3.5 Dementia or cognitively friendly environments and communities

3.5.1. Introduction

The characteristics of the built environment can constitute a barrier to the autonomy and well-being of people, or contribute to promoting the maximum degree of independence, autonomy and well-being, they can increase the limitations or help compensating them as the disease progresses.

Our society has faced multiple and profound changes during the last decades:

• the demographic changes
• the transformations in family structures
• the new role of women in society
• the modification of preferences of elderly regarding their own ageing

All this transformation is leading us to rethink some of the pillars on which our existing wellness model was based.

Among the factors that determine the quality of life, the environment where an elderly person lives is a fundamental resource, not only with regard to the physical part, but also the emotional bond that develops with the space where they live. as with the neighborhood and  the connection with the world in general (Yanguas, Sancho, Del Barrio, 2012).

The importance of this “continent” where we want to live as we get older, is presented as an inescapable aspect when analyzing this new scenario of ageing that is presented to us today.

3.5.2. The design of suitable environments

The design of suitable environments for the elderly, which respond to their needs and preferences, is a discipline that has an increasing presence and impact in the design of person-centered care models, particularly in people with dementia.

These models of care are beginning to assume within their approaches the evidence that the design of the environments where people live influences deepeply their quality of life and the development of the disease, if any, or the way in which it can be deal with it.

In this sense, the design of therapeutic environments is increasingly included within non-pharmacological approaches to minimize the effect that dementias produce on people’s capacities.

An environment designed specifically for people with dementia can strengthen and stimulate the use of the capacities that are maintained, slow down their loss, and replace those that are being lost.

An environment considered, designed and executed properly to respond to the specific needs of the people who inhabit and/or use it can become a very useful tool to reduce the symptoms associated with dementias such as ambulation, disorientation, agitation, social withdrawal  and others.

In the 1970s, the relationship between the environment and people began to be analyzed (Theory of environmental pressure, Lawton and Nahemow, 1973), and since the beginning of the 90s it has been investigated to determine what role the environments can play within non-pharmacological therapies for people with dementia.

Understanding which elements of the environment produce well-being and which provoke conflicts, reduces the capacity for enjoyment and restricts the skills that they can still maintain (Lawton 2001, Calkins 2001, Wahl and Oswald 2011, Verbeek 2011).

According to the environmental competence model (Lawton 1984), the environment-person relationship is determined by the relationship between the level of personal competence and the environmental demand: the lower the competence of a person, the influence of the environment on their capacities is greater.

It can be concluded that the physical environment has a special influence on people in a situation of dependency, and on people who suffer from cognitive impairment. It is necessary to design environments that promote maximum autonomy and integration, as well as physical and psychological well-being and maximize people’s capacities, that is, facilitating environments.

Personal competence depends on factors such as health, sensory abilities, cognitive and motor skills. Environmental demand, on the other hand, is determined by the real physical characteristics of the surroundings, and by the subjective ones.

There are several environmental factors and characteristics that are related to objective and subjective well-being, for example: accessibility, security, light, noise, type of access, view to the outside, decoration, privacy, spaces of socialization, the size of the rooms, their organization or vision, etc.

When a person is in a situation of dependency or suffers from cognitive impairment, memory, thinking, movement, orientation, understanding, calculation, learning, language or the ability to make judgments other than simple can be affected. These disorders are related to reduced control of emotions, social behavior, and motivation. According to the team from the Imserso Alzheimer’s State Reference Center (CREA, Spain), it has been shown that some psychological and behavioral symptoms of dementias, such as depression, apathy, wandering and aggressiveness, are susceptible to improvement through environmental modifications.

People’s memory, cognitive and functional impairment problems make them more vulnerable to environmental influences (Briller et al., 2001), since these people “only know what they see”, they have great difficulties to interpret everything that they see and surrounds them, which generates great confusion and anguish. They are much more vulnerable to changes in their environment. In fact, when a person with dementia is institutionalized, going from living at home to living in a care center, it is one of the moments of greatest anguish and stress for that person, who does not understand what is happening, what surrounds him, who is surrounding him, and they can even respond with a certain aggressiveness to that anguish.

It is in these moments when the environments play a fundamental role: depending on how these environments are thought and designed, they can minimize these bad feelings.

3.5.3. Therapeutic objectives or key aspects

From the literature on environmental gerontology and design for people with dementia, we can extract the therapeutic objectives or key aspects that an environment should meet in response to the needs and the cognitive and behavioral characteristics of people.

