Professional Care Facilities for Persons with Dementia

The Villa Serena Model, Characteristics and Guidelines
by Thomas Elin JD, Catherine Harris PhD, RNCS, Gustavo Román, MD

Introduction
Most families strive to provide care at home for their loved ones with Alzheimer’s disease (AD) or other forms of dementia, well into the course of the disease. Help is available from educational programs and community services, but at some point along the continuum of the illness, family caregivers may become ill themselves, or are unable to cope with the stress caused by the relentless, 24-hour, 7-day-a-week caregiving. Then it becomes necessary for family caregivers to investigate care services in a professional setting. This often occurs when the patient is no longer continent or when their behavior becomes unsafe and too difficult to handle in a family residence. Options for placement include Day Care programs, Group Homes, Residential Care Settings (intermediate care) and specialized dementia care units in nursing homes (“skilled” care facilities). In the United States, residential care programs have proliferated because they are designed to be more home-like and can be geared to optimize cognitive and functional ability. Though residential care facilities are monitored by state regulatory agencies for safety and quality, they can be more creative in care approaches because they are not subject to the more stringent federal government regulations (Institute of Medicine [IOM], 2001).

In this chapter, we will describe Villa Serena, a model of dementia care that has received considerable attention in the US for its innovative approaches to environmental design; scientific and creative care; as well as education of staff, families, the professional community, and the general public. The chapter will discuss family needs and selection of a care facility; environmental design; and assessment of client and family on pre-admission, admission and at periodic intervals during their stay in the facility. It will also address care planning and implementation, staff training, activities, family participation, and the incorporation of current research into practice.

The Placement Decision
Placing a loved family member in a nursing home or other care center outside the home is a momentous decision. For some it conjures up abandonment and broken promises. The decision to place someone is never easy, but it may be the best one for both the person with dementia and their caregivers. Though home care has many advantages, it is becoming rare for a family to be able to care for their family member at home during the entire illness. At some point in the course of the illness, the safety of the patient and the health of the caregiver require professional supervision and care (Alzheimer’s Association, [AA], 1992).
Published guidelines assist families in the selection of a facility once the decision has been made to place a family member in a residential care unit. One good example is a publication by the Alzheimer’s Association of the US titled, “Residential Care: A Guide for Choosing a New Home” (1998). Basic considerations include the facility’s philosophy of resident care and family involvement, and any religious affiliation. Also of interest would be the location of the facility for ease of visitation, space allocation for the patient – both private and communal, and safety factors such as secured doors and windows, indoor and outdoor wandering areas and the availability of medical or emergency care. In addition, the family will want to inquire about staffing patterns, staff training, experience and expertise of supervisory and administrative staff, dietary services, activities of daily living as well as leisure activities, outings, and exercise program.

Villa Serena Residential Care
Villa Serena was founded and organized in 1989 as a model for residential care of persons with Alzheimer’s disease and related dementias. The mission of the program is to promote a meaningful life for affected individuals and their families from diagnosis of dementia to the terminal stage of the illness. The program emphasizes state of the art care in an enhanced environment that includes care strategies, architectural innovations, skilled staff, and family support and involvement in the program. At the core of the program is the affiliation with universities or dementia research centers for the purpose of expediting integration, for the benefit of Villa Serena residents’, of the best and most relevant research, academic education, and specialized care. Centers throughout the United States and international sites collaborate to share referrals, data bases, innovations, research results, developments in facility management and long-term dementia care industry trends.
Philosophy: Villa Serena programs are based on the belief that, despite decline in mental or cognitive function, persons with dementia are purposefully directed, have dignity, wish to be independent and autonomous, can experience pleasure, and have a contribution to make. We also believe that a human and physical environment can be created and maintained that supports these abilities based on scientific and humane caring principles.
Quality dementia care is a work in constant progress. There are researchers and expert clinicians in the United States and around the world involved in the development of innovative strategies to improve the care of individuals with dementia and their families. Villa Serena’s philosophy is based on the belief that we must continue to study and develop ever more effective and humane methods of dementia care that would promote the dignity, independence, and pleasurable experiences of residents and the satisfaction of their families.
Administration: Ideally, a dementia care program should be supervised by persons knowledgeable and experienced in dementia care and that has a therapeutic rather than a maintenance philosophy of care (Gold, 1991). In addition to managing a safe, clean and attractive facility within a budget, an administrator must have a genuine empathy and concern for the welfare and professional growth of the staff. This will promote a positive atmosphere in the facility that will carry over to humane care for the residents and their families.
Research: Villa Serena is committed to stay abreast of research
developments and expert literature, integrating the best of new findings into the everyday care of dementia patients. Through the close affiliation and working relationship with university health care institutions, Villa Serena actively supports ongoing research by offering office and clinic space for researchers and access, with appropriate consent procedures, to residents and families. Villa Serena does not conduct research per se, but takes relevant published research and applies findings to the care being provided in Villa Serena environments. Research results are analyzed for appropriateness to the Villa Serena Program, translated into policies and procedures that are integrated in a timely manner into care practices and operation of the facility.

