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
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) 7504180x230
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
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
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
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
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
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
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
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
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
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
Co-existing Disabilities
• The cognitively impaired person is less
able to cope with other disabilities that
may limit his/her autonomy
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
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
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
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
Environment and Culture
• People benefit where every individual is
openly recognized as being equally
important and worthy of respect
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
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)
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
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
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
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
The Physical Environment
• If the floor and walls blend into one
another, distances become very difficult to
judge accurately
• Bathrooms should be visible
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
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
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
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
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
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
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
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
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
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.”
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
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.
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.