Design for dementia

B. ARCH DISSERTATION APRIL 2022

A Dissertation submitted in partial fulfillment of the requirements for the award of Bachelor’s Degree in Architecture of Cochin University of Science and Technology Submitted by Miss. A Merlin Gomez Guided by Prof. Praseen Chandra Mohan

Marian College of Architecture and Planning Kazhakoottam, Thiruvananthapuram Email:marianarch.in@gmail.com Mob: 8281388111 www.mcap.edu.in

DESIGN FOR DEMENTIA:PERUSING ELEMENTS IN ARCHITECTURE FOR PEOPLE WITH DEMENTIA IN GERIATRIC CARE CENTRES EIGHTH SEMESTER

1

1 Introduction Background

Sensory means, “of or relating to sensation or to the senses sensory stimulation.” As defined by Merriam Webster. Sensory design is the type of architecture that helps build habitable spaces that activates the senses, namely touch, sound, smell, sight, sound, of a human being, letting them experience the space in a different light. It helps evoke the senses of a person, bringing back memories from the past that have been subconsciously imprinted in the memory.

Dementia is an illness of old age, usually characterized by a progressive decline in cognitive functions from the previous level. Loss of memory for recent events is a classical feature. A number of cognitive functions including new learning, intelligence, decision making, executive functioning and language are affected, besides the memory. It mainly affects older people; only 2% of cases start before the age of 65 years. After this, the prevalence doubles with every five year increment in age. Dementia is one of the major causes of disability in late life. Prevalence of dementia in India is reported to be 2.7%. As age increases, the prevalence of dementia increases. Mean age of presentation is relatively younger at 66.3 years in India, about 10 years less than in the developed countries. With the increasing elderly population and reduced joint family system in our country, dementia poses a great challenge.

Dementia is one of the major causes of disability in late life. There are various types of dementia including Alzheimer’s disease, vascular dementia, Lewybodydementia, frontotemporal dementia etc., all of which are caused by reactions in the brain. These types of dementia cannot be reversed and are nearly impossible to treat. There is also dementia caused due to excess alcohol consumption, unhealthy lifestyle and other external injuries or impacts.

Dementia is usually noticed not by the individual, but by people around them. They have various difficulties like memoryloss, communication, complexityin visual and spatial abilities, reasoning or problem solving, handling difficult tasks, planning and organizing, coordination and motor

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

functions etc. They are usually very confused and disoriented. Apart from these, dementia can also cause various psychological issues like personality changes, depression, anxiety, paranoia, agitation, hallucination etc.

As dementia is a progressive illness, treating and curing them is almost impossible. But, the development of the disease can be prolonged and in very rare cases be overcome if handled with proper care and methods. This is where sensory design plays the role of healing, or as in this case, prolonging dementia. Main elements of sensory design, visual implantation, cognitive development, evocation of memory through all five senses, are used to help prolong the illness along with other factors like sustainable healthy living and participatory architecture.

In the current scenario of India, it is estimated that there is a rise in about 25% occupancy of old age homes every year and people who are in need of constant medical attention are also put in these homes due to lack of knowledge of geriatric centres and are often confused. Geriatric centres are those centres that take care of senior citizens with terminal illness that require around the clock assistance. These are the centres where the senior citizens with dementia will receive proper care at, and also provide facilities of a retirement home.

Unlike the West, in India most of the elderlypeople live with their families and most patients with dementia are taken care of by their families. With the increasing elderly population and reduced joint family system in our country, dementia poses a great challenge. Cost of providing institutionalized care, paying care providers including physicians, long term care/nursing homes and hospitals, medication, community based care, over the counter medications and other out of pocket expenses. Even insurance plans are not available for the treatment of dementia as it is progressive.

Need of the study

In geriatric centres, there dwell a lot of people with a wide variety of illnesses. Various design methods are used to usually incorporate sustainable and participatory design into the architecture of the space, considering all patients alike. But this might not be enough for a patient suffering with memory loss or dementia. The present prevention, care and management methods of dementia might not be accessible for everyone. This does not mean they should be neglected. The management methods mentioned are very much evident that they can be solved through architectural design strategies at various scales. Instead of searching for new ways of finding

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

sources to afford these methods, thoughts can be applied and various design strategies based on sustainability, sensory design, participatory design can be practiced so that in some or the other way, costs can be cut and made available to everyone.

