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  Physical environmental designs in residential care to improve quality of life of older people (Review)

  Harrison SL, Dyer SM, Laver KE, Milte RK, Fleming R, Crotty M  

  Harrison SL, Dyer SM, Laver KE, Milte RK, Fleming R, Crotty M. Physical environmental designs in residential care to improve quality of life of older people. Cochrane Database of Systematic Reviews 2022, Issue 3. Art. No.: CD012892. DOI: 10.1002/14651858.CD012892.pub2.

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Physical environmental designs in residential care to improve quality of life of older people (Review)  

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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T A B L E   O F   C O N T E N T S

ABSTRACT…………………………………………………………………………………………………………………………………………………………………………….. 1

PLAIN LANGUAGE SUMMARY………………………………………………………………………………………………………………………………………………….. 2

SUMMARY OF FINDINGS………………………………………………………………………………………………………………………………………………………… 4

BACKGROUND………………………………………………………………………………………………………………………………………………………………………. 7

OBJECTIVES………………………………………………………………………………………………………………………………………………………………………….. 8

METHODS…………………………………………………………………………………………………………………………………………………………………………….. 9

RESULTS……………………………………………………………………………………………………………………………………………………………………………….. 13

Figure 1………………………………………………………………………………………………………………………………………………………………………….. 14

Figure 2………………………………………………………………………………………………………………………………………………………………………….. 19

Figure 3………………………………………………………………………………………………………………………………………………………………………….. 20

DISCUSSION………………………………………………………………………………………………………………………………………………………………………….. 29

AUTHORS' CONCLUSIONS……………………………………………………………………………………………………………………………………………………… 33

ACKNOWLEDGEMENTS………………………………………………………………………………………………………………………………………………………….. 34

REFERENCES………………………………………………………………………………………………………………………………………………………………………… 36

CHARACTERISTICS OF STUDIES……………………………………………………………………………………………………………………………………………… 43

DATA AND ANALYSES……………………………………………………………………………………………………………………………………………………………… 79

Analysis 1.1. Comparison 1: Home-like vs. traditional environment, Outcome 1: Quality of life…………………………………………….. 79

Analysis 1.2. Comparison 1: Home-like vs. traditional environment, Outcome 2: Behaviour, mood and depression………………… 80

Analysis 1.3. Comparison 1: Home-like vs. traditional environment, Outcome 3: Function…………………………………………………… 83

Analysis 1.4. Comparison 1: Home-like vs. traditional environment, Outcome 4: Global cognitive function……………………………. 84

Analysis 1.5. Comparison 1: Home-like vs. traditional environment, Outcome 5: Quality of care ………………………………………….. 84

Analysis 1.6. Comparison 1: Home-like vs. traditional environment, Outcome 6: Serious adverse eCects………………………………. 85

Analysis 2.1. Comparison 2: Refurbishment vs. traditional environment, Outcome 1: Quality of life……………………………………… 85

Analysis 2.2. Comparison 2: Refurbishment vs. traditional environment, Outcome 2: Behaviour, mood and depression…………. 86

Analysis 2.3. Comparison 2: Refurbishment vs. traditional environment, Outcome 3: Function…………………………………………….. 87

Analysis 2.4. Comparison 2: Refurbishment vs. traditional environment, Outcome 4: Quality of care……………………………………. 87

Analysis 3.1. Comparison 3: Special-care units for dementia vs. traditional environment, Outcome 1: Behaviour, mood and depression………………………………………………………………………………………………………………………………………………………………………

87

Analysis 3.2. Comparison 3: Special-care units for dementia vs. traditional environment, Outcome 2: Function…………………….. 89

Analysis 3.3. Comparison 3: Special-care units for dementia vs. traditional environment, Outcome 3: Global cognitive function… 89

Analysis 4.1. Comparison 4: Group living corridor vs. group living non-corridor design, Outcome 1: Behaviour, mood and depression………………………………………………………………………………………………………………………………………………………………………

89

Analysis 5.1. Comparison 5: Lighting intervention  vs. control lighting, Outcome 1: Behaviour, mood and depression……………. 91

Analysis 5.2. Comparison 5: Lighting intervention  vs. control lighting, Outcome 2: Behaviour, mood and depression: depression 4-6 weeks………………………………………………………………………………………………………………………………………………………………………..

92

Analysis 5.3. Comparison 5: Lighting intervention  vs. control lighting, Outcome 3: Behaviour, mood and depression: agitation 4-6 weeks………………………………………………………………………………………………………………………………………………………………………..

