| Bautrant et al.
5
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To determine whether environmental rearrangements of the long-term care nursing home can affect disruptive behavioral and psychological symptoms of dementia (BPSD) in residents with dementia |
Case study Participants: 19 patients, mean age of 86.3 years. Six patients had Alzheimer’s disease Place: long-term care nursing home Number and duration of disruptive BPSD were systematically collected and analyzed over 24 h or during late hours during each 3-month period
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Skylike ceiling tiles in part of the shared premises Progressive decrease of the illuminance at night (6:00–8:00 PM) together with soothing streaming music Reinforcement of the illuminance during the day Walls painted in light beige Oversized clocks in corridors Color (dark blue) of night team clothes different from that of the day team (sky blue)
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No significant change in the patients’ dependency, risk of fall, cognitive or depression indexes, or treatment between phases 1 and 2 Number of agitation/physical aggression, screaming, and the mean duration of wandering episodes significantly decreased The number of patients showing wandering was significantly lower, and the mean duration of the episodes decreased, especially during the late hours
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| Ludden et al.
13
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To show how insights from environmental psychology and advances in technology can inform a user-centered multidisciplinary design approach |
Case study Participants: not informed Place: care center for people with dementia A brief meta-review of reviews Two exploratory case studies in which technology-enhanced prototypes were implemented
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Six handrails, with different textures, colors, and sounds were designed to match existing scenes along the walking path of the psychogeriatric ward: the sewing room, kitchen, cinema, living room, garden, and farm Installed at the corridor of the ward, and a variety of technology-enhanced nature scenes were designed. All scenes portray a still spacious scene (first layer); a vista to look out over. The second layer comprises a multitude of animated fascinating elements to look at
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The textures and colors of the handrails stimulated further exploration and tactile interaction The VR nature scenes were highly successful in promoting a positive and relaxed atmosphere, and in promoting social engagement among residents at the care center and family visiting These designs promoted social engagement (virtual nature), reduced restlessness (both cases), and facilitated wayfinding (experience handrail)
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| Varshawsky et al.
6
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To observe graphic designed room doors that are visually appealing and to investigate if a design similar to house doors would be a successful approach and environmental change to reduce wandering |
Pilot project Participants: Nine residents Place: resident care home Revised Algase Wandering Scale was used to evaluate the effects of the change on wandering (pre- and post-intervention)
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Eleven unique custom graphic designs for individual room doors (each door provided multiple approaches to assist with wayfinding and visual recognition: color, location, architectural design, and originality)
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Improvement in wandering in the mornings and early evenings Reductions in all behaviors (persistent walking, eloping, and spatial disorientation) were demonstrated after implementation of the new door designs The individuals were observed commenting on the color of their door with visitors to ensure they knew which room they lived
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| Bracken-Scally et al.
14
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To evaluate the impact of dementia-inclusive modifications made to two emergency department bays in a large acute care hospital |
Case study Participants: 10 service users (family carer/member and 16 service providers (staff and key stakeholders) Place: acute care hospital Survey of service providers Interviews with family carers, service providers, and key stakeholders Audit data (at two time points) to evaluate the impact of the modifications
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Panels were placed around the walls An electronic display showing the day of the week and time was placed above the entrance Blue and green tones were chosen to replace the clinical white of the walls Standard lighting was replaced with an adjustable system The curtains separating the bays from the corridor were replaced with a movable hard screen Two fixed foldable chairs were installed in each of the bays Storage units were installed Unused equipment was removed
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Orientation and navigation within the modified bays were improved though the technical issues with the orientation aid were highlighted This lighting and use of calming colors, together with the addition of noise-reduction bay screens, served to reduce sensory stimulation The provision of adequate space and seating for family carers was extremely beneficial
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| Chaudhury et al.
15
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To examine the impact of environmental renovations in dining spaces of a long-term care facility on residents’ mealtime experience and staff practice in two care units |
Case study Participants: 10 residents at the beginning, 9 at the end, and 17 care aides and nurses Place: A dementia SCU and a non-dementia SCU Pre- and post-renovation ethnographic observations in the dining spaces of the care units and a post-renovation staff survey Four months after the renovations, a staff survey was conducted
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Lightning fixtures Wooden-look flooring Decorative items, like vases Wall paintings New height-adjustable tables allowed table height to be altered to accommodate wheelchairs Relocation of the nursing station away from the dining area
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In the DEAP, the greatest improvement was the support of the functional ability Proper lighting allowed residents to see their food and tablemates clearly, as well as contributed to a non-institutional and more homelike ambiance Glare continued to be an issue after renovation on both units, which can cause spatial disorientation for residents as they move in and about the space. Regarding the strong color contrast between sections of flooring, it made them think there were stairs and caused them to “avoid walking on the hardwood.” The open kitchen design made the dining area much more obvious to recognize for residents with cognitive impairment The design of having a unit kitchen provided the option of creating a familiar sensory environment related to food and stimulated the residents’ appetite
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| Wahnschaffe et al.
