Telly On” – Older People, Dementia and the Potential of Television
The older we get the more time we spend in front of the television. For some this will summon up the classic negative image of the couch potato, sitting passively in front of the screen. But changes in the quality of content and the way it is available have opened up a new role for television as a creative force for good in the lives of older people, including people with dementia.
The meaning of TV
The meaning of TV has undergone a huge change in the last decade. There is no longer a dependency on a single flow of broadcast material. Technology and investment have transformed consumer choice and control over what is available and how it is accessed. The high quality of current programmes and access to a rich history of broadcasting have become routine. Any distinction between TV and other media such as tablets and smart phones is now arguably far less clear.
This naturally raises questions about how best to make new technology work in care settings. How should the TV be handled alongside other technologies? Are there really new opportunities in using new and different content? Should some types of programme be used more than others, or is it still just general entertainment? We address these and other issues in a small set of recommendations at the end of this paper.
But firstly we must recognize that TV still retains a special, symbolic significance in care homes. It sets the tone of the shared areas, the overall atmosphere for resident, for their families and for staff. TV is part of both personal and private spaces in care settings; choices about what is “on” the screen, and who makes them are by no means straightforward; the impact of different types of programme on people with dementia is not always clear-cut.
This wider context is important. TV defines the domestic. It is literally part of the furniture, a source of comfort and continuity between home and care home. And in a care home setting the TV set is an important consideration in the design of the whole care environment.
Research and Evidence
There is however little relevant research on the impact of TV and digital technology in care settings. In fact the majority of research has really brought out more about the negative impact of TV consumption on the lives of older people, especially in care home settings. This should not be shrugged aside lightly but the world has changed. In the past TV may have often acquired a poor reputation, reflected in quotes like the following about care homes:
“…residents stuck in dismal rows of armchairs, telly on, dreary atmosphere, terrible food, and often that tell-tale smell of wee…”
“Telly on” is a phrase that because of its inclusion in such quotes gives the impression that TV is in itself a source of bad care. The idea that TV is a “less worthy” way of passing the time or entertaining people has been wide-spread, part of the wider negative image of care homes which prevailed in the past – and to a degree persists today. Many health writings emphasize that watching TV is bad for your health, on the basis that when used as an alternative to exercise or social interaction it does cause harm. In contrast the growth of arts-based therapy and more social activities have gained a strong foothold as an antidote to TV.
Understanding TV and care
TV has a variety of meanings for older people. A Dutch study (Van Der Goot, M., Beentjes, J.W.J and Van Selm, M. (2012) Meanings of television in older adults’ lives: an analysis of change and continuity in television viewing. Ageing and Society 32(1), 147-168.) looked at how viewing patterns changed in complex ways in response to personal experience. For example during a period of loss we can find television plays an important part in helping us adapt to our new circumstances. This will also be true for carers facing the perceived loss of the person they are caring for as the effects of dementia progress. Tastes also changed with some types of programme becoming more important and older people themselves reflecting a wide range of views about the value of TV to them.
Research has shown that the habit of watching TV is established years before retirement or ageing, and before people need care. In a paper entitled “Watching Television in Later Life” Britt Oestlund and others from Lund University in Sweden found that there was much to be done to use TV to improve quality of life in care settings. They said:
“The results prove that TV viewing is far from a passive activity. Instead, it makes a significantly greater contribution than previously reported to fulfilling the social needs of this population. The analysis defines TV viewing as a way of remaining socially integrated, structuring daily life, coping with disengagement and satisfying the needs for reflection and contemplation.”
This research is confirmed by other writers. A major problem for older people and people with dementia is loneliness. Research from Kathleen Reid at the Centre for Media Literacy explores the role of TV in the lives of older people. She outlines a stereotype of old people staring at TVs, fearful of the outside world and listless, as if the TV were their only friend. Her research contradicts that image. She found that older people find TV an important window into the world. She says that it is impossible to generalise about how old people will use TV because they are all individuals with different interests and abilities. The only thing they have in common is their age, she says. They are not passive consumers of television and people creating programming will not succeed if they don’t take account of the wide range of older people’s preferences.
The variation in what people enjoyed according to her research depended on their age, income bracket, education, gender, their environment, and whether or not they had organisational contacts, like being a member of a club. Randers (Randers, I et al in Journal of Applied Gerontology (Vol. 22 No. 2, pp. 289-309) and others report that in some places watching TV is the only socialising activity that older people can take part in.
