Dementia and Architecture Graduation booklet

Living Knowhere Summary of research and design on architecture and dementia

AneĹžka ProkopovĂĄ

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Tutors: research tutor Theo van der Voordt design tutor Robert Nottrot building technology tutor Ype Cuperus

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Preface With every attempt to start this work and describe the experience with my grandmother’s dementia that led me to this topic, I became more hesitant to share the reason at all. Not because I would be ashamed or sad; just because I could not find the right way to introduce it. Finding a balance between sentiment and cold facts seems impossible. Of course, there are many scars and slashes, many emotions and many sad memories, which invite to present it as a sad touching story but I did not want to do that.

It would be unfair because it is not just that. Dealing with the disease has been a whole pallet of experiences with its highs and lows.

It is not easy and it brings many difficult moments to life but at the same time, it also brings many good things. There are many memories I am extremely happy for and altogether, it is just another huge lesson our grandmother has to teach us. Seeing the disease progress makes you reflect upon your life, upon life in general and upon things you consider relevant and important.

It has helped me learn to appreciate things I used to neglect and realize the importance of simple, basic things; things which remain present even when all the others are forgotten; things that are natural to us but we tend to rush through them.

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My grandmother is now no longer able to remember my or her name, she does not recognize where she is but she is still happy when she is outside in the sun, she cheers up when she sees us no matter that she often thinks we are somebody else. She is extremely grateful for any laugh we share, for any warm touch. She is happy when we are all together and in a good mood. She shows us even now what the important things are and what we should learn to enjoy.

Despite all the difficulties and bittersweet feelings, I consider myself lucky to happen to learn from her even now when the disease is progressed. The whole experience has been the motivation and reason that brought me to this topic and although I do not want to call my grandmother a reference or a research method, this experience will naturally be incorporated in the research. Seeing many people including my grandmother struggle and getting lost in many of the nursing homes naturally stirred many thoughts about what really matters in space and what are the simple, essential things people truly enjoy. It has led to thoughts about how space can help us enhance the very basic enjoyments of our true self even when we no longer remember which those are.

AneĹžka ProkopovĂĄ, 2015

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How to read This is an extract of an academic research conducted in Explorelab Graduation studio at TU Delft. It summarizes its main findings and supplements them with pictorial part. It is divided into four main parts.

First one, Introduction, explains reasons that led me to explore and elaborate this topic. It tries to show why also environment is an important element in the wellbeing of people with dementia. It summarizes and highlights some key relations between the consequences of dementias and architecture.

Second part, Reality, tests this theory in practice and describes my experience with existing dementia care institutions. It points out main aspects of buildings for elderly which often cause troubles and explains why.

Following part, tries to learn from the previous ones and introduces a list of qualities, Design patterns, that contribute to a safe, enriching and understandable environment, so much needed for people who are insecure because of their disease.

Based on all three, the last one, Design, describes my design proposal which tries to implement all the principles discussed before.

I find it very important to say that this research is focused solely on buildings and spaces they create. By no means it intends to criticize or comment on work of all the committed and good-hearted people that help people with dementia make their lives better everyday. I truly admire their work and although I talk about some elderly homes’ deficiencies, it never includes the people inside. On contrary, by analyzing the buildings and learning by working on this graduation, I hope to one day

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be able to improve the conditions not only of people with dementia but also of the many people taking care of them.

Within the whole text I will refer to people with dementia differently in order to avoid repetition as well as to follow the way they are called in various elderly homes. Sometimes they are referred to as clients, sometimes as patients or residents. Many times I will also use “they� which however does not express my attitude towards people with dementia.

Neither do I see them as a secluded group nor as a homogeneous group of people. Although they have the disease in common, it is a diverse group of people often including our relatives, partners, friends, neighbors and one day maybe even us ourselves.

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1. Part one Introduction

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Introduction Due to our aging population, numbers of people with dementia are constantly increasing, while both the cause and cure are still unknown. At the end of a lifetime, after all a person has been through, it is hard to let go. It is hard to let go on home, on memories, on one self. Due to the disease, many things become insecure and one’s life starts falling apart as pieces of which it consists gradually fade away.

Moreover, being diagnosed any kind of dementia within our hyper-cognitive society, which values and requires fast adaptation and constant learning, often means bearing a stigma of disability and uselessness, nevertheless one’s previous status. It means being excluded from the society’s center not only economically and socially, but many times also literally by means of being moved from home into a special care unit.

There are many passionate people doing their utmost best to improve the situation and raise awareness about the disease, but the influence of a built environment is still very often neglected despite the fact that many people spend last years of their lives in various elderly homes.

With no way back and no other place to go, numbers of elderly are bounded to institutions and spaces provided. They experience less and less changes of environments as they no longer have the need or the right to do so. With dementia progressing, life outside of the caring home becomes more demanding and peoples’ life sphere gradually shrinks. At a certain point, it shrinks in between walls of the care unit only and continues till the point where it becomes the person himself and his immediate bodily surroundings.1 It tells us how important the direct environment is, as it may contain the whole life of a person at each moment here and now.

1 Dementia, Design and Technology : Time to Get Involved, ed. Britt Östlund Päivi Topo, vol.

24, Assistive Technology Research Series (2009).

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Fig.1 With no doubts architecture comes long after the love of family, patience of carers and their devotion, but it is an important aspect which can significantly contribute to people’s well being.

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Fig.2

Dementia in general is a brain illness due to which cognition and/ or behavior is damaged to the point where everyday life functioning is impaired.1 Dementia is however only a so called umbrella term for cluster of disease, out of which Alzheimer’s disease is the most common.2 1 Cindy D. Marshall Anne M. Lipton, The Common Sense Guide to Dementia for Clinicians and Caregivers (New York, NY: Springer Science+Business Media, 2013).

2 Feddersen, Lost in Space: Architecture and Dementia.

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There are about 60-70% of people with dementia in most care facilities in developed countries2 and due to consequences of the disease, they gradually become more and more dependent on their surroundings. The more disabled they are, the bigger influence the built environment has.

The more progressed the disease is, the less they can modify the space around. If therefore not designed with care and understanding, quality of peoples’ life can be significantly lowered. On contrary, designs based on knowledge, attention and apprehension of the disease can help avoid unnecessary stress in its later stages. 3 Such process of learning from dementia can not only help people feel more comfortable but it can also help architects broaden their sense of space, its boundaries and its qualities. It can help enlarge their notion of environment when seen through eyes of disability. People with dementia are not the only disabled community and there are many ways of perceiving space and architecture. Approximately 15% of the world’s population live with some disability4 and it is therefore worth understanding and accepting various notions of space where disabilities, including dementia, offer a guiding hand.

Learning to design for dementia is also a great chance to take a step back and reflect on the society as a whole. Getting to know the disease and its consequences is an opportunity to shift our focus back towards the basic, sensory experience of architecture which is to provide shelter and enrich our lives at every moment.5 Coming back to basics through environments which are safe, aesthetically pleasing through materials, lights, sounds or scale and proportions are beneficial to all of us, no matter the diagnosis.

2 Päivi Topo, “Technology Studies to Meet the Needs of People with Dementia and Their Caregivers: A Literature Review,” Journal of Applied Gerontology 28, no. 1 (2009).

3 G. Marquardt and P. Schmieg, “Dementia-Friendly Architecture: Environments That Facilitate Wayfinding in Nursing Homes,” Am J Alzheimers Dis Other Demen 24, no. 4 (2009).

4 United Nations Enable, “Factsheet on Persons with Disabilities,” in Development and human rights for all, ed. Secretariat for the Convention on the Rights of Persons with Disabilities (United Nations Secretariat).

