Environmental interventions to support orientation and social engagement of people with Alzheimer’s disease

ABSTRACT The built environment can be a home to compensatory strategies aimed at increasing the independence of elderly people with Alzheimer’s disease, by mitigating the cognitive impairment caused by it. Objective: The aim of this study was to find out which interventions were performed in indoor environments and observe their impacts on the relief of behavioral symptoms related to the disorientation of elderly people with probable Alzheimer’s disease. Methods: A systematic review was carried out using the preferred reporting items for systematic review and meta-analyses criteria in the MEDLINE/PubMed database. Two researchers carried out the selection of the studies, following the same methodology. The third author contributed during the writing process and in the decision-making. Results: Of note, 375 studies were identified and 20 studies were included in this systematic review. The identified interventions were classified into environmental communications and environmental characteristics. Conclusions: Environmental communications had positive results in guiding and reducing agitation. In contrast, while reducing behavioral symptoms related to orientation, environmental characteristics showed improvements mainly in social engagement and functional capacity.


INTRODUCTION
D ementia is an umbrella term for several diseases which affects the brain in a way that compromises one's cognitive processes, behavior, and ability to carry on daily tasks. 1 It is claimed to be the "major cause of disability and dependency among older adults worldwide." 2 Under those circumstances, the number of people diagnosed is increasing: from the estimated 50 million in 2019, the scale of the issue becomes three times worse, rising to 152 million people in 2050. 1 Alzheimer's disease (AD) is the most common form of dementia, contributing to 60-70% of the total cases.
Although dementia is related to the progressive and global decline of cognition, there are some skills and abilities that can still be accessed through design. 3 In this spectrum, the role that the built environment plays in supporting people with dementia can be either therapeutic or debilitating: it can be a home for compensatory strategies designed to bypass the cognitive impairment caused by the disease or a barrier for their independent functioning. 4 Different professions are researching in this field, adding new levels to the understanding of the needs of elderly people with dementia in their relationship with the surrounding environment. Architects, such as Margaret Calkins, and sociologists, such as John Zeisel, carried out the reviews of the studies in this area and achieved certain principles, or therapeutic objectives, 4 and design elements such as "exit control, walking paths, common spaces, privacy and personalization, garden access, residential-ness, sensory comprehension, and support for capacity" were correlated with reduced behavioral symptoms. 3 Nevertheless, the most accessible and least costly ways of adapting to the environment seem to be those made through small interventions. In this context, this review aims to contribute to the development of a better understanding of their impacts, systematizing research evidence.

Bibliographical survey
This systematic review of the literature was performed in accordance with the preferred reporting items for systematic review and meta-analyses (PRISMA) criteria, and the database searched was MEDLINE/PubMed. In the first place, the combinations between key words for the research were as follows: "Alzheimer disease OR dementia AND wandering OR exiting OR wayfinding OR orientation OR room finding OR ambulation OR mealtimes OR dining OR agitation OR apathy AND interventions OR modifications OR renovations OR environmental OR physical environments OR door NOT review." In addition, articles included were peer-reviewed, made in English language scientific literature without data restriction, and are specific to elderly people with dementia and interventions made in interior environments.
The exclusion criteria were other systematic reviews, scoping reviews, reviews of literature, animal studies, articles about pharmacological interventions, assessment tools, or concerning interventions not made in the environment, or made in an external environment. In addition, the term dementia was used to broaden the search, but if the article was explicitly about only other types of dementia (e.g., frontal lobe dementia, Parkinson's dementia, Lewy body dementia, and vascular dementia), it was excluded.
The first author reviewed all keywords, titles, and abstracts of articles from the search results and identified which met the criteria for further review. Both first and second authors reviewed the full articles and reached an agreement in which to include, based on the question "What interventions were made in the interior environment to lessen the behavioral symptoms related to disorientation and to improve social engagement on older persons with probable Alzheimer's disease?" The third author contributed during the writing process and decision-making.

Study selection
The results of the search for the systematic literature review are shown in Graph 1. It is observed that the search strategy resulted in a total of 375 articles, of which only 37 met the criteria for reviewing the full article. Out of these, 20 were qualified. Most of these studies were carried out in the United States (n=5), four studies were carried out in Canada, two in the United Kingdom, two in Germany, three in other European countries, and one in Australia. In addition, three studies did not specify in which country they were developed.
