By: Greg Irwin, AIA As a long-time senior housing architectural firm, Irwin Partners Architects is frequently discussing with its clients, what kind of design scheme works best for their dementia model. We are also frequently asked what a dementia building should look like for them. At times it is frustrating to be asked this question and other times it makes you want to laugh.
We try to explain to people that there is no standard approved dementia building that everyone wants. There are numerous concepts that have been used in the past 15-20 years for many different reasons. Here are the most commonly seen designs:
- Pod designs
- Corridors based designs
- A series of home-like buildings, housing a dozen or so residents on a single campus
- Remodels from Assisted living to Dementia
- Home conversions
- Large communities
- Small communities
- Multiple levels of care including memory care.
In have talking with many organizations about their design philosophy, each one has solid reasons why they believe in their concepts. Each group tends to have similar philosophies, but priorities them in different orders. The re-arrangement of priorities surprisingly has created lots of options that have spread into other types of car. Some of the priorities that are defining success, the purpose and money.
Defining Success
As they say, Success is in the eye of the beholder. It this case we need to decide who the beholder is; the resident, the family, the operations or the profits the project can generate. We would like to believe that its about the resident and there quality of life. It is when they are laughing or smiling. It is when they are calm. It is when they are participating in activities. It is when their families think they are happy. Unfortunately, with this terrible disease, these outcomes are not as easy as asking a question and getting an answer and becomes each developers question to answer
Purpose
After touring and designing many dementia communities I am convinced there is no single model that is demonstrably better than another. I have found there are several key considerations in choosing the right design concepts:
1. Humans are all unique – I have often thought it would be interesting to create a memory care campus that had different styles of buildings. I believe that some residents may do better in one design and that others do better in another design. This makes sense, because we don’t all want or need the same things in our personal residents today. Some people like loud music and others want a quiet place to be by themselves.
2. It Depends on Management Philosophy – When it comes to management philosophy, it seems more about prioritize and in what order you organize them. Is it important to view every unit. Is it important to be able to have activity zones. Is it important to have quiet areas. The important factor is that the design, support the philosophy of the operation.
3. Realistic vs. Idealistic – In working with the design of a project many times it comes down to realistic situations, not idealistic goals. Can you fit what you want on the property you have to meet your idealistic ideas. Does the weather, staffing, food services influence a buildings design. We all have goals and dreams for projects, but at the end of the day we need to be able to building, manage them and make money.
Return on Investment
Every community needs to pencil out financially. The profit schedule may change if the company is a for profit or not-for-profit, but rarely does any business set out to loose money. What market is the project going after, high profile or afford ability. This perhaps sounds cynical, but ultimately communities will not make a profit if they are not meeting the needs of residents and their families. I would be interesting in hearing what works for you and why it works? Irwin Partners Architects was founded in 1966 by Carl Irwin and has been working in the senior housing sector since the late 60’s. We have worked on over 300 dementia projects since the 80’s. When it comes to dementia care, we can help you figure out what works for you and your market.
Don’t miss a single issue of Senior Housing Forum, subscribe today. It is free! We do not sell or share your contact information. The posts are practical and never too long. Go to the main page of Senior Housing Forum and on the right hand side you will see a place to enter your email to subscribe. You will receive notification when a new article is posted. You can unsubscribe at any time.
Finally: If you know anyone who is looking at emergency call systems I would appreciate the opportunity to talk with them about Vigil Health Solutions.
From LinkedIn Groups
Group: SENIOR LIVING CONNECTION
Discussion: The Best Design for Dementia Residents;
Greg,
So good to see that you are willing to look at the whole picture. Having ramped two large Assisted Living communities from the two by four stage through both of which had memory care and having managed existing programs; I find that the design was often done to market to the adult children who are placing parents. The design and decorating is often to appeal to what we may like for comfort in our own homes and not looking at the practicality and functionability of the memory impaired residents. We were recently remodeling one of our memory care units and the decorator come in with 6 different bold outstanding patterns that she wanted used in conjuction with each other. They were distracting for all of us and so we know if would have been distracting for the residents.
