If you can dream it ... long term care professionals tell us what really works when caring for Alzheimer's or Dementia residents.

Editor's Note: Episcopal Church Home-Memory Care Center of Excellence photos courtesy of Bryan Moberly Photography.

Bob Elmer, administrator, The Carriage House at the Elms end The Elms in Westerly, R.I.

The Carriage House is home to 25 Dementia patients and The Elms is an independent and assisted living facility.

Which type of design features makes caregiving and operations easier for an Alzheimer's or dementia population?

Caregiving: When we designed the Carriage House, one of the things that made it successful is the openness of it all. You can literally stand in one end of the building and see the other end. We have three atriums that allow in a great deal of light. One section we designed to give a sense of being outside with stone walls, wicker furniture and a trellis with ivy. All rooms are on the periphery of the building.

On the other side of the facility is a more formal sitting room area. In the middle of the community is a second lounging area with two TVs in case the guys and the gals want to see different things. Each of the lounging areas is capped by an atrium.

Openness is the key. Staff doesn't have to turn around and wonder what's happening and where it's happening. The atrium gives the resident a feeling of openness. They don't feel confined or trapped. They can walk a lot.

Operations: The open design allows a lot of flexibility. You're not locked into an environment where it's all or nothing with anybody. When we have five entertainment, you can conduct an activity in one end with the people who wish to participate and have residents in the other end doing what they want to do.

Which features should a facility definitely avoid?

One mistake we made was allowing an architect to talk us into automatic flushing toilets. When you have a population who puts things into the toilet that aren't supposed to be in there and it automatically flushes, it creates problems.

What new trends do you see becoming popular?

We're beginning to understand this population better and we're doing new things to our environment: We've taken wallpaper-trim accents that are traditionally placed at the top of a wall and switched it to the bottom, because Alzheimer's patients look down while they walk. This way, when the Alzheimer's patients walk they can see it.

Facility staff and administrators are really taking the time to get to know their residents. We're doing a cultural assessment of them: If you have a guy who likes to tinker and we don't have anything for him to do, he'll take the building apart.

Kathleen O'Brien, senior vice president of programs and community services, National Alzheimer's Association, Chicago, Ill.

Which type of design features makes caregiving and operations easier?

Caregiving: It is very important to understand that design is just one component of good care. The other component is to have strong coaching programs for the caregiving staff to emphasize individual care.

Regarding design features, small and more homelike environments are more conducive to quality care. People are not used to going to a dining room and eating with 10 people. It could very well lead to more agitation, more withdrawal, and the resident may begin to lose weight.

Be careful about ovestimulation with lighting and how many elements going on at once in the environment. And, allowing the family to bring personal items is important, along with conducting a close monitoring of the patient.

What new trends do you see emerging?

One emerging issue is being sensitive that the environment and the food and the activities are culturally appropriate, and that we are sensitive to particular ethnic backgrounds. If you have an Asian Pacific resident and you serve them mashed potatoes, it will be foreign to them. They might become agitated, withdrawn and won't eat.

Susan E. Lanza, administrator, Llanfair House, Wayne, N.J.

Lanza is speaking at the 2004 National Alzheimer's Conference about decorating and creating a dementia-friendly environment.

Which type of design features makes caregiving and operations easier?

Caregiving: Two elements help: environmental aspects and staff. Both are key. There are simple things that you can do with lighting, noise and smell.

Bathing, grooming and toileting. There is a great deal of fear for residents in there. It is an uncomfortable, unnatural place that doesn't look like home. In many institutions, it is a large room. Make this area look more like home by curtaining it off into smaller spaces. Use fabrics and non-institutional vanities from places like Home Depot.

Adapt the space for the person's level of disease. For a person who is a more advanced case, we might put them into a cozy chair with aromatherapy, surrounded by curtain with a painting on it. We are de-institutionalizing the environment to calm and soothe the person.

Dining. Use color to make a contrast between the plate and mat, for example, so things are easy for the resident to use. Use music in the background to cue people that it's time for meals and to provide a calm environment. In our facility, we have four dining groups. We divide them out so that higher-functioning residents eat together. We do this so they can socialize at the same level, and so that care provided is individualized.

