2. SummerIEt6 1992. The Importance of Exterior. Environment for Alzheimer Residents: Effective Care and Risk Management by Patrick Mooney and P. Lenore ...
Volume 5, No. 2
SummerIEt6 1992
The Importance of Exterior Environment for Alzheimer Residents: Effective Care and Risk Management b y Patrick Mooney and P . Lenore Nicell, CHE
lthough some may believe that patients with Alzheimer’s disease and related disorders are unresponsive to environment, evidence shows that environments especially designed for cognitively impaired seniors can maintain or increase their level of functioning.’**These studies have suggested that the cognitively impaired are actually more sensitive to environment, so that a relatively minor improvement in a health care facility environment may show a disproportionate benefit to residents. Some publications make the point that the value of the physical environment as a therapeutic aid is little re~ognized,3’~ partly because what work has been done to show that environment influences behaviour has been done with well seniors. Studies on the implications of environment for institutionalized
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Gestion des soins de sant6
seniors have also focused on interiors with little emphasis on the use of exterior environments.
Designing environments for residents w i t h Alzheimer’s disease and related dementias Providing care for patients with Alzheimer’s disease and for people with other dementing illnesses poses considerable challenges for family members and institutions. Since the publication of The 36-Hour Day5 in 1981, which described the way demented people experience the world as their cognitive processes deteriorate, new levels of awareness of the impact of the environment on behaviour and well-being have developed steadily. They are described in Design for Dementia,4 which typifies properly designed environments as providing prosthetic support. Prosthetic 23
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supports are defined to be devices or elements that provide additional functional support to compensate for limited capabilities. Considering that the victims have memory impairment, intellectual decline, temporal and spatial disorientation, impaired ability to communicate and make logical decisions, and decreased tolerance to high and moderate levels of stimulation, special design elements are needed. The British Columbia Long Term Care Association developed Guidelinesfor Planning and Development of Special Care Units? which identifies optimal environments as those that offer freedom of movement while providing only safe choices. When creating environments for the cognitively impaired, the process must include the addition of elements that promote recognition of place and objects, thereby eliminating frustrating impediments.
Exterior space Exterior spaces are exceedingly important because so many of the residents with dementia are mobile and often walk a great deal. Observation has shown that this exercise helps to reduce the frustrations and anxiety that characterize all dementias. Dead-end corridors, locked doors and crowding all create frustration which may illicit catastrophic behaviour. It is also important for such patients to be able to choose to walk as long as they want. The ability to make a choice and then proceed without encountering obstacles helps residents to use residual skills, thereby shifting the focus away from behaviour that may be selfdestructive or assaultive.
Exterior facilities a t Cedarview Lodge The original exterior facilities at Cedarview Lodge were unsafe. Environmental hazards included slippery sloping banks, ankle-tangling shrubs, curbs along a fire lane over which residents tripped, and a border of uneven ground. In periods of rain the concrete reflected a glare that was disorienting to residents. Falls were frequent and, because the area was large, staff often failed to see them occur. Some falls resulted in serious injury, which prompted the administrator to initiate the development of a special care garden, free of such hazards. Disoriented residents often became confused and stuck at one location in the garden, upsetting other residents and requiring staff intervention. Consequently, a newly-designed facility opened in May 1990 implementing the following design criteria. The exterior area was designed to: reduce glare on pathways and entry ways; provide a continuous loop pathway so that residents were naturally led back to the building entry, thereby avoiding disorientation;
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contain a central trellis and tree grove, which were to act as landmarks and allow residents to orient themselves; be enclosed, but with the surrounding fence screened in such a way that residents were not attracted to the site edge; contain plants that are non-toxic so that there is no danger of poisoning from ingesting plant material; contain footpath lights and handrails intended to minimize the danger of residents falling in the garden by providing continuous even lighting and support; contain some seasonal colour but be low key, rich in familiar fragrances, and intended to soothe rather than visually stimulate the residents; and increase the apparent size of plantings, as there was a relatively high ratio of walkway to planted area. There were four seating areas, all partially shaded and planted to give an illusion of privacy. This study is a post-construction evaluation of the efficacy of this special care exterior environment.
Study design The study compared incident reports for four months in two consecutive years (I1,12) (Table 1).Two general categories were compared: facilities with exterior environments (B1, B2) and those without (B3, B4, B5). A PAMIE (physical and mental impairment of function e ~ a l u a t i o ntest ) ~ was used to determine the relative uniformity between the populations (A) in each of the institutions at the beginning of the study. (Two facilities [B4, B51 had no PAMIE test done because they were added after the initial study was begun to validate the rather dramatic findings). In the two garden facilities (Bl, B2), on-site observations (Factor S) were conducted half-way through the final period of the study (two months in 1990)to compare the efficacy of the two garden designs.
Incident reports
.
