Development and Evaluation of the Environment and Communication Assessment Toolkit with Speech-Language Pathologists

Carrie Bruce, M.A., CCC/SLP,1 Jennifer A. Brush, M.A., CCC-SLP,1 Jon A. Sanford, M.Arch,1 and Margaret P. Calkins, Ph.D.1

ABSTRACT

Communication dysfunction that results from dementia can be exacerbated by environmental barriers such as inadequate lighting, noisy conditions, poor or absent environmental cues, and visual clutter. Speech-language pathologists (SLPs) should address these environ- mental barriers as part of a comprehensive treatment plan for clients with dementia. The Environment and Communication Assessment Toolkit for Dementia Care (ECAT) was evaluated by SLPs to determine: (1) changes in awareness of environmental factors prior to and after training; (2) impact of the ECAT on practice as measured by changes in the number of environmental modifications recommended and made prior to and after training; (3) utility of the information as measured by the helpfulness, amount of new information, and usefulness of the ECAT; and (4) usability of the ECAT materials based on ease of use. The SLPs used the ECAT with clients with dementia who had functional limitations and required substantial assistance with daily activities. Results indicate that the ECAT is an effective tool for SLPs, providing information about the impact of the environment on com- munication and supplying sufficient resources to make recommenda- tions and implement effective interventions. The ECAT successfully increased awareness of environmental modifications, influenced the practice of recommending environmental modifications, and had utility

in diverse aspects of clinical practice. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

KEYWORDS: Dementia, environmental modifications, communication environment, environmental interventions

1I.D.E.A.S., Inc., Kirtland, Ohio. Semin Speech Lang 2013;34:42–52. Copyright # 2013 by Address for correspondence: Jennifer A. Brush, M.A., Thieme Medical Publishers, Inc., 333 Seventh Avenue, CCC-SLP, I.D.E.A.S., Inc., 8055 Chardon Rd. Kirtland, New York, NY 10001, USA. Tel: +1(212) 584-4662. OH 44094 (e-mail: [email protected]). DOI: http://dx.doi.org/10.1055/s-0033-1337394. Speech Pathologists in Long-Term Care; Guest Editor, ISSN 0734-0478. Jennifer A. Brush, M.A., CCC-SLP 42 ENVIRONMENT AND COMMUNICATION ASSESSMENT TOOLKIT/BRUCE ET AL 43

Learning Outcomes: As a result of this activity, the reader will be able to (1) describe the impact of the environment on communication of clients with dementia; (2) consider how environmental assessment can be incorporated into existing clinical practices; and (3) identify common environmental modifications that clinicians reported recommending.

Communication disorders associated with Toolkit for Dementia Care (ECAT) that was dementia can lead to agitation, restlessness, and designed to enable clinicians to identify social aggressive or resistive behaviors during assis- and physical environmental barriers and identi- tance with personal care.1–3 These disorders fy environmental interventions that would fa- often result in dependence or excess disability in cilitate communication in individuals with a variety of self-care activities that involve dementia.15 communication between partners, including bathing, dressing, and eating.4–6 Although it is difficult to estimate the full clinical signifi- IMPORTANCE OF THE ISSUE cance of communication problems between care Dementia can affect quality of life, impair level of providers and clients with dementia, improving functioning, reduce social interactions, and pos- communication between these two groups of- sibly result in the expression of behaviors that can fers a very tangible treatment target.7 disrupt communication between care providers Traditionally, communication, like other and care recipients.16,17 This not only creates abilities, has been linked to individuals’ func- stress in care providers but can also negatively tional deficits. However, research has shown affect the efficacy of rehabilitation therapy pro- that communication is also impacted by the grams, as clinicians often “give up” doing therapy environment and that modifications to the when they cannot communicate effectively with environment, such as adjusting light and sound a client.18,19 Moreover, communication deficits levels, can improve communication skills in can lead to reduced participation in social activi- individuals with dementia.8–14 ties and increased social withdrawal.7 Due to their specialized training as well as Concurrently, care environments that neg- their professional scope of practice, speech- atively challenge or do not reinforce the re- language pathologists (SLPs) are in a unique maining skills and abilities of persons with position to address the environmental barriers dementia can lead to excess disability and that affect communication in clients with de- therefore do not support speech therapy goals mentia. However, there have been no compre- or facilitate maintenance of skills learned in hensive assessment tools or educational therapy.20 Recent studies suggest that contex- resources that enable clinicians to evaluate the tual factors play an important role in clients’ communication environment adequately, miti- comfort levels and performance of daily activi- gate the impact of environmental barriers, and ties and, consequently, are vital to providing facilitate communication through environmen- effective care for individuals with dementia.13,21 tal interventions. As a result, the identification For example, van Hoof and colleagues discuss This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. of environmental barriers to and facilitators for how individuals with dementia may not be able effective communication is rarely included in to appropriately communicate their discomfort treatment plans developed for individuals with with environmental stimuli such as air and dementia. When environmental modifications odors, light and lighting, and noise and room are considered in treatment plans, they are, as acoustics and suggest the need to optimize these Bourgeois has suggested, often applied to ev- aspects of the environment based on the known eryone in the same manner, regardless of diag- age- and dementia-related changes a person nosis or severity of symptoms.8 may experience.21 Moyle and colleagues also This article reports on the evaluation of an reported on the use of environmental modifi- assessment protocol and resource guide called cations to decrease negative stimulation that the Environment and Communication Assessment can impact information processing and 44 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 34, NUMBER 1 2013

