Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-5 for details. Applying the Person–Environment–Occupation Model to Improve Dementia Care

Carin Wong, MS staff. The CNA went on to describe that this behavior disrupted USC Mrs. T.H. Chan Division of Occupational Science and Occupational the other residents trying to eat in the dining room. In response Therapy in the Herman Ostrow School of Dentistry to the escalation of behaviors, the CNA reported that they had University of Southern California, Los Angeles stopped trying to feed her and left her alone. Concerned about Mrs. Jones’ risk for weight loss, an occupational therapy screen Natalie E. Leland, PhD, OTR/L, BCG, FAOTA was requested. USC Mrs. T.H. Chan Division of Occupational Science and Occupational On observing Mrs. Jones in the dining room, the occupa- Therapy in the Herman Ostrow School of Dentistry tional therapist (OT) noticed that she was sitting at a table with University of Southern California, Los Angeles a white tablecloth, and her food included mashed potatoes, cauliflower, and diced chicken served on a white plate. When This CE Article was developed in collaboration with the AOTA’s observing Mrs. Jones and the CNA staff, the OT also noticed Productive Aging Special Interest Section. that the staff positioned themselves to either Mrs. Jones’ left or right when trying to encourage her to eat, as they were often also encouraging other residents to eat and/or feeding other ABSTRACT residents at the same time. When interacting with Mrs. Jones, it The purpose of this article is to introduce the Person–Environ- was evident that the staff had startled her, which then triggered ment–Occupation (PEO) Model as a framework to improve her agitation and yelling. The OT determined that the barriers dementia care in nursing homes and provide examples from to feeding included lack of contrast among the table, plate, and literature that can be framed within the model. The interaction food, as well as staff being positioned outside of Mrs. Jones’ between the person, environment, and occupation is described line of sight, thereby limiting initiation of self-feeding and to promote participation and provide quality care for residents facilitating the negative behaviors. On completing the occupa- with dementia. The PEO model can be used by occupational tional therapy evaluation, the therapist determined three areas therapy practitioners to develop innovative approaches to relating to feeding that needed to be addressed: (1) the environ- dementia care and improve quality of life. ment (e.g., adding more color contrast to the place setting), (2) Mrs. Jones’ positioning during meals, and (3) staff training on LEARNING OBJECTIVES strategies for feeding. After reading this article, you should be able to: Occupational therapy addressing the environment. Based 1. List the components of the PEO Model on her knowledge of dementia and understanding of the envi- 2. Differentiate the relationships within the PEO Model ronment’s role in self-feeding for persons with dementia, the OT 3. Identify the different components that consist of the person, identified that limited color contrast was an issue. Specifically, environment, and occupation as dementia progresses, an individual’s vision changes, resulting 4. Identify strategies for engaging nursing home residents with in greater difficulty distinguishing objects of similar color. Thus, dementia within the PEO Model a white plate on a white tablecloth with mostly white food was difficult to see. To address this barrier, the OT worked with the CASE EXAMPLE kitchen and CNA staff to provide a colored plate for Mrs. Jones The charge nurse on the nursing home unit entered the dining to create contrast between the food and table. room at lunchtime and observed Mrs. Jones sitting at her table, Occupational therapy enhancing resident-staff interac- but she was not eating. The food on her plate had not been tions during eating—positioning and approach. Based on touched. Mrs. Jones had previously been able to eat inde- her clinical training, the OT knew that it was more effective to pendently after food was set up in front of her, although she sit directly in front of the individual with dementia so as not required additional time to do so. After observing Mrs. Jones to startle them. As dementia progresses, peripheral vision can for a few minutes, the charge nurse approached the certified decrease over time. Thus, sitting to the side of the resident is nursing assistant (CNA) and asked about Mrs. Jones’s status. confusing, as the staff person is not in a direct line of sight and The CNA stated that this pattern of behavior had been occurring has an unfamiliar voice, which triggers anxiety and resistance. for a few weeks. The CNA and other CNAs had tried to feed her, In response, the OT educated and trained the day shift CNAs on but Mrs. Jones would get agitated, start yelling, and try to hit the the recommended place to sit when working with Mrs. Jones,

