Original Article
The Importance of Exterior Environment for Alzheimer Residents: Effective Care and Risk Management

https://doi.org/10.1016/S0840-4704(10)61202-1Get rights and content

Evidence shows that environments especially designed for cognitively impaired seniors can maintain or increase their level of functioning. Little emphasis has so far been placed on the prosthetic role that may be played by exterior environments. This study attempted to determine the value that specially designed exterior spaces may have in reducing undesired behaviours, thereby minimizing risks to the patients and potential liability to the institution.

The researchers tested that (a) poor environments increase residents' frustrations and can precipitate catastrophic behaviour and (b) freedom of movement and opportunities to avoid crowding, noise and excess stimulation minimize the frequency of aggressive behaviour.

The researchers found that the use of exterior environments reduced incidents of aggressive behaviour, and contributed significantly to a risk management program.

Résumé

Les données indiquent que les milieux spécialement conĉus pour les personnes âgées atteintes de trouble cognitifs peuvent maintenir ou augmenter leur niveau d'aptitude. Le rôle prothétique qui peut être joué par les environnements extérieurs a reĉu peu d'attention. Cette étude visait à déterminer l'utilité des espaces extérieurs spécialement conĉus pour réduire les comportments indésirables, minimisant ainsi les risques pour les patients et la responsabilité éventuelle de l'établissement.

Les chercheurs ont vérifié si (a) les environnements médiocres accroissent les frustrations des résidents et peuvent déclencher un comportement catastrophique et (b) si la liberté de mouvement et les possibilités d'éviter le surpeuplement, le bruit et la stimulation excessive minimisent la fréquence du comportement agressif.

Les chercheurs ont constaté que l'utilisation d'environnements extérieurs a réduit les incidents de comportement agressif et contribue significativement à un programme de gestion des risques.

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:

  • 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

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.

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    Design for Dementia: Planning Environments for the Elderly and Confused

    (1988)
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