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Environmental Determinants of Quality of Life in Nursing Home Residents with Severe Dementia

Josep Garre-Olmo, PhD,*† Secundino López-Pousa, PhD,*†‡ Antoni Turon-Estrada, PhD,‡

Dolors Juvinyà, PhD,§ David Ballester, BSN,§ and Joan Vilalta-Franch, PhD*†‡

OBJECTIVES: To determine the relationship between quality of life (QOL) and environmental factors of temper- ature, noise, and lighting in nursing home residents with severe dementia.

DESIGN: Cross-sectional, observational, analytical.

SETTING: Eight public, long-term care nursing homes in the province of Girona, Spain.

PARTICIPANTS: Random sample of 160 nursing home residents with severe dementia.

MEASUREMENTS: Functional and cognitive impairment, pain, neuropsychiatric disturbances, and QOL were deter- mined using standardized instruments. Temperature, noise, and lighting in bedrooms, dining rooms, and living rooms were measured in the morning and afternoon using a mul- tifunction environment meter in a standardized manner.

RESULTS: Adjusted multivariate linear regression models demonstrated that environmental measures were indepen- dently associated with QOL and related factors. High tem- perature in the bedroom was associated with lower QOL (standardized b = 0.184), high noise levels in the living room were associated with low behavioral signs of social interactions (b = 0.196), and low lighting levels in the bed- room were associated with number of signs of negative affective mood (b = �0.135).

CONCLUSION: The QOL of nursing home residents with severe dementia was related to environmental factors such as temperature, noise, and lighting. The monitoring of these environmental factors may improve these individ- uals’ QOL. J Am Geriatr Soc 60:1230–1236, 2012.

Key words: dementia; quality of life; nursing homes; long-term care; health facility environment; environ- ment design

Severe dementia is the last stage of the progressive impairment of central nervous system functions, which

inevitably leads to absolute dependence on others. Individ- uals with severe dementia require assistance with basic activities of daily living such as feeding, dressing, washing, and using the bathroom, as well as continuous 24-hour supervision. These individuals are unable to recognize fam- ily or caregivers, and their communication abilities are severely impaired.1 Severe dementia is also a risk factor for opportunistic infections, nutritional and urinary disor- ders, endocrine alterations, and concomitant neurological disorders.2

An international consensus panel estimated the num- ber of worldwide dementia cases to be 24 million, with an estimated doubling of this number every 20 years assum- ing no changes in mortality rates, effective prevention strategies, or curative treatments.3 Epidemiological research suggests that severe dementia represents approxi- mately 20% of prevalent cases and that 20 to 40% of resi- dents in residential care facilities and more than 50% of nursing home residents have moderate or severe dementia.4

Over the past decade, the focus of long-term care has shifted from the manner of care delivery (the process of care) to the effect of care on residents (the outcomes of care).5 One goal of the American Geriatrics Society Core Writing Group of the Task Force on the Future of Geriat- ric Medicine is to ensure that every elderly person receives high-quality, patient-centered health care.6 The shift to patient-centered care, also referred to as “culture change,” began in the 1990s, and it involves a change from an emphasis on safety, uniformity, and medical concerns to resident-directed health promotion and quality of life (QOL) by considering the caregiving environments.7 The Pioneer Network and the Eden Alternative are examples of patient-centered care models.8 The seminal work of Tom Kitwood was important for the avoidance of neurode- generation-induced depersonalization in individuals with dementia and the acknowledgment that they are people who experience life and relationships.9 These results

From the *Research Unit, Institut d’Assistència Sanitària, Girona, Spain; †Department of Psychology, University of Girona, Girona, Spain; ‡Memory and Dementia Assessment Unit, Institut d’Assistència Sanitària, Girona, Spain; and §Department of Nursing, University of Girona, Girona, Spain.

Address correspondence to Josep Garre-Olmo, C/o Dr Castany s/n, 17190 Salt, Girona, Spain. E-mail: [email protected]

DOI: 10.1111/j.1532-5415.2012.04040.x

JAGS 60:1230–1236, 2012

suggest that the primary outcomes should include the qual- ity of care that is provided and the QOL that residents of care facilities achieve.

