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Long-stay care for people with dementia in Ireland currently occurs in five residential types: health board geriatric homes, welfare homes, district hospitals, private nursing homes and voluntary homes. While we have estimates of the number of people with dementia in each type of care, the figures that are available are likely to be significantly underestimated (Browne, 1996). Therefore, while we can speculate that somewhere between 6,000 and 9,000 long-stay residents, equal to approximately one third to one half of all residents (Ineichen, 1990), suffer from dementia we cannot be sure of the validity of these figures. The absence of hard information on this issue is surprising, given the availability of sophisticated assessment scales to measure cognition, and the

captive nature of the population under observation4. It is difficult to plan for care in residential settings, particularly in the area of nursing care and the skills mix of providers when the accuracy of population estimates remains an issue. This deficiency in data collection needs to be resolved immediately through a careful audit of dementia in long-stay care settings.

The majority of people with dementia who are in residential care in Ireland are looked after in generic long-stay facilities (see Table 4.2). Care in public institutions has evolved along workhouse lines, with the emphasis on physical and medical needs rather than on the needs arising from cognitive impairment. It is easy, therefore, to agree with the recent recommendation of Ruddle et al, (1997) that health boards should provide residential accommodation adapted to the individual needs of the person with dementia as a matter of urgency. The private sector has been equally reluctant to invest in special facilities for people with dementia. Very few private nursing homes have developed special

accommodation, or design features, for people with dementia, due mainly to the cost of such adaptations. Environmental design is now widely regarded as crucial in the care of people with dementia. Some people have argued that design is as critical an ingredient in residential care as nursing care, or the approach to the organisation of care within the facility (Calkins, 1988). Good models in environmental design emphasise smallness, normal domestic

facilities, appropriate decor linked to the memory of residents, appropriate stimulation, easy access, and opportunities to observe the daily life of the unit (Fleming and Bowles, 1987).

The focus on design, linked to consumer preference and empowerment, is evident in more recent residential developments for people with dementia in other countries. Marshall, (1993, 1997) is a good example of current thinking on design, emphasising as she does small-scale units, home-like environments, visual landmarks, controlled stimuli, single rooms furnished to the taste of residents, and safe outside and/or conservatory space. While most of the work on design has been centred on residential care it is important not to forget the role of home environmental modifications, given the fact that the majority of people with dementia live at home. This is a neglected area of enquiry but one which is very important given the impact of environment on the well-being of people with dementia wherever the location (Gitlin and Corcoran, 1996).

A growing trend in other countries has been the development of specialist care units (SCUs) for people with dementia, attached, more often than not, to

mainstream long-stay facilities (Woods, 1995; Downs and Marshall, 1997). This development recognises that some people with dementia require in-patient care geared to their particular needs. There is no standard definition of a

special care unit, although experts in dementia care agree on the following five characteristics (Mentes and Buckwalter, 1998):

• admission of residents with cognitive impairment

• staff specification, selection and training

• activity programming for the cognitively impaired

• family programming and involvement

• segregated and modified physical and social environment

The scale of the operation is a very important consideration in SCUs. The emphasis is on smaller sized units, designed and fitted to resemble a home away from home, offering appropriate activities, a spatial layout to facilitate

wandering, and attention to colour and sound. Existing SCUs vary in terms of size, structure, philosophy of care, staffing and organisation, and cater for very diverse populations (Lefoy et al, 1997; Williams and Trubatch, 1993). The heterogeneity of provision in this area makes it difficult to pass judgement on the overall effectiveness of these units. The development of a consensus on whether SCUs are effective, and if so, how and for whom, is, therefore, likely to be a slow process (Sloane et al, 1995; Mentes and Buckwalter, 1998).

Nevertheless, SCUs are an increasing feature of the residential landscape. The Confused and Demented Elderly units (CADE) in New South Wales cater for people with high levels of challenging behaviour in eight-bed units. In the United States, SCUs tend to be designed with the needs of the mid-stage

dementia resident in mind (Kovach, 1996). In Sweden, group homes have been developed as an alternative to traditional residential care. Suitably adapted ordinary housing is used to promote the domestic and social abilities of people with dementia. In France, small units for dementia sufferers are also a feature of the care landscape, with the emphasis again on homely provision of care in a secure and safe environment. In the UK, the Domus Project facilitates new patterns of group living, where people with dementia largely fend for

themselves, with support from appropriate care services. The results from the Domus Project are positive with evaluations showing more interaction among residents, less depression, and a lower rate of general decline, than for people with dementia in conventional residential settings (Dean et al, 1993; Murphy et

al, 1994). There is strong international support for the positive impact of small

scale residential settings, providing homely care in an appropriate physical environment, on the quality of life of people suffering from dementia (Carr and Marshall, 1993). This explains why the general policy trend in most countries

is for this size and type of structure, although the proportion and type of people with dementia in such settings varies from country to country.

There are some specialist dementia units in this country, but there is no

universal approach to the care of people with dementia in residential settings. People with dementia without significant behavioural problems tend to end up in conventional generic long-stay facilities, both public and private, while

people with challenging behaviours tend to be treated in psychiatric institutions. During the consultations process we heard many stories of the difficulty of getting ambulant dementia patients with only mildly disruptive behavioural problems into long-stay facilities, especially into private nursing homes. This is an unsatisfactory state of affairs and one that must be addressed immediately through the provision of small-scale, domestic-oriented, specialist units

associated with mainstream long-stay facilities. Mostly, this will only require the modification and adaptation of existing buildings, but new investment may be required in some cases. Some people with dementia and associated

behavioural problems will continue to require long-stay psychiatric care. Design and environmental issues are equally important in this setting.

The Alzheimer unit attached to Highfield in Dublin and the order of St. John of God nursing home in Shankill, Co. Dublin are good examples of what can be achieved when attention is given to the issues of staffing, environment and design for people with dementia. Similarly, the recent establishment of a dedicated dementia unit in St. Mary's long-stay hospital in Castlebar is a good example of what can be achieved through the fusion of geriatric and psychiatric services with the objective of an improved service for confused elderly people needing specialist care. Staffing and training, combined with physical

environment and design, are the key ingredients for a more person-centred approach to residential care for people with dementia.

19. We recommend the provision of small-scale, domestic-oriented, specialist units attached to conventional long-stay facilities for people with dementia without significant behavioural problems, but who need long-stay care.