Envieronmental Design for Dementia

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Other design guidance does demand verificationthrough empirical research, however. Empirical re-search is needed to resolve situations in which con-flicting design recommendations are offered. Re-search is also warranted when recommended designsolutions are of unknown effectiveness or when de-sign recommendations have major or controversialimpacts for cost or quality of life. Research on designand dementia has been conducted in earnest since atleast 1980, yet findings of many studies remain un-known among designers and facility administrators.In the following sections, we review and analyze ex-isting studies of design and well-being for peoplewith dementia to enhance the design of dementia fa-cilities and to provide direction for future research.

Methods

Several strategies were used to identify potentialstudies for review. The first involved a key-wordsearch of four major databases: Psych Abstracts,Medline, MAGS, and CAT (see Appendix A, Note 2).Potential studies were also identified by reviewing allissues (1980 or later) of several journals in gerontol-ogy and environment-design research (see AppendixA, Note 3). Finally, reference lists were inspected forall studies included in this review. In each case, arti-cles, books, and chapters identified as potentially rel-evant (by title and by abstract if available) were col-lected and assessed for appropriateness.

Studies included in this review met the followingcriteria: a report of empirical research (see AppendixA, Note 4), published 1980 or later (see Appendix A,Note 5), written in English, with an emphasis on peo-ple with dementia or their families or staff caregivers,and with a substantial (though sometimes secondary)

emphasis on the relationship between the design of the physical environment

and the well-being of people with dementia, their families, and/or staff.

For thisreview, the physical environment was loosely de-fined as the domain of relevance to architects, inte-rior designers, facility managers, and/or administra-tors or caregivers undertaking environmental designor renovation. Thus, research on issues such as light-ing, furnishings, and outdoor space was included.Research on microscale product design (e.g., pros-thetic devices to facilitate eating) or on the sensory orsocial environment outside the purview of designers(e.g., incorporation of music and pets) was excluded, aswere studies that did not examine actual environmentsor actual impacts. Well-being was defined broadly, toinclude factors such as residents activities of daily liv-ing (ADL), physical well-being, cognitive function, andproblem behaviors; family members well-being; andstaff well-being and job performance. Seventy-one re-search reports were included in the review. Because of this selective search strategy, we may have overlookedsome relevant material in the review.

Research Design and Sample Size

Much research on design and dementia comprisessmall size samples. For example, more than 30% of

the studies reviewed used samples of fewer than 30participants; many included less than 10 participants.Sample sizes reflect the limited populations of resi-dents at the single facility in which many studieswere conducted, the high rates of resident mortality,and facilities limited populations of residents incomparable stages of dementia. Although they raiseconcern for the validity and generalizability of find-ings, studies with small samples were included so asnot to severely restrict the scope of this review. Re-search designs and samples are described in Table 1.

Results

The rate of research on design and dementia is in-creasing: from 6 research reports from 19811985, to17 research reports from 19861990, to 26 researchreports from 19911995, and to 21 research reportsalready published since 1996 (see Table 1). This sec-tion summarizes findings from the research reportsreviewed, according to the organizational frameworkpresented earlier (i.e., planning principles, general at-tributes of the environment, building organization,and specific rooms and activity spaces). The sum-mary is followed by a discussion and analysis of ex-isting research on design and dementia.

Planning Principles

These studies examine broad decisions regardingthe development of dementia care settings. Studiesexamined impacts for well-being following reloca-tion of people with dementia to new environments,use of respite and day care environments and of spe-cial care units (SCUs), and exposure to various groupsizes of residents.

Relocation to New Environments.

Findings aremixed regarding the impacts of relocating peoplewith dementia to new environments (Robertson,Warrington, & Eagles, 1993; Seltzer et al., 1988; seeAppendix A, Note 6). When moved together as intactunits of residents and staff, people with dementia ap-pear to suffer few or no adverse impacts from reloca-tion (Anthony, Procter, Silverman, & Murphy, 1987;McAuslane & Sperlinger, 1994; Robertson et al.,1993). The more pleasant environment of a new fa-cility may partially explain the lack of negative im-pact for relocated residents (according to McAuslane& Sperlinger, 1994). In contrast, residents with de-mentia who are moved individually appear to sufferhigher rates of depression and mortality following re-location (Anthony et al., 1987; Robertson et al.,1993). This effect holds when residents undergo ori-entation to ease relocation. Staff members also reportdecreased job satisfaction (attributed to anxiety) priorto moving, which returns to premove levels of satis-faction following relocation (McAuslane & Sper-linger, 1994).

Respite Environments.

Respite environments of-fer temporary care for people with dementia and pro-vide relief to families. The impacts of respite environ-


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ments on people with dementia appear to be relatedto individuals functional levels and to the type of en-vironment. In an examination of 37 clients of respiteservices, Seltzer and colleagues (1988) found that,following a 2-week respite stay, lower functioning in-dividuals showed small improvements in ADLs, whereashigher functioning individuals showed a small de-cline in ADLs. Both effects were minor, and neithergroup revealed any changes in cognitive status fol-lowing respite. In a study of 85 people with demen-tia, use of respite environments for approximately 2weeks was associated with little deterioration andwith improvements in cognitive function and mood(Ulla, Johanna, & Raimo, 1998). Improvements wereattributed to the therapeutic philosophy and careplan of the SCUs, and to the SCUs homelike envi-ronments. Thus, findings largely support the use of respite as an alternative to home care alone, becausenegative impacts of respite are limited.

SCUs.

