Final Documentation
Allison Kelly ARCH 600 Evidence Based-Design for Healthcare
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
AIA Academy of Architecture for Health | Research Initatives Committee
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Literature Review
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
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Introduction -- In-patient geriatric behavioral health facilities specifically for dementia are more complex -- Dementia patients need copious amounts of attention and supervision as they lose cognitive ability and sense of orientation -- How can we create spaces that allow people living with dementia to feel comfortable, and successfully navigate the world around them?
What is Dementia? -- Dementia is an umbrella term that covers a broad range of certain medical conditions. For example, Alzheimer's disease is the most common type of dementia. -- Patients with dementia have difficulty with their day-to-day memory, concentration, organization, and even the completion of a sequence of tasks. -- Dementia affects the ability to understand language, for example, carrying out a conversation or finding the right words. Patients struggle with orientation regarding what time of day it is, or where they are. They may also experience hallucinations.
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
Sense of Place -- In a literature review conducted by JM Torrington and PR Tregenza (2006), it discusses that it is hard for a patient with dementia to recognize their place. --Sufferers "retain personality and awareness of a long life, and intelligence persists, but with increasing severity of the disease, there is a loss of ability to recall recent events." -- They may have memories of the past, but are only aware of their present, causing feelings of confusion. -- "Place" is somewhere that people can recognize their surroundings and expect people to act a certain way; therefore, they behave a certain way. -- It is easy for dementia patients to lose their sense of place in a nursing home because there may be a residential feel, but the materiality, smell, or size of a room is different than that. -- In a study conducted by Wilkes L, Fleming A, Wilkes BL, et al (2005), they said that when patients were in a facility that was furnished with residential pieces from their "eras of design" resulted in less agitated, anxious behavior. They also seemed to wander less, which could lead to less confusion if they are in a facility with turns in the corridors.
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Layout
Outdoor Environments
-- In a study done by Marquardt and Schmieg (2009), they analyzed data on how easily people could navigate different facility layouts. -- When observing patients navigate, I shaped, L shaped, H shaped, and continuous paths around an inside courtyard, it was clear that patients with mild dementia had little trouble navigating the overall space. -- People with moderate and severe dementia showed pronounced disorientation issues when navigating spaces were anything but I-shaped units. -- Proximity of dining, living, and activity areas -- More people per square unit
--In an article within the Journal of Housing for the Elderly Clare Cooper Marcus (2007), an Alzheimer's Garden Audit Tool was made available based on other studies done. The Audit tool discusses beneficial ways of design to create supportive spaces for dementia residents.
Dining Area -- The design of dining areas tremendously affects the patients' irritability, anxiety, interaction, and nutritional intake. -- Family style vs Pre-plate -- Kitchenettes, and the idea of independence 7
AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
-- Visibility of the door -- Hardware -- Thresholds -- Continuous paths, no hard cornered intersections -- Supervision from nurses station -- Patios -- Shadows -- Landmarks -- Level paths -- Railings -- Curbs -- Wide paths -- Tinted concrete -- 70:30 greenery vs hard surfaces -- Different experiences, quick transitions of sensory features
Materiality
Lighting
-- Home like materials and textures
-- Dementia patients experience the world on a "sensory level" and react emotionally.
-- Durability, cleanliness, reflectiveness, finish, replaceable -- Colors
-- Windows, views, light and dark cycles, seasons, weather, and human activity help them to feel connected to society.
-- Landmarks
-- Restlessness
-- In a study done by Passini and colleagues (2000), they found that when way finding a facility, residents did not rely on color-coded floors to locate their floors or room. Instead, they relied on furniture, numbers, names, and women even utilized photographs of them from a younger age.
-- Avoid isolation -- Observe for longer periods -- Decrease wandering -- Increase socialization
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Discussion -- There seemed to be a difference in the limitation of design based on if a patient had mild or severe dementia. -- It was consistent in multiple studies that dementia patients did better in smaller, more intimate communities. -- Residents per square foot -- What creates a feeling of community? -- Layouts, connectivity with nature -- Connectivity to society -- Home-like sense of place
Implications for Future Research --This review would be better complete if there were more information on what stimulates the brain of dementia patients. --However, we also know that certain things can be overstimulating, such as the reflectivity of certain materials. This information would be beneficial when picking out finishes or know what art to hang up. It would also be useful if there were a study done that separated the findings based on the type of dementia, or severity of disease.
