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Physical Enviornmental Cues That Support Activities of Residents with Dementia in Special Care Units

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Physical Enviornmental Cues That Support Activities of Residents with Dementia in Special Care Units
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BAJAJ, PREETA ( Author, Primary )
Copyright Date:
2008

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Alzheimers disease ( jstor )
Assisted living ( jstor )
Backyards ( jstor )
Caregivers ( jstor )
Dementia ( jstor )
Dining ( jstor )
Diseases ( jstor )
Observational research ( jstor )
Older adults ( jstor )
Signage ( jstor )

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University of Florida
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University of Florida
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Copyright Preeta Bajaj. Permission granted to the University of Florida to digitize, archive and distribute this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.
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12/1/2003

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PHYSICAL ENVIRONMENTAL CUES THAT SUPPORT ACTIVITIES OF RESIDENTS WITH DEMENTIA IN SPECIAL CARE UNITS By PREETA BAJAJ A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF INTERIOR DESIGN UNIVERSITY OF FLORIDA 2003

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Copyright 2003 by Preeta Bajaj

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This document is dedicated to the residents of the special care unit.

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iv ACKNOWLEDGMENTS I would sincerely like to thank Dr. John P. Marsden for his continuous encouragement, timely feedback and suggested improvements on my report, without which it would have been impossible for me to produce the desired result. I would especially like to thank Dr. M. Jo Hasell for helping me throughout my research and the writing process of this thesis. I extend my gratitude to the executive director and caregivers at the special care unit where this study was conducted. I thank them for their time and cooperation. The knowledge that they shared helped me formulate my suggestions. I would also like to thank Yun for her assistance during the study period. I would like to take this opportunity to express my thanks to the Interior Design faculty and non-faculty members for sharing their knowledge and for all their help throughout my two years of study in the Colle ge of Design, Construction, and Planning. I would like to thank my family and friends for their patience, support and encouragement. Finally, I would like to thank the University of Florida for providing me with such a great overseas educational experience. I will cherish the memories throughout my life.

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v TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES............................................................................................................vii LIST OF FIGURES.........................................................................................................viii ABSTRACT....................................................................................................................... ..x CHAPTER 1 INTRODUCTION........................................................................................................1 Statement of Purpose....................................................................................................2 Objectives..................................................................................................................... 3 Significance..................................................................................................................3 2 DEMENTIA.................................................................................................................6 Symptoms.....................................................................................................................7 Cognitive Symptoms.............................................................................................7 Behavioral Symptoms...........................................................................................8 Stages of AlzheimerÂ’s Disease...................................................................................10 Special Care Units for the Cognitively Impaired.......................................................11 3 CUEING SYSTEMS TO SUPPORT BEHAVIOR....................................................14 Layout of Special Care Units......................................................................................15 Cues for Intended Use................................................................................................17 Landmarks..................................................................................................................18 Sensory Stimulation....................................................................................................19 Sound...................................................................................................................19 Color....................................................................................................................20 Tactile Cues.........................................................................................................21 Aroma..................................................................................................................22 Signage.......................................................................................................................2 2 Summary.....................................................................................................................26

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vi 4 RESEARCH METHODOLOGY...............................................................................27 Research Setting.........................................................................................................27 Instruments and Procedure.........................................................................................31 Observations...............................................................................................................33 Interviews...................................................................................................................34 Signage.......................................................................................................................3 4 Pilot Test..................................................................................................................... 35 5 RESULTS...................................................................................................................37 Dining Area Observations..........................................................................................37 Dining Area1.....................................................................................................38 Dining Area2.....................................................................................................40 Staff Interview Response............................................................................................42 Reasons for Entering...........................................................................................42 Effectiveness of Signage.....................................................................................46 Backyard Observations...............................................................................................47 Staff Interview Responses..........................................................................................49 Reasons for Attempting or Not Attempting to Go Outdoors..............................49 Effectiveness of Signage.....................................................................................51 6 DISCUSSION.............................................................................................................53 Limitations..................................................................................................................54 Dining Area Recommendations..................................................................................55 Backyard Recommendations......................................................................................58 Suggestions for Further Studies..................................................................................63 Conclusion..................................................................................................................64 APPENDIX A OBSERVATION SHEETS........................................................................................66 B STAFF INTERVIEW QUESTIONS..........................................................................68 C SIGNAGE...................................................................................................................70 LIST OF REFERENCES...................................................................................................72 BIOGRAPHICAL SKETCH.............................................................................................77

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vii LIST OF TABLES Table page 5-1 Dining area-1: Results co llected from observations................................................40 5-2 Dining area-2: Results co llected from observations................................................42 5-3 Backyard: Results collected from observations.......................................................46 5-4 Weather Conditions through the four-week study period as noted from the weather channel........................................................................................................50

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viii LIST OF FIGURES Figure page 3-1 The pavilion plan......................................................................................................15 3-2 The clustered plan....................................................................................................16 3-3 Typographs...............................................................................................................23 3-4 Pictographs...............................................................................................................2 3 4-1 Layout plan of the special car e unit at Westend care community............................28 4-2 Dining area -1. (Entry c1)........................................................................................28 4-3 Dining area –2 (E ntries b2 and c2)...........................................................................29 4-4 Exit door (e) to backyard..........................................................................................29 4-5 Fenced backyard as seen from exit door (e).............................................................30 5-2 Dining area-1: Total cases observed for looking and entering (LK_ENT), looking and leaving (LK_LV), and ente ring without looking or by removing chair (NOLK_ENT).................................................................................................39 5-3 Dining area-2: Total cases observed for looking and entering (LK_ENT), looking and leaving (LK_LV), and ente ring without looking or by removing chair (NOLK_ENT).................................................................................................41 5-4 Movement pattern for resi dents entering Dining area-2..........................................43 5-5 Dining area-2: Total cases for reside nts entering from point a2, b2 and c2.............44 5-6 Backyard exit: Total cases observed (TOT_RES), going through the door after looking or not looking at the sign (GO_THRU), looking at the sign (LOOK), and not looking at the sign (NO_LOOK).................................................48 5-7 Backyard exit: Total number of cases observed (RES1) to total number cases in which residents went outdoors (GT1).........................................................50 6-1 Dining areas: A) Existing Plan with entries a1, b1, c1 and a2, b2 and c2 B) Plan with modified entry points a, b and c for dining areas 1 and 2...................56

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ix 6-2 Outdoor space: A) Existing plan, B) Plan with modified courtyard space..............59 6-3 Outdoor space: A) Existing view from the living area. B) Sketch with picnic tables..............................................................................................................60 6-4 Outdoor space: A) Existing view, B) Sket ch with modified walkways and raised planters.....................................................................................................................62

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x Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Master of Interior Design PHYSICAL ENVIRONMENTAL CUES THAT SUPPORT ACTIVITIES OF RESIDENTS WITH DEMENTIA IN SPECIAL CARE UNITS By Preeta Bajaj August 2003 Chair: John P. Marsden Major Department: Interior Design This study examined the use of text and graphic signs as a cueing strategy that may help to mitigate two problem areas in one special care unit in Florida. The literature encourages the use of multiple cueing systems in settings designed for cognitively impaired older adults. However, researchers do not universally agree upon the characteristics and effectiveness of color, nomenclature, and graphics in signage. In addition, few studies have been conducted to test assumptions that have been made with respect to the design and use of signage. Based on previous research on environmental cues, the text and graphics signs were used to (a) discourage resident entry into the dining areas while they were being cleaned and (b) encourage independent resident access to the outdoor courtyard. This was accomplished by observing residents over a four-week period before and after signs were introduced and interviewing staff. The signs for the dining area included vertical and floor “stop” signs. The signs for the courty ard included a wall graphic and a floor arrow with the letters “backyard.”

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xi Data analysis of observations revealed that the vertical stop signs were effective in discouraging residents from entering the di ning areas during cleaning. In contrast, the floor sign was more effective than the wall graphic in encouraging residents to access the courtyard. Staff interview responses about th e effectiveness of the signs varied. Although definitive conclusions could not be drawn, a number of design and activity interventions that may be more effective for the desired outcome were recommended based on resident behaviors. This study revealed that while designers must understand the special needs of cognitively impaired older adults, it is imperative to understand human behavior in the context of the physical and organizational environment to generate interventions and strategies. Thus, the greatest contribution of this study was that it used a researchoriented process to understand the environment-behavior relationships in one assisted living special care unit for older adults with dementia.

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1 CHAPTER 1 INTRODUCTION “With mirth and laughter let old wrinkles come.” [Merchant Of Venice] ~ William Shakespeare ~ Aging is inevitable. People are living longer and staying healthier due to advancement in technology and medicine and changes in lifestyle. The elderly population numbered 35 million in 2000, which represented 12.4 percent of the total population of the United States. But future projections indicate that there will be at least 70 million Americans over the age of 65 in the year 2030, which will represent 20 percent of the total population (Administration on Aging, 2000). However, when old age approaches it is not as welcomed as the quote by Shakespeare suggests. People undergo sensory and muscular changes that affect their daily life activities. A growing number of older people become dependent on social and physical support systems. Old age thus, raises concerns for the older adult (how am I going to age), their families (who is going to take care of whom), the social and economic policy makers (how many public dollars should be spent) and the service delivering professionals (who will pay me how much to deliver services) (Schwarz & Brent, 1999). One group of service delivering professionals includes architects and designers. Changing demographics present challenges fo r this group of professionals. Older people are diverse and their perceptions may vary from the general population. Lawton (1980) states:

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2 Although the most important generalization in gerontology may be that older people are, on the whole, pretty much like the rest of us, there is an important additional message: where the capabilities of older people do differ from those of younger people, unique needs requiring unique satisfiers may result. Hence the suggestion that what is good for people in general will be good for the elderly is only partly true. (p. X) Thus, design for older adults cannot be based solely on the intuitive and imaginative program created by the designer, requirements provided by family members or on the restrictions determined by the client. Designers must understand the special needs of older adults. Research indicates that the designed environment can compensate for declining abilities of older adults (Lawton, 1979). In contrast, a poorly designed environment can have adverse effects such as extreme reactions and aggressive behaviors by the cognitively impaired elderly (Brawley, 1997). Statement of Purpose The purpose of this study is to use a research oriented process to understand the physical environment in one assisted living special care unit, for older adults with dementia in Florida. As stated by this facilityÂ’s brochure, the program for the special care unit is designed to help slow the disease process through programs, nutrition and a unique environment. More specifically, the purpose of this study is (a) to examine two problems associated with the environment that were identified by the executive director of the special care unit and (b) to suggest possible strategies to address the problems based on research findings. The two problem areas include the following: 1. The special care unit has two dining locations. Each dining area is partially enclosed by three feet high walls and has three distinct entry points. After lunch some of the residents are often hyperactive and wander aimlessly. The wandering residents enter the dining areas while they are being cleaned. Residents tend to lose their balance on the wet floor, and a fall can lead to fractures and other serious injuries. Verbal cues to redirect and discourage these residents have been

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3 futile. Chairs have been used as physical barriers to prevent the residents from entering the dining areas. The management is seeking design strategies that will discourage residents from entering the dining areas when they are being cleaned. 2. One of the important characteristics of special care units is outdoor access for residents. Management at this facility would like to encourage the residents to spend time outdoors. Being outdoors has many advantages. Residents can engage in physical exercise. The outdoors will keep residents oriented to day and night and seasonal changes, which affect their internal body clock. The outdoors can be restorative when stressors such as crowding and noise within the building are avoided. Because wandering is an important concern, the surrounding courtyard is fenced and has a locked gate that is camouflaged. The environment does not have any physical cues that encourage the residents to locate and access the courtyard on their own. Most of the residents who spend time outdoors do so under the supervision of family or a staff member. Objectives The use of text and graphic signs is one cueing strategy that may help to mitigate the problem areas in the special care unit (SCU) th at is the focus of the study. The specific objectives are to explore whether or not text and graphic signs can 1. Discourage residents with dementia from entering the dining area when it is being cleaned. 2. Encourage residents with dementia to access an outdoor courtyard. Significance Currently, there are nearly 18 million people with dementia worldwide. This is projected to rise to around 34 million by 2025 with 71 % living in developing countries. Approximately 4 million Americans have AlzheimerÂ’s and it is estimated that by the year 2050, 14 million Americans will be afflicted with some form of dementia (AlzheimerÂ’s Association, 2002). Epidemiological studies i ndicate that the prevalence of dementia doubles every 5 years between the ages of 65 and 85 (Green, 2001). Even though statistical data have not been compiled, the risk of falling is believed to be more likely in older adults with dementia residing in the unfamiliar setting of a