encourage orientation through improved signs communication between caregivers and resi- and lighting to assist clients who engage in dents with dementia. To demonstrate the ef- wandering behaviors.13 fects of these factors, several studies have Clearly, the American Speech-Language- manipulated lighting and contrast, reduced Hearing Association recognizes the importance noise, and added communication aids or cues of social and physical environment factors on in the long-term care environment to minimize communication as evidenced by its adoption of or eliminate barriers and improve communica- the constructs and language from the World tion and functional abilities. Health Organization’s International Classifica- Lighting and enhanced visual contrast can tion of Functioning, Disability and Health support both communication and the rehabili- (ICF) into its Preferred Practice Patterns for tation process. Lighting and contrast conditions the Profession of Speech-Language Pathology are important to consider as age- and dementia- and Scope of Practice in Speech-Language related changes in the eye and visual processing Pathology.22–24 The ICF is a model of health systems, such as sensitivity to glare, acuity and activity performance that is based on the reduction, impaired motion and color discrimi- interaction between an individual’s body struc- nation, and diminished contrast sensitivity, can ture/functional abilities and the context (includ- have profound negative effects on a client’s ing the physical and social environments) in visual abilities.21,29,30 Noell-Waggoner sug- which activity occurs. Although occupational gests that lighting interventions such as provid- therapists have historically embraced this ing indirect lighting sources that can be ecological, person-environment fit approach adjusted, filtering direct light through sheer through a variety of models that identify the draperies and shades, and incorporating natural complexity of person-environment-occupation lighting are a central part of the foundation of a interactions,25–28 SLPs have limited discipline- supportive environment and a practical inter- specific models and frameworks that compre- vention to support remaining abilities in long- hensively consider person-environment term care, including supporting communica- interactions. tion.31 For example, a study to examine the Despite the lack of person-environment impact of improved lighting and table setting interaction resources geared to the profession, contrast on clients’ oral intake during meals SLPs are held accountable for promoting im- found that these modest environmental changes proved “quality of life by reducing impairments had positive effects not only on caloric intake, of body functions and structures, activity limi- but also on the frequency of client-staff con- tations, participation restrictions, and barriers versations, the frequency with which clients created by contextual factors.”24 This suggests started conversations, and the number of ques- that it is necessary for clinicians to understand tions that clients answered with on-topic the relationship between environmental factors responses.32 and a client’s communication abilities as well as Changes to the auditory environment can identify environmental interventions to improve also lead to more focused and less stressed the client’s communication performance. To this interactions, making communication easier be- end, the ICF clearly provides an important tween people with dementia and their care This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. framework for SLPs to represent how a client’s providers. The person’s ability to use compen- functional characteristics, such as vision and satory strategies to overcome normal age-relat- hearing, can interact with the physical and social ed declines in hearing is negatively influenced environment to impact how he or she commu- by dementia.33 Reducing noise through modi- nicates while performing activities of daily living. fying sound levels and introducing better acous- tic materials has been shown to enhance sleep,34–36 which could reduce daily fatigue ENVIRONMENTAL FACTORS AND and delirium that also impede communication. COMMUNICATION Other studies have suggested that noise can A variety of environmental factors, including cause significant stress in people with dementia the visual and auditory environments, can affect and that building design should focus on ENVIRONMENT AND COMMUNICATION ASSESSMENT TOOLKIT/BRUCE ET AL 45 reducing distressing noise levels and introduc- ment process to determine how communication ing calming sounds.37–40 can be improved. Another example, Blackstone Supplementing the environment with and Hunt Berg’s Social Network, examines communication aids or cues has also been social environmental aspects such as effective shown to increase communication between staff communication strategies for specific commu- and people with dementia. Several researchers nication partners.51 Although both of these have reported success using verbal announce- examples demonstrate concern for the commu- ments and signs,41,42 cue cards,43 diaries and nication environment in making decisions for watches,44 and memory aids.45–48 Memory evaluation and treatment, neither provides suf- books with autobiographical information and ficient guidance on the specific features (e.g., daily schedules with prompts have also been lighting) of the environment that should be reported to increase clients’ frequency of utter- investigated, attributes that should be measured ances, duration of speaking time, and range of (e.g., light level), or the best treatment inter- discourse characteristics.49 ventions for a specific deficit.

