The Assessment of Long-Term Care Environments for Wayfinding Design.

OBJECTIVES: The purpose of this article is to compare three different methods to assess the complexity of a long-term care (LTC) environment for wayfinding before and after an environmental design intervention. The methods include space syntax (SS), the Wayfinding Checklist (WC), and the Tool to Assess Wayfinding Complexity (TAWC). BACKGROUND: Wayfinding is important to maintain older adults' independent functioning. The design of environments can impact wayfinding ability by providing support; this can be via building structure or by environmental design features such as signage and landmarks. Few methods or tools have been scientifically validated to assess environments for wayfinding complexity. In order to compare environments in terms of complexity and to measure the impact of interventions, valid and reliable tools are necessary. METHODS: This article discusses the results of the use of three wayfinding design assessment tools using three routes in one LTC environment. The results of the three tools are discussed. RESULTS: SS analysis could quantitatively measure the complexity of routes using integration values, which indicates connectedness. The TAWC and the WC were able to measure differences in visual field scores pre- and postenvironmental intervention. There were limitations to each tool: the lack of psychometric properties for the TAWC and the WC, and the lack of ability to measure changes in design features within visual fields with SS. CONCLUSIONS: Multiple tools to assess environments for wayfinding design may be needed in studies that test environmental interventions. Future research is needed to provide psychometric testing for the tools.

The Environmental Audit Screening Evaluation: Establishing Reliability and Validity of an Evidence-Based Design Tool.

Background and Objectives: Current assessment tools for long-term care environments have limited generalizability or ability to be linked to specific quality outcomes. To discriminate between different care models, tools are needed to assess important elements of the environmental design. The goal of this project was to systematically evaluate the reliability and validity of the Environmental Audit Screening Evaluation (EASE) tool to better enable the identification of best models in long-term care design to maintain quality of life for persons with dementia and their caregivers. Research Design and Methods: Twenty-eight living areas (LAs) were selected from 13 sites similar in organizational/operational commitment to person-centered care but with very different LA designs. LAs were stratified into 3 categories (traditional, hybrid, and household) based primarily on architectural/interior features. Three evaluators rated each LA using the Therapeutic Environment Screening Scale (TESS-NH), Professional Environmental Assessment Protocol (PEAP), Environmental Audit Tool (EAT-HC), and EASE. One of each type of LA was reassessed approximately 1 month after the original assessment. Results: EASE scores were compared against the scores of 3 existing tools to evaluate its construct validity. The EAT-HC was most closely related to the EASE (r = 0.88). The PEAP and the TESS-NH were less correlated to the EASE (r = 0.82 and 0.71, respectively). Analysis of variance indicated that the EASE distinguished between traditional and home-like settings (0.016), but not hybrid LAs. Interrater and inter-occasion reliability and agreement of the EASE were consistently high. Discussion and Implications: Neither of the 2 U.S.-based existing environmental assessment tools (PEAP and TESS-NH) discriminated between the 3 models of environments. The EAT-HC was most closely aligned with the EASE and performed similarly in differentiating between the traditional and household models, but the dichotomous scoring of the EAT-HC fails to capture environmental nuances. The EASE tool is comprehensive and accounts for nuanced design differences across settings.

Evaluation of environmental assessment tools for settings for individuals living with dementia.

Introduction: The overarching goal of research on physical settings for individuals living with dementia is to identify associations between designed features within the built environment and outcomes of interest. Over the past three decades numerous environmental assessment tools have been developed in several countries, responding to a changing set of care industry values that increasingly prioritize a holistic, quality-of-life-driven person-centered care (PCC) model over a biomedical approach to long-term care (LTC) provision. This article reviews the diversity, constructs, strengths, and limitations of existing environmental assessment tools and identifies gaps for future tool development. Methods: A systematic literature search was conducted using four databases (Medline, CINAHL, PsycInfo, and Avery Index) and terms related to health-care environments and assessment tools. Results: A total of 13 environmental assessment tools for people living with dementia within shared residential settings were identified. Evaluation of the environmental assessment tools includes a synthesis of published data for each tool's reliability, validity, ease of use, interpretability, strengths and weaknesses, as well as a comparison of various tool characteristics including date of development, country of origin, applicable care setting(s), number and variety of measures and underlying constructs, format, and descriptive versus evaluative content. Discussion: While the shift to person-centered values encompasses all aspects of care and care settings, the majority of person-centered definitions exclude the important role of the designed, physical environment. However, this review of environmental assessment tools clearly demonstrates that newer tools are embracing the full array of PCC values. In the United States, this is shown in the shift from tools designed to assess segregated dementia care settings to tools that integrate the needs and preferences both of individuals living with and without dementia. Next-generation tools need to specifically address the household model of design. Highlights: The overarching goal of research on physical settings for individuals living with dementia is to identify associations between designed features within the built environment and outcomes of interest.A systematic literature search identified a total of 13 environmental assessment tools for people living with dementia within shared residential settings; these tools were then described and evaluated based on reliability, validity, ease of use, interpretability, strengths, and weaknesses.This review of environmental assessment tools clearly demonstrates that newer tools are embracing the full array of person-centered care values.

