Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...

 
Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
Dementia-Friendly Care Homes
Best practices in dementia care
March 2020

Report prepared by
Kishore Seetharaman and Habib Chaudhury
Department of Gerontology, Simon Fraser University
Developed in consultation with:
Michael Kary, B.C. Care Providers Association
Barbara Lindsay, Alzheimer Society of B.C.
Jennifer Stewart, Alzheimer Society of B.C.
Mariana Hudson, Alzheimer Society of B.C.

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Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
Contents

Executive Summary............................................................................................... 3
Introduction........................................................................................................... 6
Methods................................................................................................................. 9
Findings on Staffing, Education and Training................................................... 11
      1.1. Education & Training........................................................................................ 11
      1.2. Staffing & Care Practices.................................................................................. 17
Findings on Physical Environment..................................................................... 22
      2.1. Domestic scale................................................................................................... 22
      2.2. Orientation and wayfinding............................................................................ 23
      2.3. Privacy and visual accessibility......................................................................... 25
      2.4. Physical accessibility, safety, and comfort........................................................ 27
      2.5. Appropriate sensory stimulation and minimizing perceptual distortion...... 28
      2.6. Familiarity and homelikeness........................................................................... 30
Community Consultation................................................................................... 31
      3.1. Staffing, Education, and Training.................................................................... 32
      3.2. Physical Environment........................................................................................ 37
Conclusion........................................................................................................... 41
References........................................................................................................... 43
Appendix A: Infographic Handout.................................................................... 50
Appendix B: Agenda of Community Forum...................................................... 54
Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
Executive Summary

An estimated 64% of residents in              and (ii) education, training, staffing, and
British Columbia’s (B.C.) long-term           care practices. The project was conducted
care (LTC) homes live with dementia           in partnership with the Department of
(Seniors Advocate of British Columbia,        Gerontology at Simon Fraser University
2018), which indicates the importance         and the Alzheimer Society of BC
of responsive staff care practices for        (Alzheimer Society) and in collaboration
optimizing the quality of life (QOL) of       with other stakeholders. The synthesized
residents living with dementia, as part       set of guidelines sets the stage to explore,
of any policy and program to improve          among various possibilities, the benefits
care in LTC. To address this issue, BC Care   and pitfalls of developing a designation
Providers’ Association (BCCPA) initiated a    program for Dementia Friendly Care
project with the aim to identify the best     Homes in British Columbia. The guidelines
practices for people living with dementia     identified in this project would be of
living in care homes in two key areas:        benefit to BCCPA members and other
(i) physical environment of the setting,      care providers in inspiring and informing

Dementia-Friendly Care Homes                                                            3
Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
initiatives to create a more dementia              (iv)	PCC training should be customized to
friendly care home in terms of the quality               different staff roles and tailored to
of care interactions and the physical                    the issues and challenges they face.
environment.                                       (v)	training should incorporate issues
Forty grey literature sources (e.g., reports            of family involvement and cultural
based on guidelines from health ministries,             competence.
regional health authorities, regulatory            (vi)	sufficient time and resources must
agencies, care provider organizations,                    be provided to staff to translate
advocacy organizations, and research                      training into practice, e.g., PCC
groups) were reviewed to examine                          facilitator to provide ongoing and
relevant policies and programs in Canada,                 follow-up training.
USA, UK, and Australia. The review of
                                                   (vii)	monitoring and performance
the grey literature was followed by
                                                          evaluations should be conducted to
community consultation at a forum with
                                                          ensure the practice of PCC values.
stakeholders from care homes, regional
health authorities (RHAs) across British         • In the area of Staffing and Care Practices,
Columbia, and the B.C. Ministry of Health,         the literature suggests that:
and people living with dementia and                (i)	higher staff-to-resident ratios
caregivers. Findings from the literature                should be in place.
synthesis were presented to the attendees
                                                   (ii)	multiskilled workers should
of the forum, which informed discussions
                                                         be hired.
to identify initiatives for implementation
                                                   (iii)	care aides are part of the team
in the short term, areas that need to be
                                                          and should be included in
prioritized for support from RHAs or the
                                                          decision-making.
Ministry of Health, and resources in B.C. that
are necessary for the proposed initiatives.        (iv)	care aide assignments should
                                                         reflect the importance of building
Findings and Recommendations                             strong relationships with residents.

• In the area of Education and Training,           (v)	open communication should be
  the literature suggests that:                         employed to facilitate information
                                                        sharing between staff.
     (i)	all staff groups should have a
          comprehensive understanding of         For the Physical Environment in care
          the meaning of person-centred          homes, the literature suggests the
          care (PCC).                            following criteria:

     (ii)	family members should receive         • familiarity and homelikeness:
           PCC education.                          (i)	care homes should have small
     (iii)	PCC training programs should be             households with separate dining
            evidence-based.                             and activity spaces.

4                                                              Dementia-Friendly Care Homes
Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
(ii)	décor and furnishings must reflect      (iv)	signs with clear visual and
        a familiar and homelike character.            textual information provided at
  (iii)	private rooms should be in neutral           appropriate locations.
         colours to encourage residents to      (v)	outdoor areas should have single
         personalize their spaces.                   exit/entrance.
  (iv)	the exterior of the care home           (vi)	outdoor paths should have a raised
        should be less institutional and              coloured edge.
        more homelike.                        • privacy and visual accessibility:
• physical accessibility, safety,               (i)	bedrooms should be single-
  and comfort:                                       occupancy with private bathrooms.
  (i)	bathrooms should be equipped             (ii)	common activity spaces and
       with unobtrusive grab bars and                 bathrooms should be visible from
       spacious enough to accommodate                 the hallway.
       care aides.
                                                (iii)	all spaces should have clear views
  (ii)	brightly-coloured handrails should             of the outdoors.
        be provided in hallways to be
                                                (iv)	storage cabinets should provide
        supportive of mobility limitations.
                                                      clear access of personal belongings
  (iii)	door frames should be in                     and safe items.
         contrasting colour to be easily
                                                (v)	staff workstations should be
         perceptible.
                                                     located near hallways.
  (iv)	outdoor spaces should be
                                                (vi)	exit doors should be concealed
        surrounded by a high fence
                                                      behind artwork.
        camouflaged with landscaping.
                                              • appropriate sensory stimulation:
  (v)	seating should be provided at
       appropriate intervals along indoor/      (i)	spaces should be provided with
       outdoor paths.                                appropriate acoustic and visual
                                                     stimulation.
• orientation and wayfinding:
                                                (ii)	high-noise spaces should be located
  (i)	interior layouts should be legible
                                                      away from quiet spaces.
       with continuous pathways that
       don’t end in dead-ends.                  (iii)	wall-art should not contain real-life
                                                       objects.
  (ii)	landmarks should be provided at
        major decision points.                  (iv)	floor finishes should be non-
                                                      reflective without sharp colour or
  (iii)	memory boxes should be provided
                                                      material differences.
         outside residents’ rooms and
         activity spaces.                       (v)	lighting should be regulated to
                                                     avoid hard shadows.

