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Improving Physical Environments for Dementia Care: Making Minimal Changes for Maximum Effect
The physical environment can play a significant role in treatment for and associated outcomes of LTC facility residents with dementia. The purpose of this article is to discuss the needs of this population and highlight research that demonstrates how relatively simple design modifications to the physical environment of existing facilities can have significant benefits for this population. Future research should explore how the physical environment impacts individuals at different stages of dementia, since many studies focus only on individuals with early-stage dementia or ignore the severity of dementia altogether. In addition, any adaptations to the physical environment should take into account factors such as ethic diversity, the needs of visiting families, and the potential to integrate community activities. (Annals of Long-Term Care: Clinical Care and Aging 2010;18[5]:43-45)
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Introduction
Within the healthcare profession there is a growing recognition that the physical environment can play a significant role in the treatment of patients and associated outcomes. One area that has received considerable attention over the last two or three decades has been the design of environments for people with dementia, and some extensive reviews of the research in this field have been published.1 The purpose of this article is to highlight research that demonstrates how “cost-effective” (ie, relatively simple) design modifications to the physical environment of existing long-term care (LTC) settings can have significant benefits for people with dementia.
While we recognize that the majority of people with dementia are cared for within their own home environment, the expected increase in this condition will inevitably result in more individuals being cared for in specialized units. Our hope is that by raising awareness of relatively low-cost environmental changes in healthcare environments such as LTC settings, the impact may be greater than more extensive reviews that highlight the importance of such large-scale changes as building configuration and the provision of garden spaces. This article will discuss three aspects of the physical environment: (1) environmental safety features; (2) manipulation of the physical space to support a variety of activities; and (3) the importance of signage and ensuring optimum levels of stimulation for residents.
Before reviewing research in this area, it is necessary to briefly explain both the rationale for including studies in this review and the theoretical explanations for the importance of the physical environment for dementia. The design of the environment for an individual with dementia can be incredibly important for the well-being and independence of that person. For this purpose it is useful to think of dementia as a disability, one that causes a steady decrease in a person’s cognitive abilities. Lawton’s “environmental docility hypothesis”2 states that normal living environments can be increasingly disabling for a person with a disability, especially as the disability worsens. However, the positive side to this theory, according to Lawton, is that even the smallest environmental modification can have a disproportionate effect on the well-being and independence of a person who is disabled by his/her environment.
Another useful perspective to consider is the “behavior-constraint approach.”3 This is commonly used in Environmental Psychology research and is concerned with a person's perceived control over his/her environment. Individuals may experience negative affect and discomfort if they perceive that they are losing control over their environment as a result of a constraint being present; examples of this for dementia sufferers are many and varied, and would include the inability to find a particular room or location due to a lack of visual access because of the presence of doors without windows.
Research on dementia and the physical environment is multidisciplinary in nature, and, as a consequence, there is a great deal of variation in terms of quality (eg, methodology used, sample size, operationalization of variables). For the purposes of this review it was decided to include only research studies that met certain methodological criteria. First, all studies must have a focus on a change or adaptation to the physical environment as their primary purpose and utilize a valid comparison (eg, a control group, pre-/post-test or cross-sectional design). In addition, we have only included studies that made some attempt to control relevant extraneous variables, had sound data collection tool(s), and included inferential statistical analysis.
Environmental Safety Features
Keeping residents safe can be one of the biggest concerns when designing dementia care environments due to such associated agitated behaviors as wandering. There are a number of environmental safety features that can be used in order to keep residents safe in their environments. A secure perimeter should be provided (ideally with unrestricted access to an outdoor area), and the measures used to create these should be unobtrusive and disguised as much as possible.
Researchers have investigated the effects of specific design features in seven Special Care Units (SCUs) for people with dementia in the United States.4 They found that having unobtrusive and disguised safety features was negatively correlated with levels of depression in residents. It is thought that with these safety features, residents tend to make fewer attempts to exit the unit and are given more freedom to wander by caregivers due to the environment being perceived as safer. One body of research has looked at how using simple environmental modifications to disguise main exits can affect the number of exit attempts made by residents. Placing a mirror in front of an emergency exit was found to significantly reduce the number of observed exit attempts in a group of nine residents in one facility.5 However, as the authors themselves pointed out, there are drawbacks to this modification, as people with dementia can often become distressed when faced with their own reflection.
Other studies have found that placing a simple beige cloth over the doorknob was most effective at reducing exit attempts as compared to six other interventions.6 Another study suggested that where a door opened onto a safe outside area, it may be more beneficial to leave the door open.7 This point receives support from a study that suggested that environments with too great an emphasis on safety have been found to have a negative association with the quality-of-life scores for residents in that environment.8
In summary, providing unobtrusive safety measures can result in greater feelings of control and independence, and reduced depression; however, too much emphasis on safety can negatively impact quality of life. In relation to the previously discussed theories, having too many obtrusive safety measures in the environment may be perceived by dementia sufferers as constraining their behavior and reducing their independence.
