Is it fair to segregate the most vulnerable simply because their distress disrupts others? If so, at what cost does this isolation come?
These are questions that many in the aged care sector are beginning to ask, particularly when it comes to the practice of locking residents with dementia in Memory Support Units (MSUs).
In these units, the sight of residents trying to leave or staring longingly outside is common, reflecting their desire to explore beyond the confines of their environment.
For many, locked doors are seen as a necessary safety measure to prevent wandering, but is this separation actually in their best interests? Does it serve to protect, or does it deepen feelings of entrapment and erode fundamental human rights?
Michael Page, a registered nurse, clinical educator, and co-founder of Open the Doors 2030, argues that it’s time to rethink this approach, supported by real-world evidence of the benefits of opening the doors of MSU’s and watching residents flourish.
Reconsidering Dementia Care
Page has dedicated much of his career to dementia care and advocates for a shift towards more open, compassionate care models that prioritise understanding and meeting the needs of residents.
“Locked doors, in the view of many, are a safety measure, but we are not operating detention centres. These people are seeking to exit, and we need to ask ourselves why that is. Whether that stems from fear, boredom, or the inability to communicate that this is their home – it’s not person-centred care.”
Page contends that locking residents away often exacerbates the very behaviours it aims to control by disregarding the deeper, often unspoken needs of people with dementia.
He emphasises the importance of understanding and addressing residents’ distress, so that care becomes an empowering partnership rather than a restrictive imposition.
“People living with dementia can be highly sensitive to noise and light, and they’re not operating rationally anymore – they are operating emotionally. When you go into an MSU, they are usually very noisy – so by definition, you are not providing the right type of environment.”
“The MSU minimises risk at the expense of those inside. If you’re providing dementia care and you have to have locked doors, you don’t understand dementia,” he asserts.
Ananda Aged Care: A Real-World Example
Ananda Aged Care operated two homes in Adelaide, Findon and Hope Valley, each with a Memory Support Unit designed to foster person-centred care. Findon’s MSU, the Rose Wing, is a female-only space with eight beds.
Previously a secure unit, it began opening its doors in December 2018. At Hope Valley, the MSU—known as the Derwent Wing—houses 17 residents and also transitioned to open doors in February 2019.
Initially, the doors were opened for a few hours daily, allowing residents from the MSU to explore the broader facility. This freedom encouraged them to seek spaces where they felt comfortable rather than being confined.
The decision to move away from locked MSUs reflected Ananda’s commitment to a resident-focused care model, transitioning from task-based care to genuine person-centred care.
This shift was supported by a one-year training package from Dementia Training Australia, which included an environmental assessment of the MSUs.
The assessment focused on ten principles of design to reduce confusion, agitation, and depression, while enhancing wayfinding, social interaction, and engagement for residents.
The training and design changes gave both residents and staff the confidence to embrace the open-door policy.
Overcoming Apprehension and Reaping Rewards
Initially, neither residents nor staff were accustomed to this new approach. Residents took time to venture beyond their unit, while staff were hesitant about the potential risks.
However, after a few days, both groups adjusted. At Findon, residents began exploring the broader facility, and a resident previously fixated on the locked doors found inner peace. With the newfound freedom, she even began helping staff by posting flyers around the home.
At Hope Valley, staff were initially resistant, fearing increased falls or residents leaving the home. After additional training and reassurance, the doors were opened from 9:30 a.m. to 4:45 p.m. Families welcomed this decision and were thrilled at the reduction in isolation for their loved ones.
Despite initial fears, Ananda reported a 50% reduction in behaviours requiring incident response compared to the prior three years of data.
Staff confidence and satisfaction also significantly improved, with a 90% increase in reported enjoyment and confidence among staff, who are now eager to work within the MSUs.
Ananda’s adoption of a uniform-free policy and a dedicated staffing model has fostered a more positive environment for both residents and staff in these previously high-stress areas.
A Call to Action
Beyond his work with Ananda, Page’s advocacy has taken on a broader mission. Open the Doors 2030, a global movement of aged care innovators and advocates co-founded by Page, is calling on aged care providers worldwide to embrace a more inclusive, dementia-enabling approach.