Generally, SCUs are segregated units thataccommodate only cognitively impaired individuals,such as those with dementia. SCUs distinguish them-selves by offering one or more special features, in-cluding dementia-appropriate activities, small groupsof residents, special staff selection and training, fam-ily involvement, and specialized design (see alsoBerg et al., 1991). According to a survey of 31 SCUsin five states, the most typical, distinguishing envi-ronmental features of SCUs (compared to nonspecial-ized units) include smaller size units, fewer residentrooms, and more designated private rooms (Mathew& Sloane, 1991). SCUs are further characterized bythe presence of private dining rooms, separate andlarger activity rooms, and access to the outdoors

(Mathew & Sloane, 1991). The effectiveness of SCUs for people with demen-tia has been subject to debate. A complete review of this multifaceted research is beyond the scope of thisarticle, in which we focus on the physical environ-ment only (for reviews, see Maslow, 1994; Teresi,Grant, Holmes, & Ory, 1998; Weisman et al., 1994).General information on the impacts of SCUs warrantmention, however. Studies show associations be-tween SCU environments and improvement orslowed decline in residents communication skills,self-care skills, social function, mobility, and affec-tive responses (Benson, Cameron, Humbach, Servino,& Gambert, 1987; Greene, Asp, & Crane, 1985; Mc-Cracken & Fitzwater, 1989; Skea & Lindesay, 1996).Additionally, SCUs are associated with reductions inbehavior disturbances, abnormal motor activity, apa-thy, and hallucinations among residents (Annerstedt,1993; Bellelli et al., 1998; Benson et al., 1987;Greene et al., 1985; McCracken & Fitzwater, 1989;Swanson, Maas, & Buckwalter, 1993).

Other positive impacts of SCUs reported in thesestudies include reduced emotional strain among rela-tives and increased competence and satisfactionamong staff (Annerstedt, 1993; Wells & Jorm, 1987;see Appendix A, Note 7). Segregation of dementiaresidents into special units also appears to benefit

residents without cognitive impairments. Cogni-tively intact residents are found to suffer declines inmental and emotional status when living in closeresidential proximity to people with dementia (Ter-esi, Holmes, & Monaco, 1993; Wiltzius, Gambert,& Duthie, 1981).

Alternately, SCUs are reported to have little or nopositive effect on residents wandering, cognition,functionality, and behavior, or on staff job satisfac-tion or job pressure (Bellelli et al., 1998; Chafetz,1991; Holmes et al., 1990; Ramrez, Teresi, Holmes,& Fairchild, 1998; Saxton, Silverman, Rica, Keane, &Deeley, 1998; Skea & Lindesay, 1996; Swanson etal., 1993; Webber, Breuer, & Lindeman, 1995). Re-ports of findings do not distinguish between SCUswith and without special environmental features. Manystudies of SCUs include small sample sizes and lackcomparison groups (see Table 1 for details.)

It is difficult to assess whether specialized designfeatures in SCUs have any impact on people with de-mentia. First, SCUs are not comparable, because whatis considered an SCU varies enormously (Maslow,1994; Teresi, Holmes, Ramrez, & Kong, 1998). Sec-ond, most SCUs do not use extensive specialized de-sign features (U.S. Office of Technology Assessment,1992, in Maslow, 1994). Further, special features usedin SCUs (staffing, activities, design, etc.) are frequentlytreated by researchers as one global intervention(Weisman et al., 1994; see Appendix A, Note 8). Thus,potential impacts from individual design features (pri-vate rooms, minimal sensory stimulation, etc.) are ob-scured by simultaneous modifications in other arenas.When used, design features may not be identified byresearchers as highly significant aspects of the specialintervention (cf. Skea & Lindesay, 1996; Swanson etal., 1993). For these reasons, the impact of specializeddesign cannot be easily distinguished in much existingresearch on the effectiveness of SCUs.

Day Care Centers.

Only one study was identifiedthat specifically examined the design of day care cen-ters in terms of therapeutic impacts. In this research,relocation of a day care center to an enhanced facility(including safety and surveillance features, an en-closed garden, and more space for day health pro-grams and activities) was associated with positive andnegative changes in staff stress and quality of care (Ly-man, 1989). Following the move, staff stress shiftedfrom that prompted by space shortages to (lower)

stress associated with specific spatial configurations(e.g., difficulty involving clients in activities in new,larger activity areas). Negative impacts on quality of care associated with limited space (e.g., insufficientspace for clients to conduct specific activities as longas desired) were also reduced following relocation.

Group Size and Clusters of Residents.

Design guidessuggest that units with fewer residents may reduceoverstimulation among people with dementia bycontrolling noise and by limiting the number of peo-ple each resident encounters. This recommendationis supported by research findings, including those of


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a major survey of 53 SCUs in four states (Sloane etal., 1998). According to this study and others, largerunit sizes are associated with higher resident agita-tion levels and with increased intellectual deteriora-tion and emotional disturbances (Annerstedt, 1994;Sloane et al., 1998). Further, residents in larger unitsexhibit more frequent territorial conflicts, space inva-sions, and aggressiveness toward other residents (Mor-gan & Stewart, 1998). In contrast, people with de-mentia residing in smaller units experience less anxietyand depression and more mobility (Annerstedt, 1997;Skea & Lindesay, 1996). Small group sizes are alsopositively associated with increased supervision andinteraction between staff and residents (McCracken &Fitzwater, 1989) and with social interaction andfriendship formation among residents (McAllister &Silverman, 1999; Moore, 1999; Netten, 1993). Noconsistent numbers are offered for what constitutes alarge or a small unit.

Smaller facilities offer additional benefits for resi-dents and staff. In a comparison of 28 residents of group living facilities (see Appendix A, Note 9) and31 residents of traditional nursing homes, residents of group living displayed higher motor functions andslightly improved or maintained ADLs and requiredless usage of antibiotics and psychotropic drugs (An-nerstedt, 1993; see Appendix A, Note 10). In thesame study, relatives with family members in groupliving units reported lower levels of strain and betterattitudes toward dementia care than relatives of resi-dents in nursing homes. Staff members also experi-enced benefits associated with group living facilities.Staff in group living units reported greater compe-tence, more knowledge in dealing with dementia,and greater job satisfaction than did their counter-parts in nursing homes (Annerstedt, 1993).