Effect of Ambient Bright Light on Behavioral and Psychological Symptoms in People With Dementia: A Systematic Review.

Background and Objectives: Behavioral and psychological symptoms of dementia (BPSD) commonly occur in persons living with dementia. Bright light (BL) interventions have shown some positive impact on BPSD. Ambient lighting is a more efficient approach to delivering BL with better compliance and less staff workload than individual-based lighting interventions. Yet, its effect has not been systematically reviewed. This review synthesized research evidence on the effect of ambient BL on BPSD. Research Design and Methods: This review searched literature from PubMed (Medline), CINAHL, Scopus, Web of Science, and Cochrane in February 2021. Original research testing the effect of ambient BL on BPSD in persons with dementia was included. Two reviewers independently screened, extracted data, and assessed the quality of each article. Results: Nine studies were reviewed with 1 randomized controlled trial and 8 quasi-experimental studies. The sample size ranged from 14 to 89 participants across care settings. While not all studies showed positive results, evidence from multiple studies revealed the positive effect of ambient BL on depressive symptoms and agitation in persons with dementia. The ambient BL that showed a positive effect targeted at approximately 350-750 lux, 4,500-9,325 K, and/or circadian stimulus = 0.375-0.4 for 10-12 hr a day for 4 weeks or longer. Evidence on other BPSD was mixed or too limited to draw conclusions. Discussion and Implications: A preponderance of evidence suggests that, when properly designed and implemented, ambient BL shows promise in reducing depressive symptoms and agitation. Future research, using more rigorous designs, is needed to further test the effect of ambient BL on BPSD with attention to lighting parameters, measurement approaches, and intervention fidelity.

Advancing Research on Care Needs and Supportive Approaches for Persons With Dementia: Recommendations and Rationale.

The first National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers was held on October 16-17, 2017, at the National Institutes of Health. In this paper, participants from the Summit Session on Research on Care Needs and Supportive Approaches for Persons with Dementia summarize the state of the science, identify gaps in knowledge, and offer recommendations to improve science and practice in long-term care. Recommendations cover 4 areas focused on persons living with dementia: (1) symptoms (behavioral and psychological symptoms of dementia, function, cognition, and sleep); (2) dementia care settings (physical and social environments, home, and residential care); (3) living with dementia (living well with dementia, living alone with dementia, and living with dementia and intellectual and developmental disabilities); and (4) technology as a cross-cutting theme. The participants identify 10 of the most pressing research issues based on the findings from their collective papers. Final Summit recommendations included those presented by session participants and will be used to advise federal agencies and other organizations that fund research.

From Research to Application: Supportive and Therapeutic Environments for People Living With Dementia.

The evidence about the role the designed and built environment plays in supporting individuals living with dementia has been steadily mounting for almost 40 years. Beginning with the work of M. Powell Lawton at the Weiss Pavilion at the Philadelphia Geriatric Center, there are now dozens of researchers who are exploring how the environment can be either supportive and therapeutic, indeed even serving as a prosthetic for various changes in cognition, or be a barrier to independent functioning and high quality of life. Two recent literature reviews published on the impact of environmental factors and characteristics on individuals living with dementia clearly delineate evidence that the environment can have a therapeutic or a debilitating impact on individuals living with dementia. Rather than duplicate these excellent reviews, this article puts the knowledge gleaned from this research into the shifting context that is long-term care. This article begins with an exploration of the evolution of approaches to the design of spaces for individuals living with dementia from traditional or medical models, to special care units (SCUs), to person-centered care (PCC), which is the organizing theme of this supplemental issue. A novel, person-centered way of conceptualizing the domains of environmental systems is then presented and used as the framework for structuring recommendations and creating supportive and therapeutic environments for individuals living with dementia. Although there are distinct pathophysiological and behavioral manifestations of different forms of dementia, there is almost no evidence that suggests alternative environmental characteristics are better for one type of dementia over another. Thus, this article will refer to "individuals living with dementia" as opposed to Alzheimer's disease or other specific forms of dementia. Further, this article only addresses residential environments: homes in the community, independent and assisted living residences and nursing homes. It does not address other settings, such as hospitals or hospice, or work and public community spaces, such as stores. It is recognized that individuals living with dementia do spend time in all these spaces, and fortunately, there is growing interest in creating more dementia-friendly communities, but they will not be addressed in this article. Most of the research that has been done has focused on shared residential settings, so that will be the primary focus on this article.

