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Living well with the dementia app. Back to the future?



Various inventions were predicted for 2015 in the film “Back to the Future”.

Of course, an invention is not the same as an innovation.

There is a subtle difference between these two words, but the difference is an important one.

An invention is the formulation of new ideas for products or processes, but an innovation is all about the practical application of new inventions into marketable products or services.

According to top HSJ pioneer, Dr Amir Hannan, innovation has a specific definition.

About doing or making something completely new that has never been done before, which leads to a material change in thinking, behaviour or outcomes.

One of the brilliant inventions/innovations was the “hover board”.

hoverboard

Probably a good thing these haven’t been invented for the mass market yet – though some clever bod has come up with a prototype – the baggy jeans and Converse look is just so Nineties.

 

 

The background to the modifiable factors relating to dementia are well rehearsed.

Approximately half of dementia cases might be attributable to known modifiable protective and risk factors (Smith and Yaffe 2014). The protective factors include the factors that determine brain development in early life such as maternal nutrition and health, and nutrition and cognitive development in early years. Education and lifelong learning also protect against dementia as does involvement in social networks. The risk of dementia is raised by substance abuse in adolescents and young people, head injuries and depression. Dementia also shares important risk factors with the major non-communicable diseases (NCDs) including cardiovascular disease, diabetes, cancers. These are the behavioural risk factors of physical inactivity, smoking, alcohol and poor diet, and the linked intermediate risk factors such as high blood pressure, raised cholesterol and obesity.

There has been some difficulty in getting this relatively simple public health message across.

This is illustrated, for example, by the rather resistant belief amongst people that ‘nothing can be done about dementia’. In fact, an enormous amount can be done to promote living well with dementia. And some factors may indeed slow rate of progression or delay onset, in a way we don’t properly understand yet.

Some campaigning initiatives have started to gain momentum, though. This infographic is from the Alzheimer’s Disease International “World Alzheimer Month”.

reduce the risk

And there are developments afoot in the provision of information for patients.

Here’s an example of what Highbury Grange Medical Practice seem to be offering.

The aim is for all patients in England will have access to their GP medical records online by 31st March 2015.  This means you can have secure access to relevant parts (current medications, immunisations and allergies)of your record from devices that can access the internet.

And now Sir Bruce Keogh has got really into ‘wearable technology':

It sounds reasonably convincing.

Prof Sir Bruce Keogh believes that gadgets similar to fitness trackers, which are growing in popularity, and others resembling games consoles will revolutionise the monitoring of patients’ health, especially those with a serious condition.

And…

“Technology is emerging which enables those to be brought together and transmitted through mobile phones or other methods where health professionals can analyse them and act upon any warning signs,” Keogh says.

Wearable technology could easily prove useful for people with heart failure – one of the most common causes of admission to hospital – and thus relieve the strain on overcrowded hospitals.

“I see a time where someone who’s got heart failure because they’ve had a previous heart attack is sitting at home and wearing some unobtrusive sensors, and his phone goes, and it’s a health professional saying: ‘Mr Smith, we’ve been monitoring you and we think you’re starting to go back into heart failure. Someone’s going to be with you in half an hour to give you some diuretics’,” says Keogh.

Technology “enables you to predict things, to act early and to prevent unnecessary admissions, thereby not only taking a load off the NHS but, more importantly, actually keeping somebody safe and feeling good”.

For people living well with dementia, simple apps could be made which could be installed on smartphones.

smartphone apps

For certain persons living with dementia, prone to “wandering” (a term I very strongly dislike), GPS location devices might be of interest; but by no stretch of imagination are these devices relevant to all people living with dementia.

The app might also be able to monitor aspects of cardiovascular health. There is a strong link between cardiovascular health and cerebrovascular health, and indeed the success of tackling cardiovascular risk factors in primary care has caused some interest in the possible falling in England of the prevalence of dementia.

I have often ‘complained’ to other specialists in dementia how little we know about how easily people living with dementia, across different types of dementia, at different extents of ‘severity’, cope with all technology designed to help them live with dementia.

But it is possible that such apps could be designed to be compliant with the Equality Act (2010), offering giant lettering for those people with visual object perception problems, or ‘read aloud’.

There could be a set of questions like ‘Do you have trouble remembering dates?’, ‘Do you have problems remembering phone numbers”, “Do you have problems cooking?”, which could trigger further intervention by a community occupational therapist.

