The Effect of Environmental Design in Managing Behaviour al Problems and Meeting the Needs of People with Dementia

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

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% Dementia Net: Bridging Gaps in Service Provision

3. 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 Dementia Net: Bridging Gaps in Service Provision

4. Causes of Problem Behaviours? • Cognitive Changes • Personal History and Experience • Physical (functional, sensory) • Environmental and Interpersonal Factors Dementia Net: Bridging Gaps in Service Provision

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 Dementia Net: Bridging Gaps in Service Provision

6. Personal History and Experience • History of Abuse/Neglect • Personality/Coping Skills • Interests and Activities • Willingness to Accept Change • Education and Occupational Status Dementia Net: Bridging Gaps in Service Provision

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) Dementia Net: Bridging Gaps in Service Provision

8. Environmental • Unfamiliar Surroundings • Clutter • Loud Noises • Lighting Levels • Mirrors • Confusing Cues • Change in Routine • Unfamiliar People • Too Much Activity • Rushing • Other Agitated People • Bathing/Dressing Dementia Net: Bridging Gaps in Service Provision

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 Dementia Net: Bridging Gaps in Service Provision

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 Dementia Net: Bridging Gaps in Service Provision

11. Study Design Issues • Anecdotal Evidence • Small Samples • Duration of Evaluation • Total-Built Environment • Control/Comparison Groups Lacking Dementia Net: Bridging Gaps in Service Provision

12. Findings? • Mixed • Equivalent Clinical Care • Staff Ratios & Training • Quality of Life Dementia Net: Bridging Gaps in Service Provision

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. Dementia Net: Bridging Gaps in Service Provision

14. 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); Dementia Net: Bridging Gaps in Service Provision

15. 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. Dementia Net: Bridging Gaps in Service Provision

16. PD Clark Project • Ottawa • P.D. Clark Facility – Bungalows (specialized setting) • P.D. Clark Facility – Houses (traditional setting) • St. Patrick’s Home of Ottawa Inc. • Centre d’accueil Champlain (specialized setting) • Centre d’accueil Champlain (traditional setting) • Toronto • Dorothy Macham Home • Calgary • Bethany Harvest Hills • Carewest Signal Pointe Dementia Net: Bridging Gaps in Service Provision

17. 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). Dementia Net: Bridging Gaps in Service Provision

18. 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 Dementia Net: Bridging Gaps in Service Provision

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. Dementia Net: Bridging Gaps in Service Provision

20. OVERALL DESIGN Between Groups Open Concept Bungalow Open vs. Closed Concept Closed Concept Bungalow Comparison Residents Environment/Within Practice “Standard” Environment/ Between Practice Comparison Sites Dementia Net: Bridging Gaps in Service Provision

21. Facility Level Measures • Resident Profile • Staff/Resident Ratios • Workload • Specialized Services • Skill/Training Profile Dementia Net: Bridging Gaps in Service Provision

22. Care Process/Outcome Indicators Medication Physical restraint use Incidents Unexpected adverse events Weight loss Specialized services Dementia Net: Bridging Gaps in Service Provision

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. Dementia Net: Bridging Gaps in Service Provision

24. 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. Dementia Net: Bridging Gaps in Service Provision

25. 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 Dementia Net: Bridging Gaps in Service Provision

26. Distinguishing Features • Familiarity/Homelikeness • Lighting • Visual/Tactile Stimulation • Olfactory Dementia Net: Bridging Gaps in Service Provision

27. 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. Dementia Net: Bridging Gaps in Service Provision

28. FACTORS Supportive and Respectful Environment • Meaningfulness • Belonging • Reduced Behaviour • Problems • Good Clinical Care • Social Environment • Interactions • Communication… • Physical Environment • Lighting • Space • Privacy • Open vs Closed Designs… • Organizational Structure • Direct Care Practices • Staff Ratios and Training • Scheduling • Philosophy… Piecing the Puzzle Dementia Net: Bridging Gaps in Service Provision

29. 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 Dementia Net: Bridging Gaps in Service Provision