ECAT Jennifer Brush Webinar - AlzPossible


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Presentation made December 7, 2011 on AlzPossible ( - material is copyrighted.

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  • When I design interventions for Dementia, I take all of these goals into consideration-I think they are all equally important. And the environment has a role in supporting each goal-so to provide opportunities for reminiscence, we may develop a memory book for the person to use as an external communication tool. And we will talk about memory books later. To Maintain receptive language skills, we may label items in their room or increase the use of signs.
  • When we assess the environment we look at environmental barriers and facilitators. So, a barrier prevents someone from functioning at their highest level and a facilitator enhances someone’s functioning.
  • Unfortunately, communication disorders are often misunderstood and can go unrecognized and there fore Create difficulties between caregivers and care recipients, resulting in dependenceexcess disability
  • 97% of the healthcare professionals who used the toolkit said it gave them new tools to use with clients who have dementia.
  • Some clients may be able to perform activities by relying primarily on cue cards or objects arranged in the correct sequence. For example, one set of researchers (Namazi and Johnson, 1992) demonstrated how a clothing closet can be set up with visual cues so that only one outfit is visible at a time and the clothes can be hung in the order that they usually put on. In this study, the need for direct physical assistance was reduced by one-third to one-half and dressing independence increased by 19%. Even if a specially designed closet is not possible, the same effect can be achieved by using a hanger that fits over the door, which has the clothes hanging in the correct order.  While cues are more frequently associated with sequencing or decision making during activities, they are also used for supporting wayfinding and orientation. The most common type of cue for wayfinding is a sign. Signs can incorporate text and/or graphics depending on what needs to be conveyed and the preserved abilities of the clients. For instance, for clients who present with impaired expressive abilities, a sign may alleviate the need to verbally ask for directions to a desired location. Or, if clients have impaired receptive language skills, signs can provide visual input to replace auditory directions given by caregivers. Signs should be large, simple, and have visual contrast. Most people find signs with dark lettering on a light background easiest to read. Letters should be at least one inch tall. Graphics should not be too visually complex or conceptually abstract and should have a clear image. Signs should be placed where people are most likely to see them. Many older adults will miss signs that are located on the upper sections of doors because they have limited upper body range of motion and they tend to walk looking at a three foot and lower level. When clients walk with a stooped posture, they may not see their room signs at the height at which signs are typically mounted. Caregivers can supplement required signs by experimenting with additional signs for these clients on the lower section of the wall.
  • People with dementia often have difficulty adjusting to new or unfamiliar environments. Displaying personal items and personalizing their own spaces can help people relate to and remember people, places, and objects by compensating for deficits in declarative memory. Increasing personalization also reduces the institutional image of hallways and creates more distinctive spaces providing orientation cues for individuals. Personal items can be displayed in hallway cases to encourage clients to find their rooms. These display cases are large and contain glass shelves that are lit to maximize visibility of objects within. Research has subsequently shown that objects in these cases, if chosen carefully, can improve clients’ abilities to locate their own room by 50%. The more significant the objects or the stronger the memory associated with the objects, the better these objects assisted people with locating their own room (Namazi, Rosner, and Rechlin, 1991).
  • Clients with dementia experience a reduction in capacity for processing stimulation. As a result an environment with significant amounts of visual clutter can be overstimulating and create difficulties locating a desired item, focusing on an activity, or remembering the sequence of tasks. Common examples of environmental clutter include posting signs for both clients and caregivers in a hallway, and storing too many grooming products on limited bathroom surfaces. As an environmental strategy, visual organization means commonly used items are clearly visible, furniture is arranged to support effective communication, and relevant visual cues are prominently displayed. In the hallway, methods to improve visual organization include reducing the size or visual impact of caregiver signage (e.g. make the “clean linen room” sign smaller, with less contrast, and hang it higher on the wall) and creating more emphasis on the client-oriented signage (e.g., the “dining room” sign is larger, has greater contrast, and is in a prominent location). Appropriately arranging furniture or activity items can also assist clients who are having trouble seeing. Organizing items by category such as putting the cup, toothpaste, and toothbrush together in one place can serve as a useful cue.  Maximize Sightlines Being able to remember the location of important destinations, such as a toilet behind a closed door, can be problematic for people with dementia. Additionally, the cognitive and language impairments experienced by people with dementia can decrease their ability to communicate the need to use the toilet to their caregivers. Therefore, providing a clear line of sight to needed locations or items can compensate for deficits in expression and memory related to wayfinding. Research has found that increasing the visibility of toilets by providing a clear line of sight can be very effective in maintaining continence. There are also grab bars with internal LED lights for night-time use.
