De Gamles By - An outdoor environment for elderly and people with dementia

De Gamles By An outdoor environment for elderly and people with dementia

Health Design 2015-2016 STUDENT: C.F. Malekakis [rcx893] TEACHERS: V.L. Lygum, U.K. Stigsdotter

Abstract

N

owadays, the pace of population aging is much faster than in the past, with projections showing an increase of the world’s population over 60 years from 12% to 22% in the period 2015-2050 (WHO 2015). While this demographic shift poses challenges, longevity also provides potential opportunities with their extent heavily depending on one factor: health (WHO 2015). The objective of this project is to propose a design solution that incorporates health promoting qualities using the Evidence-Based Design (EBD) process. The site regards the outdoor environment of a Copenhagen’s neighborhood, where care centers for elderly and people with dementias are accommodated.

Contents Introduction

Site Target Group Design

01. PROJECT AIM

1.

02. METHODS

3.

03. METHODOLOGY

4.

04. THEORIES

5.

05. LOCATION

7.

06. CONTEXT

8.

07. ANALYSIS

9.

08. DEFINITIONS

11.

09. BENEFITS

13.

10. GUIDELINES

14.

11. DIAGRAMMATIC SITE PROGRAM

15.

12. DESIGN SOLUTION

17.

14. REFLECTIONS & CONLUSION

19.

15. REFERENCE LIST

20.

Introduction Project aim

T

he current project presents the redesign process of the outdoor environment of Kastanjehusene care center for elderly (buildings A, B, C, and D) and Klarahus care center for people with dementias (building F). The design aims to incorporate health promoting qualities to the site located in the “De Gamles By” neighborhood in the NorthWest region of Copenhagen city, Norrebro.

C

F

B a

D

Oblique imagery of “De Gamles By” neighborhood, Copenhagen NV, Denmark.

1.

Designer: Baker Barrios. Photo: Clare Cooper Marcus.

Garden at a residential memory care facility. The Serenades by Sonata, Longwood, Florida.

Gardens in healthcare facilities are landscapes designed for a specific population; in this case seniors and people with dementia, and therefore should establish an age-friendly environment.

Moreover, they often have a specific purpose, for example encouraging seniors to get outside for exercise, sunlight and fresh air. These environments in order to be effective in their aim and avoid adverse effects, should be designed using evidence-based health design (EBHD).

The health promoting qualities are related to physical, mental and social health of the residents, also known as the salutogenic health perspective (Antonovsky 1996, Bengtsson and Grahn 2014), in order to approach an improved holistic state of well-being. This is important because, apart from the physical health which is known to decline in a person’s later life, mental health and emotional well-being are as important in older age as at any other time of life (WHO 2015). Additionally, psychological health is associated with promoting social interaction skills (Marcus & Sachs 2014).

While the design concerns an institutional setting, the outdoor environment must be accessible both to the residents and the public. However, it is important to mention that strong focus has been given on the benefits of the care centers residents and less on benefits for staff and visitors.

2.

Methods “Evidence-Based Design (EBD) is the process of basing decisions about the built environment on credible research to achieve the best possible outcomes.”

The Center for Health Design

Identification of health benefits we are aiming at.

How will we design?

Evidence to back up the proposal.

Target group attributes and characteristics

Programming EBHD

Aesthetic and practical landcape architectural skills

Best research/ practice evidence

Design

Evaluation

The Evidence-Based Health Design process. In this case, the evaluation process is not applicable.

Nowadays, awareness about how good or bad design may influence people’s well-being is increasing among the architectural and decorative design disciplines of both indoor and outdoor spaces (Stigsdotter & Grahn 2002). By following the process of EBHD we can ensure that the design will conclude to a landscape where the experiences and activities in the environment are in harmony with the user’s background and health condition, and will therefore promote an overall sense of well-being. Such an instorative environment strengthens a person’s identity and self-esteem and makes him feel part of a meaningful context (Stigsdotter & Grahn 2002). Specifically, considering the most challenging section of our target group, most progressive dementias, including Alzheimer’s disease, are irreversible (Alzheimer Association), and central to the ethics of dementia care is enhancing well-being and making the most of the strengths that are still present within a person (Schwarz & Rodiek 2007).

3.

