The Design of Healthcare Facilities for People with Dementia

University of Salford College of Science & Technology School of the Built Environment BSc (Hons) Architectural Design and Technology

The Design of Healthcare Facilities for People with Dementia Research Report

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The Design of Healthcare Facilities for People with Dementia Research Report

Author

Liana Candido Martins University of Salford, United Kingdom Federal University of Cearรก, Brazil Supervisor

Dr Ricardo Codinhoto University of Salford, United Kingdom

October 2014 !

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The Design of Healthcare Facilities for People with Dementia Research Report

Contact Details Liana Candido Martins – lianalcm@gmail.com Dr Ricardo Codinhoto – r.codinhoto@salford.ac.uk !

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RESEARCH REPORT: THE DESIGN OF HEALTHCARE FACILITIES FOR PEOPLE WITH DEMENTIA

ACKNOWLEDGEMENTS ______________________________________________________________________

This study was made possible through the support of the Science without Borders scholarship program sponsored by CNPq - Conselho Nacional de Desenvolvimento CientĂ­fico e TecnolĂłgico, of Brazilian Ministry for Science, Technology and Innovation.

I wish to thank Dr Ricardo Codinhoto for his invaluable help and supervision in this research, and for making time available to assist me through all stages, without his contribution and knowledge this study would have not been achieved. Also, Isabella Carolline Souza and Professor Rob Smith, for their helpful aid at the initial phase of this research. And, finally, sincere thanks are also due to the staff at University of Salford, for the welcome and facilitation of my stay in the UK.

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RESEARCH REPORT: THE DESIGN OF HEALTHCARE FACILITIES FOR PEOPLE WITH DEMENTIA

ABSTRACT ______________________________________________________________________ Aims: The purpose of this research is to analyse the importance of interventions in the physical environment of healthcare settings for people with dementia, identifying the principles that can assist designers, architects and planners to provide a healthcare environment that improves the quality of life and preserve the dignity of the elderly. This paper reports findings from a systematic review Methods: A systematic review of literature regarding the built environment healthcare settings and the outcome of patients and staff in dementia health care. The review includes a discussion of evidence-based design.

Results: The studies suggest that the environment can affect health, including physiological, psychological, clinical and behavioural effects. Architectural design consideration is important in mental health settings, especially for patients with conditions such as dementia that have such a difficulty in expose dissatisfaction.

Environment features have also been found to affect staff, and improvements can be made to address these effects in a positive perspective. The lack of a specific guideline in the design of dementia facilities has been compensated with the common understanding of the basic needs for accommodating comfortably people living with dementia.

Conclusions: There is still need to reach a deeper level of understanding the impact of designed environment on health. In the review, it was possible to find some evidence of such impact, but there is still little certain. Finally, further research is needed in this area to fit within the framework of ‘evidence-based design’.

Keywords: Dementia Care, Built Environment, Evidence-Based Design, Systematic Literature Review, Design Guidelines.

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RESEARCH REPORT: THE DESIGN OF HEALTHCARE FACILITIES FOR PEOPLE WITH DEMENTIA

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CONTENTS ______________________________________________________________________ Acknowledgements

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Abstract

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List of Figures

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List of Tables

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1. Introduction

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1.1. Aims of the Research

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1.2. Research Questions

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2. Research Method

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2.1. Database Search

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2.2. Internet Search

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2.3. Selection Criteria

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2.4. Language

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2.5. Quality Assessment

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2.6. Data Extraction Strategy

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3. Evidence-based Design

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3.1. Evidence-based Healthcare Design

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3.2. Evidence-based Design for Dementia

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4. Systematic Literature Review

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4.1. The Synthesis Process

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5. The Healthcare Environment for People with Dementia

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5.1. The Elements of the Built Environment in the Healthcare Setting

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5.2. Health Outcomes of Dementia Patients

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5.3. The Environmental Impact in the Health Outcomes of Dementia Patients

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6. Analysis: Environment and Outcomes In Dementia Care 6.1. Function

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6.1.1. Acoustics

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6.1.2. Lighting

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6.1.3. Ventilation and Temperature

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6.1.4. Wayfinding

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6.1.4.1. Colours

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6.1.4.2. Function Stability

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6.1.4.3. Graphic and Verbal Information

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6.1.4.4. Home-Likeness

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6.1.4.5. Reference Points

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6.1.4.6. Visual Access

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6.2. Specific Areas

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6.2.1. Away Place and Living Room

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6.2.2. Bathroom

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6.2.3. Bedrooms

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6.2.4. Dinning Room

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6.2.5. Garden

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6.2.6. Kitchen

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6.3. General Characteristics

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6.3.1. Colour

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6.3.2. Doors

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6.3.3. Elevator

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6.3.4. Floor

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6.3.5. Furniture

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6.3.6. Size and Space

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7. Conclusion

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7.1. The Limitations of the Research

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7.2. Final Considerations

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8. References

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9. Appendices

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9.1. Appendix 1 – Map of Variables !

