Co-Design of a Sleep Improvement Intervention for Persons Living With Dementia Boarding in the Emergency Department

Abstract

Background: Persons living with dementia (PLWD) frequently experience prolonged stays in the emergency department (ED), an environment poorly suited to their complex needs. Sleep disruption is common in this setting and may heighten delirium risk. While inpatient sleep interventions show promise, their adaptation to the ED remains unexplored. This study used a co-design approach to identify strategies to promote sleep for PLWD boarding overnight in the ED.

Methods: We conducted a qualitative co-design study using semi-structured interviews and focus groups with ED nurses, technicians, caregivers of PLWD, and community advisors. Participants were recruited from two Massachusetts EDs, a post-acute rehabilitation facility, and a community advisory board. Transcripts were analyzed thematically using a combined inductive-deductive approach informed by the Consolidated Framework for Implementation Research (CFIR).

Results: Twenty-six participants (15 ED clinicians, 3 caregivers, 8 community advisors) contributed perspectives. Three overarching domains emerged: (1) current practices-participants described the ED as a noisy, brightly lit, and disruptive environment that undermines sleep; (2) potential solutions-stakeholders suggested structured nighttime routines, clustering of care tasks, noise and light reduction strategies, delirium carts offering non-pharmacologic interventions, and greater caregiver involvement; and (3) barriers and facilitators-participants emphasized staffing constraints, lack of dementia-specific training, and the need for local "champions" to sustain interventions. Community advisors stressed tailoring approaches to individual patient needs and involving caregivers in decision-making.

Conclusions: Through participatory co-design, we identified multilevel strategies to improve sleep for PLWD boarding in the ED. Interventions that reduce environmental stimulation, integrate familiar routines, and enhance staff dementia training may mitigate sleep disruption and delirium risk. Future work will evaluate implementation feasibility and downstream effects on patient outcomes across diverse ED settings.