Dementia Gateway: The environment

Noise levels

'Having a good acoustic environment can support inclusion and reduce confusion in people with dementia.'

McManus and McClenaghan (2010)

Explore the links below now to read a range of practical suggestions:

• 1. The impact of noise on people with dementiaOpen

  The impact that noise has on people with dementia is rarely considered by care staff or managers on a day-to-day basis. And yet, noise that is acceptable to care staff may be particularly distressing and disorientating for a person with dementia, especially at busy times of day such as shift change-over and mealtimes.

  The training DVD Supporting Derek (Watchman et al 2010) shows the detrimental effect that low-level noise has on a resident with dementia called Derek. This DVD shows that background noise that staff find acceptable is actually overwhelming for Derek, and this leads him to become increasingly and unnecessarily agitated and confused.

• 2. Explaining the link between dementia and distress caused by noiseOpen

  Of all the senses, hearing is the one that has the most significant impact on people with dementia in terms of quality of life. This is because dementia can worsen the effects of sensory changes by altering how the person perceives external stimuli, such as noise and light. As hearing is linked to balance this also leads to a greater risk of falls either through loss of balance or through an increase in disorientation as a result of people trying to orientate themselves in an environment that is overstimulating and noisy.

  We know that often people with dementia respond on a sensory level rather than intellectually, for example they will note the body language or tone of voice of staff rather than what they actually say (van Hoof et al, 2010). This sensitivity can change over time and even during the course of a day. This is because people with dementia have a reduced ability to understand their sensory environment. When this is combined with age-related deterioration in hearing, the reality is that people react to their environment rather than being supported or enabled by it.

  If other senses are overloaded at the same time as hearing (such as sight, touch, smell and taste) the effect can be a dramatic change in the behaviour of a person with dementia. For this reason, care staff often identify mealtimes as being especially problematic. Research highlights the importance of appropriate background noise for maximum enjoyment at mealtimes, even for people who do not have dementia (Woods, 2010).

  Cohen and Mansfield (1995) identified that nursing home residents were more likely to pick at objects if subjected to continual noise, thus increasing agitation. Other research suggests that 'wandering' behaviour may be a way for the person with dementia to try to remove themselves from an overstimulating situation (Price, 2007) (for more on this, see the feature on 'Walking' in the section, 'Difficult situations').

• 3. Noise problems in bathroomsOpen

  Specific rooms can have specific problems: acoustics in the bathroom can be particularly difficult. Flowing water, and the flush of the toilet, for example, can create a confusing or sudden noise (for more on this, see the feature on 'Toilets and bathrooms' in this section). Yet singing in the bathroom can be lovely and may even help with reducing agitation if it is a song or tune that is recognisable and enjoyed by the person with dementia.

• 4. Noise problems in dining areasOpen

  Within the dining area the noise from a television or radio that often is not listened to or watched, staff talking to each other, the clatter of dishes and cutlery all contribute to a sense of disorientation. Removing unnecessary noise can reduce the risk of behaviours such as aggression and frustration in response to an environment that is too noisy or inappropriately noisy, such as music played continually that is not enjoyed or recognised by the person (for more on this, see the feature on 'Kitchens and dining areas' in this section).

• 5. Noise problems in open spacesOpen

  Be aware of open spaces: some sounds appear louder in open spaces, for example noises from crockery in a kitchen and dining area, the wheels of a tea trolley or the sound of conversations or laughing. Shift changeover can be especially noisy in a care home, just as the start and end of the day can be in day facilities – and this is often noticed most in common open spaces.

• 6. Noise problems at nightOpen

  Noise at night can result in disturbed sleep which in turn can lead to problems during the day, such as lack of concentration, and difficulty communicating and performing during the day.

  Staff working at night need to be aware of the importance of noise reduction, and be alert to whether noise from equipment such as a tumble drier or a security light can be heard at night. Some noises – for example, a washing machine – may be absorbed into the normal sounds of daytime but seem much louder during the quiet of the night.

• 7. Physical changes to help reduce noise levelsOpen

  Marshall (2001) has long been an advocate of designing buildings in a way that supports people who have dementia, enabling them to remain independent for as long as possible. Not only does this enhance self-esteem, it reinforces the person's identity and quality of life. Appropriate stimulation is still required but not so that it overwhelms the senses. Appropriate stimulation means something that is familiar enough to be understandable, but does not create boredom.

  As care providers, offering appropriate levels of stimulation for people with dementia will almost certainly mean trying to reduce noise levels. This applies both to the interior of a building and externally, in both working and social spaces. We need to consider noise within all care settings where people with dementia live and socialise, whether this is a formal care environment or a person's own home.

