Dementia care

Low fidelity and high fidelity prototyping, Nursing commitment to the food journey in acute hospitals, creating resources to support dementia patients, nursing culture drawback to development of soft facilities, how talking mats develop communication, technology and food pictures help dementia patients.

Dementia is an umbrella term for a brain disease that cause gradual and long-term decrease in the ability of thinking and remembering, which affects the individual’s daily functioning. Common symptoms include linguistic problem, decreased motivation, forgetfulness, emotional problems, anxiety, lack of consciousness and agitation in rare cases. There are different types of dementia, within which the most common type of dementia is Alzheimer’s disease, which contributes about 70% of the dementia cases (Verbeek et al. 2012). Globally, this disorder is affecting around 36 million people (World Health Organization 2012). In 2013, 1.7 million people died, having dementia. It has also been revealed that this disease affects mostly the aged people (Dupuis et al. 2012). Women are also has been seen to be more affected compared to men. There are several behavioral problems, from which the dementia patients suffer. There are a number of rehabilitation processes, which helps these people to improve their self-esteem and make them capable of doing their ADLs without having assistance from others.

As the disease is caused due to brain disorder, proper nutrition is very important for these people. It is because for a person with dementia, poor nutrition can increase behavioral symptoms and can cause weight loss. Jeon et al. (2012) reported that proper nutritional diet and physical exercise could help the dementia people to enhance their quality of life by enhancing their self-esteem. It has also been revealed that poor appetite is a common problem in the dementia patients. Poor appetite, physical disability, sensory disabilities and poor appetite can make eating and drinking difficult for a dementia patient. There are several issues or physical problems due to which they felt difficulty in eating and drinking (Gräske et al. 2012). One common problem is depression, which is most often linked with the dementia patients. The person might be depressed due to loss of social contact and autonomy in life. Depression makes the eating and drinking process more difficult. Communication is another significant problem that makes it difficult for dementia patient to have proper nutritional diet. They often cannot communicate about their urge of having food (Cahill et al. 2012). Medication dosage can also cause change of appetite. Constipation is another common problem is dementia patients, as it is a common problem in geriatric patients and dementia generally affects older people. Pain, tiredness and loss of physical activity can also be the significant cause of irregularity and poor diet of a dementia patient (Wortmann 2012). The main symptom of the dementia disorder, forgetfulness promotes the patient’s malnutrition and poor appetite. Thus, nurses have to be more careful and responsible for monitoring dementia patient’s diet and encourage their appetite. There are various ways of dealing with the challenging eating and drinking behavior of the dementia patient. Gitlin et al. (2012) reported that talking mat is one of the most effective way of encouraging appetite of the dementia patients. Talking mats can help the dementia patients to communicate with the caregiver properly and reduces the chance of forgetfulness. It helps the dementia patients to understand the importance of communication regarding having proper diet. Here, the current literatures would be reviewed regarding the dementia care within acute hospital, food care and the nursing culture towards food and the use of talking mats in dementia care.

Nursing staff culture towards food

Dementia patients have several difficulties in completing their daily activities, due to their cognitive and sensory impairments. In acute hospital, dementia care is a continuous challenge for the health care professionals, who are assigned with the problem of healing the patient’s primary acute illness (Stein-Parbury et al. 2012). In addition, the second condition of the patients is more challenging regarding the aspects of health care support for the patients. The wider community of practice in terms of healthcare business facilities has the additional challenge of providing the patient living with dementia the opportunity to eat for health and maintain nutritionally balanced whilst staying within the acute hospital.  Regarding the food services, several concerns have been raised throughout the research within the acute care hospitals (Gandesha et al. 2012). These concerns include financial budgetary constraints, commitment to change and culture related to the ward side and catering services. If the first element is taken into consideration as a blocker, it has been reviewed that 78% of inactive catering managers in the NHS counteract any changes affecting upon their daily routine (Gitlin 2012). Thus, the acute care hospitals have to undertake adequate techniques to deal with the food service and related issues for the dementia patients.  

Meeuwsen et al. (2012) reported several mealtime challenges, while working with the dementia patients in residents or long-term hospital care. These challenges include refusing to eat, becoming too distracted to eat, rejecting food, inability to use utensils properly, difficulties in chewing and inability of recognizing food. These challenges can make the frontline caregiver frustrated, while trying to encourage patients to eat and drink.

