Dissonance in the dining room: a study of social interaction in a special care unit

Resonating moments: Exploring socio-material connectivity through artistic encounters with people living with dementia

In this article, I introduce insights from new material feminist theories into the understanding of connectivity on the basis of an aesthetic analysis of artistic encounters with people living with dementia. I draw on data from a situated art intervention conducted within the Resonance Project at a residential care home in Northern Norway where researchers, artists, health-care professionals, people living with dementia and family members came together in co-creative music sessions. I analyse two resonating moments from the sessions by way of an abductive process, oscillating between theory, written notes, video recordings and my own embodied experiences in the field. I discuss the ways in which materiality, listening and the group matter when it comes to our ability to connect during the sessions. Based on these findings, I conclude that the notion of socio-material connectivity provides an entrance point for studying different ways of relating to people living with dementia and enquiring into relations that matter.

Social interactions of persons with dementia living in special care units in long-term care: A mixed-methods systematic review

BACKGROUND

Special care units are a well-utilized approach in the long-term care for persons with dementia. A therapeutic goal of such settings is to provide meaningful engagement and a sense of community that is crucial for the overall quality of life. In recent years, several studies followed this notion by investigating residents' social interactions and the influence of the environment on these interactions.

AIMS

This review aims to synthesize the literature on the social interactions of persons with dementia living in special care units.

DESIGN

A mixed-methods systematic review was conducted.

METHODS

Literature was searched in PubMed, CINAHL, PsycINFO, the Cochrane Library and Web of Science databases. Additionally, reference lists of relevant articles were searched. Studies were screened, data were extracted and the quality was appraised. Separate syntheses were conducted for qualitative and quantitative studies, which were subsequently merged in the final mixed-methods synthesis.

RESULTS

In total, 18 articles were included, investigating large-scale, small-scale and homelike special care units and green care farms. Residents in special care units experience few social interactions but more than those in the comparative groups. Opportunities to interact are only marginally seized. Interactions typically occur in small groups and are facilitated by familiarity and the organizational environment. Residents mainly rely on staff members to create social interaction, for example initiating or facilitating resident-to-resident interaction.

CONCLUSION

Although the evidence base is increasing, it is still fragmented and built on different concepts, interventions, control groups and measurements. Nevertheless, the first conclusions suggest a positive impact of special care units on residents' social interactions. Although the review yielded a more comprehensive picture of residents' social life, further high-quality research built on a sound theoretical background is needed.

How do inpatient psychiatric nurses make sense of and respond to behaviours in dementia? An Interpretative Phenomenological Analysis

Objectives: Existing literature demonstrates that nurses' understanding of behaviours in dementia influences their responses to persons with dementia. However, there is limited research on the psychological processes involved in how nurses make sense of the behaviours and how these impact on responding, and a dearth of such literature from inpatient acute dementia settings. This study explored how inpatient psychiatric nurses make sense of and respond to behaviours in dementia. Method: This study employed Interpretative Phenomenological Analysis (IPA), a qualitative method that explores in detail how participants make sense of their experiences. Eight inpatient psychiatric nurses were recruited from two inpatient services within a National Health Service Mental Health Trust. Semi-structured interviews were conducted to gain an in depth understanding of their experience. Transcripts of the interviews were then analysed using IPA. Results: Four interrelated themes were identified: 'Effort to sense make', 'Pressures of the organisation', 'Balancing personal and professional selves: The underlying emotional connection'; and '"Looking back on it…"'. Conclusions: The study highlighted that sense making is a dynamic process, which occurs through a range of psychological processes and can change moment by moment dependent on the influences on the nurse. It demonstrated that nurses need to be supported to move flexibly through a range of emotional connections, which were found to underlie the negotiations made at work and influence sense making and responding. Nurses may benefit from space to reflect and formulate their understanding of clients, but further research is required to determine the effectiveness of this.

