Dementia- friendly environment for elderly people with dementia

Introduction

Introduction: Dementia is a disorder of brain which causes a change in the brain in such a way that a person will lose his thinking, remembering as well as behavioural capability. In other words, dementia causes impairment of the cognitive ability of a person to such an extent that it becomes very difficult for the individual suffering from dementia to communicate with the society. Dementia occurs mostly in elderly people and it is the one of the main causes of dependency among the elderly population. Dementia is a progressive disorder which is not curable but definitely the process of progression can become slow when a friendly environment is created for them so that the elderly people with dementia can behave normally as well as participate in different day to day activities and that is possible by providing mental support to them .The intervention by nurses can play a major role in providing a friendly environment for elderly people with dementia as very often it becomes highly impossible or stressful for the family members to deal with the situation as they were unaware of how to handle the situation .The goal of creating a dementia friendly environment is for promoting people with dementia in decision making(NICE 2006).The improvement of health and wellbeing of elderly people with dementia ensuring quality life with equal treatment opportunities is the major aim of dementia friendly environment.( Lin S-YL et.al 2015).The acceptance as well as inclusion of dementia patients in decision making by providing a physical and social environment which promotes their independence as well as participation is the main concept behind dementia friendly environment(Crampton J et.al 2012) Background and context: Nurses have a significant role in improving the quality of life of elderly people suffering with dementia as they are most often neglected, abused and not accepted whole heartedly by the society. The intervention by nurses can provide equal rights to them and they can live with dignity .There are many ways by which nurses can help them to lead a normal happy life like encouraging and providing assistance to them by promoting their self-determination, educating the families by providing them necessary materials for preparing the family members to cope up with the situation ,improving the provision of dignified dementia care in which palliative care is provided to the person with respect .But despite of several interventions which are equally important to improve the quality of life of the elderly people with dementia the most important intervention required today is to provide them social acceptance and respect. Dementia is increasing day by day and according to WHO 50 million people are affected with dementia and it is estimated that by 2030 the number will reach 82 million and subsequently 152 million by 2050.The prediction of the increasing figures by WHO is a matter of concern but the main problem which immediately has to be taken care of is the attitude of the people towards the dementia patients. The main problem in the society is the lack of knowledge of the people about dementia which ultimately leads to marginalisation of those living with dementia (WHO 2012). Appropriate nursing intervention to create awareness and provide necessary education to the society can overcome the marginalisation and without which it is not possible to provide optimum care to them. Better quality life can be provided by reducing the marginalisation and nurses can play a significant role for providing social respect to elderly people with dementia. The intervention of nurses as an advocate to provide social respect to them can improve their lifestyle and a dementia friendly environment will be created where they will get equal rights and respect in the society. Aim of report: The main aim of the report is to focus on the most powerful obstacle in providing quality life to the elderly people with dementia and that is Stigmatisation. Stigmatisation prevents early diagnosis and it is possible to overcome the problem by proper health promotion ((Bratass, Bjugan, Wille, & Hellzeen, 2010). There is no possibility of quality life due to stigmatisation (Alzheimer’s Society, 2009). Discrimination of the elderly people with dementia is a major social problem and active participation of mental health nurses can educate the society and reduce the barrier that causes social exclusion. Most of the evidences are not very significant and very less is known regarding the interventional strategies used by the nurses to reduce stigma (Thornicroft, G. 2006) and limited information is there regarding the discrimination done in middle- and low-income countries (Yang, LH et.al 2010) and the role of nurses to reduce the discrimination to make the elderly people with dementia lead a respectful life with dignity. Research Question: How do mental health nurse reduces public stigmatisation in elderly patients with dementia and prevent discrimination creating a dementia friendly environment? A systematic review is planned which will provide evidences regarding the intervention by the mental health nurses specifically in middle- and low-income countries to reduce the discrimination done with the elderly people with dementia. This survey is planned to get an idea about the extent to which mental health nurses are participating to prevent social exclusion of elderly people with dementia. The purpose of the study is to identify the gap and collect evidences reflecting the areas where improvisation is required so that in the future a dementia friendly environment is created. Search Strategy: The systematic review is planned mainly via online platform i.e. by searching different electronic databases like PubMed, Cochrane Library, Medline, the Social Science Citation Index (SSCI) and Global Health, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google scholar etc. Different terminologies like mental health, stigma, discrimination, social injustice, inequity in services, mental disorders, interventional strategies are used in our search to select ten best papers which will help to critically analyse the problems faced by elderly people with dementia and collect necessary evidences highlighting the intervention by mental health nurses in this specific area where social acceptance are required to be provided to them. This in turn will give us a picture of the society and how in different countries nursing intervention is reducing the barriers and to what extent they are able to create a dementia friendly environment.