If someone living with dementia notices their legs going stiff, or they have trouble walking, a referral to a community physiotherapist could be triggered.

If someone living with dementia notices the development of a ‘sweet tooth’, a referral to a community dietitian could be triggered.

And so on.

There might be ‘menus’ which are more suitable to caregivers, who are often spouses, or children (particularly daughter and daughter in laws), but including paid carers. There are clearly ethical issues here.

I anticipate such apps will be of interest to people who’ve just been given a diagnosis of dementia, but the usual criticisms will hold (i.e. it’s another ‘to sell’ to someone with a personal budget, it’s “typical privatisation of health and care). But I feel we should be looking into the social prescribing of facility to those who desire them, as an alternative to expensive drugs which can have limited efficacy.

Back to the future..

or back to planet Earth.

 

 

 

 

 

 

Further reading

Smith D. and Yaffe K. (2014) Letter: Dementia (Including Alzheimer’s Disease) can be Prevented: Statement Supported by International Experts. Journal of Alzheimer’s Disease 38: 699–703 DOI 10.3233/JAD-132372

 

 

 

 

Background to the world of assistive technology



AT1

It is widely propagated in the media that the two major drivers for ‘increased costs of caring’ for the National Health Service (NHS) comprise the ageing population, as well as the increasing rôle that technological advances will play. Both factors are of course subject to ferocious debate regarding the economic sustainability for the NHS, but certainly one potent myth is that assistive technologies are always expensive. This is not true, and the field of assistive technologies is ever expanding.

David Gems (2011) argues that gerotechnology is at the heart of living well in the context of aeing:

[Another] goal of research on ageing is to improve the health of older people. Here, biogerontology is akin to other biomedical research topics, sharing with them the goal of understanding the biological mechanisms that underlie pathology. The particular value of such understanding is that it enables the development of therapeutic treatments, leading to improved health and wellbeing.
A formidable challenge still remains in the relative lack of evidence for pursuing good design principles as well as assistive technologies in improving living well with dementia. For example, the National Dementia Strategy (2009) provides the following.

The evidence base on design principles is sparse, but there is consensus on key principles and a number of good practice checklists are available. There is a more substantial evidence base to show the opportunities offered by assistive technology and telecare to enable people with dementia to remain independent for longer, and in particular to help the management of risk. But the data on newer approaches are still sparse and inconclusive. An evaluation of one scheme demonstrated cost effectiveness and reports of improved quality of life. Large-scale [Department of Health] field trials of such technology are currently under way.

Dementia conditions have the potential to make day-to-day life more difficult. It is clearly very difficult to ‘know’ what an individual feels in terms of his or her wellbeing, even if he or she is unaffected by dementia, even though a conceptual framework of general consciousness is now under way (see, for example, Crick and Koch, 2003). Indeed, as Greenfield (2002) explains, the relationship between the words ‘consciousness’ and ‘mind’ merit attention.

Emotions play a critical role in the evolution of consciousness and the operations of all mental processes (Izard, 2009). Little things like mislaying keys, forgetting to turn off the taps or leaving the gas unlit can prove frustrating or even create hazards.

Orpwood (2007) has argued that mechanisms underlying consciousness and qualia are likely to arise from the information processing that takes place within the detailed micro-structure of the cerebral cortex. It looks at two key issues: how any information processing system can recognise its own activity; and secondly, how this behavior could lead to the subjective experience of qualia. In particular, it explores the pattern processing capabilities of attractor networks, and the way that they can attribute meaning to their input patterns and goes on to show how these capabilities can lead to self-recognition. That paper suggests that although feedforward processing of information can be effective without attractor behaviour, when such behaviour is initiated, it would lead to self-recognition in those networks involved. It also argues that attentional mechanisms are likely to play a key role in enabling attractor behaviour to take place.

There has become a growing feeling that ‘assistive technologies’ (AT) may provide more support for the carer than for the individual with dementia (Kinney et al., 2004), or to ease service provision. However, there have been some noteable exceptions to this focus on security and safety, such as the work of Topo and colleagues (Topo et al., 2004) on the enjoyment of music, and Alm and colleagues (Alm et al., 2005) on general reminiscence.

