Thesis Design Dissertation Research Book

REMINISCE OF A MEMORY Dementia Care and Resource Facility

BY

KASTURI S. WAGH

FIFTH YEAR B. ARCH IXth SEMESTER-PART1

L.S. RAHEJA SCHOOL OF ARCHITECTURE AFFILIATED TO MUMBAI UNIVERSITY

2016-2017

PREFACE The smoke slowly disappears; I can see clearly again. I am sitting on a rocking chair in a room that looks oddly familiar. It reminds me of my own living room. At least, I think it does. It has changed quite a bit. The sofa in the corner was not there before, the television set has changed its position and even the coffee table looks new.

The young lady in white, sitting across stands up to answer the door.

“How is he now?” Enquired the guest.

I continue to hum, ignoring the discussion at the door until I hear the word „granddaughter‟ dropped in the conversation between the lady in white and the young girl who looked in the early twenties.

This can‟t be about me. I only just got married a week ago. I can‟t be a grandfather I am not even a father as yet, I thought to myself.

“Excuse me, do I know you? What is your name?” I ask the lady in white.

“Um...Sheetal, sir, “she stutters. “I am your nurse.”

“Oh, that‟s a nice name.” I study her carefully, blatantly ignoring the bit about her being my nurse. “But I think Ragini suits you better. Now, tell me,” I continue. “Why do you keep saying that I have a granddaughter?”

She nods her head sadly. “That is because you do, sir. You have two daughters and a son. Not only are you a father, you are a grandfather”.

“But that‟s ridiculous! Why wouldn‟t I remember this?”

Even though I was quite familiar with Alzheimer‟s which I studied as part of our school curriculum, this was my very first encounter with this memory-snatching condition that deteriorates a patient‟s brain as time passes by. This is my grandfather...

Alzheimer‟s alters memories, making it difficult for one to manage the day to day chores and eventually intimidates them to become completely dependent on their family members or caregivers. As I found out further, it is a disease that affects a lot of people. Unfortunately, most family members are completely unaware of its existence in the first place and generally misunderstand it as a normal cycle of ageing or sometimes, even madness. There is an obvious

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and glaring lack of awareness and well-designed infrastructure for the people affected by dementia and hence, I felt the need for a facility that would not only help the people suffering from dementia but also act as a support system for their families.

Alzheimerâ€&#x;s disease is like a plague that affects each and everyone in the family knowingly or unknowingly.

I, therefore, dedicate my thesis to all the families who are struggling to cope up with this crippling condition.

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ABSTRACT We spend our lives making memories; going over them again and again till they have been hardwired into our minds. They are the measure of our lives. What are we without the aid of our memories? They help us to learn, to laugh and to remember. So imagine waking up one day to have completely forgotten these events. Imagine seeing the world through a foggy window that you cannot quite rub away. Imagine not being able to remember the people you love, the life you have lived up to that point. If just the thought of it is scary enough, imagine living with a chronic and psychosomatic condition like dementia.

Our minds automatically jump to our grandparents the minute we start thinking about the silver years of our lives which are yet to come. The role of grandparents or the elderly has always been significant in our lives especially here, in India where a lot of young adults prefer staying with their parents. The role of grandparents is becoming more and more central to family life in the 21st century as the world is marching forward with dual employment in houses, where the job of looking after the children is generally taken up by grandparents as it takes off a lot of burden off of the parents shoulders as they feel safe knowing that their child is looked after by their own parents rather than unknown people at the children day care facilities. But what happens if your grandfather fails to recognise you one day? What if he suddenly becomes vociferous and aggressive? Do you stop loving him? Do you just overlook it as a natural part of ageing? Would you be comfortable enrolling them into a regular old age home? Will you be willing to take out time from your work or will either member of your family sacrifice their jobs at the expense of reduced income which would, in turn, affect the care of the concerned family member? Dementia is a very sensitive issue - right from taking care of the person at home to making a decision of enrolling the loved one into a special facility because that, in turn, affects each and every person in the family knowing or unknowingly.

As far as members of the family are concerned, there is no greater disappointment than their favourite elderly being unable to recognise them, especially when they might have connected and related particularly well to them while growing up.

The worldâ€&#x;s population is ageing and with all the new medical revelations and breakthroughs, the life expectancy has increased, resulting in a gradual increase in the overall population.

However, this increase in life expectancy coupled with the change in lifestyle has also resulted

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in an increase in the number of people being diagnosed with Dementia, especially Alzheimer‟s. So much so that Dementia is emerging as a major public health crisis affecting each and every part of the world.

Increased prevalence of diabetes, hypertension, and stroke due to changes in lifestyle has started affecting people younger than 65 years of age resulting in an early onset of dementia making dementia a growing concern which will affect each of us directly or indirectly at some point in our lifetime.

Alzheimer‘s is an enemy that attacks from the shadows. It snatches every little bit of everything that makes you, you. It scratches at a person‘s dignity till every last bit of it has been chipped away. Unfortunately, we as of now are not sufficiently prepared to tackle this enemy

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AIM The aim of this project is to design a special care facility for people living with Dementia and other disorders under its umbrella. The facility will serve as an example for future designs elsewhere in India. It will provide flexible, part-time care apart from residential care, creating a different kind of marriage between the staff, patients and their family members. It will also have a facility that caters to the training of the nurses and the caregivers. It will be a one of a kind facility which will help spread awareness. In its execution, the facility will be breaking away from others in its typology and will attempt to be true to its intent.

Even though a building doesn‘t have the ability to cure dementia, it can improve the quality of life of the users.

OBJECTIVES The thesis will look into how and why a special care facility for people suffering from dementia is the need of the hour. It will thoroughly examine the existing facilities to see what they lack. Eventually, the main objective is 

To spread awareness about the disease and to provide a state of the art facility which would serve as an example for future designs



The aim is to make the life of the patient easier and better using architectural design and its elements as catalysts.



Studying about various factors like colour schemes, materials, etc. and then implementing the same in the design programme is also be a part of the objective.

METHODOLOGY OF STUDY The research methodology will comprise of a profound study of the signs, causes and characteristics of dementia. It will also help understanding of how dementia affects the person and in turn the family members and the caregiver, by having a dialogue with dementia-

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afflicted families. Thereafter, it will include an intensive study of the existing Indian scenario.

The research will also look into the workings of the existing facilities and study them on the basis of three major criteria's -contextual analysis, programmatic analysis, and formal analysis.

The contextual analysis will be done on a macro scale which will include the urban study; for example the connectivity to the main city and accessibility, the number of hospitals in the vicinity. The programmatic analysis will be carried out on a micro scale which will include the programme of the facilities and the zoning. The formal analysis will include the physical study which will look into the spatial context and design philosophy as well as study of different materials.

NEED FOR STUDY In India, there are more than 4 million people having some form of dementia today and worldwide, at least 44 million people are living with dementia (Alzheimerâ€&#x;s Association, 2016). Despite the magnitude; there is gross ignorance, stigma and lack of awareness in India which are the main reasons for a very low diagnosis.

The increasing burden of care on family, direct or indirect, caring for a person with Alzheimerâ€&#x;s or dementia can be a challenging task and the quality of life not only of the person living with dementia but also of the caregiver is affected. People are following the trend of nuclear families nowadays from the west. But nuclear family set ups with diminishing family support affects care and caregiving. Also, most of the young adults in the family migrate overseas for better job opportunities and other members of the family spend more time at workplaces rather than homes which affect the care of elderly people.

In India, the current capacity of care centres and support organisations fall pathetically short when compared to the dire need. Lack of such special care facilities forces people to enrol patients with dementia in old age homes which are not specialised in the field of dementia. But also due to the negative image carried by the nursing homes, families are often hesitant to put elderly family members in a home; however, they themselves are also ill-equipped to provide for the necessary type of care.

Most care centres do not reflect on the fact that they are the final home of residents while still providing the necessary medical requirements.

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Most of the existing facilities are merely rented bungalows or floors in a building that are run by private NGO‟s. But in spite of the valiant efforts being made by these organisations they lack architectural interventions that can benefit the health of the patients. The ageing population is changing and it is time we think about the architecture for them.

“Nowadays the old age homes do not admit patients with dementia and on the other hand there are no special facilities that are up to the mark in our country”, said Mrs Vidya Shenoy, secretary General of ARDSI.

LIST OF CASE STUDIES ALZHEIMER’S RESPITE CENTRE, DUBLIN (internet case study) What is it: Alzheimer‟s respite Centre is a care facility in Dublin, Ireland designed by a famous architect- Niall McLaughlin in 2009. It is a facility that has respite care along with residential care. It is one of a kind as the facility has been designed keeping in mind the varied groups of users from an architectural point of view. Unlike many other elderly care facilities; the Respite centre is a building dedicated only to the care of dementia patients.

Purpose: To understand the design interventions and ideologies used by the architect and the programme and the working of the facility.

THE HOGEWEYK- DEMENTIA VILLAGE (internet case study) What is it: It is the world‟s first and only village in Netherlands which resides people suffering from dementia. It is a village set up with houses, supermarkets, movie theatres especially for dementia patients along with round the clock medical facilities. Such a facility is very large compared to the rest of the centres and boasts of a completely different typology altogether.

Purpose: To understand the concept, ideologies, programmes and the working of the village.

JAGRUTI REHABILITATION CENTRE, PUNE (physical case study) What is it: It is a rehabilitation centre which is about 10 km ahead of Pune. It is a residential building which initially catered to patients suffering from mental disorders like schizophrenia,

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depression etc. The centre now boasts of a separate building dedicated solely to dementia patients.

Purpose: To examine and study the existing scenario of the care facilities in India.

HARMONY HOME- KOTTAPADDY,KERALA (physical case study) What is it: The Harmony home is a full-time residential care centre initiated by the Alzheimerâ€&#x;s And Related Disorders Society of India (ARDSI). The centre is intimate with not many residents and functions in a rented bungalow.

Purpose: To understand the workings of a full-time residential care and also to study the status of the existing facilities in Kerala as it is aware of dementia and has taken a few initiative to help the people and families suffering from the same.

DIGNITY FOUNDATION DAY CARE CENTRE- BYCULLA (physical case study)

What is it: It is the only day care centre in Mumbai that caters solely to people living with dementia. It is located in an industrial services building in Byculla east.

Purpose: to understand the workings and the concept of day care centres and also to learn about the programme of the centre.

COMPREHENSIVE DAY CARE CENTRE,KERALA (physical case study)

What is it: It is one of the main day centres in Kerala. The centre has also started a Research and development centre which helps the people with dementia and their family understand the condition better.

Purpose: Kerala being a dementia friendly state, has the maximum numbers of residential and day care facilities for people affected by dementia. The purpose of the visit was to study the positives of the day care centre which could be then compared to the care centre studied in Mumbai and come to a conclusion.

SMRUTHIPADHAM, ERNAKULAM, COCHIN(physical case study) What is it: Smruthipadham is a full-time residential care facility along with an old age home initiated by the state government of Kerala in collaboration with the ARDSI.

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Purpose: Smruthipadham is the only centre in India that is run by the state government. This facility was initiated with a view to becoming an example for all the other states of India and an encouragement for all the state governments to actively take part in making India dementia friendly. Thus it was important to visit the facility and study its strengths and weaknesses to get a clear idea.

SITE SELECTION In-depth research about dementia and its repercussions lead to a conclusion that the ideal site for the facility would be on the outskirts of the city for the day care centre to function well and also the people with dementia are sensitive to their surroundings and need a quiet and a serene environment.

The criteria for the site would depend on Accessibility, Public, transport facility, Green cover, Noise buffer and Existence of a hospital in the locality.

Keeping that in mind, the probable sites would be in Navi Mumbai– as it is away from the fast life of Mumbai but still well connected to the city, Vasai-Virar, Mankhurd in the eastern suburbs of Mumbai would also make a good site.

LIMITATIONS AND CONSTRAINTS The existing facilities in India lack the necessary infrastructure and design ideologies hence, I will have to rely on the secondary sources of data for the designing of the facility. Due to the sensitive nature of the topic, most of the facilities refuse to grant permission to conduct case studies and click photographs which would have greatly added to my efforts.

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TABLE OF CONTENTS PREFACE ................................................................................................................................ 1 ABSTRACT............................................................................................................................. 3 AIM .......................................................................................................................................... 5 OBJECTIVES .......................................................................................................................... 5 METHODOLOGY OF STUDY .............................................................................................. 5 NEED FOR STUDY ................................................................................................................ 6 LIST OF CASE STUDIES ...................................................................................................... 7 

ALZHEIMER‟S RESPITE CENTRE, DUBLIN (internet case study) ............................. 7



THE HOGEWEYK- DEMENTIA VILLAGE (internet case study) ................................. 7

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JAGRUTI REHABILITATION CENTRE, PUNE (physical case study) ......................... 7

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HARMONY HOME- KOTTAPADDY,KERALA (physical case study) ......................... 8

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DIGNITY FOUNDATION DAY CARE CENTRE- BYCULLA (physical case study) .................................................................................................................................. 8

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COMPREHENSIVE DAY CARE CENTRE,KERALA (physical case study) ................. 8



SMRUTHIPADHAM, ERNAKULAM, COCHIN(physical case study) .......................... 8

SITE SELECTION ...................................................................................................................... 9 LIMITATIONS AND CONSTRAINTS ..................................................................................... 9 CHAPTER ONE 13 

WHAT IS DEMENTIA? .................................................................................................. 14

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IS DEMENTIA A REPERCUSSION OF OLD AGE? .................................................... 15

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WHAT ARE THE DIFFERENT TYPES AND CAUSES OF DEMENTIA?................. 16

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MILD COGNITIVE IMPAIRMENT............................................................................... 21

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WHO DOES DEMENTIA AFFECT? ............................................................................. 23

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WHAT ARE THE DIFFERENT STAGES OF DEMENTIA? ........................................ 24

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CHARACTERISTICS OF DEMENTIA ......................................................................... 26

CHAPTER TWO 28 

OVERVIEW..................................................................................................................... 28

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GLOBAL SCENARIO .................................................................................................... 29

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ESTIMATION OF NUMBERS OF PEOPLE WITH DEMENTIA AROUND THE WORLD .................................................................................................................. 30

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INDIAN SCENARIO ....................................................................................................... 32

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PREVALENCE OF DEMENTIA BY AGE OVER TIME ............................................. 33

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STATE-WISE ESTIMATES OF NUMBERS OF PWD IN INDIA ............................... 34

CHAPTER THREE ................................................................................................................... 38 

OVERVIEW..................................................................................................................... 38

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RESOURCES NECESSARY FOR DEMENTIA CARE ................................................ 39

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RESIDENTIAL CARE SERVICES IN INDIA ............................................................... 42

CHAPTER FOUR 45 

OVERVIEW..................................................................................................................... 45

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TARGET GROUPS AND THEIR ISSUES..................................................................... 46

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THE PERSON LIVING WITH DEMENTIA .................................................................. 46

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THE CAREERS/ INVISIBLE PATIENTS...................................................................... 50

CHAPTER FIVE 52

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OVERVIEW..................................................................................................................... 52

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COST OF DEMENTIA IN INDIA .................................................................................. 53

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WHAT DOES INDIA LACK? ........................................................................................ 54

CHAPTER SIX: SPACE- Case studies ..................................................................................... 56 

OVERVIEW..................................................................................................................... 56

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THE IMPORTANCE OF SPECIAL CARE FACILITIES IN DEMENTIA ................... 57

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Alzheimer‟sRespite centre, Dublin .................................................................................. 58

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The Hogeweyk- Dementia village, Netherlands .............................................................. 64

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Jagruti Rehabilitation centre, Pune ................................................................................. 69

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Dignity Daycare centre, Byculla -Mumbai ...................................................................... 77

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Comprehensive Daycare centre, Ernakulam -Cochin ...................................................... 82

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SMRUTHIPADHAM- A Government initiative, Kerala ................................................ 87

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Harmony Home, Kottapaddy-Kerala ............................................................................... 92

CHAPTER SEVEN: SPACE .................................................................................................... 98 

OVERVIEW..................................................................................................................... 98

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ARCHITECTURAL INTERVENTIONS ........................................................................ 99

CHAPTER EIGHT: SPACE- site selection ........................................................................... 103 

VASAI-VIRAR ........................................................................................ 113

REFERENCES

115

LIST OF FIGURES ................................................................................................................. 118 LIST OF TABLES122 LIST OF ABBREVIATIONS ................................................................................................. 123

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CHAPTER ONE OVERVIEW This chapter being the most crucial part of this book attempts to throw light on what dementia is, through in-depth study and research. It includes various quotes from personal experiences and interviews with various doctors and non-government organisation workers (NGO). The subtopics covered in this book are as follows: 

What is dementia?



