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Physical environmental designs in residential care to improve
quality of life of older people (Review)

  Harrison SL, Dyer SM, Laver KE, Milte RK, Fleming R, Crotty M  

  Harrison SL, Dyer SM, Laver KE, Milte RK, Fleming R, Crotty M.
Physical environmental designs in residential care to improve quality of life of older people.
Cochrane Database of Systematic Reviews 2022, Issue 3. Art. No.: CD012892.
DOI: 10.1002/14651858.CD012892.pub2.

  www.cochranelibrary.com  

Physical environmental designs in residential care to improve quality of life of older people (Review)
 

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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T A B L E   O F   C O N T E N T S

ABSTRACT…………………………………………………………………………………………………………………………………………………………………………….. 1

PLAIN LANGUAGE SUMMARY………………………………………………………………………………………………………………………………………………….. 2

SUMMARY OF FINDINGS………………………………………………………………………………………………………………………………………………………… 4

BACKGROUND………………………………………………………………………………………………………………………………………………………………………. 7

OBJECTIVES………………………………………………………………………………………………………………………………………………………………………….. 8

METHODS…………………………………………………………………………………………………………………………………………………………………………….. 9

RESULTS……………………………………………………………………………………………………………………………………………………………………………….. 13

Figure 1………………………………………………………………………………………………………………………………………………………………………….. 14

Figure 2………………………………………………………………………………………………………………………………………………………………………….. 19

Figure 3………………………………………………………………………………………………………………………………………………………………………….. 20

DISCUSSION………………………………………………………………………………………………………………………………………………………………………….. 29

AUTHORS’ CONCLUSIONS……………………………………………………………………………………………………………………………………………………… 33

ACKNOWLEDGEMENTS………………………………………………………………………………………………………………………………………………………….. 34

REFERENCES………………………………………………………………………………………………………………………………………………………………………… 36

CHARACTERISTICS OF STUDIES……………………………………………………………………………………………………………………………………………… 43

DATA AND ANALYSES……………………………………………………………………………………………………………………………………………………………… 79

Analysis 1.1. Comparison 1: Home-like vs. traditional environment, Outcome 1: Quality of life…………………………………………….. 79

Analysis 1.2. Comparison 1: Home-like vs. traditional environment, Outcome 2: Behaviour, mood and depression………………… 80

Analysis 1.3. Comparison 1: Home-like vs. traditional environment, Outcome 3: Function…………………………………………………… 83

Analysis 1.4. Comparison 1: Home-like vs. traditional environment, Outcome 4: Global cognitive function……………………………. 84

Analysis 1.5. Comparison 1: Home-like vs. traditional environment, Outcome 5: Quality of care ………………………………………….. 84

Analysis 1.6. Comparison 1: Home-like vs. traditional environment, Outcome 6: Serious adverse eCects………………………………. 85

Analysis 2.1. Comparison 2: Refurbishment vs. traditional environment, Outcome 1: Quality of life……………………………………… 85

Analysis 2.2. Comparison 2: Refurbishment vs. traditional environment, Outcome 2: Behaviour, mood and depression…………. 86

Analysis 2.3. Comparison 2: Refurbishment vs. traditional environment, Outcome 3: Function…………………………………………….. 87

Analysis 2.4. Comparison 2: Refurbishment vs. traditional environment, Outcome 4: Quality of care……………………………………. 87

Analysis 3.1. Comparison 3: Special-care units for dementia vs. traditional environment, Outcome 1: Behaviour, mood and
depression………………………………………………………………………………………………………………………………………………………………………

87

Analysis 3.2. Comparison 3: Special-care units for dementia vs. traditional environment, Outcome 2: Function…………………….. 89

Analysis 3.3. Comparison 3: Special-care units for dementia vs. traditional environment, Outcome 3: Global cognitive function… 89

Analysis 4.1. Comparison 4: Group living corridor vs. group living non-corridor design, Outcome 1: Behaviour, mood and
depression………………………………………………………………………………………………………………………………………………………………………

89

Analysis 5.1. Comparison 5: Lighting intervention  vs. control lighting, Outcome 1: Behaviour, mood and depression……………. 91

Analysis 5.2. Comparison 5: Lighting intervention  vs. control lighting, Outcome 2: Behaviour, mood and depression: depression
4-6 weeks………………………………………………………………………………………………………………………………………………………………………..

92

Analysis 5.3. Comparison 5: Lighting intervention  vs. control lighting, Outcome 3: Behaviour, mood and depression: agitation
4-6 weeks………………………………………………………………………………………………………………………………………………………………………..

93

Analysis 5.4. Comparison 5: Lighting intervention  vs. control lighting, Outcome 4: Function 4-6 weeks………………………………… 93

Analysis 5.5. Comparison 5: Lighting intervention  vs. control lighting, Outcome 5: Function……………………………………………….. 93

Analysis 5.6. Comparison 5: Lighting intervention  vs. control lighting, Outcome 6: Global cognitive function……………………….. 93

Analysis 6.1. Comparison 6: Dining space redesign vs. traditional environment, Outcome 1: Quality of life……………………………. 94

Analysis 6.2. Comparison 6: Dining space redesign vs. traditional environment, Outcome 2: Behaviour, mood and depression…. 94

Analysis 6.3. Comparison 6: Dining space redesign vs. traditional environment, Outcome 3: Function………………………………….. 94

Analysis 6.4. Comparison 6: Dining space redesign vs. traditional environment, Outcome 4: Global cognitive function…………… 95

Analysis 6.5. Comparison 6: Dining space redesign vs. traditional environment, Outcome 5: Serious adverse eCects……………… 95

Analysis 7.1. Comparison 7: Garden vignette vs. traditional environment, Outcome 1: Behaviour, mood and depression……….. 95

APPENDICES…………………………………………………………………………………………………………………………………………………………………………. 95

HISTORY……………………………………………………………………………………………………………………………………………………………………………….. 109

CONTRIBUTIONS OF AUTHORS………………………………………………………………………………………………………………………………………………. 110

DECLARATIONS OF INTEREST………………………………………………………………………………………………………………………………………………… 110

SOURCES OF SUPPORT…………………………………………………………………………………………………………………………………………………………. 110

DIFFERENCES BETWEEN PROTOCOL AND REVIEW…………………………………………………………………………………………………………………… 110

Physical environmental designs in residential care to improve quality of life of older people (Review)

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NOTES………………………………………………………………………………………………………………………………………………………………………………….. 111

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[Intervention Review]

Physical environmental designs in residential care to improve quality of
life of older people

Stephanie L Harrison1,2,3, Suzanne M Dyer1, Kate E Laver1, Rachel K Milte4, Richard Fleming5, Maria Crotty1

1Flinders Health and Medical Research Institute, College of Medicine and Public Health, Flinders University, Adelaide, Australia. 2Registry

of Senior Australians, South Australian Health and Medical Research Institute, Adelaide, Australia. 3Liverpool Centre for Cardiovascular

Science, University of Liverpool, Liverpool, UK. 4Caring futures institute, Flinders University, Adelaide, Australia. 5School of Science
Medicine and Health, University of Wollongong, Wollongong, Australia

Contact: Stephanie L Harrison, [email protected]

Editorial group: Cochrane ECective Practice and Organisation of Care Group.
Publication status and date: New, published in Issue 3, 2022.

Citation: Harrison SL, Dyer SM, Laver KE, Milte RK, Fleming R, Crotty M.Physical environmental designs in residential care
to improve quality of life of older people. Cochrane Database of Systematic Reviews 2022, Issue 3. Art. No.: CD012892. DOI:
10.1002/14651858.CD012892.pub2.

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

A B S T R A C T

Background

The demand for residential aged care is increasing due to the ageing population. Optimising the design or adapting the physical
environment of residential aged care facilities has the potential to influence quality of life, mood and function.

Objectives

To assess the eCects of changes to the physical environment, which include alternative models of residential aged care such as a ‘home-
like’ model of care (where residents live in small living units) on quality of life, behaviour, mood and depression and function in older
people living in residential aged care.

Search methods

CENTRAL, MEDLINE, Embase, six other databases and two trial registries were searched on 11 February 2021. Reference lists and grey
literature sources were also searched.

Selection criteria

Non-randomised trials, repeated measures or interrupted time series studies and controlled before-aJer studies with a comparison group
were included. Interventions which had modified the physical design of a care home or built a care home with an alternative model of
residential aged care (including design alterations) in order to enhance the environment to promote independence and well-being were
included. Studies which examined quality of life or outcomes related to quality of life were included. Two reviewers independently assessed
the abstracts identified in the search and the full texts of all retrieved studies.

Data collection and analysis

Two reviewers independently extracted data, assessed the risk of bias in each included study and evaluated the certainty of evidence
according to GRADE criteria. Where possible, data were represented in forest plots and pooled.

Main results

Twenty studies were included with 77,265 participants, although one large study included the majority of participants (n = 74,449). The
main comparison was home-like models of care incorporating changes to the scale of the building which limit the capacity of the living units
to smaller numbers of residents and encourage the participation of residents with domestic activities and a person-centred care approach,

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compared to traditional designs which may include larger-scale buildings with a larger number of residents, hospital-like features such as
nurses’ stations, traditional hierarchical organisational structures and design which prioritises safety.

Six controlled before-aJer studies compared the home-like model and the traditional environment (75,074 participants), but one
controlled before-aJer study included 74,449 of the participants (estimated on weighting).  It is uncertain whether home-like models
improve health-related quality of life, behaviour, mood and depression, function or serious adverse eCects compared to traditional designs
because the certainty of the evidence is very low. The certainty of the evidence was downgraded from low-certainty to very low-certainty
for all outcomes due to very serious concerns due to risk of bias, and also serious concerns due to imprecision for outcomes with more
than 400 participants. One controlled before-aJer study examined the eCect of home-like models on quality of life. The author stated
“No statistically significant diCerences were observed between the intervention and control groups.” Three studies reported on global
behaviour (N = 257). One study found little or no diCerence in global behaviour change at six months using the Neuropsychiatric Inventory
where lower scores indicate fewer behavioural symptoms (mean diCerence (MD) -0.04 (95% confidence interval (CI) -0.13 to 0.04, n = 164)),
and two additional studies (N = 93) examined global behaviour, but these were unsuitable for determining a summary eCect estimate. Two
controlled before-aJer studies examined the eCect of home-like models of care compared to traditional design on depression. AJer 18
months, one study (n = 242) reported an increase in the rate of depressive symptoms (rate ratio 1.15 (95% CI 1.02 to 1.29)), but the eCect of
home-like models of care on the probability of no depressive symptoms was uncertain (odds ratio 0.36 (95% CI 0.12 to 1.07)). One study (n
= 164) reported little or no diCerence in depressive symptoms at six months using the Revised Memory and Behaviour Problems Checklist
where lower scores indicate fewer depressive symptoms (MD 0.01 (95% CI -0.12 to 0.14)). Four controlled before-aJer studies examined
function. One study (n = 242) reported little or no diCerence in function over 18 months using the Activities of Daily Living long-form scale
where lower scores indicate better function (MD -0.09 (95% CI -0.46 to 0.28)), and one study (n = 164) reported better function scores at
six months using the Interview for the Deterioration of Daily Living activities in Dementia where lower scores indicate better function (MD
-4.37 (95% CI -7.06 to -1.69)). Two additional studies measured function but could not be included in the quantitative analysis. One study
examined serious adverse eCects (physical restraints), and reported a slight reduction in the important outcome of physical restraint use
in a home-like model of care compared to a traditional design (MD between the home-like model of care and traditional design -0.3% (95%
CI -0.5% to -0.1%), estimate weighted n = 74,449 participants at enrolment).

The remaining studies examined smaller design interventions including refurbishment without changes to the scale of the building, special
care units for people with dementia, group living corridors compared to a non-corridor design, lighting interventions, dining area redesign
and a garden vignette.

Authors’ conclusions

There is currently insuCicient evidence on which to draw conclusions about the impact of physical environment design changes for older
people living in residential aged care. Outcomes directly associated with the design of the built environment in a supported setting are
diCicult to isolate from other influences such as health changes of the residents, changes to care practices over time or diCerent staC
providing care across shiJs. Cluster-randomised trials may be feasible for studies of refurbishment or specific design components within
residential aged care. Studies which use a non-randomised design or cluster-randomised trials should consider approaches to reduce risk
of bias to improve the certainty of evidence.

P L A I N   L A N G U A G E   S U M M A R Y

Physical environmental designs in residential care to improve quality of life of older people

What is the aim of the review?

There is an increasing older population worldwide and an increase in the numbers of people living with dementia. It has been suggested
that improving lived area designs may improve quality of life, mood, and ability to perform daily living activities of aged care residents.
The aim of this Cochrane review was to examine the eCects of diCerent physical environmental design changes in residential aged care
to determine the eCect on quality of life for the residents. The review authors collected and analysed all relevant studies to answer this
question and found 20 studies.

Key messages

We are uncertain of the eCects of design changes in residential aged care to improve quality of life for residents because more high-quality
studies are needed.

What was studied in the review?

The review studied changes to physical environmental design in residential aged care, referring to any changes to the environment in
which residents live, in an aim to improve their quality of life. These may be large-scale or small-scale changes. Large-scale changes can
be changes to the design of residential care such as changing from the currently used lived-area designs to home-like designs with smaller
numbers of residents living together. Small-scale changes may involve refurbishing the lived area or changing a single part of the lived area
such as lighting. We included studies which compared diCerent large-scale or small design changes in residential aged care, or compared
design changes to currently used lived-area designs and examined the eCect of design changes on quality of life, behaviour and daily living

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activities for the residents. There is no one definition of quality of life agreed upon, but most definitions include multiple aspects of a
person’s expectations for their life, such as physical, mental, and emotional health, social activity and life situation.

What are the main results of the review?

The review authors found 20 relevant studies that took place in nine diCerent countries (Australia, Canada, Germany, Italy, the Netherlands,
Spain, Sweden, the UK and the USA). The main design change which was investigated was the eCect of creating a ‘home-like’ model of care
which usually involved creating small-scale living units for residents and changes to care practices such as changes to staCing or choices
residents had on daily routines. 

Six studies examined changes to the size of the building to limit the number of residents per living unit ranging between six and fiJeen
residents per living unit, in addition to changing care practices, for example, changes to staCing, or changes to the choices residents had
for their daily routines. One study examined quality of life, but there was insuCicient information presented to draw conclusions. Three
studies examined behaviour; one study found little or no diCerence in behaviour and two studies provided insuCicient information to draw
conclusions. Two studies examined depression and reported little or no diCerence in depressive symptoms or the eCect was uncertain. Four
studies examined daily living activities; one study reported improvement in daily living activities, one study reported little or no diCerence
in daily living activities, and two studies provided insuCicient information to draw conclusions. One study reported a reduction in serious
adverse eCects (the use of physical restraints).  We are uncertain of the eCects of home-like models of care on quality of life, behaviour,
depression, daily living activities or serious adverse eCects because the certainty (confidence) of the studies was determined to be very
low due to issues with study design.

The other fourteen studies examined smaller design interventions such as refurbishment without changes to the scale of the building,
special care units for people with dementia, diCerent corridor designs, bright lighting, redesign of the dining room and an indoor garden.

How up-to-date is this review?

The review authors searched for studies up to February 2021.

Physical environmental designs in residential care to improve quality of life of older people (Review)

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S U M M A R Y   O F   F I N D I N G S

Summary of findings 1.   Whole-facility changes: Home-like models compared to traditional environment for older people living in long-term
residential care

Whole-facility changes: Home-like models compared to traditional environment for older people living in long-term residential care

Patient or population: older adults living in long-term residential care including, but not limited to, dementia-specific care settings
Settings: long-term residential care
Intervention: home-like models (features of home-like models may include buildings which limit the capacity of the living units to small numbers of residents, designs to
encourage the participation of residents with domestic activities and a person-centred care approach)
Comparison: traditional design (traditional design may include larger-scale buildings with a larger number of residents, hospital-like features such as nurses’ stations, tra-
ditional hierarchical organisational structures and design which prioritises safety)

Illustrative comparative risks
(95% CI)

Outcomes

Assumed risk

Traditional de-
sign

Corresponding
risk 

Home-like
model

Relative effect
(95% CI)

Follow-up time

No of Partici-
pants
(studies)

Certainty of
the evidence
(GRADE)

Comments

Health-related quality
of life 

Dementia-specific
quality of life measure
(QUALIDEM) 

(higher scores = better)

N/a N/a Not estimable

6 months and
12 months

33 (1 controlled
before-after-
 study)

⊕⊝⊝⊝

very low1
2 domains (feeling at home and care relation-
ship) were examined in an analysis adjusted for
baseline differences between the groups; 7 oth-
er domains were unadjusted. The author stat-
ed “No statistically significant differences were
observed between the intervention and control
groups.”

Global behaviour N/a N/a Not estimable

6 months

257 ⊕⊝⊝⊝

very low2
One study found little or no difference in glob-
al behaviour change at 6 months using the NPI
(N = 164; MD -0.04 (95% CI -0.13 to 0.04)); two

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Neuropsychiatric Inven-
tory (NPI),

Neuropsychiatric Inven-
tory-Nursing Home ver-
sion (NPI-NH) and

Nurses Observations
Scale for Geriatric Pa-
tients (NOSGER)

(lower scores = better)

(3 controlled
before-after
studies)

  additional studies (N = 93) reported global be-
haviour endpoint data, but the data were un-
suitable for determining a summary effect esti-
mate. 

Depression

Revised Memory and
Behaviour Problems
Checklist (RMBPC) and

Mood Scale Score (MSS)

(lower scores = better)

N/a N/a Not estimable

6 months and
18 months

406 (2 con-
trolled be-
fore-after stud-
ies)
 

⊕⊝⊝⊝

very low3
Depressive symptoms 18-month change using
the MSS (1 study, N = 242; RR 1.15 (95% CI 1.02
to 1.29))

Probability no depressive symptoms 18 months
using the MSS (1 study, N = 242; OR 0.36 (95% CI
0.12 to 1.07))

Depressive symptoms 6-month endpoint using
the RMBPC (1 study, N = 164; MD 0.01 (95% CI
-0.12 to 0.14))

Function

Activities of daily living
(ADL) long-form scale
(lower scores = better),
Interview for the Dete-
rioration of Daily Living
activities in Dementia
(IDDD) (lower scores =
better)

N/a N/a Not estimable

6 months and
18 months

499
(4 controlled
before-after
studies)

⊕⊝⊝⊝

very low4
Function 18-month change using the ADL long-
form scale (1 study, N = 242; MD -0.09 (95% CI
-0.46 to 0.28))

Function 6-month endpoint using the IDDD (1
study, N = 164; MD -4.37 (95% CI -7.06 to -1.69))

Two additional studies: measured function
with the Barthel Index but were not included in
the quantitative analysis:

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Or Barthel Index (higher
scores = better)

• One study (data were insufficient): authors
stated: “interactions between settings and
development over time could not be proved”.

• One study (results were not adjusted for dif-
ferences in baseline characteristics): authors
stated function declined in both the interven-
tion and control groups but “more sharply” in
control group.

Serious adverse effects

Physical restraints, re-
ported as percentage
points (lower = better)

23 per 1000* 20 per 1000** MD -0.3%
(-0.5% to -0.1%)

Follow-up: Un-
clear

Unclear
(weighted es-
timate 74,449
participants at
enrolment)
(1 study)

⊕⊝⊝⊝

very low5
 

No further adverse effects were examined.

Unclear length of follow-up (reported as up to 5
years)

CI: Confidence interval; MD: Mean difference;OR: Odds Ratio; RR: Risk ratio

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 The certainty of evidence was downgraded two levels for risk of bias (high risk of bias on six items including high risk of selection bias, performance bias, detection bias, attrition
bias, and other (diCerences in baseline characteristics and potential residual confounding)) and two levels for imprecision (only 33 participants).
2The certainty of evidence was downgraded two levels for risk of bias (all studies at high risk of bias on at least six items) and one level for imprecision (< 400 participants).
3The certainty of evidence was downgraded two levels for risk of bias (all studies at high risk of bias on six items).
4The certainty of evidence was downgraded two levels for risk of bias (high risk of bias on at least six items) and one level for imprecision (499 participants in total across outcomes
but reported across diCerent measures).
5The certainty of evidence was downgraded two levels for risk of bias (high risk of bias on five items including high risk of selection bias, performance bias, detection bias and
other (method of selection of facilities unclear, potential residual confounding, significant diCerences in baseline characteristics and significant diCerences for many baseline
outcome measures)).
*Assumed risk for the control group was derived from the study reporting this outcome (2.3%).
**Corresponding risk based on a diCerence of 0.3%.
 

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B A C K G R O U N D

Description of the condition

The population is ageing worldwide. Life expectancy has increased
and people are living longer in older age, particularly in high-
income countries (WHO 2015). There were 901 million people
aged 60 years and older worldwide in 2015 and, by 2050. this
figure is projected to more than double to nearly 2.1 billion (UN
2015). Although information regarding population ageing is well
established, the patterns of health and quality of life for older
people remain unclear (WHO 2015).

Many older adults experience physical and/or cognitive impairment
as they age which may result in the need for care and support from
others in order to manage activities of daily living. A significant
decline in function may result in the need for long-term care.
With an increasing number of people living to an older age, there
will be an increase in the proportion of the population who will
require accommodation in residential aged care (WHO 2015). A
large proportion of those who reside in residential aged care
(also called care facilities, care homes, nursing homes, residential
homes, skilled-nursing facilities or assisted-living facilities) are
living with dementia, and the number of people living with
dementia globally is expected to increase. There are currently 46.8
million people living with dementia and this figure is expected to
double every 20 years, to 131.5 million people by 2050 (ADI 2015).
An ageing population and an increasing number of people living
with dementia is likely to increase demand for residential aged
care. Therefore, it will be increasingly important to ensure that
these facilities provide an environment which ensures that quality
of life is optimised in advancing age.

Quality of life for residents in  residential aged care has been
referred to as the degree to which the well-being of an individual is
maintained, including social activity, physical activity and health,
and whether or not this meets their expectations (Post 2014).
Maintaining quality of life in advancing age is important, both for
those living in the community and those living in residential aged
care. However, people who live in residential aged care are more
likely to experience a reduced quality of life compared to those
living in the community (Kane 2003). Moving from the community
to living in residential aged care is oJen associated with a decline
in quality of life that may be due to loss of independence and
purpose (Bradshaw 2012; Olsen 2016). Interventions to maximise
quality of life for people who live in residential aged care should
be prioritised. Implementing interventions which may improve
quality of life for people living in care facilities also has the
potential to positively impact the residents, staC and families of
the resident. Many factors may impact quality of life for people
living in residential aged care and people with dementia, including
health status, availability of activities, social participation, standard
of care provided and the physical environment. The impact of
therapies such as music therapy, art therapy and functional
analysis-based interventions for people living with dementia
on factors related to quality of life, such as behaviour, have
been examined in previous Cochrane reviews (Deshmukh 2018;
Moniz Cook 2012; Van der Steen 2018).

Description of the intervention

Maximising quality of life for people living in residential aged care
includes providing models of care that encourage engagement in

meaningful activities and care which fosters ongoing independence
(Tolson 2011). Changing the physical environment refers to
changing features of the care facility which are constantly available
to the resident, rather than temporary approaches. The physical
environment of care facilities can be altered in an attempt
to improve the quality of life of the residents. Deciding how
the physical environment of residential  aged care may be best
enhanced to benefit the residents is an emerging area of research
(Fleming 2010).

Traditionally, care facilities adopted a medicalised model of care,
meaning that facilities were designed and operated similarly
to hospitals, rather than homes for the residents (WHO 2015).
More recently, care facilities are being encouraged to oCer
diCerent models of care, which are designed to improve quality
of life for the residents by adapting the facilities to create a
more stimulating environment, which encourages individuals to
maintain independence for longer (Ausserhofer 2016). However,
the ability to oCer diCerent models of care may be impacted by
factors such as the varied funding models for residential aged care
in diCerent countries.

This ‘person-centred’ approach may involve redesigning or
building new facilities to create a more home-like environment
where residents live in small groups and which have been
specifically designed to look and feel more like a domestic
home (Chenoweth 2014). These home-like models of care have
been developed in diCerent countries including Australia (Dyer
2018), Germany (Wolf-Ostermann 2012), Japan (Funaki 2005),
the Netherlands (Te Boekhorst 2009) and the USA (Afendulis
2016,  Zimmerman 2016). These models may oCer diCerent
components regarding how they are designed and operated, but
the underlying concept of providing a home-like environment to
improve quality of life is consistent.

In the USA, the Green House model is gaining popularity. These
facilities promote person-centred care for older people by oCering
small houses where a home-like environment is maintained,
meaningful activities are accessible and teams of certified nursing
assistants are available (Zimmerman 2016). The Eden Alternative
was also originally established in the USA and has since been
implemented in Europe, Asia and Australia (Brownie 2011). The
Eden Alternative has some similarities to the Green House model of
care as it also aims to create a home-like environment to enrich the
lives of the residents, but rather than purpose-built small houses,
the Eden Alternative aims to improve the existing environment,
using methods such as the introduction of animals and plants
(Coleman 2002).

Other small-scale home-like environments specifically designed for
people with dementia have been adopted in various countries in
Europe, North America and Australia, but are oJen implemented in
diCerent ways (Verbeek 2014).

Changes to the physical environment do not always involve
large-scale changes. Instead, the environmental changes may
be small, such as tailored lighting designed to improve sleep
quality and behaviour (Figueiro 2014), or improved access to
outdoor spaces and gardens to improve well-being (Whear 2014).
Previous studies have suggested that techniques to enhance the
physical environment of care facilities may improve activities
of daily living function, quality of life, and mood, as well as
lowering hospital admissions (Ausserhofer 2016; Chenoweth 2014;

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Zimmerman 2016). However, the evidence for the impact of small-
scale or large-scale whole-facility changes to the model of care on
the quality of life of residents remains unclear.

How the intervention might work

Studies have shown that staC of care facilities are responsive to
the idea of enhancing the physical environment of their facilities.
Many facilities have reported implementing small environmental
changes (Tesh 2002), but fewer residential aged care facilities have
adopted large-scale environmental interventions such as changing
from more traditional models of residential aged care to smaller
home-like environments (Doty 2007).

As there are a wide range of interventions that can be implemented
to improve the physical environment, there will be diCerent ways
in which the interventions might work. For example, increased
access to outdoor spaces may improve mood and levels of physical
activity. Increased lighting during the day may help to improve
circadian rhythm, improve sleep patterns for residents and aCect
mood (Joseph 2015). Improvements in these types of outcomes
have been associated with improved quality of life amongst older
adults (Livingston 2014). Interventions such as ‘dementia-enabling
environments’ have been designed to encourage residents with
dementia to maintain independence for longer and increase
opportunity for engagement in meaningful activities, with the aim
of improving quality of life for the residents by helping them to feel
valued and purposeful (DEEP 2015).

Older adults prefer greater choice of living accommodation and
higher quality of services (Brownie 2013). Moving to  residential
aged care can be daunting, as it is a major change from the family
home, and can result in declines in psychological health (Ellis 2010).
Improving the physical environment could help the residents to
maintain normality and establish routine. As a large proportion
of people moving to residential aged care have dementia, it is
important to recognise that the unmet needs of these individuals
can lead to changed behaviours, or behavioural and psychological
symptoms of dementia (BPSD) (Lyketsos 2000). Although most
previous research has focused on therapies for the individual
experiencing changed behaviours or the staC caring for them,
environmental interventions may also have positive eCects on
behaviour.

Why it is important to do this review

Previous reviews have been conducted in relation to the physical
environment of care facilities and various outcomes. However,
these reviews generally do not evaluate the quality of the included
studies and do not undertake a quantitative analysis of the
study findings. Current available reviews suggest that certain
environmental changes can improve outcomes for residents and
staC of facilities (Ausserhofer 2016; Joseph 2015; Marquardt 2014;
Soril 2014).

The majority of the research summarised in previous reviews
suggests that studies which have examined environmental changes
to residential aged care facilities have focused on specific
component interventions, such as outdoor gardens, reduced
facility size and changes to lighting (Joseph 2015). Other reviews,
including only studies of people with dementia, have found a
broad range of interventions to improve the built environment,
but provide inconsistent evidence to suggest which interventions

are more favourable for certain outcomes, such as behaviour (Soril
2014).

Similarly, a recent scoping review of home-like environments
in care facilities concluded that although some studies showed
positive improvements in certain outcomes, further evidence is
needed in order to determine the eCectiveness of home-like models
of residential aged care compared to traditional models on quality
of life (Ausserhofer 2016). However, a diCerent review examining
the built environment for people with dementia concluded that
design interventions are largely beneficial for many outcomes
for people with dementia including behaviour, activities of daily
living function, well-being, social abilities, orientation and care
outcomes, but the evidence for cognitive function was inconsistent
(Marquardt 2014).

It is important to consider risk management of the environmental
interventions, as there may also be adverse eCects from some
environmental modifications, in particular falls. Falls in residential
aged care for older adults are common and can have serious
consequences, including fractures, reduced independence and
death (Cameron 2018). Changes to the physical environment,
particularly with regard to floor surfaces, furnishings or accessibility
to spaces, may increase falls. Therefore, consideration of the
evidence for both the benefits and harms of physical environmental
changes are important in order to establish recommendations.
Redesign of the built environment may also specifically be
introduced to reduce the risk of falls in residential aged care, and
these have been examined in a previous Cochrane review (Cameron
2018).

We are unaware of any high-quality systematic review that has
examined the eCectiveness of both small-scale and large-scale
environmental changes to care facilities to improve quality of life
of all residents (i.e. not limited to a subgroup). There are a wide-
range of interventions that could come under the umbrella term
of the ‘physical environment’, but largely this review refers to
features of a care facility which have been specifically altered to
improve quality of life for the residents. Furthermore, previous
reviews have included uncontrolled before-aJer studies and cross-
sectional studies which is discouraged by the Cochrane EPOC group
because ‘it is diCicult, if not impossible to attribute causation
from such studies’ (EPOC 2016b). Similarly, many prior reviews
include controlled before-aJer and cluster-randomised studies
which have only a single site enrolled in one or more arms of
the study, where outcomes are inherently confounded by site
eCects. A more detailed discussion of existing reviews is included
in the Discussion. Investigating ways to improve the quality of life
of residents not only benefits the residents themselves, but also
benefits the staC in the facilities in which they reside and family
members of the resident.

O B J E C T I V E S

The primary objective was to assess the eCects of changes to
the physical environment or alternative models of residential
aged care that enhance the environment on the quality of life
of the residents. The secondary objective was to assess whether
the eCects of changes to the physical environment or alternative
models of residential aged care that enhance the environment have
a diCerent impact on quality of life according to whether the
population are living with dementia.

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M E T H O D S

Criteria for considering studies for this review

Types of studies

We included randomised trials and cluster-randomised trials, as
these are considered the ‘gold standard’ study design to assess
the eCectiveness of an intervention. However, due to the limited
feasibility of implementing environmental design interventions
in care facilities in randomised trials, we also included other
study designs. We included non-randomised trials, controlled
before-aJer studies, interrupted time series studies and repeated-
measures studies that met the EPOC Group study design criteria
(EPOC 2016b) and provided a comparison to traditional care
facilities or alternative physical designs. Interrupted time series
were required to measure observations at a minimum of  three
data points before and three data points aJer the intervention.
Only controlled before-aJer and cluster-randomised studies which
had more than one control and intervention site were included.
Within the context of whole models of care, studies were
considered as before-aJer studies if outcomes were reported
on or before  admission and at a minimum of one follow-up
time point. We included full-text studies, conference abstracts
and unpublished data obtained via correspondence with authors.
We included studies irrespective of their publication status and
language of publication.

Types of participants

We included studies of older adults residing in care facilities,
requiring some level of nursing care beyond room and board. We
included studies where ≥ 80% of the participants are aged 65 years
and over (mean age ≥ 65 years).

Types of interventions

We included studies examining interventions which have modified
the physical design of a residential aged care facility or built a
facility with an alternative model of residential aged care in order
to enhance the environment to promote independence and well-
being. The included interventions were design features that have
been specifically implemented to improve the quality of life of the
residents. The list of included interventions below indicates many,
but not all, possible interventions that were eligible for inclusion.
We have generated this list from an examination of previous reviews
and a review of a website which has been designed to show
enabling environments in residential aged care facilities (DEEP
2015).

Cochrane EPOC recommendations for grouping interventions are
based on four main themes (delivery arrangements, financial
arrangements, governance arrangements, and implementation
strategies) (EPOC 2016a). Within these groups are categories
and subcategories; due to the nature of the review, all of
the interventions fit within the ‘delivery arrangements’ group
as described below. We have further categorised the potential
interventions according to a previous review (Joseph 2015). They
include structural and non-structural interventions as follows.

Delivery arrangements

Category: Where care is provided and changes to the healthcare
environment.

Subcategory: environment (changes to the physical or sensory
healthcare environment, by adding or altering equipment or
layout, providing music, art).

• Whole-facility model
◦ Home-like models of residential  aged care, such as the

Green House model (Zimmerman 2016). These interventions
are multi-component and will include both changes to the
physical environmental design and changes to the model of
care provided. It is not possible to distinguish the influence
of the design component of the intervention from other
components of the intervention. Studies will be further
categorised by whether the intervention is a facility built
specifically to facilitate the proposed model of care, or
refurbishment of existing facilities.