The incorporation of the QOL construct is relatively recent in dementia research, but significant advances in its conceptualization have been achieved, and several approaches to data collection have been developed for the assessment of QOL in individuals with dementia. These methods include self-reports,10,11 proxy reports by a family member or caregiver,12 direct observation by trained raters of behaviors that are assumed to be related to QOL,13 and a combination of these methods.14 These approaches have strengths and weaknesses.15 The use of proxy reports is the most appropriate method for the collection of informa- tion on QOL in individuals with severe dementia because of their limited communication abilities and low self- awareness.16

Several determinants of QOL in individuals with dementia have been identified, and institutionalized individ- uals with dementia have a lower QOL than nursing home residents with dementia in community dwellings.17,18

Disease severity may contribute to this difference.19

The institutional environment exerts a fundamental effect on people with dementia,20 who may benefit from a wide range of environmental interventions.21 Several behaviors of individuals with dementia are interpreted as the communication of unmet basic needs and reactions to a nonadapted environment, such as sensory overload, in a person-centered model of care.22 The institutional environ- ment contributes to the QOL of individuals with dementia by capitalizing on resident strengths and reducing demands. Lawton’s environmental docility hypothesis states that environmental pressure accounts for a greater proportion of behavioral outcomes as personal competence diminishes. Therefore, a greater influence of the environ- ment on behavior produces a lower level of competence.23,24

The current study assessed the relationship between QOL and institutional environmental factors, such as tem- perature, noise, and lighting levels, in nursing home resi- dents with severe dementia. The provision of thermal comfort is important, according to the person-centered model of care, because a person with severe dementia may react inadequately to the thermal environment. Noise level is related to poor sleep, distraction from completing a task, agitation, and fear in individuals with dementia.25

Light exposure is a stimulus for circadian rhythms, the suppression of pineal melatonin production, the elevation of core body temperature, and the enhancement of alert- ness.26 An increase in lighting beyond normal levels improves sleep patterns and reduces the behavioral and psychological symptoms of dementia (BPSD).27 It was hypothesized that temperature, noise, and lighting would affect the QOL of institutionalized individuals with severe dementia based on the environmental docility hypothesis.

METHODS

This study used a cross-sectional design to evaluate the degree of association between QOL and thermal, lighting, and acoustic environments in a random sample of institu- tionalized participants with severe dementia.

Participants

Participants were recruited from eight public long-term care nursing homes in the province of Girona, Spain. All residents in these facilities could participate in the study if they met the inclusion criteria. Eligible participants were diagnosed with severe dementia as defined by a Global Deterioration Scale (GDS) score of 6 points or greater.28

Exclusion criteria included diagnoses of mental retardation or schizophrenia. The medical staff at each center identi- fied all potentially eligible participants based on their medical records. A random sample of 20 participants per center was selected. A staff member at each nursing home informed the closest relative of each selected candidate and requested approval for participation. The institutional review board of the Institut d’Assistència Sanitària approved the research protocol, and written informed con- sent was obtained from each participant’s closest relative or legally authorized representative.

Study Variables, Measures, and Procedure

Demographic and clinical data (e.g., age, sex, dementia diagnosis, and onset of dementia) were retrieved from medical records, and the Mini-Mental State Examination (MMSE)29 was administered when possible.

The Quality of Life in Late-Stage Dementia (QUA- LID),30 the Barthel Index (BI),31 the Neuropsychiatric Inventory—Nursing Home (NPI-NH),32 and the Pain Assessment in Advanced Dementia (PAIN-AD)33 were administered to the nurses who were responsible for each participant’s nursing care and who had extensive firsthand knowledge of each participant’s health status (one nurse from the morning shift and one nurse from the afternoon shift). Information on age, amount of experience, amount of time working in the center, amount of time of providing healthcare to the participant, and amount of daily contact time with the participant was collected. The QUALID is a proxy informant‐based scale that includes 11 positive and negative dimensions of concrete and observable mood and performance items. The frequency of occurrence of these items during the previous week is rated on a 5-point Likert scale. Total scores range from 11 (best QOL) to 55 (worst QOL) points. The internal consistency (Cronbach alpha) of the scale is 0.76, and the interrater reliability (the intra- class correlation coefficient (ICC)) is 0.82.30 The Spanish version of the QUALID scale was developed using stan- dard methodology for instrument translation,34 and satis- factory levels of internal consistency (Cronbach alpha = 0.74) and acceptable interrater reliability (ICC = 0.95) were observed. The Spanish adaptation of the QUALID suggested a multidimensional structure with three possible underlying dimensions of QOL in individu- als with advanced dementia based on the results of a prin- cipal components factor analysis: behavioral signs of discomfort (Cronbach alpha = 0.71), behavioral signs of social interaction (Cronbach alpha = 0.70), and signs of negative affective mood (Cronbach alpha = 0.68). These factors accounted for 56.1% of the total QUALID score variance.

