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
ECAT for Dementia Care Manual

iii

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

IDI_0011_guide_8.5x11_CS3.indd 3

11/14/11 3:20 PM

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 Modifications in the Care Community
Examples of Significant Environmental Modifications

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

63

Developing Visual Cues and Reading Material

78

Section 4 | Recommendations and Resources

Lighting 79
Sequencing Cues

85

Personal Space Signs

86

Where to Purchase Supplies for Environmental Modifications

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
iv

ECAT for Dementia Care Manual

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

IDI_0011_guide_8.5x11_CS3.indd 4

11/14/11 3:20 PM

Introduction

What Is ECAT
and Who Should Use It?

ECAT is the first 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
theimpact 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 briefly
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.

iStockphoto.com/digitalskillet

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 find 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 deficits among clients with dementia and the
types of interventions for overcoming those deficits.

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.

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 deficits 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 modifications 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 difficulty 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 modifications that help address the communication
difficulties 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
specific characteristics to meet the clients needs.

ECAT for Dementia Care Manual

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

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 first 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 first 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
significant increase in knowledge of environmental assessment and modifications 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 modifications prior to and after training was highly
significant (p = .000). Based on changes in scores on a 10-item test of material, knowledge of environmental
modifications 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 modifications 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 modifications prior to training, the number of modifications 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 significant (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 modifications, but also in different modifications. Prior to training,
the majority of clinicians reported using half of a list of 20 environmental modifications. After using ECAT
for 2 months, the majority of clinicians used three-quarters of the modifications, 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 modifications. The significant increase in the use of many of the modifications
coincided with significant reductions in several modifications 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 significant differences in cost of environmental modifications between pre-training
and use of ECAT, the cost of environmental modifications 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 benefited 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.