  • Contrast helps people with low vision to distinguish between different objects in the environment. It can also help draw the attention of people who have difficulty staying on task or establishing orientation.Studies have shown that “healthy older persons require about three times as much contrast as younger persons for the detection of objects in the environment” (Tideiksaar, 1997). Further studies have shown that individuals with dementia present with significantly more contrast perception impairment than cognitively intact older adults (Gilmore & Whitehouse, 1995). Lack of environmental contrast can affect communication about care activities. For instance, if a caregiver is assisting a client to brush her teeth independently and the toothbrush is the same color as the counter on which it rests, even if the caregiver says to pick-up the toothbrush, the client (not being able to see it easily) may not pick it up. The client may then be considered resistive to care. This situation can easily escalate simply because the caregiver does not realize that the client has a vision problem. Providing a toothbrush that contrasts in color with the counter might easily resolve this situation.   The environment can help communicate the location of the toilet if a brightly colored toilet seat contrasts with a white bathroom floor, and if the floor and walls contrast with the white toilet. To test if this change might be effective before investing in new seats, place a strip of colored tape around the edge of the seats. Changing the color of the toilet seat is also more cost effective than changing the color of the bathroom floor.
  • Glare is a source of intense light in one’s immediate view. Glare greatly contributes to excess disability as it reduces attention span, adds to confusion and agitation and increases the risk of falls. Light sources, both daylight and artificial, should be balanced to minimize glare. This will make the environment more comfortable and safe for clients with dementia. There are two broad categories of glare. The first type is direct glare which is intense light from an immediate source. Examples include unshielded light bulbs or direct sunlight coming in from the windows. The second type is indirect glare, which is intense light that is reflected from a surface, such as light from a shiny floor. Windows and the area around windows are often places with both types of glare. Because older adults are sensitive to glare, all windows in a care setting should have some means of filtering or blocking light. Vertical and horizontal blinds are not the best choice because they create slits of light and dark which can be very disorienting to people with dementia. If they are metal, the light may reflect off the blinds, causing even more glare. Window treatments using sheer curtains or shades allow light to be diffused without totally blocking the view. Windows should also have a means of completely blocking out the view such as curtains or closed shades. The reason for this is that windows can act like mirrors at night which can be disturbing to clients.  In healthcare settings, shiny clean floors are often a source of indirect glare. It is important for staff and administrators to know that clean does not have to mean shiny. Instead of polishing floors, consider buffing floors with a cleanser that provides a matte finish. Numerous administrators have reported that families are upset when they try this method, thinking that the care community is not as clean as it was before. To avoid negative reactions, consider writing letters to family members explaining that the care community is eliminating the shine, because the glare is detrimental to people with dementia.   Optimize Auditory AspectsMinimize Background Noise Individuals with dementia have a difficulty filtering out irrelevant noise from the environment and focusing on relevant sounds related to their communication partner. When noise bothers people with dementia, it can cause them to become agitated and restless or to try to leave the unit, so the environment should be as quiet and peaceful as possible. Also, background noise hinders communication because it greatly affects the ability of people with dementia to hear and focus on tasks requiring cognitive attention. It is particularly disturbing for those who wear hearing aids since these devices amplify background noise. Noise includes other people, running water, and appliances such as televisions, radios, icemakers, heating and cooling systems, and floor cleaners. This type of noise should be reduced or eliminated whenever possible to allow clients to maximize their hearing. Background noise can become especially problematic in the dining areas because people often raise the volume of their voices to compensate for high background noise (Lane & Tranel, 1971). The increased sound level from louder conversations adds to the background noise, which can cause conversation with dining companions to be extremely difficult (Lane & Tranel, 1971). Incorporating acoustical treatments, such as acoustic ceiling tiles and acoustical panels on walls, can help reduce background sound levels and make the dining experience more pleasant and successful.
  • ECAT Jennifer Brush Webinar - AlzPossible

    1. 1. Role of Healthcare Professionals• Work in collaboration with older adults to fill in the gaps of their abilities Use Modify the preserved environment abilities Continually Involve educate and families support staff
    2. 2. Goals for Supporting Communication Encourage Maintain participation receptive in meaningful language social skills activities Provide Increase opportunities opportunities to for retain roles reminiscence Stimulate Promote verbal awareness of responses surroundings and maintain verbal skills Create opportunities for success
    3. 3. Communication Interventions Santo Pietro & Ostuni Practice everyday skills that recur in daily life Develop Focus on skills activities that that theuse preserved environment will abilities support Plan activities that match the routines of the care community
    4. 4. Behavioral Strategies for AD Bayles & Kim, 2003 Elaborate info at Cues at retrieval Involve client encoding to requiresame as info used actively in encoding thinking beyond its to encode basic attributes Use motorUse material that is Link information to movements at logically related larger category encoding Use written Use real life stimuli information
    5. 5. Environmental InterventionsImprove communicationduring ADLsImprove communicationbetween resident and staffSupport development ofmeaningful relationships
    6. 6. Environmental Cues Help clients know what to expect Put the client Reduce in the situation Environmentaldistracting Cues that will triggerstimulation the right pattern Use colors are textures to provide information
    7. 7. Environment Barriers to communication and functioning • Low light • Poor contrast • Small printFacilitators tocommunicationand functioning• Wayfinding cues• Large print labels• High contrast
    8. 8. Communication Disorders In Long Term Care Communities• Misunderstood, unrecognized• Create difficulties between caregivers and care recipients, resulting in – dependence – excess disability – stress among care providers1• Leads to reduced participation in social activities and increased social withdrawal2 1. Steeman et al., 1997; Williamson & Schulz, 1993 2. Potkins, 2003
    9. 9. Research on the Communication Environment Rearranging furniture Providing conversational partnersChanging lighting and contrast Adding plants, pictures, home-like furnishings Offering group activities Using AAC and other communication boards POSITIVE OUTCOMES
    10. 10. Assessing Communication Existing instruments used by SLPs in residential care communities • Communicative behaviors • Memory, orientation, attention, etc. • ADLs, IADLs • Social behaviors and mental health None of these instruments include assessment of environmental barriers and facilitators
    11. 11. Assessing Environment - Models only describe or categorize potential environmental factors - Environmental assessment instruments address: • awareness and orientation; • functional abilities stimulation; • safety and security; privacy; personal control; • task performance • social contact None of these instruments include significant measures of communication-relevant environmental factors
    12. 12. Environment & Communication Assessment Toolkit for Dementia Care Brush, Calkins, Bruce, & Sanford (2011)• Developed over three years• Tested with over 200 clients with dementia by over 95 speech-language pathologists, nurses, occupational and physical therapists• Funded by the National Institute on Deafness and Other Communication Disorders
    13. 13. Phase I Results demonstrated Developed resources a 100% increase in and demonstrated 30 speech-language the number offeasibility of the Toolkit pathologists tested the environmental for evaluating Communication interventions that the bedrooms and Toolkit with clients speech-language bathrooms in long- with dementia. pathologists term care settings. recommended for clients.