Dementia-Friendly Care Homes                                                               5
Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
Introduction

According to the Alzheimer Society of       Advocate revealed that 64% of residents
Canada (2019), there are currently over     at B.C.’s care homes live with dementia
564,000 Canadians living with dementia,     (Seniors Advocate of British Columbia,
which is approximately 7.1% of all          2018). It is important therefore to consider
Canadian older adults (Public Health        the QOL issues of residents living with
Agency of Canada, 2017), and this           dementia in care homes. New care models
number is expected to rise to 937,000       (e.g., Dementia Village, the Butterfly Care
in the next fifteen years. Providing        Model, and the Eden Alternative) serve
services for older adults living with       as prime examples of culture change
dementia has been earmarked as one          in LTC through physical environmental
of the B.C. Government’s strategic          interventions, renewed staffing
priorities in healthcare. Dementia has      models, and PCC practices in order to
become an important area of focus in        improve resident and staff outcomes
LTC (British Columbia Ministry of Health,   (BC Care Providers Association, 2017;
2017). A 2018 report by the B.C. Seniors    SafeCare BC, 2015).

6                                                     Dementia-Friendly Care Homes
Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
Research suggests that the physical           (i) environmental design and physical
environment of LTC can facilitate the         infrastructure and (ii) education, training,
achievement of a number of therapeutic        staffing, and care practices. A review
goals (i.e., the desired relationship         and synthesis of grey literature were
between the environment and residents         conducted on these two topics to cover
living with dementia in LTC) which            relevant policies and programs from
include (i) maximizing safety and security;   various jurisdictions in Canada, including
(ii) maximizing awareness and orientation;    British Columbia, where the findings of
(iii) supporting functional abilities; (iv)   this review are expected to be applied
facilitating social contact; (v) providing    in, along with Alberta and Ontario,
privacy; (vi) providing opportunities for     where several care organizations have
personal control; and (vii) regulating        adopted PCC in the past decade. Grey
sensory stimulation (Chaudhury, Cooke,        literature sources from USA, UK, and
Cowie, & Razaghi, 2017). Besides the          Australia are also reviewed as they have
design of the physical environment,           several national and regional policies and
training, education, staffing, and care       programs based on PCC.
practices can also positively influence the
quality of care (QOC) and residents’ QOL.
There are several provincial education
and training programs that are offered to
care-providers who work with residents
living with dementia to better prepare
them to deliver PCC for LTC residents,
to improve the QOC and increase staff
outcomes and safety (BC Care Providers
Association, 2016; Canadian Institute for
Health Information, 2018).
The “Dementia-Friendly Care Home”
research project is a part of a British
Columbia Care Providers Association
(BCCPA) Strategic Plan Project and
has been conducted in collaboration
with the Department of Gerontology
at Simon Fraser University and the            This project will provide rationale for the
Alzheimer Society of B.C. The aim of          project partners to work with the Ministry
this research is to identify the best         of Health, BCCPA members and health
national and international practices          authorities to entrench dementia-friendly
implemented in care homes for people          principles into B.C.’s care homes. As part
living with dementia in two key areas:        of this endeavour, a ‘dementia-friendly

Dementia-Friendly Care Homes                                                            7
Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
care home’ designation would be                with the national objective to improve
provided to care homes that have               the QOL of people living with dementia
followed guidelines including, but not         and caregivers (Public Health Agency of
limited to, those referenced in this report,   Canada, 2019). This involves (i) providing
both in terms of environmental design          holistic and culturally-appropriate care
and training, education, staffing, and care    to individuals living with dementia;
practices. Besides assembling a set of best    (ii) building the capacity of care providers
practices, criteria, and design principles,    to provide high-quality care by evaluating
this report also explores the challenges       dementia care guidelines, best practices,
and benefits of establishing a dementia-       and evidence; and (iii) enabling care
friendly care home designation program         providers to access requisite resources and
in B.C. The findings from this project         training for delivering high-quality care
are also expected to support BCCPA’s           (Public Health Agency of Canada, 2019).
advocacy efforts through the Canadian          The findings from this report will address
Association of Long-Term Care (CALTC) to       these goals and objectives by proposing
inform the priorities outlined in Canada’s     recommendations and solutions to have
first National Strategy on Dementia. The       real-world impact and improve the QOL of
objectives of this research align closely      residents living with dementia in LTC.

8                                                           Dementia-Friendly Care Homes
Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
Methods

To identify grey literature sources             “British Columbia.” Selected professionals
pertinent to the two key domains of this        and administrators at the Regional Health
synthesis (i.e., (i) staffing, education, and   Authorities in Ontario, Alberta, and
training, and (ii) physical environment         British Columbia were also contacted to
of LTC homes), an initial search was            gain access to internal documents that
conducted on platforms including                were not available publicly. This process
Google Search and the Canadian                  identified one-hundred-and-fifty-six
Electronic Library using combinations           (156) items. An initial scan of all the
of keywords that include: “dementia,”           documents was conducted to select items
“staffing,” “environment,” “care home,”         with sufficient emphasis on dementia-
“design,” and “best practices.” Location-       specific programs or policies relating to
specific searches were also conducted           staffing, education, and training, and/or
using the aforementioned keywords,              physical environment for resident care.
followed by “USA,” “UK,” “Australia,”           Through this process, one-hundred-and-
“Canada,” “Ontario,” “Alberta,” and             thirteen (113) items were eliminated and

Dementia-Friendly Care Homes                                                            9
Dementia-Friendly Care Homes - Best practices in dementia care March 2020 - BC Care Providers ...
forty-three (43) grey literature sources
were included for the final review. The
final list of items includes national and
provincial government policy documents,
as well as organization-level reports on
best practice guidelines. Twenty-eight (28)
of these items focussed on staffing,
education, and training, while fifteen (15)
emphasised the physical environment
for dementia care. Fifteen (15) out of
the forty-three (43) items were national,
provincial, and organization-level reports
from Canada. The table below indicates
the frequency of items by type under both
domains. The sources reviewed here were
not assessed for quality as this was not a
systematic review.

