WAY-FINDING THROUGH DEMENTIA ABSTRACT Recent research has shown links between the built environment, mental health and cognitive impairment, proving that the design of the built environment has a direct influence on people’s emotional wellbeing and general quality of life. With this in mind, is it possible to create architecture and urban environments that influences the human psyche, working well for the ‘average’ person but also influencing and affecting the overall wellbeing of those with disabilities- physical and mental? Looking particularly at older people suffering from dementia and how their daily lives are affected by its conditions, this essay explores ways in which neighbourhoods can assist in the therapy of dementia rather than a hinder it.
‚The study of reciprocal relationships between people and their total environment over the past several decades demonstrates that the architectural settings is more than a background variable and may exert significant influence on the behaviour and quality of life of individuals and groups.‛ (Dunlop, 1994)
DEMENTIA According to the 2001 census the amount of people over the age of 65 has, for the first time ever, grossly outnumbered that of children in the country, with the most significant difference in increase being of those aged 85 and over. But as life expectancy rises so does the health problems and risks associated with ageing, in particular dementia. As it stands at the moment there are over 820,000 people in the UK living with some form of dementia and 25 million people’s lives directly affected by this condition, be it through a family member or a close friend. (Dementia Care News, 2011). As the population of the ‘older generation’ continues to rise the number of dementia cases is directly related to this and ‘the likelihood of developing dementia increase for 1 in 50 between the ages of 65 and 70 to 1 in 5 over the age of 85’ (Mitchell, Burton, & Raman, 2004, p. 1). It is predicted that by 2040 over 1.2 million people will be living with dementia, 1 in 3 of which will pass away due to a cause directly associated. It is thought that if scientists could delay the onset of dementia by five years, then we could halve the number of people who die with the disease. We are all, no doubt, familiar with the basic characteristics of dementia, but unless you are a member of the medical health service and/or have had first had experience with it through a family member or friend then it is unlikely that you will be fully educated with what is meant by the term ‘dementia’. The NHS states that dementia ‘is a syndrome that
is associated with an ongoing decline of the brain and its abilities, such as memory, thinking, language, understanding and judgement. They may also have problems controlling emotions or behaving appropriately in social situations’. Dementia, like any other disease, affects people differently depending on their specific circumstances, it is therefore hard to produce a precise definition and diagnose. Dementia covers a broad range of symptoms that develop due to specific diseases and conditions affecting the brain. The most common cause of dementia is Alzheimer’s disease. Alzheimer’s disease is the development of ‘plagues and tangles’ within the brain structure, resulting in the death of brain cells. It is a steadily progressive and irreversible deterioration of a person’s mental capacity. Furthermore Alzheimer’s is ranked number four, in the developed world, as the cause of death in elderly people, after cardiovascular disease, cancer and cerebrovascular disease. Vascular dementia is the second most common form. Unlike Alzheimer’s which progresses slowly over a number of years, vascular develops over a matter of months. It occurs when the flow of blood through the body is interrupted, Stopping the blood flow to the brain causing the brain cells to die and resulting in brain damage. Other diseases include Lewy Body Disease, Korsakoff’s syndrome, Frontotemporal Dementia and Dementia Pugilistica. (Dementia Centre). As the condition develops the person becomes increasingly forgetful, eventually becoming unable to recall simple events and conversations that have just taken place, and may even get disorientated and lost trying to find their way about familiar places. In the later stages this can become so severe that the person may not able to recognise their own partners and their children and the family may be unable to recognise them due to change in personality. It is believed that our life experiences help develop our own character and personality, making us who we are, so what do you become when you don’t remember any of your own past? Just imagine seeing the person you love and for them to have no recollection of who you are. It is almost like a death but as the person is still physically there you are unable to grieve for their loss. By ‘the end’ ‚the brains
ability to adjust to changes in the environment (for example, by heat regulation, control of the heart and breathing or resistance to infection) eventually deteriorates to such an extent that life can no longer be supported‛ (Dunlop, 1994, p. 5). Through this, the ‘sufferer’ doesn’t even have their own memories to comfort themselves, to create a better quality of life. So why do we, as architects and designers, need to be aware of this?
