Caregiving and dementia/Topics/Environmental design
This NPA focuses on environmental design and assistive technology in caring for people with dementia.
This page highlights key aspects of environmental design and assistive technology for caring for the health, safety, and well-being of people with dementia, based on peer-reviewed research reviews.
The evidence base
Substantial effort put into gaining a better understanding of key features of good environments for people with dementia has been made since the 1980s, although significant gaps in the literature exist, particularly with regard to people with advanced dementia. The research literature was systematically reviewed by Fleming, Crookes, and Sum (2008) and Fleming (2010)., a project funded by the Australian Government through the University of New South Wales based Dementia Collaborative Research Centre and Fleming (2010). The environmental features correspond to the sub-scales of the Environmental Audit Tool.
Safe and secure
One of the most common problems associated with caring for people with dementia in an environment that has not been designed for their use is that of keeping them safe from the danger of wandering away and perhaps getting lost or run over. The most obvious response to this problem is to provide a secure perimeter, preferably one that allows for safe wandering and access to an outside area.
Positive effects have been found when unobtrusive means are used to provide a secure perimeter.
Annerstedt clarified the purpose of providing a safe environment as enabling the resident to have the opportunity to focus on the identity preserving features of group living:
“The safety provided in group living makes environmental barriers easy to overcome. Energy can be used to extend the territory and the demented can benefit from everyday activities, the accessibility of cues in social life and the external memory aids built into the setting”
In summary, the evidence supports the use of unobtrusive safety features but warns against over-emphasis on safety.
There is a range of evidence that supports the view that small numbers of people in dementia units are better than large numbers, however it is not conclusive. The evidence also suggests that the combination of small size with the other attributes of specialised units is not demonstrably beneficial in the later stages of dementia.
The relationship between behavioural disturbance and the size of the space in which the group lives has been investigated in two studies which suggest a lack of association between the amount of space available in a ward and the level of behavioural disturbance.. Elmstahl et al go on to observe that units with ‘a smaller proportion of communication area’ tended to have higher levels of disorientation and lack of vitality in their residents’. Other studies have found increased social interaction and less agitation for smaller compared to larger dining spaces.
In summary, there is a range of evidence supporting the proposition that small size, in the sense of number of people living together, is associated with a variety of positive outcomes for people with dementia. These include slower decline in ADL skills, more sustained interest in the environment, less aggressiveness, less anxiety, less depression, less use of psychotropic medication and a higher level of community. However it is impossible to quantify the contribution that the size of the unit makes in comparison with the other environmental factors that are commonly associated with a purposely designed, small unit e.g. homelikeness, safety and familiarity.
Enhancement of visual access
People with dementia stand a better chance of finding something if they can see it from where they are, thus environments should be designed for 'total visual access'.
Reduce unwanted stimulation
People with dementia have difficulties in dealing with high levels of stimulation. Their ability to screen out unwanted stimuli appears to be reduced. They can become more confused, anxious and agitated when over stimulated. Common causes of over stimulation are busy entry doors that are visible to residents, clutter, PA systems, alarms, loud televisions, corridors and crowding.
In summary, there is good evidence to show that the area of stimulus control is important to the well being of people with dementia. When levels of stimulation are optimum residents with dementia sleep better, are less verbally aggressive, less behaviourally disruptive and more able to dress themselves. While it is often impossible to tease out the effects of staff attention in the studies there is sufficient evidence to suggest that the levels of stimulation themselves have an effect which can be either positive or negative.
Highlight important stimuli
One form of highlighting is the provision of signs and aids to wayfinding and it is integral to the design of many special environments for people with dementia. However, there is limited evidence of the effectiveness of highlighting important stimuli in environments for people with dementia.
Planned wandering has two components:
- the provision of a well defined path and
- the access the path provides to a range of experiences that might encourage the person with dementia to engage in something other than wandering.
No methodologically sound investigations of the use of a well defined path were found. It is usually the case that the wandering path will include an outdoor section and there is literature on the effect of access to the outdoors.
Access to a secure out door area has been shown to be one of the defining features of an SCU. The beneficial effects on levels of agitation of being able to get outside have been well demonstrated  and described in the section on security. However there is very little empirical evidence of the effect, beneficial or otherwise, of being outside.
There have been studies of environments that have outside areas incorporated into their design as an amenity to be used by residents but it is impossible to identify the relative contribution that the outside area has made to the beneficial effects, in this case of maintaining the function of the residents.
An Australian study was the first to demonstrate empirically an increase in pleasure associated with being in a landscaped garden, seemingly at least in part because it was conducive to quality one-on-one relationships.
Being surrounded by familiar belongings can assist people dealing with dementia.
Opportunities for privacy and community
This principal combines factors such as familiarity, variety, specific function and personalisation. It suggests the need for spaces that range from the public to the private, including separate and varied social spaces.
In summary, there is good evidence for the provision of a variety of spaces in environments for people with dementia as they assist in reducing anxiety and depression while improving social interaction and may assist the resident to find their way around.
Domestic with scope for ordinary activities
The rigorous assessment of the effects of providing a homelike environment have taken two basic forms, a comparison of care in a homelike facility with care in the community and comparisons between facilities that vary in their level of homelikeness.
In summary, the strongest evidence specifically on the provision of homelike environments supports the idea that they reduce aggression and may have a beneficial effect on levels of agitation. When the homelikeness is part of an intervention that includes enhanced staff skills and knowledge there is strong evidence of beneficial effects on quality of life, anxiety and interest in surroundings. People with dementia living in such surroundings can be expected to do as well as those living at home with the type of community supports (i.e. access to respite and day care). However there are no grounds for believing that a homelike environment will slow functional decline.
