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U R B A N D E S I G N F O R A L Z H E I M E R P R E V A L E N T P O P U L AT I O N S
Jack Sardeson University of Cambridge
Architecture and Urban Design Pilot Thesis
CONTENTS 1
Ellipsis - the omission from a sentence or other construction of one or more words that would complete or clarify the construction.
CONTENTS 2
. . .
Abstract
C O N T E N T S
1.0 - Outline Alzheimers Disease.............................................................6 Alzheimers in the UK...........................................................7 2.0 - Approach Urbanisation.......................................................................10 Intergration.........................................................................15 3.0 - Design Site.....................................................................................19 Spatial Orientation.............................................................23 Temporal Oreintation..........................................................27 Conclusion.........................................................................33 Picture References............................................................35 Bibliography........................................................................37
CONTENTS 3
ABSTRACT 4
. . . A B S T R A C T Figure 1. Drawing portraying the difficulty of navigating the city with dementia
In 2050, 3.2% of Britain’s population will be living with some form of dementia.1 As of yet, architecture has still to respond sufficiently to the needs of this demographic, with all existing care-home structures — despite wide-ranging internal variations across typologies — cultivating a segregative approach to care on both geographic and social planes. As such, there is an urgent need to develop evidence-based, dementia friendly architecture, integrated at the city scale. This paper hopes to address this question, analysing the need to both urbanise and integrate such communities and how architecture can uniquely facilitate this shift, to provide dementia friendly care centres within the metropolis. 1 M Prince and others, Dementia UK: Update (Second Edition) (Alzheimer’s Society, November 2014), p. 45.
ABSTRACT 5
‘Instead of building more homes for the elderly and importing care staff from eastern Europe, building policies, planning law, regional planning and state subsidies need to be revised in order, to put it bluntly, to upgrade our cities to meet the needs of large sections of society that are rapidly approaching old age and to learn from the widely acknowledged shortcomings of greenfield housing schemes. While the state spends its time adjusting pension schemes and care subsidies, they neglect to deal with the associated hardware, namely the need for an urban structure capable of providing needs for the elderly 2.
2 Eckhard Feddersen and Insa Lßdtke, Lost in Space: Architecture and Dementia, trans. Julian Reisenberger (Berlin: Birkhäuser, 2014) p. 137.
OUTLINE 6
. . .
Alzheimer’s Disease
O U T L I N E
In 2016, dementia became the leading cause of death in the UK, accounting for 11.6% of all recorded deaths.3 Although dementia comes in many forms, 60-70% of dementia cases are caused by Alzheimer’s disease, described by neurologist Dr. Dick Swabb as a ‘premature, accelerated and severe process of ageing’ 4. This neurodegenerative disease causes memory loss, disorientation, aggression, cognitive decline, insomnia, dysphagia, incontinence, loss of speech, and eventual loss of cerebral cortex function and death.5 While the symptoms expressed vary between individuals, Alzheimer’s is roughly categorized by its stages of progression; early stage or ‘Mild’ (first year or two), middle stage or ‘Moderate’ (second year to fifth year), and late stage or ‘Severe’ (beyond the fifth year).6 From diagnosis of ‘Mild’ stage dementia, the median life expectancy for an Alzheimer’s patient is 7.1 years. However, with more than 100 compounds currently in development and five symptom alleviating drugs recently approved in the US, this duration is predicted to increase significantly over the next few decades.7 As such, and with no cure currently available, it is imperative that we develop new care structures that can cater for larger numbers of dementia patients for longer periods of time.
3 Elizabeth McLaren, ‘Deaths Registered in England and Wales: 2015’, Office for National Statistics, 2016, pp. 1-8. 4 Prince, p. 7; Dick Swaab, We Are Our Brains: A Neurobiography of the Brain, from the Womb to Alzheimer’s (New York, 2014). 5 NHS, Alzheimer's Disease, <https//.www.nhs.uk/Conditions/Alzheimers-Disease/Pages/Symptoms.asp x> [accessed 28/03/2017]. 6 Beatrice Duthey, ‘Priority Medicines for Europe and the World: “A Public Health Approach to Innovation”’, 2013, WHO, p. 6. 7 Duthey, p. 36.
OUTLINE 7
Alzheimer’s in the UK
1 2 3
Alzheimer’s is not a symptom of aging but the probability of development does increase exponentially after the age of 65.8 In the UK, dementia currently affects approximately 5-8% of individuals over the age of 65, 15-20% of over 75 year olds, and 25%-50% of over 85 year olds.9 54% of those affected are considered to be in the mild stage of the disease, 32% to be moderately affected and 12.5% as living with severe dementia.10 The cost to the UK economy is currently £26.3 billion with an average cost per patient of £32,350.11 With a rapidly ageing baby boomer generation, the number of people with Alzheimer’s is set to increase dramatically over the next few decades. By 2050, two million people (3.2% of the UK population) and will cost an impossible £59.4 billion per annum.12 The care force, too, will have to grow; by as early as 2025 it will require an additional 1 million formal care workers.13 (It should be noted that this estimate does not take into account the possible implications of Brexit upon the care force, which currently relies on migrant workers for 34% of its staff.14) 8 Prince, p. 11. 9 Gesine Marquardt, ‘Wayfinding for People with Dementia: A Review of the Role of Architectural Design’, Health Environments and Design Journal, 4 (2011), p. 78. 10 Prince, p. 12. 11 Prince, p. 17. 12 Fraser Lewis and others, ‘The Trajectory of Dementia in the UK - Making a Difference’, Office of Health Economics, 2014, p. 1. 13 Ben Franklin, ‘The Future Care Workforce’, ILC, 2014, p. 5. 14 Franklin, p. 13.