In an open letter to providers, Page and his colleagues encourage organisations to prioritise “inclusive, dementia-enabling homes with no exclusion or locked areas” as part of their strategic goals for 2025-2030.
The letter urges leadership teams to consider Human Rights Day on December 10th as an ideal moment to publicly commit to this transformative vision.
“We respectfully request the Board, Executive, or key stakeholders in every organisation’s leadership team to consider this goal as a strategic priority,” Page writes.
Open the Doors 2030 offers free resources, a global community of practice, and a culture of progressive learning to support providers in this shift.
For Page and the Open the Doors 2030 movement, the future of dementia care lies in creating environments that respect autonomy, foster community, and recognise the dignity of each resident.
I agree, no locked doors. The care needs to be more creative that’s for certain. However, staff in RACFs tend to be task orientated and have a list to chop through. Keeping everyone in a smaller space makes it easier for staff to conduct the necessary cares.
I am certain that staff within these facilities are capable of more, but time and inadequate staffing, mean that it is not always possible.
My first concern is staffing levels. My mum lives in a facility without a dementia specific unit. She is also bed bound. Another resident who unfortunately suffered from dementia was fixated on my mum’s room. Mum was attacked in her bed at 6am and nobody came to her aide when she pressed the buzzer and was also calling out. My mum’s door needed to be locked at all times due to the other resident trying to get to her. Finally the other resident was moved to a different area.
The facility has to have the front door locked often and visitors wait to be granted entry when the “wanderer” is up and about. That’s fine on week days when there is front desk staff but on the weekend folks wait for the registered nurse to open it, adding more stress to his or her day. Many considerations to ponder.
I am sorry, but I could not disagree more! as an Aged Care consultant across many organisations, I see the benefit to the mobile older person with higher levels of confusion due to cognitive impairment residing in a purpose-built secure environment with specialist staff. Having confused people wandering around a large expanse without the appropriately skilled and staffed ratio places them and other older frail people at risk. Please be mindful of the coroner’s cases of confused older people hitting frail older people due to insufficient supervision and skilled care. Those who are mobile and cognitively impaired often require higher levels of staff supervision and engagement than other older people.
“….a large expanse without the appropriately skilled and staffed ratio.” Curious question, are you implying doors need to be locked because of people with dementi, or inappropriate environments and staffing? Given environments that are enabling not disabling and appropriately skilled and staffed ratios, would you have a different view?
I totally agree Kathryne. In our experience, no dementia care specialist regularly onsite, a facility lacking appropriately trained staff, a facility that had consistently not met the aged care quality standards, insufficient staffing levels, and a workforce with a task-oriented approach instead of a person-centered model of care is a recipe for disaster. All aged care residents have the right to quality care and to live in a safe and comfortable environment. My late mother was in a facility with no MSU. She was bedbound, very frail and suffering from advanced dementia. We were very concerned for Mum’s safety. She did not have the capacity to call for assistance. There were many instances where she had sustained ‘unwitnessed’ bruising and skin tears. Over the years we had witnessed other residents with dementia who were confused and lost wandering about the facility and wandering in and out of Mum’s room, one in particular was fixated on entering her room, defecating in her bed, another lying in her bed and spitting on the floor. On one occasion an unidentified person had defecated in her wheely walker in the days when Mum was cognisant and mobile. On another occasion I witnessed a resident wearing putrid, urine-soaked clothing crawling on his hands and knees into Mum’s room touching and pulling at the electrical leads of her air-pressure mattress. Prior to Mum’s passing we had witnessed an altercation outside Mum’s room between two angry and confused gentlemen with dementia who regularly wandered about. Despite family members raising concerns, management systemically stonewalled and dismissed our concerns in relation to residents with dementia wandering about 24/7 and Mum’s well-being and safety. Sadly, earlier this year a staff member was stabbed by one of the gentlemen who regularly wandered about the facility lost and confused. Thankfully the staff member’s injuries were not life-threatening. It is disturbing and disappointing that such a tragic and serious incident occurred. As a result, the poor, confused gentleman was moved to another facility. I hope he is now receiving the appropriate dementia care he so desperately needed and deserved. I still carry the trauma and mental anguish of the inadequate care management and the systemic inaction and punitive approach and responses to the issues raised concerning Mum’s care and safety. On a positive note, my mother did receive excellent end of life/palliative care in the final days of her life thanks to her wonderful, experienced and caring GP, and to my lawyer and advocate who attended several meetings with the facility’s GM et al to ensure Mum did receive the respect and quality care she so deserved and that we expected especially during the final stage of her life.