Methodology This report constitutes an in-depth investigation of an outdoor environment design case study, where extensive data collection and in-depth knowledge of the study group has to precede the design process (Quan 2009).

Since the topic is of high complexity, the appropriate methods have been used to gain insight.

Documents

Observations

Literature research conducted on keyword and theme based search regarding: the theories associated with the value of nature for human health and well-being, and our specific target group characteristics and needs.

Casual observations of space usage during the programmed site visits.

Registration and analysis of sensory stimuli.

Drawings

Site analysis: context, climatic conditions, topography, shadow study.

Identification of relevant theories and conceptual drawings.

Interviews with staff members

Qualitative approach - Structured interview. (personal perspectives, experiences and interactions).

4.

Theories The following theories have been selected by a literature review as a tool for assessing the value of nature to human health and well-being, and comprehend the healing influence deriving from a supportive garden.

The Biophilia hypothesis: Kellert and Wilson 1995 The biophilia hypothesis suggests the existence of an inherent human inclination to affiliate with nature. Nowadays, in the modern world, this bond continues to be critical to people’s physical, mental health and well-being. The benefits of contact with nature often depend on repeated experience, because this biological tendency needs to be nurtured and developed in order to become functional.

Aesthetic-Affective theory: Ulrich 1984 R. Ulrich in Aesthetics and Affective Response to Natural Environments (1983) suggests that the initial response to an environment is a generalised affect, a biological reaction which can be independent of and primary to cognition. When a man is in a natural or garden environment and his affections judge it as safe, his positive feelings increase.

Attention-Restoration theory: Kaplan and Kaplan 1989 Nowadays, in our world which is overflowing with information, people increasingly experience mental fatigue. ART argues that people can enhance their concentration ability after spending time in nature. This is possible through “soft fascinations”, which are plentiful in the natural environment where a person can reflect upon in “effortless attention”.

5.

Painting by: Elaine Plesser

While the belief in the therapeutic benefits of nature contact may be noted in the ancient times, the first well controlled empirical test of this hypothesis was first published in 1984 by Roger Ulrich using existing data from a hospital setting. The study reported that patients recovering from surgery who had a window view of a natural environment (trees) required shorter postoperative hospital stays, gave fewer negative evaluative comments to the nurses, and consumed less potent analgesics than patients who had a view to a brick wall.

Kaplan, Kaplan and Ryan in With People in Mind (1998) support these findings.

They suggest that seeing through a window can help one imaging being away from the environment that is causing him to be mentally fatigued and help him relax.

6.

Site

Location Denmark

Nørrebro

7.

Copenhagen

Context De Gamles By, has traditionally been an area designated for health care; established in 1919 with the merging of the hospital and retirement housing of Copenhagen Municipality. Nowadays, the area has mixed functions, consisting of a church, health care and children institutions, residential areas, and a number of administrative and technical functions.

Until recently, the area was totally enclosed, but today it is accessible through various entrances.

The neighborhood is being used both by the De Gamles By residents as well as by the surrounding residents of Norrebro district.

8.

U ses

&F unct i o ns S WO ec o lo g T y& S S ens had C l i mate ow ory st i s mulat ion

Analysis

The site analysis is an integral part of any landscape architecture study, and therefore should be included in this study aswell.

Current state fences minibus stop

landmark

bikesheds & other storage units paved groun dcover lawn ground cover parking main vehicu lar pedestian ci rculation

screening former dem entia deck

Identified rooms: open

9.

spread

glade

circulation

Helpful

Harmful

Internal

SWOT External

Sensory Stimulation Models Wind rose

A

A-B

Graphs by: meteoblue.com

Maximum temperatures

B-C

D Cloudy, sunny, and precipitation days

E-F

Nørrebro’s climate conditions

10.

Target group

By Henry Dreyfuss Associates. MIT Press, 1974.

The site accommodates a range of users that consist of the residents of Kastanjehusene care center for elderly and Klarahus care center for people with dementias, in addition to their family members, the staff members as well as visitors from around Copenhagen which are all are all welcome to use the space, as it is public.