Environmental Design
Residential dementia care facilities evolved as a middle ground approach between the “board and care” homes, where a perhaps loving but often inconsistent quality of care was provided, and the more rigid nursing home environment. Building construction is often in conjunction with an Assisted Living complex, where dementia care is only one part of a community of elder living arrangements. Free-standing dementia units, such as Villa Serena are gaining in popularity and careful consideration is being given to the environmental design to accommodate the declining abilities of the dementia patient (IOM, 2001).

Persons with dementia are potentially vulnerable due not only to the cognitive impairment, but also to the physical disabilities of the aging process. Thus the building must, first of all, be a safe haven, where residents are free to wander inside and out of doors, but with secured egress and hazard free walkways, and safety from dangerous equipment and supplies (Calkins, 1988; Cohen & Weisman, 1991) . At the same time, the setting should respect the dignity and autonomy of the individual, promote a positive mood and a sense of belonging, encourage independence, and support remaining skills (AA, 1992; Calkins, 1988). Also seen as a priority is that the physical environment be conducive to meeting physiological needs including nutrition and hydration, sleep, exercise, hygiene, and the medical needs that inevitably arise in any older population. Specific characteristics of a building designed for care of dementia patients must take into consideration their declining function and self esteem (Gold, 1991). A description of the Villa Serena setting will highlight some of the architectural features that serve to address dementia specific needs.

Villa Serena is located in a wooded residential-office building zone, with access from a side street, but also is close to a major motorway for rapid transport. Deer and other wildlife are often encountered in the neighborhood. It is also conveniently close to the University of Texas Health Science Center and other major medical facilities for ease of routine medical appointments or emergency care needs of the residents. Unlike many US residential facilities (single story “cross” shaped building), Villa Serena is an architecturally pleasing two-story structure (the upstairs houses administrative offices and the UT Dementia Research Center) with a Texas Colonial period motif, native stone exterior and upstairs balconies. A balustraded portal faces the landscaped circular driveway with both a stairway and handicapped entryway. The intent is to present a familiar façade that befits the culture of the region, that has ease of access, is attractive to residents, families and passers-by without blaring out its purpose as a dementia care facility.

The reception area has attractive regional art and a reception counter where a receptionist and a visitor sign-in form are located. To one side of the reception area is a large carpeted parlor area with local art and furnishings. This room can be closed off and used to meet with families for resident care planning, to receive visitors, counsel families, and for special occasion private gatherings for residents and their families. The other side of the reception area is a larger carpeted room with dining tables and a piano. This room has glass doors with lace curtains that can also be closed. Higher functioning residents dine regularly in this room and parties and sing-alongs for all residents are held there. The architecture and reception area arrangement presents a degree of normality that residents and families find inviting and reassuring as well as being beneficial for interaction with the public. Residents are not hidden from view and the public is available to the residents. The appearance of an institution is negated, barriers are minimized, and residents are able to bring up associations from the past (Cohen & Weisman, 1991).