The BI includes 10 items based on the level of inde- pendent functioning in activities of daily living. The BI

JAGS JULY 2012–VOL. 60, NO. 7 ENVIRONMENT AND QUALITY OF LIFE IN DEMENTIA 1231

assesses dimensions such as feeding, movement from wheelchair to bed, bathroom use, movement on and off of the toilet, bathing, walking on a level surface, ascending and descending stairs, dressing, and bowel and bladder control. The BI score ranges from 0 (worst score) to 100 (best score) points. The psychometric properties of the BI are acceptable: internal consistency (Cronbach alpha = 0.98), interrater reliability (Pearson correlation coefficient (r) = 0.89), and test–retest reliability (Pearson r = 0.89).35

The NPI-NH is a modified version of the original instrument that measures psychiatric symptoms in nursing home residents with dementia. A structured interview for- mat assesses 12 domains of psychiatric symptoms that are commonly observed in people with dementia: delusions, hallucinations, agitation or aggression, depression, anxiety, euphoria, apathy, disinhibition, irritability, aberrant motor behavior, night-time behavior, and appetite or eating changes. Minor modifications to the NPI allow the profes- sional staff at the care facility to act as informants for the NPI–NH. A screening question establishes the presence or absence of symptom clusters in each resident domain. A series of in-depth questions is asked to examine specific behaviors if the response to the screening question is affir- mative. The score for each domain is calculated by multi- plying the frequency by the severity, and the sum of all domains yields an overall score (range 0–144, 0 indicates normal behavior and 144 indicates severe behavioral and psychological symptoms).

The PAIN-AD is an observational scale that includes five items that assess breathing, negative vocalization, facial expression, body language, and consolability on a 3-point Likert scale. The score ranges from 0 (no pain) to 10 (severe pain). The internal consistency is moderate (Cronbach alpha 0.50–0.85), but test–retest reliability (ICC = 0.89) and interrater reliability (ICC = 0.75) are strong.36

Two interviewers collected the data and administered the questionnaires at each center. These interviewers were trained in the study protocol before study initiation, and they homogenized the scoring criteria and the procedure used to measure the environmental variables. Resident clinical information was obtained from 152 nurses who participated in the study (78 from the morning shift and 74 from the evening shift). The mean age and the fre- quency of participant contact were similar between both work shift groups. The morning shift nurse group had more healthcare work experience (12.5 vs 9.3 years; Stu- dent t = 4.7; degrees of freedom (df) = 151; P < .001), years working in the nursing home (9.4 vs 5.8 years; Stu- dent t = 5.4; df = 151; P < .001), and months of familiar- ity with the participants (21.4 vs 14.6 years; Student t = 3.1; df = 151; P = .003) than the evening shift nurses. Use of physical restraint measures in beds or wheelchairs was determined by asking the nurses: “During the last month, has the resident required physical restraint mea- sures during the day or the night?” The temperature, atmospheric noise, and light level were measured in each participant’s bedroom and in the dining room and living room of each nursing home using a DT-8820 environment meter (Shenzhen Everbest Machinery Industry Co. Ltd., Shenzhen, Guangdong, China). This industry-certified meter measures light levels from 0.01 to 20,000 Lux with

an accuracy of ± 5%, temperature from approximately �20 to 750°C (~�4–1,400°F) with an accuracy of ± 3.5% (±2°C (35.6°F)), and sound levels from 35 to 100 dB (65–130 dB for AC frequency weighting) with a 0.1-dB resolution and an accuracy of ±3.5 dB. The environmental variables in each room were measured in the morning and afternoon. The exposure of each participant to the temper- ature of each room was the mean of the four measures for each room (twice in the morning and twice in the after- noon). The atmospheric noise level in each room was mea- sured in five trials at 5-minute intervals. The exposure of each participant to the noise of each room was the mean of the 10 measures for each room (5 in the morning, 5 in the afternoon). The light level was assessed in the corners of each room, and the mean value of the four measure- ments was recorded. The exposure of each participant to the light level of each room was the mean of the eight measures for each room (4 in the morning, 4 in the after- noon). Data collection at each center was performed dur- ing 1 week, and data were collected for four participants each day. Data were collected between April 21 and July 4, 2008.