• Outdoor modifications
◦ Access to and design of outdoor spaces (e.g. outdoor dining

spaces, easy access to a safe enclosed environment, sensory
gardens, Men’s Shed).

• Building layout
◦ Design of dining spaces.

◦ Increase in helpful stimuli (way-finding cues, natural light,
visibility of key amenities such as the toilet, use of contrast to
highlight helpful features and fixtures).

• Furniture, fixtures and equipment
◦ Home-like environments (e.g. variety of furniture to produce

a non-institutionalised feel).

◦ Inclusion of unobtrusive safety measures.

◦ Paint colours.

◦ Colour contrast of furniture.

◦ Changes to lighting (e.g. flexible lighting, buildings designed
to optimise natural light).

◦ Improvements in visual access (legibility) of the internal
spaces to enable residents to see their destination.

◦ Reduction in unhelpful stimuli (e.g. noise, clutter, glare).

◦ Introduction of familiar furniture, fittings, memorabilia.

• Indoor privacy/social interaction modifications
◦ Non-shared rooms (single-resident rooms).

◦ Designated quiet rooms.

◦ Smaller intimate seating areas to promote socialisation.

◦ Kitchen designs which promote opportunities for
engagement.

◦ Reminiscence rooms.

◦ Improving facilities that encourage links with the community
(better facilities for visitors, volunteers or children).

◦ Increasing number of social rooms.

Subcategory: size of organisations (increasing or decreasing the
size of health service provider units)

• Changes in scale of the building.

• Reduction in number of residents living together.

Exclusions: Studies which examined temporary interventions
applied as a management/treatment tool at an individual resident
level, such as light therapy, music therapy or sensory therapy (e.g.
Snoezelen) were excluded.

The comparison for this review was:

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• usual care (any residential aged care facility design which meets
the national accreditation standards for residential aged care,
but without specific enhancements, as described above); or

• alternative physical environmental designs.

Types of outcome measures

Studies were only included if they reported the primary or
secondary outcomes of interest, including quality of life and other
outcomes considered likely to impact quality of life for residents.
This is because this review was focused on interventions aimed at
improving quality of life and outcomes related to quality of life, not
interventions aimed at improving safety. Only outcomes measured
at the same time points were synthesised in meta-analyses;
outcomes measured at diCerent time points were synthesised
separately. Outcomes measured using diCerent scales or with
diCerent assessors could be included in the same data synthesis if
the outcome of interest was the same.

Primary outcomes

• Health-related quality of life (as measured on internationally
recognised scales such as the EuroQol (EQ5D); 36-Item Short
Form Health Survey (SF-36); Health Utilities Index (HUI); and
Adult Social Care Outcomes Toolkit (ASCOT) instruments).

• Behaviour, mood and depression (as measured on recognised
quantitative scales, e.g. global measures with the Challenging
Behaviour Scale, agitation measured with Cohen-Mansfield
Agitation Inventory (CMAI)). DiCerent sub-domains of behaviour,
mood and depression were assessed separately.

• Function
◦ Basic function (as measured by activities of daily living

(ADL) as measured on recognised scales such as the Barthel
Index, or individual quantitative measures of basic self-care
activities (i.e. ability to dress independently)).

◦ Instrumental function (as measured by ADL-recognised
scales such as the Lawton’s instrumental ADL scale,
or individual measures of instrumental function (e.g.
independence in shopping, using the telephone)).

Secondary outcomes

• Global cognitive functioning
◦ Measured with any validated measure, e.g. Alzheimer’s

Disease Assessment Scale cognitive subscale (ADAS-cog);
Mini Mental State Examination (MMSE); Repeatable Battery
for the Assessment of Neuropsychological Status (RBANS);
Cambridge Cognition Examination (CAMCOG).

• Quality of care
◦ Number of bedfast residents, catheter use, pressure ulcers

and hospital readmissions.

• Serious adverse eCects
◦ Including falls and the use of physical restraints.

• Outcomes for carers including mood/depression, quality of life
and burden
◦ Measured with any established tool, e.g. carer mood

or depression measured with Geriatric Depression
Scale; Hospital Anxiety and Depression Scale; Centre
Epidemiological Studies-Depression Scale; Montgomery‒
Åsberg Depression Rating Scale; General Well-Being Scale;
carer quality of life measured with SF-36; EQ5D; World Health
Organization Quality of Life Questionnaire (WHOQOL-BREF);

and carer burden measured with Zarit Burden Inventory;
Perceived Stress Scale; Family Caregiving Burden Inventory.

• Outcomes for staC including staC knowledge, attitude, self-
eCicacy, quality of life, stress (or burnout), and work satisfaction
◦ Measured with any established tool, e.g. Satisfaction in

Nursing Care and Work Scale, Caregiver Stress Scale (CSS),
Strains in Nursing Care Scale, Maslach Burnout Inventory
(MBI), StaC Attitude Questionnaire (SAQ), and the Quality of
Work Life Questionnaire

In the protocol, we reported that secondary outcomes would
include “dementia-specific measures (e.g. global behaviour
measures with the Neuropsychiatric Inventory, depression as
measured with the Cornell Scale for Depression in Dementia)”.
However, it is considered that these measures should not be
examined separately to behaviour as some measures including
the Neuropsychiatric Inventory may be used for people not
living with dementia and all depression measures should also be
considered as one outcome. Therefore, we removed “dementia-
specific measures” as a secondary outcome. As ‘behaviour,
mood and depression’ is a broad category, we did not think it
was appropriate to combine measures of diCerent behavioural
outcomes, therefore, these were analysed separately. Only the two
behavioural outcomes considered most informative are included in
the Summary of findings tables. These included global behaviour
measures, as global behaviour scales incorporate questions about
a range of behaviours and depression, as this is a common and
important negative mood symptom in residents of aged care
homes. In the Summary of findings tables, we also grouped
the outcomes ‘measures of basic function’ and ‘measures of
instrumental function’ under one outcome ‘function’.

Search methods for identification of studies

The authors of this review developed a search strategy
in collaboration with the Cochrane ECective Practice and
Organisation of Care (EPOC) Information Specialist.

Electronic searches

We undertook a comprehensive search of the Cochrane Database
of Systematic Reviews for related systematic reviews.

We searched the following databases for primary studies, from
inception to 11 February 2021.

• MEDLINE Ovid (1946 onwards);

• Embase Ovid (1974 onwards);

• Cochrane Central Register of Controlled Trials, (CENTRAL; 2021,
Issue 2) in the Cochrane Library;

• CINAHL PLUS (Cumulative Index to Nursing and Allied Health
Literature), EbscoHost (1982 onwards);

• PsycINFO EBSCO (1967 onwards);

• Dissertations and Theses, ProQuest;

• Science Citation Index Expanded, Web of Science, Clarivate
(1945 onwards);

• Conference Proceedings Citation Index ‒ Science, Web of
Science, Clarivate (1990 onwards);

• Social Care Online (www.scie-socialcareonline.org.uk).

Search strategies are comprised of synonyms for diCerent potential
environmental design interventions and diCerent terms for care

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facilities in both natural language and controlled vocabulary terms.
We did not apply any limits on language. All search strategies are
available in Appendix 1.

We used filters to limit retrieval to appropriate study designs.

Searching other resources

Trial registries

• WHO ICTRP (World Health Organisation International Clinical
Trials Registry Platform; www.who.int/ictrp; to 30 November
2017). This was not available at the time of the updated search
on 11 February 2021 and therefore, was not included.

• US National Institutes of Health Ongoing Trials Register
(www.ClinicalTrials.gov; to 11 February 2021).

• ANZCTR (www.anzctr.org.au; to 11 February 2021).

The search strategies for the trial registers are also provided
in Appendix 1.

Grey literature

We conducted a grey literature search to identify studies not
indexed in the databases listed above. We searched the following
websites on 11 February 2021 for terms including nursing home
OR residential OR long term care AND architecture OR design OR
environment:

• OpenGrey (www.opengrey.eu);

• Agency for Healthcare Research and Quality (AHRQ;
www.ahrq.gov), first ten pages returned;

• National Institute for Health and Clinical Excellence (NICE;
www.nice.org.uk);

• NHS Evidence (www.evidence.nhs.uk).

Although not originally planned, we also decided to search the
following websites because we identified them as potentially
relevant for this review aJer publication of the protocol. The
following websites were also searched on 11 February 2021:

• Housing Learning and Improvement Network (Housing LIN;
www.housinglin.org.uk);

• Dementia Training Australia (www.dta.com.au);

• Google Advanced Search (www.google.co.uk/
advanced_search), first ten pages returned.

We also reviewed reference lists of all included studies and
relevant systematic reviews of alternative models of residential
care to identify additional potentially eligible primary studies. We
conducted cited reference searches for included studies which
examined whole-facility models in Science Citation Index, Web of
Science, Clarivate on 22 June 2018.

Data collection and analysis

Selection of studies

We downloaded all titles and abstracts retrieved by electronic
searching to a reference management database (Endnote) and
removed duplicates. SLH screened all titles and abstracts for
inclusion and a second reviewer (SMD, RKM, KEL or staC listed
in the acknowledgements section) also independently screened
titles and abstracts for inclusion. We retrieved the full-text study
reports/publications and two review authors (SLH and SMD, RKM

or KEL) independently screened the full texts, identified studies for
inclusion and identified and recorded reasons for exclusion of the
ineligible studies using Covidence. We resolved any disagreement
through discussion. We collated multiple reports of the same study
so that each study, rather than each report, was the unit of interest
in the review. We recorded the selection process in suCicient detail
to complete a PRISMA flow diagram (Liberati 2009).

Data extraction and management

We used  Covidence  soJware to complete data collection. Two
review authors (SLH and SMD, KEL or RKM) independently
extracted the following study characteristics from the included
studies.

• Methods: study design, number of study centres and location,
study setting, withdrawals, date of study, follow-up;

• Participants: number, mean age, age range, gender, severity
of condition, diagnostic criteria, ethnicity, country, inclusion
criteria, exclusion criteria, other relevant characteristics;

• Interventions: intervention components, comparison, fidelity
assessment;

• Outcomes: main and other outcomes specified and collected,
time points reported;

• Notes: funding for trial, conflicts of interest, ethical approval.

We resolved disagreements by consensus. We contacted authors
of included studies/reviews to seek unpublished results/data or
clarify study reports. We entered the extracted data into Review
Manager 5 (Review Manager 2014). The most important time points
for outcomes were considered to be in the range 3 to 6 months
as this allows adequate time for an intervention to have an eCect,
but is not such an extended follow-up that it will be against a
background of large functional or cognitive decline or increased
mortality in residents.

Assessment of risk of bias in included studies

Two review authors (SLH and KEL, RKM or SMD) independently
assessed risk of bias for each study using the criteria outlined in the
Cochrane Handbook for Systematic Reviews of Interventions (Higgins
2011), and the guidance from the EPOC group (EPOC 2017a). Any
disagreement was resolved by discussion. We assessed the risk of
bias according to the following domains.

• Random sequence generation

• Allocation concealment

• Blinding of participants and personnel

• Blinding of outcome assessment

• Incomplete outcome data

• Selective outcome reporting

• Other bias: baseline outcome measurements similar, baseline
characteristics similar, protection against contamination

For interrupted time series studies, we assessed the risk of bias
according to the following domains.

• Allocation concealment

• Incomplete outcome data

• Selective outcome reporting

• Intervention independent of other events

• Shape of the intervention eCect prespecified

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• ACect/influence of intervention on data collection

• Other bias: any additional potential sources of bias identified

We judged each potential source of bias as ‘high’, ‘low’, or ‘unclear’
and provided a justification for our judgement in the risk of bias
tables including a quote from the study where appropriate. We
assigned an overall low risk of bias if we judged all domains to have
a low risk of bias, an overall high risk of bias if we judged one or
more domains to have a high risk of bias, and an overall unclear risk
of bias if we judged one or more domains to have an unclear risk
of bias (i.e. not clearly reported). We summarised the risk of bias
judgements across diCerent studies for each of the domains listed.
We did not exclude studies on the grounds of their risk of bias. We
contacted study authors to clarify risk of bias for ‘unclear’ items for
studies providing quantitative outcomes suitable for pooling.

When considering treatment eCects, we took the risk of bias into
account for the studies that contributed to that outcome and
incorporated it into our grading of the certainty of the evidence.

We conducted the review according to the published protocol and
reported any deviations from it in the DiCerences between protocol
and review.

Measures of treatment e?ect

We estimated the eCect of the intervention using risk ratio/risk
diCerence, rate ratio or odds ratio (as appropriate) for dichotomous
data, and mean diCerence or standardised mean diCerence for
continuous data, together with the 95% confidence interval. We
ensured that an increase in scores for continuous outcomes could
be interpreted in the same way for each outcome, explained the
direction to the reader, and reported where the directions were
reversed, if this was necessary.

For randomised trials, we used study endpoints in preference to
change from baseline data, if possible, as recommended in Chapter
7 of the Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2011). For interrupted time series studies, we planned to
abstract the diCerence in slope and the diCerence in level pre-
to post-intervention. We planned to report the post- versus pre-
intervention diCerence (adjusted for trends) at specific time points.
If the diCerences were not available in the primary reports, we
planned to attempt re-analysis using data from graphs or tables
based on the EPOC-specific guidance for analysis of interrupted
time series studies.

Unit of analysis issues

For cluster-randomised trials, where possible, we extracted data
which took the eCect of clustering into account. When clustering
was not taken into account, we planned to attempt to account
for the eCect of clustering by dividing the original sample size by
the design eCect, as described in Chapter 16.3 of the Cochrane
Handbook for Systematic Reviews of Interventions (Higgins 2011).

Dealing with missing data

We contacted investigators in order to obtain missing outcome
data. If a standard deviation needed to determine a mean
diCerence was not available, the standard deviation was obtained
from other available data such as a standard error, confidence
intervals, t statistic or P value that related to a diCerence between
means in two groups, in line with the Cochrane Handbook for

Systematic Reviews of Interventions (Higgins 2011). However, if
the studies were non-randomised and the reported means were
unadjusted for potential confounding factors, we did not attempt
to produce an eCect estimate. If the study was a repeated measures
study or interrupted time series and a statistical comparison of time
trends before and aJer the intervention were not provided; we re-
analysed the results as recommended in EPOC 2017c.

Assessment of heterogeneity

We examined heterogeneity using the I2 statistic which quantifies
the percentage of the total variation across studies that is
due to heterogeneity rather than chance (Higgins 2003). We
used Cochrane guidance to interpret the I2 statistic (0% to
40% might not be important; 30% to 60% may represent
moderate heterogeneity; 50% to 90% may represent substantial
heterogeneity; and 75% to 100% may represent very substantial
(‘considerable’) heterogeneity) (Higgins 2011).

Assessment of reporting biases

We attempted to contact study authors, asking them to provide
missing outcome data where applicable. If no response was
received, and the missing data were thought to introduce serious
bias, we planned to explore the impact of including such studies in
the overall assessment of results. If we were able to pool more than
10 trials, we planned to create and examine a funnel plot to explore
possible publication biases, interpreting the results with caution
(Sterne 2011). We did not assess reporting biases using a funnel plot
as there were too few studies for each comparison and outcome.

Data synthesis

We undertook meta-analyses only where this was meaningful, i.e.
if the treatments, participants, and the underlying clinical question
were similar enough for pooling to make clinical sense. Fixed-
eCects models were used, but random eCects would be considered
if we were concerned about the influence of small-study eCects
on the results of a meta-analysis in which there was evidence of

between-study heterogeneity (I2 > 0) as described in Chapter 10
of the Cochrane Handbook for Systematic Reviews of Interventions
(Higgins 2011). Where multiple trial arms were reported in a single
trial, we included only the relevant arms. For non-randomised
studies, only studies which reported results adjusted for potential
confounding factors were planned to be reported in forest plots
using the “estimate from the model that adjusted for the maximum
number of covariates” as recommended in Chapter 13 of the
Cochrane Handbook for Systematic Reviews of Interventions (Higgins
2011). For repeated measures studies, if the authors did not
conduct a statistical comparison of time trends before and aJer the
intervention, we re-analysed the results as recommended in EPOC
2017c. We statistically compared time trends using a segmented
regression model which included the time elapsed since the start of
the study, a dummy variable indicating the pre-intervention period
or the post-intervention period, and an interaction term between
the time elapsed and the dummy variable as predictors and the
mean scores as the outcome variable.

Where pooling of outcomes was not appropriate, we completed
a structured synthesis of the results. We provided structured
tabulations of results across studies grouped by the intervention
examined (e.g. all studies which examined a whole-facility ‘home-
like’ model of care were grouped together) and further grouped
by the outcome category (e.g. health-related quality of life). Forest

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plots were included when more than one study examined the
same intervention and outcome, and data were available for
presentation in a forest plot.

Subgroup analysis and investigation of heterogeneity

We planned to carry out the following subgroup analyses, but there
were insuCicient data to perform these.

• Level of nursing care provided by the facility (high/intermediate/
mixed). The levels of care of the facilities reflect the levels of
dependence of the participants. (Cameron 2018).

• Cognitive status (i.e. dementia versus no dementia/mixed
population)

Sensitivity analysis

We planned to perform sensitivity analyses defined a priori to
assess the robustness of our conclusions and explore their impact
on eCect sizes, but there were insuCicient data to perform these.

• restricting the analysis to published studies; and

• restricting the analysis to studies with a low risk of bias.

Summary of findings and assessment of the certainty of the
evidence

We created a Summary of findings table for the main intervention
comparison (whole-facility ‘home-like’ model compared to usual
care or alternative designs) and included main outcomes — primary
eCectiveness outcomes of health-related quality of life; measures
of behaviour, mood and depression; measures of function; plus
serious adverse eCects.  Only the main intervention comparison
was included in a Summary of findings table as this is the largest
scale design change which captures a variety of diCerent design
alterations and is considered the most important comparison.
“Behaviour, mood and depression” is a primary outcome. As this
outcome encompasses a large range of possible outcomes and
measures, only the two considered most informative were included
in the Summary of findings table. These are: global behaviour
measures (as these capture a range of these outcomes) and
depression as this is a common and important negative mood
symptom in residents of aged care homes. As described in the Data
extraction and management  section, the most important time

points for outcomes were considered to be in the range 3 to 6
months. Therefore, outcomes within this range were reported in the
Summary of findings table, where available.

Two review authors (SLH and SMD or KEL) independently assessed
the certainty of the evidence (high, moderate, low, and very low)
using the five GRADE considerations (risk of bias, consistency
of eCect, imprecision, indirectness, and publication bias) (Guyatt
2008). We used methods and recommendations described in
Section 8.5 and Chapter 12 of the Cochrane Handbook for
Systematic Reviews of Interventions (Higgins 2011), and the EPOC
worksheets (EPOC 2017b), and used GRADEpro GDT soJware
(GRADEpro GDT 2015). Randomised trials start at high certainty
of evidence and non-randomised trials start at low certainty
of evidence before the five GRADE considerations are assessed.
We resolved disagreements on certainty ratings by discussion
and provided justification for decisions to down or upgrade the
ratings using footnotes to the table with comments to aid readers’
understanding of the review, where necessary.

R E S U L T S

Description of studies

Twenty randomised controlled, before-aJer or repeated measures
studies of large- or small-scale changes to the environmental
design of aged care facilities were included in this review.
The comparison groups varied, but included comparison
to  any  alternative environmental design. Details of the
interventions and comparisons are provided in the  Included
studies section.

Results of the search

The electronic search returned 19,393 records, and 157 records
(grey literature or reference lists of studies)  were identified from
other sources. AJer removal of duplicates, 11,117 unique records
were screened, and 10,670 citations were excluded based on
titles and abstracts. We assessed the full-text for 447 records
and identified 20 completed studies eligible for inclusion in this
review (reported in 34 records). One ongoing study was identified
and one study awaiting classification.  Figure 1  shows the study
selection process.

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Figure 1.

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Included studies

See Characteristics of included studies.

Study design and country

Of the 20 included studies, five were randomised trials (Chenoweth
2014; Galik 2021; Mathey 2001; Nijs 2006; Riemersma-vanDerLek
2008), two were randomised cross-over trials (Figueiro 2019;
Hopkins 2017), 12 were controlled before-aJer studies (Afendulis
2016; Annerstedt 1993; Burack 2012; Dettbarn-Reggentin 2005;
Diaz-Veiga 2014; Elmstahl 1997; Frisoni 1998; Kenkmann 2010; Te
Boekhorst 2009; Wolf-Ostermann 2012; Wylie 2001; Yoon 2015),
and one was a repeated measures study (Marcy-Edwards 2011).
All of the randomised trials were cluster-randomised as the
facilities were randomised to receive the intervention (Chenoweth
2014; Galik 2021; Mathey 2001; Nijs 2006; Riemersma-vanDerLek
2008).  Hopkins 2017  and  Figueiro 2019  did not specifically state
the studies were cluster randomised, but as the intervention
(lighting) was installed in communal living areas in both of these
studies, it is assumed these studies are also cluster randomised.
The studies were conducted in nine diCerent countries including
the USA (n = 6,  Afendulis 2016; Burack 2012; Figueiro 2019;
Galik 2021; Wylie 2001; Yoon 2015), The Netherlands (n=4 Mathey
2001; Nijs 2006; Riemersma-vanDerLek 2008; Te Boekhorst 2009),
the UK (n=2  Hopkins 2017; Kenkmann 2010), Sweden (n =
2,  Annerstedt 1993; Elmstahl 1997), Germany (n = 2,  Dettbarn-
Reggentin 2005; Wolf-Ostermann 2012) and single studies from
Australia (Chenoweth 2014), Spain (Diaz-Veiga 2014), Italy (Frisoni
1998) and Canada (Marcy-Edwards 2011).

All studies except five reported sources of funding (Burack 2012;
Dettbarn-Reggentin 2005; Diaz-Veiga 2014; Mathey 2001; Wylie
2001). The funding sources for the majority of studies were
research or city councils, charitable organisations, government
health organisations, universities or a mixture of these. Riemersma-
vanDerLek 2008  reported that Philips Lighting BV, Braun, and
Cambridge Neurotechnology supplied material for the study
at reduced cost.  Figueiro 2019  reported that the following
manufacturers provided in-kind lighting products: GE Current, a
Daintree company; OSRAM Sylvania; Ketra; and Sharp Corporation.
Ten studies reported no conflicts of interest and eight studies did
not report conflicts of interest. One study (Hopkins 2017) stated no
financial, personal, potential conflicts of interest in the conduct of
the study or in the manuscript development. The authors stated
that although Philips Lighting supplied the light fitments, they had
no part in the design of the protocol nor in the analysis of the data.
They stated two co-authors were co-directors of Stockgrand Ltd
and one co-author had in the past received research grant support
from Philips. One co-author was an employee of Philips Research.
Nine studies did not report ethical approval and eleven studies
reported ethical approval details. One further study (Figueiro 2019)
stated neither the funding agency nor the in-kind contributors had
any role in the design, methods, data analysis, or preparation of
the manuscript. Four co-authors received research grant support
from the National Institutes of Health, OCice of Naval Research, the
United States General Services Administration, and industry (Acuity
Brands; Axis Lighting; GE Current, a Daintree company; OSRAM
Sylvania; Ketra; USAI Lighting; Armstrong Ceilings and Walls; Philips
Lighting; Cree; View Glass; Marriott International).

Participants

The 20 studies included 77,265 participants. There was one very
large study which was unclear on the number of participants
included in the analyses used in this review, but weighted
sample percentages indicate an estimated 74,449 participants at
enrolment (Afendulis 2016). The remaining 18 studies included
2816 participants and sample sizes ranged from 34 (Marcy-Edwards
2011) to 601 (Chenoweth 2014). Two studies did not report mean
participant age (Afendulis 2016; Wylie 2001) and most studies
reported mean age by group allocation (intervention and control).
Reported mean participant age in studies which did report this
ranged from 75 (Nijs 2006) to 87.7 years (Kenkmann 2010) in
the intervention or control groups. Thirteen studies reported the
proportion of participants with dementia (range 0% to 100%).
One study included only participants without dementia (Nijs
2006) and nine studies included only participants with dementia
(Chenoweth 2014; Diaz-Veiga 2014; Elmstahl 1997; Figueiro 2019;
Mathey 2001; Riemersma-vanDerLek 2008; Te Boekhorst 2009;
Wolf-Ostermann 2012; Wylie 2001). Overall, 68% of participants
were women and 32% were men, in the 14 studies for which
this information was available (Annerstedt 1993; Chenoweth 2014;
Dettbarn-Reggentin 2005; Diaz-Veiga 2014; Figueiro 2019; Frisoni
1998; Galik 2021; Marcy-Edwards 2011; Mathey 2001; Nijs 2006;
Riemersma-vanDerLek 2008; Te Boekhorst 2009; Wolf-Ostermann
2012; Yoon 2015).

Description of the interventions

Whole-facility model

Home-like models of care

Eleven studies (two randomised trials, nine controlled before-
aJer studies) reported on changes to the physical environment
in conjunction with changes to the whole model of care
(e.g. changes to staCing such as more consistent staCing and
residents having more choice and control over daily routines
and activities) in comparison to traditional design and care
(Afendulis 2016; Annerstedt 1993; Burack 2012; Chenoweth
2014; Dettbarn-Reggentin 2005; Diaz-Veiga 2014; Galik 2021; Te
Boekhorst 2009; Wolf-Ostermann 2012; Wylie 2001; Yoon 2015).
The ‘traditional design’ comparators included: settings which had
not adopted a ‘small house model’ (Afendulis 2016), large long-
term care hospitals (Annerstedt 1993), settings with a ‘typical
nursing home organisational structure and standard administrative
and departmental hierarchy of care’ (Burack 2012), ‘nursing
home typical organisational structures’ (Dettbarn-Reggentin 2005),
settings which has ‘provision of public health services in
accordance with the health needs of the residents, the formal
registration of care tasks and activities, and the prioritisation of
safety both in the design of the spaces and the organisation’ (Diaz-
Veiga 2014), larger-scale settings (Te Boekhorst 2009), special care
units for people with dementia (Wolf-Ostermann 2012), ‘traditional
nursing homes’ (Wylie 2001), traditional large scale nursing
homes, with hospital-like features and traditional hierarchical
organisational structures (Yoon 2015), or residential aged care
settings which did not receive a refurbishment intervention
(Chenoweth 2014, Galik 2021).

Of these, six controlled before-aJer studies incorporated changes
to the scale of the building which limited the capacity of the living
units to small numbers of residents (this ranged from six to 15
residents assigned per living unit) (Afendulis 2016; Annerstedt 1993;

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Dettbarn-Reggentin 2005; Te Boekhorst 2009; Wolf-Ostermann
2012; Yoon 2015). These interventions usually involved design
changes to areas which both the residents and staC would use (e.g.
kitchen and laundry room).

Nine studies (five randomised trials, three controlled before-aJer
studies, one repeated measures study) reported interventions
which did not incorporate changes to the whole model of
care (Elmstahl 1997; Figueiro 2019; Frisoni 1998; Hopkins 2017;
Kenkmann 2010; Marcy-Edwards 2011; Mathey 2001; Nijs 2006;
Riemersma-vanDerLek 2008).

Refurbishment

Five of the studies (two randomised trials, three controlled
before-aJer studies) which examined physical design changes in
conjunction with changes to the whole model of care did not
incorporate changes to the number of residents living in a unit but
were smaller refurbishments and design changes of the existing
home (Burack 2012; Chenoweth 2014; Diaz-Veiga 2014; Galik 2021;
Wylie 2001).  Burack 2012  included changes to the bedrooms and
common living areas including encouraging the use of personal
items for the residents to individualise their bedrooms and
design changes to the common areas to create a “calm, peaceful
environment” (e.g. table cloths and centrepieces, artwork for
walls and painted murals) in conjunction with changes to person-
centred care such as consistent staCing, meaningful activities,
community structure changes and family involvement. Chenoweth
2014  examined changes to the physical environment with or
without changes to the whole model of care (person-centred care).
The authors stated that changes to the environment involved
using the Environment Audit Tool (EAT) to “identify features of the
home that could be improved” (Fleming 2011). The recommended
environmental changes included altering the safety, accessibility
and utility of outdoor spaces, a greater variety of social spaces
and changes to colour and addition of objects with an aim to
improve way finding and familiarity with a budget of AUD$10,000
per home. However, the authors have reported that there were
diCiculties in implementation of some design features at some
facilities within the time frame of the study. Facilities which also
received changes to person-centred care had experts in person-
centred care train five staC from each of the facilities over 32 hours
oC-site (Chenoweth 2014).  Diaz-Veiga 2014  examined the Etxean
Ondo model which includes design of physical-organisational
environments similar to domestic settings, favouring personal
privacy as well as opportunities for choice, participation in
daily life activities and social interaction, set apart by the
creation of domestic environments, the development of important
activities and organisational processes based on the daily life
and the resources of residents, families and professionals.  Galik
2021  examined a Function and Behavior Focused Care (FBFC)
model which included an examination of opportunities for physical
activity and engaging in functional tasks as well as barriers to these
activities. Based on these assessments, modifications in policy
and the environment were made.  Wylie 2001  examined the Eden
Alternative which incorporates pets, plants and children to daily life
and provides daily opportunities to give as well as receive care by
promoting resident participation in the daily routine of activities.

Special-care units for people with dementia

One controlled before-aJer study examined a special care unit
for people with dementia in comparison to traditional nursing
homes (Frisoni 1998). This intervention incorporated the following

components: ten two-bed rooms, a large wandering area, a dining
room, and a separate area for structured activity (physical and
occupational therapy); exit doors were secured by magnetic locks
opening with a digital code, noxious stimuli were minimised, wall
colours were made neutral, and way-finding cues were used to help
residents identify diCerent areas.

Group living corridors

One controlled before-aJer study examined a comparison between
diCerent building layouts within a group living unit (Elmstahl
1997). Group living units were built for six to eight residents with
dementia and incorporated a specifically designed community area
comprising a living room, laundry, kitchen and dining room shared
by residents and staC. A corridor design to the group living units was
compared to a non-corridor design (L-shaped, H-shaped or square
design).

Alternative physical environmental design (without whole-facility
changes)

Lighting

Three randomised trials examined lighting interventions (Figueiro
2019; Hopkins 2017; Riemersma-vanDerLek 2008). One study
compared high colour temperature (17000 K) blue-enriched white-
light in communal areas compared to low colour temperature
(4000 K) white light (Hopkins 2017); the higher the degrees Kelvin
the brighter the lights will appear. One study installed a large
number of fluorescent tubes in the common living room and lights
were on between 9 am and 6 pm and increased light intensity
between 10 am and 6 pm, whereas the control facilities had half
the number of tubes with concealed band-stop filters and were
installed at a greater distance from the eye (Riemersma-vanDerLek
2008). The third study examined lighting designed to provide high
circadian stimulus (Figueiro 2019). Custom-built floor luminaires,
light boxes and light tables were used, timers activated lights
according to wake times, and lights were placed in the person’s
bedrooms or in common area until 6 pm. The control lighting
provided low circadian stimulus with the light delivery method
varying depending on where the participant spent most of his/her
day.

Dining area redesign

Three studies (two randomised trials, one controlled before-
aJer study) examined changes to the dining room to create a
family-style, restaurant-style or improved ambiance environment
(Kenkmann 2010; Mathey 2001; Nijs 2006).  Nijs 2006  examined
a family-style dining intervention which included changes to the
design components of the dining room (table cloths, plates and
glasses, full cutlery, flower arrangements) and changes to the
dining service (cooked meals served on tables, greater choice
of meals, resident choice for timing of meals compared to
meals served on a pre-plated tray with none of the design
features described in the intervention). The second study which
examined a restaurant-style dining intervention also included table
cloths and flower arrangements in addition to food displayed
for residents to see, fewer tables in the dining room, white
crockery with side plates, drinks machine available at all times
and snacks available anytime (Kenkmann 2010). This intervention
also included increased choice of meals and increased choice
in timing of meals by opening the dining area for 90 minutes
with several sittings.  Mathey 2001  examined an ‘improved meal
ambiance’ intervention which included changes to the design of

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the environment: plant or flowers placed on every table, suCicient
lighting, background music chosen by the residents, table cloths
and trays and covers removed from the table. Further changes were
also employed including increasing the number of nurses during
meal times and distinguishing meal times from other activities,
e.g. medications handed out before the start of the meal and no
cleaning activities in the dining room during meal consumption.

Garden vignette

One repeated measures study  with no control group examined a
garden vignette (Marcy-Edwards 2011) which involved the creation
of a designated area that contained clusters of gardening and
nature-related objects, positioned in a highly visible, high traCic
space. The vignette included all objects required to accomplish
the activity of gardening: a garden centre table; soil, plastic pots,
garden seeds, light plastic garden tools, and a plastic watering can;
scented, colourful and edible plants, glossy gardening magazines
with engaging pictures; and large artificial flowers to attract
attention. When the garden vignette was in place, all residents had
unobstructed exposure and access, 24 hours per day.