Resident Living Space: Common Areas.
The resident living space should also have a sense of openness, with familiar objects as well as areas for small groups to interact. The layout of the space as well as the interior design must be attractive yet simple with visible destinations and clear directions, to reduce confusion and promote understanding of the environment (AA, 1992). Carpeted hallways need to be wide enough for three or four people to walk comfortably abreast and well lighted with indirect light to prevent glare. Bathrooms should be clearly marked at convenient locations along the way. Handrails for safety are essential and interest areas, such as a comfortable settee, an aquarium or attractive artwork serve to redirect the resident as they pass. Furniture needs to be sturdy and easy to keep clean, as well as comfortable and attractive. There are a number of furniture manufacturers who design and construct reasonably priced furniture especially for residential care facilities that embody these attributes.

Visible access to an outside area, with a secured perimeter, offers peaceful activities such as bird watching or other contact with nature. The area should have paths that are safe with occasional seating to accommodate fatigue and opportunities to socialize (Brawley, 1997; Coons, 1988). The secured outdoor areas at Villa Serena have non-poisonous native plants with some raised beds for residents to putter in. The paths gently direct the resident to the entry door of an atrium, aviary or a covered portal with rocking chairs. Hallways have clear contrast at the floor to wall intersection, and are color coded (blue for east-west and maroon for north-south) to promote way finding.

Activity and Dining Areas:
Mealtime can be a pleasurable event, but it is a highly active time and so can be stressful when many people converge with accompanying clutter, noise, and staff traffic. Villa Serena has intermediate areas for communal dining and group activities as well as sunny sitting rooms for more intimate dining, say for a resident and a family member. A small alcove could accommodate individual mealtime and the quieter setting can reduce confusion, encourage appetite, aid digestion and improve satisfaction with the dining experience. The smaller more intimate space can also be used for the one-to-one interaction and activities needed by individuals with more advanced dementia (Cohen & Weisman, 1991).
Private Areas: The resident’s own private space, while needing to recognize safety features of any other part of the building, can be as individual as the resident and the family choose. Ideally, the resident may bring furniture, pictures, art objects, linens, plants, and other personal belongings to make their space as familiar and comfortable as possible. Some residents may wish to have a long-time pet, a radio or television, or a desk with typewriter or computer terminal. Residents and families should be advised of the risks associated with valuable art or jewelry that cannot be always kept secure from other resident’s inadvertent handling. Most importantly, the resident’s private space should be respected as their home and their autonomy and dignity as host or hostess recognized.

Assessments: Pre-Admission and Admission
Presumably an individual considered for admission to a Residential Care Facility has had a battery of assessment tests and a diagnosis of dementia by a qualified physician. Pre-admission screening has more to do with assessing for appropriate assignment to program levels, care planning, and serves as a baseline for the person’s progression in the illness (AA, 1997). A pre-admission home visit by the nurse or social worker to conduct the assessment is ideal. The staff member has the opportunity to observe the patient and his or her family in their own setting, which provides valuable information about life style, relationship patterns in the family, and behavior issues.
Standard assessment tools administered on pre-admission include the Mini-Mental State Examination (MMSE) (Folstein et al., 1975), the Geriatric Depression Scale (GDS) (Yesavage et al., 1983), the Functional Assessment Staging Tool (FAST) (Reisberg, 1988), and the Philadelphia Geriatric Center Functional Profile (Lawton, 1971) which includes function in Activities of Daily Living, Instrumental Activities of Daily Living, and Minimal Social Behavior. If these instruments have been administered by the attending physician recently and are on file, time and stress for the family could be lessened by obtaining those records. However, the home visit as an opportunity to observe and provide information and reassurance to the family should not be overlooked.

If there is a considerable time lapse between the family’s decision to place their family member and the availability of the room, these tests need to be repeated on admission. Added to those already mentioned would be the any of a number of Behavior, Social, and Motivation rating scales. An example is the Caretaker Obstreperous-Behavior Rating Assessment (COBRA) (Drachman et al., 1992). In order to plan for the best quality of care, facility staff would also need to obtain information, formal or informal regarding life style and daily routines of the resident, spiritual needs, and language and cultural factors that influence daily life. At Villa Serena, the objective assessments are updated on a quarterly basis, to track the progression of the disease and to make modifications in the plan of care. Assessments are also performed when any “change of status” occurs that necessitates evaluation of the situation. Data from all the assessments, over time, are compiled into a composite Score Summation Form for ready review by nursing or medical personnel. The data can also be tapped, with appropriate protocol, for research purposes.