‚Because
a unit must be skilfully designed and founded on a firm knowledge base, the architect should be thoroughly interviewed. They should be able to answer basic questions about sensory perceptual changes that occur with aging in relation to the environment and should be knowledgeable about manifestations of dementia that exacerbate normal bio physical decline‛ (Dunlop, 1994, p. 4)
DESIGNING FOR DEMENTIA The architect strives to create environments that provide everyone with the best quality of life as possible, regardless of their conditions or situation. Around 80% of people with dementia continue to live in their own homes, including a third of people with severe dementia, and it is estimated that almost a quarter live alone (Blackman, Mitchell, & Burton, 2003, p. 4). It has been proven that the stability of remaining in a familiar surrounding with familiar faces is beneficial and delays the onset of dementia. Moving a person with dementia into a new unfamiliar environment can have a debilitating effect on their level of disorientation and confusion. ‘Design Guidelines’ for dementia care homes has established a direct connection between the design of internal environments and the perceptual and way-finding abilities of residents’ (Mitchell, Burton, & Raman, 2004, p. 2). Which is a great start but surely care homes should be a last resort. To allow the dementia sufferer to stay at home for as long as possible the design of the urban built environment will play a vital role. There have been recent innovations in the design of care homes over the past couple of years. Some architects are now starting to take notice of recent studies in designing specifically for older people with dementia and have now put an emphasis on the importance of unambiguous and familiar surroundings. The ‘Design Guidelines’ show that ‘if
bedrooms, bathrooms and living rooms in care homes resemble those of ordinary private residences, people with dementia are more likely to be able to understand what is expected in each setting and to find their way around’ (Blackman, Mitchell, & Burton, 2003, p. 6). But what has been discovered to be the most valuable asset is the use of
environmental cues, for example, short corridors each with frequent cues and views outside are easier to navigate through than long repetitive corridor. Dementia friendly guidelines give advice on materials, texture and colours. It is thought that a distinct change in floor colour can be useful in establishing dangerous areas whilst busy patterns and poor contrast between floors and walls can be confusing and cause dizziness. Also, coarse-textured flooring can make walking difficult due to older people’s poor balance and gait shuffling. Impaired depth perception means that shiny, reflective surfaces can be misinterpreted as wet and slippery and sharp pattern or colour contrast as different levels. Colour coding has proved to be an unsuccessful way-finding tool as it is far too complex for people with dementia to understand and remember. Much progress has been made regarding these guidelines, with more research underway. Unfortunately, there have only been a few studies that have addressed dementia friendly design with regards to the urban environment. Next time you are walking down the street take a look around and note all the uneven pavements, the heavy traffic of vehicles and people, the poor street lighting, the environmental cues that have aided your journey. Things that you come across that made you feel uncomfortable and ‘unfriendly’ are likely to be much worse for someone with dementia. Yet it is due to these and the fear of becoming lost that few venture into the outdoors, ultimately becoming housebound. However the social, physical and psychological benefits of confident and proficient use of the outdoor environment for people with dementia are abundant.
‚Elderly individuals with dementia are amongst the most devalued members of our society, regardless of their lifelong characteristics and contribution… [the person with dementia} bears the double stigma of age and mental handicap‛ (Burton & Mitchell, Inclusive Urban Design, Streets for Life, 2006, p. 19)
DISABILITY DISCRMINIATION ACT 1995 Disability has now been legally recognised as a cognitive and sensory impairment as well as a physical condition. With this in mind could dementia, although an illness, not also be classified as a disability and if so then why are their needs not taken into consideration by professionals whilst designing the wider built environment. The DDA have created provisions to ensure the ease of access and use of buildings, services and facilities for people regardless of gender, age or ability. But to meet these requirements focus has been put on the accessibility needs of younger people with physical disabilities, such as ramps for wheelchairs users and textured paving slabs and road crossings for the visually impaired. Both of these things an elderly person with dementia could struggle with. They seem to have concentrated on the stereotypical idea of what a disability is rather than the environmental barriers that are created for ALL people. The design of buildings and the built environment have the ability to impede or facilitate people’s movements and mobility. This power should be used to include everyone in society, not exclude those who need it most.