Figure 2. The blue indicates the area covered if all current dementia patients in the UK lived in London. The blue line indicates the projected number by 2050.
Figure 3. 1 12.5% Severe Dementia 2 32.1% Moderate Dementia 3 54.4% Mild Dementia
OUTLINE 8
3
4
£26 Billion cost to UK economy £32,350 per person
2
1
2
Figure 4. 1 Unpaid Care - £11 Billion 2 Social Care - £10 Billion 3 Healthcare - £4Billion 4 Other Costs - £11 Million
With the social and financial demands of the dementia population so high, techniques are being developed to make care cheaper and more efficient. In 2005, Japan initiated an Alzheimer’s care scheme that successfully trained four million volunteers in four years while elsewhere new innovations in robotics and AI technology are being trialled within care settings to further reduce the need for paid human workers.15 However, both schemes function within the segregative system currently in place. It is the contention of this thesis that an integrative and urbanised care structure would facilitate a more socially and economically durable system for a dementia prevalent population.
15 Mayumi Hayashi, ‘The Lessons Japan Has for the UK on Dementia’, The
Guardian, 2013 <http://www.theguardian.om/society/2013/jun/11/dementia-lessons-from-japan-hunt> [accessed 16 January 2017].
OUTLINE 9
APPROACH 10
. . .
Urbanisation
A P P R O A C H
In 1954, Ernest Burgess explained how the topical preference for relocating the elderly to open rural spaces was due to a diminished availability of familial support in urban settings, itself the result of urbanisation’s challenge to the economic basis of the extended - In line with Burgess’s theory, from 2001 to 2011, the rural care home population in the UK increased by 4.1% while its urban counterpart increased by only 0.8%.17 However, this prevailing trend for periphery living and care will become increasingly untenable as the Alzheimer population increases. With the centralization and urbanization of most civic structures within cities, important staff and medical resources as well as important familial connections are often out of reach of rural care homes. Cross-referencing location with working population, retired population, and dependent population of regions in the UK it is possible to create maps, such as Figure 6,7, that identify care homes at risk of such isolation. On the map, the number of beds at each care home is represented by circle size, while colour indicates the home’s risk of isolation and staff shortage in the next 35 years; the darker the highlighted region and the lighter the colour of the circle, the higher the home’s risk. Generated using data from the Care Quality Commission (CQC), the map reveals a dangerous deficiency of beds for the elderly in England. With only 465,000 beds, the UK is fundamentally ill equipped to cater for the projected two million dementia patients of 2050.18 However, the map also identifies a possible solution: it demonstrates that the most statistically viable place to situate a new care system would be within our cities.
16 Ernest W. Burgess, ‘Social Relations, Activities, and Personal
Adjustment’, American Journal of Sociology, 59.4 (1954), 352–60.
17 Judith Torrington, ‘What Developments in the Built Environment Will
Support the Adaptation and “Future Proofing” of Homes and Local Neighbourhoods so That People Can Age Well in Place over the Life Course, Stay Safe and Maintain Independent Lives’, Government Office for Science, 2014, p. 7. 18 Torrington, 'Developments in the Built Environment', p. 12.
Figure 5. Current position and isolation of care-homes in the UK.