Providing a Variety of Spaces
The idea of providing a choice of location for residents is important. This includes manipulating the physical space in order to give people with dementia a choice of spaces for activities and opportunities for social interaction with scheduled activities, while also affording them different levels of privacy.2,9 While this is relatively easy to do in newly designed facilities, in pre-existing LTC settings it is more difficult; however, it can be accomplished by rearrangement of furniture in larger rooms and introducing some low-level dividers or partitions to break up the space. It has been found that daytime location of residents in dementia care units was associated with quality of life, and that providing residents with a choice of different spaces to go to can have a positive impact on quality of life.10
One study that focused on a renovation of a dementia care facility in a psychiatric ward found that providing more, but smaller, recreational spaces resulted in higher levels of use than having one large room.11 The authors also found that disruptive outbursts in the dining room were reduced after the room was divided into smaller segments. Researchers used an observational study in a women’s geriatric ward to assess the impact of arranging the furniture in a large lounge area into four separate areas: one set up for watching television, one for reading, one for social interaction, and the final one for group activities.12 They found that after these changes had been put in place, there was a decrease in pathological behaviors such as rocking or talking to oneself and an increase in resident-staff interaction. They did, however, observe an increase in individual passive behavior. Although the reason for this is not clear, the authors speculate that it may indicate an increase in patient tranquillity, as they are adjusting to their new surroundings and have substituted their internal stimulation (pathological behaviors) for external stimulation.12
A similar study collected behavior-mapping data following a renovation of a psychiatric ward and day room.13 This study found that the introduction of low dividers to separate the room into smaller, more private areas resulted in the patients spending more time in the center of the room, and making use of that space rather than the perimeter of the room, where the highest usage was found before the renovation.
In summary, providing an environment that supports a range of different activities for individuals with dementia can help reduce negative outcomes such as anxiety and depression while supporting behaviors such as social interaction. From a theoretical perspective, environments that do not support or promote a range of different activities for residents with dementia are likely to result in passive or docile behavior.
Signage and Levels of Stimulation
Ensuring that residents of dementia care facilities are provided with an optimum level of stimulation is also important. Overstimulation and understimulation have both been found to have a negative impact on behavior. One study that was discussed earlier measured stimulation levels of SCUs and found that when sensory input was “understandable and controlled,” there was a significant decrease in the amount of verbal aggression reported in the environment.4 Likewise, research has identified a link between such environmental factors as noise and temperature on the reported levels of specific agitated behavior in people with dementia.14 It has also been demonstrated that quieter environments are associated with better orientation, and that particular types of noise such as loud talking and clapping were associated more with overstimulation.15
In terms of lighting, it is important that care is taken to ensure that levels of lighting are appropriate to help compensate for the poor eyesight of older adults with dementia. If the lighting levels are too low, this can have a negative effect on their ability to find their way, as they have difficulty perceiving cues and signs.16 Orientation cues and signs are essential in environmental design for these residents, and signs for way-finding must be relevant to the residents and easy to understand and perceive. These include the use of personalized memorabilia displayed in a memory box outside the bedroom to help residents identify their own rooms.17 This effect was more pronounced when the memorabilia related to the early part of the residents’ lives and included a picture of them when they were younger.18 The placement of signs also has been found to be important for these residents.7 Placing lettering and arrows on the floor was most effective at directing people to the toilet; this is thought to help compensate for the downward gaze or stoop of most people with dementia.
Creating a multisensory environment such as a Snoezelen® Therapy room as a way to provide stimulation for residents with dementia has recently become popular and has been found to have a beneficial effect on dementia behaviors. One study found that residents appeared happier, less bored, and more likely to interact with others immediately after a multisensory session,19 with similar results found in another study in which the authors reported that residents appeared happier immediately after a session.20
In summary, providing optimum levels of stimulation are associated with positive emotional and behavioral outcomes. Again, from a theoretical perspective, providing optimum levels of stimulation is likely to compensate for some of the disabling effects of the environment, and reduce docility and passivity in residents with dementia.
To conclude, this brief literature review has identified a number of important, cost-effective recommendations for environmental design and dementia. While these recommendations are supported by well-conducted research, it is clear that there is still a need for research of this type in order to expand and develop the evidence base. One key aspect that we would like to highlight for future research is the way in which outcomes are defined and measured. Despite our attempts to review research that was methodologically rigorous, it became clear that some of these studies were somewhat vague about their outcome variables (eg, “Residents appeared less sad after the intervention”). Greater clarity of what these outcomes are and how they are measured is essential for understanding the impact of any environmental change.
It would also be helpful for future research to explore how the physical environment impacts individuals at various stages of dementia. Many studies that investigate the impact of changes to the physical environment only focus on individuals with early-stage dementia or ignore the severity of dementia altogether. Finally, with respect to LTC environments for dementia, it is important that any adaptations to the physical environment take into account factors such as ethic diversity, the needs of visiting families, and the potential to integrate community activities.
While we recognize the need for scientific research on all aspects of the physical environment of institutions that accommodate residents with dementia, it is hoped that by focusing this article on relatively simple environmental features we might stimulate more stakeholders to recognize and consider how their current environment may impact quality of life for these residents.
The authors report no relevant financial relationships.
Dr. Edgerton and Ms. Richie are from The University of the West of Scotland, School of Social Science, Psychology Division, Paisley.
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