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4 long-term care community. The Center for Disease Control reports that falling is the leading cause of injury and deaths in the elderly with most victims being elderly women. Lach, Reed, Smith, & Carr (1995) studied behavior that resulted in accidents in a community of 35 residents with Alzheimer’s disease. Thirty seven percent of the caregivers in this study reported wandering as the most common safety problem that resulted in residents getting lost, falling, and suffering from cuts (Silverstein, Flaherty, & Tobin, 2002). Wandering presents a significant management problem for the staff at long-term care communities. While wandering in and of itself is not disruptive, it often results in agitation, rummaging or trespassing (Briller, Calkins, Marsden, Proffitt, & Perez, 2001). Caregivers spend considerable time and energy in redirecting residents and minimizing disruptive behaviors. “An appropriately designed environment can make management of cognitively impaired residents much easier and more pleasant for the staff” (Calkins, 1988, p.34). The physical environment should allow safe wandering within the building by reducing disorientation and confusion. Wandering into unsafe places can be reduced through cueing systems. In a qualitative study, which entailed interviewing 13 caregivers, Salmons (1999) reported that caregivers used a wide variety of environmental interventions such as camouflaging and cueing along with verbal cues to redirect residents (Silverstein et al., 2002). Access to an outdoor space for fresh air and sensory stimulation is essential for everyone. Health benefits for older adults going outdoors include decreased sleep disorders and depression, and improved circadian rhythms and

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5 mobility (Brawley, 1997). Cueing systems can be used to encourage residents to experience outdoor spaces that are safe and secure. The literature, however, presents a contrasting array of recommendations for using signage as cueing aids in settings for cognitively impaired residents. Researchers do not universally agree upon the characteristics and effectiveness of color, nomenclature and graphic signage that should be used in long-term care communities with special dementia care units. In addition, few studies have been conducted to test assumptions. For example, the use of stop signs to discourage residents from entering or exiting has been suggested by Silverstein et al. (2002) but no em pirical studies have be en conducted to test their effectiveness. While the use of typographs and pictographs as signage for bedrooms and toilets has been studied empirically, pictographs have not been studied with respect to outdoor access. The subsequent chapter will be aimed towards understanding dementia, the commonly occurring AlzheimerÂ’s disease (AD), its symptoms, and the growth of special care units for the cognitively impaired individuals. This shall be followed by a review of the empirical research and recommendations available on the design of special care units with an emphasis on cueing systems to support behavior of residents with dementia.

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6 CHAPTER 2 DEMENTIA The word dementia comes from the Latin words dis , meaning away from, and mens , meaning mind . Dementia to most people implies ‘out of one’s mind’ or ‘the failure or loss of mental powers’, and it is often misunderstood as a specific disease (Aronson, 1994; Hoffman & Platt, 2000). Dementia is actually a group of symptoms, which may accompany certain diseases or physical conditions (Alzheimer’s Association, 2002). Diagnostic criteria, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R), includes (1) memory impairment; (2) at least one additional cognitive change such as aphasia, apraxia, difficulty with abstraction, visuospatial impairment, impaired judgment, or personality change; and (3) associated functional impairment (American Psychiatric Association 1987 as cited in Emery & Oxman (Eds.), 1994). While there are several diseases that may cause dementia, population-based studies (Katzman 1986; Mortimer & Hutton, 1985; Weiler 1987) suggest that Alzheimer’s disease (AD) accounts for 50 % to 60 % of all dementia cases (cited in Gutman (Ed.), 1992). The other causes include vascular dementia, multi-infarct dementia, Pick’s disease, Binswanger’s disease, Parkinson’s disease, and Lewy body disease (Silverstein, Flaherty, & Tobin, 2002). Dr. Al ois Alzheimer first described Alzheimer’s disease in 1906. The disease attacks a part of the brain and reduces the person’s control over their memory, thought and judgment.

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7 With AlzheimerÂ’s as one of the prime causes of dementia, its victims can be classified as late-onset or early-onset (S ilverstein et al., 2002). Ninety percent of the cases, which are typically over age 65, fall under the late-onset or sporadic category. The early-onset or familial category comprises 1 to 9 % of the cases. People who experience early-onset Alzheimer, are typically in their 40s, 50s or early 60s. There appears to be a definite genetic link associated with an early onset of the disease. The average life expectancy from the appearance of symptoms is about 8 years (U.S. Congress, 1987), with symptoms usually occurring 24 years before diagnosis (Berg & Morris, 1994 as cited in Silverstein et al.). Symptoms The symptoms of AlzheimerÂ’s disease are both cognitive and behavioral. While symptoms are specific to individuals, most of these worsen with time (Aronson, 1994). Some of these symptoms may be mistaken as normal changes that occur over the life span. As a person ages they may experience some sensory problems, such as hearing and vision loss, that can be corrected with aids. Another example is forgetfulness where the thought is eventually recovered. In AlzheimerÂ’s disease, there is at first the degeneration of brain cells. As the disease progresses, these brain cells gradually die leading to atrophy or shrinkage of the brain. Hence, what may be thought of as just forgetfulness is in reality memory loss, which means that the lost t hought cannot be recovered. AlzheimerÂ’s disease is progressive and degenerative, and there is no medical treatment or cure to reverse this process. Cognitive Symptoms Human memory is categorized into three types based on the involvement time and the experience involved (Edwards, 1994). The first type, called the sensory register, is

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8 very transitory and does not affect behavi or beyond a fraction of a second. The second or the short-term memory is related to immediate use and may last from several seconds to 2 or 3 minutes. The third is the long-term memory, which is largely a congregate storehouse of lifetime experiences. In order to respond to the demands of the environment, each of these has an equally important role and none can be said to be more important than the other. For older adults suffering with AlzheimerÂ’s, the sensory register may remain relatively intact. It is the patientÂ’s short-term memory, which is the first to be affected. Its effects are evident, for example, when an older person cannot remember a phone number long enough to dial it. Memories of long ago are more available than recent events. Thus long-term memory seems to remain unaffected. However, careful testing might reveal that even in the early stages the long-term memory is highly selective, more restricted, and increasingly repetitious (Edwards, 1994). As the cognitive abilities of the individual are hampered, there is a decrease in judgment and the ability to learn new things. There is also decline in orientation, abstract reasoning, and problem solving abilities. These changes may affect the ability of the person to communicate and the capacity to survive independently. Behavioral Symptoms Cognitive deficits are not the only changes associated with AlzheimerÂ’s disease. Intellectual impairment is complicated with behavioral and mood disorders. Memory loss and failure to remember the past may cause depression and withdrawal. Another behavioral quandary that can be seen in patients with AlzheimerÂ’s is trespassing and rummaging. Ironically, these people may be labeled as antisocial.

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9 Loss of communication skills may prevent an individual from expressing physical pain, which may cause screaming and agitation. Cohen-Mansfield (1986) and her colleagues have conducted extensive research focusing on agitated behaviors. They defined agitated behavior as “socially inappropriate verbal, vocal or motor activity that is not necessarily a by-product of a medical condition” (cited in Gutman, 1992, p.22). Agitated patients often make strange noises, seek attention, pick at things, make strange movements and pace aimlessly. Personal events and lack of control over life activities may also cause a person to get agitated, especially for people in the early stages of developing dementia. Agitation can be also caused by the inability to do tasks within the unfamiliar environment of a long-term care facility. The most commonly occurring behavior in people with dementia is wandering, largely due to disorientation. A study by Milke (1989) defines wandering as a cluster of behaviors, which include restless locomotion, absconding, navigational difficulties, searching, and group walking (cited in Gutman, 1992). Working off restlessness is one of the reasons why patients may wander. Wandering can also be attributed to the medications that a patient is taking. It is important to note “wandering differs from wayfinding in that the person walks without having a destination in mind and without knowing where she or he is” (Passini, Pigot, Rainville, & Tetreault, 2000, p. 688). In contrast, wayfinding is a problem solving process. It deals with a person’s ability to reach his or her destination by making decisions based on their cognition and perception of the spatial environment (Passini, 1992). Wandering may be more of a problem for th e caregivers in long-term care facilities, not for the individual with dementia. First, caregivers are concerned about the safety and

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10 health of the wanderer. Estimates by the AlzheimerÂ’s Association (1998) indicate that during the course of the disease as many as seven out of ten people with AlzheimerÂ’s disease or a related dementia will wander from home or a care facility and become lost (cited in Silverstein et al., 2002). Wandering is often the prime cause of falls, hip fractures, elopementsattempting to exit, deaths and other hazardous outcomes (cited in Silverstein et al.). Second, wandering can strain interpersonal relations of residents living in long-term communities. A study by Bernier and Small (1988) indicated that wandering and entering another residentÂ’s room was rated as the most disruptive behavior out of 22 possible disruptive behaviors (Hoffman & Platt, 2000). Stages of AlzheimerÂ’s Disease AD can be diagnosed with 90 percent or more accuracy using physical and neurological exams, mental status exams, brain imaging, laboratory tests and a detailed history of the progress of the disease. A lthough 8 years is the average life expectancy, people with AlzheimerÂ’s can live for 20 years or more. The various stages of their disease can be loosely organized into three categories (Silverstein et al., 2002). Early stage. Lasting for a duration of 1 to 3 years, people in the early stage of AlzheimerÂ’s require less supervision and lead a normal lifestyle with minimal changes. While the degenerative process of the brain cells has begun, memory loss is temporary and momentary. Complex tasks that require understanding, planning or calculations may take a little longer than usual and may start affecting productivity at work. People in the early stage are aware of their illness and have the cognitive ability to seek help. Middle stage . Lasting for a duration of 2 to 8 years, people in the middle stages require help with their activities of daily living such as bathing, toileting, grooming, ambulation, medication supervision and/or eating. Memory loss is prominent with

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11 increased difficulty in remembering events from the recent past and disorientation to time, place and people. Psychiatric health declines with a rise in anxiety, paranoia and hallucinations. Late stage . This stage of the disease last for about 1 to 3 years and requires complete care. The brain cells degenerate completely causing the person to have poor recent and remote memory. They are unable to communicate. Final areas of decline include the major organ systems, which are controlled by the autonomic nervous system, thereby leaving the person completely dependent on caregivers. Special Care Units for the Cognitively Impaired Most dementia patients are cared for at home, at least in the earlier stages of the disease, and the caregiver is usually the spouse or a close family member (Cohen & Weisman, 1991). As the disease progresses, family members are often compelled to seek caregiving services within the community due to a lack of effective treatments, knowledge and resources. It may be noted, “it is usually behavioral problems such as wandering and agitation rather than cognitive impairments that result in the institutionalization of patients with dementing illness” (Steele, Rovner, Chase, & Folstein, 1990, as cited in Silverstein et al., 2002). Research studies (Hawes, 1995; Hyde, 1995; Holbrook, 1993; Kane & Wilson, 1993; Regnier, 1992; Evans et al., 1989, as cited in Hyde, 1996) indicate that among residents of assisted living and other reside ntial care settings, 30 to 40 percent suffer from Alzheimer’s and related disorders. While there is an ongoing debate about the segregation or integration of the physically frail and the mentally frail, there has been a prevalence of special care units in U.S. nursing facilities since the mid-1960s and early 1970s (Chafetz & Namazi, 2001). Beginning in 1990, special care facilities have spread

