Facility Design Improves Dementia Residents' Social Well-Being

By Jamie Santa Cruz

Specialized design features must be considered in planning residential facilities to optimize quality of life for patients with dementia.

Multiple studies suggest a relationship between the design of a physical environment and the social interaction that takes place in that environment.1-6 Ongoing research from the University of Kansas underscores the importance of facility design for dementia residents in particular, showing that careful design can result in deeper, better quality social interaction among residents—a finding that has significant implications for improving the well-being of those living with dementia.7

"With baby boomers moving toward their golden years, the need for effective long term care facilities, particularly for those with dementia, is growing at a rapid pace," says Farhana Ferdous, PhD, a lecturer in the school of architecture at the University of Kansas. "So far there is no established cure for Alzheimer's disease, but architectural design can offer a lot by changing behaviors and attitudes of the residents and caregivers."

Accessibility and Visibility
Ferdous's ongoing research is based on a pilot study published two years ago, in which she and coauthor Keith Diaz Moore, PhD, dean of the college of architecture and planning at the University of Utah, used spatial syntax theory to examine how the spatial configuration of long term care facilities (LTCFs) could impact the social interactions of residents with cognitive impairments. Space syntax relies on the objective measurement of specific environmental characteristics—such as visibility and proximity—that can be applied to any physical setting. Using these objective measurements, Ferdous and Diaz Moore were then able to compare specific features of LTCF environments with the types of social interactions occurring in those environments, thereby identifying elements of an environment that encourage various forms of social interactions.

The key finding of the pilot study was that spaces that are less accessible and less visible generate better quality social interactions among residents than spaces with greater accessibility and visibility. "Architectural configuration not only influences conversation but also the type of conversations likely to occur in certain locations," Ferdous says.

In particular, out-of-the-way spaces such as nooks in a corridor  or areas with just two or three chairs tend to generate longer lasting, deeper conversations, whereas social interactions in large open areas tend to be shorter and more superficial—possibly limited only to salutations. "Where you actually see the deeper engagement in conversation is in spaces that have some degree of privacy and that are somewhat removed from the main path in the facility," Diaz Moore says.

Even within larger more open and more accessible spaces, furniture arrangement can impact the type of interactions that occur, Ferdous says. Within such larger environments, clusters of two or three chairs in an arrangement that provides some sense of controlled access and privacy appear to encourage social interactions of greater depth, she explains.

The findings regarding the effects of visibility and accessibility run counter to the results of previous space syntax literature, Diaz Moore says. Previous work on space syntax has focused only on identifying environments that produce moresocial interaction, without distinguishing among various types of interaction or considering the length, depth, or quality of a given interaction. Thus, he says, much earlier literature has recommended creating social spaces on a larger scale, where the intent is for interactions among 8 to 10 people. Those kinds of spaces trigger certain kinds of interactions, Diaz Moore says, but not the deeper, longer lasting interactions that have been shown to have the greatest therapeutic effect. "There's more to it than just quantity of social interaction; we've got to worry about the quality of it," he says.

Whereas the pilot study focused on only three LTCFs located in Kansas, Ferdous has received a new grant from the Toyota Foundation to expand her research to more facilities. Fall 2017 will mark the beginning of the use of the same methodology to examine 10 to 12 facilities across the United States, attempting to extrapolate her findings on the local level to the country as a whole.

The ongoing research could help relieve some burdens on caregivers, Diaz Moore says. To date, it has been common to assume that people with dementia need more facilitation in order to engage in deeper, more meaningful conversations, and therefore facilities tend to be designed for large group interaction on the grounds that a staff member needs to be present to orchestrate the social interaction. "But it may very well be that if we create little conversation groups of two or three chairs and something that might serve as a focus point—whether it's a newspaper or whatever might trigger conversation—that would probably facilitate conversation on its own for whoever chooses to sit there," Diaz Moore says.

Importance of Environmental Design for Dementia Residents
Environmental design is important for the general population but even more so for individuals with lowered competencies, says Margaret Calkins, PhD, executive director of the Mayer-Rothschild Foundation, who has published extensively on environmental gerontology. According to the environmental press model, developed by M. Powell Lawton, environments exist on a spectrum: at one end are environments that are excessively complex and require extensive cognitive processing to navigate ("excessive press" environments); at the other end are sensory deprivation environments that are excessively understimulating ("zero press" environments). Either extreme is detrimental and produces dysfunction.

Importantly, the amount of environmental press that an individual can tolerate differs based on an individual's level of cognitive functioning. "As your competencies decrease—as they do with someone who is living with cognitive impairment and dementia—the amount of environmental press you can manage is less," Calkins says. "It's much easier for a person to get into an environment where the environment is making too many demands on the individual for them to be able to cope successfully." The implication, she says, is that environmental design must be a greater priority for individuals with lowered competencies.

