Original ArticleThe Importance of Exterior Environment for Alzheimer Residents: Effective Care and Risk Management
Section snippets
Designing environments for residents with 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
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
Exterior facilities at 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
Study design
The study compared incident reports for four months in two consecutive years (11, 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 evaluation)7 test 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, B5] had no PAMIE test done because they were added after the
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,
Facilities
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
PAMIE test
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) withdrawn/apathetic and (10) ambulatory.
For this study, the scale was completed by nurses who had a daily
On-site observations
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
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
Research hypothesis
The researchers attempted to test the following hypotheses:
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Poor environments per se increase residents' frustration and can precipitate catastrophic behaviour, given that other care standards and staff skills are similar.
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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
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.
References and notes (8)
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Design for Dementia: Planning Environments for the Elderly and Confused
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