5 Eckhard Feddersen, Lost in Space: Architecture and Dementia, ed. Insa Lüdtke (German National Library: Birkhauser Verlag, 2014).

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Fig.3

Loss of cognitive abilities that occurs with dementia leads to impairments in memory, reasoning, planning, and behaviour.1 As the disease progresses, many things become confusing and it becomes hard to relate oneself to the surrounding world.

1 Gale Encyclopedia of Medicine. S.v. “Dementia.� Retrieved November 10 2014 from http://medical-dictionary.thefreedictionary.com/Dementia

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Fig. 4 Nowadays within our globalized society, such relentless consequences of the disease are difficult to accept and majority people try to avoid it.1 The fact that a person with dementia suddenly or gradually slips into a state of complete dependence and becomes lost in space and time are considered horrifying.2 Because there is very little chance to actually meet and get to know people who have dementia personally, they are often portrayed as a homogeneous group and many other misinterpretation follow.3 Unless people happen to experience the disease themselves, they tend to stereotype. Elderly homes being usually enclosed institutions often enhance this prejudice of having no more life when dementia is diagnosed. However, with support of a family, carers and also the environment, the disease does not by far have to be that scary.

1 Dementia, Design and Technology : Time to Get Involved, 24.

2 Uriel Cohen, Contemporary Environments for People with Dementia (Baltimore: Johns Hopkins University Press, 1993).

3 Europe, “The Ethical Issues Linked to the Perceptions and Portrayal of Dementia and People with Dementia.�

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Fig. 5 On the other hand, the disease is not an easy thing to deal with.

Very often accompanied by disorders such as depression, aggression, sleep disorders or delusion, dementia is difficult to handle for the person as well as for his or her relatives. Although there is only one person with dementia, it always strikes the whole system and many are influenced. 1 For a good reason it is said that with dementia, you see a person die twice, once in mind and then again in the body. Taking care for a person with dementia can therefore be an extremely demanding and emotional process.

1

Feddersen, Lost in Space: Architecture and Dementia.

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We could ask ourselves why we try to maintain our cognitive faculties for as long as possible so desperately, when having to do so constructs a stressful situation both for those still healthy and even more for people with dementia. Due to the consequences, people with dementia gradually become lost in space and time. With only basic abilities remaining, learned motoric, instincts and occasional awakenings, it becomes hard to perform everyday tasks as well as to remember way through a complicated building.

By making environments in which it is not necessary to rely only upon reasoning and cognitive faculties, not only life with dementia would be more relaxed and less stressful. Saying this, there are multiple questions to ask ourselves.

Do we build spaces that are too rational and too factitious?

What does it say about the way we design our homes if later on they become strange and confusing?

May these spaces, to some extent, contribute to and provoke the disease?

Without knowing the answers, shifting our focus towards designing environments where loss of such faculties is not considered a tragedy but rather a transition into something new, dealing with the change might be much easier. For that matter, comparison with less cognitive and more rural societies reveals a different perspective upon the problematic. Although there is only little known about perceiving dementia within societies and nations that are more spiritual and aesthetic, it already tells a lot about how different can an approach to such things like dementia be. It clearly shows that the way we see it is not the only one, and that it just very much corresponds with our modern society’s values.

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For instance, within most American Indian tribes, there is a prevailing idealization of the elderly in general, with common practice of worshiping their wisdom and moral standards.1 In some cases, the elder with dementia is viewed as a person who is even more honourable and wiser, achieving a high spiritual knowledge. His unclear, incoherent speech and unexpected changes in behaviour are generally accepted as a sign of being in a different world, with unknown language and different customs.

Within most tribes, although there are slight differences, dementia is a state in which the person is already half way in the next world. It is a state where the spirit has already proceeded into the spiritual, peaceful world while the body remains and prepares to leave. Caring for such a body is therefore considered an honour and represents a sacred work. Dementia is hardly ever considered an obstacle but rather an unquestionable plan and intention of the Creator, given to a person for ultimate learning. As such it does not require any intervention and any form of prolonging this process is considered unnatural since it prevents the spirit from leaving, when its purpose is accomplished. 2 Western medicine, on contrary, tries to keep the body alive for as long as possible while the spirit might be already gone. Whether it is correct or not, the fact is that both the spirit and the body, using the dualism of American Indians, naturally need safe and suitable environments to live and leave peacefully. For that, architecture has to strip to its fundamental qualities to provide strong and confident support to this subtle, frail process.

Another comparison with cultures and societies such as American Indians sheds more light upon our understanding of the topic and life in general.

Divided into stages as we grow up, life offers discrete challenges and difficulties in each one of them. Whereas within the native Indian tribes, transition into every significant period of life is marked by a certain ritual and celebration, such rituals are slowly disappearing from our rushed society and none of the phases is fully recognized. It is neither celebrated nor clearly marked 1 Lori L. Jervis and Spero M. Manson, “American Indians/Alaska Natives and Dementia,” Alzheimer Disease and Associated Disorders 16, no. 2 (2002).

2 MSN Levanne R. Hendrix, RN, GNP, PhD, “Health and Health Care for American Indian and Alaska Native Elders,” (San Francisco: University of California).

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and as a result, people cannot truly identify with any of them or progress successfully to the next.3 Because there is no recognition of passing on to the next phase, some of them are neglected and almost feared, especially the last one.

With elderly, the transition is often hard to accept because the old age is, on contrary from the Indians, not recognized as a significant or relevant period of time. It is often underestimated and old people are generally thought of as no longer useful. Their wisdom is very little recognized and their potential is often not taken into account. Already speaking about older people but not to them suggests that they are not seen as active and jointly responsible members of society.4 Because this phase of life is not given enough recognition within our society, it is hard to deal with. Talking to various elderly showed that moving to a nursing home is usually thought of as an abrupt jump into a terminal stage of life which has no importance. It is often considered as a sign of losing control and influence.

Unfortunately, many nursing homes treat people in that manner, giving them no responsibilities and no chances to participate. On contrary, they often close old people off from the society with no chance to contribute. It is especially wrong because even in the late stage of the disease, there is a lot to learn from old people. Be excluding them, dementia becomes something distinct and uncommon to majority of the society while it is an important part of life of many people.

Despite their old age and some disabilities, old people as well as people with dementia have a lot to teach. Not only they know stories we do not and possess valuable experience and knowledge, but they also offer a unique opportunity to think about life and its values. Although people are slowly starting to be interested again in old traditions and crafts where elderly offer a strong link, nursing homes are usually not designed to be a place for such sharing

3 Christopher Alexander, Sara Ishikawa, and Murray Silverstein, A Pattern Language : Towns, Buildings, Construction (New York: Oxford University Press, 1977).

4 Feddersen, Lost in Space: Architecture and Dementia.

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2. Part two Reality

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Site visits Connection between the disease and architecture becomes even more evident after visiting several elderly homes. Experiencing the everyday life within, including patients, staff as well as visitors, reveals where the environment has the biggest impact. It helps reveal further aspects of how environment can shape the way people live in a building but also and mainly, it reveals very much of the problematic in general. It clearly shows how big the problem is and how many people struggling with dementia there are. I could see how much they have in common but also how much they differ. Their symptoms are often similar, but ways they deal with them are individual. Lives people have lived differ significantly as well as their personalities. Sadly, existing buildings often treat them generically despite the enormous determination and effort of carers.

During my visits, I could meet many nurses, social workers and even volunteers. Their job is difficult, demanding both physically and mentally and still, they are positive, caring and very strong. Every day, they do their job for a low salary, but with a very big amount of love. They are without any doubts more important than the building itself and yet, often the building makes their job harder by lacking storage space or by being too large. They are very often not just a caregiver, but also a friend.