Sample Size and Statistical Analysis

The sample included 160 participants, which was calcu- lated as the size necessary to detect an effect size of 0.1 in a multivariate linear regression with a maximum of eight predictors, a 0.05 alpha risk, and a statistical power of 0.8. This sample size yielded a coefficient of determination (r2) of 0.1.

Descriptive analyses were performed on all study vari- ables, using central tendency and dispersion measurements for quantitative variables and relative and absolute fre- quencies for qualitative variables. The bivariate analyses of the association between total QUALID score and the underlying dimension scores and the environmental mea- sures were assessed using the Spearman correlation coeffi- cient. Four stepwise linear regression models were fitted to total QUALID scores and QUALID underlying dimension scores as dependent variables to assess the relative contri- bution of the environmental variables on participants’ QOL. The independent variables included the mean temperature, noise, and light values of each room. Other variables included as control variables in the model were PAIN-AD score, MMSE score, NPI-NH score, BI score, physical restraint, and mean number of hours participants stayed in each room.

The results are expressed as absolute numbers with percentages and means with standard deviations. A statisti- cal significance of .05 was used to compare hypotheses. Data processing and analysis were performed using SPSS version 15.0 for Windows (SPSS, Inc., Chicago, IL).

RESULTS

One hundred sixty participants were included in this study. The clinical and demographic characteristics of the study participants are listed in Table 1; 18.4% were permanently bedridden, 11.3% had pressure ulcers, 94.4% required diaper use, 48.8% had been physically restrained in beds or wheelchairs during the last month, 62.5% required

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pureed or mashed food, 13.1% maintained normal solid feeding, 13.1% received a soft diet, and 8.1% required enteral nutrition.

The mean temperature (morning and afternoon) of all rooms (bedroom, dining room and living room) was 25.8 ± 1.3°C (78.4 ± 34.3°F). The mean noise level of all rooms was 48.5 ± 6.1 dB, and the mean light level was 362.8 ± 240.5 Lux. The medians and ranges of each envi- ronmental measure for each room and period of the day (morning/afternoon) are listed in Table 2.

Total QUALID score was found to be correlated with MMSE score (rho = �0.303, P < .001), BI score (rho = �0.428, P < .001), NPI-NH score (rho = 0.388, P < .001), and PAIN-AD score (rho = 0.608, P < .001).

No differences in QUALID scores were found between participants who had or had not been physically restrained during the past month (24.2 vs 23.4 points; Student t = 0.664, df = 158, P = .51).

Total QUALID score correlated with noise level of the bedroom (rho = 0.198, P = .01) and light level of the dining room (rho = 0.194, P = .04). Temperature was not associated with total QUALID score. Table 3 reveals the results of correlation analyses between the underlying QUALID dimension scores and the environmental mea- sures of each room and the time of day.

Multivariate analyses demonstrated that total QUA- LID score and QUALID underlying dimension scores were differently associated with the environmental measures and clinical characteristics. The environmental measures were independently associated with other clinical characteristics of the participants such as PAIN-AD, NPI-NH, BI, and MMSE scores (Table 4). All multivariate linear regression

Table 1. Clinical and Demographic Characteristics of the Study Participants (N = 160)

Characteristic Value

Age, mean ± SD 82.6 ± 11.6 Sex, n (%) Male 37 (23.1) Female 123 (76.9)

Duration of dementia, years, mean ± SD 6.5 ± 4.8 Duration of residence in long-term care, years, mean ± SD

3.9 ± 3.4

Mini-Mental State Examination score, mean ± SD (range 0–30)a

4.1 ± 6.3

Barthel Index score, mean ± SD (range 0–100) 10.5 ± 19.3 Pain Assessment in Advanced Dementia score, mean ± SD (range 0–10)

3.2 ± 1.5

Neuropsychiatric Inventory—Nursing Home score, mean ± SD (range 0–144)

8.8 ± 10.5

Quality of Life in Late-Stage Dementia total score, mean ± SD (range = 11–55 points)

23.9 ± 6.9

Behavioral signs of discomfort 7.2 ± 3.4 Behavioral signs of social interactions 11.1 ± 3.3 Signs of negative affective mood 5.0 ± 2.8

Physical restraint, n (%) 78 (48.7) Global Deterioration Scale score, n (%) (range 0–7) 6 62 (38.7) 7 98 (61.3)

a Complete administration (n = 57, 35.6%), partial administration and

weighted score according to number of items answered (n = 52, 32.8%),

unable to respond and scored 0 (n = 51; 31.6%).