Care Planning and Implementation
It is extremely important that the family or guardian be involved in the care planning and implementation process from the very beginning. As families seldom place their family member in early stages of the disease, at the time of admission, the resident’s ability to articulate needs and interests is limited, and it is necessary to call upon the family to supply the needed information (AA, 1997). The person with dementia may have lost the ability to interpret and articulate feelings of pain and discomfort. Difficulties encountered in assisting with a morning shower could be avoided if it were known that the individual habitually takes a warm bath at bedtime instead. At Villa Serena, a detailed history from the family of bathing and grooming practices, hobbies, recreation, sleep, diet, and other patterns of daily living are obtained, documented and incorporated into planning of care.
The comprehensive assessment information obtained serves as the basis for initial care planning. However, care planning is a dynamic process and continues throughout the resident’s stay at Villa Serena, capitalizing on observations of staff, family participation, progression of the illness and new research findings. Routine formal care planning sessions with primary care staff are held weekly or monthly depending on the status of the resident. Quarterly care plan meetings with the activities director, dietary staff, the family, and the physician, if possible, review updated assessment data and provide the structure for the resident’s changing needs. In addition, a family or any team member observing a problem may request a team meeting at any time. These plans for care are documented and care staff are instructed in their implementation.

Care plans focus on the specific needs of a resident, should be flexible, and behavioral or outcome oriented. For example, “The resident will walk in the garden for 20 minutes at least five days per week during the coming month (May).” Content to be considered in planning meetings include:

• Family involvement, beneficial and problematic
• History of illnesses and list of active diagnoses
• Assessment Data: baseline to current
• Medical and clinical needs including medication
• Psychosocial and emotional needs
• Spiritual and cultural considerations
• Personal care needs
  • Bathing, dressing, grooming, and oral hygiene
  •  Ambulation
  •  Toileting and incontinence
  •  Visual and auditory aids
  •  Comfort care
  •  Sleep patterns
• Daily activities and physical exercise
• Nutrition and hydration
• Communication needs and techniques
• Behavior challenges and management

Reisberg (1984) has proposed that patients with Alzheimer’s disease (AD) experience a reversal of developmental levels in approximately the same order that the skill levels were acquired from birth. This research has shown that, not only behavioral and cognitive skills take the same path of reverse development, but neurologic signs such as the grasp response, rooting, and sucking which are lost as an infant develops, return again in stages 6-7 of AD (Reisberg et al., 1992). Nursing research (Matteson et al., 1997) has correlated the concept of “reverse development” in AD with Piaget’s developmental stages (Piaget, 1952) and applied these findings to the care of persons with dementia. At Villa Serena, care approaches regarding activities of daily living, such as bathing, dining, and dressing and some behavior problems, are applied based on the developmental level at which the resident is functioning. Clearly there are differences in the function of a developing child and a regressing adult. These differences relate to size, autonomy, dignity, and self esteem. Adults with regressing functional ability should never be treated as children. However, the adult AD patient’s behavior can be understood by knowing the developmental level and interventions can be likened to those one would use with a child or adolescent at a similar developmental level.