They provide support at any time and very often they are the only company people have left. They guide patients through every day, without hesitations, many times all over again and the environment should make it as easy as possible.

Because many current buildings were not built to be a place for seniors, let alone seniors with dementia, they unfortunately do not do so. Formerly being mass accommodations for workers or students they preserve an impersonal, dull and unfamiliar atmosphere. Many of them are then deficient and unable to meet the needs of people with lowered or no

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cognition, with distorted spatial orientation, and with very frail health and mental condition in general caused by the disease. Poorly designed places are not only unsuitable for people with distorted perception, but also questioned by healthy people, creating an unpleasant working environment. Such buildings however offer a chance to learn from in order to avoid mistakes in the future.

Although places I had a chance to visit varied significantly in sizes, organization and also in the general approach, some crucial aspects of their built environment repeated more often than others. Following pages show some of the main aspects that were reappearing in many institutions and which prove to be problematic in relation to dementia. They also very well illustrate how building layout influences many other elements and how some other categories determine each other.

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Fig.6

Long corridors with no point of orientation Many buildings are organized in long corridors with private rooms alongside. In such long corridors one has to remember where he wants to go and how to get there which becomes difficult with dementia. With no visual contact with an end destination, corridors offer no chance to relate oneself to something in space and become therefore very confusing. They provide no stimulation and no natural activity to join. On contrary, they are discouraging and demotivating with sound echoed, with lack of daylight and with many doors leading to other peoples’ rooms.

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Fig.7

Dead ends Dead ends are known to be difficult for people with dementia.1 When they finally arrive at the end, it is difficult for them to understand why it is suddenly not possible to continue walking. Setting on a journey which has no end destination can be very confusing and frustrating.

1

Feddersen, Lost in Space: Architecture and Dementia.

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Fig.8

Storey Many buildings are designed in multiple floors to accommodate and help as many people in one place as possible. However, if one floor cannot work as an independent unit, it becomes hard for people to grasp it. Having to remember a complex way through a building during which there are many distracting elements seemed to be very difficult even for some people with early dementia that I talked to. Because of the difficulties, many people are discouraged from going and therefore lack benefits of various activities organized in different parts of the building. It needs human power and help of carers to get people to places of interests if these are not at reach and comfortably found.

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Fig.9

Abrupt changes Very often there is an abrupt difference between the private space and the public one. Right behind the door of a room, there is a public space mostly in form of a long corridor. That leads either to a common space or represents a common space itself. There is commonly no transition or a semi-private space to adjust to the new amount of people and level of activity. Moreover, the public space that people step into is usually quite featureless, lacking any kind of stimulation. Not being inviting, it makes people discouraged and apathetic.

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Fig.10

Privacy traded for solitude Private rooms offer a great chance for personalization. They preserve people’s privacy, their dignity and an atmosphere of how people used to live for most of their lives.

However, regarding old people’s common fear to engage in new, unknown activities, people in private rooms very often feel demotivated to leave the room without assistance. Especially with dementia, people may be afraid of failure and embarrassment, and they are very often inclined to stay safely in their rooms. This urge tends to be even stronger if the outside environment is confusing and complicated. Staying inside however leads to solitude which was mentioned as the main negative factor by all the people I had a chance to talk to during my visits.

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Fig.11

To never be alone On contrary, some care institutions I could see are designed to accommodate two or more people in one room. Living with others seriously questions dignity, individuality and privacy of each person and causes many troubles. There is no place to be alone and no place to spend time with the family or friends alone.

Having constantly somebody around can be very frustrating even for a healthy person and the more it can be frustrating for a person with dementia who have no means to change the situation.

Certain level of sharing however seems beneficial. Talking to various nurses revealed that when living in two, people often help each other and keep each other busy. In two it becomes easier to take courage and initiate action. Mutual interaction stimulates the brain and is therefore a welcome source of activity.

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Fig.12

Unclear definition of spaces Often there are spaces with no clear purpose. It can be a corridor serving as a substitute for a living room or spaces combining different functions together. Such a setting is neither familiar nor pleasant and it can be uncomfortable for people with dementia but also for their relatives who come to visit. Although there are usually elements trying to evoke a recognizable living room like ambiance, not knowing what to do increases the restlessness of residents and uneasiness of their families.

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Fig.13

Finding a way back Returning back home after a demanding day is a soothing feeling for every person. Therefore having troubles finding it can be extremely frustrating. In many elderly homes, door to a person’s room are marked with numbers. Such differentiation is however only relevant to people in the early stage of dementia who usually form a minority in elderly homes. Most of the patients come in the moderate or severe phase when reading and understanding of the written text is nearly impossible. For them it then becomes difficult to find a way back unless there is a nurse or some other significant feature that would help them.

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Fig.14

Barriers Majority of buildings in general are based on commonly known barriers taken for granted; barriers that are visible and reasonably explainable – walls, ceilings, floors or furniture. They can however be questioned by people with dementias, because in later stages of the disease people are no longer capable of such reasoning and analyzing. They do not cognitively think but instinctively rely upon senses and intuitive motoric and their space is then formed by entirely different barriers. Very common barrier, repeatedly appearing in elderly homes, is reflective floor material. Despite the fact that such floors are easy to clean and hygienic, they often resemble a liquid surface and can therefore be thought of as a dangerous obstacle.

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Fig.15

Balance Colours have a great power to distinguish important elements as well as to give a recognizable atmosphere to a certain space. However if not used with care, colours and materials can cause many troubles. Changes in floor color or in its height used for no significant reason make people hesitate. Because old people’s mobility is fragile in many cases, even a small change in height level can get people out of their balance or make them stumble.

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Fig.16

Colour Usually, walls are painted with expressive colors. Yellow, green or orange colour often dominate the space, especially in the corridors.

Unfortunately, despite the good intentions, final result is rather confusing, blurring everything together. When everything is already colored, it is hard to emphasize important elements or places. The overall contrast is lowered and orientation becomes more difficult as nothing stands out.

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Fig.17

Nature Nature was many times described as a desired element and preferred as a view from window. Organization in floors however leads to the fact that besides ground floor, no other floor has access outside. Sometimes, elderly homes have balconies but there is no easy way to reach a garden. Very often, people are therefore deprived of this priceless source of relaxation.

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Fig.18

Nothing to help with Lack of possibilities to engage in familiar, stimulating activities not only cuts short on stimulation but also prevents people from feeling engaged and needed. Without having a possibility to participate, people can never feel like at home. If the space does not provide opportunities for daily activities or cues for participation, people are only left with wandering. There are very few spaces where people can keep up with their habits and routines and therefore they are often detached from their normal everyday lives.

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Fig.19

Autonomy People with dementia often have very few chances to decide about their environment and about the way they live. Although it is impossible for safety reasons to give people complete freedom, certain level of autonomy is welcome as it makes people feel independent.

Besides deciding about their daily routines, there are many activities that people with dementia can help with. Unfortunately, in many cases they have very few opportunities to do so. Meals are usually prepared and brought to them. Plates are then also washed somewhere else. Laundry is washed and dried outside of people’s reach and the same happens with many other things. As a result people are detached from these routines and spaces where these take place.

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Fig.20

Size There are usually many opportunities to interact with others as there are many people in the nursing homes. With those numbers it however often has a negative effect. With only a few chances to be alone, people can quickly become frustrated by the amount of other people. For example, in canteens, many people gather at the same time. Lots of them need assistance with eating and may might feel ashamed for that. With so many people in one big space, it quickly becomes a loud, crowded, and stressful place. People can get anxious and many of them try to leave. Without a chance to divide the space into smaller places, the noise and frustration level spirals up.

