The TESS-NH efficiently assesses discrete elements of the physical environment and has strong reliability and validity. The SCUEQS provides a quantitative measure of environmental quality in institutional settings.

Research on the impact of the built environment in long-term care settings continues to grow. This article focuses on work conducted and published since 2000, when an earlier review on research on dementia and design was published. The vast majority of research that addressed neurological conditions in residents in long-term care settings (assisted living and nursing homes) relates to Alzheimer's disease and related dementias.

The evidence about the role the designed and built environment plays in supporting individuals living with dementia has been steadily mounting for almost 40 years. Beginning with the work of M. Powell Lawton at the Weiss Pavilion at the Philadelphia Geriatric Center, there are now dozens of researchers who are exploring how the environment can be either supportive and therapeutic, indeed even serving as a prosthetic for various changes in cognition, or be a barrier to independent functioning and high quality of life. Two recent literature reviews published on the impact of environmental factors and characteristics on individuals living with dementia clearly delineate evidence that the environment can have a therapeutic or a debilitating impact on individuals living with dementia. Rather than duplicate these excellent reviews, this article puts the knowledge gleaned from this research into the shifting context that is long-term care. This article begins with an exploration of the evolution of approaches to the design of spaces for individuals living with dementia from traditional or medical models, to special care units (SCUs), to person-centered care (PCC), which is the organizing theme of this supplemental issue. A novel, person-centered way of conceptualizing the domains of environmental systems is then presented and used as the framework for structuring recommendations and creating supportive and therapeutic environments for individuals living with dementia. Although there are distinct pathophysiological and behavioral manifestations of different forms of dementia, there is almost no evidence that suggests alternative environmental characteristics are better for one type of dementia over another. Thus, this article will refer to "individuals living with dementia" as opposed to Alzheimer's disease or other specific forms of dementia. Further, this article only addresses residential environments: homes in the community, independent and assisted living residences and nursing homes. It does not address other settings, such as hospitals or hospice, or work and public community spaces, such as stores. It is recognized that individuals living with dementia do spend time in all these spaces, and fortunately, there is growing interest in creating more dementia-friendly communities, but they will not be addressed in this article. Most of the research that has been done has focused on shared residential settings, so that will be the primary focus on this article.

There is growing evidence that exposure to bright light may improve circadian rhythms in individuals with dementia residing in shared residential settings. The vast majority of this research uses electric bright light boxes. However, the outdoor environment not only provides exposure to bright light but to natural elements which have been shown to have a restorative effect across a broad range of situations. Previous research that sought to explore the impact of time spent outdoors on sleep and/or agitation in individuals with dementia was hampered by low time spent outdoors. This project, conducted in three nursing homes (n = 17), used actigraphy, validated proxy measures of sleep and agitation and direct observation to explore the impact of increased time outdoors on sleep and agitation. The repeated measures design assessed residents with dementia under four conditions: winter/no activity, winter/inside activity, summer/no activity and summer/outside activity. Re-Margaret Calkins, PhD, is President, IDEAAS Inc. and Board Chair, IDEAS Institute,

Efforts to improve end-of-life care have increased during the past decade. The goals of these efforts include increasing patient autonomy and reducing or more selectively using intensive medical interventions near the end of life. In this light, examination of community-to-community variations in end-of-life practices may serve to clarify the values and goals of different populations, as well as the roles of patients, families and professionals in bringing about specific patterns of medical care. This study examined the use of feeding tubes among Kansas nursing home residents between Jan. 1, 1994, and June 30, 1998 (n = 78,895), using the Minimum Data Set. Residents with very severe, persistent and irreversible cognitive impairment (n = 4,847) were included in the study population. The location of nursing homes in urban, midsize and rural counties was an independent variable. Feeding tubes were used in 19.3 percent of the urban nursing home residents, 8.0 percent of the residents in midsize counties and 6.4 percent of the rural residents. The rate of feeding tube use was significantly higher in urban counties for most subpopulations, including men, women, whites, nonwhites, and those eligible and ineligible for Medicaid. The observed rural-urban differences in feeding tube use near the end of life may be associated with differences in access to surgical or nursing services, differences in the relationships between providers and consumers of care in different communities or differences in rural and urban cultures. Qualitative research may be useful in clarifying the roles of each of these factors.

The Professional Environmental Assessment Procedure (PEAP) was developed as a global quality-assessment measure for use by trained professionals in special care units for older people in dementia units of nursing homes. The PEAP consists of nine ratings whose relationship to another assessment device, the Therapeutic Environment Screening Schedule (TESS), is reported. Although designed to be multidimensional, the PEAP as tested in 43 special care units seems to reflect primarily a single evaluative dimension. It correlates highly with the TESS and may be used either separately or in combination with the TESS.

Purpose: There is debate about the relative merits and costs of private versus shared bedrooms in nursing homes, particularly in light of the current efforts at creating both cost-efficient and person-centered care facilities. The purpose of this project was to explore the extent to which there is evidence-based information that supports the merits of three different bedroom configurations: traditional shared, enhanced shared, and private. Design and Methods: We developed a framework of four broad domains that were related to the different bedroom configurations: psychosocial, clinical, operational, and construction or building factors. Within each dimension, we identified individual factors through the literature, interviews, and focus groups, with the goal of determining the breadth, depth, and quality of evidence supporting the benefits of one configuration over another. Results: The vast majority of factors identified in this study, regardless of whether there was solid empirical data, information from the focus groups, or other anecdotal evidence, indicated better outcomes associated with private rooms over shared rooms in nursing homes. Cost estimates suggest that construction cost (plus debt service) differences range from roughly $20,506 per bed for a traditional shared room to $36,515 for a private one, and that such differences are recouped in less than 2 years if beds are occupied, and in less than 3 months if a shared bed remains unoccupied at average private-pay room costs. Implications: Despite limited empirical evidence in some areas, this project provides the foundation for an evidence-based life-cycle costing perspective regarding the relative merits of different bedroom configurations.

The first National Research Summit on Care, Services, and Supports for Persons with Dementia and Their Caregivers was held on October 16-17, 2017, at the National Institutes of Health. In this paper, participants from the Summit Session on Research on Care Needs and Supportive Approaches for Persons with Dementia summarize the state of the science, identify gaps in knowledge, and offer recommendations to improve science and practice in long-term care. Recommendations cover 4 areas focused on persons living with dementia: (1) symptoms (behavioral and psychological symptoms of dementia, function, cognition, and sleep); (2) dementia care settings (physical and social environments, home, and residential care); (3) living with dementia (living well with dementia, living alone with dementia, and living with dementia and intellectual and developmental disabilities); and (4) technology as a cross-cutting theme. The participants identify 10 of the most pressing research issues based on the findings from their collective papers. Final Summit recommendations included those presented by session participants and will be used to advise federal agencies and other organizations that fund research.