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Evidence Based Design of Physical Environments for People with Dementia -…
Evidence Based Design of Physical Environments for People with Dementia
Evidence Base
Statistics?
Roughly 200 different kinds of dementia
One of, if not the biggest cause of death in many countries
More than 50% of RAC residents & upwards of 90% in many cases.
Many care providers have a designated 'dementia' care wing, but statistics of dementia prevalence in care homes there is strong cause for all RAC environments to be designed to provide cognitive support required by people with dementia. In future - ALL RACF settings should contain high quality dementia design!
60-75% of people with a diagnosis of dementia remain living in their own community.
Evidence Grades
High Quality Formal Research
Med-Low quality formal research
'Expert' guidance
Personal/Professional experience
Gray literature (e.g. Building Regs)
Building regulations are almost always implemented as a means of protecting life and preserving occupant health. Whilst more onerous fire safety requirements in residential care, versus other building types, recognise the limited physical mobility of a cohort of older people, there are very few examples worldwide of regulations -even in care homes - that support cognitive impairment.
Evolution over time
Historic Residential Care Focus
Recently evolving for Hospitals and Public Spaces
Older evidence remaining broadly correct
Refined and nuanced understanding
Differing needs of Individuals
Changing needs over time - design for life stages
Quality of life - optimising life living with the condition.
Design quality is improving over time - but still has significant room for improvement.
Evidence Types
Dementia Specific
Age Related Impairment
Evidence from Wider Fields
Health
Environmental Psychology
Environmental Science
Social Sciences/Public Health
Ecology and Climate Change
Universal Design
Philosophical Underpinnings
Human Rights
WHO definitions(?)
Disability only occurs where impairment meets poor design...
Disability Rights/Discriminisation
Dementia Design Principles
Optimising RAC design - (per the floorplans illustrated)
Fewer residents per household - potentially having several households within a neighbourhood as a way of optimising operational elements - but preferably set amongst a normal mixed and multigenerational neighbourhood.
More floor area per resident
not simply about making every space bigger (as long as communal spaces are not overcrowded and space allows for movement of wheelchairs and lifting devices) - but more about social choice and opportunity such as the provision of alternative lounge and dining spaces, activity spaces etc. Wider corridors also allow for the casual interaction that help build relationships and sense of community (that protect from loneliness and depression).
Ground floor tend to be better than upper floor located units.
Access to outdoor spaces
Facilitating meaningful activities and ADLs as forms of therapy, providing a sense or purpose, and as means of preserving and even improving functional independence.
High degree of cognitive accessibility. This is preferably provided through spatial arrangement that optimises visual access. Failing that the use of well designed signage or layouts that remove wayfinding decision making allowing residents to 'follow their nose' to find the spaces they are looking for.
Examples might include: Seeing communal spaces (dining and lounges) upon stepping out of the bedroom; being able to see between the lounge, dining, and kitchen spaces; ensuring the doors to toilet spaces are visible from key social spaces.
Movement, Visual Access, Privacy vs Social Interaction, 'Invitation' (to undertake meaningful activities, to use a variety of welcoming spaces, to be involved in (or just observe) different types of social interaction.
Move towards design to prevent or delay dementia
Design Assessment
Consistency /Reliability
Checking design quality without the need for 'expert' input; or as an object means of reviewing and discussing an environment.
Existing tools including the DSDSC's DDAT tend to be well suited for assessing existing environments - but can be used in an informal way to guide the design process for new
The DSDC's DDAT is well established as the most extensive validated tool of its kind. Studies involving use of the DDAT by both experienced and novice assessors have shown high rates of consistency in assessment outcomes making the DDAT a reliable means of detailed assessment of dementia design quality. This book recognises the impact of the DDAT in helping to define benchmarks of dementia design quality, and as a celebration of exemplary output in skilful implementation of dementia design by designers and builder builders, and to the clients with the forethought and outlook that considered how their commissions could improve the lives of their tenants, clients, or customers.
Design Process
The earlier in process that design decision are made the better. Whilst the design process is to some degree iterative, early design decisions can predetermine the available options later design decisions. Many of these are difficult to undo at later stages. Planning approval for example can legally lock-in some key elements dementia design related to layout planning limiting subsequent change, whilst design changes after construction could be prohibitively expensive to implement.
The illustrated plans were amongst the most highly rated layouts for dementia design quality as determined by research (Quirke 2019) which assessed 90 international best-practice examples using dementia design assessment from the EAT (Fleming 2011) which is based on the same formal research evident cease as the DDAT.
The importance of these early design decisions have historically been somewhat underrated. Considering that XX% of queries in the DDAT refer to plan-based design decisions - these have a significant potential impact on the resulting dementia design quality - or potentially affecting the award grade under the DSDC's Dementia Design Accreditation programme.
Early design determines important factors including community and amenity (sitting the facility in the right place to begin with), and environmental health impacts (Sun/Exercise/Air Pollution)
Critical Precedents
DSDCs International Work
Design evidenced to improve wellbeing
Aesthetic qualities are less important
Cross-cultural design principles
Core Principles
Local Manifestations
Reflecting culture, Care Model etc
Recognition that Social elements (e.g. Care) and Physical environment must work together
No designer want to reinventing the wheel so make use of precedent designs as a way of informing their proposals. However the use of precedents can be dangerous as those accepted without critical assessment of what works for the occupants and why, poses a risk that occupant wellbeing suffers as a result.
No perfect solution - but precedents known to address key evidence based principles may form good starting points.
Variety of factors
Care Model
Person Centre care models are preferred but may not be implemented.
The interpretation of 'Person Centred care may also vary by culture, or organisation.
RAC design which does not reflect the care model is unlikely to support optimal wellbeing for residents .
Climate
Affects relationship with outdoor spaces - whether shelter is from wind and rain, hot overhead sun, or conversely to need to maximise exposure to sunlight (for purposes of vitamin D, Nitric Oxide, and orientation to the time of day).
Culture
English, Japanese, Aboriginal Australian cultures may required significantly different physic care environments.
Traditional ways of living, activities, roles. Issues of identity and memory related to History, Geography, Religion and Race.
Physical Context
Size and Shape of Site
Density - including whether multiple storeys are retired.
The floorplans illustrated along side this text represent a selection of some of the highest rated floor plan layouts we found in research that analysed 90 RAC units from professional dementia design publications. We have not illustrated the many floorpan types from this research which performed poorly - but the outcomes confirm the need for critical evaluation - even when presented with information endorsed by those with some expertise.
Includes examples form Asia, Australia, Europe, and North America.