WWW.AOTA.ORG ARTICLE CODE CEA0518 CE-1 Continuing Education Article Download the CE Exam Click here to purchase and take the exam for CE credit. including suggestions for positioning for the CNAs and Mrs. of independence (Nazarko, 2009). To understand and identify Jones. the best interventions to inform a person-centered approach Specifically, in the dining room, there were tables set for up to dementia care in a nursing home, the purpose of this article to six people as well as smaller café tables for two people. The is to situate occupational therapy practitioners’ approaches to OT and CNAs tried having Mrs. Jones eat at one of the café dementia care within the context of the person–environment– tables during her meals, which was deemed successful, as the occupation (PEO) theoretical framework. agitation and yelling decreased and feeding improved. To ensure follow through, the therapist worked with the various CNA PEO MODEL shifts to promote carryover and ensure that the staff sat directly The PEO Model was developed to provide a framework for deliv- in front of her, providing one-step prompts to eat. Finally, a ering services that encompass a client-centered approach (Law training session was scheduled with the family members that et al., 1996). There are three components to the model: the came in each weekend for Sunday lunch to educate them on the person, the environment, and the occupation (Law et al., 1996). new strategies for meals. Before discharge from occupational The person is an individual with a unique set of identities, expe- therapy services, the therapist provided one-on-one training riences, and abilities. The environment is a broad domain that sessions with each of the CNAs in the facility and documented comprises physical, social, cultural, and socio-economic factors. the resulting maintenance program, summarizing the recom- Occupation refers to the functional tasks and activities that the mendations for Mrs. Jones. Copies of the detailed document individual engages in. The PEO Model is built on the theory were placed in the CNA communication log as well as Mrs. that interaction of the person, environment, and occupation Jones’ chart and served as a guide for CNA staff caring for her in facilitates participation. If there is a good fit of these constructs, the future. The guidance included: meaningful participation increases, whereas a poor fit can • Using a colored plate for all meals threaten engagement or performance. The fit between the PEO • Sitting at one of the café tables for two, with the CNA interaction is defined by the quality of a person’s experience sitting across from Mrs. Jones, directly in her line of sight with regard to their level of satisfaction and functioning (Strong • Limiting communication to simple, one-step commands et al., 1999). in an effort to prompt Mrs. Jones to eat, thereby limiting Consequently, the interconnected relationship presented in excessive side conversations, which were a distraction and the PEO Model can provide a framework for understanding peo- confusing ple with dementia and provide client-centered care. By encom- passing the person with the occupation and nursing home INTRODUCTION environment, different factors interact as a barrier or facilitator As the U.S. population ages, the number of people with demen- to providing quality care. Specifically, the PEO Model can be tia will continue to increase (Alzheimer’s Association, 2014; used to understand and develop person-centered interventions Ortman et al., 2014). As dementia progresses from the early for people with dementia. to late stages of the disease, it causes cognitive decline, the inability to make decisions or communicate, and a decrease in DEMENTIA WITHIN THE PEO MODEL functional and cognitive abilities (McDonald et al., 2010). As Within each domain, several factors interact with and influence the disease advances, people require more assistance with their dementia care (see Figure 1 on p. CE-3). The person domain ADLs and other unmet care needs, which can lead to long-term includes the physical and cognitive levels of people with demen- nursing home placement (Zimmerman et al., 2013). As of 2012, tia as well as their attitudes, preferences, and personality before residents with dementia made up 48.5% of the nursing home the diagnosis. Individuals with dementia may experience mem- population, a percentage that is expected to increase as the pop- ory loss, confusion, unclear thinking, decline in problem-solv- ulation ages (Harris-Kojetin et al., 2013; Ortman et al., 2014). ing skills, loss of interest in usual activities, and behavioral This client population is at risk for poor outcomes, including symptoms (e.g., aggression, agitation, anxiety), which can affect weight loss, accidental falls, morbidity, and mortality (Navar- their ability to participate in activities and overall quality of life ro-Gil et al., 2014; Sylliaas et al., 2012). Thus, the Centers for (Torpy et al., 2004). The environment domain focuses on both Medicare & Medicaid Services (CMS; 2013) has identified indi- the physical and social contexts. The physical environment for viduals with dementia as a high priority population in need of a long-term nursing home resident with dementia includes the quality improvement. The CMS initiative emphasizes enhancing physical structure of the nursing home, such as the indoor and client outcomes and overall quality of life through person-cen- outdoor space, including lighting, noise, placement of furniture, tered approaches. To this end, federal priorities are bringing and outdoor resident areas (Degenholtz et al., 2006). The social client-centered care to the forefront of health care delivery. environment in this context incorporates the facility policy; Client-centered care is an important component to provid- administrative and nursing staff; other residents in the facility; ing quality dementia care by enabling the individual to retain and family, caregiver, and friend support (McFadden & Lun- personal worth, decision-making opportunities, and a feeling sman, 2010). For people with dementia, the occupation domain

CE-2 ARTICLE CODE CEA0518 MAY 2018 Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page CE-5 for details.

