Recalling the memories - Design Dissertation on creating spaces for Alzheimer's

DISSERTATION ON

“Recalling the Memories” BACHELOR’S OF ARCHITECTURE SOUTH POINT SCHOOL OF ARCHITECTURE DEENBANDHU CHHOTU RAM UNIVERSITY OF SCIENCE AND TECHNOLOGY, MURTHAL (SONEPAT), HARYANA

ABHINAV BANSAL 15026006001 DECEMBER – 2019

This report submitted is in partial fulfillment of the requirement for degree of B.Arch.

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SOUTH POINT SCHOOL OF ARCHITECTURE DEENBANDHU CHHOTU RAM UNIVERSITY OF SCIENCE AND TECHNOLOGY, MURTHAL (SONEPAT), HARYANA

DECLARATION I hereby declare that I, Abhinav Bansal, Roll no. 15026006001, am the soul author of this report, “Recalling the memories” and that no part of this report has been submitted for the award of a Degree or Diploma to any other University or Institution.

This dissertation report submitted by me, in partial fulfillment of the requirement for the award of Degree of ‘Bachelor in Architecture’ to ‘Deenbandhu Chhotu Ram University of Science and Technology’ as a record of my original research work.

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Signature of student Date

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SOUTH POINT SCHOOL OF ARCHITECTURE DEENBANDHU CHHOTU RAM UNIVERSITY OF SCIENCE AND TECHNOLOGY, MURTHAL (SONEPAT), HARYANA

CERTIFICATE This is to certify that the Dissertation Report submitted in the partial fulfillment of the requirements of the Degree of Bachelor of Architecture is the bonafide work Abhinav Bansal, Roll no. 15026006001, who carried out research work under supervision in the South Point school of Architecture, Sonepat.

We recommend that the report be placed before the examiners for their consideration for the award of Bachelor’s Degree.

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Ar. (Dissertation Coordinator)

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Date

Date

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AKNOWLEGDEMENT I owe a great thanks to many people who helped and supported me during the preparation of this Dissertation report. I would like to express my sincere gratitude to all those who have guided and helped me, specially to my senior Swati Singh. I have taken efforts in this topic.

I extend my deepest thanks to

, the coordinator for my dissertation, for guiding

and correcting various documents of mine with attention and care. She has taken pain to go through the report and make necessary correction as and when needed.

I would also thank my Institution, 'SOUTH POINT SCHOOL OF ARCHITECTURE, SONEPAT’ and the faculty members without whom this Dissertation report would have been a distant reality.

I also would like to express my gratitude towards my family for the encouragement which helped me in completion of this project.

My thanks and appreciations also go to my friends and people who have willingly helped me out with their abilities.

I also extend my heartfelt thanks to my all well-wishers.

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Recalling the Memories

Abstract The thought behind this study was to understand the human psychology, why they react to certain things and can there this behavioral reaction be used in favor of healing their problems and improving their lifestyle. Human psychology itself is very broad and vast field to explore, therefore the specific user group was selected for the search.

Among other user groups, the old-age group is the one which somehow gets left out. The idea was to study and analyze the psychological issues in old age group and to give them priority.

There are several diseases that causes psychological issues, Alzheimer's disease is the most common among them which results in memory loss. Alzheimer's disease has become the global issue in old-age group, which is increasing at a rapid growth. It causes cognitive impairment and is still incurable. Cognitive impairment results in the loss of memory and unstable mental condition This dissertation focuses on designing the spaces for such people. Spaces that can trigger the brain to activate by stimulating through senses. Understanding the disease of Alzheimer's to its depth core and the perspective of the people facing the problem.

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Introduction As compared to physical illness, the mental illness has always been in a shadow and is always been ignored in the initial stages, which later results in mental instability. Even the point of view of the people towards mental disorder has always been something to be ashamed off and such that it should be kept secretive or personal. Specially in a culture we live in. But in recent times the perspective towards mental illness has been changing and is being addressed.

The most common disease in old-age group is dementia which results in the loss of memory and behavioral dysfunction of human being. Memory is one of the unique aspect of human existence that individualizes and sets us apart from one another. It is human nature to learn from, share and think fondly of our memories. Unfortunately, with the continual progression of aging, millions of people are robbed of this precious gift.

Ageing and mental health are the two least likely of any group with a long term health condition or disability to:   

work be in a steady, long-term relationship be socially included in mainstream society.

Discrimination and not treating them well leads to their problem to worse. Unhealthy mind set leads the brain to over-thinking and stresses the brain. Hence consideration of these individuals are very important and hence it is our duty to fit them in the society as they are also the part of it.

National condition of the disease Population of the people with cognitive impairment is increasing at a rapid growth. In India, more than 4 million people are estimated to be suffering from Alzheimer's and other forms of dementia, giving the country the third highest caseload in the world, after China and the US. Worldwide, at least 44 million people are living with dementia, making the disease a global health crisis that must be addressed.

Photograph by : Robert Ullmann

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Aim This dissertation briefly aims at various methods of designing a comfortable space with extensive experience of environment for cognitive impaired specially in Alzheimer's Disease, individuals by understanding their perception of space through their functional senses.

Objective : 1. To understand psychological reaction of the people to the built environment.

2. To understanding Alzheimer's Disease and its different stages.

3. To understand how they perceive spaces around them.

4. To analyze how a space can be designed more safe, accessible and hospitable.

5. Case Studies.

Need of identification This dissertation serves the purpose of identifying ways of designing spaces for individuals who have lost their cognitive ability (completely and partially) by extending basic parameters and understanding the perspective and impact of space on their senses which ultimately connect them back with environment and also elevate their experience in space.

Scope This dissertation's immediate scope is to understand the alzheimer's disease deeply and how cognitive impaired individual's senses get stimulated by the environment which makes it necessary to enhance sensorial quality of the space. This study will cover the causes, types, social and emotional effect on cognitive impaired individuals which will help to understand their problems better. This research is also concern with their perception of space and related sufferings.

Limitations :  

This study only with the Alzheimer's disease and other related dementia's only, not with other problems or diseases related to brain.

Designing is studied keeping mind the old age group.