Inclusion criteria:

1. It should focus on the care and support that is provided to the elderly people with dementia by the care givers and the nurses.
2. The strategies that are used by the nurses to reduce the barriers that an elderly people with dementia faces in the society must be analysed.
3. The reason of prevalence of social injustice and the effective measures that can be used to provide them a dementia friendly environment.

Exclusion criteria:

1. The studies mentioning other mental disorders will be excluded
2. The studies focussing in other areas of nursing intervention in dementia patients are excluded.

Summary of the evidence: The survey of the selected papers and systematic reviews is done to construct a table summarising the evidences focussing the nursing interventions and the possible outcome achieved to create a dementia friendly environment. The investigation is based on systematic review to measure the social rejection and isolation of elderly people with dementia in different classes of society and the active role of the mental health nurses to reduce the barrier and provide them dementia friendly environment. The papers that are selected are as follows:

1. Naaheed Mukadam & Gill Livingston (2012) Reducing the stigma associated with dementia: approaches and goals AGING HEALTH VOL. 8, NO. 4
2. Duffin, Christian (2014) Dementia-friendly neighbourhoods Nursing Older People. Mar 24, Vol. 26 Issue 2, p16-17. 2p.
3. Cleusa Pinheiro Ferri, K. S. Jacob (2017) Dementia in low-income and middle-income countries: Different realities mandate tailored solutions PLOS MEDICINE Published: March 28, 2https://doi.org/10.1371/journal.pmed.1002271
4. Fleming, R., Bennett, K. A., Preece, T. & Phillipson, L. (2017). The development and testing of the dementia friendly communities environment assessment tool (DFC EAT). International Psychogeriatrics, 29 (2), 303-311
5. Pia Kontos, Alisa Grigorovich (2018) Raising the curtain on stigma associated with dementia: fostering a new cultural imaginary for a more inclusive society Critical Public health Pages 91-102 Volume 30, Issue 1
6. Jessica A. Young, Christopher Lind, J B Orange, Marie Y. Savundranayagamd (2019) Expanding current understandings of epistemic injustice and dementia: Learning from stigma theory Journal of Aging Studies Volume 48, March 2019, Pages 76-8
7. Susanne Spittel,1,2 André Maier,1 and Elke Kraus (2019) Awareness challenges of mental health disorder and dementia facing stigmatisation and discrimination: a systematic literature review from Sub-Sahara Africa J Glob Health. Dec; 9(2): 020419.
8. Suh‐Mian Wu PhD, RN Hsiu‐Li Huang PhD (2019) Dementia‐friendly community indicators from the perspectives of people living with dementia and dementia‐family caregivers https://doi.org/10.1111/jan.14123
9. Yu-Tzu Wu, Carol Brayne, Zhaorui Liu, Yueqin Huang, Ana Luisa Sosa, Daisy Acosta & Matthew Prina (2020) Neighbourhood environment and dementia in older people from high-, middle- and low-income countries: results from two population-based cohort studies BMC Public Health volume 20, Article number: 1330
10. Lillian Hung, Sharon Leitch, Ryan Hung, Alison Phinney (2020) Creating dementia-friendly and inclusive communities for social inclusion: a scoping review protocol BMJ Open Volume 10, Issue 6