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12 from nursing facilities to other options that have evolved in the last decade such as assisted living and adult day care centers (Sloane & Lindeman, 1996, as cited in Chafetz & Namazi). Dementia-specific special care units are targeted to residents who are ambulatory, confused, have a range of behavioral problems and require 24-hour supervision (Hoffman & Platt, 2000). Special care units, as the name suggests, are “special” and are designed to provide the residents with a highly sophisticated physical environment, a well-planned activity program, and a well-trained facility staff (Chafetz & Namazi). At present, the number of assisted living facilities providing specialized dementia care, or the number of beds available in such special care units is unknown (Chafetz & Namazi, 2001). The very existence of special care units faces many pragmatic problems (Aronson, 1994). First, there is little or no reimbur sement for special care units in assisted living. Second, for smaller facilities, segregating one group of residents from the other may not be economically viable. Third, demented individuals may be mildly, moderately or severely impaired, and the special care units should be geared towards the characteristics of the people being served. As the severity of the disease increases, the needs of resident will likely increase necessita ting a transfer to a long-term care unit. Hoffman and Kaplan (1998) listed 10 most common problems of special care units that were identified by 77 participants at an international conference (cited in Hoffman & Platt, 2000). Some of these include concerns about inadequate staffing and lack of training, inadequate admission criteria, problems with families, and inadequate funding for dementia programs. A common concern, however, was the physical design of the special care unit. Some of the design problems that most special care units faced included

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13 safety and orientation of residents in stai rwells and long corridors, easily accessible exits, lack of secure wandering areas, poorly designed furniture, confusing wallpaper or carpet patterns and high glare floor finishes. Designing a health care facility for the mentally impaired elderly is difficult as the parameters of dementia are often vague (Dunkelman, Dressel, & Aronson, 1994). Dementia is not a static disease and the rate at which dementia disorders progress in residents is not uniform. The guidelines for the design of specialized dementia care units are limited and need to keep up with the changing psychosocial model of care. While, most special care units are designed for th e convenience and efficiency of staff or administration, the needs of the residents are often overlooked. They are provided with locked, segregated wings or units under the pretext of a safe environment. For this study it is assumed that the primary goal of a special care unit is to care for people with AlzheimerÂ’s disease, and interventions are intended to enhance the quality of life of residents with dementia.

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14 CHAPTER 3 CUEING SYSTEMS TO SUPPORT BEHAVIOR People try to “read” the environment for cues as to how they should act and what they should do. ~ Calkins, 2002 ~ Cognitively impaired individuals differ from cognitively intact individuals with respect to their perception and understanding of the environment. Cognitively impaired people may maneuver and use the environment in ways other than originally intended. In the absence of cueing aids, they become lost and try to figure out things themselves. The search for information to facilitate orientation may cause frustration, anger or agitation (Zgola & Bordillon, 2001). Cues are required for cognitively impaired older adults to orient them to people, time, place or location. Cues are also indicator s of appropriate behavior (Zeisel, Hyde, & Levkoff, 1994). For example, a change in the tactile surface of flooring is a cue that aids a resident in sensing the difference between a tiled hallway and a carpeted dining room if one area is tiled and the other is carpeted. In addition, aromas from the dining area may help the resident to locate the dining room during meal times. The overall goal in special care units is to provide multiple cueing systems to support resident behavior (Briller, Proffitt, Perez, Calkins & Marsden, 2001). Some residents are able to read and understand signs, while others have lost that ability to do so. In addition, cues can have different meanings to each individual. A beautifully woven quilt on the wall may be pleasing to one person or a painful reminder of a past event to another person. Therefore, multiple cueing, or providing the same information in

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15 different ways directed to several different senses, will provide pertinent information to a greater number of residents than would a single orientation cue (Calkins, 1988). However, the design of one cue may affect the success of the other by a large magnitude. For example, color cues for orientation and safety may be affected by interior lighting. The most common cueing systems include Layouts that provide views of the desired place and the path to it Cues for intended use Landmarks Sensory cues Signage Layout of Special Care Units The literature suggests two distinct layouts of special care units (Calkins, 1988; Cohen & Weisman, 1991; Briller et al., 2001) that facilitate orientation. The first scheme, the pavilion plan, is based on the organizing principle of a widened hallway. Rooms are distributed around a central open area and this allows residents a complete view of the space. In such an arrangement, other physical cues are important to help residents locate their own rooms, as doors on either side of the hallway may look alike. These shall be discussed later in the chapter. Figure 3-1. The pavilion plan

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16 In figure 3-1, both the dining area and the staff work area are a part of the central hallway space thereby facilitating direct surveillance by the staff. In a post-occupancy evaluation of the pavilion plan at a nursing home special care unit, Lawton, Fulcomer, and Kleban (1984) found that residents spent less time in their rooms and more time in the widened hallway participating in social activities (cited in Briller et al., 2001). Thus, the central location of social spaces in the pavilion plan may improve visibility, orientation and participation of residents. Figure 3-2. The clustered plan The second scheme or the butterfly plan is based on the organizing principle of several clusters, with each consisting of a small number of bedrooms arranged around a central living area. The visual distinctiveness of each cluster helps residents in finding their own rooms. The staff work area has clear visual access of the central area. The dining room is broken up into two areas, with each serving two clusters. Since all areas are not visible to the resident from the central space, informational cues are necessary in this layout to aid residents in making decisi ons about which way to go. The clustered plan is less institutional and a more homelike manageable arrangement and leads to higher levels of orientation (Calkins, 1988).

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17 Cues for Intended Use The central shared living spaces within a special care unit are not merely living rooms. Residents spend a major portion of their day in these areas, either for formal activities and therapies, or during unscheduled free time. Activities areas, which do not have any specific physical cues indicating behavior, may create confusion and result in agitation (Zeisel, Hyde & Levkoff, 1994). A study conducted by Moore (2002) in a day care center for older adults with dementia found that the arrangement of chairs and tables serves as a cue to residents. While a cluster of 4-6 chairs encourages group activities, a single rocker or an armchair will encourage the resident to just sit back and watch others engaged in activities. Similarly, the seating arrangement in the dining area is a cue for residents about the use of the room (Calkins, 1988). Bright placem ats and tablecloths are some of the other cues that indicate the use of the dining space. A change in floor color, a low rail or a low wall signals the location of the dining area within the widened hallway plan of special care units. Cueing elements should be well thought about as the décor and ambience of the dining room can entice the person to eat (Zgola & Bordillon, 2001). Food preparation may not occur in the special care unit due to potentially hazardous appliances and objects. However, therapeutic kitchens, which are often linked with dining spaces, can be used to prepare occasional meals, snacks and special treats to yield olfactory cues or engage residents in activities. Marsden, Meehan & Calkins (2001) found that familiar cues such as standard appliances, and homelike décor help to support recreational group activities in therapeutic kitchens. They also found that food that is served family style is a familiar cue compared to food served from institutional carts on trays.

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18 Views to outdoor spaces help residents get accustomed to day and weather conditions and season changes. Windows and glass doors located along the walking paths attract residents towards natural light. This encourages the residents to use the doorways to move outside. However, doors and windows located at the end of corridors can create disturbing glare and confusion. Hence, the location of windows and views to outside within the layout is critical. Landmarks Landmarks are defined as orientation cues that establish a clear reference point and act as focal points within functionally different spaces. Buildings and monuments serve as focal points or landmarks for a city. Similarly, landmarks can be created for interior spaces by using distinctive architectural elements or by accommodating unique activities in smaller alcoves (Coons, 1985; Kromm & Kromm, 1985 as cited in Cohen & Weisman, 1991). The effectiveness of cues is strengthened when they are strong, bold, varied and distinctive (Brawley, 1997). Artwork, paintings, hanging quilts, tapestry or furniture items to which residents are particularly attached such as a grandfather clock, a chest or a rocking chair may also serve as cues in special care settings. Another landmark that is frequently used in special care settings is display boxes outside resident rooms. The conventional style of using nameplates and room numbers are meaningless guides as the ability to comprehend written words and numbers typically diminishes with dementia (Brawley, 1997). To become effective, nameplates and numbers have to be used in combination with other cueing aids such as display cases or memory boxes. Namazi, Rosner, and Rechlin (1991), in an empirical study, discovered that personal memorabilia in memory boxes increased residentsÂ’ ability to locate their rooms

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19 by 50 percent. Items related to the residents’ own childhood years such as photos or objects from home were more reliable cues than objects without personal meaning. Their study emphasized that object selection was crucial to cueing, rather than the display case itself. The results from this study were corroborated by another study conducted by Nolan, Mathews, Truesdell-Todd, and VanDorp (2002). However, Nolan et al. used photographs of residents from over 50 year s ago. Present day photographs generated responses such as “some old woman picture.” Thus as Cohen and Weisman (1991) suggest “landmarks need not be monumental in size or character; however, they should offer either a special meaning or a unique spatial identity.” (p.71) While landmark cues can be used to facilitate an appropriate behavior such as finding your way, they can also serve as aides in modifying inappropriate behavior such as wandering or unwanted exiting. In studies conducted by Dickinson, McLain-Kark, and Marshall-Baker (1995) and Namazi, Rosner , and Calkins (1989), door knobs or panic bars that were covered with a cloth panel or painted to blend with the door color were successful in reducing exit attempts by residents. This intervention had the same effect whether or not mini blinds were used to restrict light from exit door windows (Dickinson et al.). Sensory Stimulation Sounds, visual images, smells and kinesthetic experiences, whether used individually or in combination, provide sensory cues for the cognitively impaired residents (Zeisel, Hyde, & Levkoff, 1994). Sound The impact of using sound as a cueing device is unclear. Some have stated that listening to and making music has a positive psychosocial impact on individuals with

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20 dementia (Haitsma & Ruckdeschel, 2001). One study, conducted by Rundi and colleagues (1999) in special care units, demonstrated that music had a calming effect especially if it was in the resident’s language of origin (cited in Haitsma & Ruckdeschel, 2001). As a positive cue, music and sound from an activity room can attract other residents into the space and encourage activity (Brawley, 1997). In contrast, others have stated that sounds from televisions, radios, machines and ventilation units, motorized equipments, and traffic are confusing for th e memory-impaired individual, and contribute to agitation and anxiety (Hiatt, 1984; Torrington, 1996). This may have something to do with the origin and combination of sounds. Zeisel (1999) stated that overhead paging and piped-in music systems confuse residents, whereas, naturally occurring sounds such as a resident playing a piano, a dinner bell, and visitors chatting should be encouraged. Color Cognitively impaired residents often mistake one object for another. One simple cue to indicate appropriate behavior and reduce perceptual difference is color. While color-coding can be a highly creative endeavor, it is imperative that the information being communicated through color is consistent throughout the physical settings. Predictability and order can be achieved in the environment through consistent repetition of color systems (Cohen & Weisman, 1991). In public space, contrasting colors for doors and walls facilitate recognition of access points (Torrington, 1996). Contrasting colors can help in the identification of stair nosing and changes in level or gradient ther eby simplifying the visual environment. Color and contrast is especially important in bathrooms. In bathrooms, a variety of colors can be used to distinguish the toilet seat, sink, shower areas, and garbage pail from the surrounding floor and walls. This reduces confusion for the residents. Variety in décor,

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21 color and contrast through the use of varied furniture, fabrics and finishes makes the environment more manageable and comprehensible for the residents (Zeisel, 1999). While it helps in distinguishing various objects in one room, it also helps in distinguishing one room from another. However, it is critical to achieve the right blend of color and contrast in settings for cognitively impaired older adults. Changes in floor color can be interpreted as a step or a hole due to problems with depth perception. Another example is the use of decorative, bright and colorful wallpaper patterns, which are used as an aid in distinguishing spaces. For some residents, the wallpaper can cause frustration when they attempt to pick patterns such as “flowers” off the wall. The use of color in settings for cognitively impaired older adults is controversial. Aranyi and Goldman (1980) state that when color is used to distinguish personal spaces it is important to remember that people respond best to colors, which are in sympathy with their own emotional condition. This is difficult to address when dealing with mentally challenged users. Hiatt (1984) states that the stimulation effect of color is lost when it becomes familiar. The literature on color-coding suggests that color should be used in conjunction with other design cues. It also notes that the appearance of color is impacted by the interactive effects of light, texture and the person’s vision. Good lighting is essential for residents to view any cueing syst em, which may include use of color, display cases or signage. Light in itself attracts people and it has been observed that cognitively impaired people are drawn to light (Torrington, 1996). A change in illumination levels is a cue that can help residents to distinguish between various spaces. Tactile Cues Textures provide important sensory cueing for residents with low vision. Multiple textures used in the environment can signal surface through wall and floor coverings.