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Methodology :

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Content Chapter 1. Psychology and Architecture  

Relationship between architecture and psychology Diagram model by Jon Lang

Chapter 2.Brain, Cognitive Impairment & Alzheimer's Disease.  Brain and its parts  Symptoms and causes  Different Stages of Alzheimer's disease Chapter 3. The brain and the senses.  Relation of the brain and the sensory system  Five senses (touch, sight, hearing, smell, taste)  Light and sound therapy Chapter 4. Perception of cognitive impaired.  Understanding the perception of the space  Common visual deficits  Hallucinations and Delusions Chapter 5. Design Considerations based on research papers.         

Households Residential Quality Way-finding and orientation Independence control and flexible rhythms Safety and security Entry and Egress Spa and bathing Outdoor Spaces Active engagement

Chapter 6. Case Studies.  

Alzheimer’s respite centre, Dublin, Ireland Ementia village ‘de hogeweyk’, Weesp, Netherlands

Conclusion Bibliography 9

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Chapter -1 Architecture and Psychology The creative process has everything to do with the psyche and psychic function. Architecture has to do with the utilization of space. Oscar Niemeyer claimed, “The ultimate task of the architect is to dream. Otherwise nothing happens. “ Relationship between architecture and psychology The relationship between architecture and psychology is very vast, covering topics ranging from different concepts of design and psychology. One end of the spectrum is the very obvious finding on environmental psychology which is about the relationship between humans and natural environments. This then feeds into how we design in a way that maintains this connection between us and nature, or that it mimics it into form.

Findings from the field of environmental psychology shows that humans are aesthetically attracted to natural contents and to particular landscape configurations. These features are also found to have positive effects on human functioning and can reduce stress. However, opportunities for contact with these elements are reduced in modern urban life. It is argued how this evolution can have subtle effects on psychological and physiological well-being. These can be countered by integrating key features of natural contents and structural landscape features in the built environment.

We can then look at the more architecture related psychological effects we experience from color and dimension of space. Creating a space that commands a desired type of thought is achievable, through correcting thresholds, dimension and colors we can create space that encourages the type of behavior we desire.

The color blue automatically triggers associations with the ocean and sky We automatically think about diffuse light, sandy beaches and lazy summer days. This sort of mental relaxation makes it easier for us to generate thoughts and relates it with our personal experiences; we’re less focused on what’s right in front of us and more aware of the possibilities generating in our imagination.

Psychologist Joan Meyers-Levy, at the Carlson School of Management, conducted an interesting experiment that examined the relationship between ceiling height and thinking style. She demonstrated that, when people are in a low-ceilinged room, they are much quicker at solving anagrams involving confinement, such as “bound,” “restrained” and “restricted.” In contrast, people in high-ceilinged rooms excel at puzzles in which the answer touches on the theme of freedom, such as “liberated” and “unlimited.” According to Levy, this is because airy spaces prime us to feel free.

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Furthermore, Levy found that rooms with lofty ceilings also lead people to engage in more abstract styles of thinking. Instead of focusing on the particulars of things, they’re better able to zoom out and see what those things have in common. The difference between “item-specific” versus “relational” processing.

What is the character of the settings or elements that can trigger such immediate affective states?

These reactions can be provoked by some typical structural landscape features.

To understand the process of reaction or behavior of a person to such enviornment can be understood by the Diagram model by Jon Lang.

Figure 1 : Model by Jon Lang

The information about the enviornent is obtained through the perception , If there is any stimuli in the envionment, we perceive it through our senses then we interpret it by cognitive affect (such as reasoning and problem solving) . It results in the spatial behavior of the individual to the particular spce or enviornment with the emotional response.

Basically the data obtained through perception is guided by a plan called schemata, which finally results in the need or motivations of the enviornent.

By understanding the relation between psychology and architecture through various examples and the scientific model by Jan Lang. It could be applied in healing the psychological state of a person. Hence creating the spaces that can stimulate the senses. Creating the emotional aspect to the elements of design arranged to form an impact.

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Chapter -2 The Brain, Cognitive Impairment & Alzheimer's Disease.

Humans have five vital organs that are essential for survival. These are the brain, heart, kidneys, liver and lungs. Among these organs brain is the one which contorls the whole body by receiving and sending the signals to other organs through the nervous system.

The Brain The brain is an amazing organ that controls all the functions of the body. It interprets the information from the outer world and embodies the essence of the mind and soul. Intelligence, creativity, emotion and memory are a few of the things controlled by the brian.

The brain receives information through our five senses: sight, smell, touch, taste, and hearing. It assembles the messages in a way that has meaning for us, and can store that information in our memory. The brain controls our thoughts, memory and speech, movement of the arms and legs, and the function of many organs within our body.

The brain is composed of three main parts: Cerebrum: is the largest part of the brain and is composed of right and left hemispheres. It performs higher functions like interpreting touch, vision and hearing, as well as speech, reasoning, emotions, learning, and fine control of movement.

Cerebellum: is located under the cerebrum. Its function is to coordinate muscle movements, maintain posture, and balance.

Brainstem: acts as a relay center connecting the cerebrum and cerebellum to the spinal cord. It performs many automatic functions such as breathing, heart rate, body temperature, wake and sleep cycles, digestion, sneezing, coughing, vomiting, and swallowing.

Right brain – left brain The cerebrum is divided into two halves: the right and left hemispheres. They are joined by a bundle of fibers called the corpus callosum that transmits messages from one side to the other.

Each hemisphere controls the opposite side of the body.

Figure 2 : human brain

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If a stroke occurs on the right side of the brain, your left arm or leg may be weak or paralyzed. Brain being the controller of the body, is when affected by any disease, it misbalances the whole body which somehow affects the working of other organs directly or indirectly. Affecting of the brain leads to the deterioration of brain cells which results in the cognitive impairment.

Cognitive impairment

Figure 3 : Left-Right brain

Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. Cognitive impairment ranges from mild to severe. With mild impairment, people may begin to notice changes in cognitive functions, but still be able to do their everyday activities. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently.

Causes There are several reasons that results in Cognitive impairment.

Hence Dementia is one of the major and most common reason that causes Cognitive impairment specially in old ages. It easily affects the people above 60.

Figure 4 : forgotten memory

What Is Dementia?

Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—and behavioral abilities to such an extent that it interferes with a person's daily life and activities.

These functions include memory, language skills, visual perception, problem solving, selfmanagement, and the ability to focus and pay attention.

Some people with dementia cannot control their emotions, and their personalities may change.