93

Analysis 5.4. Comparison 5: Lighting intervention  vs. control lighting, Outcome 4: Function 4-6 weeks………………………………… 93

Analysis 5.5. Comparison 5: Lighting intervention  vs. control lighting, Outcome 5: Function……………………………………………….. 93

Analysis 5.6. Comparison 5: Lighting intervention  vs. control lighting, Outcome 6: Global cognitive function……………………….. 93

Analysis 6.1. Comparison 6: Dining space redesign vs. traditional environment, Outcome 1: Quality of life……………………………. 94

Analysis 6.2. Comparison 6: Dining space redesign vs. traditional environment, Outcome 2: Behaviour, mood and depression…. 94

Analysis 6.3. Comparison 6: Dining space redesign vs. traditional environment, Outcome 3: Function………………………………….. 94

Analysis 6.4. Comparison 6: Dining space redesign vs. traditional environment, Outcome 4: Global cognitive function…………… 95

Analysis 6.5. Comparison 6: Dining space redesign vs. traditional environment, Outcome 5: Serious adverse eCects……………… 95

Analysis 7.1. Comparison 7: Garden vignette vs. traditional environment, Outcome 1: Behaviour, mood and depression……….. 95

APPENDICES…………………………………………………………………………………………………………………………………………………………………………. 95

HISTORY……………………………………………………………………………………………………………………………………………………………………………….. 109

CONTRIBUTIONS OF AUTHORS………………………………………………………………………………………………………………………………………………. 110

DECLARATIONS OF INTEREST………………………………………………………………………………………………………………………………………………… 110

SOURCES OF SUPPORT…………………………………………………………………………………………………………………………………………………………. 110

DIFFERENCES BETWEEN PROTOCOL AND REVIEW…………………………………………………………………………………………………………………… 110

Physical environmental designs in residential care to improve quality of life of older people (Review)

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NOTES………………………………………………………………………………………………………………………………………………………………………………….. 111

Physical environmental designs in residential care to improve quality of life of older people (Review)

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[Intervention Review]

Physical environmental designs in residential care to improve quality of life of older people

Stephanie L Harrison1,2,3, Suzanne M Dyer1, Kate E Laver1, Rachel K Milte4, Richard Fleming5, Maria Crotty1

1Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, Australia. 2Registry

of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, Australia. 3Liverpool Centre for Cardiovascular

Science, University of Liverpool, Liverpool, UK. 4Caring futures institute, Flinders University, Adelaide, Australia. 5School of Science Medicine and Health, University of Wollongong, Wollongong, Australia

Contact: Stephanie L Harrison, [email protected]

Editorial group: Cochrane ECective Practice and Organisation of Care Group. Publication status and date: New, published in Issue 3, 2022.

Citation: Harrison SL, Dyer SM, Laver KE, Milte RK, Fleming R, Crotty M.Physical environmental designs in residential care to improve quality of life of older people. Cochrane Database of Systematic Reviews 2022, Issue 3. Art. No.: CD012892. DOI: 10.1002/14651858.CD012892.pub2.

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

A B S T R A C T

Background

The demand for residential aged care is increasing due to the ageing population. Optimising the design or adapting the physical environment of residential aged care facilities has the potential to influence quality of life, mood and function.

Objectives

To assess the eCects of changes to the physical environment, which include alternative models of residential aged care such as a 'home- like' model of care (where residents live in small living units) on quality of life, behaviour, mood and depression and function in older people living in residential aged care.

Search methods

CENTRAL, MEDLINE, Embase, six other databases and two trial registries were searched on 11 February 2021. Reference lists and grey literature sources were also searched.

Selection criteria

Non-randomised trials, repeated measures or interrupted time series studies and controlled before-aJer studies with a comparison group were included. Interventions which had modified the physical design of a care home or built a care home with an alternative model of residential aged care (including design alterations) in order to enhance the environment to promote independence and well-being were included. Studies which examined quality of life or outcomes related to quality of life were included. Two reviewers independently assessed the abstracts identified in the search and the full texts of all retrieved studies.

Data collection and analysis

Two reviewers independently extracted data, assessed the risk of bias in each included study and evaluated the certainty of evidence according to GRADE criteria. Where possible, data were represented in forest plots and pooled.