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22 While, variation in textures can be used in larger areas such as hallways, too much variation in smaller areas should be avoided as it may increase confusion. Aroma Smells can be used to signal activities and to help residents identify specific rooms (Calkins, 1988; Hiatt, Sloane, & Mathew, 1991). Aromas from the kitchen can help to create a sense of anticipation for dining. When food is prepared off the unit, authors Zgola and Bordillon (2001) suggest brewing co ffee at breakfast or boiling a little pot of beef bouillon at mealtime to introduce aromas. The smells of soaps or other bath products can signal bathing. Picking fresh herbs or flower s are sensory experiences that can help to orient residents with dementia to the time of the year (Briller et al., 2001). Aroma also has a strong influence on the mood of both the residents and the staff members. Delicious fragrances increase enthusiasm levels thereby increasing the appetite of residents. Familiar fragrances can also be comforting and relaxing for the residents. An important point to remember when providing olfactory cues is our senses get accustomed to smells when we are exposed to a smell for too long and then they may not be perceived. Moreover, due to the diminished sense of taste, which is linked to the olfactory system, older people generally prefer more intense flavors. Hence, as suggested by Briller et al. (2001), fragrances and flavors should be a little stronger for the older residents with dementia to appreciate them. Signage In the book Wayfinding: People, Signs and Ar chitecture, Passini (1992) stated that graphic information is needed by people primarily for three purposes 1. Orientation and general information about the setting required for decision making within a setting.

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23 2. Directional information to destinations, which is required for decision execution. 3. Identifications of destinations, which is required to conclude the decision making and execution process. Signage is a graphic cue that conveys visual messages. Signs are used to indicate appropriate behavior and tell us exactly what to do or what not to do such as “no smoking” or “no entry”. Signage can be informative as with bulletin boards or directional by pointing us to destinations. Signs are a part of visual communication design, which is constructed to affect the knowledge, attitudes and behavior of people (Frascara, 1997). Signage that is used to convey information in settings for older adults is classified based on its graphic style typographics or pictographics. Typographics, which are the most commonly used signs for communication, rely mainly on letterform, digits, words, or phrases for communication (Figure 3-3). On the other hand, pictographics are symbols or icons representing reality that may be hand or computer generated (Figure 3-4). Although a combination of color and shape can be used to provide a richness of information, pictographs are frequently quite abstract (Paul & Passini, 1992). Figure 3-3. Typographs Figure 3-4. Pictographs

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24 Research is needed to understand the affect of color contrast and interior lighting on the readability of interior signs. LomperskiÂ’s (1997) study on enhancing interior building sign readability for older adults indicated that sign readability was decreased as illuminance contrast decreased. Another finding that conflicts with the literature indicates that, for older adults, sign readability can be achieved with similar hue combinations as long as value differences are present in the sign. The Americans with Disability Act of 1990 (ADA) suggests guidelines for the use of typographic signage in buildings for older adults. These include the following: Dark letters that contrast with the light background by at least 70 percent. Sans Serif typeface. Letters and numbers with a width-to-height ratio between 3:5 and 1:1. Minimum character height of 3 inches. Use of lower case letters Any permanent names or labels are raised characters accompanied with Grade 2 Braille. Signs are made of non-reflective material and mounted 60 inches above the finished floor level. While ADA and the rest of the literature suggest generic guidelines that need to apply to all buildings with older adults, recommendations for the use of signage in environments for cognitively impaired older adults are few and contradictory. Torrington (1996) states that use of symbols or logos may be indecipherable to some residents and hence suggests the use of old fashioned language. Conversely, in recommending strategies for creating better care environments , Brawley (1997) states that pictures are more valuable than words for cueing and direction, although silhouettes of a man or a woman are not particularly successful. In the book Housing Options for People with Dementia, Zeisel (1999) stresses the need for using signs and pictures that include objects.

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25 Typographics, such as name plaques and room numbers, are traditional orientation cues that have become increasingly ineffective for the dementia population (Namazi, Rosner, & Rechlin, 1991). Namazi and Johnson (1991) conducted a quasi-experiment to study the effectiveness of four nomenclatures such as “toilet” and “restrooms” on the wayfinding abilities of cognitively impaired residents in a special care unit. The study also used the drawing of a homelike toilet with a water tank attached as one of the environmental cues. Results from the study indicated that residents in the early or moderate stage of dementia were most likely to use public toilets in response to the signage that was a combination of a wayfinding arrow on the floor along with the word “toilet.” Of all the wall signs that were used in the study (i.e., “restrooms,” “toilets,” and the graphic of a homelike toilet), the sign lettered with the word “toilet” was the most meaningful. Residents can also be conditioned to respond to signage. In a study conducted by Hussain (1982-83), three dementia residents were conditioned to develop negative or positive associations with attention-getting signage, which included large, colored, cardboard geometric shapes that were used to reduce exit attempts (cited in Day, Carreon, & Stump, 2000). While one of the shapes used for the study was positively associated with the resident’s favorite food, the other shape was negatively associated with the sound of loud clapping. The study suggests that conditioning residents to respond to the signage reduced wandering near exits and stairways. In another recommendation to discourage residents from entering or exiting, Silverstein et al. (2002) suggested the use of a large NO! or a stop sign on doors. However, no empirical evidence for the same has been provided.

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26 Christenson (1990) questions the use of graphics as they may enforce an institutional feeling, which is a direct conf lict with the “homelike” goal of special care units. Zgola and Bordillon (2001) suggested red velvet ropes to prevent residents from entering the dining areas and removing table settings. Once again, no empirical evidence for the same has been provided. Summary Cueing systems are required to provide residents with dementia with a simpler, user-friendly environment. Another goal of cueing systems is to minimize the dependence of residents on caregivers in reaching their destinations and using spaces (Briller et al., 2001). Clearly, the literature encourages the use of multiple cueing systems in settings designed for cognitively impaired older adults. The key to their success will be in effective design and mutual supportiveness that conveys consistent and accurate information (Brawley, 1997). While the effectiveness of some of the cueing systems has been empirically tested, much more research is needed in order to provide designers with guidelines that can make a significant difference in environments for cognitively impaired individuals. This study takes on the aspect of signage and explores its effectiveness in mitigating the problem areas in one special care unit.

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27 CHAPTER 4 RESEARCH METHODOLOGY The literature review in Chapter 3 provided insight into the physical environment of a special care unit (SCU). The objective of this study is to explore the efficiency of cueing systems in a real life context in a special care unit. The following is a description of the research setting of a special care unit in Gainesville, Florida called the Westend care community, the study participants, and the instruments and procedure used for data collection. It should be noted that Westend care community is a pseudonym granted to the special care unit within the long term care facility. It bears no reference to the organization and is being used as a means of confidentiality for both the organization and its participants. Research Setting The study was conducted at the Westend care community, a special care unit designed for older adults with dementia, with the permission of the executive director. The configuration of the SCU is rectangular with four clusters of four bedrooms with private baths and two clusters of six bedrooms with private baths along the perimeter (Figure 4-1). The entry to each cluster includes a small common area called the den. Each of the six dens has been designed to connect residents with activities from their past: a nursery, kitchenette, dressing area, office space and two lounge areas.

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28 Figure 4-1. Layout plan of the special care unit at Westend care community The central space of the facility is divided into a living area with dining areas on each side (Figures 4-2 and 4-3). Each dining area is enclosed by three feet high walls and has three distinct entry points marked as a1, b1, c1 and a2, b2 and c2 (Figure 4-1). The staff uses dining chairs to block the entrie s to discourage residents from entering while the dining areas are being cleaned from 1:30 pm to 2:30 pm. Figure 4-2. Dining area -1. (Entry c1)

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29 Figure 4-3. Dining area –2 (Entries b2 and c2) The path around the central living and dining spaces divides the public and private areas and is the walking path for the residents. This central path has two exit doors marked as (d) and (e) on the floor plan that connect to the enclosed outdoor courtyard (Refer to Figure 4-1). Figure 4-4. Exit door (e) to backyard One exit door (e) is kept unlocked between 10:00am and 4:00pm during most times of the year depending on the weather conditions (Figure 4-4). The exit door (d), which is

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30 closer to the living area, is not used for outdoor access and remains locked since it does not have a roof overhang. Both of these door s are connected outside by a circular paved walkway. The outdoor courtyard is surrounded by a fence and has locked gates (Figure 45). The courtyard has a paved walking path with flowerbeds and a seating bench under the roof overhang near the exit door. This serves as an outdoor respite area for caregivers. Figure 4-5. Fenced backyard as seen from exit door (e) While the door (e) to the courtyard may be left open for residents to access the courtyard independently, there are no graphics that encourage them to go outdoors. Residents usually access the courtyard under the supervision of staff or family members. The management encourages group activities during pleasant weather conditions but this is again under the supervision of caregivers. Participants At the time the study was conducted, the facility had twenty-four residents in the middle to late stages of dementia. All residents undergo clinical screening for dementia and vision before they are admitted. Five residents were also physically frail and use wheelchairs. One other resident was rec overing from a hip fracture during the study

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31 period and was temporarily in a wheelchair. Residents ranged in age from 72 years to 94 years. Nineteen of the residents were females supporting the demographics that women are at a greater risk for dementia since they live longer. Of all the residents, twenty-three of them were Caucasian and one was Hispanic. While the staff varies from day to day, there were a total of ten who worked on th e unit over a period of 24 hours. The number of staff members working during the c ourse of study varied from 3-6. Lunch is served around 11:45 am. Most of the residents who are mobile and can walk to the dining area independently are seated in dining area 1. Thus, dining area –1 is known as the high functioning area. Nine reside nts dine in dining area –2 which is known as the low functioning area because these resi dents suffer from greater physical and/or cognitive impairments. Instruments and Procedure The study tested the effectiveness of text and graphics signs, to discourage or encourage resident behavior, through observation of residents before and after signs were introduced. Follow up interviews with staff were conducted to gain insight into the behavior of residents and effectiveness of the nomenclature used. The study was conducted over a four-week period. Resident behavior was observed from 12:00 am to 3:00 pm, Monday to Friday for four weeks. The backyard exit was constantly monitored from 12:00 am to 3:00 pm, unless it was raining. The two dining areas were monitored during the time they were being cleaned from 1:30 pm to 2:30 pm. A timeline for the project is summarized below. After the Institutional Review Board approved the project, a consent form was presented to the executive director of the Westend care community and the research protocol was explained. Permission to use the layout plan and to take pictures was also

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32 granted. The executive director informed all family members or guardians of the participants who were observed about the study. The staff members were also asked to sign a consent form to participate in the interviews. Week 1Pretest period This phase entailed observing resident behavior: 1. In the absence of any signs at the dining area entries. 2. In the absence of any environmental cues at the outdoor courtyard access points. Staff members were asked some open-ended questions to gain their insight into the behavior of residents without any signs to affect their behavior. Week 2Introducing free standing stop signs and a backyard graphic on the wall This phase entailed observing resident behavior: 1. In the presence of vertical stop signs to discourage residents from entering the dining areas while they were being cleaned. 2. In the presence of a backyard graphic on the wall, which was mounted to encourage residents to access the outdoor courtyard independently. Week 3Replacing all vertical signs with stop signs, directional arrows and text on the floor This phase entailed observing resident behavior: 1. In the presence of stop signs affixed to th e floor to discourage residents from entering the dining areas while they were being cleaned. 2. In the presence of a directional arrow and the words “backyard” on the floor, which were used to encourage residents to access the outdoor courtyard independently. Week 4Removing all signs All signs to discourage and encourage resident behavior were removed from the environment. This phase entailed observing resident behavior:

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33 1. In the absence of any physical signs at the dining area entries. 2. In the absence of any environmental cues at the outdoor courtyard access exit. The staff was interviewed about the effectiveness of the nomenclature used for the study. Observations Checklists (Appendix A) were developed to document the sequence of events at entries a, b and c in dining areas 1 and 2 and the backyard exit (e). Behaviors that were noted in the dining areas before signs were introduced included pausing at any of the three entry points, walking away, entering the dining, no reaction or other unexpected behaviors. After the signs were introduced, behaviors noted included pausing at any of the three entry points, looking at the sign, walking away, entering the dining, no reaction to the sign or other unexpected behaviors. Events or actions for the backyard that were documented before the sign was introduced included pausing, looking at the door, touching the door, touching the door knob, pushing the door, walking away, going through the door, no reaction or other unexpected behaviors. Events or actions for the backyard after the signs were introduced included pausing, looking at the sign, looking at the door, touching the door, touching the door knob, pushing the door, walking away, going through the door, no reaction to the sign or other unexpected behaviors. Observations were recorded in the checklist based on the number of cases that were observed within an interval of 30 minutes. The behavioral pattern was noted with a check mark in the appropriate column. Multiple check marks were used to indicate a repetitive action by the same resident during the 30-minute interval. One observer sat close to each dining area in order to observe the residents unobtrusively.

