Course content – PFLEGE-16
8. Module 7 · Environmental design (milieu)
8.3. Case, consolidation & transfer
Two cases and what to take away
The ‘hole’ in the floor
Mrs L. suddenly refuses to enter a particular corridor, becomes anxious and turns back. The team is at a loss. A carer looks at the situation from Mrs L.’s perspective and realises: Mrs L. (impaired contrast vision) perceives a dark floor covering/a dark doormat as a ‘hole’ that she does not want to step into. After the dark area is removed/adapted, Mrs L. walks through the corridor again without worry. The case shows how altered perception in dementia explains behaviour – and how adapting the environment (with an understanding of the inner world) solves the problem.
Mr Ferreira and the front door
Mr Ferreira (fictitious), 79, repeatedly goes to the front door of his care home in the late afternoon and tries to open it. Staff are worried, and one proposes locking the corridor at the end of the day. Chloe (fictitious), a carer, notes that he was a bus driver who ended his shift at five. The team walks the route with him. They find that the corridor ends at a blank wall with a fire door, that the television in the lounge is loud at that hour, and that the only seat faces the door. They change three things. A circular route is opened through the garden room, a seat with a view of the garden replaces the one facing the door, and a carer invites him at 4.45 p.m. to “check the route”. A small bus-timetable board hangs on the wall. He still goes to the door occasionally, but he now walks the loop most afternoons and returns calmer.
Analysis. (1) The behaviour had a meaning: a daily routine from his working life (Module 5). (2) The environment offered no safe alternative, because the corridor was a dead end (Figure 7.3). (3) Noise and the position of the seat added pressure (Figure 7.2). (4) The team chose to give the urge a safe outlet instead of restricting him; a locked corridor could amount to a deprivation of liberty that needs approval (section 1831(4) BGB) and would add frustration. (5) The invitation at a fixed time created an anchor point (Module 6). (6) The team should still check for pain, hunger and the toilet, and review the plan if he shows signs of distress.
Why is the environment called “therapy” in dementia care?
Name three perception traps.
How do you recognise too much stimulation?
Why choose circular routes?
What does section 1831(4) BGB cover?
What is the best first step in a walk-through?
Key messages
- The environment works every hour of the day and is a powerful, often underestimated factor.
- Perception changes in dementia can turn a mat into a hole and a mirror into a stranger.
- Aim for balanced stimulation, with a quiet place and a lively place within reach.
- Light, noise and contrast are the cheapest levers. Change one thing at a time and check.
- Secure the hazard, not the person. Circular routes give movement a safe outlet.
- In Germany, longer-term or regular deprivation of liberty needs court approval (section 1831 BGB).
- Where in your workplace does someone hesitate, stop or avoid a spot, and what might they see?
- Which of your own habits (a loud radio, a bright light at night) add to the stimulation around people?
- Which small change could you suggest to your team this week, and how would you check that it helped?
- ☐ I look at a space from the person’s eye level, in daylight and in the evening.
- ☐ I note where people hesitate, stop or avoid and I look for the cause.
- ☐ I reduce noise and glare before I look for other explanations.
- ☐ I check that walking routes have no dead ends and have places to rest.
- ☐ I change one thing at a time and share the result with the team.
Exercise: Walk through your area with ‘dementia eyes’: does the environment promote orientation and safety? Is there overstimulation, confusing patterns, shadows, ‘hole’ effects, unsafe routes? Note down one improvement to the milieu design.