THE STUDY One of the reasons for the lack of research into dementia friendly designs is due to the difficulty in finding appropriate methods to carry out the work. In the past reliance has been put on the opinions of policy makers, professionals, care workers and carers, none of which have to personally deal with the everyday struggle of having dementia. A 3 year research project by the Wellbeing in Sustainable Environments Research Units of Oxford Institute of Sustainable Development (WISE) into examining how the outdoor environment could be made dementia friendly has just come to a conclusion. The study was unlike any done before as it was mainly founded upon information directly from the people with dementia, investigating their perceptions, experiences and use of the outdoor environment. Helping to identify the design factors that influence their ability to use and negotiate their local neighbourhood successfully. The main objectives of the study were as follows: To investigate how older people with dementia interact with the outdoor environment, the nature and quality of their experiences, and their understanding of the outdoor
environment. To identify design factors that influence the ability of older people with dementia to successfully use the outdoor environment To offer preliminary guidance (at all scales, from urban design to the design of street furniture) for designing dementia-friendly outdoor environments. (Mitchell, Burton, & Raman, 2004)
The study comprised of 45 ambulant people over the age of 65 who either live at home or in sheltered accommodation and still regularly used the outdoor environment. 20 of who had dementia in the mild to moderate stages. The process was dived into 3 parts: Interviews using a questionnaire and book of photographs Accompanied walks using observation schedule Environmental analysis using checklist of environmental characteristics.
(Mitchell, Burton, & Raman, 2004)
The results proved that people with dementia are far more restricted, their reluctance to use public transport limits their destination choices to within close walking distance. They were also less aware of any changes made in or around their local area, indicating that any redevelopment could seriously affect their way-finding skills. Whilst on the accompanied walks, nearly one third of people with dementia lost their way compared to the few that admitted getting lost in their interview. Loss of concentration, road crossings and junctions, following not so familiar routes and excessive visual stimuli or information were the main causes. The majority look for landmarks and environmental cues to aid their journey and were quick to realise when they were lost. ‘The fact that those with way-finding problems are more conscious of their need to develop way-finding techniques suggests
that their local neighbourhoods are currently not legible enough to prevent them from losing the way… these findings demonstrate that people with dementia rely increasingly on the legibility of their local neighbourhoods, especially t road crossings and junctions, as their ability to concentrate, to be aware of their surroundings and follow new routes, maps and directions decreases’ (Mitchell, Burton, & Raman, 2004)
STREETS FOR LIFE ‚Designers must be aware of the fact that designing for the ‘average’ person is a thing of the past. The challenge of designing the
‘friendly street’ is a formidable one. The end product must not present a hazard t anyone: young or old, fit or frail .‛ (Burton & Mitchell, Inclusive Urban Design, Streets for Life, 2006, p. 23)
If we take all that we have learnt so far regarding the behavioural and medical characteristics of dementia and there consequences along with the research and development of dementia friendly design in homes and care homes, then apply these principles to the study findings, we can begin to see how to design dementia friendly streets. By making the outside environment more accessible it will ameliorate the sense of isolation and anxiety experienced by people with dementia, giving them greater independence, autonomy and confidence. Whilst stimulating the mind and reaping the psychological, physical and social benefits. Through the research gathered by WISE, a new design concept has been developed. ‘Streets for Life’ addresses the 6 key principles that are thought to be the answer in making the built environment dementia friendly. Dementia friendly urban design should create places that are; o Familiar o Legible o Distinctive o Accessible o Comfortable o Safe
FAMILIARITY A person’s ability to understand their surroundings is extremely reduced due to spatial disorientation forgetfulness and confusion. This can also increase the likeliness of becoming lost and the inability to correctly follow routes and maps. People with dementia are still able to retain new information, but this new knowledge will never become an automatic memory and will require prompting. It is because of this that people with dementia find it difficult to learn from their mistakes. It’s therefore important that dementia friendly neighbourhoods are familiar. This could be achieved through environmental cues that connect with any memories they may have. There is a general conception of what certain places should look like, a stereotypical mental image, for example when you think city hall, you are probably greeted with the image of your home’s city hall, grand, decorative and old. To come across a building that is not what you are used to or expecting can be slightly confusing. But we are able to adjust, learn and accept. When design does not follow these familiar visual styles people struggle to understand them. Similarly people with dementia are unable to fully comprehend modern design. Simple designs that we take for granted, such as sliding doors instead of swinging, things that we have grown up with are not the ‘norm’ for the older generation. So long as technology and design progresses, this is always going to be an issue. In 40 years time the ‘new modern designs’ will be popular and things used today will be obsolete.