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LIST OF FIGURES ______________________________________________________________________ Figure 1. Number of People with Dementia in the UK, in 2013 (Alzheimer’s Society, 2014).

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Figure 2. Projected Number of People with Dementia in the UK (Alzheimer’s Society, 2014).

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Figure 3. Evidence-Based Design Wheel (Geboy, 2007)

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Figure 4. Reference and Conditioning Agents

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Figure 5. Built Environment Component

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Figure 6. Health Outcomes and Quality Assessment Criteria

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LIST OF TABLES ______________________________________________________________________ Table 1. Searched Databases

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Table 2. Selected Keywords

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Table 3. Quality Assessment Criteria (Codinhoto, 2008)

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Table 4. Stages of the Synthesis Process (Cooper, 1982 and 1998)

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1. INTRODUCTION ______________________________________________________________________ The understanding of the relationship between people and their environment requires a broad discussion of the theoretical perspectives of environment behaviour studies.

These studies, supported by evidence, suggest that the physical environment has a substantial impact on behaviour and attitudes.

Everyone is vulnerable to environmental influences, especially new-borns and older people due to their frail conditions. Considering this, the healthcare environment must be improved in order to provide a therapeutic environment and ameliorate the negative effects of the environment in their lives.

The diseases afflicting the senior population, which has an increased occurrence as a result of the growth of the elderly population, particularly in developed countries, have been investigated and recognized in medical and scientific area. Among these diseases, according to Alzheimer’s Society, dementia affects 7,1% of the total agestandardised +65 population (based on 2013 data) (Figure 1), in other words, 1 in every 79 (1.3%) of the entire UK population, and 1 in every 14 of the population aged +65 years. There are over 40,000 people with early-onset dementia (under the age of 65 years) in the UK. At the current estimated rate of prevalence, there will be 850,000 people with dementia in the UK in 2015 (Figure 2). However, improvements to education standards, cardiovascular health, activity levels and other known risk factors may all help reduce dementia incidence and prevalence in the future (Alzheimer’s Society, 2014).

Since the formulation of national dementia strategies for England (Department of Health, 2009), Scotland (The Scottish Government, 2010), Wales (Welsh Government, 2011), and Northern Ireland (Department of Health, Social Services and Public Safety, 2011), and the Prime Minister’s challenge on dementia (Department of Health, 2012), the concern for the care of people suffering with dementia has increased in the UK. This report discusses the effects of the built environment in the healthcare setting for people with dementia, and the growing need for facilities designed to address the !

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residents’ physical, psychological and physiological needs and facilitate the function of staff. A well-planned environment can reduce the anxiety and confusion levels of residents focusing in the privacy and dignity issues, and the support of a space and time orientated scheme.

Figure 1. Number of People with Dementia in the UK, in 2013 (Alzheimer’s Society, 2014).

Figure 2. Projected Number of People with Dementia in the UK (Alzheimer’s Society, 2014).

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1.1. Aims of the Research The purpose of this research is to analyse the importance of interventions in the physical environment of healthcare settings for people with dementia, identifying the principles that can assist designers, architects and planners to provide a healthcare environment that improves the quality of life and preserve the dignity of the elderly.

This will be made possible through the discussion of how the built environment affects the care of people suffering from dementia by analysing previous research studies and providing a systematic review of the evidence of such effects in the health outcomes.

1.2. Research Questions The questions involved with the conduction of this research are: 1. What is an evidence-based design and how does it relate with the healthcare environment and more specific with the design of facilities for people with dementia?

2. What is a systematic literature review and what is its process?

3. What is the relation between the built environment and the health outcomes and how does it related to dementia care?

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2. RESEARCH METHOD ______________________________________________________________________ The aim of this research was to summarize and discuss how the built environment affects the care of people suffering from dementia by analysing previous research studies and providing a systematic review of the evidence of such effects in the health outcomes.

The effect of an environment in the everyday life of a person with dementia may be assessed in many ways; considering the perspective of architects, healthcare providers, family of users and the users themselves (for example, how the colour of the room may affect their stress level).

In order to create an evidence-base of such effects, a literature review was the strategy adopted for this study. A literature review can synthesise past research by drawing overall conclusions from many separate investigations that address related or identical hypotheses (Cooper, 1998). The intention in this compilation of data is to form an evidence-base to assist in the design of environments for people with dementia, in order to understand and improve their quality of life.

Considering this approach, the research method described next was considered the most efficient for the task proposed.

2.1. Database Search The first step was to identify the databases available for the search of the content necessary for this study. The databases, searched electronically for relevant published literature, were selected due to their descriptions indicating the necessary coverage of the subject of this study, as seen in Table 1.

In addition, selective searching of the references of included papers was conducted.

Literature reviews previous to this study were also scanned.

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Table 1. Searched databases.