While handing the dementia patients, nurses have to be more careful about the patient’s satisfaction, as a whole. For dementia patients, communication and an emotional support is very essential. However, in most cases, nurses are not always readily handling the situation efficiently. Nurses often show reluctance in establishing a strong positive relationship with the dementia patients (Wortmann 2012). As the dementia patients have cognitive impairment followed by the communication difficulties, often nurses working with the dementia patients become irritated and exhausted, which negatively affects the nurse-patient relationship. It also reduces the quality of care and enhances patient’s dissatisfaction.

In acute care hospitals, nurses have shown to face several challenges, while handling dementia patients. One of the most relevant effects is inadequate nutritional benefits of the patients, followed by ill health, weight loss and progressing impairments. Thus, nurses have to be more concerned about the nutritional benefits of the patients along through the improvement in food culture of the dementia patients (Gandesha et al. 2012). There are several unique challenges for providing fresh, nutritious and high quality food to dementia patients, especially in an acute care hospital. Usually, the catering service providers do not want to make specific food for patients in different ward, but innovation in food culture can have a greater positive impact upon the dementia patient’s health. Especially, encouraging people with dementia for eating well and in a regular basis can be challenging. Thus, an innovative and care-centered food culture is very important for dementia patients. McGinley (2015) argued that great food can be highly powerful for people with dementia to combat with their high-care needs. Thus, nurses and other care staffs need to focus on innovative food culture. Identifying and implementing innovative technologies, which combines both appealing presentation and good nutrition should be promoted by the nursing culture in the acute care hospital. Talking mat has been implemented by several hospitals, which has achieved success significantly.

Importance of food and nutrition for patients diagnosed with dementia

Food and nutrition is very much important for the patients of dementia. A routine should be carried out for the nutritional screening like what are the dietary preferences and needs of individual dementia patient required should be recorded (Easterling, and Robbins 2008). The nursing staff should act on to ensure any type of assistance the patient requires during the meal times. The food should be made appetizing (Amujo 2015). Advice should be taken from the expert if it is required modify the texture of the food. Different food should be kept separate to improve the quality of eating experience. Language therapist should be appointed for the patients who are suffering from swallowing and speech problems. The amount of food and fluid taken by the patient must be recorded and later on it should be surveyed to find out the pattern of the food intake of the patient.

 The food must be accessible and available every time even in between the meal times. While eating there should not be any rush the patient should be allow to eat in a relax mode (Hartwell et al. 2013). There should be no time limit for completing the meal. Discreet assistance should be provided to the people who have difficulty in eating. Finger foods should be offered to those who have difficulty in using cutlery (McGinley 2015). and provide adapted cutlery and crockery so that the people become enable to feed themselves where appropriate. It should be ensured that there is presence of sufficient staff to provide assistance to those who need it during the meal times. Though socializing is encouraged during meal times but still privacy should be provide to the patient who difficulty in eating so that they does not feel embarrassing or their dignity must not be hampered. If there are insufficient staffs at the time of meal then it is better to introduce a system of staggered mealtimes.

The family member and the friends should be encouraged to visit and provide support during meal times. It should be ensured that the staffs have the skill to communicate with the people who have dementia and communication difficulties. In this respect the visual aids like pictorial menus, non-verbal communication skills may be helpful. In the case people having cognitive and communication difficulties information should be gather about their needs and preferences from the people who knows them. The food should be freshly prepared. Awareness should be raised among the staff regarding the risk of malnutrition and importance of providing good nutritional care.

Caring staff should be appointed for the patients who are staying at home and it should be ensured that the home care staffs have skill and sufficient time should be allocated to them so that they can prepare the meal of choice for the patient. The dementia patients should be encouraged to drink a lot of water regularly and throughout the whole day. Training, education and information should be provided to the caregiver and care staff about the benefits of good hydration. The patient should be provided clean water 24 hours a day.

The talking mats are one of the best technologies for assisting dementia patients in hospital or residential care homes. Talking mats were developed in a research project by Murphy in 1998, which has become a well-researched communication tool. It involves a talking mat, which allows Velcro symbols to be placed on it (Passalacqua and Harwood 2012). This tool aims to facilitate the discussion about a topic using picture cards on the mat. It can improve the communication skills of the patient and can help to enhance their self-esteem, thereby enhancing the overall effectiveness of the therapeutic processes for the dementia patients. In the case of dietary concerns, if the topic of the discussion is placed at the top of the mat along with two or more choices, the communication becomes easy and the caregiver would be able to know the food choices and preferences of the patient (Jurgens et al. 2012). Anyone can be benefitted with communication difficulties using the talking mats. The resources designed for the food preferences helps the patients to enhance their knowledge regarding the healthy diet and right food for them. It also enhances the food culture in the hospital. As the result of the entire procedure, the likelihood of the patient’s positive heath outcomes enhances.

