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 Models for Older Persons with Dementia in Emergency Departments

Emergency departments should implement four key design principles—sensory-adapted environments, enhanced wayfinding, dementia-friendly physical spaces, and circadian lighting—alongside a person-centered care model to improve outcomes for older persons with dementia and/or BPSD. 1

Four Key Design Principles for Dementia-Friendly Emergency Departments

1. Sensory-Adapted Environment

Creating a sensory-balanced environment is crucial for reducing agitation and confusion in persons with dementia:

• Implement sound-absorbing materials to create designated quiet areas that minimize sensory overload, which is a common trigger for BPSD 1
• Use appropriate temperature control and comfortable seating to promote sensory comfort 1
• Reduce ambient noise which can exacerbate confusion and agitation in patients with dementia 1

This principle addresses the vulnerability cascade that occurs when persons with dementia are exposed to overstimulating environments, as identified in research showing that the chaotic ED setting combined with dementia results in unwanted clinical outcomes 2.

2. Enhanced Wayfinding and Orientation

Clear orientation cues help reduce confusion and anxiety:

• Install enhanced signage with large, high-contrast text and simple pictograms to help with orientation 1
• Place clocks, calendars, and orientation boards in each patient area to support temporal orientation 1
• Create spaces that allow for personal items from home to be displayed, providing familiar reference points 1

Research indicates that disorientation contributes to behavioral symptoms and increases caregiver stress during ED visits 3. These design elements directly address the finding that persons with dementia are often "waiting and worrying" in unfamiliar environments 4.

3. Dementia-Friendly Physical Space

Physical environment modifications that promote safety and independence:

• Use light-colored walls with matte finish to reduce glare and enhance visibility 1
• Design spaces without unnecessary barriers, with non-slip flooring and handrails to prevent falls 1
• Provide sturdy chairs with armrests to facilitate safe transfers 1
• Use extra-thick/soft pressure-redistributing foam mattresses to prevent skin breakdown 1
• Implement flexible room configurations that can be adjusted based on patient needs 1

These modifications address the finding that physical design significantly influences usability and activity in healthcare spaces, ultimately affecting patient outcomes 5.

4. Circadian-Supportive Lighting

Lighting designed to support natural rhythms:

• Implement soft lighting with exposure to natural light to reduce delirium and improve recovery times 1
• Use lighting that supports circadian rhythms to reduce sundowning behaviors 1
• Balance lighting to avoid glare while maintaining adequate illumination for safety and orientation 1

This principle addresses the disruption to normal sleep-wake cycles that often occurs in institutional settings, which can worsen BPSD symptoms 1.

Care Model: Person-Centered Approach

The most appropriate care model to complement these design principles is a person-centered approach:

• Focus on the older person-caregiver dyad as the unit of care, recognizing that both need support during ED visits 3
• Implement regular staff training in dementia recognition and communication techniques to ensure all ED personnel can effectively interact with persons with dementia 1
• Prioritize non-pharmacological interventions for agitation, such as de-escalation techniques and reorientation before considering restraints 1
• Create protocols for assessment using validated tools like the Brief Confusion Assessment Method (CAM) 1
• Establish clear discharge planning that includes caregiver education and appropriate follow-up 1

This care model directly addresses the finding that nurses need support to blend technical- and relationship-centered care in the ED setting 4.

Implementation in Emergency Departments

To incorporate these principles into ED practice:

1. Create dedicated dementia-friendly zones within the ED that incorporate all four design principles
2. Develop a phased implementation plan based on available resources 1
3. Train all ED staff in dementia care competencies and communication techniques 1
4. Implement contact-free monitors for patients at high risk of falls or wandering 1, 6
5. Establish clear protocols for assessment, intervention, and discharge planning 1

Ethical Considerations

Several ethical considerations must be addressed when implementing these design principles and care approaches:

• Autonomy vs. safety balance: Designing environments that promote independence while ensuring safety requires careful consideration of risk management 2
• Dignity preservation: Environmental design must support dignity by avoiding infantilization or institutional aesthetics 5
• Equitable resource allocation: Prioritizing cost-effective interventions that benefit multiple patient populations ensures ethical resource distribution 1
• Restraint minimization: Physical and chemical restraints should be minimized, using the least restrictive option for the shortest time when absolutely necessary 1
• Informed consent challenges: The ED environment and care model must accommodate decision-making support for those with cognitive impairment 2

Research shows that persons with dementia may experience disparities in treatment in the ED 4, making these ethical considerations particularly important to address through both environmental design and care approach.

The combination of these four design principles with a person-centered care model creates an emergency department that can better meet the needs of older persons with dementia and/or BPSD, potentially reducing negative outcomes and improving the experience for patients, caregivers, and staff alike.