There is a lot of information out there on dementia-friendly design, but how do we know which advice to follow and which features to focus on? While there is no one-size-fits-all solution, there appears to be a need for more guidance in this area, discovers JUDE BARBACK.
Dementia-friendly design is not a new concept. A lot of international research has gone into revealing what best practice looks like in terms of how a residence that is suited to people with dementia should look and feel.
But is it still just research on the pages or is it taking a tangible form in new dementia units? Are our existing rest homes and hospitals suitable for the increasing numbers of people suffering from dementia?
Before we can address these questions, we need to ask the obvious one: what is dementia-friendly design?
What is dementia-friendly design?
It is widely recognised that a building and an environment can have a significant effect on a person with dementia. As
William McMorran of Architectonicus in the UK says, “architecture won’t solve dementia, but it can help.”
McMorran, the architect responsible for the design of Bradbury Court, a new dementia care home in Malvern, UK, says, “If we can build the right environment, people look and feel better [and the] best way of helping people cope [with dementia] is to see the activity right in front of your eyes.”
But what is the “right environment”?
In the same way that management styles and approaches to care can support or hinder people’s wellbeing, their environment also has the ability to aid or hamper their social connection and sense of self; it can encourage independence or force dependency.
Underlying dementia-friendly design are the principles of maintaining good health; supporting individuals’ choices, interests, lifestyles, and need for privacy; making up for any sensory and cognitive impairment; offering choice; and providing safety and security while supporting independence. In the same way a building should compensate for the needs of someone in a wheelchair with ramps, lifts, and space for turning, a building should compensate for the impairments of someone with dementia in its design. That said, no two dementia sufferers are the same, each differing in age, type and degree of impairment, attitude, and background, and therefore flexibility should be incorporated into design to acknowledge this as well as the changing needs of individuals.
Putting research into practice
Certainly, there is a lot to consider. A study led by Richard Fleming found that despite substantial evidence-based information to inform the design of residential aged care facilities for people with dementia, many appear to have been designed without clear application of the evidence base, thus highlighting what Fleming and colleagues describe as “a gap in the knowledge translation process”.
Fleming found that those facilities designed with the input of managers who were fully aware of the evidence-based principles of dementia design were of significantly higher design quality than those where the managers were ill-informed.
His research shows that once aged care providers are aware of the principles, they appear to find ways to implement them. The article suggests that if the next generation of residential aged care facilities is to be suitable for people with dementia, the facility managers must be made aware of the available design principles, architects encouraged to be more active in sharing their knowledge and ways found to improve the exchange of knowledge between the parties. Up-to-date guidelines should be provided free through well-respected agencies, and a method for showcasing well-designed facilities should be developed, says Fleming.
It is difficult to gauge whether Fleming’s findings are reflected in New Zealand dementia units, but from the facilities INsite has been in touch with over recent years, it seems apparent that the more input and knowledge acquired by the operator and manager, the more collaboration with the architect, the better the end result.
Sprott House provides a good case in point. Prior to commissioning Duncan Lodge, its dementia unit, the general manager, the architects, and a board member went to Australia on a fact-finding mission to discover what worked – and what did not – in Australian dementia units. They also read up on all the relevant research. This mission helped inform decisions on many aspects of the lodge.
There’s no place like home
Often the difficulty for the decision-makers of a new build or refurbishment dementia design project comes from knowing which areas to prioritise or compromise, especially when it comes to dealing with a limited budget, limited building space, or factoring in existing buildings.
Warwick Bell of BKB Team Architects says that achieving a homely feel to a unit while adhering to security features is a common balancing act.
“The décor and fabric of the facility can be made to be homely, so it comes down to the entry and exit from the secure area – that has to be discreetly handled and not made to feel as if it is containment.”
Homeliness is an important attribute. Design for people with dementia should look to engage people, support their needs and capabilities, and give meaning, comfort, and safety. Comfort cannot be derived from the institutional feel of many hospitals and healthcare facilities with their long corridors, stark rooms, and harsh lighting. Instead, a homely environment is the goal in dementia-friendly design, one that adds continuity and familiarity to everyday life and encourages the continued involvement of family and friends.
Familiar domestic features – like sofas and pictures on the wall in the lounge – help people with dementia make connections between staff, families, and residents. Areas that are designed for individual use, like bedrooms, should be personalised so people feel in control and able to maintain their privacy.
