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ENVIRONMENTAL DESIGN CAN BENEFIT DEMENTIA CARE

Professor of Architecture and Gerontology School of Architecture University of Southern California Los Angeles, CA 90089

Creating Successful Dementia Care Settings: Volume One, Understanding the Environment Through Aging Senses, by Sherylyn H. Briller, Mark A. Proffitt, Kristin Perez, and Margaret P. Calkins. Health Professions Press, Baltimore, MD, 2001, 63 pp., no price listed (paper).

Creating Successful Dementia Care Settings: Volume Two, Maximizing Cognitive and Functional Abilities, by Sherylyn H. Briller, Mark A. Proffitt, Kristin Perez, Margaret P. Calkins, and John P. Marsden. Health Professions Press, Baltimore, MD, 2001, 201 pp., no price listed (paper).

Creating Successful Dementia Care Settings: Volume Three, Minimizing Disruptive Behaviors, by Kristin Perez, Mark A. Proffitt, and Margaret P. Calkins. Health Professions Press, Baltimore, MD, 2001, 147 pp., no price listed (paper).

Creating Successful Dementia Care Settings: Volume Four, Enhancing Identity and Sense of Home, by John P. Marsden, Sherylyn H. Briller, Margaret P. Calkins, and Mark A. Proffitt. Health Professions Press, Baltimore, MD, 2001, 183 pp., no price listed (paper).

The main theme of this four-volume series is the relationship between care provision and the physical environment. Most caregiving manuals focus on the medical and behavioral aspects of care provision. The range of topics typically covered includes drug treatments, communications techniques, diversion strategies, effective programs and activities, staff training considerations, and the integration of family and friends. Consequently, environmental factors have been regarded as secondary influences relative to other caregiving priorities.

This book series turns the conventional approach on its head by using the environment as a point of departure for a discussion about caregiving. In a health care context, where pills and procedures are often the first line of defense, a discussion about acoustics, lighting, outdoor space, noise control, and bathing equipment seems at first far-fetched. However, the text quickly provides compelling causal evidence that connects these factors with resident behavioral issues and problems. After reading through the series one becomes far more sensitive to the hundreds of factors that can make a difference in the environment in both a positive and negative way.

One of the differences between this book series and previous work dealing with physical design attributes of dementia environments is the focus on fixtures, accessories, furnishings, carpets, wall coverings, window and ceiling treatments, and lighting. These are items that are typically replaced every 5–7 years. When architects write about this topic they usually deal with the organization of common spaces, the design of the dwelling unit, the sequence of entry spaces, the placement of outdoor courtyards, and general considerations relating to circulation corridors. In this work, Calkins and her colleagues focus on environmental attributes that can be easily manipulated. For example, the discussion about concerns regarding elopement centers on disguising exit doors, building higher courtyard fences, installing electronic monitoring equipment, and using signage. Most of the strategies are doable in existing environments and do not require large scale and costly construction efforts. Although persuasion strategies such as diversion and redirection are introduced, the discussion often centers on how the environment can be used in conjunction with these "communications" methods.

The authors also suggest ways in which meager resources can be combined with other tried and tested communications methodologies to solve complicated problems. Their recommendations reflect the belief that many behavioral concerns can be fixed with the right words and the appropriate environmental tools rather than reliance on mind-numbing medications. The underlying premise throughout the texts is that problems can be solved in a practical way that utilizes innovation and creative thinking along with relatively simple interventions. One of the great aspects of this publication is how it challenges the staff to think creatively about how to solve specific problems.

Format
The four books are written in a way that makes them easy to use as reference guides. The index is very detailed and cross-references all four volumes. An issue raised in the first volume about orientation cues is followed up with references to artwork, furniture, and outdoor spaces in the fourth volume and to a discussion regarding therapeutic considerations in the second volume. A consistent format throughout the four volumes makes them easy to read and use. It is an extremely effective organizing device.

Each topic is treated from three major perspectives. First, a treatment begins with a discussion of the problem from the perspective of the older person. The intention of this exercise is to give you a personal as well as scientific understanding of what a resident is experiencing. The authors' rationale is that seeing the world from the resident's perspective forces you to evaluate and select the best solution. For example, in the third volume, combative behaviors are defined in detail. The causes of combative behavior are identified, the history of using restraints is reviewed, and telltale symptoms like agitation are described. As part of this topic a case study is used to illustrate potential problems. Contemplating the problem of combative behaviors from the perspective of a confused resident provides the reader with a better understanding of and feel for the dynamics involved.