LIMITATIONS OF CURRENT SLP AIM OF THE PRESENT STUDY ASSESSMENT PRACTICES The ECAT was developed by a team of SLPs Despite the importance of environment factors, and architectural researchers specializing in clients’ communication performance is often environments for people with dementia, with assessed in a clinical setting that does not reflect a large contribution from a multidisciplinary the environment in which the client typically advisory panel of experts in communication spends time. In a long-term care setting, for disorders, dementia, and environmental inter- instance, a clinician may take clients to an office ventions for people with dementia. The ECAT to assess speech, language, or cognitive func- provides background information about the tioning. Unfortunately, the way that a person impact of the environment on communication, performs in a therapy office may be quite an assessment protocol as well as resources that different than the way she performs in places clinicians can use to measure the environment, where there are a greater variety of different and a compendium of typical environmental contextual factors such as background noise, modifications from which clinicians can make lighting levels, or visual stimulation. A clinician informed recommendations for intervention. It must understand how important it is to assess is particularly sensitive to the communication both how a client performs in a clinical setting needs of older people with speech, language, as well as in the day-to-day living setting. cognitive, and sensory impairments (because Although typical speech-language pathol- people with dementia typically experience mul- ogy communication performance assessments tiple comorbidities) who live in long-term care do not include environmental factors, a few settings. exceptions are found within certain specialty The ECAT has three components (the areas of speech-language pathology practice Manual, Assessment Tools, and Intervention such as augmentative and alternative commu- Resources), which have been designed for This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. nication. For example, Beukelman and Mir- clinicians to evaluate both public (e.g., dining enda developed the Participation Model for and living rooms) and personal (e.g., resident assessment that includes social and physical bedrooms and bathrooms) spaces in the long- aspects of the environment.50 The social envi- term care setting. The manual primarily focuses ronment sections include communication part- on providing background information on de- ner skills and knowledge, policy and practice mentia and the impact of the environment on barriers, and attitudinal issues. The physical communication (Introductory Materials). It environment component addresses how adap- also includes descriptions of environmental tations to physical spaces, locations, or struc- modifications and links them to specific func- tures (e.g., lowering a table to an appropriate tional limitations that effect communication height) should be explored during the assess- (Environmental Intervention Strategies). The 46 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 34, NUMBER 1 2013