Dementia Care Work in Singapore: Embodied Relations and Power Dynamics

Based on research at a dementia day-care center in Singapore, I discuss how embodied care relations proceed amidst cultural expectations on aging, dementia, and care work. Engaging with approaches that conceptualize "care" as either empathy or control, I argue that care between older people with dementia, their families, and care workers can be understood as a reiterative, dialogic process whereby care participants strive to keep pace with each other, however briefly, due to cognitive decline, care workers' own limitations, and particular family difficulties. Care vacillates between practices of control, surveillance, and recognition, and comprises dynamic rather than enduring power relations.

Struggling to maintain individuality - Describing the experience of food in nursing homes for people with dementia

PURPOSE OF THE STUDY

To describe the food and dining experience of people with cognitive impairment and their family members in nursing homes.

DESIGN AND METHODS

Interviews and focus groups with people with cognitive impairment and their family members (n=19). Thematic analysis was undertaken using NVivo10 data analysis software package to determine key themes.

RESULTS

The main themes identified tracked a journey for people with cognitive impairment in nursing homes, where they initially sought to have their individual needs and preferences recognised and heard, expressed frustration as they perceived growing barriers to receiving dietary care which met their preferences, and ultimately described a deterioration of the amount of control and choice available to the individual with loss of self-feeding ability and dysphagia.

IMPLICATIONS

Further consideration of how to incorporate individualised dietary care is needed to fully implement person-centred care and support the quality of life of those receiving nursing home care.

‘If they don't use it, they lose it’: how organisational structures and practices shape residents’ physical movement in care home settings

Older people living in long-term facilities (nursing and residential homes providing 24-hour care) spend the majority of their time inactive, despite the known health and wellbeing benefits of physical activity and reduced time spent sedentary. In order to successfully embed interventions that aim to increase physical activity or reduce sedentary behaviour, it is necessary to understand the features of the care environment that influence residents’ routine patterns of movement. Drawing on an organisational perspective, this paper explores the structures and mechanisms that shaped different care practices concerning residents’ movement in two contrasting care homes in the north of England. This study adopted an ethnographic approach, using a combination of qualitative observations, informal conversations and interviews. A grounded theory approach to data analysis was adopted. The findings illustrate the importance of translating espoused values of care into tangible and acceptable care practices, systems of management, staff training and development, and the use of care planning in residents’ routine patterns of movement. Understanding how organisational factors shape routine movement among care home residents will help inform the development of embedded and sustainable interventions that enhance physical activity and reduce sedentary behaviour. This study is part of a wider programme of research developing and testing a complex intervention, embedded within routine care, to reduce sedentary behaviour among care home residents.

Healthcare personnel’s experiences of enhancing social community for people living in dementia special care units

Building trustworthy relationships that promote equal participation is a fundamental feature of daily living in dementia care. Creating a social community is thus a key component of quality of life for residents in dementia special care units. The aim of this study was to explore healthcare personnel’s experiences of enhancing social community in common spaces in dementia special care units. A qualitative descriptive design consisted of four focus-group interviews with 15 healthcare personnel. The transcribed interviews were analyzed inductively using qualitative content analysis. The findings revealed that healthcare personnel’s experiences of enhancing social community in common spaces were related to three main themes, expressed as dilemmas between knowing versus not knowing each other, safety versus unsafety and presence versus absence . Our analysis indicates that to enhance social community, it is essential for healthcare personnel to be able to create different forms of proximity to residents: physical, narrative and moral. Moreover, the meaning and role of ‘proximity’ in dementia care should be further explored as organizational context influences spatial-structural practices and may disrupt proximity in dementia care.

Offering architects insights into experiences of living with dementia: A case study on orientation in space, time, and identity

Due to memory loss, people with dementia are increasingly disorientated in space, time, and identity, which causes profound experiences of insecurity, anxiety, and homesickness. In the case study presented in this article, we explored how architecture can support people in coping with this challenge. We took a novel approach to offer architects insights into experiences of living with dementia. Starting from a critical realist and constructionist approach, we combined ethnographic techniques with an architectural analysis. This case study offers insights into the experiences and activities of a woman living with dementia within the architectural context of her home. We describe how the physical and social environment provided her guidance through sequences of day-to-day activities. This study highlights how architecture can support people with dementia in orientating by accommodating places for (1) everyday activities and (2) privacy and togetherness.

