While we work hard for a dementia cure in the future there is a lot that can be done to make life easier for people who live with dementia now. In this blog I want to focus on what can be done in the design of the environment.
All the best design ideas are based on understanding what a person with dementia might find hard, and what could help. Everyone with dementia is different, and the experience of dementia changes over the years for any individual affected. There are some patterns. The person often finds it difficult to adapt to anything new, or unfamiliar. It’s not unusual to lose things or to become disorientated even in a familiar environment. Memory is an issue. Unnecessary noise can be disabling because it makes it hard to concentrate. This is true for anyone, but in dementia, there is less spare cognitive capacity to cope with distraction.
One criticism of what has come to be known as “dementia friendly design” is that it might be institutional, or brutal in décor. A sign on the door can help you to remember what is behind that door, but signs would be unusual in a domestic setting and it has been said make the place look “institutional”. People need to be flexible and practical about this. If the choice is between elegance and finding the toilet fast, I know what I’d pick. There is nothing less elegant than being caught short because the bathroom door is not dead obvious.
A person with dementia might be living in their own home, or temporarily in another place such as a hotel or a hospital, or they might decide to live in a care home or nursing home. There are design essentials for each of these. Some things don’t cost much and can be done without much disruption. Some of the other ideas are more expensive and would involve a significant change so should be thought of at the earliest stage such as the fit out of a care home, or when moving to a new home in later life.
I don’t have dementia, but I consider that future possibility. I hope to live to be 100 and still be in my own home. By that age I probably have a 50% chance of having dementia and so making my home dementia friendly is future proofing it. It can still look homely and comfortable. If I am choosing a floor covering, which can be expensive and is meant to last my lifetime, I can choose one with wild patterns, or one that is smooth and self-coloured. It is not just a matter of taste. A person is more likely to trip if they misperceive the pattern on the floor and it distracts them when they’re trying to walk across it. So, my floor coverings are smooth, matt, and avoid major changes in colour at thresholds between rooms. A fall and a fracture leading to hospital admission is one of the junctions for someone with dementia that diverts them from home to a care setting.
Elements of design potentially could delay the day when a person with dementia would have to go to live in a care home. I have seen very many lovely care homes where I would gladly move into one day. But not too soon.
One basic requirement is to increase the light level as much as possible. Most people with dementia are older and some are very old. This means that they have the normal changes of aging including reduction in their visual acuity. The structures in the aging eye become yellow and as a result colours are harder to distinguish – and that’s without any other problems of the eye that would require spectacles or surgery, and eye problems that can’t be cured. Many older people are anxious about the cost of fuel and may economise on the electricity that is required to brightly light their home. It is a false economy if as a result the person has a fall or becomes more confused because their environment is hard to interpret at low light levels. When you can’t remember where things are, being able to see them helps. Stress is reduced if you can find things easily and people with dementia may be easily stressed.
To increase the light level inside the home, use the brightest available bulbs for the light fittings. In day time, simple things like keeping the window glass clean, keeping vegetation away from the outside, making sure that the curtains can be pushed right back to allow the maximum amount of light into the room, all make a difference. I choose light coloured wall paints and curtains so that even if I am in the house with the curtains closed in winter there is good reflection from my lamps to make the room as bright as possible. However, if the person with dementia is accustomed to a particular décor, it may be too late to change some things. They might agree to the change, but wake up the next day having forgotten that, and not understanding why the walls and drapes are a different colour. They might even think they are in the wrong house.
A recent fashion in care homes was to create a simulated historic environment, such as a “fifties” sitting room. The problem is that every resident’s home would have been different then, depending on social, environmental, and ethnic characteristics, so landing on one clichéd decade was no better than modern furniture with classic shapes. People with dementia are not living in the past. Another fashion was to festoon the interior with masses of sensory stimulation, but this didn’t always help create a calm environment and one fire officer told me of concerns about fire hazard. Obviously, there is a happy medium to aim for.
There are many sources of information about what works. It is important to distinguish between ideas based on sound evidence, ideas that have some credibility, and things that are being pushed by commercial interests who really are making it up as they go along. Good sources of advice include the Dementia Services Development Centre at the University of Stirling (www.dementia.stir.ac.uk/our-services/for-designers). This advice is from modern professional architects embedded in an internationally famous dementia centre, and it is based on evidence. Internationally there is also The Dementia Centre at HammondCare (www.dementiacentre.com/design) which offers a tool for checking out devices, as well as environments. The associates working there have produced guidelines on toilets and other specific areas. All with the involvement of people who are living with dementia across the globe.
The hardest thing for people with dementia is stress. It sometimes gives rise to distressed responses that families and carers cannot support at home. Anything you can do to create a dementia-friendly, easy to use, stress free environment will be good for everyone.
Professor June Andrews