Designing residential environments for living better with dementia

Care providers need to move from a negative disabling approach to a more positive enabling mind-set that respecting residents as adults who have rich histories and can live meaningful lives. A ‘dementia friendly’ environment is argued to compensate for disability and should consider both the importance for the person with dementia of his/her experiences within the environment. Such environments aim at building on what people living with dementia, rather what they cannot do, allow them to experience the highest possible quality of life.  A literature on designing facilities for people with dementia, which has accumulated over the last 40 years, or so, provides support for the inclusion of a number of features into care homes that accommodate people with dementia. There is converging evidence that intelligent design of buildings, if regarded as a therapeutic resource, can promote well-being and functioning of people with dementia.

There has been increasing interest, overall, in the use of non-pharmacological interventions to improve dementia symptoms and the wellbeing of residents with dementia and their carers.  Previous studies examining modifications to the built environment have drawn from a number of design principles and frameworks for dementia care homes and suggest that purposeful design of one’s surroundings may play an active role in promoting a sense of well-being and improved functionality. The increased sensitivity of persons with dementia to environmental conditions occurs because the illness can reduce the individual’s ability to understand the implications of sensory experiences in residential care settings. As a result, agitated behaviours, increased confusion, delusions, and other psychiatric disturbances are readily triggered by environmental stimuli.

Inappropriate physical environment of the dining room is one of the most frequent concerns voiced by staff in nursing homes. Dining rooms are often loud and overstimulating places in care homes. In terms of physical environments, designs which provide balanced and controlled stimulation, and features that assist orientation, compensate for disability, and promote involvement in everyday activity are sought. With the aging population, research in home environments has developed a new focus of “environmental geriatrics” which includes professionals with backgrounds in anthropology, architecture, geography, occupational therapy, psychiatry, psychology, and other fields, as well as people living with dementia and caregivers. But dementia is not just about old people.

The focus of long-term care settings for the elderly has gradually changed from curing diseases to improving their quality of life, especially in countries which have been experiencing the aging of the population. In terms of the concept of care, the term “person-centered care” has already generated a lot of attention. Many terms (e.g., resident-centered care, individualised care, consumer-directed care, patient-centered care, self-directed care) share the same basic concepts and definitions. A person-centred approach is considered to emphasise residents’ unique personal preferences and needs in order to guide caregivers, thus enabling the individualisation of care plans and care routines to improve quality of life and compensate for their impairment. Person-centered dementia care requires shift in attitudes, behaviours, and systems replacing the traditional model of care that primarily focuses on the “tasks.” This is a best practice concept guiding efforts to improve residents’ quality of life in long-term care facilities. The care philosophy recognises that individuals have unique values, personal history, and personality.

Kitwood who advocated for the critical importance of personhood stressed the importance of taking a holistic perspective in relating to and caring with the person with dementia. For example, including a person with dementia in conversations at mealtimes would be considered as “positive person work”, as it contributes to recognising that person as a valued person. Dawn Brooker also illustrated Kitwood’s philosophy of person-centered care using a “VIPS” framework—“V” as valuing the individual as a full member of society, “I” as providing individualised approach, “P” as understanding the perspective of the person living with dementia, and “S” as providing a social environment that supports well-being of the person.

The environment needs to be able to support remaining ability rather than operate to diminish it, and to support the development and maintenance of relationships. The design of physical environments within residential aged care facilities (RACFs) can improve or worsen wellbeing in people with dementia irrespective of level of care from nursing staff. In Australia, the Building Quality for Residential Services Certification guides the building quality of RACFs in general, but this legislation does not offer any standards catered specifically to a person-centred dementia unit design. A groundbreaking assessment tool for the ward environment was developed in collaboration with NHS trusts participating in “The King’s Fund’s Enhancing the Healing Environment” (EHE) programme. Since then over 70 care organisations have been involved in field testing the tools. These tools have been informed by research evidence, best practice and over 300 survey responses from those who have used the tools in practice. Each of the sections draws on this evidence to develop a rationale for effecting change in care environments. This rationale also addresses, to some extent, the visuospatial experiences often associated with dementia. Making accommodations for the cognitive problems which people with dementia face is a fundamental aspect of overcoming disAbilities: for example the intelligent use of signage in care homes can make a tremendous difference. It’s also known, further, that intelligent use of colours and textures can enhance the lived experience of people living with dementia in residential care settings.

