Approximately a quarter of acute care hospital beds in the United Kingdom are occupied by patients living with dementia (Royal College of Psychiatrists 2019). Providing high quality person-centred care to those with dementia and other forms of cognitive impairment is essential but challenging, as these patients may have particular needs that are not immediately recognizable to the staff responsible for their care. These can relate to communicating their preferences and assistance with nutrition and/or other basic activities. Where the provision of care fails to cater for their needs, people with dementia may suffer harm and distress, such as falls, immobility, incontinence, and functional decline (Hermann, Muck, and Nehen 2015). This is why the Royal College of Psychiatrists recommends that hospitals have special systems in place to care for this patient group appropriately (Royal College of Psychiatrists 2019).

One way to improve the quality of care of people with dementia is to introduce visual identifiers—signs and symbols attached above patients’ beds, on their person, or in their notes to direct attention to particular aspects of patient care. These tools can be used to indicate the presence of a variety of different risks or considerations, including visual impairment, hearing loss, and falls risk. In the context of caring for people with dementia, they aim to indicate a dementia diagnosis (or cognitive impairment more broadly) to those involved in patient care, so that they might better respond to the needs of patients with dementia. In addition to the heterogeneity around the purpose and scope of identifiers, a range of different terms are also used, such as “Cognitive Impairment Identifier” (Yates, Theobald, and Morvell 2009; Murray, et al. 2019); in this paper we refer to “visual identifiers.”

There is no systematic data about the global use of visual identifiers for patients with dementia; it is, however, known that they are used in Australia and the United States for cognitive impairment and delirium more broadly. In Australia, the Dementia Care in Hospitals Program was developed in 2004 by Ballarat Health Services; the use of a bedside Cognitive Impairment Identifier is one component of this programme (MacDermott, et al. 2017). It has since been implemented in a number of hospitals across four Australian states, and other similar programmes have been introduced with modification to suit the local context (Fox et al. 2023).

In the United Kingdom, the 2019 Royal College of Psychiatrists National Audit of Dementia Care reports that 93 per cent of general hospitals in England and Wales use a visual identification system of some description in their wards (Royal College of Psychiatrists 2019). These identifiers can vary across hospitals and can take the form of wristbands, patient profile documents, symbols, or notices placed above a patient’s bed and/or in their patient notes, or notifications in digital systems, for example. However, the presence of visual identification schemes in hospitals does not guarantee that they are used consistently or have been subject to formal evaluation.

There are a variety of identifiers in use; each has slightly different purposes, ranging from increased efficiency to promoting person-centred practice. Some visual identifiers are part of established national schemes and others locally developed. Some act as standalone identifiers of cognitive impairment, and others—such as the Butterfly Scheme—use visual identifiers as components in a wider care approach (Kuberska, et al. 2022).

These technologies were introduced with the intention of enabling good quality care for people with dementia, but inconsistent, improper, or unreflective use may undermine their objectives. Evidence suggests that these technologies can sometimes lead to less personalized care and become a shorthand for a routinized response or can quickly become invisible and blend into an ocean of signage, posters, and notices, medical records, and forms that proliferate in the ward (Featherstone, Boddington, and Northcott 2020). The implementation of similar tools for multiple applications may also contribute to an abundance of competing wristbands or signage above patients’ beds and potentially lead to confusions or dilute the impact of the dementia visual identifier.

There is, however, an appetite for their use, as shown by a recent survey of practice in U.K. hospitals which reported that staff responses were largely positive about key functions of the identifiers (Kuberska, et al. 2022). The authors also found that those in hospitals that do not currently use visual identifiers tended to be enthusiastic about their potential. Respondents identified some advantages, such as supporting staff to tailor their approach to the patient, especially those who are not a regular part of the care team. On the other hand, they also raised concerns about staff making assumptions about the homogeneity of needs of people with identifiers, as well as the ethical and legal implications of unclear consent processes.

Currently, there is no overarching framework for considering how a visual identification system should be developed and implemented. In this paper we propose a set of ethically and legally grounded principles that can be used to guide the implementation of these systems for the benefit of patients with dementia.