Copyright 2012 by Health Professions Press, Inc. All rights reserved.

Contents
About the Authors Acknowledgments v vii

Introduction | What Is ECAT and Who Should Use It?

ECAT Manual Assessment Instruments Intervention Procedures and Resources ECAT Development 2 2 2 3

Section 1 | ECAT Manual

Introduction 5 What Is Communication? 5 Impact of Communication Disorders 5 Impact of Communication Interventions 5 Impact of Environment on Communication 7 Environment, Ability, and Performance 8 Competence and Environmental Press 9 11 International Classification of Functioning, Disability and Health (ICF) From Body Structure to Environmental Interventions 12 Body Structure and Function 12 12 Normal Aging Changes in Cognition, Memory, and Language 12 13 Changes in Vision Changes in Hearing 15 Dementia 17 Changes in Cognition and Memory 20 Changes in Expressive and Receptive Language 22 23 Changes in Vision Changes in Hearing 24 Design Strategies 25 26 Optimize Cognitive Aspects Maximize Cues 26 Personalize Spaces and Materials 28 Optimize Visual Aspects 30 Enhance Lighting 30 Enhance Visual Organization 32 Maximize Sightlines 32 Maximize Contrast 33 Minimize Glare 35 Optimize Auditory Aspects 35 Minimize Background Noise 35 Minimize Reverberation 37
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Environmental Interventions 38 Toileting, Bathing, and Grooming 39 Dressing 40 Orienting to Time/Location 41 42 Controlling Ambient Conditions Engaging in Leisure and Social Activities 42 45 Navigating Throughout the Care Community Dining 46 Environmental Interventions as Part of Treatment Planning Process Implementing Modications in the Care Community Examples of Signicant Environmental Modications 47 50 51

Section 2 | Assessment Instruments

Introduction 53 Objectives 53 Assessment Structure Assessment Forms Gray Scale to Assess Contrast Gray Scale Contrast Tool Type Size Reading Test Sound Intensity Assessment Light Intensity Assessment 54 54 58 59 60 61 62

Section 3 | Intervention Procedures

Interventions Based on Environmental Assessment Results Developing Visual Cues and Reading Material 63 78

Section 4 | Recommendations and Resources

Lighting 79 Sequencing Cues Personal Space Signs Where to Purchase Supplies for Environmental Modications 85 86 87

References 88

ECAT Assessment Instruments & Intervention Tools CD-ROM

Evaluation of Personal Spaces Evaluation of Public Spaces Sequencing Cues Personal Space Signs Gray Scale Contrast Tool Type Size Reading Test
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Copyright 2012 by Health Professions Press, Inc. All rights reserved.

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What Is ECAT and Who Should Use It?

Introduction

Environment & Communication Assessment Toolkit (ECAT) for Dementia Care was designed to be used by clinicians who work withclients with dementia in long-term care settings. Speechlanguage pathologists, occupational therapists, physical therapists, nurses, and other direct care staff will nd ECAT useful for identifying environmental barriers and facilitators to communication and developing appropriate interventions to support communication. Prior to using ECAT, clinicians should have a basic understanding of communication decits among clients with dementia and the types of interventions for overcoming those decits. ECAT is the rst resource of its kind to guide clinicians through learning about the impact of the environment on communication and to provide practical tools for identifying interventions to improve communication. Considering the environment as a major contributor to communication performance, ECAT for Dementia Care represents a new way of thinking about assessment and intervention to improve communication in clients with dementia. It is a toolkit of materials intended to provide clinicians with a complete package for learning about the im pact of the environment on communication, measuring environmental barriers tocommunication, and identifying environmental facilita tors that support effective communication. The components of ECAT include a Manual, Assessment Instruments, and Intervention Procedures. Each is described briey below.

Communication Environment Facilitator:

Feature or characteristic of the environment that supports effective communication

Communication Environment Barrier:

Feature or characteristic of the environment that interrupts or interferes with effective communication.

The way we communicate with others and with ourselves ultimately determines the quality of our lives. Anthony Robbins
ECAT for Dementia Care Manual
Copyright 2012 by Health Professions Press, Inc. All rights reserved.

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ECAT Manual
The ECAT Manual is an educational tool that has been designed to provide the clinician with greater knowledge about the impact of the environment on communication performance in the long-term care setting. It discusses how functional limitations associated with dementia can impact a persons ability to communicate, and how the physical and social environment can help compensate for these limitations. The manual begins by introducing the contributions of body function and impairment to reductions in capacity, including a discussion of functional communication decits due to age-related changes as well as the effects of dementia. It also presents the goals for reducing environmental demands on communication. These performance goals will be the basis for making decisions about environmental modications to facilitate communication during activities of daily living. After reading this guide, the reader will be aware that there are many types of environmental interventions that can be made to ameliorate typical problems that people with dementia have communicating during routine activities.

The learning objectives of the ECAT Manual are to help the clinician:

 ain a better understanding of how the environment impacts various aspects of communication for a G client with dementia  nderstand how to identify environmental barriers that impact communication during routine U activities Learn about a wide range of environmental interventions that support communication

Assessment Instruments
The Assessment Instruments in Section 2 comprise instructions and a set of tools for collecting the information necessary to identify environmental barriers and facilitators, including the assessment forms, a gray scale to assess contrast, a reading test to determine appropriate type sizes, and sound and light level meters. The core of the Assessment Instruments are the two assessment forms. They serve as a comprehensive clinical instrument for determining the characteristics of the environment that create difculty in a clients communication performance. Clinicians will use them to systematically assess the ways in which the environment may be creating barriers to the clients ability to communicate successfully, and to use environmental facilitators to develop appropriate intervention strategies to overcome those barriers.