Comparators

For changes to the whole model of care, the comparators
were ‘traditional nursing homes’ (Wylie 2001,  Yoon
2015), ‘psychogeriatric nursing homes’ (Te Boekhorst 2009),
nursing homes with ‘typical organisational structure’ (Burack
2012,  Dettbarn-Reggentin 2005) long-term care hospitals
(Annerstedt 1993), special care units for people with dementia
(Wolf-Ostermann 2012), facilities which have ‘prioritisation of
safety in design and organisation’ (Diaz-Veiga 2014) or matched
non Green House model facilities (Afendulis 2016).  Chenoweth
2014  compared the adoption of the person-centred environment
to regular monitoring of any unplanned changes to the
environment.  Elmstahl 1997  compared a corridor design to a
non-corridor design. The studies of lighting comparators were
low colour temperature white light (Hopkins 2017)  or  half the
number of fluorescent tubes installed in the intervention group
with concealed band-stop filters that were installed at a greater
distance from the eye (Riemersma-vanDerLek 2008). For the
dining interventions,  the comparator was usual care (Kenkmann
2010; Mathey 2001; Nijs 2006). The special care units were
compared to traditional environments (Frisoni 1998).  The garden
vignette intervention did not have a comparator group as this was
a repeated measures study (Marcy-Edwards 2011).

Fidelity assessment

One of the studies carried out a fidelity assessment (Galik
2021). Galik 2021 reported evidence of fidelity in terms of delivery
of the intervention (583 staC educated, completion of environment
and policy assessments, development of care-plans and ongoing
mentoring and motivating of the staC). There was also evidence
of knowledge of the intervention (98% correct on the Knowledge
Test for the intervention). There was evidence of adoption of
the intervention in the intervention facilities. This was based on
improvements in environments and policies to improve function
and physical activity (environment assessment increased from 13.5
(SD 2.07) to 15.12 (SD 0.99), and policy changes increased from 8.50
(SD 3.85) to 10.87 (SD 2.41)). There was also an increase reported in
the number of care activities. Chenoweth 2014 reported diCiculties
in implementing changes to the physical environment within the
time frame of the study (Chenoweth 2014). Of the facilities that

were randomised to receive the environment intervention, the
authors reported that only 47% at post-intervention and 54%
at eight months follow-up had implemented the environment
intervention, and of the facilities that had been randomised to
receive the environment intervention with person-centred care
training, only 14% and 27% had implemented the environment
intervention, respectively. Reported diCiculties in implementing
the environment intervention included: a) delays in finding
contractors to complete the design changes within the study
timeframe, b) management at facilities  implementing changes
which diCered from the recommended changes or management
at facilities not happy to implement the suggested changes (e.g. a
plan to make the outside area more accessible involved losing a
bedroom which the home was not prepared to do), c) quotations
for the interventions being beyond the budget of the project or the
home, d)  changes to management in the home during the study
period, e) safety issues for residents with the proposed changes
or f) feasibility of the intervention in relation to complying with
building codes. In some instances, where the management of the
home were not happy with the proposed changes or the cost of
the changes was above budget, the project team were able to
work with the home to adapt the proposed changes to fit within
budget and the study time frame, but this was not always feasible.
Furthermore, facilities that were not randomised to receive the
intervention may have initiated design improvements during the
study period which could not be controlled for. One other study
examining implementation of the Eden Alternative reported one
of the facilities  which received the intervention discontinued its
implementation and was then evaluated as part of the control
group, but reasons for discontinuation of the intervention were not
detailed in the study (Wylie 2001).

Outcomes

Primary outcomes

Health-related quality of life

Seven studies were included that reported health-related quality of
life (Chenoweth 2014; Diaz-Veiga 2014; Mathey 2001; Nijs 2006; Te
Boekhorst 2009; Wolf-Ostermann 2012; Wylie 2001). Twelve studies
were included that did not report health-related quality of life,
but reported other, related, secondary outcomes (Afendulis 2016;
Annerstedt 1993; Burack 2012; Dettbarn-Reggentin 2005; Elmstahl
1997; Frisoni 1998; Galik 2021; Hopkins 2017; Kenkmann 2010;
Marcy-Edwards 2011; Riemersma-vanDerLek 2008; Yoon 2015).
Health-related quality of life was measured using the following
assessments in single studies: Dementia Quality of Life (DEMQOL)
Proxy  (Chenoweth 2014), QUALIDEM: a dementia-specific quality
of life measure  (Wolf-Ostermann 2012), Life Satisfaction Index
(LSI)  (Wylie 2001) and Dutch Quality of Life of Somatic Nursing
Home Residents questionnaire  (Nijs 2006). The quality of life
in late-stage dementia (QUALID) and FUMAT  were used in  Diaz-
Veiga 2014 and the Sickness Impact Profile (SIP) and Philadelphia
Geriatric Centre Morale Scale (PGCMS) were used in Mathey 2001.
Quality of life was reported at six months (Nijs 2006), eight months
(Chenoweth 2014), up to 12 months (Diaz-Veiga 2014; Mathey 2001;
Wolf-Ostermann 2012) and up to 18 months (Wylie 2001) follow-up.
Although  Te Boekhorst 2009  did include Dementia Quality of Life
(DQoL) and QUALIDEM measures in their study, these findings were
not included in the review because only results at six months were
reported without baseline results or change in quality of life over
time.

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Behaviour, mood and depression

FiJeen studies reported on behaviour, mood or depression
(Annerstedt 1993; Burack 2012; Chenoweth 2014; Dettbarn-
Reggentin 2005; Elmstahl 1997; Figueiro 2019; Frisoni 1998;
Galik 2021; Hopkins 2017; Kenkmann 2010; Marcy-Edwards 2011;
Riemersma-vanDerLek 2008; Te Boekhorst 2009; Wolf-Ostermann
2012; Yoon 2015). Behaviour,  mood or depression was measured
by the Neuropsychiatric Inventory (NPI) in five studies, where
three studies used the standard version (Frisoni 1998; Marcy-
Edwards 2011; Te Boekhorst 2009), one study used the nursing
home version (Wolf-Ostermann 2012) and one study used the
questionnaire format (Riemersma-vanDerLek 2008). The Cohen-
Mansfield Agitation Inventory (CMAI) was also used in seven
studies (Burack 2012; Chenoweth 2014; Figueiro 2019; Frisoni 1998;
Galik 2021; Riemersma-vanDerLek 2008; Wolf-Ostermann 2012),
the Organic Brain Syndrome (OBS) scale was used in two  studies
(Annerstedt 1993; Elmstahl 1997) and the Philadelphia Geriatric
Centre ACect Rating Scale (PGCARS) in one  study (Riemersma-
vanDerLek 2008). The Hospital Anxiety and Depression (HAD scale)
was used in three  studies, in two  studies (Kenkmann 2010;
Riemersma-vanDerLek 2008) specifically to measure anxiety and
in one  to measure depression (Hopkins 2017). Depression was
measured using the  Cornell Depression Scale in four  studies
(Figueiro 2019; Frisoni 1998; Galik 2021; Riemersma-vanDerLek
2008), the Revised Memory and Behaviour Checklist (RMBPC) in
one study (Te Boekhorst 2009) and the Mood Scale Score (MSS) in
one study (Yoon 2015). The Index of Social Engagement (ISE) and
Revised ISE (RISE) were used to measure social engagement in Te
Boekhorst 2009 and Yoon 2015, respectively. Resistiveness to care
was measured using the Resistiveness to Care Scale in one study
(Galik 2021).

Behaviour was reported at six months follow-up (Te Boekhorst
2009), six and 12 months follow-up (Annerstedt 1993; Wolf-
Ostermann 2012) and agitation at eight months follow-up
(Chenoweth 2014).  Burack 2012  reported on verbal agitation,
forceful behaviours and physical agitation at two years follow-
up.  Marcy-Edwards 2011  also reported behaviour in a repeated
measures study over five phases of 14 days each;  the
measurements were repeated multiple times in the 14-day
period and the mean measurements for days, evenings and
nights were presented. Six studies reported behaviour and
depression at four weeks follow-up (Figueiro 2019; Hopkins 2017),
three months follow-up (Frisoni 1998) and 12 months follow-up
(Elmstahl 1997; Galik 2021; Kenkmann 2010).  Yoon 2015  reported
depressive symptoms at 18 months follow-up.  Riemersma-
vanDerLek 2008 reported behaviour and function at multiple time
points (six weeks, six months, 12 months, 18 months and 24
months follow-up).  Yoon 2015  and  Te Boekhorst 2009  reported
social engagement at 6 months (Te Boekhorst 2009) and over
18 months (Yoon 2015).  Dettbarn-Reggentin 2005  reported social
behaviour at 12 months.

Function

Nine studies reported on function (Chenoweth 2014; Dettbarn-
Reggentin 2005; Figueiro 2019; Frisoni 1998; Nijs 2006; Te Boekhorst
2009; Wolf-Ostermann 2012; Yoon 2015). Function was measured
by the  Barthel Index in four studies (Dettbarn-Reggentin 2005;
Frisoni 1998; Galik 2021; Wolf-Ostermann 2012), the Interview for
the Deterioration of Daily Living activities in Dementia  (IDDD) in
one  study (Te Boekhorst 2009), the  Bedford Alzheimer’s nursing

severity scale in one  study (Frisoni 1998), the Nursing Home
physical performance test in one study (Dettbarn-Reggentin 2005),
and Activities of Daily Living (ADLs) in three studies; the ADL long-
form scale was used in one study (Yoon 2015); the Minimum Data
Set Activities of Daily Living Scale (MDS-ADL) was used in one study
(Figueiro 2019), and the Nurse-informant adaptation of the scale by
Katz and colleagues was used in one study (Riemersma-vanDerLek
2008).

Function was reported at three months (Frisoni 1998), six months
(Nijs 2006; Te Boekhorst 2009), eight months (Chenoweth 2014), six
and 12 months (Dettbarn-Reggentin 2005; Wolf-Ostermann 2012),
four and 12 months (Galik 2021) and 18 months (Yoon 2015) follow-
up.   Figueiro 2019  was a cross-over trial with a 14-week protocol
which comprised of two 1-week baseline measurement periods
and two 4-week lighting intervention/control periods, separated
by a 4-week washout period. Data were collected during the
baseline measurement weeks (weeks 1 and 10) prior to each 4-week
intervention/control period and once again during the final week of
each intervention/control period (weeks 5 and 14).

Secondary outcomes

Global cognitive functioning

Seven studies reported on global cognitive functioning (Dettbarn-
Reggentin 2005; Frisoni 1998; Kenkmann 2010; Riemersma-
vanDerLek 2008; Te Boekhorst 2009; Wolf-Ostermann 2012; Yoon
2015). Global cognitive functioning was measured with the
Mini Mental State Examination (MMSE) in six  studies (Dettbarn-
Reggentin 2005; Frisoni 1998; Kenkmann 2010; Riemersma-
vanDerLek 2008; Te Boekhorst 2009; Wolf-Ostermann 2012), the
Clinical Dementia Rating in one  study (Frisoni 1998) and the
Cognitive Performance Scale (CPS) in one study (Yoon 2015). Global
cognitive function was reported at three months (Frisoni 1998),
six months (Kenkmann 2010; Wolf-Ostermann 2012), 12 months
(Dettbarn-Reggentin 2005; Te Boekhorst 2009; Wolf-Ostermann
2012) and 18 months (Yoon 2015). Riemersma-vanDerLek 2008 also
reported cognitive function at multiple time points.

Quality of care

Two studies reported on quality of care (Afendulis 2016; Chenoweth
2014). Chenoweth 2014 used the Quality of Interactions Schedule
(QUIS) to measure quality of care and Afendulis 2016 used number
of bedfast residents, catheter use, low-risk and high-risk pressure
ulcers, rehospitalisations and avoidable rehospitalisations as
quality of care measures.

Afendulis 2016 reported these outcomes at up to 5-year follow-up
and  Chenoweth 2014  reported these  at post-intervention at four
months and eight months follow-up.

Serious adverse e?ects

Three studies reported on serious adverse eCects (Afendulis
2016; Frisoni 1998; Kenkmann 2010).  Afendulis 2016  and  Frisoni
1998  reported use of physical restraints over five years and three
months respectively.  Frisoni 1998  reported frequency of falls in
three months and Kenkmann 2010 reported number of falls in 12
months.

Outcomes for carers

No included studies reported outcomes for carers.

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Outcomes for sta?

No included studies reported outcomes for staC.

Ongoing studies

One ongoing study was identified (see  Characteristics of
ongoing studies for details). This ongoing national cross-sectional
monitoring study is examining quality of life, quality of care and
staC outcomes in diCerent styles of aged care facilities every two to
three years in The Netherlands. Between 47 and 144 facilities have
participated in the four cycles conducted so far (Willemse 2011).
The study aimed to compare “traditional large scale nursing homes,
nursing home wards in a home for the aged, large nursing home
where group living home care is provided, group living homes
nearby the mother facility and stand-alone group living homes
in the community” (Willemse 2011). Whilst all the potentially
relevant analyses identified from the study thus far have been
cross-sectional, future publications will be monitored for studies
that meet the inclusion criteria for this review.

Studies awaiting classification

One study was identified which is awaiting classification. Kolberg
2020 is a cluster-randomised trial examining a lighting intervention

in common living areas in eight aged care facilities. A conference
abstract and thesis have been published showing the results of the
study. There is insuCicient information in the conference abstract
and thesis to determine if the study should be included.

Excluded studies

We excluded 406 studies following full-text review; 290 were
excluded due to ineligible study design, such as the study only had
one intervention and control site or was a longitudinal study but did
not have a measure before the intervention, i.e. before admission to
a facility; 100 were excluded because the intervention was ineligible
such as temporary therapies or changes to care practices without
any changes to the environmental design of the facilities; and
16 were excluded because the care setting was ineligible such as
living in an assisted living setting with no nursing care required.
The Characteristics of excluded studies section details the reason
for exclusion of studies which might be expected to be included in
this review to explain why they are excluded.

Risk of bias in included studies

See Figure 2 and Figure 3.

Figure 2.   Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages
across all included studies.

Random sequence generation (selection bias)
Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias): All outcomes
Blinding of outcome assessment (detection bias): All outcomes

Incomplete outcome data (attrition bias): All outcomes
Selective reporting (reporting bias)

Other bias
Intervention independent of other changes (ITS)

Shape of the intervention effect pre-specified (ITS)
Intervention unlikely to affect data collection (ITS)

0% 25% 50% 75% 100%

Low risk of bias Unclear risk of bias High risk of bias

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Figure 3.   Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.

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Afendulis 2016 – – – – ? ? –

Annerstedt 1993 – – – – – + –
Burack 2012 – – – – ? – –

Chenoweth 2014 + ? – – ? + +
Dettbarn-Reggentin 2005 – – – – – – –

Diaz-Veiga 2014 – – – – ? + –
Elmstahl 1997 – – – – + – ?
Figueiro 2019 ? ? ? ? ? + +

Frisoni 1998 – – – – + + –
Galik 2021 + ? – – ? + ?

Hopkins 2017 ? ? – – – ? ?
Kenkmann 2010 – – – – – + –

Marcy-Edwards 2011 – + + + ? – +
Mathey 2001 ? ? – ? – ? –

Nijs 2006 – + – ? – + –
Riemersma-vanDerLek 2008 + + + + – + +

Te Boekhorst 2009 – – – – – + –
Wolf-Ostermann 2012 – – – – – + –

Wylie 2001 – – – – – + –
Yoon 2015 – – – – – ? –

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Allocation

Random sequence generation

Thirteen studies were rated as having high risk of bias because
randomisation was not applied (Afendulis 2016; Annerstedt 1993;
Burack 2012; Dettbarn-Reggentin 2005; Diaz-Veiga 2014; Elmstahl
1997; Frisoni 1998; Kenkmann 2010; Te Boekhorst 2009; Wolf-
Ostermann 2012; Wylie 2001; Yoon 2015) or a non-random
component to sequence generation (including the first letter of
the ward name) was used (Nijs 2006). Three studies (Chenoweth
2014; Galik 2021; Riemersma-vanDerLek 2008)  were rated as
having low risk of bias as they described an appropriate
method of randomisation. Three studies (Figueiro 2019; Hopkins
2017; Mathey 2001) were rated as having unclear risk of bias
because randomisation was stated, but no  specific details were
reported. Marcy-Edwards 2011 was a repeated measures study and
therefore this was not applicable.

Allocation concealment

Thirteen studies were rated as having high risk of bias because
randomisation was not applied (Afendulis 2016; Annerstedt 1993;
Burack 2012; Dettbarn-Reggentin 2005; Diaz-Veiga 2014; Elmstahl
1997; Frisoni 1998; Kenkmann 2010; Marcy-Edwards 2011; Te
Boekhorst 2009; Wolf-Ostermann 2012; Wylie 2001; Yoon 2015). Two
studies were rated as having low risk of bias because adequate
allocation concealment was reported (Nijs 2006; Riemersma-
vanDerLek 2008). Five studies was rated at unclear risk of
bias because allocation concealment details were not specified
(Figueiro 2019; Galik 2021; Hopkins 2017; Mathey 2001) or  it was
unclear where the randomisation sequence was stored (Chenoweth
2014).

Blinding

Blinding of participants and personnel

One study was rated as having low risk of bias as blinding of
outcome assessment and blinding of participants and personnel
were both adequately described (Riemersma-vanDerLek 2008).
Seventeen studies were rated at high risk of bias for blinding of
participants and personnel as this was not feasible (e.g. where
residents or staC who are aware of group allocation provided the
data) (Afendulis 2016; Annerstedt 1993; Burack 2012; Chenoweth
2014; Dettbarn-Reggentin 2005; Diaz-Veiga 2014; Elmstahl 1997;
Frisoni 1998; Galik 2021; Hopkins 2017; Kenkmann 2010; Mathey
2001; Nijs 2006; Te Boekhorst 2009; Wolf-Ostermann 2012; Wylie
2001; Yoon 2015).  One study was rated as having unclear risk of
bias as the study stated “facility staC were not informed of any
diCerences between the lighting interventions”, but it was unclear if
any diCerences had been observed (Figueiro 2019). Marcy-Edwards
2011  was a repeated measures study and therefore this was not
applicable.

Blinding of outcome assessment

Three studies were rated as having unclear risk of bias as none
reported specific details of blinding (Figueiro 2019; Mathey 2001;
Nijs 2006). One study was rated as having low risk of bias as
adequate descriptions of blinding of the outcome assessment
was provided (Riemersma-vanDerLek 2008). FiJeen studies used
outcomes where blinding was not feasible (e.g. residents or
staC who were aware of group allocation provided the data)
(Afendulis 2016; Annerstedt 1993; Burack 2012; Chenoweth 2014;

Dettbarn-Reggentin 2005; Diaz-Veiga 2014; Galik 2021; Te Boekhorst
2009; Wolf-Ostermann 2012; Wylie 2001; Yoon 2015) or outcome
assessment was not blinded (Elmstahl 1997; Frisoni 1998; Hopkins
2017; Kenkmann 2010).  Marcy-Edwards 2011  was a repeated
measures study and therefore this was not applicable.

Incomplete outcome data

Eleven studies were rated as having high risk of bias as there
was high loss to follow-up (> 20%) (Annerstedt 1993; Dettbarn-
Reggentin 2005; Hopkins 2017; Kenkmann 2010; Mathey 2001;
Nijs 2006; Riemersma-vanDerLek 2008; Te Boekhorst 2009; Wolf-
Ostermann 2012; Wylie 2001; Yoon 2015). Eight studies were rated
at unclear risk of bias due to  information not being provided
by group allocation (Burack 2012), or the reasons for dropout
(Chenoweth 2014), did not report loss to follow-up over time
(Afendulis 2016; Diaz-Veiga 2014; Figueiro 2019) or reported large
loss to follow-up, 30% aJer randomisation, but it was unclear which
randomised group the participants belonged to (Galik 2021). Three
studies were rated at low risk of bias due to adequate (> 85%, Marcy-
Edwards 2011  and > 90%,  Elmstahl 1997) or no loss to follow-up
(Frisoni 1998).

Selective reporting

Thirteen studies were rated as having low risk of bias as their
results matched what was reported in a protocol, trial registration
or methods section for non-randomised studies which did not have
a protocol  (Annerstedt 1993; Chenoweth 2014; Diaz-Veiga 2014;
Figueiro 2019; Frisoni 1998; Galik 2021; Kenkmann 2010; Marcy-
Edwards 2011; Nijs 2006; Riemersma-vanDerLek 2008; Te Boekhorst
2009; Wolf-Ostermann 2012; Wylie 2001). Three studies were rated
at high risk of bias due to not reporting outcomes which were
described in the methods (Burack 2012; Dettbarn-Reggentin 2005;
Elmstahl 1997). Four studies were rated at unclear risk of bias
because they did not have published protocols and were based on
data from the Minimum DataSet (MDS) which included many fields
from the MDS which were not reported; (Afendulis 2016; Yoon 2015)
or were randomised trials that did not report details of a study
protocol or trial registration (Hopkins 2017; Mathey 2001).

Other potential sources of bias

Thirteen studies were rated at high risk of bias (Afendulis 2016;
Annerstedt 1993; Burack 2012; Dettbarn-Reggentin 2005; Diaz-
Veiga 2014; Frisoni 1998; Kenkmann 2010; Mathey 2001; Nijs
2006; Te Boekhorst 2009; Wolf-Ostermann 2012; Wylie 2001; Yoon
2015). Reasons for being rated at high risk of bias included
diCerences in baseline characteristics (Afendulis 2016, Annerstedt
1993, Burack 2012, Frisoni 1998, Kenkmann 2010, Mathey 2001, Nijs
2006, Te Boekhorst 2009; Wylie 2001, Wolf-Ostermann 2012, Yoon
2015), diCerences in baseline outcome measures (Afendulis 2016;
Annerstedt 1993; Burack 2012; Dettbarn-Reggentin 2005; Diaz-
Veiga 2014; Frisoni 1998) and potential for contamination (Mathey
2001; Wylie 2001). Twelve studies were non-randomised studies,
therefore residual confounding was a potential source of bias
(Afendulis 2016; Annerstedt 1993; Burack 2012; Dettbarn-Reggentin
2005; Diaz-Veiga 2014; Elmstahl 1997; Frisoni 1998; Kenkmann 2010;
Te Boekhorst 2009; Wolf-Ostermann 2012; Wylie 2001; Yoon 2015).
Three studies were rated at unclear risk of bias (Elmstahl 1997;
Galik 2021; Hopkins 2017); two studies did not report baseline
characteristics by group allocation (Elmstahl 1997; Hopkins 2017);
one study reported outcome measures in little detail (Hopkins
2017); and in one study there appeared to be diCerences in one

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of the outcomes but no statistical analysis was performed (Galik
2021). Four studies were rated at low risk of bias for having no
statistically significant diCerences between groups at baseline,
no statistically significant diCerences in outcome measures at
baseline, having the intervention assigned at the level of the
care facility and no other potential sources of bias identified
(Chenoweth 2014; Figueiro 2019; Marcy-Edwards 2011; Riemersma-
vanDerLek 2008).

Intervention independent of other changes

Marcy-Edwards 2011 was a repeated measures study and therefore
the criteria for risk of bias also included ‘intervention independent
of other changes’, and was rated as having unclear risk of bias as
it was not reported that the intervention was not independent of
other changes in time nor was there compelling evidence that the
intervention was independent.

Shape of the intervention e”ect prespecified

Marcy-Edwards 2011 was also rated at high risk of bias for ‘shape
of the intervention eCect prespecified’ because the baseline data
collection was spread over four weeks.

Intervention unlikely to a”ect data collection

Marcy-Edwards 2011 was rated at low risk of bias for ‘intervention
unlikely to aCect data collection’ as the sources and methods of
data collection were the same before and aJer the intervention.

E?ects of interventions

See: Summary of findings 1 Whole-facility changes: Home-like
models compared to traditional environment for older people
living in long-term residential care

Whole-facility model

A summary of the evidence for home-like in comparison to
traditional models of care is provided in Summary of findings 1.

Home-like model versus traditional environment

Six controlled before-aJer studies compared the home-like model
and the traditional environment (136,419 participants) (Afendulis
2016; Annerstedt 1993; Dettbarn-Reggentin 2005; Te Boekhorst
2009; Wolf-Ostermann 2012; Yoon 2015). One controlled before-
aJer study did not report participant numbers according to their
exposure (Afendulis 2016).

Health-related quality of life

It is uncertain whether home-like models improved health-related
quality of life because the certainty of the evidence is very low
(1 study; 33 participants; very low-certainty evidence). No eCect
estimate could be derived because of the unavailability of the data.
The certainty of the evidence was downgraded from low-certainty
to very low-certainty because of very serious concerns due to risk
of bias and imprecision.

One controlled-before aJer study examined quality of life (Wolf-
Ostermann 2012). Outcomes were measured at baseline, six
months and 12 months by examining multiple domains from
the QUALIDEM, where high scores indicate better quality of
life.  Although 56 participants were included in the study, only
33 participants completed the follow-up and were included
in the analysis. The authors examined nine domains of the

QUALIDEM including care relationship, feeling at home, social
relations, positive self-image, restless tense behaviour, having
something to do, positive aCect, negative aCect and social
isolation. Two  domains (feeling at home and care relationship)
were examined in analyses adjusted for baseline diCerences
between the groups and the seven other domains were examined in
unadjusted analyses. The author stated “no statistically significant
diCerences were observed between the intervention and control
groups.” (Analysis 1.1).

Behaviour, mood and depression

It is uncertain whether home-like models improved behaviour,
mood and depression because the certainty of the evidence
is very low (3 studies for global behaviour; 257 participants;
very low-certainty evidence, and two studies for depression; 406
participants; very low-certainty evidence).  The certainty of the
evidence was downgraded from low-certainty to very low-certainty
because of very serious concerns due to risk of bias, and also
serious concerns due to imprecision for global behaviour. Meta-
analyses could not be completed because of diCerences in the
outcomes reported.

Five controlled before-aJer studies compared the home-like model
to a traditional environment (625 participants) and reported
data for a home-like model versus traditional environment on
behaviour, mood and depression outcomes (Annerstedt 1993;
Dettbarn-Reggentin 2005; Wolf-Ostermann 2012; Yoon 2015; Te
Boekhorst 2009). Two studies (Annerstedt 1993; Wolf-Ostermann
2012) reported results for sub-domains of behaviour, three studies
(Dettbarn-Reggentin 2005,  Te Boekhorst 2009    Wolf-Ostermann
2012) examined global behaviour, two studies (Yoon 2015; Te
Boekhorst 2009) examined social engagement and two studies
(Yoon 2015; Te Boekhorst 2009) examined depression.

For global behaviour, Te Boekhorst 2009 used the Neuropsychiatric
Inventory (NPI), Wolf-Ostermann 2012 used the NPI-Nursing Home
version (NPI-NH) and  Dettbarn-Reggentin 2005  examined global
behaviour using the Nurses Observation Scale for Geriatric Patients
(NOSGER). For depression,  Te Boekhorst 2009  used the Revised
Memory and Behaviour Problems Checklist (RMBPC) and  Yoon
2015  used the Mood Scale Score (MSS). For subdomains of
behaviour,  Annerstedt 1993  used the Organic Brain Syndromes
(OBS) scale to report outcomes for dyspraxia, hallucinations,
lack of vitality, dysphasia, paranoia, aggressiveness, depression,
clinical variations, restlessness, and Wolf-Ostermann 2012 used the
Cohen-Mansfield Agitation Inventory (CMAI) to report changes in
verbal agitation, physical non-aggressive and physical aggressive
behaviour. For all of these measures, lower scores indicate fewer
behavioural symptoms. For social engagement,  Yoon 2015  used
the Index of Social Engagement (ISE) and Te Boekhorst 2009 used
Revised Index of Social Engagement (RISE), and higher scores
indicate better social engagement.

Behaviour, mood and/or depression outcomes were examined at
baseline (Annerstedt 1993; Dettbarn-Reggentin 2005; Te Boekhorst
2009; Wolf-Ostermann 2012; Yoon 2015), three months (Yoon
2015), six months (Annerstedt 1993,  Dettbarn-Reggentin 2005,Te
Boekhorst 2009,  Wolf-Ostermann 2012,  Yoon 2015), nine months
(Yoon 2015), 12 months (Annerstedt 1993,  Dettbarn-Reggentin
2005,  Wolf-Ostermann 2012,  Yoon 2015), 15 months (Yoon 2015),
and 18 months (Yoon 2015).

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Dettbarn-Reggentin 2005  did not adjust results for baseline
diCerences between the groups, but the authors stated there was
a “significant influence of the residential group environment on
the social behaviour and state of mind of the residents”. The
results from  Wolf-Ostermann 2012  stated for global behaviour:
“interactions between settings and development over time could
not be proved”. No eCect estimate for Wolf-Ostermann 2012 could
be derived because of the reporting of the data.  Results from  Te
Boekhorst 2009 suggested little or no diCerence in global behaviour
(mean diCerence (MD): -0.04, 95% Confidence Interval (CI) -0.13 to
0.04; Analysis 1.2.1; 1 study).

Results on depression outcomes could not be combined in a meta-
analysis because  Yoon 2015  examined the change of depression
and probability of having zero depressive symptoms whereas  Te
Boekhorst 2009  reported the endpoint depression results.  Yoon
2015  indicated an increase in depressive symptoms over 18
months with a home-like model of care (rate ratio 1.15, 95% CI
1.02 to 1.29;  Analysis 1.2.2; 1 study with 242 participants), but
the eCect on the probability of zero depressive symptoms was
uncertain (odds ratio (OR) 0.36, 95% CI 0.12 to 1.07;  Analysis
1.2.2; 1 study).  Te Boekhorst 2009  found little or no diCerence
in depressive symptoms at six months (MD 0.01, 95% CI -0.12
to 0.14;  Analysis 1.2.2; 1 study). It is uncertain whether home-
like models of care improve depressive symptoms because the
certainty of this evidence is very low.

Annerstedt 1993 reported that “a diCerence in clinical changes was
significant” between the intervention and control groups aJer six
months in dyspraxia (spatial disorientation) and depression, but
aggressiveness increased among the intervention group (Analysis
1.2.3).  Wolf-Ostermann 2012  found little or no eCect on verbal
agitation, physical non-aggressive or physical aggressive behaviour
with the home-like model.

Results for social engagement could not be combined in a
meta-analysis because  Yoon 2015  examined the change of social
engagement and probability of not being socially engaged over 18
months, whereas  Te Boekhorst 2009  reported social engagement
over six months.  Yoon 2015  had contradictory findings with little
or no diCerence in change in the level of social engagement over
18 months (rate ratio 0.99, 95% CI 0.82 to 1.19;  Analysis 1.2.4; 1
study with 242 participants), but an increase in probability of social
engagement (a decrease in the probability of not being socially
engaged) for those in a home-like model of care (OR 0.76, 95% CI
0.62 to 0.94;  Analysis 1.2.4; 1 study).  Te Boekhorst 2009  found an
increase in social engagement at six months (MD 0.79, 95% CI 0.11
to 1.50; Analysis 1.2.4; 1 study with 164 participants). It is uncertain
whether home-like models of care improve social engagement
because the certainty of this evidence is very low.

Function

It is uncertain whether home-like models improved function
because the certainty of the evidence is very low (4 studies;
499 participants; very low-certainty evidence).  The certainty of
evidence was downgraded from low-certainty to very low-certainty
because of very serious concerns due to risk of bias and serious
concerns due to imprecision (499 participants in total across
outcomes but reported across diCerent measures and at diCerent
time points). Meta-analyses could not be completed because of
diCerences in follow-up times and availability of data.

Four controlled before-aJer studies (499 participants) assessed
function (Dettbarn-Reggentin 2005; Te Boekhorst 2009; Wolf-
Ostermann 2012; Yoon 2015). To measure function,  Yoon
2015  used the Activities of Daily Living (ADL)-long form scale,  Te
Boekhorst 2009  used the Interview for the Deterioration of Daily
Living activities in Dementia (IDDD) and both  Wolf-Ostermann
2012 and Dettbarn-Reggentin 2005 used the Barthel Index. Lower
scores indicate better function for the ADL-long-form scale and
IDDD, whereas higher scores indicate better function for the Barthel
Index.

Function was measured at three months (Yoon 2015), six months
(Te Boekhorst 2009,  Yoon 2015,  Wolf-Ostermann 2012), nine
months (Yoon 2015), 12 months (Yoon 2015  ,  Wolf-Ostermann
2012, Dettbarn-Reggentin 2005) and 18 months (Yoon 2015).

Wolf-Ostermann 2012  stated for functional status: “interactions
between settings and development over time could not be
proved”. Dettbarn-Reggentin 2005 stated that function declined in
both the intervention and control groups, but function declined
“more sharply” in the control group (Analysis 1.3).

Yoon 2015 reported little or no diCerence in change in function over
18 months aJer admission (MD -0.09, 95% CI -0.46 to 0.28; Analysis
1.3; 1 study).  Te Boekhorst 2009  reported an increase in function
(decreased IDDD score) for those in a home-like model of care six
months aJer admission (MD -4.37, 95%CI -7.06 to -1.69; Analysis 1.3;
1 study).

Global cognitive function

It is uncertain whether home-like models improved global cognitive
function because the certainty of the evidence is very low (4 studies;
569 participants; very low-certainty evidence).  The certainty of
evidence was downgraded from low-certainty to very low-certainty
because of very serious concerns due to risk of bias and imprecision
(569 participants in total across outcomes but reported across
diCerent measures and at diCerent time points).  Meta-analyses
could not be completed because of diCerences in follow-up times
and availability of data.