The effect of environmental change on residents with dementia

This qualitative study aimed to identify and describe the relatives' and staff's perceptions of environmental change on residents with dementia. Data were collected from audio-taped relative and staff focus group interviews at an aged care facility in Western Sydney. The transcribed data from the focus groups were thematically analysed and categorized. Three major categories emerged from the analysed data: the special care unit as a family home, therapeutic environment and work environment. Relatives and staff identified that the overall design of the unit impacted on the residents' functioning and quality of life, sense of freedom, level of agitation, sleeping patterns and weight. Relatives reported that the environment was conducive to visiting and to children, and staff reported that the working environment was improved because of its layout and equipment. This study has shown that special care units can make a difference to the quality of life of residents and improve conditions for relatives and staff.

Associations between social network characteristics, cognitive function, and quality of life among residents in a dementia special care unit: A pilot study

Social integration has a significant influence on physical and mental health. Older adults experience an increased risk of social isolation as their social networks contract. The purpose of this study is to examine associations between dementia special care unit residents' overall well-being and cognition with structural aspects of their coresident relationships. Design and Methods Measures of social network structure were calculated from self-reported social contact data within three cohorts of residents in one dementia special care unit. Pearson correlations were used to describe associations between overall quality of life and cognition, with network characteristics indicative of social integration. Results Approximately half the ties sent or received were reciprocated and positive associations were found between social integration and quality of life. However, inconsistent associations were found between social integration and cognitive function. Friendship ties were more frequent between people of adjacent cognitive status categories. In addition, comparing across personal networks, residents tended to be tied to residents of higher quality of life status (43.3%, n = 13 personal networks) as opposed to lower (30%, n = 9 networks) or same (26.7%, n = 8 networks). There is a strong positive correlation between quality of life and respondent's betweenness centrality, suggesting that individuals with high quality of life tend to be important intermediaries between others in the community. Implications Among the "oldest old," quality of life and cognitive function are unevenly distributed, yet these health indicators tend to cluster in social networks. This reinforces that while quality of life may be highly individual, it is in part linked to relationships with others.

Field observations into the environmental soul: spatial configuration and social life for people experiencing dementia

This article focuses on the important, facilitating role architectural design plays in social interaction within long-term care facilities (LTCFs) serving people with dementia. Here, we apply space syntax, a set of theories and techniques for the analysis of spatial configurations, as an objective measure of environmental characteristics. Almost 150 rounds of behavioral observations were collected in the social spaces of 3 LTCFs. Using the visibility and proximity metrics of space syntax, the locations of occurrence of various social activities in relation to the furniture and spatial layout on architectural floor plans have been identified. The results did not confirm the space syntax hypothesis that spaces with greater visibility and proximity promote more social interaction. Further analysis revealed that when in settings with better visibility and accessibility, the residents were more likely to engage in low levels of interaction. High-level social interactions actually were more likely to occur in settings providing greater privacy (eg, less visibility and accessibility). The findings suggest an important nuance that architectural configuration factors impact not only the likelihood but also the type of conversations likely to occur in certain locations. This would have implications for both design and staff training on how best to utilize social spaces for therapeutic effect, particularly within the context of person-centered care.

The use of common spaces in assisted living schemes for older persons: a comparison of somatic and dementia units

This study explores how common spaces in assisted living schemes for older persons are used by the residents. Observation studies, group interviews with staff and individual interviews with residents, relatives, architects and key stakeholders in the context of Swedish elder-care were conducted. Common spaces are the major location for in-house social interaction on the units. The results show a higher presence on the dementia units, compared to the somatic units. No significant correlation was found between the residents' mobility limitations and their degree of presence in the common spaces. The results also suggest a contradiction between the staff's intentions to provide a social context and the capabilities of the residents. Although common spaces are not used much between meals, the residents stress their importance for social interaction, suggesting that common spaces have important qualitative aspects, rather than quantitative. The results also show that few of the residents used the common spaces together with their relatives. The increasing use of assistive technology creates a shortage of space, suggesting a conflict between the efforts to create a home-like environment and the use of assistive technology.