This dissertation paper mainlyfocuses on perusing tactile elements in architecture for people with dementia in geriatric care centres for making their life easier and to make care and treatment for dementia available and accessible to everyone.

HYPOTHESIS

Use of sensorydesign strategies while designingold age homes and geriatric care centres can help peoplewith dementiato mitigatethe effects ofthe condition andimprovequalityoflife,positively affecting their mental and physical health.

AIM

Study how architectural design elements can be incorporated in geriatric centres and formulate a comparative analysis based on various architectural parameters to help people with dementia attain treatment and care, and to help mitigate the effects of their condition.

OBJECTIVES

01. To study in detail the relationship between dementia and architecture by analysing the movement and general behaviour characteristics portrayed by people with dementia.

02. To cite and analyse how various tactile design elements are and can be used in various geriatric centres for wayfinding and to increase their safe movement.

03. Toformulateparameters basedonwhichgeriatric centrescanbedesignedtoaccommodate people with dementia.

RATIONALE OF STUDY

“Though those with dementia might forget us, we as a society must remember them.”

Scott Kirshenbaum

Marian College of Architecture and Planning, Thiruvananthapuram

People with dementia are usually confused and lack understanding skills. For this reason, they are not allowed into the public without surveillance. Even under surveillance, they might get out of hand due to gap in memory between two time frames and lack of ability to recollect events or situations. They are usually locked up in their homes or sent to geriatric care centres or old age homes. Old age homes and geriatric centres are not specifically designed to accommodate these people, but a larger population of patients. Designing and installing structures just for them are highly expensive and a luxury many cannot afford.

This is how the need to explore methods to integrate sensory design methods into existing care homes came into vision. As architects, it is not only our duty to make habitable spaces for those who can afford and manage, but also make life easier for those that are helpless and are usually neglected. To be able to make a small difference in at least one person’s life, was what led to the concreting of the dissertation topic.

SCOPE

The number of elderly populations in India keeps on increasing at a steady rate every year. Along with aging, comes various health related issues, among which dementia, now a days, is very common. There is no said treatment or medicines to completely cure dementia. There are rarely any insurance policies that cover dementia, as it is a progressive illness, making it even harder for some of the population. One of the primary ways to combat the illness is to prolong it. This can be done byfollowing a healthylifestyle. The other way of achieving it is through usage of sensory design techniques in care centres. But, due to the generalized design of care centres accommodating a large group, dementia again goes unnoticed and the need to heavily medicate the patient arises.

To make life easier for people with dementia, this research paper focuses on evaluating sensory design techniques to achieve better mental and physical health of people with dementia. It takes into account the often-ignored user group but with a high share of population in the country.

LIMITATIONS

This research paper had a few limitations that had to be considered before its in depth study and analysis.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

01. Doesnotcoverin depthstudyofsustainableandparticipatorydesigntechniquesseparately

02. Limitation of study to geriatric care centres, does not include in a residence or on a macro level

03. Study takes into account only the senses of touch and sight in sensory design.

RESEARCH METHODOLOGY

A thorough research on design techniques and methods to make life easier for the elderly was conducted, out of which dementia was identified and confirmed for further study.

Mission valley Travancore trust foundation located in Karukachal, Kottayam, a geriatric care centre specialized for people with dementia was identified and studied as live case study.

Two different literature case studies were also selected, to understand the requirements of a geriatric centre specialized for dementia, as follows:

1. Genting dementia centre, Kuala Lumpur

2. The Korongee dementia village, Australia

Alongside, the following literature reviews were also studied and analysed

1. What has architecture got to do with dementia care? Explorations of the relationship between quality of life and building design in two equal projects

2. Designing environments for people with dementia: a systematic literature review

These papers were thoroughly read for the identification of sensory design elements to mitigate the illness. All necessary data were collected and refined and then a detailed analysis of the study is done and a final conclusive analysis based on comparative analysis is drafted, along with abstract, introduction, body, and conclusion.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