                                              Staffing, Education,      Physical
                   Type
                                                   & Training         Environment
Provincial - Canada                                     2                   -
Government - US, UK, Australia, etc.                    2                   -
Regional Health Authority - Canada                      5
Health Authority - UK, Australia, etc.                  -                    2
Organizations - Research synthesis                      2                    -
Organizations - Evaluation                              4                    3
Organizations - Guidelines                             10                    9
Organizations - Summary                                 1                    -
Articles in news media                                  2                    1
Total                                                  28                   15

10                                                         Dementia-Friendly Care Homes
Findings on Staffing, Education
and Training

1.1. Education & Training                  out their daily routines (Alzheimer’s
                                           Association, 2006). PCC training equips
Knowing how to engage with people          LTC staff with the requisite skills to
living with dementia is essential to       explore the meaning of certain behaviour
provide individualized, PCC. Looking       from the person’s standpoint, thereby
beneath the surface of responsive          facilitating better prevention, early
behaviours and cultivating a nuanced       intervention, and effective management
understanding of the range of factors      of responsive behaviours (Alberta
that might be contributing to this         Health Services, 2014). By promoting a
requires LTC staff to be adequately        personalized care approach, PCC training
trained in person-centred dementia care,   could improve the overall QOC for
with special emphasis on issues such as    residents living with dementia in LTC.
social engagement, pain management,
                                           There are some examples of training
therapeutic fibbing, and involving
                                           programs focused on PCC that have been
residents in planning and carrying
                                           adopted by multiple provinces in Canada,

Dementia-Friendly Care Homes                                                    11
including Ontario, British Columbia                    The DementiAbility program being
and Alberta. These include:                            adopted in Ontario, for example,
  (i)	
      Gentle Persuasive Approach                       trains staff to engage residents
      (GPA), which enables care staff to               living with dementia in activities
      successfully apply communication                 that maximize their abilities and
      strategies to diffuse responsive                 interests (Ontario Long Term Care
      behaviours and ensure positive                   Association, 2018).
      outcomes for people living with             (iv) T
                                                        raining for Dementia Care
      dementia and family members                      Mapping, which is a tool that
      (Chappell, Bornstein,                            applies the PCC approach to assess
      & Kean, 2014).                                   the QOC in LTC, is provided in
  (ii)	
       P.I.E.C.E.S. (Physical, Intellectual            different countries by trainers and
       and Emotional health, maximizing                organizations affiliated with the
       the Capabilities of the individual,             University of Bradford (University
       Environment and Social needs),                  of Bradford, 2019).
       which offers a systematic,               The following sections describe: (i) needs
       individualized framework for             and challenges; (ii) outcomes; and
       detection, assessment, care              (iii) recommendations for the training and
       planning, and identifying                education of LTC staff in dementia care.
       appropriate care strategies for
       older adults living with dementia        1.1.1. Needs and challenges
       (Alberta Health Services, 2014;          associated with staff education
       British Columbia Ministry of             and training
       Health, 2016).
                                                a) Understanding Person-centred Care
  (iii)	Other examples of PCC training
                                                The first and foremost step in providing
         programs include Supportive
                                                PCC is facilitating adequate training
         Pathways in Alberta, which
                                                to enable LTC staff to develop a
         is focussed on issues such as
                                                comprehensive understanding of the
         collaborating with families,
                                                meaning of PCC. An objective of PCC
         creating normal living
                                                training is to encourage care staff to
         environments, providing
                                                reflect upon their motivations to work
         meaningful activities, supporting
                                                with residents living with dementia
         responsive behaviours, sexuality
                                                (Bamford et al., 2009). Providing PCC
         and intimacy as a part of a
                                                training to all LTC staff members,
         normalized life experience, and
                                                including those who are not in direct
         ensuring safety and security for the
                                                caregiving roles (e.g., housekeepers,
         person, other residents and staff
                                                cooks, drivers), would ensure that there
         (Alberta Health Services, 2014).
                                                is consistent understanding of the

12                                                           Dementia-Friendly Care Homes
meaning of PCC across the LTC workforce,      what staff members perceive as challenges
enabling any staff member to extend           is imperative to deliver training and
support to residents whenever needed          education that is relevant to everyday
(Alzheimer Society of Canada, 2011;           care practice (Alzheimer’s Society, 2007).
Armstrong et al., 2019; Bamford et al.,       An example of this is training LTC staff
2009; Vancouver Coastal Health, 2017).        to involve family members in the care
Without this training, it is evident that     routines of their loved ones (Alzheimer’s
there will be varied and contradictory        Society, 2007). Such awareness training
understandings of PCC among care staff.       will enable staff to understand family
Inconsistent understandings deter care        members’ perspectives and better assess
staff from realizing the full potential for   residents’ care needs (Carers Trust, 2016).
implementing person-centred values in         The planning and delivery of this training
dementia care (Bamford et al., 2009).         program need to be done in consultation
Framing the delivery of PCC as mandatory      with family members (Carers Trust, 2016).
through stringent regulations that do not
account for the delivery of appropriate
and adequate training forces care homes
to adopt PCC as a label, without care staff
having clear and uniform understanding
of what it means (Bamford et al., 2009).
Therefore, it is necessary to institute
PCC training at the provincial level
with adequate dedicated funding from
the government (Chappell et al., 2014;
Dementia Initiative, 2013; Ministry of
Health and Long-Term Care, 2016).
b) Contextualization of training
It has been found that the best practices
learned through training and education
differ significantly from care practices
actually followed in LTC (Alzheimer
Society of Canada, 2011). There is a need
to bridge this gap and ensure that the        Contextualizing PCC training includes
content of training programs critically       responding to the need for cultural
examines and corresponds to existing          competency among LTC staff (Bamford
care practices, so that the training is       et al., 2009; British Columbia Ministry
responsive to the specific issues faced       of Health, 2016), including the needs of
by LTC staff (Alzheimer’s Society, 2007;      residents who are part of the LGBTQ2S+
Bamford et al., 2009). Understanding          community (Alzheimer’s Society, 2007).

