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This project was funded by the Department of Veterans Affairs (VA) as a part of a national pilot program to design interventions that would support caregivers of older veterans. The specific project described here employed in-home messaging units, which are already widely used by the VA in disease-management programs, as a device to educate and support family caregivers (CGs) of older, functionally impaired veterans. The primary goal of the pilot program was to improve the well-being of both family CGs and their veteran care recipients (CRs) by (a) engaging CGs more actively and effectively in their veterans’ care, and (b) directly addressing the emotional needs of caregivers themselves. A three-group quasi-experimental design (instrumental support, instrumental+emotional support, wait-list control) was employed. Outcomes from the perspective of the caregiver, care recipient, and the health system were evaluated. In this paper, we further describe the experimental design of the program, the role o...

Objective To evaluate the effect of ambient bright light therapy (BLT) on agitation among institutionalized persons with dementia. Methods High intensity, low glare ambient lighting was installed in activity and dining areas of a state psychiatric hospital unit in North Carolina and a dementia-specific residential care facility in Oregon. The study employed a cluster-unit crossover design involving four ambient lighting conditions: AM bright light, PM bright light, All Day bright light, and Standard light. Sixty-six older persons with dementia participated. Outcome measures included direct observation by research personnel and completion by staff caregivers of the 14-item, short form of the Cohen-Mansfield Agitation Inventory (CMAI). Results Analyses of observational data revealed that for participants with mild/moderate dementia, agitation was higher under AM light (p = 0.003), PM light (p

Objective: The purpose of this one-year pilot study was to obtain preliminary information on the effects of an outdoor activity program, in comparison to an indoor activity program, on sleep and behavior in nursing home residents with dementia. Structured activity programs have been shown to improve dementia-related behavior problems, and there are some indications that improved behavior is associated with improved sleep. Previous research has shown that sleep disturbance is common in nursing home residents, and that limited exposure to light bright enough to entrain circadian rhythms contributes to their sleep problems. Thus, we expected to see improvements in behavior in both the outdoor and indoor activity groups, but improvements in sleep in the outdoor activity group only. Methodology: A two-group (outdoor program, indoor program) two phase (baseline, intervention) design was used. Subjects were randomized to the outdoor or indoor program groups. Sleep and behavior disturbance were assessed ...

OBJECTIVES: To assess the effect of ambient bright light therapy on depressive symptoms in persons with dementia. DESIGN: A cluster-unit crossover intervention trial involving four lighting conditions: morning bright light, evening bright light, all-day bright light, and standard light. SETTING: The common areas of two geriatric units in a state-operated psychiatric hospital inNorth Carolinaand in a dementia-specific residential care facility in Oregon. PARTICIPANTS: Sixty-six older adults with dementia. INTERVENTION: Ambient bright light therapy was delivered through a high-intensity, low-glare lighting system installed in the public areas of study units at both sites. Each lighting condition was provided for multiple 3-week periods in a predetermined sequence. MEASUREMENTS: Staff caregivers completed the Cornell Scale for Depression in Dementia (CSDD) in the last week of each 3-week period to provide information about participants’ moods. RESULTS: Analysis indicated a sex-by-treatment interaction (P 5.008). Significant sex differences were found in CSDD scores in response to evening light (P 5.003), all-day light (P 5.001), and standard light (P� .001). Depressive symptoms were lowest for women and highest for men during morning light. CONCLUSION: Findings do not support the use of ambient bright light therapy as a treatment for depressive symptoms in persons with dementia, although a subpopulation of persons with dementia may benefit from this intervention. It is likely that individual rather than unitlevel interventions are a more effective strategy for delivering bright light therapy for this population. J Am Geriatr Soc 55:1817–1824, 2007.