1.9.1. RESEARCH DESIGN

Fig 1.9.1.1: Flowchart showing research methodology

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

1.9.2. TIMELINE OF STUDY

Fig 1.9.2.1: Chart showing timeline of study

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

2

Data collection

Introduction

Dementia is an illness of old age, usually characterized by a progressive decline in cognitive functions from the previous level. Loss of memory for recent events is a classical feature. A number of cognitive functions including new learning, intelligence, decision making, executive functioning and language are affected, besides the memory. It mainly affects older people; only 2% of cases start before the age of 65 years. After this, the prevalence doubles with every five year increment in age. Dementia is one of the major causes of disability in late life. Prevalence of dementia in India is reported to be 2.7%. As age increases, the prevalence of dementia increases. Mean age of presentation is relatively younger at 66.3 years in India, about 10 years less than in the developed countries. With the increasing elderly population and reduced joint family system in our country, dementia poses a great challenge.

Dementia is one of the major causes of disability in late life. There are various types of dementia including Alzheimer’s disease, vascular dementia, Lewybodydementia, frontotemporal dementia etc., all of which are caused by reactions in the brain. These types of dementia cannot be reversed and are nearly impossible to treat. There is also dementia caused due to excess alcohol consumption, unhealthy lifestyle and other external injuries or impacts.

Dementia is usually noticed not by the individual, but by people around them. They have various difficulties like memoryloss, communication, complexityin visual and spatial abilities, reasoning or problem solving, handling difficult tasks, planning and organizing, coordination and motor functions etc. They are usually very confused and disoriented. Apart from these, dementia can also cause various psychological issues like personality changes, depression, anxiety, paranoia, agitation, hallucination etc.

Geriatric centres are those centres that take care of senior citizens with terminal illness that require around the clock assistance. These are the centres where the senior citizens with dementia will receive proper care at, and also provide facilities of a retirement home.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

2.1.1 Types of dementia

• Alzheimer's disease

• Vascular dementia

• Lewy body dementia

• Frontotemporal dementia

• Mixed dementia

2.1.2 Diagnosis

Cognitive changes

• Memory loss, which is usually noticed by someone else

• Difficulty communicating or finding words

• Difficulty with visual and spatial abilities, such as getting lost while driving

• Difficulty reasoning or problem solving

• Difficulty handling complex tasks

• Difficulty with planning and organizing

• Difficulty with coordination and motor functions

• Confusion and disorientation

Psychological changes

• Personality changes

• Depression

• Anxiety

• Inappropriate behaviour

• Paranoia

• Agitation

• Hallucinations

2.1.3 Management

• Increased mental, physical, social activities

• Vitamins

• Cardio vascular risk factors

• Healthy diet

• Clean air

• Reduction of sound pollution

• Quality sleep

• Visual implantation

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

People with dementia tend to show drastic changes in their behavior. There are manyreasons why a person’s behavior may change. Dementia is a result of physical changes in the brain, and these can affect the person’s memory, mood and behavior. Sometimes, behavior may be related to these changes, but at othertimes,thebehaviormaybetriggeredbychanges in theperson’s environment, health or medication. Some of the changes brought about are:

Sleeping problems: Problems with sleeping are common for people with dementia. Some people sleep during the day and are awake and restless at night. Some are no longer able to tell the difference between night and day, while others are simply not as active as they used to be and so need less sleep.

Problems with sleeping or late evening agitation are often a stage in dementia that eventually passes. Many people with dementia sleep more during the later stages of the illness. Sleeping problems may be caused by physiological or medical causes including:

● Brain damage (caused by the dementia) that affects the ‘biological clock’ in the brain that directs our sleep patterns

● Illness such as angina, congestive heart failure, diabetes or ulcers

● Pain caused by conditions such as arthritis

● Urinary tract infections that cause a frequent need to urinate

● Leg cramps or ‘restless legs’, which can indicate a metabolic problem

● Depression that causes early morning waking and an inability to get back to sleep

● Side effects of medication, such as antidepressants and diuretics

● Snoring and sleep apnoea

● Aging causes sleep patterns to change so that some people need more sleep and some need less.