How is dementia different from old age?



What are the different types and causes of dementia?

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Who does dementia affect?



What are the different stages of dementia?

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Characteristics of dementia

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WHAT IS DEMENTIA? By definition, Dementia is a syndrome in which there is deterioration in memory, thinking, behaviour and the ability to perform everyday activities

(WHO factsheet, 2016).

it is a

brutal

condition that has been affecting people for over a hundred years but was not known to them as it is now ,due to lack of awareness. Dementia is not a single disorder but is an umbrella term that refers to a group of disorders that mainly affect the cognitive strength of the person, Figure 1 : The dementia Umbrella.

his/her memory and eventually takes over day

SOURCE: alznorcalblog.org

to day life of that person. Mr.Prasad C.F of

Figure SEQ Figure \* ARABIC 1 source: Alzheimer‟s

Cochin Harmony home rightfully states that

Dementia should not be termed as a disease because it is rather a state of mind. ―It is estimated that there are approximately three million people with dementia in India and the number is rapidly increasing. In spite of the high prevalence, there is very low awareness about the disease among the public and the medical fraternity.‖- Alzheimer‟s and Related Disorders Society of India (ARDSI).

The trademark of this gruesome malady is to take a toll on a person‟s memory and other mental faculties such as language, judgment, planning and impairment of day to day activities which tarnishes it beyond repair.

Figure 2 Conceptual image indicating fading of memories SOURCE: health wise digest

Memory is the tool that aims to lend meaning to our mind, without the aid of which our mind may fall prey to chaos and unstructured designs.

Imagine the predicament of someone who wakes up every day and looks at the world through eyes cloaked with confusion and panic, stares into faces are anticipating a spark of familiarity.

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IS DEMENTIA A REPERCUSSION OF OLD AGE?

Mrs Vidya Shenoy the General Secretary of Alzheimer's and Related Disorders Society of India (ARDSI) confirms that this is a question that is most commonly asked to doctors and NGO activists. Though this condition accounts for striking as early as thirty, only a small fraction of the population bends to its will before the mid- sixties. Thus, we observe that a major chunk of the population over sixty years of age is diagnosed with dementia-related disorders. Scientists and doctors have been able to prove that dementia is not a normal part of ageing but is a severe condition of the brain. Recent studies show that increased prevalence of diabetes, hypertension and stroke due to change in lifestyle has started affecting people younger than 65 years of age resulting in an early onset of dementia.

Table 1: Difference between dementia and old age SOURCE: The Marilyn Denis Show

―People think it‘s an old-age person‘s disease. It‘s like cancer was 25 years ago: you didn‘t mention the C word. Cancer activists have done an excellent job of de-stigmatizing it, putting it out there, and making a disorder that needs attention. Alzheimer‘s is still behind the eight ball on that score‖- Dr Ronald Peterson- Director of Mayo clinic Alzheimer‘s disease Research Centre. (Hart)

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WHAT ARE THE DIFFERENT TYPES AND CAUSES OF DEMENTIA?

Dementia is not a single condition or a disease but a term used for a group of disorders.

Therefore, it would be wrong to call dementia a “disease” or people suffering from dementia as “patients” as they do not need to be admitted into mental institutions or psychiatric wards of hospitals states Mr Prasad.

In earlier times, when this condition was not known to people, scientists had no answers about the cause of such a condition and this condition was hidden from the world due to lack of knowledge. People regarded it as a taboo, evil or sometimes even madness. But now due to progress in science and awareness, it is certain that dementia is not some kind of witchcraft or madness, but a severe condition of the brain in which people get gobbled up in time. There are certain diseases and incidents that could result in dementia.

The most common types of dementia are outlined below:

ALZHEIMER'S DISEASE -Alzheimer's disease was first described by Alois Alzheimer in 1906.

(Alzheimer's Disease International).

It is the most common cause of dementia and accounts for

50%-75% of all cases. Alzheimer‟s is a disease that destroys brain cells and nerves, disrupting the transmitters which carry messages in the brain, particularly those responsible for storing memories. During the course of Alzheimer's disease, severe depletion of nerve cells is seen in various parts of the brain. The temporal lobe and hippocampus develop gaps between them which result in shrinkage of the size of the brain, which in turn affects the ability to store and

process

new

information. This mostly results in loss of ability to speak or carry out certain activities.

The exact reason behind the death of the nerve cells is still unknown but

Figure 3: Scans of brains showing difference between Alzheimer‟s , mild cognitive impairment and normal brain SOURCE: Alzheimer‟s Disease and dementia

there are some specific appearances that show in the brain of the patient after death.

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The sad part of this disease is that even in a world where people have travelled to the moon and back, the doctors can only be a 100% sure about their diagnosis after the post-mortem that is when they get a chance to dissect the brain of the affected after death.

There are mainly 2 types of Alzheimer’s: ● Familial Alzheimer‟s – this kind of disease is observed in families which follow a certain inheritance pattern. ● Sporadic (seemingly random) - this is the kind in which no obvious inheritance pattern is seen.

Symptoms Typically, Alzheimer's disease begins with episodes of memory loss, difficulty in remembering and following their daily routine or mood swings. As Alzheimer's is a progressive disease, the person may: ●

Tend to forget names of family members and friends or even their faces.

●

Get easily disoriented and confused

●

Get confused when handling money or driving a car

●

Might undergo changes in their personality

●

Experience mood swings or become convinced that someone is trying to steal from them or hurt them, hallucinations to some extent

●

The most distinctive habit is to wander aimlessly which results in the person suffering from Alzheimer‟s getting lost.

VASCULAR DEMENTIA – Destruction of blood vessels from our body poses a great threat to the oxygen supply. If oxygen is cut off from the brain, the brain goes into a series of mini strokes which may cause vascular dementia. This type of dementia accounts for 20%30% of all cases of dementia.

The mini-strokes that cause vascular dementia are often so slight that they cause no immediate symptoms, or they may cause some temporary confusion. However, each stroke destroys a small area of cells in the brain by cutting off its blood supply and the cumulative effect of a number of mini strokes is often sufficient to cause vascular dementia. Vascular dementia and REMINISCE OF A MEMORY- Dementia Care and Resource Facility

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Alzheimer's disease frequently occur together and they may often act in combination to cause dementia.

Symptoms Mental decline is likely to have a clear start date and symptoms tend to progress in a series of steps following each attack, suggesting that small strokes have been occurring ●

The person suffering from vascular dementia may face severe depression, mood swings and sometimes get attacks of epilepsy

●

Some areas of the brain may be more affected than others. Consequently, some mental abilities may be relatively unaffected

DEMENTIA WITH LEWY BODIES - Dementia with Lewy bodies is very similar to Alzheimer's disease as in this case also there is depletion and of nerve cells in some parts of the brain. It takes the name from the abnormal collections of protein, known as Lewy bodies, which occur in the nerve cells of the brain.

Symptoms Half or more of people with Lewy body disease also develop signs and symptoms of Parkinson's disease; hence most of the families confuse dementia with Parkinson‟s disease.

Otherwise, all the other symptoms are very similar to those that occur during Alzheimer‟s disease.

FRONTOTEMPORAL DEMENTIA (Dementia with Lewy bodies) - Dementia with Lewy bodies is very similar to Alzheimer's disease as in this case also there is depletion and of nerve cells in some parts of the brain. It takes the name from the abnormal collections of protein, known as Lewy bodies, which occur in the nerve cells of the brain.

Symptoms Half or more of people with Lewy body disease also develop signs and symptoms of Parkinson's disease; hence most of the families confuse dementia with Parkinson‟s disease.

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Otherwise, all the other symptoms are very similar to those that occur during Alzheimer‟s disease.

Frontotemporal dementias are studied to be a relatively rare cause of dementia and typically develop as early as in the forties and fifties than Alzheimer's disease. As the name suggests, the frontal lobe of the brain is particularly affected in early stages.

Frontal lobe dementia is caused in a similar way

Figure 4: An analysis of MRI data showing the pattern of brain tissue loss in Alzheimer‟s disease (green) and frontotemporal dementia (red) SOURCE: UCSF School of Medicine

to Alzheimer's disease which involves a progressive decline in a person's mental abilities over a number of years. Damage to brain cells is more localised than in Alzheimer's disease and usually, begins in the frontal lobe of the brain.

Symptoms Almost all of the symptoms are very similar to those that occur during Alzheimer‟s disease.

MIXED DEMENTIA – in this type of dementia, the person is diagnosed with one or more type of dementia.

For example Alzheimer‟s disease along with LewyFigure 5: Mixed dementia Source: ASPE Office of the assistant secretary for planning and evaluation

body dementia. ("Alzheimer's Disease International")

Figure 6 : Types of dementia SOURCE:springchicken.com

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Alzheimer‘s does not have the drama of a heart attack or the thud of an automobile wreck, but it works slowly, destroying mind, stealing life in a tedious, silent dance of death (DeBaggio)

So far there is no cure for this hellish disease, but medications and management strategies may temporarily improve the condition of the person coping with dementia.

OTHER CAUSES OF DEMENTIA Even though the percentage of chances of getting dementia is less, there are other diseases, disorders and habits that may result in dementia. Such cases are specially observed amongst the category of the people falling below the age group of 65. These causes include: ● If a person has been in a coma for more than 24 hours , he/she may develop a possibility to get dementia.

Figure 7 : An individual fighting stress and depression SOURCE: ETPanach.com

● alcohol-related brain damage can lead to dementia ● smoking cigarettes and tobacco ● corticobasal degeneration, ● progressive supranuclear palsy, ● HIV infections pose the danger of getting dementia ● Nowadays a lot of people are getting diagnosed

Figure 8: Habits like smoking can cause dementia SOURCE: blogreverb.com

with YOD (Young Onset Dementia) because of stress, blood pressure and diabetes issues and also the changing lifestyle and the way of living. ● Some people with Parkinson's disease or Huntington's disease develop dementia as the illness gets worse.

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● People with Down's syndrome are also at a particular risk of developing Alzheimer's disease as they get older.

MILD COGNITIVE IMPAIRMENT

Mild cognitive impairment is a condition in which people face slight cognitive related problems such as forgetfulness. These problems are severe as compared to the regular old age related problems but not as severe as those faced by the people suffering from dementia.

Mild cognitive impairment is not a type of dementia but research shows that people with MCI have an increased risk of developing dementia and about 10-15 % of this group might progress to develop dementia.

Risk factors causing dementia

Non-modifiable factors

RISK FACTORS Potentially Modifiable factors

• Vascular Disease

Age

• Family history

• Hypertension

• Female sex

• Diabetes

• Depression

• Dyslipidemia

• Head trauma

• Nutritional deficiency (Vit B)

• Mutation on 1,14,21 chromosome

• Smoking

• Down‟s syndrome

• Alcohol • Obesity

• Diet INDIA REPORT 2010 Prevalence impact, costs Table 2: Risk factors causing dementia SOURCE: THE DEMENTIA and services for dementia



MCI may also be caused due to other conditions such as anxiety, sleep apnea, smoking, depression, physical illness and side effects of medication.

•

These conditions can be qualified as the side effects of the fast-paced modern life that everyone follows today.

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•

Some people with MCI do not go on to develop dementia, and a small number of people will even get better.

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WHO DOES DEMENTIA AFFECT? YOUNG ONSET DEMENTIA

People with dementia who start to experience the symptoms before the age of 65 years, are often described as 'younger people with dementia' or are said to be suffering from „youngonset dementia‟. Another term for this is “Early-onset Dementia‟ or „Working Age Dementia‟ - as the age group before 65 years is termed as the working class.

Young onset dementia is caused by broadly similar diseases that cause dementia in older people ('late-onset dementia'), but there exist some important differences. ● It has been observed that all Young Onset Dementia are caused due to familial Alzheimer‟s due to defect in genes and they account for almost 10% of the people suffering from dementia. ● Other diseases that may cause young onset dementia are front temporal lobar degeneration, stroke, Parkinson‟s disease, Lewy bodies and other neurological conditions. ● Brain injury, HIV-AIDS and alcohol may also cause dementia in younger people ● Since dementia is rare in younger people, symptoms of these diseases may be difficult to diagnose accurately and initial misdiagnosis may delay appropriate treatment and care. Early-onset dementia is more likely to be hereditary than late-onset dementia.

LATE-ONSET DEMENTIA Dementia in almost all cases is diagnosed in elderly people ageing from 65 onwards. In 2005, Alzheimer‟s disease International (ADI) commissioned a panel of experts to review all available epidemiological data and reach a consensus estimate of prevalence in each of 14 world regions. The panel estimated 24.3 million people aged 60 years and over with dementia in 2001, 60% living in LMIC. Each year, 4.6 million new cases were predicted, with numbers affected nearly doubling every 20 years to reach 81.1 million. (KS et al.)

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WHAT ARE THE DIFFERENT STAGES OF DEMENTIA?

Dementia is a condition in which the symptoms faced by each and every person are unique and different. The nature of dementia varies from person to person depending upon their personalities, their likes and dislikes, their state of mind, etc. before he/she has been diagnosed with dementia. Based on these factors a person with dementia would either have a heightened sense of emotion or will be completely detached from it, which is still not yet conclusive and one will have to wait and ascertain the situation with time.

Dementia could be put across in three stages: Early stage – first year or two from diagnoses, middle stage – second to a fourth or fifth year from diagnosis and late stage – fifth year and after.

These are normally taken as guidelines as the speed of deterioration of the person living with dementia varies from person to person. Dementia is a progressive disorder that is irreversible in nature and it starts to mark its territory in the brain from the day one of diagnosis.

EARLY STAGE The early stage is the most difficult stage, as it is generally difficult to diagnose. It is difficult not only for the patient but for the family as well. In some cases,The patient knows something is wrong with him/her but is unable to get to the root of it.This makes the person irritable, scared and detached at times. This stage is difficult and extremely sensitive as it is overwhelming for the patient and for the family. In this stage, the symptoms start from zero but quickly progress to something that‟s unforeseen.

• Memory starts taking a toll as this is the main characteristic of the condition. The patients start to forget small things or show repetitive behaviour.

• The persons may face language problems as emotions run high and as this is the starting point things can get a little scary for them. Thus they might have trouble putting forward their wants and needs.

• They might become moody and seem to look tired, might show mood swings and seem disinterested in things they liked doing before.

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MIDDLE STAGE As the disease progresses, the condition of the person living with dementia starts to decline.

The diagnosis becomes certain and the doctors can be sure about the kind of dementia the person has developed. New characteristics start showing and the ones that existed previously worsen. Most families seek help from residential or day care services at this stage. ● The person starts to forget more frequently, now the person becomes incapable of recognising people, forgets names of people, gets disoriented very quickly ● The new characteristic that is observed is the habit of wandering as the person develops this habit to wander and this can get the person lost, he/she could get hurt during this time. This is a very serious issue. ● the person is unable to recognise familiar and unfamiliar places at home or outside ● the person may have hallucinations (seeing or hearing things which are not really there) this may scare the person and this, in turn, can lead to aggressive behaviour. ● In the second stage, the person becomes quite moody and there may be some aggressive outbursts about small things. ● There is very little or no bladder control at all.

LATE STAGE OR SEVERE STAGE This stage is the one where the person seeks total dependence on family members or caregivers. As this is the last stage, most people suffering from dementia are bedridden with a limited scope for any physical activity. ● The Person is confined in one room as he becomes bedridden and is incapable of moving around. ● It becomes difficult for the person to recognise familiar faces and objects. ● They might have difficulty in eating and digesting. ● They have almost no control over their bladders.