Dementia ranges in severity from the mildest stage, when it is just beginning to affect a person's functioning, to the most severe stage, when the person must depend completely on others for basic activities of living.

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Figure 5 : Types of Dementia

The causes of dementia can vary, depending on the types of brain changes that may be taking place. Alzheimer's disease is the most common cause of dementia in older adults. Other dementias include Lewy body dementia, front temporal disorders, and vascular dementia. It is common for people to have mixed dementia—a combination of two or more types of dementia. For example, some people have both Alzheimer's disease and vascular dementia.

Alzheimer's Disease Alzheimer’s disease is an irreversible, progressive brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. In most people with the disease—those with the late-onset type—symptoms first appear in their mid-60s. Earlyonset Alzheimer’s occurs between a person’s 30s and mid-60s and is very rare. Alzheimer’s disease is the most common cause of dementia among older adult

Figure 6 : Healthy brain and Alzheimer's brain

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The disease is named after Dr. Alois Alzheimer. In 1906, Dr. Alzheimer noticed changes in the brain tissue of a woman who had died of an unusual mental illness.

Her symptoms included memory loss, language problems, and unpredictable behavior. After she died, he examined her brain and found many abnormal clumps (now called amyloid plaques) and tangled bundles of fibers (now called neurofibrillary, or tau, tangles).

These plaques and tangles in the brain are still considered some of the main features of Alzheimer’s disease. Another feature is the loss of connections between nerve cells (neurons) in the brain. Neurons transmit messages between different parts of the brain, and from the brain to muscles and organs in the body. Many other complex brain changes are thought to play a role in Alzheimer’s, too.

This damage initially appears to take place in the hippocampus, the part of the brain essential in forming memories. As neurons die, additional parts of the brain are affected. By the final stage of Alzheimer’s, damage is widespread, and brain tissue has shrunk significantly.

Causes Like all types of dementia, Alzheimer's is caused by brain cell death. It is a neurodegenerative disease, which means there is progressive brain cell death that happens over time. In a person with Alzheimer's, the tissue has fewer and fewer nerve cells and connections. Autopsies have shown that the nerve tissue in the brain of a person with Alzheimer's has tiny deposits, known as plaques and tangles, that build up on the tissue. The plaques are found between the dying brain cells, and they are made from a protein known as beta-amyloid. The tangles occur within the nerve cells, and they are made from another protein, called tau. Researchers do not fully understand why these changes occur. Several different factors are believed to be involved.

Figure 7 : Condition of brain in Alzheimer's

Risk factors Unavoidable risk factors for developing the condition include: 15

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aging

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a family history of Alzheimer's

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carrying certain genes

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Different Stages of Alzheimer's The progression of Alzheimer's can be broken down into three main stages Trusted Source: 

preclinical, before symptoms appear

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mild cognitive impairment, when symptoms are mild

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dementia

In addition, the Alzheimer's Association describes seven stages along a continuum of cognitive decline, based on symptom severity. The scale ranges from a state of no impairment, through mild and moderate decline, eventually reaching "very severe decline." A diagnosis does not usually become clear until stage four, described as "mild or early-stage Alzheimer's."

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Chapter -3 The Brain and the Sensory System.

What is a Sensory System?

Sensory systems detect stimuli—such as light and sound waves—and transduce them into neural signals that can be interpreted by the nervous system. In addition to external stimuli detected by the senses, some sensory systems detect internal stimuli—such as the proprioceptors in muscles and tendons that send feedback about limb position. Sensory systems include the visual, auditory, gustatory (taste), olfactory (smell), somatosensory (touch, pain, temperature, and proprioception), and vestibular (balance, spatial orientation) systems.

Relation of the brain and the sensory system Each sensory system sends signals to the brain.

It's up to the brain to interpret these signals and come up with a response. To do this, the brain often combines information from multiple sensory systems—a process called sensory integration.

Sensory signals first enter the brain through the thalamus (except for olfaction, which bypasses this area). From there, it is routed to a sensespecific area of the cortex. Cortical areas, in turn, send signals to the brain's "association areas," which combine information from multiple senses.

Figure 8 : Brain

The Five Senses as Receivers and Gateways to the Human Mind The main function of our senses is to make us to feel the world around us. “Our eyes see it, our ears hear it, our nose smell it, our tongue taste it, and these along with a few other senses provide us with most of the knowledge that we have about the world”. This also happens when we enter a new space and we begin to notice it, recognize it, and then evaluate it. This process of discovering, affects our sensation in the space and influences our opinion about it. .

“The five senses are each gateways of healing. The eyes which give us sight are gateway to color healing; the ears which give us hearing are a gateway for music therapy; the sense of touch lends itself to massage; the sense of smell to aromatherapy and the sense of taste to our diet.”12 Thus the surrounding environment has a massive effect on the user, mentally and physically. This results that the human behavior in an architectural space is considered a reaction to the effect of that space on the user and his/her senses. Therefore, the concern of the architects is always to 17

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create an appropriate physical environment that helps the user and improves his physical and psychological condition. This fact made Hansard says: “We shape our buildings and afterwards our buildings shape us” and even more. Roger Ulrich, who is concerned with the effect of the built environment on the well-being of the user, agrees on that and says: “There is increasing scientific evidence that poor design works against the well-being of patients” In this perspective, the central goal of architects and designers should be to improve wellness by creating physical surroundings that are “psychologically supportive”.

The Gestalt School of Psychologists reveals the importance of the relationships between stimuli for the sense we make, and the context. “The most crucial property is that our experience of our environment is notably temporal and sequential”.15 It is scientifically proofed that the visual perception for any built environment is influenced by the movement of the user in that environment and the acoustical level in it.16 This makes the architects deal with their designs with a great concern; they do not limit their interest to one sense and neglect all other senses. “As designers, we create physiological and psychological sets of relationships that have to do with all the senses.”

Five senses (Psychological aspect of healing) 

Sight

The sense of sight allows individuals to take in their surroundings with the eyes. Depth, shadow, light, color and form are all perceived by sight. Our sense of sight may begin to deteriorate with age and as Juhani Pallasmaa warns in The Eyes of The Skin we must not rely only on our sense of sight. “The very essence of the lived experience is moulded by hapticity and peripheral unfocused vision. Focused vision confronts us with the world whereas peripheral vision envelops us in the flesh of the world. 