● Overtiredness, causing tenseness and inability to fall asleep

● Not enough exercise, so the person does not feel tired

Hoarding: People with dementia may often appear driven to search for something that they believe is missing and to hoard things for safekeeping. Some causes of hoarding behaviours include:

● Isolation when a person with dementia is left alone or feels neglected, they may focus completely on themselves. The need to hoard is a common response

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

Dementia

● Memories of the past events in the present can trigger memories of the past, such as living with brothers and sisters who took their things, or living through the Depression or a war with a young family to feed.

● Loss people with dementia continually lose parts of their lives. Losing friends, family, a meaningful role in life, their income and a reliable memory can increase a person’s need to hoard

● Fear a fear of being robbed is another common experience. The person may hide something precious, forget where it has been hidden and then blame someone for stealing it.

Wandering: Wandering is quite common among people with dementia and can be very worrying for those concerned for their safety and wellbeing. The person’s failing memory and declining ability to communicate may make it impossible for them to remember or explain the reason they wandered.

Develop an action plan for when a person with dementia wanders, such as notingthe clothing they were wearing, and contacting neighbours and the police. Reasons that a person with dementia might wander include:

● Changed environment

● Loss of memory

● Excess energy

● Searching for the past

● Expressing boredom

● Confusing night with day

● Continuing a long held habit

● Agitation

● Discomfort or pain

● Believing they have a job to perform.

Sun downing: People with dementia may become more confused, restless or insecure late in the afternoon or early evening. This is known as sun downing and these behaviour changes can become worse after a move or a change in routine. The person with dementia may become more demanding, restless, upset and suspicious, disoriented and even see, hear or believe things that aren’t real, especially at night. Attention span and concentration can become even more limited. Some people may become more impulsive, responding to their own ideas of reality, and this may place them at risk.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Repetitive actions: People with dementia may say or ask things repeatedly. They may also become very clinging and shadow the person caring for them, even following them to the toilet. These behaviours can be very upsetting and irritating for families and carers. Managing repetitive behaviour. Things that you can do to help manage repetitive behaviour in dementia include:

● If an explanation doesn’t help, distraction sometimes works. A walk, food or doing a favourite activity might help.

● It may help to acknowledge the feeling expressed. For example, ‘What am I doing today?’ maymean that the person is feeling lost and uncertain, and a response to this feeling might help.

● Do not remind the person that they have already asked the question.

● Repetitive movements may be reduced by giving the person something else to do with their hands, such as a soft ball to squeeze or clothes to fold.

Verbal outbursts: Verbally disruptive behaviours among patients with dementia are common. The behaviours include screaming, yelling, cursing, calling out, repeating words and phrases, and making noises that may not include words, such as moaning or whining. Verbal disruption is a great source of caregiver burden and patient distress. Ongoing behavioural problems often result in premature nursing home placement.

The prevalence of verbally disruptive behaviours among patients with dementia is high, with up to 25% of patients living in the community and 50% of those who reside in nursing facilities displaying at least one verbally disruptive behaviour. Verbal disruption is more likely to occur in the later stages of dementia, when the patient is less able to communicate using language and speech.

Risk factors for the development of verbal disruption include more advanced dementia, hearing loss, multiple chronic medical conditions, and decline in communication skills. It is vital that all new verbal disruption be evaluated for an underlying cause, as more than half of the behaviors are likely related to a medical, physical, or care needs problem.

Hallucinations: Hallucinations are false perceptions of objects or events involving the senses. These false perceptions are caused by changes within the brain that result from Alzheimer's, usuallyin thelaterstages ofthedisease.Theperson mayseethe faceof aformerfriend in acurtain or may see insects crawling on his or her hand. In other cases, a person may hear someone talking and may even engage in conversation with the imagined person. Alzheimer's and other dementias

Marian College of Architecture and Planning, Thiruvananthapuram

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

are not the only cause of hallucinations. Other causes include:

● Schizophrenia

● Physical problems, such as kidney or bladder infections, dehydration, intense pain, or alcohol or drug abuse

● Eyesight or hearing problems

● Medications

Agitation: Anxiety and agitation may be caused by a number of different medical conditions, medication interactions or by any circumstances that worsen the person's ability to think. Ultimately, the person with dementia is biologically experiencing a profound loss of their ability to negotiate new information and stimulus. It is a direct result of the disease. Situations that may lead to agitation include:

● Moving to a new residence or nursing home

● Changes in environment, such as travel, hospitalization or the presence of houseguests

● Changes in caregiver arrangements

● Misperceived threats

● Fear and fatigue resulting from trying to make sense out of a confusing world

Aggression: In the later stages of dementia, some people with dementia will develop what's known as behavioural and psychological symptoms of dementia (BPSD).