21
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To test the impact of a dynamic lighting system on agitation and rest-activity cycles in patients with dementia |
Research article Participants: 15 residents with dementia Place: nursing home The residents were assessed with the Cohen Mansfield Agitation Index (CMAI) before and after the lighting intervention Rest-activity cycles were monitored for 6 months by using a wrist-worn activity watch
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There were no differences in circadian amplitude and other circadian variables before and after the lighting installation The dynamic lighting in the living room significantly reduced the agitated behavior in demented patients, indicating short-term benefits from higher daily light exposures
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| Hung et al.
20
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To examine the influences of dining room renovations and enhanced mealtime practices on the quality of residents’ experiences and staff practices |
Qualitative study Participants: 12 staff members and 2 unit managers Place: A dementia SCU and a non-dementia SCU Staff focus groups and unit managers’ interviews after the completion of the renovations An assessment tool (DEAP) was developed to conduct a systematic environmental evaluation of the dining rooms in each unit pre- and post-renovations
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A dining room with two open kitchens was created Each renovated kitchen was equipped with steam tables and ovens to prepare food The kitchen offered a microwave, fridge, coffee machine, and cabinets of glasses and cutlery. Although the meals were prepared and cooked in a large central kitchen, the unit kitchen had the capacity to cook soup, bake bread and pastries, and so on Furniture and finishing were renewed to enhance homeliness of the dining room New homelike flooring with a wooden look flooring replacing the old vinyl sheet Higher quality recessed lighting and modern ceiling light fixtures were added New dining tables and chairs were brought into the space
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Before the renovation, the SCU scored 33 out of 68 in the total score of DEAP. In the post-renovation evaluation with the DEAP tool, the SCU was rated 41/68 The non-SCU scored 29/68 in the total score of DEAP. In the post-renovation, the non-SCU was rated 44/68 in the total score of DEAP Before renovation, noise, lighting, and clutter were major complaints in both dining rooms A supportive physical environment enables people with disabilities greater personal control and autonomy A domestic homelike atmosphere made the place more inviting for social engagement Access to the kitchen, participation in meal-preparing activities, and household chores are not only opportunities for residents to maintain remaining skills but those familiar and meaningful activities can also provide them a sense of achievement, contribution, and inclusion
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| Mazzei et al.
7
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To examine how the physical environment influenced the spatial behaviors of an understudied population, that is, a small sample of residents living in a traditional acute care hospital, who were then moved to a purpose-built dementia care hospital wing |
Case study Participants: Six residents with dementia, ambulatory, and know to engage in aggressive behaviors Place: Two acute care settings from a hospital The data were observational and related to spatial behaviors. In both environments, residents were observed during their most active time of day, mostly between 2 PM and 5 PM
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Camouflage murals on exit doorways (depicted as bookcases) Circular wandering path (instead of the previous linear configuration) Private bedrooms with adjoining rooms for the majority of residents (instead of the 4-bed wards) Introduction of an outdoor patio Use of clocks, memory boards, and individual photos in bedrooms or entries to bedrooms, for residents Clutter-free hallway Opportunities for natural light in the unit were increased
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Patients spent 24% less time in the nursing station area and more time in their bedrooms and the dining room There is a clear trend toward decreasing numbers of pacing events per day for all residents The wall murals on the door exits had some influence but were not completely effective in masking doors and deterring pacing behaviors. Reasons for this might be that some residents were still cognitively aware of people coming in and out through these doors despite their bookcase camouflage
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| Padilla et al.
8
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To present effective non-pharmacological intervention strategies for dementia-driven wandering |
Case report Participant: an 80-year-old man with AD Place: adult day care center A Spanish translation of the original Algase Scale was used to evaluate wandering behavior
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Eight strips of 4 × 105 cm black tape were placed with 4 cm between each other and 25 cm from the exit door Another four strips of the same type were placed on the glass door, 25 cm from the floor
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The results showed a significant decrease in wandering behavior frequency in the subject The environmental intervention acted as a subjective barrier to the patient, although the patient was unable to report his subjective perception of the environmental modifications made in the intervention In addition, other residents with dementia with significant cognitive deficits, like our subject, did not approach the area with subjective barriers. It has been shown that every escape attempt was due to a delay of time without receiving attention from the staff
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| Lancioni et al.