OBJECTIVES: To determine whether high-intensity ambient light in public areas of long-term care facilities will improve sleeping patterns and circadian rhythms of persons with dementia. DESIGN: A cluster-unit crossover intervention trial involving four conditions: morning bright light, evening bright light, all-day bright light, and minimum standard light. SETTING: The common areas of two geriatric units in a psychiatric hospital and a dementia-specific residential care facility. PARTICIPANTS: Sixty-six older adults with dementia. INTERVENTION: Ambient bright light of approximately 2,500 lux, delivered through a low-glare lighting system installed in the dining and activity areas. Participant exposure averaged 2.5 to 3.0 hours for the morning and evening interventions and 8.4 hours for the all-day intervention. MEASUREMENTS: Nighttime sleep using wrist actigraphy and daytime activity using nonobtrusive daytime observations. RESULTS: Night-time sleep increased significantly in participants exposed to morning and all-day light, with the increase most prominent in participants with severe or very severe dementia (mean increase 16 minutes (P=.008) for morning, and 14 minutes (P=.01) for all-day). Morning light produced a mean phase advance of 29 minutes (P=.02) and evening light a mean phase delay of 15 minutes (P=.06). Effects on daytime sleepiness were inconsistent, and the number of sleep bouts, mesor, amplitude, intradaily variability, and interdaily stability were not significantly different, indicating that the overall strength of day and night activity rhythms did not change significantly under any treatment condition. CONCLUSION: Bright light appears to have a modest but measurable effect on sleep in this population, and ambient light may be preferable to stationary devices such as light boxes.

OBJECTIVES: To improve nighttime sleep in nursing home patients. DESIGN: Controlled clinical trial. SETTING: Eight community nursing homes enrolled two at a time. PARTICIPANTS: Of 1,077 patients assessed in the eight nursing homes, 638 (59%) were eligible, and consent was obtained for 273 (43% of those eligible). Of the 230 who underwent baseline assessments, 173 completed the immediate-intervention phase of the trial (77 in the intervention group and 96 in the control group). A total of 160 subjects completed the intervention (77 in the immediate-intervention group and 83 in the delayed-intervention phase). INTERVENTION: Trained research staff provided the intervention, which included daytime physical activity and attempts to keep subjects out of bed, evening bright light exposure, a consistent bedtime routine, nighttime care routines designed to minimize sleep disruption, and strategies to reduce nighttime noise. Subjects from one nursing home received the intervention (Group 1), whereas subjects in the second nursing home served as a control group (Group 2); then Group 2 received the intervention. MEASUREMENTS: Primary outcomes included measures of sleep recorded using wrist actigraphy in all subjects and polysomnography in a subgroup of subjects. Secondary measures included assessments of mood and behavior using the Neuropsychiatric Inventory, the Geriatric Depression Scale, and behavioral observations. RESULTS: There were no significant differences in any of the primary actigraphic sleep outcome measures between the intervention and control group after the immediate-intervention phase of the trial. In the 160 subjects who completed the intervention, there were no significant changes in any actigraphic measure of nighttime sleep, nor were there any significant changes in measures of sleep in the 45 subjects who had baseline and intervention polysomnography. CONCLUSION: This multicomponent, nonpharmacological intervention conducted by trained research staff had no effect on nighttime sleep in this sample of nursing home patients. Enhanced nonpharmacological interventions should be developed and tested and combined with environmental interventions to mitigate noise when feasible. Adjunctive drug therapy may be needed to improve sleep in a substantial proportion of this population and should be tested in addition to nonpharmacological interventions in rigorous clinical trials.

For people with disabilities, sports arenas should provide equal opportunities to participate in all aspects of the experience -- from being able to see the sporting event from seats of their choice to being an integral part of the crowd. This paper reports findings from post-occupancy evaluations (POEs) that were conducted at ten sports facilities in major U.S. urban areas. The POEs were undertaken in order to make recommendations to the Access Board for changes to the Americans with Disabilities Act Accessibility Guidelines (ADAAG) regarding assembly seating. Although the POEs focused on the range of issues in ADAAG related to accessible seating, five issues clearly stood out as primary factors affecting seating quality: (1) number and size of wheelchair spaces, (2) companion seating, (3) dispersal of accessible seating, (4) integration of accessible seating, and (5) sightlines over standing spectators.