Triggers stimulating behavior changes

● New or unfamiliar caregivers or separation from loved ones

● Lack of routine, such as no "agenda" to help orient to surroundings

● No activity, no stimulation and/or isolation

● Too much activity or sensory overload

● Lack of orientation cues, such as ways to find the bedroom or bathroom

● Lighting that might be too bright, not bright enough or creates shadows

● White noise such as a lawn mower outside or an appliance humming inside the home

● Room temperature too hot or too cold

● TV or radio that is left on all the time can cause confusion

● Clutter

● Shiny floors: What might look nice and clean to you could look like ice or standing water to a dementia patient.

● Mirrors: When a dementia patient looks into a mirror, they often do not recognize themselves or they can get "lost" in the depth of the mirror.

Marian College of Architecture and Planning, Thiruvananthapuram

● Colour contrast: Too much or too little colour contrast can be disorienting for dementia patients. For example, an all white bathroom can be disorienting because it can make it difficult to see the difference between the toilet set and the wall or the floor. And too much contrast can be problematic as well.

● Two toned carpet, checker board tile or black door mats can look like holes in the floor to a dementia patient.

● An environment that is overwhelming to their senses, a place is too loud or too crowded.

● Being surrounded by too many unfamiliar faces, including having too many caregivers at a time.

● A change in environment (e.g., going to visit a place they haven’t been before or making changes to their assisted living apartment or suite).

● Being hungry or thirsty or in need of a bathroom.

● Having someone approach too quickly or from the side where their peripheral vision might be impaired.

● Being confused about their location and how they got there.

● Having someone talk too loudly or forcefully to them.

● When personal space is invaded, whether it is by a friend or family member or a stranger when you are out in a public place.

● Misunderstanding directions or questions from a loved one or a conversation that is occurring nearby.

● Being startled by a loud noise or by loud voices.

● When an environment is too hot or too cold to get comfortable in

● Feeling demeaned or disrespected by friends, family, or caregivers.

● Low self esteem caused by an inability to communicate and care for themselves.

● Side effects from, interaction with, or adverse reaction to medications.

Architecture and dementia

Within our hyper cognitive society, which values and requires fast adaptation and constant learning, being diagnosed with any kind of dementia means bearing a stigma of uselessness and disability, despite one’s previous status. It means being excluded from the society’s centre not only economically and socially, but also literally by means of being moved from home into a special care unit. With no way back and no other place to go, many people spend the last years of their lives in such a situation, dependent on help from others. Involuntarily bound to the space provided, they experience less and less changes of environments as they no longer have the need or the right to do so. With dementia progressing, life outside of the caring home becomes more demanding and their life sphere gradually shrinks. At a certain point, it shrinks in between walls of the care unit and continues till the point where it becomes the person himself and his immediate bodily surroundings. In the late stage of dementia, one single room becomes the whole world.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

In this sense, designs of such places are clearly an extremely sensitive matter to work with. Their importance is immense, yet tremendously fragile to grasp because they have to work with what is left deep inside our minds and bodies when the disease progresses. Because of that, it requires a lotofattentionandapprehensiontodealwiththemcorrectly.Itrequiresunderstandingofdementia and its consequences as well as apprehension of demented peoples’ perspectives. The latter is especially crucial because people with dementia are very often excluded from the design process, although they know best what is most suitable for them.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

Reviews and case studies

3.1 Review I

3.1.1 Introduction

What has architecture got to do with dementia care? Explorations of the relationship between quality of life and building design in two equal projects.

Two projects in the EQUAL program explore aspects of the influence building design has on the quality of life of people with dementia. Design in Caring Environments (DICE) examined the quality of life of people in residential care homes in relation to building design features.