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34 Interviews Staff interviews were conducted in weeks one and four. The staff were asked openended questions (Appendix B) to gain their insi ght into the behavior of residents before and after the intervention. Signage The signs for the dining areas and the backyard exit (e) were introduced in weeks two and three. Signs designed for the study were based on the important assumption that the cueing system had to be familiar to the residents. Because many cognitively impaired individuals walk with their heads lowered, the vertical signs used in week two were replaced by floor signs in week three. Dining . Stop signs are a common appearance in our day-to-day lives. Hence, stop signs used in the study were similar in proportion and color to the octagonal traffic stop sign. The stop signs used in week two (Appendix C, Figure -1) were self-standing structures made of cardboard. No hard material like wood or metal was used to prevent injuries, which could result if residents became agitated. The height of the vertical structure was three feet six inches, which was level with the height of the enclosing wall of the dining area. Three 16-inch octagonal stop signs were used at the entry points a, b and c in both dining areas 1 and 2 (Refer to Figure 4-1). The vertical stop sign for the dining areas were replaced with similar 16-inch octagonal stop signs on the floor in week three (Appendix C, Figure -2). The signs on the floor were covered with clear contact paper to prevent tripping hazards. The observers placed all signs after lunch was over and all residents had moved out from the dining areas. The signs were removed only after the dining rooms had been cleaned and the floor

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35 was completely dry and safe for the residents to walk on. These signs were then placed in a locked and secure storage closet. Backyard . The graphic used in week two, for encouraging residents to go outdoors included an outline of a yellow sun and a green tree with a blue background. The six-inch high letters “backyard” were yellow in color and written below the graphic (Appendix C, Figure -3). The overall size of the graphic was 38 inches by 24 inches. The graphic was placed above the existing exit sign and hence its size was limited by the available wall space. The colors of the sign were a contrast to the beige wall color. Since one of the important goals of the community is to create a home like environment, the word backyard was used on the sign instead of the words courtyard or garden. A directional arrow and six-inch high letters “backyard” replaced the graphic on the wall in week three (Appendix C, Figure 4). The arrow and the text were yellow in color as they provided maximum contrast with the red and blue colored carpet flooring. The directional arrow and the text were affixed to the floor using clear contact paper at 12 noon and removed at 3:00 pm. All signs were then placed in a secure closet not accessible to the residents. Pilot Test The study started with a three-day pilot test period. The aim of this pilot study period was to compare the reliability of the observations that were conducted in dining areas -1 and 2 by two observers. This pilot study or the trial run was conducted to assess whether the research protocol was realistic and workable. During the pilot test period, both the observers observed the residents in dining area -2. All observations were noted in the checklist. After the three-day test period observations were compared and an inter reliability of 90% was achieved.

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36 The pilot study period helped in preparing for any unexpected behaviors or questions from the residents that could arise during the actual study period. The observation time for data collection was reduced after the pilot study period. It was observed that residents in dining area –1 st arted gathering for lunch around 11:20 am and residents in dining area-2 were also brought in at the same time. Because of this there was minimal activity during 11:00am 12 noon and the observation time was changed from to 12 noon to 3:00 pm instead of 11:00 am to 3:00 pm.

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37 CHAPTER 5 RESULTS The objective of this study was to test the effectiveness of text and graphics signs as a way to (a) discourage residents from entering the dining areas and (b) encourage residents to access the outdoor area. This was accomplished by observing residents, in an assisted living care facility over a four-week period and conducting interviews with staff. Data that were collected based on observati ons of dining area-1, dining area-2 and the outdoor area were analyzed using SPSS. Staff in terview responses were content analyzed and themes were identified. Dining Area Observations For both dining areas 1and 2, residents were observed when chairs were used to block entry points a, b and, c and before signs were introduced (week one), when vertical stop signs were located at entry points (week two), when stop signs were mounted on the floor (week three), and after signs were removed and chairs were used once again to block entries (week four) (Figure 5-1). Behavi ors that were noted included the following: (a) A resident looked at a sign and entered the space anyway (b) A resident looked at a sign and did not enter the space, (c) A resident entered a space without looking at a sign or by removing a chair.

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38 Figure 5-1. Layout Plan showing dining areas 1 and 2 with entry points a, b, and c. Dining Area1 Week 1 . The baseline data collected at the Westend care community during the first week of study indicated that 17 residents entered dining area-1. In all instances, the residents moved the chairs aside and entered the dining area when it was being cleaned. Only 5 instances were noted in which chairs were successfully used as cueing aids to discourage residents from entering the dining area (Figure 5-2). Week 2 . When the vertical stop signs were introduced at entrances a1, b1, c1 in week two (Figure 5-1), a total of 30 instances were noted in which residents entered the dining area. Fifteen of the cases consiste d of residents looking at the stop sign and entering the dining area anyway when the floor was wet. The remaining 15 cases included instances in which residents appeared to be oblivious to the stop sign when they entered the dining area. The number of cases in which residents looked at the sign and did not enter the dining area was 21 (Figure 5-2).

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39 Figure 5-2. Dining area-1: Total cases obs erved for looking and entering (LK_ENT), looking and leaving (LK_LV), and en tering without looking or by removing chair (NOLK_ENT). Week 3 . The floor signs replaced the vertical stop signs in week three. Twenty-six cases were observed during this week where residents entered the dining area in the presence of the floor signs. These included 3 cases in which the residents looked at the stop sign and still entered the dining area. Twenty-three cases were noted in which residents appeared to be oblivious to the floor sign when they entered the dining area. One resident noticed the stop sign on the floor and did not enter the dining area (Figure 52). Clearly, the vertical stop signs were more effective than floor signs in preventing the residents from entering the dining area.

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40 Week 4 . In the post-test period, all signs were removed and 25 instances were noted in which residents entered the dining area. Chairs successfully prevented residents from entering the dining area 4 times (Figure 5-2). Table 5-1. Dining area-1: Results collected from observations Week 1 17 casesentered 5 cases chairs successful Week 2 30 casesentered 15 cases – looked at the sign 15 cases – oblivious of sign 21 cases – looked and did not enter Week 3 26 casesentered 3 cases – looked at the sign 23 cases – oblivious of sign 1 case – looked and did not enter Week 4 25 casesentered 4 cases – chairs successful Dining Area2 Week 1 . During the first week of study, residents entered dining area2 eleven times. In all observed cases, residents moved the chairs and entered the dining area (Figure 5-3). Week 2 . When the vertical stop signs were introduced at entrances a2, b2, c2 in week two (Figure 5-1), a total of 18 instances were noted in which residents entered the dining area. Eleven of those cases included residents looking at the stop sign and entering the dining area anyway. In the remaining 7 instances, the residents were oblivious to the stop sign when they entered the dining area. The number of cases in which residents looked at the sign and did not enter the dining area was 17 (Figure 5-3).

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41 Figure 5-3. Dining area-2: Total cases obs erved for looking and entering (LK_ENT), looking and leaving (LK_LV), and en tering without looking or by removing chair (NOLK_ENT). Week 3 . The floor signs replaced the vertical stop signs in week three. Residents entered the dining area in the presence of the floor signs 16 times. Residents looked at the stop sign and still entered in nine of the 16 cases. Seven instances were noted in which residents ignored or did not see the sign on th e floor when they entered the dining area. Eight cases were observed in which the residents noticed the stop sign on the floor and did not enter (Figure 5-3). Clearly, the vertical stop signs were more effective than floor signs in preventing the residents from entering the dining area. Week 4 . In the posttest period, all signs were removed and 18 instances were noted in which residents entered the dining area. Only 1 instance was noted in which the

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42 resident looked at a chair and changed her mind about entering the dining area (Figure 53). Table 5-2. Dining area-2: Results collected from observations Week 1 11 casesentered Week 2 18 casesentered 11 cases – looked at the sign 7 cases – oblivious of sign 17 cases – looked and did not enter Week 3 16 casesentered 9 cases – looked at the sign 7 cases – oblivious of sign 8 case – looked and did not enter Week 4 18 casesentered 1 cases – chair successful Staff Interview Response Responses from 6 staff interviews suppl emented by notes taken during observation provided valuable insight into why residents with dementia enter dining areas. All caregivers agreed that it is important to discourage residents from entering the dining areas when they are being cleaned due to the risk of potential falls. One caregiver stated that redirecting and preventing residents fr om entering the dining areas often made the residents agitated. A total of 98 cases were recorded for residents entering dining area-1. The number of cases for residents entering dining area-2 was 63. Reasons why residents enter the dining area and staff perceptions regarding the effectiveness of signage to discourage access follow. Reasons for Entering Wandering . Sixty percent of the caregivers stated that wandering is an important reason why residents enter the dining areas. One caregiver stated that entering the dining area is a “part of their routine”. During the four-week observations, wandering or restless locomotion was responsible for 30 % of the cases in which residents entered dining area1. In 10 % of these cases, residents entered the dining area led by another resident. In the

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43 remaining cases the goal of the resident entering dining area-1 was unclear to the observer. In dining area-2, 64 % of the entries were attributed to wandering. Residents entered the dining area with another resident in 15% of the cases. In 20 % of the cases, the reason for the resident entering dining ar ea-2 was unclear. Residents entered dining area-2 through points b2, and c2 as a shortcut to their rooms 18% of the time (Figure 54). Figure 5-4. Movement pattern for residents entering Dining area-2 Additionally, in 11 % of the cases residents would walk straight into the dining area immediately after they came out of their room s. This behavior was not observed in dining area-1 as most of the resident rooms, opposite entry points b1 and c1, were those of residents in the late stage of dementia with or without physical impairment making them greatly dependent on caregivers. This behavior was not seen at entry points a1 and a2 as residents living opposite these entries would sit in the dens after they came out from their rooms. These dens were designed as lounge areas and have more seating than the other

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44 four dens. In addition, the width of the opening at points a1 and a2 is narrower than the opening at points b1, b2, c1 and c2. As show n in Figure 5-5, residents entered dining area-2 through points b2 and c2 more often than through point a2. Figure 5-5. Dining area-2: Total cases for re sidents entering from point a2, b2 and c2. Table settings . Sixty percent of the caregivers stated that residents walked into the dining areas because they were attracted to the table settings, bright colored tablecloths, napkins and silverware. Residents also entered the dining area to move dining chairs and rearrange furniture. Of the total number of residents entering the dining areas, 30 % of the cases in dining area-1 and 16% of the cases in dining area-2 can be attributed to this cause. Cleaning . Twenty percent of the caregivers stated that residents walked into the dining areas to help them with cleaning. Residents were attracted to carts, buckets, and

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45 brooms. It was observed that in 6 % of the cases for dining area-1 and 8 % of the cases for dining area-2, the resident would enter to offer help to a staff member who was cleaning. Kitchen cleaning . Twenty percent of the caregivers thought that residents wanted to help clean the kitchen, which is only visible in dining area-1 through a large window. Fifteen percent of the observed instances of residents entering the dining area was attributed to this cause. In addition, in 5% of the cases, residents who entered the dining area asked the caregiver in the kitchen for more food such as ice cream and cookies. Place for retreat . Residents who had been walking within the unit entered dining area-1 (10% of the cases) or dining area-2 (8% cases) to sit and rest for a few minutes. This included one instance in which the resident entered and sat in the dining area because he wanted to stay away from an agitated resident who was present in the living room. Twenty percent of the caregivers agreed that residents entered the dining area when they wanted to get away from the other residents and did not wish to participate in any social activities. Social interaction . In the low functioning dining area-1, a few residents were slow and would take more time to finish lunch. So me of these residents would continue eating long after all other residents had finished. Als o, a few residents at times were agitated and did not wish to leave the dining area. In 2 % of the cases for dining area-1 and 4 % of the cases for dining area-2, other residents would enter to talk and interact with a resident sitting in the dining area.