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CHARACTERISTICS OF DEMENTIA

Dementia symptoms vary depending on the cause, but common characteristics include :

• they have poor short term memory which makes it difficult for them to remember familiar faces

• they have difficulty in remembering phone numbers and addresses Cognitive effects

• they easily get confused and overwhelmed • It becomes difficult for them to register new information and even if they do, they forget very quickly.

• they have difficulty in completing the everyday tasks like brushing their teeth, combing their hair and may need assistance

• get confused in they skip a step in their daily routine and may get Functional effects

irritated

• May have a problem to express their emotions, wants and needs

• Become sensitive to loud noises • They may show repetitive behaviour Behavioural effects

• They could become physically aggressive • They may seem disinterested in activites and chores

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• They may show signs of aggressiveness • They may get severe mood swings Psychological effects

• They might go into depression or anxiety if they are not taken care of properly or if no one keeps a tab on their medicines.

• They may feel neglected if proper care is not taken as their emotional levels are high Table 3 Characteristics of Dementia SOURCE: Based on personal interviews

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CHAPTER TWO OVERVIEW Dementia is propagating and touching thousands of lives every day all around the world. This chapter aims at studying the global impact of dementia by providing exact statistics from reliable sources. The chapter then will continue to study the impact of dementia on India on a macro scale as well as micro-scale. On a macro level, the chapter will be inclusive of all the statistics of the number of people living with dementia in different states of India. The chapter will include the types of resources necessary for treatment of dementia along with a list of existing facilities around India.

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GLOBAL SCENARIO

Figure 9: The Global Impact of Dementia SOURCE: Dementia partnerships.com

In 2005, Alzheimerâ€&#x;s disease International (ADI) commissioned a panel of experts to review all available epidemiological data and reached a consensus estimate of prevalence in each of 14 World regions. The panel estimated 24.3 million people aged 60 years and over with dementia in 2001, 60% living in low and middle-income countries (LMIC). Each year, 4.6 million new cases were predicted, with numbers affected nearly doubling every 20 years to reach 81.1 million by 2040. Incidence was estimated from prevalence and mortality. The estimates were provisional, due to limited data. (Dementia: A Public Health Priority)

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ESTIMATION OF NUMBERS OF PEOPLE WITH DEMENTIA AROUND THE WORLD

Having applied the age-specific, or age- and sex-specific, prevalence estimates

to

UN

population

projections, it was estimated that 35.6 million people worldwide were living with dementia in 2010. Western Europe is the

with the highest

number of people with dementia (7.0 million), closely followed by East Asia with 5.5 million, South Asia with 4.5

Figure 10: Estimated number of people living with dementia in the year 2030 around the major countries of the world SOURCE – Datingdementia.com

million and North (Dementia: A Public Health Priority)

According to the WHO report on dementia, 2012; America has the maximum number 4.4 million people living with dementia. The nine countries with the largest number of people with dementia in 2010 (1 million or more) were China (5.4 million), USA (3.9 million), India (3.7 million), Japan (2.5 million), Figure 11: Numbers of prevalence studies, by year of data collection and income level of the country where the research was carried out SOURCE: World Alzheimer Report 2015 The Global Impact of Dementia An Analysis of prevalence, Incidence, cost And Trends

Germany (1.5million), Russia (1.2 million), France (1.1 million) Italy (1.1 million) and Brazil (1.0 million).

(Dementia: A Public Health Priority)

The

total number of people with dementia worldwide is projected to almost double every 20 years, to 65.7 million in 2030 and 115.4 million in 2050. Much of the increase is attributable to increases in the numbers of people with dementia in LMIC in 2010, 57.7% of all people with dementia lived in LMIC, and this proportion is expected to rise to 63.4% in 2030 and 70.5% in 2050. (Dementia: A Public Health Priority) REMINISCE OF A MEMORY- Dementia Care and Resource Facility

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These projections were taken into account by population growth and demographic ageing.

World regions fall into three broad groups.

High-Income countries start from a high base but

will

experience

only

a

moderate

proportionate increase – a 40% increase in Europe, 63% in North America, 77% in the southern Latin American cone and 89% in the developed Asia Pacific countries. Other parts of Latin America and North Africa and the Middle East start from a low base but will

Figure 12: statistics comparing Alzheimer‟s with breast and prostate cancer SOURCE: Mydmentedmom.com

experience a particularly rapid increase – 134–146% in the rest of Latin America, and 125% in North Africa and the Middle East. China, India and their neighbours in South Asia and Western Pacific start from a high base and will also experience rapid growth – 107% in South Asia and 117% in East Asia. Projected increases in sub-Saharan Africa (70–94%) are modest.

(Dementia: A Public Health Priority)

―…Alzheimer‘s disease burdens an increasing number of our nation‘s elders and their families, and it is essential that we confront the Challenge it poses to our public health…‖ Ex-President Barack Obama, United States of America, 2011

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INDIAN SCENARIO

"The World over, 44 million people are living with dementia of some form, with over 4 million Indians contributing to this figure, making dementia a global health crisis."- Dr Sunil Mittal, Delhi-based senior consultant psychiatrist at Cosmos Institute of Mental Health and Behavioral Science PTI | Sep 21, 2016, 06.59 PM IST

The number of people living with dementia in the year 2010 was 3.7 million as stated in the India Report on dementia by ARDSI. This number has shot to 4.1 million people living with dementia in India in the year 2016 as confirmed by Mrs Vidya Shenoy, Secretary General of ARDSI. In just a mere time span of six years, there has been an increment of 0.4 million people. It is, therefore, time to take dementia seriously and the government ought to declare it as a national priority.

Estimation of the year 2010 and Future Projections Prevalence of Dementia

by Age and Gender The survey in the year 2010 showed that out of 3.7 million people affected by dementia; 2.1 million were women and about 1.5 million were male.

This led to a conclusion that, since the prevalence of Figure 13 : Prevalence of Dementia in India, 2010 dementia seems to be more SOURCE: groundreportindia.com among women, dementia could be gender related.

The fact that women in India, live longer than the men due to scientific reasons was taken into consideration. However, studies of the age-specific incidence of dementia among older people show no significant difference for women and men. (KS et al, 2010)

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PREVALENCE OF DEMENTIA BY AGE OVER TIME

Mostly, the people who develop dementia at the age of 60 years to 75 years show a steady decline in their state of mind. The people suffering from dementia in the age group of 75 and up, show a rapid decline in their health as they have already accelerated to the 2nd or the 3rd stage of the disorder.

Figure 14: Trend in dementia prevalence by age over time (2010-2050) SOURCE-www.alzheimer.org.in

FUTURE PROJECTIONS OF DEMENTIA In the ARDSI dementia report 2010,the future projections were estimated on the assumption that prevalence of dementia would be stable over time, which may not be true. It had been kept in mind that.

For example, in India, the number of people with AD and other dementias is increasing every year because of the steady growth in the older population and stable increment in life expectancy (KS et al, 2010)

Figure 15: Estimation of number of PwD over 60 years in India between 2000 and 2050 SOURCE- www.alzheimer.org.in

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STATE-WISE ESTIMATES OF NUMBERS OF PWD IN INDIA

In the ARDSI

dementia Report for 2010, State-wise estimates were made using meta-

analyzed prevalence estimation for India .The projected number of people aged 65 and older with dementia for years 2011, 2016 and 2026 varied by state and region in

India

and

corresponding

variability in a number of people with dementia was also observed.

The percentage change in dementia between the base year 2006 and each of the subsequent time periods was then calculated. (KS et al,2010) By 2026, more than 500,000 older PwD are expected to be living in Uttar Pradesh and Maharashtra.

In other states, Rajasthan, Gujarat, Bihar,

West

Bengal,

Madhya

Figure 16: Projected changes between 2006 and 2026 in number of people living with dementia by State

Pradesh, Orissa, Andhra Pradesh,

SOURCE- www.alzheimer.org.in

Karnataka, Kerala and Tamil Nadu around 20,000 to 40,000 PwD are

expected within the next 26 years. Compared to 2006, Delhi, Bihar and Jharkhand are expected to experience 200% (or greater) increment in a total number of dementia cases over the 26 year period. Other states (Jammu and Kashmir, Uttar Pradesh, Rajasthan, Madhya Pradesh, West Bengal, Assam, Chhattisgarh, Gujarat, Andhra Pradesh, Haryana, Uttaranchal, Maharashtra, Karnataka and Tamil Nadu) are estimated to experience 100% (or more) change in a number of people older PwD. (KS et al, 2010)

The increased numbers of PwD will have a great impact on the statesâ€&#x; infrastructures and health care systems, which won't be up to the mark at that time since this disorder is not taken seriously. The projected increases in the Southern region are not as marked as those in other regions of India, however, a large proportion of people aged 65 would result in more PwD. (KS et al, 2010)

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PROJECTED

NUMBERS

OF

PEOPLE

LIVING

WITH

DEMENTIA IN EACH STATE OF INDIA IN COMPARISON TO THE YEAR OF 2006

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PROJECTED

NUMBERS

OF

PEOPLE

LIVING

WITH

DEMENTIA IN EACH STATE OF INDIA IN COMPARISON TO THE YEAR OF 2006

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PROJECTED

NUMBERS

OF

PEOPLE

LIVING

WITH

DEMENTIA IN EACH STATE OF INDIA IN COMPARISON TO THE YEAR OF 2006

Table 4: Projected number of people in India compared with dementia SOURCE: ARDSI dementia India Report 2010

The above studies clearly show that there is a severe need for infrastructure in the coming period as the number of persons living with dementia is going to keep on increasing as the time goes by.

Community-based intervention targeting older PwD and their carer should be developed and their cost-effectiveness and feasibility have to be established.- (KS et al.)

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CHAPTER THREE OVERVIEW

This chapter lists the various resources that are necessary for the treatment of people suffering from dementia there by doing an in-depth analysis of each of the service required. The chapter then proceeds to list down all the possible resources all over India and comparing it with the facilities that were available in 2010.

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RESOURCES NECESSARY FOR DEMENTIA CARE

―A long-term care centre with stay facilities is the need of the hour for dementia patients.‖R Gopalakrishnan, a social worker, runs Anand Rehabilitation Centre in Nalasopara Sandhya Nair | TNN | May 16, 2011, 05.21 AM IST

 FULL-TIME RESIDENTIAL CARE SERVICES EXCLUSIVE FOR DEMENTIA PATIENTS Full-time residential care services are facilities where people living with dementia are cared for a long period of time. Such facilities are different from old age homes as people living with dementia may need round the clock medical assistance. Thus, it is very important for all the staff members to have special training to care for PwD. These full-time care services are as good as final homes for people living there. Most of the full-time care centres in India are rented thus they lack the infrastructure and the personal touch the place

Figure 17: A pleasant site of a caregiver caring for the patients SOURCE:alz.org

needs to make the people living there feel at home. India developing at an alarming rate almost erasing the line between work hours at office and leisure time to spend with family at home.

Time schedules are as chocker blocked as the roads of the country. Thus, given such a situation it becomes difficult to care for a person living with dementia at home and that is why people opt for long-term residential care where their loved one is not lonely and gets medical help round the clock.

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 DAY-CARE SERVICES Mumbai has only one dedicated day-care centre for seniors with dementia. And only a handful of senior day-care centres in all.A draft BMC policy in 2013 envisioned one day-care centre for seniors in every municipal ward in Mumbai — which would mean a total of 227 across the city and suburbs.

But there has been no move yet to implement this policy.

Pankti Mehta Kadakia, Hindustan Times, Mumbai Updated: Aug 17, 2015, 22:38 IST

The day-care centres for people suffering from dementia are similar to day-care centres for children. Such kind of a facility is not only beneficial to the person living with dementia but also to the career. Some families are not comfortable with keeping their loved one far away from home.so, for such families the day-care centre gives them the much needed free time to take care of personal chores, go to work and Figure 18: Activities at SOURCE:news.asiaone.com

a

day

care

centre

revive and rejuvenate themselves. As for the people suffering from dementia, this

becomes a place to socialise with new faces every day, take part in various activities arranged by the day-care centre. The various services that most of the daycare centre's offer are : 

Transport facilities such as a pick-up and drop-ups



Exercises and games



Various activities



Anger management classes



Music therapies , speech therapies

 RESOURCE CENTRES OR DOMICILIARY HELP Resource centres are basically centres which provide necessary help to the families of people living with dementia. These centres ideally should be set up in all the cities as most of the times; the families go to such centres to gather information on dementia and to ask queries about the disorder. These centres also provide domiciliary help to families by arranging awareness talks and programmes in certain parts of the city. The centres also provide training

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sessions for a month long to train the nurses and the families. These resource centres organise memory screening camps in villages to spread awareness. Domiciliary services as sending professionals home to take care of the person living with dementia can be arranged. ARDSI in India has taken the necessary step to have at least one resource centre by starting ARDSI Chapters all over India.

 MEMORY CLINICS Memory clinics are set up in each and every super specialised hospital. One is asked to visit a memory clinic when the General physician

suspects

dementia. The idea behind memory clinic is that the Figure 19: A memory screening session at a hospital

doctors at the memory clinic SOURCE: shadithyahospital.com

specialise

in

dementia

and

would do a thorough check up along with some tests and help figure out more about the condition.

 HELPLINES Helplines help solve and gather information about dementia over the phone. Most of the resource centres look after this. The main reason for help lines is that; people living with dementia have a tendency to wander which can lead to the person getting lost. There are special helplines for such cases that may help find the lost person.

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RESIDENTIAL CARE SERVICES IN INDIA

According to the ARDSI India dementia report that came out in the year 2010, there were only five full-time residential care facilities exclusively for persons living with dementia in India.

This was because there was almost no awareness in most of the parts of the country. The above map shows the approximate numbers of residential and day care services exclusively for people suffering from dementia. Memory clinics are not shown on the map as almost all the big hospitals are set up with memory clinics.

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CITIES

MUMBAI

FULL-TIME DAY CARE RESIDENTIAL CENTRES CARE CENTRES

ASSISTED LIVING FOR DEMENTIA PATIENTS WITH OTHER CONDITIONS

Resource centres FOR DEMENTIA CAREINFORMATIO N,SUPPORT

A1 Snehanjali– Nalasopara west

Dignity day care centreByculla

A silver amore – Thane, Dignity Lifestyle Retirement TownshipNeral

ARDSI MUMBAI CHAPTERAishabai college of education , Byculla

Nightingales day care centres – 4 no‟s

Nightingales TrustDhanvantri Hospital Society Palliative Care Unit Chaitanya mental health care centre

ARDSI BANGALORE CHAPTER

Nightingales centre for BANGALORE Ageing and Alzheimer‟s

PUNE

Jagruthi Dementia cares centre

--------CHENNAI

DELHI

Chronic care dementia facility

SRCF Elder Care & Training Centre DEMCARES day care centre, ARDSI CHENNAI CHAPTER Daycare centre

---------

ARDSI DELHI VARDAAN CHAPTER old age home EPOCH elder care

GOA

---------

---------

---------

ASSAM, MANIPUR, MIZORAM

---------

---------

---------

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ARDSI PUNE CHAPTER

ARDSI CHENNAI CHAPTER, DEMCARES RESOURCE AND TRAINING CENTRES

ARDSI DAY CARE CENTRE

ARDSI Goa chapter, SANGATH ARDSI guhawathi chapter, ARDSI Mizoram chapter, ARDSI Manipur 43

HYDERABAD Heritage Elder Care Services

KERALA CITIES

Harmony home, Malabar Harmony home, Snehasadanam respite care,

--------KOLKATA

BIHAR

ARDSI activity centre

---------

ARDSI Chapter

ARDSI national Comprehensive Smruthipadham office , ARDSI day care, day Kozhikode care at Aluva, chapter,Kottayam Chapter,Pathanam thitta chapter, Trivandrum chapter, ARDSI Calcutta Dementia Daycare Centre

Day care centre

by Helpage India

---------

ARDSI Calcutta chapter

ARDSI Bangalore chapter

Table 5: A list of the resources available all across India SOURCE: Dementia Care notes

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CHAPTER FOUR OVERVIEW When we talk about dementia, we must also take into account the extent of individual care as required by an individual suffering from dementia . In this chapter, we will explore the topic while also trying to understand the struggle that they have to live with each day. We will study the implications of the condition and also try to understand it through real life stories of people taking care of family members who are victims of it. Another aim here is to try and study the role or caregiver

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TARGET GROUPS AND THEIR ISSUES

Dementia is not a one- way disorder, it is actually a three- way condition that knowing or unknowingly touches each and everyone at some point in time in their lives. ―Alzheimer‘s is like trying to describe air. You know it‘s there but you cannot feel or see it until the storm comes and the wind blows the tired, dead leaves to the ground to rot‖(DeBaggio). Dementia not only affects the person living with it but also has a great impact on the person‟s family members. The society also gets affected by dementia in one way or the other. Thus, the 3 main nodes that get affected by dementia are: 1. The person living with dementia: Since the person is suffering from this painful malady, he/she goes through a lot down the road to dementia.

