Unit 2, Activity 4, Learning in Care Settings - Environmental Factors
Environmental factors
by Robbie Norval
Preamble: This piece of work was undertaken as part of the writer’s PhD at Glasgow Caledonian University entitled “an exploration of the contributions of social enterprises in delivering non-pharmaceutical interventions for older adults and people living with dementia.”
Date: 17th of August, 2020
External factors to consider whilst teaching older adults and people living with dementia
In addition to building up a rapport with the students and staff members consideration should also be given to environmental factors which affect the delivery of the intervention. Environmental factors which can influence the teaching sessions are wide-ranging from the lighting of the room to the number of students who are attending the classes. This sub-section is to provide some insight into how to strike the right balance in creating a pleasant learning environment for the students.
Physical setting
The design, layout, fixtures and fittings are significant for people living with dementia- they need to be accessible and consider physical and mental impairments that people living with dementia may have (Gifford, 2007). This varies substantially depending on the purpose of the building: with care homes catering solely for older adults, whereas certain community buildings such as community centres or church halls are for general use of different members of the public.
Settings for people living with dementia should be as accessible as possible and incorporate core values which reflect the concepts of personalisation and humanisation. Calkins (2018) developed a set of five recommendations of best practice describing the need for settings to create a sense of community, enhance comfort and dignity, support concern and safety, provide opportunities of choice, and offer opportunities for meaningful engagement.
Understanding the functionality of a room is of pivotal importance for people living with dementia as it allows them to recognise the space and to associate what tasks are appropriate to undertake in that area (Wrublowsaky, 2017). To help create a dementia friendly environment physical props are useful in forming a visual image of what the purpose of the room is. For the context of an activity space that may be to
include the presence of books, games or magazines to help illustrate the intended use of the room (Chaudhury et al., 2013). Meaningful engagement can also be enhanced by the layout of seating, with small clustered seating arrangements more likely to stimulate discussion (Calkins, 1988). Moreover, placing participants so that they can see the facilitator with their backs facing the traffic of the room helps to block out excess distractions, and can also increase social engagement (Jarrott, 2011).
Time
The timing of the intervention can affect the energy, motivation and attention levels of participants. Care homes and hospital settings are often quite habitual and will have times of the day dedicated to either visitation or protected for mealtimes (Protected Mealtimes Policy, 2004). Therefore, most interventions tend to be fitted around basic care needs such as meal times, bathing or personal care. Evening interventions are rarer due to earlier bed times caused by ageing and the subsequent effect that ageing has on energy levels.
Burgio et al. (2001) and McCann et al. (2004) both state that people living with dementia are more likely to exhibit less disruptive behaviour in the morning, this is possibly linked with having higher energy levels. Although conversely, Cohen- Mansfield (2010) found that both engagement and attention rates were constantly higher regardless of the type of intervention for people living with dementia between the hours 14.00 and 17.00 rather than during morning sessions.
A further interesting comment about the importance of the time of day in delivering non-pharmaceutical interventions is the phenomenon of sundowning. Sundowning is a phrase used to describe increased agitation for people living with dementia, it tends to occur in the late afternoon/early evening. Sundowning is more prevalent during the during the winter and in locations situated on a more northerly latitude.
Although, the reasons for sundowning remain unclear, some researchers link it to circadian rhythm, lower staffing levels and increased disorientation due to earlier darkness.
Lighting and Noise
The lighting and noise of a room can play a notable difference in the involvement of participants living with dementia in non-pharmaceutical interventions and additionally has an impact in the quality of life for older adults (Sorensen and Brunnstrom, 1995).
Cohen-Mansfield (2010) found that attention and engagement duration of participants were higher when the lighting was normal in comparison to a darker setting, furthermore that bright lighting had a markedly negative effect on the participants. The Illuminating Engineering Society (IES, 1998) have written guidelines about best practice lighting for older adults and although not tailored for activity spaces it does provide a practical overview of appropriate lighting conditions for people living with dementia.
Additionally, research (Gilmore, Groth, & Thomas, 2005) showed that people living with Alzheimer’s disease are less likely to perceive contrast in objects and colours, therefore the use of heightened contrasts for materials in non-pharmaceutical inventions is necessary. Older adults are also more likely to have a reduction of both contrast and illuminance, decreasing their level of retinal function, and resulting in a more negative affiliation with glare (Torrington, 2007).
Natural sources of light are also important to help reduce the risk of sundowning and seasonal affective disorder. During winter periods the introduction of light exposure can help alleviate anxiety and sleep deprivation (Ibid).
