An Australian Approach to Design For Older People with Dementia

Importance of the Environment

The role of the built environment in the management of older people with dementia has been well recognized over recent years, and a number of design considerations have been identified (Fleming and Bowles 1987, Calkins 1988, Cohen and Weisman 1991, Marshall 1998). The design of a setting can influence what people are able to do, how they feel and how they relate to one another. Through sensitive design a person's abilities and independence can be maximized, improving the quality of life for the older person and reducing the cost of providing care.

Key Design Principles

When designing for people with dementia it is essential to provide an environment that enables residents to use their remaining abilities and skills to the highest possible level. The Australian experience has shown that the concepts of Small, Domestic, Close to Community, Managing Environmental Stimulation, Visual Access, Familiarity, Planned Wandering, Privacy and Community, Security and Safety, and Accessibility are particularly important in this regard. Through the sensitive application of these principles an environment can be created for a person with dementia that maintains their lifestyle and affirms their dignity.

It is important to recognize that these concepts are seen as a starting point for design and not as design solutions. As principles they represent an approach to design but not a blueprint or prescription for an ideal setting. As the illustrations accompanying this article will show, these principles can be interpreted in a number of ways and the ideas that are presented in this article are given as examples only. It is also important to note that these design concepts are interrelated principles which influence and impact on each other. Flexibility is particularly important. Residents are likely to come from a diverse range of experiences and backgrounds, and a flexible environment will be required to ensure that a range of needs can be met at different times.

Small

The scale of the environment should be one of the first elements to be considered when designing for people with dementia. A building of an appropriate scale will allow a person to "fit" into the building and have a sense of place. In addition, the scale of a building can have a significant impact on our personal feelings: when we walk into a restaurant we feel very different from when we enter a family dining room. The number of people we interact with is also critical, and small groups have been found to be important when caring for people with dementia. A small group reduces the number of people a person with dementia needs to relate to, and reduces the number of decisions they have to make.

Domestic

Broadly speaking, a domestic environment is one that is homelike in character and promotes a sense of well-being in people. A homelike environment cannot be neatly described, but is generally understood as a place where people have lived (or perhaps would like to have lived). It is not the same for everyone as it is governed by a person's previous experiences and expectations.

A domestic environment allows people to continue their way of life as far as they are able. The inclusion of kitchens, for example, encourages people to do everyday things (such as drying dishes), recognizing that these are some of the tasks a person with dementia can still do. This is important as it allows people to use their remaining skills and maximise their abilities. In this way a domestic environment is also able to affirm a person as they do things successfully and gain a sense of achievement.

Close to Community

The facility should be situated in a residential area, close to shops and other neighbourhood services. It is important that people are able to maintain their links with the community, for example, by visiting the local shopping centre. It is also important that people continue to maintain their social networks wherever possible, and contact with the wider community, friends and family should be encouraged.

Being close to the community can give people with dementia the opportunity to interact with the community and receive encouragement and support, while continuing their way of life and maintaining relationships. It is also important to provide an opportunity for the wider community to interact with people with dementia. This can avoid the isolation of people with dementia, increase community understanding, and encourage family involvement.

Managing Environmental Stimulation

It is essential to minimize unwanted stimuli within the environment (such as service areas). This can limit the number of decisions a person has to make and can help reduce confusion. On the other hand, important stimuli should be emphasized (such as the kitchen where staff and other residents can be found, or a door leading to a toilet). This can direct people to important places and help them to negotiate the environment.

Cueing can play an important role in highlighting or minimizing stimuli and can take many forms. Redundant cueing is an important tool in this regard. The use of redundant cueing recognizes that people are affected by dementia in different ways and accordingly have a range of abilities.

It is not possible to know which element will enable a confused person to recognize where they are or what they are supposed to do. Redundant cueing provides someone with a number of "cues", in the hope that one or more of these will strike a chord. These cues may take the form of colour coding, panelling on a door, placement of a window, or the presence of personal belongings. It should also be noted that redundant cueing must be used with great skill to ensure that a confused person does not become overstimulated and bombarded with messages which they can't distinguish, and as a result, more confused than ever.

Visual Access

Confusion may be reduced by caring for the older person in a well-planned environment that maximizes visual access. Residents should be given clear choices about where they wish to go and what they will find there, both as they move through the building and as they enter particular rooms. This limits the inclusion of corridors in the design and results in the staff being able to see the residents almost all of the time. It will also affect the types of doors that are used and the placement of these. Designing for visual access reduces anxiety in both staff and residents, and assists residents in finding their way.

Familiarity

Familiarity is important for a person with dementia as it promotes a sense of well-being and calm.

A familiar environment will help a person feel that they are still in control of a situation and are able to function effectively, rather than being left with a sense of panic as they are unable to recognize things and feel the world "slipping away".

A familiar environment is created through the use of recognizable building elements, and the careful selection of furniture and decor so that it is recognizable. Attention needs to be given to the selection of decor to ensure that it is appropriate, and allowance made for personal furniture and mementos. It is believed that the dementing person recalls the distant past more easily than the recent past. Recent furniture designs and decor may be less recognizable than decors that they enjoyed in their younger days.