Home modifications can enhance the independent living of older adults with mobility limitations; however, obtaining modifications to make the home more accessible often requires resources beyond those of the mobility-limited resident. Personal interviews with independently-living adults with mobility limitations were completed to determine who was responsible for the accessibility modifications present in their homes. Forty-six respondents in two rural counties in North Carolina answered questions concerning who identified the need for the modifications, who financed or provided materials, and who provided the labor. The majority of the respondents were limited-income elderly females. Of seven modifications reported by at least five respondents (grab bars, entry ramp, stools/seats of shower or tub, commodes, hand-held showers, raised toilet seats, and walk-in/roll-in showers), the need was most often identified by someone other than the individual with the mobility limitation. The source of financ...

Most people intuitively understand that the spaces they occupy are an important aspect of their lives. In contrast, the physical environment is largely ignored by most professions in explaining or predicting important individual, group, and organizational factors as well as in conducting professional activities. The model of team effectiveness proposed by Strasser and Falconer incorporates the environment. However, the environmental component of this model raises a number of questions about what aspects of the physical environment are important and why. Four conceptual frameworks from environment and behavior research are used to explore these questions: (1) Lawton’s Environmental Press Model, (2) Barker’s Behavior Setting Theory, (3) Archea’s Visual Access and Exposure Model, and (4) Hillier and Hanson’s Space Syntax Model.

Objective: To conduct an in-depth examination of the environmental and behavioral circumstances associated with falls and near-falls experienced by elderly individuals and to evaluate the usefulness of reenactment as a method for studying falls. Design: Observational and self-report data of incidents were obtained through a reenactment procedure. Environmental characteristics were documented with physical measurements, visual inspection, and photography. Setting: Incidents occurred inside participants' homes, and reenactments were conducted at incident sites. Participants: Subjects were 15 community-dwelling, relatively healthy individuals, age 70 to 81 years. Main Outcome Measures: Incidents were analyzed to determine patterns of interaction of individuals' personal characteristics, environmental use behaviors, and environmental characteristics. Results: Seven patterns were identified: collisions in the dark, failing to avoid temporary hazards, preoccupation with temporary conditions, frictional variations between shoes and floor coverings, excessive environmental demands, habitual environmental use, and inappropriate environmental use. Conclusions: There is a dynamic interaction between environmental conditions and behavior involving use of the environment and its implications for falls in older people. Although some incidents involved familiar environmental and behavioral risk factors, less familiar factors also were critical contributors to the incidents. Successful elimination of these factors is likely to be closely related to an individual's perception that an environmental or environmental use problem is correctable, motivation to undertake changes in the environment, and a desire to integrate changes into daily activities.

Environmental change offers an attractive approach to falls prevention, particularly as part of multidimensional intervention strategies. This article reviews and summarizes prior research that has examined environmental factors in falls experienced by older people in community and long-term care settings. Limitations of this research as a basis for falls prevention activities also are discussed. Studies that focused on environmental hazards as well as those that examined the interaction of environmental conditions and environmental use activities from a situational perspective are included. The first group of studies suggests an approach to falls prevention centered on hazard removal; the second group suggests an approach centered on the provision of more supportive environments that reduce excessive environmental demands. Environmental change and falls prevention in long-term care and community settings, including common barriers to change among older individuals living in the community, are discussed.

Bettye Rose Connell is director of Research and Design Development at the Center for Accessible Housing, North Carolina State University. She also is a research architect and chief of the Environmental Section at the Rehabilitation Research and Development Center on Aging, Atlanta Veterans Affairs Medical Center. She earned her PhD in Architecture from Georgia Tech. Her research has focused on accessible housing needs and housing evaluation; affordable, accessible rural housing; and home modifications. Dr. Connell has authored and coauthored a number ojjournal articles and book chapters, and is a frequent presenter at professional meetings. Jon A. Sanford is the coordinator for the Housing Evaluation Program at the Center for Accessible Housing, North Carolina State University and a research architect at the Rehabilitation Research and Development Center on Aging, Atlanta Veterans Affairs Medical Center. He holds a BS degree in Psychology from Duke University, and BS in Architecture and MArch degrees from Georgia Tech. Mr. Sanford has extensive research experience related to the independence and safety of older people and those with disabilities. He has recently completed several projects that evaluated the effectiveness of home environments in supporting the needs of people with disabilities.

