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An Indoor Environmental Approach

The high road to profitable Assisted Living (AL) communities is based on a simple premise: Healthier indoor environments mitigate conditions of the elderly, providing a better atmosphere for well-being, retention and admissions.

A 2018 study reports “cognitive deficit and dementia are significantly underdiagnosed and undertreated in assisted living settings” and while improvements in diagnostics between 2004-2011 raised the frequency of dementia diagnosis in AL communities from 57% to 67% of residents, there is much work to be done.1

This echoes the findings of an earlier broad-based US study that found 47% of residents past age 85 had dementia, with general prevalence ranging from 40% to 67%.2

Since more than half of seniors in AL communities have dementia, knowing how healthful indoor spaces assist with cognitive disability, then understanding and adopting best practices, is both the right thing to do − and good business.

Here is a summary of the science:

Lighting and Dementia

Increasing daytime indoor light levels is helpful as it helps reset circadian rhythms for better nighttime sleep, and eases symptoms of “disturbed cognition, mood, behavior, and functional abilities.” Melatonin supplementation at night, but only used in conjunction with increased daytime lighting, seems to aid sleep in the evenings.3

Exposure to natural outdoor light and appealing exterior views is also therapeutic:

“The well-being of those who are physically and cognitively frail is affected by their overall exposure to the cycle of day and night, to sunlight and view.”4

What You Can Do: Arrange for outdoor activities in which exposure to natural light and outdoor scenery is a regular part of the residents’ day. Indoors, install broad-spectrum lighting such as color-balanced LEDs which are energy efficient, bright, and provide both blue and red frequencies to emulate natural light. Use diffusers over indoor fluorescent or other light fixtures to reduce glare (e.g., see Amazon for Light Diffusers).

Sound and Dementia

A quiet environment is healthful: “Acoustics are of particular importance to people with dementia, who suffer from cognitive deficits and react to noise in a different way than others. As a result of their age, they often have a hearing impairment and this together with the dementia can lead to confusion, distraction and problems with orientation due to sound.”5

What You Can Do: Buy an inexpensive decibel (dB) meter (<$25 online) to determine background sound levels based on Noise Curve (NC) ratings. A private room should be at NC 25-30 which equates to about 35-40 dB (measurements should be taken when the space isn’t occupied). Other acoustic factors include sound isolation and room acoustics. Installing acoustic ceiling tiles often helps, as does adding acoustic panels to walls or as partitions that absorb or reflect and direct sound as needed.

Double-pane or triple-pane exterior windows can help as both thermal and acoustic insulation. 

IAQ (Indoor Air Quality) and Dementia

Airborne pollutants such as carbon dioxide, VOCs (volatile organic compounds) and particulates tend to build up indoors.

In general, indoor air is the main route of exposure to contaminants. Dr. Michael Berry, author of Protecting the Built Environment, Clean for Health said: “[Each] day, individuals ingest about two pounds of food, four pounds of liquid, and 30 pounds of air.”6

The elderly are especially vulnerable. In AL communities, “adverse effects [of airborne contaminants] were greater … in those aged >80 years.”7

The US EPA lists three main ways to improve indoor air quality:8

  1. Remove the source
  2. Ventilate
  3. Purify the air

Removing sources begins with making a list, such as:

  1. Cleaning supplies that pollute
  2. Materials that off-gas
  3. Leaky vacuum cleaners

For more ideas, see the Healthy Facility Brief – Steps for Protecting Indoor Air Quality.

Ventilation is next. In AL communities, “adverse effects [of airborne contaminants] were greater in the case of poor ventilation…”9

Ventilation: Striking a Balance

It’s important to strike a balance between thermal comfort and indoor air quality. These values are somewhat at odds since ventilation tends to drive up the costs of heating or cooling.

“Potentially, simple measures could provide health benefits to Elderly Care Center residents and workers, such as insulating ceilings, walls, and windows, without giving up natural and passive ventilation solutions.”10

Heat Recovery Ventilators (HRVs) and Energy Recovery Ventilators (ERVs) help as they bring in fresh air, exhaust stale indoor air, while transferring the heat or cooling energy to the incoming airstream.11

Air Purifiers: Last But Not Least

Purifying the air is last but not least, especially if the air to be cleaned can be processed in sufficient amounts to make a difference. If using a portable air purifier, pay attention the Clean Air Delivery Rate (CADR) which tells you how large a room can be treated by the device. If using a portable unit, close off the area in which the air is to be cleaned so the purifier can properly process the space.

Be aware that particulate capture mostly occurs by passing air through physical filter media (e.g., pleated microfilters, HEPA), whereas gaseous pollutants are not removed by pleated or HEPA-type filters but require different media such as activated carbon or activated alumina.

An interesting development is ionizing air purifiers that install within HVAC ducts; working in tandem with existing HVAC filtration systems to enhance particulate removal while reducing VOC levels and airborne pathogens. The ionization apparently causes dust particles to clump, making them easier to remove by the HVAC’s filter media. The units also have ozone capturing technology to minimize ozone in the space both from the ionization process and other sources such as copiers, outdoor air pollution, and more. See A New Approach to Air Purification.

What You Can Do: Remove sources of pollution, insulate, ventilate, then purify the air as needed. Consider an Energy Recovery Ventilator (ERV) to bring in fresh air and remove stuffy air, while saving energy by transferring indoor warmth or cooling to the supply air via an energy-exchange mechanism.

References

  1. Prevalence, Recognition, and Treatment of Dementia in Assisted Living FacilitiesDementia and Geriatric Cognitive Disorders, 2018
  2. Dementia and Assisted Living,The Gerontologist, 2007
  3. Effect of Bright Light and Melatonin on Cognitive and Noncognitive Function in Elderly Residents of Group Care Facilities, JAMA, 2008
  4. Lighting for people with dementia, Lighting Research and Technology, 2007
  5. The Impact of Sound and Room Acoustics in Healthcare Facilities: A Room Acoustic Intervention Study in A Dementia Clinic in Munich, INTER-NOISE and NOISE-CON Congress and Conference Proceedings, 2016
  6. Protecting the Built Environment, Clean for Health, 1994
  7. Indoor air quality, ventilation and respiratory health in elderly residents living in nursing homes in Europe, European Respiratory Journal, 2015
  8. Improving Indoor Air Quality, EPA, Retrieved 5/29/18
  9. Indoor air quality, ventilation and respiratory health in elderly residents living in nursing homes in Europe, European Respiratory Journal, 2015
  10. Indoor Air Quality and Thermal Comfort−Results of a Pilot Study in Elderly Care Centers in Portugal, Journal of Toxicology in Environmental Health, Part A, 2013
  11. Testing for Energy Recovery Ventilators and Energy Saving Analysis with Air-Conditioning Systems, 9th International Symposium on Heating, Ventilation and Air Conditioning (ISHVAC) and the 3rd International Conference on Building Energy and Environment (COBEE), 2015

Allen Rathey is the principal of the Healthy Facilities Institute (HFI), director of the Indoor Wellness Council (IWC), and author of articles about best practices in cleaning and indoor environmental management. Linked In: www.linkedin.com/in/allen-rathey.

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