However, the influence of engineering on the quality of life research has come to a fore in most recent years (for example Orpwood et al., 2007). The INDEPENDENT study has been specifically aimed at designing technology to support quality of life. This collaborative project involved academic engineers, social scientists and architects, together with representatives of user groups and a manufacturer. The design work was based on a comprehensive user survey in which people with dementia themselves highlighted the factors which affected their quality of life. These data were analysed through a series of multidisciplinary workshops through the whole consortium.

There have been, nonetheless, a number of concerns raised about the assistive technology. Roger Orpwood submitted the following comment to the consultation held by the Nuffield Council on Bioethics summarised in ‘Dementia: ethical issues’ between May 2008 and July 2008.

Care professionals often express concern about the use of assistive technology because they see it as something to replace human care. There is no doubt that there is a real danger that some purchasers may see it in this way, either to save money on the part of local authorities, or to reduce the need for direct support on the part of relatives. Those of us involved in developing such equipment see it more as augmenting human care rather than replacing it. However there are some things technology can do that is better than human support. It doesn’t get tired or frustrated, it can operate 24 hours a day, and it clearly doesn’t get upset by the behaviour of the person with dementia. There is evidence from our own work that technology can provide a much clearer picture of how the user is getting on than can care staff. Our last client in London had a major sleep problem that no-one had picked up, but as soon as our sensor network was turned on the problem shouted at us. So technology has an important role to play, and can do some things better than human carers, but it cannot be a replacement for human care, and all the expression of feeling, empathy and understanding that humans can provide. There are major ethical concerns if it is viewed as a replacement.

Suggested readings

Crick F, Koch C. (2003) A framework for consciousness, Nat Neurosci, 6(2), pp. 119-26. [Review.]

Department of Health (2009). Living well with dementia: A NationalDementia Strategy: Putting people first, London: Her Majesty’s Stationery Office, available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168221/dh_094052.pdf

Gems, D. (2011) Tragedy and delight: the ethics of decelerated ageing, Philos Trans R Soc Lond B Biol Sci, 366(1561), pp. 108-12.

Greenfield, S. (2002) Mind, brain and consciousness, British Journal of Psychiatry, 181, pp. 91-93.

Izard, C. (2009) Emotion theory and research: highlights, unanswered questions and emerging issues, Annu Rev Psychol, 60, pp. 1-25.

McKinney, K.M., Kart, C.S., Murdoch, L.D., and Conley, C.J. (2004) Striving to provide safety assistance to families of elders: the SAFE house project, Dementia, 3, pp. 351-370.

Nuffield Council of Bioethics. (2009) Dementia: ethical issues, available at: http://www.nuffieldbioethics.org/sites/default/files/Nuffield%20Dementia%20report%20Oct%2009.pdf.

Orpwood, R. (2007) Short communication: neurobiological mechanisms underlying qualia, Journal of Integrative Neuroscience, 6(4), pp. 523–540.

Topo, R., Maki, K., Saarikalle, K., Clarke, N., Begley, E., Carhill, S., Arsenlind, J., Holthe, T., Morbey, H., Hayes, K., and Gillard, J. (2004) Assessment of music-based multimedia program for people with dementia, Dementia, 3, pp. 331-350.

Preface to my book: “Living well with dementia: where the person meets the environment”



Volumetric MRI dementia

Volumetric MRI dementia

 Introduction

According to the Department of Health’s “Improving care for people with dementia” (2013), there are around 800,000 people with dementia in the UK, and the disease costs the economy £23 billion a year. By 2040, the number of people affected is expected to double – and the costs are likely to treble. There is no doubt therefore about the scale of the problem, and it needs the finest minds in showing leadership on how to enable individuals with dementia to live better, and indeed live well.  The Prime Minister’s Challenge on dementia (“Challenge”) (2012) set out a renewed ambition to go further and faster, building on progress made through the National Dementia Strategy, so that people with dementia, their carers and families get the services and support they need. This Challenge wished to address in particular certain issues, such as the observation that the number of people with dementia is increasing, that currently the diagnosis rates are thought to be low, and there is sadly a lack of awareness and skills needed to support people with dementia and their carers. Whilst it is possibly difficult to find a ‘miracle cure’ for dementia, it is a reasonable aspiration for individuals with dementia (and their immediates) to have as best a quality-of-life as possible, and it is not necessarily the case that subtle but significant improvements in quality-of-life will “cost the earth”.

