Revisiting design philosophies for desegregating dementia environments

This past April, the Design for Aging (DFA) Knowledge Community hosted an education session titled “Design Philosophies for Desegregated Dementia Environments.” Among the key takeaways from this informative webinar, attendees were reminded of just how much progress has been made in the design of dementia-care environments over the last three decades. The pivot from institutional settings to more residential and home-like models is largely what has defined this progress, although larger systemic changes have also occurred as policy makers considered how towns and cities engage with older adults suffering from cognitive loss.

One area where less progress has been made, however, is in matters of integrating dementia-care environments at the community level. According to the webinar’s host, Max Winters, a senior associate with Perkins Eastman, this failure to make headway has left a “significant gap in the continuity of environmental scales” for residents. “When dementia environments are treated as ‘other’ spaces, apart from the surrounding community—our normal world—then it stigmatizes those environments and the people in them.”

A Brief History

Less than 30 years ago, on an average day approximately 500,000 older Americans in hospitals or nursing homes were physically restrained. Then, in 1996, a grant-funded education program called the Pennsylvania Restraint Reduction Initiative (PARRI) was enacted, and by 2015 the state saw a 97.6% drop in physical restraint use in senior care environments.

PARRI and other advocacy programs around the country, such as Dementia Friendly America, were largely responsible for shifting people’s perceptions about how to care for older adults. Through efforts to enhance the quality of life for people experiencing dementia, the idea of “memory support” began to take hold within the growing senior living industry. In these new memory support communities, older adults were no longer subjected to institutional environments modeled after psychiatric hospitals.

While the widespread adoption of memory support environments became more common and improved the quality of life for residents, even the best of these facilities in the U.S. limited dementia residents to a relatively compact footprint, either as a secured unit within a larger senior living community, or as a standalone building.

In the Netherlands in 2009, a new kind of memory support community opened, called Hogeway. At Hogewey, residents were given free access to a village at a real-world scale, which proved that people living with dementia could thrive when given more freedom. This experimental and innovative community helped developers and operators realize that memory support environments could expand beyond a very limited footprint and in fact be part of a much larger community.

The Tension Between Spaces

Within the full spectrum of private and public places that people frequent, neighborhoods bridge the gap between intimate spaces and the city scale. The neighborhood is where people gather and build the bonds of community, and those bonds in turn lend a richer texture to feelings of “home.”

In a senior living community, amenity spaces and living areas are where that neighborhood-level socialization occurs. Providing activities at the neighborhood scale helps connect dementia residents to their community. Art classes, performances, games, dining, and other leisurely pursuits provide opportunities for residents to develop meaningful relationships with others, and because those activities occur in the public realm, it makes sense to design them at scales that differ from resident units.

“Certain activities feel abnormal in a residential setting. And it can be outright confusing for someone with cognitive loss” when their public and private spaces (and lives) become too blurred. When residential and communal spaces are too integrated, both in terms of scale and aesthetics, “you can lose that social benefit, and then that scale of living is compromised,” says Winters.

Principles for Innovation

When it comes to designing the dementia-care environments of the future, Winters highlights several worthwhile strategies with proven results:

• Grouping like-minded seniors with similar interests and schedules together helps ease the transition of moving into a new space.
• Providing access to natural environments facilitates multi-sensory engagement.
• Decentralizing a facility’s resources empowers frontline staff to be more proactive caregivers.
• Blurring the lines between front-of-house and back-of-house activities to help deinstitutionalize staff operations and create a more residential environment.

There are other innovative measures critical to creating authentic living experiences, but the real impact stems from “how we apply them and make these decisions,” says Winters. Thoughtful design is imperative to giving residents an authentic and enriching home environment.

Winters points to some important questions that collectively define the criteria for evaluating design and programming decisions:

• Does this space look and feel normal or institutional?
• Are programming decisions made unilaterally or do staff and residents have autonomy?
• What element of risk is involved?

“A fulfilling life always involves some amount of risk,” says Winters. “If we cut that off and create environments that feel overly secure, then we need to ask how much harm that’s inflicting on residents? You can have a secure perimeter without locking people in.”

Whether housing models for dementia care are suburban or urban in nature (pastoral or vertical), Winters points out that a “residential aesthetic” is just as important as having public realm spaces with their own distinct character. “We need to make up that ground when it comes to connecting these older adults with their communities and neighborhoods. And the best part is there are many ways to achieve this. It’s not just aspirational.”

Early Adopters in North America

Developers in the U.S. and Canada are beginning to focus more on bringing a dementia village like Hogewey to North America. While some modifications are necessary to accommodate cultural differences, a handful of forward-thinking developers are keen to the challenge. Three case studies highlighted in the presentation include:

• The Enclave, East Coast, U.S. (still in design)
• Baycrest Memory Support, Toronto, Ontario
• United Active Living, Calgary, Alberta

Each of these projects brings innovative ideas to creating memory support communities here in North America. For more detailed information about these communities, download a recording of the webinar.

Closing Thoughts

According to the Population Reference Bureau (PRB), a nonprofit organization that collects statistics for research and other academic purposes, experts project that by 2030 more than 9 million Americans could have dementia, and that number could grow to nearly 12 million by 2040. For those elders living in assisted living and nursing care environments today, a recent study showed that upwards of 70% of residents ages 70 and older are reported to have some form of dementia. That means that with people living longer lives, and a cure for Alzheimer’s and other dementias not yet available, the number of older adults needing memory support environments will continue to grow.

We must continue to innovate to improve the quality of life for older adults with dementia. As presented in this webinar, we know there is still a great deal of room for improvement in memory support environments, and big gaps to fill at the neighborhood scale of living. How can we better design memory support communities to provide an authentic, neighborhood-focused experience for residents? Are you seeing or hearing any new ideas that might be game changers for the industry?