I find that the best people to talk to is the director of the unit, the staff who work on the unit and Administrator to understand the flow of the unit and type of residents they serve. Understanding how each room of the unit functions for the resident is key to then planning a layout. Some residents do well with open concept others find it too stimulating and distracting. We have some models that have a lot of cubbied areas off pods and residents cannot find the living areas and walk in circles. The best people to talk to are the ones who work and understand the residents. Good for you that you recognize the differences needed for the clientele served.
Posted by Charlene Brosius
Group: Senior Care Services Companies
Discussion: The Best Design for Dementia Residents
Great article since it brings to light a very complex and umet need… Along with the ROI do not forget people suffering with any dementia, specially Alzheimer’s need to walk…be outdoors, and some had the frontal lobe impulse of sprinting.
Gardens and outdoor structures are a must. Thank you for this article!
Posted by Doris Bersing
From LinkedIn Groups
Group: Senior Housing Forum (www.seniorhousingforum.net)
Discussion: The Best Design for Dementia Residents
I have been in the senior design arena for 17 years so I thought I knew a lot. Then my father was diagnosed with dementia 10 years ago … then I really started learning. I beleive it depends on what stage a person is in … my father transitioned through different stages where some things worked and some didn’t. I do beleive there is a middle to late stage where smaller is better and developing relationships with caregiver and other residents is key … even if it doesn’t look like what you imagine it to.
I used to think these big open “household” areas that combine activity/dining/living areas and make sense in nursing would hold true for dementia. Not necessarily true … I have watched my father in socks walk through dropped food and spilled milk in a dining area too many times! We need to provide a way for those areas to be open and screened from view if it is right after meals so the caregivers can get it cleaned up without “roaming residents” using their socks as mops. Few will sit down somewhere and not go back to where the “action” is.
Site lines to a toilet is critical! Not just from bed but in public areas as well! My Dad never stayed in his own room for long, but he could never find a public toilet in any large common areas … doors are always shut. We know better than that.
What is good for nursing and a small group may not always work as well for dementia … residents are going to change over time and the environment needs to be able to adjust with them to work with staff not against them. Would love to hear more about others have discovered.
Posted by Greg Hensley
From LinkedIn Groups
Group: Faith Based Senior Living Executives
Discussion: The Best Design for Dementia Residents
This article asks more questions than it answers, and to be sure there are many such questions that need to be answered by the provider for whom we are designing before we put pencil to paper. Books have been written on this subject, and one I would highly recommend is Design Innovations for Aging and Alzheimer’s by Betsy Brawley ( http://www.betsybrawley.com/index.php?option=com_content&task=view&id=1&Itemid=2 ).
Based on my own experiences working with clients on the planning and design of dedicated memory care projects I have found the following key principles to be applicable to all or most:
* Security – Not just in the sense of monitoring entrances and exits or avoiding hazardous conditions (although that’s important, too), but also in how the spaces are arranged and configured to be warm, inviting, comfortable, and homelike. This is both calming and helps obviate the propensity to try to elope.
* Residential Scale – Whether in the form of neighborhoods, “pods”, small houses, or whatever, elders with dementia more often than not do better in environments where the number of new faces is kept to a minimum, i.e. 8 to 12 residents with 2 to 3 consistent universal workers per household. This is true for mealtimes as well. I find that households with their own common residentially scaled kitchen, dining room, and living room work best. Avoid any through-traffic at all costs!
* Connection with Outdoors – Both for orientation to time of day and season, as well as to provide an attractive diversion, and preferrably accessible by residents without staff intervention, weather permitting. I have found that secure gardens work best, espcially if they are surrounded by the building and not just a 6-ft. picket fence.
* Purposeful Activity Stations – To engage residents in familiar activity patterns (recalling roles they may have had earlier in life) and help distract them from aimless wandering or inappropriate behaviors.
* Minimal Corridors – Try to avoid long double-loaded corridors or corridors with dead-ends (especially if there is a window or a door at the end). If at all possible (and it’s not always possible, especially in renovations), create opportunities for residents who wish to ambulate to do so by way of one or more closed circuits.