According to Calkins, successful environmental design for individuals with dementia must take into account a variety of concerns, including those related to privacy, quality of stimulation, way finding and orientation, control, and territoriality.

Although there is an array of concerns to consider, social interaction is a particularly important one. According to Ferdous, previous research suggests that residents themselves place a higher value on social environment than on other aspects of a care facility. Furthermore, positive social interaction is a valuable therapeutic intervention that has been shown to reduce many of the challenging behaviors associated with dementia, such as agitation.8

Beyond Accessibility and Visibility
While Ferdous' and Diaz Moore's research has focused specifically on accessibility and visibility, Calkins adds that a number of other environmental aspects have been shown to influence social interaction among long term care residents. For example, she says, at a very discrete level is the issue of chair placement—chairs should be placed at right angles rather than side by side, and they should be placed at an appropriate distance for conversation, recognizing that older adults may have difficulties with hearing or vision and may need to be in closer proximity for conversation than younger counterparts.

Additionally, environments designed for dementia residents should provide props for conversation. "People who are living with dementia often have a harder time figuring out how to initiate conversational interactions," Calkins says. "They have lost the ability to pick up on an interesting topic and just start talking about it. So you want to design the spaces so there is access to props and things that will support easy communication." For instance, a small grouping of chairs in front of a window with a meaningful view—where residents can discuss the horses in the pasture across the way, or the birds perched on the fence post—will generate far better interactions than a grouping of chairs in a blank room.

Along similar lines, environmental designers who want to stimulate social interaction must think in terms of providing activities for residents to engage in side by side. "Social engagement works best when you're doing something together," Calkins says. On a micro level, this might mean providing access to games or hobbies such as knitting or crocheting. On a larger level, it might mean designing kitchen facilities for resident involvement. According to Calkins, the former thinking was that kitchens are hazardous, so it would be better to serve residents their food on a tray in the dining room. Now, however, experts in LTCF design encourage residents to become engaged in helping to prepare part of the meal. "If they don't want to do the work—and some of them don't—they can sit there and talk with the staff. If she's making a carrot cake, you can talk about, 'What's your favorite flavor of cake? Did you ever make carrot cake? Do you like this kind of frosting or that kind of frosting?' Relationships are built on those kinds of conversations."

Looking to the Future
According to Calkins, newer communities or those that have had recent renovations typically do a relatively good job of incorporating elements that encourage quality social interactions. The challenge, she says, is that many care facilities—particularly nursing homes—are several decades old and have not seen meaningful renovations. At the time these older facilities were built, the assumption was that residents would spend their days either in bed or in a single shared multipurpose dining/game room. That sort of design, she says, "is just not supportive of a meaningful life that can be filled with lots of joyous moments," and thus the US has a long way to go to improve the living environments for the nation's dementia residents.

It's a challenge that facility designers and managers need to take seriously, however. "All too often we think of people with dementia as suffering loss, and we depersonalize them," Diaz Moore says. "But when you actually get to talk with a person with dementia and interact with them, you realize that the humanity is still there, the person is still there. The quality of life for them should be of no less value than the quality of life for the rest of us."

— Jamie Santa Cruz is a freelance writer based in Englewood, Colorado.

References

1. Cioffi JM, Fleming A, Wilkes L, Sinfield M, Mier JL. The effect of environmental change on residents with dementia: the perceptions of relatives and staff. Dementia. 2007;6(2):215-231.

2. Davis S, Byers S, Nay R, Koch S. Guiding design of dementia friendly environments in residential care settings: considering the living experiences. Dementia. 2009;8(2):185-203.

3. Kang H. Correlates of social engagement in nursing home residents with dementia. Asian Nurs Res. 2012;6(2):75-81.

4. Kovach C, Weisman G, Chaudhury H, Calkins M. Impacts of a therapeutic environment for dementia care. Am J Alzheimer Dis Other Dement. 1997;12(3):99-110.

5. Lawton MP, Fulcomer M, Kleban M. Architecture for the mentally impaired elderly. Environ Behav. 1984;16(6):730-757.

6. Lawton MP, Simon B. The ecology of social relationships in housing for the elderly. Gerontologist. 1968;8(2):108-115.

7. Ferdous F, Moore KD. Field observations into the environmental soul: spatial configuration and social life for people experiencing dementia. Am J Alzheimers Dis Other Demen. 2015 Mar;30(2):209-18.

8. Coons D. Specialized Dementia Care Units. Baltimore, MD: 33. Johns Hopkins University Press; 1991.