Environment Issues: The Human Environment

Welcome to the educational program Environment Issues: The Human Environment. This program will help you to understand how the quality of life of those with dementia is affected by people around them and why positive interactions are critical for good care. It will present some principles for improving human interactions and creating environments for comfort.

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This is Lesson 21 of The Alzheimer’s Caregiver. You may view the topics in order as presented, or click on any topic listed in the main menu to be taken to that section. We hope that you enjoy this program and find it useful in helping both yourself and those you care for. There are no easy answers when it comes to the care of another, as every situation and person is different. In addition, every caregiver comes with different experiences, skills, and attitudes about caregiving. Our hope is to offer you useful information and guidelines for caring for someone with dementia, but these guidelines will need to be adjusted to suit your own individual needs. Remember that your life experiences, your compassion and your inventiveness will go a long way toward enabling you to provide quality care.

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Human Environment

The human environment includes all the people involved in the care of the person with dementia, whether it be in the home or in a care facility. The human environment calls upon the patience, creativity, knowledge, and skills of all members of the care team. The people who contribute to the human environment are responsible for ensuring a life of love, respect, autonomy and safety for those suffering from dementia.

In addition to being knowledgeable about the disease and its effects, members of the human environment must also come to know the person with Alzheimer’s very well. This is best done by talking with them and doing activities together, which can give people a feeling of being loved and connected with others. Although one main caregiving responsibility is to keep the care recipients safe and healthy, other important responsibilities include respecting their individual preferences, contributing to their self-esteem, and building a trusting relationship.

Case Study 1

Let’s take a look at an interaction between Robert, who has Alzheimer’s disease, and Sally, his daytime caregiver.

Love, Respect, and Autonomy

Love and respect in the relationship is important because caring for those affected by dementia can become very frustrating. For example, people with Alzheimer’s often insist on doing things at very inconvenient times. They can become easily agitated and may refuse routine activities such as brushing their teeth or combing their hair. In most cases, it is best to allow them to do as they like at their own pace and schedule. You can also try to avoid these situations by giving them some sense of control by offering choices to the person at their level of understanding. For example, ask the person “Do you want to bathe in the tub or take a shower”, rather than just asking, “Do you want to bathe?”

Encourage those with dementia to do as much for themselves as they can. This will help them to maintain their remaining skills and promote their self-esteem. Provide assistance only when needed using cues, prompts, demonstration, and guidance.

You may also want to consider leaving individuals alone at times to do things for themselves if it is safe. Before you leave them alone, you should feel confident about their ability to perform activities by themselves. To assess this, ask yourself the following questions: Do they become confused or unpredictable under stress? Can they recognize a dangerous situation and dial 911 or find other ways to get help in an emergency? Are they generally content within the home or facility, or do they wander and become disoriented? When left alone do they become agitated, depressed, or withdrawn? Finally, do they continually try to pursue hobbies that warrant supervision, such as cooking, making repairs or woodworking? Keep in mind that as the disease progresses, these questions will need to be continually readdressed.

Principles of Good Communication

Good communication skills are needed in order to provide positive human environments. Some basic principles include showing respect. You can do this by addressing individuals by their preferred names and/or titles and by using good manners. People learn about good versus bad manners in early childhood and those memories tend to persist into the later stages of dementia. Because of this, people with dementia can usually appreciate good manners, so try to say please and thank you, as you would when speaking to anyone else. You can also show respect by inviting individuals to participate in something rather than demanding that they do it. Do not talk down to those with dementia or treat them like children. Instead, you should keep the conversation simple, but at an adult level. Avoid using eldertalk, which is similar to baby talk or the use of a high pitched, sing-song tone of voice. And if the individuals are in the room, do not discuss them with others as if they are not present, even if you think they do not understand.

In conversation, it’s best to avoid topics that you know can trigger challenging behaviors. If the topic is unavoidable, try approaching it in different ways or in different settings that may be more relaxing.

You should also be sensitive to the early signs of challenging behaviors. This includes paying attention to people’s feelings and emotions rather than their words. There may be signs in their body language or mannerisms that immediately precede problematic behaviors. If you see the early signs, try to back off or divert their attention onto another subject.

Keep in mind that words are not the only form of communication. It is very important to effectively use non-verbal forms of communication, such as facial expressions, tone of voice and body language to convey how you feel. This is especially important when someone is having difficulty understanding the conversation. Remember that a smile, a gentle touch, and a kind voice can express so much more than words.

Case Study 2

Now let’s take a look at another way Sally could have handled the situation with Robert.