Despite the stage or progression of the illness, persons with dementia can and should be able to continue meaningful lives. However, due to declining organizational ability, a daily plan of care must include structure and activities that tap into residents’ preserved abilities while supporting those lost. Activities should offer potential for success, create a bond between the caregiver and the person with dementia, provide structure and accept the person at his or her functional level. (Nissenboim,1996). Activities are commonly thought of as the crafts, games and outings offered to dementia patients. However, in a residential setting, an activity is any interaction with the environment. This includes activities of daily living, such as bathing, dining, a conversation with another resident, a game of Bingo, or a trip to the zoo. Zgola (1995) identifies activities as self-care activities (bathing, grooming), activities that are productive (folding towels, gardening), and leisure activities (dancing, a game or an outing).
Activities of Daily Living (ADLs). ADLs include those routine activities most people take for granted, with little thought for planning and describing. Bathing, dressing, and toileting require intact proprioception and ideomotor communication. Loss of these functions can be a source of great frustration for a resident with dementia or, they can be reassuring and satisfying when care is taken to ensure success for the resident. These are the very early tasks we teach our children and are at the core of an individual’s sense of autonomy and mastery of self and the environment. . Unfortunately for dementia patients, these automatic behaviors are often lost early in the course of the illness due to apraxia. The person will still have the desire and the physical ability to accomplish the activity, but lack the ability to organize, initiate and carry them out. At the same time, personal care activities afford important opportunities for caregivers to spend quality time with the resident. They provide sensory stimulation, tap into old memories and skills, and allow expression of independence while building self-esteem. A dining experience or a trip to the beauty shop can also provide social interaction and a rediscovery of social roles.

A detailed discussion of the various activities involved in personal care is beyond the scope of this writing, however, the basic tools for quality application of approaches include a sound knowledge of the effects of the disease on the parts of the brain responsible for apraxia, aphasia, and agnosia. Caregivers will need to understand the guiding principles that promote a successful experience for the patient. These include building rapport, providing structure, promoting autonomy and independence, assuring safety and comfort, and allowing the patient to experience success. Having had the training, caregiving staff also need the confidence to use their own initiative in problem solving, as no one approach will succeed all of the time. Applying knowledge of the reverse development in AD referred to above can be helpful in assisting with ADLs (Matteson et al., 1997).

Caregivers, especially women, who have raised children, often have a knack in working with dementia residents, having developed similar skills in their child rearing years. A high percent of direct caregivers at Villa Serena are women, in their forties to fifties, who show a natural ability to manage care of residents skillfully and enjoy the work as well. A spirit of happiness and enjoyment pervades the setting that carries over to the residents and their families.
Lifework Activities. Familiar productive activities offer opportunities for mastery and pride in accomplishment. Tasks such as preparing food, folding linen, or gardening can reinforce identity and pride. “The challenge is to take familiar tasks and successfully adapt or modify them, thereby providing continued purposeful participation (Hellen, 1995).” These activities promote concentration and draw upon previously learned skills, often preserved into the later phases of the illness. Shop or kitchen work can include women dusting furniture, peeling vegetables or stirring a cake and men assembling a carpentry project for a birdhouse or sanding wood. These must be safe and performed in an atmosphere of pleasurable camaraderie. It is very important to provide mental stimulation for dementia patients. Though they have lost certain qualities of cognitive ability, with stimulation, some may be partially regained and remaining skills preserved for a longer period of time (Beisgen, 1995). Villa Serena’s activity program encourages the use of the senses and the intellect that also ensure success for the resident. Word games, sentence completion, poetry and drama promote imagination and cognitive function. Activities with children touch the resident’s parental instincts as well as images of their own childhood. Small children integrate easily with adult persons with dementia and intergenerational activities with this age group can be mutually satisfying. However, it may be difficult for adolescents or teenagers to appreciate the difficulties in speech, both receptive and expressive, and may be embarrassed by the functional losses of the resident. Villa Serena recognizes the need and the right for all people to have opportunities for expression of their religious or spiritual preferences. Persons with AD continue to respond to their faith through long remembered rituals and music that validate them as persons. Sunday worship or other religious observances are regularly held, and families are invited to hold traditional rituals or memorials in the resident’s apartment or the main lounge whenever the occasion arises.

Leisure Activities.
Activities that engage a resident in their daily life should reflect as nearly as possible their cultural identity and individual life-style, provide a sense of accomplishment and stimulate optimal mental, physical, and social functioning (Zgola, 1995). Special events and outings can bring fresh energy into the facility. Outings at Villa Serena have included a children’s play, a summer picnic in the park, and a wedding of one of the activities’ staff. Reviewing the past, as in “reminiscence” is a universal process that all enjoy. This can be done on a one-to-one basis or in small groups, using objects, pictures, or music to stimulate memories. Music and movement through dance promote physical and mental health. Villa Serena may host a tea dance, a sing-along, or a walk in a local nature center for families or other community persons to attend. The arts provide ways to express emotions and worries without the complexity of language. Through creative arts, residents can utilize their preserved strengths, have some degree of control and feel competent and useful.

