10 design principles to create a better environment for people with dementia

Professor Richard Fleming is the Director of the NSW/ACT Dementia Training Study Centre. A key element of his work is translating knowledge around dementia-friendly environmental design into practice. Informa Healthcare had the chance to speak to him about how the built environment affects people with dementia. We will publish his responses to a number of different issues over the next few weeks. In this edition we are examining in what ways the built environment affect the lives of people with dementia.

The effect of the environment on people with dementia can be explained by reference to 10 principles:

1. Unobtrusively reduce risks – safety 

People with dementia require an internal and external environment that is safe, secure and easy to move around if they are to make the best of their remaining abilities. However, obvious safety features and barriers will lead to frustration, agitation and anger and so potential risks need to be reduced unobtrusively.

2. Provide a human scale – size

The scale of a building will have an effect on the behaviour and feelings of a person with dementia. The experience of scale is determined by three factors:

1. The number of people who the person encounters
2. The overall size of the building
3. The size of the individual components, such as doors, rooms and corridors

 A person should not be intimidated by the size of the surroundings or confronted with a multitude of interactions and choices. Rather the scale should help the person feel in control.

3. Allow people to see and be seen – visual access features

The provision of an easily understood environment will help to minimise confusion. It is particularly important for people with dementia to be able to recognise where they are, where they have come from and what they will find if they head in a certain direction. When they can see key places, such as a lounge room, dining room, their bedroom, kitchen and an outdoor area they are more able to make choices and find their way to where they want to go. Buildings that provide these opportunities are said to have good visual access. Good visual access opens up opportunities for engagement and gives the person with dementia the confidence to explore their environment. It can also enable staff to see residents from where they spend most of their time. This reduces their anxiety and the anxiety of the residents.

4. Reduce unhelpful stimulation – stimulus reduction features

Because dementia reduces the ability to filter stimulation and attend to only those things that are important, a person with dementia can become stressed by prolonged exposure to large amounts of stimulation. The environment should be designed to minimise exposure to stimuli that are not helpful. The full range of senses must be considered. Too much visual stimulation, for example, is as stressful as too much auditory stimulation.

5. Optimise helpful stimulation – highlighting useful stimuli

Enabling the person with dementia to see, hear and smell things that give them cues about where they are and what they can do, can help to minimise their confusion and uncertainty. Consideration needs to be given to providing redundant cueing for example by providing a number of cues to the same thing, recognizing that what is meaningful to one person will not necessarily be meaningful to another.  A person may recognize their bedroom, for example, because of a view, the presence of furniture, the colour of the walls, the light fitting or the bedspread. Cues need to be carefully designed so that they do not become unhelpful stimulation.

6. Support movement and engagement – Provision for wandering, circulation and access to outside area

Aimless wandering can be minimised by providing a well-defined pathway, free of obstacles and complex decision points, that guides people past points of interest and gives them opportunities to engage in activities or social interaction. The pathway should be both internal and external, providing an opportunity and reason to go outside when the weather permits.

7. Create a familiar space – Familiarity

The person with dementia is more able to use and enjoy spaces and objects that were familiar to them in their early life. The environment should afford them the opportunity to maintain their competence through the use of familiar building design (internal and external), furniture, fittings and colours. This will involve an understanding of the personal background of the people living in the environment.  The involvement of the person with dementia in personalising the environment with their own familiar objects should be encouraged.

8. Provide opportunities to be alone or with others – Privacy and community

People with dementia need to be able to choose to be on their own or spend time with others. This requires the provision of a variety of spaces, some for quiet conversation with one or two others and some for larger groups, as well as spaces where people can be by themselves. These internal and external spaces should have a variety of characters, for example a place for reading, looking out of the window or talking, to cue the person to what is available and stimulate different emotional responses.

9. Provide links to the community – Community links

Without constant reminders of who they were, a person with dementia will lose their sense of identity. Frequent Interaction with friends and relatives can help to maintain that identity. This is made easier when the person is admitted from the local community as friends and relatives are able to drop in easily.

The environment must include spaces for the resident and their visitors to use within the unit and in its immediate surrounds. These need to be attractive and comfortable to encourage visitors to come and spend time.  Stigma remains a problem for people with dementia so the unit should be designed to blend with the existing buildings and not stand out as a ‘special’ unit. Where possible a ‘bridge’ should be built between the unit and the community by providing a space that is used by both the community and people with dementia. Where the unit is a part of a larger site, there should be easy access around the site so people with dementia, their families and friends can interact with other people who live there.

10. Providing opportunities for engagement with ordinary life – Domestic activity

The environment should be as homelike as possible, recognising that older people are there to live, and so need access to opportunities for engagement with life.  An environment that focuses on engagement with life allows residents to make decisions and exercise choice and independence, both in the way they spend time and what they do. The environment should allow older people to continue to do the things that they have done throughout their lives.

The available evidence suggests that a well-designed environment will:

Prof Richard Fleming will deliver a presentation about dementia-friendly environmental design at the National Dementia Congress, to be held on the 20^th and 21^st February 2014 in Melbourne. Now in its 5^th year, the event examines case studies and the latest innovations from across the whole dementia pathway, from diagnosis to end of life, focusing on the theme of “Making Dementia Care Transformation Happen Today”.

Related articles

– Improving dementia care: ask those who have lived with the illness (theguardian.com)
– Dementia, music and the loss of self, by Helena Lee (mustudents.wordpress.com)