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Systematic review

The physical environment for people with dementia

  • Year: 2009
  • By: Norwegian Knowledge Centre for the Health Services
  • Authors Landmark B, Kirkehei I, Brurberg KG, Reinar LM.
  • ISSN (digital): 1890-1298
  • ISBN (digital): 978-82-8121-265-7

This review examines effects of the built environment and elements therein on people with dementia.


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Key message

This review examines effects of the built environment and elements therein on people with dementia.

Dementia diseases lead to degrees of disabilities that progressively involve caretakers up to stages of complete helplessness and is at present the most common reason for transfer of elderly to care programs. 80% of institutionalized elderly in Norway have cognitive impairments. We have summarized results from 8 systematic reviews and 11 primary studies on the therapeutic design of environments for people with dementia.

The results should be interpreted cautiously because of methodological limitations in the present studies. Adaptations in the physical environment can lead to positive effects on activities of daily life, behaviors, and quality of life. The overall configuration of a building can affect level of orientation amongst people with dementia. Uniqueness in common rooms, short corridors, calm surroundings and few decision points eased orientation. Spatial orientation and accessibility was better in small grouped units with associated common places. Neutral design and colours, and low sensory stimulus are associated with fewer catastrophe reactions and less medication. Visual modification and adaptations can lead wanderers to move in safe areas. There is some evidence to support camouflaging exit door or doorknob against elopement. There were not significant effects of preventing falls amongst people with dementia. Signs and colour codes have small effects on people with cognitive impairments, depending on degree of dementia. Increasing environmental lighting (towards daylight levels) reduced behavioural disturbances, supported spatial orientation and had a modest effect on length of sleep.

Small units with a noninstitutional environment gave less behavioural challenges among people with dementia, but specific features are ill-defined. Less combined multiuse spaces, greater variation and less crowding resulted in less cognitive stress, depression and social isolation amongst Alzheimers patients. Single rooms with the opportunity for individual and home-like character, personal furnishing and objects resulted in less psychiatric symptoms. Highly accessible toilets (visible, open-door and close to bed and common rooms) led to increased use among residents.

The physical environment has not been shown to affect the progression of dementia. Purpose-built environment has positive effects on quality of life.

Summary

Background
This review examines the effects of the built environment and elements therein on people with dementia. Dementia is a collective term of several diseases that permanently and progressively reduce cognitive functions and is probably the single most important factor leading to transfer to care programs for the elderly. In late stages dementia leads to complete helplessness and 80% of institutionalised elderly in Norway now have cognitive impairments. In total 68 000 people in Norway suffer from dementia, a figure that is expected to double the coming 30 years. We have focused on the therapeutic design of environments for people with dementia.

To enhance and adapt the communal care program for people with dementia and cognitive impairments, the Norwegian government initiated a study to develop the evidence base concerning the homes and institutional care for these patients. In the dementia plan 2015 ”den gode dagen” one of the main aims is to build and modernize institutional care and home environments with features that are adapted for people with cognitive impairments. The guidelines for the Husbanken funding of fulltime residential care in institutions and homes for the elderly require all new building projects using funds from the investment grant to be built and adapted for people with dementia and cognitive impairments.

Methods
The following databases were systematically searched (last update 14.1.2009): Cochrane Database of Systematic Reviews, Cochrane CENTRAL, Database of Abstracts of Reviews of Effects, DARE, HTA, MEDLINE, EMBASE, PsycINFO, SveMed, OT Seeker and SINTEF Byggforsk to identify systematic reviews and primary articles. In addition, manual searches through reference lists in relevant reports and excluded reviews were performed. After selection from abstract and title, articles were assessed in full-text, and articles that met inclusion- and exclusion criteria were scored for quality in design and method.

Results
3388 unique titles were retrieved. After reading title and abstract, 192 articles were assessed in full-text, resulting in 8 systematic reviews and 11 research articles that met the inclusion criteria. Meta-analysis was not possible because of heterogeneity and the results are summarized in narrative with examples in figures and text.

Conclusions
The results should be interpreted cautiously because of methodological limitations in the present studies. Elements in the physical environment have positive effects on activities of daily life, behavioral aberrances, and quality of life.

The overall configuration of a building can affect level of orientation. Uniqueness in common rooms, short corridors, calm surroundings and few decision points eased orientation. Spatial orientation and accessibility was better in small units with associated common places. Small units with a homelike environment gave less behavioural challenges among people with dementia, but specific features are ill-defined.

Neutral design and colours, and low stimulus is associated with fewer catastrophe reactions and less medication. Visual modification and adaptations can wanderers to move in safe areas. There is some evidence to support camouflaging exit door or doorknob against elopement.

There were not significant effects of preventing falls amongst people with dementia. Signs and colour codes have small effects on people with cognitive impairments, depending on degree of dementia. Increasing environmental lighting (towards daylight levels) had a limited effect on length of sleep, reduced behavioural disturbances and supported spatial orientation.  Uniqueness in common rooms, less combined multiuse spaces, greater variation and less crowding resulted in less cognitive stress, depression and social isolation amongst Alzheimers patients. Single rooms with the opportunity for individual and home-like character, personal furnishing and objects showed less psychiatric symptoms. Highly accessible toilets (visible, open-door and close to bed) led to increased use among residents.

The physical environment has not been shown to affect the progression of dementia. Purpose-built environment may have positive effects on quality of life.