Planned Wandering

Planned wandering is important as it helps people to know where they are and where they should go. The environment should respond to a person's need to move about, without encouraging movement as a goal in itself. Planned wandering should strive to ensure that wandering is purposeful and a positive experience, rather than simply taking up people's time.

Orientation devices can be used to assist a person to find their way. Buildings can easily become labyrinths, with doors opening off corridors and passages that appear the same at every turn. A demented person can find such an environment daunting and can be left feeling lost and frustrated. The placement of features and the use of natural light can help people know where they are in a building and recognize what is around them.

Privacy and Community

A balance between private and communal space is essential. People with dementia require a range of opportunities for social interaction. Spaces are needed for being on one's own, with one or two intimate friends, and in larger groups. The inclusion of a variety of lounge rooms, verandahs, and alcoves, for example, will allow people to retreat or be with others according to their need at a particular time. It also provides flexibility.

Security and Safety

It is essential that a safe environment is provided for people with dementia. People with dementia are often fit and mobile and are able to walk considerable distances. It is vital that the building gives them the opportunity to move about without a sense of restriction that can lead to frustration. On the other hand, it is essential that the confused person is not able to leave the facility at will and get lost in the neighbourhood or hit by a car. Attention should also be given to the design of services such as gas, electricity and water, so that residents are able to use sinks, stoves and kettles in a way that minimizes or avoids risk.

Accessibility

It is important to allow residents' residual abilities to be maximized through an accessible environment. Essential supports should be incorporated in a clear but subtle manner, so that independence can be encouraged. Designing an enabling environment is essential when designing for people with dementia. It is important to focus on what residents can do, and avoid creating barriers for people. This will encourage them to use their remaining skills and maybe learn some new ones.

Diversity of Responses

There can be enormous variety in responses to these key design principles as we meet particular people's needs and life experiences at a certain place and time. Australia is a diverse country, not least in terms of cultural background, climate, population density and way of life. Such diversity has challenged us to ask: "What might these principles mean in different situations?" Given the diversity within Australia, we believe we are well placed to explore this question further and consider what key design principles may mean in different settings.

Case Studies: Himawari & The Pines

Over the last two years, time has been spent comparing the design of two facilities for people with dementia. As part of a joint Australia Japan Research project, Himawari group home in Japan and the Pines hostel in Australia have been examined with a view to identifying whether common design principles can be seen in both facilities, although the appearances of the buildings at first glance are quite different.

Himawari group home for people with dementia is situated outside the rural township of Ofenatu. It is on the same site as a threestorey nursing home, a dialysis day treatment clinic, and a day centre for people with dementia. The Shokyu-kai Clinic Foundation operates it.

The Pines is a purpose-designed hostel for people with dementia that is operated by the Hammond Care Group. Situated in the suburb of Hammondville in NSW the Pines is located on a site which caters to older people by providing Independent Living Units, Hostel, and Nursing Home care in a variety of settings.

Both facilities follow the key design principles outlined above, but in different ways. Himawari is a facility for eight people, with a friendly kitchen and dining room, and a field for residents to work in. Circulation is along a single corridor that leads from the kitchen to the single bedrooms. Residents are able to furnish their own rooms, and choose whether to have a tatami mat finish, futon or bed. Residents are able to socialize around the dining table, sit on the outdoor terrace, spend time in their rooms, or in the alcove. The Pines hostel is home to 40 people, who live in three houses that are linked by a service corridor. Each house has two bedroom clusters that open off a social area with a lounge, dining, kitchen and laundry. The kitchen acts as the hub of the house, and staff and residents have a clear view of the bedroom corridors from this room. Residents are also able to come to the kitchen along a garden path that is linked to the bedroom corridors. Residents have single rooms, which they decorate with furniture and mementos. Sitting alcoves are located at the end of the bedroom corridors and provide alternative places for people to spend time.

The diversity of response to key design principles is perhaps best highlighted by the way in which opportunities for privacy and community have been provided at Himawari and the Pines. Both Himawari and the Pines recognize the need to provide for community and privacy, offering residents opportunities to sit and chat with other residents or retreat. At Himawari the importance of providing a place where older Japanese women can sit and exchange secrets and gossip was emphasized. This space needs to be relatively private (so that they will not be overheard). The focus should be internal. This is in sharp contrast to a sitting alcove that is provided at the Pines. In Australia alcoves are ideally designed to give people an opportunity to sit as small groups and take in a view or look to a garden. Alcoves are also situated to allow people to be a part of the action so that they are not isolated. Concern is usually expressed that if alcoves are out of the way they will not be used.

Concluding Remarks

The Australian experience has shown that it is possible to identify a number of design principles that are important when designing for people with dementia. Within Australia we have seen considerable variety in the outcomes of this design approach and it is clear that there are a variety of ways of responding to these concepts: there is no single design solution. We believe that our recent experience in Japan suggests the possibility of using a common set of design principles as a starting point for designing for people with dementia in other countries too. We look forward to continuing to explore the use of these principles, so that the quality of environments for people with dementia can be improved and assist people with dementia to live lives that are fulfilling.