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46 Search for personal belongings . Two percent of the cases, observed in dining area-1, consisted of residents entering in search of a personal belonging such as a TV remote or walking cane. No such observations were noted in dining area-2. Table 5-3. Backyard: Results collected from observations Reason for entering Observations dining area -1 Observations dining area -2 Wandering 30% cases 64% cases Table settings 30% cases 16% cases Cleaning 6% cases 8% cases Kitchen cleaning 20% cases Place for retreat 10% cases 8% cases Social interaction 2% cases 4% cases Search for personal belongings 2% case Effectiveness of Signage The analyzed observational data for dining area-1 and dining area-2 clearly indicate that the vertical stop signs were more effective than floor signs in preventing the residents from entering the dining area. In both dining ar eas, the vertical stop signs also attracted a higher number of residents to the entry points. The staff members, however, did not unanimously agree on the effectiveness of the vertical signs. Forty percent of the staff members believed that vertical signs were more successful then the floor signs in preventing residents from entering the di ning areas. Another 40 % of staff members believed that the floor signs combined with verbal cues were more effective than the vertical stop signs. However, the caregivers al so noticed unusual behavior due to vertical signs. Some residents talked to the signs while others became agitated by the signs and asked them to be removed. Twenty percent of the caregivers were not sure about which sign worked better for all residents of the community. The caregivers stated that as

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47 residents vary greatly in their level of cognitive impairment, it was difficult to come to a conclusion. Backyard Observations As mentioned in the previous chapter, while the exit door (e) (Figure 5-1) to the courtyard may be left unlocked for residents to access the courtyard independently, there are no graphics that encourage them to go outdoors. As with the interior spaces, residents were observed over a four-week period. Any behavior observed at the exit door was recorded. Other behaviors noted separately included residents going through the exit door whether or not they looked at signage. When signs were introduced, the number of residents who looked at the signs whether or not they entered the backyard and residents who did not look at the signs and entered were recorded. Week 1 . The baseline data collected at the Westend care community during the first week of study indicates 68 instances in which residents were observed pausing, looking at the door, touching the door, touc hing the door knob, pushing the door, walking away or going through the door. Of these cases, residents independently went through the exit door into the courtyard 10 times (Figure 5-6). Week 2 . When the backyard graphic was attached to the wall above the existing exit sign in week two, a total of 74 instances were observed in which residents paused, looked at the sign, looked at the door, touched the door, touched the door knob, pushed the door, walked away, went through the door or indicated no reaction to the sign. Of the 74 instances, twelve cases were observed in which residents went through the backyard exit. In all 12 cases, none of the residents looked at the backyard sign before they went through the door into the courtyard. While 3 cases were observed in which residents looked at the graphic sign, none of these resi dents went through the door (Figure 5-6).

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48 Figure 5-6. Backyard exit: Total cases observed (TOT_RES), going through the door after looking or not looking at the sign (GO_THRU), looking at the sign (LOOK), and not looking at the sign (NO_LOOK). Week 3 . The floor arrow and text replaced the wall sign in week three. Ninety-four cases were observed during this week in which the resident paused, looked at the sign, looked at the door, touched the door, touched the door knob, pushed the door, walked away, went through the door or indicated no reaction to the sign. Of the 94, twenty-one cases were observed in which residents went through the backyard exit independently into the courtyard. These included 9 cases in which residents went through the door after looking at the floor sign and 12 cases in which the residents went through the door without looking at the floor sign. The number of cases in which residents looked at the sign was 15 (Figure 5-6). Residents were often attracted to the floor sign and attempted to pick it off the floor. It was noted during observations that some of the residents

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49 misunderstood the floor sign. They seem to have perception problems because they did not want to step on the sign and were extremely cautious when walking close to the sign. In comparison to the graphic on the wall, floor signs clearly attracted more residents. Week 4 . In the post-test period 93 instances were noted in which residents paused, looked at the door, touched the door, touched the door knob, pushed the door, walked away or went through the door into the courtyard. Twenty-two instances were noted in which the residents went through the door into the courtyard without any assistance from the caregiver (Figure 5-6). Staff Interview Responses Responses from 6 staff interviews suppl emented by notes taken during observation provided valuable insight into the behavior of residents with respect to the outdoor exit. While the management at the community wants to encourage the residents to spend time outdoors, only sixty percent of the staff members agree that residents should be encouraged to go outdoors independently. Twenty percent of the staff members stated that only a few residents should be enc ouraged to go outdoors independently. The remaining 20 % objected to all resident s going outdoors independently. All staff members however, were concerned about the safety and security of residents. The following is a description of reasons why re sidents attempt to go outdoors while others do not and staff perceptions regarding the effectiveness of the signs. Reasons for Attempting or Not Attempting to Go Outdoors Weather conditions . During the four-week period, the number of residents going through the door into the courtyard was 65. More residents were observed going outdoors on mostly sunny days (Figure 5-7 and Table 5-4). They expressed their desire to go outdoors by saying, “I like to walk outside” and “It is nice out there”. Some residents

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50 would walk to the door and go outdoors while others would make no such attempts. Once outdoors residents would take a walk in the courtyard and then sit on the bench for a few minutes before returning indoors. Figure 5-7. Backyard exit: Total number of cases observed (RES1) to total number cases in which residents went outdoors (GT1) Table 5-4. Weather Conditions through the four-week study period as noted from the weather channel. Week 1 Week 2 Week 3 Week 4 Sunny 74, 54 Sunny 68, 42 Clouds 66, 42 Sunny 75,50 Sunny 71, 39 Sunny 65, 37 Clouds 65, 40 Mostly Cloudy 70,52 Sunny 60, 39 Mostly Sunny 66, 39 Sunny 64, 41 Partly Cloudy 73,56 Rain 68, 57 Mostly Cloudy 68, 40 Mostly Sunny 70, 48 Scattered Thunderstorms 75,56 Rain 67, 46 Mostly Sunny 72, 56 Mostly Cloudy 72,48 Some Rain 71,49 On bright sunny days residents made remarks such as, “It looks hot out there”. In addition, on cloudy days the residents when poi nting towards the courtyard made remarks

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51 such as, “It is raining outside” and “It looks cold out there”. No attempts were made to go outdoors on bright sunny and cloudy or rainy da ys. Thus weather conditions were an important factor affecting the resident’s desire to go outdoors. Reliance on caregivers . Most residents have been conditioned to go outdoors only when accompanied by a staff or a family member. Even when the doors to the courtyard were unlocked during the study period, few residents attempted to go outdoors. Past experiences . Going outdoors was also related to the person’s life experiences. One resident in the community would look out side from the glass door but would never go outdoors. Interviews with staff revealed th at the resident always went out with his spouse and would never go outside alone. Another example was of a resident who liked going outdoors to sit on the porch and observe airplanes as this was related to his past profession. Levels of impairment . The number of residents going outdoors can be attributed to the differences in the level of physical and/or cognitive impairment. For example, during the study it was observed that in 22 cases, residents touched the door and tried to push it open. However, a lack of physical strength prevented them from opening the heavy door and going outdoors. This was even more difficult for residents in wheelchairs. Inside activities . Activities taking place in the living room had a significant influence on the number of residents going outdoors. Similar to the dining areas, it was observed that fewer residents went outdoors wh en they were involved in inside activities that involved listening to music. Effectiveness of Signage Collected data indicates that the floor arrow and text were more effective than the graphic on the wall in encouraging residents to go outdoors. Eighty percent of the staff

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52 members, on the other hand, believed that neither the wall graphic nor floor signs were effective in encouraging residents to go out doors. They believed that residents did not read text placed on the wall. While the residents tried to read the floor sign, the word “backyard” was difficult to comprehend. More residents observed the floor sign because they perceived it as a step or a hole. The remaining twenty percent of the staff members believed that floor signs if used constantly for a longer time could encourage residents to go outdoors. All staff members stated that conditioning was a critical factor affecting resident behavior, as residents had not been conditioned to go outdoors independently.

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53 CHAPTER 6 DISCUSSION The positive impact of any intervention may be short lived but this fact alone does not diminish the value of the intervention. ~ Hatisma & Ruckdeschel, 2001 ~ Signs, text and arrows, a part of visual communication design, are used to convey appropriate behavior in settings. While the Americans with Disability Act of 1990 (ADA) and the literature suggest generic guidelines for signage that is applicable to all buildings with older adults, specific recommendations for the use of signage in environments for cognitively impaired older adults are few and contradictory. Moreover, empirical research that has addressed signage has largely been conducted in special care units and skilled nursing facilities. It is unknown whether the findings from these studies are applicable to other housing options such as assisted living that differ with respect to philosophy, models of care, physical environments, and regulations (Day, Carreon, and Stump, 2000). The study that is the focus of this thesis was conducted in one assisted living special care unit for older adults with dementia in Florida. The study used a researchoriented process to address two real world problems in the physical environment that were identified by the executive director of the special care unit. In particular, management sought design strategies to di scourage residents from entering the dining areas when they are being cleaned after lunch and strategies to encourage residents to access the outdoor courtyard independently. These problems are a cause of stress to the caregivers and affect movement and independence of residents.

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54 Building upon previous research conducted in nursing homes, the study tested the effectiveness of text and graphics signs to discourage or encourage resident behavior. Vertical and floor “stop” signs, similar in proportion and color to the octagonal traffic stop sign, were introduced in the dining areas. A wall graphic consisting of an outline of a yellow sun and a green tree with a blue background and the yellow letters “backyard” as well as a yellow colored floor arrow with the yellow letters “backyard” were used at the courtyard exit. Twenty-four residents in the middle to late stages of dementia were observed before, when, and after signage wa s introduced. Six staff members were also interviewed to assess resident behaviors and the effectiveness of signage. Data analysis of observations revealed that the vertical stop signs were effective in discouraging residents from entering the di ning areas during cleaning. In contrast, the floor sign was more effective than the wall graphic in encouraging residents to access the courtyard. Staff interview responses about the effectiveness of the signs varied. The contradictory findings may be due to methodological limitations. Limitations Several limitations were noted. First, this study was conducted at an assisted living special care unit. One of the most important f eatures of such units is the small number of residents. Thus, confidence in findings may be limited by the small sample size that is available in most special care units. Second, the level of residents’ physical and cognitive impairments plays a significant role when testing the effectiveness of design interventions. Each resident’s stage of dementia should have been tracked in conjunction with observed behaviors. Third, the physical environment is difficult to measure especially when the social and organizational contexts are considered. For example, it is unclear what effect