TV viewing does increase after the age of 50. There are as many theories as there are studies. TV is an escape from the world or it is a window into the world. It is a positive substitute for going to church or other groups, or not. It is easier to deal with than people. There is a good anecdotal account of affirmative use of the TV where the writer describes the positive effect of watching Wimbledon with a housebound 87 year old.
“She especially loves Wimbledon – she’s watched it all her life. But the real delight is that for once she is included in a great national event and feels part of everyday life. That is the challenge when it comes to creating daytime television that reaches the full expectations of older people – who do not suddenly want less … because they are watching during daylight hours.”
In a paper entitled “Older People and Television Viewing in Japan” the author points out that the habit of “watching TV all the time” is regarded as undesirable, as if there are always purposes and activities that people ought to have that would be more fulfilling. The question being asked is whether the TV watching causes the person to have a less fulfilling time or whether they watch TV because they don’t have a more fulfilling thing to do.
There is however reason for optimism. Choice has been opened up. The quality of programme content that is available online, not least as a result of the increasing availability of high speed WiFi, has transformed the possibilities open to older people whether at home or in care settings. This revolution in access should mean a richer life for older people.
But decisions on what TV content works best in communal areas needs careful thought. Programmes which might seem to be thought to be “calming” can have the opposite effect. One person’s confusion can be another one’s calming. TV is not purely a matter of personal choice. It should be part of a carefully thought through approach to individual care but the dangers of making everything about care rather than fun or life has to be watched. TV remains entertainment, a core part of feeling happy and orientated.
The overall conclusion has to be that it is important to be realistic and honest about the opportunities. We need to look at TV with our eyes open.
Recommendations for care homes
So what are the practical, evidence-based steps that every care home can take to make the benefits of digital technology available to more people?
1 Understand and respect the difference between watching TV in public and private spaces.
Watching TV is sometimes private because the person may want to be alone, or to enjoy something different from others. But sometimes watching TV is a shared public experience, because the person may be taking part in a big event that is watched in a group, such as Wimbledon, or a football match.
There is no reason why the domestic pattern of individual choice of programme cannot be met in a care home setting. It simply needs careful thought and imaginative use of the opportunities now offered by multi-channel TV and other on-demand content.
The key thing is to maximise the value of residents having TV in their own rooms, so they can now watch what they want, when they want, if they have access to the right package that is selected for their particular needs or preferences.
2 Make sure that TV is user-friendly for everyone.
The consumer champion Which? has provided advice entitled “Which? Elderly Care” that includes a section on watching the television comfortably¹⁰. It talks about making the TV user friendly for older people. Remote controls with large numbers of small buttons are a problem, particularly as they are all different. Jumbo or giant remote controls are infinitely preferable. Advice is given about using hearing aid technology to avoid deafening the neighbours and causing disputes by having the television too loud. In care homes it is important to provide headphones particularly in communal areas to allow other people to do other activities while someone is watching loud TV. Advice on how to do this is provided, including contacts for the Action on Hearing Loss shop and information on how to get a free license for people over the age of 75.
3. Challenge assumptions about what TV means in a care setting.
Carers and care staff, who are younger, can help bridge the gap between how residents now consume the new active possibilities and the more traditional and passive viewing patterns of older people in their care.
This argues for what Ostlund describes as a deeper understanding of TV viewing. Her work challenges the ambivalence amongst some staff about TV. They feel it breeds passivity which may make their working lives easier in some ways but it clearly reduces the lived experience of those they care for.
“Instead, TV contributes to structuring daily life, to satisfying old peoples’ needs for reflection and contemplation and to remain socially integrated. As such, TV viewing makes a significant contribution to their capacity to cope with disengagement in old age and can be used as a way of promoting communication and well-being in geriatric care.”
(Ostlund, B. (2010) Watching television in later life: a deeper understanding of TV viewing in the homes of old people and in geriatric care contexts. Scandinavian Journal of Caring Sciences 24, 233-243.)
4. Staff need to be present to help make TV as positive and active as possible for residents.
TV is an active occupation, not a passive one, so staff should be available to comment on what is on, discuss it, and even change the programme if people become uncomfortable.
This is about more than making use of content to support reminiscence or meaningful activities. TV includes key signals to the passage of time, weather, the time of year, time of the week (Songs of Praise or live streaming of religious services of other kinds) and offers a wider range of possibilities for residents than staff would understand without guidance.