Familiar Streets for Life are likely to be places where: Streets, open spaces and buildings are long established. Any change is small scale and incremental. New developments incorporate local forms, styles, colours and materials. There is a hierarchy of street types, including main streets, side streets, lanes and footpaths. Places and buildings are in designs familiar to or easily understood by older people. Architectural features and street furniture are in designs familiar to or easily understood by older people (Burton & Mitchell, Inclusive Urban Design, Streets for Life, 2006, p. 63)
LEGIBILITY It has been suggested that the design layout of dementia care homes can be directly reflected into the urban layout, improving way-finding and orientation. Just like corridors, short, gentle winding streets have shown to be more useful than long straight streets as it is deemed as ‘more interesting’ and are therefore more likely to make the pedestrian maintain concentration. But this alone does not resolve the issue-
‚To become completely lost is perhaps a rather rare experience for most people in the modern city. We are supported by the presence of others and by special way-finding devices; maps, street numbers, route signs, bus placecrds. But let the mishap of disorientation once occur, and the sense of anxiety and even terror that accompanies it reveals to us how closely it is linked to our sense of balance and well-being‛ (Burton & Mitchell, Urban design for longevity) Environmental cues and landmarks are essential to help encourage the memory, these cues and landmarks will only be successful however, if they re encountered on a regular basis. It is therefore important that they remain in situ.
Legible Streets for Life are likely to have: A hierarchy of street types Blocks laid out on an irregular grid based on an adapted perimeter block pattern Small street blocks of varying length from around 60-100m Well-connected streets Gently winding streets with open ended bends and corners greater than 90º Short, fairly narrow streets Forked, staggered and T-junctions rather than cross-roads Places and buildings with clearly visible, obvious and unambiguous functions and entrances Minimal signage giving simple, essential and unambiguous information at decision points Street furniture and other latent cues positioned at decision points and where visual access ends. (Burton & Mitchell, Inclusive Urban Design, Streets for Life, 2006, pp. 76-77)
DISTINCTIVENESS The presence of distinctive features throughout the dementia friendly neighbourhood, whether it be a tree in a garden or public art or even a public telephone can help aid wayfinding. The repetition of architectural styles, materials and features that you commonly find on residential streets and cul-de-sacs should be avoided as this can cause confusion.
Distinctive Streets for Life are likely to have: Local character. Varied urban and building form. Small, informal, welcoming and understandable local open spaces with varied activities and features. A variety of open spaces, such as public squares, village greens, allotments and parks. Streets, places, buildings and architectural features in a variety of local styles, colours and materials. A variety of historic, civic and distinctive buildings and structures. A variety of places of interest and activity. A variety of aesthetic and practical features, such as trees and street furniture (Burton & Mitchell, Inclusive Urban Design, Streets for Life, 2006, p. 91)
ACCESSIBILITY With age comes reduced stamina, frailness and a reduced sense of balance. It is therefore no surprise that accessibility is the one key requirement that has actually been considered in today’s built environment. Being able to access a building with ease is something that many people over look until they have to experience it themselves. Trying to open up a door whilst carrying all your shopping bags is a simple yet difficult task. It is only when we provided ourselves with a slight handicap that we can get a slight insight into what life is like for someone living with it.