General Attributes of the Environment

These studies investigate desired qualities of theoverall facility environment. Studies have examinedeffects on well-being associated with noninstitutionalcharacter, levels of sensory stimulation, lighting lev-els, and design modifications for safety.

Noninstitutional Character.

Design guides frequentlyendorse the use of noninstitutional design features,such as homelike furnishings and personalization, topromote well-being among residents. This endorse-ment is supported by research findings, though stud-ies often compare facilities in which many featuresvary (e.g., staff training, activity programming), in ad-dition to environmental design. Noninstitutional en-vironments characterized as having homelike orenhanced ambiance (personalized rooms, domes-tic furnishings, natural elements, etc.) are associatedwith improved intellectual and emotional well-being,enhanced social interaction, reduced agitation, re-duced trespassing and exit seeking, greater prefer-ence and pleasure, and improved functionality of older adults with dementia and other mental illnesses(Annerstedt, 1994; Cohen-Mansfield & Werner, 1998;

Kihlgren et al., 1992; McAllister & Silverman, 1999;Sloane et al., 1998). Compared with those in tradi-tional nursing homes and hospitals, residents in non-institutional settings are less aggressive, preservebetter motor functions, require lower usage of tran-quilizing drugs, and have less anxiety. Relatives re-ported greater satisfaction and less burden associatedwith noninstitutional facilities (Annerstedt, 1997; Co-hen-Mansfield & Werner, 1998; Kihlgren et al., 1992).Staff also prefer less institutional, enhanced environ-ments (Cohen-Mansfield & Werner, 1998).

Noninstitutional environments are not entirely bene-ficial, however. A higher degree of homelikeness isassociated with greater restlessness, more distur-bances (tied to greater assertion of independence),and increased disorientation and deterioration of diet(Elmsthl, Annerstedt, & hlund, 1997; Kihlgren et al.,1992; Wimo, Nelvig, Adolfsson, Mattsson, & Sand-man, 1993). Studies also show that mortality and de-cline rates for residents do not significantly improvein noninstitutional units when compared with tradi-tional settings (Annerstedt, 1994; Phillips, Sloane,Howes, & Koch, 1997; Wimo et al., 1993). Further,noninstitutional design requires supportive caregiv-ing to be effective. In an ethnographic study of onefacility, institutional caregiving practices (charac-terized as inflexible and formal) were described asundermining the therapeutic potential of the home-like environment (Moore, 1999).

Sensory Stimulation.

Residents face difficultieswith sensory overstimulation, which may increasethe distraction, agitation, and confusion associatedwith dementia. Sensory overstimulation may be ex-acerbated by the normal hearing loss that accompa-

nies aging and the further hearing loss associatedwith dementia, both of which may increase confu-sion and reduce social interaction and self-esteem(Brawley, 1997; see Appendix A, Note 11). (Visualdeficits, discussed later, further increase overstimula-tion.) At the same time, sensory deprivation has beenidentified as a potential problem in many dementiacare environments (Cohen & Weisman, 1991).Design guides call for appropriate levels of sensorystimulation, striking a careful balance between envi-ronmental overstimulation and deprivation. Recom-mendations include removing unnecessary clutter,providing tactile stimulation in surfaces and wallhangings, and eliminating overstimulation from tele-visions, alarms, and so forth (cf. Evans, 1989; Hall,Kirschling, & Todd, 1986).

Researchers have identified characteristics and lo-cations linked with high levels of sensory stimulationin environments for people with dementia. In an eth-nographic study of one skilled nursing facility, over-stimulation is associated with loud noises (loud talk-ing, singing and clapping, etc.), with crowding anddisruptive behavior from other residents, and withfrightening experiences (e.g., scary movies, costumes;Nelson, 1995). High stimulationas measured byagitation levelswas found to occur in elevators,corridors, nursing stations, bathing rooms, and other


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residents rooms, whereas low stimulation has beenobserved in activity and dining rooms (Cohen-Mans-field, Werner, & Marx, 1990; Negley & Manley, 1990).Detailed descriptions of these spaces were not pro-vided by researchers.

Overstimulation may impair residents ability toconcentrate. Limited stimulation activity areasmade by hanging cloth partitions to eliminate viewsto ongoing activityreduce distractions among resi-dents by up to two-thirds (Namazi & Johnson,1992b). Use of partitions increased the ability to fo-cus on a task among residents in all stages of demen-tia by eliminating some visual and especially audi-tory distractions (e.g., noise, talking).

Findings on the effects of low stimulation units aremixed. Use of a neutral design and color scheme,elimination of stimulation, and consistent daily rou-tines have been shown to reduce behavioral distur-bances, curtail use of physical and chemical restraints,and encourage weight gain (Bianchetti, Benvenuti,Ghisla, Frisoni, & Trabucchi, 1997; Cleary, Clamon,Price, & Shullaw, 1988). Similarly, in one quasi-experiment, 13 residents of an SCU that incorporatedstructured resident routines and reduced stimulationdisplayed fewer catastrophic reactions and more pos-itive interactions, compared with nine residents inlong-term care (Swanson et al., 1993). Reduced stim-ulation units have had little effect in regulating sleeppatterns, decreasing urinary incontinence, or dis-couraging wandering, however (Bianchetti et al.,1997; Cleary et al., 1988; Swanson et al., 1993; seeAppendix A, Note 12).