The new media options also open up bespoke programming in individuals’ rooms as well in shared spaces. It requires creativity and imagination in care staff as a permanent part of their daily thinking to attend to this as much as the other technology which supports care for the resident. It needs to become a mainstream responsibility not something which can be handed off to an activities’ coordinator.
There is no evidence that particular types of programme are more stimulating or useful in managing conditions than others. Nor is there evidence that longer or shorter programmes are inherently preferable. These are local decisions best made by staff, residents and relatives together based on their own experience.
Problems really come when TV is used to “babysit”, as a substitute for active care and engagement by staff with people with dementia and their carers. There will inevitably be times when this might be necessary, but the impact of passive viewing on health suggests this should never be the norm.
Care homes could make creativity in using TV and on-line content part of the continuing skills development for all staff, as a core professional skill.
5. Do not make assumptions about choices of programmes.
A crucial element of reducing stress for people with dementia is providing what they prefer and removing irritants. It is crucial to get to know what the older person with dementia in a care home enjoys and to support them to have this, but not at the expense of others in terms of noise and monopolizing of public spaces.
Staff need to be vigilant in assessing the actual reaction to programmes rather than assuming it will be predictable and positive. There is no evidence for example that what might be considered bland or calming programmes, for example on nature or on animals, has that effect on people with dementia. Real nature and actual animals may do so, but images on a screen are different. It is far more important to get the overall design of the environment right.
It is revealing that innovative outreach schemes by museums and art galleries, such as “Meet me at MOMA”, enable small numbers of people to engage with stimulating objects and art works in person. This brings all sorts of benefits from socialisation and stimulation. On demand TV offers real possibilities for similar benefits in care home settings, becoming available to many more people, for whom a journey out might be increasingly problematic. This is not an alternative to a stream of entertainment or sport, but it could form part of a commitment to creative and active use of TV with wider benefits.
6. Be creative and imaginative, so TV promotes healthy ageing.
New technologies allow complete control over timing and blend of programming. Care homes can in effect develop their own channels, mixing traditional live broadcast, when that is needed, with more chosen content, which perhaps provides the basis for group activities or validates the interest of residents. Staff do this for themselves at home, but from our work at DSDC over many years in care settings, it seems there are still barriers to bringing this personal creativity into their work for the benefit of residents.
There is real potential for carers also to help programme, to watch and to support the creative use of TV at home and in care homes. This needs active encouragement and support by care home owners. They can play an active role in helping decide content which maintains connections to entertainment and educational content which has been a part of the life of the person with dementia up to that point. This might include the obvious stimulus of dedicated history or sports nostalgia programming or, perhaps more importantly, current programmes which keep people connected to the here and now, rather than assuming dementia means automatically a focus on the past. Some writers suggest that active use of information and media in this way may go further and actually promote healthy ageing. (Niemela, R., Huotari, M. and Kortelainen, T. (2012) Enactment and use of information and the media among older adults. Library & Information Science Research 34, 212-219.)
7. Make the most of TV for staff as well residents.
New digital packages also offer possibilities for staff. The Social Care Institute for Excellence (SCIE) website on Social Care TV talks about what a good care setting looks and smells like. That is an example of where content is really helpful for staff who work in those environments, and by extension their residents. All the information they need about caring for people and the right environment is available on televised resources like this, accessed on line when the time is convenient at work or at home.
TV and on-line content is still underused in this way by many employers. The creative use of available content can help promote a greater collective sense of learning at work and in itself stimulate a different way of looking at the care environment and the place of TV in it.
8. Consider the TV as part of the active design of the care environment.
Not everyone wants to watch TV all the time and the creation of a “viewing theatre” that is not the normal communal area can help make it possible for interest groups to watch what they want together. The design of the room may also help with viewing movies together in a congenial cinema like environment.
A regular audit of the role of the use of TV in the care home should be included in care planning and environmental audit programmes. Involving external expertise, including from broadcasters and content-providers, should be considered.
TV is increasingly included in the list of benefits in well-respected care homes, rather than being seen as a guilty secret. “TV On” can be a positive part of every care home and should be from now on.
Professor June Andrews, Author of Dementia – The One Stop Guide
Mark Butler, Director of The People Organisation, Ltd
This is an edited version of a research report commissioned by Sky Corporation and published in 2016.