Motivation and emotion/Book/2017/Environmental design for people living with dementia

Environmental design for people living with dementia:
What aspects of environmental design are important for the well-being of PLWD?

Multimedia presentation (3 min)

Overview

Dementia is an umbrella term used for a number of progressive neurodegenerative diseases affecting cognitive, behavioural, and emotional functioning (Holmes & Armin, 2016) affecting around 47 million people worldwide, with the total number of people affected expected to almost triple by 2050 (World Health Organisation, 2017). With dementia typically being a disease that affects people later in life, a common misconception is that it is a normal part of aging.

Signs and symptoms of dementia differ between individuals, with the severity depending on the stage of the disease. Early stage signs and symptoms include forgetfulness, losing track of time, and becoming lost in familiar places (World Health Organisation, 2017). These symptoms are often overlooked as the beginning of the disease and seen as general forgetfulness that is a part of aging. As the disease progresses into the middle stage it becomes clear the present sign and symptoms are dementia related - difficulties with communication, needing help with personal care, behavioural changes, and forgetting recent events and people's names start to restrict an individual's independence (World Health Organisation, 2017). Finally, later stage signs and symptoms result in near total dependency, with severe memory disturbances, difficulties with motor control, an inability to recognise family and friends, and behavioural changes that may result in aggression (Torpy, Lynm, & Glass, 2009).

Diagnosis of dementia is extremely difficult (Nazarko, 2009). The first step to a dementia diagnosis is generally completed by a general practitioner (GP) following concerns over the individual's level of functioning. The process of obtaining an official diagnosis involves taking a history of the individual being assessed - their occupational and educational history, medication, and prior drug use. A physical examination involving blood and urine testing is also used to rule out other diseases or illnesses that may the cause of dementia-like symptoms. Finally, mental tests such as the Mini-Mental State Examination may be used to assess the individual's level of cognition.

Figure 1. Strengthening the brain to prevent cognitive decline

Types of Dementia	Key Characteristics	Risk Factors
Alzheimer's	60-70% of all dementia cases Impaired short-term memory Disorientation	Genetics Age Lack of physical activity Drug and alcohol use Smoking Hypertension Education level Stroke Abnormal build up of various proteins in the brain
Vascular	25% of all dementia cases Interrupted blood flow in brain Progressive cognitive impairment
Lewy Body	15% of all dementia cases Build up of Lewy bodies Impaired visuospatial functioning

While there is no cure for dementia many strategies and interventions have been developed to help manage the disease or help slow the decline of cognitive impairment (Agency for Healthcare Research and Quality, 2004). Research suggests good nutrition and physical activity early in life is one such strategy that acts as a preventative measure to developing dementia (Morris, 2016; Blondell, Hemmersley-Mather, & Veerman, 2014). However, from the onset of the disease treatment options are limited. Pharmacological options are utilised to help manage behavioural symptoms, while psychotherapy may be used to help improve cognitions (National Collaborating Centre for Mental Health, 2007), with the intended purpose of improving the individual's well-being and overall quality of life. With the efficacy of current treatments limited, the use of alternative therapies such as healthcare architecture is gaining interest. Manipulating the environment in which people with dementia are living in has shown promising results in improving the well-being of the individuals. Hogeweyk, a small village in the town of Weesp, Netherlands is pioneering the way in providing quality care for elderly people living with dementia, with its design catering to the unique needs of each resident.

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Salutogenic Model of Health

In 1979 Aaron Antonovsky coined the term salutogenesis to describe an approach to health and well-being that focusses on an individual's resources and capacity to move in a health promoting direction (Lindström & Eriksson, 2005), rather than focussing on obstacles and deficits to good health. The Sense of Coherence concept is an important aspect of the salutogenic model that comprises of 3 elements - comprehensibility, manageability and meaningfulness. Antonovsky defines the sense of coherence as:

"a global orientation that expresses the extent to which one has a pervasive, enduring though dynamic feeling of confidence that (1) the stimuli deriving from one's internal and external environments in the course of living are structured, predictable and explicable; (2) the resources are available to one to meet the demands posed by these stimuli; and (3) these demands are challenges, worthy of investment and engagement." (Antonovsky, 1987, p. 19).