Design guidance argues that certain levels of sen-sory stimulation may be required to promote engage-ment in activities and interaction and to minimizewithdrawal among people with dementia (cf. Calkins,1988). The positive impacts of sensory stimulationhave received limited research. The experimentalWeiss Institute of the Philadelphia Geriatric Centerwas designed to maximize positive sensory stimula-tion; this facility featured resident rooms opening di-rectly to a central open space. The spatial configura-tion was intended to enhance residents orientationand engagement in activities (Lawton, Fulcomer, &Kleban, 1984). Indeed, in a postoccupancy evalua-tion of the Weiss Institute, residents were found tospend less time in their rooms and were more atten-tive to activity following relocation to this facility(Lawton et al., 1984). In a related study, a high stimu-

lation environment (including orientation aids, recre-ational materials, and extensive reality orientationprograms) was associated with increased moraleamong 16 staff members in one unit, compared withmorale among 13 staff members in a traditional de-mentia unit (Jones, 1988). The focus on increasingstructure and resident orientation in the high stimula-tion unit suggests other possible explanations for en-hanced staff morale in this unit.

Lighting and Visual Contrast.

People with demen-tia face particular visual deficits, including difficulty

with color discrimination, depth perception, and sen-sitivity to contrast (Cronin-Golumb, 1995). These def-icits exacerbate normal changes in vision that ac-company aging, such as irritation from glare andchanges in color perception (Brawley, 1997). Designguides for dementia environments recommend strate-gies to reduce glare, increase contrast where appro-priate, and minimize confusion concerning depthperception. Design guides also recommend increas-ing overall light levels and exposure to bright light(cf. Brawley, 1997).

Compared with other older adults, people with de-mentia are exposed to inadequate levels of brightlight (described as light exceeding 2,000 lux; Camp-bell, Kripke, Gillin, & Hrubovcak, 1988). In findingsfrom two studies involving 24 and 10 residents, re-spectively, bright light treatment consistently regu-lated circadian rhythms and improved sleep patternsamong people with dementia (Mishima et al., 1994;Satlin, Volicer, Ross, Herz, & Campbell, 1992; seeAppendix A, Note 13). Results are mixed concerningthe impact of bright light on agitation (Lovell, Ancoli-Israel, & Gevirtz, 1995; Mishima et al., 1994; Satlinet al., 1992).

Most often, research on the effects of bright lightis conducted under laboratory conditions, requiringspecial equipment and the restraint of residents. Theeffects of bright light as a regular environmental fea-ture have received limited attention. One quasi-experimental study was identified in which researchersexamined the effect of ceiling-mounted light fixturesthat provided high intensity illumination (7902,190lux; Van Someren, Kessler, Mirmiran, & Swaab, 1997).Bright light administered in this fashion fostered be-havioral improvements and increased circadian restactivity rhythms among 22 people with severe de-mentia. Residents in facilities with low overall lightdisplayed higher agitation levels (Sloane et al., 1998).Residents in units with inadequate lighting showedno difference in psychiatric symptoms compared withresidents in units with ample lighting, however (Elm-sthl et al., 1997).

Little research on the impacts of visual contrast indementia care environments was identified, thoughthis strategy is frequently recommended to enhancelegibility or clarity of the environment. In one quasi-experiment, 13 residents with dementia ate more anddisplayed less agitation when dining arrangementsincorporated brighter light and heightened color

contrast (i.e., high contrast tablecloths, place mats,dishes; Koss & Gilmore, 1998).

Safety.

Residents attempts to leave facilities orhomes present a major safety concern for staff andfamily caregivers. Design solutions to prevent un-wanted exiting often do so by exploiting residentscognitive deficits. For instance, in a study involvingnine residents of a psychogeriatric ward, a full lengthmirror placed in front of the exit door reduced resi-dents exit attempts by half (Mayer & Darby, 1991). Areverse mirror had a similar, but less significant ef-


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fect. Impacts were attributed to residents loss of memory of personal identities; accordingly, residentsmay have been distracted from exiting when engagedor frightened by the image of an approaching strangerin a mirror (Mayer & Darby, 1991).

Another design strategy capitalized on the likeli-hood that, because of problems with depth percep-tion, people with dementia may interpret two-dimen-sional patterns on the floor as three-dimensionalbarriers. In a quasi-experiment with eight residents,such two-dimensional grids successfully eliminatedmost exit attempts for some residents (Hussian &Brown, 1987). In other studies, two-dimensional gridseither increased or failed to decrease residents exitattempts (Chafetz, 1990; Namazi, Rosner, & Calkins,1989). Failure to reduce exiting was attributed to thepresence of glass doors and adjacent large windows,which offered views to attractive, nearby outdoorspaces (see also Morgan & Stewart, 1999). Attractiveviews were hypothesized to distract residents fromtwo-dimensional grids or to entice residents to over-come their aversion to these optical illusions. In astudy involving seven SCU residents, installation of closed, matching miniblinds that restricted light andviews through exit door windows decreased exit at-tempts by half (Dickinson, McLain-Kark, & Marshall-Baker, 1995).

Other design strategies also created optical illu-sions that reduced unwanted exiting. The addition of a cloth panel to camouflage a door knob or panicbar eliminated exit attempts for most residents(Dickinson et al., 1995; Namazi et al., 1989). (Bothof these studies used fewer than 10 residents.) Thiseffect held irrespective of the color or pattern of thecloth cover (Namazi et al., 1989) and with and with-out the use of miniblinds to cover windows (Dickin-son et al., 1995). Disguising the door knob itself (witha knob cover or by painting the knob to blend withthe door) reduced exit attempts to a lesser extent(Dickinson et al., 1995; Namazi et al., 1989).

Finally, conditioning residents to respond to atten-tion-getting signage also reduced exit attempts. Threeresidents with dementia who were conditioned to de-velop negative associations with supernormal stim-uliin this case, large, colored, cardboard geometricshapes placed near exits (Hussian, 198283; see Ap-pendix A, Note 14)wandered less into doors andstairways bearing those images.

Accommodating residents exit attempts, rather

than discouraging them, also generated positive out-comes. Unlocking doors to allow access into secureoutdoor areas was associated with significant de-creases in agitation in a quasi-experiment involving12 residents (Namazi & Johnson, 1992d). Reducedagitation was tied to increased autonomy as well asto outdoor usage.