How Talking Mats works

One of the significant issues of the dementia patients is the communication difficulties, which is a major reason behind their lowered self-esteem and poor health outcomes. The key focus of using talking mat is to eliminate the communication barrier between the caregiver and the dementia patient and improving the interaction as well as the capability of the patients to perform the daily living functions of the patients (Ryan et al. 2012). The talking Mats Limited is a social enterprise and the company’s vision is to improve the life style of the people living with communication difficulties, including dementia patients as well as to make it easy for the caregivers to interact with those patients, by increasing the capability of the patients to communicate effectively about things that matter to them.

Talking mats involve useful communication symbols tool, based on the extensive research and it is designed by the speech and language therapists. The talking mats use unique and specifically designed picture communication symbols, which are attractive to people from all age groups. It is used by the clinical practitioners, careers and support workers, working with diverse range of health, residential, hospital and educational settings (Sadowsky and Galvin 2012).

It is an interactive resource, using three different sets of picture communication symbol. These include topics, options and visual scale, along with a space on which to display them, which is known as the ‘mat’. The display screen can be either physical, digital space or a textured mat, such as a smart board, computer screen a tablet or a computer screen.  Sometimes, simple hard copy of pictures is used to communicate with the patients on simple black card board (Murphy and Oliver 2013). The overall aim is to reduce he communication barriers within the patients and care givers. The top scale allows the participants to highlight their feelings about each topic and options. The visual top scale is adapted according to the topic or questions the caregiver wants to discuss with the patients. In case of dementia patients, during mealtime, this talking mat can be used for asking their food preferences or their willing to eat, where symbols of ‘hungry’, ‘not hungry’ or a third option may be there like ‘not sure’. They can also use options such as ‘I like’, ‘I don’t like’ or ‘not sure’ (Dupuis et al. (2012). Once the topic has been selected, the patient is given some options, one at a time and asked to think about their feelings regarding those options. Then, they are allowed to place the symbols under the appropriate visual scale.

Talking mats can help people with dementia and their family careers to feel more involved in decision making about the management of their everyday life. People with dementia have been reported that Talking mats clarified their thoughts and enabled them to express themselves. The analysis of the previous literature’s data, it has been showed that, compared to the usual communication methods, talking mat framework helps dementia patient to feel more involved in decision making about the food preferences and choices (Jootun and McGhee 2011). Te choices offered to them helps the dementia patients to convey their thoughts to their family members or careers and they feel valued through the enhancement of their self-esteem. Through the pictorial framework, patients are encouraged to enhance their food related awareness in a meaningful way. As the communication is done through some symbols and pictorial substances, talking mats are helpful for encoraging the dementia patients.

Benefits of using talking mats

Talking mat is used for enhancing the communication efficiency, as it provides a thinking tool for enabling people to explore issues and helping them to structure and verbalize their thoughts. In addition, the act of physically moving the picture symbols assists patients to organize their thoughts in a logical way (Bartlett 2012). This tool is effective enough, as it allows the participants to express both of their positive and negative feelings, thereby reducing the tendency of people to acquiesce. Additionally, taking mats help people to comprehend their views as well as assists in providing the effective way for expressing their feelings about the topic at that particular time. The structured and consistent format of the talking mats helps the people with dementia to keep concentration on the topic as well as for the listener to follow the track of conversation (Murphy and Boa 2012). This tool is helpful for all the age group of people to express their preferences or feelings. This tool is also helpful to the people with dementia, as they might have learning disability, by assisting them in understanding what is involved in a decision and in giving their opinion.

