1. Environmental Influences on People with Dementia Patrick Arbore, Ed.D. Founder & Director, Center for Elderly Suicide Prevention & Grief Related Services Institute on Aging, San Francisco, CA

2. Center for Elderly Suicide Prevention & Grief Related Services (CESP) 24-hour Friendship Line for the Elderly – 800-971-0016 Individual Grief Counseling and Traumatic Loss Groups Medication Oversight Project Contact: parbore@ioaging.org or (415) 750- 4180x230parbore@ioaging.org

3. National Alzheimer’s Association This year (2011), the first baby boomers turn 65 While AD is not normal aging, age is the greatest risk factor for the disease AD is a progressive and fatal brain disorder that causes problems with memory, thinking and behavior AD kills but not before it takes everything away from the person

4. National Alzheimer’s Association An estimated 10 million baby boomers will develop AD Of those who reach the age of 85, nearly one in two will develop AD Unless there is a treatment or cure, AD will become the defining disease of the Baby Boom generation Today 5.3 million Americans have AD

5. AD Try to imagine not being able to take care of yourself – Can’t dress yourself, can’t shower yourself, can’t go to the bathroom by yourself – That’s Alzheimer’s Disease

6. Overview of the Environment What does the environment tell us – The general style, layout and atmosphere tells us what we can expect, how we should behave, whether or not we belong there, and whether we will get what we need there If the setting appears institutional, it tells us that there are important people in charge

7. Overview We go to institutions to do business or to have things done to us Many cognitively impaired older people assume a passive role in institutional settings They may worry about how meals are paid for or when they are supposed to leave A home environment is more suitable

8. Overview The physical environment can do much to alleviate difficult behavior: Ensuring security, emotional as well as physical Accurately reflecting the individual’s identity and promoting self esteem Offering opportunities for meaningful occupation and independence

9. Negative Environments Some physical environments can contribute to altercations or hostile behavior Dead-end corridors, especially ending in locked doors, can create traffic problems that can raise anxiety levels Restless residents are attracted by the door, go towards it, and are frustrated to find it locked

10. Negative Environments When the person becomes agitated and sees other people coming towards him, he/she may bump someone or push someone and scuffles break out Narrow doorways create similar problems of shoving and pushing

11. Privacy Privacy is a powerful need that is often difficult to accommodate Private rooms are usually taken by people who can afford them Residences that accommodate persons with AD are making rooms available according to need Shared accommodations are sometimes desirable

12. Privacy If roommate situations are available, it is advisable to prevent one person from passing through the space of the other Bookshelves and room dividers can avoid antagonism and prevent disputes

13. Co-existing Disabilities The cognitively impaired person is less able to cope with other disabilities that may limit his/her autonomy

14. Features that Spark Memories Look carefully at the environment and check whether alternative perceptions might occur Bars on windows or doors might trigger thoughts of bank tellers – the person may ask for money from his/her account only to be frustrated when staff indicate that they have no money here – to them it looks like a bank teller window

15. The Environment and Identity Most people want their environment to reflect their being in the manner they prefer People do not want to appear childish or incompetent Orientation boards that announce the day, weather, next meal etc. states that the people here do not know what is happening

16. Environment and Identity It might be better for a cognitively impaired person to have windows where they could look out and see the weather It might be better to have large calendars with month and date easily visible A large clock that indicates time of day The smells from the kitchen can announce that a meal is being prepared

17. Environment and Culture Everyone thrives in an environment that accommodates the individual skills, needs, and limitations of all its members People benefit where information, responsibility, and influence are openly shared People benefit where failure of a person to meet a norm is not a fault

18. Environment and Culture People benefit where every individual is openly recognized as being equally important and worthy of respect

19. Mayo Clinic on Alzheimer’s Disease Environment – Can have a definite impact on the person with AD’s behavior A noisy room may seen overwhelming Groups of visitors may trigger agitation When outside, it may be easier to avoid large, loud settings Familiar destinations may be easiest

