What’s a bus shelter doing in a dementia ward in Singapore?

The Straits Times: What’s a bus shelter doing in a dementia ward in Singapore?

In the heart of Yishun Community Hospital’s (YCH) dementia ward stands an unexpected structure – a bus shelter.

Unlike the bustling transit points scattered across the island, no buses stop here. Instead, it offers patients with dementia a sense of comfort and familiarity.

Ms Julia Lau, a senior staff nurse at YCH, conceived the idea of having a bus shelter in the ward after completing her advanced diploma in gerontology and undergoing dementia care training.

Working in an environment where 90 per cent of the patients have cognitive impairments, Ms Lau and her colleagues frequently encounter challenges in managing them as they tend to roam or become disoriented.

“It often takes considerable time to calm patients who are experiencing emotional breakdowns and confusion, especially when they express a strong desire to go home, even though they are still unfit for discharge,” she says.

In an attempt to address the issue, Ms Lau and her team placed MRT and SMRT bus logos on the ward’s glass doors, so patients would associate the doors with a transit station rather than an exit.

They hoped the logos would prevent patients from wandering out. However, the team realised these were not enough.

Although the logos were helpful, they were unable to convey the sense of familiarity or realism that a well-designed replica, such as a bus shelter or MRT station, can evoke.

While travelling along Upper Thomson Road in July 2024, Ms Faith Tan, nurse manager at YCH, noticed that the old bus shelters were being replaced with a new design.

She contacted the Land Transport Authority (LTA) to ask if any could be repurposed to support dementia care at the hospital. The authority put her in touch with its bus shelter contractor, Shincon Industrial.

Representatives from Shincon and LTA visited YCH to understand how the bus shelter would be used and the benefits it could offer.

Ms Tan says that while Shincon did not have any spare shelters, it offered to build a customised one for the hospital at no cost.

In December, the bus shelter was set up, offering a space for patients with dementia to sit and reminisce in an otherwise unfamiliar environment.

How does it help patients with dementia?

The bus shelter can bring comfort and positive feelings, especially for those who feel a strong desire to leave or “go home” when hospitals seem unfamiliar and stressful, says Ms Lau.

When patients say they want to go home, staff now use a validation technique where they acknowledge and validate their feelings.

“We offer methods of travelling, such as waiting for the bus. As the shelter serves as a visual cue for waiting, it reduces the patients’ urge to wander and look for a way home,” Ms Lau notes.

“This approach respects the patients’ reality and reduces their anxiety and frustration. We also offer companionship, as if we were assisting them with their journey,” she adds.

Ms Tan Yi Xue, assistant nurse clinician at YCH, says that before the installation of the shelter, staff and caregivers often had to closely follow wandering patients, risking direct confrontation. They also had to monitor patients in case they fell.

With the bus shelter, she says staff and caregivers can direct the patients to sit and wait, allowing conversations to take place with less anxiety.

The bus shelter is also part of reminiscence therapy as familiar landmarks can evoke memories of past routines, travel and social experiences, says Ms Lau.

Healthcare staff may ask about the mode of transport they used to take, how much fares used to cost, their favourite travel destinations and even specific bus numbers and their routes. This can help trigger cognitive function and memory recall.

For Madam Foo Ah Boy, 87, who was diagnosed with early-stage dementia in January, the landmark provides a sense of comfort. She was admitted to Khoo Teck Puat Hospital (KTPH) after a fall that dislocated her shoulder, and was later transferred to YCH.

Her son Ray Hua, 55, a director of sales and marketing in the hospitality industry, says: “Seeing bus numbers triggers memories for my mum, especially since she used to take a bus from Yishun to visit her aunt in Geylang. She is more cheerful now as the bus shelter gives her something to look forward to and keeps her engaged.”

Ms Suriahni Sulaimanjee, a 41-year-old associate executive in the healthcare industry, was surprised to see the bus shelter when she visited her father in the ward.

Her father Sulaimanjee Ahmad Patail, 82, was warded for a mild fracture in his hip after a fall.

He was also found to have mild cognitive impairment. His memory has declined slightly and his hearing has weakened.

Ms Suriahni says her father finds the bus shelter a comfortable place to sit, and a good change from lying in bed.

The shelter also encourages patients to exercise.

Ms Hazel Ting, a senior physiotherapist at YCH, says some patients occasionally decline rehabilitation sessions.

“But we try to encourage them by saying, ‘Let’s go for a walk’. When they take a break at the bus shelter during their walk, they are more willing to do exercises such as sit-to-stand movements and seated knee extensions,” she adds.

Bus shelter ‘not a silver bullet’

The concept of therapeutic bus shelters is not new. It has been implemented for patients with dementia in hospitals and nursing homes abroad.

For example, two bus stops at Wokingham Hospital in England serve as a comforting reference point for its dementia patients.