Participants were, primarily, 269 elderly people with dementia, whose type was not usually specified in the articles. However, 50 participants with AD were mentioned, but considering that they are usually 60-70% of the total cases of dementia, we can estimate their number to actually reach about 188 elderly people. Beyond them, 57 others participated in the studies, being service providers, as unit managers (n=18), and service users, as family members or nurses (n=39). Three articles did not inform the number of participants involved in their researches, since the studies evaluated the environment itself, were case studies, or considered only three major groups of participants, being families, staff members, and volunteers.
In addition, the search revealed interventions developed in the interior of any care environment, being dementia special care units (SCUs) (n=7), hospitals (n=4), nursing homes (n=5), long-term care facilities (n=2), and adult day care centers (n=2). Interventions comprise modifications in the interior environment that aim to enable the use of the remaining abilities of people with dementia.

RESULTS
A synthesis table was structured to identify all the selected studies (Table 1), listing the year of the publication, the country in which the study was based, their design, and the journal in which it was published. Another table was created to summarize the results of the review, and the articles were listed with their interventions, objectives, methods, and findings ( Table 2). • The textures and colors of the handrails stimulated further exploration and tactile interaction • The VR nature scenes were highly successful in promoting a positive and relaxed atmosphere, and in promoting social engagement among residents at the care center and family visiting • These designs promoted social engagement (virtual nature), reduced restlessness (both cases), and facilitated wayfinding (experience handrail)    To explore whether music, live, or prerecorded is effective in the treatment of apathy in subjects with moderate to severe dementia • RCT • Participants: 32 subjects with moderate to severe dementia and with diagnostic criteria for apathy • Place: subjects were recruited from residential and nursing homes • Each subject was randomized to 30-minute music or silent periods and was video recorded, and the muted recording was analyzed every 3 min using dementia care mapping to assess the quality of engagement to the blinded music intervention • The communal area of the residential-care or nursing-home facility was used for the music intervention. Music periods comprised three different activities, each of 30 min duration. One 30-min period consisted of silence alone, one 30-min period consisted of the playing of background prerecorded music, and one 30-min period consisted of the playing of live music from session musicians  • A portrait-type photograph from early adulthood and a large-print sign with a sentence indicating the resident's name were both placed outside each study participant's room • All participants improved during the intervention phase. There was over a 50% mean increase in participants' ability to accurately locate their own room following the intervention Hewawasam 12 To capitalize on the observation that many individuals who suffer from dementia of Alzheimer's type appear to perceive two-dimensional patterns as barriers • Study • Participants: 10 patients with mean to severe dementia • Place: NHS trust hospital ward for the elderly mentally infirm • The design was based on an ABABA single-subject design that incorporated several baseline (control) observations, one before and one after each experimental manipulation • Of note, 3.8 cm strips of black tape applied 3.8 cm apart to the blue vinyl floor, extending in front of the exit door. They were applied in one of two configurations, grid A -horizontally, and grid B -vertically • All 10 patients showed varying degrees of changes to their normal gait while crossing the grid. These changes were manifested by some hesitation and deliberation before crossing and/or stepping over the eight-strip • Five patients, of which four had a diagnosis of AD, showed a statistically significant reduction in the number of door contacts  in this theme in some of its dimensions. There are interventions to reduce ambulation and excessive stimulation of the patient, 5-8 attempts to prevent exit or escape, 6,8-10 door testing, 11,12 and improvements in orientation/location. 6,7,13-17 But how do people with dementia know where to go? The answer is when they manage to perceive the next object of place. Like everyone else, they move around unknown places through landmarks. Therefore, they need a place that communicates with them. In this sense, the interventions that had this purpose were classified as environmental communications. Among them were camouflages (n=3), tracks (n=9), barriers (n=3), and signs (n=3).
Camouflage interventions are those that try to hide the exits, whether portraying them as shelves, 7 miniblinds or panels, 9 or as a painted mural. 11 The last two had positive impacts, as they reduced the frequency of exit attempts and door testing. The first was not entirely effective in stopping such behaviors, and one of the reasons attributed to this fact was that some residents were still cognitively aware of the entry and exit of people through the doors, despite a camouflage from the bookcase. These strategies are in line with the findings of Zeisel 4 who stated that some doors attract the natural curiosity of the human brain and should be less inviting, as invisible as possible.