SD = standard deviation.

Table 2. Environmental Characteristics of Nursing Home Facilities

Characteristic Bedroom Dining Room Living Room

Temperature, °C [ºF], median (range) Morning 25.8 (17.7–29.3) [78.4 (63.8–84.7)] 25.6 (22.0–28.6) [78.0 (71.6–83.4)] 25.5 (22.0–29.1) [77.9 (71.6–84.3)] Afternoon 26.5 (22.0–33.0) [79.7 (71.6–91.4)] 26.1 (22.3–30.0) [78.9 (72.1–86.0)] 26.2 (22.3–30.8) [79.1 (72.1–87.4)]

Noise, dB, median (range) Morning 36.2 (30.6–71.7) 48.0 (31.7–70.1) 54.8 (39.1–69.1) Afternoon 39.2 (30.3–68.8) 54.8 (32.7–64.8) 56.3 (34.9–68.3)

Light, Lux, median (range) Morning 134.6 (6–1,140.2) 452.0 (31.0–1,342.0) 493.0 (20.2–1,342.0) Afternoon 85.2 (0.5–1,025.2) 364.7 (22.0–1,195.0) 250.5 (14.7–1,195.1)

Resident hours/day, mean ± SD

16.4 ± 4.3 0.9 ± 1.2 6.1 ± 3.9

Table 3. Bivariate Relationship Between Quality of Life in Late-Stage Dementia Underlying Dimension Scores and Environmental Measurements in Each Room

Spearman rho (P-Value)

Location

Behavioral

Signs of

Discomfort

Behavioral

Signs of Social

Interaction

Signs of

Negative

Affective

Mood

Bedroom Temperature �0.055 (.05) �0.023 (.77) 0.022 (.78) Noise 0.095 (.23) 0.040 (.62) 0.055 (.49) Light 0.091 (.26) 0.169 (.04) 0.084 (.29) Hours/day 0.170 (.03) 0.215 (.006) 0.155 (.05)

Dining room Temperature �0.036 (.69) �0.009 (.92) 0.070 (.43) Noise 0.066 (.46) 0.069 (.44) 0.098 (.27) Light 0.088 (.32) 0.204 (.02) 0.116 (.19) Hours/day �0.174 (.03) �0.181 (.02) �0.210 (.008)

Living room Temperature �0.109 (.21) �0.015 (.86) 0.072 (.41) Noise 0.085 (.33) �0.112 (.20) 0.084 (.34) Light 0.207 (.03) 0.072 (.047) 0.200 (.01) Hours/day �0.161 (.04) �0.157 (.048) �0.089 (.26)

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models were adjusted according to the number of hours that participants stayed in each room; care center; PAIN-AD, NPI-NH, MMSE, and BI scores; and physical restraint.

DISCUSSION

This cross-sectional study of nursing home residents with severe dementia demonstrated that environmental factors such as temperature, noise, and lighting are related to the QOL of the residents. The environmental docility hypothe- sis suggests that institutionalized individuals with severe dementia are sensitive to the effects of simple environmen- tal factors because of their limited cognitive and functional abilities to influence or escape their immediate physical surroundings. The results of the current indicated that high temperature levels and many hours spent in the bedroom were associated with lower QOL. High noise levels in the living room were associated with fewer behavioral signs of social interaction, and low light levels in the bedroom for participants who spent many hours there was associated with more signs of a negative affective mood. Previous research on the effect of physical environmental variables in nursing home residents has focused on individual out- comes, such as aggressive behavior during showers and baths (light, sound, temperature, and humidity)37 or prob- lematic vocalization (temperature and humidity).38 Both of these studies reported negative results. The cross-sectional nature or the measurement procedures used may have pre- vented the detection of a relationship in these studies. A recent study using a psychometric instrument to assess the quality of the physical environment demonstrated an asso- ciation between environmental factors and neuropsychiat-

ric symptoms and QOL in assisted living residents with and without dementia,39 but the current study is the first to examine the association between environmental factors such as temperature, noise, and light levels and QOL in nursing home residents with severe dementia, so compari- sons with the literature are limited.