Since the participants in the study were generally not lucid and unable to respond to questionnaires, incident reports became the main instrument with which to describe their behaviour. Incident reports may be defined as written descriptions of unexpected happenings that may or do represent a risk to person, property or facilities; they are an important component of a risk management program. A previous study has categorized incidents into: falls, found on floor, fractures/head injuries, lacerations/bruises, scalds/burns, choking and eye injury, missing, aggression and other.8 The original intention was to compare the effects of (a) a special care garden with (b) an exterior use area (i.e., not designed for use by Alzheimer residents) with (c) a non-garden institution. However, the results were so striking that two other non-garden institutions were Healthcare Management FORUM
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0
T B1 82 83
2 months S S
4 months
B4
A
Residents with Alzheimer's disease and related dementia
for residents in special care. Another facility had an exterior use area that was not specially designed for special care residents. The third facility had no exterior use area. After an initial review of the data, two other non-garden institutions were included in the study. To maintain subject confidentiality, the facilities will be referred to as the special care garden, the exterior use area and the non-garden facilities. Since a single variable (i.e., exterior use) was manipulated while all other factors were maintained as constants, changes in resident behaviour can be attributed to the manipulated variable.
B1 Access to specially designed exterior facility
PAMIE test
8 2 Access to an exterior area not specially designed
added in a further attempt to validate or negate initial findings. Incident reports from all facilities were compared for four months and for the same four months the following year in all five participating facilities. Instructions given to staff for the reporting of incidents in the five study facilities were similar. Staff members reported incidents in writing to nurses who investigated and brought the report to the administrator's attention.
The PAMIE7 is a behaviour-rating scale that has proven sensitive to functional change in the older institutionalized resident. This 77-item scale has 10 factors: (1)self-care/dependent, (2) belligerent/irritable, (3) mentally disorganized/confused, (4) anxious/depressed, (5) bedfast/moribund, (6)behaviourally deteriorated, (7) paranoid /suspicious, (8) sensorimotor impaired, (9) withdrawdapathetic and (10) ambulatory. For this study, the scale was completed by nurses who had a daily opportunity to observe the subjects in their normal setting and who had good knowledge of resident condition. All participants in the initial three facilities were tested before the study using the PAMIE (Factor T). Generally, the three populations were found to be similar in levels of functioning, with the special care garden facility having a somewhat higher level of mobility than the other two facilities; 86%compared to 62% and 61%,respectively. Residents of the facility with the exterior use area were less dependent for self-care and perhaps for this reason were less belligerent and irritable. Conversely, residents at the nongarden facility were the most belligerent and irritable and the most dependent for self-care.
Facilities
On-site observations
The five participating facilities operated special care units housing similar types of residents. The four facilities from British Columbia's lower mainland, and one on Vancouver Island, had similar numbers of residents in special care units (between 25 and 31). Each resident had been found to require intermediate care level three by provincial ministry of health assessors. The criteria for admission included behaviours that placed the resident at personal risk or risk to others. All residents had Alzheimer's disease or a related dementia that impaired them to such a degree that they could not be managed in ordinary intermediate care facilities. The facilities were also staffed and run according to the same provincial standards.
The authors familiarized the nurses at the two facilities with exterior use areas with a process for reaching inter-observer agreement and the observation form used to record resident behaviour. Two nurses observed residents for 45 minutes, morning and afternoon, on the same day at both sites. At first, the nurses observed the same subject for 15 minutes and their records were compared to establish inter-observer agreement. Once observer agreement had been reached, each nurse then recorded her own independent observations for other patients. The date and time period were recorded and the residents' activity outside was noted:
83 No exterior facility B4 No exterior facility, no PAMIE test 85 No exterior facility, no PAMIE test I 1 All incident reports, all facilities, May - August previous year (1989) I 2 All incident reports, all facilities, May - August year of the study (1990)
S T
On-site observation in B1 and B2 only, the garden facilities PAMIE test
.
Name Time Inlout Dominant Activity First Activity Seen
The facilities included Cedarview Lodge, the one facility with an exterior use area designed especially Gestion des soins de sante
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Table 2: Incident reports for 1989 and 1990 Non-garden institutions Special care garden 81
Exterior use area 82 1990
83 #
R 0.08
0
1.48
10
0.36
0
1.92
10
B4
I
1989 #
1990
R
R
#
85
I
1989
1990
#
R
#
R
4
0.13
5
0.25
20
1.0
0
0.33 32
1.06
3
0.15
24
1.2
36
0
0
1
0.05
2
0.10
0
1.2
9
0.45
46
2.32
36
0
0
0.33 36
1989 #
1990
R
R
0
10
0.42
1.5
82
3.42
1
0.04
1.50 93
3.88
0
R =rate of incident # = number of incidents
Behaviours included walking, complaining, sitting, socializing and so on, and included comments about the appropriateness of the behaviour (e.g., sitting on the bench or on the sidewalk). On-site observations were made at two months in both facilities that had exterior care facilities (Factor S ) to determine inadequacies in either garden design. Since resident populations that have Alzheimer‘s disease or related dementias deteriorate over time, the non-garden group (Factors B3, B4 and B5) was necessary for control purposes. At both garden facilities (B1 and B2) the behaviour of participants in the exterior areas was recorded by two nurses who worked at the facility and therefore were not likely to influence resident behaviour.