16
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(a) To extend the use of the technology-based program with auditory cues to five new patients with Alzheimer’s disease
(b) To compare the effects of this program with those of a program with light cues, to determine whether the latter program could be a viable alternative to the former |
Study Participants: Five patients, with lower to moderate AD Place: day center Within each session, a patient was to reach five of those destinations/rooms to deliver and/or pick up small objects and meet a staff person present there The measures recorded during the travel sessions were (a) the travels programmed and whether they were carried out correctly and (b) the duration of the travels
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A system with auditory cues included a sound source at each of the destinations and a portable control device to activate and deactivate those sources. The recordings available consisted of short sentences encouraging the patient to walk to the destination A system with light cues differed in that light sources replaced the sound sources. Each light source contained two green strobe lights, which emitted approximately one flash per second until the patient reached the destination
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Both program conditions were effective from the initial sessions. The mean percentages of correct travels varied between slightly below 90 and over 95 Psychology students provided higher scores for the program using light cues on all six items of the questionnaire
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| Barrick et al.
23
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To evaluate the effect of ambient bright light therapy on agitation among institutionalized persons with dementia |
Research article Participants: 66 older persons with dementia Place: a psychiatric hospital unit and a dementia-specific residential care facility Outcome measures included direct observation by research personnel and completion by staff caregivers of the 14-item, short form of the Cohen-Mansfield Agitation Inventory (CMAI)
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Analyses of observational data revealed that for participants with mild/moderate dementia, agitation was higher under AM light, PM light, and all daylight than standard light There was a trend toward severely demented participants being more agitated during AM light than standard light In no comparison was agitation significantly lower under any therapeutic condition, in comparison to standard lighting
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| Gnaedinger et al.
22
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To improve the quality of care and of life for veterans with dementia by renovating the existing dementia care lodges in ways that reflect a new awareness of the impact of the built environment on persons with dementia. |
Case study Participants: not informed Place: a lodge inside a geriatric residential care facility Staff members, families, and volunteers were surveyed for their observations and opinions after renovations were complete
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The 32-bed was separated into two smaller lodges A new homelike kitchen, living room, and dining room were built Painting murals were used to camouflage exit doors in common areas Non-institutional finishes and furnishings were used A silent resident call system was installed
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All three groups surveyed remarked that the lodges are now more homelike, pleasant, calm, quiet, relaxing, and welcoming Residents are “really more at peace” and are engaging in more “normal” behavior, such as curling up on a couch by a fireplace or participating in making tea with a family member in the kitchen Ratings of residents’ quality of life increased Design team members should give consideration to lighting as a means of attracting residents to preferred living areas
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| Holmes et al.
19
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To explore whether music, live, or prerecorded is effective in the treatment of apathy in subjects with moderate to severe dementia |
RCT Participants: 32 subjects with moderate to severe dementia and with diagnostic criteria for apathy Place: subjects were recruited from residential and nursing homes Each subject was randomized to 30-minute music or silent periods and was video recorded, and the muted recording was analyzed every 3 min using dementia care mapping to assess the quality of engagement to the blinded music intervention
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The communal area of the residential-care or nursing-home facility was used for the music intervention. Music periods comprised three different activities, each of 30 min duration. One 30-min period consisted of silence alone, one 30-min period consisted of the playing of background prerecorded music, and one 30-min period consisted of the playing of live music from session musicians
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The majority of subjects (69%), regardless of dementia severity, showed a significant and positive engagement to live music Engagement to prerecorded music was nonsignificant, with just 25% of all subjects showing positive engagement No subjects showed any evidence of experiencing a state of ill-being during either the live or prerecorded music sessions
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| Schwarz et al.