Assessment Tools component contains instruc- • Time 4 (T4) was an optional survey given tions on evaluating the environment using the 3 months after the formal study finished to see provided assessment instruments including if and how SLPs were still using the ECAT questionnaires that guide the clinician through voluntarily. evaluating the environment, sound and light level meters and usage instructions (Using Awareness was assessed by changes in knowl- Light and Sound Level Meters), a reading edge of environmental modifications based on test that helps identify the appropriate text scores between T1 and T2, assessed using an size for the client, a contrast scale to determine online 10-item test of material in the ECAT. the optimal levels for the client, and a compen- Impact was evaluated by the changes in the dium of potential environmental modifications number of clinicians making environmental to support communication (Assessment Refer- modifications and number of modifications ence). The Intervention Resources component recommended between T1 and the T3 (2 includes details on types of lighting and re- months after posttraining) and T4 (5 months search about the effects of lighting as well as after posttraining) periods. Utility was assessed reproducible communication environment ma- at T3 and T4 by SLPs’ evaluation of the terials such as sequencing cue cards (Sequenc- helpfulness of the materials, usefulness of the ing Cards) and signs. information, and the amount of new informa- This article reports on the effectiveness of tion that specific parts of the ECAT added to the ECAT in meeting the practice needs of the participant’s clinical knowledge. Usability SLPs in long-term care settings for determin- was assessed by ratings of the ease of using the ing environmental barriers to communication materials at T3 and T4. among clients with dementia and developing strategies for environmental modifications to facilitate communication. Effectiveness of the PARTICIPANTS ECAT was measured by four factors: aware- A total of 71 clinicians (i.e., SLPs, nurses, ness, impact, utility, and usability. physical and occupational therapists) were recruited to evaluate the ECAT while using it with clients who had a diagnosis of demen- METHODS tia. All of the clinicians reported providing This study was conducted over a 12-month services for clients with dementia who had period, and data were collected through ques- functional limitations performing activities of tionnaires administered at four points in time daily living. Therapeutic interventions during and treatment plan information on clients col- the study addressed cognition, dysphagia, ex- lected twice. pressive/receptive communication, fine motor coordination, gross motor coordination, • Time 1 (T1) included a pretest focusing on physical aspects of eating, and/or range of clinicians’ general knowledge of environmen- motion. tal modifications and treatment plan infor-