* Managed Sensory Stimuli – This includes ample but carefully modulated natural and artifical lighting, absence of noxious sounds (e.g. alarms, paging, PA systems, etc.), properly functioning and well-controlled HVAC systems, and appropriate smells, such as the aroma of food being prepared at mealtimes.
* Wayfinding – Try to use “landmarks”, color schemes, and other devices to help residents orient themselves with the facility as much as possible.
* Toilets – I would almost say “the more the better”. Certainly an obvious and accessible unisex toilet room should be available at every dining and activity room to provide visual cueing and to avoid “accidents”. Counting on residents to return to their own rooms for toileting is unrealistic and doomed to failure.
This is but a small sampling of the many planning and design issues to be considered and addressed. Many of these and other concepts are explored further in an article that I co-authored, a link to which can be found on my website: http://www.LifePLACEDesigns.net/news.html . Scroll down to “It Began With a Promise”.
Posted by Robert Pfauth
From LinkedIn Groups
Group: Memory Care Professionals
Discussion: The Best Design for Dementia Residents
1) never ending walking space
2)Lots of areas for chairs in hallways
3)Dining room that will accomodate family as well as residents
4) Covered outdoor area, sunroom
5) Private showers in the room with visible toilet (not white)
6) Small residences with large activity and small activity areas
7) Quiet spaces for relaxation (Snoezelin)
8) Lots of tactile art on every wall
9) Restrooms near activity area and dining room
10) Lots of natural light
Of course you can have the perfect environment, but it means nothing without the perfect well trained staff and leadership.
Posted by Mary Poole
I agree with all but two of your recommendations Mary. Chairs in the hallways can lead to increased falls. And with Snoezelen rooms staff have to really be aware of residents with seizure disorders as they are extremely sensitive to flashing lights and stimulation like it.
From LinkedIn Groups
Group: Senior Safety and Security for Long Term Care
Discussion: The Best Design for Dementia Residents
I was looking forward to an article with descriptions of best practices or case studies–disappointing to this reader.
Posted by Donna Cusano
From LinkedIn Groups
I can understand your disappointment. I think the problem is that it is almost impossible to really figure out what is best, or perhaps it means that best is in the eyes of the beholder. I have been in many memory care communities and with wildly different designs and care philosophies. I think the biggest challenge in figuring it out is that if the staff has bought into a particular philosophy there is going to be a lot of successful outcomes and if the staff does not believe in a particular design it won’t be successful. Which I guess would suggest that design is not as important as maybe we think . . . . . I don’t know. It is why having conversations is so important.
Steve Moran
From LinkedIn groups
Group: Experts on Seniors
Discussion: The Best Design for Dementia Residents
Interesting article. He provides a nice perspective on the variety of considerations when designing for dementia residents. The one design that I never find in any type of assisted living community is assisted housing in which the couple may remain together. I think in the early stages of dementia this would be helpful. The spouse would not have to provide “all care” until the situation became unmanageable if this option was available.
I recognize some CCRC’s offer in home care services that provide the type of support I am thinking of. I just find that most of the time if a person needs daily assistance the communities that exist expect them to move into a studio space without their spouse.
It is difficult to determine what is the best design for a person with dementia without input from family members. I hope we will find ways to encourage proactive planning so that residential choices will be made by the people who will actually live in the residence.
Beyond that it will always be true that facilities will be built to provide good cash flow, ease of service delivery and ideal conditions for the way management wants to operate the program. Thanks for posting this article @Steve.
Posted by Adero C E Allison, PhD
Good Article . I’d like to see more like this with concepts that discuss incorporation of industry memory/ behavioral therapies/treatments implementation with the pyhysical attributes of the building designs.
I would love to work with some really creative innovators for these types of projects infusing the dementia therapies with the environmental surroundings!
I waited years to see this need finally being addressed.
Great work.