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55 medication, family visits and doctorÂ’s appointments had on the number of residents entering the dining areas and going outdoors. In addition, no two special care environments are alike. Two parallel settings with similar design features should have been studied so that results from each could be compared. With stronger findings, the interventions could then be studied in different environments. Fourth, cognitively impaired individuals get attuned to the environment. The conditioning of residents in long-term care environments shall always have a detrimental effect on the study. The use of interventions during the brief study period may not be sufficient to overcome these effects. Finally, the study was conducted in Florida during the month of February in order to allow residents to go outdoors and enjoy the pleasant weather conditions during this time of the year. However, unexpected rain and thunderstorms were some of the factors that had an effect on the outcome and were beyond the researcherÂ’s control. Dining Area Recommendations Although the vertical stop signs may have acted as a barrier that discouraged entry into each dining area, the signs also attracted more residents to the entries and led to unusual behavior. This may be why staff could not agree on the effectiveness of the signs. Staff interview responses concerning reasons why residents entered the dining areas provided additional information that can be used to generate strategies that may be more effective for the desired outcome. Relocate entry points . The number of instances of residents entering the dining areas may be reduced if entry points b and c are not directly opposite the dens (Figure 61). Since the entries to the dens are located directly opposite dining area points b and c, residents often walk straight into the dining area immediately after they come out of their

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56 rooms. In addition, wandering residents use the dining area as a shortcut to walk back into their rooms. Relocating the entry points will serve as a visual and physical barrier for residents in both the above-mentioned cases. In addition, sliding gates similar in height and color to the low dining walls may be installed at all entry points. These gates when closed will camouflage the entries when the staff is cleaning the dining area. Figure 6-1. Dining areas: A) Existing Plan with entries a1, b1, c1 and a2, b2 and c2 B) Plan with modified entry points a, b and c for dining areas 1 and 2 Reduce distractions . Even though the two dining areas are identical in design, they vary greatly in their décor especially with respect to the color of flooring and tablecloths. Dining area-1 is based on a yellow color palette while dining area-2 is based on a blue color palette. More entry cases were observed in dining area-1, and staff noted that residents are attracted to the bright colored table settings. To minimize distractions, table settings and silverware for the next meal should be set up only a few minutes before A

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57 the meal is ready to be served. In addition, ambient lighting within the dining areas should be reduced when staff members are cleaning the dining area Increase activities . One strategy for modifying resident behavior is to provide more activities while the dining areas are being cleaned. It was noted during observations that fewer residents wandered into the dining areas when activities that involve listening to and making music were taking place. Music therapy, for example, not only keeps residents occupied, it has other positive outcomes such as improved affect, increased engagement with staff members and increased food intake (Hatisma and Ruckdeschel, 2001). Mentally challenged individuals are most comfortable with activities that are repetitive and familiar and utilize well-leaned skills (Aronson, 1994). Observations indicated that residents walked into the dini ng areas to help staff members with cleaning. Thus, providing opportunities in one of the dens for cleaning and other domestic chores such as folding laundry may be another strategy to discourage entry into the dining areas. Allowing residents to rearrange furniture in the dens may decrease the number of residents who enter dining areas to move dining chairs and rearrange furniture. Redirect residents . The staff should modify rather than try to extinguish the wandering behavior of residents. Redirecti ng residents and providing outlets where they can wander after lunch may discourage residents from entering the dining areas. This includes encouraging residents to go outdoor s. Going outdoors may help reduce anxiety and restlessness that causes residents to wander into the dining areas. It may also provide retreat areas for residents who wish to get away from agitated residents.

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58 Backyard Recommendations Although the floor arrow and text were more effective than the wall graphic as cues to encourage residents to go outdoors, no defi nite conclusions can be drawn about using these signs at the Westend care community. Staff members thought that residents observed the floor sign more than the wall sign because they perceived it as a step or a hole. Hence they believed that neither the wall graphic nor floor signs were effective in encouraging residents to go outdoors. However, there is little doubt that residents should be encouraged to go outdoors. Allowing residents to walk in a safe and contained area is a healthy form of exercise and helps to reduce their energy levels. Yet, concerns about falling and losing balance limits residentsÂ’ freedom. Observations and staff interview responses can be used to generate strategies that are more effective to encourage residents to go outdoors. Divide the courtyard . The walkway in the courtyard at present extends behind the building and the staff is unable to see the residents once they go outdoors. Hence, it is recommended that the courtyard be broken up into smaller sections for direct visual access for residents and staff members (Figure 6-2). Dividing the existing courtyard into two smaller courtyards will create a smaller and more manageable outdoor environment. The exit doors (d) may be left unlocked for the residents to go outside independently. The living area is the central space and the focus of activity. The staff members can monitor residents using the smaller courtyard from this space (Figure 6-3). Modify doors . Doors with large glass panels will allow increased visibility of the outside space and encourage residents to go outdoors. Moreover, doors made from lighter materials will allow residents with reduced physical strength to access the outdoor space

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59 without being dependent on caregivers. Door handles should be designed for convenient and easy access for residents in wheelchairs. Figure 6-2. Outdoor space: A) Existing plan, B) Plan with modified courtyard space. Provide seating areas . Picnic tables and comfortable garden chairs may be set up in the smaller courtyard space to allow reside nts to sit and spend time outside. This would provide a place for retreat and encourage residents who wander into dining areas or go back to their room when bothered by the noise and activity in the unit (Figure 6-3). This space may also be used for family visitations.

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60 Figure 6-3. Outdoor space: A) Existing view from the living area. B) Sketch with picnic tables. While the smaller courtyard can serve as a sitting area for residents, the larger courtyard may be used for outdoor group activities. As weather was an important factor that contributed to the number of resident s going outdoors, a roof patio that provides shaded seating spaces should be provided for residents to sit outdoors. Furniture provided in both courtyards should be comfortable and residential in style. A B

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61 Modify landscaping . The staff members limit residentsÂ’ freedom to access the courtyard due to concerns about falling and losing balance. It is recommended that all level differences in the courtyard should be removed and the courtyard should be designed on grade with the indoor space. Paved surfaces should be glare free, non-slip and have uniform texture and color. Leveled wa lkways that provide a series of longer and shorter routes should be provided to allow re sidents to choose their path (Figure 6-4). All flowerbeds should be replaced with potted plants or raised planters that are accessible to residents in wheelchairs. However, these should not be placed close to the fence to avoid physically fit residents from using these as a foothold to climb over the fence. Flowering trees, shrubs and perennials will orient residents towards seasonal changes. Vines may be planted along the perimeter to camouflage the fence (Figure 6-4).

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62 Figure 6-4. Outdoor space: A) Existing view, B) Sketch with modified walkways and raised planters. All recommendations should be directed towards making the environment safe and secure. The safer the environment, the more likely caregivers are to let residents make their own decisions about being outdoors and staying independently. A

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63 Suggestions for Further Studies Simple pictographs . Residents in special care units are not be able to rely on their memory when navigating the environment. When, pictographic signs are used to orient mentally impaired residents, they should be simple and based on recognizable themes from previous life experiences. Various hand drawn or computer generated graphic signs depicting flowers, birds, trees, or a person doing yard work may be used to encourage residents to go outdoors. Short typographs . It is recommended that in future studies, typographic signs that use text should be short and easy to comprehend by a person with a short attention span. For example, a staff member suggested using different phrases such as “lets go outside for a walk” to encourage residents to go outdoors. However, notes taken during observations revealed that one of the resident understood the word “backyard” as alphabets “a, b, and c”. Thus future studies using short nomenclature should be conducted in settings. Some of the possible words that may be used to encourage residents to go outdoors include “go”, or “out”. Signage position . Future studies should also test the use of the same signage in different positions. For example, the vertical stop signs were present at the entry points and the wall graphic was placed on the wall close to the exit door. While this study indicates that the backyard wall graphic sign wa s not effective in encouraging residents to go outdoors, it is important to study the position of the sign at different wall locations close to the exit door. A study testing the effectiveness of the courtyard sign placed on the exit door can help in understanding the effect of location and placement of signs within the setting. It shall also bring to light the effect of natural and artificial lighting on signage used within the interior space.

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64 Cueing elements . Future research should test the use of a variety of cueing elements to discourage or encourage resident behavior in special care units. Red velvet ropes as suggested by Zgola and Bordillon (2001) may used to prevent residents from entering the dining areas and removing table settings. Another method that was suggested by a staff member to prevent residents from entering incorporates the idea of installing three feet high wooden gates similar to those used in old saloons. These gates could be installed two feet above the floor and closed temporarily when the dining areas are being cleaned. However, residents have been conditioned to enter the dining areas as per their choice. The effect of a strong physical barrier on the behavior of residents needs to be tested empirically before such gates are installed. Increased caregiver and resident participation . Future research should allow increased involvement of caregivers and residents while designing the instruments and determining the procedure for the study. Reside nts may be asked about the signage before it is introduced in the environment. For example, if it was know prior to the study that the word “backyard” would be read by some residents as alphabets a, b, and c then other possible nomenclature could have been tested. Extended pilot test periods may allow researchers to get a better understanding about the likes, dislikes, physical and mental abilities of their participants. Conclusion The variability and unpredictability in the behaviors and symptoms of cognitively impaired older adults makes designing for dementia a challenging task. Special care units have been developed to respond to this challenge. These settings provide residents with a highly sophisticated physical environment, a well-planned activity program, and welltrained facility staff. However, environmental problems such as those identified at the

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65 Westend care community prevent residents from enjoying the well-designed space. This study revealed that while designers must understand the special needs of cognitively impaired older adults it is imperative to understand human behavior in the context of the physical and organizational environment to generate interventions and strategies. Thus, the greatest contribution of this study was that it used a research-oriented process to understand the environment-behavior relationships in one assisted living special care unit for older adults with dementia. Although definitive conclusions could not be drawn, a number of design interventions were recommended to manage behaviors. These interventions may reduce stress for staff, increase job satisfaction, and provide staff with more time for residents. Most importantly, these modifications will improve the quality of life of cognitively impaired older adults in long-term care settings by allowing them to lead an independent life.

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66 APPENDIX A OBSERVATION SHEETS Table –1. Backyard observation sheet CHECKLIST WEEK DATE LOCATION TIME BACKYARDRESIDENTPAUSING LOOKING AT SIGNS LOOKING AT DOOR TOUCHING DOOR TOUCHING DOOR KNOB PUSHING THE DOOR WALKING AWAY GOING THROUGH DOOR TO THE BACKYARD NO REACTION TO SIGN OTHER OBSERVED BEHAVIORSwall floor 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

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67 Table –2. Dining area observation sheet CHECKLIST WEE K DATE LOCATION TIME DININGRESIDENT ENTRY POINT (A/B/C) PAUSING LOOKING AT SIGNS WALKING AWAY ENTERING THE DINING NO REACTION TO SIGN OTHER OBSERVED BEHAVIORS REACTIONS/NOTESpost floor 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

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68 APPENDIX B STAFF INTERVIEW QUESTIONS Week 1Pretest Period Dining Areas 1. Why do you need to discourage residents from entering the dining areas during cleaning? To what degree is this a problem? 2. Why do residents walk into the dining areas after lunch is over? 3. In one afternoon, on average, how many residents walk into the dining areas while they are being cleaned? 4. What are some of the methods you use to prevent residents from entering? 5. What are some of the methods you might want to use? 6. Do you think designing signage to prevent them from entering might be a possible alternative? Outdoor Courtyard 1. In your opinion, do residents like to go outdoors? Do they express their desire to go outdoors? 2. How much time do they usually spend there? 3. Do residents go outdoors independently or do they need to be guided by you? If they need your guidance do they ask for help? Do they show any signs? (Such as going close to the exit door, touching it, or pushing it) 4. Do you think residents should be encouraged to go outdoors? Are there any benefits to this? 5. What could be a possible way of encouraging them to go outdoors? 6. Do you think designing signage to encourage them to go outdoors might be a possible alternative?

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69 Week 4Removing All Signs And Arrows Dining Areas 1. Do you think the stop signs were successful in discouraging residents from entering the dining areas? 2. Which one of the two alternatives (free standing stop signs or floor mounted stop signs) was most successful? 3. How did the residents react to these signs? 4. Did you notice some unusual behavior by the residents due to these signs? 5. What can be some of the ways to increase the effectiveness of these signs? Outdoor Courtyard 1. Do you think the graphics, text and arrows were successful in encouraging residents to go outdoors? 2. Which one of the two alternatives (graphics and text on wall/ arrows and text on floor) was more successful? 3. How did the residents react to these signs? 4. Did you notice some unusual behavior by the residents due to these signs? 5. What can be some of the ways to increase the effectiveness of these signs?