It is intended that this book should not just of interest in the UK, as the problems in healthcare are relevant to all jurisdictions. Thinking about how society should respond does pose some jurisdiction-specific issues; for example, this book refers to legislation in the UK such as the Equality Act (2010) or the Mental Capacity Act (2005), or regulations in health and safety relevant to building design in the UK. However, a consideration of the global issues in public health leads one quickly to appreciate the complexity of the economic case for improving wellbeing in individuals in dementia and their immediates, and that there are many people who are genuinely interested. Whilst indeed there has been a lead through the Prime Minister’s Dementia Challenge (2012), it is clear that previous administrations in England have latterly decided to prioritise dementia as a public health priority (for example, the National Dementia Strategy, “Living well with dementia” (2009)).

The ‘ecosystem’ of interested parties is large, and it is striking that there are so many passionate ‘#dementiachallengers’ on Twitter daily for example who are always a source of contemporary information, enthusiasm and innovation. There are currently huge advances being made in research and policy, and it is only possible through dementia communities ‘working together’ to keep abreast of them all. For that reason, this book has necessarily had to include electronic references, and I have tried to maintain links as correct as up-to-date at the time of publication. However, please feel free to look for any related information anywhere, and please do not use this book as an authoritative source of information to rely on necessarily. This book is intended simply as an introduction to a vibrant field, and certainly please be guided by healthcare professionals regarding individual care. The text of this book provides general principles, which I hope you might find interesting.

NICE quality standard 30 on ‘supporting people to live well with dementia’

In April 2013, NICE published its quality standard 30 on ‘supporting people to live well with dementia’. This quality standard was intended to cover the care and support of people with dementia. It applies to all social care settings and services working with and caring for people with dementia.

NICE quality standards are supposed to describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. NICE quality standards draw on existing guidance, which provide an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement.

The areas covered in this ‘quality standard’ includes:

Statement 1. People worried about possible dementia in themselves or someone they know can discuss their concerns, and the options of seeking a diagnosis, with someone with knowledge and expertise.

Statement 2. People with dementia, with the involvement of their carers, have choice and control in decisions affecting their care and support.

Statement 3. People with dementia participate, with the involvement of their carers, in a review of their needs and preferences when their circumstances change

Statement 4. People with dementia are enabled, with the involvement of their carers, to take part in leisure activities during their day based on individual interest and choice.

Statement 5. People with dementia are enabled, with the involvement of their carers, to maintain and develop relationships.

Statement 6. People with dementia are enabled, with the involvement of their carers, to access services that help maintain their physical and mental health and wellbeing.

Statement 7. People with dementia live in housing that meets their specific needs.

Statement 8. People with dementia have opportunities, with the involvement of their carers, to participate in and influence the design, planning, evaluation and delivery of services.

Statement 9. People with dementia are enabled, with the involvement of their carers, to access independent advocacy services.

Statement 10. People with dementia are enabled, with the involvement of their carers, to maintain and develop their involvement in and contribution to their community.

 Overview

The aim of this book was not to provide a prescriptive text for this quality standard. I hope the book will be useful for a ‘diverse audience’, in other words anyone interested in the diagnosis, investigation or management of dementia, with especial emphasis on improving wellbeing; such interested people might particularly include the general public, psychologists, innovation specialists,, psychiatrists, neurologists, geriatricians, general medical physicians, nurses, public health physicians, medical students, engineers, economists, psychologists, commissioners and hospital managers. It is therefore extremely hard to find all this information ‘in one place’, and it is hoped that this book will help to provide a much needed overview and to build bridges between different ‘silos’ of thinking.

The approach of the National Dementia Strategy: Living well with dementia (from the Department of Health) (2009) devotes the whole of its chapter 5 to the issue of living well with dementia. In the preceding chapter to this Strategy, chapter 4on ‘early diagnosis’, the approach described is obviously inclusive:

 “From our consultation, and based on a successful DH pilot and the DH cost- effectiveness case, it appears that new specialist services need to be commissioned to deliver good-quality early diagnosis and intervention. Such services would need to provide a simple single focus for referrals from primary care, and would work locally to stimulate understanding of dementia and referrals to the service. They would provide an inclusive service, working for people of all ages and from all ethnic backgrounds.”

