Introduction
The Irish National Dementia Strategy states that up to 29% of all patients entering a general hospital may have dementia and that the costs associated with dementia care in acute hospitals is approximately €21 million per year. In discussing the care of people with dementia in hospitals, Cahill et al concur with the literature and argue that this can be a frightening and distressing experience. The hospital setting can prove challenging for many people due to the change of environment, stress and possible sleep deprivation . This may lead to poorer health outcomes, particularly for a person with dementia. When a person with dementia becomes hospitalised without the dementia having been diagnosed, the situation can be worse and may lead to additional problems such as injuries, malnutrition, over or under medication, or similar. Moyle et al argue that many hospitals are not designed to care for people with dementia, and this not only undermines their care, but also adds to the burden of care for the staff. According to these authors, negative factors in the typical hospital can include; communication difficulties due to the busy hospital setting; multiple and competing stimuli; and inability to deal with wandering. They also speak about the important supporting role played by family members and caregivers, a role which is often hard to maintain within the hospital setting. In light of these findings, the results of The Irish National Audit of Dementia Care in Acute Hospitals 2014 are very significant. This audit has found that 94% of hospitals have no dementia care pathway in place, and that people with dementia will often experience poor health outcomes; remain longer in hospital; and are at greater risk of mortality once admitted to hospital. To help alleviate the many issues faced by a person with dementia in the hospital setting, a number of environmental interventions have been suggested over the years; most of these are drawn from the long term residential care settings (i.e. Marshall 1998) and focus on the creation of calm and home-like settings, wayfinding, the use of multiple cues for orientation, other such design features. Other proposed interventions are hospital specific and include: consistent bed location; patient orientation; good levels of light during waking hours; memory cues such as clocks, calendars and family photos, frequent family visits; the provision of opportunities for activity and mobility; and assistance with activities of daily living to maintain independence. More recently the King’s Fund EHE Programme has focused on dementia friendly hospital design and has developed a set of overarching design principles with the aim of improving patient and staff outcomes including: Easing decision-making; Reducing agitation and distress; Encouraging independence and social interaction; Promoting safety; and Enabling activities of daily living. To achieve these outcomes the programme promotes the following design principles; legibility (the ability to understand spaces); orientation; wayfinding; familiarity; and meaningful activity.
Proposed Cochrane Review
The aim of this review is to evaluate the impact of hospital planning and design approaches and interventions to improve conditions for people with dementia and assist family members or carers in their supporting role. To investigate the impact of various design principles and measures, studies will be reviewed that examine the effectiveness of a range of design interventions. Given the complexity of the hospital environment and the need to ensure that all key locations, and building components are considered, the following framework will be used to structure the review of the various studies: Site Location, Approach, entry Onsite Circulation – planning and design interventions to improve accessibility, usability, and orientation for people with dementia and also provide greater support for carers (i.e. appropriate exterior circulation routes, external wayfinding, respite or resting areas etc.)
Building Entry and Internal Circulation – interventions to improve ease of access, interior wayfinding and orientation, respite or rest areas, increased legibility through visual access, etc.
Key Internal and External Spaces – planning and design interventions that position spaces in appropriate locations, create calm and legible spaces that support easy orientation etc. Building Components – fittings, finishes, signage, technology, artwork etc.
Internal Environment – thermal comfort, acoustic, and lighting interventions that address the cognitive and physiological needs of people with dementia. In line with Drahota et al [6] these interventions will include: 1) ‘positive distracters’ that provide sensory stimulation (not as part of a therapy); 2) interventions that reduce environmental stressors; and 3) multi-faceted interventions that blend various interventions.
Outcomes to be examined
The primary outcomes to be examined will include a range of validated health related measured outcomes including: anxiety; quality of sleep, aggressive and challenging behaviours; length of stay etc. The secondary outcomes will include non-health related carer outcomes such as: satisfaction levels; anxiety; ability to continue supporting the person with dementia throughout the visit, etc.
Studies to be examined
Searches will be conducted using key databases such as MEDLINE, PUBMED, EMBASE, and Cochrane Reviews. Randomised Control Trials (RCTs) are often difficult to conduct in relation to studying the effectiveness of design interventions and therefore a wide range of studies will be reviewed including: RCTs, controlled trials and Interrupted Time Series (ITS), and Controlled Before and After studies (CBAs). To expand the review beyond the traditional clinical databases, design based and multi-disciplinary sources such as PLOS One and HERD (Health Environments Research & Design) Journal will also be examined.