24
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To determine whether design interventions affect desirable behavioral outcomes in nursing home residents with dementia |
Case study Participants: not informed Place: long-term care facilities Pretest and post-test design for data collection and a combination of quantitative and qualitative methods PEAP was used to conduct the focused evaluation of the facility before and after environmental modifications Two focus group interviews were conducted with facility staff members
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The architecturally dominant central nurses’ station was replaced with an aviary, introducing a smaller nurses’ station The dining areas were decentralized for smaller groups of residents The interior design was improved by adding appropriate lighting and carpeting
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The newly built cluster arrangement scored higher in all eight areas of the PEAP instrument compared with the scores of the facility before renovation The three areas of (1) maximize awareness and orientation, (2) provision of privacy, and (3) facilitation of social contact had the highest variation in the pre- and post-renovation PEAP scores The general reaction from the staff was that replacing the prominent nurses’ station with the aviary reduced the institutional ambiance in the facility However, some staff members were concerned that residents sitting near the aviary were engaged in passive behavior
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| Nolan et al.
18
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To evaluate the effect of an environmental modification designed to provide residents of a special care unit with easy access to information about mealtimes |
Clinical trial Participants: 35 residents with AD Place: SCU at a nursing home An ABAB reversal design across mealtimes was used to determine whether the intervention changed the frequency of residents’ requests for food or meal-related statements before mealtimes
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Large clock (d=16 in) hung in the dining room Large-print sign (22 × 28 in) that identified mealtimes in the dining room hung below the clock, constructed of poster-board
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Similar effects of the treatment were replicated across all three mealtimes (breakfast, lunch, and dinner) The intervention decreased residents’ repetitive statements and questions regarding food and mealtimes The staff stated that they believed the signs that helped them reduce residents’ pre mealtime confusion and agitation
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| Kincaid et al.
11
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To examine the effect that a wall mural painted over an exit door had on decreasing door-testing behaviors of residents with dementia |
Study Participants: 12 residents with a diagnosis of dementia Place: SCU at a nursing home Data were collected both before and after the wall mural was painted The door-testing behavior was the dependent variable, and the physical appearance of the entrance/exit doorway was the independent variable
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Wall mural painted on the entrance/exit doorway to disguise it. It is a two-door with windows that need to remain functional, only opened by a keypad. It was painted from the floor to the ceiling, covering the doors and adjoining walls
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The findings indicate that when a wall mural is painted over the entrance/exit doorway, the frequency of door testing does decrease Out of the 12 residents who were active at the doors, only 3 remained active at the doors after installation of the wall mural Two types of door-testing behaviors decreased significantly after the installation of the wall mural. Type 1: walking up to the door and pushing or pulling calmly and Type 2: using a team effort, which had a significant decrease
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| Nolan et al.
17
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To evaluate the impact of placing two external memory aids outside participants’ bedrooms |
Multiple-baseline experiment Participants: Three residents with AD Place: SCU at a nursing home for people with dementia Each resident’s ability to locate her own room was assessed by using a direct observation technique A multiple-baseline design across subjects was used to evaluate the effect of the photograph and sign on room finding
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| Hewawasam
12
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To capitalize on the observation that many individuals who suffer from dementia of Alzheimer’s type appear to perceive two-dimensional patterns as barriers |
Study Participants: 10 patients with mean to severe dementia Place: NHS trust hospital ward for the elderly mentally infirm The design was based on an ABABA single-subject design that incorporated several baseline (control) observations, one before and one after each experimental manipulation
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Of note, 3.8 cm strips of black tape applied 3.8 cm apart to the blue vinyl floor, extending in front of the exit door. They were applied in one of two configurations, grid A – horizontally, and grid B – vertically
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All 10 patients showed varying degrees of changes to their normal gait while crossing the grid. These changes were manifested by some hesitation and deliberation before crossing and/or stepping over the eight-strip Five patients, of which four had a diagnosis of AD, showed a statistically significant reduction in the number of door contacts
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| Dickinson et al.
9
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Horizontal mini-blind on the window panels in the exit doors, blue (surrounding door/door frame) Cloth barriers, with cotton fabric, also blue
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Exiting decreased 44% with the blind closed With just the cloth barrier, exiting decreased dramatically, for a reduction of 96% With both the blind and cloth barrier, attempted exits decreased 88%
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| Chafetz
10
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To extend the findings of Hussian and Brown (1987) to a nursing home setting |
Research study Participants: 30 residents, all with some type of dementia Place: long-term care unit ABA research design Continuous frequency data were collected by unit staff. The dependent variable of main interest was the frequency of door openings, as indicated by the sounding of the buzzer when a resident opened either exit doors
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The clear ineffectiveness of the grid in this setting confirms that individuals with dementia will cross the grid on their way to a glass door or a double-wide door Glass doors allow residents a full view of the visually attractive and physically unrestricted spaces that lie beyond, therefore distracting the residents’ attention from the grid
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