For higher-functioning people, we provide more restaurant-style serving and allow them sometimes to help in the serving. With the lower-level functioning residents, we assign more caregivers and ask them to cue the residents when to eat. We serve food that is easier to eat without utensils, such as soup in a cup, French fries, or meatloaf cut into tiny pieces. Some people eat on the run. We feed them a piece as they walk their circuit.

Artwork and landmarks. Purchase or make interactive artwork such as an antique-looking radio in a long corridor. The resident can stop and turn the knob. It can provide an interactive moment together with a caregiver or family member, and it breaks up the long corridor.

We use murals on our fire doors, with permission from our local fire marshals. This decreases elopement by disguising the locked door. [Residents] walk past this particular door. Before, they would push the door to get out and begin to get frustrated.

A special calming place. We've created a place with sensory equipment in a dimmed and quiet area. So, when residents get agitated, this area reduces the amount of stimuli.

None of these things work 100 percent of the time, but they do decrease anxiety and provide some structure and increase residents' independence and autonomy.

Operations: The residents really need to be segregated, because they have specific needs you must address. When I first got here, it was a hodge-podge. Residents' physical needs were met but it was noisy and chaotic. It took three years to get here. We did it in phases.

What turned out to be a performance improvement has changed our entire culture and building. With permission from the families, we use a videotaping system to ferret out the problems each resident may face. Through observation, you can figure out whether it might even be the gender of a caregiver upsetting the resident.

Which features should a facility definitely avoid?

Don't put things in the pathway, don't allow any paging overhead and don't allow a lot of glare. We don't put mirrors on doors. Residents see an old face and they don't remember themselves being old. It scares them and they move away from the door.

The lesson we learned is that it's a team effort. This is not a project that any team should do without giving it a lot of thought. Without an interdisciplinary approach, it won't work.

Emily Morgan, speech language pathologist RehabWorks, Newtown, Pa.

Morgan works with a number of facilities as a resource person and teaches courses on Alzheimer's and Dementia.

Which type of design features makes caregiving and operations easier?

Caregiving: With Alzheimer's patients, the more you can keep them socially connected and stimulated, the easier it is for caregivers. Interacting with others and nature is very beneficial for the resident and reduces the caregiver's burden of care. If you can, create a path or walking path--that tends to be a soothing behavior for that resident.

If someone is losing their sight--or for many Alzheimer's patients, their brains can no longer register visual cues--color contrasts create a problem. Going from light to dark carpet can make a resident feel like they are failing from a cliff. If you don't have a visual perception of depth, when you move from dark to light carpet you might feel like you have to take a big step. And, many residents don't like hearing aids or glasses, so they will often take these off.

What is your favorite success story?

One facility that worked really well had alcoves. They were perfect seating places for residents, We put a park bench in one of them with wallpaper that looked like the woods. There was actually a sound-activated tape recorder that played waterfall and bird sounds. So, when a person sat on the bench, the noises came out very softly. Another alcove created a beach scene and had a beach shovel, shells and sand. Another had children playing on the ground with a carousel-type seating arrangement.

We monitored how often people sat there. It became a favorite place. Even the people who tended to wander liked these places. They even allowed themselves to be given water there, and stayed more hydrated that way.

Wendy Lantz, senior vice president of clinical services, also of RehabWorks, Newtown, Pa.

Lantz is also a licensed occupational therapist.

How do you make the caregiving of Alzheimer's patients easier?

Remove clutter. Make sure things like rugs, shoes and nursing carts are always in the same place and not lying around. Label items for residents and keep them in the same spot--hopefully, in very familiar types of places.

Try to keep things simple in design. Use solid colors for placemats and wallpaper. Many facilities try to make things more beautiful with patterns, but that makes things very difficult for these types of patients because of overstimulation.

Jenny Burton, RN, former director of special care units Franklin United Methodist Community, Franklin, Ind.

She continues to work with Alzheimer's patients as the unit manager of residential assisted living.

Which type of design features makes caregiving and operations easier?

Caregiving: Bathrooms. Make those larger and wide enough so you can get the person in there without a struggle. You don't have to [be able to] turn around and close the door. That can make them feel anxious and suffocated.