Residents Age ranges from 56 to 102 Keeping in mind that the needs and abilities of people change as they age, it is also important to consider that the abilities of individuals in the same age group are substantially diverse (CEN/ CENELEC 2014). Therefore it is important to recognize the functional and cognitive limitations range from comparatively low impairment to more extreme forms (CEN/CENELEC 2014) and also consider that a person might experience multiple disabilities.

Wheelchair users. Handicapped and Elderly.

Accordingly, the design considerations about the various impairments in sensory (vision, hearing, touch, taste/smell and balance), physical (dexterity, movement, manipulation, voice, strength and endurance) and cognitive abilities (intellect, memory, and language/literacy) (CEN/CENELEC 2014) should be incorporated in the design proposal.

To ensure that the space can be used by as many people as possible without the need for adaptation and is thus accessible, the whole design process incorporates the philosophy of “Universal Design” or else known “design for all” (DfA).

Mixed ability of self-control 11.

“Outdoor design must provide for more restricting disabilities yet offer a range of opportunities” (Marcus & Sachs 2014)

by: Cerise Douc ture ède Pic

Defining... ...aging

A

ging is a biological process; the result from the impact of molecular and cellular damage accumulated over time, which results to a decline in physical and mental capacity, an increasing risk of disease (WHO 2015).

Common health issues associated with aging include (WHO 2015): hearing loss, cataracts and refractive errors, back and neck pain and osteoarthritis, chronic obstructive pulmonary disease, diabetes, depression, and dementia. Some people even suffer from several of these issues. Moreover, there are observations of loss of muscle weight, bone density and decrease in balance abilities. Difficulty of sleeping is also a common issue that in some cases can lead to depression. Finally, older people have lower rehabilitee- and adaptation capability that makes them more susceptible.

...dementia

D

ementia: is an overall term that describes a range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person’s ability to perform everyday activities. Alzheimer’s disease is the most common type of dementia, while Vascular dementia, which occurs after a stroke, is the second most common. The formerly widespread belief that serious mental decline is a normal part of aging has been proved incorrect (Alzheimer Association).

Memory loss and other symptoms of dementia (Alzheimer Association): Impairments in memory (short-term), communication and language, ability to focus and pay attention, reasoning and judgment, and visual perception are core mental functions that are associated with dementia. While symptoms of dementia may vary greatly, in order to consider a person suffering from dementia at least two of the aforementioned mental functions must be significantly impaired. Moreover, many dementias are progressive, meaning symptoms start out slowly and gradually get worse.

12.

Bei ng M i ld o uts e x erc i de Soc i al i se F eel c o ntact S o ft i n g F ash safe i nat ion

Benefits

Information deriving from the interview with the staff members are paired with the literature review findings in order to extract the potential benefits of our target group interaction with a supportive garden setting.

Elders

dementia

Alternative spaces, fresh air & sunlight 1

general

Various activities & experiences 1

Evoke resident’s memories (familiarity, plants, smells, etc.) 1,4

Sensory stimulation 1,4,6

Improves orientation ability especially in the time dimension 6

Sense for well-being & quality of life 1

Inspires creative self-expresion 6

Improve self-esteem 4 Vitamin D production 1 Activate muscles/ ameliorate balance 1

physical

Maintain and ameliorate functional abilities.

Enchances verbal expresion 6

Reduced risk of fall 4 Reduced risk of type-2 Diabetes & strokes 1

Most restorative for people with low tolerance of others have the most restorative benefits 1,3

Better sleep patterns 1,4 Enhanced concentration ability 3,4

psychological

Lesser stress & anxiety.

Improves cognitive functioning 1,4 Reduce pain perception (distraction) 4 Improved mental health.

Sense of choice and control 1

&

1

13.

Decrease agitation & aggressive behavior 1,3,4,6 Better sleep patterns & increased duration 1,4 Fewer demands on staff at night & less medication can be translated in cost savings 1,4

improved staff morale 1,5 .

Marcus and Sachs 2014, 2 Interviews with staff 2015, 3 Ottosson and Grahn 2005, 4 Detweiler, et al. 2012, 5 Chalfont 2007

p les des

ign

pri

nc i

Guidelines

Sim pli var c i t y i et y balance em p has se q i uence s scale

side rati

l

con

positive distraction / ‘being away’

Security Privacy

sense of belonging / familiarity

* Stimulation Encouragement Facilitate

h

al activi ty

involvement in design process

window view

Independence

e

awareness of the gardens existence

ic ys

Choice Accessibility/

e nc

of contr ol

ra

*

Culture Aesthetics Maintenance Functionality Sustainability Safety

variety and adequate number of spaces/choices

p

s

gen e

on

The knowledge of our target group and the potential benefits they might experience from a garden, are conveyed into design guidelines to provide a program for the design process of the study case.