This article focuses on results only from This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. mation for two clients with dementia with the SLPs. At the pretraining phase (T1), the whom the clinicians worked in the previous sample was comprised of 28 SLPs, all of whom 2 months. were women. More than 96% of the partic- • Time 2 (T2) was the posttest taken within ipants were Caucasian (n ¼ 25), with the 1 month of receipt of the ECAT for knowl- remaining three clinicians being African- edge gain after reading the ECAT. American, Hispanic, and American-Indian • Time 3 (T3) was a survey given after 2 months ethnicities. The participating clinicians ranged of using the ECAT with two clients and inagefrom20to60years,althoughthevast treatment plan information for two clients majority were between the ages of 20 and with dementia with whom clinicians worked 40 years (n ¼ 20). One clinician dropped out in the previous 2 months. before T2 and five clinicians dropped out ENVIRONMENT AND COMMUNICATION ASSESSMENT TOOLKIT/BRUCE ET AL 47 before T3. This left 22 clinicians remaining for their two clients. This increased to 4.8 at T3 and the T3 period. At T4, 5 months after post- to 7.35 at T4. Post hoc analyses indicate that training, 18 of the T3 clinicians completed the there were significant differences between T1 questionnaire, 16 of whom had voluntarily and T4 (p ¼ 0.001) and T3 and T4 continued to use the ECAT as part of their (p ¼ 0.007), although the difference between clinical practice. T1 and T3 was not significant. The three most common recommenda- tions were: create external memory aids RESULTS (84.2%), reduce noise (82.8%), and provide We were interested in individual SLP perfor- signage (78.3%). From T1 to T4, there were mance over time and used paired t tests in the significant increases in several modifications analysis. Therefore, data are only reported for including: maximize visibility of toilet clinicians who completed the relevant assess- (p ¼ 0.004); label items (p ¼ 0.012); make ments for each factor. bedroom visually distinctive (p ¼ 0.016); modify closet ( p ¼ 0.028); and improve access to TV, radio, or phone ( p ¼ 0.038). Awareness In addition, several modifications that did not Using a paired sample t test, the clinicians who reach statistical significance between T1 and took the pretest had a mean score of 5.19% on T4 demonstrated a clear trend of approaching the 10-item knowledge test at T1. At T2, after significance. These included: increase con- training with the ECAT materials, the same trast, which increased from 56.3% at T1 to clinicians (n ¼ 24) scored almost 1.6 percent- 93.8% at T4 (p ¼ 0.052); improve way-find- age points higher, a 30% change in score ing cues, which increased from 50.0% at T1 to (6.77%; p < 0.000). 81.3% at T4 (p ¼ 0.055); modify lighting controls, which increased from 12.5% at T1 to 43.8% at T4 (p ¼ 0.064); enhance lighting, Impact which increased from 56.3% at T1 to 87.5% at Impact was assessed in several ways. First, the T4 (p ¼ 0.070); and rearrange furniture, number of clinicians who made modifications which increased from 43.8% at T1 to 75.0% was tracked. Second, the number of modifica- at T4 (p ¼ 0.070). tions they recommended was recorded. Finally, cost of modifications implemented was also COST OF ENVIRONMENTAL MODIFICATIONS tracked. Among those clinicians who responded to questions of cost, there were no significant NUMBER OF CLINICIANS WHO MADE differences in cost of environmental modifica- ENVIRONMENTAL MODIFICATION tions across T1, T3, and T4. Among the 11 RECOMMENDATIONS clinicians who reported on cost for their two At T1 baseline, prior to implementing the clients at T1, over one-third (36.4%) of the ECAT, 62% of the clinicians recommended clinicians reported that the modifications didn’t at least one environmental modification for cost anything, almost half (45.5%) indicated This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. their clients. At T3, the overall frequency of that modifications cost between $1 and $100, clinicians who made recommendations in- and the remainder (9.1%) reported that the creased slightly to 64%. The overall frequency modifications cost between $101 and $250. of clinicians making recommendations in- When asked about the cost of their most creased to 89% at T4. successful environmental modification, all of the clinicians reported that the cost was less NUMBER OF ENVIRONMENTAL MODIFICATION than $100. At the end of the study (T4), the RECOMMENDATIONS percentage of clinicians making modifications At T1, the clinicians who reported recommend- for less than $100 was 87.5%. Again, 100% ing environmental modifications recommended reported the cost of their most successful mod- an average of 4.75 modifications for each of ification at less than $100. 48 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 34, NUMBER 1 2013

Utility that the information was easy to understand, with the majority (52.4%) rating the strength HELPFULNESS of agreement at 6 on the 7-point scale. Clinicians were asked to rate the helpfulness of Eighteen (85.7%) had some level of agree- the ECAT during the first 2 months after ment (rating 5, 6, or 7) with the statement training (T3) on a 4-point Likert scale. Over that the ECAT was easy to use, with the half the SLPs (56.4%) gave the ECAT the majority (42%) rating the ease of use as 6. highest rating (very helpful), whereas 22.2% Only one clinician reported that she had some rated it a 2 and 16.8% rated it as somewhat difficulty matching her findings to potential helpful (score of 3). modifications.