Four controlled before-aJer studies (569 participants) reported
global cognitive function as an outcome (Dettbarn-Reggentin
2005; Te Boekhorst 2009; Wolf-Ostermann 2012; Yoon 2015).
Two studies used the Mini-Mental State Examination (MMSE)
(Dettbarn-Reggentin 2005; Wolf-Ostermann 2012), one study used
the standardised MMSE (Te Boekhorst 2009) and one study used
the Cognitive Performance Scale (CPS) (Yoon 2015). Higher scores
indicate better global cognitive function, except for the CPS where
lower scores indicate better global cognitive function.

Global cognitive function was measured at three months (Yoon
2015), six months (Te Boekhorst 2009, Yoon 2015, Wolf-Ostermann
2012), nine months (Yoon 2015), 12 months (Yoon 2015  ,  Wolf-
Ostermann 2012,  Dettbarn-Reggentin 2005) and 18 months (Yoon
2015).

Yoon 2015  did not conduct any analysis to examine the evidence
of an eCect, and the means reported were unadjusted for potential
confounding factors. Dettbarn-Reggentin 2005 suggested a sharper
decline in MMSE scores over time for the control group compared
to the intervention group, but the results were not adjusted for
potential confounding factors.  Wolf-Ostermann 2012  suggested
better MMSE scores for those in a home-like model of care at

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baseline to six months and little or no diCerence at 12 months,
but the results were also not adjusted for potential confounding
factors (Analysis 1.4).  The results from the study by  Te Boekhorst
2009 showed that home-like models of care made no diCerence to
global cognitive function   (MD 0.54, 95% CI -1.43 to 2.50;  Analysis
1.4; 1 study).

Quality of care

It is uncertain whether home-like models of care improved quality
of care because the certainty of the evidence is very low (1
study; weighted estimate 74,449 participants; very low-certainty
evidence). The certainty of evidence was downgraded from low-
certainty to very low-certainty because of very serious concerns due
to risk of bias.

One controlled before-aJer study (weighted estimate 74,449
participants at enrolment) examined quality of care by reporting
the number of bedfast residents, catheter use, high-risk pressure
ulcers, low-risk pressure ulcers, hospital readmissions and
avoidable hospital readmissions as proxy measures for quality
of care (Afendulis 2016).  Afendulis 2016  comprised the majority
of the participants in this review, but did not examine any of
the primary outcomes.  Quality of care outcomes were assessed
between January 1, 2005 and September 30, 2010 to determine
the frequency of occurrence. The study estimated diCerence-
in-diCerence regression coeCicients for the pre-post diCerence
in the home-like model homes minus the pre-post diCerence
in traditional homes. The coeCicients suggested the diCerence
in percentage points (e.g. percentage of hospital readmissions)
between the home-like model of care and traditional model, with
lower scores indicating better quality of care according to the proxy
measures. The follow-up time in this study was unclear.

For those in a home-like model of care,  Afendulis 2016  reported
a reduction in the number of bedfast residents (MD -0.3%, 95%
CI -0.4% to -0.2%;  Analysis 1.5; 1 study), catheter use (MD -4.1%,
95% CI -6.1% to -2.1%;  Analysis 1.5; 1 study), low-risk pressure
ulcers (MD -1.9%, 95%CI -2.5% to -1.3%;  Analysis 1.5; 1 study),
hospital readmissions (MD -5.5%, 95% CI -10.2% to -0.8%; Analysis
1.5; 1 study) and avoidable hospital readmissions (MD -3.9%, 95%
CI -7.6% to -0.2%;  Analysis 1.5;  1 study).  AJer accounting for
multiple comparisons, the authors indicated that these diCerences
were statistically significant. Whilst these diCerences may be small
in percentage terms (representing a range of 0.3% for bedfast
residents, to 5.5% for hospital readmissions), given the large
numbers of residents living in aged care homes, these values
could translate to large numbers of individuals at a regional or
national level. Any improvement in such critical outcomes that
are likely to impact on quality life may be considered clinically
meaningful.  Afendulis 2016  reported that a home-like model of
care may have little to no eCect on high-risk pressure ulcers (MD
-1.2%, -3.8% to 1.4%; Analysis 1.5; 1 study), but the evidence is very
uncertain.

Serious adverse e”ects

It is uncertain whether  home-like models of care reduce physical
restraint use as the certainty of the evidence is very low (one study;
weighted estimate 74,449 participants). The certainty of evidence
was downgraded from low to very low due to very serious concerns
about the risk of bias.

One controlled before-aJer study (Afendulis 2016)  examined
serious adverse eCects. This study reported a slight reduction in
the use of physical restraints for those in a home-like model of care
(MD -0.3%, 95%CI -0.5% to -0.1%;  Analysis 1.5; 1 study) between
January 1, 2005 and September 30, 2010 (Afendulis 2016). The
authors conducted analyses accounting for multiple comparisons
and reported that this finding was not statistically significant. As
discussed above, although the diCerence observed represented
0.3% of residents, any improvement observed in such a critical
outcome is potentially clinically meaningful. No other serious
adverse eCects were examined or reported in any of the included
studies. However, as the certainty of the evidence is considered very
low, there is uncertainty in this finding.

Outcomes for carers

No included studies reported on outcomes for carers.

Outcomes for sta”

No included studies reported on outcomes for staC.

Refurbishment versus traditional environment

Five studies examined refurbishment of care homes in conjunction
with measures to develop person-centred care compared to
a traditional environment (1357 participants). Three studies
were controlled before-aJer studies (Burack 2012; Diaz-Veiga
2014; Wylie 2001) and two studies were cluster-randomised
trials (Chenoweth 2014; Galik 2021).  Burack 2012  examined
refurbishment in conjunction with person-centred care referred to
as ‘culture change’ compared to a traditional environment and
traditional care.  Diaz-Veiga 2014  examined refurbishment using
the Etxean Ondo model which aims to develop a domestic setting
in conjunction with person-centred care.  Wylie 2001  examined
refurbishment using the Eden Alternative which introduces pets,
plants and children in addition to person-centred care. One
cluster-randomised trial (Chenoweth 2014) studied the eCect of
a person-centred environment (with or without person-centred
care) compared to a traditional environment and traditional
care, and the development of the person-centred environment
and person-centred care involved the use of the Person-Centred
Environment and Care Assessment Tool (PCECAT). A diCerent
cluster-randomised trial (Galik 2021) examined an intervention
called Function and Behavior Focused Care for the Cognitively
Impaired (FBFC) compared to an education-only control group.
Within the FBFC intervention, FBFC research nurses examined the
environment to identify opportunities for physical activity and
engaging in functional tasks as well as barriers to these activities
and based on these assessments, modifications in policy and the
environment were made.

Health-related quality of life

It is uncertain whether refurbishment comprising of a person-
centred environment improved health-related quality of life
because the certainty of the evidence is very low (MD 3.00, 95%
CI -1.91 to 7.91; 1 study; 143 participants; very low-certainty
evidence; Analysis 2.1). The certainty of evidence was downgraded
from high-certainty to very low-certainty  due  to very serious
concerns because of risk of bias and serious concerns due
to imprecision. A further two studies examined the impact of
refurbishment on quality of life, but these were not randomised
trials and due to heterogeneity in the interventions, a meta-analysis
was not performed.

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Three studies (820 participants) examined quality of life
(Chenoweth 2014; Diaz-Veiga 2014; Wylie 2001) comparing
refurbishment with the traditional environment. One study was
a randomised trial (Chenoweth 2014) and two were controlled
before-aJer studies (Diaz-Veiga 2014; Wylie 2001).

Quality of life was measured using DEMQOL Proxy (Chenoweth
2014), FUMAT scale (Diaz-Veiga 2014), QUALID scale (Diaz-Veiga
2014) or Life Satisfaction Index (LSI) (Wylie 2001). For all of these
measures, higher scores indicate better quality of life, except the
Qualid where lower scores indicate better quality of life. Quality
of life was measured at baseline (Chenoweth 2014; Diaz-Veiga
2014; Wylie 2001), six months (Diaz-Veiga 2014; Wylie 2001), four
months  (Chenoweth 2014),  eight months (Chenoweth 2014), 12
months (Wylie 2001), and 18 months (Wylie 2001).

A mean diCerence in  quality of life with refurbishment, with and
without person-centred care (PCC), compared with a traditional
environment was estimated post-intervention (with PCC: MD 3.00,
95% CI -1.20 to 7.20; without PCC: MD 2.00, 95% CI -2.19 to 6.19) and
at eight months (with PCC: MD 2.00, 95% CI -2.91 to 6.91; without
PCC: MD 3.00, 95% CI -1.91 to 7.91) (Chenoweth 2014). It is uncertain
whether a person-centred environment, with or without person-
centred care improves quality of life because the certainty of this
evidence is very low.

Findings from the two controlled before-aJer studies were
uncertain (Analysis 2.1). Diaz-Veiga 2014 reported that “in the post-
study phase, the experimental group showed much  better  levels
in quality of life (QUALID) in comparison to the control group”, but
the authors did not adjust the results for the baseline diCerences
between the groups.

For individuals  with mild levels of cognitive impairment, the
authors stated no “significant diCerences” between the groups
were recorded at the post-evaluation stage. Wylie 2001 also did not
adjust for baseline diCerences between the groups.

Behaviour, mood and depression

It is uncertain whether refurbishment comprising of a person-
centred environment improved agitation because the certainty
of the evidence is very low (1 study; 143 participants; MD 4.00,
95% CI -9.21 to 17.21; very low-certainty evidence). The certainty
of evidence was downgraded from high-certainty to very low-
certainty due to very serious concerns because of risk of bias and
serious concerns due to imprecision. Refurbishment comprising
the FBFC intervention may make little or no diCerence to agitation
or depression (agitation: MD -0.72, 95% CI -2.63 to 1.20, 1 study,
  low-certainty evidence; depression: MD -0.73, 95% CI -1.93 to
0.47,1 study ; low-certainty evidence).  The certainty of evidence
was downgraded from high-certainty to low-certainty because of
serious concerns due to risk of bias and serious concerns due
to imprecision. One further non-randomised study examined the
impact of refurbishment on behaviour, mood and depression, but
due to heterogeneity in the interventions and follow-up times, a
meta-analysis was not performed.

Three studies (1138 participants) examined behaviour (Burack
2012  ;  Chenoweth 2014; Galik 2021).  Chenoweth 2014  and  Galik
2021 are randomised trials while Burack 2012 is a controlled before-
aJer study. All three studies used the Cohen-Mansfield Agitation
Inventory (CMAI) for outcome measurement, where lower scores
indicate fewer behavioural symptoms. Behaviour was measured

at baseline (Burack 2012; Chenoweth 2014; Galik 2021), four
months  (Chenoweth 2014; Galik 2021),  eight months (Chenoweth
2014),  12 months (Galik 2021) and 24 months (Burack 2012). One
study (Galik 2021) also examined resistiveness to care using the
Resistiveness to Care Scale where lower scores indicate lower
resistive behaviours, and depression using the Cornell Scale for
Depression in Dementia (CSDD) where lower scores indicate fewer
depressive symptoms.

The FBFC intervention may make little or no diCerence to
depression compared to an education control (low-certainty
evidence) aJer four months (MD -0.73, 95% CI -1.93 to 0.47; Analysis
2.2.1; 1 study) or 12 months follow-up (MD -0.04, 95% CI -1.35
to 1.26;  Analysis 4.1; 1 study). This intervention may also make
little or no diCerence to agitation (low-certainty evidence) at four
months (MD -0.72, 95% CI -2.63 to 1.20; Analysis 2.2.2; 1 study) or
12 months follow-up (MD -0.36, 95% CI -2.41 to 1.69; Analysis 2.2.2;
1 study). The FBFC intervention may make little or no diCerence
to resistiveness to care (4 months, MD -1.56, 95% CI -2.71 to
-0.40; Analysis 2.2.2; 1 study; 12 months, MD 0.32, 95% CI -0.29 to
0.94; Analysis 2.2.2; 1 study).

Burack 2012 examined refurbishment in combination with ‘culture
change’ and reported a slight reduction in forceful behaviours
(MD -0.06, 95% CI -0.10, -0.02;  Analysis 2.2.2;  1 study with 101
participants) and physical agitation (MD -0.070, 95% CI -0.136 to
-0.004; Analysis 2.2.2; 1 study), but little or no diCerence in verbal
agitation (MD 0.110, 95% CI -0.004 to 0.224; Analysis 2.2.2; 1 study).
However, the impact of the intervention on behaviour is uncertain
because the certainty of this evidence is considered very low.

The eCect of a person-centred environment on agitation, with or
without PCC, was uncertain (without PCC: MD 2.00, 95% CI -11.29
to 15.29; Analysis 2.2.2; 1 study; with PCC: MD 7.00, 95% CI -5.66 to
19.66; Analysis 2.2.2; 1 study post-intervention; 8 months follow-up
without PCC: MD 4.00, 95% CI -9.21 to 17.21; Analysis 2.2.2; 1 study;
with PCC: MD 13.00, 95% CI -0.22 to 26.22; Analysis 2.2.2; 1 study;
very low-certainty evidence).

Function

Refurbishment may make little or no diCerence to function (low-
certainty evidence). The certainty of evidence was downgraded
from high to low due to serious concerns about risk of bias and
imprecision. One randomised controlled trial examined the FBFC
intervention with the Barthel index, where higher scores indicate
better function (Analysis 2.3; 4 months: MD 1.24, 95% CI -3.34
to 5.81; 12 months: MD 1.49, 95% CI -3.53 to 6.50; 1 study, 336
participants).

Global cognitive function

No included studies reported on outcomes for global cognitive
function.

Quality of care

It is uncertain whether refurbishment comprising of a person-
centred environment improves quality of care because the
certainty of this evidence is very low (1 study; 143 participants;
MD 0.00, 95% CI -8.34 to 8.34; very low-certainty evidence). The
certainty of evidence was downgraded from high-certainty to very
low-certainty because of very serious concerns due to risk of bias
and serious concerns due to imprecision.

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One randomised controlled trial examined quality of care (601
participants) from refurbishment compared to the traditional
environment (Chenoweth 2014) using the Quality of Interactions
Schedule (QUIS), where higher scores indicate better quality of
care. The outcome was measured at baseline, four months (post-
intervention) and eight months. The findings suggested an increase
in quality of care at post-intervention for the intervention group
both with or without PCC (without PCC: MD 8.00, 95% CI 1.03 to
14.97;  Analysis 2.4; 1 study; with PCC: MD 13.00, 95% CI 6.02 to
19.98;  Analysis 2.4; 1 study; post-intervention). At eight months
(four months aJer the intervention), the eCect on quality of care
was uncertain (without PCC: MD 0.00, 95% CI -8.34 to 8.34; Analysis
2.4; 1 study; with PCC: MD -2.00, 95% CI -9.67 to 5.67; Analysis 2.4;
1 study).

Serious adverse e”ects

No included studies reported on outcomes for serious adverse
eCects.

Outcomes for carers

No included studies reported on outcomes for carers.

Outcomes for sta”

No included studies reported on outcomes for staC.

Special care units versus traditional environment

One controlled before-aJer study (66 participants) examined
a special care unit for people with dementia compared with
a traditional environment (Frisoni 1998). The results were not
considered suitable to contribute to the quantitative analysis as
they were unadjusted for diCerences in baseline characteristics of
the participants.

Health-related quality of life

No included studies reported quality of life.

Behaviour, mood and depression

It is uncertain whether special care units for people with
dementia improved behaviour because the certainty of the
evidence is very low. Frisoni 1998 examined global behaviour and
subdomains including delusions, hallucinations, agitation, anxiety,
euphoria/elation, disinhibition, irritability/lability, abnormal motor
behaviour and sleep using the Neuropsychiatric Inventory (NPI),
agitation using the CMAI and depression using the Cornell
Depression Scale. For all measures, lower scores indicate fewer
behavioural symptoms and these were measured at baseline and
three months.

In this study, the unadjusted results suggested special care units
were associated with a reduction in global behaviour (Analysis
3.1.1), depressive symptoms (Analysis 3.1.2) and in delusions,
hallucinations, agitation and sleep (Analysis 3.1.3). The traditional
environment was also associated with  a reduction in global
behaviour (Analysis 3.1.1), reduction in anxiety and euphoria/
elation (Analysis 3.1.3), but conversely was associated with an
increase in depressive symptoms (Analysis 3.1.2); however, the
certainty of evidence is very low. The eCect of special care units
on agitation measured by CMAI demonstrated at three months was
uncertain (Analysis 3.1.3).

Function

It is uncertain whether special care units for people with dementia
improved function because the certainty of the evidence is very
low.  Frisoni 1998  examined function using two measures: the
Bedford Alzheimer’s nursing severity scale and the Barthel Index;
for both measures, higher scores indicate better function. Function
was measured at baseline and three months. The eCect of special
care units on function using either of the measures was uncertain
(Analysis 3.2).

Global cognitive function

Cognitive function was assessed in  Frisoni 1998  using the MMSE
(higher scores indicate better cognitive function) and Extended
Clinical Dementia Rating (higher scores indicate more severe
cognitive impairment). Global cognitive function was measured
at baseline and three months. The eCect of special care units
on cognitive function was uncertain using either of the measures
investigated (Analysis 3.3).

Quality of care

No included studies reported on outcomes for quality of care.

Serious adverse e”ects

Frisoni 1998 investigated serious adverse eCects by the frequency
of falls and use of physical restraints at baseline and three months,
but it was unclear if the numbers were referring to the overall
number of falls and use of physical restraints or the number of
people who fell or were exposed to physical restraints; therefore,
these data were not included in this review. It was uncertain if there
was a diCerence in falls at three months between the intervention
and control groups, but for physical restraints the authors reported
that “while their use in cases did not increase aJer 3 months, a
significant increase was apparent in controls”.

Outcomes for carers

No included studies reported on outcomes for carers.

Outcomes for sta”

No included studies reported on outcomes for staC.

Corridor versus non-corridor design

One controlled before-aJer study (105 participants) examined a
corridor design compared with a non-corridor design in group living
units (Elmstahl 1997).

Health-related quality of life

No included studies reported on outcomes for quality of life.

Behaviour, mood and depression

It is uncertain whether a corridor design or non-corridor design
improves behaviour, mood and depression because the certainty
of evidence was very low (OR 8.82, 95% CI 1.14 to 68.22 for
depression, 1 study; 105 participants; very low-certainty evidence).
The certainty of evidence was downgraded from low-certainty to
very low-certainty because of very serious concerns due to risk of
bias and serious concerns due to imprecision.

Elmstahl 1997  examined 11 sub-domains of behaviour using the
Organic Brain Syndrome (OBS) scale including aggressiveness,
depression, dyspraxia, hallucinations, lack of vitality, dysphasia,

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paranoia, restlessness, disorientation (recent memory, time and
identity), and lower scores indicate better behaviour. Behaviour
was measured at baseline and 12 months. Results were analysed as
the proportion of participants who experienced the behaviours and
odds ratios < 1 favoured the corridor design.

Elmstahl 1997  reported a decrease in depression for those in the
non-corridor design compared to the corridor design (OR 8.82,
95% CI 1.14 to 68.22;  Analysis 4.1.1; 1 study). The eCect of a non-
corridor design compared to a corridor design on other behavioural
measures was uncertain (aggressiveness: OR 2.02, 95% CI 0.56 to
7.27; dyspraxia: OR 4.57, 95% CI 0.76 to 27.35; hallucinations: OR
1.06, 95% CI 0.05 to 22.09; lack of vitality: OR 0.23, 95% CI 0.04 to
1.47; dysphasia: OR 0.87, 95% CI 0.08 to 9.73; paranoia: OR 0.12,
95% CI 0.01 to 1.24; restlessness: OR 0.21, 95% CI 0.04 to 1.00; recent
memory: OR 0.87, 95% CI 0.31 to 2.42; time: OR 0.66, 95% CI 0.22 to
2.01; identity: OR 1.23, 95% CI 0.56 to 2.68 (Analysis 4.1.2, 1 study).

No included studies reported on outcomes for global behaviour.

Function

No included studies reported on outcomes for function.

Global cognitive function

No included studies reported on outcomes for global cognitive
function.

Quality of care

No included studies reported on outcomes for quality of care.

Serious adverse e”ects

No included studies reported on outcomes for serious adverse
eCects.

Outcomes for carers

No included studies reported on outcomes for carers.

Outcomes for sta”

No included studies reported on outcomes for staC.

Alternative physical environmental design without whole-
facility changes

Lighting intervention versus control lighting

Three cluster-randomised trials (291 participants) studied the eCect
of lighting interventions on long-term residential care compared
to control lighting (Figueiro 2019; Hopkins 2017; Riemersma-
vanDerLek 2008). The studies did not take clustering in to account
in their estimates and provided insuCicient data to correct
analyses for cluster-randomised trials as described in the Cochrane
Handbook (Higgins 2011).

Health-related quality of life

No studies examined quality of life.

Behaviour, mood and depression

It is uncertain whether bright lighting improves global behaviour
because the certainty of this evidence is low (MD 0.50, 95% CI
-1.80 to 2.80; 1 study, 74 participants; low-certainty evidence).
The certainty of evidence was downgraded from high-certainty to
low-certainty because of serious concerns due to risk of bias and

serious concerns due to imprecision. It is uncertain whether bright
lighting improves depression because the certainty of evidence
is very low (SMD -0.22, 95% CI -0.45 to 0.01; 3 studies; very

low-certainty evidence; I2 = 64%). The certainty of evidence was
downgraded from high-certainty to very low-certainty because of
very serious concerns due to risk of bias and serious concerns due
to imprecision.

Riemersma-vanDerLek 2008  examined global behaviour in  94
participants in a randomised trial using the questionnaire format
of the NPI (NPI-Q) and withdrawn behaviour using the Multi
Observational Scale for Elderly Subjects (MOSES) and mood using
the Philadelphia Geriatric Centre ACect Rating Scale (PGCARS).
For all measures, lower scores indicate better behaviour except
for the PGCARS (for positive mood higher scores indicate better
positive mood). Behaviour, mood and depression were measured
at baseline, six weeks, six months, one year, 1.5 years and two years.

Riemersma-vanDerLek 2008  reported little to no eCect on global
behaviour (MD 0.50 (95% CI -1.80 to 2.80) at six months;  Analysis
5.1.1; 1 study; low-certainty evidence).

The eCect of bright lighting on depression was examined
by Riemersma-vanDerLek 2008 and Figueiro 2019 using the Cornell
Scale for Depression in Dementia (CSDD) and Hopkins 2017 using
the depression subset of the hospital anxiety and depression
(HADD) scale. There was little or no diCerence in depression at four
to six weeks (SMD -0.22, 95% CI -0.45 to 0.01; Analysis 5.2; 3 studies,

very low-certainty evidence, I2 = 64%).  Depression was further
examined at longer time points by Riemersma-vanDerLek 2008, but
little to no eCect on depression was reported at six months, 12
months, 18 months or 24 months (Analysis 5.1.2).

Hopkins 2017  assessed anxiety as a behaviour outcome using
the anxiety subset of the Hospital Anxiety and Depression (HADA)
scale and lower scores indicate lower anxiety levels. Anxiety was
assessed at four weeks. and  Hopkins 2017  reported little or no
diCerence in anxiety at four weeks (MD -0.10, 95% CI -1.67 to
1.47; Analysis 5.1.3; 1 study). Riemersma-vanDerLek 2008 reported
little or no eCect on distress, withdrawn behaviour, positive
mood and  negative mood (Analysis 5.1.3). This study did report
a reduction for those in the bright lighting intervention group in
withdrawn behaviour at 18 months only (MD -4.30, 95% CI -7.45
to -1.15; Analysis 5.1.3; 1 study) and a reduction in negative mood
only at 24 months (MD -2.70, 95% CI -4.80 to -0.60; Analysis 5.1.3;
1 study). Two studies (Figueiro 2019; Riemersma-vanDerLek 2008)
examined the impact of increased lighting on agitation using the
CMAI, and lower scores indicate better behaviour. There was little
or no diCerence in agitation at four to six weeks (SMD -0.16, 95%

CI -0.45 to 0.14;  Analysis 5.3; 2 studies, low-certainty evidence, I2

= 17%). It is uncertain whether bright lighting improves agitation
because the certainty of this evidence is low.

Function

It is uncertain whether bright lighting improves function because
the certainty of this evidence is low (SMD -0.29, 95% CI -0.69 to 0.00;
2 studies, 179 participants; low-certainty evidence). The certainty
of evidence was downgraded from high-certainty to low-certainty
because of serious concerns due to risk of bias and serious concerns
due to imprecision.

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Two cluster-randomised trials (94 participants) assessed the eCect
of bright lighting on function (Figueiro 2019; Riemersma-vanDerLek
2008).  Function was assessed by the nurse-informant adaptation
(NI-ADL) of the scale by Katz and colleagues (Riemersma-vanDerLek
2008) and the Minimum Data Set Activities of Daily Living
Scale (MDS-ADL) (Figueiro 2019), and higher scores indicate
more functional limitations. Riemersma-vanDerLek 2008 measured
function at baseline, six weeks, six months, one year, 1.5 years
and two years and Figueiro 2019 measured function at four weeks.
There was little or no diCerence in function at four to six weeks
(SMD -0.29, 95% CI -0.69 to 0.00;  Analysis 5.4;  2 studies, low-

certainty evidence, I2 = 0%). Riemersma-vanDerLek 2008 reported
an increase in function (decrease in NI-ADL scores) at 18 months
and 24 months (Analysis 5.5; 1 study), but there was little to no
eCect at six months or 12 months.

Global cognitive function

It is uncertain whether bright lighting improves global cognitive
function because the certainty of this evidence is low (MD 1.20, 95%
CI -1.56, 3.96; 1 study; 74 participants; low-certainty evidence). The
certainty of evidence was downgraded from high-certainty to low-
certainty because of serious concerns due to risk of bias and serious
concerns due to imprecision.

One cluster-randomised trial (87 participants at six weeks) assessed
the eCect of bright lighting in communal living spaces during the
day on global cognitive function  (Riemersma-vanDerLek 2008).
Cognitive function was assessed using the MMSE and higher scores
indicate better global cognitive function. Global cognitive function
was measured at baseline, six weeks, six months, one year, 1.5 years
and two years. There was little to no eCect on global cognitive
function at the five follow-up times between six weeks and 24
months (Analysis 5.6).

Quality of care

No included studies reported on outcomes for quality of care.

Serious adverse e”ects

No included studies reported on outcomes for serious adverse
eCects.

Outcomes for carers

No included studies reported on outcomes for carers.

Outcomes for sta”

No included studies reported on outcomes for staC.

Dining space redesign versus usual environment

Three studies examined the eCect of dining interventions (403
participants) in long-term residential care compared to the usual
dining environment (Kenkmann 2010, Mathey 2001 and Nijs 2006).
Two studies were cluster-randomised trials (Mathey 2001; Nijs
2006) and one study was a controlled before-aJer study (Kenkmann
2010).

Health-related quality of life

It  is uncertain whether dining space redesign improves health-
related quality of life because the certainty of this evidence is very
low (2 studies; 283 participants; very low-certainty evidence).
This certainty of the evidence was downgraded from high to

very low because of very serious concerns due to risk of bias
and serious concerns due to imprecision. Meta-analysis was not
possible because one of the studies reported results as percentage
changes over time without adjustment for clustering.

Two studies (283 participants) measured the eCect of dining space
redesign on quality of life (Mathey 2001; Nijs 2006). Quality of life
was measured by the Dutch Quality of Life of Somatic Nursing Home
Residents questionnaire (Nijs 2006 ) or the Sickness Impact Profile
(SIP) and the Dutch version of the Philadelphia Geriatric Center
Moral Scale (PGCMS) (Mathey 2001). Higher scores in the tools
used indicate better quality of life. Quality of life was measured at
baseline (Mathey 2001; Nijs 2006), six months (Nijs 2006) and 12
months (Mathey 2001).

Nijs 2006 reported a higher quality of life for those with the family-
style dining intervention; there was less decline in quality of life
in the intervention group (MD 6.10, 95% CI 2.10 to 10.10; Analysis
6.1; 1 study) and results were adjusted for clustering and baseline
characteristics of the residents.  Mathey 2001  reported results
as percentage changes over time and a summary is provided
in  Analysis 6.1.  Mathey 2001  did not adjust for clustering and did
not provide suCicient data to perform correct analyses for cluster-
randomised trials as described in the Cochrane Handbook (Higgins
2011). The authors reported SIP scores had “significantly declined”
in the control group, “stayed stable” in the intervention group, and
PGCMS scores remained “relatively stable” in both the intervention
and control groups.

Behaviour, mood and depression

One study (120 participants) examined the eCect of dining space
redesign on anxiety using the HAD scale (Kenkmann 2010). Anxiety
was measured at baseline and 12 months. The results were not
considered suitable to contribute to the quantitative analysis as
they were unadjusted for diCerences in baseline characteristics
of the participants; a summary is presented  in  Analysis 6.2. The
authors did not comment on the statistical significance of the
results.

No included studies reported on any further outcomes for
behaviour and depression.

Function

It is uncertain whether dining space redesign improves function
because the certainty of evidence is very low (MD 3.20, 95% CI 0.90
to 5.50; 1 study; 178 participants; very low-certainty evidence). This
certainty of the evidence was downgraded from high to very low
due to very serious concerns due to risk of bias and serious concerns
due to imprecision.

One study (178 participants) examined change in function using the
Nursing Home Physical Performance test and higher scores indicate
better function (Nijs 2006). Function was measured at baseline and
six months.  Nijs 2006  reported better function for those with the
family-style dining intervention, as there was less decline over time
(MD 3.20, 95% CI 0.90 to 5.50; Analysis 6.3; 1 study).

Global cognitive function

One study examined the eCect of dining space redesign on global
cognitive function using the MMSE (Kenkmann 2010). Global
cognitive function was measured at baseline and 12 months.
The results were not considered suitable to contribute to the

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quantitative analysis as they were unadjusted and are presented
in  Analysis 6.4. The authors commented that “there was no
evidence that the food and drink intervention had an impact on
residents cognitive functioning”.

Quality of care

No included studies reported on outcomes for quality of care.

Serious adverse e”ects

It is uncertain whether dining space redesign impacts the rate or
risk of falls because the certainty of this evidence is very low (rate
ratio 0.76, 95% CI 0.57 to 1.01; 1 study; 120 participants; very low-
certainty evidence). The certainty of evidence was downgraded
from low to very low because of very serious concerns due to risk of
bias and serious concerns due to imprecision.

One study examined serious adverse eCects through an adjusted
rate of falls and proportion of people falling at baseline and 12
months (Kenkmann 2010).  Kenkmann 2010  reported little to no
eCect on the rate of falls (rate ratio 0.76, 95% CI 0.57 to 1.01; Analysis
6.5, 1 study). The risk of falling (i.e. the proportion of people falling)
in 12 months is also presented in Analysis 6.5 but the results were
unadjusted, and the authors commented that diCerences between
the groups “were not statistically significant”.

Outcomes for carers

No included studies reported on outcomes for carers.

Outcomes for sta”

No included studies reported on outcomes for staC.

Garden vignette versus traditional environment

One repeated measures study (33 participants) examined the
eCect of a garden vignette in long-term residential care using five
phases: two intervention phases and three washout phases (Marcy-
Edwards 2011).

Health-related quality of life

No included studies reported on outcomes for quality of life.

Behaviour, mood and depression

It is uncertain whether a garden vignette improves global behaviour
because the certainty of this evidence is very low (MD 12.8, 95% CI
-10.7 to 36.3; 1 study; 33 participants; very low-certainty evidence).
The certainty of evidence was downgraded because of very serious
concerns due to risk of bias and very serious concerns due to
imprecision.

The authors had not conducted a statistical comparison of time
trends before and aJer the intervention; we re-analysed the results
as recommended in EPOC 2017c. Global behaviour was measured
with the NPI-NH and lower scores indicate fewer behavioural
symptoms. The eCect of a garden vignette on global behaviour was
uncertain (MD 12.8, 95% CI -10.7 to 36.3; Analysis 7.1; 1 study).

Function

No included studies reported on outcomes for function.

Global cognitive function

No included studies reported on outcomes for global cognitive
function.

Quality of care

No included studies reported on outcomes for quality of care.

Serious adverse e”ects

No included studies reported on outcomes for serious adverse
eCects.

Outcomes for carers

No included studies reported on outcomes for carers.

Outcomes for sta”

No included studies reported on outcomes for staC.

D I S C U S S I O N

Summary of main results

The main objective of this review was to determine the eCects of
changes to the physical environment of residential aged care or
alternative models of residential aged care on the quality of life of
older residents. The included studies compared home-like small-
scale models of care to more traditional large-scale models of care.
We also included studies which examined interventions which were
not changes to the whole building, but refurbishment or changes to
one or more design components. These changes included changes
to lighting, design of the dining room or addition of a garden
vignette. There were too few studies included to examine whether
dementia alters the eCects of changes to the physical environment
or alternative models of residential aged care on quality of life.