Staging of Activities.
AD varies widely in cognitive and functional decline and the accompanying characteristics. General guidelines for planning activities capitalize on retained abilities and assuring opportunities for success, experiencing pleasure, and enlarging the social world. The progressive nature of AD requires adapting activities to the stage or level of ability of the resident. For example, an individual in early AD (FAST 4-5) has more ability to express interests and needs, and maintain talents and hobbies, however may experience more frustration as he or she realizes that it is becoming more difficult to accomplish tasks that once were basic (Nissenboim, 1996). In the middle stages of AD (FAST 5-6), the person is disoriented to time and place, has difficulty concentrating on the task, and may pace or wander. These individuals require more structure, more cueing, and activities that require physical energy. In more advanced stages (FAST 6-7), the resident may not be able to participate in a group or in activities that require coordination. They may be able to enjoy watching others, but activity approaches focus on one-to-one nurturing and comforting interaction (1996). Two methods employed at Villa Serena are designed to address the different needs at progressive stages of AD: Cluster and Graded Activities.

Cluster Programming.
Cluster programming refers to a method of assigning residents to an activity based on their functional ability and social skills. An assessment is made of a resident’s functional abilities, sociability and interests and they are invited to join a cluster group based on similar interests and abilities. Activities are rated according to complexity and social interaction. Examples of clusters include: highly sociable (larger groups, more complex tasks), special needs (small group, simple tasks, one-on-one interventions), and physically active but low tolerance for social contact (one-on-one or solo, gardening, provide “stuff” to sort through). Activities for each cluster are planned based on the preserved abilities, interests and social responses.

Activity Grading.
Residents may have similar interests but differing abilities. Activity grading refers to the ability to break down any activity into levels of difficulty to accommodate the abilities of any individual who is interested in being involved (Zgola, 1997). A resident participates in the activity at the level they are capable. It preserves the opportunity of an individual to be included in an enjoyable activity but doesn’t tax or frustrate them with tasks that are too complex. For example, a higher functioning resident may help to select the recipe and mix ingredients for cookies, while a resident with less coordination may listen for the timer to go off.

Animals and Pets.
Animals are a part of everyday life for most people, and many animals, particularly household pets, such as dogs and cats have beneficial abilities that have yet to be generally recognized. Though research on health and animal-human bonding is limited, a number of studies have suggested there are cardiovascular benefits, stress reduction, and promotion of a sense of well-being (Dembecki & Anderson, 1996). There is also evidence of improvement in depression and grief responses and animals have been shown to be therapeutic for autistic individuals (Friedman et al., 1980). Service animals have long been associated with assistance to the blind. Animals are now trained to assist individuals with other physical, mental, and emotional disabilities, including dogs trained to work for individuals with Alzheimer’s disease.

Dr. William Thomas (1996) advocates animals in nursing home environments. Villa Serena has two friendly (partially declawed) cats that live in one of the courtyards. Occasionally a resident will bring a dog or cat to live with them in their apartment. The Delta Society’s “Pet Partners” volunteers bring therapy dogs into the facility to interact with residents and the occasion is eagerly awaited by them all. Clearly safeguards need to be in place for the inclusion of animals. The Delta Society of the US and Delta Society International provides protocols for safe handling of animals in nursing homes and residential care.

Staff Training
Because of the wide range of activities in a residential care facility, staff must have broad training in care of the elderly and in the specific needs of individuals with dementia. Further, because of the family atmosphere promoted in these facilities, staff must be cross-trained beyond their primary role responsibility. Residential care facilities have developed with the goal of presenting a home-like atmosphere. This is reflected in the location, the design and furnishings of such facilities. The population of residents, families and personnel associated with the building are considered to be a “community.” The Alzheimer’s Association stresses the importance of multi-role responsibility. “Persons with dementia generally cannot distinguish the focus of responsibility of various staff members. Alzheimer care depends on a blurring of roles and all staff must respond promptly to a resident’s needs” (AA, 1992, p. 31) regardless of their primary work role.