    14. 14. Phase II The assessment was 63 speech-language The Toolkit resource developed to evaluate pathologists,guide and assessment the public spaces of occupational instruments were long-term care therapists, physical expanded and facilities: circulation therapists, and nurses evaluated with a spaces, dining tested the larger group of room, restroom, and Communication therapists leisure activity areas. Toolkit for six months.
    15. 15. Impact The number of environmental modifications used with clients after training was greater. IMPACT Average number The cost of of modifications environmental recommended modifications by clinicians was less than increased $100• For more information on the research outcomes go to or email
    16. 16. What challenging behaviors do youobserve in people with dementia that you think may be caused by aspects of the environment?
    17. 17. Design Guidelines and Strategies• Optimize cognitive aspects of the environment – Personalize spaces and materials – Maximize cues
    18. 18. Getting Dressed
    19. 19. Controlling Ambient Conditions
    20. 20. Memory Books• Written and picture cues, in the form of Memory Wallets or Memory Books, can aid in the retrieval of personal information necessary to maintain conversations between persons with AD and their caregivers (Bourgeois, 1990).• Reduce the frequency of ambiguous and repetitive verbalizations• Increase turn-taking and topic maintenance• Reduce partner prompting and conversational dominance – Bourgeois, 1993; Hoerster, Hickey, & Bourgeois, 2001
    21. 21. Personalize Spaces
    22. 22. Design Guidelines and Strategies• Optimize visual aspects of the environment – Enhance lighting – Enhance visual organization – Maximize sightline – Maximize contrast – Minimize glare
    23. 23. Using the Environment to Improve Intake (Brush, 2001) • Examined the impact of increased lighting and table setting contrast on intake for people with dementia. – 25 residents (1 nursing home, 1 assisted living facility) – All with a physician-diagnosis of dementia
    24. 24. Dining
    25. 25. Enhance Visual Organization
    26. 26. Color Contrast Helps to Healthy older distinguish person requires 3xbetween different as much contrast types of objects as younger person Increase contrast to help see better • light floor, dark table, light plate • contrasting colored edge on surfaces
    27. 27. Maximize Contrast
    28. 28. Controlling Ambient Conditions ON OFF
    29. 29. Minimize Glare
    30. 30. Design Guidelines and Strategies• Optimize auditory aspects of the environment – Minimize background noise – Minimize reverberation
    31. 31. What are the environmental barriers?
    32. 32. What are the environmental barriers?
    33. 33. What are the environmental barriers? What are the facilitators?
    34. 34. What are the environmental barriers? What are the facilitators?
    35. 35. What are the environmental barriers? What are the facilitators?
    36. 36. Helpful Resources• lighting information••• Toolkit available from: Health Professions Press• Brush, J., Calkins, M., Bruce, C., & Sanford, J. (in press) Environment and Communication Assessment Toolkit for Dementia Care. Health Professions Press.• Brush, J.A., Threats, T., & Calkins, M. (2003). Perceived functioning of a nursing home resident. Journal of Communication Disorders, 26 (5), 379-394.• Calkins, M., & Brush, J. (2003). Designing for dining. Alzheimer’s Care Quarterly, 4 (1), 73-76.• Brush, J. A., Meehan, R. A., & Calkins, M. P. (2002). Using the environment to improve intake in people with dementia. Alzheimer’s Care Quarterly, 3 (4), 330-338.• IDEAS Institute (2002). IDEAS for a Better Visit. J. Brush (Ed.), IDEAS Institute: Author.• Bourgeois, M. (2007) Memory Books and Other Graphic Cuing Systems: Practical Communication and Memory Aids for Adults with Dementia. Health Professions Press.