Surveillance is considered essential by staff formaintaining safety in environments for people withdementia (Morgan & Stewart, 1999). Design inter-ventions may have unintended consequences for staff surveillance opportunities. In interviews with ninestaff members and nine relatives associated with a

newly designed SCU, staff reported that the new fa-cilitys low density, private resident rooms, enclosedcharting spaces, and secluded outdoor area and ac-tivity spaces impeded staff surveillance and increasedtime spent locating and monitoring residents (Morgan& Stewart, 1999). Ease of surveillance also has nega-tive consequences. In an evaluation of the Weiss In-stitute, staff interaction with residents was found todecrease following occupation of this new facility(Lawton et al., 1984; see also Liebowitz, Lawton, &Waldman, 1979). Because the facilitys open designaccommodated staff surveillance from the nursesstation, direct staff contact with residents may havebeen minimized.

Preventing falls among residents is another keysafety concern (cf. Morgan & Stewart, 1999; Pynoos& Ohta, 1991; Scandura, 1995). Design interventionshave demonstrated some success in reducing resi-dents falls. A significant reduction in falls was re-ported in one SCU with the introduction of alterna-tive furnishings that put residents closer to the ground(i.e., bean bag chairs, futons, and mattresses placedon the floor; Scandura, 1995; see Appendix A, Note15). In other research, environmental modificationsintroduced into home environments to reduce fallswere judged effective by 12 dementia caregivers at a7-month follow-up (Pynoos & Ohta, 1991). Thesemodifications included tub and stair rails, a nonskidbath mat, and a bath chair.

Building Organization

Studies of building organization examine the de-sirable arrangement of spaces within facilities. Issuesinvestigated include residents orientation and way-finding, and the impact of providing outdoor spacesin dementia care facilities.

Orientation.

Disorientationconfusion regardingplace, time, personal identity, or social situationiscommon among people with dementia (Cohen &Weisman, 1991). Design guides suggest numerousstrategies to enhance orientation, including improve-ments for wayfinding (e.g., landmarks, signage) andprovision of information from the environment (e.g.,allowing views to accessible outdoor areas to increaseresidents orientation to time of day and season).

Research confirms that residents orientation de-pends, in part, on the physical environment. In a

study of 79 dementia residents at 13 long-term carefacilities, higher levels of orientation were associatedwith quiet environments (Netten, 1993). Researcherstheorized that disorientation followed residents at-tempts to shut out noisy environments. Not surpris-ingly, wayfinding among residents was judged lesssuccessful in facilities with low lighting levels in pub-lic areas (Netten, 1989).

Design strategies intended to enhance orientationappeared to aid at least some residents. Staff mem-bers reported that orientation among residents wassupported by design modifications that includedroom numbers and use of distinguishing colors for


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resident rooms and doors (Lawton et al., 1984). Instudies with eight residents, large signs improved res-ident orientation, when incorporated with orientationtraining (Hanley, 1981); signs alone had minimal ef-fect on residents orientation, however.

The type of orientation device may make a differ-ence, though research on this question is limited toone experiment involving 10 SCU residents. Whendisplayed in cases outside resident rooms, personallysignificant memorabilia were somewhat more likelyto help residents find their rooms than were displayswithout personal significance (Namazi, Rosner, &Rechlin, 1991). Personally significant memorabiliawere most useful for those with moderate dementia;higher functioning residents were able to orient withnonsignificant memorabilia as well, and lower func-tioning residents were aided by neither.

Orientation is further impacted by building config-uration. Simple building configuration is associatedwith resident orientation, when residents are alsoprovided with explicit environmental information(Passini, Rainville, Marchand, & Joanette, 1998). In aquasi-experiment with 105 residents in several groupliving facilities, residents were found to experiencegreater spatial orientation in facilities designed aroundL-, H-, or square-shaped corridors, compared with fa-cilities with corridor designs (Elmsthl et al., 1997).Corridor designs were also associated with higher de-grees of restlessness and dyspraxia and with reducedvitality and identity (Elmsthl et al., 1997). Residentsin facilities with more hallway space demonstratedless disorientation and less lack of vitality (Elmsthl etal., 1997).

In survey research with 104 residents in severalhomes, higher levels of orientation were identified incluster facilities (comprised of small units of resi-dent rooms and associated common spaces), com-pared with larger scale communal facilities (com-mon spaces separated from resident rooms and sharedby larger groups of residents; Netten, 1989). In clus-ter facilities, higher levels of orientation were associ-ated with complex decision points and longer corri-dors, which allowed meaningful choices betweenplaces residents used (Netten, 1989). In communalfacilities, heightened orientation was associated withshort corridors and simple decision points, which al-lowed residents to travel only short distances withoutprompts and did not force residents to choose be-tween spaces they did not use (Netten, 1989).

Provision of Outdoor Areas.

Design guides rec-ommend access to the outdoors to maintain home-likeness, to accommodate activities, and to increaseresidents exposure to light and sun. Limited researchfindings support the value of outdoor spaces to re-duce aggression among people with dementia. In alongitudinal study of five facilities with and withoutoutdoor spaces, researchers found that violent epi-sodes among residents decreased over time in facili-ties with outdoor environments, whereas violent epi-sodes increased during the same time period infacilities without outdoor environments (Mooney &

Nicell, 1992). Residents walked outdoors more often(for short periods of time) in a facility with a specialtherapeutic garden (Mooney & Nicell, 1992).

Specific Rooms and Activity Spaces

This research investigates the design of particularrooms within the facility. Studies examine the designof bathrooms, toilet rooms, dining rooms, kitchens,and resident rooms, as these impact well-being amongpeople with dementia and others.

Bathrooms.

For people with dementia, bathing isan experience that frequently compromises dignityand autonomy. Design recommendations emphasizeincreasing independence and control in bathing (e.g.,choice of shower or tub bath), promoting a morehomelike bathing experience (e.g., less institutionaldesign), and assisting caregivers during bathing (addi-tional space, grab bars, etc.).

