There has been increasing interest in the impact of physical environments on continued quality of life for persons with intellectual disabilities as they experience symptoms of dementia. There is both work with the generic population with dementia to draw upon (see references), targeted work with persons with ID and on-going work in Ireland involving multiple services providers and in the US with a consortium of agencies in New York State that are the basis for a range of recommendations for the remediation of key environmental concerns and to support ageing in place.
Ageing in place
When symptoms of dementia are present, living in the community simply for the sake of living there, regardless of the quality of life that is possible, may be as indefensible as automatic movement into more restrictive settings. It is incumbent upon services providers to examine their settings and to work with families in looking at their homes to find relatively low-cost improvements that sustain ageing in place and quality of life for the person with dementia. For most individuals, this affects the design of house in which they live as it reduces the home-like quality, character and appearance of the home itself- Chafetz (1991) suggests that there are seven dementia-related areas that need to be addressed: (1) Simplification of the environment, (2) Way finding and Orientation (3) Furniture (4) Noise (5) Illumination (6) Colour, and (7) Flooring. In a project working with 10 providers and 6 family homes in New York State (McCallion and Nickle 2005), we added (8) Bathroom Management, (9) Kitchen Safety and (10) Supports for Wandering.
Simplification of the environment
Key activities were the elimination of clutter, trip hazards, confusing layouts and other barriers to independence and offering assistance where there were risks for confusion, or falls. Specific helpful modifications included:
- Installing double railings on stairs
- Installing hand grips at the top of a step or stairway
- Calling attention to steps with contrasting colours, reflective tape
- Reducing the height of a step by adding a mini-ramp or second step
- Replacing steps with ramps
- Replacing raised doorsills with flat plates.
In several cases masking the doors (using door posters and strategically placed large plants) of areas families or staff did not want the individual entering also contributed to environmental simplification.
Way finding and orientation
A three step process was found effective in guiding these efforts (McCallion and Janicki 2002):
- Environmental scanning: examining the home for environmental barriers to ageing in place, wayfinding and quality of life
- Environmental labeling: giving clues and prompts to support continued independent navigation of the home. This included painting important doors different colours and putting signs on doors, in hallways and on key appliances such as the refrigerator and TV.
- Environmental flooding: Finding multiple ways to support continued independence, e.g., not only labeling the door to the kitchen, but leaving that door open to give as many senses as possible (hearing and smell as well as sight) clues as to where it was located so that the person with dementia would find it on their own.
Selection of furniture that is sturdy, simple and versatile is particularly recommended (Brawley 1997). Particular recommendations include:
- Light-weight items such as lamps secured or removed
- Table tops/cloths smooth and pattern free
- Furniture such as tables with rounded edges that are not sharp
- A variety of seating choices in day rooms and dining rooms
- Large dining room tables replaced with small ones seating 3-4 people
- Seating areas provided in long corridors.
Hard, smooth surfaces and materials reflect rather than absorb sound waves. The acoustics of environments can be improved by installing carpeting, acoustic tile, ceiling baffles, heavy wall hangings, curtains and other sound-absorbing materials (Brawley 1997). Particular attention was paid to the acoustics of dining rooms and day rooms, the reduction of background noise from TV and radio/stereo and to helping staff/families understand the impact of their own social interaction to noise levels.
Shadows are a common source of visual illusions in persons with dementia (Brawley 1997). Efforts therefore targeted dispersing direct sunlight with curtains or tinted glass, avoiding glare by using indirect lighting controlled with dimmer switches and addressing sudden changes in light levels between and within rooms. In several homes, flooring was found to add to the problems: reflective surfaces such as shiny, waxed floor tiles contributed to light problems and were replaced. A particular problem for some is that mirrors often cause confusion; the person may not recognise their own image. This was assessed individual by individual and in two cases the mirror was removed from a bedroom.
Colours in the red to yellow range are more accurately perceived by persons with dementia than blues and greens; solid colours or simple patterns are better than complicated or highly unusual designs (Brawley 1997; Calkins 1988). The opportunity was recognised to use colour in furnishings, floors and walls to assist in creating visual contrast. Pale colours blend easily with other pale colours, so instead in several cases service providers and families chose colours that were attractive and homelike, but which also offered contrasts: e.g., the presence of a handrail on a wall was better communicated by utilising a contrast colour. Similarly, in several homes a white light switch was contrasted with a dark switch plate, a toilet seat of a different colour contrasted a white toilet and a dark place mat under a light dinner plate offered additional visual clues.
Flooring presented the greatest concerns in family homes. Here there were more likely to be throw rugs in hallways, and patterned tiles in kitchens. However, group homes were more likely to have highly polished floors which presented their own concerns. In several cases flooring was replaced with simpler surfaces.
Two issues were of concern in bathrooms, the availability of adaptive supports and measures for water safety/control. Again there were differences between group homes and family homes. Group homes were more likely to have walk-in showers, so a primary intervention in family homes was the installation of grab bars, and hand-held, adjustable-height shower hoses and nozzles; training was also offered on the appropriate use of shower chairs. For group home staff training in shower chair use was also beneficial. Management of water was important in both settings because of fear of water damage and of individuals harming themselves with overly warm water. The temperature of water was reduced in several cases, automatic temperature mixers and shut-off mechanisms installed in others.
Critical issues in kitchens were to find ways to improve access in areas that encourage independence as long as it remained safe and to limit access when abilities and understanding had diminished to the point that supervision was necessary (Hutchings 2000). The desire of many clients to continue to access kitchen areas was recognised, so that the complete limiting of access to the kitchen was discouraged. Instead, cleaning supplies were relocated or placed in a designated locked cabinet; shut-off valves for water and the stove/cooker were installed, the arc of the kitchen tap was limited to the area over the sink and protective covers were placed on electrical outlets. In contrast, access was improved by labeling cabinets, leaving key utensils, ingredients and dishes on countertops so they could be more easily located and making sinks and countertops more wheelchair accessible.
Support for wandering
Given weather conditions in New York state (hot summers and cold snowy winters), attention was paid to creating safe indoor and outdoor wandering opportunities. Gated and fenced garden areas were created, paths more clearly marked and pleasant areas created in gardens and on porches that encouraged the individual to sit quietly, as well as to wander freely and safely outside. Within the living unit, indoor walking paths were created that were free of clutter and offered opportunities to sit if the person became tired. There was also attention to safety issues. Silent alarms were installed on outer doors to alert staff or families that a person was leaving the building or an area where they knew the person was safe.
New construction will necessarily be expensive and the resources are increasingly difficult to locate. Also the numbers of persons with ID and dementia are growing at such a rate that the most effective approach to living situations will be the support of ageing in place. There will always be a need for at least some specialised units, but attention to low-cost environmental modifications in support of safety, maintenance of independence and quality of life will be the best strategy for the majority of providers and family carers.