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3. Part three Design patterns

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Obviously, there still is only little known about what kind of environment positively influences people with dementia and how environments could be improved. Dementia in general is still not entirely understood which makes it even more difficult to apply some rules on designs. However, every step towards a better understanding is important.

Spending time with people with dementia is bittersweet. It is sad on one hand but at the same time it has the power to show us what people hold on to and therefore what matters. Because dementia, as sad and difficult it is, has the power to strip us, humans, from all our roles, statuses and expectations, it can clearly show what truly matters in life as well as in space. Learning from the disease brings us back to basic qualities we all share as human beings and which are equally beneficial to all of us.

Talking to people about buildings and about their life within them very often slipped to talking about food they are served, nurses and their help or families and frequency of their visits. We often arrived to talking about what they do or what they would like to do but cannot. It was a great lesson to learn about architecture because it shows that it is not space that matters in the first place. It is not space that people remember the most. On contrary, it is the people within, the time they share and things they do together.

Architecture can however help enhance these moments by providing suitable and pleasant spaces for them to happen. It can help people meet by creating less confusing environments, it can help them engage in activities by making them visible and accessible. Although they sometimes remain apathetic, when given attention or stimulation people with dementia cheer up. They enjoy an evening sun as much as most other people. Following list of patterns is therefore applicable to any building although derived and mainly aimed at buildings for people with dementia.

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Fig.21

Safety Loosing many abilities, certainties and trust in themselves, people with dementia need a strong and solid support from their families, caregivers but also from the environment. Such a space should provide sense of safety and security at any moment. That contributes to greater self-assurance and a better quality of life.1 Only if a person feels secure in a place, he or she can freely do what they really enjoy. By compensating for defects caused by dementia, architecture can create a pleasant place to live, eliminate unnecessary stress and enhance the confidence of people. There are many ways environment can contribute to this sense of security which go far beyond using railings and being wheelchair accessible. Some of them are described further.

1

Feddersen, Lost in Space: Architecture and Dementia.

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Fig.22

Non-institutional character Architecture has a power to create link between presence and past.

By being recognizable even in later stages of dementia, it can provide a sense of familiarity and normality. In such case, people can find familiar aspects of their living environment and the ambiance of how they lived for much of their lives. Architecture can help create this sense of normality to allow people relate themselves to it and accommodate their everyday routines and habits. Space allowing familiar actions helps people feel at home and many design guidelines therefore call for a home-like, personalized atmosphere.

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Fig.23

Readability of the environment With dementia, both cognitive and behavioral ability to reach spatial destinations is significantly lowered. Such loss of orientation in space can be a horrifying experience and therefore the building should offer a solid support instead of being an obstacle. Straight layouts of circulations, no dead ends and as little changes in direction as possible are proving to be beneficial. Too many options in form of too many doors or too many decorations can cause confusion and loss of attention. On contrary, space with a clear composition which is easy to overlook reduces stress from not knowing where to go.

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Fig.24

Compact building layout Small building or small independent units within one building eliminate the need to remember directions. When everything is at reach and preferably also visible, people can react and decide at a moment without having to memorize and find their way. Compact layouts with short distances offer clear overview which is beneficial both to people with dementia as well as to their care givers. Resulting elimination of corridors and dead ends contributes to the overall easiness.

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Fig.25

Visual contact Having visual contact with main points of the building reduces stress from having to search for a particular place. Seeing the possibilities eliminates the cognitive, decision making process.

Once a person has eye contact with a destination, he or she does not have to seek for it anymore. Opening spaces one to another for better visual connections also allows sounds and smells to spread. These are valuable cues for people with dementia, evoking feelings and memories and making it easier to arrive to a desired destination.

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Fig.26

Sensory stimulation When due to the disease, cognitive faculties are declined or lost, what remains are direct sensations. Because they are processed by a part of brain which remains intact the latest, sensations have the power to trigger memories and emotions till very long. Sensory stimulation brings relaxation even at a late stage of dementia and architecture possesses qualities and means to achieve such experience. It is important that a building itself is a rich source of diverse sensory experiences ranging from materials and atmospheres to activities. Providing stimulation which is natural, coming from everyday activities makes people stimulated in a pleasant and familiar way.

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Fig.27

Dignity When there is need for other people helping with private, daily activities such as getting dressed, having a shower or using a toilet, there is very little dignity left. Very often, personal pride is scarified for the sake of safety and functionality. When already so many abilities, skills and achievements one can be proud of are slipping away, preserving as much as possible of what is left of the person’s self-respect is important.

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Fig.28

Privacy Having therefore a personal, safe space, with own belongings and familiar surroundings is important. For people with dementia their room becomes a whole world and the only reminder of how the person used to live. With their private space, they always have a space to return to, space which resembles home and recalls memories.

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Fig.29

Social interaction Need of human contact is very important for every person. Although with dementia interest in other people gets significantly lowered, interaction with others is a way to keep challenged and involved. Mutual communication recedes with progression of the disease, but there are means to enhance it. Accommodating people in small groups in which they have better chance to remember one another helps feel more relaxed. Arrangement of rooms and furniture can help and guide people to a certain behaviour and so too it can accommodate an easy interaction.

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Fig.30

Zoning It is important to offer different levels of privacy so that everybody can find where he or she feels best. If there are places to be alone, to be with others, places to just watch the others or to be with a family, the whole place becomes a rich pallet of possible experiences.

Alternating levels of privacy together with semi-public and public spaces creates different environments for different kinds of social activities and therefore everybody can find something suitable.

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Fig.31

Transitions Creating transitions between different spaces and levels of privacy gives people the time to settle and adjust to the change. Small in-between spaces can link places with different functions, noise and activity levels. Such gradual flow between spaces makes the whole building less rushed and more soothing. It gives it peace which comes back to all people inside.

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Fig.32

Subtle cues Differentiation of spaces for people with dementia can be marked by various means. Barriers that are less obtrusive than a physical wall such as changes of materials, colors, columns, ceiling heights or levels of light, allow for smooth orientation within a building.

Besides signings and pictures, these are more natural, subtle cues which can be used to guide people through the space. Creating various patterns of light and dark spaces enhances people’s movements and so does changing heights of ceilings. Transitioning from a lower space to a higher, brighter one is accompanied by curiosity and therefore it can help people initiate their journey. Vice versa, retreating to a more enclosed space can be enhanced by lowering the ceiling.

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Fig.33

Comprehension Clear distinction of spaces and mainly of their functions gives people comprehensive indications of what to do and how to behave.

Basic spaces such as kitchen, dining area or a living room are inscribed deep in people’s memories and create a familiar environment. Unlike „day rooms“, „therapy rooms“ or corridors, these core spaces indicate well what they are for. Knowing what to do, feeling relaxed and calm is equally beneficial to people with dementia as well as to their carers and visitors.

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Fig.34

Flexibility Environments of elderly homes are surprisingly dynamic. As a natural part of their ever changing nature, people die and are exchanged by new ones regularly. Moreover, the disease progress with different speed with each person and every person deals with it his or her own way. In each stage, people have different needs and their life sphere gets smaller. Meanwhile, there can be couples formed and new friendships discovered. Families come and spend time in the space as well as therapist and sometimes animals. Buildings should therefore be able to adapt to all these situations by being flexible and vivid.