Research results Incident reports
Analysis of the incident reports for the five facilities led to some interesting findings (Table 2). For incidents of violence, falls and total incidents, the two facilities with gardens showed little or no change between 1989 and 1990. In the facilities that did not have gardens there was a significant increase in the incidents recorded in the three categories. When the change in rates of incidents in the facilities with gardens was compared to those without gardens, the dramatic effect which may be attributed to the garden environment was clearly evident (Tables3 and 4). In the garden institutions, the rate of violent incidents declined by 19%between 1989 and 1990 while the total rate of incidents fell by 3.5%over the same period. In the non-garden institutions, the rate of violent incidents increased by 681%and the total rate of incidents increased by 319%.
An increase in the number of incidents each year is expected, which reflects the progressive deterioration of cognitive and ambulatory processes that occur over time in people who have Alzheimer’s disease. The degree of increase in the non-garden groups was startling compared to the garden groups. This indicates that whether gardens are designed especially for Alzheimer‘s disease patients or not, gardens beneficially affect behaviour and, by extension, quality of life for such residents. Spearman’s rank correlation Spearman’s rank correlation was chosen to make comparisons between the incident reports at given facilities. The Spearman’s rank correlation possesses a power efficiency of about 0.9 when compared to parametric tests and is well suited to comparisons of this sort. The calculations of Spearman’s rank correlation are quite straightforward. Rates of occurrence for each category are listed for the five facilities. The differences are calculated and then squared. The total of the squared values is used in the following formula:
r/s = 1 - (6cd2) N3 -N
where N = the number of conditions and d = difference. Spearman’s rank correlation was computed for the rate of incidents of violence in the garden institutions for the four-month study period. The value of 0.13 showed a very low level of correlation between the non-garden and the garden institutions when rates of incidents were compared, indicating large differences in the prevalence of incidents. A value of 0.65 indicates a reasonable similarity, a value of 0.90 a strong similarity.
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Table 3: Percent change in incidents in 1989 and 1990. 700 ._ _
I
Table 4: Comparison of rate of change in incidents in institutions with gardens and institutions without gardens in 1989 and 1990.
I 1 1, I I
I
650 600 550 500
Garden arwD
:,of incident
Rate 1989
Rate 1990
Violence
0.3333
0.2678
2.6274
2.5357
incidents
400
Non-aarden WOUD
Change
3.5.1
psa,t;
Rate % 1990 Change
0.06750
0.4594
6817
0.7432
2.3698
3197
I
300
Discussion 200
100
0 Violence All incidents Garden Non-Garden Garden Non-Garden
On-site observations There were two significant differences in resident behaviour observed in the special care garden and the exterior use area. One is the dominance of walking as an activity. As a first activity, walking was 16%more frequent in the special care garden than in the exterior use area; as a dominant activity, it was 32%more frequent. This is a strong indicator that the design features that were intended to promote safe walking did do so. These features were: a figure-eight walkway (i.e., no dead-ends), prominent handrails and a flat, smooth, minimum glare concrete walk (Figure 1). Also, in the special care garden, all residents were observed to move through the garden without confusion and appeared to be at ease. In the exterior use area, 42%of the residents were observed to move through the environment without confusion. Generally, residents appeared to enjoy being in the garden but 25% appeared ill at ease. One resident exhibited agitated behaviour in the gard,en.Observers’ comments indicated that the behaviour was partly due to poor garden design (i.e., a resident nearly upset a lightweight plastic chair but was prevented from falling by an observer). The same resident complained of the wind for the entire time she was in the garden.
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Research hypothesis The researchers attempted to test the following hypo theses: Poor environments per se increase residents’ frustration and can precipitate catastrophic behaviour, given that other care standards and staff skills are similar. Freedom of movement, opportunities to avoid crowding, noise or too much stimulation, and being able to be in the garden as desired will have a favourable impact on residents’ feelings of comfort and security, thus minimizing the frequency of behavioural disruptions recorded as “incidents“. All comparisons between the garden and nongarden institutions (i.e., rates of violence, percent change in violence, falls and total incidents and Spearman’s rank correlation) support the original hypotheses.
.