2. The family most importantly the career: Dementia affects the family in the worst possible way. Imagine the mental strain of the family members living with a person affected by dementia. Just looking at their loved ones go through pain every other day. The person affected by dementia becomes a hundred percent dependent on the family members for every small little thing.

3. The society: The expenditure for the treatment and other facilities for persons with dementia are looked after the government in many countries. This may a times burdens or puts a strain on the society as a whole.

THE PERSON LIVING WITH DEMENTIA

“I am being gobbled up in time. The words are under control but the letters that form the words squirm in their own directions” ( DeBaggio) Dementia is unique and different for each and every person. There is no “typical” dementia patient as such. Every person showcases different symptoms and characteristics depending upon the condition of the brain. Thus “one size fits all” type of care is not the right type of care for patients with dementia. According to ARDSI, all types and all stages of dementia need some care or the other. This does not imply that they should all be regarded as needing care.

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Needs for care were assessed in the 10/66 Dementia Research Group‟s population-based studies in Latin America, India and China. The needs for care among those with dementia (Clinical Dementia Rating 1 or above indicating mild or >mild dementia) from the Indian centres are summarised. (Alzheimer‟s and Related Disorders Society of India, New Delhi)

Figure 20: Need for care depending on the severity of dementia SOURCE: alzheimer.org.in

In most cities, between 50 and 70% of those with dementia were rated as needing care, and most of those needing care needed „much care‟. Needs for care varied by level of dementia, with 30% of those with mild dementia, 69% of those with moderate dementia, and 88% of those with severe dementia needing much care. In the urban Indian centre of this study, 78.5% of those with dementia needed much care. In the case of the rural Vellore, the proportion needing much care was 33.3 %.(KS et al.)

The person living with dementia may start forgetting familiar faces and names but the common trait that is observed is that the person does remember certain things from the past, certain events from the past that have taken roots in the memory of the person a long time back. Thus the short-term memory is compromised but some of the long-term memories stay intact.

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An instance from a personal experience: A few months back, when I visited a care centre in Pune to meet the people living there and to understand more about the psychology and needs of people living with dementia. Old women came to me and asked me how I was doing. After some time she told me that she was waiting for her father to come pick her up from the centre. This woman was 90 years old.

The woman did not know she was affected by dementia but she remembered some instance that had happened in her life and remembered the fact that her father always used to pick her up from school as a child. This was my first-hand experience with a patient who was in the second stage dementia.

"Depending on which part of the brain gets affected, patients also develop judgment and language problems as well as difficulty in performing day-to-day activities such as using a toothbrush or buttoning a shirt. If the posterior part of the brain is affected, they can't recognise a familiar face or even themselves," averred Dr G Butchi Raju, professor and head of the department of neurology at King George Hospital (KGH). (Mehta) One of the earliest signs is changes in personality or the personality traits becoming more rigid. Explaining, neuropsychiatric Dr C Radhakanth said, "For example, if a person has obsessive-compulsive disorder (OCD), is a perfectionist or is suspicious by nature, they tend to display this trait even more prominently. Instead of adapting, they become more exaggerated and exhibit some kind of personality disorder. Secondly, they develop minimal cognitive impairment or mild forgetfulness and forget stuff like where they kept keys or purse or can't recall names. The loss of memory later progresses into an inability to find one's home address or recognising even friends and family members."(Mehta)

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At first, all these small things like forgetting names and getting a little disoriented may seem like itâ€&#x;s all a natural part of ageing, but it is necessary to act on it before it goes out of hand.

Figure 21: The fear of stigma in case of people suffering from dementia SOURCE: alznorcalblog.org

Most of the country still believes in denial for they fear becoming a social outcast after being diagnosed with any illness, terminal or otherwise. Some people are not comfortable enrolling their parents in a care facility solely because they are scared of what might happen to their reputation. This leads to keeping the person with dementia at home without proper care. And as we know from earlier chapters that persons with dementia are on a rollercoaster of emotions throughout the day. It is, therefore, important to get diagnosed in time and put the well-being of the person living with dementia before anything else.

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THE CAREERS/ INVISIBLE PATIENTS The experiences of the people, caring for people suffering from dementia is something that is not often talked about. In a family with everyone looking after the person with dementia, there is one person who handles the maximum amount of work. This person emerges out to be the caregiver. The career caters to the needs of the person living with dementia around the clock.

The person living with dementia becomes fully dependent on his/her career. The wives/ husbands, daughter, son, daughter-in-law are generally the careers here in India. Profession careers can also be hired who could give home services.

Being a career is considered to be the toughest task to date. It has been observed that most of the careers go through certain psychological disorders such as anxiety, depression as they devote their lives to caring for their loved ones.

This can have certain negative impacts on their lives such as detachment from social activities, Figure 22: percentage of female care givers SOURCE: alzheimersresearchuk.org

Figure source- Alzheimer's Association

etc. It is also observed that 61 % of caregivers are women.

Most caregivers are faced with multiple

problems at work and home. This most of the time leads to quitting of jobs which can frustrate the career to some extent. Thus family caregivers play a very big role in the lives of the people suffering from dementia. It has been well documented that the careers are more prone to undergo psychological problems and disorders during the course of caregiving.

.VOICES

FROM INDIA

One day, I got out of the car and turned and saw mum waiting by the door, a beaming smile on her face. ―Did you have a good trip?‖, she asked. ―Have you eaten anything? You are lookingsothin!‖ And then she called me by the name of her only brother – the man who had disowned her

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when she got married against her family‘s wishes; the man she had never spoken to for over 50 years; the man who was long dead. (Kishore)

If you do not have any support, you may have to put your loved one into an institution, but you can, of course, visit them several times a week, right? No support needed for that, right?

A word of caution, sometimes institutions will be mirroring your attitude towards your loved one. If you don‘t visit them often, the staff there may feel it is okay to not pay attention to a patient who is not getting checked on often. It‘s wrong, but it‘s true. If money could buy everything, would we not have bought physical wellbeing for our loved one? So remember, your responsibility doesn’t end with institutionalisation, rather it begins there. You have to walk that extra mile to let your loved one know that you care, even if you can’t keep them at home with you. (carers foundation) (Kishore)

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CHAPTER FIVE OVERVIEW This chapter will try to explore the costs of dementia in India. This chapter proceeds to study the ideologies of formal and informal care in India. Therefore, while trying to analyse it from a financial point of view, it will also talk about where India lacks when it comes to dementia care.

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COST OF DEMENTIA IN INDIA

The major impact of dementia as studies in previous chapters is on the person living with dementia, the family or the career and the society.

Dementia care can be divided into two categories namely, formal care and informal care. Now, formal care is basically care given by care centres, nursing homes, hospitals or even day care centres. These formal care centres generally have specific criteria for admission and certain monthly or yearly fees. In India, most of the care centres or facilities for persons with dementia are run by Alzheimer‟s and Related Disorders Society of India (ARDSI). Almost all the ARSDI centres have flexible fees that depend on the income of the family wanting to enrol the person with dementia. Otherwise, as ARDSI is a non-profit organisation, they do accept charity and donations from families who are capable of doing so.

Informal care is care provided within the four walls of the house. Informal care can pose lots of problems and can be a bit tricky. Informal care puts a lot of stress on the career and the family psychologically and economically as one has to comprise their jobs to be with their loved one as they require round the clock assistance. In this case, formal care tends to be a little lighter on the pocket and mind and also ensures the professional care of the person living with dementia.

With an estimated 3.7 million PwD in 2010, the calculated total societal cost of dementia for India was estimated to be INR 147 billion. While informal care is more than half the total cost (56%, INR 88.9 billion), nearly two-thirds (29%) of the total cost is the direct medical cost (INR 46.8 billion). The total cost per person with Dementia is INR 43,285. (KS et al.)

It has been studied and concluded that dementia greatly affects the developing countries more than it affects the developed nations. Dementia is definitely a greater problem for average lowincome countries like India. The burden of dementia is increasing by the minute and so are the people living with dementia. This is a challenge that the government of India should take up before it is too late and make policies which could help lessen the burden of dementia on the families and the society. ―The impact and cost analysis clearly foresees a ‗wake-up call‘ in terms of planning and providing services, infrastructure, capacity building and training at every level.”- ARDSI report 2010. (KS et al.)

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WHAT DOES INDIA LACK?

Apart from India, all the other countries in the world have special policies made by the government to help minimise the burden of dementia. In India, the government of Kerala has initiated a full-time care facility at Cochin in a joint venture with ARDSI. It is time to take dementia seriously by making a few changes in the society with a helping hand from the government.

•

The services in India are not even

close

to

being

proportional to the number of patients getting diagnosed with

dementia.

This

condition is a progressive condition of the brain and the numbers of people getting dementia are only going to rise. Thus it is time to match up to those rising numbers

Figure 23: Barriers to Dementia Care in India

and help our loved ones.

SOURCE: alzheimer.org.in

•

It is commendable that some NGO‟s are trying to make India dementia friendly, but the existing facilities in India are not up to mark in sense of infrastructure as the places are generally rented bungalows or nursing homes that cannot be remodelled as ideal dementia homes.

•

Thus, infrastructure is a major problem faced by India as opposed to other countries where there are special dementia care centres with suitable architecture that help the patients with dementia. Good architecture has a potential to act as

a catalyst to

improve the health of people living with dementia for example- the respite centre in Dublin, Ireland.

•

As mentioned earlier government should adopt policies that will reduce the societal burden and help families take better care of the PwD.

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•

Awareness programmes such as awareness talks show s need to be encouraged not only in the village areas but also in the cities as awareness is the key to success.

Sufficient awareness in public will help de-stigmatise this memory sucking condition.

•

Training centres for caregivers is a must as persons with dementia need a specialised care which is not the same as care given at the old-age homes.

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CHAPTER SIX: SPACE- Case studies OVERVIEW This chapter looks into the importance of special care infrastructure in the course of dementia mostly concentrating on the aspect of “spaces� through personal inferences taken from the study of various existing dementia care facilities in India and abroad. This chapter is of utmost importance as it forms the roots of designing a facility for dementia care after skilfully weighing the pros and cons of the studied facilities.

The internet case studies that have been documented above are of two different typologiesone a facility for dementia care and the other one, a larger facility more like a township for dementia care. These case studies are chosen to help understand the difference in scale for both the designs and to help understand the different concepts. The case studies will help understand the ideology behind the designs and throw light on various architectural elements that have been used.

Whereas, the physical case studies are documented with a view to understanding the condition of the existing facilities around India. To understand the strengths and the weaknesses of these facilities and what they lack. The physical case studies helped understand the people living with dementia better, helped understand their behaviours and traits along with a basic idea of what is required for designed such a facility.

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THE IMPORTANCE OF SPECIAL CARE FACILITIES IN DEMENTIA

Need for infrastructure in special care facilities There is a dire need of special care infrastructure in the course of the fight against dementia in todayâ€&#x;s time. While the existing facilities for dementia are doing the best they can, the concept of spaces still remains unexplored and restricted.

The number of facilities down in the south of India is more than compared to the number of facilities otherwise around India. This proves that there is a lot more awareness about dementia in the southern region and people are trying to understand and contain it by taking necessary actions. All these facilities are located in an environment which is best suitable for people living with dementia. These places have a certain kind of aura that can bring a person back into existence.

Being surrounded by nature makes one get connected to it in a way that is not possible in the metropolitan cities like Mumbai. Nature has the ability to calm the mind and takes the person with dementia back to a time when there used to be less of a concrete jungle and more of open spaces, which they tend to like.

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INTERNATIONAL CASE STUDIES Alzheimer’sRespite centre, Dublin (design

case

study)

Architect: Niall McLaughlin Year: 2009 Typology: Respite and a day care Centre Strength: 11 beds and up to 25 patients for day care

Figure 24: Alzheimer's Respite centre, Dublin SOURCE: architizer.com

OVERVIEW The Alzheimer‟s Respite centre in Dublin by Niall McLaughlin is a project by the Alzheimer‟s Society of Ireland. The society preferred an outsider to design a structure for patient‟s sufferings from Alzheimer‟s thus; they divided the project into 2 phases: phase 1 that included an in-depth research about Alzheimer‟s and Phase 2 included a design proposal for the same.

After the in-depth research the architect came to a conclusion that the building would have 2 major purposes: •

promote community solidarity and

•

strengthen a person‟s sense of orientation

Unlike many other facilities, Respite centre is one of a kind as it only caters to people suffering from Alzheimer‟s.

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CONCEPT The architect thought of designing a facility which would be flexible in its use and provide a sense of solidarity among the elders. The architect wanted the place to promote a good balance between the staff, the elderly user and the family.

The facility is designed keeping in mind the traits of people affected by Alzheimer‟s .Some of them are: • The cognitive ability of the mind is compromised and their memory is affected thus they have trouble remembering certain things • They also can become simply disoriented and are liable to wandering.

•On prime of this they're old and sometimes have a problem with walking.

DESIGN PARAMETERS The main aim of the design is framing a community and aiding orientation.

Planning Planning is crucial as the people need to be reminded where they are at all times as they are prone to wandering and might get lost. 

The facility is planned in such a way that the interconnected routes that flow through the courtyards, gardens , rooms are all linked to each other bringing the person who takes any possible route back to the social core of the facility. This helps the people wander or roam within the facility without feeling lost.

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Figure 25: Ground Floor plan SOURCE: architizer.com



Due to this there is a continuous movement or flow from the inner spaces to the outer spaces without feeling lost or overwhelmed.



A unique feature in the design is the series of brick walls that create a labyrinth-like space which enclosed the gardens that follow the person who walks through.



The labyrinth-like walls give a sense of protection to the people within.



The facility is designed inside the 18th Century walls, the building is surrounded by a series of gardens, each oriented in a different direction (north, south, east, west) and each planted appropriately to its orientation (courtyard, orchard, allotment, lawn).

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Figure 26: Exterior view of the facility SOURCE: architizer.com



There are windows throughout the facility. They allow a clear view of the gardens and thus if one moves through the interior of the facility, one could follow the sun like a clock experiencing different lighting and shadows throughout the day.



For people with Alzheimer‟s this type of connection with the building is important as they are very sensitive to their surroundings.

OTHER ELEMENTS TO BE KEPT IN MIND WHILE PLANNING 

Another most important element of designing is the material and the colours used.

People suffering from Alzheimer‟s may have problems related to their vision as most of them are already above the age of 65, thus colour coordination is a must. It is important that the colour of the toilet doors and other appliances need to be of different colours. If the toilet seat is also the same colour as the toilet then the patients can easily get confused and scared which might lead them to aim badly or, worse still, miss the seat completely and fall which can cause

serious injury.

Figure 27: Internal view of the facility showing colour coding for the walls SOURCE: architizer.com

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Similarly, shiny floors can appear to look like water and they will not feel safe walking on them and may get disoriented and fall. 

The architect has made sure that distances between seating areas are short and the passages are wide enough to fit wheelchairs.



windows and lighting have been designed to minimise glare and shadow 

the floor, skirting and walls, doors

are clearly differentiated by use of colour and tone 

It is made sure that the flooring

doesn‟t have any patterns as that might irritate the user. 

