Most residents of nursing homes have cogni­tive impairment, and the majority of those indi­viduals have dementia. Providing a supportive environment for people with moderate to severe dementia requires certain specialized design and
intervention features. This need has resulted in the development of special care units in many nursing homes.

Well-designed special care units for people with dementia provide a supportive and therapeutic set of programs that help the person function at the highest level possible. Optimally, staff who work in special care units receive special training in work­ing with persons with dementia. The best units have physical design elements that take functional limitations into account; for example, the hallways of some facilities are designed in such a way that if residents wander, they merely follow the interior halls or exterior path in a circle so that they do not leave the building or the complex, and the decorat­ing is done in a way to minimize confusion. Most facilities have residents with cognitive impairment wear wrist or ankle bands that trigger alarms if they wander beyond a certain point or exit the facility, another safe way to provide opportunities for resi­dents to move about freely but safely. The best facili­ties also permit residents to bring a few personal items as reminders of their past in order to provide a more homelike environment. They also provide a private dining area in a family-like setting in order to minimize possible negative interactions between residents with dementia and residents without cog­nitive impairment.

Selecting the right special care unit for a per­son with dementia must be done carefully (Paris, 2008). As noted in the competence-environmental press model, as competence declines the environ­ment must provide more support in order for behavior to be optimized. So the special care unit must have the right level of environmental sup­port at the placement, as well as the availability of additional levels of support when the person’s competence level continues to decline. Memory aids should be built into the unit, such as color- coded halls. Staffing levels and training are key, as is the range of intervention programs and activities available. Such programs should be research based, such as ones based on the Montessori techniques discussed in Chapter 10.

The research-based staff training required at the best special care units includes several aspects of

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caring for older adults with moderate to severe cog­nitive impairment:

• Appropriate and effective communication techniques (as discussed later in this section)

• Behavioral management techniques to address aggressive or agitated behavior (a common symptom in dementia)

• Appropriate techniques for assisting with personal health and hygiene that protect residents’ dignity

• Appropriate methods for dealing with incontinence

• Appropriate techniques for handling sexuality in persons with dementia

• Effective techniques for controlling wandering (in addition to physical design aspects of the facility)

• Appropriate ways of supervising or assisting with eating

• Appropriate techniques and interventions to address memory failure and disorientation

• Appropriate techniques for assisting with mobility (e. g., walking, using a wheelchair)

Training in these areas will not guarantee high – quality care, but it will increase the likelihood of it.

Research indicates that upon admission resi­dents of special care units are younger and are more

behaviorally impaired than general nursing home residents when both exist in the same facility (e. g., Gruneir et al., 2008a; Nobili et al., 2008). Residents of special care units tend to have lower hospitalization rates and use of physical restraints (Nobili et al., 2008) and a higher rate of use of antipsychotic medication (Gruneir et al., 2008a). The increased quality of care residents of special care units receive is more the result of a difference in philosophy of care between nursing homes with and without spe­cial care units than it is due to the special care unit itself (Gruneir et al., 2008b). Given that the use of physical restraints is associated with higher mor­bidity (Reid, 2008), it may be that nursing homes that include special care units also have different approaches for dealing with problem behaviors that help avoid the use of physical restraints.