Beyond ADA Accessibility Requirements: Meeting Seniors' Needs for Toilet Transfers.

PURPOSE: To identify the optimal spatial and dimensional requirements of grab bars that support independent and assisted transfers by older adults and their care providers. BACKGROUND: Although research has demonstrated that toilet grab bars based on the Americans with Disabilities Act (ADA) Accessibility Standards do not meet the needs of older adults, the specific dimensional requirements for alternative configurations are unknown. METHODS: A two-phased study with older adults and care providers in residential facilities was conducted to determine the optimal requirements for grab bars. Seniors and caregivers in skilled nursing facilities performed transfers using a mock-up toilet. In Phase 1, participants evaluated three grab bar configurations to identify optimal characteristics for safety, ease of use, comfort, and helpfulness. These characteristics were then validated for using ability-matched samples in Phase 2. RESULTS: The optimal configuration derived in Phase 1 included fold-down grab bars on both sides of the toilet (14" from centerline [CL] of toilet, 32" above the floor, and extended a minimum of 6" in front of the toilet) with one side open and a sidewall 24" from CL of toilet on the other. Phase 2 feedback was significantly positive for independent and one-person transfers and somewhat lower, albeit still positive, for two-person transfers. CONCLUSION: The study provides substantial evidence that bilateral grab bars are significantly more effective than those that comply with current ADA Accessibility Standards. Findings provide specific spatial and dimensional attributes for grab bar configurations that would be most effective in senior facilities.

Honoring Individual Choice in Long-Term Residential Communities When It Involves Risk: A Person-Centered Approach.

Nursing homes that are working on adopting person-centered care (PCC) practices express concerns about giving residents the freedom to make their own decisions and the accompanying risks. This challenge is especially true for those who are at the beginning of the PCC change process. Although the Centers for Medicare and Medicaid Services regulations are clear that residents have the right to a dignified existence and self-determination, and that the facility must protect and promote their rights, examples abound of care communities coercing, cajoling, or requiring residents to do things they do not want to do (e.g., take medications), or the reverse of not letting them do what they want (e.g., eat a regular diet). The current article discusses a process that helps care communities follow the regulations about education and offering choices while honoring resident preferences and documenting the process for surveyors. [Journal of Gerontological Nursing, 42(8), 12-17.].

Development and evaluation of the environment and communication assessment toolkit with speech-language pathologists.

Communication dysfunction that results from dementia can be exacerbated by environmental barriers such as inadequate lighting, noisy conditions, poor or absent environmental cues, and visual clutter. Speech-language pathologists (SLPs) should address these environmental barriers as part of a comprehensive treatment plan for clients with dementia. The Environment and Communication Assessment Toolkit for Dementia Care (ECAT) was evaluated by SLPs to determine: (1) changes in awareness of environmental factors prior to and after training; (2) impact of the ECAT on practice as measured by changes in the number of environmental modifications recommended and made prior to and after training; (3) utility of the information as measured by the helpfulness, amount of new information, and usefulness of the ECAT; and (4) usability of the ECAT materials based on ease of use. The SLPs used the ECAT with clients with dementia who had functional limitations and required substantial assistance with daily activities. Results indicate that the ECAT is an effective tool for SLPs, providing information about the impact of the environment on communication and supplying sufficient resources to make recommendations and implement effective interventions. The ECAT successfully increased awareness of environmental modifications, influenced the practice of recommending environmental modifications, and had utility in diverse aspects of clinical practice.

Evidence-based long term care design.

Research on the impact of the built environment in long-term care settings continues to grow. This article focuses on work conducted and published since 2000, when an earlier review on research on dementia and design was published. The vast majority of research that addressed neurological conditions in residents in long-term care settings (assisted living and nursing homes) relates to Alzheimer's disease and related dementias.

Exploring the cost and value of private versus shared bedrooms in nursing homes.

PURPOSE: There is debate about the relative merits and costs of private versus shared bedrooms in nursing homes, particularly in light of the current efforts at creating both cost-efficient and person-centered care facilities. The purpose of this project was to explore the extent to which there is evidence-based information that supports the merits of three different bedroom configurations: traditional shared, enhanced shared, and private. DESIGN AND METHODS: We developed a framework of four broad domains that were related to the different bedroom configurations: psychosocial, clinical, operational, and construction or building factors. Within each dimension, we identified individual factors through the literature, interviews, and focus groups, with the goal of determining the breadth, depth, and quality of evidence supporting the benefits of one configuration over another. RESULTS: The vast majority of factors identified in this study, regardless of whether there was solid empirical data, information from the focus groups, or other anecdotal evidence, indicated better outcomes associated with private rooms over shared rooms in nursing homes. Cost estimates suggest that construction cost (plus debt service) differences range from roughly $20,506 per bed for a traditional shared room to $36,515 for a private one, and that such differences are recouped in less than 2 years if beds are occupied, and in less than 3 months if a shared bed remains unoccupied at average private-pay room costs. IMPLICATIONS: Despite limited empirical evidence in some areas, this project provides the foundation for an evidence-based life-cycle costing perspective regarding the relative merits of different bedroom configurations.