To

distinguish

between

toilets,

rooms and non-access, coloured walls are in key positions to aid orientation  Figure 28: View of the gardens and abundance of light from the windows proves to be beneficial for the health of the patients SOURCE: architizer.com

there are no dark corridors or dead

ends 

there are continuous handrails throughout

the facility 

Staff rooms have been situated to allow for constant passive contact with residents and all rooms are connected but can be isolated if necessary.



The architect has tried to make the corridors less boring by adding seating‟s that could be used by the residents if they feel tired while walking the corridors also use of colours help make it lively.

INFERENCE The case study on Alzheimer‟s Respite Centre in Dublin threw light mainly on the architectural aspect. It helped understand the importance of small details that can help make the design stand out and dementia-friendly. It stressed the importance of colour schemes while designing a dementia care facility, helped understand the Figure 29: Bright walls of the facility SOURCE:

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also helped understand the importance of green spaces and how important it is to have a connection between nature and the architecture. It helped get a basic a gist of all the spaces that need to be designed for a dementia care facility.

The Respite centre is a working example which proves that the right architecture and infrastructure is the need for the hour to help the people with dementia live a better life.

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The Hogeweyk- Dementia village, Netherlands

Architect:Molenaar&Bol&VanDillen Architekten, Vught Location: Heemraadweg 1, 1382 GV Weesp, Netherlands Year: 2009 Typology: dementia village Strength: 23 houses for 152 dementiasuffering seniors.

Figure 30: View of the facility showing play of solid-void SOURCE: trendzified.net

OVERVIEW The Hogeweyk is a village for people suffering from dementia which was completed in 2009.

It is situated in an industrialised suburb of Amsterdam. The architect has tried to design Hogeweyk as a village from 1950â€&#x;s.

In 1992, Hogeweyk was just another ordinary nursing home in Weesp, a suburb 20-minute drive from Amsterdam, Netherlands. It was run just like any other care facility for people with dementia but it was run in all the wrong ways with locked doors, crowded dayrooms, nonstop TV, nurses in white coats and, of course, heavy medication. However, when Yvonne van Amerongen, who worked there, suddenly lost her father she other co-workers started to think about the type of facility they hoped their relatives would live in, for the final stage of their lives.

Hogeweyk is designed right in the residential area and people living around it can catch a glimpse of the elderly living at Hogeweyk.

The dementia village was designed keeping in mind 2 main objectives.

They were:

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

To provide a safe and a familiar environment for people suffering from dementia .Hogeweyk aims to counter the negative feelings like confusion, anxiety, etc. that is most commonly seen in people living with dementia.



To keep the residents active and happy by engaging them in various programmes.

CONCEPT: Hogeweyk is a unique and one of a kind facility in the world. The main concept behind designing Hogeweyk was to give the people suffering from dementia the second chance at life.

The dementia village is a facility that is designed as per the parameters of a city in which all the residents are people diagnosed with dementia. Other people living there are round the clock doctor and nurses and caregivers. The most striking feature is that the aim of this project is to give the people suffering from dementia a normal life thus, all the staff that is, the nurses, caretakers are in clothes other than their uniforms. This helps create a hyper-reality in which the residents feel safe and free to do as they wish without feeling like being watched all the time.

DESIGN PARAMETERS 

Occupying 15,310 square meters, of which 7,702 is not built on, Hogeweyk, is designed as a full-fledged village or a township with streets, alleys, large squares, fountains and a park so that residents can enjoy the life they would otherwise not be able to outside the closed gates.



The facility is designed to have all the amenities like a theatre, a restaurant, a café, a supermarket, a barber/ beauty salon, a post office that are required in the day- to – day life.



The panning is done in such a way that all the spaces flow into each other and are well connected with no dead ends as this would upset the patients.



The solid to void ratio is well thought of while designing as each complex has been designed in a way that it opens up in a courtyard or a green recreational space.

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

All the roads and streets are interconnected along with green recreational spaces which are also interlinked to make it safe for the residents to walk freely without feeling

Figure 31: Ground floor plan SOURCE: twistedsifter.com

overwhelmed. 

Each green space that is designed in Hogeweyk has a different purpose. For example, the theatre square can be used for street theatre; the boulevard has stores along it, the green space outside the nursing home can be used for physical therapy.



Green spaces help stimulate the mind and promote the well-being of the residents.



The architects have not forgotten that since this is a village for people affected by dementia, there needs to be a nursing home for sensorimotor stimulation and a physiotherapist. 

The

homes

called

as

building blocks in general design are the main feature of the facility.

These blocks define the character of the spaces. The building block is chosen according to the lifestyle preferred by the resident.

Figure 32: Plan showing flow of green spaces SOURCE: hogeweyk.dementiavillage.com

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

Hogeweyk was projected

66

in a way so that the block of apartments forms a boundary from the outside world and there is no need for fences and walls to keep residents inside. 

.Each

apartment has around 220 square metres and is home for 6 up to 7 people. It is

better for people to live in small groups in one house at it makes them feel at home and have a family of their own once again. 

Every house has three common areas: a kitchen, a lounge, and a dining room.



Each house is allocated a team of caregivers to help the residents in their day to day chores like washing, cleaning and also keep a check on each individual living in the house.



Every apartment has a wide glass

Figure 33: View of the grocery store at de Hogeweyk

window that leads to the street or

SOURCE: trendzified.net

to some garden 

For example, the residents in artisan lifestyle are all proud of their trade. They are plumbers, carpenters, etc. The interiors of these houses are done to suit the preferences of the people living in it. The layout of the house is solid and traditional.

INFERENCE Both the international case studies are very different from each other in the sense of the concept, typology and design. The Alzheimer‟s Respite centre in Dublin is a small facility for about 10-20 people whereas the De Hogeweyk is a much larger facility – more like a township as compared to the Respite centre.

De Hogeweyk is the very first township or village in the world and is one of a kind. The concept of this facility is to give people with dementia a second chance at life after getting

Figure 34: Various interiors of the houses SOURCE: twistedsifter.com

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diagnosed with Alzheimerâ€&#x;s or dementia. This case study helps gain a different perspective on designing a facility for dementia care.

This case study helps to understand the project on a larger urban level scale. Various planning factors such as the importance of solid-voids, green spaces and the concept of not having gates but forming a boundary with the help of houses that creates a boundary has proven to be very helpful.

The concept of providing different architectural styles for people with different preferences, helps people feel comfortable and at home.

Therefore, both the case studies have helped understand the power of design and architecture in the course Figure 34 : Image showing the central courtyard

of dementia.

SOURCE:cnn.com

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Jagruti Rehabilitation centre, Pune PHYSICAL CASESTUDY-Present case scenario Founder: Dr Amar Shinde Location: Hadapsar, Pune Year: 2015 Typology: Residential building Strength: 51 people suffering from dementia

Figure 35 External view of the dementia building

OVERVIEW This cases study aims at understanding the workings of the existing facilities in the field of dementia. The Jagruti Rehabilitation centre is a new venture started by Dr Shinde in the year 2015 after the successful workings of the facility he had started in the year 2008 for people suffering from mental disorders.

The facility is located 10km further from Pune on the Pune-Solapur road and a few km away from Hadapsar. The facility is located in a fairly residential area but still away from the city of Pune. It is housed in a residential building of stilt + 4 floors and a total of 16 flats and 51 persons living with dementia. The facility consists of 2 buildings- a psychiatric centre with patients with mental disorders like Schizophrenia, manic depression, etc. and the other one that was recently started exclusively for people suffering from dementia.

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Figure 36 : Google earth image showing Jagruti Rehab centre and the main road

Figure 38: Google earth image showing the two buildings and the surrounding farms

The psychiatric centre and the facility for dementia care are separated by an inner road. The head office where Dr Shinde sits is located in the psychiatric centre but he does daily rounds in the morning at the dementia care centre as well. The dementia care building is still under construction and it houses a total of 51 people living with dementia.

CONCEPT: The dementia care facility along with the psychiatric care is not a government aided facility and is managed solely by Dr Shinde who is also the founder of the facility. The main aim of the centre was to take an initiative in setting up a special care facility for people with dementia and setting an example. The reason behind setting up the facility in a residential building, according to Dr Shinde was to give the people living in it a homely feeling, a feeling of REMINISCE OF A MEMORY- Dementia Care and Resource Facility

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togetherness and family, where they would live together in a single unit just like they had before at the dementia facility. The centre also acts as a respite centre where the person can be enrolled for a short period of time.

SITE AND SURROUNDINGS: The facility is deliberately set up a little outside the bustling city of Pune and a little on the village side. The reason behind this is that the people with dementia are extremely

sensitive

to

their

surroundings. The city has a lot of hustle and bustle throughout the day that could disturb the well-being of the people. Therefore the facility is set up amidst the greenery of Manjiri farms

Figure 39: Image showing surrounding farms

that gives the inhabitants a beautiful view of the farms surrounding them.

PLANNING AND DESIGN DETAILS: STILT FLOOR The dementia care facility started in the year 2015 thus, it is fully not constructed. The stilt floor is still under construction and should be fully furnished and in-use by next year confirmed Dr Shinde. 

The stilt area is accessed by a gate that is kept locked throughout the day by a security guard. It is easily assessable by the provision of ramps.



The stilt area is designed to have consultation room where people concerned about dementia could visit for check-ups and scans along with a waiting room.



This floor would have a fully furnished kitchen with a dining area accessed by a ramp.

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

There is also a space allocated for yoga or other recreational activities which again can be accessed by a ramp.

Figure 40: Stilt Level Plan

FIRST FLOOR The building has one lift through with the residents commute along with a staircase that is unlikely to be used by the patients. Construction is still in progress for the first floor as well. 

The first floor would have a female doctor‟s ward where the female doctors on call could take respite. It would similarly have a male doctors ward for the on- call male doctors to rest.



The first floor has an ICU room which would be used in case any patient got serious and required immediate first aid or medical attention.

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

The ICU or first aid room is an important part of the design or planning as the patient is normally over the age of 65yr and will suffer from other illnesses as well .Hence this room would cater for situations when any patient would need intensive care.

Figure 41: First floor plan

SECOND- FOURTH FLOOR The second to fourth floors have the same layout. The second and third floor is occupied by men who suffer from dementia whereas the fourth floor is home to the women who suffer from the same.

Each floor has a caregiver or a nurse who looks after the people living on that floor. Other than that the staff includes the sweeper and the cleaner who come and go throughout the day.

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ROOMS 

Each floor has a total of 4 flats out of which 3 flats are on sharing basis for six people whereas one is a single flat for one person.

Figure 42: Typical floor plan ( 2nd-4th floor)



The flats are designed to have balconies that overlook the beautiful Manjiri farms. This greenery has a soothing effect on the people living in the facility.



The entrance to the floor is locked at all times from outside by the caregiver with a floor to ceiling grill.



Each flat has 1 bathroom,1 kitchenette, a TV set and balconies with grills



All the beds are single beds used in the hospitals with a small barricade that prevents the person from falling off the bed.



Each toilet has railings and handles that people can make use of to prevent themselves from falling.

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INFERENCE This case study helped me understand the present scenario of the facilities around Pune. This facility was different from the other typologies that I studied as this facility was designed as a residential building for people suffering from dementia. The location of the facility proves to be beneficial for the people with dementia as they are away from the noisy city.

The aim of the facility to provide people with a home that they would share works well but the people only interact with their roommates.

SCOPE OF IMPROVEMENT The main gates of the facility are locked at all times along with the passage entrances. This gives a jail like a feel to the whole facility where people are just locked in and wandering is not promoted. People living with dementia have a tendency to wander and a facility should be designed in a way that it promotes wandering in a way that the people are in a safe environment but donâ€&#x;t feel like

Figure 43: Image showing grills shut at the passage entry

they are restricted or constantly being watched.

The facility had no special provisions for the families of the patients to stay overnight or in times of emergencies. It is important to keep in mind the families of the patients along with the people suffering from dementia.

The dining area is designed on the ground floor and there is a provision only for one

Figure 44: View of the toilet showing no handrails or antiskid

lift, thus it would be very taxing to bring

tiles

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each and every person down at the same time for lunch or dinner. As of now, every person is given food on their beds thus this does not let people

communicate

with

one

another as the facility lacks a community space where all the patients could interact with one another.

Figure 46: Stilt area to be used for recreational activity

There is no colour coding in the toilets. The floor colour is the same as the toilet appliances this can cause confusion in the minds of the people living there.

The material used is not anti-skid and this could be very dangerous for people living with dementia.

Figure 45: Ramps for easy access

Figure 47: Kitchen being used as rooms

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Dignity Daycare centre, Byculla -Mumbai PHYSICAL CASESTUDY-Present case scenario Founder: Dr Sheilu Sreenivasan Location: Byculla east, Mumbai Year: 2004 Typology: Daycare Centre for people suffering from dementia Strength: 9 Noâ€&#x;s

Figure 48: Interior vie of Dignity Day

OVERVIEW

Care centre

The dignity day care centre was founded by Dr Sheilu Sreenivasan 11 years ago in 2004. Even today, this is the only daycare centre the city has to offer for people suffering from dementia.

The centre initially had a total of 15 patients but now is down to 9. The total capacity of the day care centre is about 20 people at a time. The centre is open from Monday- Friday from 9 am- 4pm.

The centre has trained staffs that include a General physician, a Psychologist, a Social Worker and trained attendants.

CONCEPT The centre was started in order to give a few hours relief to the caregivers and the family who look after their loved ones 24/7 and to do their personal chores. The aim of the centre is also to provide a stimulating environment for people suffering from dementia via various therapies and to help them keep their minds busy.

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SITE AND SURROUNDINGS The day care centre functions right in the middle of the bustling city. It on the ground floor as it would be difficult for the people to climb up stairs. The centre functions in a rented room of 3M X 9M in the Byculla service industries building.

The admin and officers that manage the day care centre are also located in the same building complex.

The day care the centre was deliberately started in the city rather than on the outskirts because keeping it in the city meant easy and fast transportation.

Figure 49: Byculla service industries building

\PLANNING

AND

DESIGN

DETAILS:

Figure 50: Plan of the day care centre

There is not much of a planning that can be seen in the infrastructure of the day care centre solely for the fact that it is rented. The facility is a column less room of 3m X 9m with one side that is closed by grills and the opposite side of the entrance to the facility. Thus, there is only one side that brings in natural light and ventilation.

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The facility does not have attached toilets thus the caregivers have to take every person and go all the way outside the room when the person with dementia has to use the toilet or change clothes.

The Facility has been dementia proofed by using soft vinyl tiles which ensure the safety of the people using the facility.

The room is quite big enough for the people to move around if they need stimulation or they feel the need to stretch a bit.

A full-fledged kitchen is not required thus the provision of a small kitchenette is made for making tea coffee for the affected.

DAILY SCHEDULE The day care centre has a fixed schedule that is followed every day by the caregivers and the people suffering from dementia.

9:00 Am – 11:00 Am: There are two cars that the centre owns. These two cars pick up and drop off the people with dementia at their doorsteps. One car picks up the people staying in Bandra, Santa Cruz and Andheri whereas the second car picks up people from church gate.

11:00 Am – 11:30 Am: The cars arrive at the facility at around 11:00 Am, tea and coffee are served and a prayer is performed.

Figure 51: People playing carom with the care giver

11:30 Am – 1:00 Pm: The patients engage in various exercises like cycling or yoga 1:00 Pm – 2:00 Pm: The patients are served lunch and before that they are taken to the washrooms one by one 2:00 Pm- 3:30 Pm: The people with dementia then engage in various activities 3:30 Pm – 4:00 Pm: Tea and coffee is provided and they are taken to the washrooms one by one before leaving for home 4:00 Pm: the cars then leave to drop off the patients to their respective homes

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ACTIVITIES There are numerous activities at the centre for the people to engage in some of them are 

Carom boards are at all times occupied by the patients and their carers



Memory games like Sudoku and children‟s games like puzzles are encouraged as these games keep the people with dementia occupied and help to boost their memory skills.



Yoga and physiotherapy are also practised.