NEW INFORMATION At T3, the degree of new information included DISCUSSION in the different sections of the ECAT was rated This study demonstrated that the ECAT is an on a 4-point scale from 1, “all of the information effective tool for clinicians in providing infor- was new,” to 4, “none of the information was mation about the impact of the environment on new.” Overall, 54% of the information from communication and provides resources to make different sections was rated as “all” or “most” of and implement recommendations for interven- it being new, and only 6% of the sections were tions. Overall, the ECAT demonstrated success rated as having no new information. The SLPs in improving awareness of environmental mod- were least familiar with the environmental ifications, affecting the practice of recommend- strategies and sound and light meter use (64% ing environmental modifications, having utility and 81% rating these as all or mostly new in diverse aspects of clinical practice, and being information, respectively) and were most famil- usable. The ECAT was also valuable in that it iar with sequencing cards (52% indicating there facilitated treatment for clients with dementia was some or no new information). who had a range of functional limitations and difficulties with various activities of daily living USEFULNESS that required speech-language pathology Every clinician indicated at T3 that the ECAT services. provided new treatment options to use with The most valuable findings were related to clients with dementia. The usefulness of the the significant increase in the number and type ECAT was further assessed on a 7-point Likert of modifications that clinicians recommended scale on seven questions about future use in after training with and using the ECAT. On practice, information usefulness, practice value, average, the frequency of recommendations and usefulness in working with clients, care rose almost 25% over the course of the study, assistants, families, and administration. At T3, indicating that clinicians were recommending the overall mean response to all of the questions more environmental modifications per client at was 5.55, and this increased to 6.02 at T4. Some the end of the study compared with the start. A of the strongest responses at T4 were: it had majority of the recommendations made by useful information (90.5% largely or strongly clinicians focused on supporting clients through This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. agreed), added value to their clinical practice modifications that optimize cognitive aspects of (76.2% largely or strongly agreed), and they will the environment such as labeling items, provid- use it in the future (71.4% largely or strongly ing time orientation cues, developing sequenc- agreed). ing cues, creating external memory aids, and providing signage. Clinicians overwhelmingly stated that the Usability ECAT added value to clinical practice and The usability of the ECAT was measured at would benefit their clients. Additionally, all of T3 on a 7-point Likert scale to assess how the clinicians reported that the ECAT provided easy the information was to understand and more treatment options for their clients and all use. Twenty of 21 respondents (95.2%) agreed but one indicated they would continue to use ENVIRONMENT AND COMMUNICATION ASSESSMENT TOOLKIT/BRUCE ET AL 49 the ECAT in the future. Furthermore, the ACKNOWLEDGMENTS usability of the ECAT was rated positively, This research was supported through NIH with a majority of the clinicians reporting that it grants #DC008916 awarded to I.D.E.A.S., was easy to use and the information was easy to Inc. We would also like to thank Amanda understand. Kerr and Hannah Fleder for their help in This study had some limitations that assisting the research team. should be noted. As is typical in longer-term studies, we had some attrition in participants over time. Despite this decline in subjects, 16 of REFERENCES the 18 SLPs who responded at T4 indicated that they continued to use the ECAT with 1. Kolanowski AM, Richards KC, Sullivan SC. Deri- clients, even though this was not requested as vation of an intervention for need-driven behavior. Activity preferences of persons with dementia. part of the study. Our goal at T4 was to J Gerontol Nurs 2002;28:12–15 determine if clinicians who had been trained 2. Swearer J, Drachman D, O’Donnell B. Trouble- with the ECAT would continue to use it some and destructive behaviors in dementias. J Am voluntarily. Not only did the majority of T3 Geriatr Soc 1998;36:784–790 SLPs (72%) continue to use it, but more 3. Teri L, Larson EB, Reifler B. Behavior disturbance environmental interventions were being includ- in dementia of the Alzheimer types. J Am Geriatr ed in treatment plans over time. The sustained Soc 1988;37:109–116 4. Brush JA, Threats TT, Calkins MP. Influences on interest in using the ECAT indicates that the perceived function of a nursing home resident. J ECAT is valued among SLPs as a useful clinical Commun Disord 2003;36:379–393 treatment resource for working with clients 5. Sloane PD, Hoeffer B, Mitchell CM, et al. Effect who have dementia. of person centered showering and the towel bath on Another limitation was our lack of com- bathing-associated aggression, agitation, and dis- parison to a control group that did not receive comfort in nursing home residents with dementia: a the ECAT. Although this was partially ad- randomized, controlled trial. J Am Geriatr Soc 1994;S2:795–804 dressed through the pre- and postdesign of this 6. Sloane PD, Honn VJ, Dwyer SAR, Wieselquist J, study, it would be useful in the future to Cain C, Myers S. Bathing the Alzheimer’s patient compare trained and untrained groups over in long term care: results and recommendations time, particularly to make associations between from three studies. Am J Alzheimer Dis 1995;10: clients’ functional limitations, activity difficul- 3–12 ties, and skilled services to recommended envi- 7. Potkins D, Myint P, Bannister C, et al. Language ronmental modifications. Finally, our data are impairment in dementia: impact on symptoms and care needs in residential homes. Int J Geriatr all based on self-reports from clinicians, which Psychiatry 2003;18:1002–1006 introduces possible problems with inaccurate 8. Bourgeois MS. Communication treatment for recall of client or modification details. adults with dementia. J Speech Hear Res 1991; The overall goal of speech-language pa- 34:831–844 thology intervention is to optimize an indi- 9. Gottesman LE. Resocialization of the geriatric vidual’s ability to communicate in ecologically mental patient. Am J Public Health Nations Health valid environments. Therefore, having a focus 1965;55:1964–1970 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. 10. Kihlgren M, Bra˚ne G, Karlsson I, Kuremyr D, on an environment that supports an individu- Leissner P, Norberg A. Long-term influences on al’s communication needs becomes an impor- demented patients in different caring milieus, a tant and necessary part of the rehabilitation collective living unit and a nursing home: a descrip- process. The ECAT both supports systematic tive study. Dementia 1992;3:342–349 and individualized assessment of the environ- 11. McCracken AL, Fitzwater E. The right environ- ment and provides education and resources on ment for Alzheimer’s: which is better - open versus barriers and facilitators to effective communi- closed units? Here’s how to tailor the answer to the patient. Geriatr Nurs (Minneap) 1989;10:293–294 cation that will enable clinicians in long-term 12. Melin L, Go¨testam KG. The effects of rearranging care settings to minimize or eliminate barriers ward routines on communication and eating be- to communication and introduce communi- haviors of psychogeriatric patients. J Appl Behav cation facilitators. Anal 1981;14:47–51 50 SEMINARS IN SPEECH AND LANGUAGE/VOLUME 34, NUMBER 1 2013