Conclusion -- The design of a building affects how they feel, as well as how social they are. -- Being aware that patients greatly struggle with their orientation is key to beginning a design, and every detail down to the finishes could mean all the difference for how a resident experiences the world.
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
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Best Practice Case Study
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
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Alzheimer residence for the ‘Foyer la Grange’ Coueron, France
SQ FT 9, 762
OWNER/AFFILIATION Harmony Habitat
ARCHITECT(S) Mabire Reich
INSERT CAPTION
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
Image Sources: ARCH Daily
COMPLETION DATE January 2014
Alzheimer residence for the ‘Foyer la Grange’ Coueron, France
NORTH
Site Location
ABOUT | DESIGN INTENTIONS This design intends to create a homelike environment that will allow residents with dementia to feel better orientated. One of the most challenging symptoms of dementia is disorientation, so by including specific
Campus Plan
landmarks, patterns, colors, ect., we can try to minimize feelings of confusion. The addition known as 'Foyer la Grange' is unique in the fact that it strives to promote panoramic views. Dementia patients enjoy feeling connected
to the outside world and making sure there is an abundance of views to observe makes them feel as if they are apart of society. This facility intends to not feel like a facility at all, but a home.
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Alzheimer residence for the ‘Foyer la Grange’ Coueron, France Design Goals SAFETY HOME LIKE ENVIRONMENT SENSORY STIMULATION
Key Spaces The key spaces in the resident's specific living areas are the gathering spaces, terraces, private rooms, and circulation located in the extension on the south side of the building. The gathering space is lit up by both north and southeast-facing windows. The north windows have views of the garden, and the south window has views of city, water, and Eglise-Saint Symphorien. These views allow residents to feel connected to the world around them. They may venture out onto the terraces if they so wish. The circulation is an essential part of this design. Dementia patients tend to wander, so a critical element of the design was to keep a core with texture and curved edges. This feature helps residents when they feel disorientated, and makes decision making a tad less confusing. The patient's private rooms are analyzed on the next page.
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KEY SPACES : Medical Support Administrative Space Service Resident Room Gathering Terrace Circulation
Image Sources: ARCH Daily
AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
Alzheimer residence for the ‘Foyer la Grange’ Coueron, France
GROUND LEVEL:
RESIDENT ROOMS: 13 ROOM DESIGN The rooms are arranged so that a pair of bathrooms could fit in between the two bedrooms utilizing those spaces. This allows for no protruding walls, indents in the walls, or small alcoves in the room. All of these instances can confuse a resident with dementia. This system also allows for natural light in half of the bathrooms. The false concrete ceilings carry out the language used throughout the rest of the building, while also contributing to thermal comfort. AIA Academy of Architecture for Health | Research Initatives Committee
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Alzheimer residence for the ‘Foyer la Grange’ Coueron, France
Design Strategies
Non-Institutional Characteristics In many studies, it is clear that homelike environments help residents with dementia feel more comfortable than traditional "nursing home furniture." Furniture from their era leads to more socialization, less agitated behavior, and less wandering. The difference in furnishings has been proven to make residents feel more at ease. Foyer la Grange does an average job at this, as the furniture in the living spaces is not extremely modern.
Independence Independent spaces can be achieved by providing independent activity spaces, for example, introducing kitchenettes in dining spaces. Small kitchens allow for a certain level of responsibility that is not too much, yet allows the residents to feel as if they are back at home.
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
Alzheimer residence for the ‘Foyer la Grange’ Coueron, France
Views Views allow for a connection to the outside world, and an abundance of sunlight. The residents have views of the city, water, landmarks, and a garden. All of the private rooms also have views out to one of these different sights. The variation in scenery helps to stimulate the residents, and increase their mood.
Wayfinding Different colors and patterns allow for residents to orientate themselves. The core rooms in the resident's living space are all support spaces, but it uses a special material and soft corners to be very distinguishable. The use of contrasting colors also helps residents in wayfinding. The two very different views also allows for residents to better understand where they are in the facility.