Figure 1: The Person-Environment-Occupation Model for dementia Person • Physical Level • Cognitive Level • Preferences • Attitudes Participation • Personality

Environment • Physical environment: Occupation • Nursing home • Routine residence • Frequency • Social environment: • Methods • Nursing Staff • Tasks • Residents • Meaning • Family/caregiver support

includes the activities provided in the nursing home, routines, recommended changes to her environment to accommodate her and the timing and required abilities for these tasks. visual impairment. The degree of overlap among the person, environment, and Research has evaluated the effect of physical environment occupation factors reflects the ability of participation among modifications on the negative behavioral symptoms among residents with dementia. When the environment and occupa- individuals with dementia, specifically symptoms of agitation, tion adjust to the abilities of the person, then participation is aggression, and anxiety (Maseda et al., 2014; Milev et al., considered successful. 2008). Intervention approaches include altering the appearance of a typical nursing home to create multiple small-scale and RELATIONSHIP BETWEEN PERSON AND ENVIRONMENT home-like facilities and creating multisensory stimulation envi- The primary focus of research exploring the person and envi- ronments, which were found to improve the quality of life for ronment interaction has been on the physical environment. residents (Maseda et al., 2014; Milev et al., 2008; Verbeek et al., The physical environment of a nursing home includes the 2009). Implementing a multisensory stimulation environment resident’s bedroom and bathroom, common areas, lounges, and increased activity engagement and improved behavior and mood dining rooms as well as the lighting, space, and life-enriching for residents in nursing homes (Maseda et al., 2014; Milev et al., features in these areas (Degenholtz et al., 2006). According to 2008). The multisensory stimulation environment can adjust to Degenholtz and colleagues (2006), residents with lower levels the preferences and the abilities of the individual to reflect the of cognitive or functional abilities report a higher quality of life person–environment interaction. when living in an environment with life-enriching features and Research has also demonstrated improvement in client less noxious stimuli. As shown in the PEO Model, the environ- outcomes when the social environment is modified to support ment is able to promote the person’s functional and cognitive individuals with dementia. When equipped with the knowl- skills, and allow the individual to adapt to their health declines. edge to understand dementia symptoms, the progression of the This is reflective of Mrs. Jones’ case example, where the OT disease, and the cause of negative behaviors, nursing staff were