An ecological framework of place: situating environmental gerontology within a life course perspective

This article presents an emergent heuristic framework for the core environmental gerontology concept of "place." Place has been a central concern in the field since the 1970s (Gubrium, 1978) for its hypothesized direct relationship to identity, the self, and agency--suggestive of the appropriateness of lateral theoretical linkages with developmental science. The Ecological Framework of Place (EFP) defines place as a socio-physical milieu involving people, the physical setting, and the program of the place, all catalyzed by situated human activity and fully acknowledging that all four may change over time. The article begins with a concise overview of the EFP before moving on to consider it within three theoretical terrains: place theory, developmental science theory, and environmental gerontology theory. The EFP will be argued to be a place theory which subsumes themes of emergent environmental gerontology theories within a developmental science perspective. Implications for theory, method and practice are discussed. One of the strengths of the model is its ability to serve both research and practice, as is exhibited in its ability to incorporate applied design research and inform architectural decision-making so often lacking in other environmental gerontology models. Place should be viewed as an integrative concept providing opportunities for both environmental gerontology and developmental science to more critically concern the profound role places have in terms of agency, identity and sense of self over the life course.

Exploring the function and use of common spaces in assisted living for older persons

OBJECTIVE

This exploratory study examines the function and use of common spaces in assisted living facilities (ALFs) from the residential and workplace perspectives.

BACKGROUND

The impact of the physical environment on human activities in healthcare settings has been emphasized in many studies. Few studies, however, have explored the daily use of common spaces and the impact on the usability of ALFs.

METHODS

Four explorative methods-observation, group interviews, individual interviews, and questionnaires-were used to investigate 14 ALFs in Sweden. The study involves residents, staff, relatives, architects, and people responsible for planning and construction of eldercare. This research strategy combines quantitative and qualitative methods to enhance the validity of the results. Method triangulation and data triangulation were used and the data were analyzed using Qualitative Content Analysis (QCA).

RESULTS

The results show that residents and staff have different objectives for use and these differences affect usability, although explicit conflicts are rare. The residents, staff, and other stakeholders have different views about the demarcation of home and workplace and the role of common spaces as venues for social interaction.

CONCLUSIONS

Both the residential and the workplace perspective must be considered when planning assisted living facilities. Otherwise, inherent conflicts between these perspectives will manifest as a result of the physical design. Common spaces have diverse functions that are reflected in their spatial organization. Therefore, ALFs should be designed so the intended function of a specific space is apparent to all users.

KEYWORDS

Built environment, elderly, planning, satisfaction, staff.

Pioneering partnerships: Resident involvement from multiple perspectives

Resident involvement in residential care homes is a challenge due to shortcomings of consumerist and formal approaches such as resident councils. The PARTNER approach aims to involve residents through collective action to improve their community life and wellbeing. The purpose of this article is to provide insights into the process of resident involvement by the PARTNER approach from the perspectives of multiple stakeholders, including residents, volunteers and staff members. A responsive evaluation was conducted, using participant observations, semi-structured interviews with residents, volunteers and professionals (n=16), and three focus groups. The findings show that critical elements in this process of resident involvement were the agenda-setting by residents, the formation of a cohesive resident group, the sharing of experiences and stories, the development of collective action, and the development of partnerships between residents and professionals and other stakeholder groups. Residents developed actions (gallery parties and a buddy project) to strengthen social interactions and realized these with the help of volunteers and professionals. We conclude that bringing residents together around a shared topic creates room for activism and leads to empowerment, feelings of social belonging and learning processes. We argue that it is a worthwhile enterprise to further develop structural partnership relations between residents, volunteers and staff in residential care homes.

The feasibility of measuring social networks among older adults in assisted living and dementia special care units

BACKGROUND

Studies indicate that social integration has a significant influence on physical and mental health. Older adults experience an increased risk of social isolation as their social networks decline with fewer traditional opportunities to add new social relationships. Deaths of similar aged friends, cognitive and functional impairments, and relocating to a nursing home (NH) or assisted-living (AL) facility contribute to difficulties in maintaining one's social network. Due to the paucity of research examining the social networks of people residing in AL and NH, this study was designed to develop and test the feasibility of using a combination of methodological approaches to capture social network data among older adults living in AL and a dementia special care unit NH.