Figure 9 : eye

Touch

The sense of touch provides physical interaction and engagement. Within the built environment the sense of touch and the interaction it has with the human flesh possesses the potential to trigger cognitive and physical responses. This might include seeing shadows and light on a textured surface which may cause an individual to curiously reach out and touch the wall. To interact with objects one touches or feels them in turn triggering the brain to activate in order to comprehend. We not only feel textures such as rough or

Figure 10 : skin

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smooth, but also as hot to cold. 

Hearing

Hearing has the ability to make an individual take notice and experience their surroundings, whether it be the chirping of a bird or the echo of a vast space. In the book I’m Still Here: A Breakthrough Approach to Understanding Someone Living with Alzheimer’s, John Zeisel expresses that even though an individual has Alzheimer’s disease they are still living in the present moment and all possess unique capabilities. Founder of a program called ARTZ (Artists for Alzheimer’s) Zeisel feels that music and the arts can touch individuals living with the disease like nothing else can. Music has been shown to trigger memories and enable patients to freely express themselves. 

Smell

Smell is a sense that is often overlooked in the experience of architecture. In the design and construction of spatial environments material choices have the ability to create a fragrant environment. For example, cedar wood design elements such as railings, window trim and built in furniture can omit a memorable aroma. Different types of hardwoods and surface treatments such as paint, varnish, and plaster can all produce architectural aromas. Each individual is unique and has been exposed to different scents through their own distinct lived experiences. Some of the smells that may be present in the retirement residence design could possibly trigger different memories from individual residents past. 

Figure 11 : ears

Figure 12 : Nose

Taste

“‘The taste of the apple ... lies in the contact of the fruit with the palate, not in the fruit itself; in a similar way ... poetry lies in the meeting of poem and reader, not in the lines of symbols printed on the pages of a book. What is essential is the aesthetic act, the thrill, the almost physical emotion that comes with each reading.’”41 This quote by Jorge Luis Borges describes the sense of taste occurring through an interaction. One cannot use Figure 13 : Tongue

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their sense of taste without participating in the experience of eating. The materials used to construct the environment are not able to evoke the sense of taste. Through architecture spaces can be provided such as kitchens and dining rooms to allow for the experience of taste to occur Light and sound therapy Research in mice reveals that an innovative light and sound stimulation therapy can clear toxic plaque buildup in the brain and reduce some of the symptoms of Alzheimer's disease and impaired cognitive functioning.

The hallmarks of Alzheimer's disease in the brain include the formation of beta-amyloid plaques and the amalgamation of tau, a toxic protein that disrupts the correct functioning of neural networks.

Recent research has suggested that people with this form of cognitive impairment also experience brain wave disruptions.

Figure 14 : Sound therapy

Neurons (brain cells) produce electrical oscillations of various frequencies, which are called "brain waves."

Research has shown that in Alzheimer's disease, individuals experience a disruption in the activity pattern of gamma waves, the brain waves with the highest frequency.

In recent years, a team of scientists from the Massachusetts Institute of Technology (MIT) in Cambridge has been uncovering evidence Trusted Source that certain types of light stimulation can reestablish the equilibrium of gamma waves and reduce the accumulation of beta-amyloid in mouse models of Alzheimer's.

Now, the same team, working under the guidance of MIT Prof. Li-Huei Tsai, has found that a combination of light and sound therapy can have a significant effect in improving cognitive functioning in these mouse models.

Encouraged by these findings, which appear in the journal Cell, the researchers are now organizing a clinical trial to test the effects of this novel therapy in humans with this neurodegenerative condition.

Figure 15 : Amyloid plaques in brain nerves

Auditory stimulation brings benefits In their previous study, Prof. Tsai and colleagues employed a light stimulation treatment, which involved exposing mouse models to lights flickering at 40 Hertz for 1 hour per day.

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At that point, the researchers found that this approach helped reduce levels of both beta-amyloid plaques and phosphorylated tau proteins in the rats' brains.

Moreover, the team observed that the light stimulation boosted the activity of microglia, a type of neural cell that plays a role in the immune response and works by clearing up cellular debris.

However, this previous research focused only on changes to the brain's visual cortex. In the current study, the scientists decided to go one step further and try to treat other brain regions that are involved in memory and learning processes by using sound stimulation to rebalance gamma brain waves.

Thus, they went ahead and exposed mice to 40 Hertz sounds for 1 hour a day for 7 days continuously. This auditory stimulation had the effect of reducing beta-amyloid levels not only in the auditory cortex but also in the hippocampus, a brain region that plays a key role in processing and recalling memories.

"What we have demonstrated here is that we can use a totally different sensory modality to induce gamma oscillations in the brain," says Prof. Tsai.

"And secondly," she adds, "this auditory-stimulation-induced gamma can reduce amyloid and Tau pathology in not just the sensory cortex but also in the hippocampus."

More importantly, when the researchers tested the effect of this sound stimulation treatment on the rats cognitive abilities, they found that the mice's memories had improved and that they performed much better on a test that required them to find their way out of a maze by recalling landmarks.

At the end of the treatment, the mice's ability to remember objects that researchers had previously exposed them to had also improved.

Combined approach yields best results In terms of its physiological impact, the auditory stimulation not only triggered microglial activity but also had an effect on blood vessels and circulation. This, the researchers hypothesize, could help further reduce the levels of toxic proteins in the brain.

The team then combined light and sound stimulation therapy and were surprised to find that this treatment had an even better effect.

The researchers found that the combination approach of both therapy led to the elimination of beta-amyloid plaques in more brain regions, including the prefrontal cortex, which is essential to higher-order cognitive functioning.

Moreover, it offered a more intense boost to microglial activity. "These microglia just pile on top of one another around the plaques," notes Prof. Tsai, calling the effect "very dramatic."

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"When we combine visual and auditory stimulation for a week, we see the engagement of the prefrontal cortex and a very dramatic reduction of amyloid."

Prof. Li-Huei Tsai The team also found that when they discontinued the treatment after the first week, its positive effects fade away within just a week, which suggests that specialists may have to keep this therapy continuously.

Prof. Tsai and colleagues have already proceeded to a finding that the new combination therapy is safe in humans, and they are currently enrolling participants with early-stage forms of Alzheimer's in a clinical trial that they have designed to assess the treatment's effect on people.