  Three main areas to examine when thinking about noise reduction and acoustics in a building are:

  (1) Absorption: This is the extent to which sound is absorbed. (2) Transmission: This is how sound is carried between one area and another, such as between rooms. (3) Insulation: This is the extent to which walls, floors and ceilings can stop noise being transmitted. How effective a surface is at deflecting noise will depend on how heavy the surface is – the heavier the construction the harder it is for vibration and the better insulation.

  (McManus and McClenaghan, 2010)

  McManus and McClenaghan (2010) recommend the following strategies:

  • reduce use of materials with high sound such as brickwork, concrete and plasterboard
  • make sure there are no air passages or gaps around doors
  • make sure that mortar joints are filled between walls and ceilings during construction
  • use floating floors to reduce impact noise from footsteps, trolleys or doors closing
  • use sound absorbing curtains plus wall and floor coverings to limit the amount of reverberation.

• 8. Practical changes to help reduce noise levels Open

  As well as making changes to the physical environment, we also need to recognise how our care approach will influence noise levels. Below are some suggestions of things we can do to reduce noise levels.

  …in a care home and day facility

  • Limit the use of background music. Find out what music or songs individuals prefer and arrange for this to be played at an appropriate level for short periods of time. If the chosen music can be heard by more than one person with dementia, find out if everyone else wants to listen too. Other people may become anxious or agitated if they do not like the music.
  • Turn off the television in the living or day room unless someone is specifically watching a programme, in which case turn it off when it ends. The television and radio should not be turned on just for staff to watch or listen to.
  • Be aware of noise from specific devices, such as staff pagers, alarms, doorbells or telephones. Try to minimise these types of noises , which can be intrusive, especially when combined with other background noise and at night times.
  • Although people with dementia can be encouraged to help set the table for mealtimes this should not involve a lot of people or a lot of cutlery and crockery being moved around at one time due to the potential noise it will create.
  • Don't talk across someone and don't communicate with other staff in a language that is not understood by the person with dementia.

  …in a person's own home

  • Turn off the television or radio before you start to speak to the person with dementia (explaining to them and their family the importance of this).
  • Speak clearly and slowly and expect to repeat what you say.
  • Be aware of any noises in the home that may be misinterpreted by the person with dementia and may result in hallucinations being wrongly suspected. This may include noise from a neighbouring property, a clock ticking loudly, the central heating system, water pipes when the toilet is flushed or similar sounds that the person no longer recognises and may be frightened by.
  • Make sure hearing aids (and glasses) are clean and working.
  • Talk to family members about all of the above points as they may find them helpful too.

  …in a hospital

  • Good communication with the person who has dementia is essential to relieve anxiety – remember to use short sentences, repeat what you are doing and why, and don't talk over the person.
  • Do not leave a person with dementia alone in a cubicle with closed curtains – if the person cannot see where or who noise is coming from, this will be confusing for them.
  • Consider how noisy the ward is and how this can be reduced during both day and night. Although some noise may be unavoidable, minimising this can reduce agitation and encourage better sleep. Be aware of the possibility of delirium due to hearing deficits or lack of sleep.
  • Make sure hearing aids (and glasses) are clean and working.
  • Remove any distractions, for example, turn off the television and reduce or stop conversation, especially at mealtimes.
  • Try to minimise the amount of time a person with dementia has to spend in an Accident and Emergency department as these are particularly busy and noisy places. Find out if the person could move to a quieter area accompanied by staff or family to reduce anxiety.

• 9. Managing noise positivelyOpen

  A limited amount of noise can be a good thing. One study noted positive interventions when 30 minutes of appropriate music was played – and 'appropriate' meant that it was the musical choice of the individual with dementia and played for a limited time at a volume that could be heard but was not overly loud or overstimulating (Holmes et al, 2006). Calming and quiet music or singing may be helpful too, for example, on a one-to-one basis if a person with dementia is awake during the night.

  Appropriate sound levels can improve communication as the person can focus on one interaction or task. While having no background noise at all may feel strange to some people – for example, an activities worker may feel more comfortable running an arts group with music playing in the background –silence or the simple low level noise of conversation may actually help a person with dementia to concentrate on the task before them.

  Often the benefits of silence for people with dementia are underestimated. A person with dementia may respond some time after being spoken to if they are given enough time to process the information. We need to remember that a person with dementia may need silence to process information.

Over to you!

Click here to do a quick activity that will deepen your understanding of this topic. The activity can be done alone or with colleagues and you can also download a copy. Trainer's notes have also been provided.

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