Therese, love to here more about what you are thinking about regarding thererapies. Our job is to be creative thinkers in creating spaces that solve problems. We are always interested in learning more about what problems need to be solved. I personally believe in shall houses of 6 for a truly residential model. Unfortunatly it wouldn’t be profitable. We have worked with dr. Thomas on the small side and Silverado on the large side, so we have worked with some of the best. To find more design solutions we need to here from people working in the field daily. The best researches in the world will never understand what families and staff go through on a daily basis.
From LinkedIn Groups
Group: Assisted Living Professionals
Discussion: The Best Design for Dementia Residents
I like what Pfaugh had to say. I have two dementia stand alone facilities, one with 16 beds and one with 24 beds. We also have a stand alone distinct 70 bed ALF for non demented folks . I have worked on the floor in all of the facilities and no longer do since our company has grown to more than dementia units. I feel I have a good grasp of what is right and what is not.
I think our size is generally better than those larger facilities for dementia residents. I also know more critical than design is how the staff is trained and performs and how interaction with families and community participation takes place.
People are different, dementia or not, so one design over another just does not cut it. Do what you feel that you can manage well, that is in providing decent security, good food, good service, love, cleanliness, comfort where ever possible, error less medication management, a very nice outdoor area both shaded and partially in the sun and then more love and passion for what you do. We have aquariums and birds. Pets can do wonders for most.
Robert R. Hilger
From LinkedIn Groups
Group: Senior Care Services Companies
Discussion: The Best Design for Dementia Residents
I agree, Doris. People need a connection with the natural environment, but in a safe way. The Eastern Kentucky Veteran’s Center has an enclosed courtyard next to their Alzheimer’s Unit (a locked unit). The residents can go outside for a walk, fresh air, hear the birds sing, and see the trees, bushes and plants. It provides a peaceful place for them to enjoy the outdoors safely.
Posted by Regina Ford, MBA, CAPS
From LinkedIn Groups
Group: ALFA – Assisted Living Federation of America
Discussion: The Best Design for Dementia Residents
This is a good article and each situation is different. I have assisted in the design of several facilities and have found that small is better with open areas; great lighting, color and directional planning is key. I will follow you and as an administrator we are left to deal with the mistakes made by owners and architects.
Posted by Dorothy Passarella, M.S.
From LinkedIn Groups
Group: Senior Living & Care Professionals
Discussion: The Best Design for Dementia Residents What are your thoughts about the best design style for dementia residents?
The best design is “simple” with a circular pattern and rooms opening up to a center
room or courtyard. Having had experience with several designs I am happy to share my experience, as a consultant for over 20 years. Please contact me if you want to share more info. It is very exciting to see the success of this concept.
[email protected]
Posted by Dorothy Passarella, M.S.
I would be interested in talking to you about a possible interview on my radio show Alzheimer’s Speaks. Let me know if you are interested in chatting. You can contact me via my blog http://alzheimersspeaks.wordpress.com/ or shoot me an email at
Lori @ AlzheimersSpeaks .com
I separated the above address as to not get spammed
Thanks
Lori
From LinkedIn Groups
Group: Senior Living, the way it ought to be…, Consulting and more
Discussion: The Best Design for Dementia Residents
Client proposed a variation on a circadian matrix for their dementia unit – roughly 1/3 of population to be each on a different “clock” – their management philosophy was that with 3 shifts of staffing, the resident load would be spread out and they’d be able to provide more attention to each resident. Artificial lighting is supposed to create normalcy of clock time.
Interested in your take on that.
Posted by John Hrivnak, AIA, MBA, NCARB, LEED AP
From LinkedIn Groups
Group: ALFA – Assisted Living Federation of America
Discussion: The Best Design for Dementia Residents
One level – LOTS of open area to walk and wander (preferably in a circles – so we never get lost), smaller bedrooms with large gathering areas for events (including ample space for family members). Kitchens in each area for cooking and allowing residents to participate. Just some thoughts for you ~
Posted by Lisa O’Toole
Are smaller bedrooms consistant with other movements in dementia. Many people are looking at making the units larger so they can have a spouse live with them. Some believe that the room should be large enough to feel like a bedroom in there house. Some want them to have a one bedroom unit, where they have their own sitting room (living room). Should each room have direct access to the outside?
