Open Access Kent State (OAKS)

Research has shown that communication is affected by the environment and that modifications can improve communication skills in individuals with dementia. Poorly designed environmental features contribute to unsatisfactory responses or behaviors in individuals with cognitive impairment. Environmental modifications must be customized to the person, setting, and activity. Assessment provides a practical means of systematically acquiring that information, translating it into appropriate recommendations, and evaluating the success of those recommendations. This indicates the need for an environmental assessment that is individualized, not only to enhance clinical reasoning and judgment, but also to provide a basis for evidence-based, person-centered practice.

Outline

• SIZE
• NONINSTITUTIONAL DESIGN
• SIGNAGE
• SENSORY STIMULATION
• SAFETY
• OUTDOOR SPACES
• CONCLUSION
• REFERENCES Neighborhoods, clusters, and households. Curio cabinets at bedroom entrances. All private rooms. Decentralized staff work spaces. Home-like décor . These are but a few of the design features that are commonly seen in dementia care settings, which are usually described as being better than the old way of designing long-term care buildings. But just because something is popular doesn't necessarily mean it's better. After all, nursing homes built in the 1960s weren't designed to be ugly or dysfunctional. It's just that our thoughts about what constitutes good design have changed. How much of that change is based on research? Some, but probably not as much as you might think. * This column, and the one in the next issue, will examine how environmental research has impacted the design of dementia care settings in particular, and increasingly, long-term care settings in general. What we are learning is that probably 95% of what is good for people with dementia (such as increased personalization, control and autonomy, better orientation cues, etc) is also good for other, noncognitively impaired residents (and visitors and staff, too). Tracing the impact of research on the practice of designing environments for people with dementia is difficult. Design and construction is a lengthy and expensive process. Two or more years may pass between the time the design process begins (ideally with input from the eventual users of the building—the residents, family members, and staff) and the building is actually completed and ready for occupancy. Then it can easily take another year before all the kinks are worked out and the users settle into a more comfortable routine.

OBJECTIVE:

To develop an observational instrument that describes the ability of physical environments of institutional settings to address therapeutic goals for persons with dementia.

METHODS:

A National Institute on Aging workgroup identified and subsequently revised items that evaluated exit control, maintenance, cleanliness, safety, orientation/cueing, privacy, unit autonomy, outdoor access, lighting, noise, visual/tactile stimulation, space/seating, and familiarity/homelikeness. The final instrument contains 84 discrete items and one global rating. A summary scale, the Special Care Unit Environmental Quality Scale (SCUEQS), consists of 18 items. Lighting items were validated using portable light meters. Concurrent criterion validation compared SCUEQS scores with the Professional Environmental Assessment Protocol (PEAP).

RESULTS:

Interrater kappa statistics for 74% of items were above.60. For another 10% of items, kappas could not be calculated due to empty cells, but interrater agreement was above 80%. The SCUEQS demonstrated an interrater reliability of.93, a test--retest reliability of.88, and an internal consistency of.81--.83. Light meter ratings correlated significantly with the Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH) lighting items (r =.29--.38, p =.01--.04), and the SCUEQS correlated significantly with global PEAP ratings (r =.52, p <.01).

DISCUSSION:

The TESS-NH efficiently assesses discrete elements of the physical environment and has strong reliability and validity. The SCUEQS provides a quantitative measure of environmental quality in institutional settings.

Communication dysfunction that results from dementia can be exacerbated by environmental barriers such as inadequate lighting, noisy conditions, poor or absent environmental cues, and visual clutter. Speech-language pathologists (SLPs) should address these environmental barriers as part of a comprehensive treatment plan for clients with dementia. The Environment and Communication Assessment Toolkit for Dementia Care (ECAT) was evaluated by SLPs to determine: (1) changes in awareness of environmental factors prior to and after training; (2) impact of the ECAT on practice as measured by changes in the number of environmental modifications recommended and made prior to and after training; (3) utility of the information as measured by the helpfulness, amount of new information, and usefulness of the ECAT; and (4) usability of the ECAT materials based on ease of use. The SLPs used the ECAT with clients with dementia who had functional limitations and required substantial assistance with daily activities. Results indicate that the ECAT is an effective tool for SLPs, providing information about the impact of the environment on communication and supplying sufficient resources to make recommendations and implement effective interventions. The ECAT successfully increased awareness of environmental modifications, influenced the practice of recommending environmental modifications, and had utility in diverse aspects of clinical practice.

Long-term care facilities are increasingly incorporating some sort of kitchen, often referred to as a therapeutic kitchen, for resident, staff, and family use through remodeling efforts or new construction. A study, consisting of five site visits and a questionnaire mailed to 631 facilities providing dementia care, was conducted to identify physical features that are typically included in therapeutic kitchen design and to explore how these features support daily use in relation to activities programming and food service systems. Findings indicate that universal design features should be incorporated to a greater extent and certain features are more common, reinforce homelike imagery, or enhance safety. Results also suggest that a higher number of residents participate in more recreational activities, such as baking, than they do in household chores, such as meal set-up, and therapeutic kitchens are not always linked to food service systems.

This article describes a pilot research project designed to develop and test the efficacy of place-based models as a foundation for structuring dementia care settings. Placebased models of care provide a holistic and readily comprehensible context for facilities structuring dementia care settings. A place-based model of care uses the concept of place (eg, home or resort) as the organizing principle for understanding multiple dimensions of a setting including organizational, social, operational, and physical elements. Although this pilot research was based on a relatively small number of sites, results indicate that there may be a link between quality of care/quality of life and systematically applied place-based models of care.

The Professional Environmental Assessment Procedure (PEAP) was developed as a global quality-assessment measure for use by trained professionals in special care units for older people in dementia units of nursing homes. The PEAP consists of nine ratings whose relationship to another assessment device, the Therapeutic Environment Screening Schedule (TESS), is reported. Although designed to be multidimensional, the PEAP as tested in 43 special care units seems to reflect primarily a single evaluative dimension. It correlates highly with the TESS and may be used either separately or in combination with the TESS.

This study explores the association ofphysical environments with the behaviors and care ofpeople with dementia. In order to have a comparative understanding, environmental settings of a traditional nursing facility and an innovative dementia care unit on the same campus were selected. Behavioral observations were done on 12 residents before and after their move ftrom the traditional facility to the dementia care unit. Resident and staffusage and behaviors in the shared spaces were systematically recorded and analyzed Findings include increased use ofthe activity spaces, increased social interaction among the residents, and more interactive than assistive behavior between the staff and residents

Alzheimer's is a progressive, degenerative disease that impairs the ability of the affected individuals to function independently. At the broadest level, there are 3 classes of interventions: pharmacologic, cognitive training, and environmental (physical and social) manipulation. The focus of this article is on this third class of interventions. For years, both long-term care facilities and families who provide care to people with dementia have worked to create physical and social environments that enhance or at least serve to maintain the ability of an individual with dementia to function as independently as possible. Unfortunately, the state of our knowledge about which strategies are most effective is hampered by the lack of a theoretical framework that specifically links physiologic changes that occur in the brains of individuals with dementia with aspects of the environment. This article, the first in a 2-part series, reports on the development of such a framework.