The literature search identified six studies for the main comparison
(Afendulis 2016; Annerstedt 1993; Dettbarn-Reggentin 2005; Te
Boekhorst 2009; Wolf-Ostermann 2012; Yoon 2015), but the
certainty of evidence was very low with all the studies being
non-randomised and usually of small sample size. A large study
by Afendulis 2016 included the majority of the participants in the
review.  Afendulis 2016  examined a home-like model of care (the
Green House model) compared to traditional care, but the study
was non-randomised and rated at high risk of bias. The study also
only  reported on quality of care measures rather than any of the
prespecified primary outcomes of interest in this review.

Clinical heterogeneity involving diCerences in interventions,
comparisons and outcome measures precluded pooling of study
results on most occasions. In addition, there was variation in
the methods of statistical analyses including whether the study
reported results unadjusted or adjusted for diCerences in baseline
characteristics of the participants. For the main comparison, we
were not able to pool any studies. There were also insuCicient data
to  explore  whether changes to the physical environment have a
diCerent impact depending on whether the population is living with
dementia.

For the primary outcomes, one study examined the eCect of home-
like models on quality of life and stated “no statistically significant
diCerences were observed between the intervention and control
groups” (Wolf-Ostermann 2012). Three studies examined global
behaviour for a home-like compared to traditional model of care

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(Dettbarn-Reggentin 2005; Te Boekhorst 2009; Wolf-Ostermann
2012). One study found little or no diCerence in global behaviour
change at six months and two additional studies examined global
behaviour, but these were unsuitable for determining a summary
eCect estimate. Two studies examined depression for the main
comparison (Te Boekhorst 2009; Yoon 2015). AJer 18 months, one
study reported an increase in the rate of depressive symptoms,
but the eCect of home-like models of care on the probability of
no depressive symptoms was uncertain (Yoon 2015). One study
reported little or no diCerence in depressive symptoms at six
months (Te Boekhorst 2009). Four studies examined function as
an outcome for the main comparison (Dettbarn-Reggentin 2005; Te
Boekhorst 2009; Wolf-Ostermann 2012; Yoon 2015). DiCerences in
the study design and reporting made interpretation diCicult. One
study reported evidence of a positive eCect of a home-like model
compared to a more traditional model on function and one
study reported little or no diCerence in function. Two additional
studies measured function but could not be included in the
quantitative analysis. One study examined quality of care and
reported a reduction in the number of bedfast residents, catheter
use, low-risk pressure ulcers and avoidable hospital readmission,
but reported little or no diCerence in high-risk pressure ulcers
(Afendulis 2016). One study reported a slight reduction in the use
of physical restraints, but no other serious adverse eCects were
examined (Afendulis 2016). The certainty of evidence was rated
as very low on GRADE for all outcomes for the main comparison;
therefore, it is uncertain whether a home-like model of care
aCects outcomes including  quality of life, behaviour, mood and
depression, function or serious adverse eCects.

In addition to the main comparison, included studies also
compared interventions which focused on one or more design
components within residential aged care. Five studies examined
the eCect of refurbishment of residential aged care facilities in
conjunction with measures to improve person-centred care (Burack
2012; Chenoweth 2014; Diaz-Veiga 2014; Galik 2021; Wylie 2001).
Three studies (one randomised trial) assessed quality of life but
it is uncertain whether refurbishment compared to traditional
environments improved quality of life because the certainty of
evidence was very low.

Three studies examined the impact of refurbishment on behaviour
(Burack 2012; Chenoweth 2014; Galik 2021). Two randomised trials
examined the impact of refurbishment on behaviour; one found
little or no diCerence in behaviour with the intervention (Galik
2021), and the eCects in the other trial were uncertain (Chenoweth
2014).  One further non-randomised study examined the eCect of
refurbishment in combination with ‘culture change’ (Burack 2012).
Three sub-domains of behaviour were examined in relation to this
intervention and a reduction in forceful behaviours and physical
agitation was found, but there was little or no diCerence in verbal
agitation. However, it is uncertain if refurbishment with culture
change improves behaviour as the certainty of evidence was very
low.

One randomised trial examined the impact of refurbishment on
function. Refurbishment comprising the FBFC intervention may
make little or no diCerence to function (low-certainty evidence). No
studies examined the eCect of refurbishment on serious adverse
eCects.

One non-randomised study examined the eCect of a special care
unit for people with dementia (Frisoni 1998). This study did

not adjust results for potential baseline diCerences between the
groups; therefore, the results should be interpreted with caution
and the eCects on behaviour, function, physical restraints and falls
are considered uncertain. No studies examined the eCect of special
care units on quality of life or quality of care.

One non-randomised study (Elmstahl 1997) examined the eCect
of a corridor vs non-corridor design and reported a decrease
in depression associated with the non-corridor design, but the
certainty of evidence was very low. The eCect of a corridor design
on 10 other measures of behaviour was uncertain. Therefore,
whether a corridor vs non-corridor design within group living units
is preferable for behaviour is uncertain. No studies examined the
eCect of a corridor versus non-corridor design on quality of life,
quality of care, function or serious adverse eCects.

Three cluster-randomised trials examined the eCect of lighting
interventions (Figueiro 2019; Hopkins 2017; Riemersma-vanDerLek
2008). All of the studies reported results at short-term follow-
up (four to six weeks) and one study also reported results
at longer follow-up (Riemersma-vanDerLek 2008, up to 24
months).  However, there was  large loss to follow-up in the study
by Riemersma-vanDerLek 2008 and little or no eCect was reported
for global behaviour. Pooled data from the three studies showed
little or no diCerence in depression at short-term follow-up. Two
cluster-randomised trials assessed the eCect of bright lighting on
function (Figueiro 2019; Riemersma-vanDerLek 2008). There was
little or no diCerence in function at four to six weeks. The certainty
of evidence was low, therefore, the eCects of lighting for behaviour
or function are uncertain. No studies examined the eCect of lighting
interventions on quality of life, quality of care or serious adverse
eCects.

Two cluster-randomised trials and one non-randomised trial
examined the eCect of dining space redesign  (Kenkmann 2010;
Mathey 2001; Nijs 2006). One randomised trial (Nijs 2006) found
better quality of life and function for participants receiving a family-
style dining intervention over six months. The other two studies
did not conduct appropriate adjustments for potential confounding
or clustering. One study reported better function with a family-
style dining intervention, as there was less decline over time (Nijs
2006). Another reported little to no eCect on the rate of falls
(Kenkmann 2010). However, it is uncertain whether dining space
design eCects quality of life, function or rate of falls because
the certainty of evidence was very low. One study examined the
eCect of dining space redesign on anxiety, but the results were
not suitable to contribute to the quantitative analysis as they
were unadjusted for diCerences in baseline characteristics of the
participants (Kenkmann 2010). No studies examined the eCect of
dining space redesign on quality of care.

One repeated measures study examined the eCect of a
garden vignette intervention using 14-day phases incorporating
intervention and washout phases (Marcy-Edwards 2011). The eCect
of a garden vignette on global behaviour was uncertain, and the
eCects of a garden vignette on other outcomes were not examined.

Overall completeness and applicability of evidence

We used a comprehensive search strategy, and therefore we are
likely to have identified all studies that meet the inclusion criteria
for this review, but we cannot be certain. Whilst a number of grey
literature sites were searched, it is possible that some studies that

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have not been published in mainstream literature databases were
not identified. The studies included were from many countries
including the USA, the Netherlands, the UK, Sweden, Germany,
Spain, Italy, Canada and Australia and some included studies
were published in non-English languages (one German and one
Spanish). Included studies were published over a prolonged period
(24 years) and, over this time, residential aged care  policies
and practices have changed. Therefore, the  applicability of some
older studies to current practice, in particular, where there is
a comparison to ‘standard care’ may be reduced; the earliest
included study was published in 1993 (Annerstedt 1993).

We could not make robust conclusions from the evidence due to
the limited number of eligible studies identified and variability
in design, interventions, outcomes, instruments used to assess
outcomes, and statistical analysis approaches. The wide variability
in outcomes assessed and measures used generally prevented
pooling of the data. The majority of the evidence for large-
scale design interventions was from non-randomised studies.
For the  lighting and dining interventions, four of five studies
were randomised, most likely due to the increased feasibility of
conducting this type of study. Studies also varied by which type
of statistical analyses were performed, whether endpoint data or
change over time data were analysed, whether the studies adjusted
for potential confounding factors and which potential confounding
factors were adjusted for in analyses. Five cluster-randomised
studies were included in the review. Two of these studies took the
eCect of clustering in to account in their analyses (Chenoweth 2014;
Nijs 2006). The other studies did not adjust for clustering and did not
provide suCicient data to perform adjusted analyses for clustering
as described in the Cochrane Handbook (Higgins 2011).

In accordance with Cochrane EPOC review guidance, only
controlled before-aJer and cluster-randomised studies which had
more than one control and intervention site were included.
Therefore, many studies which only reported results for one
intervention and/or one control site were excluded from the review
(including Kane 2007; Reimer 2004).

In addition, observational study designs were required to
include  pre- and post-intervention measures (i.e. controlled
before-aJer studies or repeated measures). This excluded a
number of studies which did not include pre-intervention baseline
measures  (i.e. a measure of participant outcomes on admission
to care), including  De Boer 2017; De Rooij 2012; Verbeek 2014.
For example,  Verbeek 2014  investigated small-scale home-like
environments in comparison to traditional environments for  259
residents with dementia. The study  suggested positive eCects on
outcomes including fewer physical restraints and psychotropic
medicines, but little or no diCerence in behaviour and quality
of life. However, by not including pre-intervention measures,
determining the eCect of the intervention is limited. Similarly, De
Boer 2017 has reported increased social interaction in residents of
green care farms in comparison to traditional facilities, but no pre-
intervention measures were reported.

A total of 77,265 participants were included in 20 studies, but
most (n = 74,449) of these participants were from a single
study. Therefore, most of the studies included small numbers
of participants (range 34 to 601). Most of the included studies
for large-scale design interventions were non-randomised which
means that even well-designed studies are only likely to provide
low level evidence. However, for whole models of care, conducting

randomised trials is rarely feasible. While a clustered design of
refurbishment is possible, this is unlikely to be able to capture
large-scale changes to the physical size and design of the buildings.
In contrast, randomised trials for smaller scale interventions such
as lighting or dining changes are more feasible, and several
randomised trials were identified.

Identified evidence was only suCicient to allow for the pooling
of data from two randomised studies for one outcome for
one comparison (depression with lighting interventions) and
heterogeneity for this outcome was substantial. Most of the
evidence was from individual studies which were usually modest
in size and likely to be underpowered. For all outcomes and
comparisons, the certainty of evidence was very low.

Studies generally did not report fidelity assessments. One
randomised study examined the eCects of an intervention which
involved assessing the environment with the Environmental
Audit Tool and identifying areas for improvement. This study
reported diCiculties in implementing the proposed design changes
(Chenoweth 2014). Similarly,  Wylie 2001  reported that one of
the facilities  which received the Eden Alternative  intervention
discontinued its implementation, but did not state the reasons for
this.

Some included studies did not measure quality of life as an
outcome which is a limitation of the review. We included
studies which examined other primary outcomes and secondary
outcomes,  because these included outcomes are likely to impact
quality of life for residents. Care home residents are oJen
unable to complete health-related quality of life questionnaires for
themselves and the validity of quality of life measures for care home
residents has been questioned (Usman 2019). Therefore, we think
it is important to consider multiple outcomes which impact quality
of life for residents, not only self- and proxy-reported quality of life
measures.

The searches for this review were completed during the coronavirus
2019 (COVID-19) pandemic, but all the included studies were
conducted prior to the start of the COVID-19 pandemic. This review
focuses on quality of life, thus infection-related outcomes were not
included in the protocol. Since this time, questions have arisen
regarding the role of the design of residential aged care facilities in
infection control (Werner 2020). Older people living in residential
aged care have been disproportionately impacted by the COVID-19
pandemic in many countries including the UK and the US. Based on
data from 22 countries to January 2021, 41% of all COVID-19-related
deaths were of people living in aged care (Comas-Herrera 2021). It
has been suggested that alternative architectural designs of aged
care facilities may benefit both resident quality of life and infection
control (Anderson 2020). However, others have questioned whether
home-like designs contain the necessary infrastructure for tight
infection control (Ibrahim 2020). Other characteristics which may
have impacted rates of COVID-19 infections in residential aged
care settings include ownership, staCing, provider size and resident
characteristics (Bach-Mortensen 2021). Further research on the
impact of design of residential aged care and the impact on
infection rates and outbreak control is needed. This should be in
conjunction with addressing issues regarding funding, staCing and
support for residential aged care facilities which will impact quality
of life for residents (Oliver 2020).

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Quality of the evidence

For the main comparison of home-like models  compared
to traditional models of care, attrition was oJen high. OJen studies
did not adequately report the numbers lost to follow-up, the
reasons for loss to follow-up or diCerences between those lost to
follow-up and those not lost to follow-up. If reasons for loss to
follow-up are imbalanced across the groups, this is likely to impact
on the estimate of eCect and introduce bias to the study findings.

For all controlled before-aJer studies, random sequence
generation and allocation concealment is rated at high risk of
bias as these criteria cannot be met for this  study design.
There was also a lack of adjustment for diCerences in baseline
characteristics of participants in many studies. By not adequately
adjusting for diCerences in baseline characteristics, the potential
for confounding factors influencing the results is high. In addition,
it is possible that not all likely confounding factors (e.g. public
versus private ownership, resident access to healthcare) were taken
into account in the included studies, and the design of many of
the included studies means that they are particularly prone to
bias from lack of adjustment for confounding factors. Four studies
were rated at high risk of bias and four studies were rated at
unclear risk of bias for selective outcome reporting as they listed
outcomes in their methods and did not report results. However,
56% of studies reported results as indicated in the methods or
protocol and were rated at low risk of bias for selective reporting.
Only two studies were considered to be at risk of contamination
of the intervention in the control group, as for most studies the
participants of the intervention and control groups were living in
diCerent facilities or living units. However, one study reported one
of the control sites had previously implemented and discontinued
the intervention,  and one study randomised wards within one
home; therefore, contamination was likely. Of the included studies,
67% were rated at high risk of bias for other bias, mainly due to the
potential for residual confounding associated with the use of non-
randomised study designs.

Few studies examined serious adverse eCects as an outcome.
Falls risk is an important factor to include in the consideration of
any environmental design changes, however, falls outcomes were
frequently not reported.

There are feasibility and ethical considerations when considering
the design of a study to assess whole-facility changes to the model
of care and design of the built environment. For instance, oCering
improved environments to only some residents on a site may be
perceived as inappropriate to both residents and family members.
Furthermore, when examining the impact of changes to the whole
facility it is diCicult to eCectively isolate the impact of the built
environment from the impact of other changes to the model of care
such as care practice changes or staCing changes. It is also diCicult
to adequately account for changes to the health of residents
with progressive diseases over time. This review highlights the
complexities of care and quality of life in residential aged care
settings. Design elements may be important factors in decision-
making for families, but other elements including model of care
should also be considered.

Potential biases in the review process

As the list of included interventions was broad, identifying relevant
studies was challenging. We minimised publication bias by using

a comprehensive search strategy of multiple databases, including
trial registers and grey literature. Authors of completed studies
identified in trials registers for which study publications were
not been identified were contacted, as were authors of studies
identified only as conference abstracts. We did not restrict the
search strategy by language and non-English language studies
were included in the review (Dettbarn-Reggentin 2005; Diaz-
Veiga 2014).  Correspondence with authors provided additional
information on study methods and results. However, we cannot be
certain that there was no publication bias in the included studies.
Each study was assessed by two reviewers working independently
at all stages of the study selection process, and we were careful
not to exclude relevant studies. Yet,  it is still possible that there
are additional relevant studies which were not identified  that
would have met the inclusion criteria. The data extraction, risk of
bias assessment and GRADE assessment for each study was also
conducted in duplicate by two reviewers working independently.

Agreements and disagreements with other studies or
reviews

Marquardt 2014  conducted a review with a systematic search
of the design of the physical environment for people with
dementia living in residential aged care. The review included 169
studies with a broad range of study designs and the review also
included temporary therapies; six of the studies were eligible
for inclusion in the current review. The review included 30
studies of small-scale home-like environments and the review
suggested that there was a potential improvement in function and
social abilities,  no evidence for a beneficial eCect on cognition
and  conflicting results for behaviour. The review assessed the
quality of the studies by focusing on the study design and did not
assess other methodological issues or risk of bias. In a scoping
review, Ausserhofer 2016 examined the eCect of home-like models
of care in comparison to usual care in residential aged care for
older people. The review completed a broad but comprehensive
literature search and included 14 studies, three of which met the
inclusion criteria for the current review. The review authors did
not critically appraise the risk of bias of included studies. The
review authors concluded that there was evidence of “benefit
related to physical functioning of residents living in dementia-
specific small houses and satisfaction with care of residents living
in non-dementia-specific small houses compared with those living
in traditional nursing homes”. However, no benefit was found
for other outcomes for residents, family or staC. Overall, the
authors stated there was limited evidence on home-like models of
residential aged care and a stronger evidence base was needed,
which accorded with the conclusions of this review.  Ausserhofer
2016 did not rate the certainty of the evidence.

A 2009 Cochrane review of special care units for people with
dementia experiencing behavioural problems included eight
studies, of which four provided data suitable for analysis (Lai
2009).  The review included studies reporting on the outcomes of
behaviour and physical restraint use. One of these studies (Frisoni
1998) was also included in the current review. Outcome data
came from single studies and no eligible RCTs were identified.
The authors commented that almost all the positive outcomes of
special care units  in the review came from a single study (Nobili
2006). The authors concluded that there was no strong evidence
for benefit of special care units, however the design features of

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special care units are oJen focused on increased safety rather than
improving resident quality of life.

Joseph 2015  included 66 studies in a systematic review of the
physical environment of residential health, care and support
facilities. The review had much broader inclusion criteria than the
current review in terms of setting (e.g. including assisted living
and rehabilitation facilities), study design (e.g. including cross-
sectional studies) and outcomes (e.g. including physical activity
engagement and medication errors). The authors stated that the
quality of the studies varied, with some studies with stronger
designs having data from very few participants and that additional
research was needed. Nevertheless, the authors stated that the
review indicated that “the built environment is an important
component of the care provided in residential care settings”.

A systematic review of use of the physical environment to support
people with dementia included 72 studies conducted in any
setting including the home (Woodbridge 2018), although most were
from residential settings. The review focused on the outcome of
function, i.e. everyday tasks. No specific inclusion/exclusion criteria
by study design were applied, nor were any quality appraisal
tools applied to the included studies. The authors concluded that
“more work is needed to extend theoretical understandings of how
people with dementia interact with their environments so that
these spaces can be designed to further support activities of daily
living performance”.

A healthy technology assessment by the Canadian Agency for
Drugs and Technologies in Health (CADTH) included a “limited
literature search” in 2010 of the eCects of the Eden Alternative
and Green House designs (CADTH 2010). Three non-randomised
studies were included in this assessment which we identified in
our search, but the studies did not meet the inclusion criteria. The
authors also concluded that evidence was limited and noted issues
in attrition bias and adoption of design principles by residential
aged care facilities.  Brownie 2013  reviewed person-centred care
interventions which included eight studies which examined the
Eden Alternative, Green House model or facility-specific person-
centred care; one of the included studies  was included in the
current review. The review concluded that the Eden Alternative
was associated with significant improvements in boredom and
helplessness, but also noted limitations in study designs and
potential for confounding bias. Our review only identified one
study which examined the Eden Alternative that met the inclusion
criteria; in that study, the authors found little or no diCerence in
quality of life.

There have been many studies conducted examining  non-
environmental design interventions  to improve quality of life
for older adults living in residential aged care. A systematic
review of organisational level person-centred care for people
with dementia found a significant eCect for quality of life post-
intervention, but this review included hospital care and extra-
care community housing in addition to residential aged care
(Chenoweth 2019).  Non-pharmacological interventions such as
music therapy and function-analysis based interventions can be
eCective in improving behavioural symptoms for people with
dementia without associated serious adverse eCects (Dyer 2017).
A Cochrane review of music therapy for people with dementia
found that at least five sessions of a music-based therapeutic
intervention probably reduced depressive symptoms, improves
behavioural problems and may also improve quality of life and

emotional well-being (Van der Steen 2018). Another systematic
review has concluded that receptive music therapy could reduce
agitation, behavioural symptoms, and anxiety in older people with
dementia, and appears to be more eCective than interactive music
therapy (Tsoi 2018). A  Cochrane review of functional-analysis-
(FA)-based interventions for people with dementia included 18
RCTs and found  positive eCects for certain outcomes at post-
intervention, but not follow-up, including the frequency of reported
challenging behaviour  and for caregiver reaction (Moniz  Cook
2012). In people with dementia, animal-assisted therapy may have
a slight reduction in depressive symptoms (Lai 2019). While several
of these reviews did not focus specifically on residential aged
care settings, there is a high prevalence of cognitive impairment
and dementia in people living in these settings (Lang 2017), so
interventions with demonstrated benefit may be of value.

A 2016 Cochrane review of interventions to optimise prescribing
for older people in residential aged care included 12 studies.
Many of the included interventions had multiple components
and  oJen involved  a  review  of medicines with a pharmacist
and doctor (Alldred 2016).  The authors found  no evidence
of benefit of the interventions with respect to reducing
adverse drug events or death, but one of two included
studies which investigated quality of life  reported a  slower
decline in health-related quality of life with low-certainty
evidence.  Selected studies also indicated that multicomponent
interventions may provide benefits. A randomised controlled trial
of a multicomponent intervention  combining communication,
systematic pain management, medication review, and activities
in 33 nursing homes found, although quality of life worsened
significantly during the intervention, quality of life was improved
at 4 to 9-month follow-up (Husebø  2019). Another  randomised
trial examined a multicomponent intervention combining person-
centred  training for staC  and a system for triggering appropriate
review of antipsychotic medicines in 69 residential aged care
facilities. The study reported improvements in agitation and quality
of life for the residents and deemed the intervention to be cost-
eCective when compared with usual care (Romeo 2018).

Overall, previous reviews have indicated that the physical
environment is an important consideration when determining
interventions to improve quality of life for residents in aged care
facilities, but the quality of evidence is mixed and there is a lack
of definitive high-quality evidence. There is also some evidence to
suggest  non-pharmacological interventions  or approaches  which
do not alter the physical environment may positively impact quality
of life.

A U T H O R S ‘   C O N C L U S I O N S

Implications for practice

While 20 studies were included in this review, there was variation
in the interventions and outcomes assessed and the certainty
of evidence was low or very low for all outcomes investigated.
Thus, there is currently insuCicient evidence on which to draw
conclusions about the impact of physical environment design
changes for older people living in residential aged care. Additional
studies that examine the eCects of physical environmental designs
of residential aged care facilities are required to improve the quality
of evidence available.

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Implications for research

Individually randomised trials for larger-scale interventions of the
physical environment for older people living in residential aged
care such as changing the scale of the building and whole model
of care are unlikely to be feasible. A planned randomised trial of
people living with dementia on admission to special care facilities
or traditional care had to modify the design due to too few people
being wait-listed for admission during the time period of the
study (Reimer 2004). Nevertheless, to improve the quality of the
evidence available, careful consideration of alternative methods
for design should be made by study authors  such as cluster-
randomised,  stepped-wedge randomised trials and interrupted
time series with three data points before and aJer changes.
Although non-randomised studies will have potential for risk of bias
which cannot be altered due to the lack of randomisation, non-
randomised studies can be optimised to reduce the risk of bias and
improve the certainty of evidence from these studies. For example,
many non-randomised studies were excluded from this review for
having only one intervention and/or control site which cannot be
considered for inclusion in Cochrane EPOC reviews because “the
intervention is completely confounded by study site making it
diCicult to attribute any observed diCerences to the intervention
rather than to other site-specific variables”. Many studies were also
excluded because they did not include a control group, or they
did not include measurements before the intervention (e.g. on
admission to residential aged care) which also limits the usability of
the results from such studies and the evidence cannot be included
in Cochrane EPOC reviews to inform current evidence. The certainty
of evidence was oJen downgraded due to the imprecision of results
and, therefore, studies with larger sample sizes of participants
across multiple sites are warranted. Other items of risk of bias that
were oJen deemed high risk were due to inadequate reporting of
and adjustment for baseline characteristics and baseline outcome
measures of the population being studied, or inadequate reporting
of outcomes to be assessed in the methods or study protocol (or
not stating reason for choice of outcomes assessed if using a data
source with many potential fields). Whilst some prospective cohort
studies address these criteria, the lack of reporting participant
measures before the intervention (e.g. on admission for whole
models of residential aged care) meant that they did not meet the
inclusion criteria for this review.

When conducting studies on older people living in residential
aged  care, attrition due to mortality or ill-health will be an issue
in most populations. Adequately reporting loss to follow-up and
reasons for diCerences between those lost to follow-up by group
allocation is critical to the interpretation of results. When planning
the study, the expected attrition should be considered when
determining an appropriate sample size.

Studies should investigate outcomes which are important to both
residents and carers including, but not limited to, quality of life,
behaviour, function, cognitive function, quality of care, serious
adverse eCects, outcomes for carers (including quality of life,
mood and carer burden) and outcomes for staC (including staC
knowledge, attitude, self-eCicacy, quality of life and burnout).
Outcomes should be measured using instruments which have
been validated in older people living in residential aged care.
Although residual confounding factors will always be a risk of bias
in non-randomised studies, statistical analyses in non-randomised
studies should plan analyses during the study design stage,

including adequate data collection to allow for adjustment for
many potential confounding factors. Cluster-randomised trials
should statistically adjust for the eCect of clustering as those
which do not take clustering into account create a unit of
analysis error and produce over-precise results (Higgins 2011).
Guidelines and a checklist for reporting interventions are available
such as the template for intervention description and replication
(TIDieR) checklist and guide (HoCmann 2014) and study authors
should follow these guidelines to ensure they clearly describe
the intervention and control arms of studies. Any diCiculties in
implementing the intervention should also be fully reported, either
in the main paper or as supplementary material. As shown in this
review, isolating eCects of the built environment in a controlled
setting whilst minimising bias can be diCicult to achieve in a
residential aged care setting due to other changes which may
occur, such as changes in care practices and changes to the health
of the residents. Future studies should be aware of any changes
which are likely to occur to the staCing structure or health of
the residents during the study period and plan for appropriate
statistical analyses to account for these changes.

Cluster-randomised trials are feasible for studies of refurbishment
of  residential aged care or interventions focusing on a specific
design component within a care home (e.g. dining room redesign or
lighting). When considering refurbishment in long-term residential
aged care, issues in implementing design changes for a specific
budget and time frame, as described in the study by  Chenoweth
2014,  should be considered during the development of the
study protocol. Blinding should be carried out on all personnel,
where feasible, including those conducting all analyses and those
assessing the outcomes, where possible (e.g. patient-reported
outcomes, such as quality of life, would be collected in the
knowledge of the intervention received whereas others, such as
functional ability measures, can be collected by an independent
clinician who is blinded) (EPOC 2016a).

A C K N O W L E D G E M E N T S

We acknowledge the help and support of Cochrane ECective
Practice and Organisation of Care (EPOC). The authors would also
like to thank the following editors and peer referees who provided
comments to improve the protocol: Signe Flottorp (EPOC Editor),
Paul Miller (EPOC Information Specialist), Julie Udell (external Peer
Referee), and Jemma Hudson (EPOC Statistician); also Elizabeth
Royle and Copy Edit Support for copy editing the protocol. We
would also like to thank the following editors and peer referees
who provided comments to improve the full review: Phillippa
Carnemolla (Content expert, external), Nick Seemann (Content
expert, external), Brian Duncan (Consumer, external), Harrison
Davies (Consumer, external), JC Han (Assistant Managing Editor,
EPOC), Denise O’Connor (Contact Editor, EPOC), Cristián Mansilla
(Associate Editor, EPOC), Noah Ivers  (Associate Editor, EPOC),
Paul Miller (Information Specialist, EPOC) and Jennifer Hilgart
(Statistical Editor, Public Health and Health Systems’ Network
Editorial & Methods Department). We would also like to thank Anne
Lethaby for copy-editing the review.

National Institute for Health Research (NIHR), via Cochrane
Infrastructure, gave funding to the ECective Practice and
Organisation of Care (EPOC) Group. We also acknowledge Ms
Natalie May, Ms Megan Winsall, Dr Wendy Shulver, Dr Justine Irving

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and Dr Helena Kopunic for assistance in initial abstract and title
screening of some citations for full-text review (in duplicate with
study authors) and assistance with grey literature searching. We
thank Jenni Suen for research assistance. The views and opinions
expressed herein are those of the authors and do not necessarily
reflect those of the Systematic Reviews Programme, NIHR, National
Health Service (NHS), or the Department of Health.

The Australasian Satellite of the Cochrane EPOC Group is funded by
Cochrane.

The contents of the published materials are solely the responsibility
of the administering institution — Flinders University and The
University of Woollongong — and the individual authors identified,
and do not reflect the views of the NHMRC or any other funding
bodies or the funding partners.

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R E F E R E N C E S
 

References to studies included in this review

Afendulis 2016 {published data only}

Afendulis CC, Caudry DJ, O’Malley AJ, Kemper P, Grabowski DC,
Thrive Research Collaborative.Green house adoption and
nursing home quality. Health Services Research 2016;51 Suppl
1:454-74.

Annerstedt 1993 {published data only}

*  Annerstedt L, Gustafson L, Nilsson K.Medical outcome of
psychosocial intervention in demented patients: one-year
clinical follow-up aJer relocation into group living units.
International Journal of Geriatric Psychiatry 1993;8(10):833-41.

Annerstedt L.An attempt to determine the impact of group
living care in comparison to traditional long-term care on
demented elderly patients. Aging Clinical and Experimental
Research 1994;6(5):372-80.

Annerstedt L.Group-living care: an alternative for the
demented elderly. Dementia & Geriatric Cognitive Disorders
1997;8(2):136-42.

Annerstedt L.On group-living care for the demented elderly:
experiences from the Malmo model. Ann Arbor Lunds
Universitet 1995;C405957:69.

Burack 2012 {published data only}

Burack OR, Reinhardt JP, Weiner AS.Person-centered care and
elder choice: a look at implementation and sustainability.
Clinical Gerontologist 2012;35(5):390-403.

*  Burack OR, Weiner AS, Reinhardt JP.The impact of culture
change on elders’ behavioral symptoms: a longitudinal
study. Journal of the American Medical Directors Association
2012;13(6):522-8.

Chenoweth 2014 {published data only}

Chenoweth L,  Jeon YH,  Stein-Parbury J, Forbes I, Fleming R,
Cook J,  et al.PerCEN trial participant perspectives on the
implementation and outcomes of person-centered dementia
care and environments. International Psychogeriatrics
2015;27(12):2045-57.

*  Chenoweth L, Forbes I, Fleming R, King MT, Stein-Parbury J,
Luscombe G, et al.PerCEN: a cluster randomized controlled
trial of person-centered residential care and environment
for people with dementia. International Psychogeriatrics
2014;26(7):1147-60.

Chenoweth L, King M, Luscombe G, Forbes I, Jeon YH,
Parbury JS, et al.Study protocol of a randomised controlled
group trial of client and care outcomes in the residential
dementia care setting. Worldviews on Evidence-Based Nursing
2011;8(3):153-65.

Chenoweth L.The Percen study: supporting client and care
outcomes in the residential dementia care setting. Alzheimer’s
and Dementia 2011;7(4 Suppl 1):S292.

Dettbarn-Reggentin 2005 {published data only}

Dettbarn-Reggentin J.Study on the influence of environmental
residential groups on demented old people in nursing home
residents [Studie zum einfluss von wohngruppenmilieus auf
demenziell erkrankte in stationären einrichtungen]. Zeitschri/
Fur Gerontologie Und Geriatrie 2005;38(2):95-100.

Diaz-Veiga 2014 {published data only}

Diaz-Veiga P, Sancho M, Garcia A, Rivas E, Abad E, Suarez N, et
al.ECects from the Person Centered-Care model on quality of
life of cognitive impaired persons from gerontological centers
[Efectos del Modelo de Atención Centrado en la Persona en la
calidadde vida de personas con deterioro cognitivo de centros
gerontológicos]. Revista Espanola de Geriatria y Gerontologia
2014;49(6):266-71.

Elmstahl 1997 {published data only}

Elmstahl S, Annerstedt L, Ahlund O.How should a group living
unit for demented elderly be designed to decrease psychiatric
symptoms? Alzheimer Disease and Associated Disorders
1997;11(1):47-52.

Figueiro 2019 {published data only}

Figueiro M, Rea M.Tailored lighting intervention to improve
sleep in patients with dementia. Sleep Medicine  2019;64:S115.

Figueiro MG, Kalsher M, Plitnick B, Rohan C, Rea MS.Tailored
lighting intervention for Alzheimer’s patients and its eCects on
sleep, mood and agitation. Sleep 2018;41:A113-A114.

*  Figueiro MG, Plitnick B, Roohan C,  Sahin L, Kalsher M,
Rea MS.ECects of a tailored lighting intervention on sleep
quality, rest-activity, mood, and behavior in older adults with
Alzheimer disease and related dementias: a randomized clinical
trial. Journal of Clinical Sleep Medicine 2019;15(12):1757-67.

Frisoni 1998 {published data only}

Bellelli G, Giovanni GB, Bianchetti A, BoCelli S, Guerrini GB,
Scotuzzi A, et al.Special care units for demented patients: a
multicenter study. Gerontologist 1998;38(4):456-62.