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70 APPENDIX C SIGNAGE Dining Areas Figure-1. Vertical stop sign introduced in week 2. Figure2. Floor stop sign introduced in week 3.

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71 Backyard Figure3. Wall graphic introduced in week 3. Figure4. Floor sign introduced in week 3.

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72 LIST OF REFERENCES Alzheimer’s Disease and Related Disorders Association, Inc., Alzheimer’s Association. (2002). Statistics about Alzheimer’s disease . Available from Alzheimer’s Association Website, http://www.alz.org Alzheimer’s Disease and Related Disorders Association, Inc., Alzheimer’s Association. (2002). What is Alzheimer’s disease ? Available from Alzheimer’s Association Website, http://www.alz.org Aranyi, L., & Goldman, L.L. (1980) Design of long-term care facilities . New York: Van Nostrand Reinhold. Aronson, M.K. (Ed.). (1994). Reshaping dementia care — Practice and policy in longterm care . Thousand Oaks, CA: Sage Publication Ltd. Bechtel, R.B. (1997). Environment & Behavior: An Introduction . Thousand Oaks, CA: Sage Publications Ltd. Barnett, E. (2000). Including the person with dementia in designing and delivering care . London: Jessica Kingsley Publishers Ltd. Blasch, B.B., & Long, R.G. (1994). Environmental information needs for wayfinding by special populations. Journal of Rehabilitation Research and Development , 30(31): 293-294. Brawley, E.C. (1997). Designing for Alzheimer’s disease: Strategies for creating better care environments . New York: John Wiley & Sons, Inc. Brawley, E.C. (2001). Environmental design for alzheimer’s disease: A quality of life issue. Aging & Mental Health, 5(1): 79-83. Briller, S. H., Calkins, M.P., Marsden, J.P., Proffitt, M.A., & Perez, K. (2001). Creating successful dementia care settings: Maximizing cognitive and functional abilities . Baltimore: Health Profession Press (Vols. 1-4). Brown, B., Wright, H., & Brown, C. (1997, Spring). A post-occupancy evaluation of wayfinding in a pediatric hospital: Research findings and implications for instruction Journal of Architectural and Planning Research , 14(1): 35-51. Calkins, M.P. (1988). Design for Dementia: Planning Environments for the Elderly and the confused . Owings Mills, MD: National Health Publishing.

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73 Calkins, M.P. (1996). Dissertation on conceptualizing and assessing environmental press in special care units for people with dementia . University of WisconsinMilwaukee. Calkins, M.P. (2002, Spring). Building ideas. What is your building saying? AlzheimerÂ’s Care Quarterly , 3 (2): 179-180. Carpman, J.R., Bush-Brown, A., & Davis, D. (Eds.). (1992). Hospitable design for healthcare and senior communities . New York: Van Nostrand Reinhold. Carpman, J.R., & Grant, M.A. (1993). Design that cares: Planning health facilities for patients and visitors . Chicago: American Hospital Publishing, Inc. Chafetz, P.K., & Namazi, K.H. (Eds.). (2001). Assisted living: Current issues in facility management and resident care . Westport, CT: Auburn House. Christenson, M. A. (1990). Aging in the designed environment . New York: The Haworth Press, Inc. Cohen, U., & Day, K. (1993). Contemporary Environments for people with Dementia . Baltimore: The Johns Hopkins University Press. Cohen, U., & Weisman, G.D. (1991). Holding on to Home: Designing Environments for People with Dementia . Baltimore: The Johns Hopkins University Press. Day, K., Carreon, D., & Stump, C. (2000). The therapeutic design of environments for people with dementia: A review of the empirical research. The Gerontologist , 40(4): 397-416. Department of Health and Human Se rvices, Administration on Aging. (2000). Information on the Aging from Census 2000 . Available from Administration on Aging Website, http://www.aoa.gov Dickinson, J., McLain-Kark, J., & Marshall-Baker, A. (1995). The effects of visual barriers on exiting behavior in a demented care unit. The Gerontologist , 35: 127130. Dickinson, J., & McLain-Kark, J. (1996). Wandering behavior associated with AlzheimerÂ’s disease and related dementias: Implications for designers. Journal of Interior Design , 22(1): 32-38. Dunkelman, D.M., Dressel, R.C., & Aronson, M.K. (Ed.). (1994). Reshaping dementia care . Thousand Oaks, CA: Sage Publications, Inc. Edwards, A.J. (1994). When memory fails-Helping the AlzheimerÂ’s and dementia patient . New York: Plenum Press.

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74 Edwards, A.J. (2002). A Psychology of orientation: Time awareness across life stages and in dementia . Westport, CT: Praeger Publishers. Emery, V.O.B., & Oxman, T.E. (Eds.). (1994). Dementia: Presentations, differential diagnosis, and nosology . Baltimore: The Johns Hopkins University Press. Frascara, J. (1997). User-centred graphic design: Mass communication and social change . London: Taylor & Francis Ltd. Green, R.C. (2001). Diagnosis and management of AlzheimerÂ’s disease and other dementias . Caddo, OK: Professional Communications, Inc. Gutman, G.M. (Ed.). (1992). Shelter and care of persons with dementia . Simon Fraser University, Canada: The Gerontology Research Center. Hatisma. K.V., & Ruckdeschel, K. (2001, Summer). Special care for dementia in nursing Homes: Overview of innovations in programs and activities. AlzheimerÂ’s Care Quarterly , 2 (3): 45-56. Hiatt, L.G. (1984). Conveying the substance of images: Interior design in long-term care. Contemporary Administrator , 6: 86-89. Hiatt, L.G., Sloane, P.D., & Mathew, L.J. (Eds.). (1991). Dementia units in long-term care . Baltimore: The Johns Hopkins University Press. Hoffman, S.B., & Platt, C.A. (2000). Comforting the confused: Strategies for managing dementia . New York: Springer Publishing Company, Inc. Hyde, J. (1996, March/April). Alzheime r friendly assisted living regulation. American Journal of AlzheimerÂ’s Disease , 11(2): 2-9. Laurenhue, K. (2002, Winter). Resource review and reflections: Enhancing the spirit of place. AlzheimerÂ’s Care Quarterly , 3(1): 91-94. Lawton, M. P. (1979). Therapeutic environments for the aged. In D.Canter & S. Canter (Eds.), Designing for therapeutic environments. A review of research (pp. 233276). Chichester, England: John Wiley and Sons. Lawton, M.P. (1980). Environment and aging . Monterey, CA: Brooks/Cole Publishing Company. Lawton, M.P., Fulcomer,M., & Kelban, M. (1984). Architecture for the mentally impaired. Environment and Behavior , 16: 730-757. Lomperski, T.J. (1997). Enhancing interior building sign readability for older adults: Lighting color and sign color contrast. Journal of Interior Design , 23(2): 17-27.

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75 Marsden, J.P., Meehan, R.A., & Calkins, M.P. (2001, September/October). Therapeutic Kitchens for Residents with Dementia. American Journal of Alzheimer’s Disease and Other Dementias . 16(5): 303-311. Moore, K.D. (2002, Winter). Observed Affect in a Dementia Day Center — Does the Physical Setting Matter. Alzheimer’s Care Quarterly . 3(1): 67-73. Nagy, J.W. (2002, Winter). Kitchens that help residents reestablish home. Alzheimer’s Care Quarterly , 3(1): 74-77. Namazi, K.H., Rosner, T.T., & Calkins, M.P. (1989). Visual barriers to prevent ambulatory Alzheimer’s patients from exiting through an emergency door. The Gerontologist , 29: 699-.702 Namazi, K.H., & Johnson, B. (1991). Environmental cues to reduce problems of incontinence in Alzheimer’s disease. American Journal of Alzheimer’s care and Related Disorders and Research . 6: 22-28. Namazi, K.H., Rosner, T.T., & Rechlin, L. (1991). Long-term memory cueing to reduce visuo-spatial disorientation in Alzheimer’s disease patients in a special care unit. American Journal of Alzheimer’s care and Related Disorders and Research , 6: 1621. Nolan, B.D., Mathews, R.M., Truesdell, T.G., & VanDorp, A. (2000,Winter). Evaluation of the effect of orientation cues on wayfinding in persons with dementia. Alzheimer’s Care Quarterly . 3(1): 46-49. Norris, K.A., & Krauss, I.K. (1992). In R.L. West, and J.D.Sinnott. (Eds.). Everyday memory and aging: Current research and methodology . New York: SpringerVerlag New York Inc. Passini, R. (1992). Wayfinding in architecture . New York: Van Nostrand Reinhold. Passini, R., Rainville, C., Marchand, N., & Joanette, Y. (1998, Summer). Wayfinding and dementia: Some research findings and a new look at design. Journal of Architectural and Planning Research , 15(2): 133-151. Passini, R., Pigot, H., Rainville, C., & Te treault, M. (2000). Wayfinding in a nursing home for advanced dementia of the Alzheimer’s type. Environment and Behavior , 32(5): 684-710. Paul, A., & Passini, R. (1992). Wayfinding: People, signs, and architecture . New York: McGraw-Hill Book Company. Regnier, V. (1994). Assisted living housing for the elderly: Design innovations from the United States and Europe . New York: Van Nostrand Reinhold.

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76 Rylan, E.V. (1995). Dissertation on the impact of interior design on the dining abilities of the elderly residents in assisted living and nursing homes . Virginia Polytechnic Institute and State University, Blacksburg. Schwarz, B., & Brent, R. (Eds.). (1999). Aging, autonomy and architecture: Advances in assisted living . Baltimore: The Johns Hopkins University Press. Silverstein, N.M., Flahert y, G., & Tobin, T.S. (2002). Dementia and wandering behavior: Concern for the lost behavior . New York: Springer Publishing Company, Inc. Stephens, L.P. (Compiler) (1969). Reality Orientation: A technique to rehabilitate elderly and brain-damaged patients with a moderate to severe degree of disorientation . Washington DC: American Psychiatric Association. Taira, E.D. (Ed.) (1991). The mentally impaired elderly: Strategies and interventions to maintain function . New York: The Haworth Press. Torrington, J. (1996). Care homes for older people . London: E & FN Spon. Zeisel, J. (1999). Housing options for people with dementia . Ontario, Canada: Canada Mortgage and Housing Corporation. Zeisel, J., Hyde, J., Levkoff, S. (1994, March/ April). Best practices; an environment – behavior (e-b) model for Alzheimer’s sp. American Journal of Alzheimer’s care and Related Disorders and Research , 9: 4-21. Zimmerman, S., Sloane, P.D., & Eckert, K.J. (Eds.). (2001). Assisted living: Needs, practices, and policies in residential care for the elderly . Baltimore: The Johns Hopkins University Press. Zgola, J., & Bordillon, G., (2001). Bon Appetit! The joy of dining in long-term care . Baltimore: Health Professions Press.

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77 BIOGRAPHICAL SKETCH Preeta is originally from India and belongs to the city of New Delhi, the capital of India. After successfully completing her formal education in the field of science, her ardent desires to choose a field of study that was closely related to the lives of people and simultaneously nurtured and enhanced her artistic and creative ability gradually crystallized into the profession of architectur e. Preeta earned her five-year Bachelor of Architecture degree from School of Planning and Architecture, India in 2000. After one year of work experience in an exhibition and interior design firm, which comprised both, office and site experience, Preeta decided to pursue higher education in the field of interior design from the United States. She joined the University of Florida in fall 2001 for the masterÂ’s degree program at the Co llege of Design, Construction, and Planning. While having worked on numerous projects for professors in the field of history of interior architecture and gerontology, Preet a was appointed as a graduate teaching assistant for IND 3125. The College of De sign, Construction and Planning selected Preeta as one of the recipients of the International Student Academic Award for 2003. Upon her graduation in summer 2003, Preeta wishes to pursue a future career in interior design.