Other activities like dancing, music are also practised.



During festive seasons, activities related to the festivals like for example preparation of rangoli, colouring and painting of lamps are observed.

Figure 52: Patient enjoying morning exercises

Figure 54: creativity of the patients

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Figure 53: Patient solving children puzzles

Figure 55: Creative side of the patients

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INFERENCE The dignity day care centre is situated in the middle of the busy city. The centre offers car services for pickups and drop-offs. There is enough staff to look after every individual and the staff members take good care of the people enrolled at the centre.

There are a number of activities and games that take place at the centre which helps the people suffering from dementia. There is various physiotherapy exercise machines like cycling and thera band exercises which prove to be beneficial to the people suffering from dementia.

Figure 56: physiotherapy exercises

SCOPE FOR IMPROVEMENTS The programme set by the centre is very good but they lack certain details. The day care centre has one big opening for natural light and ventilation to enter into the structure which is shut by grills. The other sides of the structure are dead walls without any openings.

Dignity daycare centre is set up in a commercial building and does not have any open area or green cover that would benefit the people using the facility. Thus, the centre in Mumbai lacks the surroundings and the ambience that is needed to care for the people suffering from dementia.

The day care centre in Kerala had the provision of beds for people to rest during the day which lacked in the Mumbai day care centre.

The Centre in Mumbai did not have attached toilets for the people to use. Every time someone had to use the washroom, the caregiver has to take the person outside the care centre to the public common washrooms.

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Comprehensive Daycare centre, Ernakulam Cochin PHYSICAL

CASESTUDY-Present

case

scenario Founder: Dr Jacob Roy Location: Ernakulam, Cochin Year: 1997 Typology:

Daycare

Centre

suffering from dementia

for

people Figure 57: Exterior view of the day care centre

Strength: 20 Noâ€&#x;s

OVERVIEW The comprehensive day care centre was the first dementia care facility that was established by Dr Jacob Roy- the founder of Alzheimerâ€&#x;s and Related Society of India (ARDSI) in the state of Kerala. The day care centre has a total strength of 20 people with a total of four staff members along with a care manager and an administrator. The centre is open from MondayFriday from 9:00 Am to 4:00 Pm. The centre also hosts a research and a development centre that has been newly launched. It has all the information regarding dementia and caregiving and it is open to the public who are in search of answers and want to know more about dementia.

The day care centre has specially trained staff for caregiving along with an on call doctor who visits the centre once a month and a nurse. The patient staff ratio is 3:1

CONCEPT The basic concept behind starting a day care centre was to provide respite to the family and the caregivers for some time during the day to do their daily chores and to rejuvenate along with providing special care at the daycare centre through various activities and games for the

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people living with dementia. A day care centre also allows the concerned persons with enough stimulation in the sense that their surroundings are more encouraging as compared to a dull environment at home.

The idea behind the research and development centre is to have all the information about dementia at one place which could be accessible for people who want to learn more about the deadly malady. This would be beneficial for students who would like to do research for their studies or families who are seeking information.

SITE AND SURROUNDINGS The day care centre is situated right in the city of Ernakulam. The surprising part about the centre is that even though it is in the city, the location of the facility is such that one would easily mistake it for being on the outskirts of the city. This is because the facility is surrounded by greenery and the whole vibe of the place feels earthy with old trees and bushes around it. The facility is a standalone ground floor structure. It is essential for the day care centre to be in the city rather than on the outskirts because that helps in easy transportation.

Figure 58: Image showing the green cover around the day care centre

PLANNING AND DESIGN DETAILS: The facility is a rented stand-alone structure with an abundance of the green cover surrounding it.

The structure has two entrances- front and back entrances. The front entrance opens into a waiting area which flows into the cabin of the project manager.

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There are two more office spaces that overlook into the main day care centre which belongs to the admin. The back entrance is normally where the car is parked thus the entry and exit of the

Figure 59: Plan of the Day care centre

people with dementia are generally from the back entrance.

It is better to have separate entrances for the people with dementia because otherwise the people would get disturbed or distracted easily due to constant coming and going of other people .The main day care centre is a column-less room with attached toilets. The room comprises of a number of carom boards and tables and chairs for the people living with dementia. The centre also has a couple of beds for people who feel like taking a nap during their time at the day care centre. The centre has windows on its two sides and a grill on the third side

Figure 60: Internal view of the day care centre

which ensures plenty of natural light throughout the day and cross ventilation. This makes the people feel comfortable and not claustrophobic during their time at the centre.

The flooring is consciously made of soft vinyl tiles which are safe for people suffering from dementia. The centre doesnâ€&#x;t make use of plastic chairs as those kinds of chairs might topple easily. The facility uses sturdy chairs with a special type of upholstery that can be easily cleaned when soiled by the patients as the patients have a very weak control over their bladders.

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DAILY SCHEDULE 9:00 a.m-11:00 a.m- The car leaves the facility to pick up the clients from their houses.

11:00 a.m- 11:30 a.m- All the usual people living with dementia arrive at the centre and they are given refreshments like tea and coffee.

11:30 a.m-12:00 p.m- there is a prayer session first which is then followed by certain exercises and motor activities 12:00 p.m – 12:30 p.m- Lunch that has been sent by their family members is served to them 12:30 p.m- 3:30 p.m – Music and dance therapy and activity session 3:30 p.m – 4:00 p.m- Refreshments are served once again 4:00 p.m -5:00p.m – the cars once again leave to drop people to their respective houses.

ACTIVITIES The centre offers a couple of activities like: 

The people are encouraged to play certain memory boosting games such as puzzles, Sudoku, etc.



Other games like ball passing etc. that improve the motor activities are also encouraged



Activities like playing carom, colouring books, making craft items



There are also music and dance therapies that take place



Other physiotherapy activities like walking, yoga are observed at the facility



The facility is surrounded by greenery; thus people are taken on small walks by their caregiver if they feel down or a little agitated



Apart from activities for the people suffering from dementia, there are other activities like counselling of family members if they need it, hosting gatherings of family members and the enrolled people with dementia, awareness programmes are also hosted wherein school children are brought in to mingle with dementia affected people.

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INFERENCE The day care centres are located amidst the bustling city. The centre offers pickup and drops up services. The centre has a set of activities and a routine that is followed by the users. These activities help keep the minds of the people suffering from dementia busy and active.

The Comprehensive day care centre although in the city, has a lot of greenery and open space which is used for outdoor activities.

The centre has a series of windows on two sides and an opening with grills on one making the structure well ventilated at all times with an abundance of natural light. This makes the structure more open and lively.

The day care centre in Kerala had the provision of beds for people to rest during the day. The centre lacks a pantry or a kitchen area.

The centre has attached bathrooms with the necessary handles for support which the Mumbai centre lacks.

According to my study, even though the facility in Kerala is rented, a lot of thought is put into selecting the right surroundings and the right infrastructure for the day care to function.

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SMRUTHIPADHAM- A Government initiative, Kerala PHYSICAL CASESTUDY-Present case scenario Founder: Government of Kerala, Social Justice

Department

Alzheimer‟s

and

(SJD)

Related

and

the

Disorders

Society of India (ARDSI) Location: Edavanakkad, Ernakulam Year: 2015 Typology: A full-time residential care Centre for people with dementia and an

Figure 61: View of the courtyard surrounded by rooms

old age home Strength: 10 people affected by dementia

OVERVIEW The awareness on dementia has caught on in the state of Kerala as it has the maximum number of centres for dementia care. Smruthipadham is an initiative by the state government of Kerala in collaboration with the Alzheimer‟s and Related Disorders Society of India (ARDSI).

Dementia and old age home is situated inside a government-run medical complex which was initially built for the rehabilitation of the Tsunami affected people.

The total capacity of the facility is of 15 dementia ridden people and the staff to patient ratio is 1:1. A psychiatrist doctor visits the facility for check-up‟s every twice a month whereas an Ayurvedic doctor visits every twice a week.

CONCEPT The main agenda behind starting a government run dementia care organisation was to set up an example for the other government bodies across India. The main objective of the

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government was to maximise the utilisation of locally available resources and people and with existing infrastructure to help people that were affected by dementia and their family.

The concept of having an old age home along with a dementia care brings about a symbiosis where the people staying in the old age look after the people suffering from dementia giving rise to a sense of community and family.

SITE AND SURROUNDINGS The government run dementia care facility is located in the city district of Ernakulam Kerala.

The facility was first built for the rehabilitation of the people who were affected by the tsunami but now is home to 15 dementia affected people. It is a great effort by the ARDSI and the government of Kerala but the infrastructure is not designed especially for dementia care as the objective of the government was to utilise an existing facility.

The old age and dementia care facility are located inside a primary health care government building. This makes it easy for the daily check-ups and treatments of the people residing in the care centre. Since the medical facilities are a few steps away, it becomes convenient in case of medical emergencies.

PLANNING AND DESIGN DETAILS: Even though the facility was not specifically designed to be used by the people suffering from dementia, the government of Kerala and the ARDSI team has made sure to make the necessary changes and improvements to the structure.

The facility is a ground+1 floor structure which accommodates the people living with dementia on the ground floor as it would be tough for these people to climb two flights of stairs, and the first floor is accommodated by the people staying in the old age home.

The facility has an office area for the project manager and also a room for him and his family.

The project manager is 24/7 at the facility making sure the facility runs well.

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Figure 62: Plan of the facility

That facility has a central courtyard around which the rooms and wards are located. This central courtyard is the main element of the design as it becomes a social where all the activities and exercises take place. The central courtyard also ensures natural light and cross ventilation in all the surrounding rooms. This helps in improving the well-being of the people staying at the facility.

Ramps to access the central courtyards are provided.

ROOMS There are a total of 10 rooms out of which 6 rooms are on the ground floor for the people suffering from dementia and the remaining 4 rooms are on the upper floor for the elderly people staying at the old age home. All the rooms are on sharing basis with 3-4 beds. Each room has an attached toilet. The rooms are flooded with daylight due to the light coming from windows and the light from the central courtyard.

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DINING AND KITCHEN The dining room is a big room with a central table and it overlooks the courtyard. The dining room is a place where all the people living in the centre get a chance to interact with one another and it becomes easy for the staff to look after everyone which otherwise would have been very taxing to give food to each and every person individually in their rooms. The dining room being a little away from the rooms encourages movement and walking which is good for the health of the people affected by dementia.

ACTIVITES Various activities and games take place in the central courtyard and the dining room on a daily basis. Most of the activities include childrenâ€&#x;s games, like passing the ball, snakes and ladders, sudoku , various puzzles that boost the cognitive strength of the brain.

Various therapies like music therapies, dance therapies, yoga are also practised at the centre.

INFERENCE It is commendable that the state government of Kerala has taken the initiative to start a facility for dementia care in collaboration with ARDSI. The facility has been retrofitted to be used as a dementia care facility. It is located inside a primary health care building which proves to be beneficial for the people using the facility as first and or any medical attendance needed is at a walking distance.

SCOPE FOR IMPROVEMENT The gates to this facility are again kept locked throughout the day which imparts a feeling of being caged. The facility has a central open courtyard, but that is the only source of recreational and open space for the people living there. The facility lacks open spaces and green cover which is essential for the healing process. There is no activity area as such because the courtyard is too narrow to hold all the people also the area is too restricted to make provision for sitting.

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The rooms are all on the ground floor and on sharing basis where people can interact with roommates and not feel lonely. There is abundant light from the windows and the courtyard.

All the rooms have big and attached toilets with necessary handrails.

The facility lacks a medical room or a small dispensary where daily check-ups could be held.

The dementia care facility is shared by the old age home thus, the staff members are shared by both the facilities. The dementia care facility is shared by the old age home thus, the staff members are shared by both the facilities.

The office where the project manager sits does not directly look into space where he can personally keep an eye on each and every person which can be seen in the other care centre in Kerala.

Thus the facility lacks the feeling of a community or togetherness as every individual spends most of the time in their bedrooms.

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Harmony Home, Kottapaddy-Kerala PHYSICAL CASESTUDY-Present case scenario Founder: Dr Jacob Roy Location: Kottapaddy, Kerala Year: 2005 Typology: A full-time residential care Centre for people with dementia Strength: 10 people

Figure 63: External view from the office

OVERVIEW Harmony Home is a full-time residential care facility by ARDSI founded by Dr Jacob Roy in the year 2005. The facility is in the village of Kottapaddy in Kerala which is a 3-hour long drive from Cochin. The centre is set up in a rented bungalow. The facility is home to 10 people suffering from dementia. According to the project manager, all the people living at the centre are from financially strong families.

The staff to patient ratio is 1:1 at Harmony Home centre. The project manager and his family live in the same complex as it is important for him to look after the workings of the facility. .

CONCEPT The main concept of this facility is to keep the environment as homely as possible. In Kerala the awareness regarding Dementia is relatively high as compared to other states, thus Kerala is striving hard to have at least one facility in each district to help people with dementia and their families.

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SITE AND SURROUNDINGS Kottapaddy is a small but beautiful village on the outskirts of Kerala. This facility in Kottapaddy is in the interiors of the village. The facility has a large plot area with an abundance of greenery surrounding it. This gives the whole facility a very positive and an earthy vibe. The site for the facility is deliberately not chosen in the main city of Kerala because according to the project manager, the people living with dementia like to relive their memories in a relaxed and nature-friendly setting instead of the fast life

Figure 64: view of the surroundings

in the cities.

The people living with dementia as mentioned above are very sensitive to their surroundings and a calmer surrounding has a positive effect on their well-being. People living with dementia can get moody and aggressive at times, thus in times like these, when the people are agitated, they are bound to make noise, and this, in turn, can cause a lot of disturbance to the neighbourhood. Thus it is better to design a full-time care facility a little away from the fast city life.

The abundant open space that is there on the plot is used at the times of festivals, or sometimes yoga and games are hosted. This place is also used during awareness campaigns

PLANNING AND DESIGN DETAILS: The facility is in a rented bungalow. The facility has two structures – a bungalow and an outhouse with wards and the project manager office. The bungalow is a ground +1 structure

with

the

ground

floor

accommodated by the people living with dementia and the upper floor is used by the project manager and his family Figure 65: View of Activity area

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no floor to ceiling grills that make the people think they are in some kind of a jail. There is an only a small gate at the entrance. On entering the bungalow is a semi-open porch which forms the activity area for the people staying there. This is the space which is used the most during the day by the people as this space looks out into the greenery and is flooded with natural light and ventilation throughout the day. The activity area has a number of carom boards and tables and chairs that can be used for other activities.

The activity area is kept lively throughout the day by playing old music that the people staying there enjoy.

All the spaces in the bungalow flow into each other but the bungalow is massive and due to interlinking of spaces, it can get a bit confusing.

Figure 66: Plan of the facilities

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ROOMS There is one ward and a total of 3 rooms on sharing basis in the bungalow whereas the outhouse has one ward. The rooms in the bungalow do not have attached toilets to the rooms. There is a common bathroom area.

There is one room especially for the patient's check-up when there are doctor visits. There is also a special dispensary

Figure 67: View of the ward

room to store the medicines. The rooms all have single hospital beds and windows with lots of natural light and ventilation.

The wards are generally used for people who have reached the severe stage of dementia and are bedridden most of the times.

DINING AND KITCHEN The activity area flows into the dining room which has a big central table enough to sit 15 people. This dining room overlooks in the semi-open activity area creating greater interactive space. Thus one side of the dining room opens up into the activity space whereas the another side opens up into a semi-open back veranda passage that looks out into the open greenery.

This room is also used during other activities like colouring, painting etc.

The kitchen is relatively far away from the designated room which is a little inconvenient to the staff. But as this facility is in a rented bungalow, no modifications are allowed. Thus the services part of the facility is a bit overlooked.

ACTIVITES Various activities and games take place in the central courtyard and the dining room on a daily basis. Most of the activities include childrenâ€&#x;s games, like passing the ball, snakes and ladders, sudoku , various puzzles that boost the cognitive strength of the brain.

Various therapies like music therapies, dance therapies, yoga are also practised at the centre.