A ‘timely diagnosis’ is only of benefit, it is felt if there is a ‘useful’ intervention in dementia: this is described in chapter 4 has having three essential components: making the diagnosis well, breaking the news of the diagnosis well to the individual with dementia and their immediates, and providing directly appropriate treatment, information, care and support for such individuals. This timely book is part of a drive to dispel the notion that ‘nothing can be done’ in the context of management of dementia, even if current pharmacological therapies might have limited efficacy. The book is an overview of the field, describing what ‘wellbeing’ actually means, and why it is important in the context of national policy. The book quickly establishes the importance of the ‘person’ in discussing dementia care, including independence, leisure and other activities, and, in the final stages, end-of-life care, which is a discussion which should not be avoided. No individual with dementia should be abandoned in relation to his or her environment, and indeed there is much evidence to support the idea that the environment can be optimised to improve the wellbeing of an individual with dementia and his/her immediates. Considerations include home and ward design, the use of assistive technologies and telecare, and the ‘built environment’. A constructive interaction of an individual with his or her environment is clearly vital, and this includes understanding communication issues, how to champion the rights of an individual living well with dementia through independent advocacy, and the way in which ‘dementia friendly communities’ can be supported.

Contents

  1. Introduction
  2. What is “living well with dementia”?
  3. Measuring living well with dementia
  4. Socio-economic arguments for promoting living well with dementia
  5. A public health perspective on living well in dementia, and the debate over screening
  6. The relevance of the person for living well with dementia
  7. Leisure activities and living well with dementia
  8. Maintaining wellbeing in end-of-life care for living well with dementia
  9. Living well with specific types of dementia: a cognitive neurology perspective
  10. General activities which encourage wellbeing.
  11. Decision-making and an introduction to advocacy in living well with dementia
  12. Communication and living well with dementia
  13. Home and ward design to promote living well with dementia
  14. Assistive technology and living well with dementia
  15. Ambient-assisted living well with dementia
  16. The importance of built environments for living well with dementia
  17. Dementia-friendly communities and living well with dementia
  18. Conclusion

Chapter synopses

It is possible to read each chapter in this book independently, and indeed each chapter is independently referenced.

Chapter 2 is an introduction to the whole book. Introduces the concept of what is like to ‘live well with dementia’. Investigating wellbeing has broadened the scope of previously overly narrow approaches to healthcare, in measuring outcomes. This chapter also introduces the idea that it is grossly unfair to consider ‘dementia’ as an unitary diagnosis, as in fact the term is a portmanteau of hundreds of different conditions at least. There has been a growing trend that ‘dementia’ and ‘memory problems’ are entirely synonymous, and this has added unnecessary noise to the debate. Dementia care is currently done in a number of different settings, and assisted living may be of increasing relevance in a drive to encourage individuals to live well independently with dementia.

Chapter 3 presents the formidable challenges of how ‘living well’ might be measured in general. There are issues about how quality of life measures change as a dementia progresses, what the relationship might be between wellbeing and physical health, and how wellbeing in dementia should be measured accurately at all.

Chapter 4 looks at the current socio-economic arguments for promoting a wellbeing approach in dementia. There are a number of converging cases for considering wellbeing, such as the economic case, the ethical case and a case based on social equality. While resources are limited, serious considerations have to be made as to which interventions are truly cost-effective, including of course the assistive technologies.

Chapter 5 presents the background for dementia as a public health issue in the UK. There is also a very active debate as to whether one should ‘screen’ for dementia. A core aim of the National Dementia Strategy (1999) is therefore to ensure that effective services for early diagnosis and intervention are available for all on a nationwide basis. It is argued, in this Strategy, that “the evidence available also points strongly to the value of early diagnosis and intervention to improve quality of life and to delay or prevent unnecessary admissions into care homes.”

Chapter 6 considers how and why being a ‘person’ has become so central to living well with dementia in academic and practitioner circles. In a way, the approach of ‘person-centred care’ is a historic one, but it has been a consistent strand of English health policy developing into contemporaneous views of integrated and whole-person care. This chapter also introduces ‘personhood’, and the approach of ‘dementia care approach’.

Chapter 7 addresses the specific rôle of leisure activities for an individual with dementia. Leisure activities are generally considered for many to be beneficial for the mental and physical wellbeing of individuals with dementia, and there are specific problems to be addressed such as the reported levels of relative inactivity in care homes.