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Operational Modeling
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
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Operational Modeling & Data-Driven Programming Johnson County, Kansas
Demographics Total Population: ~600,000 Population by Age Range Population by Age Category
13%
14%
12%
14%
14%
13%
11% 6%
0-9
Sex
1019
2029
3039
4049
5059
6069
7079
0%
0%
3%
8%
3% 80+
Race and Ethnicity 80%
White
4%
0%
5%
Black
Native
Asian
Islander Other Two+ Hispanic
Johnson County is located in the northeast corner of Kansas and has a population of 591,178. Johnson County is ranked number one in the state when it comes to length of life, and resident health. There is a need for mental health facilities specifically regarding serious mental illness (SMI), any mental illness (AMI), or suicidal thoughts and having a major depressive episode. In regards to dementia, there are many highly rated in-patient facilities in the area.
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
Background According to the 2015 community health assessment survey, in Kansas, the age-adjusted suicide rate is 13.2% and 15.7% of adults are diagnosed with depressive disorder. The supply of available mental health resources can be measured by the number of mental health facilities, beds, the measure of waiting lists, and the supply of mental health providers. According to the ‘Directory of Mental Health Resources, 2017,’ in Johnson County, there are three psychiatric residential treatment facilities, one community mental health center, one consumerrun organization, and two residential care facilities. The table shows the overall mental health care facilities in Johnson County. According to ‘County health rankings and roadmaps’, the ratio of Johnson county residents to mental health care facilities is 450:1. Thirty percent of Johnson County is designated as a Mental Health Professional Shortage Area (HPSA). This designation is used to identify the area experiencing a shortage of mental health professionals. This designator only takes into account the psychiatrists but does not include psychologists, clinical social workers, psychiatric nurse specialists, and marriage family therapists.
Facility Type
Description
Availability
Services
Severity
Psychiatric
Provide out-of-home
Nurses, counselors,
• Strengths-based;
Low
Residential
residential psychiatric
psychologists, and psychiatrists.
• Culturally competent;
Medium
Treatment Facility
treatment to children and
• Trauma-informed; and
High
adolescents.
• Medically appropriate
Residential Care
Provide housing and
Staff available 24- hours in this
• No treatment services provided
Facilities
support to persons with
long term assisted living facility.
for mental health conditions.
mental illness who need
Primarily nonclinical staff to
• Patients receive treatment
housing and/or support to
assist with daily tasks.
through CMHCs or other
live in community.
Low
outpatient options.
Community Mental
Provides community-based
Nurses, social workers,
• Outpatient services for adults;
Low
Health Centers
public mental health
mental health professionals,
• Outpatient services for children;
Medium
services.
psychiatrists and medical
• Behavioral health screening for
High
doctors— 24-hour out-patient
patients;
support.
• Must accept all patients.
Community Crisis
Provides short-term
Nurses, addiction counselors,
• 24-hour assessment and triage;
Low
Centers
stabilization for people in
peer support, recovery
• Crisis observation;
Medium
mental health crisis.
coaches, triage specialists.
• Short-term crisis stabilization;
High
Outpatient and Inpatient
• Sobering bed.
stabilization (up to three days).
Other Mental Health Resources in Johnson Coutny A lack of mental health care facilities could lead to higher rates of depression and anxiety in the geriatric age group. Considering their age, they may have not gotten the help they needed when they were children, or adults because of pricing, societal pressures, or the lack of facilities. Including safe, and supportive spaces for those with dementia is crucial to their well being.
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Operational Modeling & Data-Driven Programming Johnson County, Kansas
Administration
Results of Simulation
Patient Care Unit Support
Staff Area
Patient Area
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
Staff Area 15.1%
Administration 8.2%
Patient Care Unit Support 15.4%
Patient Area 61.3%
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Operational modeling and data-driven programming Johnson County, Kansas
Space Program
No.