Bianchetti A, Benvenuti P, Ghisla KM, Frisoni GB, Trabucchi M.An
Italian model of dementia special care unit: results of a
pilot study. Alzheimer Disease and Associated Disorders
1997;11(1):53-6.

*  Frisoni GB, Gozzetti A, Bignamini V, Vellas BJ, Berger AK,
Bianchetti A, et al.Special care units for dementia in nursing
homes: a controlled study of eCectiveness. Archives of
Gerontology and Geriatrics 1998;26:215-24.

Galik 2021 {published data only}

Galik EM, Resnick B, Holmes SD, Vigne E, Lynch K, Ellis J, et
al.A cluster randomized controlled trial testing the impact of
function and behavior focused care for nursing home residents
with dementia. Journal of the American Medical Directors
Association 2021;22(7):1421-8.

Physical environmental designs in residential care to improve quality of life of older people (Review)

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Hopkins 2017 {published data only}

*  Hopkins S, Morgan PL, Schlangen LJM, Williams P, Skene DJ,
Middleton B.Blue-enriched lighting for older people living in
care homes: eCect on activity, actigraphic sleep, mood and
alertness. Current Alzheimer Research 2017;14:1053-62.

Middleton B, Hopkins S, Morgan PL, Barrett D, Schlangen LJ,
Skene DJ.ECects of blue-enriched and control white light on
activity levels and timing in older people living in care homes.
Journal of Sleep Research 2010;19:188.

Kenkmann 2010 {published data only}

Kenkmann A, Hooper L.The restaurant within the home:
experiences of a restaurant-style dining provision in residential
homes for older people. Quality in Ageing & Older Adults
2012;13(2):98-110.

*  Kenkmann A, Price GM, Bolton J, Hooper L.Health, wellbeing
and nutritional status of older people living in UK care homes:
an exploratory evaluation of changes in food and drink
provision. BMC Geriatrics 2010;10:28.

Marcy-Edwards 2011 {published data only}

*  Marcy-Edwards D, Wardell R, Simon J, Hansen J, Baden L,
Grant N.The eCect of vignette activity on the neuropsychiatric
behaviours expressed by individuals with dementia, living
in long-term care. Alzheimer’s and Dementia 2011;7(4 Suppl
1):S644-S645.

Marcy-Edwards D.Engaging at a Garden Vignette: the ECect on
Neuropsychiatric Behaviour in Moderate to Severe Dementia
(thesis). Calgary, Canada: University of Calgary, 2014.

Mathey 2001 {published data only}

Mathey MF, Vanneste VG, De Graaf C, De Groot LC, Van
Staveren WA.Health eCect of improved meal ambience in a
Dutch nursing home: a 1-year intervention study. Preventive
Medicine 2001;32(5):416-23.

Nijs 2006 {published data only}

Nijs KA, De Graaf C, Kok FJ, Van Staveren WA.ECect of family
style mealtimes on quality of life, physical performance, and
body weight of nursing home residents: cluster randomised
controlled trial. BMJ 2006;332(7551):1180-4.

Riemersma-vanDerLek 2008 {published data only}

Riemersma-van Der Lek RF, Swaab DF, Twisk J, Hol EM,
Hoogendijk WJG, Van Someren EJW.ECect of bright light and
melatonin on cognitive and noncognitive function in elderly
residents of group care facilities – a randomized controlled trial.
JAMA 2008;299:2642-55.

Te Boekhorst 2009 {published data only}

Te Boekhorst S, Depla MF, De Lange J, Pot AM, Eefsting JA.The
eCects of group living homes on older people with dementia: a
comparison with traditional nursing home care. International
Journal of Geriatric Psychiatry 2009;24(9):970-8.

Wolf-Ostermann 2012 {published data only}

Fischer T, Wolf-Ostermann K.The Berlin study on structures
and outcomes of <<WohngemeinschaJen>> for people
with dementia (DeWeGE), a small-scale living arrangement

[Die Berliner studie zu versorgungsstrukturen and
versorgunsergebnissen von Wohngemeinschafrern
fur menschen mit demenz (DeWeGe)]. Zeitschri/ fur
Gerontopsychologie & Psychiatrie 2008;21(3):179-83.

*  Wolf-Ostermann K, Worch A, Fischer T, WulC I, Graske J.Health
outcomes and quality of life of residents of shared-housing
arrangements compared to residents of special care units –
results of the Berlin DeWeGE-study. Journal of Clinical Nursing
2012;21(21-22):3047-60.

Wylie 2001 {published data only}

Wylie R.Impact of the Eden Alternative™ on Texas Nursing
Homes Residents’ Quality of Life: a Psychosocial Perspective
(thesis). Texas, United States: Texas State University, 2001.

Yoon 2015 {published data only}

*  Yoon JY, Brown RL, Bowers BJ, Sharkey SS,
Horn SD.Longitudinal psychological outcomes of the small-
scale nursing home model: a latent growth curve zero-
inflated Poisson model. International Psychogeriatrics
2015;27(6):1009-16.

Yoon JY, Brown RL, Bowers BJ, Sharkey SS, Horn SD.The eCects
of the Green House nursing home model on ADL function
trajectory: a retrospective longitudinal study. International
Journal of Nursing Studies 2016;53:238-47.

Yoon JY.The eCect of Green House nursing home model on the
health outcome trajectories. University of Wisconsin Madison
2013.

References to studies excluded from this review

Auer 2017 {published data only}

Auer S,  Kienberger U, Pascher P, Geck M, Hofmann B,
Viereckl C.Small-scale group living versus traditional nursing
home for persons with dementia [WohngemeinschaJ versus
traditionelles pflegeheim für personen mit demenz. Eine
vergleichende beobachtungsstudie.]. Pflegewissenscha/
2017;3/4:156–65.

Barrick 2010 {published data only}

Barrick AL, Sloane PD, Williams CS, Mitchell CM, Connell BR,
Wood W, et al.Impact of ambient bright light on agitation
in dementia. International Journal of Geriatric Psychiatry
2010;25(10):1013-21.

Bergman-Evans 2004 {published data only}

Bergman-Evans B.Beyond the basics. ECects of the Eden
Alternative model on quality of life issues. Journal of
Gerontological Nursing 2004;30(6):27-34.

Bonardi 1989 {published data only}

Bonardi E, Pencer I, Tourigny-Rivard MF.Observed changes in
the functioning of nursing home residents aJer relocation.
International Journal of Ageing and Human Development
1989;28(4):295-304.

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Trusted evidence.
Informed decisions.
Better health.

Cochrane Database of Systematic Reviews

Bond 1999 {published data only}

Bond GE, Fiedler FE.A comparison of leadership vs. renovation
in changing staC values. Nursing Economics 1999;17(1):37-43.

Chafetz 1991 {published data only}

Chafetz PK.Behavioral and cognitive outcomes of SCU care.
Clinical Gerontologist: Journal of Aging and Mental Health
1991;11(1):19-38.

Chang 2013 {published data only}

Chang YP, Li J, Porock D.The eCect on nursing home resident
outcomes of creating a household within a traditional
structure. Journal of the American Medical Directors Association
2013;14(4):293-9.

Cohen-Mansfield 1998 {published data only}

Cohen-Mansfield J, Werner P.The eCects of an enhanced
environment on nursing home residents who pace.
Gerontologist 1998;38(2):199-208.

Coleman 2002 {published data only}

Coleman MT, Looney S, O’Brien J, Ziegler C, Pastorino CA,
Turner C.The Eden Alternative: findings aJer 1 year of
implementation. Journals of Gerontology. Series A, Biological
Sciences and Medical Sciences 2002;57(7):422-7.

De Boer 2017 {published data only}

De Boer B, Bozdemir B, Jansen J, Hermans M, Hamers JPH,
Verbeek H.The Homestead: developing a conceptual framework
through co-creation for innovating long-term dementia care
environments. International Journal of Environmental Research
and Public Health 2021;18(1):57.

De Boer B, Hamers JP, Beerens HC, Zwakhalen SM, Tan FE,
Verbeek H.Living at the farm, innovative nursing home care
for people with dementia – study protocol of an observational
longitudinal study. BMC Geriatrics 2015;15:144.

De Boer B, Hamers JP, Zwakhalen SM, Tan FE, Beerens HC,
Verbeek H.Green Care Farms as innovative nursing homes,
promoting activities and social interaction for people With
dementia. Journal of the American Directors Association
2017;18(1):40-6.

De Rooij 2012 {published data only}

De Rooij AH, Luijkx KG, Declercq AG, Emmerink PM,
Schols JM.Professional caregivers’ mental health problems and
burnout in small-scale and traditional long term care settings
for elderly people with dementia in the Netherlands and
Belgium. Journal of the American Medical Directors Association
2012;13(5):486.e7-11.

De Rooij AH, Luijkx KG, Schaafsma J, Declercq AG,
Emmerink PM, Schols JM.Quality of life of residents with
dementia in traditional versus small-scale long-term care
settings: a quasi-experimental study. International Journal of
Nursing Studies 2012;49(8):931-40.

De Rooij I, Luijkx K, Declercq A, Schols J.Small-scale living
facilities in the Netherlands and Belgium: a longitudinal study
on patient outcome; Fourth European Nursing Congress.
Journal of Clinical Nursing 2010;19:139.

Falk 2009 {published data only}

Falk H, Wijk H, Persson LO.The eCects of refurbishment
on residents’ quality of life and wellbeing in two Swedish
residential care facilities. Health and Place 2009;15(3):687-94.

Giggins {published data only}

Giggins OM, Doyle J, Hogan K, George M.The impact of a cycled
lighting intervention on nursing home residents: a pilot study.
Gerontology & Geriatric Medicine 2019;5:2333721419897453.

Hermer 2017 {published data only}

Hermer L, Bryant NS, Pucciarello M, Mlynarczyk C,
Zhong B.Does comprehensive culture change adoption via
the Household model enhance nursing home residents’
psychosocial well-being? Innovation in Aging  2017;1(2):igx033.

Holmes 1990 {published data only}

Holmes D, Teresi J, Weiner A, Monaco C, Ronch J,
Vickers R.Impacts associated with special care units in long-
term care facilities. Gerontologist 1990;30(2):178-83.

Inventor 2018 {published data only}

Inventor 2018.Longitudinal eCects of activities, social
environment, and psychotropic medication use on behavioral
symptoms of individuals with Alzheimer’s disease in nursing
homes. Journal of Psychosocial Nursing & Mental Health Services
2018;56(11):18-26.

Kane 2007 {published data only}

Kane RA, Lum TY, Cutler LJ, Degenholtz HB, Yu TC.Resident
outcomes in small-house nursing homes: a longitudinal
evaluation of the initial green house program. Journal of the
American Geriatrics Society 2007;55(6):832-9.

Klosinska {published data only}

Kłosińska U, Derejczyk J, Benek I, Szczepanek A,
Derejczyk G.Look around-architectural interventions in LTC
home and professional stress of formal caregivers. European
Geriatric Medicine  2019;10:S179.

Kok 2017 {published data only}

*  Kok JS, Berg IJ, Blankevoort GCG, Scherder EJA.Rest-activity
rhythms in small scale homelike care and traditional care for
residents with dementia. BMC Geriatrics 2017;17(1):137.

Kok JS, Van Heuvelen MJ, Berg IJ, Scherder EJ.Small scale
homelike special care units and traditional special care units:
eCects on cognition in dementia; a longitudinal controlled
intervention study. BMC Geriatrics 2016;16:47.

Kok 2018 {published data only}

Kok JS, Nielen MMA, Scherder EJA.Quality of life in small-scaled
homelike nursing homes: an 8-month controlled trial. Health &
Quality of Life Outcomes 2018;16(1):38.

Kubsch 2018 {published data only}

Kubsch SM, Tyczkowski BL, Passel C.The impact of the Eden
Alternative on hope. Nursing & Residential Care 2018;20(2):91-4.

Physical environmental designs in residential care to improve quality of life of older people (Review)

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

38

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Library

Trusted evidence.
Informed decisions.
Better health.

Cochrane Database of Systematic Reviews

Lee 2016 {published data only}

Lee SY, Chaudhury H, Hung L.ECects of physical environment on
health and behaviors of residents with dementia in long-term
care facilities: a longitudinal study. Research in Gerontological
Nursing 2016;9(2):81-91.

Lum 2008 {published data only}

Lum TY, Kane RA, Cutler LJ, Yu TC.ECects of Green House
nursing homes on residents’ families. Health Care Financing
Review 2008;30(2):35-51.

Molony 2011 {published data only}

Molony SL, Evans LK, Jeon S, Rabig J, Straka LA.Trajectories of
at-homeness and health in usual care and small house nursing
homes. Gerontologist 2011;51(4):504-15.

O’Connor 1991 {published data only}

O’Connor BP, Davidson H, GiCord R.Window view, social
exposure and nursing home adaptation. Canadian Journal on
Aging 1991;10(3):216-23.

Palm 2019 {published data only}

Palm R, Trutschel D, Sorg CG, Dichter MN, Haastert B,
Holle B.Quality of life in people with severe dementia and
its association with the environment in nursing homes: an
observational study. Gerontologist 2019;59(4):665-74.

Pomeroy 2011 {published data only}

Pomeroy SH, Scherer Y, Runkawatt V, Iamsumang W,
Lindemann J, Resnick B.Person-environment fit and functioning
among older adults in a long-term care setting. Geriatric Nursing
2011;32:368-78.

Potter 2018 {published data only}

Potter R, Sheehan B, Cain R, GriCin J, Jennings PA.The impact
of the physical environment on depressive symptoms of
older residents living in care homes: a mixed methods study.
Gerontologist 2018;58(3):438-47.

Reimer 2004 {published data only}

Reimer MA, Slaughter S, Donaldson C, Currie G,
Eliasziw M.Special care facility compared with traditional
environments for dementia care: a longitudinal study of
quality of life. Journal of the American Geriatrics Society
2004;52(7):1085-92.

Scott 2014 {published data only}

Scott TL, Masser BM, Pachana NA.Multisensory installations
in residential aged-care facilities: increasing novelty and
encouraging social engagement through modest environmental
changes. Journal of Gerontological Nursing 2014;40(9):20-31.

Steiner 2020 {published data only}

Steiner B.Assisted living facilities in inpatient and outpatient
settings [Wohn- und hausgemeinschaJen in stationären und
ambulanten settings]. Zeitschri/ Fur Gerontologie Und Geriatrie
2020;53(6):505-12.

Varshawsky {published data only}

Varshawsky A, Traynor V.Live behind the orange door –
the eCects of changing suite doors for individuals living

with dementia. Australian Nursing & Midwifery Journal 
2018;25(7):38-9.

*  Varshawsky AL, Traynor V.Graphic designed bedroom doors
to support dementia wandering in residential care homes:
innovative practice. Dementia – International Journal of Social
Research and Practice 2021;20(1):348–54.

Verbeek 2014 {published data only}

Verbeek H, Van Rossum E, Zwakhalen SM, Kempen GI,
Hamers JP.Small, homelike care environments for older
people with dementia: a literature review. International
Psychogeriatrics 2009;21(2):252-64.

Verbeek H, Zwakhalen SM, Van Rossum E, Ambergen T,
Kempen GI, Hamers JP.Dementia care redesigned: eCects of
small-scale living facilities on residents, their family caregivers,
and staC. Journal of the American Medical Directors Association
2010;11(9):662-70.

*  Verbeek H, Zwakhalen SM, Van Rossum E, Ambergen T,
Kempen GI, Hamers JP.ECects of small-scale, home-
like facilities in dementia care on residents’ behavior,
and use of physical restraints and psychotropic drugs: a
quasi-experimental study. International Psychogeriatrics
2014;26(4):657-68.

Verbeek H, Zwakhalen SM, Van Rossum E, Kempen GI,
Hamers JP.Small-scale, homelike facilities in dementia care:
a process evaluation into the experiences of family caregivers
and nursing staC. International Journal of Nursing Studies
2012;49(1):21-9.

Zwakhalen SM, Hamers JP, Van Rossum E, Ambergen T,
Kempen GI, Verbeek H.Working in small-scale, homelike
dementia care: eCects on staC burnout symptoms and job
characteristics. A quasi-experimental, longitudinal study.
Journal of Research in Nursing 2018;23(2-3):109-22.

References to studies awaiting assessment

Kolberg 2020 {published and unpublished data}

Johnsen Hjetland G.The ECect of Bright Light on Sleep in
Nursing Home Patients with Dementia (PhD thesis). Norway:
University of Bergen, 2021.

*  Kolberg E, Pallesen S, Johnsen Hjetland G, Nordhus IH,
Thun E, Flo-Groeneboom E.The potential of bright light
treatment in the management of depression and anxiety
in dementia during winter. Journal of Sleep Research
2020;29(Suppl 1):P309.

References to ongoing studies

Willemse 2011 {published data only}

Prins M, Willemse BM, Heijkants CH, Pot AM.Nursing home care
for people with dementia: update of the design of the Living
Arrangements for people with Dementia (LAD) study. Journal of
Advanced Nursing 2019;75(12):3792-804.

Physical environmental designs in residential care to improve quality of life of older people (Review)

Copyright © 2022 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

39

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Library

Trusted evidence.
Informed decisions.
Better health.

Cochrane Database of Systematic Reviews

Smit D, De Lange J, Willemse B, Pot AM.Predictors of activity
involvement in dementia care homes: a cross-sectional study.
BMC Geriatrics 2017;17:175.

Smit D, Willemse B, De Lange J, Pot AM.Wellbeing-enhancing
occupation and organizational and environmental contributors
in long-term dementia care facilities: an explorative study.
International Psychogeriatrics 2014;26(1):69-80.

*  Willemse BM, Smit D, De Lange J, Pot A.Nursing home care for
people with dementia and residents’ quality of life, quality of
care and staC well-being: design of the Living Arrangements for
people with Dementia (LAD) study. BMC Geriatrics 2011;11:11.

Willemse BM.Working conditions and person-centredness of the
dementia care workforce: impact on quality of care, staC and
resident well-being. Vrije Universiteit Amsterdam: Amsterdam,
the Netherlands (accessed prior to 12 Feb 2022).

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Alldred DP, Kennedy M, Hughes C, Chen TF,
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Anderson RM, Grey T, Kennelly S, O’Neill D.Nursing home design
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HoCmann TC, Glasziou PP, Bourton I, Milne R, Perera R,
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Husebø 2019

Husebø BS, Ballard C,  Aarsland D,  Selbaek G,  Slettebo DD,
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2014;15(10):697-705.

WHO 2015

World Health Organization.World report on ageing and health.
www.who.int/ageing/events/world-report-2015-launch/en/
(accessed 20 March 2017).

Willemse 2014

Willemse BM, Depla MFIA, Smit D, Pot AM.The relationship
between small-scale nursing home care for people with

dementia and staC’s perceived job characteristics. International
Psychogeriatrics 2014;26(5):805-16.

Willemse 2015

Willemse BM, De Jonge J, Smit D, Visser Q, Depla MFIA,
Pot AM.StaC’s person-centredness in dementia care in relation
to job characteristics and job-related well-being: a cross-
sectional survey in nursing homes. Journal of Advanced Nursing
2015;71(2):404-16.

Willemse 2016

Willemse BM.Working Conditions and Person-Centredness of
the Dementia Care Workforce: Impact on Quality of Care, StaC
and Resident Well-Being (thesis). Amsterdam, The Netherlands:
Vrije Universiteit Amsterdam, 2016.

Woodbridge 2018

Woodbridge R, Sullivan MP, Harding E, Crutch S, Gilhooly KJ,
Gilhooly MLM, et al.Use of the physical environment to support
everyday activities for people with dementia: a systematic
review. Dementia (London, England) 2018;17(5):533-72.

Zimmerman 2016

Zimmerman S, Bowers BJ, Cohen L, Grabowski DC, Horn SD,
Kemper P, THRIVE Research Collaborative.New evidence on
the Green House model of nursing home care: synthesis of
findings and implications for policy, practice, and research.
Health Services Research 2016;51(S1):475-96.

References to other published versions of this review

Harrison 2017

Harrison SL, Dyer SM, Laver KE, Milte RK, Fleming R,
Crotty M.Physical environmental designs in residential care
to improve quality of life of older people. Cochrane Database
of Systematic Reviews 2017, Issue 12. Art. No: CD012892. [DOI:
10.1002/14651858.CD012892]

 
* Indicates the major publication for the study

C H A R A C T E R I S T I C S   O F   S T U D I E S

Characteristics of included studies [ordered by study ID]

Study characteristics

Methods Study design: Controlled before-after study

Number of facilities: unclear (total of GreenHouse, control and excluded GreenHouse owned “legacy”
homes: 190; 12 intervention and 178 control)

Participants N = 74,449 (weighted sample)

Mean age: not reported.

% Female: not reported.

% Dementia: 33.9

Afendulis 2016 

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Mean number of comorbidities: not reported
Country: USA

Inclusion criteria:

Nursing homes:

• that adopted the GreenHouse (GH) model over the period 2005 to 2010 (from list provided by The
Green House Project)

• were in operation in the period prior to adoption – non-GH nursing home organisations matched at
facility-level by OSCAR (Online Survey, Certification, and Reporting)

• nursing home level data for each GH nursing home plus matched on state and year of adoption, using
nearest neighbour matching

• matched on these covariates: nonprofit ownership, for-profit ownership, government ownership,
chain status, small size (75 beds or fewer), medium size (76–125 beds), large size (126 or more
beds), rural location, above median Medicaid share, above median Medicare share, above median pri-
vate-pay share, and a nursing home-level aggregate activities of daily living (ADL) score (0 if less than
4 on a scale of 0–5, 1 otherwise), with propensity score weighting

Exclusion criteria:

• Residents who were not entitled to Medicare Part A in the month of admission

• Residents who died during the month of admission

• Residents who were enrolled in the Medicare Advantage program during the month of admission

Interventions Type of intervention: Home-like model

Name of intervention: Green House model.

Design features: Small buildings (maximum 12 residents) and fit the style of surrounding neighbour-
hood

Other features that differed: Residents have more control over daily activities.

Control: Matched by multiple facility characteristics, state and year that did not adopt the Green House
model, not a “small house” model

Outcomes The following outcomes were reported:

Rehospitalisations, avoidable rehospitalisations, bedfast residents, catheter use, pressure ulcers (low
risk and high risk) and use of physical restraints

Follow-up: Up to five years

Notes Study supported by the Robert Wood Johnson Foundation. Conflicts of interest: None. Ethical ap-
proval: not stated.

Data reported on “Legacy” units within the GreenHouse organisation (that were not GreenHouse model
of care homes) were excluded.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk Controlled before-after study

Allocation concealment
(selection bias)

High risk Controlled before-after study

Afendulis 2016  (Continued)

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Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Blinding not feasible

Incomplete outcome data
(attrition bias)
All outcomes

Unclear risk Loss to follow-up not stated

Selective reporting (re-
porting bias)

Unclear risk No protocol; likely to be many fields in MDS not reported

Other bias High risk Method of selection of facilities unclear and potential residual confounding.
Significant differences in baseline characteristics. Significant differences for
many baseline outcome measures

Afendulis 2016  (Continued)

Study characteristics

Methods Study design: Controlled before-after study

Number of facilities: 6 (3 intervention and 3 control)

Participants N = 56 (intervention: N = 28; control: N = 28)

Mean age (SD): Intervention: 82.8 (5.0), control: 81.6 (5.0)

% Female: Intervention: 89.3, control: 82.1

% Dementia: not reported

Mean number of comorbidities: not reported

Country: Sweden

Inclusion criteria:

• Intervention residents: Alzheimer’s, vascular dementia or mixed according to DSM-III criteria (severity
of dementia II to IV on Berger’s scale)

• Control residents: matched by age, gender, diagnosis and level of dementia to the intervention resi-
dents

Exclusion criteria:

• Patients suffering from physical illness, clinically estimated to become terminal within 1 year

Interventions Type of intervention: Home-like model

Design features: 8-10 residents, situated in ordinary blocks of flats in suburbs, specially adapted for
people living with dementia. Flats had private areas with 1 or 2 rooms with toilet and shower, kitchen,
living room, dining room and laundry room available to staC and residents. StaC/patient ratios were
similar in the two types of care (0.69 in group living; 0.71 in traditional). However, the intervention staC
were responsible not only for patient care but also for cooking, cleaning, washing, transportation and
activating therapies.

Annerstedt 1993 

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Other features that differed: StaC familiar with resident biographies. A group living project was con-
nected to a clinic, responsible for the geriatric care in a certain area corresponding to 20% of the per-
sons 65 years old or older of the population in the community.

Control: Offered in three big long-term care hospitals, mostly with wards of 50 patients and original-
ly designed for acute medical care or rehabilitation. The care was usually organised in four separate
groups in order to break the large-scale design of the physical environment. Each of these groups in-
cluded both somatic long-term care patients with and without dementia. StaC training was seldom reg-
ularly scheduled and surveyed most aspects of geriatric care, favouring physical items.

Outcomes The following outcomes (measurement scale) were reported:

Dyspraxia, hallucinations, lack of vitality, dysphasia, paranoia, aggressiveness, depression, clinical vari-
ations, restlessness, recent memory and identity (Organic Brain Syndrome Scale: OBS Scale)

Follow-up: 6 months and 12 months

Notes Sponsorship source: Swedish Medical Research Council, the Swedish Council for Social Research,
Alzheimer Foundation and Medical Foundation at Lund University. Conflicts of interest: Not stated. Eth-
ical approval: Not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk Controlled before-after study

Allocation concealment
(selection bias)

High risk Controlled before-after study

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Blinding not feasible

Incomplete outcome data
(attrition bias)
All outcomes

High risk 21% loss to follow-up

Selective reporting (re-
porting bias)

Low risk All outcomes discussed were reported.

Other bias High risk Possible confounding, unadjusted results. Significant baseline differences in
the time the participants had been institutionalised prior to relocation; partici-
pants in traditional facilities received more neuroleptic treatment. Differences
in baseline outcomes e.g. dyspraxia and identity not controlled for.

Annerstedt 1993  (Continued)

Study characteristics

Methods Study design: Controlled before-after study

Burack 2012 

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Number of facilities: 13 (7 intervention and 6 control)

Participants N = 201 enrolled, 101 analysed (intervention: N = 50; control: N = 51)

Mean age (SD): Intervention: 83.8 (8.8), control: 83.5 (9.8)

% Female: Intervention: 62, control: 67

% Dementia: 59 (not reported by intervention and control groups)

Mean (SD) number of comorbidities: 4.3 (1.9) (intervention: 4.2 (1.9) and control: 4.4 (2.0))

Country: USA

Inclusion criteria:

Facilities

• Intervention: 2 to 3 pilot communities at each of 3 nursing home campuses for a total of 7 communities
operated by one provider. Nursing and administrative staC chose communities with well-functioning
teams (2 communities each at 2 of the campuses, and 3 communities at the third campus) to pilot the
culture change intervention to optimise the potential for a successful culture change transformation.

• Comparison: 2 communities at each campus were identified to serve as a comparison group (for a total
of 6 comparison communities), selected by administrative and nursing leaderships’ clinical expertise
to best match the culture change group by the level of care needed by elders, staC team functioning,
number of elders in the community, and the environmental community structure.

Residents

• Living in community for at least 3 months, 60 years or older

Exclusion criteria:

• Not reported

Interventions Name of intervention: Culture change model

Design features: Environmental changes were implemented in elder rooms and common areas, with a
focus on person-centred care. Elders and their family members were encouraged to individualise elder
rooms with personal items, decoration, and pictures. Within the common areas, attention was given to
creating a calm, peaceful environment. In the dining areas, new table cloths were purchased, centre-
pieces were placed on tables, art work decorated the walls, and water and juice were easily accessible
to elders at all times. Hallways were decorated with painted murals and new wallpaper. The outsides
of the elders’ rooms were individualised to facilitate easy room recognition for the elders. Additionally,
homey nooks were created at the end of hallways with comfortable seating. Noise level was addressed
by discontinuing the overhead paging system and turning oC TVs and radios when they were not being
actively used.

Other features that differed: Community co-ordinators, education, organisational and community
structure changes, meaningful activities and resident choice, family involvement, reduced floating and
consistent staCing

Control: Continued to function along the nursing home’s pre-culture change model, following the typi-
cal nursing home organisational structure and standard administrative and departmental hierarchy of
care

Outcomes The following outcomes (measurement scale) were reported:

Behaviour: forceful behaviours, physical agitation and verbal agitation (Cohen-Mansfield Agitation In-
ventory: CMAI)

Follow-up: 2 years

Burack 2012  (Continued)

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Notes Sponsorship source not reported. Conflicts of interest: None. Ethical approval: Not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk Controlled before-after study

Allocation concealment
(selection bias)

High risk Controlled before-after study

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Blinding not feasible

Incomplete outcome data
(attrition bias)
All outcomes

Unclear risk Large loss to follow-up; no differences between those lost and those with fol-
low-up, but this not reported by group allocation

Selective reporting (re-
porting bias)

High risk Only reported behavioural outcomes, not changes in ADLs or cognition. CMAI
overall score not reported and reported according to specific groupings

Other bias High risk Culture change communities selected based on “well-functioning teams” to
optimise potential for successful transformation. Significant baseline differ-
ences in ADLs and race reported. Significant differences in baseline outcome
measurements

Burack 2012  (Continued)

Study characteristics

Methods Study design: Cluster-randomised controlled trial.

Number of facilities: 38 (8 control, 10 PCE, 10 PCC, 10 PCE + PCC)

Participants N = 601 (person-centred environment (PCE): 154, person-centred care (PCC): 155, PCE + PCC: 150, usual
environment (UE, control): 142)

Mean age (SD): PCE: 84 (8), PCC: 84 (8), PCE + PCC: 84 (7), control: 86 (7)

% Female: PCE: 66, PCC: 67, PCE + PCC: 70, control: 77

% Dementia: 100

Mean (SD) number of comorbidities: not reported. % > 3 comorbidities: PCE: 35, PCC: 51, PCE + PCC: 55,
control: 68

Country: Australia

Inclusion criteria:

Residential aged care home

Chenoweth 2014 

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• Government accreditation and building certification; high-level care homes; accessible by sealed
road, located within a 500 km radius of Sydney, Australia; with room for improvement in both PCE and
PCC according to the Person-Centred Environment and Care Assessment Tool (PCECAT), a validated
44-item rating instrument with three domains designed for evaluation of residential aged care. The
PCECAT 4-point scale was rescored 0 (the best possible rating) and 1, 2, 3 (the worst possible ratings,
ranked).

• A total “room for improvement score” (RFI) was calculated by summing across items (20 items in do-
main 2 (care services), and 19 in domain 3 (environment)). Homes that scored 1–3 for both care ser-
vices and environment RFI were considered eligible.

Participants

• Self-consent, proxy consent or Guardianship Tribunal consent

• Recorded dementia diagnosis

• Permanent stay

• Admission at least 3 months prior to baseline

• Assessed high care needs and presence of agitation

• Ability to participate over the life of the study (e.g. no florid mental illness or end-stage dementia)

Exclusion criteria:

• Did not meet inclusion criteria

Interventions Type of intervention: PCE or PCE + PCC

PCE: Two chief investigators with expertise in Person-Centre Environment design and a Master of De-
sign research student took responsibility for implementing the PCE interventions at each of the 10 PCE
and 10 PCE + PCC sites. The Environment Audit Tool (EAT) was employed to evaluate the relationships
between operations and space in terms of effectiveness and ideal resident care, and determining re-
quired environmental changes to meet PCE principles at the sites. Discussions of EAT findings were
held with the home’s executive staC and managers to initially determine their understanding of the
dysfunction generated for residents through the poor physical environment features identified. Plan-
ning then occurred with these senior staC to determine the best ways to undertake the most essential
and inexpensive environmental changes required. Planned modifications to the environment were un-
dertaken in some homes where feasible by a contracted building company. The environment interven-
tions, agreed to by the managers and priced by the contractor, were as follows: (1) two facilities need-
ed extensions of activity space made by covering balconies or areas that were previously open; (2) two
facilities had changes made to internal walls that would allow better visual access to activity and bed-
room spaces; (3) one facility was to be altered to provide access to a courtyard from a dining area need-
ed for activity and group activities; (4) two facilities needed internal divisions with added partitions to
reduce the overstimulation in larger group spaces; (5) two facilities had walls removed to make sitting
areas visible to residents passing in the corridor; (6) one facility had fire doors relocated to improve ac-
cess to the garden and (7) the remaining facilities all had some variation of external paving, new sitting
areas in gardens or covered spaces in a landscaped exterior. All these changes were considered to pro-
vide maximum benefit in achieving improved support or staC undertaking PCC-focused activities while
engaging with residents.