APPROACH 11
I S O L A T I O N CARE HOMES - ENGLAND Number of homes plotted = 15765 Source: Care Quality Commission Source: Office of National Statistics
55° N
Rossendale 54° N
Beds: 832 Working Age Pop.: 12.3
Lincoln
Beds: 1029 Working Age Pop.: 15.7
53° N
Leicester
Beds: 2741 Working Age Pop.: 41.8
Bromsgrove
Beds: 1434 Working Age Pop.: 21.8
Tandridge
Beds: 1248 Working Age Pop.: 18.2
Reigate and Banstead
Camden (lowest value)
Beds: 2198 Working Age Pop.: 26.5
Beds: 344 Working Age Pop.: 25.6
Elmbridge
Beds: 1632 Working Age Pop.: 25 52° N
Surrey Heath
Beds: 1212 Working Age Pop.: 16.4
East Hampshire
Beds: 1678 Working Age Pop.: 25.2
Hastings (highest value) Beds: 1612 Working Age Pop.: 18.5
Bournemouth
Beds: 2542 Working Age Pop.: 36.5
Taunton Deane
Beds: 1835 Working Age Pop.: 26.1
51° N
LONDON
Worthing Torbay
Beds: 2349 Working Age Pop.: 37.9
Beds: 1800 Working Age Pop.:25
City of London Beds: 0
SITE NIGHTINGALE HOUSE SW12 8NB (Largest Dementia Care Home in England) Built: 2011 Beds: 215 Staff: 320
x4 KEY ISOLATION %* 0%
+1 BED
NUMBER OF BEDS
100%
+215 BED
COUNTY ISOLATION %
10%
70%
Figure 6. Future risk of care-homes in F U T U E (2050). R I S K theRUK
APPROACH 12
CARE HOMES - ENGLAND
Number of homes plotted = 15765 Source: Care Quality Commission Source: Office of National Statistics
55° N
54° N
Fylde
Risk: 16.1 Population density: 76.6 Retired population: 21.4
North Norfolk Risk: 15.5
Population density: 101.7 Retired population: 34 53° N
Bromsgrove
Risk: 15.3 Population density: 93.4 Retired population: 21.8
Tendring
Risk: 17.8 Population density: 148.5 Retired population: 46.6
Tandridge 52° N
Risk: 15 Population density: 83.1 Retired population: 18.2
Rother
Risk: 20.8 Population density: 89.8 Retired population: 29.9
Reigate and Banstead Risk: 15.8 Population density: 138.6 Retired population: 26.5
Hastings
Risk: 18.4 Population density: 87.2 Retired population: 18.5
Bournemouth
Risk: 15.1 Population density: 168.1 Retired population: 36.5
Taunton Deane
Risk: 16.7 Population density: 109.4 Retired population: 26.1
51° N
LONDON
SITE Isle of Wight
Risk: 14.9 Population density: 140.5 Retired population: 39.6
Torbay
Risk: 17.4 Population density: 134.3 Retired population: 37.1
Worthing
Risk: 17.4 Population density: 109.4 Retired population: 26.1
Eastbourne
Risk: 17.2 Population density: 97 Retired population: 25.8
Hammersmith and Fulham Third lowest risk district in England Risk: 1.9 Population density: 169.7 Retired population: 20.7 Beds: 329
District of Richmond upon Thames Highest life expectancy of London districts. Source: Office of National Statistics Risk: 5.1 Population density: 190 Retired population: 29.6 Beds: 990
x4 KEY RISK CLINICS IN 2040 0%
+1 BED
NUMBER OF BEDS
100%
+215 BED
COUNTY RISK
+0
+30
APPROACH 13
Not only would urbanized settings for care homes enable greater and more efficient access to resources and staff but the metropolitan context in itself offers significant benefits to Alzheimer patients. Staying physically, socially active and independent is thought to ‘build cognitive reserve’ and thus reduce the severity of the condition.19 However, despite this, the Alzheimer’s Society found that 35% of people with dementia got out at most once a week and those over 85 spent 90% of the time at home.20 While the disorientation that many Alzheimer patients encounter using public transport or busy streets are considerable disadvantages of the urban setting, its high density layout ensures all facilities are close together, enabling Alzheimer patients to move more safely between sites. As Henri Snel, a Dementia and Design specialist at the Sandberg Institute, suggests, provided simple measures were instituted in the urban setting, those with mild to moderate dementia (86% of patients) would still be able to operate independently in the public realm.21 Indeed, according to one ‘Neighbourhoods for Life’ study, a system structured around ‘hubs within a ten-minute walking distance’ would enable people ‘to retain independence for longer’.22 In 1981, the introduction of yellow ‘tactile flags’ in urban areas enabled two million blind and visually impaired people to independently navigate almost all road crossings in England. Now a legal requirement under the Disability Discrimination Act, it begs the question: if there is soon to be an equivalent number of those with dementia, should there not be a similar consideration in the urban fabric? In the 1960’s, the construction of Del Webb’s Sun Cities witnessed the arrival of a metropolitan care structure to America, along with its highly successful branding of ‘social ageing and its associated idealistic imagery.’23 These cities promised the elderly an exclusive sun and leisure filled retirement, entirely accessible by golf cart. However, rather than truly integrate within the urban context, Sun 19 Alzheimer’s Association, ‘2014 Alzheimer’s Disease Facts and Figures’,
Alzheimer’s and Dementia, 10.2 (March 2014) 47-92 (p.15).
20 Sarah Lewis, ‘Dementia and Town Planning’, RTPI, 2017, p. 15; S
Adams and K White, Older People Decent Homes and Fuel Poverty: An Analysis Based on the English Housing Conditions Survey (London: Help the Aged, 2006). 21 Henri Snel, interviewed by Jack Sardeson, 02 February 2017. 22 Lynne Mitchell and Elizabeth Burton, ‘Dementia-Friendly Cities: 23 Jay Sokolovsky, The Cultural Context of Aging: Worldwide Perspectives (Westport: Praeger, 2009), p. 468.
Figure 7. WHO suggested criteria for an ‘Age Friendly City’
Outdoor spaces and Buildings Transportation Housing Social Participation Respect and Social Inclusion Civil Participation Communication and Information Health Services
APPROACH 14
Figure 8. Nomadic Changpa Buddhist Gompa India Figure 9. Hotel of Liberation Varanasi India Figure 10. City Square Alfama Portugal
Cities provide their own distinct urban condition, disconnected from family and wider society in much the same way as isolated rural homes. As such, important ‘anchoring’ memories that require repeated reinforcement from wider contexts are not suitably addressed; ‘the familiar becomes all too unfamiliar.’24 In this way, they are symptomatic of what James C. Scott identifies as the failure of the High Modernist City: the ‘rigid segregation of function’, and therefore do not offer a sustainable option for dementia populations of the future.25 What is needed is not an urban context within a care home structure but rather a care structure embedded and integrated within the urban setting, in other words: an integrated urbanisation.