Music as a Therapy It is a type of expressive art therapy that uses music to improve and maintain the physical, psychological, and social well-being of individuals—involves a broad range of activities, such as listening to music, singing, and playing a musical instrument.

Music has been used as a therapeutic tool for centuries and has been shown to affect many areas of the brain, including the regions involved in emotion, cognition, sensation, and movement.

What happens in a music therapy session?

The intervention methods employed in music therapy can be roughly divided into active and receptive techniques. When a person is making music, whether by singing, chanting, playing musical instruments, composing, or improvising music, that person is using active techniques.

Receptive techniques, on the other hand, involve listening to and responding to music, such as through dance or the analysis of lyrics. Active and receptive techniques are often combined during treatment, and both are used as starting points for the discussion of feelings, values, and goals.

Figure 16 : Playing instrument in music therapy

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Chapter 4.

Perception of cognitive impaired.

People with dementia can have difficulties with vision and perception which causes them to misinterpret the world. The process of seeing is complicated and there are many points where things can go wrong. Disturbances in vision and perception can cause behavioral challenges and even safety risks. Caregivers who understand this will be better able to support their loved one and modify their physical environment, so they can remain at home longer.

The Eyes and Brain Work Together Because Alzheimer’s is a disease of the brain and many seniors also have vision changes and age-related eye conditions like cataracts and macular degeneration, various kinds of visual mistakes can occur. Let’s consider the basics of the visual process. First, information is transmitted from your eyes to your brain where it is then interpreted. Your other senses, thoughts and memories contribute information that influences your interpretation. Next, you become aware of what you have seen, forming a perception. These visuoperceptions can be inaccurate or faulty depending on the function of the eyes and the area of the brain that is diseased, causing distress for the affected person as well as their caregivers.

Common Visual Deficits In Alzheimer’s dementia, there are five main areas of visual deficit that can cause mistakes in perceptions: motion detection, peripheral vision, depth perception, color perception, and contrast sensitivity.

Reduced ability to detect motion. Some people are unable to detect movement. They perceive the world as a series of still photos, rather than an ongoing video like most people see.

This view of the world can cause affected persons to become lost, even in familiar surroundings. Following a moving object can be difficult and impacts the ability to comfortably watch television or do any activity involving fast motion.

Depth perception. Individuals with Alzheimer’s can lose their depth perception. They have a hard time judging distances, changes in elevations or distinguishing between a threedimensional object and a flat picture. They may reach to pick up the flowers on a floral fabric or step up when they come to a border on a carpet as if it were a step.

Figure 17 : brain and eyes

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Reduced peripheral vision. People’s field of vision narrows as they age; but for some with Alzheimer’s disease, it narrows dramatically. They may be unable to see to either side when gazing forward, resulting in disorientation and a tendency to bump into things. They may be startled by someone approaching them or need to suddenly veer to miss a wall.

Color perception. Though colors often diminish with age, persons with Alzheimer’s seem to have a greater deficit and will have difficulty recognizing colors, especially in the blue-violet range. Coordinating clothing may be a problem.

Contrast sensitivity. Not just color, but detecting gradients of color also is reduced in persons with Alzheimer’s. They will have trouble picking out objects that are surrounded by similar colors. For example, a person may have difficulty finding the toilet in a bathroom where the floor, walls and toilet are all white.

Problems with Object and Facial Recognition Alzheimer’s dementia can cause problems with the recognition of objects and faces causing an inability to name what is seen.

Common Visual Perception Mistakes 

Illusions – when a person sees a "distortion of reality." This may result from a characteristic of the object. A shiny floor may be perceived as wet or a face may appear in a patterned curtain.

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Misperceptions – what the person sees is a ‘best guess’ at the inaccurate or distorted information the brain receives from the eyes. This is usually the result of damage to the visual system from diseases like cataracts or glaucoma. For example, a shadow on the carpet could be mistaken for a hole in the floor or reflections in a mirror can be mistaken for an intruder.

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Misidentifications – damage to specific parts of the brain can lead to problems identifying objects and people. For example, distinguishing between a son, husband or brother may become difficult or a green pillow might be called a "cabbage."

It is easy to see how these mistakes affect daily activities. They can lead to problems reading and writing, watching TV, moving around the home, and using the bathroom. Visuoperceptual errors can even lead to the person saying or doing strange things that make others think they are having delusions. However, what the person is experiencing is not a delusion; delusions are based on incorrect reasoning or "delusional thinking." These mistakes are the result of damage to the visual process involving the eyes and brain.

A Word About Hallucinations and Delusions People with Alzheimer’s can experience hallucinations and delusions, but these are different from visuoperceptual mistakes. A visual hallucination involves perceiving or seeing something that is not there in the real world. (as simple as seeing flashing lights, or as complex as seeing animals or people). Hallucinations are sensory experiences that are imagined and can involve a combination of the senses -- what a person sees, smells, hears, tastes, or feels.

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There is also another condition worth mentioning which can cause hallucinations in people with vision loss-- Charles Bonnet Syndrome. This type of hallucination is solely visual and explained as a mirage or "phantom vision" of sorts. It usually occurs in older adults who are mentally healthy. Sometimes consultation with a neurologist or other specialist is necessary to rule out any serious disorders that may mimic Charles Bonnet syndrome [such as migraine, epilepsy, brain tumors, dementia, Parkinson's disease, or mental illness, for example]. For most patients, however, just knowing that they aren't becoming mentally ill and that the symptoms will eventually subside is all the treatment they need. Treatments and interventions are discussed in the section referenced on Charles Bonnet.

Unlike a hallucination, a delusion involves a set of false beliefs.

An Alzheimer’s patient with delusions may become suspicious of the people around them, believing that caregivers are trying to trick them or steal from them. Delusions are based on incorrect reasoning or "delusional thinking." Memory loss and cognitive changes create confusion and seem to contribute to such irrational beliefs.

Figure 18 : view from parking lot

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Chapter 5.

Design Considerations for Alzheimer’s Disease

Based on industry research, copious feedback from the personal experiences of a wide variety of family and professional caregivers, Perkins Eastman’s more than 20-year history of designing residences for people with dementia, and the Alzheimer’s Foundation of America’s expertise, the following is a summary of what Perkins Eastman and the Alzheimer’s Foundation of America consider best practices in design for care settings for people with Alzheimer’s disease.