Database AMED - Allied and Complementary Medicine Database (via Ovid) ASSIA - Applied Social Sciences Index and Abstracts (via ProQuest)

British Nursing Index (via ProQuest)

CINAHL - Cumulative Index to nursing Allied Health (via EBSCO) DAAI - Design and Applied Arts Index (via ProQuest) Google Scholar

HMIC - Health Management Information Consortium (via Ovid) MEDLINE (via Ovid)

Description Database produced by the Health Care Information Service of the British Library. Covers a selection of journals in complementary medicine, palliative care, and allied professions.

Indexing and abstracting database covering health, social services, psychology, sociology, economics, politics, race relations and education. Updated monthly, ASSIA provides a comprehensive source of social science and health information for the practical and academic professional. Contains records from over 650 journals published in 16 different countries, including the UK and US. Database for support of practice, education, and research for nurses, midwives, and health providers in the UK or following UK practice. It provides references to literature in the most relevant nursing and midwifery journals. Also included are relevant nursing articles from selected medical, allied health, community and health management journals. Coverage is mainly titles published in the UK, plus a selection of important international nursing titles.

Database provides indexing for more than 3,000 journals from the fields of nursing and allied health. Contains more than 2.3 million records dating back to 1981.

Database of abstracts and bibliographic records for articles, news items, and reviews published in design and applied arts periodicals from 1973 onwards. DAAI contains more than 212,000 records, with around 1,200 new records added in each monthly update.

Search engine for many disciplines and sources - articles, theses, books, abstracts and court opinions, from academic publishers, professional societies, online repositories, universities and other web sites.

Database from two sources, the Department of Health's Library and Information Services (DH-Data) and King’s Fund Information and Library Service (King’s Fund Database). Covers health service, hospital administration and management, public health, service development and NHS organisation.

Created by the National Library of Medicine, covers the international literature on biomedicine, including the allied health fields and the biological and physical sciences, humanities, and information science as they relate to medicine and health care. Information is indexed from approximately 5,400 journals published worldwide.

The search terms used in the databases were a selection of keywords about dementia, design, health care and outcomes. Previous to the search, a discussion with a group of researchers involved with the subject area was used to define the keyword list.

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Table 2. Selected keywords.

1. Health Alzheimer OR Dementia OR Mental Disorder OR Cognitive Disorder OR Treatment OR Care OR Impair*

2. Individual Elderly OR Old Age OR Staff OR Family OR Community OR Ageing OR Residents OR Older People

4. Outcome Stress OR Aggressive Behavior*r OR Safety OR Identity OR Control OR Visibility OR Orientation OR Effective OR Well-being OR Quality OR Independence

3. Built Environment Nursing Home OR Environment* OR Facilities OR Home Care OR Public OR Neighborhood OR Outdoor OR Design

5. Design Light* OR Colo*r OR Corridor OR Home Like OR Noise OR Garden OR Open Space OR Visual Access Or Landscape* OR Window OR Texture OR Acoustics

The Boolean operators “and” and “or” were used to produce more relevant results. The “and” operator was used to join different categories of keywords, defining the search; and the “or” operator was used to join similar keywords of the same category, broadening the search. The truncation technique, “*”, was also used to widen the search, including various word endings and spellings.

2.2. Internet Search Considering the limitation of time and resources, and the magnitude of the literature available, a selective search of the Internet was taken during June/July 2014. The following websites were identified and searched in an attempt to identify relevant material: Age UK www.ageuk.org.uk AGE Platform Europe www.age-platform.eu Ageing, Disability and Home Care – Department of Family and Community Services (NSW Government) www.adhc.nsw.gov.au Alzheimer’s Research UK www.alzheimersresearchuk.org Alzheimer’s Society www.alzheimers.org.uk Healthcare Design Magazine www.healthcaredesignmagazine.com Help the Aged www.helptheaged.org.uk National Building Specification - Publication Index www.thenbs.com/PublicationIndex NHS UK www.nhs.uk !

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2.3. Selection Criteria The database search resulted in more than 1200 abstracts related to this study. The selection of articles was based on the screening of titles, keywords and abstracts of the papers identified by the electronic search. This selection was designed to eliminate irrelevant information and resulted in 190 articles and papers.

The selection of abstracts was focused on papers with qualitative or quantitative approaches, with case studies and comparative studies. However, to increase the number of information on the subject, office related guidelines and theoretical studies were also considered. All studies and guidelines had to include persons with dementia, at any stage of the disease, and/or staff and family directly in touch with them; and discuss the physical environment.

Physical environment was defined in this study as the area relevant to architects, facility managers, interior designers and outdoor designers. Every aspect of the built environment was considered, including fittings and furnishings.

After the selection of the abstracts, the reading of the methodology, discussions and conclusions of each paper was conducted to confirm the relevance and to assess the quality to the study. Finally, studies rated as poor quality were excluded.

On completion of the screening, 117 studies remained.