Studies have shown that creating familiar landmarks helps reduce agitation and anxiety in patients.

But an article published by the Israel Journal of Health Policy Research in 2019 showed that while the goal was to reduce the number of dementia patients trying to escape from nursing homes, the bus stops could also increase their frustration and the feeling of being deceived.

Dr Sarah Chan, a Chan Heng Chee Research Fellow at SUTD’s Lee Kuan Yew Centre for Innovative Cities, says the use of a landmark like a bus shelter in a dementia ward serves as a navigational aid.

However, the environmental psychologist emphasises that a bus shelter or other familiar landmarks should be more than just a symbolic feature.

She says: “A fake bus shelter alone is not a silver bullet. Its value lies in how it is used, for example, by serving as a safe space for reminiscence therapy or social interactions.”

Bus shelter and bus decals at KTPH

KTPH introduced a bus shelter decal and a bus decal on the walls of its acute geriatric ward in August 2024.

KTPH’s deputy director of nursing, Madam Yiap Pok Ling, who conceived the idea in 2023, says the imagery evokes a sense of normality and connection to the outside world.

Nurses often engage patients with dementia by pretending to wait for a bus at the decal, says Ms Siti Nur Aisyah Ibrahim, senior staff nurse at KTPH.

“As they wait, nurses may chat with the patients about where they might be going, which can spark cherished memories and distract them from distressing thoughts,” she adds.

For example, one patient, who frequently became agitated, calmed down when “waiting” for a bus.

She excitedly talked about past trips, allowing caregivers to redirect her thoughts more easily.

KTPH also introduced a coffee shop setting in its geriatric outpatient clinic in 2019.

Ms Loh Sook Gin, assistant nurse clinician at KTPH, says the former head of the geriatric department observed that the clinical environment was not conducive to fostering communication and bonding between frail patients and their families.

A setting like this also puts patients at ease.

For instance, a patient who was reluctant to attend check-ups began looking forward to appointments, referring to them as “going for kopi with friends”.

“Coffee shops are a quintessential part of Singapore life where thoughts are shared and food provided in a relaxed manner. Now, they have the opportunity to spend time together in such a setting while waiting for medical assessments and appointments,” she adds.

How other hospitals and a nursing home are helping senior patients thrive

To create a relaxed environment for elderly patients, Alexandra Hospital (AH) incorporated nostalgic fixtures and designs in its geriatric medicine ward in 2018.

Named Rasa Sayang, which means Feeling of Love, the ward houses patients aged 65 and above who have one or more geriatric health conditions, including dementia, delirium and functional decline.

A key feature of the ward is an older version of a bus shelter set against a wall decorated with a decal of Heap Seng Leong, a traditional coffee shop that has been operating since the 1970s.

This is complemented by a kopitiam-style seating area, where patients, staff and caregivers can interact and reminisce together.

A long corridor in the ward is also lined with wallpaper depicting old shophouses.

Dr Arthi Premkumar, associate consultant at AH’s healthy ageing programme, says the vintage-themed interior encourages patients to explore as part of physiotherapy sessions.

The ward also houses patients with delirium, who often experience confusion and a disrupted sense of time, leading them to sleep during the day and remain active at night.

To regulate their sleep patterns, ceiling panels that mimic the sky can be adjusted to indicate day or night.

At St Andrew’s Nursing Home in Taman Jurong, nostalgic wall decals and fixtures evoke memories of a bygone era.

They are catered to residents living with dementia, psychiatric conditions and other health conditions.

The nursing home features displays like a Peranakan kueh shop, post office, vintage music store and a flower shop reminiscent of those in Little India.

Dr Daniel Lee, cluster chief executive officer at St Andrew’s Nursing Home, says these installations help residents feel connected to their past and encourage engagement with their surroundings.

The activity room, for instance, mimics an old HDB void deck, with a provision shop and a barber.

Upon leaving the room, seniors can take a leisurely walk down a 1970s “street” lined with shops.

“Residents who may otherwise be withdrawn often become more animated when they see a familiar shop or cultural reference that resonates with their experiences,” says Dr Lee.

Jurong Community Hospital (JCH) also introduced a “living room” in its dementia ward.

Set up in 2021, the space is adorned with antique items like vintage movie posters, analogue phones and old soft drink bottles.

Adjunct Assistant Professor Kelvin Koh, medical director at JCH, says the area helps to create a home-like environment and can reduce anxiety and confusion.

Patients are able to recall experiences and share their knowledge about the nostalgic items, such as their names, usage and how frequently they were used, adds Ms Veronica Lau, an occupational therapist at JCH.

“Some of these memories are fond ones, and I have witnessed patients smiling as they point to these items, which is rare for some of them,” she adds.

Amrita Kaur is a journalist at The Straits Times, where she covers the evolving healthcare landscape in Singapore, including mental health and wellness.