Contemporary Issues for Environmental Research in Long-Term Care Settings

Abstract

Research on long-term care environments has made great strides over the past decade. It gained prominence in the 1960s with the work on territorial behavior of Robert Sommer (Sommer & Dewar, 1963; Sommer & Ross, 1958) and Powell Lawton (Lawton, 1970a; Lawton, 1970b), who were among the first researchers to explore systematically how manipulating the physical environment affected both behavior and psychological states. There was a lull in research in the subsequent decade, with little progress. However, the tide began to turn again in the 1980s, and we now have growing evidence of the myriad ways the environment interacts-for better or worse-with older adults and their caregivers. This paper is not meant to provide an exhaustive review of the literature. Rather it addresses some of the better reviews that have been published and then explores where there are gaps-in our knowledge, in our methods, and in our approach to what needs more scrutiny.A Brief HistoryIt is important to note that care units for people with dementia (SCU-Ds) served, in large part, as the impetus for examining the role of the physical environment in shared residential longterm care. [Author's note: In this article, the terms long-term care and long-term care settings will be used to denote nursing homes, assisted living, congregate housing, and other shared residential settings commonly inhabited by older adults]. As increasing numbers of people with dementia entered long-term care settings, particularly nursing homes, it became clear that their needs often were not aligned with what nursing homes were designed to provide. Nursing homes originally developed as subacute hospitals for people with chronic conditions who would benefit from daily nursing care. People with dementia, however, often did not need significant nursing care; they needed a structured and supportive setting with caregivers knowledgeable about memory loss, communication, and strategies to maximize residual strengths. Thus, much of the early work on environments in long-term care settings focused on SCU-Ds.Initially SCU-Ds were considered separate, special settings. However, this exclusionary focus on dementia care settings is now changing, for two reasons. First, many research efforts have failed to demonstrate that SCU-Ds have measurable benefits over traditional care settings (Chappell & Reid, 2001). Second, it is now acknowledged that the majority of people in both nursing homes and assisted living centers have some level of cognitive impairment. According to the first quarter 2007 Minimum Data Set Active Resident Report, 17.5% of nursing home residents have a diagnosis of Alzheimer's Disease and 38% have a diagnosis of dementia other than Alzheimer's Disease, but 72.8% have problems with short-term memory and 51.1% have problems with long-term memory (Centers for Medicaid and Medicare Services, 2007). Several research reports indicate that a majority of individuals living in assisted living facilities also have some level of cognitive deterioration (Alzheimer's Association, 2007).Because of the initial focus of SCU-D research, most of the early attempts to summarize the literature on long-term care environments also focused on this setting. A review conducted in 1988 found only five published empirical studies of SCU-Ds, plus four unpublished studies (Ohta & Ohta, 1988). By 1992, the Office of Technology Assessment identified 15 studies (U.S. Congress Office of Technology Assessment, 1992). Two years later, Weisman, Calkins, and Sloane (1994) found 21 studies. These are still relatively small numbers of studies. By 2000, Day and colleagues identified 71 reports of empirical research on dementia design (Day, Carreon, & Stump, 2000). More recently, Joseph completed a review of research on the design of long-term care settings in general (not dementia specific) and identified more than 250 peer-reviewed articles (Joseph, 2006). …