The third table was made to resume and analyze the research evidence collected, highlighting the relations between the type of interventions, their impact on the environment, and their outcomes (Table 3).
References to home furnishings and finishes, which were used to improve functional capacity, social engagement, and wayfinding, were widely cited in the researched articles. These findings are in agreement with Zeisel, who suggested homemade qualities (i.e., decoration, furniture, and lighting) to reduce aggression and other symptoms. 3 Cues are usually utilized to suggest appropriate spatial behaviors, 3 and this type of intervention had compatible results from this review: the major impact was on the wayfinding of the residents, reducing behaviors of exiting and wandering. The use of signage also proved to be an effective intervention, reducing agitation and wandering and improving wayfinding.

DISCUSSION
Patients who are unable to identify the paths to the desired locations experience anxiety, confusion, mutism, and even panic. 4 In contrast, even people with dementia walk with purpose when they are able to understand where they are and where they are going. 3 Thus, among the studies listed in this review, 12 aimed to intervene Barrier interventions focused on creating obstacles to prevent people with dementia from trying to access places they should not have to. Thus, taking advantage of the fact that people with AD have a deficiency in contrast sensitivity, 4 three studies used strips of black tape, with different measures and distances, on the near floor and on the exit doors. 8,10,12 Two studies had positive results, showing a significant decrease in ambulation 8 and in the number of door contacts. 12 Contrary to these, another study 10 showed no effects. This negative result was attributed to the fact that the intervention was carried out on a glass door that allowed residents "a complete view of the visually attractive and physically unrestricted spaces that are beyond," thus distracting them from the grid. In addition, in another article, 15 it was mentioned that individuals with dementia avoided walking on the wooden floor. This was interpreted as a reaction to the strong contrast of colors created between the sections of the floor, which made them think they were stairs.
Still, on the topic of contrast deficiency in people with dementia, an intervention sought, by means of panels placed around the walls, to add enough contrast to help them distinguish breaks between walls and floors and between objects and their background. 14 This intervention had positive results, increasing its capacity for orientation. In the same study, the walls were painted in shades of blue and green to replace an earlier The signaling interventions identified were the landmarks placed in the environment. Among them were six handrails, with different textures, colors, and sounds, designed to match the neighboring rooms (i.e., kitchen, cinema, sewing room, living room, garden, and farm). 13 These handrails facilitated orientation and reduced restlessness.
Contrary to the previous proposal to hide doors to unsafe places, doors to safe destinations should be as inviting as possible. 3 One of the interventions proposed bedroom doors with a personalized design, with positive results both in ambulation and in behaviors (reducing output and improving wayfinding). 6 Two other types of interventions using light and hearing aids were tested, and both conditions were effective in improving the wayfinding. However, the results of the light cues scored higher.
In the field of signs, the use of clocks 5,7,18 was introduced to guide residents in time. In addition, a portrait photo of early adulthood and a large-letter sign with a phrase indicating the resident's name were placed outside the room of the participants in one of the studies. 17 In particular, personal items that refer to the past, achievements, and social roles help people with dementia to support their sense of identity. 3 With this in mind, this study demonstrated improvements, increasing the participants' ability to locate their rooms by more than 50%. The number of studies is indicated by the number of symbols in each field; "+" indicates the increase of the outcome and "-" indicates the decrease of the outcome. The "ø" indicates an absence of impact in the outcome.
the height to accommodate wheelchairs proved to have a great influence on the functional support capacity. 15 In contrast, the installation of fixed chairs in the stalls of an acute care hospital 14 had a positive impact on social engagement, allowing family caregivers to be with the elderly people for longer and more comfort.
On the issue of social engagement, scenes of virtual nature were projected in the corridor of an infirmary at a service center. 13 This intervention created a relaxed atmosphere that stimulated social involvement not only among residents but also with visiting family members and, additionally, reduced agitation behaviors.
Dementia along with old age weakens the signals sent to the brain by each sense individually. 4 This makes it more difficult for elderly people to understand the environment around them. Two studies addressed this issue, installing storage units 14 and a so-called silent resident system, 21 removing unused equipment, and replacing the curtains that separated the bays of an intensive care hospital with rigid mobile screens. 14 These interventions alleviated the confusion and helped patients to better understand their environment.
