Dementia Gateway: The environment

Case study: Finding your way

Margaret was having difficulty finding her way around a care home.

Background

Margaret, a 92-year-old woman, had recently moved into a medium-sized care home. From the start, staff reported that Margaret was getting lost and asking for help finding her way around the home. On a number of occasions staff had found Margaret arguing with another resident, Miss S, in Miss S's room.

Margaret became very distressed by these disputes, especially as Miss S accused her of stealing. On one occasion, Margaret became so upset that the GP was called and Margaret was given medication to 'calm her down', as it was described.

Margaret seemed to be getting lost in the morning. She appeared to be looking for someone or something. Usually, the staff became aware of a problem in Miss S's room while they were trying to serve breakfast in the dining room. Often, when Miss S went back to her room after breakfast, she found Margaret there.

The staff of the care home felt positive about the changes. Relatively simple and inexpensive alterations – such as the plant – made a big impact.

Read the full case study:

Understanding the situation - 1. Research and development findingsOpen
The most important thing is to establish what is happening and why. Understanding Margaret's behaviour was vital. The words 'wandering' and 'challenging behaviour' could be used in this situation, but they aren't very helpful labels: they don't tell us what the person is actually doing. In order to draw together information on what causes it and how we can address it, we need to describe the actual behaviour.

Kerr and Cunningham (2004) have argued that incidents such as these are better understood if staff keep a record of key things such as:
- What was happening before the incident, in this case, with Margaret and Miss S?
- What was the actual behaviour that happened, for example, what were people saying or doing?
- How did others respond to the incident, or what were the consequences of the incident?
The section 'Difficult situations' of the Dementia Gateway provides a lot of useful guidance on this area.

As we came to understand Margaret's needs better we were able to consider how to improve the environment to help Margaret find her way around the home. We referred to guidance such as the Cantley and Wilson (2002) report. A number of design guides are now available to assist care homes to improve their care environments including the 2008 publication, Best practice in design for people with dementia, and the Alzheimer's Society's guide to the dementia care environment (2006). Go to the 'Additional resources' box within this case study, or look at the 'Useful dementia resources' section within the Dementia Gateway.
Understanding the situation - 2. Views collected from key peopleOpen

We consulted a number of people. Margaret was the key person – we listened to her first and foremost. Margaret told us that she did not understand where she was and what was going on. When we spent time listening to Margaret, she became calmer and more settled. In her own way, Margaret was able to say what was going on and what she was trying to do.

The care staff team also shared important information as we tried to build up a picture of what was going on. A member of the cleaning team described what was going on when the care staff were busy serving breakfast. Miss S was upset that Margaret was going into her bedroom and searching through her belongings. It was important to listen to Miss S's concerns and to try to find solutions.

We also spoke with Margaret's daughter, in particular about placing a memory box outside Margaret's door as a way of helping Margaret to be able to locate her room.
ActionsOpen
We hoped to:
- provide better signage and prompts or triggers to help Margaret find her way within the home
- remove the need for use of medication to 'calm' Margaret
- improve relationships between Margaret and Miss S.
Margaret's key worker updated Margaret's care plan each month and in particular reviewed progress on these three goals.

First, staff agreed with Margaret that they would come to get her for breakfast every morning before she made the mistake of going into the wrong room. They agreed a time with Margaret. The home management decided to repaint the doors in the corridors so that they were a different colour from the walls, and the doors for toilets were all painted the same colour to make it easier to find them. They changed the signs on the doors to show a picture – as well as the word – for the room or place behind the door. The signs were hung at a height that made reading easy. Often signs are set at a height suitable for staff and visitors and not for residents, who tend to be shorter. Well researched design guidance from the Stirling Dementia Services Development Centre (2008) says the base of the sign should be 4ft from the ground.

We placed a memory box outside Margaret's room. It contained items that Margaret had chosen to put in it and that would help her to identify her room. It was important to choose things that really meant something to Margaret. For example, Margaret did not recognise recent photos of herself, so she and her daughter chose a photo of when she was in her 40s standing at the front door of her house.

We also supported Margaret to choose an item that she could use to help orient her to her bedroom – this can be very helpful for some people with dementia. Margaret chose a distinctive bright plant with red leaves and we placed this on a shelf near her bedroom door. The staff of the care home felt positive about the changes. Relatively simple and inexpensive alterations – such as the plant – made a big impact. Margaret clearly valued the plant: she was drawn to it and talked positively about it often. Staff could contribute to and implement the changes with more of their own ideas, and this was also very important.

Margaret said she was very pleased that someone was coming now to help her find her way to the dining room. She also appreciated the time staff took to explain the different signs to assist in her orientation.
ResultsOpen

Margaret began to find her way about the home more easily. In particular, she didn't make the mistake of going into Miss S's room. The thing that seemed most helpful to Margaret was the new signage, in particular the sign near Miss S's room and the sign for the dining room. Margaret would walk up close to the sign on Miss S's bedroom door and read it. Realising that it was someone else's room she was drawn to a sign nearby that indicated the direction to the dining room.

Over time, Margaret also found her bedroom without the need for assistance. Even though Margaret's eyesight was not good, she was able to see the red plant near her room. Margaret also told everyone about the photo of her outside her room and the story behind it. Staff also found that they were able to reinforce the purpose of the photo as a tool to help Margaret find her way – they didn't plan to, but it came naturally as part of a positive interaction with Margaret.

We asked Margaret what she would like in her memory box. She put objects about her life in it, including a photo of herself. She also chose the plant to go near her room. Margaret also had time to talk about why she was getting lost and staff therefore understood her needs better. Margaret's daughter helped with the process of making the memory box.
Advice for othersOpen

Careful design of places used by people with dementia can help them to negotiate the environment more easily. A critical question is: what does the project manager or architect know about dementia-friendly design? If poor decisions are made about the environment, staff time will be taken up responding to the problems caused by the environment for people with dementia. Good design can be planned into routine refurbishment of a space. In addition, the cost of making retrospective changes is costly and often unnecessary.

Design for people with dementia is core to good care. Simple changes can make a big difference to the person with dementia and to the staff caring for them.

Often these changes don't cost a lot. The plant used to help Margaret find her way was not expensive. Re-painting of the doors of the care home was already planned and changing the colours to aid contrast only added to the costs slightly. The quality of interaction with Margaret was increasingly positive and in fact took less time. Margaret did not need assistance to find her room as much and staff didn't need to spend lots of time responding to the distress of Miss S and Margaret.
Financial implicationsOpen

Care homes can be improved gradually over time, and this means costs are spread out too – everything doesn't have to be done at once. Also, improvements can be made when things need replacing anyway, through wear and tear. It is important to make informed decisions when these spending opportunities come along, as otherwise costs may increase. For example, if Margaret cannot find the door to the toilet because it is not clear, then she is more likely to have an incontinence episode which is, in effect, caused by the environment. This has costs in terms of staff interventions to assist Margaret in getting changed, laundry costs and floor cleaning costs, as well as the unnecessary negative impact on Margaret.