Major factors that influence QOL in individuals with dementia in long-term care facilities have been identified during the last decade. Six elements of care require special attention in the assessment of QOL in individuals with advanced dementia: depression, behavioral symptoms, pain, food and fluid intake, activity involvement, and mobility.23 The current results confirm those of previous studies and indicate that BPSD (measured using the NPI- NH scale), pain (measured using the PAIN-AD scale), and functional dependence (measured using the BI scale) are strong predictors of the QOL in individuals with severe dementia.

This study focused on nursing home residents with severe dementia in contrast to broader research on envi- ronmental characteristics. Three specific components of the indoor environment were objectively measured: tempera- ture, light, and noise. These stimuli contribute to residents’ comfort and well-being.

The ratio of temperature in the bedroom to number of hours spent in the bedroom was associated with QOL. Individuals with advanced dementia remained in the bed- room for long periods of the day and were less active than other individuals. This situation may alter basal metabo- lism and the circadian rhythmicity of body temperature.40

Satisfaction or displeasure with the thermal environment might be detected in these individuals by observing their behavior. For example, a study demonstrated that nursing

Table 4. Regression Models of Variables Predicting Total Quality of Life in Late-Stage Dementia (QUALID) and QUALID Underlying Dimension Participant Scores

b (P-Value)

Independent Variables

Model 1

(r2 = 0.535)

Model 2

(r2 = 0.620)

Model 3

(r2 = 0.223)

Model 4

(r2 = 0.382)

Pain Assessment in Advanced Dementia score 0.390 (.001) 0.458 (.001) 0.032 (.77) 0.437 (.001) Neuropsychiatric Inventory—Nursing Home score 0.339 (.001) 0.411 (.001) 0.107 (.37) 0.168 (.12) Barthel Index �0.125 (.10) �0.076 (.28) �0.133 (.19) 0.008 (.92) Mini-Mental State Examination score �0.094 (.20) 0.084 (.21) �0.241 (.01) �0.030 (.72) Physical restraint 0.019 (.81) �0.018 (.8) �0.001 (.99) 0.089 (.31) Hours/day in bedroom 0.410 (.001) 0.264 (.07) 0.112 (.28) 0.437 (.02) Hours/day in dining room 0.098 (.96) 0.133 (.16) 0.033 (.80) 0.041 (.73) Hours/day in living room 0.392 (.02) 0.296 (.049) 0.228 (.03) 0.357 (.05) Temperature in bedroom 0.312 (.003) 0.249 (.007) 0.178 (.18) 0.197 (.09) Temperature in dining room 0.376 (.29) 0.568 (.08) �0.034 (.94) 0.127 (.76) Temperature in living room �0.505 (.10) �0.739 (.02) �0.140 (.75) �0.108 (.78) Light in bedroom 0.112 (.23) 0.002 (>.99) 0.065 (.52) �0.216 (.048) Light in dining room 0.194 (.20) 0.159 (.24) 0.199 (.31) �0.037 (.83) Light in living room �0.053 (.70) �0.079 (.53) �0.011 (.95) �0.020 (.90) Noise in bedroom 0.107 (.17) 0.108 (.13) 0.065 (.52) 0.006 (.95) Noise in dining room �0.187 (.08) �0.119 (.22) 0.136 (.32) �0.050 (.68) Noise in living room 0.070 (.42) 0.079 (.31) 0.102 (.04) 0.105 (.29) Center �0.109 (.29) �0.181 (.06) 0.074 (.58) �0.177 (.14)

Dependent variables: Model 1, QUALID total score; Model 2, QUALID behavioral signs of discomfort score; Model 3, QUALID behavioral signs of social

interaction; Model 4, QUALID signs of negative affective mood score.

r2 = coefficient of determination.