13. Moyle W, Olorenshaw R, Wallis M, Borbasi S. 28. Kielhofner G. A Model of Human Occupation: Best practice for the management of older people Therapy and Application. 2nd ed. Baltimore, MD: with dementia in the acute care setting: a review of Williams & Wilkins; 1995 the literature. Int J Older People Nurs 2008;3: 29. Brawley EC. Designing for Alzheimer’s Disease. 121–130 Strategies for Creating Better Care Environments. 14. Skea D, Lindesay J. The evaluation of two models New York, NY: John Wiley and Sons, Inc.; 1997 of long-term residential care for elderly people with 30. Kergoat H, Kergoat MJ, Justino L, Robillard A, dementia. Int J Geriatr Psychiatry 1996;11:233– Bergman H, Chertkow H. Normal optic nerve 241 head topography in the early stages of dementia 15. Brush J, Calkins M, Bruce C, Sanford J. Environ- of the Alzheimer type. Dement Geriatr Cogn ment and Communication Assessment Toolkit for Disord 2001;12:359–363 Dementia Care (ECAT). Baltimore, MD: Health 31. Noell-Waggoner E. Light: an essential interven- Professions Press; 2012 tion for Alzheimer’s disease. Alzheimer’s Care 16. Hopper T. Long-term care residents with demen- Quarterly 2002;3:343–352 tia: assessment and intervention. The ASHA Lead- 32. Brush J, Meehan R, Calkins M. Using the envi- er 2004;24:10–11 ronment to improve intake for people with demen- 17. Le Dorze G, Julien M, Genereux S, LArfeuil C, tia. Alzheimer’s Care Quarterly 2002;3:330–338 Nacennec C, LaPorte D, Chanpagne C. The 33. Weaverdyck SE. Intervention to address dementia development of a procedure for the evaluation of as a cognitive disorder. In: Coon DH, Ed. Spe- communication occurring between residents in cialized Dementia Care Units. Baltimore, MD: long-term care and their caregivers. Aphasiology John Hopkins University Press; 1991:224–244 2000;14:17–51 34. Berg S. Impact of reduced reverberation time on 18. Steeman E, Abraham IL, Godderis J. Risk profiles sound-induced arousals during sleep. Sleep for institutionalization in a cohort of elderly people 2001;24:289–292 with dementia or depression. Arch Psychiatr Nurs 35. Novaes MA, Aronovich A, Ferraz MB, Knobel E. 1997;11:295–303 Stressors in ICU: patients’ evaluation. Intensive 19. Williamson GM, Schulz R. Coping with specific Care Med 1997;23:1282–1285 stressors in Alzheimer’s disease caregiving. Geron- 36. Southwell MT, Wistow G. Sleep in hospitals at tologist 1993;33:747–755 night: are patients’ needs being met? J Adv Nurs 20. Helen C. Doing lunch: a proposal for a functional 1995;21:1101–1109 well-being assessment. Alzheimer’s Care Quarterly 37. Bakker R. Sensory loss, dementia, and environ- 2002;3:302–315 ments. Generations 2003;27:46–51 21. van Hoof J, Kort H, Duijnstee M, Rutten P, 38. Burgio L, Scilley K, Hardin JM, Hsu C, Yancey J. Hensen J. The indoor environment and the inte- Environmental “white noise”: an intervention for grated design of homes for older people with verbally agitated nursing home residents. The dementia. Build Environ 2010;45:1244–1261 Journals of Gerontology: Series B 1996;51B: 22. World Health Organization. International Classi- P364–P373 fication of Functioning, Disability and Health. 39. Day K, Carreon D, Stump C. The therapeutic Geneva, Switzerland2001 design of environments for people with dementia: a 23. American Speech-Language-Hearing Association review of the empirical research. Gerontologist Preferred Practice Patterns for the Profession of 2000;40:397–416 Speech-Language Pathology; 2004. Available at: 40. Dewing J. Caring for people with dementia: noise www.asha.org/policy. Accessed on February 26, and light. Nurs Older People 2009;21:34–38 2013. 41. Hanley IG. The use of signposts and active training