MAY 2018 ARTICLE CODE CEA0518 CE-3 Continuing Education Article Download the CE Exam Click here to purchase and take the exam for CE credit. able to implement behavioral management programs to provide and wandering (Kovach, 2000). Kovach and colleagues (2004) better care for the residents and reduce behavioral symptoms believed arousal imbalance, defined as being awake in an arousal (DeYoung et al., 2002; Galik et al., 2008). The person–envi- state for 1.5 hours or longer without any change, causes those ronment interaction between the nursing staff and the individ- behavioral symptoms. Lack of activity for a period of time or ual’s health status ameliorated some of the negative effects of overstimulation results in imbalance. After observing the Mrs. dementia. Jones’ daily routines, the OT adjusted her daily activity schedule For residents with dementia, their family and caregivers are accordingly to reduce the occurrence of arousal imbalance. also an integral component of the social environment. Having Within the PEO framework, occupations take into the contact and meaningful engagement with family can contribute account the timing and frequency of the task, and how it can to the psychosocial well-being of residents, even those with affect the person. If an activity is given when a resident is over- limited cognitive abilities (Bauer & Nay, 2003). To maintain the stimulated, then negative outcomes can occur, such as aggres- relationship between the resident and their family, one study sion. However, if there is a fit with the timing and frequency incorporated family participation into the activity program at of the activity, then the resident will become engaged (Kovach, the nursing home (Cochran et al., 2001). Family and significant 2000; Kovach et al., 2004). For Mrs. Jones, understanding her others were invited to attend certain activity programs, which routines and the best time to have meals could affect whether were found to increase engagement and interaction among the she engaged in eating. resident, family members, and staff. Research on the relationship between the person and envi- RELATIONSHIP BETWEEN ENVIRONMENT AND OCCUPATION ronment has shown that the environment encompasses differ- Changes in the environment can be facilitators of or barriers ent factors (physical and social). The different components that to the outcomes of occupations. A few studies have examined make up the environment can influence the person’s abilities the effects of environmental design on activities as occupa- and functional level. When the environment is adapted to meet tions. Cutler and colleagues (2006) evaluated a set of nursing the needs of the person, it can improve participation among home facilities and found that many of the residents’ rooms and residents with dementia. other parts of the facility were often bare. Living in facilities that cause sensory deprivation have been found to exacerbate THE RELATIONSHIP BETWEEN PERSON AND OCCUPATION negative behavioral symptoms, which can lower overall quality The person–occupation relationship examines how the activity of life and cause inactivity (Cutler et al., 2006). Similarly, some affects the individual with dementia. Residents with dementia facilities do not have the resources to provide quality activity usually prefer activities that address their psychological and programs that could improve the quality of life for residents social needs (Harmer & Orrell, 2008). However, inactivity (Kolanowski et al., 2006). When the environment is unable to and lack of interest in activities is common among residents provide the positive characteristics for activity participation, with dementia (Altus et al., 2002). In addition, as the condi- adjustments need to be made in the PEO model (Strong et al., tion progresses, cognitive and functional ability declines; this 1999). can reduce engagement in activities and lower quality of life Having an environment that promotes participation can (McDonald et al., 2010). Many of the activities that are offered cause positive environment–occupation interaction. One in nursing homes are inappropriate, and residents do not find intervention moved the structured activity program of a facility them meaningful, which is a key component for quality of from an indoor program to an outdoor program (Connell et al., life (Harmer & Orrell, 2008). Using the person–occupation 2007). The purpose of this change in environment was to allow interaction, activities can be designed based on the individual’s the residents to be exposed to bright light, while participating personal preferences and abilities, to increase engagement. in an activity to promote participation. Mrs. Jones’s situation Engagement can be achieved when activities are modified also illustrated this type of interaction. The plate and food to accommodate the residents’ cognitive and functional ability, lacked contrast (environment), which contributed to her lack of personality, and previous interests (Buettner et al., 2006; engagement in eating (occupation). Thus, changing the color of Cohen-Mansfield et al., 2006; Kolanowski et al., 2011; van der the plate to match her current abilities was needed. Ploeg et al., 2013). These interventions engaged residents in an individually tailored activity. Designing activities that consider THE PEO INTERACTION the person domain of the PEO model allows for an increase in The studies of dementia care in nursing homes that were participation. reviewed focused on fragments of the PEO model. When However, research is limited on the daily routines of resi- looking at dementia care, there were no studies that imple- dents in nursing homes with dementia and how the routines mented the entire PEO model. However, there was one study affect the activities they participate in. Alterations or disrup- that looked at the PEO interaction when evaluating meaning- tions in an individual’s daily routines can create stress that ful activities within nursing homes, although not specifically triggers behavioral symptoms, such as agitation, aggression, on residents with dementia (Green & Cooper, 2000). Twenty

CE-4 ARTICLE CODE CEA0518 MAY 2018 Earn .1 AOTA CEU (one contact hour and 1.25 NBCOT PDU). See page below for details. nursing home matrons from different facilities in the United Kingdom were interviewed regarding their nursing home and how they facilitated meaningful activities for their residents. How to Apply for Framing their analysis within the PEO framework, Green and Continuing Education Credit Cooper (2000) were able to recognize how the PEO interaction played a role in engagement of meaningful activities. The per- A. To get pricing information and to register to take the exam son focus consisted of the decline in health, increase in frailty, online for the article Applying the Person–Environment– and preference of choosing their activities. The environment Occupation Model to Improve Dementia Care, go to focus included the organizational level (e.g., control by the http://store.aota.org, or call toll-free 800-729-2682. matron, creativity, resourcefulness, flexibility) and the physical level (e.g., home comforts, characteristics of the nursing home). B. Once registered and payment received, you will receive instant The occupation focus consisted of the activity being individual- email confirmation. ized, varied, familiar, and broad in range. To accommodate for a C. Answer the questions to the final exam found on pages CE-6 & decline in the residents’ abilities (the person), the nursing home CE-7 by May 31, 2020. staff (the environment) had to be flexible and creative when designing an individualized activity (the occupation). Green D. On successful completion of the exam (a score of 75% or more), and Cooper (2000) advocated for further research and using the you will immediately receive your printable certificate. model to encourage purposeful activities.