Main results

Twenty studies were included with 77,265 participants, although one large study included the majority of participants (n = 74,449). The main comparison was home-like models of care incorporating changes to the scale of the building which limit the capacity of the living units to smaller numbers of residents and encourage the participation of residents with domestic activities and a person-centred care approach,

Physical environmental designs in residential care to improve quality of life of older people (Review)

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compared to traditional designs which may include larger-scale buildings with a larger number of residents, hospital-like features such as nurses' stations, traditional hierarchical organisational structures and design which prioritises safety.

Six controlled before-aJer studies compared the home-like model and the traditional environment (75,074 participants), but one controlled before-aJer study included 74,449 of the participants (estimated on weighting).  It is uncertain whether home-like models improve health-related quality of life, behaviour, mood and depression, function or serious adverse eCects compared to traditional designs because the certainty of the evidence is very low. The certainty of the evidence was downgraded from low-certainty to very low-certainty for all outcomes due to very serious concerns due to risk of bias, and also serious concerns due to imprecision for outcomes with more than 400 participants. One controlled before-aJer study examined the eCect of home-like models on quality of life. The author stated "No statistically significant diCerences were observed between the intervention and control groups." Three studies reported on global behaviour (N = 257). One study found little or no diCerence in global behaviour change at six months using the Neuropsychiatric Inventory where lower scores indicate fewer behavioural symptoms (mean diCerence (MD) -0.04 (95% confidence interval (CI) -0.13 to 0.04, n = 164)), and two additional studies (N = 93) examined global behaviour, but these were unsuitable for determining a summary eCect estimate. Two controlled before-aJer studies examined the eCect of home-like models of care compared to traditional design on depression. AJer 18 months, one study (n = 242) reported an increase in the rate of depressive symptoms (rate ratio 1.15 (95% CI 1.02 to 1.29)), but the eCect of home-like models of care on the probability of no depressive symptoms was uncertain (odds ratio 0.36 (95% CI 0.12 to 1.07)). One study (n = 164) reported little or no diCerence in depressive symptoms at six months using the Revised Memory and Behaviour Problems Checklist where lower scores indicate fewer depressive symptoms (MD 0.01 (95% CI -0.12 to 0.14)). Four controlled before-aJer studies examined function. One study (n = 242) reported little or no diCerence in function over 18 months using the Activities of Daily Living long-form scale where lower scores indicate better function (MD -0.09 (95% CI -0.46 to 0.28)), and one study (n = 164) reported better function scores at six months using the Interview for the Deterioration of Daily Living activities in Dementia where lower scores indicate better function (MD -4.37 (95% CI -7.06 to -1.69)). Two additional studies measured function but could not be included in the quantitative analysis. One study examined serious adverse eCects (physical restraints), and reported a slight reduction in the important outcome of physical restraint use in a home-like model of care compared to a traditional design (MD between the home-like model of care and traditional design -0.3% (95% CI -0.5% to -0.1%), estimate weighted n = 74,449 participants at enrolment).

The remaining studies examined smaller design interventions including refurbishment without changes to the scale of the building, special care units for people with dementia, group living corridors compared to a non-corridor design, lighting interventions, dining area redesign and a garden vignette.

Authors' conclusions

There is currently insuCicient evidence on which to draw conclusions about the impact of physical environment design changes for older people living in residential aged care. Outcomes directly associated with the design of the built environment in a supported setting are diCicult to isolate from other influences such as health changes of the residents, changes to care practices over time or diCerent staC providing care across shiJs. Cluster-randomised trials may be feasible for studies of refurbishment or specific design components within residential aged care. Studies which use a non-randomised design or cluster-randomised trials should consider approaches to reduce risk of bias to improve the certainty of evidence.

P L A I N   L A N G U A G E   S U M M A R Y

Physical environmental designs in residential care to improve quality of life of older people

What is the aim of the review?

There is an increasing older population worldwide and an increase in the numbers of people living with dementia. It has been suggested that improving lived area designs may improve quality of life, mood, and ability to perform daily living activities of aged care residents. The aim of this Cochrane review was to examine the eCects of diCerent physical environmental design changes in residential aged care to determine the eCect on quality of life for the residents. The review authors collected and analysed all relevant studies to answer this question and found 20 studies.

Key messages

We are uncertain of the eCects of design changes in residential aged care to improve quality of life for residents because more high-quality studies are needed.

What was studied in the review?