Figure 11. Sun City Arizona USA 8
10
9
11
24 Feddersen, p. 103. 25 James C. Scott, Seeing Like a State: How Certain Schemes to Improve
the Human Condition Have Failed (New Haven: Yale University Press, 1998), p. 110.
APPROACH 15
Integration The existing care-home typologies in the UK can be roughly organised along a continuum, with four key groups: Care Homes, Specialised Housing, Respite Clinics, and Adapted Mainstream Housing.26 Despite important design variations, these typologies can all be described as examples of segregative care. In each case, the consequent lack of integration has significant implications for the quality of care experienced by dementia patients.
Figure 12. Alcacer Do Sal Portugal Care-Home
The most common typology, care homes, provide accommodation in protected, generally gated, environments. Predominantly consisting of single rooms with shared communal spaces, they offer 24 hour care and services for residents. Despite offering a greater level of support than any other typology, they tend to restrict independence and isolate individuals from previous familiarities. Indeed, a recent DICE study of care-homes found that when safety and health were rated highly, quality of life scores were rated low, suggesting that the protected environment of the care home comes at a high price.27 More flexible than care homes, specialised housing encompasses sheltered-living, extra-care, and a retirement village structure. Epitomising the ‘age-in-place’ philosophy of purpose built accommodation, they allow people to familiarise a custom-built environment whilst also providing an institutional system of care, available when and if required. However, despite often including shared social spaces, recent research by Age UK found that a large proportion of the designs used for sheltered housing ‘was not always conducive to encouraging public interaction’.28 Additionally, as Sarah Waller CBE observes, while modern features may appeal to buyers they are frequently inappropriate for the perception sensitivities of dementia.29 In this way, specialized housing fails to provide a care system that is sufficiently integrated, or indeed, even supportive of patient integration within its internal setting. 26 Richard Best and Jeremy Porteus, ‘Housing Our Ageing Population:
Plan for Implementation (HAPPI 2)’, Parliamentary Group on Housing and Care for Older People, 2012, p. 12. 27 Chris Parker and others, ‘Quality of Life and Building Design in Residential and Nursing Homes for Older People’, The University of Sheffield, 2004, p. 94. 28 Marian Barnes, Beatrice Gahagan, and Lizzie Ward, ‘Older People, Well-Being and Participation’, University of Brighton, 2013, p.4. 29 Sarah Waller, interviewed by Jack Sardeson, 21 March 2017.
Figure 13. De Plussenburgh Netherlands Age-in-Place
APPROACH 16
Figure 14. Alzheimer Respite Clinic Dublin Respite Clinic
Figure 15. Up Pixar The ideal AMH condition
Respite Clinics offer a break for the patient and carer. Generally well equipped with experienced staff, these homes operate on a hotel-like model, offering stays of approximately 2 weeks for a fee. These do not seek to integrate the patient into the care setting, but rather to alleviate the pressures of home-care, providing a necessary short-term solution. However, while beneficial for carers, moving Alzheimer patients to and from an unfamiliar environment can have ‘debilitating effects on their level of confusion and disorientation’. With no integrated care services to provide follow up support, respite clinics can often cause long term complications.30 In Adapted Mainstream Housing (AMH), the patient’s home is retrofitted to compensate for neurodegeneration and frailty. AMH is a particularly attractive solution as one retains a known environment whilst also benefiting from specialist features usually found in institutional care settings. 60% of the over 65 population own their property outright so that, especially with the introduction of ‘assistive technology’ (sensors in the home that notify a centralised care service should you fall or leave the gas on etc.), AMH is a popular option.31 In 2017, Worcester County Council began offering residents non-means tested grants for the purpose of adapting their homes for dementia. The private home, however, also inhibits integration with the local community through the very privacy that it advocates. In recent years, technological innovations including ‘therapeutic robots’ have been developed to provide a companion for those living alone. These robots range from baby seals to fully interactive humanoids but all seek to compensate for rather than to solve the isolation barrier. Indeed, as Dr. Carol Brayne has suggested, such technological interventions tend to increase one’s isolation, citing E.M Forster’s dystopian fiction ‘The Machine Stops’, in which technological communication replaces all genuine social interaction, generating a universal quarantine.32
Figure 16. 1900 - Removal from city 2000- Peripheral living 2050 - Integrated city 30 Mitchell, p. 90. 31 Torrington, 'Developments in the Built Environment', p. 5. 32
Carol Brayne, interviewed by Jack Sardeson, 14 November 2016.