INDEPENDENT (Investigating Enabling Environments for People with Dementia) is a current project with the aim of developing technologies to enhance quality of life by supporting enjoyable activities. One aspect of INDEPENDENT is an exploration of the interaction between spatial settings and meaningful activity, to highlight factors that support and enable activity and to identify barriers. Findings from both projects suggest that a more creative approach to the management of buildings would enhance the well being of residents; under use of facilities is common. Meaningful space that supports activity is therapeutic but spaces that give confused messages are common in buildings used by older people. Tools to evaluate buildings have a potential role in the long term management of facilities to help identify underused spaces, spatial confusionandbarrierstoactivity.Qualityoflifewasshowntobepoorerinbuildingsthatprioritize safety and health; buildings that support activity positively by providing good assistive devices, giving people control of their environment and affording good links with the community have a positive association with well being.

3.1.2 Analysis

Space combined with activityare powerfullymeaningful to people with dementia (as to everyone) but can easily be misinterpreted. There are implications here for design guidance. Successful spaces are those that carry unambiguous meaning. The conflict between, for example providing a ‘homelike’ atmosphere in a space of a size never found in a domestic house could be more clearly recognised. Furniture and fittings chosen for their homeliness may look inappropriate and

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

incongruous in a space of the scale of a dining hall and increase confusion rather than make people feel ‘at home’. A realistic appraisal of how a space will be perceived may be more helpful than an overall assumption that everything should be selected for its ‘domestic’ qualities. It appears to be important for well being that the physical environment should be designed to support activity by providing good physical support, providing opportunities for activity to happen, and providing settings that are recognisable at a multi sensory level and appropriate for their function. Space combined with activity are powerfully meaningful to people with dementia (as to everyone) but can easily be misinterpreted. There are implications here for design guidance. Successful spaces are those that carry unambiguous meaning. The conflict between, for example providing a ‘homelike’ atmosphere in a space of a size never found in a domestic house could be more clearly recognised. Furniture and fittings chosen for their homeliness may look inappropriate and incongruous in a space of the scale of a dining hall and increase confusion rather than make people feel ‘at home’. A realistic appraisal of how a space will be perceived may be more helpful than an overall assumption that everything should be selected for its ‘domestic’ qualities. It appears to be important for well being that the physical environment should be designed to support activity by providing good physical support, providing opportunities for activity to happen, and providing settings that are recognisable at a multi sensory level and appropriate for their function. The indications are that architecture does have an impact on the well being of people with dementia, and this can be positive when space supports and enables activity or negative when it curtails or restricts. Health and safety considerations can impact negatively on well being especially where the effect of them is to restrict activity. There is a largely unrealised potential for buildings to be used more effectively, without necessarily involving costly reconfiguration. A creative approach to the on going management of buildings can unlock resources; however, the process needs to take into account the complex interactions between people, support networks, place, technology and culture. Designed space and technology could bring pleasure and increase well being for people with dementia in many ways but it is a complex process to instigate, embed and sustain any particular intervention. Spatial meaning can be substantially compromised in an incremental process that nobody notices. There is a strong case to be made for a regular design audit of space as it evolves over time using a methodology similar to the design matrix described here. Space combined with activity are powerfully meaningful to people with dementia (as to everyone) but can easily be misinterpreted. There are implications here for design guidance. Successful spaces are those that carry unambiguous meaning. The conflict between, for example, providing a

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

Fig 3.1.2(a): Analysis chart

‘homelike’ atmosphere in a space of a size never found in a domestic house could be more clearly recognised. Furniture and fittings chosen for their homeliness may look inappropriate and incongruous in a space of the scale of a dining hall and increase confusion rather than make people feel ‘at home’. A realistic appraisal of how a space will be perceived may be more helpful than an overall assumption that everything should be selected for its ‘domestic’ qualities. It appears to be important for well being that the physical environment should be designed to support activity by providing good physical support, providing opportunities for activity to happen, and providing settings that are recognisable at a multi sensory level and appropriate for their function.

