Environmental interventions as alternatives to pharmacological treatment for dementia

Environmental Interventions for Patients With Dementia

Dementia is a neurocognitive disorder that has been treated in various ways throughout all history. The modern era has proposed pharmacological interventions in the past but these have proved dangerous and degrading to the quality of life that dementia patients and their loved ones prefer. For this reason, environmental interventions have emerged as an alternative method for treating elderly dementia patients. This intervention method consists of altering the environment in which the patient lives by accommodating for the needs of the patient with clearly identifiable pathways, open spaces for communication, naturalistic settings, adequate stimuli and private rooms for quiet. This paper discusses the fundamental principles of environmental interventions for patients with dementia and includes a justification for this approach as a suitable alternative to prevailing psychoactive drug interventions. It also includes a discussion of the historical context of the disorder, its current description according to the DSM-V and a guideline for home design so as to effect a proper environmental intervention.

Environmental Interventions for Patients with Dementia

Introduction

Psychotropic and pharmacological interventions can have harmful or damaging side effects on patients with dementia and for this reason health care providers are examining the possibility of environmental or psychosocial interventions in order to help manage patients with dementia (Mayo Clinic, 2015).

Dementia is a term that is used to describe "impairments in cognitive and intellectual ability, memory, language, reasoning, and judgment that interfere with everyday functioning" (Agency for Healthcare Research and Quality, 2014). This cognitive disorder is one that typically impacts the elderly community as cognitive functions deteriorate with the onset of age. As of 2010, more than $200 billion were being spent on care for patients with dementia (Agency for Healthcare Research and Quality, 2014). However, dementia remains a disorder that is inconsistently understood and therefore inconsistently treated. Moreover, the impact of pharmacological interventions introduces new and unnecessary risks into the treatment of the patient. A better approach to stabilizing patients with dementia can be found in environmental interventions, which this paper will now describe.

History

Kyziridis (2005) shows that in the past, philosophers such as Plato stated that "if head and body are to be well, you must begin by curing the soul," (p. 43). Kyziridis' study focuses on the history of "schizophrenia," but as Kyziridis notes, the term "schizophrenia" simply means "spit-mind" and it was first coined by Blueler in the first part of the 20th century in an attempt to redefine what psychologists had identified as a form of dementia. Thus, the two disorders are not so disparate, as even the DSM-V suggests in its new classification of dementia as a major neurocognitive disorder.

How then have ancient cultures and older cultures treated patients with what are now called neurocognitive disorders? The ancient Greeks had a number of methods, as Plato has indicated, and many of them were oriented towards environmental interventionist methods -- such as the placing of the patient in a natural setting that was conducive to peaceful and harmonious feelings: a view of hills, nature, birds, flowers, sky, trees, where fresh air was in abundance -- this was one approach. Another approach was to use music therapy as a mood stabilizer (i.e., music would be played so as to help calm the patient). Other cultures as in China or India, used religious ritual interventions; the Romans lent themselves more to Grecian practices. In the Middle Ages, the Christian era adopted a strategy that was a cross between the Eastern and the Western methods, as it attempted to distinguish between spiritual ailment and physical or psychological ailment and treat accordingly. The method during this era was also based on environmental interventionist orientations and was geared towards satisfying quality of life aims and reducing the rate of incidence of disruptive or unruly behavior (Kyziridis, 2005).

In the modern era, in conjunction with the rise of Industrialization and mass-production and the detachment from Old World (i.e., medieval or classical) methodology in favor of Enlightenment studies, medicine has taken a more un-natural approach in terms of utilizing laboratory chemicals as neuro-applications and treatment for patients suffering from cognitive disorders. In many cases, such treatment has not been effective in stabilizing the patient with any view towards maintaining or contributing to the patient's quality of life. Pharmacological treatment, in fact, has been a contributor in a number of the mass shootings in America in recent years, as SSRIs are one of the common characteristics to be found among these incidences. When this is considered alongside the modern era's approach to treating elderly dementia patients as though ignoring the manner in which the world throughout all history has dealt with this subject, it becomes apparent that an environmental intervention may be exactly what is needed for treating a disorder for which there has not as of yet been identified any real cure.

The Implementation and Impact of Environmental Intervention

One's environment has a profound impact on the way that one thinks and acts, as numerous studies in numerous sectors have shown, from business organizational workplace studies to urban cities and planning studies to medical studies regarding the impact of environment/communities on rate of incidence of diabetes (Shinew, Stodoloska, Roman, Yahner, 2013). The point is that environments impact everyone at a psycho-social level and can be responsible for boosting morale, elevating or depressing the mood, and effective harmonious or discordant thoughts. When such findings are applied to the treatment of dementia patients, it becomes evident that environmental intervention is a strategy that is rooted in a universal phenomenon of respecting how environments affect people.

