The Built Environment in Dementia Care Settings: Let’s Make a Difference!

A homelike (both in scale and décor) living and dining area creates a familiar and comforting environment for persons with dementia

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The physical or built environment (architecture, interior design) has a fundamental role to play in creation of a therapeutic dementia care setting. Alzheimer Catalonia Foundation, founded in 1988, is a non-for profit organization offering services to the people diagnosed with dementia, families in the role of caring, and professionals working in the dementia care sector.

  • The environment is a crucial indicator of person centered care
  • The foundations’ aim and mission are the improvement of the quality of life for people living with dementia

Habib Chaudhury, PhD; Department of Gerontology, Simon Fraser University Vancouver, Canada.
Josep Vila Miravent, MSC, licensed psychologist, Alzheimer Catalunya Fundació, Barcelona, Catalonia, Spain.
Elena Fernández Gamarra, MSC, licensed psychologist, Alzheimer Catalunya Fundació, Barcelona, Catalonia, Spain.

The physical or built environment (e.g., architecture, interior design) has a fundamental role to play in creation of a therapeutic dementia care setting. Unsupportive physical environmental features can contribute to “challenging” behaviours in people with dementia, e.g., spatial disorientation, anxiety, agitation, social withdrawal. On the other hand, a supportive physical environment can reduce challenging behaviours and enable positive behaviours, e.g., reduce anxiety and agitation, increase competence in activities of daily living, reduce disorientation, increase in personal autonomy, reduce risk of falls. The physical environment can play an important role in transforming the culture of long-term care to become more person-centered. We can develop a responsive physical setting to support a person’s preferences, hobbies, routine taking into account her/his physical functioning, sensory changes and cognitive status. The environment is a crucial indicator of person centered care that essentially honors the identity of residents, support their quality of life and well-being.

In most long term care facilities, the activity room is a key space where residents spend a lot of time during a 24 hour period. The main activity room should be easily accessible from all or most of the resident bedrooms to allow residents to move safely and independently between their bedrooms and the activity space. This means the activity space should be close, preferably within 10-12 steps of the resident bedrooms. As the resident comes out of her/his room, the social space should be visible immediately or after a few steps. The size of the activity space is important. Large activity spaces have high level of physical environmental (e.g., noise, artificial lighting, glare, unfamiliar environment) and social stimulation (e.g., lot of people, rushed staff) that can contribute to anxiety, frustration and agitation behavior in residents with dementia. Smaller activity spaces can not only have reduced level of stimulation, but are also more effective in creating a more homelike space with positive environmental stimulation. The type and arrangement of furniture need to be carefully considered. The type and design of chairs, couches, tables, etc. should be taken into consideration to address the limitations in physical functioning and sensory perceptions, e.g., height of the seating, presence of armrests on chairs, rounded edges of tables, contrasting colors between chair seat and carpet, etc. Arrangement of the chairs and tables can facilitate conversation and social interaction among residents, e.g., placing chairs at right angles to one another, creating conversational groupings with seating. This type of social interaction supportive furniture arrangement is call sociopetal arrangement, whereas the chairs lined again the walls or far apart are known as sociofugal arrangement. We need to create more sociopetal furniture arrangement so that residents can see each other’s faces and be part of a smaller social group.

Lack of appropriate lighting will influence residents’ ability in mobility, social interaction, activities and way finding. Natural lighting should be used as much as possible. Artificial lighting should have a combination of ambient and area lighting to not only ensure sufficient amount of lighting, but to also provide a residential ambience. In order to create a homelike setting, personally or culturally meaningful objects have a critical role. Objects from residents’ past (e.g., photographs, artwork, scrapbooks, memorabilia, personal furniture) provide a sense of familiarity and comfort. Also, objects with cultural, historical or religious value can provide a sense of continuity and a source of positive stimulation. These objects can offer recognition of the residents as unique individuals and an opportunity for celebration of their accomplishments.