Familiarity is an important concept. The research is fairly consistent: when designing living environments for people with dementia, care should be taken to make sure that rooms and spaces are recognisable and familiar to people with dementia so that their use is obvious and unambiguous. While modern architecture might favour multi-purpose spaces, this may not be appropriate in a dementia-friendly design. A separate living room and dining room works better than a single generic shared space.
For all the allure of a strikingly innovative design, it is important to remember that older people, and especially those with dementia, may be more comfortable in an environment that they can relate to from their past experiences of ‘home’.
Bell agrees. “One should always remember with design for this age group that one needs to create a homely environment in line with the home environments they have been brought up in. Not all have experienced flash city apartments or international-style architecture – probably over 80 per cent of residents are comfortable in their suburban weatherboard house.”
St Joseph’s Home of Compassion’s dementia unit epitomises homeliness and familiarity with its pitched roofs, the use of a residential gutter profile around the internal courtyard, and the selection of materials such as cedar weatherboards, clear-finished plywood, and timber-look vinyl.
Navigating the research
Most theories around layout and navigation for dementia units appear to be in accord. Facilities should strive for as few corridors as possible and keep them short and wide with no dead-ends or blind bends.
Systems that feature textured handrails and visual cues can help residents navigate their way around. Internal way-finding cues, such as potted plants, ornaments, and artwork are popular. Plenty of windows providing interesting views, natural light, and ventilation help to build a connection with the outside world and also help with orientation.
In many cases, facilities may not have the luxury of forgoing corridors or adding windows, especially if they are working under the constraints of an existing building. However, it appears that many are doing their best to make navigation as straightforward as possible.
At St Josephs, circulation routes have been kept wide and continuous to avoid dead-ends, where residents could become confused. ‘Bus stops’, small seating areas along the way, have been included to allow residents to enjoy a view or an activity.
Dead-ends are also minimised at Duncan Lodge, Sprott House’s dementia unit, and ‘walkers’ have a roundel around which they can walk – or they can walk in a figure of eight using the pavilion so that they do not necessarily have to tread the same path all the time.
Inevitably there are some areas where there is conflicting research about what constitutes best practice. One contentious area is the effectiveness of signs and colour coding. There is also some debate about the use of contrast.
The University of Stirling’s Dementia Services Development Centre (DSDC) suggests that contrast can draw attention to something important, such as a toilet seat or a light switch, however sudden contrast in flooring can make a floor look uneven, like a step, and cause hesitation and unsteadiness.
Warwick Bell says his firm takes the available research and information carefully into account and treads cautiously when it comes to contentious features like contrast that can be both a positive and a negative.
Marja Steur, Chair of the National Dementia Cooperative, says that various facilities use different philosophies, like The Eden Alternative, for example, which can help inform certain design decisions. The Eden Alternative is all about transforming care environments to promote quality of life for all involved – older people and their carers.
The Spark of Life approach, a practical implementation of the Eden Alternative, is adopted by many dementia units and also plays a part in informing design. By actively moving away from a medical view of dementia care, to a lifestyle approach, means that emphasis is placed on designing an environment focussed on making life comfortable for the person rather than all about catering for their medical needs.
Dr Hans Becker, the keynote speaker at the Ageing Asia Workshop held earlier this year, says the design of housing and communities helped create opportunities for happiness, and for people to be able to grow old in their own homes, with services coming to them as they needed them.
The Ageing Asia Workshop provided a good opportunity to debate different ideas about care philosophies. Sharing experiences is vital to informing which dementia-friendly design elements are to be adopted.
Steur says the Hammond Care international design school has also been recommended by some, as a useful way to learn from the experts and share experiences. The school, which takes the form of a conference with presentations, workshops, and forums, but also has site visits and practical sessions, will be held in Sydney in late June this year and is aimed at architects, designers, commissioners, planners, project managers, decision-makers, dementia specialists, dementia service managers, and other health care professionals involved in dementia care.
Points of interest
A new or refurbished dementia unit can often carry a price tag that can put some operators off the whole notion. However, certain design elements can be incorporated at little cost but to great effect.
Spark of Life advocates generally agree that points of interest are an important aspect of a dementia facility, helping to encourage curiosity and engage people’s interest.
