A therapeutic environment is an environment that is supportive of each individual and recognizes that people with dementia are particularly vulnerable to chaotic environmental influences. It is individualized, flexible, and designed to support differing functional levels and approaches to care (Campernel & Brummett, 2010).
Philosophy of Care
Environment is dictated by an organization’s philosophy of care—a framework that identifies care goals and values. A healthcare organization’s philosophy of care may differ from that of the family. Family members have the right to know and should feel free to question a center’s philosophy of care:
- Is the center’s philosophy for caring consistent with your beliefs?
- Does the center provide services to persons at all stages of dementia?
- What conditions or behaviors determine whether a center will admit or retain someone with dementia?
- Is dementia care provided in a separate unit or as an integrated part of center’s services?
- Is the center’s philosophy and practice of handling “difficult behaviors” compatible with your views?
- What is the center’s philosophy in using physical restraints to deal with certain behaviors?
- Does the center recommend the use of psychoactive drugs to treat behaviors? (California Advocates for Nursing Home Reform, 2016)
Dementia Friendly Care
In long-term care, the term “dementia friendly” is a philosophical approach that is commonly used. It focuses on the experience of people with dementia and advocates for positive attitudes and behaviors toward dementia. It seeks to treat people with dementia and their caregivers with dignity and respect and calls for an end to stigma. It seeks community support for people affected by dementia so they can “live well with dementia.” The Japanese “Dementia Friends” model is a good example in which a remarkable 6 million friends (4.6% of the population), lightly trained by 105,000 dementia champions, are driving innovative community programs across the country (ADI, 2015).
In 2004, Japan’s government launched a nationwide campaign, 10-Year Plan to Understand Dementia and Build Community Networks, which inspired the nationwide campaign to train 1 million “cognitive disorder” supporters. The program has been copied in the United Kingdom. Courtesy Alzheimer’s Disease International. From https://www.alz.co.uk/dementia-friendly-communities/dementia-friends
Person-centered care is a dementia-friendly philosophical approach holding that a person with dementia deserves kind and supportive treatment and the rights we reserve for any other individual—namely dignity, respect, and autonomy. Person-centered care has the potential to reduce unwanted behaviors and improve both client and staff outcomes (van de Ven et al., 2014).
Implementation of person-centered care depends not only on caregivers acquiring skills and knowledge but also on adapting the entire care context to both clients’ and caregivers’ needs and preferences. This means that there must be flexibility in the organization (Desrosiers et al., 2014).
Person-centered care is the opposite of task-centered care. In dementia care, it involves practices aimed at helping clients establish relationships and be treated as individuals with their own life history and interests (Desrosiers et al., 2014).
In the Netherlands and several other European countries, an innovative person-centered approach called “green care farms” has been developed to provide day care services and 24-hour nursing home care to people with dementia (de Boer et al., 2015). Green care farms offer a broad selection of activities, including caring for plants and animals, and encourage clients to engage in tasks suited to their level of dementia and physical capabilities.
The Physical Environment
There is a profound and direct connection between the environment and the way people feel and behave. Buildings thoughtfully designed for the care of people with dementia encourage community, maximize safety, support caregivers, cue specific behaviors and abilities, and redirect unwanted behaviors (Campernel & Brummett, 2010). This approach to dementia care considers the consequences of the built environment on the well-being of clients with dementia (Rijnaard et al. 2016).
For long-term care facilities, there is a trend toward designing facilities to be as homelike as possible. This idea was pioneered in Sweden in the 1980s, where a homelike environment for people with dementia was tried for the first time. Today, similar concepts can be found all over the world, from Green Houses in the United States, to group homes in Japan, small-scale living arrangements in the Netherlands, and German shared-housing arrangements (Gräske et al., 2015).
All of these concepts challenge the traditional view, in which care is organized around nursing and medical tasks and the needs of the institution. Living arrangements in small and homelike settings are built around person-centered care, respecting residents’ needs and choices. Daily routines include meaningful activities to encourage normal living while tasks focus on household chores such as cooking and baking (Gräske et al., 2015).
Specific design principles have been shown to reduce unwanted behaviors and enhance a sense of well-being in people with dementia. These include:
- Providing private spaces and a separate room or recess for sleeping or napping
- Providing easily accessed public spaces and places for semi-private interactions
- Keeping public spaces clean and getting rid of odors
- Providing sunlight, ventilation, and getting rid of dark nooks and crannies
- Providing views to the outside
- Replacing institutional, centralized nursing stations with smaller, residential-looking stations
- Creating spaces to cue specific behaviors (activity kitchen, art and music therapy area, bistro/bar, rummaging room, library, coffee shop/internet café, quiet room, living room)
Left: Residential-looking, smaller-scaled nurses’ station. Right: a room for rummaging. Source: Campernel & Brummett, 2010. Used with permission.
Outdoor design ideas for people with dementia and memory disorders include:
- Arranging outdoor spaces to resemble a natural community.
- Creating continuous circulation routes with looping pathways and areas of interest.
- Including clients in the design of new features such as walking paths and gardens.
- Creating safe, purposeful, heated, and accessible outdoor areas.
- Offering attractive landscaping, gardens, and pleasing views (Rijnaard et al. 2016).
Left: Safe, looping wandering paths with areas of interest along the way. Right: A memory-care facility with home-like outdoor porch area for seating and reflection. Source: Campernel & Brummett, 2010. Used with permission.