A simple thing like putting the toilet paper where they can reach it is also important. We used to have it behind the door. You had to pull the door around to reach the toilet paper. It's now beside the commode and at a higher angle. Make sure the counter space gives you enough room to put your towels and washcloths.

The counters also need to be low enough so if residents are in a wheelchair they can reach the faucets and the sink.

Which features should a facility definitely avoid?

We used to have rails in the kitchen and dining room to help them walk. They don't work, especially for the men. They want to climb over them. If you put them higher, they will just try to climb under them. We finally did away with them in the east and west units.

Bill Keane, director of special programs Mather Lifeways Institute on Aging, Evanston, Ill. In designing a new facility, what features make caregiving easier?

It's critical to know what your program is about. You can only do that once you know the mission and values that drive your organization and subsequently define your program. That really drives what kind of services you provide and what kind of staff you need to recruit. It will drive what your programming will be like. You may not necessarily be able to do vanilla programming. You will have to work with people in different functional groups. That will take a pretty highly skilled staff.

The role of the family in creating the program is important, particularly if you're making design changes. When we were making changes in our nursing care center, I did [several] focus groups with families. We educated them about the program's philosophy and we solicited their input. Because of that, we took our beauty parlor out of a very busy and noisy area in the basement and put it in a more dementia-friendly area.

Which features should a facility definitely avoid?

The biggest mistake occurs when everybody is not on board. The planning process for any new facility or renovation has to be all-inclusive. An outside planner can't drive it. The people who are going to actively live and work in the space must be involved and asked to provide input in the design. And, make sure your interior design and architects have experience in dementia care.

ADVICE FROM THE EXPERTS

Programming & Planning

"Alzheimer's disease impacts the family and friends of the patient in ways that have seldom been addressed in current design and planning."--Jury Chair George Pressler.

* Recognize that protecting the patient with security and safety measures is the primary issue to be addressed.

* Plan the individual space with "visual identifiers" to remind the resident of the necessary steps of daily living, such as personal hygiene.

* Incorporate memorabilia of the resident's past into the design to benefit the patient and remind caregivers that the patient is a whole person.

* Depict the patient's family tree with names, photos, dates, and significant events of each relationship.

* Personalize each resident's front door with color, unique design features, and photographs.

* Design the personal living space as an open plan to allow the patient to see all areas of their own environment to remind them of locations of bathrooms and entry doors.

* Recognize that a facility will include residents with varying degrees of Alzheimer's, so allow for differing levels of socialization in the shared spaces.

* Plan for maximum visualization and observation of all areas for the staff.

* Design spaces that easily allow for family and friends to comfortably interact with the patient, such as guest chairs and tables.

* Consider all aspects of nature in all spaces through incorporation of natural light, gardens, sounds, smell, and touch.

Architectural Design 

"Promote design elements that encourage effective wayfinding, and design special visual features that help residents with orientation."--Juror Armando Gonzalez.

* Provide interior and exterior walking areas that promote visual access to all resident functions.

* Include large, yet comfortable and easy-to-access conversational sitting areas, both inside and outdoors.

* External functions should be controlled to avoid residents wandering outside the facilities.

* Promote the use of natural light throughout the facility.

* Provide a country-kitchen environment that is accessible by residents to promote individual access and group involvement.

* Avoid formula solutions and work to inspire creative design alternatives that respond to client values and project guiding principles.

* Within reason, encourage all aspects of the facility to promote resident independence and discourage design solutions that promote dependence.

Interior Design

* "Alzheimer's is a disease that deteriorates the brain over time."--Juror Kay Trimmer.

* Design for a special core environment.

* Understand that the environment influences the behavior of the individual.

* Design facilities to enhance function in all aspects of the living environment.

* Create a sense of safety, which can contribute to the quality of life.

* Establish design solutions that reinforce independence for people.

* Realize that sensory changes are always taking place in the aging process.

* Each person has their own personal feelings dictated by their individual culture.

* Design to encourage patients to get up to enhance different degrees of mobility.

* Introduce Green design.

* Research the therapeutic goals of light, pattern, texture and color.