2.4. Language Studies published in English, Portuguese or Spanish were eligible for inclusion, with the keywords translated to the other languages.

2.5. Quality Assessment A quality assessment using the model provided by Codinhoto (Codinhoto, 2008) (see Table 3) was performed to provide an evaluation of the overall quality of the identified studies.

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Table 3. Quality Assessment Criteria (Codinhoto, 2008).

Generalisation

Findings Use

Method

Background

Element

Quality Assessment Criteria

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Level 0-Absence

1-Low

2-Medium

3-High

Not Applicable

The article does not provide enough information to assess this criterion.

Poor awareness of existing literature and debates. Under or over referenced.

Low validity of theory.

Basic understanding of the issues around the topic being discussed. The theory weakly is related to data.

Deep and broad knowledge of relevant literature and theory relevant for addressing the research.

Good relation theory-data.

This element is not applicable to the document or study.

The article does not provide enough information to assess this criterion.

Data inaccuracy and not related to theory. Flawed research design.

Data is related to the arguments, though there are some gaps.

Research design may be improved.

This element is not applicable to the document or study.

The article does not provide enough information to assess this criterion.

The ideas are difficult to implement or consider as an input in designing the building.

It’s possible to use the information available in the paper, but data needs to be deployed.

Data strongly support arguments.

Besides, the research design is robust: sampling, data gathering, data analyses is rigorous.

Data is ready for designer’s consideration in designing the building.

The article does not provide enough information to assess this criterion.

Only to the population studied.

It is possible to generalise to population of similar.

High level of generalisation.

This element is not applicable to the document or study.

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This element is not applicable to the document or study.

RESEARCH REPORT: THE DESIGN OF HEALTHCARE FACILITIES FOR PEOPLE WITH DEMENTIA

2.6. Data Extraction Strategy In order to facilitate the interpretation, all information gathered from the studies was mapped in a pre-defined table provided by Codinhoto (Codinhoto, 2008) that was edited to fit this research purpose (see Appendix 1). The information extracted from the studies was classified into a set of variables as seen: •

Participant, which could be patients, staff, family or community, and in the case of patients, patients’ condition and gender;

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Built environment, location, settings, components, functions and characteristics;

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Health outcomes, psychological and others.

The relation between variables was identified as a plus sign (+), in case of a positive impact, a minus sign (-), in case of a negative impact, a plus-minus sign (±), in case of both positive and negative impacts, and an empty sign (ø), in case of no sign of positive or negative impacts.

The studies quality was also included in this mapping, accordingly with the quality assessment criteria shown in Table 3.

The variables will be further discussed in chapter 6 of this report.

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3. EVIDENCE-BASED DESIGN ______________________________________________________________________ The “evidence-based” approach, in its broadest form, is the application of the evidence derived from scientific researches into decision-making policy. This approach is commonly used in Medicine, and Evidence-based Medicine (EBM) supports that, to the greatest extent possible, decisions and policies should be based on evidence, not just the beliefs of practitioners, experts or administrators.

The evidence-based approach can be applied to many areas other than Medicine with the intention of incorporate the best research evidence into practice. This approach can also improve the healthcare environment in a safer manner by comprehending the effects of the environment design on patients and staff with the help of behaviour researches.

3.1. Evidence-based Healthcare Design Evidence-based design (EBD) is an approach to environmental design (architectural, interior, and landscape) that aspires to base design decisions on documented research and well-established best practices, with the aim of improving outcomes (Geboy, 2007).

In healthcare designs is used to create environments that are therapeutic, supportive of family involvement, efficient for staff performance, and restorative for workers under stress (Hamilton, 2003).

According to Hamilton (2003) the evidence-based practice can be assorted in four “levels” to identify different commitments to which architects use EBD on behalf of their clients. At level 1, there is an effort to stay current with the literature available and its use in design specifications. At level 2, the practitioners take one step further and the concern with the outcome of the design and hypothesis regarding it become part of the intervention process. At level 3, besides worrying about the current information available and hypothesizing about the outcome of their design interventions, practitioners expose their work and findings to the public, contributing to the field. At level 4, in addition to the other steps, practitioners also expose their findings by publishing in quality journals that require review by qualified peers. However, Hamilton (2003) also talks about another level, the “level-zero practitioners”, those who !

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understand the concept of the environment effect on the lives of those users, and know the existence of evidence to support conclusions about those effects, but often take isolated comments and interpret in a way to fit their design proposals without the actual evidence-based analysis.

The concern with a designed environment more informed about the outcomes of its intervention is important in the healthcare setting. According to Geboy (2007), it’s possible to identify from the collective findings of the studies 12 outcome-linked environmental factors that directly contribute to the healing environment. The result of this analysis is illustrated as an Evidence-based Design Wheel (Figure 1). The factors are linked together with the concept of the healing environment, which comprise a comprehensive, strategic, evidence-based set of design responses that create therapeutic healthcare environments, curative settings that support healing and improve the healthcare experience (Geboy, 2007).