Accessible Streets for Life are likely to have: A mix of land uses. Housing located no further than 500m from local primary services and facilities, including general food store, post office, bank, GP surgery/health centre, green space, public toilets, public seating and public transport stops. Housing located no more than 800m from local secondary services and facilities, including open spaces, a library, dentist, optician, place of worship, community and leisure facilities , Entrances at ground level whenever possible with flush thresholds. Public seating every 100m to 125m. 2m wide flat footpaths. Gentle slopes rather than one or two small steps where slight level change is unavoidable. Gates/doors with no more than 2kg pressure to open and levers rather than knobs. Level changes that are clearly marked and well lit with guards, handrails and non-slip, non-glare surfaces. (Burton & Mitchell, Inclusive Urban Design, Streets for Life, 2006, pp. 102-103)
COMFORT Walking along side a busy road can be frightening and disturbing for anyone but these excessive external stimuli can cause agitation and anxiety for people with dementia which could then lead to confusion and disorientation. It is therefore important to limit crowds, control noise and audio or visual information.
Comfortable Streets for Life are likely to have: Calm, welcoming feel. Familiar buildings and features in designs older people recognise. Small, quiet well-defined open spaces, free from motorised traffic and with seating, lighting, toilets and shelter. Quiet side roads as alternative routes away from crowds and traffic Some pedestrianised areas to offer protection from traffic. Acoustic barriers such as planting and fencing to reduce background noise. Enclosed bus shelters with seating and transparent walls or large clear windows. Enclosed telephone boxes. Ground level conventional public toilets in view of buildings and pedestrians. (Burton & Mitchell, Inclusive Urban Design, Streets for Life, 2006, p. 114)
SAFETY Visual impairment, brittle bones, bad hearing and poor balance can all lead to injury, a dementia friendly neighbourhood must take all this into consideration and adapt. With older people requiring five times more lighting than younger adults, lighting that may be suitable for you can be can reduce the ability to see obstacles and makes depth hard to perceive. Broken pavement slabs that could normally be avoided become a real hazard for someone whose reflexes are slow. The decrease in hearing makes any warnings difficult to hear which could potentially be fatal.
Safe Streets for Life are likely to have; A mix of uses. Buildings, doors and windows facing the street. Clearly marked bicycle lanes separate from footways. Pedestrians separated from traffic by trees, on-road parking or bicycle lanes. Signal-controlled pedestrian crossings with visual signals on both sides of the crossings and audible cues at a pitch and timing suitable for frail older people. Traffic calming measures in clear colour and textural contrast to footways and pedestrian crossings. Wide, well-maintained, clear footways. Flat, smooth, non-slip paving. Grates and drains flush with paving and openings smaller than walling stick or shoe heal size. Trees with narrow leaves that do not stick to the pavement when wet Spaces and buildings designed and oriented to avoid areas of dark shadows or bright lights. Street lighting adequate for people with visual impairments (Burton & Mitchell, Inclusive Urban Design, Streets for Life, 2006, p. 128)
CONCLUSION From the design and placement of street furniture to irregular street layouts, building styles and signage. It all comes together to create an environment that directly influences the orientation and way-finding abilities of older people with dementia. By creating an environment that understands the needs of its users it is possible to influence the mental wellbeing of people as well as physical. Referring back to the question I asked at the start of this essay ‚is it possible to create architecture and urban environments that influences the human psyche, working well for the ‘average’ person but also influencing and affecting the overall wellbeing of those with disabilities- physical and mental?‛ I have come to the conclusion that not only is it possible, the medical research proves it, but it is much overdue. With the rise in people with dementia set to increase indefinitely then something must be done to make the quality of life better now. By creating an environment that even older people with dementia can use effectively, it can assist everyone who uses it regardless of any disability. Confusion, forgetfulness and physical impairment are things that affect us all at time to time, so by creating an environment that aids navigation, orientation, movement and creates peace of mind, the benefits will spread beyond people with dementia.
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