Figure: Talking Mat

(Source: Murphy et al. 2007)

There are a number of reasons behind the effective process of using talking mats in helping people to express their feelings. The clinical research provided evidences supporting the beneficial nature of talking mats, to express patient’s feelings by:

Supporting comprehension:

• It focuses on essential words and omits non-essential language, thereby reducing barrier
• Gives information in multiple channels including visual, auditory and tactile
• It helps people to process the concepts by breaking information in manageable, understandable and small portions
• It reduces memory demands, which is a very attractive and positive point for dementia patients
• Reduces distractibility
• It allows sufficient time to the patient for processing the information and respond accordingly (Murphy et al. 2014)

Improving quality of information

• It allow the patient to say ‘no’, thereby improving patient’s rights
• It avoids direct confrontation
• It provides structured framework to the care givers for open questions
• It gives the control to the person being interviewed
• Through the use of talking mats, feedbacks can be given to the patient’s family, carers and professionals
• Through its use, maintaining or developing relationship with patients becomes easier

The tool can also be personalized:

• By providing relevant and motivating topic
• Using it in a relaxed way to get to know someone
• Using throughout a wide range of ages and abilities
• As it does not require literacy
• By augmenting existing communication system

Various symbols are used in the talking mats relevant to the service or activity regarding which the communication is necessary. For meal time, the use of talking mats help in engaging people with dementia to gain nutritional benefits.

 Malnourishment can enhance the likelihood of poor wound healing, infections, immune deficiency, pressure ulcers, low blood pressure, anemia and other issues. Inadequate drinking of water can lead to dehydration, which are associated with complications like urinary tract infection, constipation, pneumonia, renal disease, hypotension or delirium. On the other hand, lack of adequate fluid intake and nutrition can negatively affect the behavior and mood of the patient along with the progress of the dementia disorder. Thus, it is very much important to maintain the nutritional balance in dementia patient’s diet. In this context, several strategies are used by the caregivers to encourage healthy and nutritional diet of the dementia patients. Barker and Board (2012) has claimed that as many as 85 % of acute care hospital residents or residents of long-term care homes, are undernourished and 60 % residents are shown to be suffered from dehydration (Alzheimers.org.uk 2016). On the other hand, unintended weight loss is associated with the long-term residential care for dementia.

According to Boardman et al. (2015), “the mealtime is a time when people have the greatest opportunity to do something to which he or she is familiar with, comfortable and noninvasive. It is a chance for the individuals to achieve real success”. Therefore, this process can enhance the self-esteem of the person. The caregivers thus, need to become more familiar with the patient and their food preferences, while understanding their ability to manage the process of eating (Jones 2012). However, learning the food preferences for the person along with the food restrictions can be a time-consuming process including trial and error.

While designing the talking mat for the dementia patient, with a aim of improving the nutritional benefits, the ‘topic’ would be ‘breakfast’, ‘lunch’, ‘supper’, ‘dinner’ or ‘snacks’. The visual scale would include the eating symbols and the patients would be provided with some options of healthy foods, which are important for their nutritional benefits (Kelly et al. 2012). The talking mat can be used in planning the menu with the consent of the patient. In the case of dementia care in acute care hospital, the care providers use the talking mats, for ensuring the food preferences of the patients, to educate patient, encouraging patients for having the nutritional meal and to make the communication easier.

Resources designing for the mealtime talking mat will include eating and drinking mats including all the food preferences for the patient. Initially, the visual scale will be determined by including the symbols of ‘like’, dislike’ and ‘neutral’. Then the options will be provided to the patients. For example, if the talking mat is designed for the breakfast, for drink, the patient will be provided with the pictorial options of orange juice, tea, coffee and milk. The patients, according to their preferences, would put the pictures under ‘like’ or ‘dislike’ column (Nolan 2012). If it is the time of snacks, the pictorial options would include some healthy food images along with some of the tasty foods, which are usually no recommended to the dementia patients. Here, in this situation, if the patient selects and mark an unhealthy food as ‘liked’, the caregiver would remind the patient about the importance of nutritional balance for their better health outcomes (Shea 2012). Therefore, at a time, taking mat can be used as the communication tool at mealtime as well as it ca used as the educational tool.

Figure: Symbols in Talking Mat

(Source: www.talkingmats.com 2016)

The talking mat can also be designed as the educational tool to enhance the awareness of the patients about the healthy diet and the importance of healthy diet in their life. Here, the symbols of health, meals, impact on heath and things that might help can be used. It will help the person to think about what is good to eat and why it is good to it. In one hand, it will educate the patient, but the talking mat eliminates the need of memorizing things, which is very helpful to the dementia patients, as they usually undergoes cognitive impairment and thereby experiencing forgetfulness (Barker and Board 2012). Usually, it hinders the normal communication within the staffs and patient and enhances both patient’s and nurse’s dissatisfaction, but with the use of talking mats, the misinterpretation, incorrect medication administration and patient’s dissatisfaction is reduced. It has been proved in several hospitals in Victoria, Australia. In addition, the talking mat can also include the equipments needed by an individual for meal. They can also provide options of equipments and these options should be colorful and attractive. For example, pictures of fork, spoon, bowl, plate and others can be provided and patient are allowed to select their favorite equipment for the having the meal (Jones 2012). It enhances the sense of logical thought process. In addition, the satisfactory communication leads to a good and trustworthy relationship within the patient and caregivers. In this way this tool reduces repetitive behavior and help to keep the participants engaged in the conversation.