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The centre also celebrates all the festivals by inviting the families of patients living there. The facility also organises for awareness programmes. This keeps the environment jolly and lively where the people staying at the facility get a chance to meet new faces every now and then.

INFERENCE The Harmony home in Kottapaddy is the ideal location for a facility for dementia care. The facility is located a little on the outskirts of the city where there is an abundance of open spaces, greenery and tranquillity.

One of the best things about this facility is that the facility has a big semi-open activity area which is used during the day.

This is the place where all the residents of the facility come together and interact throughout the day. There are no grills or locks, all the doors are open and do not impart a feeling of being caged and trapped.

Figure 68: Office space overlooking the activity area

The office is positioned in such a way that the project manager can see the activity are and keep an eye on the residents. There is a provision made for an ambulance car in case of emergencies and the facility has a dispensary room where all the medicines can be stored and the doctors can examine the residents during their visits.

SCOPE FOR IMPROVEMENTS The facility is in a rented bungalow which is old and not in a very decent state. Any modifications to the structure were not allowed by the owner making it a little difficult for ARDSI to make the facility dementia friendly.

The bungalow is very old with old paint and cracks. The planning of the bungalow is a little complicated as the spaces flow into each other but not in an orderly manner, therefore, all the rooms are labelled indicating the purpose of the

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Figure 69: Image showing unplastered and old walls

96

rooms for the residents to understand which room they are entering.

The outhouse where the ward is placed is a little away from the activity zone but encourages movement and walking.

The kitchen is far away from the dining area causing a little inconvenience to the staff. There is no colour scheme that has been followed or the flooring is not changed as modifications were not allowed. These factors are lacking at present in the facility.

The centre has a single common bathroom catering to all the residents. It is better if the rooms have an attached bathroom.

The centre gives a positive vibe to the people visiting the centre and to the ones who call it their home the location and the surrounding is so far the best that I have visited and is apt for a dementia care facility. But the facility lacks small architectural details that would make the life of the residents better.

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CHAPTER SEVEN: SPACE OVERVIEW Architecture plays a crucial part in the lives of people. If used to its right limits, architecture can become a catalyst in the treatment of the people. It has the power to intensify the senses and it conveys an unspoken message to the person looking or feeling the designed space that affects the human state of mind. Architecture has the power to talk to us through its elements.

When there is a perfect balance in all the elements of the design, it fulfils the emotional and mental needs of the person and an interaction takes place between the user and the structure.

Architecture can invoke certain feelings like anger, tranquillity, through its design. Behaviour of people can be altered with the use of certain architectural elements. Through certain aspects of architecture like colour, lighting, the behaviour or the mood of the user can be manipulated.

This chapter has been written by studying and taking inferences from various case studies.

This chapter aims at understanding various design parameters while designing a facility for people affected by dementia.

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ARCHITECTURAL INTERVENTIONS

There are various architectural interventions that could be put to use when designing for people living with dementia. The most important element would be planning and zoning of the facility or space. While designing it is very important to keep the behaviour of the person using it in mind. That is the key to a successful design. In the case of people suffering from dementia, they get easily disoriented and are lost in time.

Space and time: People with dementia perceive space in a different way. As the age group of these people is 65 and up ,they tend to like spaces which are old, spaces in which they grew up as opposed to the modern type of spaces that the younger generation tends to admire. The late boomers like a space that would take them back in time, a space in which they would not feel alien to them. People suffering from dementia, as studied in previous chapters have a tendency to wander. This becomes second to nature for some people. It is difficult to curb it and also inhumane to lock someone in. this is where the element of planning comes to the rescue.

Orientation can also be considered in a sense as orientating one's own self in space, time, and identity means situating oneself in a spatial organisation, a pattern of events, and social structures respectively. (Van Steenwinkel)

Planning and zoning Planning and zoning play a very important role in designing a care facility for people with dementia. We can compare the planning of a dementia care facility to a planning of cities. For example, if a city has similar and repetitive roads pattern, with similar houses along the road, it adds to confusion and identity of a place for a regular person let alone a person with dementia .

Such design mistakes should be avoided while dealing with designing a dementia care facility.

The image of the city In The Image of the City Kevin Lynch (2000), an urban planner, deals with the spatial organisation of cities as it is experienced by their citizens, and presents the cases of three American cities, namely, Boston, New Jersey, and Los Angeles. He concentrates on one particular “visual quality”, that is, the “legibility of the cityscape”, by which he means “the ease with which its parts can be recognised and can be identified with a coherent pattern” (Lynch, 2000, p. 2). (Van Steenwinkel)

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According to Lynch, a legible city provides people a framework that gives them a possibility of choice and a starting-point for the acquisition of further information, guides and organizes activity, fulfils a social role, offers emotional security (as in “the sweet sense of home”) and a basis for individual growth (Lynch, 2000, pp. 3–5). Besides these potentials, Lynch emphasises way-finding (which he seems to equate with orientating) as “the original function of the environmental image, and the basis on which its emotional associations may have been founded” (Lynch, 2000, p. 125): (Van Steenwinkel) Lynch states 5 important elements that can act as building blocks for the designer: 1. Paths - Paths are the channels along which the observer or the user of the space customarily, occasionally, or potentially moves. They may be streets, walkways, transit lines, canals, railroads. They guide the observer through space. If the paths of a city are confusing, the whole of the city looks unplanned and chaotic.

2. Edges - Edges are the linear elements but they are not considered as paths by the observer.

They are the boundaries that separate two phases. Edges should be rather continuous and seamless. Highways, rivers, railways act as edges and can also be elements that help in orientation.

3. Districts - Districts are the medium-to-large sections of the city with certain similar characteristics and the observer can mentally enter “inside of”.

4. Nodes - Nodes are points, the strategic foci spots in a city into which an observer can enter. Nodes need not be only small points but they can also be squares, etc. Nodes need to have a unique feature inside for it to stand out and become unique.

5. Landmarks - Landmarks are another type of reference points, but in this case, the observer does not enter within them, they are external. They are usually a rather simply defined as physical objects like buildings, stores, etc. They need to be unique keeping in mind that singularity is the key physical characteristic of landmarks.

Lynch uses these five elements to map the image of the city, and he notes that “what is being mapped here is an abstraction, not physical reality itself but the generalised impressions that real form makes on an observer indoctrinated in a certain way” (Lynch, 2000, p. 143). Such images are “used to describe or recollect the city in the absence of the real thing” (Lynch,

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2000, p. 152) (Van Steenwinkel) He also states that all these five elements together, not individually help to design a dense and a working city in all aspects.

These five elements can help in designing a facility or a township for people living with dementia.

It is also necessary while planning to make sure the spaces flow into each other, make sure the corridors don‟t have dead ends because this might leave the person feeling confused and overwhelmed.

Uses of colours –people with dementia are highly sensitive to their surroundings. Thus a soothing colour scheme will have a calming effect on their minds. Moreover, since the people are already elderly, they might have vision problems, thus it is important to have a different colour scheme where the walls and the door are of different material and different colours and do not camouflage.

Flooring: the flooring material needs to be soft but comfortable for the movement of wheelchairs as many of the people suffering from dementia use wheelchairs. The flooring of hallways and bathrooms need to be of an antiskid material. It is better if the flooring doesn‟t have any patterns because the patterns could confuse and disorient the people suffering from dementia.

Chairs: The chairs, on the other hand, should not be made of plastic as those a light weighed and could easily topple. Also, the material should be one that can be easily cleaned as people living with dementia have bladder control issues.

Safety needs: are to be taken care of as in case of people suffering from dementia as sharp protruding objects might be dangerous for them Nurses respite room – is an essential part of the design for nurses or caregivers to take the much-needed respite in case if they need to stay overnight.

Provision for a stay of family members- this provision is a must in a facility like this as it is certain that the family would like to visit their loved ones as in when they want or during days when the patients don‟t keep well.

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Light therapy- It is a known fact that natural light has certain positive effects on the people suffering from dementia. Thus there need to be abundant openings in the facility which bring in natural light.

But most importantly, space should make the people living there feel at home.

CONCLUSION Thus, architecture not only plays a very big role in the lives of people affected by dementia but also in the lives of their caregivers and the staff that looks after them. From the statistics given in the book, we can see that there is a dire need of infrastructure in the field of dementia in India when compared to the rising numbers of people getting affected each year. Therefore it is time to spread awareness, take initiative like other countries of the world and try to create a stronger support system for those beaten down by dementia.

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CHAPTER EIGHT: SPACE- site selection The ideal site for a project like this (a residential facility along with a day care and resource centre) would be on the outskirts of the city but well connected to the city by all the modes of transport, where the users can enjoy the tranquillity of nature away from the fast city life without the noise and pollution.

CRITERIA FOR SITE SELECTION: 

Accessibility



Public transport facility



Abundant Green cover



Noise buffer



Existence of a hospital in the locality

Accessibility - The reason for the facility to be close to the city is for the functioning of the day care centre. If a place far away from the city is selected for the facility, the travel would be very long and taxing for picking up and dropping people to and from the city. public transport-The facility should be well connected by public transport so that during any emergency, the families should be able to reach the facility in time.

Abundant green cover- it is proved that nature has a therapeutic effect on the minds of the people Noise buffer- Another reason for not designing a facility in the city is that people with dementia can be a bit difficult to handle. They can get very aggressive for little things like taking a bath and this could disturb the people in the surrounding area. The patients should feel mental peace and should not get irritated with the noise pollution as they are very sensitive to noise in their condition Existences of a hospital in the locality- people with dementia are generally old and they need medical assistance throughout their care, they also suffer from other disorders that need daily check-ups.

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WHY MUMBAI? It is estimated that Maharashtra by the year of 2026 would have close to 5 lakhs of people suffering from dementia. Mumbai being the centre of all activities still lacks in the field of dementia, where most of the households are burdened by work with irregular office hours and are in need of facilities that would help them look after their loved ones.

Having said that, there is a wave of awareness regarding dementia today in Mumbai and being metropolitan, the city has the capacity of providing an infrastructural base which can be used an example for the other cities to follow. Thus, the facility would function better and thrive in Mumbai where there is already a sense of awareness and a dire need of dementia care facilities to match the rising number of dementia ridden people rather than in a place where there is less awareness.

Mumbai and navi Mumbai have one or two residential facilities for dementia care, one-day care centre, one resource centre, but that is not enough to cater to 5 lakhs of people in the near future. Mumbai needs a well-designed, affordable facility that brings all the above facilities under one roof for a more effective result.

PROBABLE SITES According to the site criteria and the in-depth study of dementia and its repercussions, the probable sites would be on the outskirts of the main city of Mumbai.

Cidco has taken up the development of brownfield places in Navi Mumbai along with the greenfield lands. Navi Mumbai being well connected to the eastern express highway makes travel easy for people travelling from Mumbai to Navi Mumbai and vice versa. Thus, it would make the travel to and from the day care centre easy. Navi Mumbai also fits the criteria as it has a lot of green coverage and is close to nature with the scenic mountains acting as backdrops.

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NAVI MUMBAI Navi Mumbai is a planned township of Mumbai developed by CIDCO (city Industrial Development Corporation of Maharashtra) which is off the west coast of the Maharashtra.

Navi Mumbai was developed mainly to decongest the heavy population crisis faced by the city of Mumbai. It is scenic with a range of hills on one side and a creek on the other side. It is well connected to the city by the Mumbai-Pune Highway which makes travelling is easy and fast.

Navi Mumbai has 14 well-planned nodes. Along with that, 45% of the land is reserved for green areas. This ensures plenty of green breathing spaces in navi Mumbai. Navi Mumbai also has a range of super speciality hospitals which have memory clinics and screening camps for dementia. With the inception of navi Mumbai as early as 1971, there is the humongous scope of development in terms of the infrastructure of healthcare facilities. 

KHARGHAR

Kharghar is one of the nodes developed by CIDCO in Navi Mumbai. Kharghar fits the criteria for site selection well as the city has a well-developed network of transport facilities. It is connected to the city of Mumbai by the Sion-Panvel Highway and one would take approximately 1 and half hour by car during traffic hours to travel from Mumbai to Kharghar.

Kharghar railway station lies on Central Railway's Harbour line. It usually takes about 65 minutes to reach Kharghar by train from Chatrapati Shivaji Terminus (CST). There is a proposal for the first phase of Navi Mumbai Metro to be from "Belapur" to "Pendhar" which will be via Kharghar.

Thus, in case of emergencies, the family members can choose from a number of transport facilities to reach the facility.

Kharghar has a range of multi-speciality hospitals in its vicinity which will be an added bonus. .

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SITE A

Railway Station Hospitals Site under consideration

Figure 70: Google earth plan showing site A in Kharghar

Site under consideration Green spaces Residential Public Utilities Institutional Water body

Commercial +Residential

Figure 71: Google earth plan showing site A; showing surrounding land use according to the nodal plans developed by CIDCO

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The first probable site in the region of Kharghar is near the Saraswati college of Engineering.

The site is demarcated as „institutionalâ€&#x; in the land use map developed by cidco which would help the design be true to its intent. There are upcoming residential and commercial schemes which have been proposed around the site.

The site is in Kharghar which is already away from the fast city life of Mumbai with an added bonus of being further away from the city of Kharghar. This would ensure less noise pollution and would make the facility a bit isolated.

The site is close to Mumbai Highway and Kharghar Railway station which would make the commute easy and fast for the day care services and also for the staff working at the facility.

The site is embedded in lush greenery with an abundance of open spaces where the users of the proposed facility can breathe in fresh air and use the open spaces for therapeutic purposes.

The site has a picturesque range of hills on one side. It has been proven that one heals better when surrounded by nature.

Kharghar Medicity Hospital being just a few blocks away from the site would be an added bonus as it is always better to have a hospital close by in case of emergencies and for monthly check-ups.

Thus, this site fits the bill of criteria well.

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SITE B

Site under consideration Hospitals Railway Station Figure 72: Google earth plan showing site B

Site under consideration Area under high FSI Institutional Residential Green spaces Public utility Plot for future development Water body Commercial+ Residential 12.5% scheme Figure 73: Google earth plan showing site B; showing surrounding land use according to the nodal plans developed by CIDCO

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This site is also in Kharghar near DAV international school. The site is demarcated as „future developmentâ€&#x; in the land use map developed by CIDCO. The site has a school nearby which is an added bonus as it would be great to spread awareness about dementia. This would help the resource centre which would be a part of the facility greatly as rallies and awareness talks could be arranged for the students to take part in. This would be a great opportunity for the students as the children are our future and they should be well prepared to face this ghastly condition.

The site is near a residential area so that could be an inconvenience for the users as well as for the people staying close by. Thus the design would have to look into ways to create a sound buffer.

Even though the site does not have the view of the mountain ranges, it has a beautiful view of the water body.

As far as transport facilities are concerned, the site is well connected to the Mumbai-Pune highway. The Kharghar railway station is a bit away from the site as compared to the previous site. There are a number of medical facilities in the proximity like eye clinics and super speciality hospitals like Kharghar Medicity Hospital, Om Navjeevan Hospital, etc, which offers memory screening tests for dementia.

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 VASHI Vashi is the first node in Navi Mumbai to be developed by CIDCO. It is on the outskirts of Panvel. Thane creek and the Arabian Sea surround Vashi making it scenic and beautiful.

Vashi is well connected to the main city by road and rail both. It takes about 50 minutes to travel from Mumbai to the Vashi station. There are two railway options to travel from Mumbai western suburbs are either via Wadala or via Dadar. Vashi also has well-developed roadways that connect to the main city of Mumbai. If one catches the new eastern Highway, one would reach Vashi in about 1 hour 30 minutes. Auto-rickshaws, buses and taxis are easily available to making the transport system of Vashi strong.

As in the case of hospitals, Vashi has a wide range of various super speciality hospitals in its vicinity which would be an added advantage to the facility.

 MANKHURD Mankhurd is a suburb in eastern Mumbai. It is just within the boundaries of the city. It is the last stop in the city of Mumbai before Navi Mumbai. The Vashi Bridge is what ties Vashi to the city of Mumbai.