APPROACH 17
What Forster’s dystopia shares with all four typologies is a common desire to recompense artificially for isolation rather than to challenge it. In this sense, a typology that provides integrative and integrated care – as opposed to compensating or substituting within a segregative system – is yet to be developed. Some steps in the right direction have, however, been taken. For example, the ‘Hub and Spoke’ model, currently being trialled by a the Gibeleich Alterzen community in Zurich offers independent living and care home options connected by shared services – shops, a canteen, and a laundry. Vitally, the facility relies upon its proximity to local volunteers and resources in order to operate.33 In Japan, an informal alternative to this model, known as ‘Suzunoya’ is taking shape, with volunteers offering locals all-day care and drop-in facilities within their own home.34 Here, I suggest that it is possible to preserve and bring together the various strengths of each typology within a structure that is fully integrated within the urban context of London. This integrative system would consider the public urban streetscape as much part of the architecture of care as the typologies themselves, generating a connected ‘Dementia Friendly District’ (DFD). Importantly, this would not only mediate some of the inherent flaws of the existing typologies of care but form a durable framework for new ones. These new Alzheimer friendly forms could then offer a flexibility of care options enabled by their integration with the city and DFD.
33 Torrington, 'What Developments in the Built Envrionment', p.11. 34 Mayumi Hayashi, ‘Dementia Care in Japan Is Being Solved through
Volunteer Schemes, Not Government’, The Guardian, 18 November 2014 < https://www.theguardian.com/social-care-network/2014/nov/18/dementia-c are-japan-community-volunteer-schemes> [accessed 28 March 2017].
Figure 17. DFD (Dementia Friendly District) Hammersmith
APPROACH 18
DESIGN 19
35 WHO, Global Age-Friendly Cities A Guide (Geneva, 2007).
D E S I G N
If evaluated using the eight-point checklist from the World Health Organisation’s ‘Age Friendly Cities’ guide and CQC data, the UK city borough most suited for the first DFD scheme would be Hammersmith and Fulham, with both accessible green space and overground transport links.35 The Wetlands Nature reserve and Thames walk provide a rural open space within the city centre, ideal for wandering, while the Hammersmith and City Line runs exclusively above-ground from Hammersmith to Paddington, making it easier for those with dementia to orientate themselves using public transport. Additionally, Charring Cross Hospital sits centrally in the site and the borough itself is situated between two boroughs with the highest life expectancy in the UK. From this area, I outlined the perimeters of the DFD and selected three locations from a range of vacant and imagined sites to test a series of design experiments: the vertical space above and around Hammersmith’s heavily congested urban centre, the disused space running parallel to the train line and, finally, an imagined bridge crossing the river between the city and the Wetlands centre. The following chapter explores how each integrated site proposal has been adapted to address two primary Alzheimer architecture features: Spatial Orientation and Temporal Orientation.
. . .
Site
Figure 18. DFD mapped Hammersmith and Fulham.
DESIGN 20
Hammersmith and Fulham Third lowest risk district in England Risk: 1.9 Population density: 169.7 Retired population: 20.7 Beds: 329
Old Oak Road
W3 7HL Beds: 6
Train Site Richford Gate W6 7HZ Beds: 8
2 Coverdale Road W12 8JL Beds: 6
Vertical Site Angela House W6 9LS Beds: 6
Aerial View
St Vincents Home W6 9QHBeds: 92
Nazareth House
Clifton Gardens
W6 8DB Beds: 95
W4 5TZ Beds: 43
Charing Cross Hospital Beds: 511
Talgarth Road W14 9DD Beds: 10
London Cyrenians Housing W14 9JH Beds: 9
St Mary's Convent
W4 2QE Beds: 59
SITE
Alzheimer Friendly Zone
Bridge Site District of Richmond upon Thames LONDON
Highest life expectancy of London districts.
Source: Office of National Statistics Risk: 5.1 Population density: 190 Retired population: 29.6 Beds: 990
SITE
Viera Gray House
SW13 9PP Beds: 38
Wetland Centre
x4
Cambuslodge UK Limited SW6 2TT Beds: 5
DESIGN 21
Figure 19. DFD mapped Hammersmith and Fulham
DESIGN 22
Figure 20. DFD mapped Hammersmith and Fulham
DESIGN
23
Spatial Orientation One of the first regions affected by Alzheimer’s Disease (in its most common form, which makes up 90-95% of cases) is the hippocampus. Located in the medial temporal zone, the hippocampus specifically stores memories of mapped space, as multiple experiments have demonstrated, including one in which London taxi drivers famously asked to recall routes through the city while lying in a PET scanner.36 The early damage to the hippocampus causes significant ‘spatial disorientation’, which a recent study confirmed to be the primary reason for institutionalisation of dementia patients.37 As such, spatial legibility is an integral component of any Alzheimer friendly scheme. The first proposal, a series of vertical constructions above and around Hammersmith and City station, initially poses a problem for spatial legibility. The preferred construction method for vertical buildings involves indistinguishable, stacked floor plates that are spatially and economically efficient but difficult for Alzheimer patients to navigate. In the Netherlands, the De Plussenburgh retirement high-rise project has attempted to mitigate this problem by using floor-to-celling coloured glass in circulation areas, enabling residents to clearly differentiate between floors. However, each floor in the De Plussenburgh building is still accessed by an elevator, which can, as a 2000 report found, be a major barrier for Alzheimer patients.38 This is due to the disease’s impairment of the Prectneus, an area of the brain that cognitively maps environmental information beyond the perceptual range of vision. This proposal takes into account both the efficacy of a stacked structure and the need for an actively orientating navigation system between floors, suggesting a Guggenheim inspired spiral ramp as the central circulation space. While the Sonweid care home in Switzerland uses a linear ramp to encourage mobility, the Hammersmith tower’s spiral allows the tower’s centre to be hollowed out, providing residents with direct views across the space to colour-delineated floors as well as facilitating the infiltration of natural light through the building. Although some contemporary dementia designs advocate the use of specific colour sets, ‘no research has yet suggested that 36 Rita Carter, Mapping the Mind (Berkeley: University of California Press,
1998), p. 116.
