flatmate Michael was finding mealtimes more and more upsetting and frustrating, not least because he usually helped prepare the meals that James was throwing on the floor.
ActionsOpen

The care team set in train a number of actions. First, the team agreed that they should adopt a consistent approach to mealtimes with James. For example, they made sure to try to include James as far as possible in food preparation. They only displayed one course at a time to avoid confusion. They started speaking in short sentences without complex instructions.

They also tried to be check possible physical causes: checking if James was showing signs of being in pain, and checking his eyesight and glasses prescription.

The team tried to ensure that all staff were aware that mealtimes needed to be planned and thought about carefully. Staff agreed to open the curtains fully to achieve better lighting in the room. They also made plans to create a separate dining area using screens, so that meals were not taken in the same area used for watching television and socialising. The television, which was usually on during mealtimes, was turned off, and instead music that James found calming (and was not unpleasant for Michael) was played for around 30 minutes during a mealtime to offer a more relaxed atmosphere.

Staff made sure that finger food was available during the day and night. The team hoped that James would be more inclined to eat if he was prompted by the sight of food.
ResultsOpen

James started eating more, although not always at typical or regular mealtimes. The finger food really helped with this. His weight loss continued for a while, although at a much slower rate.

Taken all together, the changes left James feeling much more relaxed and able to interact positively at mealtimes with staff and with Michael. He was also not under pressure to eat at mealtimes due to the availability of finger food.

Staff talked to James about the changes that they were implementing. In the process of spending more time talking to him about his preferences in food and in music the level of interaction increased with James using both verbal and non-verbal methods.

Michael was asked if he was in favour of changing the environment at mealtimes. He actively supported this by helping with the changes and by making sure that food was available that he knew James liked. Michael assisted staff by removing finger food if he noticed it had been available for a while or replacing it when he thought James may need a change.

Staff were surprised at the effect of the music on James. They started to introduce this at other times of day when James appeared distressed. This proves effective when the right type of music is played and if it is not played indefinitely (Holmes et al, 2006).
Advice for othersOpen

In this case, it was important that all of the changes were understood by the whole staff team – if the changes were going to last. A staff member who didn't appreciate the value of the right music or the importance of contrast in colour in table preparation may have unintentionally caused further distress. Promoting a consistent approach in the care and support of people with dementia is essential.
Financial implicationsOpen

In this situation, the costs of changing the environment were negligible. The greater expense was the staff training. Investment in staff training to provide the best possible support for people who have a learning disability and dementia cannot be underestimated.