Selwyn Wilson Carlile Home features several walls that have been carefully selected as points of interest. Each is covered in an interesting wall paper designed to capture the interest of residents. One displays quotes from all over the world and manager Rachael Hall says, “One man with dementia comes to look at it every day and just stands there and cracks up [with laughter].”
Another popular example is memory boxes – frames or boxes displaying certain things from a different era, designed to evoke certain memories and capture the interest of residents.
Making sense of dementia
Sensory rooms and gardens are becoming more prevalent in dementia units, as well as rest homes and hospitals, a sign that the research is being heeded by many. A sensory space ultimately serves to manipulate the environment in order to positively affect the way an individual processes and integrates sensory information. Sensory modulation, so the science goes, has the potential to increase self awareness, self esteem, communication, social interaction, and the ability to nurture the self and to cope with life’s challenges.
Oceania’s Aspen Rest Home in Tauranga recently opened new sensory rooms and gardens, designed to calm or uplift residents. Inspired by a training session run by Nic Jenkins, an occupational therapist from Mental Health Services, Aspen’s Diversional Therapist,
Marilyn Liddington, prompted discussions about setting up a sensory room at the home. With much input from Jenkins and a visit to the sensory room at Tauranga Hospital, Aspen gradually got its own sensory room.
The room features music and pictures, programmed specifically to help calm or invigorate, a water feature providing soothing sounds. There is aromatherapy with someone providing a hand massage, fidget mats to get rid of stressful energy, weighted lap dogs to provide comfort. There are different types of comfortable chairs to suit different tastes.
At the official opening, manager Olwyn Kunz compared the room to a hotel spa, describing it as a “spa with a purpose” as the one-on-one therapy helps to tailor the resident’s experience to their needs.
“We have started using the room with residents who demonstrate an immediate need for the therapy. Our goal is to integrate the use of the sensory room in to the personal care plans of every resident, so they can visit the sensory room on a regular basis and gain the benefits even before there’s any obvious need,” said Kunz.
“So far we have had great results, whether it’s been to treat depression, confusion and restlessness, or insecurity.”
Aspen also intends to extend the concept outdoors, creating a sensory garden.
The great outdoors
Many aged care facilities recognise the importance of a sensory outdoor space. Gardens filled with herbs, highly scented plants, textured shrubs can help calm or uplift residents.
Lonsdale dementia unit in Foxton, Manawatu has a sensory garden that allows residents to step into a comfort zone aimed to decrease their anxiety and improve their mood, physical health, and mobility. It includes a beach area, a green for activities such as lawn bowls, an aviary, bus stop, letter box, barbeque, garden bed, and a washing line; all helping to provide the all-important cognitive and sensory stimulation. The garden extends down one side of the ‘L’-shaped unit, allowing residents the freedom to go in and out of the unit and enjoy use of the garden as they please.
Points of interest are a good idea for dementia gardens. Ideally gardens should include different points of interest, such as a bird bath, clothes line, mail box, or a bus stop. Sunny, sheltered seating areas, such as a communal patio or barbecue area, encourage social interaction. Ideally, these should extend from indoor social or communal rooms.
A garden plays an important role in providing a place for residents to get fresh air and the necessary vitamin D. It is a place for exercise and activity, particularly for people with dementia who walk a lot, and consequently, should have a circular path rather than a straight path.
Residents often value the opportunity to help with planting and many rest homes consequently provided a resident’s green house with access to gardening tools. A men’s shed is a popular variation on this. Peria House in Opotiki won two awards at last year’s NZACA conference for establishing a ‘Bloke’s Shed’ in partnership with Alzheimer’s Eastern Bay of Plenty. The shed was aimed to meet the needs of men with dementia within the rest home as well as those in the community still living at home.
Yet, Sprott House made the decision not to include a men’s shed, after they found from their fact-finding mission to Australia that these were seldom used by residents.
It is clear, despite the mounting ‘best practice’ literature and evidence, that there is, thankfully, no kit-set, one-size-fits-all answer to creating a dementia-friendly environment. In addition to following the research out there, operators need to be guided by their care philosophies, their residents’ needs, their architect’s knowledge, and their instincts about what will work best for them. However, perhaps there is also a need for more awareness in this area, as Fleming’s research suggests – freely available dementia design guidelines and the opportunity to showcase good examples might prove beneficial to the sector as it continues to grow.