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Fig.35

Nature One can never have enough of nature. Nature changes during seasons, even during the daytime and as such it is a natural indicator of time. It serves as a reference and helps position oneself in time and space. For every human being as well as for people with dementia, nature provides unique source of relaxation and stimulation. Access to nature relieves and freshens up, it provides opportunities for walks, gardening as well as for meditation and contemplation.

Well-structured and designed outdoor space which leaves space for all of these activities and others can enhance the quality of life to a great extent. Equally important is bringing nature inside the building in form of plants or animals.

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Fig.36

Lightning In old age, certain level of impairment, such as mobility difficulties or problems with hearing and vision, are natural. To help compensate for the latter, amount of light has to be higher than normal.

Ideally, majority of light comes from a natural source because sunshine is not only pleasant but also very beneficial. Furthermore, creating alternating areas of light and dark within the building can enhance and guide people’s movements as well as can an enhanced strategy of day and night light rhythms improve sleeping disorders.

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Fig.37

Colour Use of colour can play a vital role in strengthening an atmosphere of security and well-being. Use of typical local materials and colours helps link the place to its regional context and therefore makes it easier to dwell in and relate oneself to it. Colour however has to be applied in harmony with other forms, materials, textures and surfaces to create a balanced, understandable composition. Colour can enhance contrast between significant elements or softly mark a different zone or area but it should always be used with care.

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Fig.38

Materials Use of materials which are not only pleasant to look at but also tactile and stimulating contributes to the overall richness of the environment. Without being offensive, natural, well-known materials are easy to understand for people with dementia. In balance with furniture and colors, materials can help accentuate and distinguish certain spaces. Unlike materials that are reflective, slippery or difficult to clean, well chosen materials can increase the overall experience of both people with dementia as well as their carers.

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Fig.39

Autonomy In well-designed settings, people with dementia can still maintain their independence. Within safe boundaries, it is possible to still use their remaining skills and give them thus a desired piece of autonomy. The environment doesn’t have to be deficit-oriented, preventing from mistakes and damages by not allowing any actions. It can, on contrary, enhance peoples’ remaining skills and inclinations. Providing spaces for activities that people can still do gives them chances to feel needed and independent.

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Fig.40

Sense of belongings If there are activities to join and help with, people will naturally feel more at ease and part of the whole. Feeling responsible, needed and valuable in your surroundings is one of the fundamental conditions to feel comfortable and at home. Environment can prepare ground for such therapeutic concept where people are part of daily activities and have options to join or not.

Activities of everyday nature are familiar to people and as such they offer a chance to keep up with what they had been doing their whole life. Cooking, grooming, watering plants and many other activities that people can engage in give them a sense of responsibility and belongings.

Moreover such activities provide natural source of many stimulation.

They are both a therapy as well as part of a normal life. Creating spaces for these activities and their cues gives life to the building as well as to the people.

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Fig.41

Functionality Enough storage space, short distances or clear overview all contribute to easiness of the care home. Well though of building which considers all what is happening inside can provide pleasant living and working environment. Smooth work of nurses saves their time and energy which can then be given to people with dementia.

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4. Part four Design proposal

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With all these patterns and guidelines in mind, I set out to come up with a design which would merge them together in a harmonious environment.

The resulting design of a care center is a conjunction of desired qualities, relations and atmospheres. Starting with requirements on the experience of a person with dementia, the building naturally started developing itself from the innermost place. Conventional approach of starting from a bigger scale proved to be inappropriate and the only natural way to think about the building was the one of a perspective of a person inside.

Thinking about everyday routines and challenges I slowly developed the plan from a small scale of private rooms to shared and outside spaces. Resulting design is therefore a cluster of spaces, buildings and variety of outside spaces their articulation creates. The entrance as well as the most public functions are located in the center of this configuration and the further a person goes, the more private the spaces become.

Each building is a small assembly of spaces with different levels of privacy and activity. Each is naturally leading to another enhanced by cues of transition. Permanently accommodating eight people with dementia and their caregivers, each building also serves partially as a day care center. During the day, the most public part of every building welcomes a few temporary inhabitants. It allows people with dementia who still live at home but need some assistance to come, enjoy the activities and get used to the space. They are welcome to help and participate in daily life withing the building so that later if they need to move in, the change is not abrupt.

Following description will naturally follow the process of designing, starting from the innermost space and developing into the whole building.

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to be oneself to be together

trouble shared is a trouble halved

to reconcile

Journey The whole building is designed as a sequence of spaces with different qualities and atmospheres. It develops from a very personal, private space to a shared one with high level of natural, familiar activity. Along the way, there are different in-between spaces that try to enhance the journey and invite a person to make the next step.

Diversity of spaces accommodates different feelings and actions. Every person can therefore find something for him or herself.

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to be oneself to be together

trouble shared is a trouble halved

to reconcile

To be oneself Private room is the smallest, yet one of the most important part of the whole building. It is a space of identity and a constant reminder of who a person is. It is a space to retreat when everything becomes difficult, it is a space to remember.

Its dimensions make sure that the room is big enough for personal furniture while still small enough to create safe and enclosed atmosphere. There is enough space around the bed for nurses to help the person without hassle, preserving thus as much of his or her dignity as possible. Direct access to a terrace makes it easy to take the bed outside to sunshine and fresh breeze.

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Private room variation

Fig. 42

Individual Obviously, such a space to retreat and remind of who you are is different for every single person. Dementia does not make differences and affects people with all sorts of backgrounds. With different family and culture backgrounds, different prosperity, mental and physical health, life experience, values and education. With different personalities, sexual orientation, attitudes and many other aspects that effect and shape our everyday life.

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Fig. 42

Diversity As a result, each person fells secure and familiar in a different environment. Different items, materials and settings are significant for each person as they help recall different memories.

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Personalization Private rooms are thus designed in a way to allow personalization.

Within the space, different pieces of furniture and personal belongings can be brought and arranged in multiple ways. That way everyone can accommodate a piece of his or her previous life and preserve thus as much identity as possible.

Private room variatio

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Private room views Each room has a direct access outside to a small terrace. Constant visual contact with the outside nature provides a sense of time throughout days and years.

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to be oneself to be together

trouble shared is a trouble halved

to reconcile

Trouble shared is a trouble halved In between every two personal spaces, there is one which makes people bump into each other. Getting annoyed one by the other, helping each other, sharing troubles as well as laughter belongs to life and it shouldn’t be neglected in a nursing home. Having to find a compromise in daily routines or just complaining about the disease, these are all valid social activities which stimulate the brain and create a vivid, daily atmosphere. Through the shared space, people can share much more than that while still having their own personal space to retreat.

The shared living room provides space for families and visitors to spend time together in a familiar environment, perhaps to even stay over night.

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Each room has its own little terrace, easily accessible with a bed. That makes it easier for nurses to help immobile residents enjoy benefits of fresh air without having to transport the bed throughout the whole building.

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Enclosed transition zone is created at each entrance. It offers views to the rest of the building while still providing safety and support of one’s own environment.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Step by step

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Entrance alcove The transitional, semi private place created around the entrance offers enough space to accommodate significant objects. Thanks to that it is easier to recognize one’s room when returning.

By clustering two private rooms together, number of entrance door to choose from on a way back is reduced which makes it even easier to come back home.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Entrance alcoves

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Living units are multiplied in a semicircle, forming thus the private part of the whole building. The entrance spaces allow for customization and personalization resulting in rich variety of small alcoves. They protect the person on his or her way forward by creating a piece of personal territory in the shared space. Instead of eight separate entrances, there are four in total that one has to distinguish.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Nature as a constant reference of time

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Central courtyard around which the rooms entwine not only brings daylight into the building but it also provides an important reference of time. It creates a link with seasons and enhances the day and night rhythms. It invites people on their way from a room as it triggers their curiosity. Nature in the middle of the building brings valuable stimulation which is visible and accessible at any time.