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home residents with dementia requested more attention when temperatures were high during the daytime.41

Behavioral signs of social interaction were associated with noise level in the living room and the number of hours that participants remained there. In general, expo- sure to noises exceeding a quiet level of 40 to 50 dB is associated with negative outcomes, and noise levels above 55 to 60 dB have been found to trigger an increase in cate- cholamine and cortisol levels.42 The Environmental Protec- tion Agency recommends that noise levels for nursing homes remain below 45 dB during the day,43 but nursing homes in the United States exhibit noise levels between 55 and 70 dB, which is comparable with busy road traffic noise.44 A study of the sundown syndrome in institutional- ized elderly adults revealed that those with dementia with- out hearing loss were more prone to developing sundown syndrome.45 A decrease in noise levels modestly improves nighttime sleep in nursing home residents.46 The mean noise value in the living room in the current study was approximately 54.6 dB in the morning and 54.5 dB in the afternoon. The main sources of noise in the living room were alarms, intercoms, ringing phones, loud televisions, and crowds. Exposure of individuals with severe dementia to high noise levels may increase confusion and trigger fear or other negative feelings, which results in a reduced amount of social interaction.

The environmental recommendations for the design of nursing homes indicate the visual benefits of lighting (e.g., overall improvement in visibility and the prevention of falls).47 High-intensity light exposure has positive effects on circadian rhythmicity48 and the sleep patterns49 of insti- tutionalized individuals with dementia. The results of the current study indicated that low light levels in the bed- room and many hours spent in the bedroom increased the number of signs suggesting a negative mood in partici- pants. This result is consistent with that of a previous study that demonstrated an effect of light therapy in a sub- sample of individuals with severe dementia.49 Circadian system disruptions tend to parallel disease severity, and individuals with advanced dementia may be particularly responsive to light therapy.44

Several limitations must be considered when interpret- ing the results of this study. First, this study was per- formed in late spring and summer, the assessment of environmental characteristics was not simultaneous, and some environmental characteristics may change over time. Second, a cross-sectional and observational design was used, so no conclusions regarding causality can be drawn. Third, the environmental measurements were taken for each participant for only two periods of the day (morning and afternoon) for the purpose of linking the environment to particular individuals, and only the average measure- ment in the common spaces was captured and not the actual experience of the participants. Fourth, the results may not be generalizable to other population groups; it is possible that the effect of temperature might be different in hotter climates, and the effect of noise might be differ- ent in other cultures. Fifth, the increment in the number of predictors from eight to 18 variables reduced the effect size range from 0.10 to 0.14. Sixth, the assessment of the use of physical restraint was measured using a single ques- tion to the nurses, and frequency of restraint use was not

ascertained. This approach may have underestimated the real effect of physical restraints on QOL.

In conclusion, this study was an initial effort to investigate the effects of indoor physical environmental characteristics on individuals with severe dementia. The results suggest that simple interventions to adjust tem- perature, noise, and light levels may increase the QOL of institutionalized individuals with severe dementia. Room lighting and temperature levels may require moni- toring and adjustment for bedridden individuals, and a reduction in noise levels in the living room may pro- mote social interaction in individuals with severe demen- tia. The results of this study suggest that further investigation of the relationship between QOL in indi- viduals with severe dementia and the physical indoor environment of nursing home facilities is worthwhile. Specifically, a longitudinal design would assess whether these environmental variables exert a significant palliative effect on nursing home residents with severe dementia.

ACKNOWLEDGMENTS

We are grateful to all the staff at the participating nursing homes and to the participants and families who have gen- erously given their time and collaborated in the study. We wish to thank Xènia Planas Pujol for her dedication and assistance in the development and implementation of the study and to Laia Calvó Perxas for her contribution to the English version of the article.

Conflict of Interest: This research was supported by Grant 063110 from the Fundació La Marató de TV3. None of the authors have any financial interest, patents, company holdings, or stock to disclose related to this project.

Author Contributions: J. Garre-Olmo was the study coordinator and substantially contributed to the study con- cept, design, analysis and interpretation of data, and writ- ing of the paper. S. López-Pousa contributed to study design and writing of the paper. A. Turon-Estrada, D. Juv- inyà, and D. Ballester contributed to study performance and writing of the paper. J. Vilalta-Franch contributed to study concept, design, analysis and interpretation of data, and writing of the paper.

Sponsor’s Role: The sponsor had no role in the study design; collection, analysis, or interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

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