Measuring physical and social environments in nursing homes for people with middle- to late-stage dementia.

OBJECTIVES: To evaluate measures of dementia care environments by comparing a special care facility (SCF) with traditional institutional facilities (TIFs). DESIGN: A cross-sectional comparative study of nursing home environments conducted as part of a longitudinal study on quality of life for residents with dementia. SETTING: Twenty-four traditional nursing homes and one special care facility. PARTICIPANTS: One SCF with six distinct environments, 24 TIFs with 45 distinct environments, and 88 family members. MEASUREMENTS: Therapeutic Environment Screening Scale-2+ (TESS-2+); Special Care Unit Environmental Quality Scale (SCUEQS), a subset of the TESS-2+ items; Composite Above Average Quality Score (CAAQS), a composite score of all items on the TESS-2+; and Models of Care Instrument (MOCI). RESULTS: The SCUEQS did not detect a significant difference between the SCF and the TIFs (30.0 vs 27.2, P = .28). The CAAQS detected a significant difference between the SCF and the TIFs, whereby the SCF environments were rated as having above-average quality in 71.4% of the domains, compared with 57.3% for the TIF environments (95% confidence interval (CI) for difference = 2.6-25.6%, P = .02). Using the MOCI, SCF families were 1.8 times as likely to rate the SCF as a home or resort versus a hospital as TIF families rating TIFs (95% CI for odds ratio = 1.5-2.1, P < .001). CONCLUSION: The TESS-2+ CAAQS differentiated between physical environments better than the more established SCUQES. The MOCI distinguished between environments using a more holistic approach to measurement. The availability of environmental measures that are able to discriminate between specialized and traditional long-term care settings will facilitate future outcome-based research.

Influences on perceived function of a nursing home resident.

UNLABELLED: This article describes a typical, yet fictionalized woman with Alzheimer's disease during her first week at a nursing home. Readers are challenged to ask themselves in what areas of difficulty a speech-language pathologist may or may not be able to contribute to the success of this resident. The authors use the World Health Organization's International Classification of Functioning, Disability, and Health [International Classification of Functioning, Disability, and Health, 2001, Geneva, Switzerland] as the framework for assessments and the resident-centered interventions for this case study. LEARNING OUTCOMES: 1. The reader will be able to identify the four main constructs of the ICF classification system. 2. The reader will be able to identify three environmental factors that may influence the functioning of a person with Alzheimer's disease. 3. The reader will be able to discuss at least four interventions that can be implemented by a speech-language pathologist to improve a nursing home resident's participation in daily activities.

The Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH): an observational instrument for assessing the physical environment of institutional settings for persons with dementia.

OBJECTIVE: To develop an observational instrument that describes the ability of physical environments of institutional settings to address therapeutic goals for persons with dementia. METHODS: A National Institute on Aging workgroup identified and subsequently revised items that evaluated exit control, maintenance, cleanliness, safety, orientation/cueing, privacy, unit autonomy, outdoor access, lighting, noise, visual/tactile stimulation, space/seating, and familiarity/homelikeness. The final instrument contains 84 discrete items and one global rating. A summary scale, the Special Care Unit Environmental Quality Scale (SCUEQS), consists of 18 items. Lighting items were validated using portable light meters. Concurrent criterion validation compared SCUEQS scores with the Professional Environmental Assessment Protocol (PEAP). RESULTS: Interrater kappa statistics for 74% of items were above.60. For another 10% of items, kappas could not be calculated due to empty cells, but interrater agreement was above 80%. The SCUEQS demonstrated an interrater reliability of.93, a test--retest reliability of.88, and an internal consistency of.81--.83. Light meter ratings correlated significantly with the Therapeutic Environment Screening Survey for Nursing Homes (TESS-NH) lighting items (r =.29--.38, p =.01--.04), and the SCUEQS correlated significantly with global PEAP ratings (r =.52, p <.01). DISCUSSION: The TESS-NH efficiently assesses discrete elements of the physical environment and has strong reliability and validity. The SCUEQS provides a quantitative measure of environmental quality in institutional settings.