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ABSTRACT POSTOCCUPANCY EVALUATION OF ALZHEIMER S FACILITIES IN THE BAY AREA, CALIFORNIA

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ABSTRACT POSTOCCUPANCY EVALUATION OF ALZHEIMER S FACILITIES IN THE BAY AREA, CALIFORNIA The main aim of this research was to evaluate the existing design of Alzheimer s care units. The focus of this evaluation
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ABSTRACT POSTOCCUPANCY EVALUATION OF ALZHEIMER S FACILITIES IN THE BAY AREA, CALIFORNIA The main aim of this research was to evaluate the existing design of Alzheimer s care units. The focus of this evaluation was on the design of two areas: wandering paths and activity areas. Four Alzheimer s care units were selected for this study from the Bay Area, California. Postoccupancy Evaluation was employed for the assessment of the existing design of the wandering paths and the activity areas. Research methods included behavioral observations, visual analysis, and survey questionnaires. Four study sites were compared for the design of the wandering paths and the activity areas by plotting evaluation graphs and tables. Results of the study reflected the level of distracting and therapeutic elements in the design of the activity areas and the wandering paths. Based on the findings of the Postoccupancy Evaluation, recommendations were made to improve the existing design of activity areas and wandering paths at the four study sites. Ramandeep Kaur May 2009 POSTOCCUPANCY EVALUATION OF ALZHEIMER S FACILITIES IN THE BAY AREA, CALIFORNIA by Ramandeep Kaur A thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts in Art in the College of Arts and Humanities California State University, Fresno May 2009 APPROVED For the Department of Art and Design: We, the undersigned, certify that the thesis of the following student meets the required standards of scholarship, format, and style of the university and the student's graduate degree program for the awarding of the master's degree. Ramandeep Kaur Thesis Author Nancy K. Brian (Chair) Art and Design A. Sameh El. Kharbawy Art and Design John A. Capitman Health and Human Services For the University Graduate Committee: Dean, Division of Graduate Studies AUTHORIZATION FOR REPRODUCTION OF MASTER S THESIS X I grant permission for the reproduction of this thesis in part or in its entirety without further authorization from me, on the condition that the person or agency requesting reproduction absorbs the cost and provides proper acknowledgment of authorship. Permission to reproduce this thesis in part or in its entirety must be obtained from me. Signature of thesis author: TABLE OF CONTENTS Page LIST OF TABLES vi LIST OF FIGURES viii Chapter 1. LITERATURE REVIEW Introduction Alzheimer s Care Facilities Design of Activity Areas and Wandering Paths Postoccupancy Evaluation Structure of the Thesis METHODOLOGY Importance of Postoccupancy Evaluation Scope of the Study Methodology Interviews Behavioral Observations Analysis Plan COMPARATIVE ANALYSIS Indoor Wandering Paths Outside Wandering Paths Indoor Activity Areas Outside Activity Areas CASE STUDIES Aegis Gardens v Chapter Page Pacific Gardens Sunrise of Palo Alto Atria Willow Glen RESULTS AND RECOMMENDATIONS Design Evaluation Study Strengths and Contributions Study Limitations and Implications for Future Research.. 85 Design Recommendations Conclusion REFERENCES APPENDICES A. OPEN-ENDED QUESTIONNAIRE FOR WANDERING PATHS 97 B. OPEN-ENDED QUESTIONNAIRE FOR ACTIVITY AREAS.. 99 C. OPEN-ENDED QUESTIONNAIRE FOR THE DESIGNERS/ OWNERS OF THE ALZHEIMER S FACILITIES D. DEFINITION OF TERMS LIST OF TABLES Table Page 1. Elements of Evaluation for Indoor Wandering Paths Elements of Evaluation for Outside Wandering Paths Elements of Evaluation for Indoor Activity Areas Elements of Evaluation for Outside Activity Areas Comparison Table for Indoor Wandering Paths Comparison Table for Outside Wandering Paths Comparison Table for Indoor Activity Areas Comparison Table for Dining Rooms Comparison Table for Outside Activity Areas Elements of Evaluation for Indoor Wandering Path at Aegis Gardens Elements of Evaluation for Outside Wandering Path at Aegis Gardens Type of Activity Areas at Aegis Gardens Elements of Evaluation for Indoor Activity Areas at Aegis Gardens Elements of Evaluation for Outside Activity Area at Aegis Gardens Elements of Evaluation for Indoor Wandering Path at Pacific Gardens Elements of Evaluation for Outside Wandering Path at Pacific Gardens Type of Activity Areas at Pacific Gardens Elements of Evaluation for Indoor Activity Areas at Pacific Gardens Elements of Evaluation for Outside Activity Area at Pacific Gardens vii Table Page 20. Elements of Evaluation for Indoor Wandering Path at Sunrise Type of Activity Areas at Sunrise Elements of Evaluation for Indoor Activity Areas at Sunrise Elements of Evaluation for Outside Activity Area at Sunrise Elements of Evaluation for Indoor Wandering Path at Atria Elements of Evaluation for Outside Wandering Path at Atria Type of Activity Areas at Atria Elements of Evaluation for Indoor Activity Areas at Atria Elements of Evaluation for Outside Activity Area at Atria.. 