Designing Environments for People with Dementia

Front matter

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DESIGNING ENVIRONMENTS FOR PEOPLE WITH DEMENTIA

A Systematic Literature Review

Contents

List of Figures and Tables About the Authors

Acknowledgements

Background

Conclusion

The evidence base on design for people with dementia is growing but remains patchy. Research studies are often small scale, and publications often lower quality, reviewing innovations that tend to have a limited evidence base. In this review, we have highlighted areas in which design recommendations are better supported by research evidence, and indicated the strength of the evidence for each study. For each section, we have highlighted key points that emerge from a qualitative synthesis of the literature. There remain significant gaps in each of the areas considered, on which further research is merited. In concluding, we consider first the emerging methodological issues, then particular care settings, rooms, fixtures and fittings, concluding with a comment on design guidelines.

Methodological Issues

We have identified methodological issues throughout the review. Much of the research identified and evaluated was small scale, inevitably limiting its generalisability, and because it was disparate, difficult to synthesise. The review was thus limited to descriptive analysis of research findings. There was limited use of the most structured research methods, including trials and other controlled designs, and a minority (38/173) of any of the studies were assessed as being of high quality. Research in this field is needed at larger scale, and using stronger methodologies — these are not necessarily quantitative or controlled studies, but need to be more clearly specified and conducted in ways which meet quality assessment standards. This is an innovative, multi-disciplinary area, which has the potential to learn from advances in evaluation methodologies, such as realist evaluation (Pawson and Tilley, 1997) and improvement science (Taylor et al., 2014), as well as more participatory methodologies which give people living with dementia themselves an active voice in building the evidence base as in for example Tanner’s work (Tanner, 2012). The development of design in environments could learn from the 6SQuID approach (Wight, Wimbush, Jepson, & Doi, 2016) to developing evidence-based interventions which are practical and genuinely promise improvements.

Outcomes considered in the studies reviewed were varied. Many emphasised aspects of health, and some considered behaviours, such as agitation or ‘wandering’. Quality of life and outcomes which mattered more to people with dementia themselves were also considered: this is a welcome development, especially in the context of supporting person-centred approaches.

Care Settings

The available literature indicates that research has been predominantly conducted in care homes, with limited work in other residential settings. Attention to hospitals and other healthcare environments has been limited, and there is very little research located in private homes, public buildings or outside spaces. The research on care homes highlights the importance of the approach to care, and the difficulties of separating out the impact of design features from that of mode of care delivery on the quality of care. Generally, it seems, the more ‘homelike’ a care home seems to be, the better, but the evidence suggests that without an appropriate model of care design modifications alone may not produce improvements for residents. There are nevertheless indications in the care homes research of how design changes can affect people with dementia, by for example reducing levels of agitation, providing better opportunities for people to move about purposefully, or assisting with improved communication between staff and residents and between residents.

Research in hospitals has generally indicated that these environments are problematic for people with dementia, amongst other things being noisy and unfamiliar. They are generally less able to provide the privacy and opportunities to spend time together that people with dementia and their families require. There have been a small number of attempts to implement promising design from elsewhere in hospitals, but little useful evidence has accumulated. This is a clear research gap.

Evidence derived from care homes generates design principles that may be applied in other home settings, including private homes, and researchers have explored this possibility. Our own research considering guidance for people living with dementia and sight loss tested findings from literature with people in various settings including at home, with respondents being generally positive about their practicality in the context of care at home. Nevertheless, there is a need for more research which considers specifically design at home, and how design modifications alongside family and possibly also paid care may benefit people with dementia and support the carers.

Consideration of design of outdoor environments for people with dementia has been limited, and very little is included in this review. We are conscious that increasing attention is now being paid to this issue, and there is growing awareness of its importance in terms of the difficulties people with dementia face in terms of getting out and about and the benefits of doing so.

Overall, the research conducted in care settings supported the significance of the environment, but also leads us to conclude that the care provision has to be considered alongside it, complemented by an understanding of the whole person. Environments therefore need to be flexible and adaptable, to facilitate and support good care which is adaptable and sensitive to people’s needs. Not only do we need better understanding of care provision alongside environment, but we also need more research on how the environment may facilitate or inhibit good quality care.

Rooms, Fixtures and Fittings

There were several examples in the review of research which focused on particular rooms in a house or care setting, and identified and tested design features relevant to those rooms or which considered particular fixtures and fitting, such as taps, switches or door signs. There is a significant literature considering assistive technology, which tends to focus on prototypes rather than larger-scale use of technology. The review also considered research relating to more general design issues such as lighting, and colour and contrast: it was unusual for literature on particular rooms to include reference to this wider literature, illustrating a degree of fragmentation in the research record. There is disparate work on a range of design items, prototypical technologies and interventions, and research is needed which can consolidate findings and identify core principles to guide design.

In this work, the environment was considered not only as facilitating and supporting good care, but also as having a positive role to play in itself, as with the work on therapeutic kitchens. Another example is found in the work on multisensory rooms, for which considerable benefit has been claimed but for which little evidence has been established. This perspective merits further research, considering additional benefits that well-designed environments may produce.

Design Guidelines for People with Dementia

In relation to existing design guidelines, much of the stronger research supports their content, bearing in mind that professional interpretation of the meaningfulness of the results of research for implementation in real care settings has often been incorporated in the guidelines. Two key points emerge in relation to guidance in this area. First, the influence of the model of care on the effectiveness of design is clear: design modifications alone will not be fully effective unless the quality of care is high. Second, some of the variations in research results and interpretations are likely to result from the individuality of people with dementia who have been included in the studies. Given the need for care and support to be person-centred, judgement in delivering design modifications will need to be exercised: what suits one person may not suit another, and each area of design recommendations could include an indication of possible differences that should be considered.