Bathing is regarded as among the most stressfultasks in caring for people with dementia (Kovach &Meyer-Arnold, 1996; Pynoos & Ohta, 1991; Sloaneet al., 1995). Several studies examine aspects of bath-ing associated with high stress. Negative residentreactions are associated with unfamiliar or fearfulequipment or procedures (bath tub lifts, specializedtubs, getting in and out of the water, high water levelsin whirlpool baths), cold tub rooms (cold air or watertemperature, chills from slow tub filling or draining),design features that impede bathing (poor lighting,inadequate mats or handrails), and distractions (noisyequipment, running water, or distracting activitiesoutside the bathroom; Kovach & Meyer-Arnold, 1996;Lawton et al., 1984; Namazi & Johnson, 1996; Sloaneet al., 1995). Some evidence suggests that baths maybe less upsetting than showers for residents, thoughfindings are mixed (Kovach & Meyer-Arnold, 1996).

Perhaps because of their long-term positive associ-ation, natural elements had a calming effect when in-troduced during bathing in an experiment with 31residents in five nursing homes (Whall et al., 1997).Nature sounds (e.g., animal and water noises) andpictures (e.g., birds), when provided along with fa-vorite foods and distracting conversation, significantlydecreased agitation during shower baths among resi-dents with late stage dementia (Whall et al., 1997).

Toilet Rooms.

Incontinence is a major problemamong people with dementia (Namazi & Johnson,1991b). Design guides emphasize the importance of maintaining independence in toileting whenever pos-sible, such as by making toilets easy to locate and toidentify (signage, visible locations, etc.). In some in-stances, the design of toilet rooms may exacerbatetoileting problems. Staff report that small toilet roomsmake assisting with toileting difficult and that wheel-chair users are more likely to have accidents whenthe toilet room is occupied, preventing access (Hutch-inson, Leger-Krall, & Wilson, 1996).

Research findings, though limited, support the ef-fectiveness of design interventions to facilitate toilet-


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ing. One quasi-experiment involving 44 residents intwo SCUs compared residents responses to variousforms of directional signage for toilet rooms, includ-ing the word rest-room, toilet, or a graphic of afamiliar household toilet (Namazi & Johnson, 1991b).Early and moderate stage dementia residents weremost likely to locate and use public toilets in re-sponse to primary color signage affixed to the floor(responding to residents typically downcast gaze)comprising a series of arrows and the word toilet(Namazi & Johnson, 1991b). Further, frequency of toilet use increased dramatically when toilets werevisibly accessible to residents (Namazi & Johnson,1991a), though this experiment included only 14 res-idents. Residents use of toilets increased by over800% when curtains surrounding toilets (in lieu of doors) were left open, making public and private toi-lets clearly visible when not in use (Namazi & John-son, 1991a). In particular, visibility increased toiletuse among residents with more advanced dementia.

Dining Rooms and Kitchens.

Design guides offermany recommendations regarding dining and kitchenareas (cf. Calkins, 1988; Cohen & Weisman, 1991).Suggestions emphasize the importance of a familiarand normal dining experience, the need to locatedining and kitchen activity areas within each demen-tia unit or household, and the value of reducingsensory stimulation to encourage eating. Researchfindings from an experiment with 22 residents sup-port noninstitutional dining arrangements. Noninsti-tutional diningin which residents dined familystyle at small dining tables in a coffee room, insteadof from trays while seated in chairs in the corridorwas linked to increased social interaction and com-

munication during dining and to improved eating be-havior among residents (Gtestam & Melin, 1987;Melin & Gtestam, 1981). Institutional staff practices(e.g., assigned seating, institutional food service) pro-voked disruption and agitation in dining rooms withhomelike design features (Moore, 1999).

In an impact not anticipated by design guidance,relocating dining to the dementia unit of an SCUfrom a remote, centralized dining roomsignifi-cantly decreased residents aggression (Negley &Manley, 1990). Assaults were reduced by over 40%when residents were no longer crowded into eleva-tors to reach the centralized dining room (Negley &Manley, 1990). (Elevators had been sites of frequentviolations of personal space, which caused alterca-tions.) In this instance, assaults may have been fur-ther reduced by designating two dining areas on thedementia unit, thus separating higher functioning res-idents, more likely to be assailants, from lower func-tioning residents, more likely to be assault victims. Inthe same quasi-experiment, staff reported less anxietyand more time for assisting residents after movingdining to the dementia unit.

In a study on the design of environments to en-courage independent snacking, installation in kitch-enettes of small, accessible refrigerators stocked withsnacks prompted only a minimal increase in resi-

dents independent snacking (Namazi & Johnson,1992c). Transparent refrigerators, in which residentscould clearly see snacks inside, were only slightlymore effective than were conventional, dormitory-style refrigerators. Both styles of refrigerators mayhave been unfamiliar to residents. Staff provision of snacks was suggested as a possible impediment toresidents independent snacking (Namazi & Johnson,1992c).

Residents Rooms.

Design guidance emphasizesthe need for homelikeness, autonomy, and privacy inresidents rooms in dementia care facilities. The rela-tive merits of private versus shared resident rooms isa matter of debate (Cohen & Day, 1993); existing re-search provides limited guidance on this issue. Com-parisons of facilities with and without private roomstypically incorporate other architectural and pro-grammatic differences as well, thus obscuring the sig-nificance of resident room type (cf. Annerstedt, 1994,1997; Skea & Lindesay, 1996).

Lawton and colleagues (1970) presented findings

from a quasi-experiment involving 15 residents, whichsuggest that number of residents and room designmay affect levels of social interaction. This studyevaluated the renovation of a long-term care unitfrom two institutional-looking group rooms (four andfive residents, respectively), to six, less institutional-looking single rooms clustered around a commonspace. Following renovation, residents were found tospend comparatively less time in their rooms andmore time in motion and to engage in less interac-tion, compared with residents before the renovation.Reduced interaction may reflect greater choice overinteraction in private versus group rooms (Lawton etal., 1970).