Jon A. Sanford, MArch is a research architect at the Rehabilitation RD an assessment of the architectural contributions to wayfinding and spatial orientation of elderly people in new housing environments; and field-based case studies of housing occupied by disabled individuals. Currently, he has begun work in the area of situational contributions to staff stress in long-term care settings and is directing a number of projects, including: the Applicability of Accessibility Standards to Meet the Needs of Older People; Design of New Toilet Prototypes for Older and Disabled r.i!terans; Best Practices in Accessible Housing; a Survey Protocol for a National Registry of Accessible Housing, and Accessibility Standards for Assembly Areas.

To assess the effect of ambient bright light therapy on depressive symptoms in persons with dementia.A cluster-unit crossover intervention trial involving four lighting conditions: morning bright light, evening bright light, all-day bright light, and standard light.The common areas of two geriatric units in a state-operated psychiatric hospital in North Carolina and in a dementia-specific residential care facility in Oregon.Sixty-six older adults with dementia.Ambient bright light therapy was delivered through a high-intensity, low-glare lighting system installed in the public areas of study units at both sites. Each lighting condition was provided for multiple 3-week periods in a predetermined sequence.Staff caregivers completed the Cornell Scale for Depression in Dementia (CSDD) in the last week of each 3-week period to provide information about participants' moods.Analysis indicated a sex-by-treatment interaction (P=.008). Significant sex differences were found in CSDD scores in response to evening light (P=.003), all-day light (P=.001), and standard light (P/=.001). Depressive symptoms were lowest for women and highest for men during morning light.Findings do not support the use of ambient bright light therapy as a treatment for depressive symptoms in persons with dementia, although a subpopulation of persons with dementia may benefit from this intervention. It is likely that individual rather than unit-level interventions are a more effective strategy for delivering bright light therapy for this population.

To determine whether high-intensity ambient light in public areas of long-term care facilities will improve sleeping patterns and circadian rhythms of persons with dementia.A cluster-unit crossover intervention trial involving four conditions: morning bright light, evening bright light, all-day bright light, and minimum standard light.The common areas of two geriatric units in a psychiatric hospital and a dementia-specific residential care facility.Sixty-six older adults with dementia.Ambient bright light of approximately 2,500 lux, delivered through a low-glare lighting system installed in the dining and activity areas. Participant exposure averaged 2.5 to 3.0 hours for the morning and evening interventions and 8.4 hours for the all-day intervention.Nighttime sleep using wrist actigraphy and daytime activity using nonobtrusive daytime observations.Night-time sleep increased significantly in participants exposed to morning and all-day light, with the increase most prominent in participants with severe or very severe dementia (mean increase 16 minutes (P=.008) for morning, and 14 minutes (P=.01) for all-day). Morning light produced a mean phase advance of 29 minutes (P=.02) and evening light a mean phase delay of 15 minutes (P=.06). Effects on daytime sleepiness were inconsistent, and the number of sleep bouts, mesor, amplitude, intradaily variability, and interdaily stability were not significantly different, indicating that the overall strength of day and night activity rhythms did not change significantly under any treatment condition.Bright light appears to have a modest but measurable effect on sleep in this population, and ambient light may be preferable to stationary devices such as light boxes.