Links to the community
This is as a gap in dementia care research. There are no methodologically sound investigations of the impact of linking facilities with the surrounding community.
Domestic with scope for ordinary activities
While an over-emphasis on safety may have a detrimental effect there is good evidence that unobtrusive safety features improve resident well being, especially depression.
While there is evidence supporting the proposition that small size is associated with a variety of positive outcomes for people with dementia it is impossible to quantify the contribution that the size of the unit makes in comparison with the other environmental factors that are commonly associated with a purposely designed, small unit e.g. homelikeness, safety and familiarity. In a study where a strong attempt was made to control for these factors  larger numeric size was shown to be positive in that it was associated with less social withdrawal and there was no significant relationship with agitation, aggression, depression or psychotic symptoms.
The evidence for the incorporation of good visual access on the broad, unit level scale is not strong but the dramatic effect of making an important amenity, the toilet, easily seen provides good supporting evidence for the concept.
The careful reduction of unnecessary stimulation and enhancement of helpful stimulation is well supported. The evidence extends to increasing levels of illumination beyond what is usually considered to be normal. However he evidence for the effectiveness of signage in environments for people with dementia is not strong and the evidence for the use of personal memorabilia and objects as aids to orientation is limited.
There is good evidence for the provision of a variety of spaces in environments for people with dementia as they assist in reducing anxiety and depression while improving social interaction and may assist the resident to find their way around. However specific evidence for benefits of gardens per se, without enhanced staff interaction, is weak and there have been no well designed studies of the provision of wandering paths.
The provision of a familiar environment, especially when that is taken to include the provision of single rooms that facilitate personalisation, is supported.
Providing ways of linking the residential facility to the community through the inclusion of environmental features e.g. a coffee shop, is yet to be properly researched.
The difficulties of distinguishing between the social/professional environment, i.e philosophy of care, staff skills, good management practices, and the physical environment make it difficult to conclude that a homelike physical environment has a broad impact, especially in the case of people with advanced dementia. However there is good evidence that it reduces aggression. The evidence for the beneficial effects of involving people with dementia in ordinary activities of daily living is weak.
While recognising that there are substantial gaps in the literature, especially in regard to information on designing for people with advanced dementia, we may be confident about using unobtrusive safety measures; varying the ambience, size and shape of spaces; providing single rooms; design for planned wandering; provide for maximising visual access to important features and providing for stimulus control with the periodic availability of high levels of illumination.
- What difference does the environment make to the wellbeing of people with dementia: New research, a new approach to the assessment of the environment and an international comparison (Richard Fleming, University of Wollongong, Australia): Reports on the results of recent research which throws new light on the contribution that the environment makes to the lives of people with dementia in residential aged care. Compares Australian dementia specific facilities with the best in Norway, highlighting the strengths and weaknesses of both. Participants are invited to try out a new, and relatively exciting, way of assessing residential care facilities.
- Provision of timely education to aged care managers and architects involved in designing facilities for people with dementia
- Clinical workshops on environmental design for people with dementia
- Introducing environmental design for people with dementia into undergraduate architectural curricula
- Development of an audit tool based educational package to inform an understanding of the use of the physical environment in the care of people with dementia
- Fleming, R., P. Crookes, and S. Sum, A review of the empirical literature on the design of physical environments for people with dementia. 2008, Primary Dementia Collaborative Research Centre, UNSW.: Sydney, Australia.
- Fleming, R. and N. Purandare, Long term care for people with dementia: environmental design guidelines. International Psychogeriatrics, 2010. 22(7): p. 1084-1096.
- full review of the literature
- Fleming, R., An environmental audit tool suitable for use in homelike facilities for people with dementia. Australasian Journal on Ageing, in press.
- Fleming, R., I. Forbes, and K. Bennett, Adapting the ward for people with dementia. 2003, Sydney: NSW Department of Health.
- Rosewarne, R., et al., Care Needs of People with Dementia and Challenging Behaviour Living in Residential Facilities. 1997, Australian Government Publishing Service.
- Zeisel, J., et al., Environmental correlates to behavioral health outcomes in Alzheimer's special care units. The Gerontologist, 2003. 43(5): p. 697.
- Annerstedt, L., Group-living care: An alternative for the demented elderly. Dementia and Geriatric Cognitive Disorders, 1997. 8(2): p. 136-142.
- Bowie, P. and G. Mountain, The relationship between patient behaviour and environmental quality for the dementing. International Journal of Geriatric Psychiatry, 1997. 12(7): p. 718-23.
- Elmstahl, S., L. Annerstedt, and O. Ahlund, How should a group living unit for demented elderly be designed to decrease psychiatric symptoms? Alzheimer Disease & Associated Disorders, 1997. 11(1): p. 47-52.
- Cleary, T.A., et al., A reduced stimulation unit: Effects on patients with Alzheimer's Disease and related disorders. The Gerontologist, 1988. 28,: p. 511-514.
- Grant, L.A., R.A. Kane, and A.J. Stark, Beyond labels: nursing home care for Alzheimer's disease in and out of special care units. Journal of the American Geriatrics Society, 1995. 43(5): p. 569-76.
- Namazi, K.H. and B.D. Johnson, Pertinent autonomy for residents with dementias: Modification of the physical environment to enhance independence. American Journal of Alzheimer's Disease and Other Dementias, 1992a. 7(1): p. 16-21.
- Wells, Y. and A.F. Jorm, Evaluation of a special nursing home unit for dementia sufferers: a randomised controlled comparison with community care. Australian & New Zealand Journal of Psychiatry, 1987. 21(4): p. 524-31.
- Cox, H., I. Burns, and S. Savage, Multisensory environments for leisure: promoting well-being in nursing home residents with dementia. Journal of Gerontological Nursing, 2004. 30(2): p. 37-45.