Closet design was successfully used to enhanceresidents independence in dressing. In a quasi-exper-iment with eight SCU residents, specially designedclothes closets were found to increase autonomy indressing for those with middle stage dementia(Namazi & Johnson, 1992a). By presenting prese-lected clothing in an appropriate sequential order(undergarments first, followed by blouse, pants, etc.),modified closets reduced staff members physical as-sistance in dressing and enhanced residents inde-pendence.

Discussion and Conclusions

From the research reviewed, four primary types of studies on design and dementia emerge. Studies aregrouped according to their major focus (people/be-havior vs. the physical environment) and their con-ceptualization of the physical environment (global ordiscrete). Environmental comparison

studies com-pare two or more facility types for impacts on resi-dents, staff, and family (e.g., SCUs vs. skilled nursingfacilities.) Design feature

studies assess the effects of specific environmental interventions (e.g., door mod-ifications to reduce exit attempts). Studies of environmental services and policies

examine organizational


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decisions and policies for dementia care environ-ments (e.g., impacts of relocating residents to newenvironments). Studies of problem behaviors

investi-gate resident conduct that creates difficulties in care-giving (e.g., stressful aspects of bathing). One study(Netten, 1993) fit more than one type (see Table 2).Of these types, studies of design features (26 studies)and of environmental comparisons (24 studies) pre-dominate (compared with 15 studies of problem be-haviors and 7 studies of environmental services andpolicies). Studies should be evaluated according tothe type of research they represent. For example,findings from studies of environmental comparisonsshould indicate which type of environment is pre-ferred and why.

The following sections analyze findings from exist-ing studies with respect to their implications for ap-plication and future research.

Recommendations to EnhanceApplicability of Findings

The focus of this article on design application de-mands some recommendations (though tentative)concerning the therapeutic design of environmentsfor people with dementia. On the basis of existing re-search findings, dementia care environments shouldconsider the suggestions presented in Appendix Bamong others.

Application of findings is often impeded by stud-ies research design and/or methods. Confidence infindings is impaired by the frequent use of small sam-ples and the absence of comparison groups. Addi-tionally, many studies use nonequivalent comparisongroups (e.g., residents in varying or unspecifiedstages of dementia, or residents with and without de-

mentia who vary in other characteristics, such as mo-bility.) Studies do not always adjust reports of find-ings to account for baseline differences in severity of cognitive, behavioral, or physical deficits. Of the 71studies we reviewed, only 45 made reference to theresidents stage of dementia at baseline. Further, theinterrelations between design interventions has beenlargely overlooked. For example, SCUs often encom-pass multiple interventions (smaller unit size, home-like design, low level simulation, etc.). In evaluatingthe impact of SCUs, studies should consider bothwhich design features are most essential and howvarious design features work together or detract from

each other. These issues must be addressed to im-prove the validity and generalizability of future re-search findings.

Applicability of findings would also be enhancedby incorporating explicit hypotheses on the proposedrelationships between physical environments andwell-being to explain why

design features are or arenot successful. Finally, the applicability of futurestudies could be improved by thoroughly describing,in research reports, the physical context of the de-mentia environment and specific environmental modi-fications tied to well-being. These last two qualitiesare exemplified in research conducted by Namazi andcolleagues at the Corrine Dolan Center, in Chardon,Ohio (see Appendix A, Note 16).

Recommendations for Future Research

Findings from existing studies substantiate theneed for more attention to the therapeutic use of de-sign in dementia. Further research should be de-signed to confirm findings from existing research, es-

pecially from small or exploratory studies. Futureresearch should also support the call for therapeuticdesign of dementia environments and should eluci-date the particular characteristics of effective designinterventions.

Focus on Multiple Populations and Diverse Envi- ronments.

Of the 71 studies reviewed, 12 clearlyaddressed staff well-being or job performance as out-come measures of the design of dementia environ-ments; only 7 studies investigated outcomes concern-ing family members well-being or satisfaction. Withgreater focus on impacts for staff and relatives, re-search findings could provide a persuasive rationalefor design interventions that might otherwise be ne-glected. For example, in addition to impacts for resi-dent well-being, research should examine the im-pacts of noninstitutional design on staff morale andretention and on family visitation and satisfactionwith care (cf. Chapman & Carder, 1998; Hoglund,DiMotta, Ledewitz, & Saxton, 1994; Regnier, 1997).Improving staff and family well-being may also en-hance caregiving.

In addition, studies should evaluate effective strat-egies for the therapeutic design of environmentsother than long-term care and SCUs. Environmentalalternatives such as day care and assisted living oftenhave resident populations, care practices and philos-ophies, physical environments, and regulatory reali-ties that differ dramatically from the more institu-tional options that have been the focus of muchexisting research. Such environmental alternativesmay present new opportunities and new challengesfor therapeutic design interventions.

Target Research and Application to Stage of De- mentia.

Research findings on the effects of designinterventions reveal important differences in responseaccording to residents level of cognitive and behav-ioral function (see also Columbo, Vitali, Molla, Gioia, &

Table 2. Primary Types of Studies on Design and Dementia

Conceptualiztionof the Environment

Major Focus of Research

Environment People/Behavior

Global Studies ofenvironmentalcomparisons

Studies ofenvironmentalservices andpolicies

Discrete Studies of designfeatures

Studies of problembehavior


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Milani, 1998; Mirmiran, Van Gool, Van Haaren, &Polak, 1986). For example, interventions targeted topeople in early or middle stages of dementia (e.g.,closet design to promote independence in dressing;Namazi & Johnson, 1992a) may prove useless for res-idents in more advanced stages, and vice versa. Indeveloping research questions, researchers shouldcarefully consider the stages of dementia duringwhich design interventions are hypothesized to be of value (see Appendix A, Note 17). When possible,studies should include participants in different stagesof dementia, and research reports should specify thestage of dementia for research participants.