In support of the family and community philosophy, at Villa Serena, all staff who work with residents and their families, including nurses and nursing assistants, administration, housekeeping, dietary, maintenance, and volunteers are trained as ‘dementia capable.’ Maintenance personnel often assist residents in the garden to stand from sitting or to walk down the hall. Activity therapists may assist a resident with toileting, and administrative personnel will spend time in the dining room assisting a resident with a meal. Dietary personnel do not assist with toileting, but will sit and converse with a resident or assist them with their meal.

To provide the best and most current information, a wide variety of dementia care, specific education materials applicable to the interdisciplinary staff should be tapped. There are many training materials available through the Alzheimer’s Association or ADEAR. Villa Serena, training includes instructors from the university affiliates in nursing, pharmacy, medicine, and occupational therapy. The training model is based on adult education principles, which build a collaborative relationship between the instructor and the trainee and call upon trainee life experiences as a background for discussion of care issues (Foster, 1994). The intent is to promote self-confidence, a caring and professional attitude, and a sense of value to the organization. To ensure competency, pre and post-tests should be administered, and evaluation of training effectiveness obtained through objective questionnaire and feedback from participants (IOM, 2001).

Dementia-capable means to be skilled in working with people with dementia, knowledgeable about the kinds of services that may help them, and aware of which agencies and individuals provide such services (AA, 1997). Certified Nursing Assistants (CNAs) already prepared in basic hygiene and physical care practices must be given additional training in dementia care and in specific needs of the elderly population. Non-CNAs must have training in the physical needs of the elderly as well as the dementia specific training. The Villa Serena Training Manual includes the following topics as chapters:

• Introduction
• Normal Changes of Aging
• Overview of Alzheimer’s Disease: Dementia, Delirium, and Depression
• Principles of Dementia Capable Caregiving
• Communication in Alzheimer care
• Activity Based Alzheimer care
• Activities of Daily Living
• Physical Activities
• Managing Challenging Behaviors
• Nutrition and Hydration
• Social and Mental Activities
• Family Involvement
• Values, Ethics and Legal Issues
• Staff Stress and Self-Awareness

Family Involvement
Though it is often alluded to by the press that families abandon their family members when long term chronic illnesses occur, we have not found that to be true at Villa Serena. However, the caring, whether at home or after placement in a professional care facility, continues to take its toll on the health of the family members. Though increased susceptibility to physical illness is a serious problem, the greatest toll is in the mental health of the caregiver (George & Gwyther, 1986). Villa Serena considers the family members to be part of our responsibility and aggressive efforts are made to provide support for them. Support activities include an intensive orientation when their family member is admitted to the facility. Educational programs and support groups are held for families on a regular basis, and the Resident and Family Services Director holds frequent individual counseling and support sessions with them. Her office is placed at the entry suite to the facility, and visitors pass by her office whenever they visit. This logistical arrangement makes her quite accessible to families and friends and they often stop and inquire or share concerns. Families are always present at the quarterly care planning sessions and their input is critical to the ongoing care of their family member. Families are invited to attend special events and all outings. Holidays and birthdays are special times when families are encouraged to participate and families may visit any time of the day.

Conclusion
Villa Serena is a mosaic of ideas, connections, people, research and service. It is a community where the environment speaks of dignity and respect, of life and the living and love for the human spirit. The thoughtful and careful design and program planning for the physical and human environments we create for individuals with dementia may prove to be the key to continued independence and a meaningful life for these individuals and their families. The concept, philosophy, and program developed by Villa Serena have benefited from collaboration among building and interior designers, dementia research scientists and healthcare providers with input from the consumers of dementia services. We believe it is essential to the creation of top-quality care that the Villa Serena program continually evolve through this broad representation and through incorporation of the best of cutting edge research in medical, nursing, allied health care fields and design. Our affiliations with respected universities and dementia research centers is the cornerstone of this belief.

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