Regarding the light theme, two studies focused on the impact of bright light on night sleep and daytime involvement. In one of the interventions researched in this review, 23 high-intensity and low-brightness ambient lighting was installed in common areas, such as the activity room and the dining room. The analysis of the collected data demonstrated that the agitation was not significantly less in the therapeutic condition, in comparison with the standard lighting.
Another study installed a ceiling-mounted dynamic lighting system in a common area, programmed to produce high light during the day and low light at night. Although it did not impact amplitude and other circadian variables, dynamic lighting significantly reduced agitation in patients with dementia. The standard lighting replaced by an adjustable system 14 served as an element in improving the wayfinding and reduced unnecessary sensory stimulation. The improved lighting 15,24 also allowed residents to see their food and their tablemates clearly, contributing to social engagement and food intake.
One study increased the possibilities of natural light 7 and another reinforced the light during the day and progressively decreased the light at night, together with the streaming of soft music. 5 The results showed that the number of episodes of agitation and the average duration of episodes of wandering decreased significantly. In addition to this intervention with music, another study indicated that, regardless of the severity of dementia, exposure to live music is related to positive clinical white color. In this case, the shades of blue and green are considered calming colors. The observed result was a reduction in sensory stimulation. Another study painted the walls in light beige, 5 which along with other modifications, highlighted the daytime and nighttime orientation of residents.
Color selection also plays a role in the movement toward deinstitutionalization. The term non-institutional was widely used among the reviewed articles. Calkins 3 warned that the use of the preposition does not designate what design should or should not be. Despite this, some designers use the term homemade, which assumes elements such as wood instead of metal or plastic and a style that would be used in someone's home (although there is no such style).
Interventions related to the characteristics and atmosphere of the space were classified as environmental characteristics. Within these, some articles addressed the issues of light (n=6), music (n=1), home finishes and accessories (n=5), sensory stimulation (n=3), furniture (n=6), and virtual environment (n=1). Its results, in addition to improving the wayfinding, 5,7,14,15 were also in the social involvement of the person with dementia, 7,13,19 functional capacity, 15,20,21 and agitation behaviors. 22,23 Among the reviewed articles, this was exactly the point: mural paintings and wooden floors were, in fact, some of the proposed interventions. 5,14,15,20,21 These modifications are located on the topic of finishes and home accessories. The replacement of the floor by a wood-type floor was made in dining rooms, 15,20,21 kitchens, and living rooms 21 to complement the family environment that resulted in increased social engagement.
There was also an article 24 in which the nurses' central post was replaced by an aviary, and adjustments were made to "make it less institutional," such as the use of rugs. The dining and kitchen areas, in this case, were decentralized and divided into three smaller ones, for 10-12 residents, which proved to be able to enhance social contact and guidance.
This family atmosphere was complemented by the implementation of new furniture, with fully renovated kitchens and the ability to prepare quick meals, such as making soup or baking bread. 15,20,21 In one of the articles, 21 it was emphasized that "residents were more at peace," and engaged in behaviors such as participating in tea making with a family member. Two others demonstrated that an open kitchen can be more obviously recognized, creating a familiar sensory environment related to food and stimulating the residents' appetite. 15,20 In addition to the search for a family environment, the installation of new tables that allowed changing The evidence collected illustrates the relevant impact of environmental interventions on the behavior of elderly people with AD. Most of the researched studies showed that to impact the orientation of the elderly people, the environment must communicate with them, but to influence their social behavior, the characteristics of the environment must be updated, usually bringing a more homely aspect.
In any case, the use of elements from the two major intervention groups can improve the overall quality of life of patients with dementia. However, it should be noted that the changes in the physical environment must be monitored by the team, not only using it as a source of information but also training them to know how to support the person in this new environment.
Overall, this review showed a variety of possibilities for improving the interaction of people with dementia with the environment in which they live. Capacity-building strategies in the physical environment allow them to naturally use their remaining skills, remaining independent for a longer time, and therefore improving their senses of themselves. The limitations of this research mainly include the fact that most studies use a multimodal approach, making it difficult to determine the specific impact of which intervention.