80 LIST OF FIGURES Figure Page 1. Comparison of design elements for indoor wandering paths Comparison of overall design performance for indoor wandering paths Comparison of design elements for outside wandering paths Comparison of overall design performance for outside wandering paths Comparison of design elements for indoor activity rooms Comparison of overall design performance for activity rooms Comparison of design elements for dining rooms Comparison of overall design performance for dining rooms Comparison of design elements for outside activity areas Comparison of overall design performance for outside activity areas Floor plan of Alzheimer s unit at Aegis Gardens Floor plan of lower level Alzheimer s unit at Pacific Gardens Floor plan of Alzheimer s unit at Sunrise Floor plan of lower level Alzheimer s unit at Atria Chapter 1 LITERATURE REVIEW The following chapter is an introduction to Alzheimer s disease, special Alzheimer s care facilities, design of activity areas and wandering paths, and postoccupancy evaluation. Introduction Alzheimer s disease was discovered by German physician Alois Alzheimer in 1907 (Truschke, 1991). It is a chronic neurodegenerative disease that begins gradually, causing a person to forget recent events or familiar tasks (Terry, 2006). The brain is the major organ of the body affected by the disease. The frontal lobe, which controls intelligence, judgment, and behavior, is the primary area of the brain affected by Alzheimer s. The secondary area affected is the temporal lobe, which controls memory and language (Brawley, 1997). To date, 100 years after the discovery of Alzheimer s disease, there is still no medical treatment that can completely cure the disease. This is an alarming situation, considering the rapidly growing population of elderly with Alzheimer s disease (Sikanovski, 1998). Prior to 1900, American life expectancy was 30 years. This increased to 77 in 2006 (Friedland, 1998). The increased life expectancy has expanded the overall population of elderly Americans, which is projected to rise from 42 million in the year 2000 to 83 million by the year This largely 2 represents the baby boomer population (born ) (Friedland & Summer, 1999). The population with Alzheimer s will likely grow proportionally to match the increasing elderly population and is projected to be approximately 8 million by the year 2030 and 15 million by 2050 (U.S. Congress, Office of Technology Assessment, 1987). Alzheimer s disease attacks silently and tends to get unnoticed in its earlier stages. People in the initial stages of Alzheimer s disease may hardly show symptoms of the disease and may be in excellent physical condition (Warner, 1998). Eventually with the disease people start showing behavioral symptoms like losing their ability to think, wandering, agitations, social withdrawal, having impaired judgment, confused state of mind, and memory problems (Sloane & Mathew, 1991). Alzheimer s disease does not have a fixed pattern of progress, and its duration can vary anywhere from 2 to 30 years (Warner, 1998). In the earlier stages of the disease the body has higher functionality levels, with memory impaired slightly. In the middle stages, memory loss increases and the functionality levels of the body decline. In the final stages of the disease, memory is virtually lost, the body s response to the mind declines, and the person can no longer take care of himself (Warner). Designers responsible for the development of specialized care units for Alzheimer s patients are collaborating with doctors, nurses, social workers, and paraprofessional workers to play major roles as caregivers in the lives of elderly suffering from Alzheimer s (Zeisel, Silverstein, Hyde, & Levkoff, 2003). 3 Alzheimer s Care Facilities Special Alzheimer s care facilities came into existence in the 1980s as a response to a problem of some nursing home residents being poorly served by their facilities (Weiner & Reingold, 1989). The 1985 National Housing Home Survey (Hing, 1987) reported 63% of all the residents in nursing homes showed behavioral symptoms related to Alzheimer s: disorientation, confusion, and memory impairment. Nursing homes did not provide the special care required by the elderly suffering from Alzheimer s. Care patterns for residents with Alzheimer s require a lower resident to staff ratio, a positive and caring staff attitude, and a nursing home environment that is residential rather than institutional (Donat, 1986). A special care facility for Alzheimer s is one that works effectively to provide therapeutic care through stimulating activities and care programs (Sloane & Mathew, 1991). Residents living in an Alzheimer s facility can relate well to the environment that is residential and ambient: these environmental features have shown reduction in the aggression, agitation, and psychological problems related to the Alzheimer s disease (Zeisel et al., 2003). Therapeutic Environments in the Alzheimer s Care Units At