Figure 1. Evidence-Based Design Wheel (Geboy, 2007).

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3.2. Evidence-based Design for Dementia There is solid evidence that the built environment impacts the psychosocial/emotional well-being and probably physical health of individuals with dementia (Calkins, 2011).

The evidence of positive outcomes should help with the development of a common language and definitions to the design of care settings for individuals with dementia in order to directly influence the physical and psychosocial functioning of these individuals, improving their quality of life.

The next step of this research is a systematic review of the researches regarding the health outcomes related to the design of care facilities for people with dementia with the purpose of finding and compiling these evidences.

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4. SYSTEMATIC LITERATURE REVIEW ______________________________________________________________________ Systematic literature review is a fundamental step towards the development of an evidence-base. The large amount of information provided by different researchers needs to be analysed and evaluated with the purpose of creating one single source of data for any particular subject.

In the healthcare setting, the identification of the quality conclusions among the large quantity of results from different studies is crucial to define the data for the decision making process. To manage the existing information efficiently a systematic review is needed. Systematic reviews establish whether scientific findings are consistent and can be generalised across populations, settings, and treatment variations, or whether findings vary significantly by particular subsets. Continuously updated literature review can shorten the time between medical research discoveries and clinical implementations of effective diagnostic or treatment strategies (Mulrow, 1994).

The methods of a systematic review aim to minimise bias, improving the reliability and accuracy of conclusions by using an objective and transparent approach.

4.1. The Synthesis Process According to Cooper (1998), the process of research synthesis has five stages: the problem formulation, the data collection or the literature search, the data evaluation, the analysis and interpretation, and the presentation of results. The synthesis process is summarized in Table 4.

The first step in any research is the formulation of the problem to be discussed.

Followed by the literature search, the collection of data involving the elements of the target of the study. The next step is an evaluation of the gathered data, in which critical judgment is required regarding the quality of information. After the quality assessment, the next step is to analyse and interpret the gathered data, unifying the results of the researches in a systematic way. And finally, the presentation stage, in which will be create a public document describing the investigation process and results. !

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Table 4. Stages of the Synthesis Process (Cooper, 1982 and 1998).

Stage Characteristics

Research question Asked

Primary function in review

Procedural Differences that create variation in reviews conclusions

Sources of potential invalidity in review conclusions

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Stages of Research Problem Formulation What evidence should be included in the review?

Data Collection What procedures should be used to find relevant evidence?

Data Evaluation What retrieved evidence should be included in the review?

Analysis and Interpretation What procedures should be used to make inferences about the literature as a whole?

Public Presentation What information should be included in the review report?

Constructing definitions that distinguish relevant from irrelevant studies.

Determining which sources of potentially relevant studies to examine.

Applying criteria to separate “valid” from “invalid” studies.

Synthesizing valid retrieved studies.

Applying editorial criteria to separate important from unimportant information.

Differences in included operational definitions.

Differences in the research contained in sources of information.

Differences in quality criteria.

Differences in rules of inference.

Differences in guidelines for editorial judgment.

Accessed studies might be qualitatively different from the target population of studies.

People sample in accessible studies might be different from target population of people.

Nonquality factors might cause improper weighting of study information.

Rules for distinguishing patterns from noise might be inappropriate.

Omission of review procedures might make conclusions irreproducible.

Omissions in study reports might make conclusions unreliable.

Synthesisbased evidence might be used to infer causality.

Omission of review findings and study procedures might make conclusions obsolete.

Differences in operational details.

Narrow concepts might make review conclusions less definitive and robust.

Superficial operational detail might obscure interacting variables.

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Differences in the influence of nonquality criteria.

RESEARCH REPORT: THE DESIGN OF HEALTHCARE FACILITIES FOR PEOPLE WITH DEMENTIA

5. The Healthcare Environment for People with Dementia ______________________________________________________________________ 5.1. The Elements of the Built Environment in the Healthcare Setting The quality of the health care depends not only on the care itself, but also on the environment that surrounds the individual. A high quality healthcare environment can have positive influence on health and the design of such environment must focus on such effects in order to deliver a good functioning surrounding.

The built environment can be considered to include the surroundings or conditions designed and built through human intervention, where a person, animal or plant lives and operates (Codinhoto, 2008). The built environment in a healthcare setting should be centered in the patients, visitors and staff. The environment can contribute in the prevention, with the promotion of safety and stress-reduced surroundings; in the intervention, with well-designed healthcare buildings concerning the needs of the patients and the staff; and in the recovery, with a design of therapeutic spaces for assisting the healing process.

Patients with different illnesses have different needs. For some, the need might be a stimulating environment, whereas for others the priority would be to provide a quiet and private place in which to rest (Codinhoto, 2008).

Considering the many scenarios, the focus of this research is to identify the relation between the built environment and the health outcomes related to dementia care.