By road, Mankhurd is well connected to the city by the Mumbai -Pune highway. One would take about half an hour to reach Mankhurd via road. Mankhurd lies on the Harbour line of the Eastern suburban Railway. It is also the last stop in the city before the train goes ahead to Navi Mumbai.

Mankhurd has a vast chunk of land which has been taken by the mangroves which also act as a buffer area and purifies the air. This area acts a relief from the concrete jungle in the city.

There are a number of hospitals near Mankhurd but the super speciality hospitals like Appollo Spectra Hospitals are far.

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SITE C

Figure 74: Google earth plan showing site C near Mankhurd

Hospitals

Site under Consideration

Figure 75: Google earth plan showing site C; showing surrounding proposed land use according to Draft development plan for 2034

Site under Consideration Site reserved for Hospital

Octroi checkpoint nakka

Proposed Leisure park

Proposed truck ternimal

Resettlement+ Rehabilitation

No development Zone

Land served for sports

Proposed CBD

Water body

Other education

Site C is located between Mankhurd and Vashi. Thus it is equally close to both these places which place the site in the middle of two cities. The site thus is away from the hustling city life

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but is well connected to both the cities by all means of transport. By road, the Mumbai-Pune highway joins the city to the proposed site.

Both the Kharghar and Mankhurd railway stations are in close proximity to the site.

Rickshaws, taxis and buses are easily available from the site.

The site is located exactly opposite the Vashi Check Naka on the Mumbai- Pune Highway.

The plot is marked under “hospital” on the Greater Mumbai Draft Development Plan- 2034.

This plot can be a probable site as the proposed facility would be used for dementia and Alzheimer‟s care which comes under medical disorders and would need medical attention. The remaining site could be left for future hospital development that could collaborate with the dementia facility in the near future.

There is a vast chunk of land marked as a green area which would be a plus point for the facility and for the users.

Other plots surrounding the site are reserved for the police station, Truck terminus etc.

Hospitals in Mankhurd and Vashi could be used when required. Thus the site is away from residential areas, noise and pollution.

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 VASAI-VIRAR Vasai–Virar is a city and subdistrict to the west of Maharashtra and it comprises of the Palghar district which is 30 km to the North of Mumbai. The city is situated on the banks of the Vasai creek which is a part of the Ulhas River. It is basically surrounded by sea on three sides and a moat on the side of the land The western express and eastern express highway has made life simpler for people travelling from Mumbai to Vasai. Vasai is also has a well-developed railway structure. It is connected by the western as well as Central Railway.

Vasai-Virar City Municipal Corporation also started its own transport service in collaboration with Bhagirathi Transport Corporation Pvt Ltd, known as VVMT. It operates a large number of bus lines around virar.

There are a number of super speciality hospitals in the city.

SITE D

Figure 76: : Google earth plan showing site D in Vasai-Virar

Hospitals

Site under Consideration

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Figure 77: Google earth plan showing site D; showing surrounding proposed land use according to Draft development plan for 2034

No development zone

Residential zone

Transport &communication

Green Zone

Tehsil office

Public and semi public

Places of historic importance

Water body

Tentative site

The probable site is located near the Vasai Fort. It has been marked under “hospital� as per the development plan of Vasai-Virar District. The site was previously demarcated for Government offices but now has been designated as Hospital land. The land is close to the Vasai fort with a water body flowing along the site.

On one side of the site, there is no development land with abundant green cover and a water body whereas; the other side has an existing police colony along with a few residential buildings. Thus the site on the outskirts of the city boundary and looks mostly into the greenery on the other side of the city making the site feel open and away from the concrete jungle.

The site is not close to the highway but is easily accessible via other connecting roads. The Vasai Railway station is approximately 20 minutes away.

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REFERENCES REPORTS KS, Shaji et al. THE DEMENTIA INDIA REPORT 2010 Prevalence Impact,Costs And Services For Dementia. DELHI: Alzheimer‟s and Related Disorders Society of India, New Delhi, 2010. Print. shaji, k. "Dementia Care In Developing Countries: The Road Ahead". Indian Journal of Psychiatry (2009): n. pag. Print.

JOURNALS Brodaty, Henry and Marika Donkin. "Family Caregivers Of People With Dementia". Dialogues Clin Neurosci v.11(2).PMC3181916 (2009): n. pag. Print.

Ferri, Cleusa P et al. "Global Prevalence Of Dementia: A Delphi Consensus Study". The Lancet 366.9503 (2005): n. pag. Web. Shaji, KS et al. "Behavioral Symptoms And Caregiver Burden In Dementia". Indian journal of psychiatry. N.p., 2009. Print. shaji, k. "Dementia Care In Developing Countries: The Road Ahead". Indian Journal of Psychiatry (2009): n. pag. Print.

WEBSITES Kishore, Swapna. "Voices: From Indian Blogs And Sites". dementia care notes. N.p., 2016. Web. 5 Oct. 2016.

"Alzheimer‟S Screening/About The Exam - The Hill Medical Corporation". Hillmedical.com. N.p., 2016. Web. 24 Nov. 2016.

Association,

Alzheimer's.

"Alzheimer's

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Dementia

Help

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Association". Alzheimer's Association. N.p., 2016. Web. 26 Oct. 2016.

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Hart, Chelsia. "Quote: Alzheimer's Is Not An Old-Age Disease". Alzheimers.net. N.p., 2016. Web. 24 Nov. 2016.

"Alzheimer's Disease International". Alz.co.uk. N.p., 2016. Web. 5 Oct. 2016.

2015 ALZHEIMER's DISEASE FACTS AND FIGURES. 1st ed. ALZHEIMERS ASSOCIATION, 2016.

Print.

ALZHEIMER'S AUSTRALIA. N.p., 2016. Web. 28 Oct. 2016.

"DEMENTIA DAYCARE CENTRES IN INDIA". VOICE4INDIA.ORG. N.p., 2016. Web. 28 Sept.

2016.

ALZHEIMER'S AND RELATED DISORDERS OF SOCIETY OF INDIA. N.p., 2016. Web. 18 Oct. 2016.

Alzheimer's And Architecture - Jasminelabeau". Cargocollective.com. N.p., 2016. Web. 29 Nov. 2016.

"Dementia Village". Dementiavillage.com. Web. 29 Sept. 2016.

BOOKS DeBaggio, Thomas. Losing My Mind. 1st ed. New York: Free Press, 2002. Print.

Lynch, Kevin. The Image Of The City. 1st ed. Cambridge, Mass.: MIT Press, 1960. Print.

E-BOOK OR PDF Prince, Prof Martin et al. World Alzheimer Report 2015 The Global Impact Of Dementia An Analysis Of Prevalence, Incidence, Cost And Trends. 1st ed. London: Alzheimerâ€&#x;s Disease International (ADI), London, 2015. Print.

A Public Health Priority. 1st ed. united kingdom: World Health Organization, 2012. Print.

NEWSPAPER Kadakia, Pankti. "Day Care For Senior Citizens In Mumbai, But It's Not Enough". Hindustan Times 2015: n. pag. Print.

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mehta, sulogna. "Alzheimer's Agony: Fading Memory". The Times of India 2015: n. pag. Print.

The Times of India,. "City Needs Clinics To Stem Alzheimer's". 2011: n. pag. Print.

Kadakia, Pankti. "Day Care For Senior Citizens In Mumbai, But It's Not Enough". Hindustan Times 2015: n. pag. Print.

GOVERNMENT PUBLICATIONS The white house,. Presidential Proclamation -- National Alzheimer's Disease Awareness Month, 2011.

Washington D.C: Office of the Press Secretary, 2011. Print.

National Center for Biotechnology Information, U.S. National Library of Medicine,. Family Caregivers Of People With Dementia. Print.

DISSERTATION Van Steenwinkel, Iris. "Offering Architects Insights Into Living With Dementia". PHD. KU Leuven, Science, Engineering & Technology Uitgegeven in eigen beheer, 2015. Print.

BLOGS Angie, Bill et al, (2016). 2012 Top 5 Info graphics of the Year. [Blog] Alzheimerâ€&#x;s Association. Available at: http://www.alznorcalblog.org/2012/12/21/2012-top-5-infographics-year-plus-1/

.

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LIST OF FIGURES Figure 1: The dementia Umbrella http://www.alznorcalblog.org/2012/12/21/2012-top-5-infographics-year-plus-1/ Figure 2: Conceptual image indicating fading of memories http://www.healthwise-digest.com/health/alzheimers-disease-are-you-experiencing-the-memory-lossissueknow-about-the-disease-now Figure 3: Scans of brains showing difference between Alzheimerâ€&#x;s , mild cognitive impairment and normal brain http://www.healthwise-digest.com/health/alzheimers-disease-are-you-experiencing-the-memory-lossissueknow-about-the-disease-now Figure 4: An analysis of MRI data showing the pattern of brain tissue loss in Alzheimerâ€&#x;s disease (green) and frontotemporal dementia (red) https://medschool.ucsf.edu/features/examining-link-between-early-stage-dementia-and-criminalbehavior Figure 5: Mixed dementia https://aspe.hhs.gov/advisory-council-july-2015-meeting-presentation-vascular-contributions-dementia Figure 6: Types of dementia http://www.springchicken.co.uk/community/the-dementia-umbrella-2/ Figure 7: An individual fighting stress and depression http://economictimes.indiatimes.com/magazines/panache/beware-anxiety-and-stress-ups-dementiarisk/articleshow/50704994.cms Figure 8: Habits like smoking can cause dementia https://blogreverb.wordpress.com/tag/design/ Figure 9: The Global Impact of Dementia http://dementiapartnerships.com/wp-content/uploads/sites/2/adi-globalimpact-infographic.png REMINISCE OF A MEMORY- Dementia Care and Resource Facility

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Figure 10: Estimated number of people living with dementia in the year 2030 around the major countries of the world http://www.datingdementia.com/2015/03/04/alzheimers-the-worldwide-epidemic/ Figure 11: Numbers of prevalence studies, by year of data collection and income level of the country where the research was carried out https://www.researchgate.net/publication/281555306_World_Alzheimer_Report_2015_The_Global_I mpact_of_Dementia_An_Analysis_of_Prevalence_Incidence_Cost_and_Trends Figure 12: statistics comparing Alzheimerâ€&#x;s with breast and prostate cancer https://mydementedmom.com/2012/12/02/scary-stat-alzheimers-kills-more-people-each-year-thanbreast-prostate-cancer-combined/ Figure 13: Prevalence of Dementia in India, 2010 http://www.groundreportindia.com/2011/09/world-alzheimers-day-on-21st-sep-2011.html Figure 14: Trend in dementia prevalence by age over time (2010-2050) http://www.alzheimer.org.in/assets/dementia.pdf Figure 15: Estimation of number of PwD over 60 years in India between 2000 and 2050 http://www.alzheimer.org.in/assets/dementia.pdf Figure 16: Projected changes between 2006 and 2026 in number of people living with dementia by State http://www.alzheimer.org.in/assets/dementia.pdf Figure 17: A pleasant site of a caregiver caring for the patients http://www.alz.org/care/alzheimers-dementia-residential-facilities.asp Figure 18: Activities at a day care centre http://news.asiaone.com/news/yourhealth/amk-daycare-centre-seniors-dementia Figure 19: A memory screening session at a hospital http://www.shadithyahospital.com/memory-clinic/ Figure 20: Need for care depending upon the severity of dementia http://www.alzheimer.org.in/assets/dementia.pdf Figure 21: The fear of stigma in case of people suffering from dementia

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http://www.alznorcalblog.org/2012/12/21/2012-top-5-infographics-year-plus-1/ Figure 22: Percentage of female care giver http://review2016.alzheimersresearchuk.org/img/infographics/dementia-in-women.png Figure 23: Barriers to Dementia Care in India http://www.alzheimer.org.in/assets/dementia.pd Figure 24: Alzheimer's Respite centre, Dublin http://architizer.com/projects/alzheimers-respite-centre/ Figure 25: ground floor plan http://architizer.com/projects/alzheimers-respite-centre/media/115902/ Figure 26: Exterior view of the facility http://architizer.com/projects/alzheimers-respite-centre/media/115891/ Figure 27: Internal view of the facility showing colour coding for the walls http://architizer.com/projects/alzheimers-respite-centre/media/115883/ Figure 28: View of the gardens and abundance of light from the windows proves to be beneficial for the health of the patients http://architizer.com/projects/alzheimers-respite-centre/media/115881/ Figure 29: Bright walls of the facility http://architizer.com/projects/alzheimers-respite-centre/media/115882/ Figure 30: View of the facility showing play of solid-void http://www.trendzified.net/dementia-village-in-netherlands/ Figure 81: Ground floor plan http://twistedsifter.com/2015/02/amazing-village-in-netherlands-just-for-people-with-dementia/ Figure 32: Plan showing flow of green spaces http://hogeweyk.dementiavillage.com/en/stedenbouw/

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Figure 33: View of the grocery store at de Hogeweyk http://www.trendzified.net/dementia-village-in-netherlands/ Figure 34: Various interiors of the houses http://twistedsifter.com/2015/02/amazing-village-in-netherlands-just-for-people-with-dementia/ Figure 39 : Image showing the central courtyard http://edition.cnn.com/2013/07/11/world/europe/wus-holland-dementia-lessons/ Figure 310 External view of the dementia building Figure 311 : Google earth image showing Jagruti Rehab centre and the main road Figure 38: Google earth image showing the two buildings and the surrounding farms Figure 39: Image showing surrounding farms Figure 40: Stilt Level Plan Figure 41: First floor plan Figure 42: Typical floor plan ( 2nd-4th floor) Figure 43: Image showing grills shut at the passage entry Figure 44: View of the toilet showing no handrails or antiskid tiles Figure 45: Ramps for easy access Figure 46: Stilt area to be used for recreational activity Figure 47: Kitchen being used as rooms Figure 48: Interior vie of Dignity Day Care centre Figure 49: Byculla service industries building Figure 50: Plan of the day care centre Figure 51: People playing carom with the care giver Figure 52: Patient enjoying morning exercises Figure 53: Patient solving children puzzles Figure 54: creativity of the patients Figure 55: Creative side of the patients Figure 56: physiotherapy exercises Figure 57: Exterior view of the day care centre Figure 58: Image showing the green cover around the day care centre Figure 59: Plan of the Day care centre Figure 60: Internal view of the day care centre REMINISCE OF A MEMORY- Dementia Care and Resource Facility

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Figure 61: View of the courtyard surrounded by rooms Figure 62: Plan of the facility Figure 63: External view from the office Figure 64: view of the surroundings Figure 65: View of Activity area Figure 66: Plan of the facilities Figure 67: View of the ward Figure 68: Office space overlooking the activity area Figure 69: Image showing unplastered and old walls Figure 70: Google earth plan showing site A in Kharghar Figure 71: Google earth plan showing site A; showing surrounding land use according to the nodal plans developed by CIDCO Figure 72: Google earth plan showing site B Figure 73: Google earth plan showing site B; showing surrounding land use according to the nodal plans developed by CIDCO Figure 74: Google earth plan showing site C near Mankhurd Figure 75: Google earth plan showing site C; showing surrounding proposed land use according to Draft development plan for 2034 Figure 76: : Google earth plan showing site D in Vasai-Virar Figure 77: Google earth plan showing site D; showing surrounding proposed land use according to Draft development plan for 2034

LIST OF TABLES Table 4: Difference between dementia and old age SOURCE: The Marilyn Denis Show Table 5: Risk factors causing dementia SOURCE: THE DEMENTIA INDIA REPORT 2010 Prevalence impact, costs and services for dementia Table 6: Characteristics of Dementia SOURCE: Based on personal interviews Table 4: Projected number of people in India compared with dementia SOURCE: ARDSI dementia India Report 2010

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Table 5: A list of the resources http://www.alzheimer.org.in/assets/dementia.pdf

available

all

across

India-

SOURCE: Dementia Care notes - http://dementiacarenotes.in/resources/city-wise/dementia-assamguwahati-manipur-imphal/

LIST OF ABBREVIATIONS PwD: person living with dementia ARDSI: Alzheimerâ€&#x;s And Related Society of India G.P: General Physician

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