The Salutogenic Model of Health has been adopted by facilities that provide care for people living with dementia as its primary focus is the ability to maintain good health despite the dementia illness by providing an environment that allows residents to feel empowered and a experience a sense of purpose (Lindström & Erikkson, 2005), resulting in positive health outcomes and improved well-being.

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Key Features for Dementia Care

As interest in the area of healthcare architecture increases researchers have studied many aspects of environmental design to determine those that result in the most positive outcomes for people living with dementia[improve clarity]. Key aspects of environmental design aim to improve behavioural outcomes of people living with dementia by creating a comfortable, familiar environment for them to live in.

Spatial Character

Personalised spaces create familiarity with a new environment (Lee, Chaudhury, & Hung, 2014) and allow the resident to be reminded of past personal achievements, reducing aggression, social withdrawal, and promoting greater independence (Mobley, Leigh, Malinin, 2017)
Interior design should provide a level of sensory stimulation that allows the resident to feel in control of their environment, allowing them to feel comfortable where they are and reduce wandering (Yao & Algase, 2006)

Wayfinding

Clear signage and cues to assist residents in finding their way around the facility. The use of large numbers or name plates on rooms to reduce distress and anxiety associated with getting lost (Caspi, 2014)

Spatial Organisation

A supportive floor plan (L, H, or square shaped corridors) associated with improved orientation, reducing agitation and distress associated with residents feeling lost (Mobley, Leigh, Malinin, 2017)
Avoidance of long corridors and repetitive elements (e.g. doors) reduce residents confusion and likelihood of wandering out of the facility (Marquadt & Shmieg, 2009)
Fewer residents in the facility reduces the amount decision points residents are faced with when navigating their way around the facility (Marquadt & Schmieg, 2009)

Figure 3. A simple floor plan can help improve resident's orientation

Lighting

Use of appropriate lighting to reinforce normal circadian rhythm (Ellis, Gonzalez, & McEarchron, 2013), improving quality of sleep patterns (Figueiro, 2008)
Improved sleep associated with fewer mood disturbances in people living with dementia (Figueiro, 2008)

Colour/Contrast

Limiting the use of strong colours, such as red and orange can ease anxiety and distress associated with sensory overload (Mobley, Leigh, & Malinin, 2017). The use of neutral or warm colours such as white and blue reduces the sensory complexity of the space (Mobley, Leigh, & Malinin, 2017)

Hogeweyk Village

Hogeweyk care village [where?] contains 23 houses, with each design tailored to meet the individual needs of each resident. The village builds upon the salutogenic model, promoting good health by affording the residents opportunities participate in purposeful activities. Hogeweyk village provides residents with a comfortable, familiar environment in which to live. The village has been built with a social approach in mind, with 7 residents of similar backgrounds housed in one complex to promote social engagement and to challenge residents to remain active in daily life. Stuides[spelling?]} have shown a strong relationship between participation in leisure/social activities and improved well-being, with participants feeling a sense of belonging and purpose as a result (Phinney & Moody, 2011).

The architecture of Hogeweyk village has been carefully designed to take into consideration orientation abilities of people living with dementia, following square-like patterns to increase ease of orientation for residents. Access to open, outdoor spaces allows residents to live freely and independently, while still staying in a protected environment. Providing residents with opportuinties[spelling?] to challenge themselves, particpate[spelling?] in meaningful activities, live in a comfortable, functional environment has shown a dramatic improvement in dementia-related behaviours (Mobley, Leigh, Malinin, 2017).

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Conclusion

Due to the success of Hogeweyk village many other countries have started investing time and money into developing similar villages, with Australia the most recent to adopt this concept. The ability to improve an individual's well-being and quality of life without pharmacological interventions has become an important part of dementia care, with tailored, person-centered care proving to be an effective method for treating people living with dementia. A space that is well organised, easy to navigate, familiar, and allows the individual to feel in control of their environment reduces agitation, distress, and social withdrawal, allowing people living with dementia to have an increased quality of life and improved sense of purpose. Future direction for dementia care may result in more facilities shifting away from pharmacological interventions and towards the salutogenic model. To make this a reality more funding and training is required to develop facilities that provide high quality care in a supportive environment.

References

Agency for Healthcare Research and Quality. (2004). Pharmacological Treatment of Dementia. Retrieved from https://archive.ahrq.gov/clinic/epcsums/demphsum.pdf

Antonovsky, A. (1987) Unraveling the mystery of health. How people manage stress and stay well (1st ed). San Francisco, California. Jossey-Bass.