1. Households People with Alzheimer’s disease can easily be overwhelmed, confused and/or distracted when faced with large groups or spaces.25 This applies to activity participation, meal times, and even residential living arrangements. Residents can often function better in quieter, smaller groups. In addition, these small-sized groupings support resident-centered care and personal relationships among the residents, their families, and professional caregivers — an important factor given that social support has long been known to affect an individual’s emotional and physical health and general well-being

Figure 19 : Cluster of rooms

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Create small-sized groups of people, forming clusters or “households” of 10 to 14 residents.

In addition to bedrooms, households should provide a shared, resident-accessed kitchen, dining area, and living room, plus secure outdoor space. Additional areas for residents within the household may include (but are not limited to) a spa/bathing room, small den and/or activity space.

Within the household, provide small group spaces with some visual and acoustic privacy.

These spaces can be used by residents who get easily overwhelmed by crowds and noise, a common symptom of Alzheimer’s disease that can result in behavioral issues and distractions. For instance, large, noisy dining spaces have been linked with an individual’s reduced food intake.

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Avoid multi-purpose rooms. Though the general concept of flexibility is important so the building can evolve over time, multi-purpose spaces are not recommended since a person with Alzheimer’s disease may not adapt to the room’s changes in use and expected social patterns. Instead, provide small group spaces that are distinctive, like in a home. There should be designated zones for pastimes such as casual conversation, dining, cooking, and watching television.

2. Residential Qualities A setting that has an institutional look and feel is not a “home.” The residential quality of the building is very important, inside and out. Building massing (i.e., the building’s volume and shape) and internal layout, hierarchies of space and circulation (i.e., hallways, stairways, elevators, lobbies), materials and furnishings, color palettes, inaudible alarm/alert systems, and even room names (e.g., a “living room” or “den” versus a “lounge”) can make a big difference.

Figure 20 : Residential look

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Exterior massing should be articulated (with distinct elements and walls that jog to create different planes, rather than a solid, monolithic façade) and at a scale that relates to a person (i.e., “human-scale”), with residential detailing and materials appropriate to the building’s locale.

Elements that make an interior environment residential (as opposed to hotel-like or hospital-like) should be incorporated, including: a residential color palette and materials (e.g., carpeting, wood, upholstered furniture); providing diversity (e.g., of furniture styles, types and styles of lighting, varied ceiling planes); soft as opposed to hard surfaces; and details (e.g., artwork and accessories, window treatments).

Interior layout and hierarchies of space and circulation should reflect conventional residential layouts.

As a person with Alzheimer’s disease progresses through the disease, more incontinence events are likely to occur.30 Accordingly, the flooring should be very easy to clean and maintain, while still promoting mobility and a homey appearance and texture. Available options to achieve these goals have improved greatly over the past 20 years.

There should be glare-free natural lighting, residential lighting fixtures and bulbs, and table/floor lamps in addition to overhead lighting. Not only will glare-free lighting serve to create a home-like and non-institutional feel, it will also reduce the likelihood that a person with Alzheimer’s disease will misperceive the environment (e.g., light shining off 27

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a wooden floor may be mistaken as water or a wet spot) and cause confusion or even injuries.

3. Wayfinding and Orientation Wayfinding consists of three key components: knowing where you are, how to get somewhere (having a “mental map”), and recognizing when you have arrived.31 The wayfinding system in any building can be an important aspect of resident and visitor comfort, especially for those who may feel insecure in their environment. For older adults who are not as agile, experiencing balance or gait issues, facing changes in visual acuity and depth perception, and/or who are dealing with a Figure 21 : Standing clock as landmark significant change in their lifestyle, and for people with Alzheimer’s disease who may also have more difficulty adjusting to a new environment than people without cognitive loss, it is particularly important to be able to find one’s way around a building as effortlessly as possible. If residents feel secure and know they will find their way back home, they may venture out of their residence more often, socialize with others, and be more physically active.

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Spaces should be distinct, both in appearance and overall layout. Repeating or mirroring floor plans can be confusing for some people, since they may perceive households as the same. Residents may be found in the “right” room, just in the wrong household wing.33 Getting lost is sometimes due to mistaking which household to go to, rather than which room to go to. The building layout should minimize wayfinding choices to reduce confusion and disorientation.

At each decision-making point, such as hallway junctions, there should be orienting landmarks to help with wayfinding. Since distinctive cues are more memorable than subtle changes (e.g., a change in finish color), landmarks should be unique and varied, such as recognizable objects, artwork, or a view to a specific outdoor feature.

Allow for personalization and/or provide distinctive landmarks at entrances to each household cluster. Providing these kinds of cues at household entrances can offer the same wayfinding benefits as the memory box at the bedroom door, especially when the building layout is repeated Identify things and spaces by names and numbers in addition to other kinds of cues, since research has shown that people with Alzheimer’s disease typically retain recognition of words and numbers longer than many other kinds of memory.

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[RECALLING THE MEMORIES] 4. Independence, Control, and Flexible Rhythms While cultural differences and personal preferences certainly exist, many people — regardless of whether or not they have Alzheimer’s disease — value autonomy and want to live life their own way, at their own pace.

A no institutional program based on small, informal groups and flexible schedules can allow this. The physical environment can help support this kind of philosophy of care. Someone with Alzheimer’s disease can opt to sleep in and get breakfast when he or she is ready to eat, or participate in an activity as desired.

“Because people with Alzheimer’s [disease] and related dementias often have trouble adapting to changes and transitions, settings should conform to their needs and preferences, rather than demand conformity.

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Figure 22 : Sitting spaces to interact

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Have food in the household’s kitchen available at all times. Healthy snacks should be accessible; a warming cart or warming drawer could make meals available during a wider range of times as well as facilitate a greater variety of dining choices.

The environment should offer sensory cues to encourage residents to eat, from sightlines into the kitchen to smelling food being prepared. Participatory meal prep and cooking programs can also be effective.

Important items and spaces for daily activities (e.g., toilets, food, towels, even access to the garden on a nice day) should be easily seen and located to promote use47 and reduce frustration due to memory loss. Provide visual cues to highly-used items and spaces.

Separate residents’ bedrooms from activity areas or other noisy spaces so people can nap without disruption.