PCC: Kitwood’s (1997) PCC principles, using experiential and adult learning approaches, were facil-
itated by two chief investigators with expertise in PCC approaches and one expert PCC trainer from
Alzheimer’s Australia, employing train-the-trainer processes. Five staC (one Care Manager, one Regis-
tered Nurse, two Enrolled Nurses or Assistants in Nursing, one Diversion/Recreation Therapist) from
each of the 10 PCC and 10 PCC + PCE homes were involved in the PCC training. The 32-hour oC-site
training occurred over 1 week, complemented by a further 32 hours of on-site education and support
to implement PCC in daily care practices and recreation activities. Prior experiences, case studies, role
plays and simulations were utilised to develop awareness and insight of the relationship between care
and the resident’s quality of life. The PCC trainer guided and supported PCC-trained staC to employ
PCC learning resources, mentoring and role modelling in educating all care and therapy staC in PCC.
With the support of their managers and the PCC trainer, direct-care staC members were assisted to de-
velop person-centred resident care and recreation activity plans, and to implement changes in care
routines and procedures, with the focus on improving residents’ quality of life and reducing changed

Chenoweth 2014  (Continued)

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behaviours. Ongoing telephone support continued for PCC-trained staC by the PCC trainer until post-
test.

Control: Regular monitoring of any unplanned changes to the environment

Outcomes The following outcomes (measurement scale) were reported:

Quality of life (Dementia Quality of Life: DEMQOL), agitation (Cohen-Mansfield Agitation Inventory:
CMAI), quality of care (Quality of Interactions Schedule: QUIS)

Follow-up: 8 months

Notes Sponsorship source: National Health and Medical Research Council, Australia (funding source category
1), University of Technology Sydney, Australia (primary sponsor) and Australian Health Ministers-States
& Territories, Australia (secondary sponsor). Conflicts of interest: None. Ethical approval: Research
ethics approval was granted by the University of Technology Sydney Human Research Ethics commit-
tee approval number: UTS-HREC 2006-269A in November 2007, and also by the participating residen-
tial care homes. Proxy consent was obtained for all participating residents and both written and verbal
consent were obtained from a small number of residents who were able to understand and remember
the study’s purpose and procedures prior to administering the measures that required their direct in-
volvement.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

Low risk Generated using a SAS program

Allocation concealment
(selection bias)

Unclear risk Unclear where the randomisation sequence was stored

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Blinding not possible on outcomes collected involving residents, family or staC

Incomplete outcome data
(attrition bias)
All outcomes

Unclear risk 31% loss to follow-up and reasons not described. Analysis compared com-
pleters and non-completers.

Selective reporting (re-
porting bias)

Low risk Published protocol and outcomes reported in protocol were the same as in the
main paper.

Other bias Low risk No other instances for bias obvious from the study

Chenoweth 2014  (Continued)

Study characteristics

Methods Study design: Controlled before-after study

Dettbarn-Reggentin 2005 

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Number of facilities: 6 (3 intervention and number of control facilities unclear, but stated there was a
control group “for each of the three residential groups”)

Participants N = 60 (Intervention: N = 27; control N = 33)

Mean age: Intervention: 82.9, control: 83.1

% Female: Intervention: 81.5, control: 78.5

% Dementia: 100

Mean (SD) number of comorbidities: not reported

Country: Germany

Inclusion criteria:

Intervention participants

• Residents from 3 dementia-specific facilities

• Moderate or severe dementia (MMSE < 18)

• Barthel 25-50

• Not excluded based on behaviour

Control participants

• Residents from home operated by same provider

• Matched by age

• Progression of dementia and mobility (Barthel) Cognition: MMSE; function: Barthel; length of stay in
months

Exclusion criteria:

• Not reported

Interventions Name of intervention: Residential group environment

Design features: This was the focus of residential groups for people with dementia. A residential living
environment was created in small residential units that followed family structures. The size was be-
tween 6 and 12 and, exceptionally, up to 15 residents. A home-like living environment, adapted to the
residents, was created for all three segregated residential groups (13, 15, 15 residents). All three resi-
dential groups operated under the live-in kitchen model, aimed at addressing the residents’ multiple
facets (activation, communication, emotion, chronological structuring).

Other features that differed: Nursing home typical organisational structures were replaced by small-
scale design, familiarity, communication, needs-based activity and close human interaction (staC con-
sistency and staC on duty). The daily routine was not dominated by the care activity, but relied on fa-
miliar day-to-day household tasks. StaC members interacted with the residents in a trusting respectful
manner. The events of the day were aligned to the residents’ mobility, cognitive abilities as well as their
habits. The staC assigned to the participating residential groups and the control groups had compara-
ble qualifications and rosters.

Control: Nursing home typical organisational structures.

Outcomes The following outcomes (measurement scale) were reported:

Social behaviour (Nurses Observations Scale for Geriatric Patients: NOSGER), function (Barthel Index)
and cognitive function (Mini Mental State Examination: MMSE)

Follow-up: 12 months

Notes Sponsorship source not reported. Conflicts of interest: Not stated

Dettbarn-Reggentin 2005  (Continued)

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Ethical approval: Not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk No randomisation

Allocation concealment
(selection bias)

High risk Controlled before-after study

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Blinding not feasible

Incomplete outcome data
(attrition bias)
All outcomes

High risk Stated 158 residents participated and 111 available for all three surveys but re-
sults for 60 presented

Selective reporting (re-
porting bias)

High risk Stated Cohen-Mansfield Agitation Inventory measured but results not shown

Other bias High risk No adjustments made so potential for confounding. For baseline characteris-
tics: no statistical tests completed, appeared to be some differences but un-
clear if statistically or clinically significant. Baseline differences in social be-
haviour

Dettbarn-Reggentin 2005  (Continued)

Study characteristics

Methods Study design: Controlled before-after study

Number of facilities: 8 (3 intervention and 5 control)

Participants N = 119 enrolled (Intervention: N = 60, control: N = 59)

Mean age (SD): Intervention: 82.3 (5.7, mild cognitive impairment) 81.5 (7.4, severe cognitive impair-
ment), control: 82.7 (8.0, mild cognitive impairment) 82.2 (8.0, severe cognitive impairment)

% Female: Intervention: 79.8 (mild cognitive impairment) 82.1 (severe cognitive impairment), control:
78.1 (mild cognitive impairment) 82.1 (severe cognitive impairment)

% Dementia: not reported

Mean (SD) number of comorbidities: not reported

Country: Spain

Inclusion criteria:

• Cognitive impairment

Diaz-Veiga 2014 

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• Experimental group: resided in one of the 8 day or permanent cohabitation units, where the interven-
tions relating to “Etxean Ondo” were incorporated

• Control group: The members of the control group were identified from five distinct centres, three of
which coincided with the location of the cohabitation units.

Exclusion criteria:

• Absence of cognitive impairment, measured by Lobo’s Cognitive Mini Examination (MEC > 29)

Interventions Name of intervention: Etxean Ondo

Design features: Creation of domestic environments. “Comfortable, safe and accessible homelike envi-
ronments, which expedite the daily life of the residents by integrating their important preferences, cus-
toms and activities” and “physical spaces were selected that were susceptible to be adapted to the fea-
tures of domestic environments, favouring the incorporation of their own furniture and other decora-
tive and important items both in public and private spaces”.

Other features that differed: The development of important activities and organisational processes
based on the daily life and the resources of residents, families and professionals. Support staC who vol-
unteered to work in the units. Increased staC ratio “support staC ratio was increased, reducing the staC
rotation between the different areas in the centres, and providing them with continuous professional
development” and “periodical meetings of the technical staC (doctor, nurse, psychologist, etc.) with
the support teams were set up, changing the decision-making in relation to the care, with adaptations
based on the information provided by the support staC, who act as “reference professionals” for the
residents.”

Control: Provision of public health services in accordance with the health needs of the residents, the
formal registration of care tasks and activities, and the prioritisation of safety both in the design of the
spaces and the organisation.

Outcomes The following outcomes (measurement scale) were reported:

Quality of life (Quality of Life in Late-Stage Dementia: QUALID for severe cognitive impairment or Fumat
for mild cognitive impairment)

Follow-up: 6 months

Notes Sponsorship source not reported. Conflicts of interest: None
Ethical approval: Not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk No randomisation

Allocation concealment
(selection bias)

High risk Controlled before-after study

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Blinding not feasible

Incomplete outcome data
(attrition bias)

Unclear risk Did not report loss to follow-up

Diaz-Veiga 2014  (Continued)

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All outcomes

Selective reporting (re-
porting bias)

Low risk Outcomes reported as per methods

Other bias High risk No adjustments made so potential confounding. Stated statistically different
quality of life measurements between groups at baseline. Possible contamina-
tion through professional staC “reduced staC rotation” mentioned which indi-
cates there may have still been some rotation, plus technical staC meetings

Diaz-Veiga 2014  (Continued)

Study characteristics

Methods Study design: Controlled before-after study

Number of facilities: 18 (14 corridor design and 4 non-corridor design)

Participants N = 105 (Corridor design: N = 66; non-corridor design: N = 39)

Mean age (SD): Corridor design: 82.9 (5.3), non-corridor design: not reported

% Female: Corridor design: 89, non-corridor design: 87

% Dementia: 100

Mean (SD) number of comorbidities: not reported

Country: Sweden

Inclusion criteria:

• Living with dementia and admitted to group living units in Malmo, Sweden during study period

• Group living eligibility: dementia of Alzheimer’s type or vascular dementia, care planning team judged
home care situation as insufficient

Exclusion criteria:

• Not reported

Interventions Type of intervention: building layout (comparison of group living units with a corridor design versus
non-corridor design (L-shaped, square or H-shaped))

Design features: Built for 6-8 residents, with specially designed community area comprising living
room, laundry, kitchen and dining room shared by the residents and staC. Each resident has a private

area of approximately 25 m2, furnished by the resident and included a toilet and shower. Located in or-
dinary blocks of flats outside institutions. Physical environment assessed by architect in standardised
manner using Therapeutic Environment Screening Scale (TESS-2)

Outcomes The following outcomes (measurement scale) were reported:

Dyspraxia, hallucinations, lack of vitality, dysphasia, paranoia, aggressiveness, depression, clinical vari-
ations, restlessness, recent memory and identity (Organic Brain Syndrome Scale: OBS Scale)

Follow-up: 12 months

Notes Supported by the Swedish Council for Social Research. Conflicts of interest: Not stated. Ethical ap-
proval: Not stated

Elmstahl 1997 

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Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk Controlled before-after study

Allocation concealment
(selection bias)

High risk Controlled before-after study

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk No blinding

Incomplete outcome data
(attrition bias)
All outcomes

Low risk > 90% follow-up; unlikely to bias results

Selective reporting (re-
porting bias)

High risk In the methods, there was mention of measuring ADLs and MMSE but results
for these have not been reported. Also 6-month data were not reported.

Other bias Unclear risk Potential residual confounding and baseline characteristics not shown by
group. Significant differences in lack of vitality and restlessness at baseline.
Adjusted analysis accounted for other symptoms.

Elmstahl 1997  (Continued)

Study characteristics

Methods Study design: cluster-randomised trial (participants served as own controls)

Number of facilities: 8

Participants N = 52 

Mean age (SD): 85.1 (7.1)

% Female: 65.2%

% Dementia: 100

Number of comorbidities: not reported

Country: USA

Inclusion criteria: diagnosis of dementia according to Diagnostic and Statistical Manual of Mental Dis-
orders, Fourth Edition; a Mini Mental State Examination (MMSE) score between 4 and 24 points (indicat-
ing severe [≤ 10] to mild [< 25] dementia) or a Brief Interview for Mental Status (BIMS) score between 3
and 12 points (indicating severe [≤ 7] to moderate [8–12] cognitive impairment), depending on the par-
ticular facility’s evaluation procedures; and a score > 5 (indicating sleep disturbance) on the Pittsburgh
Sleep Quality Index (PSQI) questionnaire

Figueiro 2019 

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Exclusion criteria: Major organ failure, a major illness, a history of head injury, uncontrolled generalised
disorders (e.g. diabetes), obstructing cataracts, macular degeneration, blindness, or used psychotropic
medicine. Those with severe sleep apnoea or restless legs syndrome were also excluded

Interventions Lighting designed to provide high circadian stimulus. Custom-built floor luminaires, light boxes and
light tables were used. Timers activated lights according to wake times and lights were placed in the
person’s bedroom or in the common area until 6 pm.

Outcomes The following outcomes (measurement scale) were reported:

Quality of life (Minimum Data Set Activities of Daily Living Scale (MDS-ADL)), behaviour (Cohen-Mans-
field Agitation Inventory (CMAI)) and depression (Cornell Scale for Depression in Dementia (CSDD))

Notes Sponsorship source: This research was funded by the National Institute on Aging (grant
#R01AG034157); the following manufacturers are acknowledged for their provision of in-kind lighting
products: GE Current, a Daintree company; OSRAM Sylvania; Ketra; and Sharp Corporation. Conflicts of
interest: Neither the funding agency nor the in-kind contributors had
any role in the design, methods, data analysis, or preparation of the manuscript.
Figueiro, Plitnick, Roohan, Sahin, and Rea received research grant support from the National Institutes
of Health, Office of Naval Research, The United States General Services Administration, and industry
(Acuity Brands; Axis Lighting; GE Current, a Daintree company; OSRAM Sylvania; Ketra; USAI Lighting;
Armstrong Ceilings and Walls; Philips Lighting; Cree; View Glass; Marriott International). Kalsher re-
ceived research grant support from the National Institutes of Health. Ethical approval: Approved by the
Rensselaer Polytechnic Institute Institutional Review Board

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

Unclear risk Unclear as to method of sequence generation

Allocation concealment
(selection bias)

Unclear risk Did not specify details

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

Unclear risk Details of blinding not reported

Blinding of outcome as-
sessment (detection bias)
All outcomes

Unclear risk Details of blinding not reported

Incomplete outcome data
(attrition bias)
All outcomes

Unclear risk No flow of participants reported. Reported data not available for 4 participants
due to nonadherence and some data were not usable

Selective reporting (re-
porting bias)

Low risk Trial registered

Other bias Low risk Participants served as own controls.

Figueiro 2019  (Continued)

Study characteristics

Frisoni 1998 

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Methods Study design: Controlled before-after study

Number of facilities: 43 (25 SCU and 18 control)

Participants N = 66 (Special care unit (SCU): N = 31; control: N = 35)

Mean age (SD): SCU: 81 (8), control: 81 (6)

% Female: SCU: 71, control: 80

% Dementia: 100

Mean (SD) number of comorbidities: SCU: 18 (4), control: 19 (3)

Country: Italy

Inclusion criteria:

Facilities

• NHs of East Lombardia region and Milano area that admitted residents with dementia with some de-
gree of behavioural disturbance expected to stay at least 3 months

Patients

• Newly admitted

• Diagnosis of degenerative or vascular dementia according to accepted criteria, MMSE 21 or lower plus
CDR 4 or lower plus at least one behavioural disturbance of mild to moderate severity

• MMSW 16 or lower, CDR score 2-4, NPI total 24 or higher or score of 12 or more in at least one subscale

Exclusion criteria:

• MMSE 22 or higher, extended CDR scale 5 or higher (bed-bound)

• 15 days or more between admission and communication

• Incomplete data provided by NH physician in first screening form

• History of mental insufficiency, psychosis or major depression

Interventions Type of intervention: 10 two-bed rooms, a large wandering area, a dining room, and a separate area
for structured activity (physical and occupational therapy). Exit doors were secured by magnetic locks
opening with a digital code. Noxious stimuli were minimised, and wall colours were made neutral. Way-
finding cues were used to help residents identify different areas.

Outcomes The following outcomes (measurement scale) were reported:

Delusions, hallucinations, agitation, anxiety, euphoria/elation, disinhibition, irritability/lability, abnor-
mal motor behaviour, sleep and global behaviour (NPI), agitation (CMAI), depression, cognitive func-
tion (MMSE and Clinical Dementia Rating), function (Bedford Alzheimer’s Nursing Severity Scale), func-
tion (Barthel Index), falls in 3 months, physical restraints

Follow-up: 3 months

Notes Supported by European Commission (DGV). Conflicts of interest: Not stated. Ethical approval: Not stat-
ed

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk Controlled before-after study

Frisoni 1998  (Continued)

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Allocation concealment
(selection bias)

High risk Allocation not concealed

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Not blinded. Follow-up assessment carried out by same interviewer who car-
ried out baseline assessment whenever possible.

Incomplete outcome data
(attrition bias)
All outcomes

Low risk Appeared to be no loss to follow-up over 3 months

Selective reporting (re-
porting bias)

Low risk All relevant outcomes in the methods section were reported in the results sec-
tion.

Other bias High risk Possibility of residual confounding. High risk of falls outcome only; low risk for
other outcomes. Higher risk of falls (Tinetti balance and gait scale) in tradition-
al arm. Differences in behavioural disturbances at baseline (although not sta-
tistically significant) and no adjustments made

Frisoni 1998  (Continued)

Study characteristics

Methods Study design: cluster-randomised controlled trial

Number of facilities: 12 (6 intervention and 6 control)

Participants N = 336 (173 intervention, 163 control)

Mean age (SD): 82.6 (10.1). Intervention: 82.7 (9.8), control: 82.5 (10.4)

% Female: 72.0%. Intervention: 72.3%, control: 71.8%

% Dementia: not reported

Mean comorbidities (SD): 2.9 (1.6). Intervention: 2.8 (1.5), control: 3.1 (1.7)

Country: USA

Inclusion criteria: 55 years of age or older, able to speak English, currently living in the nursing home,
and scored ≤ 15 on the Mini-Mental State Examination (MMSE)

Exclusion criteria: receiving hospice or sub-acute rehabilitation

Interventions Function and Behavior Focused Care for the Cognitively Impaired (FBFC). The FBFC Research Nurse
worked with the facility Champion to assess the facility’s policies and the environment to identify op-
portunities for physical activity and engaging in functional tasks as well as barriers to these activities.
For example, corridors were evaluated for wide, clear areas for walking and outdoor access was as-
sessed. In addition, the FBFC Nurse and Champion collaborated with the activities director and reha-
bilitation staC (as available) to determine opportunities for exercise classes within the facility. Barriers
to physical activity, such as policies that unnecessarily restrict movement for fear of falls, and environ-
ments that lack rest areas and age-appropriate exercise materials also were assessed. Based on these

Galik 2021 

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assessments, modifications in policy and the environment were made, such as increasing availability
of recreational activities that included physical activity (i.e. horseshoes, resistance bands, physical ac-
tivity, BINGO), having adequate supply of chairs in dining rooms to allow for transfer out of wheelchairs
for meals, having safe access to the outdoors, placing a bench in a hallway to have a resting place when
walking, providing long-handle sponges, no spill cups, adaptive utensils as appropriate, and changing
the height of a toilet or bed to facilitate function.

Outcomes The following outcomes (measurement scale) were reported:

Depression (Cornell Scale for Depression in Dementia (CSDD)), behaviour (Cohen-Mansfield Agitation
Inventory (CMAI)), resistiveness to care (Resistiveness to Care Scale) and function (Barthel Index)

Notes Sponsorship source: National Institute on Aging grant R01 AG046217. Conflicts of interest: None. Ethical
approval: Approved by a university-based institutional review board

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

Low risk Coin toss within matched pairs

Allocation concealment
(selection bias)

Unclear risk Not specified

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk High for staC reported, functional ability, behaviour and mood

Incomplete outcome data
(attrition bias)
All outcomes

Unclear risk Large loss to follow-up, 146 (30%) after randomisation due to MMSE but un-
clear which randomised group they belonged to. Other reasons: very roughly
balanced follow-up 61% intervention group, 73% control group (119/163)

Selective reporting (re-
porting bias)

Low risk All reported as per methods

Other bias Unclear risk Differences in baseline outcome measures but no statistical significance re-
ported

Galik 2021  (Continued)

Study characteristics

Methods Study design: Randomised trial (cross-over)

Number of facilities: 8 (cross-over trial)

Participants N = 80 enrolled; N = 69 post-intervention

Mean age (SD): 85.8 (7.5)

% Female: 86.3

Hopkins 2017 

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% Dementia: not reported

Mean (SD) number of comorbidities: not reported

Country: England

Inclusion criteria:

• Resident of one of seven included care homes over 60 years of age

• Willing and able to give written informed consent or their family spend time each day in communal
rooms where lights were installed

Exclusion criteria:

• Did not meet inclusion criteria

Interventions Type of intervention: lighting (blue-enriched lighting)

Design features: High colour temperature (17000 K) blue-enriched white light in communal areas

Control: Low colour temperature (4000 K) white light

Outcomes The following outcomes (measurement scale) were reported:

Behaviour and depression (Hospital Anxiety and Depression: HAD scale and Geriatric Depression Scale:
GDS)

Follow-up: 4 weeks

Notes Sponsorship source: Cross-Council New Dynamics of Ageing (NDA) Initiative

Conflicts of interest: There were no financial, personal, potential conflicts of interest in the conduct of
the study or in the manuscript development. Although Philips Lighting supplied the light fitments, they
had no part in the design of the protocol nor in the analysis of the data. Prof. Skene and Dr Middleton
are co-directors of Stockgrand Ltd and Prof. Skene has in the past received research grant support from
Philips. Dr. Luc Schlangen is an employee of Philips Research.
Ethical approval: A favourable ethical opinion was obtained from the University of Surrey Ethics Com-
mittee and the care homes, whilst all research was carried out according to the Declaration of Helsin-
ki 2008. Informed written consent was obtained from participants or their families where participants
were unable to give consent themselves.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

Unclear risk Described as randomised but did not specify randomisation

Allocation concealment
(selection bias)

Unclear risk Did not specify details

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk No blinding reported

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk No blinding reported

Incomplete outcome data
(attrition bias)

High risk 69 completed study but 56 at most were analysed for included outcomes.

Hopkins 2017  (Continued)

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All outcomes

Selective reporting (re-
porting bias)

Unclear risk Paper did not report details of published study protocol or trial registration.

Other bias Unclear risk Age and sex reported for each care home at baseline appeared to be different,
but no statistical tests performed and no other characteristics reported. Base-
line outcomes measures reported in little detail

Hopkins 2017  (Continued)

Study characteristics

Methods Study design: Controlled before-after study

Number of facilities: 6 (3 intervention and 3 control)

Participants N = 120 (Intervention: N = 57; control: N = 48)

Mean age (SD): Intervention: 86.1 (6.7), control: 87.7 (6.8)

% Female: Intervention: 67, control: 75

% Dementia: not reported

Mean (SD) number of comorbidities: not reported

Country: UK

Inclusion criteria:

• If informed assent provided (where the resident could not self-consent), the interview only went ahead
if the resident appeared happy and relaxed during the process.

Exclusion criteria:

• Living in the care home less than two months

Interventions Type of intervention: dining

Design features: Food displayed for residents to see, fewer tables in dining room, tablecloths, flowers
on table, white crockery with side plates for vegetables, drinks machine available at all times, biscuits,
fruit, sandwiches and yoghurts on display available any time

Other features that differed: Increased choice at meals, increased number of hot meal options at break-
fast and evening meal, choice of meal at mealtime with change of mind accommodated, use of buffet
and Bain-Marie to display options to residents, dining open for 90 minutes with several sittings of resi-
dents, visitors welcome, large variety of self-service snacks available

Control: Limited choice at meals, only cold meal options available at breakfast and evening meal, res-
idents make their meal selection in advance, meals at set times with single sitting, visitors rarely eat
with residents, limited drinks and snacks available only on drinks trolley

Outcomes The following outcomes (measurement scale) were reported:

Cognitive function (Mini Mental State Examination: MMSE), behaviour and depression (Hospital Anxiety
and Depression: HAD scale) and adverse events (number of falls)

Follow-up: 12 months

Kenkmann 2010 

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Notes Funded by Norfolk City Council

Conflicts of interest: The research was funded by Norfolk County Council, and JB works for Norfolk
County Council. These links did not affect the way that the data are presented. Ethical approval:
Ethical approval for the study was obtained from the University of East Anglia, Faculty of Health,
Ethics Committee. The trial was registered as ISRCTN86057119 (see http://www.controlled-tri- al-
s.com/ISRCTN86057119).

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk Non-randomised trial

Allocation concealment
(selection bias)

High risk Non-randomised trial

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Primary outcome (falls) measured from the notes as reported by staC (who
knew the allocation)

Incomplete outcome data
(attrition bias)
All outcomes

High risk Significant incomplete outcome data (which authors themselves noted)

Selective reporting (re-
porting bias)

Low risk No evidence of selective reporting as all outcomes described in methods were
in results

Other bias High risk Potential residual confounding. Significant differences in baseline characteris-
tics between groups at baseline

Kenkmann 2010  (Continued)

Study characteristics

Methods Study design: Repeated measures study with no control group

Number of facilities: 2 (repeated measures study)

Participants N = 34

Mean age: 77.8

% Female: 33

% Dementia: 100

Mean (SD) number of comorbidities: not reported

Country: Canada

Inclusion criteria:

Marcy-Edwards 2011 

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• A diagnosis of dementia

• Presence of one or more difficult to manage behaviours

• Living in a long-term care setting

• Consent from their legal guardian to participate

• Moderate to severe dementia as indicated by Global Deterioration Scale/Functional Assessment Stag-
ing (GDS/FAST) (138, 139) scores of 5 to 7 and Mini Mental State Exam (MMSE) (139, 140) score of less
than 20

• Residence on the unit for a minimum of four weeks

• A minimum of one difficult-to-manage behaviour such as delusions, hallucinations, agitation/aggres-
sion, depression/dysphoria, anxiety, elation/euphoria, apathy/indifference, disinhibition, irritabili-
ty/lability, aberrant motor behaviour, sleep and night-time behaviour disorders, and appetite and
eating disorders

Exclusion criteria:

• Presence of intractable pain

Interventions Type of intervention: Garden vignette

Design features: Designated area that contained clusters of gardening and nature-related objects de-
signed to both attract attention and encourage self-determined interaction and exploration. Identi-
cal vignettes were established on each unit directly opposite each other but separated by a five-foot
high wall. Positioned in a highly visible, high traffic space. The vignette included all objects required
to accomplish the activity of gardening: a sturdy garden centre table; soil, plastic pots, garden seeds,
light plastic garden tools, and a plastic watering can; scented, colourful, edible plants; glossy garden-
ing magazines with engaging pictures; and large artificial flowers to attract attention. When the garden
vignette was in place, all residents had unobstructed exposure and access, 24 hours per day.

Outcomes The following outcomes (measurement scale) were reported:

Behaviour (Neuropsychiatric Inventory for Nursing Homes: NPI-NH and NPI-NH-Occupational Distress:
NPI-NH-OD)

Follow-up: Placed for 14 days then removed for 14 days and process repeated once

Notes Sponsorship source: Canadian Nurses Foundation, Dr. Ann Beckingham Scholarship and the Alberta
Registered Nurses Educational Trust Scholarship.

Conflicts of interest: Not stated.
Ethical approval: The Institutional Ethics Review Board of the University of Calgary granted ethics ap-
proval

Risk of bias

Bias Authors’ judgement Support for judgement

Allocation concealment
(selection bias)

High risk Repeated measures study, no control group

Incomplete outcome data
(attrition bias)
All outcomes

Low risk Lowest follow-up for one outcome was 29/34 = 85%.

Selective reporting (re-
porting bias)

Low risk All outcomes reported as stated in methods

Other bias Low risk Same study participants used as repeated measures study. Intervention re-
moved during washout phases

Marcy-Edwards 2011  (Continued)

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Intervention independent
of other changes (ITS)

Unclear risk No reported compelling evidence that intervention was independent, nor
that that intervention was not independent of other changes in time

Shape of the intervention
effect pre-specified (ITS)

High risk Baseline measurement spread over 4 weeks, performed at time of admission,
then intervention effect in second week of vignette rather than at the time of
intervention

Intervention unlikely to af-
fect data collection (ITS)

Low risk Sources and methods of data collection were the same before and after the in-
tervention.

Marcy-Edwards 2011  (Continued)

Study characteristics

Methods Study design: Cluster-randomised controlled trial

Number of facilities: 4 wards in one nursing home randomised (2 Intervention wards and 2 control
wards)

Participants N enrolled: Intervention: 21, control: 17. N analysed: Intervention: 20, control: 14

Mean age (SD): Intervention: 82.6 (7.5), control: 78.2 (7)

% Female: Intervention: 66.6, control: 70

% Dementia: Not reported

Mean (SD) number of comorbidities: Intervention: 3 (1.2), control: 2.3 (1.3)

Country: The Netherlands.

Inclusion criteria:

• Resident in a nursing home from one of the four wards invited to join the study

• Older than 65 years

• Resident for more than 3 months at the start of the study

Exclusion criteria:

• Parenteral nutrition

• Terminal phase of a disease

• A specific exclusion criterion for the analyses of biochemical indicators of health was applied for the
patients with severe anaemia.

Interventions Type of intervention: Dining

Design features: Plant or flowers placed on every table and sufficient lighting. Background music cho-
sen by the patients. Just before meals, tables were dressed up in the dining room with appropriate
tablecloths and dinner plates, trays and covers removed from the table, carers out of patients’ sight.
Other features that differed: Dishes served on dinner plate per course and per table, simultaneous start
of the meal per table, and possibility of receiving help when necessary. Breakfast and supper served
per table and at patients’ discretion: no ready-to-eat sandwiches. Continuous availability of coffee, tea,
and soJ drinks such as fruit juices outside meal periods. Rescheduling nursing staC timetable to have
enough nurses at mealtime (one nurse for two patients). No walking around of the nursing staC in the
dining room during meals. Medications handed out before the start of the meal to distinguish med-
ical care and meals. No interference with patients’ meal: no questions or wishes for the next meal. Pro-
gramme monitoring every trimester by both nursing staC and researchers. No cleaning activities in the

Mathey 2001 

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dining room during meal consumption. Immediately after meals, tidying up the dining-room for the so-
cial activities

Outcomes The following outcomes (measurement scale) were reported:

Quality of life (Sickness Impact Profile: SIP and Dutch version of the Philadelphia Geriatric Center Moral
Scale: PGCMS)

Follow-up: 4 months, 8 months and 12 months

Notes Sponsorship source: Not reported.

Conflicts of interest: Not stated. Ethical approval: The study protocol was approved by the ethical com-
mittee of the nursing home.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

Unclear risk Randomisation method not stated

Allocation concealment
(selection bias)

Unclear risk No details reported

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

Unclear risk Not reported

Incomplete outcome data
(attrition bias)
All outcomes

High risk 58% loss to follow-up for quality of life outcomes

Selective reporting (re-
porting bias)

Unclear risk Protocol or trial registration not mentioned

Other bias High risk Some clinical differences between groups in baseline characteristics. Statis-
tical significance of differences not reported. Likely some contamination as
wards randomised but within one nursing home

Mathey 2001  (Continued)

Study characteristics

Methods Study design: Cluster-randomised controlled trial

Number of facilities: 6 (3 intervention and 3 control)

Participants N enrolled: Intervention: 133, control: 112. N analysed: Intervention: 95, control: 83

Mean age (SD): Intervention: 78 (11.1), control: 75 (9.9)

% Female: Intervention: 70, control: 55

Nijs 2006 

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% Dementia: 0

Mean (SD) number of comorbidities: Intervention: 3 (1.4), control: 3 (1.6)

Country: The Netherlands

Inclusion criteria:

• Residing in an eligible nursing home ward (medium-sized, general population, two wards for chronic
somatic disease, long-term care, cover different parts of country, similar in organisational character-
istics)

Exclusion criteria:

• Terminal phase of disease

• Needing total parenteral feeding

• Unable to give informed consent owing to a physical or mental condition

Interventions Type of intervention: Dining

Design features: Tablecloths, normal plates and glasses, full cutlery, and flower arrangements

Other features that differed: Cooked meals served on table, greater choice at meals, residents decide
when meal begins, staC sit down with residents

Control: No tablecloth, plastic cups, pre-designed plate, divided into 3 sections, residents wear bibs.
Cooked meals served individually on pre-plated tray, residents choose meals two weeks before, staC do
not sit down, no choice in meal times

Outcomes The following outcomes (measurement scale) were reported:

Quality of life (Dutch Quality of Life of Somatic Nursing Home Residents questionnaire) and function
(Nursing Home Physical Performance test)

Follow-up: 6 months

Notes Sponsorship source: Netherlands Organisation for Health Research and Development. Conflicts of
interest: None. Ethical approval: This study was approved by the Ethical Committees of the nursing
homes and the Medical Ethical Committee of Wageningen University.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk Non-random component in the sequence generation (e.g. using first letter of
ward name)

Allocation concealment
(selection bias)

Low risk Randomisation at start of study

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

Unclear risk Allocation was blinded but did not describe details of whether the analyses
were blinded

Nijs 2006  (Continued)

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Incomplete outcome data
(attrition bias)
All outcomes

High risk Follow-up < 80%

Selective reporting (re-
porting bias)

Low risk All outcomes in methods reported in results

Other bias High risk Baseline differences between groups in age, gender and length of stay

Nijs 2006  (Continued)

Study characteristics

Methods Study design: 2 x 2 factorial randomised trial

Number of facilities: 12 (6 intervention and 6 control)

Participants N enrolled: intervention: 49, control: 45. N analysed: Intervention: 47, control: 40

Mean age (SD): Intervention: 85 (6), control: 85 (5)

% Female: Intervention: 91.8, control: 88.9

% Dementia: 100

Mean (SD) number of comorbidities: not reported

Country: The Netherlands

Inclusion criteria:

• Resident at one of 12 facilities who agreed to participate (assisted-care facilities in which residents
have their own apartment where they sleep and retreat, but spend most of the daytime in a common
living room supervised by caregivers)

Exclusion criteria:

• Nil other

Interventions Type of intervention: Lighting (bright light)

Design features: Light exposure was manipulated by installing a large number of ceiling-mounted fix-
tures with Plexiglas diffusers containing an equal amount of Philips TLD 840 and 940 fluorescent tubes
in the common living room. Lights were on daily between approximately 9 am and 6 pm. Light intensity
was increased to ± 1000 lux between 10 am and 6 pm at the 6 light facilities (active condition)

Control: An equal number of fixtures were installed, but these contained only half of the tubes, accom-
modated concealed band-stop filters, and were installed at a greater distance from the eyes.