FUTURE DIRECTIONS FOR DEMENTIA CARE USING THE PEO REFERENCES MODEL Altus, D. E., Engelman, K. K., & Mathews, R. M. (2002). Finding a practical Areas of research still need to be evaluated within the PEO method to increase engagement of residents on a dementia care unit. Ameri- interaction for dementia care in nursing homes. Interventions can Journal of Alzheimer’s Disease & Other Dementias, 17, 245–248. have been developed that address separate components of the Alzheimer’s Association. (2014). 2014 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia, 10, e47–e92. model. However, these interventions are not specific for the Bauer, M., & Nay, R. (2003). Family and staff partnerships in long-term care: A whole progression of dementia and how the PEO interaction review of the literature. Journal of Gerontological Nursing, 29(10), 46–53. changes as dementia progresses. As an individual reaches the Buettner, L. L., Fitzsimmons, S., & Atav, A. S. (2006). Predicting outcomes of advanced stages of dementia, their functional and cognitive therapeutic recreation interventions for older adults with dementia and abilities decline further and they are generally bedridden, with behavioral symptoms. Therapeutic Recreation Journal, 40(1), 33–47. sensory deprivation and complete dependence on care (Lussier Centers for Medicare & Medicaid Services. (2013). CMS national partnership to et al., 2011). The environment and occupation would have to improve dementia care in nursing homes national provider call. Retrieved from https://www.cms.gov/Outreach-and-Education/Outreach/NPC/National-Pro- adapt to the changes in the person, and research should exam- vider-Calls-and-Events-Items/2013-01-31-Dementia-Care-.html ine whether these interactions can exist when the abilities of Cochran, V., Tice, P., Clair, A. A., Otto, D. W., & Johnson, G. E. (2001). Family the person have become even more limited. ties: Activities for family and significant others dealing with late stage Additionally, within the nursing home setting, more research dementia. Activities, Adaptation & Aging, 26(2), 45–60. is needed to examine the interplay of the social environment Cohen-Mansfield, J., Parpura-Gill, A., & Golander, H. (2006). Utilization of self-identity roles for designing interventions for persons with dementia. and the person and occupation components. Limited studies Journals of Gerontology: Series B, 61, P202–P212. were found on the organizational level and specifically how Connell, B. R., Sanford, J. A., & Lewis, D. (2007). Therapeutic effects of an the nursing home organization interacted with residents with outdoor activity program on nursing home residents with dementia. Journal dementia and their participation in activities. With the CMS of Housing For the Elderly, 21, 195–209. (2013) initiative to provide quality dementia care, it is import- Cutler, L. J., Kane, R. A., Degenholtz, H. B., Miller, M. J., & Grant, L. (2006). ant to evaluate how the higher organizational environments Assessing and comparing physical environments for nursing home residents: Using new tools for greater research specificity. Gerontologist, 46, 42–51. (e.g., federal policies) affect the other factors of the PEO model. Degenholtz, H. B., Miller, M. J., Kane, R. A., Cutler, L. J., & Kane, R. L. (2006). Developing a typology of nursing home environments. Journal of Housing For CONCLUSION the Elderly, 20, 5–30. https://doi.org/10.1300/J081v20n01_02 Occupational therapy practitioners can use the PEO model to DeYoung, S., Just, G., & Harrison, R. (2002). Decreasing aggressive, agitated, or provide client-centered care and engage individuals residing disruptive behavior: Participation in a behavior management unit. Journal of in nursing homes. By understanding the PEO interaction for Gerontological Nursing, 28(6), 22–31. persons with dementia, occupational therapy practitioners are Galik, E. M., Resnick, B., Gruber-Baldini, A., Nahm, E.-S., Pearson, K., & Pretzer-Aboff, I. (2008). Pilot testing of the restorative care intervention for better able to provide high-quality care. Practitioners can also the cognitively impaired. Journal of the American Medical Directors Association, use the PEO model to evaluate innovative approaches to caring 9, 516–522. for residents with dementia in nursing homes. Green, S., & Cooper, B. A. (2000). Occupation as a quality of life constituent: A nursing home perspective. British Journal of Occupational Therapy, 63(1), 17–24.