Dementia-Friendly Care Homes                                                            13
c) Applying training to practice              outcomes to be duly evaluated so as to
The success of staff training and education   improve the impact of training on care
and positive outcomes are facilitated by a    practice. At present, there is a lack of
concurrent change in organizational ethos     routine monitoring to assess the impact
and care practices. A shared ethos that       of dementia care training on the QOC
supports and reflects the PCC approach is     for residents living with dementia (Care
necessary for the successful translation of   Quality Commission, 2014). Ramping up
PCC training into practice (Bamford et al.,   post-training evaluation can inform the
2009). However, there are several factors     provision of tailored and individualized
that may challenge this process. For          care routine and thus improve resident
instance, it is generally agreed upon that    outcomes. Supportive and effective
dedicating sufficient time is integral to     leadership is also necessary to facilitate
successfully apply lessons learned through    the successful implementation of
training into everyday practice in LTC.       training and its translation into practice
However, giving the staff the necessary       (Alzheimer’s Society, 2007).
time to put what they have learned into
                                              1.1.2. Outcomes of implementing
practice is at odds with the notion of
                                              staff education & training
maximizing the time spent on caring
for residents, which results in training      a) Improved quality of care and resident
being delivered in shorter periods of time    outcomes
(Chappell et al., 2014).
                                              P.I.E.C.E.S. training helps direct care
In a recent evaluation of dementia care       workers understand the value in taking
training, care staff reported that an         the time to know residents better and
overload of information was covered in        provides a systematic approach to identify
a shorter time frame (e.g., two days),        risks, causes, and strategies related to
instead of a more ideal, extended time        residents’ responsive behaviour (McAiney,
frame (e.g., five days). Training offered     2005; Vancouver Coastal Health, 2017).
as part of the induction program at           Effective training ensures care staff
care homes has been found to be               members know how to communicate
incomprehensive and not supplemented          with residents, which involves reading
with follow-up, in-depth training (Care       non-verbal signs and cues that may
Quality Commission, 2014). One-off            indicate residents’ lack of understanding,
training sessions usually result in staff     embarrassment, discomfort, or pain,
returning to their usual practices soon       can help considerably improve resident
after they have received training,            outcomes, e.g., pain management
which increases the need for multiple         (Alzheimer Society of Canada, 2011;
follow-up sessions (Alzheimer’s Society,      Carers Trust, 2016; Department of Health,
2007). There is also a need for training      Social Services and Public Safety, 2015).

14                                                          Dementia-Friendly Care Homes
Training facilitates care staff’s               intellectual capacity, emotional and
understanding of residents’ responsive          spiritual health, functional capabilities,
behaviour, which in turn eliminates             and environmental, social, and cultural
the administration of antipsychotic             factors (McAiney, 2005).
medication to manage agitation and              GPA and P.I.E.C.E.S. training foster group
aggression (Chappell et al., 2014;              participation, open communication, and
Cognitive Decline Partnership Centre,           team building (Alberta Health Services,
2016). Evaluation of GPA and P.I.E.C.E.S.       2014). P.I.E.C.E.S. training has been shown
training administered in six care homes         to promote team-work across different
in Vancouver (Dementia CARE Initiative)         disciplines and hierarchies within and
revealed positive behavioural outcomes          beyond the care home setting (McAiney,
for residents, decrease in the use of           2005). Dementia care training has been
antipsychotic medications and physical          suggested as offering the opportunity
restraints and increase in management of        for LTC staff members from different
responsive behaviour (Vancouver Coastal         care homes to learn from each other’s
Health, 2017).                                  experiences and share lessons learned
Evaluation of P.I.E.C.E.S. training has also    (Bamford et al., 2009).
found an associated improvement of
residents’ QOL and dignity (Vancouver
Coastal Health, 2017). PCC training also
helps care staff build trust and develop
meaningful relationships with residents
(Alzheimer’s Association, 2006). P.I.E.C.E.S.
training has also been found to enable
direct care workers in recognizing the
autonomy and choice of residents living
with dementia (Vancouver Coastal
Health, 2017).
b) Improved staff outcomes
                                                1.1.3. Recommendations for staff
Dementia care training also improves staff      education and training
outcomes (e.g., satisfaction, calm, feeling
empowered) (Vancouver Coastal Health,           a) Evidence-based training and education
2017), which has been linked to reduced         Interdisciplinary dementia education and
staff turnover (Alzheimer’s Society, 2007).     resources for health-care professionals
Evaluation of P.I.E.C.E.S. training in care     (e.g., PCC training) should be evidence-based
homes in Ontario showed that training           and supported by expert knowledge or data
increased staff members’ confidence in          on resident outcomes (British Columbia
their ability to assess physical health,        Ministry of Health, 2016).

Dementia-Friendly Care Homes                                                                15
b) Tailoring training to job roles            Training staff members in multiple skills,
Dementia care training may be more            e.g., to be care aides as well as activity
effective when it is customized to the job    aides (Canada Mortgage and Housing
role of the care staff (Care Inspectorate,    Corporation, 2015) may help reduce the
2017). Covering general content on PCC        number of staff workers in the care home
with an approach targeted towards key         and help achieve consistency in giving
staff groups may increase the likelihood      care (Alberta Health Services, 2014).
of implementing PCC within the scope          c) Educating family members
of one’s job role (Bamford et al., 2009).     Providing PCC education for family
This includes (i) offering accessible         members shortly after LTC staff have
education to direct care workers and          received training has been recommended
(ii) enhanced dementia curriculum for         for family members to better understand
health-care providers, managers, and          changes in care philosophy in the care
emerging professionals preparing to start     home (Vancouver Coastal Health, 2017).
practice (Ministry of Health and Long-        PCC education for family members should
Term Care, 2016). Additionally, providing     also involve supporting them in dealing
dementia education in institutions of         with feelings of grief and loss, navigating
higher learning is expected to increase       services, and accessing information on
dementia care competency among future         caregiving (Alberta Health Services, 2014).
health-care professionals (British Columbia
Ministry of Health, 2016).