Thanks for the comments Julie. It seems like the home you are describing was not employing best practice dementia care, and was not providing staff with sufficient training individually or as a team? OTD2030 does not suggest just opening doors and see what happens, rather a systematic and comprehensive review of the model of care, staffing requirements to allow an inclusive home and meaningful engagement so that people aren’t bored, confused and aimless. That is a possible target if providers want to do it, but many find it cheaper and easier not to. That then ‘justifies’ to them at least, the only solution is lock all people who are bored or distressed away from others because they cannot cope with them. That just creates a prison for people whose crime is having cognitive impairment.
I wholeheartedly support Michael’s vision for the future of aged care when doors will be well and truly open. Sadly, the aged care sector always has a list of reasons why it can’t happen. Subsequent Governments struggle to do more than just adding more and more tasks and compliance supported by Providers who don’t want to bite the hand that them provides funding. Can you imagine the outcry if any other industry treated others as inhumanely as this and provided continual excuses why it should be left just the way it is now? Shameful!
Well done. For years, I have said that locked doors create behaviours. As an older ex-age care worker, I hope that all doors will be open in all facilities. residents will exercise more, be social more, and be actively involved for longer,
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This is delusional. There is a case for having locked doors. Unless we can commit a staff member to be one on one for some residents. There are so many factors at play here. Are they talking about the newer style multi-floor facilities that might have an elevator and key pad in reception to navigate? Some physical barriers preventing the resident from wandering away from the facility. Do the residents you are referring to not have access to the outdoors?
What does “dedicated staffing model” mean? Interesting that the MSU is small and female only. I’m so sick of reading this garbage from so called professionals. Why wouldn’t we focus on getting the residents out of the MSU who don’t need it.
Natalie, to throw Open the Doors tomorrow would certainly cause mayhem & chaos. Perhaps it IS delusional to attempt but only because the current “system” we have accepted as the standard, is to “house” our elders living with dementia by placing them behind locked doors. Opening those doors requires a number of things put in place.
I’m not asking you to agree with me, just to help me to meaningfully understand the barriers as you see them.
What we are advocating for is changing the current system, which is accepted as the only way to deliver dementia care. It isn’t delivering quality of living when people exist in locked wards with “behaviours” that are exacerbated by the very confinement that is administered to “protect” them as they try to navigate a world that no longer makes sense to them. Surely it is respectful & reasonable to ask, can we do better? What’s to fear in asking ourselves if locking them behind closed doors is actually helping? Is there another way? Its “Black Box Thinking” as applied in the aviation industry in pursuit of excellence & safety. Excellence only arrives with challenge. According to author Syed, Black Box Thinking “. . . is about the willingness and tenacity to investigate the lessons that often exist when we fail, but which we rarely exploit.”
Residential aged care came from the hospital model & was transformed as we became enlightened & realised that there was a lot wrong with what was current practice. Change was opposed, even ridiculed, but change came nonetheless.
In 2012, I was placed in a “DSU” (Dementia Specific Unit) where I meet “L” who had a sash tied around her thighs to hold her down to her chair so that she wouldn’t stand. Her face wore a look of sheer terror as she struggled all day seemingly unable to understand why she could not move. I was told it was for her own safety. I wondered how it could possibly be safe for her psychologically as her every instinct told her she was in danger. Trapped. We don’t do that anymore because it is restraint, but it was considered “necessary” back then. My point is, that in the future people will look back aghast that we used to lock people with dementia behind closed doors & piled together a group of people who were freaked out, confused, bewildered, living in fear with an amygdala on high alert & battle ready because it was the only way we saw to care for them.
