Caregiver Joyce (left) and her mother, Celine Fernandez, in a hospital ward. Is the dogmatic insistence on four, six, or eight-bed wards necessary helpful for people with dementia and their caregivers?

Walls are not a luxury

By Jeremy Boo and Lee Xian Jie

The Ministry of Health has decided that it cannot provide subsidies for residents in Jade Circle, which was going to be a nursing home for people with dementia which planned to only provide single or twin rooms. Consequently, plans to build Jade Circle have been shelved.

The Ministry’s justification for their decision was that single or double-bedded rooms are “hard to scale or to be financially sustainable, if applied to the rest of the aged care sector”. Another suggested reason is that MOH did not want to be seen as subsidising a ‘luxury’ with taxpayers’ money. Eight-bed rooms are the norm in Singapore.

Privacy as good medical practice

Walls are not a luxury for people with dementia. When we were working on Before We Forget, a documentary project on dementia care in Singapore, we visited numerous nursing homes with dementia wards around the island. Hope Resident Living Area, part of Peacehaven Nursing Home’s collaboration with the Lien Foundation, struck us with the exceptional amount of freedom it afforded to people with dementia.

We stayed a night with one of their residents and saw over the weeks we were with him how his room was a sanctuary of sorts to him. The privacy mattered. When he got too tired from the bustle and watching eyes in the common area, he could retire to his room briefly. It was the same for the other residents.

People with dementia get easily disoriented by unfamiliar faces and they easily confuse identical beds and cupboards. When they get disorientated and confused, people with dementia often express their discomfort through disruptive behaviour.

On the other hand, when people with dementia are given personal spaces which they can personalise and grow familiar with, they act out in frustration less frequently. We saw at Hope how decreased incidents of frustration has a ripple effect of building a calming, stable atmosphere, which in turn leads to fewer emotional outbursts and other disruptive incidents.

The Ministry said in its 1993 White Paper that a “good basic medical package…will reflect up-to-date good medical practice. It will contain essential and cost-effective medical treatment of proven value. The treatment will be delivered without frills.”

Providing personal space is essential for people with dementia and can be considered good medical practice today.

In an article for Progress in Neurology and Psychiatry, psychiatrists Krishnamoorthy and Anderson wrote:

People with dementia need an environment in which they can explore and find their own personal space. Most people with dementia present little problem when left to their own devices. Environments that are restrictive can cause challenging behaviour because conflict arises from people getting in each other’s way. They may think other people are inhabiting ‘their house’ and try to eject them.

Another study has shown that people with lower cognitive strength adapt poorly to environmental stressors; sound in particular agitates people with dementia.

Curtains as walls?

Some may argue that curtains can give people with dementia the privacy and personal space they require. When we filmed Celine Fernandez who was warded for a stroke, her daughter kept the curtains closed almost permanently. Curtains helped to reduce the distraction and anxiety that Celine faced with the constant movement in the hospital ward.

But curtains are not walls. As Lien Foundation’s Lee Poh Wah has pointed out, there is a difference between staying in a hospital for the short term and living in a home for the remainder of one’s life. Curtains cannot give a sense of personal space and security that walls can. When Celine finally returned home from the hospital, it was the first time in 90 days that she slept without waking intermittently.

Are curtains cheaper?

Cost cannot be a reason to choose curtains over walls for nursing homes, especially those for people with dementia. The Ministry has said that single or double-bedded rooms are “hard to scale” and would not be “financially sustainable”.

We find this reason confounding.

The additional cost of building single or double-bedded rooms in Jade Circle would have been borne by private foundations. Jade Circle’s nursing home fees before subsidies are estimated to be between $2,800 to $3,500 a month.

This is not higher than other nursing homes, which have fees ranging from $1,200 to $3,500. It is not more expensive for residents to live in Jade Circle than another subsidised nursing home.

On the contrary, if giving personal space to people with dementia minimises “challenging behaviour”, then giving them personal space paradoxically reduces costs because less nursing intervention will be needed.

Ultimately, the Ministry needs to decide if it will heed the recommendations it set out in 1993. We must consider the needs of people and not ignore them in favour of arbitrary policy guidelines which might have been ideal for medical conditions prevalent 20 years ago.

Jeremy Boo and Lee Xian Jie launched Before We Forget to start conversations about dementia in Singapore in 2011. A documentary of the same title is available online for free.