3.2 Review II

3.2.1 Introduction

Designing environments for people with dementia a systematic literature review

On an individual level most people with dementia want to stay at home, with few opting for alternative forms of accommodation through personal choice. This provides a challenge for architects and designers to design accommodation to enable people to age in place. Dementia is a complex condition, affecting each person differently with some common symptoms. There is a temptation to think it is all about memory. However, the human brain is responsible for all our functioning so some of the challenges faced bythose living with dementia are more wide ranging. For some people perceptual abilities change causing problems with spatial awareness, judging distances and recognition of objects.

The aspiration is that people with dementia will be enabled to live where they want to be for longer, reducing the numbers of people who live in alternative care environments. This will only be possible if the knowledge, design principles and technology that is available is harnessed and integrated into the design of new buildings and external environments. Personal insights and experiences from peoplelivingwith dementiacanneverbereplacedbybooks.However,this book

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

contains insights to enable those who read it to plan and build environments that promote independence and enable people to live well with dementia.

3.2.2 Analysis

There is no 'one size fits all' to designing an environment for people with dementia. However, taking into account the following recommendations from a European funded project, Innovate Dementia, should help:

• A holistic approach to the environment should always be considered. Environments are more than physical spaces; maximizing independence, autonomy and well being comes from ensuring a person’s psychosocial as well as physical needs are met

• Design should be influenced by promoting independence and normalizing living, rather than control. Flexible care environments are important to enable people living with dementia to ‘age in place’ and prevent unnecessary admissions to care homes or hospitals

• Future environment models need to utilize the principles of dementia friendly environmental design coupled with home care style methods. These principles should cross boundaries and be applied to wherever a person is living.

3.3 Case studies

Two different literature case studies were also selected, to analyse the requirements of a geriatric centre specialized for dementia, as follows:

1. Genting dementia centre, Kuala Lumpur

2. The Korongee dementia village, Australia

Mission valley Travancore trust foundation located in Karukachal, Kottayam, a geriatric care centre specialized for people with dementia was identified and studied as live case study.

3.3.1 Literature case study I: Genting dementia centre, Kuala Lumpur

Dementia Care Centre is the result of a collaboration between Genting Group and the University of Malaya's Faculty of Medicine. It operates on a charitable basis to offer day care services to people suffering from dementia, as well as to provide information through webinars and training to caregivers, family members and professionals involved in dementia care. The centre strives to help persons living with dementia achieve the best possible

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3.3.2 LITERATURE CASE STUDY II: THE KORONGEE DEMENTIA VILLAGE, AUSTRALIA

It is located in Hobart, Tasmania Australia, with a cool temperate climate. It has a total site area of up to 1.2 acre and built area up to 30,000 sq. ft., accommodating a total of 96 residents.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

quality of life and provide support and training to their families and caregivers.

Fig 3.3.1(a): View of Genting dementia centre, Kuala Lumpur

Fig 3.3.2(a): View of Korengee dementia village, Australia

3.3.3

3.2.3.1.

Foundation Karukachal, Kottayam

It is located in the elevated region of Kottayam, Kerala. Kottayam is a city in the flanked by the Western Ghats on the east and the Vembanad Lake and paddy fields of Kuttanad on the west. It has a very cool temperature, the site on the elevated region being even colder.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

Comparitive analysis

Table 3.4 1: Comparative analysis of case studies based different trigger parameters

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

The data collected and the comparative analysis done to understand the response of users to each parameter cited, is thoroughly studied before listing out the various design elements that can be integrated into geriatric centres to help people with dementia, and also maybe beneficial to other users. Dementia is a progressive condition and cannot be cured. Only thing that can be done is prolong and mitigate the effects of it on an individual.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

Table 3.4 1: Comparative analysis of case studies based different trigger parameters

Conclusion

Due to our aging population, numbers of people with dementia are constantly increasing, while both the cause and the cure are still unknown. At the end of a lifetime, after all a person has been through,it is hardto let go. It is hardtolet goofhome, ofmemories,ofoneself. Dueto thedisease, cognitive functions are lowered or lost and many things become insecure. One’s life falls apart in pieces and is gradually stripped to pure, basic sensations and emotions. Without any reasoning ability, people with dementia gradually become lost in space and time. They are no longer able to adapt the surrounding environment to their needs and become therefore extremely dependent on what others arrange for them. With only basic abilities remaining, learned motoric, instincts and occasional awakenings, it becomeshardto perform everydaytasksas well as to findawaythrough a building.