20. Mayo Clinic Avoid doing too many activities on a single trip Plan rest periods between activities Environments can be confusing – A long hallway may be baffling to someone; mirrors might be disturbing; give cues to help the person navigate the space (use arrows taped to the wall or floor)

21. Mayo Clinic Put a picture of a toilet on the door to a bathroom Put a picture of their younger selves on the door to the bedroom The most important aspect of the environment is how it feels

22. The Physical Environment The setting must address more than the basic requirements of space, esthetic appeal, lighting, air circulation, cleanliness, and accessibility The area should be free of ambiguities It should be consistent and predictable Floor and wall areas should be distinct from one another

23. The Physical Environment Steps and other obstacles must be clearly visible The floor should be free of any markings that could be perceived as obstacles by the perceptually impaired older person Furniture should have clear limits Furniture should be distinct from its surroundings

24. The Physical Environment Traffic areas must be free of any hidden obstacles such as chair legs that extend out beyond the seat Contrasting colors can be used effectively to distinguish furniture from the surrounding area Color can be used to reinforce visual perspective in the room

25. The Physical Environment If the floor and walls blend into one another, distances become very difficult to judge accurately Bathrooms should be visible

26. Sensory Stimuli Environment must not be overly stimulating General ambiance should be subdued and neutral Background noise and movement should be minimized Soundproof barriers between activity areas are useful – providing they don’t complicate the space

27. Place and Time There should be appropriate cues to help people orient themselves to place and time Clocks (analog), large calendars, signs, articles or decorations in keeping with the seasons or holidays There should be a space for those individuals who need to be alone from time to time

28. Maintaining a Safe Environment As the person with dementia progresses with the illness, the ability to perform every day functions decreases Standing to dress may become unsafe Falls and complications from falls is a major concern Caregivers must look for actual and/or potential safety problems

29. A Safe Environment Safety actions may look like: Removing unsafe objects or personal care items Rearranging furniture Disconnecting cooking elements or microwave ovens Retraining the person to perform activities differently

30. Maintaining Body Warmth The person with dementia may not be able to verbalize being too cold or too hot A person who does not want to take their coat off may be indicating a need for a warmer room temperature The older person is more comfortable with temperatures in the middle to upper 70’s

31. Body Warmth The person with dementia may be sensitive to hot or cold water Be careful about water heaters that may be too hot for that person Luke-warm water may be preferred for drinking or oral hygiene

32. Making Decisions About Driving Signs of Unsafe Driving: Has difficulty following instructions and directions Coasts to a near stop in the midst of moving traffic Drifts into other lanes of traffic Stops abruptly without cause Presses simultaneously on the brake and accelerator or confuses the two pedals

33. Driving Delays changing lanes when obstacles appear Does not signal when turning or changing lanes Has received an increasing number of driving citations or warnings Does not check “blind spot” before changing lanes

34. Driving Gets lost in familiar places Is increasingly nervous when driving Backs up after missing an exit Falls asleep or gets drowsy while driving When these and other signs appear, it is time to assess the situation – Don’t wait for an accident

35. Thomas DeBaggio “With my failing memory every day begins new—and often ends that way, unable to negotiate a past as short as twelve hours.”

36. References Alzheimer’s Association (2011). Generation Alzheimer’s: The defining disease of the baby boomers Bridges, B. (1998). Therapeutic caregiving: A practical guide for caregivers of persons with Alzheimer’s and other dementia causing diseases. Mill Creek, WA: BJB Publishing

37. References Petersen, R. (ed) (2002). Mayo clinic on Alzheimer’s Disease. Rochester, MN: Mayo Clinic. Schmall, V., Cleland, M., and Sturdevant, M. (2000). The caregiver helpbook: Powerful tools for caregiving. Portland: Legacy Caregiver Services.

38. References Zgola, J. (1987). Doing things: A guide to programming activities for persons with Alzheimer’s Disease and related disorders. Baltimore: The Johns Hopkins University Press. Zgola, J. (1999). Care that works: A relationship approach to persons with dementia. Baltimore: The Johns Hopkins University Press.