Environment & Communication Assessment Toolkit for Dementia Care

Speech-Language Pathologists, Nurses,
and Occupational Therapists will love
this exciting new resource for dementia care!

Sharing Solutions

Environmental Modifications to Improve
the Quality of Life for People with Dementia

On this webpage we will post ideas from clinicians who have used environmental modifications to improve the quality of life for people with dementia. Please use the contact us page to write us and share your solutions.

Increasing Contrast and Visual Cues in the Bathroom and Closet can Improve Independence
A 98 year old female with dementia, living in a care community, was having difficulty choosing and accessing her clothes from her closet and would often choose soiled clothes. She had frequent bouts of incontinence and poor hygiene practices after toileting which were offensive to her roommate and others. Rehabilitation goals established with the resident's input included:

  • Resident will increase ability to complete toileting and hygiene tasks through use of environmental cues in the bathroom with minimal staff cueing.
  • Resident will independently access and retrieve clothing from her closet to change outfits.
  • Resident will accurately locate soap and wash her hands in the bathroom with visual environmental cues.

    Bathroom and Closet Before

There were several environmental barriers that impacted her ability to successfully function in her room.

  • Bathroom door was not easily visible or distinguished from surroundings. The door opened into the room in a way that limited line of sight into the bathroom.
  • Toilet was not easily distinguished from surroundings.
  • Grab bars, toilet paper, and flush handle were not easily distinguished from surroundings.
  • No cues for task completion in bathroom.
  • Sink, grooming area, and hygiene items were not easily visible, organized, or distinguished from the surroundings.
  • One closet door was broken; closet was dark, unorganized, and partially inaccessible because of a large chair in front of the door.
  • Staff described the room as noisy, cluttered, homelike, small, and dark.

Bathroom After     Closet After
Bathroom and Closet after Environmental Interventions

The staff completed the following interventions:

  • The addition of a new closet with large drawers and a pull out hanging bar increased the resident's ease of access to the closet.
  • Drawer labels determined by resident were added to facilitate dressing activities.
  • Contrast in the bathroom was increased by painting the lower half of the wall a color that contrasts from the toilet and floor.
  • A chair rail, a pump type soap dispenser with the label of "Soap", and a framed sign stating "Clean hands feel good" were also added.

The resident experienced the following positive outcomes:

  • Now, resident is able to independently access closet for clothes approximately 4 out of 7 days a week.
  • Resident's ability to complete toileting and hygiene tasks through use of environmental cues in the bathroom has increased to 80% accuracy and minimal staff cueing. Resident's incidence of incontinence has decreased 90%.

Using Outdoor Spaces to Support Communication
We would like to share a story from Jean Flores. Jean, Unit Manager at the San Francisco Jewish Home in California, was a member of the Clinical Review Panel for ECAT. After using ECAT throughout the inside of the care community with clients, she decided to apply what she had learned about environmental interventions to the outside areas of the care community. Jean is still in the process of making changes, so we will post updates about her progress, along with pictures, as we receive them. Check back regularly for updates to see how Jean and her community are doing, and perhaps you'll have some suggestions to help.

Case Study from the San Francisco Jewish Home
by Jean Flores
"Our locked dementia unit is known as the garden unit because we have a beautiful outside space. The area is about 2,000 square feet with pathways and ivy. There are two tables with umbrellas and chairs so people can go outside and relax. There are also benches built into the walkway. The walkway is concrete with a wooden railing outlining a path. The railing also separates the walkway from the trees and ivy growing in throughout the garden. There are no visual cues to help wayfinding. The benches, railings, and tables are a similar color as the cement. They do not stand out or invite the residents to use them.

Unfortunately, the paths all lead to dead ends, with locked gates. This often creates frustration for our residents as it emphasizes the feeling of being trapped, even when out in the open. We wanted to eliminate that feeling by placing something visually interesting before the end of the path. While the weather is often moderate, it can be harsh at times. It varies from too hot to too cold throughout the day, making it difficult to lead a group activity in the area. We believe that these issues can be addressed through creative interventions and teamwork, such as providing a coat rack with hats and sweaters that anyone can use. The clothes can serve as a visual cue/reminder as well. Signage could be placed by the coat rack to encourage residents to put on a sweater before going outside.

The space is actually quite nice, but extremely under-utilized. With the help of the Assessment Toolkit, we were able to identify some reasons of why the garden is not used to its full potential. Other than fresh air, which of course is important, there is not much to encourage communication and interaction. Our goal is to have both structured and self directed communication-related activities daily in the garden and allow access with supervision during certain hours of the day. We strive to have our home truly feel like a home."

February, 2011
“Here on the Jewish Home's Garden Unit, we are still putting some of these great interventions in place. Believe it or not, San Francisco is having a taste of winter right now and the weather reporters keep threatening snow! Still, our amazing activities program is pulling through. Our recreation coordinator, Dana Rosenberg is conducting gardening programs inside to prepare for our finished garden. Now, we have planted native plants on all of our newly painted planters inside the unit. We have purchased large custom painted mailboxes to serve as a visual cue that will hold garden supplies, bird watching supplies, and games outside in the garden. The supplies to fill our oversized mailboxes are ready and waiting.

We have decided to purchase a bench with storage to hold blankets and sunscreen, since our weather varies from hour to hour. Our colorful paints for the benches and gates are waiting for dry weather. Next month, we plan to have our big opening party to celebrate the new and improved garden. Our two ‘dead ends’ that were mentioned earlier are where we decided to place a mailbox full of gardening supplies, a rain gauge, and some bird feeders. This will make the path more meaningful. We have not stopped brainstorming since the project has started and hope to continue to come up with innovative ideas to enhance this beautiful space.”

March 17, 2011
“We have installed our custom mailboxes designed to serve as visual cues and added color and sensory stimulation throughout the garden. It has already made a huge difference in welcoming our residents, guiding them to communicate with co-residents, and encouraging them to manipulate the supplies independently. Rather than walking to a dead end, residents are walking toward a goal. We have a bench with blankets and coats in it for colder weather. Signs have been staked into the ground to label certain plants as well as provide whimsy and purpose. For instance, some signs say "Come Here" or “Sit in the sun”, while others say "Planted seeds" or “Ivy”. Families have started to use the garden more often during visits with loved ones. Residents who do not wish to go outside now have a beautiful view outside of their room. Our staff has observed an increase in residents gravitating towards the garden door to go outside. The Recreation coordinator has been able to diversify and increase outdoor programming“

San Francisco Jewish Home – "Before" pictures
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8

San Francisco Jewish Home – "In Process" pictures
1 | 2

San Francisco Jewish Home – "After" pictures
1 | 2 | 3 | 4 | 5


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Environment and Communication
Assessment Toolkit for Dementia Care

Speech-Language Pathologists,
Nurses, and Occupational Therapists
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Environment and Communication Assessment Toolkit for Dementia Care (ECAT)

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