5. Safety/Security There are two aspects of safety and security: actual and perceived. Not only is it important for residents to be safe and secure, but they must also feel that way. This can be a challenge since Alzheimer’s disease often produces anxieties and paranoia,50 which in turn affects someone’s health and well-being, sense of home and comfort level, ability to concentrate, participation in activities, etc. The physical environment, accordingly, needs to offer both actual and perceived safety and Figure 23 : open spaces

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security so that residents can feel confident and calm in their home.

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Staff should be able to unobtrusively monitor residents throughout the interior and exterior common spaces. However, this does not mean that the setting requires institutional hub-and-spoke building layouts with centralized nursing stations — quite the contrary. Instead, it suggests including features such as windows or wall openings between spaces for visual connections, minimized hallway distances, and areas that promote staff presence.

All water faucets should be installed with hot water mixing values, where the water temperature can be remotely fixed to prevent residents from scalding themselves.

Otherwise, a resident may burn him/herself, thinking that he or she turned on the cold water, not the hot water.

Sometimes residents need to be restricted from a certain space due to safety and/or sanitation issues. In these circumstances, a gate or sliding door can temporarily close off that area. For instance, when a meal is being prepared in the household’s kitchen, code and sanitary regulations may require the kitchen be blocked off to residents.

6. Entry and Egress Though residents with Alzheimer’s disease typically do not leave the building or sometimes even the wing they live in, many people feel the need to wander or sense that they are supposed to be somewhere, leading to agitation or elopement attempts.51 In addition, seeing people come and go, and not having that same freedom, may cause frustration or anxiety if the resident does not recognize the person approaching his or her home.52 Accordingly, entrances and exits need special consideration — from providing an appropriate level of safety/security to helping to prevent anxieties.

Figure 24 : Dead Ends

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Direct entrances toward staff and visitors, not residents (who may become agitated or frustrated by seeing people coming and going). The entrances should be welcoming, but screened from active resident areas. Views to the parking lot should be blocked, as well.

Disguise egress points, in order to minimize anxiety and decrease the chance of elopement. Entrances could be located in dimly-lit alcoves, deterring resident access.

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Doors should be off-axis (i.e., not the focal point at the end of a hallway); and could be painted and have trim that match the surrounding walls.

Secure emergency exit doors with an electric deadbolt that releases in case of a fire, allowing residents to exit to an enclosed garden or other secure area of safety.

7. Spa/Bathing Though there are many design guidelines for seniorfriendly bathrooms, there are several specific recommendations for a population with cognitive impairment. For someone with Alzheimer’s disease, the toileting and/or bathing experience has the potential to be stressful or overwhelming, and can be complex for caregivers to optimally manage. From helping to prevent falls and incontinence issues to helping to preserve dignity and assuage fears, spa/bathing spaces need special consideration.

Figure 25 : Bathroom

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In each bedroom, include an attached private bathroom, with a shower and enough space for an assisting staff person. Private bathrooms are much less institutional than shared or group bathrooms. A familiar and comfortable setting offers greater quality of life for both residents and professional caregivers. In addition, currently, assisted bathing typically only happens inside resident rooms. Separate tub rooms often go unused, though they are still sometimes required by code or made available to residents who prefer baths to showers.

Provide a direct visual connection from the bed to the toilet since a visual reminder may reduce incontinence and nighttime accidents.

Provide lockable storage cabinet(s) and/or drawer(s) for toiletries, razors and other items that residents should not have direct access to.

Bathing spaces — whether private bathrooms or shared spa/bathing rooms with therapy tubs — should be as calm and peaceful as possible to alleviate anxiety, since most people with Alzheimer’s disease have a fear of bathing and water.

Head off hoarding. Because symptoms of Alzheimer’s disease (e.g., paranoia, delusions, hallucinations) may prompt a person to hoard, a resident may try to hide items in unlikely places.58 Accordingly, shower and sink drain cover plates should be the screwed-type and difficult to remove. Also, toilets should be easy to unclog in case a resident flushes articles down the toilet (believing he/she is hiding or throwing items away).

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8. Secure Outdoor Spaces Providing unrestricted access to secure outdoor spaces — even for residents with elopement issues — is vital since it can reduce agitation and frustration, relieve stress, and improve physical fitness (from walking to exposure to sunlight that regulates mood, circadian rhythms, etc.). By giving residents a secure place to go outside, it can even help reduce elopement attempts since residents do not feel as cooped up.

Figure 26 : Outdoor sittings

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Give residents unrestricted access to a secure outdoor space, when appropriate.

Locate outdoor spaces in serene settings (e.g., not on a busy street) since “older people with dementia generally enjoy going out, but anxiety, disorientation or confusion can occur in complex, crowded or heavily-trafficked places or when startled by sudden loud noises.”

Construct walking paths that are continuous and loop back to building entrances. There should be “multiple cues that reduce demand on the user, [allowing] one to enjoy walking in a natural environment without the frustration of figuring out how to return.”

Ensure that all plantings are nontoxic and have no sharp edges or abrasive leaves, thorns, etc.

9. Active Engagement People of all ages and abilities need meaningful engagement. Purposeful activities and being able to practice remaining skills — from gardening to cooking, chatting to playing music — can promote feelings of selfworth and stave off depression and anxiety.66 People with Alzheimer’s disease, however, may need cues to initiate activity. They also need to be protected from distractions that could hinder engagement or that may become stressful and overwhelming.67 The goal is to create “stimulation but not stress.”68 By creating a physical environment that supports people’s abilities and enhances their remaining skills, residents can have a greater quality of life.

Figure 27 : Attached activity area

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To minimize overstimulation or distractions, control noise and provide options for various group sizes, including smaller groups for residents who need calmer surroundings.

Offer an assortment of designated activity spaces that can support different-sized groups, in order to accommodate residents’ varied interests, desired level of stimulation, and comfort levels.

Design the kitchen/dining area to include a large table and/or countertop where residents could sit to help prepare meals, participate in cooking programs, or interact with staff as they work in the kitchen. Staff may also use this space for charting, etc

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Chapter 6.

Case Studies 1. ALZHEIMER’S RESPITE CENTRE Project Statistics: Architect: Níall McLaughlin Architects Location: Dublin, Ireland Construction: 2006-2008 Internal floor area 1,392m2, 11 bedrooms

Figure 28 : Front View

Respite centers' are facilities that admit Alzheimer’s patients for day time care only, providing relief and support for their care-givers. This centre by Níall McLaughlin Architects was aimed to design a day facility that provided calm, logical spaces to reduce distraction, provide cues to orientation, and encourage mobility. Social interaction, a sense of community and a feeling of security or ‘home’ are also promoted through the design.