Focus on Quality of Life, as Well as Problem Be- haviors.

In the studies reviewed, impacts on prob-lem behaviors were the most common outcome mea-sure used (followed by impacts on resident ADLs,cognitive function, and social function). Becauseproblem behaviors generate much caregiver burden,caregivers and administrators may especially appre-ciate this information. The emphasis on problem be-

haviors may also indicate, however, that many re-searchers and administrators do not fully appreciatethe potential of environmental design to improvequality of life, beyond simply minimizing undesirableconduct. For greatest impact, design professionals andresearchers must continue to educate administratorsand families on the potential role of environmentaldesign for improving quality of life in a comprehen-sive way. These recommendations, if implemented,will ensure continued progress in the study and de-sign of therapeutic environments for people with de-mentia.

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Received May 19, 1999 Accepted January 19, 2000 Decision Editor: Vernon L. Greene, PhD

Appendix A

Notes 1. A small sample of design guidance includes Coons

(1987), Hiatt (1987), Hyde (1989), Lawton (1979), Pynoos,Cohen, and Lucas (1988), Regnier (1997), and Zeisel, Hyde,and Levkoff (1994).

2. MAGS is the magazine and journal article database of over 1,500 scholarly and popular journals. CAT is the catalogof the holdings of the entire University of California librarysystem. Search terms included dementia or Alzheimersand the following: home, nursing home, special care unit,SCU, day care, assisted living, design, environment, safety,dignity, homelike, independence, security, wandering, activi-ties, toilet, incontinence, kitchen, dining, resident room, pri-vacy, bathing, continuum of care, aging in place, non-institu-

tional, and barrier. Searches generating more than 400references were discarded as overly broad.

3. Journals reviewed systematically included Ageing and Society , Environment and Behavior , The Gerontologist, Jour- nal of Architectural and Planning Research , Journal of Envi- ronmental Psychology , Journal of Gerontology: Psychological Sciences , Journal of Gerontology: Social Sciences , and the

Journal of Mental Health and Aging.4. Case studies and nonpeer-reviewed work, such as dis-

sertations, were excluded, as were articles that reported only

design guidance, or that had only minor reports of research, orincomplete descriptions of research design.5. This period was identified as the time of greatest produc-

tivity in research on dementia and design. An earlier article byLawton and colleagues (1970) was also included. This articleevaluates the impact of a renovation to the Weiss Institute of the Philadelphia Geriatric Center, a premier, experimentallydesigned dementia care facility.

6. See Borup (1983) for a review of the extensive researchliterature on the effects of relocation on older adults in institu-tional settings.

7. Wells & Jorm (1987) examine the use of an SCU for re-spite versus permanent care. The authors found beneficial im-pacts for family members associated with use of this SCU forrespite care.

8. Global studies of SCUs with special environmentalfeatures include Annerstedt (1993), Bellelli et al. (1998), Ben-son et al. (1987), Chafetz (1991), Greene, Asp, and Crane(1985), Holmes et al. (1990), McCracken and Fitzwater(1989), Phillips et al. (1997), Skea and Lindesay (1996), Swan-son, Maas, and Buckwalter (1993), Webber, Breuer, and Lin-deman (1995). Table 1 describes only those studies of SCUsthat specifically note environmental features.

9. Swedish group living facilities compare to both grouphomes and SCUs in the United States. These residences for 810people are tailoredin design and in care planto the needsof people with dementia. Emphasis is placed on involvingfamilies and on making care more affordable than institutionalalternatives (Annerstedt, 1993).

10. Group living units in this study differ from traditional

nursing homes in that group living units use noninstitutionaldesign features and specialized dementia caregiving, in addi-tion to small group size.

11. Evidence suggests that the prevalence and severity of hearing loss is greater among people with dementia; however,the cause and effect relationship between dementia and hear-ing loss is not well understood (cf. Gates et al., 1995; Rapcsak,Kentros, & Rubens, 1989; Uhlman, Larson, & Koepsell, 1986;Weinstein & Amsel, 1986).

12. Similar changes in other facilities are associated withcomparable results (cf. Hall, Kirschling, & Todd, 1986).

13. Circadian rhythms refer to daily activity cycles basedon 24-hr patterns.

14. Exaggerated, simple stimuli were hypothesized to bemost effective, since subtle or complex stimuli may be difficult

for people with dementia to comprehend (Hussian, 198283).Conditioning occurred by reinforcing positive associations,such as a favorite food, with one shape, and negative associa-tions, such as loud clapping, with another.

15. Changes in furnishings were accompanied by changesin care plans to reduce demanding tasks (e.g., bathing) in theevenings, when most falls occurred. Full research methods arenot reported for this study.

16. Most of these studies are reported in a series publishedin 199192 in the American Journal of Alzheimers Care and Related Disorders and Research.

17. Calkins (1997) provides an excellent example of stage-appropriate design guidance in her recommendations for de-sign strategies to enhance care for people with late stage de-mentia.


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Appendix BRecommendations for the Therapeutic Design and Planning of Dementia Environments

Incorporate small size units. Separate noncognitively impaired residents from people

with dementia. Offer respite care as a complement to home care. Relocate residents, when necessary, in intact units rather

than individually. Incorporate noninstutional design throughout the facility

and in dining rooms in particular.

Moderate levels of environmental stimulation. Incorporate higher light levels, in general, and exposure

to bright light, in particular. Use covers over panic bars and door knobs to reduce

unwanted exiting. Incorporate outdoor areas with therapeutic design fea-

tures. Consider making toilets more visible to potentially re-

duce incontinence. Eliminate environmental factors that increase stress in

bathing.

Envieronmental Design for Dementia

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