Chapter 8 details how wellbeing is relevant also to end-of-life in dementia. This chapter considers the importance of support for carers, for the wellbeing of individuals with dementia and their carers. This chapter considers where optimal care could be given for individuals with dementia, the contribution of medication, but how it is vital to address specific issues in advanced dementia which have a direct impact on wellbeing (such as pain control).

Chapter 9 identifies that it is in fact it is impossible to consider dementia as a unitary diagnosis, and that specific forms of dementia can present their own formidable demands and issues. This chapter considers in detail how and why memory problems can be a presenting feature of dementia of the Alzheimer type, and the implications for interventions in wayfinding which could rationally improve wellbeing in such patients. The chapter also includes recent elegant work about the neural networks which are hypothesised to be important in behavioural variant frontotemporal dementia, and how this “social context network model” fundamentally affects our notion of wellbeing in such individuals.

Chapter 10 introduces ‘general activities which encourage wellbeing’, in a first chapter on the possibility of “assistive technologies” in enabling individuals with dementia to live well. Certain memories can be particularly potent in the dementia of the Alzheimer Type, and, whilst the ‘jury is possibly out’ on the validity of reminiscence therapy, the chapter discusses the possible benefits of the CIRCA project on the wellbeing of individuals with dementia. Other activities are also considered; how they may help wellbeing, such as dancing, exercise, and music.

Chapter 11 takes up an important theme in living well with dementia; that is empowering the invididual to make decisions, the law relating to capacity, and how independent advocacy services have a beneficial rôle to play. Independent dementia advocacy is a critical area of a statement in NICE QS30, and this chapter reviews types of advocacy (and its relevance to wellbeing and person-centred care), the current mental capacity legislation, and the crucial importance of diversity and equality in policy.

Chapter 12 explains why good communication is so crucial in the setting of individuals living well with, but not simply restricted to healthcare professionals. This not only appears to be in terms of providing information about the condition locally, but also face-to-face communication with people living well with dementia. This chapter looks in detail at both verbal and non-verbal methods of communication, with a view to raising awareness of their impact on living well with dementia.

Chapter 13 analyses the importance of home and ward design for improving wellbeing in dementia. ‘Therapeutic design’ is a central philosophy of good design, and this chapter has as its focus a number of different setting. General principles are described as how to wellbeing can be improved through careful design of certain parts of the house (such as balconies, bathrooms, bedrooms, living rooms and dining rooms), and considers the neuroscience of sensory considerations at play (for example in lighting and vision, and sound and hearing.)

Chapter 14 is the first of two chapters on ‘assistive technologies’ in dementia, providing an overview of this important area for living well with dementia. This chapter explains what ‘assistive technology’ is, what its potential limitations are, the INDEPENDENT project, the importance of “telehealth” (and important ethical considerations), and the design of ‘smart homes’.

Chapter 15 is the second of two chapters on ‘assistive technologies’ in dementia, looking specifically at an approach called ‘ambient-assisted living’ (AAL). The rationale behind the use of AAL in improving wellbeing is explained, as well as the general issue of how to encourage adoption of innovations in an older population. Detailed examples of specific AAL projects in improving wellbeing are described including SOPRANO, COACH and NOCTURNAL.

Chapter 16 introduces the general emphasis on the ‘built environment’ setting, and how inclusivity still drives this area of work in living well with dementia. Ageing presents its own challenges including opportunities and threats, but this chapter focuses on the remarkable initiatives which have recently taken place in improving the outside environment for individuals with dementia. The chapter details the I’DGO project, and highlights the especial importance of inclusive design for furthering wellbeing in dementia outside environments.

Chapter 17 considers how an individual with dementia lives as part of the rest of a community and society, and policy initiatives which have sought to address this. The discussion is unexpectedly problematic about a need to define what a ‘community’ might be, but the chapter includes domestic and international approaches to the ‘dementia-friendly community’, including the RSA’s “Connected Communities” and WHO’s “age-friendly communities” initiatives. As a central policy plank which is thought to be critical for developing wellbeing in individuals with dementia and their immediates, this chapter considers why dementia-friendly communities are worth encouraging at all, why there is a societal need to involve individuals with dementia in their communities, what aspects individuals with dementia wish from such communities (including the “Four Cornerstones” model), and the benefits of “resilient communities”.