Outcomes The following outcomes (measurement scale) were reported:

Behaviour (Neuropsychiatric Inventory: NPI), depression (Cornell Scale for Depression in Dementia:
CSDD), withdrawn behaviour (sub-scale of the Multi Observational Scale for Elderly Subjects: MOSES),
agitation (Cohen-Mansfield Agitation Inventory: CMAI), positive and negative mood (Philadelphia Geri-
atric Centre Affect Rating Scale: PGCARS), cognitive function (Mini Mental State Examination: MMSE),
and function (Nurse-informant adaptation of the scale by Katz and colleagues)

Riemersma-vanDerLek 2008 

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Follow-up: 6 weeks, 6 months, 12 months, 18 months and 24 months

Notes Sponsorship source: Financial and material support were provided by the Netherlands Organisation
for Health Research, The Hague, by grants 0028-300-30 and 907-00-012; the Netherlands Organisation
for Scientific Research, The Hague, by grants 016.025.041 and 051.04.010; the Stichting De Drie Lichten,
Leiden;Stichting RVVZ; Zeist by grant 01-220; Japan Foundation for Aging and Health; Hersenstichting
Nederland by grant 11F04-2.47; Internationale Stichting Alzheimer Onderzoek by grant 05511. Philips
Lighting BV, Braun, and Cambridge Neurotechnology supplied material for this study at reduced cost.

Conflicts of interest: Reported no financial disclosures
Ethical approval: The Medical Ethics Committees of Hospital De GelderseVallei, Ede, and the VU Univer-
sity Medical Center, Amsterdam, the Netherlands, approved the study.

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

Low risk Random number generator

Allocation concealment
(selection bias)

Low risk Managed by a research assistant external to the study

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

Low risk Stated caregivers blinded and no significant difference when they asked care-
givers to guess their facilities light status

Blinding of outcome as-
sessment (detection bias)
All outcomes

Low risk Assessors were blinded to allocation.

Incomplete outcome data
(attrition bias)
All outcomes

High risk High loss to follow-up

Selective reporting (re-
porting bias)

Low risk Registered on clinical trial registry – all outcomes reported

Other bias Low risk No significant differences in baseline characteristics between groups. No dif-
ferences in baseline outcome variables. Light exposure randomised by facility
protecting against contamination

Riemersma-vanDerLek 2008  (Continued)

Study characteristics

Methods Study design: Controlled before-after study

Number of facilities: 26 (19 intervention and 7 control)

Participants N enrolled: Intervention: 79, control: 132. N analysed: Intervention: 67, control: 97

Mean age (95% confidence interval): Intervention: 81.2 (79.7, 82.7), control: 83.6 (81.1, 86.1)

% Female: Intervention: 91.0, control: 73.2

% Dementia: 100

Te Boekhorst 2009 

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Mean (SD) number of comorbidities: not reported

Country: The Netherlands

Inclusion criteria:

• Psychogeriatric group living homes and psychogeriatric nursing homes or nursing homes with psy-
chogeriatric units were selected.

Group living homes

• Maximum 6 residents

• Maximum 6 units

• Situated more than 200 m from the nursing home to which they belonged

• Prepared their own meals

• Built more than 2 years prior to the start of the study

Traditional nursing homes

• Built according to the Dutch 1997 Building Regulation for Nursing Homes

• 20 residents per unit

Exclusion criteria:

• Residents not surviving to 6 months

Interventions Type of intervention: home-like model

Design features: Psychogeriatric group living homes. Criteria based on Concept Map that defined group
living care (a) had a maximum of six residents; (b) had a maximum of six units; (c) were situated more
than 200 meters from the nursing home to which they belonged; (d) prepared their own meals and (e)
were built more than 2 years prior to the start of the study.

Control: Psychogeriatric nursing homes or nursing homes with psychogeriatric units. Built according to
the Dutch 1997 Building Regulation for Nursing Homes, as these facilities offer, among other structural
improvements, only single bedrooms. Large-scale: more than 20 residents per unit were included in the
study.

Outcomes The following outcomes (measurement scale) were reported:

Quality of life (Dementia Quality of Life: DQoL), behaviour (Revised Memory and Behavior Problems
Checklist: RMBPC and the Neuropsychiatric Inventory-Questionnaire: NPI-Q), cognitive function (Stan-
dardised Mini Mental State Examination: S-MMSE), function (Interview for the Deterioration of Daily Liv-
ing activities in Dementia: IDDD), social engagement (Revised Index of Social Engagement: RISE from
the Resident Assessment Instrument: RAI) and physical restraints (nursing home physician or psycholo-
gist asked whether residents were prescribed one or more physical restraints)

Follow-up: 6 months

Notes Sponsorship source: Dutch ministry of Health Welfare and Sport, Foundation Het Zonnehuis, ActiZ or-
ganisation of care entrepreneurs

The authors had no conflicts of interests during any part of the study. Sponsors had no role in the de-
sign, collection, analysis and interpretation of the data, nor in writing the report and the decision to
submit it for publication.
Ethical approval: The study was approved by the Medical Ethics Committee of the National Institute of
Mental Health and Addiction.

Risk of bias

Bias Authors’ judgement Support for judgement

Te Boekhorst 2009  (Continued)

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Random sequence genera-
tion (selection bias)

High risk Controlled before-after study

Allocation concealment
(selection bias)

High risk Controlled before-after study

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Blinding not feasible

Incomplete outcome data
(attrition bias)
All outcomes

High risk < 80% follow-up

Selective reporting (re-
porting bias)

Low risk All outcomes reported as stated in methods

Other bias High risk Potential residual confounding. Significant differences in cognition (MMSE)
and depression scores at baseline

Te Boekhorst 2009  (Continued)

Study characteristics

Methods Study design: Controlled before-after study

Number of facilities: 112 (89 intervention and 23 control)

Participants N enrolled: Intervention: 34, control: 22. N analysed: Intervention: 20, control: 13

Mean age (SD): Intervention: 83.4 (8.1), control: 81.2 (10.4)

% Female: Intervention: 76.9, control: 23.1

% Dementia: 100

Mean (SD) number of comorbidities: not reported

Country: Germany

Inclusion criteria:

• New residents of SHA and SCU with dementia in Berlin 1 July-31 Dec 2008

• Established diagnosis dementia – MMSE 24 or below

• Moving into SHA or SCU within 14 days

• Control (SCU): Admission criteria were eligibility to benefits under the long-term care insurance
scheme, a medical diagnosis of irreversible dementia and a score of less than 18 points according to
the MMSE, severe behavioural problems according to the modified Cohen-Mansfield Agitation Inven-
tory and being able to participate in group activities and general group social life.

Exclusion criteria:

• Not reported

Wolf-Ostermann 2012 

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Interventions Type of intervention: home-like model

Design features: Small-scale living shared housing arrangements were completely disconnected from
traditional nursing homes. Often situated in large apartments in mostly urban settings, mostly 6-8 peo-
ple, which had typical structures of a flat with a kitchen, a living room and private bedrooms

Control: Special-care unit for people with dementia. Admission criteria for special-care unit for people
with dementia in Berlin were eligibility to benefits under the long-term care insurance scheme, a med-
ical diagnosis of irreversible dementia and a score of less than 18 points according to the MMSE, severe
behavioural problems according to the modified Cohen-Mansfield Agitation Inventory and being able
to participate in group activities and general group social life.

Outcomes The following outcomes (measurement scale) were reported:

Quality of life (Dementia-specific QUALIDEM), behaviour (Neuropsychiatric Inventory for Nursing
Homes: NPI-NH), cognitive function (Mini Mental State Examination: MMSE and Global Deterioration
Scale: GDS to assess severity of dementia) and function (Barthel ADL Index)

Follow-up: 6 months and 12 months

Notes Sponsorship source: Grant of the German Federal Ministry of Health ‘Leuchtturmprojekt Demenz’

Conflicts of interest: Not stated
Ethical approval: The study was approved by the Medical Ethics Committee of Charite ́–Universi-
tätsmedizin Berlin (application number EA1/109/08).

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk Controlled before-after study

Allocation concealment
(selection bias)

High risk Controlled before-after study

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Blinding not feasible

Incomplete outcome data
(attrition bias)
All outcomes

High risk Large loss to follow-up; not balanced between groups

Selective reporting (re-
porting bias)

Low risk Outcomes reported as per methods

Other bias High risk Potential residual confounding. Significant differences in gender at baseline

Wolf-Ostermann 2012  (Continued)

Study characteristics

Wylie 2001 

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Methods Study design: Controlled before-after study

Number of facilities: 5 (3 intervention and 2 control)

Participants N enrolled: Intervention: 41, control: 59. N analysed: Intervention: 25, control: 45

Mean age: Not reported

% Female: Not reported

% Dementia: Not reported

Mean (SD) number of comorbidities: not reported

Country: USA

Inclusion criteria:

Facilities

• Experimental: Texas nursing homes initiating the implementation process of the Eden Alternative™
model in their respective facilities

• Control: Texas nursing homes not initiating the Eden Alternative™ model agreed to participate.

Residents

• Facility social workers’ assessment of the residents’ cognitive ability to understand and complete
questionnaires

• Agree to participate

Interventions Name of intervention: Eden alternative

Design features: Human habitat model – pets, plants and children. Imbued daily life with variety and
spontaneity by creating an environment in which unexpected and unpredictable interactions and hap-
penings can take place. Other features: Provided daily opportunities to give as well as receive care by
promoting resident participation in the daily round of activities that are necessary to maintain the Hu-
man Habitat. De-emphasised the role of prescription drugs in the residents’ daily lives and commit-
ted those resources to the maintenance and growth of the Human Habitat. Leadership that placed the
need to improve resident quality of life over and above the inevitable objections to change

Control: Traditional nursing home

Outcomes The following outcomes (measurement scale) were reported:

Quality of life (Life Satisfaction Index: LSI)

Follow-up: 6 months, 12 months and 18 months

Notes Sponsorship source: Unclear

Conflicts of interest: Not stated
Ethical approval: Not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk Not randomised

Allocation concealment
(selection bias)

High risk Controlled before-after study

Wylie 2001  (Continued)

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Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Blinding not feasible

Incomplete outcome data
(attrition bias)
All outcomes

High risk Loss to follow-up 30% by second data collection point

Selective reporting (re-
porting bias)

Low risk Outcomes reported as in methods

Other bias High risk Potential residual confounding. Some resident and staC baseline character-
istics reported in Table 1, p. 15, no statistical comparisons performed. Differ-
ences in staC turnover between facilities. Difference in payer type and racial
mix for Eden model. Significant difference in proportion of payers for Eden
vs control (reviewer calc: Eden 301/410 vs 25/313 control; P < 0.0000001 Chi-
square Epionline). Some contamination; one control facility commenced im-
plementing the Eden alternative and then abandoned.

Wylie 2001  (Continued)

Study characteristics

Methods Study design: Controlled before-after study

Number of facilities: 13 (9 intervention and 4 control)

Participants N = 242 (Intervention: N = 93; control: N = 149)

Mean age (SD): Intervention: 87.2 (7.2), control: 85.8 (9.7)

% Female: Intervention: 73.1, control: 73.9

% Dementia: Intervention: 55.9, control: 50.0

Mean (SD) number of comorbidities: Intervention: 1.9 (1.2), control: 2.3 (1.4)

Country: USA

Inclusion criteria:

• Residing in included nursing home for at least six months

Exclusion criteria:

• Admitted for short-term rehab or hospice at the start of their stay

Interventions Type of intervention: home-like model

Name of intervention: Green House model

Design features: Home-like environment, Cluster of 2 or 3 homes with 10 residents each, private bed-
room and bathroom, large common living and dining room, no nurses stations, medication carts, pag-
ing systems

Yoon 2015 

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Other features that differed: Organisational changes to support resident quality of life, care staC have
diverse roles and greater autonomy and responsibility in daily care.

Control: Traditional large scale nursing homes, hospital-like features such as nurses stations, medica-
tion charts, paging systems. Traditional hierarchical organisational structure and traditional care staC
roles

Outcomes The following outcomes (measurement scale) were reported:

Social engagement (Index of Social Engagement: ISE), depressive symptoms (Mood Scale Score: MSS),
function (ADL long-form scale) and cognitive function (Cognitive Performance Scale: CPS)

Follow-up: Up to 18 months

Notes Study partially supported by a grant from the Robert Wood Johnson Foundation (Grant 66360; PI: SDH)
and the Clinical and Translational Science Award Program, through the NIH National Center for Ad-
vancing Translational Sciences (grant UL1TR000427; BJB)

Conflicts of interest: None

Ethical approval: Not stated

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence genera-
tion (selection bias)

High risk Controlled before-after study

Allocation concealment
(selection bias)

High risk Controlled before-after study

Blinding of participants
and personnel (perfor-
mance bias)
All outcomes

High risk Blinding not feasible

Blinding of outcome as-
sessment (detection bias)
All outcomes

High risk Blinding not feasible

Incomplete outcome data
(attrition bias)
All outcomes

High risk High loss to follow-up (62%)

Selective reporting (re-
porting bias)

Unclear risk Many outcomes on MDS so unclear how outcomes were decided

Other bias High risk Potential residual confounding. Significant difference in comorbidities at
baseline

Yoon 2015  (Continued)

ADLs: Activities of Daily Living
BIMS: Brief Interview for Mental Status
CDR: Clinical Dementia Rating
CMAI: Cohen-Mansfield Agitation Inventory
CPS: Cognitive Performance Scale
CSDD: Cornell Scale for Depression in Dementia
DEMQOL: Dementia Quality of Life questionnaire
DQoL: Dementia Quality of Life

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DSM-III: Diagnostic and Statistical Manual of Mental Disorders Third Edition
EAT: Environment Audit Tool
FAST: Fuctional Assessment Staging
FBFC: Function and Behavior Focused Care
GDS: Geriatric Depression Scale
GH: GreenHouse
HAD: Hospital Anxiety and Depression Scale
IDDD: Interview for the Deterioration of Daily Living activities in Dementia
ISE: Index of Social Engagement
MDS: Minimum Data Set
MEC: Mini-Examination Cognitive
MMSE: Mini Mental State Examination
MOSES: Multi Observational Scale for Elderly Subjects
MSS: Mood Scale Score
NDA: New Dynamics of Aging
NH: Nursing Home
NOSGER: Nurses Observation Scale for Geriatric Patients
NPI-(Q): Neuropsychiatric Inventory Questionnaire
OBS: Organic Brain Syndrome
OD: Occupational Distress
OSCAR: Online Survey, Certification, and Reporting
PCC: Person-Centred Care
PCE(CAT): Person-Centred Environment (Care Assessment Tool)
PGCARS: Philadelphia Geriatric Centre ACect Rating Scale
PGCMS: Philadelphia Geriatric Center Moral Scale
PSQI: Pittsburgh Sleep Quality Index
QUALID: Quality of Life in Late-Stage Dementia
QUALIDEM: A Dementia-Specific Quality of Life measure
QUIS: Quality of Interactions Schedule
RAI: Resident Assessment Instrument
RFI: Room for Improvement
RISE: Revised Index of Social Engagement
RMBPC: Revised Memory and Behavior Problems Checklist
SAS: Statistial Analytics System
SCU: Special Care Unit
SD: Standard Deviation
SHA: Shared Housing Arrangement
SIP: Sickness Impact Profile
TESS-2: Therapeutic Environment Screening Scale-2
UE: Usual Environment
vs.: versus
 

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Auer 2017 Longitudinal study but not before-after (no measure on admission to facility) and only one inter-
vention site

Barrick 2010 Majority of participants were from a hospital setting and could not separate out those who were
from a residential care environment.

Bergman-Evans 2004 One intervention and one control site

Bonardi 1989 One intervention and one control site

Bond 1999 One intervention and one control site

Chafetz 1991 One intervention and one control site

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Study Reason for exclusion

Chang 2013 One intervention and one control site

Cohen-Mansfield 1998 One intervention and one control site

Coleman 2002 One intervention and one control site

De Boer 2017 Longitudinal study but not before-after (no measure on admission to facility)

De Rooij 2012 Longitudinal study but not before-after (no measure on admission to facility)

Falk 2009 Longitudinal study but not before-after (no measure on admission to facility)

Giggins Before-after study with one nursing home and no comparator group

Hermer 2017 Only one intervention site.

Holmes 1990 Longitudinal study but not before-after (no measure on admission to facility)

Inventor 2018 Only one control and one intervention site

Kane 2007 Only one intervention site

Klosinska Before-after study with one nursing home and no comparator group

Kok 2017 One intervention and one control site

Kok 2018 Only one intervention and one control site

Kubsch 2018 Only one intervention and one control site

Lee 2016 One intervention and one control site

Lum 2008 Only one intervention site

Molony 2011 One intervention and one control site

O’Connor 1991 One intervention and one control site

Palm 2019 Longitudinal study but not before-after (no measure on admission to facility)

Pomeroy 2011 Repeated measures without measures before the intervention

Potter 2018 Longitudinal study but not before-after (no measure on admission to facility)

Reimer 2004 Only one intervention site

Scott 2014 Only one control site

Steiner 2020 Only one control site

Varshawsky  Before-after study with one nursing home and no comparator group

Verbeek 2014 Longitudinal study but not before-after (no measure on admission to facility)

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Characteristics of studies awaiting classification [ordered by study ID]

Methods Cluster-randomised controlled trial

Participants 69 participants

Inclusion criteria:

• ≥ 60 years and in long-term care (> 4 weeks)

• had dementia in accordance with DSM-5

• had either sleep/circadian rhythm disturbances, BPSD as identified by NPI-NH, or severely re-
duced ADL function

• provided written informed consent if the participant had capacity or, if not, a written proxy in-
formed consent from a legally authorised representative

Exclusion criteria:

• blind or might otherwise not benefit from light

• took part in another trial

• had a condition contra-indicated to the intervention

• had an advanced, severe medical disease/disorder and/or expected survival less of than 6 months
or other aspects that could interfere with participation

• were psychotic or had a severe mental disorder

Interventions Light-emitting diode (LED) ceiling-mounted bright light solution that was installed in the com-
mon rooms of four intervention units. The light setup was delivered by Glamox, using a number of
square LED units (Glamox, 1 x C95 48 CCT 6,500 K MP 47 W/4,702 lm). Glamox engineers calculated
the number of LED units needed to provide the target light levels in each common room, account-
ing for the number and direction of windows. The LED units were programmed to provide 400 lux
and 3,000 K (measured vertically) from 07:00-10:00, 1,000 lux and 6,000 K from 10:00 to 15:00, 400
lux and 3,000 K from 15:00-18:00, and 100 lux and 2,500 K from 18:00-21:00. Light values gradually
changed across 30 minutes.

Outcomes Depression: Cornell Scale for Depression in Dementia (CSDD)

Global behaviour: Neuropsychiatric Inventory Nursing Home Version (NPI-NH)

Notes Sponsorship source: The dissertation was part of the public sector Ph.D. scheme by the Research
Council of Norway (Sponsor’s Protocol Code 259987/H40), where the Department of Health and
Care, City of Bergen, has been the candidate’s employer. The candidate also received funding from
Thordis and Johannes Gahrs Fund for Promoting Gerontopsychiatric Research. The trial received
funding for the light fittings used in the trial from the Rebekka Ege Hegermanns Grant and the GC
Rieber Foundations.

Conflicts of interest: None

Ethical approval: The trial was approved by the Regional Committee for Medical and Health Re-
search Ethics, Health Region South East (project no. 2016/2246).

Kolberg 2020 

ADL: Activities of Daily Living
BPSD: Behavioural and Psychological Symptoms of Dementia
CSDD: Cornell Scale for Depression in Dementia
DSM-5: Diagnostic and Statistical Manual of Mental Disorders FiJh Edition
LED: Light-emitting Diode
NH: Nursing Home
NPI: Neuropsychiatric Inventory
 

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Characteristics of ongoing studies [ordered by study ID]

Study name Nursing home care for people with dementia and residents’ quality of life, quality of care and staC
well-being: design of the Living Arrangements for people with Dementia (LAD)-study

Methods Non-randomised study with a control group; follow-up every two years

Participants 12 residents and 15 healthcare staC randomly selected from each of the 150 living arrangements
(30 living arrangements from five different living arrangements: traditional large-scale nursing
homes, nursing home wards in a home for the aged, large nursing home where group living home
care was provided, group living homes nearby the mother facility and stand-alone group living
homes in the community). Healthcare staC were excluded if they were not working on a permanent
basis (temporary staC and student-nurses).

Inclusion criteria:

• People with a primary diagnosis of dementia

• Healthcare staC were randomly selected from 30 living arrangements for each of five categories
of living arrangements as per Interventions.

Exclusion criteria:

• Not reported

Interventions Traditional large-scale nursing homes, nursing home wards in a home for the aged, large nursing
home where group living home care was provided, group living homes nearby the mother facility
and stand-alone group living homes in the community

Outcomes Resident outcomes:

Quality of life:

Quality of life (QUALIDEM)

Pain (subscale from Minimum Data Set of the Resident Assessment Instrument: MDS:RAI)

Quality of care:

Physical restraints (type and number of times used per resident)

Psychotropic drugs (type and number of times used per resident)

Client satisfaction (Consumer Quality Index: CQ-Index)

Approach to dementia (Approach to Dementia Questionnaire ADQ)

Involvement in activities (subscale from MDS:RAI)

Sta? outcomes:

Job satisfaction (subscale job satisfaction from The Leiden Quality of Work Questionnaire: LQWQ)

Burnout complaints (Utrecht Burnout Scale: UBOS)

Workload (subscale from LQWQ)

Autonomy (subscale from LQWQ)

Social support (subscale from LQWQ)

Starting date Unclear

Contact information [email protected]

Willemse 2011 

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Netherlands Institute of Mental Health and Addiction (Trimbos-Institute), Utrecht, The Netherlands

Notes Sponsorship source: Ministry of Health, Welfare and Sports

The study is a national monitoring study in the Netherlands which will collect data every two years.
A number of cross-sectional analyses from the study have been published that are not eligible for
inclusion in this review (Willemse 2014; Willemse 2015; Willemse 2016)

Conflicts of interest: None
Ethical approval: data of people with dementia were collected via observation by the healthcare
staC. For these reasons, this study did not come within the scope of the Medical Research Involving
Human Subjects Act (WMO) and therefore it did not need approval. We came to this decision after
consultation of a representative of the Medical Ethics committee METiGG.

Willemse 2011  (Continued)

ADQ: Approach to Dementia Questionnaire
CQ-Index: Consumer Quality Index
LAD: Living Arrangements for people with Dementia
LQWQ: The Leiden Quality of Work Questionnaire
MDS:RAI: Minimum Data Set of the Resident Assessment Instrument
QUALIDEM: Dementia-specific Quality of Life measure
UBOS: Utrecht Burnout Scale
 

D A T A   A N D   A N A L Y S E S

Comparison 1.   Home-like vs. traditional environment

Outcome or subgroup title No. of studies No. of partici-
pants

Statistical method Effect size

1.1 Quality of life 1   Other data No numeric data

1.2 Behaviour, mood and depression 5   Other data No numeric data

1.2.1 Global behaviour 3   Other data No numeric data

1.2.2 Depression 2   Other data No numeric data

1.2.3 Behaviour subdomains 2   Other data No numeric data

1.2.4 Social engagement 2   Other data No numeric data

1.3 Function 4   Other data No numeric data

1.4 Global cognitive function 4   Other data No numeric data

1.5 Quality of care  1   Other data No numeric data

1.6 Serious adverse effects 1   Other data No numeric data

Analysis 1.1.   Comparison 1: Home-like vs. traditional environment, Outcome 1: Quality of life

Quality of life

Study Measure Home-like Traditional Sample size Reported significance

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QUALIDEM 
-Feeling at home (adjust-
ed, mean)
(higher scores = better)

Baseline: 55.1
6 months: 65.5
12 months: 77.4

Baseline: 58.7
6 months: 65.5
12 months: 83.2

33 Group differences in
trends over time adjust-
ed for gender and stage
of dementia:
P = 0.674
 

QUALIDEM
-Care relationship (ad-
justed, mean)
(higher scores = better)

Baseline: 68.2
6 months: 74.2
12 months: 90.5

Baseline: 69.5
6 months: 58.0
12 months: 58.9

33 P = 0.065

QUALIDEM
-Positive affect (unad-
justed mean (SD))
(higher scores = better)

Baseline: 64.3 (24.7)
6 months: 75.0 (23.2)
12 months: 79.2 (20.0)

Baseline: 68.8 (21.7)
6 months: 76.5 (23.3)
12 months: 81.2 (23.5)

33 P = 0.683

QUALIDEM
-Negative affect (unad-
justed mean (SD))
(higher scores = better)

Baseline: 49.4 (28.7)
6 months: 53.6 (25.7)
12 months: 61.7 (23.0)

Baseline: 57.7 (30.6)
6 months: 59.8 (22.2)
12 months: 58.5 (30.0)

33 P = 0.373

QUALIDEM
-Social isolation (unad-
justed, mean (SD))
(higher scores = better)

Baseline: 77.8 (20.7)
6 months: 70.6 (24.3)
12 months: 67.8 (22.2)

Baseline: 61.5 (25.9)
6 months: 63.2 (26.6)
12 months: 59.8 (28.8)

33 P = 0.456

QUALIDEM
-Social relations (unad-
justed, mean (SD))
(higher scores = better)

Baseline: 61.1 (22.1)
6 months: 67.5 (22.9)
12 months: 68.1 (18.8)

Baseline: 47.9 (17.5)
6 months: 66.2 (20.7)
12 months: 59.8 (14.9)

33 P = 0.947

QUALIDEM
-Positive self-image (un-
adjusted, mean (SD))
(higher scores = better)

Baseline: 67.8 (28.9)
6 months: 62.0 (23.5)
12 months: 68.6 (25.5)

Baseline: 69.7 (26.3)
6 months: 65.3 (33.8)
12 months: 68.5 (33.8)

33 P = 0.990

QUALIDEM
-Restless tense behav-
iour (unadjusted, mean
(SD))
(higher scores = better)

Baseline: 46.7 (34.3)
6 months: 53.9 (32.1)
12 months: 53.9 (36.3)

Baseline: 45.3 (32.9)
6 months: 54.7 (35.0)
12 months: 54.7 (32.9)

33 P = 0.226

Wolf-Ostermann 2012

QUALIDEM
-Having something to do
(unadjusted, mean (SD)),
(higher scores = better)

Baseline: 52.6 (32.5)
6 months: 51.8 (64.6)
12 months: 53.9 (33.1)

Baseline: 29.2 (28.8)
6 months: 62.5 (24.8)
12 months: 55.6 (33.6)

33 P = 0.878

Analysis 1.2.   Comparison 1: Home-like vs. traditional environment, Outcome 2: Behaviour, mood and depression

Behaviour, mood and depression

Study Measure Home-like Traditional Sample size Effect estimate or re-
ported significance

Global behaviour

Nurses Observation
Scale for Geriatric Pa-
tients (NOSGER) (unad-
justed mean)
(lower scores = better)

Baseline 15.9
6 months 16.0
12 months 15.3

Baseline 18.0
6 months 18.8
12 months 19.6

60 P < 0.01 at baseline
P < 0.001 at 6 months
P < 0.0001 at 12 months

Dettbarn-Reggentin
2005

Neuropsychiatric Inven-
tory (NPI) (unadjusted
mean (95% confidence
interval))
(lower scores = better)

Baseline: 12.1 (10.5 to
13.8)
6 months: 7.5 (6.2 to 6.7)

Baseline: 11.7 (10.9 to
12.8)
6 months 8.8 (7.5 to 10.1)

164 Adjusted MD for global
behaviour change over 6
months:
-0.04 (95% CI -0.13 to
0.04) 

Te Boekhorst 2009

Physical environmental designs in residential care to improve quality of life of older people (Review)

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Neuropsychiatric Inven-
tory-Nursing Home ver-
sion (NPI-NH) (adjusted
mean)
(lower scores = better)

Baseline 47.3
6 months 26.7
12 months 17.4

Baseline 34.1
6 months 36.6
12 months 20.5

Baseline: 56
12 months: 33

P > 0.05

Wolf-Ostermann 2012

Depression

Revised Memory and Be-
haviour Problems Check-
list (RMBPC) (unadjusted
mean (95% confidence
interval))
(lower scores = better)

Baseline 14.9 (12.8 to
17.0)
6 months 8.9 (7.4 to 10.5)

Baseline 13.1 (12.3 to
13.8)
6 months 8.0 (7.4 to 8.6)

164 Adjusted MD (95% confi-
dence interval) for global
behaviour change over 6
months:
0.01 (-0.12 to 0.14)

Te Boekhorst 2009

Mood Scale Score (MSS)
(lower scores = better)

N/R N/R 242 Adjusted RR (95% con-
fidence interval) for lev-
el of social engagement
over 18 months: 
1.15 (1.02 to 1.29)
Adjusted OR (95% confi-
dence interval) for prob-
ability of not being so-
cially engaged over 18
months:
0.36 (0.12 to 1.07)

Yoon 2015

Behaviour subdomains

Organic Brain Syndrome
(OBS) scale
-Dyspraxia (unadjusted
mean (SD))
(lower scores = better)

0-6 months:
0.95 (0.49)
0-12 months:
0.57 (0.49)

0-6 months:
0.54 (0.54)
0-12 months:
0.69 (0.69)

0-6 months:
53
0-12 months:
44

0-6 months: P < 0.001
0-12 months: P > 0.05

 OBS scale
-Hallucinations (unad-
justed mean (SD))
(lower scores = better)

0-6 months:
0.02 (0.29)
0-12 months:
0.14 (0.47)

0-6 months:
0.03 (0.36)
0-12 months:
0.14 (0.41)

0-6 months:
53
0-12 months:
44

0-6 months: P > 0.05
0-12 months: P > 0.05

Annerstedt 1993

OBS scale 0-6 months: 0-6 months: 0-6 months: 0-6 months: P > 0.05

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-Lack of vitality (unad-
justed mean (SD))
(lower scores = better)

0.05 (0.49)
0-12 months:
0.63 (0.52)

0.24 (0.47)
0-12 months:
0.31 (0.55)

53
0-12 months:
44

0-12 months: P < 0.05

OBS scale
-Dysphasia (unadjusted
mean (SD))
(lower scores = better)

0-6 months:
0.04 (0.56)
0-12 months:
0.63 (0.52)

0-6 months:
0.36 (0.48)
0-12 months:
0.42 (0.70)

0-6 months:
53
0-12 months:
44

0-6 months: P < 0.05
0-12 months: P > 0.05

OBS scale
-Paranoia (unadjusted
mean (SD))
(lower scores = better)

0-6 months:
-0.05 (0.32)
0-12 months:
0.44 (0.40)

0-6 months:
0.17 (0.37)
0-12 months:
0.28 (0.41)

0-6 months:
53
0-12 months:
44

0-6 months: P < 0.05
0-12 months: P > 0.05

OBS scale
-Aggressiveness (unad-
justed mean (SD))
(lower scores = better)

0-6 months:
0.22 (0.51)
0-12 months:
0.45 (0.45)

0-6 months:
0.09 (0.58)
0-12 months:
0.07 (0.41)

0-6 months:
53
0-12 months:
44

0-6 months: P > 0.05
0-12 months: P < 0.01

OBS scale
-Depression, anxious-
ness (unadjusted mean
(SD))
(lower scores = better)

0-6 months:
-0.19 (0.23)
0-12 months:
0.32 (0.50)

0-6 months:
0.28 (0.60)
0-12 months:
0.30 (0.49)

0-6 months:
53
0-12 months:
44

0-6 months: P < 0.01
0-12 months: P > 0.05

OBS scale
-Clinical variations (un-
adjusted mean (SD))
(lower scores = better)

0-6 months:
0.06 (0.54)
0-12 months:
0.65 (0.65)

0-6 months:
0.29 (0.75)
0-12 months:
0.16 (0.68)

0-6 months:
53
0-12 months:
44

0-6 months: P > 0.05
0-12 months: P < 0.05

OBS scale
-Restlessness (unadjust-
ed mean (SD))
(lower scores = better)

0-6 months:
-0.11 (0.28)
0-12 months:
0.22 (0.53)

0-6 months:
0.09 (0.38)
0-12 months:
0.26 (0.58)

0-6 months:
53
0-12 months:
44

0-6 months: P < 0.05
0-12 months: P > 0.05

Cohen-Mansfield Agita-
tion Inventory (CMAI),
proportion with physical
non-aggressive behav-
iour
(lower scores = better)

Baseline: 35.0%
6 months: 40.0%
12 months: 30.0%

Baseline: 46.2%
6 months: 46.2%
12 months: 53.8%

33 P > 0.05

CMAI, proportion with
verbal agitation
(lower scores = better)

Baseline: 50.0%
6 months: 50.0%
12 months: 40.0%

Baseline: 30.8%
6 months: 53.8%
12 months: 61.5%