Second, the challenges presented by combative behavior are examined from the staff perspective—"What Staff Can Do." This section starts with an assessment of the most effective strategies that are normally employed to deal with this type of problem. Staff members are challenged to think about the individual resident and his or her particular personality style. Past successful techniques are reviewed first. Strategies to deal with verbal and physical abuse are defined and familiar contexts (like the bathing room) are identified as potentially explosive circumstances.

The third perspective discussed is the environmental influence. It looks at "What the Environment Can Do" to calm the situation. For example, because taking a bath is a common cause of disruptive behavior, attention is placed on how to make this environment more pleasant and less frightening. An analysis of the types of tubs that are manufactured for bathing is carried out. The pros and cons of each type of tub are outlined and the best manufacturers and model numbers are identified.

Near the end of each topic is a list of products that could be instrumental in addressing the problem as detailed. For example, in the section on combative behaviors 34 manufacturers of tubs, showers, bathing products, acoustical treatments, paging systems, lighting consultants, aroma therapy devices, and heat lamps are identified. The information provided includes mailing addresses, Web sites, and telephone numbers. These lists of resources reinforce the practical "problem-solving" nature of this series. Although no operational feedback is provided about each of the products, one recognizes that options and choices abound.

Finally at the end of each section is a 1–2-page summary that focuses on specific solutions, techniques, and cost-effective strategies. It collects the most important facts and reformats them into no-nonsense statements that are easy to understand. The summary is action oriented, giving advice that is immediately applicable. It is also an excellent device for reviewing previous material.

Volume One: Sensory Perception
The first volume is entitled Understanding the Environment Through Aging Senses. It focuses on how the environment is perceived through the aging senses of sight, sound, touch, taste, and smell. Here, human factors information on older adults is woven throughout the text with knowledge about how sensory perception is affected by dementia. One of the key challenges is to differentiate between what might be a processing problem due to normal aging and what can be attributed to the onset of dementia. Another underlying issue is what constitutes positive and negative sensory inputs. Each sensory modality processes positive and negative inputs. Smell, for example can be noxious or sublime. Minimizing the negative and optimizing the positive can be achieved by introducing positive scents and/or eliminating the source of negative odors.

The text simplifies human factors issues making them easily understood by laypersons. For some, the information will seem too elementary. The book after all is targeted toward caregivers and their supervisors rather than professionals in the field of architecture, management, or policy. Practical suggestions abound. For example, residents with vision loss may be unable to read caregiver nametags. Introducing yourself and explaining patiently what you are planning to do takes the mystery out of the interaction, allowing a resident to feel secure about what will happen next.

Volume Two: Daily Activities
Volume Two, Maximizing Cognitive and Functional Abilities focuses on six of the most important activities of daily living. These include mobility, continence, eating, dressing, bathing, and orientation. Because independence is often defined as one's ability to carry out these basic tasks, it is important to know how the environment can facilitate the continuation of these abilities. The authors start by providing the reader with a definition of what we know about each topic. For example, with regard to mobility, older people suffer from muscular-skeletal losses, blood flow impairments, and balance control difficulties. All of these problems make it easier for an older person to fall when they are walking, and falling is a major cause of disability. However, residents with dementia are at a higher risk because of ailments like apraxia (neurological condition that affects motor-planning skills) and difficulties remembering their inabilities or limitations. The staff can help by encouraging exercise and rehabilitation programs. The environment, on the other hand, needs to have higher light levels, convenient handrail support, and furniture that is available for resting and recharging.

Each of these six characteristics is important for continued independence and well-being. Furthermore, dementia residents have particular needs and eccentricities that make these everyday activities particularly challenging. Dressing is often difficult because the sequencing of putting on clothing becomes confused. Placing the right piece of clothing in the right order on the correct appendage can be exasperating for some residents. Eating patterns can be disturbed because food can seem different in taste and texture, mouth pain can cause difficulty chewing, and dexterity problems can make it hard to get food from a plate into one's mouth. Bathing complaints are frequent in dementia facilities. Residents resist bathing for a number of reasons including some that are related to the environment. Usually bathing rooms are cold and dark, and often appear unfamiliar. Difficulties with orientation can be approached by marking environments with differentiating cues. Important destinations like public toilets should be marked to make them easier to identify.

Volume Three: Disruptive Behaviors
Volume Three, Minimizing Disruptive Behaviors identifies five problem behaviors including wandering, elopement, rummaging/hoarding, combative behaviors, and socially inappropriate behaviors. Probably one of the most troubling aspects associated with group living in a dementia-specific living environment is dealing with the sometimes unusual behaviors that are manifested by the disease. Residents often lose inhibition and the result can be salty language, aggressive acts, and disruptive behavior. If creating pleasant days for the majority of residents is a central goal, these disruptions can make that goal difficult to achieve. Although planning effectively for the number of residents and the area set aside for dining and general common space can sometimes mitigate these problems, the noise and anxiety associated with these behaviors can greatly affect the calmness of the setting. Although it is a mystery why dementia is manifested in so many ways, well-trained staff who carefully observe residents can often isolate what triggers unusual behavior. Occasionally, the desire to elope can be traced to an expressed need to "go home," or problems with anger management can be related to an unresolved frustration. Sometimes continually reassuring residents is all that is necessary because they can't recall previous explanations.