Talking mats are low-fidelity tools and thus these tools are highly accessible communication tool. These tools are also inexpensive. The mats can be designed in tablet or in computer screen. Studies have shown that the framework is capable of providing an effective tool to staffs and carers, for allowing people with dementia to communicate their needs an preferences more easily (Murphy and Boa 2012). These tools are accessible to all category patients. It is a low fidelity tool that means the tool allows the participants or users to give feedback and opinion. As a result, the communication is improved within the participants and care givers. In this system, caregivers would prioritize patient’s autonomy. Patients would not be forced to eat according to the choice of the hospital catering service; rather, the patients are allowed to express their feedback, their views about their preferences, according to which their meals are planned. Therefore, this tool supports the person-centered care. According to the feedback of the caregivers as well as the preferences of the patient, the following meals of the patient will be designed. Here, the use of pictorial symbols will help to motivate the patient’s participation in the clinical practice. In contrast to the low fidelity, if the tool was high fidelity one, there would be no options for collecting feedback and the tool might not be able to enhance patient’s autonomy and self-esteem (Bartlett 2012). Thus, the low fidelity nature of the tool is effective enough to enhance its performance and improve the nutritional benefits of the patient.

Using pictorial menu is helpful for a healthy food journey of the dementia patients, as highlighted by (Gitlin 2012). It has been seen that pictorial and symbolic communication tools used in the talking mats help the dementia patients to develop a sense of good food and healthy diet. It helps to enhance patient’s independence. On the other hand, dementia patients are not good in their behavioral aspects regarding eating and drinking. Thus, with the help of the pictorial menus, care givers can easily communicate and convey the healthy food preferences. It is also linked with patient’s health promotion for healthy food habit.  

Using pictorial menu in the acute care hospital dealing with the dementia patients involve talking mats to communicate with the patients. Several studies have shown enhanced interest of the dementia patients through the use of pictorial menus at different meal times. It makes their food journey colorful and enjoyable. Usually patients with dementia suffer from communication difficulties, due to cognitive and sensory impairment (Wortmann 2012). When someone has communication difficulties, they would be able to point out their preferable meals, according to their own choice from the pictorial menu.

The menu with featured images of fresh foods and recommended drinks, which are daily cooked on site, has been launched in different hospitals, which has shown significant benefits in improving the journey of the dementia patients. The patients, who are not able to communicate, will have the options of pointing out or voicing their choice of food through these images. Food First Dietitian Victoria Forrest, who has driven the introduction of pictorial menu alongside the catering department, perceived that it would make a real difference with the conventional food journey of the dementia patients in the acute care hospital (World Health Organization 2012). With the help of pictorial menu, people are picking up some food that they like, instead of the care giver in the ward choosing the food staffs for a patient, as because they are unable to communicate properly, as claimed by (Barker and Board 2012). For the dementia patients, the dieticians would make specific menus that are exciting as well as meet their dietary needs. The dementia patients can benefit from the menu designed with the user-friendly layout, color scheme and images of relevant animals that can promote the recognition and the interest towards eating and drinking. These pictorial menu can help to break down language barriers as well as helps in patient education, which very important part in both the palliative and dementia patient care. The pictorial menu can be made differently for breakfast, lunch, supper and dinner as well as for each day in a week. In the Countess of Chester hospital, this pictorial menu has been implemented in the department of dementia as well as the other wards of the hospital and has led to the achievement of successful outcomes.  The hospital staffs have reported improved nutritional benefits through encouraging the patient.

It has been argued by Jones (2012) “providing the choice of nutritious, appetizing meals that meet the needs and choice of individuals and supporting with eating where needed, can improve the dignity factors in the dementia care in an acute care hospital as well as in any residential care r nursing homes. The efficiency of the care services enhances with regular nutritional screening of the patient.