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Harmer, B. J., & Orrell, M. (2008). What is meaningful activity for people with van der Ploeg, E. S., Eppingstall, B., Camp, C. J., Runci, S. J., Taffe, J., & dementia living in care homes? A comparison of the views of older people O’Connor, D. W. (2013). A randomized crossover trial to study the effect of with dementia, staff and family carers. Aging & Mental Health, 12, 548–558. personalized, one-to-one interaction using Montessori-based activities on agitation, affect, and engagement in nursing home residents with dementia. Harris-Kojetin, L., Sengupta, M., Park-Lee, E., & Valverde, R. (2013). Long-term International Psychogeriatrics, 25, 565–575. care services in the United States: 2013 overview. Retrieved from https://www. cdc.gov/nchs/data/nsltcp/long_term_care_services_2013.pdf Verbeek, H., van Rossum, E., Zwakhalen, S., Ambergen, T., Kempen, G., & Hamers, J. (2009). The effects of small-scale, homelike facilities for older Kolanowski, A., Buettner, L., Litaker, M., & Yu, F. (2006). Factors that people with dementia on residents, family caregivers and staff: Design of a relate to activity engagement in nursing home residents. American longitudinal, quasi-experimental study. BMC Geriatrics, 9, Article 3. https:// Journal of Alzheimer’s Disease & Other Dementias, 21, 15–22. https://doi. doi.org/10.1186/1471-2318-9-3 org/10.1177/153331750602100109 Zimmerman, S., Anderson, W. L., Brode, S., Jonas, D., Lux, L., Beeber, A. S., … Kolanowski, A., Litaker, M., Buettner, L., Moeller, J., & Costa, P. T. (2011). Sloane, P. D. (2013). Systematic review: Effective characteristics of nursing A randomized clinical trial of theory-based activities for the behavioral homes and other residential long-term care settings for people with demen- symptoms of dementia in nursing home residents. Journal of the American tia. Journal of the American Geriatrics Society, 61, 1399–1409. Geriatrics Society, 59, 1032–1041. Kovach, C. R. (2000). Sensoristasis and imbalance in persons with dementia. Journal of Nursing Scholarship, 32, 379–384. https://doi.org/10.1111/j.1547- 5069.2000.00379.x Kovach, C. R., Taneli, Y., Dohearty, P., Schlidt, A. M., Cashin, S., & Silva-Smith, A. L. (2004). Effect of the BACE intervention on agitation of people with dementia. Gerontologist, 44, 797–806. Final Exam Law, M., Cooper, B., Strong, S., Stewart, D., Rigby, P., & Letts, L. (1996). The Person–Environment–Occupation Model: A transactive approach to occu- Article Code CEA0518 pational performance. Canadian Journal of Occupational Therapy, 63, 9–23. https://doi.org/10.1177/000841749606300103 Applying the Person–Environment–Occupation Model to Lussier, D., Bruneau, M.-A., & Villalpando, J. M. (2011). Management of end- Improve Dementia Care stage dementia. Primary Care: Clinics in Office Practice, 38, 247–264. https:// doi.org/10.1016/j.pop.2011.03.006 May 2018 Maseda, A., Sánchez, A., Marante, M. P., González-Abraldes, I., Buján, A., & Millán-Calenti, J. C. (2014). Effects of multisensory stimulation on a sample To receive CE credit, exam must be completed by of institutionalized elderly people with dementia diagnosis: A controlled May 31, 2020 longitudinal trial. American Journal of Alzheimer’s Disease & Other Dementias, 29, 463–473. Learning Level: Intermediate McDonald, R. J., Craig, L. A., & Hong, N. S. (2010). The etiology of age-related dementia is more complicated than we think. Behavioural Brain Research, Target Audience: Occupational Therapists and Occupational Therapy 214(1), 3–11. https://doi.org/10.1016/j.bbr.2010.05.005 Assistants McFadden, S. H., & Lunsman, M. (2010). Continuity in the midst of change: Behaviors of residents relocated from a nursing home environment to small Content Focus: OT Process: Intervention households. American Journal of Alzheimer’s Disease & Other Dementias, 25, 51–57. https://doi.org/10.1177/1533317508320088 1. Client-centered dementia care allows the individual with Milev, R. V., Kellar, T., McLean, M., Mileva, V., Luthra, V., Thompson, S., & Peever, L. (2008). Multisensory stimulation for elderly with demen- dementia to have all of the following except: tia: A 24-week single-blind randomized controlled pilot study. American A. Personal worth Journal of Alzheimer’s Disease & Other Dementias, 23, 372–376. https://doi. B. Decision-making opportunities org/10.1177/1533317508316681 C. Access to health care Navarro-Gil, P., González-Vélez, A. E., Ayala, A., Martín-García, S., Martínez- Martín, P., Forjaz, M. J., & Spanish Research Group on Quality of Life and D. Independence Ageing. (2014). Which factors are associated with mortality in institution- alized older adults with dementia? Archives of Gerontology and Geriatrics, 59, 2. What are the components of the Person–Environment– 522–527. Occupation (PEO) model? Nazarko, L. (2009). Providing high quality dementia care in nursing homes. Nursing & Residential Care, 11, 296–300. A. Person, environment, and organization Ortman, J., Velkoff, V., & Hogan, H. (2014). An aging nation: The older population B. Person, environment, and occupation in the United States. Retrieved from https://www.census.gov/prod/2014pubs/ C. Policy, environment, and organization p25-1140.pdf D. Public spaces, extrinsic factors, and occupation Strong, S., Rigby, P., Stewart, D., Law, M., Letts, L., & Cooper, B. (1999). Application of the Person–Environment–Occupation Model: A practical tool. Canadian Journal of Occupational Therapy, 66, 122–133. https://doi. 3. All the following from the Mrs. Jones case example are org/10.1177/000841749906600304 examples of the “person” in the PEO model except: Sylliaas, H., Selbæk, G., & Bergland, A. (2012). Do behavioral disturbances A. Having visual impairment predict falls among nursing home residents? Aging Clinical and Experimental Research, 24, 251–256. B. Having dementia C. Living in a nursing home Torpy, J., Lynm, C., & Glass, R. (2004). Dementia. JAMA, 292, 1514. https://doi. org/10.1001/jama.292.12.1514 D. Expressing negative behavioral symptoms