37 Marquardt, p. 76. 38 Marquardt, p. 86.
Figure 21. 1 Amygdala 2 Hippocampus 3 Precuneus
1 Figure 22. Sun City Ginza Japan Retirement tower
2
3
DESIGN 24
Figure 23. Guggenhiem New York
dementia patients respond to colour visually or emotionally in a different way to the general population’.39
Figure 24. Sonweid Care-Home Switzerland
Figure 26 Tower Concept Model Hammersmith
Figure 25. Concept Sketch Hammersmith
Figure 27. Tower Concept Model Hammersmith 39 Sue Benson, ‘The Use of Colour in Dementia Specfic Design’, Journal
of Dementia Care, 2002, 20–23.
DESIGN 25
Figure 28. Train Concept Model Shepherds Bush Market
The second site, along the train line, is based on the principle of an ‘integrated circulation system’, as set out in ‘Wayfinding for People with Dementia’.40 This study demonstrated that embedding ‘anchor points,’ such as activity spaces like a large eat-in kitchen between access and private spaces, significantly improved the wayfinding ability of residents. Inspired by the intersecting residential spaces found in the vernacular architecture of Procida, Italy, the train line’s circulatory route enables residents to occupy the visually interesting semi-public space without straying too far from the home. Moving further into the building, the building further mediates spatial and social navigation by allowing the kitchen/dining spaces to be opened-up, enabling fellow residents to ‘drop by’ as they traverse the walkway. This intersection of social spaces takes as its inspiration Niall McLaughlin’s Alzheimer Respite Clinic in Dublin, which breaks up wall planes and even integrates the garden into the structure to facilitate a looping circulation system.
40 Marquardt.
Figure 29. Intersecting public and private space. Procida Italy
Figure 30. Train Concept Sketch Shepherds Bush Market
DESIGN 26
Figure 31. Medieval Hospital France
Figure 33. Bridge Concept Model Wetlands
The third proposal, which re-imagines the archetype of the inhabited bridge, uses a residential layout based on findings by a report entitled ‘Dementia-friendly Cities’. This study found that the most legible of street layouts involved ‘shorts streets laid out on a deformed grid base, on an adapted perimeter block pattern, rather than 90° turns and blind bends’.41 The Alzheimer patient’s preference for ‘narrow winding streets […] with distinctive activity landmarks,’ is incorporated into and met by the residential bridge’s traditional layout of a central public corridor that opens onto riverside courtyards and vistas, in and out of which pedestrians can wander at will.42 Building upon this, the bridge invokes a two tier structure reminiscent of medieval French hospitals, such as the one depicted opposite. The illustration portrays a French hospital in the 1200’s making use of the two-tiered circulation system, with patients below and staff passively observing from above. The bridge scheme inverts this relationship, empowering the resident who may not wish to engage with the bustle below and allowing them to meander towards the nature reserve instead.
Figure 32 Bridge Concept Drawing Wetlands.
41 Mitchell, p.95. 42 Ibid.
DESIGN 27
Temporal Orientation A common misconception of memory is that it is static. In reality the brain is dynamic and a memory is never thought of in exactly the same way the second time round because you cannot fire the same synaptic pattern twice. The relevance for architecture is the sensory nature of this process; the more sensory information intertwined with a memory, the more likely you are to remember it. The ability to invoke such past memories can play an important role in comprehending how and why you are where you are. Consequently, considering the use of sensorial stimuli is crucial when creating navigable space for Alzheimer patients. Indeed, the importance of direct multi-sensory information is heightened as memories of the recent past fade away.43 In 2007, a study found that increased exposure to natural light led to ‘increased sleep duration, and less aggressive and agitated behaviour’ in people living with Dementia.44 These findings can be explained, in part, by the disease’s degeneration of the suprachiasmatic nucleus, which moderates internal circadian rhythms.45 As this function becomes increasingly inhibited, ‘environmental cues take on a larger role and help to regulate the resynchronisation of circadian rhythm’. As such, natural light – and, crucially, architecture’s ability to mediate it – plays a significant role in Alzheimer homes.46 In the tower proposal, residential units are orientated so as to frame the passing of time rather than views. The evening social spaces face west onto the sunset, kitchens face south (midday) and the bedrooms look out onto the morning horizon in the east. Additionally, all window panes are angled to minimize reflections, which can be distressing for residents who struggle to recognise their own faces. Using carefully arranged and aligned windows, the gradual change in the spectrum of light acts as a subconscious indicator of the time of day, regulating the brain’s release of melatonin and passively informing the body what to prepare for next;
43 Feddersen, p. 15. 44 Calkins, Szmerekovsky, and Biddle, ‘Effect of Increased Time Spent
Outdoors’, Journal of Housing for the Elderly, 2007, p. 84.