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Enfilade With its everlasting presence, the courtyard helps people initiate their way from private space to the open, shared one. It catches their attention and guides them along the way.

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to be oneself to be together

trouble shared is a trouble halved

to reconcile

To reconcile In every period of life and under any circumstances, it is important to stop for a while. In an elderly home it is even more important to take a breath. It is important in order to forget about the disease for a minute or to calm down before visiting a loved one with dementia.

Space designed right next to the courtyard, enclosed by private rooms and two bathrooms, offers opportunities for all of that. It offers space to linger, to walk around and to slow down. The presence of nature in the middle floods the space with light and sounds, and creates thus a space without a function but with an important purpose.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

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Fig. 43

Fig. 44

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Memories Quality and atmosphere of that particular space comes from pictorial references.

While visiting different elderly homes, I had a chance to talk to a few people with dementia. To initiate the conversation as well as to trigger some responses I brought different pictures of different spaces. Each picture evoked something else in every person but there were two pictures which received many positive comments from all the people.

All of them reported that the spaces shown in the photos reminded them of their childhood. They reminded them of times when they were happy, safe and relaxed. Both spaces were usually associated with visiting a grandmother’s house or a summer cottage.

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Vault Reinterpreting some aspects of the mentioned environments vaulted space with large openings was created in order to achieve a safe and relaxing atmosphere. It is a space to set the mind free, to take a break from whatever is happening.

It can be opened to the courtyard to create one open space flooded with fresh air.

Reflections of stained glass create a warm ambiance and invite all people to fantasize.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODE

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EDUCATIONAL PRODUCT

ESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Roofscape Variety of all the different spaces and activities they allow is enhanced by modulation of roofs. Not only their height changes accordingly to levels of privacy but they are also shaped differently to reinforce the experience of each space. Vaulted roofs in spaces around a courtyard provide more openness and more freedom. These two rooms therefore offer enough space for frequent wandering while giving many triggers for relaxation and contemplation.

PRODUCED BY AN AUTODESK

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to be oneself to be together

trouble shared is a trouble halved

to reconcile

To be together Divided in zones according to activities, the most public space of the unit offers chances to engage in different activities. It gives opportunities for familiar actions people can do together.

By being accessible, it allows people to participate, be responsible and feel part of the home. Cooking, dining as well as dish washing become normal parts of everyday as well as sources of well known stimulations.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Functionality

Homely space with no storage capacities and no service rooms is of no value and therefore the unit is completed by service and storage rooms. They are in a short walking distance for the nurses, hidden from a direct view of residents.

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to be oneself

trouble shared is a trouble halved

to reconcile

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to be oneself

trouble shared is a trouble halved

to reconcile

Sound and scent scape Diversity of sound and scent sources modulates various atmospheres throughout the unit and offer different experience in each part of the building. There are places with high intensity of stimulation while at the same time there are many spots where people can just observe and listen to what is happening from a comfortable distance. Altogether, the unit is a sequence of spaces with different levels of intensities and activities.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTOD

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DUCATIONAL PRODUCT

DESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Ceiling line Various qualities each space possesses are enhanced by heights and shapes of roofs. The whole building develops hand in hand with a principle of the more private, the lower the roof and vice versa. These height differences provide subtle cues for people to walk through the building as with

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- 100 SK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Heart of the building In the center of a public area, enclosed shelter with a fire place can be found. It is a space seen from everywhere, a landmark always to be found. It offers safe overview of the rest of the building while still being protected by its intimate atmosphere. Its lowered ceiling gives it a more enclosed character while it creates a quiet outside space for nurses and families to retreat.

PRODUCED BY AN AUTOD

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Central shelter Even from the very heart of the building, from below the lowered ceiling, the courtyard is visible.

It can be watched from the security of the central space or walked around, leading people back into their rooms.

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to reconcile to be a familz

to remember

to feel welcome

to make it a home

Family Visiting a loved one with dementia can be very demanding. Often there are no activities to do together or no place to sit alone. This design tries to offer valuable spaces not only for people with dementia but also for their friends and relatives. There are spaces to join and help with daily routines as well as spaces to take a breath. Small private living rooms offer possibilities to stay over night or to just have a nice family dinner.

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to make it work

to organize

to make it a home

to take a breath

to work without obstacles

Nurses Taking care of people with dementia is an extremely difficult job. Often the nurses are not only a care giver but very often a friend. Making their work easier saves their energy and time for the people who need it the most. Therefore the building is rather small and compact, eliminating any long distances. It opens up and offers clear overviews. There are different storage spaces and practical details. Besides that, the building is also a source of pleasant spaces to retreat to and rest for a moment.

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View lines By being open, the building offers different view lines. Having a clear overview of the space is beneficial to people with dementia but also to the caring staff. Various enfilades and sceneries develop in different places of the building, making it a pleasant space to live in. By being visually stimulating, the building keeps alive without any unnecessary clutter.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Structure To subtly contribute to the overall readability of the environment, most walls are made of bricks. Remaining walls which divide a private zone from a public one are made of concrete, carrying all the vaulted roofs and their horizontal forces.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Courtyard Columns that support vaults give rhythm to the outside courtyard as well as to the inside spaces next to it. The courtyard is an accessible, safe source of nature and endless stimulations. It can be merged with the interior by opening the windows and create thus one big space full of fresh air.

Such courtyard in the middle is also a relevant factor in a process of natural cross ventilation.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Subtle clarity To give the building an order which could then be subtly present in the space, there is an underlyng grid. Although it is not always strictly followed, it gives the spaces clarity and coherency. It makes the building understandable as everything comes into its place.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Cluster Two independent units together with two flats for independent elderly and office spaces wind around an entrance courtyard. This has a city-like atmosphere and welcomes all the visitors that come. It is a safe place for residents to enjoy a walk outside or to just sit on the bench and watch the lively atmosphere.

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PRODUCED BY AN AUTODESK EDUCATIONAL PRODU

DUCED BY AN AUTODESK EDUCATIONAL PRODUCT

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UCT

PRODUCED BY AN AUTODESK EDUCATIONAL PRODUCT

Gardens Articulation of units further forms different outside spaces which open up in steps from an enclosed garden to an open one. From every dining area there is an access outside which has a character of a private garden or a terrace. As the two buildings depart, bigger and open park like garden takes over.

PR

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Location It is important to say that this design proposal serves as a research tool. It is a building designed from inwards, resulting in a cluster of different inside and outside spaces. As such it was independent on a particular site and would have to be adjusted to each location.

As an example of its organization on a site, place in Prague was chosen.

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StarĂ˝ Prosek used to be a village near Prague but as the city started growing, this place became part of it. Due to its history it still preserves a village like character and offers many beautiful spots for walks which are in a short walking distance.

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Life around Because people with dementia cannot freely visit the city, the city has to come to them. At the furthest edge of the site, there is a natural viewing point over the whole city of Prague and a way to it leads either through a ring around or directly through the care center, passing by a restaurant and small workshops.

In-between the care buildings, various spaces come to life. People from the neighbourhood are welcome to continue working on their existing gardens while passing by an entrance. Restaurant with a refreshing beer, cakes baked by our grandmas as well as different kinds of workshops and happenings mediate an informal meeting between generations. It serves as a meeting place for people taking care of their loved ones as well as for people who are interested. Relatives and friends are allowed to continue further inside, progressing from the center public life towards the more private, outer spaces.