In the institutions without gardens, the level of incidents in all categories indicated that the lack of a garden environment has a negative impact on resident behaviour and, by inference, emotional state. The resulting increase in violence apd fallsis of concern not only for its negative effect on the residents’ quality of life, but because of its implication for risk management for the health care facility. In this type of population, no observable change in violence over a year suggests that the residents’ emotional state is similar to the way it was a year ago. As Alzheimer’s disease is progressive, this finding strongly suggests that environmental improvement contributes to maintaining emotional well-being despite inevitable deterioration. The dramatic increase in violence between 1989 and 1990 in the non-garden facilities supports this interpretation. Evaluation of design The original design criteria developed for the special care garden at Cedarview Lodge facilitated
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Figure 1 :Garden Drawing Incorporating Design Features That Promote Safe Walking.
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independent use of the garden by residents. Although the efficacy of some of the design criteria, such as having a central landmark, cannot be isolated, the layout of the garden allowed residents to move through the garden and return to the building without any confusion, and thus promoted walking. Before the garden was modified, residents spent long periods outdoors. In the newly-constructed special care garden, residents used the garden often but for shorter periods. The researchers hypothesize that residents now use the garden as part of an extended walking circuit, which includes the building corridors as well as the garden, and reflects a short attention span. The exterior use facility did not have a continuous hard-surface path, lighted walkway or central landmark. It was a large 38,000 sq. ft. amorphous space with boundaries that were not clearly visible from all areas of the garden and not strongly demarcated. It was also exposed to sun and wind, and observers recorded negative resident response to this exposure. In addition, the lightweight plastic furniture was a risk to the residents and contributed to agitation. Observations at both institutions with gardens tended to validate the original design criteria. Subsequent observations suggested that the following new design criteria should be added: Make the garden a continuous spatial unit with strongly defined boundaries, preferably through which residents cannot see. All aspects of micro-climatic comfort should be considered, which means protection from sun and wind and reduction of glare. Furniture should be heavy and stable with seat heights of about 18 inches. Ideally, the garden should be located at the end of a corridor and the exterior door should allow views and access into the garden. This is because residents tend to walk corridors and "get stuck at the end of them, not realizing that they can turn around and walk the other way. Since the tendency is to walk forward, circular or loop corridors and walkways minimize frustration. A garden at the end of a corridor is readily discovered and acts as a loop which returns residents to the building and facilitates walking. The criteria used in the design of the special care garden did not result in a significant reduction in the rate of incidents over the exterior use facility. However, they did result in an increase in ease of use and a reduction in agitated behaviour by residents. The results of this study indicate that benefits accrue to residents when they have access to an exterior environment. The original hypothesis that access to an exterior environment that allows freedom of movement, opportunities to avoid crowding and too much Gestion des soins de sante
stimulation, will reduce resident frustration, and thus minimize behaviourial disruptions, appears valid. This study is perhaps the first of its kind and is therefore to be used as an indicator of direction. It is hoped that future research will validate these results and refine our knowledge concerning the use of exterior environments as prosthetics in the care of residents with Alzheimer's disease.
References and notes 1. Lawton, M.P. 1971. The functional assessment of elderly people. Journal of the American Geriatrics Society 19(6):465481. 2. Nelson, M.N. and Paluck, R.J. 1980. Territorial markings, self concept and mental status of the institutionalized elderly. The Gerontologist 200): 9698.
3. Hiatt, L. 1985. Designing for Mentally Impaired Persons: Integrating Knowledge of People with Programs, Architecture and Interior Design. Paper read at the American Association of Homes for the Aging annual meeting 1985, Los Angeles, Calif. 4. Calkins, M.P. 1988. Design for Dementia: Planning Environments for the Elderly and Confused, National Health Publishing, Owings Mills, Md.
5. Mace, N.L. and Robins, P.V. 1981.The36-Hour Day: A Family Guide to Caring for Persons with Alzheimer's
Disease, Related Dementias and Memo y Loss in Later Life, Warner Books, New York. 6. British Columbia Long Term Care Association. 1988. Guidelines for Planning and Development of Special Care Units, British Columbia Long Term Care Association, Vancouver. 7. Gurel, L., Linn, M.W., Linn, B.S., Davis, J.E. Jr. and Maroney, R.J. 1970. Patients in nursing homes: multi-disciplinary characteristics and outcomes. Journal of the American Medical Association 2/3(1): 7377. 8. Paterson, P.L. and Loughlin, K. 1988. A test of incident reporting. Australian Clinical Review 8(28): 2630. %
Acknowledgement This research was supported in part by a grant from Health and Welfare Canada under the Alzheimer's initiatives as announced in July 1989.
Patrick Mooney, MLA, CSLA, is Assistant Professor, University of British Columbia, Landscape Architecture Program, Vancouver, B.C. P . Lenore Nicell, BHEc, Dip Diet, GHSA-LTC, CHE, is Administrator, Cedarview Lodge Intermediate Care Facility, North Vancouver, B.C. 29