From LinkedIn groups
Group: Senior Living, the way it ought to be…, Consulting and more
Discussion: The Best Design for Dementia Residents
Perhaps there are no comments because everyone else is as astonished as I am. On a practical point, what effect would this have on the staff, who after all aren’t lving in the artifically lit environment? I am intrigued as to how your client came to this approach as opposed to changing the staff shifts so the staff could effectively meet the needs of the residents . I’d love to know what you said.
Posted by Marion Adkins
From LinkedIn Groups
Group: Senior Living, the way it ought to be…, Consulting and more
Discussion: The Best Design for Dementia Residents
Best practice in the UK has increasingly emphasised the importance of natural light in dementia accommodation, Stirling University have very good guidance on this and many other aspects of design for dementia, including a self service checklist and an appraisal service. Your description sounds like a production facility, not a humane environment for the residents or staff, and completely contrary to the person centred care we are aiming for.
Posted by Ian Laight
From LinkedIn Groups
Group: Senior Living, the way it ought to be…, Consulting and more
Discussion: The Best Design for Dementia Residents
Similarly astonished when I got the suggestion from the client – primarily due to my research regarding the benefits of natural light. They countered with the availability of matching light frequencies.
Yes, I do understand that they would be able to build less s.f. resulting in savings. Yes, I do understand that their staffing model would also be effective and cost saving. Yes, I know that there are lamps that mimic natural light (sort of).
All that being said, I recommended that we find a precedent and see how it works. The precedent found was for incarcerated populations where it is working surprisingly well. (they need only 1/3 the kitchen/dining area for example)
Are dementia residents a “captive audience”? Yes and no.
This got interesting. My responses were always to keep an open mind while throwing out other considerations.
What did they do?
Tune in for the next exciting adventure…
What would you have done?
Posted by John Hrivnak, AIA, MBA, NCARB, LEED AP
Group: Senior Living, the way it ought to be…, Consulting and more
Discussion: The Best Design for Dementia Residents
John, thoughts of battery hens spring to mind! I am very commercially minded and always keen to optimise floor area / reduce costs, but this really sounds a bridge too far. Recent experience here with people who have high levels of dementia and difficult histories in a variety of secure establishments has shown how their lives can be ‘normalised’ with the right combination of accommodation and care. Relatives have commented on how they have ‘got Dad back’ after having given up on any meaningful connection being possible.
I don’t see such progress being possible in a ‘dementia farm’ but maybe I am being reactionary!
Posted by Ian Laight
Group: The Resident Experience – Changing the Experience Across the Aging Continuum
Discussion: Moving Dementia Residents into the hospital does great damage! This has huge implications for providers of senior housing.
I agree with you about dementia residents have poor outcomes when they are put in the hospital. As with ALL dementia people, they hate change of any kind. They don’t like to have their lives changed by going into the hospital or going into a nursing home. When one of my parents does have to go tot he hospital, I take as many things as I can to the room so that they feel much better about it. Especially photos, a favorite blanket, their personal things that they hang onto, etc. It makes the transition so much easier! One time I took my mother’s whole tea set and we drank tea in it every day. She loved that! One time I took my dad’s pipe, slippers that were really worn out, and his favorite pillow. These things make it so much easier for them! It’s bad enough to have to put them in the hospital…so why not accommodate them by making their rooms “more like them”? Believe me, it is much better than putting them in the hospital without any of their person things to help make the rooms more like what they are used to!!
Posted by Connie Hower
Very interesting, thank you for sharing. I actually work with senior citizens every day, helping them cover the out of pocket gaps brought on by government Medicare. I try and help them out in any extra way that I possible can, and I feel so blessed to have this opportunity available to me. I love working with the members of this generation!
Nine out of ten seniors enrolled in Medigap are satisfied with their coverage, according to a new American Viewpoint survey released today by America’s Health Insurance Plans (AHIP). The high satisfaction level among policyholders is comparable to findings from surveys conducted in 2009 and 2005. If you ever get the opportunity, feel free to check out our brand new website. We’d really appreciate any type of feedback that you may have. Thanks again for sharing!