What design principles and care model should be used in an emergency department to cater to older persons with dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning) and/or Behavioral and Psychological Symptoms of Dementia (BPSD)?

Design Principles and Care Model for Older Persons with Dementia in Emergency Departments

Emergency departments must implement specific design principles and a person-centered care model to effectively support older persons with dementia and BPSD, focusing on safety, orientation, sensory optimization, and comfort to reduce morbidity and mortality.

Four Key Design Principles for Dementia-Friendly Emergency Departments

1. Enhanced Sensory Optimization

• Lighting Modifications: Implement soft lighting with exposure to natural light to reduce delirium and improve recovery times 1
• Visual Orientation: Use light-colored walls with matte finish to reduce glare and enhance visibility 1
• Noise Reduction: Create designated quiet areas with sound-absorbing materials to minimize sensory overload that can trigger BPSD 1
• Clear Signage: Install enhanced signage with large, high-contrast text and simple pictograms to help with orientation 1

This principle enables older persons with dementia by reducing confusion and agitation triggered by overstimulating environments, which are common causes of increased BPSD in emergency settings.

2. Safety-Focused Physical Environment

• Furniture Selection: Provide sturdy chairs with armrests to facilitate safe transfers and prevent falls 1
• Enhanced Mattresses: Use extra-thick/soft pressure-redistributing foam mattresses to prevent skin breakdown and pressure ulcers 1
• Fall Prevention: Design spaces without unnecessary barriers, with non-slip flooring and handrails 1
• Monitoring Systems: Implement contact-free monitors for patients at high risk of falls or wandering 1

This principle directly addresses the high risk of falls and injuries in older persons with dementia, which are significant contributors to morbidity and mortality in this population.

3. Orientation-Supporting Features

• Memory Cues: Install clocks, calendars, and orientation boards in each patient area 1
• Familiar Objects: Create spaces that allow for personal items from home to be displayed 1
• Consistent Layout: Design intuitive pathways with clear visual cues to bathrooms and other essential areas 2
• Day/Night Distinction: Implement lighting that supports circadian rhythms to reduce sundowning behaviors 1

This principle helps maintain cognitive functioning by providing environmental supports that compensate for memory deficits, reducing confusion and the resultant anxiety that can trigger BPSD.

4. Comfort and Dignity Enhancement

• Privacy Options: Create spaces that allow for privacy during assessments and procedures 3
• Family Accommodation: Design spaces that accommodate family caregivers at the bedside 4
• Adaptable Spaces: Implement flexible room configurations that can be adjusted based on patient needs 1
• Sensory Comfort: Use appropriate temperature control, comfortable seating, and reduced ambient noise 1

This principle recognizes that maintaining dignity and comfort significantly reduces agitation and distress in persons with dementia, improving both patient experience and clinical outcomes.

Person-Centered Care Model for Implementation

The optimal care model for persons with dementia in the ED is a Person-Centered Care Approach that treats the patient-caregiver dyad as the unit of care 4.

Key Components of the Person-Centered Care Model:

1. Specialized Staff Training

   • Train all ED staff in dementia recognition and communication techniques 1
   • Develop dementia care competencies for ED nurses and physicians 3
   • Implement regular simulation training for managing BPSD without chemical restraints 1

2. Structured Assessment Protocols

   • Use validated delirium screening tools like the Brief Confusion Assessment Method (CAM) 5
   • Implement pain assessment tools specifically designed for persons with cognitive impairment 3
   • Conduct medication reviews to identify potentially inappropriate medications 5

3. Family/Caregiver Integration

   • Actively include caregivers in the assessment and care planning process 4
   • Document caregiver observations about baseline function and recent changes 4
   • Provide clear communication channels between staff and caregivers 6

4. Non-Pharmacological Approaches to BPSD

   • Prioritize non-pharmacological interventions for agitation 1
   • Create protocols for de-escalation techniques before considering restraints 1
   • Implement reorientation techniques including dry erase boards and consistent communication 1

Staff Implementation of the Care Model:

Staff will implement this approach through:

1. Triage Modifications

   • Recognize atypical presentation of illness in persons with dementia 4
   • Prioritize rapid assessment to minimize waiting time 4
   • Assign dedicated staff members for continuity of care 6

2. Communication Strategies

   • Use simple, clear language with one question or instruction at a time 7
   • Maintain eye contact and a calm demeanor 7
   • Allow extra time for response and processing 6

3. Environmental Adaptations

   • Assign patients to quieter areas when possible 2
   • Minimize transfers between different areas of the ED 4
   • Ensure adequate lighting to prevent misperceptions 2

4. Care Coordination

   • Establish clear discharge planning that includes caregiver education 1
   • Provide large-font written instructions 1
   • Ensure appropriate follow-up and home safety assessment 1

Ethical Considerations

1. Autonomy vs. Safety Balance

   • Respecting patient autonomy while ensuring safety presents a significant ethical challenge 7
   • Solution: Implement least restrictive approaches first, with clear documentation of decision-making processes when safety interventions are required 1
   • Document capacity assessments when patients with dementia refuse care 7

2. Chemical and Physical Restraint Use

   • Restraints should be minimized whenever possible 1
   • When necessary for safety, use the least restrictive option for the shortest time 1
   • Document clear indications, alternatives attempted, and monitoring plans 1
   • Regular review of restraint practices through quality improvement initiatives 1

3. Privacy and Dignity

   • The open nature of many EDs challenges privacy maintenance 2
   • Solution: Create policies that protect dignity during personal care 6
   • Train staff in maintaining patient dignity during all interactions 7

4. Resource Allocation

   • Implementing specialized environments requires significant resources 3
   • Solution: Prioritize cost-effective interventions that can benefit multiple patient populations 1
   • Develop phased implementation plans based on available resources 1

5. Surrogate Decision-Making

   • Unclear decision-making authority can delay care 7
   • Solution: Develop protocols for identifying appropriate surrogate decision-makers 5
   • Create standardized documentation for advance directives and goals of care 1

By implementing these design principles and care model within the emergency department, healthcare facilities can significantly improve outcomes for older persons with dementia and BPSD, reducing distress, preventing complications, and ultimately decreasing morbidity and mortality in this vulnerable population.