S

usage passive or active destinations that promote mild exercise promote social interaction, mainly among small groups

Familiarity

companion animals

Sence of Belonging

engagement with nature

Accessibility

durability of planting materials non toxic materials

* Quality Attractiveness Diversity

r

wayfinding

distraction l s a

Social Contact

facilitate on-site access/ Univeral Design

*The four main restorative resources of supportive gardens (Ulrich 1999)

u

ci so

enable privacy for users

*

Variability

Nat

al suppo rt

eliminate negative associated phenomena (traffic, noise, crime)

14.

Design

Diagrammatic site programming The following concepts, which are based on the requirements of our target group, have been applied in the design process.

Public / Private

The Alley forms an important axis with historical significance, that visually and physically connects the main entrance to the area with the church that acts as a landmark.

Therefore a change in use from vehicular to pedestrian circulation is suggested.

Moreover, the six Alle buildings are situated north and south of this axis, forming a tight cluster. The recommended levels of privacy conditions are determined by the gradient, ranging from light red for public to dark red for more private context.

15.

Triangle Of supportive environments The triangle of supporting environments is a model used as a tool for determining the areas of active and passive engagement with the social and physical environment, based on the individual’s subjective experience of well-being (Bengtsson & Grahn 2014).

Considering our target group, an individual experiencing low wellbeing and excessive sensibility to the environment will prefer to use areas adjusted to his residence. As the experienced state of well-being augments, he becomes capable of more outwards directed engagement and is capable of using more remote areas than the ones adjusted to his residence.

Perceived Sensory Dimensions

The perceived sensory dimensions (PSD) (Grahn & Stigsdotter 2010) have been used in a medium scale, both for means of analysis as well as a design tool.

In order to proceed to decisions about the most suitable PSD’s with respect to the target group, the identified existing PSD’s are compared with the conclusions from the interview with the staff member of the care centers and the appropriate literature review. The proposed most dominant PSD’s of the each room are illustrated here.

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Design Solution 1.

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plaza

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20. parking

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10

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Reflections & Conclusions This project is the result of the ‘Health Design’ course, held in the second block of 2015-2016 at the University of Copenhagen. An aspect of major importance for this course is the comprehension and proper use of the Evidence Based Health Design that combines (in balance) the best research/practice evidence, the target group’s attributes and characteristics with the landscape architect’s skills in the design process in order to provide a program that will achieve the best possible outcomes.

Following the presentation of the site and project’s aim, the project argues for the importance of natural environments and nature experiences regarding the experienced state of a person’s well-being. Specifically, the project presented the redesign process of an outdoor environment primary destined for use by a very sensitive target group; the neighborhood’s residents that consist of frail elderly and people with dementias. The benefits this group gains from a supportive outdoor environment were analyzed, followed by the generation of guidelines that purpose.

Finally, an outdoor design solution which considers the previous research has been proposed.

The Alley that has been decongested by the vehicular circulation and transformed to a pedestrian friendly area, and the five gardens situated by it bring together design considerations for a user supportive environment with various activities that promote the enhancement of perceived well-being, strengthen the individual’s identity and self-esteem and make them feel part of a meaningful setting. Moreover, the design ensures a pleasant view from the residents windows towards the gardens so they can enjoy them throughout the year .

For everyone seeking a place for quiet contemplation and contact with nature, the gardens of De Gumles By have the potential to become restorative spaces of the public realm, and provide a setting that can have significant health benefits.

Taken possible limitations aside, the proposal has qualities that are beneficial for the target group as well as the other potential site users; the family members, staff and in general the residents of Copenhagen.

19.

It was very interesting to learn about the target group’s needs, and what actions could be taken in order to make a supportive environment with restorative features. Especially considering that the target group is not other than our future selves and beloved ones.

20.