45 Phil Gehrman and others, ‘The Relationship between Dementia Severity
and Rest/Activity Circadian Rhythms’, San Deigo State University, 2005, p.155. 46 Gehrman.
Figure 34. By rotating Obama’s portrait the right way up the brain then recognises it as a face, making the distortion apparent. This un-percieved switch in the brain illustrates how little control we have of our own perceptions and memories
Figure 35. Care-Home in Switzerland using semi-transparent material to create soft shadows
Figure 36. Fujimoto House N for his elderly parents, partition system allows views and orientation in space.
DESIGN 28
sleep, food, etc. Other passive indicators embedded within a scheme can also serve as useful reminders; according to one care home in Cambridge, laying the table for the evening meal was a more effective way of informing the residents of a meal time than directly telling them. In the Hammersmith tower, social spaces are made visually accessible for patients by using a Fujimoto partition system, enabling them to draw upon implicit environmental cues to inform their daily rhythms.
Figure 37. Tower Apartment Circadian Rhythms Framing times of day and specturms of light.
Figure 38. Tower Apartment Concept Model Framing Sun Rise
DESIGN 29
Figure 39. Train Concept Model Rem-Pod Window
Heavily indebted to Henri Lefebvre’s Rhythmanalytics, the train line proposal explores the potential use of audible urban rhythms and routines in lieu of natural rhythms. A predictable routine is an important method of accustoming anyone to a new space; as noted in Lost In Space; ‘it is not the rooms themselves that create familiarity but the new rituals we develop to get used to them’.47 The residential units along the train line are clustered along where the line runs alongside Shepherd’s Bush Market, juxtaposing the regular sound and sights of passing trains with the sounds, sights and smells of the market. Each morning the bustle of setting up stalls signals the beginning of the day to patients above, while the dismantlement of the market, and subsequent quiet, indicates evening. Throughout this daily cycle, the Hammersmith and City, Circle, and Metropolitan lines provide a regular audible, visual, and even vibratory temporal measure. Additionally, the upper floor of each residential unit contains a ‘rem-pod,’ which enables people with dementia to reminisce in response to a familiar environment, such as a train carriage. This rem-pod proposal is unique in that it provides a multi-sensory experience, with views onto the tangibly real train track rather than onto a projection. This avoids the disorientation that Sarah Walller suggests is often caused by the 2D projections of 3D images used in traditional rem-pods.48 As Henri Snel argues, such multi sensory illusions are especially important for patients whose comprehension of the ‘real’ world has become equally illusory, bringing them comfort and pleasure.49 47 Feddersen, p. 94. 48 Waller. 49 Snel.
Figure 40. Rem-Pod Priory Care-Home UK
Figure 41. Nostalgic Home Care-Home Ohio
DESIGN 30
Figure 42. Train Concept Drawing Shepherds Bush Market
DESIGN 31
Figure 43. Bridge Concept Model Wetlands
The bridge proposal incorporates both the tower’s use of natural cycles and the train line’s use of social cycles to temporally orientate its inhabitants. Connecting the polar environments of the city and the wetlands, the bridge’s contrast encourages dynamic flow between the two sites, forming its own socially engaging space as people meander within the bridge’s vistas. A permeable louver system located beneath the roof’s glass atrium allows the chatter of pedestrians and the scents of the ground floor market retail to wash the interior space with added, rhythmic life. Located on one of the few stretches of the Thames that is orientated north-south, the long side of the bridge is south-facing, maximising light reception. With Lux level recommendations for Alzheimer homes three times higher than for a typical residence, this alignment is crucial. However, Alzheimer patients also have an increased sensitivity to glare.50 The Wall house in Chile, uses semi-transparent fabrics to control glare while continuing to maximise natural light. Importantly, the fabric also reduces harsh shadows, which are often problematic for dementia patients due to ‘impaired contrast perception.’51 As patients lose the capacity to distinguish the edges of shapes, they often mistake slatted shadows for gaps in the floor, to the extent that some care homes use black floor paint before lift entrances to deter residents from entering them. In the bridge model, a double height glass atrium capping the residential units maximises light entering the space while 50 Benson. 51 Ibid.
Figure 44. The Wall House Chile
DESIGN 32
cascades of semi-transparent curtains, hung at regular intervals, diffuse the glare to provide a consistent soft light. Hanging within reach, residents can adjust the curtains to change the light quality whilst simultaneously engaging haptically with their surroundings.
Figure 45. Raymond-Hood Manhattan Skyscraper Bridge Proposal
Figure 46. Raymond-Hood Manhattan Skyscraper Bridge Proposal
Figure 47. Bridge Concept Drawing Wetlands
DESIGN 33
Conclusion
52 Margaret Campbell, ‘What Tuberculosis Did for Modernism: The
Influence of a Curative Environment on Modernist Design and Architecture’, Medical History, 49.4 (2005), 463–88 (p. 487). 53 Mallgrave. 54 Lewis, 'Dementia and Town Planning', p. 2.