16                                                         Dementia-Friendly Care Homes
d) Translating training into practice          practices” (Dementia Initiative, 2013,
Providing staff training as an ongoing         p. 30; Ministry of Health and Long-Term
process through periodical refresher/          Care, 2016).
follow-up sessions is recommended
for successful application of training in
                                               1.2. Staffing & Care Practices
practice (Alzheimer Society of Canada,
                                               1.2.1. Needs and challenges
2011; Alzheimer’s Society, 2007;
                                               associated with staffing and care
Armstrong et al., 2019; Chappell et al.,
                                               practices
2014; McAiney, 2005). Identifying a
care worker as the site GPA and/or             a) Culture change
P.I.E.C.E.S. facilitator to provide training   Culture change initiatives that prioritize
support on a day-to-day, as-needed basis       outcome-focussed rather than task-
could potentially ensure that training         focussed care, as well as foster a ‘can
is ongoing and a part of the daily care        do’ approach, involved leadership, open
routine (Vancouver Coastal Health, 2017).      communication between staff members,
Other practice innovations that are            and empowerment of direct care staff
recommended include training-in-practice,      are essential to deliver high-quality PCC
supervised practical work, and group           with improved resident outcomes
debriefing, thereby integrating training       (Age UK Gloucestershire, 2015; Alberta
into the therapeutic milieu and bridging       Health Services, 2014; Armstrong et
the gap between training and practice          al., 2019; Beynon & Wood, 2017; Care
(Bamford et al., 2009).                        Inspectorate, 2017). Facilitating culture
Regular monitoring and performance             change also involves reconsidering
evaluations are recommended as                 traditional approaches to care and
a way of tracking the care staff’s             challenging conventional notions
application of PCC training (Alzheimer’s       of caregiving (e.g., reconsidering
Society, 2007; Chappell et al., 2014).         organizational perceptions and attitudes
Evaluation results should then be used         related to risk and augmenting resident
to make improvements to the QOC.               autonomy to boost participation in
It is recommended that care homes’             household activities, feel free to engage
leadership groups offer their support          in the outdoors, and have enhanced QOL)
and commitment to improving QOC by             (Armstrong et al., 2019).
integrating training and evaluation            Examples of culture change models in
into care practice (Care Quality               LTC include: (i) the Butterfly Household
Commission, 2014). People in leadership        Model of Care, which originated in the
positions at care homes should foster          UK and is now informing organizational
a training and learning environment            culture change in care homes across
that offers opportunities for “informal        Alberta and Ontario (CTV News, 2018);
coaching and modelling of effective            (ii) Eden Alternative, which is a PCC model

Dementia-Friendly Care Homes                                                            17
of culture change in LTC that originated     the shortage of care workers are major
in the US and is being adopted in Canada,    barriers as they tend to disrupt the
involves empowering care staff, residents,   continuity of care and relationships
and families to build care partnerships      built by staff with residents (Age UK
that afford residents and their families     Gloucestershire, 2015; Alzheimer’s
dignity, choice, and independence, while     Society, 2007). Efforts should be taken by
increasing job satisfaction among staff      the leadership in care homes to ensure
members (Eden Alternative, 2012); and        that staff members feel supported,
(iii) the Green House project, which         encouraged, and fulfilled to stay in their
is another PCC-based culture change          jobs while having sufficient opportunity
model in LTC in the US; and achieves         for professional growth and skill
personalized PCC through features such       development (Alzheimer’s Society, 2007).
as a small-scale, homelike environment,
advanced staff training, and high staff-
to-client ratio (The Green House Project,
2019). However, the lack of resources and
organizational support have been cited
as barriers to the implementation of best
practices in dementia care and culture
change within care homes (Bamford
et al., 2009; Care Quality Commission,
2014). Furthermore, there is a paucity
of evidence on (i) the impacts of these
culture change initiatives on resident’s
QOL and health-related outcomes and
(ii) which specific interventions have
the biggest impact on resident and staff
outcomes, thus challenging the ability
to draw clear conclusions from different     Consistent assignment of direct care staff
culture change approaches (Armstrong         to residents is also integral to the success
et al., 2019).                               of PCC and continuity of care. Maintaining
b) Staffing level and consistency            continuity with residents allows LTC staff
Adopting the PCC paradigm is contingent      to understand residents’ preferences and
on having adequate staff. Inadequate         needs and build trust and relationships
staffing levels tend to limit the scope      (Bamford et al., 2009). This is linked to
of care delivery to risk management,         the need to have a good understanding
thus posing a barrier to the delivery of     of individual needs, capacities, and
PCC (Alzheimer’s Society, 2007; Bamford      emotions, as part of the PCC approach
et al., 2009). High staff turnover and       (Armstrong et al., 2019). It is imperative

18                                                        Dementia-Friendly Care Homes
for staff working on different shifts to       autonomy (Alberta Health Services, 2014;
engage in clear and open communication         Dr. Robert Bree Collaborative, 2017; Eden
at the time of hand-over for an enhanced       Alternative, 2012, p. 6).
understanding of residents’ responses,
which can be particularly important for        1.2.3. Recommendations for
staff members who are not familiar with        staffing and care practices
a resident (Alberta Health Services, 2014).
                                               a) Increased resources and staffing levels
Frequent changes in staff’s assignment to
                                               Previous research indicates the need to
residents can result in confusion, which
                                               raise current staffing levels in order to
is detrimental to the staff’s ability to
                                               maintain QOC and further raise levels
deliver high-quality care (Care Quality
                                               to improve the QOC (Armstrong et al.,
Commission, 2014). Maintaining the
                                               2019). Staff stability and continuity are
stability of staff-resident relationships,
                                               recommended for the viability of PCC,
which is key to delivering PCC, is also
                                               thereby necessitating the elimination
challenged by frequent absenteeism,
                                               of factors that contribute to high staff
turnover, and recruitment of untrained
                                               turnover and redressal of operational
care staff (Chappell et al., 2014).
                                               and management issues (Alberta Health
c) Staff and resident autonomy
                                               Services, 2014; Armstrong et al., 2019).
Providing individualized care is also          It is recommended that direct care staff
determined by the direct care staff’s          be provided with adequate time for
capacity to make decisions and whether         caregiving and commensurate equitable
they feel empowered in doing so. The           wages in order to maximize the impact
involvement of direct care staff in care       of PCC on the QOL of residents living
planning and decision-making helps             with dementia (Alzheimer’s Society, 2007;
improve resident outcomes (Alzheimer’s         Armstrong et al., 2019; Beynon & Wood,
Society, 2007). Good leadership is             2017).
necessary to enable direct care staff
                                               LTC staff should have access to specialized
to feel empowered to make the best
                                               dementia care staff (e.g., dementia
decisions for residents (College of Licensed
                                               champions, dementia care specialist,
Practical Nurses of Alberta, 2015). A
                                               mental health behavioural support
strictly top-down hierarchical structure is
                                               consultant, and case managers) who can
detrimental to the decision-making capacity
                                               provide expertise and skills training as
 of LTC staff (Eden Alternative, 2012).
                                               needed on a day-to-day basis (Alberta
It is also important to empower residents      Health Services, 2014; Care Quality
and family members to actively be              Commission, 2014; Healthwatch Norfolk,
involved in making decisions related           2018; Vancouver Coastal Health, 2017).
to the care routine of persons living          This staff member will be tasked with
with dementia, thereby respecting their        coordinating ongoing in-practice training,