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Chance to learn By opening the care center to people from the neighborhood as well as to people from the whole city, dementia can be understood and accepted better. Prejudices which now exist can be dissolved and stigma placed on the disease lowered.

Dementia, although sad, offers a great chance to reflect upon what we consider relevant and upon life in general. Allowing people to encounter this lesson could be a relevant experience. Especially in today’s time where we rush to fulfill ours and other peoples’ expectation to often neglect the simple but important aspects of our lives.

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Acknowledgments One page is hardly enough to express my gratitude to each and every person who has inspired or helped me with this graduation. During the whole year I have met many people who I truly admire for who they are and for what they do. I feel honored to have had a chance to meet people who work by different means to make life of people with dementia better. Each person I talked to, no matter if it was a nurse, designer, director or a caregiver, was an important piece of this whole puzzle. Each one contributed with their insights and knowledge to the overall picture which I could have never made on my own.

Especially, I would like to express my gratitude and admiration to people with dementia who I talked to for sharing their intimate and personal feelings, joys and fears with me. I am humble and truly appreciate their openness and strength with which they live every day.

Meeting people with dementia and learning from them would however not have been possible without the support of directors and managers of elderly homes I could visit. Their openness to my research and the freedom I had has helped significantly to gain important knowledge. Seeing so many people apart from my grandmother struggle with the disease has been a strong learning moment. I am grateful to have had this opportunity because it has opened my eyes not only to how many people there are. It has also opened my eyes to how demanding the work of all nurses and carers is and how strong they need to be both physically and mentally. Thanks to having a chance to peak into the life within a nursing home, my beliefs and intentions could grow stronger.

My deep gratitude belongs also to all my mentors for their encouragements and patience. Theo van der Voordt for always being both kind and critical.

Robert Nottrot for his endless humanness and guidance in the design part and last but not least Ype Cuperus for helping me make the design practicable. I feel very honored to have met all three of them and learn from their knowledge.

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Very strong base behind this report is my family which although scattered around the world has been a great, unconditioned support. Together with friends and their ways to laugh out of troubles it has been a priceless source of encouragements.

Last and special thank you is devoted to my dearest Jirka for always being there and for reminding me constantly that the world keeps spinning.

AneĹžka ProkopovĂĄ Delft, 2015

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Full list of Bibliography (WHO), World Health Organization. “International Classification of Functioning, Disability and Health : Icf.” edited by World Health Organization. Geneva, 2011.

Alessia Cadamuro, Valentijn Visch. “‘What Remains?’: A Persuasive Story Telling Game.” In Games for Health; Proceedings of the 3rd European Conference on Gaming and Playful Interaction in Health Care, 2013.

Alexander, Christopher, Sara Ishikawa, and Murray Silverstein. A Pattern Language : Towns, Buildings, Construction [in English]. New York: Oxford University Press, 1977.

Anne M. Lipton, Cindy D. Marshall. The Common Sense Guide to Dementia for Clinicians and Caregivers. New York, NY: Springer Science+Business Media, 2013.

Bartlett, R. “Modifying the Diary Interview Method to Research the Lives of People with Dementia.” [In eng]. Qual Health Res 22, no. 12 (Dec 2012): 1717-26.

Benson, Sue. “The Use of Colour in Dementia Specific Design “. Journal of Dementia care July/ August 2002 (2002): 4.

Benyamin Schwarz, Professor Ruth Brent Aging, Autonomy, and Architecture: Advances in Assisted Living. The Johns Hopkins University Press, 1999.

Berg, Bruce L. Qualitative Research Methods for the Social Sciences: Fourth Edition. edited by Sarah L. Kelbaugh California State University: Allyn & Bacon, 2001.

Blom, Ilse. “Amarant: Encouraging the Application of Humour between Informal Caregivers and People with Dementia.” Delft University of Technology, 2014.

Boer-Lootens, Marieke de. “Wonen Voor Ouderen Met Dementie.” Graduation report, TU Delft, 2014.

Carpiano, R. M. “Come Take a Walk with Me: The “Go-Along” Interview as a Novel Method for Studying the Implications of Place for Health and Well-Being.” [In eng]. Health Place 15, no. 1 (Mar 2009): 263-72.

Central, Dementia Care. “Stages of Dementia.” About Dementia. http://www.dementiacarecentral.com/aboutdementia/facts/stages.

Cohen-Mansfield, J., and P. Werner. “The Effects of an Enhanced Environment on Nursing Home Residents Who Pace.” [In eng]. Gerontologist 38, no. 2 (Apr 1998): 199-208.

Cohen, Uriel. Contemporary Environments for People with Dementia. Baltimore: Johns Hopkins University Press, 1993.

Cotelli, Maria, Rosa Manenti, and Orazio Zanetti. “Reminiscence Therapy in Dementia: A Review.” Maturitas 72, no. 3 (7// 2012): 203-05.

Danspaleis, Het. “Het Danspaleis - Bij Ons Thuis.” http://www.hetdanspaleis.com/.

Day, K., D. Carreon, and C. Stump. “The Therapeutic Design of Environments for People with Dementia: A Review of the Empirical Research.” [In eng]. Gerontologist 40, no. 4 (Aug 2000): 397-416. de Medeiros, Kate, Erica Beall, Stephen Vozzella, and Jason Brandt. “Television Viewing and People with Dementia Living in Long-Term Care: A Pilot Study.” Journal of Applied Gerontology 28, no. 5 (October 1, 2009 2009): 638-48.

Dementia, Design and Technology : Time to Get Involved. Assistive Technology Research Series. edited by Britt Östlund Päivi Topo. Vol. 24,2009.

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Dijck, Malou van. “Feeling at Home.” Design Academy in Eindhoven: Studio Op Poten, 2014.

Edwards, N. E., A. M. Beck, and E. Lim. “Influence of Aquariums on Resident Behavior and Staff Satisfaction in Dementia Units.” [In eng]. West J Nurs Res 36, no. 10 (Nov 2014): 1309-22.

Enable, United Nations. “Factsheet on Persons with Disabilities.” In Development and human rights for all, edited by Secretariat for the Convention on the Rights of Persons with Disabilities: United Nations Secretariat.

Europe, Alzheimer. “The Ethical Issues Linked to the Perceptions and Portrayal of Dementia and People with Dementia.” edited by Alzheimer Europe’s 2013 Work Plan: Alzheimer Europe, 2013.

Feddersen, Eckhard. Lost in Space: Architecture and Dementia. edited by Insa Lüdtke German National Library: Birkhauser Verlag, 2014.

Foucault, Michel. “Des Espace Autres.” Architecture /Mouvement/ Continuité journal, 1967.

Foundation, Disabled Living. “Losing Independence Is a Bigger Ageing Worry Than Dying.” http://www.dlf.org.uk/.

Genoe, Rebecca M., and Sherry L. Dupuis. “Picturing Leisure: Using Photovoice to Understand the Experience of Leisure and Dementia.” [In English]. Qualitative Report 18 (2013 2013): 21.

Heylighen, Ann. “Challenging Prevailing Ways of Understanding and Designing Space.”

In Spatial Cognition for Architectural Design SCAD 2011 Symposium edited by Hölscher C. Bhatt M., Shipley T. , 23-40. Bremen/Freiburg: e Transregional Collaborative Research Center SFB/TR 8 Spatial Cognition Universität Bremen / Universität Freiburg., 2012.

International, Alzheimer’s Disease. “Dementia Statistics/ Alzheimer’s Disease International.” http://www.alz.co.uk/research/statistics.

Khatri, Shabina S. “Shelby Twp. Center Uses Senses to Fight Dementia.” Knight Ridder Tribune Business News, 2006 Mar 09 2006, 1.