Fleming and Purandare (2010) show that environmental design guidelines can be implemented by caretakers to provide the kind of intervention strategy that would most effectively support QOL for elderly dementia patients. These guidelines are based on their study of long-term care analyses culled from control groups, cross sectional and survey designs and pre- and post-test studies. Their finding is that when it comes to implementing environmental interventions, home designers "may confidently use unobtrusive safety measures; vary ambience, size and shape of spaces; provide single rooms; maximize visual access; and control levels of stimulation" in order to facilitate the care giver's intervention strategy (p. 1084). However, while their meta-analysis indicates as much, it also suggests that the "usefulness of signage, homelikeness, provision for engagements in ordinary activities, small size and the provision of outside space" was less conclusive in terms of being desirable aspects of environmental intervention design guidelines (p. 1084).

As Dr. Tanya Petrovich (2015) shows, dementia-design friendly homes should meet a number of characteristics. They should be visually pleasing with efficient lighting that can be easily manipulated; there should be minimal risk for falls, which is a major factor in elderly concerns; and it should be adequately stimulating.

Illustration 1. The dementia-friendly home environment.

There are even companies that will specialize in formatting existing home structures to meet the needs of dementia patients and their families. These structures are based on meeting the needs of individual patients and structuring the home is a way that is safe and stabilizing for the patient. The aim of this remodeling is to provide a better quality of life for the patient as opposed to attempting to "control" the patient's movements and activities via the use of pharmacological intervention.

The 10 principles that Petrovich (2015) employs in her assessment of how to create a suitable environment for dementia patients are the following:

1. The environment should reduce risk and allow for easy maintenance of safety and security for the patient in the home.

2. There should be a human scale, which considers the need for personal space as well as for social interaction so that the patient can still participate in communal life with family and friends when it is desired and retreat to a private setting when it is needed.

3. The third principle for effective environmental intervention design within the home is for the home structure to allow for people to be clearly visible so that the patient with dementia is not confused about where sounds or voices are coming from. If people are partially hidden by walls or half-walls yet can still be heard, this can be confusing for dementia patients who can suffer in mood as a result. Thus, to reduce such agitation, structures should consist of open floor plans for part of the building design.

4. The design should cut down on unnecessary stimulation, i.e. noise reduction and visual stimulations should be minimal.

5. Positive stimulation should be encouraged, i.e. color usage for ease of identification.

6. Movement of the patient should be easy and unrestricted with safety rails in place to assist walking as well as pathways that are clear, lit and defined

7. Spaces should be familiar to the patient in design so that they are easily recognizable and adapted to the room's purpose.

8. Rooms should offer one of two opportunities -- to be alone or to be with others, and this will determine the floor plan.

9. The home should be connected to the community via wireless connection or landline so that telehealth can be conducted if chosen

10. The design should support the overall aim of QOL for the individual patient and cater to the person's individual needs and tastes.

These principles indicate that the environmental intervention for dementia patients can be practically implemented and also individualized so long as these principles are followed.

Other groups, however, indicate that the environmental intervention should not consist solely of a home-based solution but should encompass an entire community as well. For this reason, Bupa (2015) envisions a completely dementia-friendly community by 2030 with a built environment that caters to the needs of individuals not only at home but also at the workplace, the school, with free access to technological hotspots that enhance and enable communication between homes and telenursing stations. This is a situation that would completely enhance the local community so as to make it a more benevolent force for all neurocognitive patients and not just those with dementia. The fact is that with the technological enhancements of the digital age, the need for advanced telenursing and the benefits that telehealth can bring through communications and monitoring devices within the home only serves to boost the level of environmental support for this strategic intervention. The Bupa (2015) model of environmental intervention is simply the next stage of this development and a natural integration of health care and technology with community-based awareness as a core principle in the design.

Illustration 2. The dementia-friendly community.

Conclusion

In conclusion, environmental intervention for patients with dementia is a positive step in facilitating quality of life for patients, whose disorder has no known cure. This intervention is based on the historical cultural approach of various societies through the ages and is promoted as an alternative to pharmacological interventions which can damage or negatively impact the psycho-social health of the patient and cause strain between the patient and loved ones as well as reduce the overall QOL of the patient with dementia. For this reason, an environmental intervention is recommended as it can provide adequate comfort and infrastructural support for the patient and meet both the patient's and the family's needs in terms of care and support. The best way for the intervention to succeed, moreover, is to individualize the plan and adapt it to the specific needs and tastes of the patient. This, along with the fundamental application of settings that are conducive to elderly dementia patients' requirements for open spaces and private rooms for quiet time, can ensure that the proper environmental intervention can be implemented to support the dementia patient in the 21st century. When notions of telehealth, telecommunications, and telenursing are also considered in the implementation strategy, an all-around effective approach to a beneficial environmental intervention that provides both home-care and long-distance care via monitoring can be positively impactful for the patient.