24. American Speech-Language-Hearing Association to modify ward disorientation in elderly patients. J This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Scope of Practice in Speech-Language Pathology; Behav Ther Exp Psychiatry 1981;12:241–247 2007. Available at: www.asha.org/policy. Accessed 42. McClannahan LE, Risley TR. Design of living on February 26, 2013. environment for nursing home residents: recruiting 25. Christiansen C, Baum C. Occupational Therapy: attendance at activities. Gerontologist 1974; Enabling Function and Well-Being. 2nd ed. 14:236–240 Thorofare, NJ: Slack, Inc.; 1997 43. Smith WL. Behavioral interventions in gerontolo- 26. Dunn W, Brown C, McGuigan A. The ecology of gy: management of behavior problems in individu- human performance: a framework for considering als with Alzheimer’s disease living in the the effect of context. Am J Occup Ther 1994; community. In: Association for Behavior Analysis 48:595–607 Convention. Philadelphia, PA, 1988 27. Hagedorn R. Occupational Therapy: Perspectives 44. Hanley IG, Lusty K. Memory aids in reality and Processes. Edinburgh, Scotland: Churchill orientation: a single-case study. Behav Res Ther Livingstone; 1995 1984;22:709–712 ENVIRONMENT AND COMMUNICATION ASSESSMENT TOOLKIT/BRUCE ET AL 51

45. Bourgeois MS. Enhancing conversation skills in 49. Bourgeois M, Dijkstra K, Burgio L, Allen-Burge patients with Alzheimer’s disease using a prosthetic R. Memory aids as an augmentative and alternative memory aid. J Appl Behav Anal 1990;23:29–42 communication strategy for nursing home residents 46. Bourgeois M. Conversing with Memory Impaired with dementia. Augment Altern Commun 2001; Individuals using Memory Aids. Gaylord. MI: 17:196–210 Northern Speech Services; 1992 50. Beukelman D, Mirenda P. Augmentative & Alter- 47. Bourgeois MS. Evaluating memory wallets in native Communication. 3rd ed. Baltimore, MD: P. conversations with persons with dementia. J Speech H. Brookes; 2005 Hear Res 1992;35:1344–1357 51. Blackstone SW, Hunt Berg M. Social Networks: 48. Mateer C, Sohlberg M. A paradigm shift in An Assessment and Intervention Planning memory rehabilitation. In Whitaker H, Ed. Inventory for Individuals with Complex Com- Neuropsychological Studies of Non-focal Brain munication Needs and Their Communication Injury: Dementia and Closed Head Injury. New Partners. Monterey, CA: Augmentative Commu- York, NY: Springer-Verlag; 1998:202–225 nication; 2002 This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.