METHODS

Social network analysis of both egocentric and sociocentric networks was conducted to visualize the social networks of 15 residents of an AL neighborhood and 12 residents of a dementia special care unit NH and to calculate measures network size, centrality, and reciprocity.

RESULTS

The combined egocentric and sociocentric method was feasible and provided a robust indicator of resident social networks highlighting individuals who were socially integrated as well as isolated.

Dementia and friendship: the quality and nature of the relationships that remain

Friendships are an integral part of the human experience. Yet, dementia often takes a toll on social relationships, and many friends withdraw. This research, however, focuses on friendships that remain, despite a diagnosis of dementia. It examines the quality of the friendships of people with dementia and long-term friendships. Data were collected through focus group interviews with people with early stage dementia and their care partners, and through interviews with designated friends. The findings show that people with dementia do have friends that remain and they have a wide variety of friendships, from those based on one shared activity to those of multifaceted deep relationships. The long-term friendships, which last across the various stages of dementia, appear to fall into two types: one, where the person with dementia has become more like a family member than a friend (suffusion); and the other where the diagnosis of dementia was the impetus for the relationship to become closer (progressive friendship).

Staging casual conversations for people with dementia

Social isolation is a key concern for individuals with dementia in long-term care. A possible solution is to promote social interaction between residents. A first step toward facilitating positive relationships between residents with dementia is to understand the mechanisms behind their interactions with each other, and also how their relationships with each other are built through such interactions. Drawing on casual conversations between residents in a special care unit for dementia, this paper uses systemic functional linguistics to examine how people with dementia use language to enact and construct their role-relations with each other. Results suggest people with dementia are able and willing conversationalists. However, factors such as the extent of communication breakdown and compatibility of the interlocutors may influence whether positive relations develop or not. Casual conversation is suggested to be a promising activity to encourage positive interpersonal processes between individuals with dementia in residential care.

Embodiment and dementia: exploring critical narratives of selfhood, surveillance, and dementia care

In the last decade there has been a notable increase in efforts to expand understandings of dementia by incorporating the body and theorizing its interrelationship with the larger social order. This emerging subfield of dementia studies puts the body and embodied practices at the center of explorations of how dementia is represented and/or experienced. This shift towards a greater recognition of the way that humans are embodied has expanded the horizon of dementia studies, providing the intellectual and narrative resources to examine experiences of dementia, and their interconnections with history, culture, power, and discourse. Our aim in this paper is to critically explore and review dimensions of this expanding research and literature, specifically in relation to three key narratives: (1) rethinking selfhood: exploring embodied dimensions; (2) surveillance, discipline, and the body in dementia and dementia care; and (3) embodied innovations in dementia care practice. We argue that this literature collectively destabilizes dementia as a taken-for-granted category and has generated critical texts on the interrelationship between the body and social and political processes in the production and expression of dementia.

Affordances of the Care Environment for People with Dementia—An Assessment Study

Background:

Evidence on the importance of the physical environment for the well-being of people with dementia has been growing steadily.

Objective:

This article aims to (1) introduce an assessment tool for evaluating the physical care environment for people with dementia; (2) describe the method's initial results and the subsequent feedback provided to the 10 care units; and (3) describe the follow-up results 1 year later. The goal has been to provide care workers and managers with information that affects the well-being of people with dementia and to provide this information on the care environment in the context of their own work environment.

Methods:

The assessment was part of a randomized controlled intervention using nonpharmaceutical methods to decrease behavioral and psychological symptoms of people with dementia. During the half-day visits, photographs and field notes were taken, and a final assessment was carried out via the Residential Care Environment Assessment (RCEA) tool developed at the beginning of the study and based on affordance theory. Follow-up data were gathered after 12 months.