Reference list Alzheimer Association n.d., What Is Dementia?, Alzheimer’s & Dementia, viewed 08 January 2016, <http://www.alz.org/what-is-dementia.asp> Antonovsky , A 1996, ‘The salutogenic model as a theory to guide health promotion’, Health Promotion International, vol. 11, no.1, pp. 11-18.

Bengtsson, A & Grahn, P 2014, ‘Outdoor environments in healthcare settings: A quality evaluation tool for use in designing healthcare gardens’, Urban Forestry & Urban Greening, vol. 13, no.

4, pp. 878–891.

CEN/CELENEC 2014, CEN-CENELEC Guide 6: Guide for addressing accessibility in standards, European Standardization, viewed 10 January 2016, <ftp://ftp.cencenelec.eu/EN/EuropeanStandardization/Guides/6_CENCLCGuide6.pdf> Chalfont, G 2007, Design for Nature in Dementia Care, GBR: Jessica Kingsley Publishers, London, viewed 08 January 2016, ProQuest ebrary.

Cooper, C & Sachs, N 2013, Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces, John Wiley & Sons, Hoboken.

Det Norske hageselskap 2009, Universell utforming av uteområder ved flerbolighus: veileder, Hageselskapet, Oslo, Norway.

Detweiler, M, Sharma, T, Detweiler, J, Murphy, P, Lane, S, Carman J et al. 2012, ‘What Is the Evidence to Support the Use of Therapeutic Gardens for the Elderly?’, Psychiatry Investigation, vol.

9, no. 2, pp.100-110, viewed 08 January 2016, National Center for Biotechnology Information, DOI 10.4306/pi.2012.9.2.100.

Grahn, P, Stigsdotter, U 2010, ‘The relation between perceived sensory dimensions of urban green space and stress restoration’, Landscape and Urban Planning, vol. 94, no. 3-4, pp. 264-275.

Interviews with staff, 2 December 2015.

Kaplan, R & Kaplan, S 1989, The Experience of Nature: A psychological perspective, Cambridge University Press, New York.

Kaplan, R, Kaplan, S & Ryan, R 1998, With people in mind: design and management of everyday nature, Island Press, Washington, US. Kellert, S & Wilson, E 1995, The Biophilia Hypothesis, Island Press, Washington, D.C.

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Moore, K 2007, ‘Restorative Dementia Gardens’, Journal of Housing For the Elderly, vol.21, no. 1-2, pp. 73-88.

Ottosson, J and Grahn, P 2005 ‘A Comparison of Leisure Time Spent in a Garden with Leisure Time Spent Indoors: On Measures of Restoration in Residents in Geriatric Care’, Landscape Research, vol.30, no. 1, pp.23-55.

Schwarz, B & Rodiek, S 2007, ‘Introduction: Outdoor Environments for People with Dementia’, Journal of Housing for the Elderly, vol. 21, no. 1/2, pp. 3-11.

Stigsdotter, U & Grahn, P 2002, ‘What makes a garden a healing garden?’, Journal of therapeutic horticulture, vol 13, pp 60-69 The Center for Health Design n.d., EDAC: Evidence-Based Design Accreditation and Certification, Certification & Outreach, viewed 08 January 2016, <https://www.healthdesign.org/certificationoutreach/edac/about>.

Ulrich, R 1984, ‘Aesthetic and Affective Response to Natural Environment’, in I Altman & J Wohlwill (ed.), Human Behavior and Environment, vol.6: Behavior and Natural Environment, Springer US, New York, pp. 85-125.

Ulrich, R 1999, ‘Effects of Gardens on Health Outcomes: Theory and Research’, in C Marcus & M Barnes (ed.), Healing Gardens: Therapeutic benefits and design recommendations, John Wiley & Sons, Hoboken, pp. 27-86.

Quan, X 2009, ‘An introduction to Evidence-Based Design: Exploring Healthcare and Design’, in Building the evidence base: Understanding Research in Healthcare Design (EDAC Study Guide, Volume 2, 2nd Edition), The Center for Health Design, CA, pp. 8-21.

World Health Organisation 2015, Ageing and health, Media centre, viewed 10 January 2016, <http://www.who.int/mediacentre/factsheets/fs404/en/>.

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De Gamles By Design for the future