Dementia is a growing global health priority, with 7.7 million new cases identified each year. As research efforts begin to improve our understanding of this irreversible syndrome, there is growing consensus that patient wellbeing can be improved without the use of drugs. Interventions that focus on the use of therapeutic spaces are gaining momentum but what evidence exists to support their use?
A team at the University of Exeter Medical School, supported by the National Institute for Health Research Collaboration for Applied Health Research and Care South West Peninsula (NIHR PenCLAHRC), has been conducting research into the various aspects of dementia care. Here Rebecca Whear, a specialist in health services research, describes their recent work and how it sits in the context of the growing dementia care debate.
Associated with an ongoing decline of the brain and its abilities, symptoms of dementia include memory loss and a reduction in thinking speed, language use and understanding. In 2012 David Cameron pledged to increase funding for research into dementia health and care as part of the UK’s National Dementia Strategy and since then there has been a steady flow of research findings and recommendations.
The majority of people living with dementia in the UK are supported by their close families, friends or more formal carers in their own home. However, a third live in residential care homes and at this stage are likely to be displaying more severe and challenging symptoms of the disease. Almost half of the elderly people living in residential care have dementia or dementia symptoms, a figure which increases to more than three-quarters in nursing homes. Antipsychotic medications are commonly used to manage the behavioural and psychological symptoms of dementia, but some research has suggested a clear link between this treatment and increased risk of illness and death.
Consequently there is now important and increasing interest in exploring opportunities to help people to feel better without the use of (or by reducing) medication. Such opportunities might include changes in the environment and design of the residential care setting, engagement in other activities such as spending time in a garden, and improved training for care home staff. Such changes may be able to help calm and relax residents with dementia and may also benefit other residents and the staff around them.
In some of our most recent research we analysed how spending time in a garden can affect the wellbeing of people with dementia in care homes. We also examined the perspectives of families and carers about the use of a garden as part of the care setting in order to identify information that would help in the design and use of care home gardens in the future.
Our systematic review, which analyses all available evidence on this particular question, critically assesses 17 small studies from the US, UK, Australia, China, Canada, Sweden and Finland. Most of this research looked at the impact of gardens on the wellbeing of people with dementia, but three looked at the impact of horticulture therapy. The results suggest that use of a garden may lower levels of agitation in residents with dementia but that impacts on emotional wellbeing, sleep, changes to medication and risk of falls were less certain. The views and experiences of the garden for residents, families and staff give us further insights into how the gardens are used and the impact they can have. Families said they valued somewhere pleasant to meet that stimulated interest and conversation with their loved ones, and care home staff reported the calming effects the gardens had on residents.
Importantly, our research also highlighted some barriers to using gardens, such as the perception of the garden as a hazard and limited staff time for supervision, leading to gardens being effectively inaccessible for residents.
Another area of our research looked at a range of measures that could improve the experience of mealtimes in residential care – in order to improve the nutrition and behaviour of residents with dementia. Looking at all the available research we found that a number of factors, such as playing music at mealtimes, could result in improved food intake among the elderly and better mealtime behaviour in those with dementia. We also found that introducing changes such as a wider choice of menu and more pleasant eating environment could reduce the risk of malnutrition and agitated behaviours.
Similar pieces of research have also been conducted on a range of therapies to improve the psychological and behavioural symptoms of dementia including light therapy, music therapy, reminiscence therapy and validation therapy. All of which report inconclusive findings due to the low number and poor quality of research studies conducted so far. This is characteristic of studies in this area, small study sizes, use of a variety of tools to measure the same points of interest and poor reporting of studies make it difficult to draw together a common understanding of the evidence.
Despite some positive findings, it is clear that the use of non-pharmacological interventions for people living with dementia are currently understudied and undervalued by policy makers. We really need more high quality evidence to establish clear results and ensure benefits for those living with dementia.