In this blog I return to my structured series on the building blocks for excellence in dementia care. We began to introduce the necessity of good, adaptive design two editions ago and today we further set the scene. I am hopeful that by the time we complete the introduction to design as a primary building block for excellence in care, you will already have started making adaptions to the care home where you live or work – if not, my efforts are in vain. I will try harder to reach you in the future. So let’s get started by looking at the reasons why prosthetic design matters.
As more and more healthcare settings attempt to serve a resident population that consists of large numbers of people living with Alzheimer’s disease and other related dementias, and for longer periods, it is becoming increasingly clear that design is not just an incidental concern, but is integral to a well- balanced approach to the provision of dignified caring for this vulnerable and discriminated population.
Healthy profits will still be made by care operators spending more on adapting environments, training staff and supporting relatives: in fact, paradoxically, this investment will increase profits in the future as more people are able to choose where they ‘purchase’ their care – and choose to spend their cash with you.
Physical problems experienced as we age are now acceptable within society but, depression and dementia, the most significant other contributors to loss of function in the old, are not socially acceptable. It appears in the West and increasingly elsewhere that as individual competence decreases, social stigma grows – therefore the personal, social and physical environment becomes increasingly important in determining and individuals sense of worth, their well- being.
The primary focus, therefore, for those designing for dementia and old age should be to maximise the capacity within the built and social environments to support remaining abilities, compensate for failing abilities and facilitate residents and their families in carrying out meaningful and relevant life- affirming activities.
A model for us to consider with these goals in mind is the ecological model of ageing (Lawton and Nahemow 1973), where the characteristic feature of this overarching model is that it predicts behavioural outcome by looking at an individual’s competence in relation to environmental pressure.
There is an equation, which we will return to throughout my blogs which is expressed as B=f (P, E) where B stands for behaviour and is conceptualised as a function F, of the combination of the person P, (and their competences) and E, the environment. Don’t worry if you struggled with equations at school (who did not?) as this is easily explained as:
The persons behaviour will be influenced positively or negatively by the pressures exerted upon them by the environment demands – too much bad outcomes, too little bad outcomes, just right best outcome – our job: control the pressure.
Careful design planning can facilitate mental functioning, minimise some areas of confusion, decrease real and perceived stress and allow individuals to function more independently at whatever level they may be able. Further consideration of ‘pressure’ can make care homes good for staff and attractive to relatives and friends and most importantly, maximise optimum performance and interaction between all.
Our population and their characteristics
The number of disabled older people is expected to grow rapidly, and they will form a larger percentage of the total elderly population in the future because of the changing age composition of the population and particularly the higher proportion of people living to 85 years or older. We should embrace these statistics not wince.
Eighty per cent of older people suffer from chronic limitation of mobility. Forty-eight per cent have arthritis, 29 per cent have hearing loss, 17 per cent have orthopaedic impairments, and 14 per cent have vision problems. To that list add incontinence, sensation loss, respiration, and cardiac difficulties.
Unfortunately, I could not find in my literature searches a similar list of percentages for all the really wonderful and positive contributions older people make. Perhaps this speaks volumes about our consumerist twenty- first century perspective so let me reverse the above: 52 per cent do not have arthritis, 71 per cent do not have hearing loss, 83 per cent have no orthopaedic impairments and 86 per cent have no vision problems. Most will not be incontinent, have minimal sensation loss and will have either few or well-managed respiration and cardiac difficulties and will manage well with chronic limitation on mobility – and most will be incredibly loved and respected heads of extended families and the overwhelming percentage will not experience dementia in their lifetime.
Supportive care environments: messages from current evidence
Many care home residents face multiple challenges, but strong accumulating evidence suggests environments can be designed, or redesigned, to provide support, enhance and simplify lives, and most importantly make life more enjoyable.
Key aspects of successful care schemes across extra care and care/nursing homes are:
- Specialist design for a specific population.
- Having adequate useable social space within the building as a whole.
The physical environment has a wide range of impacts on outcomes for residents, staff and visitors.
Pleasant, homely and easy to understand environments which offer opportunities for residents to improve their functioning can increase independence, mobility and encourage food and fluid intake.
Important design priorities that assist vision and way finding in dementia care environments are lighting, signposting, the use of colour, the use of colour contrast, and the use of artwork and memorabilia.
There are a lot of guidelines, recommendations and examples of good practice relating to the design of buildings and living environments for people with dementia. However, much of the information is anecdotal and, although it might be helpful, is not as yet proven (Smith et al, 2004).
There are pros and cons regarding the size of buildings. Larger schemes can be disorientating and confusing but are more likely to be able to provide a wider range of amenities and facilities and in reality attempting to push the care industry into providing smaller, more ‘normal’ environments will not work as the staffing costs will make providing care unaffordable and will be resisted.
The ‘normal’ or ‘housing’ element is, however, as important as the care aspect and there is emerging evidence from small- scale UK studies of the following:
- adequate spaces for gatherings of both large and small groups should be provided.
- there should be provision of baths as well as showers.
- Schemes should appear welcoming to relatives and friends.