Blondell, S. J., Hammersley-Mather, R., & Veerman, J. L. (2014). Does physical activity prevent cognitive decline and dementia? A systematic review and meta-analysis of longitudinal studies. Biomed Central Public Health, 14, 1-12. https://doi.org/10.1186/1471-2458-14-510

Caspi, E. (2014). Wayfinding difficulties among elders with dementia in an assisted living residence. Dementia, 13, 429-450. https://doi.org/10.1177/1471301214535134

Chen, JH., Lin, KP., & Chen, YC. (2009). Risk factors for dementia. Journal of Formosan Medical Association, 108, 754-765.

Ellis, E. V., Gonzalez, E. W., & McEarchron, D. L. (2013). Chronobioengineering indoor lighting to enhance facilities for ageing and Alzheimer's disorder. Intelligent Buildings International, 5, 48-60.

Figueiro, M. G. (2009). A proposed 24 h lighting scheme for older adults. Lighting Research and Technology, 40, 153-160. https://doi.org10.1177/1477153507087299

Gardener, S. L., Rainey-Smith, S. R., Barnes, M. B., Sohrabi, H. R., Weinborn, M., Lim, Y., ... Martins, R. N. (2015). Dietary patterns and cognitive decline in an Australian study of ageing. Molecular Psychiatry, 20, 860–866. https://doi.org/10.1038/mp.2014.79

Holmes, C., & Armin, J. (2016). Dementia. Medicine, 44, 687-690.

Lee, S. Y., Chaudhury, H., & Hung, L. (2014). Exploring staff perceptions on the role of physical environment in dementia care setting. Dementia, 13, 1-13.

Marquadt, G. (2011). Wayfinding for people with Dementia: A review of the role of architectural design. Health Environments Research & Design Journal, 4, 75-90.

Marquadt, G., & Schmieg, P. (2009). Dementia-friendly architecture: Environments that facilitate wayfinding in nursing homes. American Journal of Alzheimer's Disease and Other Dementias, 24, 333-340. https://doi.org10.1177/1533317509334959

Mobley, C., Leigh, K., Malinin, L. (2017). Examining relationships between physical environments and behaviours of residents with Dementia in a retrofit special care unit. Journal of Interior Design, 42, 49-69.

National Collaborating Centre for Mental Health (UK). Dementia: A NICE-SCIE guideline on supporting people with dementia and their carers in health and social care. British Psychological Society. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK55462/

Nazarko, L. (2009). Adressing the need for improved dementia diagnosis. Nursing & Residential Care, 11, 245-248.

Phinney, A., & Moody, E. M. (2011). Leisure connections: Benefits and challenges of particpating in social recreation groups for people with early dementia. Activites, Adaption, & Aging, 35, 111-130. https://doi.org10.1080/01924788.2011.572272

Purandare, N. (2009). Prventing dementia: Role of vascular risk factors and cerebral emboli. British Medical Bulletin, 91, 49-59.

Puzzo, D., Gulisano, W., Arancio, O., & Palmeri, A. (2015). The keystone of Alzheimer's pathogenesis might be sought in Aβ physiology. Neuroscience, 307, 26-36.

Torpy, J. M., Lynm, C., & Glass, R. M. (2009). Dementia. The Journal of American Medical Association, 302, 704.

Vracem, M. V., Spuytte, N., Declercq, A., & Audenhove, C. V. (2015). Agitation in dementia and the role of spatial and sensory interventions: Experiences of professional and family caregivers. Scandinavian Journal of Caring Sciences, 30, 281-289.

World Health Organisation (September, 2017). Dementia. Retrieved from http://www.who.int/mediacentre/factsheets/fs362/en/

Yao, L., & Algase, D. (2006). Environmental ambience as a new window on wandering. Western Journal of Nursing Research, 28, 89-104.

External Links

Fleming, R. & Bennett, K. A. (2017, February), "Environmental design resources".
Hogeweyk Dementia Village, "[1]"
Australia's First Dementia Village "[2]"

	14 million
	25 million
	36 million
	47 million
	55 million

	Memory loss
	Difficulties with communication
	Behavioural disturbances
	Loss of motor control
	All of the above

	Lighting
	Spatial organisation
	Spatial character
	Wayfinding
	All of the above