5.2. Health Outcomes of Dementia Patients Due to the broad scope of the literature review it was reported various outcomes regarding the care of people with dementia. Health outcomes for people with dementia can include pain and discomfort, depressive symptoms, decline of sleep quality and cognitive function, decline in self-care, falls, and many others. The reported relation of the outcomes with the built environment had both positive and negative effects in the psychosocial outcomes and behavioural symptoms.

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5.3. The Environmental Impact in the Health Outcomes of Dementia Patients The quality of care provided for elderly people, and especially those with dementia, remains a concern. People with dementia living in institutions “are unlikely to complain‌ and are unlikely to be heard if they doâ€?. This is partly a result of the nature and effects of their illnesses, and partly a result of societal attitudes. (Tune and Bowie, 2000).

The basic accommodation needs of people with dementia are no different from those of the rest of society. People with dementia need security, safety and comfort in a pleasant and stimulating environment. However, for people with dementia there are additional requirements, which reflect their dependency needs, resulting from impaired memory, learning and reasoning processes. (Cantley and Wilson, 2002) Over the years, there has been an increase of researches trying to identify the ideal and the essential components of a well-designed facility for dementia residents. The lack of a specific guideline in the design of dementia facilities has been compensated with the common understanding of the basic needs for accommodating comfortably people living with dementia. The design should compensate for disability; should maximise independence, reinforce personal identity, and enhance self-esteem and confidence; should demonstrate care for staff; should be orienting and understandable; should welcome relatives and the local community; and should control and balance stimuli.

However, there is no single right way to design a care home. The particularity of the individuals must be considered during the process of the design.

In the next chapter, the design features and their effect will be further discussed.

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6. Analysis: Environment and Outcomes In Dementia Care ______________________________________________________________________ As a result of this research, below is a compilation of environmental variables relating the built environment and health outcomes in dementia care.

The variables will be presented according to function, specific rooms and general characteristics. Each variable will have two discussions, about the evidence found on the effects on health outcomes, or lack thereof, and about the common guidelines suggested regarding the changes needed in case of a negative effect on the health outcomes.

6.1. Function

6.1.1. Acoustics Effect: Noise and “acoustic pollution� are related to confusion, stress, anxiety, irritation, frustration, and aggressiveness in a negative way, and it can even result in the development of high blood pressure and ulcers, in the healthcare environments.

Recommendation: Acoustic insulation must be thought and met the requirements for walls, ceilings, windows, doors and floors. And materials used must be chosen considering their power to amplify sound waves.

Separation of sector through their function is suggested, creating areas of rest, recreation and leisure.

6.1.2. Lighting Effect: Light is related to the ability to see, function, move around and consequently their orientation. Irregular lighting can produce shadow reflections and create illusions or barriers, which can increase the level of agitation and confusion.

Agitation and restlessness was reported regarding sudden changes in lighting levels.

Recommendation: Lighting must be adequate and homogeneous through all areas of !

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the facility, particularly in potentially hazardous areas such as stairs.

Glare should be avoided and diffuse lighting is more desirable than very bright lights.

Avoid sudden changes in lighting levels, such as glaring sunlight through windows, and flashing televisions. Natural light must be balanced with artificial light in order to create a more homogeneous ambience.

Light switches must be accessible, especially to people in wheelchairs.

The lighting must be design to increase the functional capability of the individual and minimize discomfort and falling risks.

The light must not change the colour of the objects in the environment.

6.1.3. Ventilation and Temperature Effect: elderly are more likely to develop respiratory tract diseases due to age related loss of temperature and oscillation. There is a direct relationship between the ventilation and temperature of the environment and the sense of satisfaction and comfort.

Recommendation: Artificial cooling and heating must be provided when needed to stabilize the environment temperature, but not in excess, to avoid respiratory tract diseases.

The humidity must be checked to maintain a comfortable level.

In areas that may develop odours, exhaust fans must be provided.

6.1.4. Wayfinding Wayfinding is an important mobility pre-requisite regarding independence and personal autonomy. The liberty of wandering inside the residence maintains the sense of independency. However, wayfinding problems can cause anxiety, confusion, and even panic. These problems can be ameliorated with the creation of small-scaled settings, allowing the wandering experience. The factors regarding wayfinding are further discussed below. !

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6.1.4.1. Colours Effect: Light colours don’t seem to help distinguish difference doors, and floor levels and may cause confusion and may cause falls and injuries.

Recommendation: The use of high contrast colours in order to improve visual communication.

6.1.4.2. Function Stability Effect: The changes in the environment functions tend to increase the level of disorientation and confusion.

Recommendation: Basic living functions such as eating and relaxing should have a permanent place or section with a permanent furniture arrangement. Recreation rooms, on the other hand, can probably still remain multifunctional.

6.1.4.3. Graphic and Verbal Information Effect: The information displayed in the setting is usually conceived for mentally alert users who are able to read and that does not correspond to the cognitive functioning of a dementia patient.

