Practice question

How can I comfort patients with dementia who are distressed?

What are twiddlemuffs is a question I have been asked many times in the months since we introduced these handmade knitted items in Exeter.

Comforting distressed patients with dementia

I have recently heard the term ‘twiddlemuffs’ used in connection with dementia care and wondered what they are and why they have become so popular?

They consist of various colourful scraps of wool shaped like a traditional hand muff but with a variety of small items sewn on them for patients to ‘twiddle’. Many have buttons, faux zips, bells and even knitted animals to find inside small pockets. Twiddlemuffs developed from a general understanding that people with dementia often find comfort from holding something with which they can interact and from keeping their hands busy. Twiddlemuffs are available to buy from dementia specialist sellers online, but they mean much more when they are created by staff, family members and local community groups. They knit some of themselves into each one and hand them over with pride in the hope they will bring a little joy and comfort to patients in distress.

After seeing their use at Warrington and Halton Hospitals NHS Foundation Trust, in February 2015 Royal Devon and Exeter (RDE) NHS Foundation Trust introduced twiddlemuffs through the trust’s dementia champions network. Beulah Hitchcock, a 90-year-old mother of one of RDE trust’s governance leads, knitted 30 to start the initiative. They were an immediate success and have been a fantastic way to engage staff and the local population to do something creative to comfort distressed patients, including those with delirium.

Personal initiative

Introducing twiddlemuffs may not be straightforward, however. Unsurprisingly, hospital bureaucracy can often get in the way of this kind of personal initiative. There will be reasonable concerns about infection control risks, which can be managed by making each item single use.

I have fielded a number of other questions, including whether twiddlemuffs should be defined as a medical device and come under those governance procedures, whether they have a Kitemark™ for safety and how to stop patients using them as weapons or attempting to eat the sewn-on items. For most of these questions a common-sense approach is required, for example by promoting them to staff as handmade knitted items from the community that staff should self-assess on handing to patients.

Pictured at the launch of the twiddlemuffs initiative at Royal Devon and Exeter NHS Foundation Trust are (from left) Gaynor Hitchcock, occupational therapist and dementia champion Rachel Elliot and Debbie Cheeseman

It is sensible to have a method of quality control to check what items have been sewn on. For example, I received one that had four sewing pins with decorative heads slotted into the corners of a small box. One can only imagine how dangerous that could have been. It was a good early lesson that not everyone knows what is appropriate for patients with dementia who are disorientated.

Staff should be reminded that they will have to assess throughout each day how appropriate it is for patients with dementia to keep twiddlemuffs because patients may become disorientated and their behaviour unpredictable. These assessments are no different from that of other items that can cause harm if thrown, such as water jugs. Regular safety checks should also be made to ensure that the twiddle items are secure and not coming loose and, if necessary, the twiddlemuff replaced.

The evidence base for twiddlemuffs is not yet available although audits are in progress. Their effect on patients would be an excellent research topic. My experience is that the first benefit is seen with ward staff as they receive a new supply delivered by a local knitters group.

Staff love receiving the twiddlemuffs and it is usual for whole ward teams to feel them and explore what is hidden inside them. More importantly, staff seem to enjoy the feeling they get when they offer one to a patient and see busy hands find rest and comfort.

Families have also praised the initiative, in particular that the hospital has thought about providing kind and lovingly made personal presents.

I recommend you try this initiative in your own clinical settings. One word of caution: once knitters begin they cannot stop and so be prepared to accept large numbers once word gets out.

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