Results:

There were several possibilities for improvements in the provision of residential care in a person-centered environment. Improvements were needed mostly in comfort and in providing opportunities for engagement, activity, and expression of identity. However, in practice, it was difficult to achieve the improvements even with an intensive intervention study.

Conclusions:

The authors conclude that the physical care environment involves a complex set of issues and stakeholders in which the impetus to fulfill responsibilities to carry out improvements can easily fall away.

The discourse of friendship: Mediators of communication among dementia residents in long-term care

One the most difficult challenges experienced by people with dementia and their caregivers is their communication. The ability to communicate is essential to creating and maintaining social relationships. Many individuals who suffer from dementia experience increased agitation and diminished social interaction in the long-term care living setting. This paper demonstrates how, through language, they construct social relationships. As part of The Friendship Study, which is an ethnographic observation of persons with dementia living in a long-term care setting, we analyzed transcripts from video- and audio-taped data and performed a discourse analysis of conversations to show how persons with dementia who live in a long-term care setting use language to create friendships. These analyses show that friendships are constructed using concepts such as conversational objects, discourse deixis, indexicality, and alignment among speakers.

Informal social interaction among residents with dementia in special care units: Exploring the role of the physical and social environments

Despite a continued recognition of the importance of relational aspects of quality of life for people with dementia, little research has examined environmental influences on informal social interaction in dementia care settings. The purpose of this ethnographic study was to identify and explore key elements of the physical and social environments that act as facilitators or barriers for social interaction among people with dementia living in special care units. We conducted in-depth interviews with staff members and completed a series of resident observations. Findings suggest that social factors such as staff work roles and resident group size, and physical factors such as a non-institutional character, the nursing station location, and adequate seating and sightlines are influential for prompting or supporting informal social interactions. Design recommendations are provided with the intent to create physical environments that foster informal social interactions among people in dementia care environments.

Nested social groups within the social environment of a dementia care assisted living setting

The social environments of people with dementia are complex and still not fully understood. Investigating how residents in a dementia care setting navigate and participate within social groups is critical as the therapeutic benefits of social engagement are unequivocal. An ethnographic study of social environments within a dementia care residence revealed that there is active socialization and even strong and lasting friendships formed between people with dementia. Many of these relationships were observed to be a part of groups, ‘nested’ within the larger social environment. These ‘nested social groups’ had unique dynamics and their structuring was often influenced by outside factors (e.g. physical environment and staff preferences). The existence of these groups has implications for the experiences and quality of life of the residents in long-term care. Nested social groups will be defined and their function within the social environment will be discussed.

Friendships among people with dementia in long-term care

Despite the growing literature on social interactions in dementia settings, few studies have investigated ‘friendships’ in people with dementia living in long-term care. ‘Social interactions’ describe communicating, verbally and/or non-verbally, at least once with another person while ‘friendship’ suggests a deeper, more meaningful connection that may include reciprocity, intimacy, and shared trust. During a 6-month, mixed-methods study, we investigated friendships among 31 assisted living residents with moderate to advanced dementia. Results revealed no correlation between test scores or demographic characteristics (except gender) and friendship dyads identified by staff. Staffs’ perceptions of residents’ friendships were not supported through our observations. We did observe friendships among residents characterized by voluntary participation and accommodation in conversation, and recognition of the uniqueness of the other. Findings suggest staff perceptions of residents’ friendships are not sufficient and that more research on this topic is needed.

The Vernacular Landscape of Assisted Living

This article is an exploration into the vernacular landscape of Assisted Living (AL), a conceptual idea borrowed from cultural geographer J.B. Jackson, which distinguishes formalized, planned space from those spaces which are unintended and often created spontaneously--vernacular. Based upon three large-scale, multi-year ethnographic studies in Maryland, we consider some of the ways people who live in AL relate to and respond to the built environment, at times subverting the intended purpose of design to make it their own. The conflict that often ensues over both planned and vernacular public and private space, we propose is ultimately the product of living within an environment that is both someone's home as well as a place of business, whose job it is to keep people safe. Within this physical context of vernacular private and public spaces, this article enriches understandings about the way autonomy and privacy expresses itself.

