Dementia Net

1
The Effect of Environmental Design in Managing
Behavioural Problems and Meeting the Needs of
People with Dementia
CAG 2005 ASEM Halifax NS
PD Clark Group CIHR Dementia-NET
Funded by Alzheimer Society of Canada
(Ottawa-Carleton)
2
Prevalence

• Prevalence of behaviour problems vary by type,
  population, level of impairment, measurement
• Physically abusive 3-61
• Verbally abusive 25.4-89
• Wandering 3-59
• Disruptive 21.8
• Sexually inappropriate 2-17

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Incidence of Behaviour Problems

• Over the course of the disease, 90 of people
  suffering with dementia will experience one or
  more behavioural problems (Patterson et al.,
  1999)

Residents -Health and Service Access -Quality
of Life Caregivers -Emotional/Physical
Health -Financial Institution
Impact
4
Causes of Problem Behaviours?

• Cognitive Changes
• Personal History and Experience
• Physical (functional, sensory)
• Environmental and Interpersonal Factors

5
Cognitive Factors

• Memory Loss
• Changes in Judgment
• Changes in Insight/Understanding
• Verbal Communication Problems
• Attention Deficits
• Inability to Follow Through/Take Instruction
• Nonverbal Communication Problems

Capacity
6
Personal History and Experience

• History of Abuse/Neglect
• Personality/Coping Skills
• Interests and Activities
• Willingness to Accept Change
• Education and Occupational Status

7
Physical

• Poor Vision/Hearing
• Medication
• Pain (Acute/Chronic)
• Incontinence
• Fatigue
• Acute Illness (e.g., UTI, fever, delirium)
• Chronic Illness (e.g., CHF, arthritis,
  psychiatric)
• Restraint Use
• Discomfort (e.g., ill fitting clothes, hip
  protectors)

8
Environmental

• Change in Routine
• Unfamiliar People
• Too Much Activity
• Rushing
• Other Agitated People
• Bathing/Dressing

• Unfamiliar Surroundings
• Clutter
• Loud Noises
• Lighting Levels
• Mirrors
• Confusing Cues

9
Design Consensus

• Homelike Design size and scale with natural
  light outdoor views
• Warm, Assuring Environment familiar, non
  reflective surfaces, varied colour designs.
• Controlled Spatial Experiences garden, outdoor
  access, kitchen activities

10
Design Consensus

• Individual privacy, choice, control,
  personalization
• Minimize Disorientation residential
  neighbourhoods, reminder cues
• Encourage Functional Autonomy engage in past
  activities, easy to find areas

11
Study Design Issues

• Anecdotal Evidence
• Small Samples
• Duration of Evaluation
• Total-Built Environment
• Control/Comparison Groups Lacking

12
Findings?

• Mixed
• Equivalent Clinical Care
• Staff Ratios Training
• Quality of Life

13
P.D. Clark Long-Term Care Facility in Ottawa

• The P.D. Clark Long Term Care Centre is a 216 bed
  facility divided in two buildings the Houses
  (168 beds) and the Bungalows (48 beds).
• The Bungalows were build in 1998 in partnership
  with the Alzheimer Society of Ottawa-Carleton and
  the City of Ottawa to
• provide home-like support to seniors suffering
  with dementia and
• offer an innovative program to seniors with
  dementia for the most difficult-to-manage
  behaviours.

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Environmental Design P.D. Clark Facility

• Barrier free rooms (e.g. bedrooms,
  wash/bathrooms, dining rooms) and corridors
• Self-contained day and night corridors for safe
  ambulation
• Residentially designed common areas and
  bedrooms (e.g. non-institutional lighting, muted
  wall colours, residential furniture)
• Non-institutionally designed cupboards and
  closets (e.g. for laundry supplies)

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• Open, common living room areas to promote quality
  interactions
• Non-institutional staff work station (e.g.
  hutch/roll-top desk)
• Residential kitchen with open access to residents
  to promote meaningful activity as well as
  stimulate appetite (e.g. through cooking odours)
• Safe, self-contained outdoor area associated with
  each Bungalow.