Dementia-Friendly Care Homes                                                           19
prioritizing topics for training (or            to help reduce behavioural symptoms
refreshers) in the future, and recommend        and improve QOL of residents living
social and environmental strategies to          with dementia in care homes (Ontario
manage responsive behaviours (Alberta           Long Term Care Association, 2018).
Health Services, 2014; Healthwatch              BSO teams support frontline staff
Norfolk, 2018; Vancouver Coastal                at their designated care homes by
Health, 2017). In addition to providing         offering dementia education, training,
on-site support, telehealth support is          and problem-solving to manage
recommended for care homes in rural or          challenging behaviours (Ontario Long
remote locations (Alberta Health Services,      Term Care Association, 2018). This
2014; Vancouver Coastal Health, 2017).          training is known to help LTC staff
Examples include:                               feel “significantly more supported
• The Regional Knowledge Coordinator            and capable of developing solutions”
  for Complex Behaviours (RKC-CB)               (Ontario Long Term Care Association,
  at Interior Health, British Columbia,         2018, p. 7).
  collaborates with care staff at different   • Challenging Behaviour Resource
  care homes on a referral basis to             Consultants, as part of the Challenging
  educate them on PCC and help them             Behaviour Program in the province of
  develop behavioural care plans for            Nova Scotia, provide consultation to
  residents with responsive behaviours.         LTC staff on “identifying biological,
  A recent evaluation (Ward & Bader,            psychological, and social indicators
  2018) of this program found that 88%          of responsive behaviours and find
  of residents who received care based          solutions” for individual residents
  on the input of the RKC-CB had lower          (Nova Scotia Department of Health and
  incidence of responsive behaviours.           Wellness, 2013, p. 11).
  The majority of care managers (84%)         Staffing levels should be increased with
  reported their satisfaction with the        a higher staff-to-resident ratio so as to
  services of the RKC-CB (Ward & Bader,       achieve the best outcomes of PCC (Alberta
  2018). The introduction of the RKC-CB       Health Services, 2014; Alzheimer’s Society,
  (i) encouraged care staff to adopt a        2007). Adopting innovative staffing
  proactive approach and seek help            models to improve staff autonomy is
  earlierrather than delaying the process;    linked to the successful adoption of
  (ii) made staff realize the need and        PCC and enhanced resident outcomes.
  value of care planning; and (iii) avoided   The Green House project (The Green
  visits to the emergency departments or      House Project, 2019) is an example of
  hospital admissions of residents.           how decentralizing and reducing staff
• Behavioural Supports Ontario (BSO),         hierarchy without increasing overall
  a provincial program in Ontario that        staffing can facilitate the formation of
  hires and trains specialized staff teams    separate self-managed teams of direct

20                                                         Dementia-Friendly Care Homes
care workers. Care aides and nursing staff     (Bamford et al., 2009). With adequate
members can consult with each other on         monitoring, leadership must ensure that
an as-needed basis, thereby significantly      the staff are aware and equipped with the
improving the autonomy of care aides.          skills required to facilitate occupation and
Relationship-building between LTC              stimulation among residents (Alzheimer’s
staff and the resident can be promoted         Society, 2007).
by hiring multi-skilled workers who            e) Staff collaboration
can combine personal care with other
                                               Interdisciplinary care team meetings,
activities (e.g., meal planning, recreation,
                                               staff case conferences, and unit huddles
and housekeeping) in order to spend
                                               that involve leadership, as well as
more “unscheduled” time with residents
                                               front-line staff (e.g., direct care staff,
(Alberta Health Services, 2014).
                                               LPNs, RNs) are recommended to enable
b) Consistent staffing                         mutual learning, information-sharing,
It is recommended that care staff be           collaborative problem-solving, and
assigned to the same residents in order to     brainstorm solutions that are tailored to
maintain consistent care practices that are    residents’ needs (Alberta Health Services,
tailored to suit the needs and preferences     2014; Bamford et al., 2009; Chappell et al.,
of individual residents (Chappell et al.,      2014; Vancouver Coastal Health, 2017).
2014). No more than eight personal care        This recommendation stems from the
assistants should be assigned to a given       need to promote flexibility, teamwork,
resident within a one-month period             and greater autonomy for front-line staff
(Chappell et al., 2014). Identifying certain   in decisions on caregiving (Armstrong
staff members as the primary caregivers        et al., 2019). Interdisciplinary meetings
for a household/unit can further improve       are best supported by optimal staffing
staffing consistency (Alberta Health           levels, good mix of skills among team
Services, 2014).                               members, and the practice of inclusive
c) Streamlined caregiving                      communication (Alberta Health Services,
                                               2014; Ministry of Health and Long-
When appropriate, the use of slow-
                                               Term Care, 2016). Collaboration and
release medications is recommended
                                               information-sharing between care homes
to reduce the frequency of medication
                                               have also been recommended in order
administration and increase opportunities
                                               to learn and exchange effective practices
for LTC staff to spend uninterrupted time
                                               and approaches from similar and different
with residents (Alberta Health Services,
                                               care settings (Armstrong et al., 2019).
2014).
d) Monitoring staff performance
Both informal and formal supervision can
contribute to a conducive management
style for the sustenance of PCC practices

Dementia-Friendly Care Homes                                                               21
Photo courtesy of The Village in Langley

Findings on Physical Environment

This section consists of design                 accessibility; (iv) Physical accessibility,
recommendations for the physical                safety, and comfort; (v) Appropriate
environment of care homes. These                sensory stimulation and minimizing
recommendations are arranged according          perceptual distortion; and (vi) Familiarity
to the various spatial levels of the            and homelikeness.
LTC environment and correspond to
different therapeutic goals (Cohen &            2.1. Domestic scale
Weisman, 1991). These goals highlight the
                                                Care homes should have a small scale
relationship between the residents with
                                                (number of spaces) in order to convey
dementia and the LTC environment and
                                                a familiar/domestic character, which in
serve as guiding principles for the design
                                                turn facilitates participation for residents,
of a therapeutic physical environment.
                                                whereas larger scales are associated with
The therapeutic goals discussed here
                                                high levels of agitation and confusion
include: (i) Domestic scale; (ii) Orientation
                                                (Fleming & Bennett, 2017; Government of
and wayfinding; (iii) Privacy and visual
                                                Alberta, 2014). Clusters of resident units