Conclusion

In conclusion, it can be said that the talking mats are very essential tools for improving the communication with dementia patients in an acute care hospital. The taking mats can effectively enhance the quality of care provided by the hospital authority as well as the residential care homes. Studies suggested that the usually dementia patients loses cognitive competency and faces difficulties in completing their daily functions including eating, drinking, bathing and other daily functions. Talking mats can helps in patient education and help in patient’s nutritional improvement. Several highlighted that due to the communication difficulties and memory impairment, the care givers often feels exhausted, while working with the dementia patients, which reduces the quality of work, but through the use of talking mats, the communication can be improved several times, enhancing the satisfaction of both the patients as well as the care givers. It also enhances patient’s autonomy and promotes dignity factors in the care provision. The catering services of the acute care hospitals often deny to take responsibilities of patient’s satisfaction, which lowers the quality of care provided, but through the use of talking mats and pictorial menus, patients are allowed to express their feelings and give their opinion in their food journey. Involvement of patients in the decision-making or their food journey encourages patients to participate positively in the journey and the rate of refusing meals is reduced, thereby improving the patient’s health outcomes as a whole. The  talking mat is a very useful tool that helps in enhancing the communication competency in the patients and helps in reducing the barriers. As it is a low fidelity tool, simple modifications can be done according to the patient’s preferences and it helps in reducing misinterpretation, while enhancing the efficiency of the nurse-patients relationship and the quality of care.

For improving the food journey of the dementia patients, the nursing staffs would have to change the perception and have to implement innovative food culture in the hospital premises. It would make their work easier, would assist in relationship building with the patient as well as would enhance the overall quality of care services provided in the acute care hospital. From this literature review, it has been revealed that the innovative technology and resource design can be beneficial for combating with the communicational difficulties as well as nutritional deficits in an acute care hospital. Further studies regarding more innovative food culture are needed for improving the food journey of the patients.

Reference List

Alzheimers.org.uk, 2016. Alzheimer’s Society – Dementia support and research charity. [online] Alzheimers.org.uk. Available at: <https://www.alzheimers.org.uk> [Accessed 2 Sep. 2016].

Amujo, A.R., 2015. Dementia and the Gap in Nutrition: A Review. Science, 3(5), pp.761-769.

Barker, S. and Board, M., 2012. Dementia care in nursing. London: Learning Matters.

Bartlett, R., 2012. Modifying the diary interview method to research the lives of people with dementia. Qualitative Health Research, 22(12), pp.1717-1726.

Boardman, L., Crichton, C. and Butterworth, S., 2015. When you cant talk about it: Using Talking Mats to enable an offender with communication difficulties to express his thoughts and beliefs.Probation Journal, 63(1), pp.72-79.

Cahill, S., O’Shea, E. and Pierce, M., 2012. Creating excellence in dementia care: a research review for Ireland’s national dementia strategy.

Dupuis, S.L., Gillies, J., Carson, J., Whyte, C., Genoe, R., Loiselle, L. and Sadler, L., 2012. Moving beyond patient and client approaches: Mobilizing ‘authentic partnerships’ in dementia care, support and services. Dementia,11(4), pp.427-452.

Dupuis, S.L., Gillies, J., Carson, J., Whyte, C., Genoe, R., Loiselle, L. and Sadler, L., 2012. Moving beyond patient and client approaches: Mobilizing ‘authentic partnerships’ in dementia care, support and services. Dementia,11(4), pp.427-452.

Easterling, C.S. and Robbins, E., 2008. Dementia and dysphagia. Geriatric Nursing, 29(4), pp.275-285.

Gandesha, A., Souza, R., Chaplin, R. and Hood, C., 2012. Adequacy of training in dementia care for acute hospital staff: Aarti Gandesha and colleagues present the results of a national audit to assess how hospital staff from different specialties rated their awareness of the needs of patients with dementia. Nursing older people, 24(4), pp.26-31.

Gitlin, L.N., 2012. Good news for dementia care: caregiver interventions reduce behavioral symptoms in people with dementia and family distress.American Journal of Psychiatry, 169(9), pp.894-897.

Gitlin, L.N., Kales, H.C. and Lyketsos, C.G., 2012. Nonpharmacologic management of behavioral symptoms in dementia. JAMA, 308(19), pp.2020-2029.

Gräske, J., Fischer, T., Kuhlmey, A. and Wolf-Ostermann, K., 2012. Quality of life in dementia care–differences in quality of life measurements performed by residents with dementia and by nursing staff. Aging & mental health, 16(7), pp.819-827.