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4. A good fit between the person, environment, and 10. What environmental intervention was shown to have a occupation: positive effect on engagement in an occupation in the A. Promotes participation environment and occupation relationship? B. Increases social support A. Having an activity program outdoors instead of indoors C. Improves cognition B. Providing exercises in a larger activity room D. Decreases risk for falls C. Dimming the lights in the activity room D. Hiring a new activity provider 5. All the following make up the environment domain of the PEO model except: A. Nursing staff 11. Which of the following are barriers in the relationship B. Dining room between environment and occupation? C. Facility policy A. Facilities that lack resources D. Eating meals B. Having an outdoor area for activities C. Using a multisensory stimulation environment 6. Research has shown that the following type of environ- D. Having a larger population of residents who are cogni- mental modification can reduce negative behavioral tively impaired symptoms: A. Having a multisensory stimulation room 12. Which recommendation made by the occupational B. Placing residents in the dining room therapist in Mrs. Jones’ case example addressed the C. Having multiple certified nursing assistants attend to the environment? resident A. Changing the color of the plate at meal times D. None of the above B. Encouraging Mrs. Jones to eat with other residents C. Having Mrs. Jones eat her meals inside her room so as 7. Which of the following statements best describes the not to disrupt the other residents person–environment relationship? D. Changing the food that was made for Mrs. Jones A. The environment has no effect on a resident’s function or cognitive abilities B. Only the social environment can reduce negative behav- Now that you have selected your answers, you are only one step away from earning your CE credit. ioral symptoms C. Different components of the environment can influence a person’s abilities and functional levels Click here to earn your CE D. The physical environment affects a person’s cognition

8. Residents with dementia usually prefer activities that: A. Are physical exercises B. Address their psychological and social needs C. Are provided in a group program D. Affect their daily routines

9. Engagement in nursing homes can be achieved when activ- ities are modified to accommodate the activities to all the following resident characteristics except: A. Cognitive ability B. Past experiences C. Personality D. Social support

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