The difficulty of distinguishing relevant from irrelevant information has also been noted.

Recommendation: Some suggest a greater use of pictograms, which attract attention and might be understood even if reading is no longer possible. Little is known about the use of pictograms for Alzheimer’s patients rather than written signs, and an exploration in that field might certainly be worthwhile.

Signs have to communicate the essential information.

6.1.4.4. Home-Likeness Effect: Once inside their rooms, dementia patients tend to recognize as their own due to the personal items.

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Recommendation: The inclusion of personal decorative elements, curtains and bed covers, and even some furniture is highly recommended.

6.1.4.5. Reference Points Effect: An ideal reference point combines form, function, and meaning. Reference points are especially important for Alzheimer’s patients who tend to operate on a sequential basis from one decision point (reference point) to the next. This, in addition to deficient spatial cognition, is probably the explanation of the poor wayfinding performance.

Recommendation: The corridors leading to the rooms and other high function points should be contrasting when compared to other elements.

An architecturally rich and articulate environment is helpful to all, but appears to be particularly important to the wayfinding of Alzheimer’s patients.

6.1.4.6. Visual Access Effect: Direct visual access to common rooms facilitates recognition and might even lead people to use a place they might otherwise not have remembered.

Recommendation: Visual access must be planned along with the needs of each room function.

6.2. Specific Areas

6.2.1. Away Place and Living Room Effect: People with dementia require a range of social interaction in order to maintain the opportunities for both privacy and community. Spaces are needed for sitting quietly alone or with one or two intimate friends, as well as in larger groups.

Recommendation: It is recommended the design of both “away place” and living room to fulfil the different needs of social interaction.

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RESEARCH REPORT: THE DESIGN OF HEALTHCARE FACILITIES FOR PEOPLE WITH DEMENTIA

6.2.2. Bathroom Effect: Bathrooms are often related to fear and cause of disorientation due to the usual clinical white colour and echo.

Private bathrooms were related to privacy and feelings of safety and comfort for residents.

The satisfaction level of the staff has a direct relation with the ability of proper sanitation, in case of incontinence, and safety when assisting residents.

Recommendation: The use of warm colours, pictures, shelves and bathroom accessories can create a positive environment, providing a safe, secure, comfortable, home-like atmosphere. All these can assist orientation and help to absorb echo.

Private bathrooms can be used to maintain the residents’ privacy, choice and control.

Non-slip flooring should be use to ensure safety during self-toileting and bathing for residents and provide ease for cleaning.

Access should be through the residents’ bedroom and residents should see bathrooms from their beds. Bathroom doors can be left open to help orient residents for toileting.

The use of support bars is highly recommended. As well as an adjustable spray head to accommodates people of various heights with a wand-type spray unit that reaches all corners of the bathroom.

6.2.3. Bedrooms Effect: There are both negative and positive reports on private bedrooms scenario. Not every resident enjoy the exclusivity of a private room that may create a private personal environment, or stimulate isolation.

Recommendation: Residents’ needs and preferences should be considered and respected. The design must considered different bedroom arrangements to meet possible choices.

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RESEARCH REPORT: THE DESIGN OF HEALTHCARE FACILITIES FOR PEOPLE WITH DEMENTIA

6.2.4. Dinning Room Effect: The environment of mealtimes impacts the nutritional intake of residents. A pleasant atmosphere, together with the use of condiments, napkins, tablecloths and correct utensils helps residents to enjoy their food more, with residents encouraged to choose their meals and serve themselves and staff being involved and eating at the meal table.

Recommendation: Particular attention should be paid to the layout and atmosphere of the eating environment to ensure that it is homely and congenial.

A fixed space should be used to address only to the eating function to improve orientation.

6.2.5. Garden Effect: Gardens are reported as a positive environment, helping maintain mobility, stimulating the appetite and promoting sleep.

The sunlight is vital for vitamin D absorption, which helps prevent fractures.

Therapeutic gardens, including scented areas, seating, raised planting areas and water features can promote the physical and cognitive functioning of older people with dementia.

Recommendation: Flowers can be picked and used by residents for sensory stimulation.

And the use of a therapeutic garden is highly recommended.

Visual access for staff must be provided at all times.

6.2.6. Kitchen Effect: In the accessible kitchen philosophy, people assist in the preparation of food and drinks, and in laying tables together with the staff, offering mental stimulation, the use of muscles and eye-hand coordination, while visual and auditory effects stimulate the appetite. !

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Recommendation: The design of the homes should pay attention for the requirements of a healthy socio environment, accessible for both patients and staff.

6.3. General Characteristics

6.3.1. Colour Effect: Different colour schemes can influence mood or activity, for example pale, clear blues and green provide a relaxing environment, yellows are cheerful, and touches of bright red encourage activity.

Colour contrast is important for people to be able to see stairs or food.

Warm colours, such as red, orange and yellow, are more stimulating than cool colours and can improve visibility and encourage the person to mobility and action.

