Imagine if, without warning, you woke up tomorrow morning in an entirely different setting: an unfamiliar place, with strange tasks and routines that were totally foreign to you. Then imagine that you are not allowed to leave or interact with anyone outside of your environment. While it sounds jarring to most of us, this experience is the unfortunate reality for many older adults living with dementia who reside in congregate living settings throughout our country. The built environment can either empower people going through this kind of upheaval in their lives or it can be an impediment that makes the transition to a new living environment frustrating and frightening.
In the last few years, Perkins Eastman has done a considerable amount of research, development, and application with senior living organizations to explore how senior living communities can better support older adults living with dementia. Here are three broad themes that have emerged from that work.
1. Balance the specific and the general
Environments that truly empower older adults living with dementia are ones with the ability to respond to the specific and unique needs of the individual. Traditional approaches congregate dozens of people together in the same environment based on basic similarities: age, gender, daily schedule, etc. But a living room that you share with 31 other people can’t possibly respond to you as an individual. It can’t have your wedding photo up on the mantle or the afghan your mother knitted for you draped over your favorite chair. But what about a living room you share with six other people? Perkins Eastman’s findings show that a seven-person residence offers a scale that allows those living there to invest personally in their environment. This response isn’t limited to a small house model, either. Creating smaller, grouped spaces within a larger floor plan, such as utilizing a midrise building to accommodate 24 seven-person households over nine floors, is a way to achieve a similar environment without starting from scratch.
In addition to reducing the scale of the house architecturally, interior design is key to acknowledging the self-expressive needs of older adults living with dementia. Balancing the specific elements that allow each household to feel unique while maintaining a level of replication that provides a cost-efficient design to construct and maintain is a challenge. One strategy to address this is a “tiered” approach, where elements like trim, flooring, and appliances are replicated across all households. In the next tier, another set of elements such as furniture, paint colors, upholstery, and accessories are specific to each household in the community but distinctive across the whole development. The final tier of personalization comes from the residents themselves, as details are designed into the spaces that allow residents to add their own touch, such as alcoves and shelves to showcase personal photos and treasured items or an area where a resident can put a favorite armchair or writing desk.
2. Define “normal” regionally and culturally
A key tenet of easing the transition from home to a residential care setting is to maintain as many of the aspects as possible that made up the person’s normal life pre-move. As soon as a care provider puts this tenet into practice, however, a series of questions quickly emerge: Normal for whom? Normal for where? And normal for when?
At the earliest stages of planning a community, crucial decisions such as where to site the building, how to organize spaces, and what cultural and regional elements to incorporate must be addressed. This is important because one person’s sense of home can be vastly different from another’s. For example, in a rural or suburban environment, a series of small, one-story buildings is very normal, while a nine-story midrise with ground-floor retail would feel very out of place.
While this seems elementary, the senior living industry historically has struggled to implement this kind of thinking. Instead, the industry has spent a lot of time and energy perfecting the “big box” assisted living/memory support building as an archetypal approach to suburban senior housing. However, the residents of these places are coming from one or two-story houses with a few bedrooms and living and dining room spaces that they shared with a small group of family members. At a moment when they’re struggling to hold onto the most basic things, such as what to eat, when to wake, and how to spend free time, we’re asking them to wake up in an environment that bears little resemblance to the one they’ve known for the better part of their adult lives.
More nuanced, but perhaps also more crucial, is considering a person’s cultural experience. The food we eat, the music we listen to, when we like to get up in the morning, and how we like to spend our time are all key factors that determine the daily rhythms of our lives. However, these are also factors that get regulated and dictated by caregivers, laws, and family, among others, when an older adult moves into a residential care setting. Smaller-scale settings, like the small house model, begin to answer this question because residents are able to maintain more autonomy and connection to their pre-dementia life, but they don’t address it fully when it comes to who actually lives together in that house. Some operators are addressing this through “lifestyle groups,” in which residents are matched into houses based on daily rhythms and personal preferences. While this may not lead to a house of dementia residents who all enjoy the same sub-genre of classical music, it may help group residents who are all late sleepers within the same household. Technology provides the opportunity to take this idea to the next level. For example, algorithms in the vein of dating apps are used to find life partners, so why can’t we use the same techniques to match older adults with roommates who won’t be turning on the television at 6 a.m. when others are trying to sleep?
3. End the segregation of residents with dementia
When it comes to empowering older adults living with dementia, there’s an inescapable contradiction between our aspirations and the realities of the environments we create. In the United States, environments housing older adults living with dementia are classified for “institutional” use. There are many vestiges of this institutional archetype, most notably the mandate that exit doors are always locked (except in case of emergency) and residents are restricted from coming or going from the building. The industry has reverse engineered the process by taking highly regulated, institutional environments and trying to make them feel normal and residential instead of designing bespoke, individualized residential environments and then layering in necessary regulations.
The first step toward a built environment that invites the integration of people living with dementia with the larger community is creating opportunities for residential care environments that overlap and intersect with the public realm they inhabit—places called “dementia-friendly zones.” Utilizing smart sensors, wearable devices, discrete health monitoring, portable devices for caregivers, and other technology that exists today, the secure boundary of a community for people living with dementia no longer needs to correspond to the footprint of a physical building or fencing. Furthermore, by using these smart devices, what constitutes a secure boundary can be customized for each resident. For one resident, caregivers may need to be alerted through a monitoring app if they leave the building, but for another resident, caregivers may need to be alerted only if they leave the bounds of the park across the street.
This same level of customization also enables the boundary to adapt for the same resident as they progress through the disease. These types of interventions eliminate the “surplus safety” approach of applying the most restrictive condition to everyone. By challenging the idea that physically locking up older adults with dementia is the only way to keep everyone safe, we’re able to allow individuals with dementia much greater personal freedom and, ideally, happiness.
Achieving authentic living
These themes aren’t merely a refinement of the principles that have led to the dementia environments we have now. They also signal fundamental shifts in the way we view older adults with cognitive impairment. Do we view them as “others” who need to be separated and hidden from our society, or do we view them as fellow humans who bring value and meaning to our neighborhoods, towns, and cities?
Living environments that personify dignity, sense of self, and culture are places that feel like home. This is what the industry must aspire to, and attain, for every member of our society regardless of chronological age or cognitive ability.
To learn more about innovations in the world of designing for people with Alzheimer’s and dementia, please contact Melissa Destout at [email protected] or Martin Siefering at [email protected].