times it has been observed that people suffering from Alzheimer s show problematic behaviors as consequences of an environment that is not therapeutic (Coons, 1985). An environment designed to comfort the brain can prevent the occurrence of behavioral symptoms like wandering and aggression (Schiff, 1990). Therapeutic environments encourage residents to 4 have freedom both to make decisions and to move around the facility (Coons & Mace, 1996). A therapeutic environment for the elderly with Alzheimer s is one that provides privacy and independence, safety and security, orientation by landmarks and clues, social interaction, and sensory stimulation (Sloane & Mathew, 1990). A majority of the residents spend 10 to 15 years of their lives in the special care facilities. Therefore, it is very important to provide an environment that feels like home to them (Brawley, 2006). Transition of people with Alzheimer s from their private homes to new, unfamiliar group environments can be confusing and overwhelming (Peppard, 1996). Some of the confusion from changing environments can be prevented by providing a similar residential environment. This helps residents to continue the important and enjoyable routine that they were following in their previous residential settings (Golant, 2003). Design of Activity Areas and Wandering Paths People who suffer from Alzheimer s need to exercise their physical and mental capabilities in order to prevent rapid decline (Butler, Forette, & Greengross, 2004). For those living in Alzheimer s facilities, exercise is carried out in activity areas and on wandering paths (Marsden, Briller, Calkins, & Proffitt, 2001). Design of activity areas and wandering paths should be such that they provide stimulation and keep residents involved during the day (Cohen & Day, 1993). Activity Areas Activity areas are the common areas of the Alzheimer s facilities where residents and the caretaking staff spend a major part of the day. These areas 5 include indoor activity rooms, dining rooms, a country kitchen, and outdoor areas. Design of the indoor activity areas in the Alzheimer s facilities varies from facility to facility. Alzheimer s facilities typically have (a) a single large activity room, which is used both for activities and dining, (b) a single large room for activities and a separate dining room with an adjoining country kitchen, or (c) multiple small-scaled activity and dining rooms. Activity rooms. Effectiveness of the program run by the facility depends on the design of the activity rooms. In facilities with a single room for activities and dining, residents lack the opportunity to move around from one location to another location. In an Alzheimer s facility, ideally the activity spaces should be designed and distributed according to the functionality levels of the residents (Boiling & Gwyther, 1991). Large activity rooms and groups are distracting due to high stimulation levels, because of which some residents with Alzheimer s disease tend to wander away (Namazi & Johnson, 1992). Residents who get disturbed with the level of noise in the activity areas like to sit in quiet, private areas. Private areas give residents who prefer to stay alone or in small groups the option of a calm environment. These areas can be indoors or outdoors (Cohen & Weisman, 1991). Multiple activity areas and simultaneous activity programs keep the residents occupied, which further prevents occurrence of behavioral symptoms (Moore, Geboy, & Weisman, 2006). Multiple activities allow the residents to choose and participate in an activity of their required stimulation level (Marsden et al., 2001). The results of a study by Zeisel et al. (2003) show 6 that variety in the activity areas reduces social withdrawal, one of the common symptoms associated with Alzheimer s disease. Activities in the activity rooms also play an important role in bringing in the residential character and taking away the institutional character from the space (Cohen & Day, 1994) Dining rooms. An Alzheimer s facility with a common room for the activities and dining fails to provide an opportunity for residents to move into a separate room during meal times. In facilities with separate dining rooms, residents get an opportunity to socialize, meet other residents, and wait for the time to take meals in the dining room (Brawley, 2006). Residents associate dining in a dining room as a part of their daily activities. A country kitchen designed with the dining room completes the basic components of a home: e.g. bedrooms, a living room, a dining room, and a kitchen (Kovach, Weisman, Chaudhury, & Calkins, 1997). A country kitchen, also called a therapeutic kitchen, is mainly used for serving meals and activities; it adds warmth and residential character to the space (Calkins, 1988). It is also used as an activity area, where residents are involved in serving meals, washing dishes, and preparing salad and cookies. Through participation in these kinds of activities, residents gain a feeling of usefulness and self-esteem (Cohen & Weisman, 1991). According to the results of the