And cool colours, such as blue and green, although ideal for reduction of tension and stress, generally are not visualised by elderly people.

Recommendation: The selection of colours should be easily accommodated to the visibility of the elderly and to provide contrast, especially between floor and wall.

The colour is important, but the contrast of colours is more essential in the healthcare environmental for people with dementia than the colour itself.

6.3.2. Doors Effect: Frustration was reported as a result of not being able to open a locked door.

Open doors were reported as a hazard.

Recommendation: Methods of disguise should be implemented. Painting the door with the same colour of the wall is an option.

All doors must be kept closed. Especially those that lead to outside environment unsupervised.

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RESEARCH REPORT: THE DESIGN OF HEALTHCARE FACILITIES FOR PEOPLE WITH DEMENTIA

6.3.3. Elevator Effect: It was reported that the use of elevators causes anxiety due to the difficulty the individuals suffer in assimilating the commands. It may also contribute to the lost sensation when the resident can’t find the proper floor level desired on account of the inability of recognizing the floor level due to memory impairment.

Recommendation: The use of elevators should be limited. When the use is indispensable in terms of the space available for the facility, each level should be autonomous regarding all the basic functions required in the daily routine, as well as the recreational and social interaction. This setting might reduce the need for the use of the elevator by the individual, except in specific cases, in which the resident may be assist by the staff.

6.3.4. Floor Effect: The use of carpets was reported as an improvement of the protection against falls when in comparison to hard flooring.

Highly patterned carpets were reported as a contributing factor of a disorientating state, particularly when looking down to use a walking aid.

Shiny floor was reported as a cause of falls due to the confusion caused by the glaring.

Recommendation: The use of carpets should be preferred over hard flooring. Carpets must be kept fresh with regular cleaning.

Carpet patterned should be thought in order to create a homogeneous look to avoid the sense of barriers. Except when that is the intent.

Shiny floors should be avoided.

6.3.5. Furniture Effect: It was reported that the use of furniture with home-like features and appropriate to the culture, ethnicity and generation of residents, improved the sense of orientation, the feeling of ownership and the sense of personal autonomy. !

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RESEARCH REPORT: THE DESIGN OF HEALTHCARE FACILITIES FOR PEOPLE WITH DEMENTIA

There is evidence of improvement in respiratory function due to proper posture guaranteed by adequate furniture. And the physical stress was alleviated with the use of adjustable sitting elements to meet the requirements of different functions.

The constant change in furniture due to maintenance was reported as disorienting.

Recommendation: A range of furniture should be available in order to promote individuality and meet individual needs. The residents’ choice should be considered in the process, especially regarding their personal space.

Furniture can be discreetly protected from staining; plastic covers are not necessary.

The arrangement of furniture in rooms can facilitate or inhibit movement, and encourage social activity or isolation.

The sitting elements should meet the correct height and be adequate to the posture needed, guaranteeing the right posture and feet stability, as well as meet the function required to offer comfort to the various body positions.

The durability of the chosen materials must be observed prior to furniture use.

6.3.6. Size and Space Effects: It was reported that compact designs help eliminate the institutional appearance, increasing the opportunities for informal social interaction, making it easier to create a homelike atmosphere, and facilitate supervision of residents.

Recommendation: It is suggested a balance between having too much and too little space, maintaining enough space to move freely and control over levels of social interaction.

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7. CONCLUSIONS ______________________________________________________________________ 7.1. The Limitations of the Research Every research has its limitations. The major issue of this research is the complexity of the task. The immense variety of components is too long to assess them all, and the relation between them is intrinsic in a way that there is difficult in separating each component to proper analysis.

The findings suggest that the physical environment, together with the human care, can affect the health of people with dementia. However, the understanding of the evidence is difficult due to the limitations of the data, mostly observed, or obtained through case studies and staff and family perspective. The patient psychological health is more difficult to assess.

It is clear there is room for improvement in all the process of this review. The common agreement of the effects of the built environment in healthcare settings is valid, but there is little evidence that is certain.

This review identifies the need for better research into the effects in order to find a better way to build the right environment for accommodate comfortably and ameliorate the conditions of the disease.

Most of the studies focus on a portion of the dementia population. No studies were located that specifically dealt with the environmental aspects of end of life issues and immobility in the late stages of dementia.

7.2. Final Considerations The available research supports the concept of the built environment effects on the health care of people with dementia, resulting in a series of features that can be analysed during the process of the design in order to enhance the quality of life of the people affected. But further research on the subject needs to be address in order to fully compile evidence-based design guidelines.

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9. APPENDICES

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9.1. Appendix 1 – Map of Variables

Figure 2. Reference and Conditioning Agents

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A1

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9.1. Appendix 1 – Map of Variables – Continuation

Figure 3. Built Environment Component

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A2

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9.1. Appendix 1 – Map of Variables – Continuation

Figure 4. Health Outcomes and Quality Assessment Criteria

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A3