Sliding interactions: An ethnography about how persons with dementia interact in housing with care for the elderly

This ethnography describes how persons with dementia interact with cognitively intact persons in housing with care for the elderly. The results, drawing upon 31 observation sessions and nine interviews, are described under the following themes, which were interpreted from the standpoint of social interaction theory: interaction with expression of satisfaction, disorientation, and dissociation. Interaction provided satisfaction, but did not always reflect a positive experience. Awareness in persons with dementia seemed to be greater than others perceived and, as a result, interaction was adversely affected by frequent well-intentioned corrections and comments. Participation in interaction can be encouraged and feelings of indignation avoided by assuming that persons with dementia are aware of their situation and how others behave toward them. Sensitivity is required to interpret individuals' expressions of desire not to participate, while simultaneously it is important to try to interpret why they want to refrain.

A home away from home: The meaning of home according to families of residents with dementia

This study sought to understand the ways in which family caregivers to institutionalized relatives with dementia perceived and experienced the relocation of their relative to a more home-like setting of care. Twenty-nine family members were interviewed through focus groups and individual interviews following the closing of two traditional care facilities and the subsequent migration of all residents to dementia cottages. Questions focused on the assessment and evaluation of quality of care. Results of this qualitative study pointed to the centrality of relationships in creating a truly homelike environment, in addition to what constitutes effective relational practice from the family perspective. We argue that the creation of a meaningful home for persons with dementia must encompass a relational orientation, both philosophically and in practice, that is inclusive of resident, staff, and family.

Placing the place, and placing oneself within it

Disorientation as experienced by persons with progressive dementia diseases involves both existential and social dimensions. Based on video observations from a small residential care unit and exploring social interaction on a micro-level, this case study focuses on how a woman with vascular dementia actively tries to make sense of an everyday lunch situation. The analysis addresses strategies used by her to contextualize where she has ended up, and also how the meaning of the place is altered in communication. Findings point to social interaction between residents as an important resource to help maintain continuity with previous social life. However, there also seems to be an impending need for caregivers to help residents patch up their broken life-stories to render everyday situations comprehensible and the setting socially meaningful. Helping them find a way of placing themselves within it — also affording a positive self-identity and continuity with previous life history — is a major challenge in daily care.

Institutionalized ghosting: policy contexts and language use in erasing the person with Alzheimer's

The ordinary social engagement of human life would not usually be considered an arena for language policy. Yet clinical evidence mounts that social interaction improves our lives as we age. Since social engagement decreases cardiovascular risks (Ramsay et al. in Ann Epidemiol 18:476-483, 2008) and delays memory loss among those living in communities (Ertel et al. in Am J Public Health 98:1215-1220, 2008), practices that prohibit social interaction threaten human well-being. For persons who have Alzheimer's disease (AD), social interaction continues to play an integral part in cognitive function and delays in memory loss, according to a longitudinal study of social networks (Bennett et al. in Lancet Neurol 5:406-412, 2007). Increasingly, person-centered care that promotes social engagement for those with AD is promoted as an institutional policy to improve outcomes of dementia care (Edvardsson et al. in Int Psychogeriatr 20:764-776, 2008). Yet the training of caregivers may neither reflect person-centered care nor include attention to communication, suggesting covert policies in practice.

Feeding difficulty in older adults with dementia

AIMS AND OBJECTIVES

To use concept analysis to identify characteristics of feeding difficulty and its antecedents and consequences that provide direction for assessment and management.

BACKGROUND

Feeding difficulty is often recognised as a common problem for older adults and is associated with weight loss, poor nutrition and risk for aspiration pneumonia. The cognitive impairment found in persons with dementia impairs the ability of these adults to complete motor and perceptual tasks required for eating and often prevent the older adult from accepting help with feeding from caregivers.

DESIGN

Systematic review.

