5 th International Dementia Care Conference Hosted by Sonas apc, RDS, Dublin 16 April 2013

1. "Supporting the Person with Dementia in Residential  Care: What Role Does the Physical Environment Play?” 5th International Dementia Care Conference Hosted by Sonas apc, RDS, Dublin 16 April 2013 Dr Maria Pierce and Associate Professor Suzanne Cahill, DSIDC’s Living with Dementia Research Programme, School of Social Work and Social Policy, Trinity College Dublin piercema@tcd.ie www.livingwithdementia.tcd.ie

2. Overview • Why design for dementia? • Impact of physical environment: evidence from research • Bringing in the voices of people with dementia • Concluding remarks

3. Why focus on physical environment? • Dementia is a leading cause of disability in later life, but no known cure for dementia • Non-pharmacological interventions will not arrest progression of condition, but are promising in lessening the effects and enhancing QOL • Built environment poses a challenge for many people with dementia, who are no longer able to adapt and instead the environment must be adapted to the person’s specific needs • Designing and modifying buildings for people with dementia holds promise and plays a role in supporting people with dementia in residential care

4. Residential care settings are complex Even the best physical environment can be undermined if the structure of the organisation, the social and physical environments are not working together in an integrated system to support the unique needs and abilities of people with dementia and their caregivers

5. International consensus regarding the principles of good design for dementia • compensate for disability • maximise independence, reinforce personal identity, and enhance self-esteem/confidence • demonstrate care for staff • be orienting and understandable • welcome relatives and the local community • control and balance stimuli  (Judd, Phippen, Marshall, 1998; Marshall, 2001)

6. International consensus regarding the design features for dementia small in size familiar style: domestic and homelike scope for ordinary activities rooms for different functions equipped with familiar fixtures and fittings single rooms good signage and multiple cues control of stimuli a safe outside space (Judd, Phippen, Marshall, 1998; Marshall, 2001)

7. Trend towards small-scale home-like physical environments

8. Impact of the physical environment • Research has demonstrates the potential that the physical environment has for contributing to the improvement of behavioural symptoms associated with dementia (e.g. Zeisel et al., 2003) • Many of the principles behind dementia design are concerned with making the spatial environment more easily understood and therefore less threatening and less likely to cause the confusion and aggressive behaviour that anxiety can arouse in PwD

9. Available evidence strongly supports: • Small groupings of residents • A variety of spaces, including single private bedrooms • Unobtrusive safety features • The enhancement of wayfinding and visual access • Optimisation of levels of stimulus, esp. increased ambient lighting • Avoidance of strong contrasts in flooring and patterns in flooring

10. The ‘lived experiences’ of dementia To create appropriate physical environments, an understanding of the ‘experiences’ of people with dementia in everyday life is important. (Davis et al., 2009)

11. ‘Living experiences’ that warrant consideration in designing care environments for people with dementia include: Presentation of self Family and social connections The eating experience Staff Personal enjoyment End-of-life experience The bedroom (Davies et al, 2009)

12. Environment as an occupational space Attention must be paid to how therapeutically designed, beautiful, and homelike architectural spaces can be transformed into alive occupational spaces, as well as to what personal and institutional contributions and commitments are needed to make such transformations a reality (Woods et al., 2005)

13. Hearing the voices of people with dementia about care buildings • Bricks and mortar versus people: Residents with dementia were quite clear in ranking what they were most concerned about: ‘the building itself was of lesser concern’. • Familiar and treasured items • Variety and choice of spaces: provide opportunities for PwD to remain engaged in everyday life in meaningful way, e.g. the bedroom for privacy • Presence of children and animals in the building • Areas with views to entrance or where staff are based most popular • Safety versus autonomy (Innes et al., 2011)

14. Most important features • Wayfinding: people with dementia and family caregivers spoke about the need for wayfinding cues to be able to find the toilet, their bedrooms and quiet spaces to be alone • Outside space: provides opportunities for activities and spending time with relatives outdoors (Innes et al., 2011)

15. Some concluding remarks • Physical environment matters, but does not in itself guarantee quality care • Need active and focused intervention of trained staff for environmental provisions to have an effect • Physical location and connection to the wider community - “a home from home” • Listening to what people with dementia who reside in long-stay residential care buildings can help us to re-imagine the physical environment

16. “ … providing the best physical environment for people with dementia is not a question of money or luck, but of good, thoughtful, person-centred design.” Stephen Judd (Judd, Phippen, Marshall, 1998)

17. Thank you

18. Acknowledgements