Noise
Noise also plays a role in the ability for people living with dementia to connect to the interventions. People living with dementia are more likely to be at risk of hearing loss as cognitive decline shares a common age-related neurodegenerative to hearing (Lindenberger, 1994). Secondly, there is a correlation between social isolation and hearing loss for older adults this is due to a deficiency of auditory input (Dawes et al., 2015). Although hearing aids can help this situation, there is still a stigma attached to wearing hearing aids, subsequently they are underused by older adults (David & Werner, 2016).
Cohen-Mansfield (2010) found that attention and engagement rates were higher when there was a moderate level of noise in comparison to a loud environment or silence. This is further supported by a study showing that people with dementia are more likely to recall answers when there is some element of background noise in comparison to silence (Foster and Valentine, 2001).
Takeaway
This section is to provide some food for thought for influential factors which lie out with direct delivery or design of materials. It is appreciated that some of these factors may be dictated by the venue and staff. However, before starting to teach older adults and people living with dementia, the tutor may want to consider the size of the group, the setting of the room, the time the teaching takes place, the light, if there is any detracting background noise. Try to think of pragmatic solutions such as rearranging the seating, using materials with clear contrasting colours, using props to create a theme, suggesting a time in the afternoon for the activity to take place, monitoring the light of the room and playing some light background music (which is linked to the theme of the intervention). The more pleasant and inclusive the environment the more likely you are to make the activity meaningful for the participant.
References
Burgio, LD, Scilley, K, Hardin, JM and Hsu, C. 2001. Temporal patterns of disruptive vocalization in elderly nursing home residents. International Journal of Geriatric Psychiatry, 16(4): 378–386.
Calkins, M. P. (1988). Design for dementia: Planning environments for the elderly and the confused. Owings Mills, MD: National Health Publishing.
Calkins, M.P., 2018. From research to application: Supportive and therapeutic environments for people living with dementia. The Gerontologist, 58(suppl_1), pp.S114-S128.
Chaudhury, H., Cooke, H., Frazee, K., Rowles, G. and Bernard, M., 2013. Developing a physical environmental evaluation component of the Dementia Care Mapping (DCM) Tool. Environmental gerontology: Making meaningful places in old age, pp.153-174.
Cohen-Mansfield, Khin Thein, Maha Dakheel-Ali & Marcia S. Marx (2010) Engaging nursing home residents with dementia in activities: The effects of modeling, presentation order, time of day, and setting characteristics, Aging & Mental Health, 14:4, 471-480, DOI: 10.1080/13607860903586102
David, D. and Werner, P., 2016. Stigma regarding hearing loss and hearing aids: A scoping review. Stigma and Health, 1(2), p.59.
Dawes, P., Emsley, R., Cruickshanks, K.J., Moore, D.R., Fortnum, H., Edmondson- Jones, M., McCormack, A. and Munro, K.J., 2015. Hearing loss and cognition: the role of hearing AIDS, social isolation and depression. PloS one, 10(3), p.e0119616.
Foster, N.A. and Valentine, E.R., 2001. The effect of auditory stimulation on autobiographical recall in dementia. Experimental aging research, 27(3), pp.215-228.
Gifford, R. (2007). Environmental psychology: Principles and practice (4th ed.). Colville, WA: Optimal Books.
Gilmore, G.C., Groth, K.E. and Thomas, C.W., 2005. Stimulus contrast and word reading speed in Alzheimer's disease. Experimental aging research, 31(1), pp.15-33.
Hospital Caterers Association (2004). Protected Mealtimes Policy, https://www.hospitalcaterers.org/media/1817/pmd.pdf (Accessed 22/02/2025)
Illuminating Engineering Society of North America. Recommended practice for lighting and the visual environment for senior living. New York: Illuminating Engineering Society of North America, 1998. Report No: IESNA RP-28-98
Jarrott, S et al., 2011. Layers of Influence: Important Contextual Factors in Directing Dementia Care Programs. Journal of Applied Gerontology. [Online] 30 (1), 113–122.
Lindenberger, U. and Baltes, P.B., 1994. Sensory functioning and intelligence in old age: a strong connection. Psychology and aging, 9(3), p.339.
McCann, JJ, Gilley, DW, Bienias, JL, Beckett, LA and Evans, DA. 2004. Temporal patterns of negative and positive behavior among nursing home residents with Alzheimer's disease.
Sörensen, S. and Brunnström, G., 1995. Quality of light and quality of life: an intervention study among older people. International Journal of Lighting Research and Technology, 27(2), pp.113-118.
Torrington, J.M. and Tregenza, P.R., 2007. Lighting for people with dementia. Lighting Research & Technology, 39(1), pp.81-97.
Wrublowsaky, R. (2017). A better long term care guidelines using evidence-based design. Presentation at 2017 Environment for Aging conference. Las Vegas, NV. 02/27/2017.
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