To improve nighttime sleep in nursing home patients.Controlled clinical trial.Eight community nursing homes enrolled two at a time.Of 1,077 patients assessed in the eight nursing homes, 638 (59%) were eligible, and consent was obtained for 273 (43% of those eligible). Of the 230 who underwent baseline assessments, 173 completed the immediate-intervention phase of the trial (77 in the intervention group and 96 in the control group). A total of 160 subjects completed the intervention (77 in the immediate-intervention group and 83 in the delayed-intervention phase).Trained research staff provided the intervention, which included daytime physical activity and attempts to keep subjects out of bed, evening bright light exposure, a consistent bedtime routine, nighttime care routines designed to minimize sleep disruption, and strategies to reduce nighttime noise. Subjects from one nursing home received the intervention (Group 1), whereas subjects in the second nursing home served as a control group (Group 2); then Group 2 received the intervention.Primary outcomes included measures of sleep recorded using wrist actigraphy in all subjects and polysomnography in a subgroup of subjects. Secondary measures included assessments of mood and behavior using the Neuropsychiatric Inventory, the Geriatric Depression Scale, and behavioral observations.There were no significant differences in any of the primary actigraphic sleep outcome measures between the intervention and control group after the immediate-intervention phase of the trial. In the 160 subjects who completed the intervention, there were no significant changes in any actigraphic measure of nighttime sleep, nor were there any significant changes in measures of sleep in the 45 subjects who had baseline and intervention polysomnography.This multicomponent, nonpharmacological intervention conducted by trained research staff had no effect on nighttime sleep in this sample of nursing home patients. Enhanced nonpharmacological interventions should be developed and tested and combined with environmental interventions to mitigate noise when feasible. Adjunctive drug therapy may be needed to improve sleep in a substantial proportion of this population and should be tested in addition to nonpharmacological interventions in rigorous clinical trials.

The objective of this pilot study was to obtain preliminary information on wayfinding information placement for NH (nursing home) residents by finding where older adults with mild dementia look during a wayfinding task. Wayfinding problems (e.g., an inability to find or recognize a destination) are common among NH residents. These behaviors have been related to falls and fractures [Buchner and Larson 1987] and are a significant source of staff stress [Bright 1986]. Wayfinding problems are person-environment problems from deficits in spatial orientation making it difficult to maintain a cognitive map of the route to a desired location, as well as with deficits that impact abilities to plan and carry out goal-directed travel and to ignore irrelevant and distracting stimuli [Liu et al. 1991; Passini et al. 1995]. Design-for best practices advocate supporting preserved wayfinding abilities. However, little attention has been given to the information placement in the NH environment to ensure that it is likely to be seen. A case report states that NH residents with dementia look down as they walk around a NH unit, looking on hallway floors and the lower part of walls (below waist level) where wayfinding information is almost never placed [Adachi 1999]. Optimal information placement has the potential to positively impact the independence, safety, and QOL of residents as well as improve staff satisfaction.

Objectives. This study investigates the process of aging in place in assisted living facilities (ALFs) and seeks to gain an in-depth understanding of the factors influencing this phenomenon in a variety of ALF contexts. Methods. Qualitative methods were used to study five ALFs for 1 year. Data collection methods included participant observation; informal and in-depth interviewing of providers, residents, and residents’ families; and review of resident and facility records. Analysis was conducted using the grounded theory approach. Results. The ability of residents to remain in assisted living was principally a function of the ‘‘fit’’ between the capacity of both residents and facilities to manage decline. Multiple community, facility, and resident factors influenced the capacity to manage decline, and resident‐facility fit was both an outcome and an influence on the decline management process. Resident and facility risk also was an intervening factor and a consequence of decline management. Discussion. Findings point out the complexity of aging in place in ALFs and the need for a coordinated effort by facilities, residents, and families in the management of resident decline. Findings further highlight the necessity of residents being well informed about both their own needs and the capacity of a facility to meet them.

Over the last few years there has been growing interest in universal design— designing in such a way that people with and without disabilities can use the same products and building elements. Universal design is not a euphemism for familiar conceptions of accessibility. Rather, it involves a fundamental shift in thinking about design, particularly with regard to designing for people with disabilities.

This paper describes the development of an information package and dispersal strategy in the housing field--the Housing Options Inventory. The package is a microcomputer-accessed data base of housing resource persons in North Carolina developed by researchers for dissemination by extension personnel.