C O N T I N U A T I O N
Neuroscience, in the past 10 years has produced insights into the workings of the human mind exponentially more reliable than those available to earlier architects. Indeed, today, it has at its disposal a more refined set of tools than ever before. It, also, however faces a greater challenge than ever before, with 74 million +65’s living in urban environments across Europe. It is vital therefore imperative that contemporary architecture aligns with contemporary neuroscience to generate an architecture appropriate to the requirements of neurodegeneration. If successful, it promises to provide not only for those with Alzheimer’s disease but for people across society. Indeed, as Sarah Lewis describes in ‘Dementia and Town Planning’: ‘If you get an area right for people with dementia, you get it right for older people, for young disabled people, for families with small children, and ultimately for everyone.’54
Figure 48. The Health House California
. . .
In recent years, the medicinal value of modernist health architecture, such as Richard Neutra’s renowned ‘Health House’ in Los Angles, has been treated with increasing skepticism. Margret Campbell, in a 2005 paper, described how the building depended on something of a placebo effect, working by ‘symbolic association rather than application of scientific method.’52 However, as Professor Henry Mallgrave counters, Neutra’s design is limited not by an approach based on ‘speculative design’ but rather by the limits inherent to medicine of that period. Extrapolated form ‘the workings of our bodies and brains’, as understood in the early 1900’s, Neutra’s ‘Health House’ can only be as successful as the treatments of its period.53
Outline 1
PICTURE REFERENCES 35
Picture References Figure.1. Sardeson, Jack, Ellipsis, 2017 Figure. 2. Sardeson, Jack, Ellipsis, 2017 Figure. 3. Sardeson, Jack, Ellipsis, 2017 Figure. 4. Sardeson, Jack, Ellipsis, 2017 Figure. 5. Sardeson, Jack, Ellipsis, 2017 Figure. 6. Sardeson, Jack, Ellipsis, 2017 Figure. 7. Sardeson, Jack, Ellipsis, 2017 Figure. 8. Sardeson, Jack, Ellipsis, 2017 Figure. 9. Sardeson, Jack, Ellipsis, 2017 Figure. 10. Sardeson, Jack, Ellipsis, 2017 Figure. 11. Sardeson, Jack, Ellipsis, 2017 Figure. 12. Sardeson, Jack, Alcacer Do Sal, 2017 Figure. 13. Sardeson, Jack, De Plussenburgh, 2017 Figure. 14. Sardeson, Jack, Alzheimerâ&#x20AC;&#x2122;s Respite Clinic, 2017 Figure. 15. Sardeson, Jack, Up, 2017 Figure. 16. Sardeson, Jack, Ellipsis, 2017 Figure. 17. Sardeson, Jack, Ellipsis, 2017 Figure. 18. Sardeson, Jack, Ellipsis, 2017 Figure. 19. Sardeson, Jack, Ellipsis, 2017 Figure. 20. Sardeson, Jack, Ellipsis, 2017 Figure. 21. Sardeson, Jack, Ellipsis, 2017 Figure. 22. Sardeson, Jack, Ellipsis, 2017 Figure. 23. Sardeson, Jack, Ellipsis, 2017 Figure. 24. Sardeson, Jack, Ellipsis, 2017 Figure. 25. Sardeson, Jack, Ellipsis, 2017 Figure. 26. Sardeson, Jack, Ellipsis, 2017 Figure. 27. Sardeson, Jack, Ellipsis, 2017 Figure. 28. Sardeson, Jack, Ellipsis, 2017 Figure. 29. Sardeson, Jack, Ellipsis, 2017 Figure. 30. Sardeson, Jack, Ellipsis, 2017 Figure. 31. J. J. Walsh, Thirteenth-Century Hospital Interior, Tonerre, illustration, in J. J. Walsh, Medieval Medicine (London : A. & C. Black, 1920) < https://archive.org/details/medievalmedicine00wals> [accessed 16 January 2016] Figure. 32. Sardeson, Jack, Ellipsis, 2017 Figure. 33. Sardeson, Jack, Ellipsis, 2017 Figure. 34. Sardeson, Jack, Ellipsis, 2017 Figure. 35. Sardeson, Jack, Ellipsis, 2017 Figure. 36. Sardeson, Jack, Ellipsis, 2017 Figure. 37. Sardeson, Jack, Ellipsis, 2017 Figure. 38. Sardeson, Jack, Ellipsis, 2017
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Figure. 39. Sardeson, Jack, Ellipsis, 2017 Figure. 40. Sapphire Consortium, Oak Priory Reminiscent Pod, 2016, photograph <https://pbs.twimg.com/media/CurSIbiXEAAjhUz.jpg> [accessed 16 January 2016] Figure. 41. Sardeson, Jack, Ellipsis, 2017 Figure. 42. Sardeson, Jack, Ellipsis, 2017 Figure. 43. Sardeson, Jack, Ellipsis, 2017 Figure. 44. Sardeson, Jack, Ellipsis, 2017 Figure. 45. Sardeson, Jack, Raymond-Hood, 2017 Figure. 46. Sardeson, Jack, Raymond-Hood, 2017 Figure. 47. Sardeson, Jack, Ellipsis, 2017 Figure. 48. Sardeson, Jack, Health House, 2017
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