METHODS

In 2006, literature searches using keywords (feeding, eating, nutrition, malnutrition, feeding assessment, dementia, ageing and concept analysis, dementia and feeding and excluding enteral feeding, tube feedings, PEG and enteral nutrition) were done in Medline, CINHAL, AGELINE and Social Science Full Text. Seventy relevant articles in English were found. After a review of the relevant articles, concept analysis was used to develop a definition of feeding difficulty, its defining characteristics and to delineate feeding difficulty from its antecedents and consequences.

RESULTS

Feeding difficulties arise at the interface between the caregiver strategies to assist the older adult with getting food into the mouth and chewing and swallowing food. A model of feeding difficulty delineates the antecedents and consequences of feeding difficulties.

CONCLUSIONS

The conceptual model of feeding difficulties provides a strong and clear organising structure for research that can be used to developed evidence based guidelines for practice.

RELEVANCE TO CLINICAL PRACTICE

The conceptual model provides directions for assessment of feeding difficulties and their antecedents. The model can be used to identify interventions that address antecedents of feeding difficulty (risk factors) and different types of feeding difficulties.

Combining case study research and systems theory as a heuristic model

The combined use of case study and systems theory is not often seen in the literature. The use of both approaches enables the specifics of the case to consider the influence of broader systems and external environments, offering in-depth exploration as well as comparative analysis between cases in the context of the system. Health care has obvious systems operating that may have developed from organizational hierarchies, funding mechanisms, or traditional service delivery of health care. Systems theory is ideally suited to examine health care and health promotion sites, such as hospitals or universities. Sites can use the principles of systems theory to explore innovation, change, and complexity of service delivery in the context of a case study approach. This article discusses how the combination of the two can act as a heuristic model, offering its application to emergency department physiotherapy as an example, to further bolster the evidence base for using such a methodology.

Activity situations on an Alzheimer's disease special care unit and resident environmental interactions, time use, and affect

Routine activity situations on an Alzheimer's disease (AD) special care unit were examined with respect to residents' social and physical environmental interactions, time use, and apparent affect. Using a computer-assisted observational tool, observers recorded prevailing activity situations and corresponding behaviors and affects of seven residents every 10 minutes, from 8:00 AM to 8:00 PM, across four days. Although meals/snacks and some activity groups were positively associated with use of physical objects and engagement in activities, residents were predominantly environmentally disengaged, inactive, or without positive affects during the most prevalent activity situations of background media, downtime, and television. Findings suggest that routine activity situations may act as potent environmental influences on the quality of life (QOL) of people with AD and mediate the effectiveness of other environmental interventions undertaken on their behalf.

Mealtimes as Active Processesin Long-term Care Facilities

Mealtimes are central to the nutritional care of residents in long-term care facilities. There has been little Canadian research to guide interdisciplinary practice around mealtimes. This study included a grounded theory approach to explore mealtime experiences of 20 people with dementia living in two long-term care facilities, and the meal-related care they received from registered nurses, health care aides, and dietitians. Theoretical sampling directed the collection and analysis of data from mealtime observations in special care units and key informant interviews with care providers. The constant comparison method was used to analyze and conceptualize the data. A substantive theory emerged with three key themes:

Each mealtime is a unique process embedded within a long-term care facility's environment. Residents are central to the process through their actions (i.e., arriving, eating, waiting, socializing, leaving, and miscellaneous distracted activities). Internal (i.e., residents’ characteristics) and external (i.e., co-resident, direct caregiving, indirect caregiving, administrative, and government activities) influences affect residents’ actions at mealtimes.

The theory suggests that optimal mealtime experiences for residents require individualized care that reflects interdisciplinary, multi-level interventions.

The therapeutic design of environments for people with dementia: a review of the empirical research

Design of the physical environment is increasingly recognized as an important aid in caring for people with dementia. This article reviews the empirical research on design and dementia, including research concerning facility planning (relocation, respite and day care, special care units, group size), research on environmental attributes (noninstitutional character, sensory stimulation, lighting, safety), studies concerning building organization (orientation, outdoor space), and research on specific rooms and activity spaces (bathrooms, toilet rooms, dining rooms, kitchens, and resident rooms). The analysis reveals major themes in research and characterizes strengths and shortcomings in methodology, theoretical conceptualization, and applicability of findings.