The review studied changes to physical environmental design in residential aged care, referring to any changes to the environment in which residents live, in an aim to improve their quality of life. These may be large-scale or small-scale changes. Large-scale changes can be changes to the design of residential care such as changing from the currently used lived-area designs to home-like designs with smaller numbers of residents living together. Small-scale changes may involve refurbishing the lived area or changing a single part of the lived area such as lighting. We included studies which compared diCerent large-scale or small design changes in residential aged care, or compared design changes to currently used lived-area designs and examined the eCect of design changes on quality of life, behaviour and daily living

Physical environmental designs in residential care to improve quality of life of older people (Review)

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activities for the residents. There is no one definition of quality of life agreed upon, but most definitions include multiple aspects of a person’s expectations for their life, such as physical, mental, and emotional health, social activity and life situation.

What are the main results of the review?

The review authors found 20 relevant studies that took place in nine diCerent countries (Australia, Canada, Germany, Italy, the Netherlands, Spain, Sweden, the UK and the USA). The main design change which was investigated was the eCect of creating a 'home-like' model of care which usually involved creating small-scale living units for residents and changes to care practices such as changes to staCing or choices residents had on daily routines. 

Six studies examined changes to the size of the building to limit the number of residents per living unit ranging between six and fiJeen residents per living unit, in addition to changing care practices, for example, changes to staCing, or changes to the choices residents had for their daily routines. One study examined quality of life, but there was insuCicient information presented to draw conclusions. Three studies examined behaviour; one study found little or no diCerence in behaviour and two studies provided insuCicient information to draw conclusions. Two studies examined depression and reported little or no diCerence in depressive symptoms or the eCect was uncertain. Four studies examined daily living activities; one study reported improvement in daily living activities, one study reported little or no diCerence in daily living activities, and two studies provided insuCicient information to draw conclusions. One study reported a reduction in serious adverse eCects (the use of physical restraints).  We are uncertain of the eCects of home-like models of care on quality of life, behaviour, depression, daily living activities or serious adverse eCects because the certainty (confidence) of the studies was determined to be very low due to issues with study design.

The other fourteen studies examined smaller design interventions such as refurbishment without changes to the scale of the building, special care units for people with dementia, diCerent corridor designs, bright lighting, redesign of the dining room and an indoor garden.

How up-to-date is this review?

The review authors searched for studies up to February 2021.

Physical environmental designs in residential care to improve quality of life of older people (Review)

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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S U M M A R Y   O F   F I N D I N G S

Summary of findings 1.   Whole-facility changes: Home-like models compared to traditional environment for older people living in long-term residential care

Whole-facility changes: Home-like models compared to traditional environment for older people living in long-term residential care

Patient or population: older adults living in long-term residential care including, but not limited to, dementia-specific care settings Settings: long-term residential care Intervention: home-like models (features of home-like models may include buildings which limit the capacity of the living units to small numbers of residents, designs to encourage the participation of residents with domestic activities and a person-centred care approach) Comparison: traditional design (traditional design may include larger-scale buildings with a larger number of residents, hospital-like features such as nurses' stations, tra- ditional hierarchical organisational structures and design which prioritises safety)

Illustrative comparative risks (95% CI)

Outcomes

Assumed risk

Traditional de- sign

Corresponding risk 

Home-like model

Relative effect (95% CI)

Follow-up time

No of Partici- pants (studies)

Certainty of the evidence (GRADE)

Comments

Health-related quality of life 

Dementia-specific quality of life measure (QUALIDEM) 

(higher scores = better)

N/a N/a Not estimable

6 months and 12 months

33 (1 controlled before-after-  study)

⊕⊝⊝⊝

very low1 2 domains (feeling at home and care relation- ship) were examined in an analysis adjusted for baseline differences between the groups; 7 oth- er domains were unadjusted. The author stat- ed "No statistically significant differences were observed between the intervention and control groups."

Global behaviour N/a N/a Not estimable

6 months

257 ⊕⊝⊝⊝

very low2 One study found little or no difference in glob- al behaviour change at 6 months using the NPI (N = 164; MD -0.04 (95% CI -0.13 to 0.04)); two

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Neuropsychiatric Inven- tory (NPI),

Neuropsychiatric Inven- tory-Nursing Home ver- sion (NPI-NH) and

Nurses Observations Scale for Geriatric Pa- tients (NOSGER)

(lower scores = better)

(3 controlled before-after studies)

  additional studies (N = 93) reported global be- haviour endpoint data, but the data were un- suitable for determining a summary effect esti- mate. 

Depression

Revised Memory and Behaviour Problems Checklist (RMBPC) and

Mood Scale Score (MSS)

(lower scores = better)

N/a N/a Not estimable

6 months and 18 months

406 (2 con- trolled be- fore-after stud- ies)  

⊕⊝⊝⊝

very low3 Depressive symptoms 18-month change

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