World Alzheimer Report 2020

The literature

Having established the usefulness of principles of design as an organising framework the report goes on to review the literature. The contributors to this section address the areas identified by ADI as being the foci of the report: residential care, hospital care, domestic homes, day care and public buildings.

Stephanie Harrison in Design and the built environment for people living with dementia in residential aged care offers a thoughtful critique of the application of the principles. While she points out the weakness of much of the research, she nonetheless is of the opinion that “there is sufficient evidence to suggest that the quality of the built environment in residential aged care can positively impact meaningful activity, behaviour and quality of life for residents. Enabling residential aged care environments which help facilitate residents to engage in indoor and outdoor activities and offer a variety of spaces whilst creating a familiar environment for the residents, are associated with better quality of life”. Tom Grey observes that

many hospitals are not designed to care for people with dementia,

not least because “Designing at a human scale is challenging in the context of large-scale and complex acute hospitals.” He describes dementia-friendly design as an inclusive approach which pays attention to cognitive impairment alongside the age-related changes such as physical frailty, mobility, visual impairments, hearing loss, and circadian rhythm difficulties. These cognitive, physical, sensory and age-related issues underpin dementia-friendly design. He is encouraged by how dementia-attuned research and design is contributing to the developing knowledge base and will contribute the support of a wide range of patients, visitors and staff of all ages, sizes, abilities and disabilities as well as people living with dementia.

He highlights the contributions made by the Universal Design approach and salutogenic design. He notes that seeking the sense of coherence aimed for in salutogenic design through meaningfulness, manageability, and comprehensibility provides a valuable design framework for healthcare architecture. Establishing a context for the recognition of the therapeutic impact of natural things, like sunlight, on stress and pain leading to reductions in analgesic medication use.

Residential and hospital care for people living with dementia are never seen as preferred options. There is a growing body of evidence on the beneficial effects of designing, or more usually, modifying peoples own homes to make them more supportive. Ash Osborne– Home modifications to support people living with dementia – observes that “The vision that drives home modifications is, quite simply, to keep things as they have been for as long as possible. To enable the person with dementia to enjoy their relationship with their past life, as embodied in their home, despite the problems introduced to their life by dementia”.

The current literature supports the conclusion that home modification is a strategy that can optimise safety, comfort and independence for a person living with dementia and enhance the quality of care while reducing caregiver burden.

By providing appropriate housing options in the community, in combination with home and social care, people living with dementia can be supported to age in place and avoid or defer a move into residential care.

Day care centres are one aspect of the social care necessary to support people with dementia living at home. The case studies in volume 2 of this report demonstrate the international acceptance of the value of day care centres and their relevance to the delivery of support in low and middle-income countries.

Jason Burton – Day Care Centre Design – provides a review of the current knowledge on day care centre design along with a great deal of practical advice on how to use the principles to design a successful centre. He emphasises the need to understand the role and outcomes the day centre service is seeking to achieve. When there is a clear vision of these the philosophy of care, model of service delivery, staff competency and skill set, and the design of the physical environment can be developed to complement each other to achieve the goals of the service and its users. He observes that misalignment of the physical environment and the service model often makes achieving service goals difficult. A service model focused on rehabilitation and physical wellness, for example, may not work well in a small house design and a model aiming to achieve wellbeing and strengthening of personhood through meaningful engagement may be difficult to achieve in a large scale building set up to deliver large group or passive entertainment activities.

He sees the day care centre as a hub of community activity providing opportunities for inter-generational programmes and purposeful activities that support community connection. He recommends systematic application of the principles of design to, for example, unobtrusively reduce risks to both protect attendees from harm and to give staff confidence to support maximum freedom of choice and movement. As day centres can be very noisy and active places he recommends that the design carefully manages stimuli in the environment and ensures good line of sight exists for transition through the day centre and out to the gardens. This is essential to assist purposeful movement and reduce a sense of ill-being.

The role of public buildings and spaces in the life of people living with dementia and, potentially at least, in supporting them to live in the community, is relatively unexplored. There is a small body of literature and its influence is beginning to be felt, particularly in the context of the promotion of dementia friendly towns and cities.

Dennis Frost is a person with dementia living in a town on the south coast of New South Wales, Australia. He has provided a response to four key articles on the design of public buildings and spaces and contributed to the field by offering a three dimensional matrix approach to dealing with the relationships between the World Health Organisation’s Domains of Age Friendly Cities, the domains of dementia friendly design (derived from the principles) and the variations in the experience of spaces with time. It has become clear to Dennis that his experience of a place is heavily determined by seasonal, weekly and diurnal variations, for example in levels of illumination, activity and temperature, and that these are very rarely accounted for in the literature.

Dennis holds the view that

‘Our expectations as we age should be to age in the community we choose, not to be consigned to a ‘specialised’ micro-community of a perceived homogeneous population.’

He is looking forward to the expansion of the knowledge on how to design enabling and accessible public buildings so that people living with dementia have the opportunity to make that choice.
In summary, there is a useful knowledge base that can be applied to designing for people with dementia. It is strongest in the residential care field and needs accelerated development in the other areas.

The next section explores how we come to have that knowledge base.