Family and Friends

If primary care is taking place in the home, the human environment will consist primarily of the immediate family, including the spouse or partner, children, and pets, who can add greatly to the persons comfort and happiness. Extended family members and friends also often help support the primary caregiver and may be present during different occasions. Because of this, all involved family members and friends need to be educated about the disease and how to handle the changes they will see. It is especially important for families and friends to learn about ways to cope with their own losses and stresses as the disease progresses.

Whether the care is being provided at home or in a care facility, involvement of the family is an essential part of the individual’s life. For those living in a care facility, family members should be involved in important decision-making related to their loved ones as members of a multidisciplinary team. A family representative needs to be included in care planning conferences and outings or events organized by the care facility. Therefore, staff should share information including health status, diagnosis, prognosis, treatment plans, and other care options with family members.

Families can be invited to participate in various activities with residents such as listening to music, watching movies, talking with residents during tea or snack time, making cookies, or birthday celebrations. In these activities, family members can see their relative having fun, and can join in the pleasure they experience. This can lessen the guilt families sometimes feel for having placed their loved one in a care facility.

In order to facilitate family visits in care facilities, space for personal visits and places to go within the institution, such as a snack bar, library, and chapel, should be provided. These can allow families to move around, share different experiences with their loved one, and meet other families if desired.

Staff and Professional Caretakers

If primary care is taking place in a facility, the human environment consists of all of the workers that make up the totality of care for the individual such as nurses and aides, but it also includes such people as kitchen workers, housekeeping staff and volunteers.

As previously stated, a compassionate heart and respect for the human condition are basic personal qualities that are beneficial in caregiving. Because there is no one way to accomplish a given activity when working with someone with dementia, caregivers need to work together and respect each other’s ways. Remember that no one person can do it alone. Caregivers all have strategies that may work sometimes and not others, or that work for one person, but not for someone else.

Licensure and credentialing by the appropriate regulatory agencies are basic for adequate care, though these regulations are only the bare essential standards, as Alzheimer’s care is very specialized and requires additional ongoing training. To ensure quality care in facilities, all staff must receive intense training on an ongoing basis and be supervised by highly qualified professionals with experience in adult education and problem-based learning methods.

A caregiver’s natural observation and caring skills are extremely valuable in dealing with the everyday activities in dementia care such as bathing and grooming, dining and sleep preparation. But all those who come in contact with residents in a facility must also be trained in their specific roles and have knowledge of dementia as well.

In addition to training, certain regulations must be in place. Regulations address standards for safety, sanitation, food service and the training and supervision of employees. This includes the screening of employees for health status and criminal background. To learn about regulations for your state, you can contact the Health Facility Licensing and Certification Bureau in your state.

Volunteers

In addition to employed staff, there are many individuals, organizations, and businesses that offer volunteer services in care facilities. Volunteers are considered central to the work of an organization. They act as essential links to the community and help personalize the care and activities in an institution. Some examples of volunteers include individuals who accompany staff and residents on outings, the musicians who come in for the Friday night dance, the college student who offers to read to residents, and the Delta Society volunteer who brings in a dog or cat to the facility for a petting activity. Under some circumstances, ministers and chaplains are contracted by the facility to provide religious services.

Just like the facility’s hired staff, volunteers need to be screened, trained, and monitored by the facility. Before interacting with Alzheimers patients, they need to learn about the disease and ways to interact with residents. They also need to understand facility regulations and the federal law about health information privacy.

It is important for caregivers to show appreciation and respect to the volunteers, who are sharing their time and talents to help other people. Formal recognition such as an annual dinner honoring volunteers and a plaque or gift to mark years of service are excellent ways to show appreciation.

Case Study 3

Let’s take a look at another interaction between Sally and Robert. Robert is sitting at the dining room table, staring out of the back window. He is listless and refuses to eat his breakfast or move from the table. Sally enters the room, stands behind him, and asks him what’s wrong. Robert ignores Sally and continues to stare out the window.

Why is Robert ignoring Sally?
  • A) He does not realize that Sally is speaking to him.
  • B) He is having difficulty understanding what Sally is saying.
  • C) He is depressed and does not want to do anything.
  • D) All of the above.

Case Study 3 Answers:

Choice A: “He does not realize that Sally is speaking to him” is a good possibility.

Because Sally was standing behind Robert as she spoke, Robert may not have realized that anyone was speaking to him. Robert may have hearing problems and may be focused on something else other than Sally. Sally should have gained Robert’s attention before starting to speak. To get people’s full attention, face them and maintain eye contact while speaking and listening. Always try to be at their eye level rather than standing above or behind them. Also try to stay in one place, so that they are not distracted by trying to follow your movements.