In a comparison of “regular” specialized care units and small, homelike specialized care units in the Netherlands, clients in the homelike care units needed less support with activities of daily life, were more socially engaged, showed less agitation over time, and needed less psychotropic medication and physical restraints. Residents of the small, homelike units awarded higher scores to aspects of quality of life, showed less negative affect and better social relationships, and were more engaged in activities (Kok et al., 2016).
Safety and Security
People with dementia need to feel safe (and be safe) without the use of physical and chemical restraints. Safety includes creating an appropriate environment as well as planning for adverse events, such as wandering away from the home or facility.
The table below illustrates some common safety hazards and measures to help make the environment more safe and secure. Since every situation is different, interventions must be tailored to match the specific circumstances.
Measures to Promote Safety and Security
Getting lost, exposure to environmental hazards
Cooking without supervision
Sickness or death
Simply living in a long-term care facility or receiving care at an adult day care center can be a source of safety and security for a person with dementia. Having regular contact with a caregiver provides a sense of privacy, safety, and security. A well-designed and well-run facility is secure, comfortable, and predictable; it is a place where one can feel at ease—a place where you can be who you are and feel connected with like-minded people (Rijnaard et al., 2016).
For caregivers, adult day care services offer a sense of safety and security. They provide family caregivers with a feeling of shared responsibility, in the sense that someone is able to take responsibility for the person with dementia if the family caregivers should become ill or die. If this happens, then the caregivers feel safe that the staff at the center know the person’s situation and condition and can provide information to other healthcare providers if needed. Adult day care centers provide the families with a sense of shared responsibility and relief while they are still active in their caregiving role (Tretteteig et al., 2017).
Schedules and Routines
Schedules and routines are an important part of any person’s life and well-being. However, when someone enters a facility, they are unable to continue with their usual routines; their lives are undeniably altered. There is a continual tension between the necessary institutional routines and the clients’ personal habits and needs (Rijnaard et al., 2016).
In traditional nursing homes and day care facilities, daily life is primarily organized around the convenience of the staff. As a result, the schedule can change dramatically from day to day. This is difficult for people with dementia because they rely on a predictable routine for orientation. A regular routine allows a person with dementia to know what to expect. Routines also give the caregivers a benchmark for evaluating a person’s behavior. A schedule for someone with dementia should:
- Be planned carefully.
- Consider each person’s capabilities and preferences.
- Continue familiar routines and schedules.
- Maintain mealtime routines.
- Maintain regular dental and healthcare appointments.
- Allow plenty of time.
- Note the effects of changes in routines.
- Consider issues that disrupt routines (ie, pain, fatigue, illness).
Caregivers responsible for maintaining a routine schedule must be flexible. People with dementia tend to be slow, so caregivers need to allow ample time for meals and activities. Attempting to rush can precipitate aggressive behaviors and frustrate both parties.
Staff as Part of the Environment
In Florida, adult day care centers must employ qualified staff to provide the services, personal assistance, and safety measures required by participants. Nearly 60% of workers in adult day care centers are aides, 18% are registered nurses, 11% are licensed practice nurses, and about 12% are social workers (Harris-Kojetin et al., 2016).
If centers provide adult day health care, the following staff members are required:
- A registered nurse or licensed practical nurse on site during the primary hours of program operation and on call during all hours the center is open; all LPNs must be supervised by an RN;
- A social worker or case manager to provide and supervise the provision of social services, including counseling for participants’ families and caregivers and compilation of a social history and psychosocial assessment of formal and informal support systems, and mental and emotional status; and
- An activity director or recreation therapist, who may be retained as a consultant. All services provided by program aides must be directly supervised by the activity director or recreation therapist (O’Keefe, 2014).
In adult day care centers in Florida, at all times staffing must be maintained to meet participants’ needs, including centers that serve persons with Alzheimer’s disease and other types of dementia (O’Keefe, 2014):
- A minimum staff ratio of 1 staff member who provides direct services for every 6 participants must be present in the center at all times.
- If licensed as a specialized Alzheimer’s services ADC center, the minimum staff-to-participant ratio is 1 staff member who provides direct services for every 5 participants with Alzheimer’s disease or other dementia.
- No fewer than 2 staff, 1 of whom has a certification in an approved first-aid course and cardiovascular pulmonary resuscitation, must be present in the center at all times.
- The owner or operator may be counted as 1 of the required staff members if he or she provides direct services and is included in the center’s work schedule. However, the owner or operator must not be counted more than once in the staff-to-participant ratio, calculated on the basis of daily census (O’Keefe, 2014).
Staff Adjusting to Resident Routines
In adult day care settings, daily life is emphasized and activities are centered on household tasks and activities. This may require a fundamental shift for staff, who must adjust their routines to the routines of the clients.
Ideally, clients are cared for by a small, fixed team of trained caregivers. Activities are organized completely, or in large part, by clients and caregivers. Staff members, clients, and family members prepare meals together, and staff members are involved in multiple tasks such as medical and personal care, domestic chores, and activities (Verbeek et al., 2009).
To encourage integration of the staff into a home-like environment, the following practices are recommended:
- Hire staff with the emotional skills to interact with people who have memory problems.
- Eliminate institutional, centralized nursing stations.
- Locate nursing and work areas throughout the building for staff convenience.
- Allow staff to control lighting and environmental levels.
- Emphasize signage for clients.
- Limit signage for staff and visitors.
- De-emphasize or camouflage doors to staff and utility areas.
- Keep staff consistent.