Intervention Procedures and Resources

Sections 3 and 4 of the ECAT Manual provide many practical recommendations and resources, including information on developing visual cues and reading material, and an overview of lighting. Instructions are also included for using the personal space signs and sequencing cards for activities of daily living that accompany the ECAT Manual in the Environment & Communication Assessment Toolkit for Dementia Care. This section includes a listing of environmental modications that help address the communication difculties that a client may have when performing daily activities. Some of the suggested interventions such as text style or size, color contrast, and signage locationmay require further assessment to determine specic characteristics to meet the clients needs.

ECAT for Dementia Care Manual

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ECAT for Dementia Care Development

ECAT for Dementia Care was developed and thoroughly evaluated by a team of speech-language pathologists and architects specializing in environments for people with dementia, with a large contribution from a multidisciplinary advisory panel of experts in communication disorders, dementia, and environmental interventions for people with dementia. The two-phase project took more than 3 years to complete and was supported by a grant to I.D.E.A.S., Inc., from the National Institute on Deafness and Other Communication Disorders, which is part of the U.S. National Institutes of Health. The rst phase of the work focused on developing resources and demonstrating feasibility of ECAT for evaluating personal spaces, including bedrooms and bathrooms, in long-term care settings. Testing of the rst version of ECAT was conducted with 30 speech-language pathologists who worked with clients with dementia. Results of the initial test of knowledge demonstrated that the therapists had a statistically signicant increase in knowledge of environmental assessment and modications after reading the ECAT information compared to their knowledge prior to being exposed to the materials. Further testing was performed with a group of six speech-language pathologist to determine the impact of ECAT on the development of treatment goals for clients with dementia. This test of utility demonstrated a 100% increase in the number of environmental interventions that the speech-language pathologists recommended for clients. In the second phase of the project, the ECAT Manual and Assessment Instruments were expanded and more rigorously evaluated with a larger group of therapists. In this phase, the assessment was more fully developed to cover the public spaces of long-term care facilities, including circulation spaces, dining rooms, restrooms, and leisure activity areas. To evaluate the effectiveness of the materials, ECAT was implemented by a diverse group of 63 speech-language pathologists, occupational therapists, physical therapists, and nurses who used the toolkit with their clients for 6 months. The effectiveness of ECAT was measured by four factors: 1) awareness of environmental interventions; 2) impact of ECAT on practice; 3) utility of the information; and 4) usability of the materials. Awareness. The increase in awareness of environmental modications prior to and after training was highly signicant (p = .000). Based on changes in scores on a 10-item test of material, knowledge of environmental modications increased from an average of 5.65 prior to training to 6.96 after training in the use of the ECAT Manual. Impact. The number of environmental modications used with clients 2 and 5 months after training was greater than those used prior to training. Although clinicians reported making a fair number of environmental modications prior to training, the number of modications recommended for clients increased from an average of 9.87 to 11.63 after the initial treatment at 2 months and 13.45 after 5 months. There were signicant (p < .005) differences between the initial training after 5 months. In fact, more than half of the clinicians continued to use ECAT on their own as part of their clinical practice after they had met the requirements of the study. Use of ECAT not only resulted in more modications, but also in different modications. Prior to training, the majority of clinicians reported using half of a list of 20 environmental modications. After using ECAT for 2 months, the majority of clinicians used three-quarters of the modications, and after 5 months the
ECAT for Dementia Care Manual
Copyright 2012 by Health Professions Press, Inc. All rights reserved.

majority used 80% of the modications. The signicant increase in the use of many of the modications coincided with signicant reductions in several modications that were frequently used prior to training and a slight reduction in skilled services, which suggests that, overall, ECAT had provided clinicians with an increased repertoire of potential interventions. Although there were no signicant differences in cost of environmental modications between pre-training and use of ECAT, the cost of environmental modications was generally less than $100. Utility. Clinicians responses to questions about the helpfulness, usefulness, novelty, and value of the information in the ECAT Manual were overwhelmingly positive. More than 9 out of 10 clinicians rated the main sections of the manual as helpful to very helpful. The degree of new knowledge included in the toolkit varied. Only one quarter of the clinicians thought that all or most of the information in the Introduction was new, whereas approximately three-quarters reported that some of the information was new. The sections on how to use the light and sound level meters were the most novel. Although not all of the information in the ECAT Manual was completely new, the vast majority of clinicians thought that it was very useful. In fact, 98% of the clinicians reported that the information provided new treatment options to use with clients with dementia. In addition, 9 out of 10 clinicians agreed or strongly agreed that ECAT for Dementia Care had useful information, added value to their clinical practice, and beneted their clients, and that they intended to use the toolkit in the future. In addition, approximately three-quarters agreed or strongly agreed that it provided the basis for working with personal care assistants, allowed the clinician to justify new interventions to the administration, and was helpful in working with family members. Usability. Clinicians agreement with statements about the ease of comprehending and using the materials was extremely high, with 96.2% agreeing or strongly agreeing that the information was easy to understand and 92.1% agreeing or strongly agreeing that ECAT was easy to use.

ECAT for Dementia Care Manual

Copyright 2012 by Health Professions Press, Inc. All rights reserved.

Copyright 2012 by Health Professions Press, Inc. All rights reserved.

Copyright 2012 by Health Professions Press, Inc. All rights reserved.

Copyright 2012 by Health Professions Press, Inc. All rights reserved.