Choice B: “He is having difficulty understanding what Sally is saying” is also a good possibility.

People with Alzheimer’s disease can have fluctuating levels of memory and function from day to day and even moment to moment. It is possible that Robert does not understand the words that Sally is saying. But without facing Robert, it will be difficult for Sally to determine if he understands her or not.

To increase the likelihood of being understood when speaking to those with dementia, first gain their attention, maintain eye contact, and use short, simple sentences. Repeat and rephrase things as needed. Use gestures and pantomime to help convey meaning. Give them time to understand and respond. And watch their body language and actions for signs of understanding.

Choice C: “He is depressed and does not want to do anything” may also be a possibility.

Many people with Alzheimer’s disease develop depression. Common symptoms of depression include social withdrawal and apathy. Depressed people can lose interest in activities and social interactions. Fortunately, there are treatments that may be able to help improve these symptoms. If you are concerned about depressive symptoms in the person you care for, you should consult a healthcare professional.

Choice D: Choice D, “all is the above,” is the best answer.

Designing for Comfort

When designing environments it is important to take into consideration the persons comfort and security as well as safety and accessibility. This includes such things as keeping the room temperature comfortable, providing adequate lighting, controlling noise, and creating a general home-like feeling.

Of course people with dementia will feel most comfortable in their familiar home, but if this is not possible, a care facility needs to make every effort to ensure that an environment is as home-like as possible.

One way for giving the care facility a more home-like environment has been promoted by Dr. William Thomas and is called the Eden Alternative. The principle of the Eden Alternative is that care facilities should not be based on a medical model of care but rather on habitats that promote human growth. Plants, children, and pets can be introduced to the facility to create this atmosphere.

Plants of various kinds, including potted plants, trees and bushes in courtyards, and gardens where residents can work, can be used to promote happiness and independence.

Activities with visiting children and grandchildren can promote a home-like atmosphere in a care facility. For example, children can be brought into a facility from local schools as part of a field trip. The children and elders can play games, sing songs, play instruments and share stories together. By playing with the children, residents can experience friendship, companionship and re-experience their own childhood as they struggle with the loneliness of dementia.

Lastly, interactions with pets, including dogs, cats, birds, and even rabbits can create interest, relax people, and stimulate happy memories. Pets can be a source of affection and touch that people with dementia sometimes lack. They can increase self-esteem and improve depression. The can also provide non-verbal acceptance for people with dementia, who are sometimes unable to communicate verbally. For example, singing or talking birds can add joy to an otherwise bland reception area or lounge. A tank full of colorful tropical fish can provide a calming effect for people with dementia.

For more help in placing animals in a care facility you can contact organizations like The Pet Partners Program of Delta Society, a volunteer program for animals and their owners.

Click here for more help in placing animals in a care facility.

Designing for Comfort (Continued)

Creating the Eden Alternative requires enthusiastic staff, residents, families and community partners. Plants, pets and children need to be a vital part of the daily lives of residents, and not just placed meaninglessly in the facility.

In addition to plants, pets and children, the Eden Alternative model also promotes anything that can improve the overall nursing home culture.

Things that can benefit the human habitat include relaxing fragrances and music. Aromatherapy using relaxing fragrances such as lavender oil and Melissa oil (also known as lemon balm) can reduce agitation and difficult behaviors, especially when combined with massage. For instance, rubbing Melissa oil on the arms and face twice a day has been shown to reduce agitation in people with late stage dementia. Music therapy has also been shown to relax people and decrease agitation behaviors. It is most effective when a person’s preferred or favorite music is played.

Any approach that is safe and helps people feel comfortable and relaxed should be considered.

Summary

In summary, the human environment consists of everyone involved in the care of the person with Alzheimer’s disease including family members, friends, professional staff, and volunteers. The people involved in caregiving need to promote love, respect, autonomy, health, and safety through their understanding of the person and the disease. It is important to respect people’s individual preferences and encourage self-care by allowing individuals to do as much for themselves as possible. Good communication skills are critical for creating a positive human environment and caring, trusting relationships. The human environment considers the person’s comfort and happiness. Some strategies for increasing comfort and happiness include creating a comfortable home environment by using plants, pets, fragrances, music. and inviting children tohelp brighten the daily lives of those with dementia.

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Written by: Catherine M. Harris, PhD, RNCS (University of New Mexico College of Nursing), and Juh Hyun Shin, PhD, RN (University of Iowa College of Nursing)

Edited by: Mindy J. Kim-Miller, MD, PhD (University of Chicago School of Medicine)

 

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