There is a certain consensus about the key aspects that an environment designed to achieve the objectives described before must comply with: compensate as much as possible for disability, maximize independence, reinforce personal identity, improve confidence, possess qualities that allow understanding the building operation and easy orientation, controlling stimulus balance, promoting social interaction, granting privacy when the option is available, providing walking paths, both indoors and outdoors etc.

KEY ASPECT 1-The human scale and home environment.

The scale or size of a building influences the behavior of all people, but particularly of a person with dementia. This scale is not only associated with the general size of the building, but also with several other factors: the number of people who make use of this space and with whom the person with dementia relates, the size of the components of the building, such as rooms , common spaces, corridors etc.

No person, least of all a person with dementia, should feel intimidated by the size of the spaces around them; rather human scale, it should help the person feel in control of the space.

KEY ASPECT 2-Personalization and familiar feeling.

The loss of belonging to a place and of property is closely associated, above all, with abandonment of the usual home and transfer to social and health institutions.

Environmental interventions aimed at maintaining one’s own personality contribute to increasing the feeling of belonging to a place, creating an affective environment and reducing agitation, stress, etc. associated with these situations. Own furniture, significant memories, objects, photographs, etc. they help maintain this identity and are more likely to be used by people with dementia.

KEY ASPECT 3-Social interaction.

Social interaction contributes to the emotional well-being of people, and of course, also in people with dementia.

Therefore, the importance of environments contributing to, facilitating and stimulating social relations is evident: spaces of adequate scale, welcoming, comfortable, with angled armchairs that facilitate conversations, in suitable groupings, with good lighting, etc. facilitate social interaction between residents, family members and caregivers.

KEY ASPECT 4-Privacy and personal control.

The decision-making option is a key aspect related to the quality of life of people with dementia. In this sense, the environment must provide privacy when necessary, the independence of people and favor an environment that supports decision-making capacity.

This environment must make it possible to choose whether to be alone or accompanied by welcoming, accessible and safe spaces in both cases and to be able to determine which of them is the one that that person prefers.

KEY ASPECT 5- Provide a sense of trust and security.

People have to feel in an environment of trust and safety, which allows them to carry out their activities without any type of obstacle and stimulates them to do so. Family members, in turn, must feel confident that their family member is in a safe, trustworthy place and that it will provide them with the best possible quality of life.

Overly obvious security measures and perceptible barriers can cause people with dementia to become frustrated, agitated and angry, so measures to ensure trust must be discreet and integrated with the environment.

KEY ASPECT 6-Maximize spatial and temporal orientation.

The spaces and rooms must be easily locatable and identifiable for people with dementia: visible from different angles, with tools associated with their use (furniture, decoration, names, posters, etc.), maintaining the position of the spaces and furniture, avoiding excessive noise to avoid distractions, using sensory cues (the smell of food in the kitchen, seeing the table set, etc.), using large clocks with symbols for daily activities on the walls, etc.

KEY ASPECT 7-Balanced sensory stimulation.

Excessive stimulation or over stimulation, especially noise, can greatly alter the behavior of people with dementia, upsetting them, stressing them, reducing their ability to concentrate, etc.

Insufficient stimulation, on the other hand, can contribute to increased apathy, further reduced social contact and isolation.

KEY ASPECT 8-Trails for wandering.

Erratic ambulation is one of the characteristics associated with Alzheimer’s. This symptom can be minimized or channeled if there are paths or routes where people can walk aimlessly, well defined, free of obstacles, without complex intersections, with points or elements of interest along the route and opportunities for social interaction.

The ideal shape of these trails is in the form of a loop, where people take a circular route and can walk until they decide to stop without anything hindering this wandering.

KEY ASPECT 9-Support the functional skills of people.

It is essential that environments help compensate for the physical, cognitive and functional disabilities of people with dementia.

This can be achieved using different methods or tools such as: adequate lighting that avoids flashes and excessive color differences that people with dementia do not know how to interpret and can paralyze them and prevent them from continuing to walk, natural light together with artificial light to help in perception depth of field, remove sharp contrasts, colors, noise and unnecessary objects to avoid distractions etc.

KEY ASPECT 10- Technology at the service of people.

It is necessary to put at the service of people with dementia, their relatives and the professionals who work with them all the available technology that can contribute to improving their quality of life, integrating it into the environments.