Hartwell, H.J., Shepherd, P.A. and Edwards, J.S., 2013. Effects of a hospital ward eating environment on patients’ mealtime experience: A pilot study. Nutrition & dietetics, 70(4), pp.332-338.).

Jeon, Y.H., Luscombe, G., Chenoweth, L., Stein-Parbury, J., Brodaty, H., King, M. and Haas, M., 2012. Staff outcomes from the caring for aged dementia care resident study (CADRES): a cluster randomised trial.International journal of nursing studies, 49(5), pp.508-518.

Jones, M., 2012. Learning & Development: Communication – Keep on talking!. Nursery World, 2012(8).

Jootun, D. and McGhee, G., 2011. Effective communication with people who have dementia. Nursing Standard, 25(25), pp.40-46.

Jurgens, F.J., Clissett, P., Gladman, J.R. and Harwood, R.H., 2012. Why are family carers of people with dementia dissatisfied with general hospital care? A qualitative study. BMC geriatrics, 12(1), p.1.

Kelly, F., McCabe, L., Innes, A. and Andrews, J., 2012. Key issues in evolving dementia care. London: Jessica Kingsley Publishers.

McGinley, E., 2015. Practical nutritional measures in patients with dementia. Journal of Community Nursing, 29(6).

Meeuwsen, E.J., Melis, R.J., Van Der Aa, G.C., Golüke-Willemse, G.A., De Leest, B.J., Van Raak, F.H., Schölzel-Dorenbos, C.J., Verheijen, D.C., Verhey, F.R., Visser, M.C. and Wolfs, C.A., 2012. Effectiveness of dementia follow-up care by memory clinics or general practitioners: randomised controlled trial.

Murphy, J. and Boa, S., 2012. Using the WHO-ICF with Talking Mats to enable adults with long-term communication difficulties to participate in goal setting. Augmentative and Alternative Communication, 28(1), pp.52-60.

Murphy, J. and Oliver, T., 2013. The use of Talking Mats to support people with dementia and their carers to make decisions together. Health & social care in the community, 21(2), pp.171-180.

Murphy, J., Gray, C. and Cox, S., 2007. Talking Mats: the effectiveness of a low technology communication framework to help people with dementia express their views. Journal of Assistive Technologies, 1(2), pp.30-34.

Murphy, K., Jordan, F., Hunter, A., Cooney, A. and Casey, D., 2014. Articulating the strategies for maximising the inclusion of people with dementia in qualitative research studies. Dementia, p.1471301213512489.

Nolan, Y., 2012. Dementia. Oxford: Pearson Education.

Passalacqua, S.A. and Harwood, J., 2012. VIPS communication skills training for paraprofessional dementia caregivers: an intervention to increase person-centered dementia care. Clinical Gerontologist, 35(5), pp.425-445.

Ryan, T., Gardiner, C., Bellamy, G., Gott, M. and Ingleton, C., 2012. Barriers and facilitators to the receipt of palliative care for people with dementia: the views of medical and nursing staff. Palliative Medicine, 26(7), pp.879-886.

Sadowsky, C.H. and Galvin, J.E., 2012. Guidelines for the management of cognitive and behavioral problems in dementia. The Journal of the American Board of Family Medicine, 25(3), pp.350-366.

Shea, T., 2012. Dementia. New York: Rosen Pub.

Stein-Parbury, J., Chenoweth, L., Jeon, Y.H., Brodaty, H., Haas, M. and Norman, R., 2012. Implementing person-centered care in residential dementia care. Clinical gerontologist, 35(5), pp.404-424.

Verbeek, H., Meyer, G., Leino-Kilpi, H., Zabalegui, A., Hallberg, I.R., Saks, K., Soto, M.E., Challis, D., Sauerland, D. and Hamers, J.P., 2012. A European study investigating patterns of transition from home care towards institutional dementia care: the protocol of a RightTimePlaceCare study.BMC Public Health, 12(1), p.1.

World Health Organization, 2012. Dementia: a public health priority. World Health Organization.

Wortmann, M., 2012. Dementia: a global health priority-highlights from an ADI and World Health Organization report. Alzheimer’s research & therapy,4(5), p.1.

www.talkingmats.com, 2016. Talking Mats | Improving communication, improving lives. [online] Talking Mats. Available at: <https://www.talkingmats.com/> [Accessed 2 Sep. 2016].