Each problem is addressed by starting with what we know. Suggestions for potential approaches are used to stretch our basic understanding of the problem. For example, in the section dealing with wandering, six factors are identified. I suspect there are probably more factors to be considered but these are a great point of departure for understanding the problem of wandering and arriving at possible new solutions. Although the solutions suggested are not exhaustive and seem familiar rather than novel, they do a good job covering the territory as we know it. More formal findings from post-occupancy evaluations of specific buildings would have improved this volume. One of the great features associated with general explanations is that they are easy to apply to many different situations. However, specific findings often have generalizable "lessons" that are even more powerful in revealing patterns of behavior or specific flaws in a building design.

One of the most controversial and interesting topics discussed in this volume is socially inappropriate sexual behavior. Although not much new territory is covered in this section, it deals with a problem that appears to be more salient today than in the past. Staff are concerned about when to intervene, and sometimes family members find that group living can result in behaviors that are inconsistent with the past character and habits of their mother or father. The relatively young persons among the elderly residents are often sexually active; things can happen when they have time on their hands and watch explicit television programs. These problems can also result from boredom and disengagement.

Volume Four: Sense of Home
Volume Four, Enhancing Identity and Sense of Home has the most to offer in terms of suggestions about how to make the place more like a "real home" as opposed to a "homelike" environment. There is probably no other topic that is more salient to potential residents and their families than this one. Living in a dwelling unit populated with staff members who are being paid to take care of you creates a major disconnect with one's image of a cozy dwelling unit. This chapter looks at the problem by examining five topics: personalization, roles and activities, privacy, autonomy and control, and residential design.

The volume begins by describing three models that coexist: the medical model, the residential model, and the hospitality model. The medical model is introduced as the historic precedent from which more enlightened approaches have evolved. The residential model is conceptualized as one approach and the hospitality model as another. The section is summarized by stating there is no "correct" or "best" philosophy. I suspect that every excellent facility has all three of these components present. However, the overwhelming desire of consumers and savvy providers is to use the residential model as the primary guiding philosophy.

This volume deals more with the architectural design of the overall environment than the others and thus provides a perspective regarding the organization of common spaces, the design of the dwelling unit, and connections to the outdoors. Plans are used, although sparingly, to describe specific spatial relationships. The section that deals with activities and roles introduces concepts like the residential-style "therapeutic" kitchen as well as the idea of sharing activities of daily living with residents to structure the day. Here, plans and sections with annotations could have provided more specific information about how to design a special kitchen for the needs of residents.

Conclusions
Although this book series provides a major step forward in our thinking about how to connect the design of the environment to the day-to-day lifestyle of older residents, in some areas it is less than 100% effective. For example, for a book that focuses on physical design attributes, many of the black and white photographs are muddy with inadequate contrast. This greatly hampers the communication of ideas. Cartoon sketches used throughout the text are far more effective in communicating simple ideas. Furthermore, the solutions displayed in the photographs are very clinical and not all that attractive. Signs that clutter spaces, glossy floor surfaces that cause glare, and busy wallpaper treatments seem very institutional.

Although a number of manufacturers with various products are outlined, no specific building installations are listed. A directory of applications would have been useful because assessing the quality of a product is very difficult to do from a brochure. It is much more effective to see the product installed and to talk with staff members about how it works or doesn't work. One of the problems associated with listing products by manufacturer is that an unbiased assessment of the product's performance is not available. It is like a "yellow pages" approach to choices.

It is a major challenge to create a publication that provides useful, implementable advice on enough topics to make the work seem comprehensive. This has been done in a very effective way with this publication series. One could argue about the validity of some solutions. However, we know very little about what works in a predictable way. The beauty of this publication is that is provides a rich collection of suggested starting points. It is perhaps incumbent on future research to clarify the effectiveness of these ideas. In that way we can view many of these ideas as potential hypotheses that need further validation. In fact, the work seems like it could be open ended with new topics and treatments added as effective research reveals refinements and new approaches to the many problems addressed. Looking at problems through the three lenses of residents, staff, and environment forces the reader to think about how these three reinforce one another and hints at the potential synergy that can occur when things are done well from each of these perspectives.

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