From the societal perspective care for dementia patients living in the community tends to cost more than care in nursing homes when functional impairment is controlled for. Care provided by family and friends in the community on the one hand saved costs of formal care but on the other hand cause informal care costs, which more than outweigh the savings (König et al., 2014). Innes, Kelly and Dincarslan (2011) have reported on a study to evaluate the reliability and validity of two tools: The Design Audit Tool and the Environmental Audit Tool developed to audit how dementia-friendly internal and external environments (specifically care homes) are for people with dementia. Analysis of the home reports identifies variation and variability in meeting “dementia-friendly principles” as specified by both tools. Areas of variability included wayfinding, the use of colour and contrast, access to outside spaces, individualisation of personal and communal spaces, lighting and opportunities to engage with the environment.

“Household model units” are often created from traditional ward type environments. They, for example, are distinguished by having approximately 16 residents, a functioning kitchen, their own front door entrance and a separation of the bedrooms from the main communal living rooms. There is a philosophy of facilitating “person-centred care”, as opposed to institutional routines, supported by a consistent team of care workers providing much of the unit management and decision making for each household. They encourage domestic style relationships between residents, staff and relatives.

On the other hand, the policy of “aging in place”, meaning the ability of individuals to remain in their home in the community, is a consistent wish and expectation of middle aged and older people. Home adaptations (environmental improvements, or in the disability legislation, reasonable adjustments) and assistive technology provision are an increasingly attractive means of helping older people to maintain their independence and enhancing their quality of life. There has been, frustratingly, little systematic research into the feasibility and cost of pursuing such a policy. The lack of definitive evidence of a link between the quality of the environment and the wellbeing of people with dementia living in that environment is somewhat surprising given the evidence that is available on the beneficial effects of specific environmental interventions. “Housing with care”, such as extra care and continuing care housing, is becoming a preferred alternative amongst commissioners of adult social care to care homes for people with dementia. Contemporary research suggests that many people with dementia can lead good quality lives in extra care housing, at least in the mild to moderate stages.

The availability of gardens or outdoor areas in residential homes may offer a range of benefits for people living well with dementia, including opportunities for active engagement with gardening, walking in an outdoor environment, and sitting in soothing surroundings.

The physical environment is therefore now emerging as an important determinant of psychosocial and health outcomes for older persons with dementia of the Alzheimer type and other dementias. Among demented residents of long-term care facilities, environmental factors have been linked to agitation, intellectual deterioration, orientation, and even sleep patterns. With more people with dementia living in care homes in the UK than ever before, there is growing recognition that the design of such internal and external spaces should meet dementia friendly principles. The availability of gardens or outdoor areas in residential homes may offer a range of benefits for people with dementia, including opportunities for active engagement with gardening, walking in an outdoor environment, and sitting in soothing surroundings.

This field is promisingly now moving fast, giving some meat to the bones of ‘dementia friendly communities’.




Innes A, Kelly F, Dincarslan O. Care home design for people with dementia: What do people with dementia and their family carers value? Aging Ment Health. 2011 Jul 1;15(5):548-56. doi: 10.1080/13607863.2011.556601.

König HH, Leicht H, Brettschneider C, Bachmann C, Bickel H, Fuchs A, Jessen F, Köhler M, Luppa M, Mösch E, Pentzek M, Werle J, Weyerer S, Wiese B, Scherer M, Maier W, Riedel-Heller SG; AgeCoDe Study Group. The costs of dementia from the societal perspective: is care provided in the community really cheaper than nursing home care? J Am Med Dir Assoc. 2014 Feb;15(2):117-26. doi: 10.1016/j.jamda.2013.10.003. Epub 2013 Dec 8.

“What’s in it for me?” The importance of the ‘built environment’ for living well with dementia

built environments

Strangely enough, with the focus of drugs, drugs, and yet more drugs, there’s been relatively scant attention for the environment in which a person living with dementia finds himself or herself in.

Improving wellbeing for a person is essentially about understanding the past and present of that person, and building on that person’s beliefs, concerns and expectations about the future. But the idea that you can ignore the environment is simply science-fiction.

The design of care homes maters. The design of hospital wards matter. The design of towns including pavings and signs matters.

Such an approach sounds ambitious and joined up, but not impossible. There’s been a long and proud history in England of understanding the social determinants of health, including housing.

The Attlee Government also extended the powers of local authorities to requisition houses and parts of houses, and made the acquisition of land less difficult than before. In 1949, local authorities were empowered to provide people suffering from poor health with public housing at subsidised rents. That very same year, unemployment, sickness and maternity benefits were exempted from tax.

Recent research suggests that wellbeing in later life is closely related to the physical environment, which is an important mediator of ageing experiences and opportunities. The physical character of the built environments or neighbourhood in particular seems to have a significant impact on the mobility, independence and quality of life of older people living in the local community.

According to a “Greenspace Scotland” report from 2008, “Trust for Nature” is a community-based conservation organisation that focuses on the protection of private land of high conservation value in the state of Victoria, Australia.