Space (NSF)
Total Square Footage
Reception Area/ Administration Waiting
1
160
160
Conference Room
2
240
480
Toilet, Public
2
120
240
Office, Admin
3
120
360
Training Room
1
300
300 1540
Patient Area 25
200
Patient Room, 2 Beds
4
300
1200
Patient Toilet/Shower
Patient Room, 1 Bed
29
70
2030
5000
Isolation Patient Room
1
200
200
Bathroom, Isolation/Seclusion
1
70
70
Patient Shower
2
70
140
Patient Toilet
2
60
120
Exam Room
2
100
200
Consult Room
2
100
200
Dining Room
1
450
450
Living Room
1
500
500
Multipurpose Room/Activity Room
1
500
500
Therapy Room
1
400
400
Patient Storage
1
500
Quiet Room
2
200
500 200 11510
Patient Care Unit Support Kitchen
1
400
400
Utility Room, Clean
1
300
300
Laundry Room
1
300
300
Medication Room
1
150
150
Storage, Equipment
1
200
200
Storage, Medical
1
150
150
Storage, Facilities
1
300
300
Trash Room
1
100
100
IT Room
1
200
200
Additional Storage
3
400
400
Storage, Kitchen
1
200
200
Housekeeping Room
1
200
200 2900
Staff Area Office, Head Nurse
1
120
120
Workstation, Ward Clerk
1
80
80
Nurse Station
2
150
300
Nurse Workroom
1
150
150
Dictation Area
1
100
100
Office, Physician
2
120
240
Workstation, Physician Assistant
1
80
80
Office, Psychologist
1
120
120
Office, Social Worker
1
120
120
1
120
Office, Dietician
120
Workstation, Nursing Supervisor
1
80
80
Additional Workstations
5
80
400
Conference Room
2
200
400
Staff Lounge
1
200
200
Staff Locker Room
1
200
200
Staff Bathroom
2
60
120 2830
25
Total Square Footage
AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
18780
Analyzing Results
When using the simulation tool, we input this information below: Selected state: Kansas Selected year: 2025 Total Population in catchment area: 100,000 Market access: 20% Population to be served by the facility: 20,000 Age group to be served by the facility: 65-110 years Genders: all genders included Veterans only: false Optimum utilization for the services: 85% Operational days in a year at the facility: 365 Selected service lines: Mental Health This resulted in an estimation of 25 single bedrooms, and 4 double rooms. This also called for 15 staff during the day. This includes 2 doctors, 3 registered nurses, and 20 other support staffers. Since we are programming a dementia care unit, it seems fair to assume there would be other admin support staff, facilities, housekeeping, kitchen, and activities employees. It’s uncertain if the staff requirement included CNAs, social workers, psychologists, dieticians, etc.
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Post Occupancy Research Proposal
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
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Abstract
-- The medical industry has made undeniable progress within the past century, through these advancements new discoveries have helped modify the way patients are taken care of. -- Through observation of patients in three different dementia units over the span of a year, the goal is to draw correlations between the architectural elements of the environment within the units and the behaviors of its inhabitants. -- These correlations could offer meaningful insight into how the needs of those afflicted with dementia could be more sufficiently met in future designs, and provide insight into potential modifications of preexisting designs. -- There is a host of evidence behind the impacts architecture can have on health and mental well being.
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
Background
--The motivation of this research is to determine how we can give dementia patients a better quality of life, specifically in special care units. --It’s important to strive for better care for people who deserve it, and better working conditions for the staff. --Evidence-Based Design has shown a positive correlation in patient and staff satisfaction.
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Research Questions
The purpose of this study is to determine what architectural features help keep geriatric dementia patients calm for extended periods of time. How can design decrease wandering? What elements lessen feelings of agitation and confusion? What is considered positive visual simulation when it comes to art, color, textures, or patterns? What affects do these positive stimulations have on people with dementia? How does it effect patients internally and externally? Do certain elements slow the progression of dementia?
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
Research Methods
What are they reacting to? -- Mixed Method
-- How do they react to the layout?
-- Behavior mapping
-- How well do they navigate?
-- 24 people per unit is ideal, with 3 different sites, that's 72 people, assuming they all units are full
-- How does light effect them? Darkness? Shadows?
-- 3 sets of data, but this data will then be combined to create a collective analysis
-- How does the sense of place impact their mood? -- How does the feel/ materiality of the facility make them feel?
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Research Methods How are they reacting? Positive Behaviors
Negative Behavior
--Intergroup Pro-sociality
--Outward Agitation
Talking to others Engaged
--Positive Verbal Expression
--Negative Verbal Expression
Expressing positive feelings Positive commenting
--Positive Non Verbal Expression
Facial Expressions (smile, calm, laughing) Observant and engaged
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
Negative non verbal expression Self injurious behavior Self Infliction Not eating
--Disorientation
No Behavior
Yelling Physically Violent
Confusion Quiet Dissociation Isolation Wandering Means of escape
Expected Outcomes
--The expected outcome is that dementia patients within a positive stimulatory environment will exhibit a slower acceleration of symptoms such as agitation, disorientation, and confusion. --It is expected that a poor overall layout, little connection to society, less lighting, and commercial like materials will decrease the welfare of the patients with dementia.