22                                                        Dementia-Friendly Care Homes
or households should be small in size        floor plans should be avoided as they are
to maximum residents’ sense of control       likely to confuse and mislead residents
(Alzheimer’s Australia, 2004; Ministry of    (Chmielewski, 2014). Circular, clutter-
Health, 2016). While households with         free hallways are more conducive for
eight to 12 residents are expected to        wayfinding than long, narrow corridors
preserve a domestic feel, household          (Centre for Excellence in Universal Design,
size should not exceed 15 residents          2015; Chappell et al., 2014).
(Alzheimer’s Australia, 2004; Fleming &      Additionally, corridor lengths should be
Bennett, 2017; Housing21, n.d.).             minimal so that residents do not have to
Households grouped and planned to            travel long distances to access common
resemble a village setting help create a     spaces in the care home (Fraser Health,
familiar community-like environment with     2018). These paths must (i) be without
self-contained and/or shared common          dead ends; (ii) end in destinations,
living spaces (Chmielewski, 2014).           (iii) away from residents’ rooms; and
Examples of this include: (i) Dementia       (iv) pass alongside activity/social spaces,
Village in Weesp, Netherlands, which         thus enabling residents to preview and/
consists of 23 small-scale group houses      or join the activity (Canada Mortgage and
designed to resemble houses in the           Housing Corporation, 2015; Chmielewski,
community, with streets, squares, gardens,   2014; Fraser Health, 2018; Housing21, n.d.;
parks, salons, music hall, supermarket,      Ideas Institute, 2010).
and restaurant; and (ii) Central Haven       Circular or looped paths should be
Special Care Home, a care home with          supplemented with stop-off points to
about 60 residents, in Saskatoon,            sit and rest, opportunities for social
Canada, which resembles a small town         interaction, and stimulating features
with a chapel, café, childcare centre, art   that promote activity and engagement
studio, educational spaces, green house,     (Fleming & Bennett, 2017; Housing21, n.d.;
community garden, auditorium, gift shop,     Ideas Institute, 2010). These paths should
and community event spaces (Canada           also offer uninterrupted visual access to
Mortgage and Housing Corporation, 2015).     important areas and entrances in the care
                                             home to promote wayfinding between
2.2. Orientation and                         spaces (Centre for Excellence in Universal
wayfinding                                   Design, 2015; Chmielewski, 2014).
The floor plan should be based on a          Cues that support orientation and
simple layout that is intuitive, can be      wayfinding include: (i) familiar and
easily remembered by the residents, and      meaningful landmarks at decision
involves a minimal number of wayfinding      points (e.g., change in direction or level)
choices (Alzheimer’s Australia, 2004;        (e.g., artwork that triggers memories,
Chmielewski, 2014; Fraser Health, 2018;      tapestries, sculptures; seating); and
Housing21, n.d.). Identical or mirrored

Dementia-Friendly Care Homes                                                              23
(ii) changes in the colour/texture of            Fleming & Bennett, 2017; Fraser Health,
surfaces (Alberta Health Services, 2014;         2018; Government of Alberta, 2014; Study,
Chmielewski, 2014; Department of Health,         n.d.). In addition to providing memory
2015; Fraser Health, 2018; Housing21,            boxes outside private spaces, function-
n.d.; Nova Scotia Department of Health,          specific memory stations (e.g., gardening
2007; Study, n.d.). Consistent colouring         or sports memorabilia and antique
of doors, signs, walls across spaces with        elements) at the entrance to common
similar functions in all units of the care       areas or group activity spaces could evoke
home will help create the distinction            familiarity and prompt recognition
between different spaces and promote             (Study, n.d.).
identification (Housing21, n.d.; Study, n.d.).
The position of cues can be manipulated
to guide residents, such as placing off-
centre photos at the end of a hallway
that are partially revealed may prompt
a resident to turn in order to see the full
photo (Study, n.d.). Different types of cues
that highlight the meaning or function
of a space should be provided to help
residents with different cognitive abilities
recognize an area. For example, to help
residents recognize their bedroom,
cues should be incorporated through              Signs should be placed at an appropriate
furniture, wall colour, signs, etc. (Centre      height from the floor and closer to the
for Excellence in Universal Design, 2015;        floor to support residents whose line of
Department of Health, 2015; Fleming &            vision is at a low-level (Department of
Bennett, 2017, p. 21; Housing21, n.d.).          Health, 2015; Fleming & Bennett, 2017;
The number of cues should be minimized           Hodges, Bridge, & Chaudhary, 2007).
so as to avoid visual clutter (Fleming &         Signage should use a combination of
Bennett, 2017).                                  words and images of an appropriate size
Memory boxes at the bedroom door                 that are linked to the function/activity
containing meaningful objects                    in the space (Alzheimer’s Australia,
(e.g., personal souvenirs, photos of loved       2004; Chmielewski, 2014; Department of
ones, cherished mementos) could serve            Health, 2015; Fraser Health, 2018, 2018;
as wayfinding cues and help residents            Nova Scotia Department of Health, 2007).
identify their respective rooms (Canada          Signs should not have non-reflective
Mortgage and Housing Corporation,                surfaces with high contrast against the
2015; Centre for Excellence in Universal         background at different lighting levels
Design, 2015; Chmielewski, 2014;                 (Centre for Excellence in Universal Design,

24                                                            Dementia-Friendly Care Homes
2015; Department of Health, 2015). The        Fraser Health, 2018; McAdam & Williams,
amount of information in the sign should      2017). Similar to indoor hallways, outdoor
be minimal to avoid cognitive overload        paths should also be continuous loops
(Department of Health, 2015).                 lined with destination points and no
Lighting can be employed to provide           dead ends, so as to avoid confusion and
directional cues to attract residents         frustration (Chmielewski, 2014; Housing
towards common spaces and activity            Learning & Improvement Network, 2013;
spaces (Canada Mortgage and Housing           McAdam & Williams, 2017). Multiple
Corporation, 2015; Greasley-Adams,            intersecting paths with varying lengths, as
Bowes, Dawson, & McCabe, n.d.). Motion        opposed to a single common path, should
or sound-activated lights or pressure         be incorporated into the outdoor space
mats equipped with light sensors that         to promote variety and choice for people
automatically turn on lights have been        with different cognitive capacities and
recommended to lead the way for               mobility challenges (Chmielewski, 2014;
residents living with dementia wanting        McAdam & Williams, 2017).
to go to the bathroom at night (Centre
for Excellence in Universal Design, 2015;
                                              2.3. Privacy and visual
Greasley-Adams et al., n.d.).
                                              accessibility
Outdoor spaces and gardens should             The LTC environment should offer
also be designed with orientation and         residents varying degrees of privacy
wayfinding cues to afford residents a         to support different functions, ranging
higher sense of control and confidence        from public (e.g., living room, dining
(Alzheimer’s Australia, 2010; Canada          room, kitchen) to private (e.g., bedroom)
Mortgage and Housing Corporation,             (Chmielewski, 2014; Fleming & Bennett,
2015; Housing Learning & Improvement          2017; Housing21, n.d.).
Network, 2013, 2013; McAdam & Williams,       To provide adequate privacy, bedrooms
2017). Providing a single point of entry      should be single-occupancy with private
to the outdoor area that is recognizable      en-suite bathrooms and equipped to
serves as a landmark for residents to use     accommodate a spouse or a visiting family
in finding their way back inside (Fleming     member, if need be (Alzheimer’s Australia,
& Bennett, 2017; Ministry of Health, 2016).   2004; Chmielewski, 2014; Department of
The paving of outdoor paths should            Health, 2015; Fleming & Bennett, 2017;
be even and have consistent colour            Ministry of Health, 2016). Providing
without patterns and dark lines and a         private kitchen and dining space
raised edge rendered in a contrasting         (in addition to a common kitchen and
colour to help residents differentiate        dining area) within residents’ rooms could
paving from green space and support           afford more flexibility for the timing and
wayfinding (Alzheimer’s Australia, 2010;      choice of meals (Canada Mortgage and
                                              Housing Corporation, 2015).