Further information

You are advised to look at specialty websites which are devoted to all the dementias (such as medical charities), which often have useful information factsheets and booklets. Also, the Department of Health and their ‘Dementia Challenge’ website is an impressive source of information. You are also advised to consult https://www.evidence.nhs.uk which has access to a number of useful contemporaneous clinical evidence sources. Online medical journals are also an excellent source of peer-reviewed research, such as the BMJ, the Lancet, and the New England Journal of Medicine.

 Looking to the future

 There are, of course, no “right answers” to many issues, and a wise person is a person who knows where to find relevant information. However, the sense of optimism and goodwill is a genuine one in UK health policy, regarding dementia. Whilst there will often be difficult debates regarding dementia such as “How willing should a GP be to make a diagnosis of dementia when a patient has only gone to see his GP because of a sore throat?” or “Should we look to research a drug which can immunise people against dementia?”, the fact there are so many bright people in the UK working in areas relating to dementia is a real credit to English health policy as it faces formidable challenges of its own.

References

Department of Health (2009). Living well with dementia: A National Dementia Strategy: Putting people first. London: Her Majesty’s Stationery Office.  Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168221/dh_094052.pdf.

Department of Health (2013) The Dementia Challenge. London: Her Majesty’s Stationery Office.  Available at: http://dementiachallenge.dh.gov.uk

Department of Health (2013) Improving care for people with dementia. London: Her Majesty’s Stationery Office. Available at: https://www.gov.uk/government/policies/improving-care-for-people-with-dementia

Department of Health (2012) The Prime Minister’s “Dementia Challenge”: Delivering major improvements in dementia care and research by 2015. London: Her Majesty’s Stationery Office. Available at: https://www.gov.uk/government/policies/improving-care-for-people-with-dementia

National Institute for Clinical Excellence (2013). Supporting people to live well with dementia (QS30). Available at: http://guidance.nice.org.uk/QS30.

UK government.  Mental Capacity Act (2005) http://www.legislation.gov.uk/ukpga/2005/9/contents

Design in dementia : a blog viewpoint by Dr Shibley Rahman



This week, I attended a superb symposium on design principles in dementia care. Whilst I may have been in the land of the Trustefarians (those borne into trust funds), actually I was in a comfortable room in a community centre in Ladbroke Grove.

My doctoral thesis at Cambridge was in a minute area of neuroscience and academic neurology, relating to dementia. I would never have thought that 11 years later that I would end up interested in something seemingly rather different, the design of environments in dementia.

There are a number of reasons why I believe tackling the environment in dementia is important, but I think ultimately I believe in the best quality-of-life possible for patients with dementia. In a society driven by targets, it has become very untrendy to measure quality-of-life and happiness, yet it is clear to me that well-being and happiness can impact on physical health, in ways that are not yet fully understood. This may be due to discoveries which have not happened yet in neuroimmunology, but just because we may not understand the phenomenon, it doesn’t mean that the phenomenon does not exist. Anecdotes provide that transplanting an advanced patient with dementia to a totally unfamiliar surrounding can be very distressing and detrimental to their physical health; one might wonder why on earth you would do this, but unfortunately thousands of people make this journey everyday from their home to a nursing or care home everyday.

This course, run by senior people at the University of Stirling, such as Prof. Mary Marshall, did not get unreasonably bogged down in the scientific evidence. This put me much at ease, as well as making the designers, architects and artists comfortable that their creativity and common-sense were not jeopardised. We discussed everything from corridors to balconies, but the discussions were open-minded. We considered how patients with dementia perceived their outside environment. For example, I learnt that colour constancy was relatively intact in most stages of Alzheimer’s disease, despite there being many potential ‘lower-level’ visual problems. This phenomenon relates simply to how the human brain perceives the colour of something relative to the background colour. This colour constancy is well known to have been utilised to great effect in the art work of Pier Monde.

The course, and my discussions with several Professors and Readers in the UK, make me convinced that we can see a paradigm shift in the design of better environments for patients with dementia, including better use of assistive technology and planning of houses and built environments. It would be even better, if we could bridge this drive with the cognitive, behavioural and activities-of-daily-living challenges posed by patients in their day-to-day life, but I remain confident that this can happen one day.

Dr Shibley Rahman

QS, BA (1st), MA, MB, BChir, PhD, MRCP(UK), FRSA, LLB(Hons)

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