Yes. It is very complex & the solution seems insurmountable. But the threat of complexity does not justify maintaining the status quo. Opening of the doors is not some philosophical fancy but a question of structural & systemic change. And it has financial implications to work through. I well understand the depth of complexity in that. Most organisational change is implemented to improve efficiency or finances. But this is a change to improve humanity & decency. We now need to improve compassion efficiency.
So this can’t be done? It is being done. Right now. I’ve seen it first hand at Community Home Australia’s 3 residential sites & their day care centre. It’s working there. Michael demonstrated it can work at Ananda Aged Care as the article discusses. But to maintain this new compassion efficiency takes permanent change that is meaningfully supported, appropriately embedded by organisations & the sector. And it takes those of us who work within the system, at the coal face & middle management, to agitate for change because we are seeing what is actually happening first hand daily on the floor. Yes, it will cost more. But it will bring bang for buck, which is a whole other discussion.
As a society, couldn’t we make looking after our elders living with dementia a priority & invest in what may well be our own future?
So Natalie, I’m not asking you to agree with me, just to help me to meaningfully understand the barriers as you see them. If nothing changes, then you get to say, “I told you so”. If things do change & it works for the betterment of all, then you would’ve been part of that change because you helped inform it. Can we talk? You can contact me via the #OTD2030 website email.
We don’t just do this for our elders. We do this for our future selves – Maurie
So far, as expected, tge reasons stayed for locking oeople up are about power and control and being able to do a job, not humanity. Invariably staffing numbers and training are the excuse not the reason. Organisations have a choice to employ trained staff and if they cant perhaps they shouldnt be operating in this kind of business?
My job description was a caretaker, but what I find interesting and reading this article, and what I would add is The pay scale for caretakers needs to improve and also we need more caretakers, particularly at these residence. That may be their job is to just walk the area to make sure that the Memory loss, patience I’m not walking out the door almost like a school
In our experience, without a dedicated dementia care specialist regularly onsite, a facility lacking appropriately trained staff, a facility that had consistently not met the aged care quality standards, insufficient staffing levels, and a workforce with a task-oriented approach instead of a person-centered model of care is a recipe for disaster. All aged care residents have the right to quality care and to live in a safe and comfortable environment. My late mother was in a facility with no MSU. She was bedbound, very frail and suffering from advanced dementia. We were very concerned for Mum’s safety. She did not have the capacity to call for assistance. There were many instances where she had sustained ‘unwitnessed’ bruising and skin tears. Over the years we had witnessed other residents with dementia who were confused and lost wandering about the facility and wandering in and out of Mum’s room, one in particular was fixated on entering her room, defecating in her bed, another lying in her bed and spitting on the floor. On one occasion an unidentified person had defecated in her wheely walker in the days when Mum was cognisant and mobile. On another occasion I witnessed a resident wearing putrid, urine-soaked clothing crawling on his hands and knees into Mum’s room touching and pulling at the electrical leads of her air-pressure mattress. Prior to Mum’s passing we had witnessed an altercation outside Mum’s room between two angry and confused gentlemen with dementia who regularly wandered about. Despite family members raising concerns, management systemically stonewalled and dismissed our concerns in relation to residents with dementia wandering about 24/7 and Mum’s well-being and safety. Sadly, earlier this year a staff member was stabbed by one of the gentlemen who regularly wandered about the facility lost and confused. Thankfully the staff member’s injuries were not life-threatening. It is disturbing and disappointing that such a tragic and serious incident occurred. As a result, the poor, confused gentleman was moved to another facility. I hope he is now receiving the appropriate dementia care he so desperately needed and deserved. I still carry the trauma and mental anguish of the inadequate care management and the systemic inaction and punitive approach and responses to the issues raised concerning Mum’s care and safety. On a positive note, my mother did receive excellent end of life/palliative care in the final days of her life thanks to her wonderful, experienced and caring GP, and to my lawyer and advocate who attended several meetings with the facility’s GM et al to ensure Mum did receive the respect and quality care she so deserved and that we expected especially during the final stage of her life.