4.1. Strategies

Taking into consideration the present condition of treatment, accessibility to treatment etc, some design strategies that can be incorporated into geriatric care centre designs are formulated they are:

 Surroundings: Peoplewith dementiaarequiteoften triggeredbyunfamiliarsurroundings and people. Dementiated people often forget recent memories and are mostly still aware of their childhood.

o Thermal comfort is a major factor in triggering the emotions and mood f a dementiated person. They are seen to be doing better in tropical climate. Hence, it is important to set the thermal condition of the space used by them to a warm temperature.

o Architecture style that had been used during their childhood of a generation can be incorporated into the centres so they can recall it as a place similar to home.

o Provision of safe spaces within their rooms is important so even if they retract into their shell, they can be somewhere familiar (due to muscle memory) and safe.

o Hoarding is another common characteristic exhibited by people with dementia. A separately allocated space within hand’s reach and visible care takers should be designed for this purpose.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

Space layout

o Simple spatial planning is preferred.

o A loop like planning strategy to be adopted, where the residents are allowed to walk about as they please, but the ultimate destination being their own space.

o There should be no blind spots, at least 70% of the structure must be visible to caretakers from any point to ensure safety.

o Intermediate spaces must be zoned for any kind of activities.

o Spaces that are safe for sleep walking.

o Avoid balconies projecting outwards.

o Sufficient air flow is require, maximum cross ventilation.

o Approach to space should be directly I line with direct vision of patient.



Finishes

o Floor finishes shouldn’t be shiny as they can give false perception of water due to person’s hallucination.

o Matt finishes to be opted maximum to reduce clogging of water.

o Too many varying contrasting colours should not be used.

o Neutral, pastel shades are the best for their eye.

o Checker designed highly contrasting flooring should also be avoided as they can intimidate the users as a large hole.

o These patients mostly may forget to wear their foot wears, so textured flooring can be helpful to notify transition in spaces.

o Cool colours are preferred to keep a calm state of mind and help insomnia.

o Mirrors also to be avoided as they can be confused looking at the person in the mirror



Light and shadow

o Lighting that might be too bright, not bright enough or creates shadows

o Shadows create depth, which can be misleading

o Eye blinding lights to be avoided and controllable lights can be fixed.

o Avoid reflective surfaces along path.

Sound

o Too much noises can trigger them.

o Soft white noises can be provided in background to help them sleep

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

o TV, radio, speakers, etch should be avoided to reduce confusion

o Noise reduction masking

o Natural barriers

o Talking too loudly around them

o Breakable objects to be avoided to resist loud noises.

The present prevention, care and management methods of dementia are not available and accessible to everyone. This does not mean they should be neglected. The management methods mentioned are very much evident that they can be solved through architectural design strategies at various scales. Instead of searching for new ways to expensive ways or to find sources to access these methods, thoughts can be applied and various design strategies based on sensory design can be practiced so that in some or the other way.

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

Marian College of Architecture and Planning, Thiruvananthapuram

Design for dementia: Perusing design elements in architecture for people with dementia in geriatric care centres

BIBLIOGRAPHY

● The Silent Patient Alex Michaelides

● Design for dementia Margaret P. Calkins

● Design for people living with dementia Emmanuel Tsekleves, John Keady

● Healing Garden David Kemp

●https://www.mhinnovation.net/sites/default/files/downloads/innovation/reports/Dementia IndiaReport.pdf

●https://www.nhp.gov.in/disease/neurological/dementia#:~:text=Prevalence%20of%20deme ntia%20in%20India,than%20in%20the%20developed%20countries

●https://www.mayoclinic.org/diseasesconditions/dementia/symptoms causes/syc 20352013Young man enjoying the landscape

● Arch Daily: Architecture broadcasting studio

● https://www.nonarchitecture.eu/2020/04/10/architecture and dementia/

● https://www.alz.org/help support/caregiving/stages behaviors/anxiety agitation#:~:text=Anxiety%20and%20agitation%20may%20be,negotiate%20new%20inf ormation%20and%20stimulus.

Marian College of Architecture and Planning, Thiruvananthapuram