In recent research by Inclusive Design for Getting Outdoors (ID’GO), 15% of questionnaire respondents (a large sample, nearing 1000 in sample size) had stumbled or fallen outside within the last 12 months. The real figure is likely to be higher, since past-year falls are often under-reported. Many of the environmental risk factors associated with outdoor falls appear to be preventable through better design and maintenance; factors including pavement quality, dilapidation and kerb height.

Abstract experiential qualities such as perceptions of ‘safety’ and ‘attractiveness’ have been identified as important factors in stated preferences for parks and green spaces and there has been much written over many years on landscape aesthetics  and how this might influence preference and use.

By contrast with research on environment and health, arguably this is a domain rich in theoretical concepts for the mechanisms behind engagement with the environment but poor in terms of tools to measure the detailed spatial and structural qualities of different landscapes in relation to how people actually use and experience them. For landscape designers, this is of crucial interest. There have been, historically, attempts to develop guidance based on general principles, but few tools actually to measure the dynamic spatial experience in practice.

A built environment for all ages is conceptualised as one that has been designed so that people can access and enjoy it over the course of their lifetime, regardless of ability or circumstance. Such environments are said to be designed “inclusively”. The I’DGO (Inclusive Design for Getting Outdoors) consortium was launched in 2004 to investigate how outdoor environments affect older people’s wellbeing and to identify what aspects of design help or hinder older people in using the outdoors. Their focus is on identifying the most effective ways of shaping outdoor environments inclusively. They support the needs and preferences of older people and disabled people, always seeking to improve their independence and overall quality of life.

I’DGO was set up to explore the ways in which being able to get out into one’s local neighbourhood impacts on older people’s wellbeing and what barriers there are to achieving this, day-to-day. The project asked the crucial question: why do we need a built environment for all ages? The first phase of research, which finished in 2006, involved over 770 people aged 65 or above. Participants were asked about their wellbeing and quality of life, how often and why they went outdoors and what features of their local neighbourhood helped or hindered their activity. Researchers also physically audited 200 residential neighbourhoods to look for barriers and benefits to getting around as a pedestrian.

The I’DGO research found quickly that older people went outdoors very frequently to socialise, exercise, get fresh air and experience nature. If they lived in a supportive environment – one that made it easy and enjoyable for them to get outdoors – they were more likely to be physically active, healthy and satisfied with life. Walking was by far the most common way that people spent their time outdoors, whether for recreation or transport (‘getting from A to B’). Participants in the I’DGO study who lived within 10 minutes’walk of an open space were twice as likely to achieve the recommended levels of healthy walking (2.5 hours/week) as those whose nearest open space was not local.

A major research goal has been to examine the specific attribute of neighbourhood streets – tactile paving at steps and crossings – and asks how this affects the biomechanics of walking and risk of falling in older people (the project run by the SURFACE Inclusive Design Research Centre and their colleagues in Health, Sport and Rehabilitation Sciences at the University of Salford). The benefits of tactile paving for blind and visually impaired people have been well established yet the system is not without its issues.

Tactile paving is not a policy area without its concerns, and a few in particular emerge from a report by the UK Health and Safety Executive. This report suggested that there is a need better to understand the extent and implications of incorrectly designed and laid tactile paving, and the toe clearance of an individual in negotiating paving ‘blisters’ and potential slip hazards. These factors appear to be crucial to older people, since many of the first phase ID’GO interviewees expressed concerns about falling
or feeling unstable on tactile surfaces and fall-related injuries are associated with loss of independence, morbidity and death in older people.

If we are to understand what qualities of the environment are important to an ability of individuals to ‘live well’, we need perhaps to acknowledge the diversity that exists in people’s capabilities, experience, desires and needs. This overall is a huge challenge for designers; the response conventionally has been to look for factors in the environment that matter to most people, or to a defined group of people, and to address those factors as if they were equally important. Yet for any individual, different qualities and elements in the environment may be a matter of indifference (e.g. certain colours if you are visually impaired) or vitally important (e.g. proximity of an accessible toilet if you have a weak bladder).

Such an approach builds on the concept of “affordance” and the reciprocal relationship between perceiver and environment. The concept of affordance links environment and human behaviour, or opportunities for action, and is therefore of particular interest in understanding how the environment might encourage or support people to be more active—a primary goal of public health policy. This is an insight of key relevance to investigating human behaviour in the landscape. As Appleton has put it, more succinctly, for any individual considering their landscape context, it helps us understand “what’s in it for me?” (Appleton, 1975).

Key text

Appleton, J. (1975) The experience of landscape, New York, NY: John Wiley.