Label, Dr. Lorne. “Dementia Facts and Statistics.” http://www.disabled-world.com/ health/aging/dementia/statistics.php.

Levanne R. Hendrix, MSN, RN, GNP, PhD. “Health and Health Care for American Indian and Alaska Native Elders.” San Francisco: University of California.

Manson, Lori L. Jervis and Spero M. “American Indians/Alaska Natives and Dementia.”

Alzheimer Disease and Associated Disorders 16, no. 2 (2002): 7.

Margaret P. Calkins, M. Arch. . Design for Dementia; Planning Environments for the Elderly and the Confused. Maryland: National Health Publishing, 1988.

Marianne Smith, Kathleen Buckwalter. “Behaviors Associated with Dementia.” AJN, American Journal of Nursing 105, no. No.7 (July 2005).

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Marie Blažková, Jiří Košťál. “Smíření - Občanské Sdružení Pro Výstavbu Hospice Pardubického Kraje.”

Mario Garrett, Ph.D. “Fear of Dementia.” online article, Psychology Today: Here to Help (2013). http://www.psychologytoday.com/blog/iage/201305/fear-dementia.

Marquardt, G., and P. Schmieg. “Dementia-Friendly Architecture: Environments That Facilitate Wayfinding in Nursing Homes.” [In eng]. Am J Alzheimers Dis Other Demen 24, no. 4 (Aug-Sep 2009): 333-40.

Network, Forensic. “Looking after Yourself: Soothing the Senses.” edited by Forensic Mental Health Services Managed Care Network. http://www.forensicnetwork. scot.nhs.uk/ office, alzheimer-architecture<. “Alzheimer-Architecture<.” http://alzheimer-architecture.nl/.

Päivi Topo, Britt Östlund. Dementia, Design and Technology : Time to Get Involved. Assistive Technology Research Series. edited by Britt Östlund Päivi Topo. Vol. 24,2009.

Půlpán, David. “V Chrudimi Je Zvláštní Hospic. Stav Umírajících Se Tam Lepší.” iDnes. cz (2010). http://zpravy.idnes.cz/v-chrudimi-je-zvlastni-hospic-stav-umirajicich-se-tam-lepsi-p44-/domaci.aspx?c=A100623_1406518_domaci_taj.

Quince, Chris. “Demography - Alzheimer’s Society.” http://www.alzheimers.org.uk/ site/scripts/documents_info.php?documentID=412.

Sarah Baillon, Erik van Diepen & Richard Prettyman. “Multi-Sensory Therapy in Psychiatric Care.” Advances in Psychiatric Treatment 8 (2002): 8.

Snow, Teepa. Making Visits Valuable and Positive. Florida 2012.

Stanley B. Klein, Shaun Nichols. “Memory and the Sense of Personal Identity.” University of California, University of Arizona.

Swaab, D. F. “Alzheimer’s Disease.” In We Are Our Brains: A Neurobiography of the Brain, from the Womb to Alzheimer’s. United States: Spiegel & Grau, 2014. televize, Česká. “Iva Holmerová, Primářka, Gerontologické Centrum.” In Civilizace, edited by Hyde Park: Česká televize, 2015.

Topo, Päivi. “Technology Studies to Meet the Needs of People with Dementia and Their Caregivers: A Literature Review.” Journal of Applied Gerontology 28, no.

1 (2009). van Hoof, J., H. S. Kort, H. van Waarde, and M. M. Blom. “Environmental Interventions and the Design of Homes for Older Adults with Dementia: An Overview.” [In eng]. Am J Alzheimers Dis Other Demen 25, no. 3 (May 2010): 202-32.

Weisman, Uriel Cohen & Gerald D. Holding on to Home: Designing Environments for People with Dementia. The John Hopkins Series in Contemporary Medicine and Public Health. The John Hopkins University Press, 1991.

Wiersma, Elaine C. “Using Photovoice with People with Early-Stage Alzheimer’s Disease: A Discussion of Methodology.” Dementia (March 15, 2011 2011).

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List of figures Figure 1 own illustration Figure 2 Illustration by Brian Cronin, http://www.briancronin.com/ Figure 3 Illustration by Brian Cronin, http://www.briancronin.com/ Figure 4 Illustration by Elisabet Ericson, http://www.elisabetericson.com/ Figure 5 Unknown author Figure 6 Alzheimer centrum Průhonice, Praha, own illustration Figure 7 Alzheimer centrum Průhonice, Praha, own illustration Figure 8 Domov pro seniory Zahradní Město, http://www.dszm.cz/ Figure 9 Domov pro seniory Zahradní Město, own illustration Figure 10 Středisko sociálních služeb Městské části Praha 9, http://www.ssspraha9.cz/ Figure 11 Domov pro seniory U Kostelíčka, http://www.ssmpce.cz/index.php/dpsk Figure 12 Domov pro seniory U Kostelíčka, own illustration Figure 13 Alzheimer centrum Průhonice, Praha, own illustration Figure 14 Domov pro seniory Zahradní Město, own illustration Figure 15 Alzheimer centrum Průhonice, Praha, own illustration Figure 16 Domov pro seniory Zahradní Město, own illustration Figure 17 Day care center in Delft, own illustration Figure 18 Středisko sociálních služeb Městské části Praha 9, own illustration Figure 19 Alzheimer centrum Průhonice, Praha, own illustration Figure 20 Domov pro seniory Zahradní Město, own illustration Figure 21 Unknown author Figure 22 Unknown author, https://www.etsy.com Figure 23 Lonely Houses: Sejkko’s Surreal Photos of Traditional Portuguese Homes, http://www.archdaily.com/ Figure 24 Tree house by Mount Fuji Architects Studio, http://www.dezeen.com/2010/08/03/tree-house-bymount-fuji-architects-studio/ Figure 25 Interiors/Atelier AM, http://aesthetically-thinking.blogspot.nl/2012/09/ma.html Figure 26 Unknown author Figure 27 Kate Forman, http://www.stylainterier.cz/ Figure 28 Trericket Mill Vegetarian Bed & Breakfast, http://www.trericket.co.uk/ Figure 29 Paul Lindsay Two Chairs – No Waiting, http://www.hopeandsons.co.nz/art-awards/ Figure 30 London bridge pedestrian alcove, http://www.london-architecture.info/LO-111.htm Figure 31 Lisa Michele Burns Photographer Figure 32 House Asama by Bow-Wow studio, https://www.japlusu.com/news/house-asama Figure 33 Grandma’s kitchen by Emmi-Kat Figure 34 Sainte Marie de La Tourette by Robert Davidov, http://davidov.com.au/media/22-blog-transitions Figure 35 Dandelion meadow, http://www.mrwallpaper.com/ Figure 36 Unknown author, http://pixcooler.com/

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Figure 37 Kirstie van Noort, https://www.flickr.com/photos/kirstievn/3778454680 Figure 38 Hliněná omítka se vzorem, http://www.claygar.cz/en/home-page Figure 39 Peeling potatoes, http://madamfelicia.org/ Figure 40 Hrabání listí, http://www.zahrada-centrum.cz/ Figure 41Multifunctional tables, https://andreeaonose.wordpress.com/2014/02/05/multifunctional-tables/ Figure 42 Alison Berman, Family portrait, http://alisonberman.com/ Figure 43 Chata Křížovice - Vysočina, http://www.chaty-chalupy-dds.cz/krizovice/ Figure 44 Hamousův statek ve Zbečně, http://www.s-detmi-na-pohodu.cz/cz-detail-646939-hamousuv-statekve-zbecne.html

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