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Limitations
--Confusion and disorientation of the participants --Possible new environments --Severity and acceleration of dementia varies from person to person --Patient privacy
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AIA Academy of Architecture for Health | Research Initatives Committee Allison Kelly
Timeline Literature Review 2 weeks
Data Collection 1 year
Site visits: 2 hours per site x 3 sites = 6 hours a week
Data Organization 1-1.5 years
Data Analysis 6 months
Write Up 6 months
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Bibliography Ball, S., Bluteau, P., Clouder, L., Adefila, A., & Graham, S. (2015). myShoes: An Immersive Simulation of Dementia. ICEL2015-10th International Conference on e-Learning: ICEL 2015. Retrieved from https://books.google. com/books?hl=en&lr=&id=ZfNrCwAAQBAJ&oi=fnd&pg=PA16&dq=myShoes: An Immersive Simulation of Dementia&ots=DGHno9N8n8&sig=SOjRAd7OjQ4D3YckOV_woiLmLjA#v=onepage&q=myShoes: An Immersive Simulation of Dementia&f=false Clare Cooper Marcus (2007) Alzheimer's Garden Audit Tool, Journal of Housing For the Elderly, 21:1-2, 179-191, DOI: 10.1300/J081v21n01_09 Doris L. Milke, Charles H. M. Beck, Stefani Danes & James Leask (2009) Behavioral Mapping of Residents’ Activity in Five Residential Style Care Centers for Elderly Persons Diagnosed with Dementia: Small Differences in Sites Can Affect Behaviors, Journal of Housing For the Elderly, 23:4, 335-367, DOI: 10.1080/02763890903327135 Habib Chaudhury, Heather A Cooke, Heather Cowie, Leila Razaghi, The Influence of the Physical Environment on Residents With Dementia in Long-Term Care Settings: A Review of the Empirical Literature, The Gerontologist, Volume 58, Issue 5, October 2018, Pages e325–e337, https://doi.org/10.1093/geront/gnw259 Home. (n.d.). Retrieved from https://alz.org/. Marquardt, G., & Schmieg, P. (2009). Dementia-friendly architecture: Environments that facilitate wayfinding in nursing homes. American Journal of Alzheimer's Disease and other Dementias, 24(4), 333-340. https://doi. org/10.1177/1533317509334959
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Nijs, K. A. N. D., Graaf, C. D., Kok, F. J., & Staveren, W. A. V. (2006). Effect of family style mealtimes on quality of life, physical performance, and body weight of nursing home residents: cluster randomised controlled trial. Bmj, 332(7551), 1180–1184. doi: 10.1136/bmj.38825.401181.7c Passini, R., Pigot, H., Rainville, C., & Tétreault, M.-H. (2000). Wayfinding in a Nursing Home for Advanced Dementia of the Alzheimer’s Type. Environment and Behavior, 32(5), 684–710. doi: 10.1177/00139160021972748 Torrington, J., & Tregenza, P. (2007). Lighting for people with dementia. Lighting Research & Technology, 39(1), 8197. Wijk, H., Berg, S., Sivik, L., & Steen, B. (1999). Colour discrimination, colour naming and colour preferences among individuals with Alzheimers disease. International Journal of Geriatric Psychiatry, 14(12), 1000–1005. doi: 10.1002/ (sici)1099-1166(199912)14:12<1000::aid-gps46>3.3.co;2-5 Wilkes L.Fleming A.Wilkes B. L.Cioffi J., & Le Miere J. (2005). Environmental approach to reducing agitation in older persons with dementia in a nursing home. Australasian Journal on Ageing , 24, 141–145. Zadelhoff, E. V., Verbeek, H., Widdershoven, G., Rossum, E. V., & Abma, T. (2011). Good care in group home living for people with dementia. Experiences of residents, family and nursing staff. Journal of Clinical Nursing, 20(17-18), 2490–2500. doi: 10.1111/j.1365-2702.2011.03759.x
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