Fleming and colleagues’ recent literature review of the design of physical environments for people with dementia, concluded that little is certain (Fleming et al, 2008) and that findings from studies existing to date support the previously published ‘consensus of views’ on principles for designing dementia- specific facilities (Marshall, 2001), which concluded that care accommodation for older people living with dementia should:
- compensate for disability
- maximise independence, reinforce personal identity, and enhance self- esteem/ confidence
- demonstrate care for staff
- be understandable and easy to orientate around
- welcome relatives and the local community, and
- control and balance stimuli.
Fleming et al (2008) also conclude that the currently available evidence also strongly supports the use of:
- Unobtrusive safety features
- a variety of spaces, including single rooms
- the enhancement of visual access, and
- the optimisation of levels of stimulation.
Baker (2002) highlighted the importance of having a communal room or space which is suitable for relatives and friends to meet should they wish. Likewise, Evans and Vallelly (2007), in their literature review of ‘Best Practice in Promoting Social Well- Being in Extra Care Housing’, concluded that features that are welcoming for friends and relatives should be incorporated.
Tilly and Reed (2008) support the view that homely and pleasant environments that provide opportunities for residents to improve their functioning and walk around with minimal risk lead to more independence in daily activities.
Reducing stress and improving well- being
Evans and Vallelly (2007) demonstrated that the layout and design of a scheme can impact on social well- being, and Chimes (2007) also stated in his design features for older people with dementia literature review, that there were evident positive correlations between built design features and quality of life.
He cautioned, however, that it is difficult to establish whether it is the design features that improve well- being in most cases because other factors, such as the social environment and philosophy of care ‘that are difficult or impossible to extrapolate’, may influence outcomes.
It is important here to draw from the views of Chimes two important observations:
- Design features have not been proven to increase well- being in care.
- Philosophy of care and the social environment may influence the outcome of research into the impact of design on well- being.
We must assume in his conclusions that Chimes refers to negative care philosophy and social environments, as relating to Kitwood’s malignant social psychology as the negating factors within the environment as opposed to the direct impact of building design, which has been well studied and well published in literature relating to sick buildings and architecture.
I am also not sure that the evidence is inconclusive as to whether built environments affect the quality of life and specifically the well- being of those living within them, but of course if staff operate a culture that is socially malignant, then this ‘pressure’ will negatively impact the effect of any environmental adaptions significantly for the worse.
If we consider that a building is only any good if it serves its purpose, studies need to contrast the lives of those living in adapted facilitative environments with good, empowered caring as opposed to those living in regular care home designs with the same positive cultures before any conclusions can logically be drawn.
Which design changes are debatable and which are not?
Before we discuss some of the supporting literature I think it is important to note the difference here between what we do know and what we do not. I don’t think, for example, that at present we know enough to definitively state that using various coloured doors to differentiate bedrooms is helpful or not? Let me explain
The argument seems to hinge on memory and that an individual will remember their room better if the doors remind them of when they were younger, perhaps a child, and the family door. However I think that argument if flawed in a number of ways in practice. (And theoretically by understanding how memory works).
Not everyone living with a dementia in care will have memory that rolls back to a specific fixed point in time, nor will they remain there. Also, with our present multi-ethnic society, childhood experiences differ widely. I think we may also have points in our memory – probably better accessed by their emotional resonance than a specific timeline – where many and varied coloured doors may feature throughout differing ‘fixed points’.
Also, if we accept the argument for time-specific memory of coloured doors, how can we be sure in a care home where there are say 30 beds on one corridor and therefore five blue doors, five red doors, five yellow doors and so on that just one specific red door will be relevant? Perhaps this approach simply encourages people to explore five red- door options before finding home?
More understandable is the argument for highlighting toilets and bathrooms and disguising exits and other doors people do not need to be attracted to. If each same- coloured door explored leads to a toilet, that seems to me to have real value and relies on retained and existing abilities rather than on a hypothetical, possibly intentional blurring of what we know about the many different forms and functions of memory.
Arguments for the use of redundant cueing make use of the individuals retained abilities and are based on an understanding of brain science. Science also supports the use of smells and colour and the deliberate use of design differentiation to highlight contrast and depth.
I don’t think we need to argue much about signage either, except perhaps the design of the signs – signage has been used to assist people to find their way around large buildings and spaces for many years now so the argument seems won. We understand that in a strange place even with full cognitive ability people need to be shown the way – it lessens stress (environmental pressure) and leads to more desirable outcomes, thus it enables and not disables.
The counter- arguments based around the aesthetics of care homes – ‘we don’t want it to look institutional’ – show a misunderstanding between institutional and functional.
Buildings that have the same carpets, colours, wall fittings and so on are institutional despite their pleasant looks whereas a building with signs and other prosthetics that assist people in finding their way around are functional and if all the other features are there too – decreases the bad pressure and plays an important bias for positive outcomes. Make the signs attractive, make sure they have words and pictograms and even colour code them – but don’t omit them. That’s not care; it is bad business.
Enough information for now – are you rushing off to make some adaptations now?
Till next time
Paul Smith – Dementia Care Expert