Evidences

A wide variety of research papers are selected online to investigate the problem elderly people with dementia are facing in the society and nursing interventions to overcome the problems. Few of the online papers are mentioned to gather evidences and construct table which will help to predict the future measures necessary to create a dementia friendly environment. It is quite significant that very less evidences are there regarding social inclusion of dementia patients which is alarming for the future as the statistics indicate that number of elderly people s with dementia will be more in the future. Datas are collected from high, middle, low-income countries

Critical appraisal of the evidence base: According to the systematic review done it is very clear that very less attention is given in this particular area where more or less every society is depriving the elderly people with dementia. In our study low-, middle- and high-income countries are assessed. The social exclusion problem is more prevailing in middle- and low-income countries compare to high income countries. Many researches reflect the adaptation of different tools to identify the problem and innovate techniques to educate the society and provide social justice to elderly people with dementia so that they get proper attention and can lead a normal life with the assistance of each and every individual of the society. Naaheed Mukadam & Gill Livingston (2012) indicates in their paper that for optimisation and improvement of health care outcome it is very important to develop anti stigma interventional strategies. According to Duffin, Christian (2014) understanding the dementia patients is very important for creating a dementia friendly environment. Moreover, Cleusa Pinheiro Ferri, K. S. Jacob (2017) has done statistical analysis of dementia prevalence in low-, middle- and high-income countries. It is estimated that there will be significant increase in the elderly people with dementia approximately 71 % in Latin America, 41% in North America, 23% in Europe ,63% and 66% in Asia and Africa respectively. The response to deal with the situation in high income countries are better than middle and low income countries. Fleming, R., Bennett, K. A. (2017) discussed about the introduction and testing of dementia friendly communities environment assessment tool (DFC EAT) which can identify the strength and weakness of different communities that can be used to support the elderly people with dementia. P kontos et.al (2018) reveals that stigmatisation is the major problem that elderly people with dementia are facing in the society which in turn is disrupting the well-being of them. They proposed a research-based drama called cracked that is with the aim of reducing stigma by the awareness of the society and involvement of the elderly people with dementia in various activities in the society But Jessica A. Young (2019) indicates that understanding of epistemic is important to provide elderly people with dementia human rights in the society. They made a comparative study of the theoretical model of stigma align and epistematic injustice model. A systemic review conducted by Susanne Spittelet.al(2019) to study stigmatisation and discrimination faced by elderly people with dementia indicates that some traditional beliefs prevails in the society which has to be taken care of by expertise .Awareness and education campaign in various sectors of SSA communities are important to reduce the discrimination. A qualitative study was conducted by Suh‐Mian Wu et.al (2019) in Taiwan for identification of dementia‐friendly communities’ indicators which clearly indicates that mental health nurses training and intervention is very mush required not only in Taiwan but other countries to reduce stigmatisation and provide elderly people with dementia a dementia friendly environment. A cohort study is done by Yu-Tzu Wu et.al (2020) to investigate the relationship between neighbourhood environment and elderly people with dementia in low-, middle- and high-income countries by the use of multi-level regression which shows a close association between daily life amenities and well being of elderly people with dementia. L Hung, S et.al (2020) reveals that dementia is increasing worldwide and reducing stigmatisation leading to social inclusion is mandatory for creation of dementia friendly environment. Discussion: We have conducted a study to critically analyse the menta health nurses’ interventions for creating a dementia friendly environment. Our study is focussed on the stigmatisation leading to social exclusion of elderly people with dementia. It is necessary that this area which is acting as a hindrance in creating a dementia friendly environment is highlighted .The research indicates that the contribution of nurses in this sector is very less. The responsibility of nurses are wide for providing high quality care to the society((Peate, 2016).Evidence based research studies are very important in addition to professional standard of practice (Ellis, 2016).The systematic review reveals that mental health nurses are not trained or are ignoring the fact that in addition to care they have to take active role and work as an advocate for reducing stigmatisation and discrimination which is directly affecting the well being of the elderly people with dementia. Dementia makes changes in the behaviour to such an extent that it becomes difficult for the relative and carer to interact with them. (Adams and Manthorpe, 2003). Elderly people with dementia cannot live or do something independently and they