Dementia-Friendly Care Homes                                                          25
To promote acoustic privacy, rest, and         belongings (Housing21, n.d.). Having
relaxation, the bedrooms should be             storage in shared spaces with clear
sound-insulated, so as to prevent sound        visual access to safe objects can support
from travelling into neighbouring rooms        residents’ engagement in household
(Alzheimer’s Association, 2006; Canada         activities, such as open shelving or
Mortgage and Housing Corporation,              cabinets with glass doors in the kitchen
2015; Fraser Health, 2018). While reducing     that offer visual access to safe cooking
ceiling heights helps improve the acoustic     equipment and ingredients and facilitate
quality of spaces, noise transference          participation in meal preparation or
between spaces may be reduced by               serving (Alzheimer’s Australia, 2004;
using vinyl flooring, acoustic linoleum, or    Centre for Excellence in Universal
carpets for floor surfaces (Department of      Design, 2015; Greasley-Adams et al., n.d.;
Health, 2015).                                 Housing21, n.d.).
Common spaces (e.g., kitchen, dining, and      Private and common spaces should afford
activity areas) must be in close proximity     views of the outdoors so as to enable
and clearly visible from hallways to           residents to orient themselves to the time
increase opportunities for accessibility,      of day or season and encourage them to
social interaction, and participation          access the outdoors (Alzheimer’s Australia,
(Chmielewski, 2014; Department of              2010; Centre for Excellence in Universal
Health, 2015; Fleming & Bennett, 2017).        Design, 2015; Chmielewski, 2014; Fleming
Bathrooms should be proximate and              & Bennett, 2017; Housing Learning &
visually accessible from common spaces         Improvement Network, 2013; Housing21,
so that residents may be prompted to use       n.d.; Ministry of Health, 2016). During
it, when in need (Centre for Excellence        poor weather conditions, windows should
in Universal Design, 2015; Fraser Health,      be screened to hide views of outdoor
2018). Innovative design solutions should      paths from plain sight (Chmielewski,
be employed to modulate the accessibility      2014).
of certain areas, such as using double         Design features, such as windows or
doors to enhance visual access to kitchens,    wall openings that offer visual access
while limiting physical access due to          between spaces may be used to support
sanitary regulations (Chmielewski, 2014).      unobtrusive monitoring of residents
Providing sufficient unobtrusive storage       by staff members (Chmielewski, 2014).
space in rooms can help minimize clutter       Staff’s visual access may also be enhanced
by enabling residents to store their           by locating staff workstations near
belongings in an organized manner and          circulation paths, thus enabling them
effectively manage their personal space        to not only monitor residents but
(Alzheimer’s Australia, 2004). Personal        also engage in informal interaction
wardrobes should have glazed doors to          and participate in everyday activities
offer residents clear visual access to their   (Chmielewski, 2014; Fraser Health, 2018).

26                                                          Dementia-Friendly Care Homes
Other environmental/technological            spacious enough to accommodate care
strategies to facilitate unobtrusive         staff for bathing or toileting (Alzheimer’s
monitoring include installing door           Australia, 2004; Fraser Health, 2018). The
sensors, bed occupancy sensors, or           bathing space should be designed to
floor sensors, which can be useful to        provide a sense of calm and peace and
alert staff to an emergency or residents     eliminate anxiety (Fraser Health, 2018).
needing assistance (Canada Mortgage          Common toilets should be provided in
and Housing Corporation, 2015; Centre        close proximity to activity spaces and
for Excellence in Universal Design, 2015;    circulation paths with unobtrusive entry
Housing21, n.d.).                            and maximum privacy (Alzheimer’s
Environmental strategies to curtail          Australia, 2004). Bathroom fixtures should
residents’ exit-seeking behaviour include    be safe to use, conveniently located, and
concealing exit doors behind artwork         easily controlled by residents (Alzheimer’s
or colour-matching protection panels         Australia, 2004). Vanity mirrors should
that match the finish of the surrounding     have shutter doors that can be closed, as
walls and camouflaging door handles          need be, to avoid confusion or distress
(Alzheimer’s Australia, 2004; Centre for     when residents do not recognize or are
Excellence in Universal Design, 2015;        not comfortable with their reflection
Chmielewski, 2014; Department of Health,     (Centre for Excellence in Universal Design,
2015; Fleming & Bennett, 2017;               2015; Chmielewski, 2014; Government
Fraser Health, 2018; Hodges et al., 2007).   of Alberta, 2014). Using heated mirrors
Exit doors should open into administrative   is recommended to avoid blurring of
areas where concerned staff members can      reflection (Centre for Excellence in
guide residents who have exited the living   Universal Design, 2015).
environment back inside (Chmielewski,        Residents living with dementia facing
2014).                                       mobility challenges should be provided
                                             with corridor handrails rendered in bright
2.4. Physical accessibility,                 colours; preferably red or yellow hues
safety, and comfort                          and not blue or green hues for maximum
                                             perception (Centre for Excellence in
Bedrooms should have ceiling lifts and
                                             Universal Design, 2015; Department of
beds set low to the floor with headboards
                                             Health, 2015; Fraser Health, 2018).
facing the bathroom to provide residents
easy access to the bathroom, which can       It is recommended to avoid doors that
be helpful especially at night (Canada       are not self-closing as they may pose
Mortgage and Housing Corporation, 2015;      as a hazard when left fully or partially
Fraser Health, 2018). Bathrooms should       open (Centre for Excellence in Universal
also allow for the operation of ceiling      Design, 2015). Threshold strips and
lifts and be provided with unobtrusive       border details at the doorway should be
supports, such as grab bars, and be          avoided as they pose barriers to residents’

Dementia-Friendly Care Homes                                                         27
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