Dining rooms should be decentralized and serving a small group (8-10) of residents. A single large centralized dining room with 30 or more residents create a high degree of social and physical environmental stimulation which trigger anxiety, confusion and frustration in the residents. Having an adjacent kitchen will provide a familiar setting that can provide opportunity for positive engagement from the residents, e.g., cleaning the kitchen counter, washing dishes, working with the staff to prepare a meal, etc. An adjacent kitchen allows the option of unit-based cooking or baking activities. It is important to point out that there are several activities that are associated with preparation of a meal, e.g., washing vegetables, peeling and cutting vegetables, setting the tables for meals, cleaning activities afterwards. All of these activities are familiar for residents and an accessible and homelike kitchen can engage them in a positive way by connecting with their life-long habits and lifestyle.

Single occupancy residents’ rooms provide privacy, support remaining functional abilities, a space for family visit, increased mobility, range of motions, improved sleep, reduction of conflicts, etc. Also private rooms provide more space for personalization as there is more space to put furniture like a table or a dresser. Also, the residents have much greater sense of control and belonging in private rooms compared to shared rooms. Irrespective of the room occupancy, it is important that the staff and family work together with the residents to bring and create personal objects (e.g., meaningful memorabilia, personal furniture items, family photographs, and bedspread. Furniture and objects that are personally meaningful and/or a homelike décor create an environment with positive stimulation for a person with dementia. Personal items, such as family photographs, provide an important opportunity for the staff to understand the resident as a whole person with personal life story and experiences, initiate conversations and have an increased sense of empathy.

Contrasting colours between the resident room doors and adjacent walls can help ease of identifi cation of resident rooms. Also, relatively bright coloured walls, homelike objects and wall hangings can reduce the institutional ambiance of a long hallway.

In three levels

It is important to note that physical environmental changes in a care home can happen at three levels: a) architecture, b) interior design and c) sensory qualities. The second two categories are very much relevant to small scale, minimal or no financial investment and easy to implement changes. These changes include rearranging the furniture in an activity room, bringing in activity materials or multisensory objects, creating an activity corner, colouring a wall, changing the furniture or adding lighting fixtures. Even small changes in the environment can make a big difference in the residents’ functioning levels and well-being. It is critical that the staff and administration understand the importance of the physical environment in creation of a therapeutic setting and take simple measures to create a responsive milieu.

Dr. Chaudhary’s expertise is part of a project implemented in Catalonia by Alzheimer Catalonia and Federació d’entitats de la tercera edat de Catalunya (FEATE). The main project goal is to develop PCC practices in services for people living with dementia. We are working in 9 care facilities. Environmental changes are one of the main project interventions.

Alzheimer Catalonia Foundation (ACF), founded in 1988, is a non-for profit organisation offering services to the people diagnosed with dementia, families in the role of caring, and professionals working in the dementia care sector. Its main area of influence in delivering services for families and those living with dementia is Catalonia, and for professional development and training is Spain.

The foundations’ aim and mission has always been the improvement of the quality of life for people living with dementia. To do so, action has been taken to educate, train and develop Person Centred Care (PCC) practices in Dementia Care Services. PCC originated in the late 80’s with Tom Kitwood as one of the main authors. In 2003, Alzheimer Catalunya gave support to translate his main publication Dementia Reconsidered.

By the year 2006, Alzheimer Catalonia signed a memorandum of agreement with the University of Bradford (UK), to train professionals and practitioners of Catalonia and Spain in PCC and Dementia Care Mapping (DCM), a method to obtain organization’s quality indicators related to people with dementia level of emotional wellbeing, engagement and positive relationships.

Within this context of PCC and DCM training, we met Dr. Habib Chaudhury, an architect trained in gerontology, specialized in environments for people living with dementia. Currently, it exists scientific evidence showing the impact of the architectural environments in the person’s quality of life. Dr. Chaudhury has been invited in several occasions by Alzheimer Catalonia to participate in conferences, workshops, seminars and site visits. Dementia Care homes site visits are aimed to provide care teams with a personalize report on environmental considerations and affordable changes to positively impact in the quality of life of people living with dementia. The report’s feedback session is a care teams’ learning process, since it solves doubts and exchange knowledge about the impact of environment on behaviours. It is known that many nursing homes can not invest in architectural changes, but transformation of current spaces guided by current research data it’s a great alternative.