always require assistance to behave normally and communicate with the environment. This is the main reason of their social isolation where people are unaware of the problem they are facing and are very often neglected or assaulted in the society. It is very difficult to create a dementia friendly environment unless this problem is taken into consideration. Elderly people with dementia are often found to hallucinate and make false statements. This causes major stress for the family members and the care givers. To avoid this situation, they are isolated from the society. But social exclusion cannot solve the problem rather make it more complicated. It is observed that elderly people with dementia is increasing and is a global concern. The creation of anti-stigma intervention strategy is the only way for having a dementia friendly environment. The implementation of the strategies requires skilled and trained mental health nurses who will act as a bridge between the society and elderly people with dementia. It is the responsibility of the mental heath nurses to educate the society, protest against the injustice done to them in the society and fight for their rights. Different researches are going on for designing different tools to reduce stigmatisation by identifying the strength and weakness of the society. But the implementation and the success depend on the nurses. It is very important that the nurses are educated so that they can educate the society and help elderly people with dementia to participate in different activities in the society. Reducing stigmatisation is important for creating dementia friendly environment. Social isolation is solely because of stigma(Ashworth, 2017).On the contrary if the communication between the elderly people with dementia and society increases it reduces stigma (Herrmann, Welter, et al., 2018).The confidence,wellbeing,quality of life slowly detoriates and eventually destroys if not handled delicately((Swaffer, 2016).The systematic review give us a clear idea that elderly people with dementia are not allowed to speak neither they are believed or their ideas are used for any constructive work. This is known as ‘epistemic injustices’ (Fricker, 2007). There are three types of stigma affecting the elderly people with dementia-Public stigma, Self-stigma and courtesy stigma (Rüsch et al., 2005). Public stigma and self-stigma are responsible for epistemic injustice in which reaction of the public towards the elderly people with dementia is predominant leading to social exclusion. Nurses are required to provide person centered care and act as an advocate for accomplishment of their interest and providing them an environment in which they will have the power to participate like other member of the society. Discrimination is not acceptable which will isolate our near and dear ones from the society. It is very mush necessary and WHO has recommended implementation of different strategies that has to be formulated according to the requirement of the respective society. The primary responsibility lies with the mental health nurses. Till date very little attention is given in this area so worldwide the problem not only persist but is increasing. Skilled nurses can educate the society, make them to understand the problem elderly people with dementia are facing, coordinate between them so that they can actively participate and share their knowledge, protect and prevent any abuse or assault and provide them social justice. But unfortunately, very little evidences are there regarding their contribution in this area for creating dementia friendly environment. The prevalence of stigmatisation is less in high income countries compare to middle- and low-income countries and one of the main reasons behind this is the participation and awareness of the nurses to deal with the situation for creating dementia friendly environment. Dissemination Plan: The study explains that mental health nurses can reduce stigmatisation and provide social justice to elderly people with dementia. But recent investigation shows that nurses are not actively participating to create a dementia friendly environment. Based on the findings it is very important to formulate a plan targeting the nurses of the society. The nurses can act as a mentor for educating the society. So, awareness program for the nurses has to be conducted where trained expertise nurses will guide the initial target audience and provide them necessary skills and training to act as a mentor in the society. The selected mental health nurses can be divided into groups to initiate educational campaign in their respective society. The mental health nurses who are taking care of elderly people with dementia are selected to participate in the educational campaign. They can remove the barrier by educating, protesting the negative attitudes of the society and also can guide the elderly people to participate in different events so as to regain their self-confidence. Conclusion: Elderly people with dementia are increasing day by day. But the main problem is that dementia is not curable and it is a progressive declination of the cognitive ability of the individual. It is such a change in the brain that the person stops behaving rationally and makes objectionable statement due to hallucinations. This creates lot of stress and uncomfortable situation for the family members and care givers. They are often misunderstood and neglected by the society. They are isolated from the society due to the unpleasant behaviour which they do unintentionally. The only way of helping elderly people