By incorporating elements of the collective memory that individuals from the Dublin area a sense of community, homeliness, calm and comfort is created, that each unique individual can connect to. When dealing with Alzheimer’s disease, the phenomena of wandering is an important design consideration. Locating the facility within an existing 18th Century historic walled garden provided an exterior boundary, which also feels familiar for the Irish residents.

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Patients have the ability to wander through the interior and exterior of the facility via halls and ramps. The interior walls and circulation are arranged in a pinwheel fashion to allow for a continuous wandering movement to occur.

Figure 29 : Interiors

Elements of the vernacular architecture and traditions of Dublin, Ireland are represented in the architectural materiality, forms, and interior features of the building. For example the facility is centered around a large fireplace which is common to the traditional homes of Ireland. “The kitchen was the central hub of the house as it was here that the cooking, washing, dining and general entertaining of neighbours took place. A big open fireplace provided heat and light and was the focal point in the kitchen.” Traditional furnishing such as the ‘Irish Dresser’ are also incorporated into the interior.

Figure 30 : Interiors

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[RECALLING THE MEMORIES] Individual rooms are provided for patients to rest during the day allowing for private spaces when needed. The ceilings are high with large windows allowing daylights to flood into the rooms. As a method of way-finding the architect used bright colors in different areas of the facility, in hopes of triggering the patients memory to a certain spaces. The hallways are oriented to allow for wandering with varying colors and textures while providing diagonal views to help with orientation. By locating the kitchen as the central element the architect provides orientation via the sense of smell by leading individuals back to a familiar place.

The alzheimer's Respite Centre by Nial Mclaughin showcases the success that design tailored to a specific group of individuals utilizing the human senses can achieve. Not only is the building aesthetically pleasing, but its design aims to help individuals through engagement, movement, orientation and memory.

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Figure 31 : Plan and elevation

2.DEMENTIA VILLAGE ‘DE HOGEWEYK’ Architect: Molenaar&Bol&VanDillen architekten, Vught (MBVDA) Location: Weesp, Netherlands Completion: 2009 Gross Floor Space: 12,000m2 23 apartments, max. 2 storey height (one double room, seven single rooms each) 152 senior citizens currently living

Figure 32 : View from the bridge

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The layout of the plan is confined by a defined perimeter plot. Programmatically the facility consists of 23 different grouped bungalow style residences. Each bungalow houses six to eight residents, grouped by means of common interests according to their personal philosophy, values and living standards to determine where their best fit in the facility may be. There are seven styles of living offered by the facility; urban, artisan, Indonesian, homey, cultural and Christian.

These lifestyles are achieved through the decor, layout, interaction of the group, interactions with the staff members and type of day to day activities. Each house has permanent staff members and the residents are allowed to move freely throughout the facility as they would in a normal home.

The ‘normal’ elements which have been incorporated into the village style plan are a theatre, grocery store, hair salon and restaurant. All of the staff for these facilities are trained to deal with people who have dementia. If a resident for example were to carry out their groceries containing a nonsensical or unnecessary purchase, the staff member will discretely take it back. There is no currency required in any of the facilities for the residents, but the activities resemble normal life as best as possible.

Figure 33 : Plan

The 23 homes became the building blocks on the site give shape to the courtyards and promenades. These exterior elements are all unique and provide stimulating environments that the residents are free to use. Wandering paths allow residents to discover unique and engaging destinations without confronting the confusion of any dead-ends. Each one of the unique outdoor spaces has a different function, including a theatre, boulevard shops and a centre for physical therapy each designed with the goal of stimulating well-being in the residents. Hogeweyks state “Green means relaxation, experiencing the seasons and good health.”57 All of the elements were designed with the residents collective memory in mind to create a recognizable atmosphere.

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Dementia Village by MBVDA is invested in the lives of the individuals who reside in the facility, by creating an atmosphere for residents lives to remain as normal as possible and provides the possibility of an enhanced quality of life. This facility is an example of how designed spaces and care programs for individuals can be achieved through sympathetic, sensorially engaging architecture, which incorporates the idea of collective memory.

Figure 34 : Open spaces and shop

Figure 35 : Activity area and outdoor sitting

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Conclusion The purpose behind this study was to highlight this problem in India, which is still incurable by medications. hence being an architecture student, it was an initiative towards alzheimer's to improve the lifestyle of the people suffering from this disease.

Architecture itself has the ability to affect the physical and emotional well-being of the person, not as quickly but effectively in a long run. Whereas using the scientific therapy and infusing it with architecture while keeping in mind the standards and the problems during alzheimer's.

Creating the spaces that triggers the mind by stimulating the senses, would itself will be an healing process. Thought was to understand the psychological reaction by Jon Lang model, on the basis of which senses has been explained in terms of healing and stimulation through them has been discussed in design considerations.

Bibliography https://mayfieldclinic.com/pe-anatbrain.htm https://www.livescience.com/37009-human-body.html https://www.nia.nih.gov/health/what-dementia-symptoms-types-and-diagnosis https://www.designindaba.com/articles/creative-work/designing-spaces-peoples-mental-healthmind https://www.samvednacare.com/blog/2018/01/22/10-tips-for-anger-management-in-dementia/ https://www.alz.org/alzheimers-dementia/what-is-alzheimers https://www.medicalnewstoday.com/articles/324749.php#1 http://www.niallmclaughlin.com/our-projects/ https://archive.org/details/thisisyourbraino00levi/page/n5 https://issuu.com/bartlettarchucl/docs/mclaughlin_02_alzheimers_s07_update http://www.perkinseastman.com/dynamic/document/week/asset/download/3421211/3421211.pdf https://academic.oup.com/gerontologist/article-pdf/40/4/397/19444428/397.pdf https://www.alz.org/media/Documents/design-environ-for-alzheimers-rl-2019.pdf https://www.researchgate.net/publication/51000566_Wayfinding_for_People_With_Dementia_A _Review_of_the_Role_of_Architectural_Design http://mingaonline.uach.cl/pdf/aus/n9/art02.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3549347/ https://www.medicalnewstoday.com/articles/324749.php https://www.goodtherapy.org/learn-about-therapy/types/music-therapy

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Notes :

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