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PD Clark Project

• Ottawa
• P.D. Clark Facility  Bungalows (specialized
  setting)
• P.D. Clark Facility  Houses (traditional
  setting)
• St. Patricks Home of Ottawa Inc.
• Centre daccueil Champlain (specialized setting)
• Centre daccueil Champlain (traditional setting)
• Toronto
• Dorothy Macham Home
• Calgary
• Bethany Harvest Hills
• Carewest Signal Pointe

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Objective 1 Frequency and Severity of Behaviour
Problems

• Comparison between specially designed dementia
  care units and features and more traditional
  settings.
• Impact of access to externally designed seasonal
  features (e.g. enclosed paths, gardens).

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Objective 2 Perceptions of Staffand Family
Members

• Perception of the impact of physical and social
  environments on the management of behaviour
  problems
• Nominal groups
• Family members
• Staff members

19
Objective 3 Impact of Environment on Quality of
Life and Meaning

• Compare the impact of external design features
  between the Bungalows and traditionally designed
  facilities on social interactions.
• Compare how internal design features of the
  Bungalows help promote purpose/meaning in
  residents with dementia
• Explore the impact of linguistically and
  culturally appropriate environments on the
  expression of meaningful and purposeful social
  behaviours, and overall quality of life, of
  residents with dementia.

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OVERALL DESIGN
21
Facility Level Measures

• Resident Profile
• Staff/Resident Ratios
• Workload
• Specialized Services
• Skill/Training Profile

22
Care Process/Outcome Indicators

• Medication
• Physical restraint use
• Incidents
• Unexpected adverse events
• Weight loss
• Specialized services

23
Resident Characteristics

• MMSE
• Cohen-Mansfield Agitation Inventory (CMAI)
• Assesses agitation in elderly persons.
• Apparent Affect Rating Scale (AARS)
• Reads the non-verbal evidence that residents
  can provide about their state of well-being.
• Multidimensional Observation Scale of Elderly
  Subjects (MOSES)
• Assesses the cognitive and psychosocial
  functioning of elderly persons.
• Functional Assessment Staging Test (FAST)
• Captures changes in functional performance and
  activities of daily living throughout the entire
  course of Alzheimer Disease.

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Physical and Social Environments

• Therapeutic Environment Screening Survey for
  Nursing Homes (TESS-NH)
• Observational tool for rating and describing the
  physical environment of dementia special care
  units.

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Therapeutic Environment Screening Survey for
Nursing Homes (TESS-NH)

• Visual/Tactile Stimulation
• Access to Outdoors
• Orientation/Cueing
• Privacy
• Noise Level
• Activities
• Staff Ratios
• Social Stimuli

• Unit Autonomy
• Exit Control
• Maintenance
• Cleanliness
• Safety
• Lighting
• Space/Seating
• Familiarity/Homelikeness

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Distinguishing Features

• Familiarity/Homelikeness
• Lighting
• Visual/Tactile Stimulation
• Olfactory

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EDEN Culture Change

• William Thomas MD (1991)
• 10 Guiding Principles
• The Three Plagues of loneliness, helplessness,
  and boredom account for the bulk of suffering in
  a human community.
• Life in a truly human community revolves around
  close and continuing contact with children,
  plants and animals. These ancient relationships
  provide young and old alike with a pathway to a
  life worth living.

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Piecing the Puzzle
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Project Research Team
CIHR Dementia-NET
Jocelyn Charles (Toronto) Carole Cohen
(Toronto) William Dalziel (Ottawa) Neil Drummond
(Calgary) Michael Eliasziw (Calgary) Linda Garcia
(Ottawa) Michèle Hébert (Ottawa) Jean Kozak
(Vancouver) Marlene Reimer (Calgary) Susan
Slaughter (Calgary) Isabelle Senecal (Ottawa)
Clinician/Administrator
Etta Fry Sharon Gray Noreen Langdon John Russell
MD Marilyn Muldoon Edward Wong MD