with dementia is by creating dementia friendly environment. The intervention by nurses is very important to provide them social justice. The implementation of different strategies to overcome epistemic injustice is to be taken as priority. Intervention by nurses can bring significant changes in the quality of life of elderly people with dementia. The evidence-based practice by nurses can bring a change to their life. The proficiency of the nurses in providing person centred care can be beneficial for both the elderly people with dementia and the society. There are various areas where nursing interventions is compulsory to get a favourable outcome or on the contrary without nursing interventions it is not possible to help the elderly people with dementia. In almost all the areas nurses are doing excellent job for helping elderly people with dementia. Nursing intervention which encourages and convinces the patients to do regular physical exercise is very appreciating which reduces many risk factors associated with the progression of dementia. They also encourage socialisation and provide support and assistance to the family members. Dementia cannot be well predicted initially as the representation is different in individual cases. Nursing intervention in this regard acts as an integral component to deal with the situation and identify the symptoms which can be better handled if detected earlier. The assessment by the nurses will help to educate the elderly people with dementia to act independently. Although nursing intervention is helping the elderly people with dementia and their family members to a large extent but still there is a significant gap which is acting as a hindrance in creating dementia friendly environment. The topic that is selected in our research is stigmatisation which is acting as a powerful obstacle for a happy life of the elderly people with dementia. It is very important to overcome the marginalisation to provide optimum health care to them. The selection of this area is done to highlight the area where minimal research is undertaken and improvement is essential globally. The research indicates that although care and protection is given to the elderly people with dementia but still, they are not having the right to participate in decision making which will not only improve their self confidence but provide them social acceptance. The intervention by nurses is definitely helping them and their family members but at the same time they are losing their self-esteem. There are many societies where they are ill-treated, neglected and isolated. Social isolation causes delay in their diagnosis as well as treatment. The intervention by the nurses must be strong to reduce sigma. The improvement in the health is the priority and that is not possible if they are not considered as a part of the society. The main problem is people are not fully aware of this condition. Dementia causes change in personality of a person and they lose control over their emotions. They continuously need supports and assistance and progressively loses their autonomy. The recognition of this group of patients at the early stage is necessary to help them to act independently in the society as long as they can do. Educating the society for helping elderly people with dementia is of priority. Ignorance of the problem will increase it and they may become a burden for the society. It is possible to tackle the situation smoothly which will reduce the stress of the family members and improve their quality of life. It is very important to consider them as a part of the society and appreciate their involvement in the society. They are to be encouraged for socialisation. As social interaction increases their self-confidences also increases. They consider themselves to be a part of the society and they have a significant role to perform in the society. This concept has to be inculcated in the mind of each and every member of the society. The implementation of different strategies requires intervention by nurses. The role of the mental health nurse is predominant in this regard .But often it is noticed that nurses are more bothered about their person care rather than providing social justice to them .It is important that they consider this also as a part of their services in addition to their normal standard protocol to care and support for them .It is noticed in different sectors of the society the nurses concentrate more on their health and provide them support in various ways to lead a normal life .But there is a difference between the normal life and quality life. The quality of the life can be improved if they are given importance in the society. Firstly, the nurses have to realise that it is their duty to act as an advocate and fight for their rights in the society. It is not possible to change the entire society. But planning and implementation of the plan is necessary to change the outlook of the people and provide them social justice. Educating the society is the responsibility of the nurses. They can organise for educational campaign to convince the people to help them to act normally and become a part of the society. In many places’ nurses are fighting for their social acceptance. If mental health nurse takes this as priority then it will be possible globally to have a dementia friendly environment for elderly people with dementia.

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References:

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Appendices:

Table1: Outcome and strategies for achievement of dementia friendly environment