study by Schwarz, Chaudhury, and Tofle (2004), facilities with multiple small dining rooms function better than those with a single large dining room. The residents in the dining rooms can be distributed according to their functionality levels. Residents with higher functionality levels who are capable of taking their meals independently 7 using a fork, a knife, and a spoon can be in one dining room. On the other hand, residents who need help or are on special or liquid diets can be in a separate dining room. Distribution of this kind helps in maintaining comfort level of the residents of varying functionality levels, which prevents chain reactions of aggressive and disruptive behaviors arising due over stimulation, and also helps in steady communication among the residents and the caretakers, which is otherwise difficult in large groups (Schwarz et al., 2004). Outdoor activity areas. Design of the Alzheimer s facilities should have an accessible and secure outdoor area. An outdoor area that is secure and has a decorative fence or natural hedges around it can also remain unlocked (Boiling & Gwyther, 1991). Having unlocked access to the outdoor areas diverts the attention of the residents from the main facility door to the door that is unlocked and takes them into an open space (Cohen & Weisman, 1991). The outdoor areas should be designed for activities like gardening, raking leaves, sweeping pathways, and weeding. The pots for gardening should be at a height that prevents residents from bending and allows residents in wheelchairs to participate in gardening activities (Marsden et al., 2001). Well-planned outside areas can be used as a place for socialization, reflection, and a place to carry out gardening activities (Heath, 2004). The outdoor area with a variety of chairs placed at multiple locations in the shaded and sunny areas fulfills the need of both private and social interaction among the residents (Lovering, 1990). 8 Wandering Paths Wandering is one of the most common behavioral disorders linked with Alzheimer s disease (Aud, 2004). Boredom and environmental pressure are two of the reasons for the onset of wandering behavior (Mace & Rabins, 1981). An environment that consists of stimulating and nonstimulating activity areas, therapeutic wandering paths, and differentiated and guided space can comfort the brain, further comforting the body (Coons, 1988). For the residents with surplus energy, wandering is a way to utilize their stored energy (Hiatt, 1980). Indoor wandering paths. Design of the wandering path should be such that it provides variation to the experience of wandering. The path should not be repetitive and monotonous. It should have landmarks and design elements that act as navigators, aid residents to move around the facility, and provide visual stimulation (Cohen & Day, 1993). A wandering path designed around the activity area is a smart design approach to involve the residents who tend to wander away (Cohen & Weisman, 1991). In a wandering path that is adjacent to or is around the activity areas, residents can passively participate in the activities while wandering. Residents can also get attracted to participate in the activity if the activity area is visible from his wandering path (Marsden et al., 2001). Outdoor wandering paths. Successful design of the wandering path is one that is safe, begins and ends at same point, is of controlled size, and can be supervised easily (Lovering, 1990). Access to the outdoor area helps residents understand the environment better, which makes the outdoor areas 9 accessible and safe for their use (Moore et al., 2006). A wandering path that is wide and clean, with distinctive landmarks like trees, life skill stations, and statues, may assist residents in finding their way (Lovering). Postoccupancy Evaluation Postoccupancy Evaluation (POE) is a tool aimed at advancement in the design of living environments for the elderly (Anderzhon, Fraley, & Green, 2007). POE is used to investigate the effectiveness of the environments that are occupied and used by humans (Zimring & Reizenstein, 1980). The procedure of evaluation is done after the building has been occupied by the users for a period of time (Heath, 2004). POE helps in examining number of problems that are left unidentified when the building is designed. Results derived from the POE identify the problems and lacking in the design which the occupants experience after using the building (Gifford, 2002). This thesis describes the POE of the activity areas and the wandering paths in the design of the Alzheimer s care facilities. It identifies the problems in the existing design of four study sites and documents recommendations for future improvements. Structure of the Thesis Chapter 1, the literature review, includes an overview of Alzheimer s disease and demographics data of the Alzheimer s population, Alzheimer s care facilities, activity areas, wandering paths and postoccupancy evaluation. In chapter 2, various design methods used for the evaluation of the activity are
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