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  • Writer's pictureSusanne Desbrow

Aged Care and Evidence Based Design

Updated: Dec 16, 2023

Evidence based research is a process of basing decisions about the built environment on credible research to achieve the best possible outcome. The following blog will examine evidenced based design in aged care and senior living facilities.

Stress in the built environment

A vibrant aged or senior woman with long curly white hair stands with her eyes closed and hands up as though she is dancing. She is wearing a yellow shirt and black pants, and the background is yellow.

Research has shown that stress, can dramatically effect the healing process of patients in medical facilities. Austrian Physician and scientist Hans Seyle published his research in 1956. This demonstrated that hormones released during stress participate in the development of many degenerative diseases including brain hemorrhage, hardening of the arteries, coronary thrombosis, certain types of high blood pressure, kidney failure, arthritis, peptic ulcers, and cancer.

Stress results from any situation that requires behavioral adjustment such as invasions of privacy, no control over noise, acute or chronic pain, separation from family and things familiar, feelings of helplessness, and loss of control over events and the immediate environment. It’s interesting to note that the negative effects of stress can be measured hours after the stressful event occurred. Worse yet, stress impacts the immune system, which is perhaps the most compelling reason to design environments that reduce stress and help people relax and feel comfortable. Stress involves the nervous system and the endocrine system. These two systems provide links between mind and body. Music has been known to have a painkilling effect when pleasure centers of the brain stimulate the pituitary gland to release endorphins, the body’s natural opiate (Campbell 1997; Taylor 1997).

Evidence and experience demonstrates that surroundings have a dramatic influence on older people's socialization, mobility and general health, all of which contribute to stress experienced. Such an intense relationship implies a heightened need for designers to use innovations in design that will encourage positive outcomes in aged care facilities. Even small, informed design decisions can have a large impact on residents’ quality of life. These are a few strategies for reducing stress.

Connection to Nature

Research shows we humans have a deep need to connect with nature. Even a partial view of a garden or interaction with a water element can immediate psychological benefits in terms of reducing anxiety and stress (Ulrich 1984; Ulrich 1999; Parsons and Hartig 2000). Biophilic design is a concept used within the building industry to increase occupant connectivity to the natural environment through the use of direct nature, indirect nature, and space and place conditions.

Control (choice)

A considerable number of studies have documented that when individuals have options or choices, it reduces stress and enables them to feel more in control (Winkel and Holahan 1986; Evans and Cohen 1987; Steptoe and Appels 1989).

Social support

Being surrounded by family and friends contributes to emotional and psychological well being. According to Kiecolt-Glaser and colleagues (1998), social support is directly related to dimensions of autonomic, endocrine, and immune function, with family ties appearing to be a key source of support relevant to physiological functioning.

Positive distraction

research in the neurosciences demonstrates that various types of sensory experiences can actually be therapeutic and can boost the immune system (Pope 1995; Taylor 1997). Humans are multisensory beings; this can be done within environments by visuals or music.

Acoustic controls

Our brains are always monitoring sounds for signs of danger, even when asleep. As a result unwanted noises can have a range of mental health effects.

Why acoustics matter in age care

As we age our hearing changes with us. An elderly ear is far more affected by room acoustics than a younger ear. We cannot hear high pitched sounds the way we used too and our audible area shrinks. This can lead to misunderstandings, frustration and confusion. People who are cut off acoustically from the external world not only lose their hearing, they are at risk of becoming socially and intellectually isolated.

People with dementia are partially affected by their acoustic environment. While people with dementia maybe able to hear normally, they can lose the ability to interpret what they hear accurately.

Controlling Reverberation and speech Clarity

According to research from Michael James HAYNE & Richard FLEMING, from the University of Wollongong, Australia. Controlling reverberation throughout the dementia care facility is important to ensure speech intelligibility is achieved (remembering that many older residents require hearing aids), reduce the impact of intruding noise from internal and external sources and achieve privacy.

Recommended reverberation times for different spaces

A chart explaining the recommended reverberation for types of areas. A chart showing recommended sound levels for different areas like sleeping (0.5 s), common areas (<1.0 s), toilets and bathrooms (minimal to be practical), kitchen and service areas (minimal to be practical), staff work areas (0.6s to 0.8s), corridors and lobbies (0.6s to 0.8s)

Recommended design sound levels for different spaces

A chart showing recommended sound levels for different areas like sleeping (35 dBA), common areas (40 dBA), toilets and bathrooms (45 dBA), kitchen and service areas (45 dBA), staff work areas (40 dBA), corridors and lobbies (40 dBA)

Lighting and daylight.

Elizabeth Brawly, author of design innovations for aging and Alzheimer's, reminds designers that residents are powerless to modify their environments. Reduced visual acuity, impaired depth perception and insufficient lighting could exacerbate fall-risks and cause daily fear that might contribute to extended anxiety, confusion and anger.

Higher lighting in the dining area means a better view of food and better appetites and calorie intake. It also has been linked to better sleep habits and a generally better quality of life for residents.

Environmental interventions that encourage mobility and independence

  • Even illumination and elimination of glare

  • Balance of daylight and electric light

  • Combination direct and indirect lighting

  • Gradual changes in light levels—(upon entry from the outdoors

  • Strong contrast—(grab bars in contrasting color)

Homelike environment

Although it may be extremely difficult to provide ‘homelike’ settings, research has shown that the benefits of these ‘homelike’ residences are significant, and its importance should not be underestimated (see Chaudhury & Cooke, 2014).

Green Houses senior living in the US provide innovative residential care for people with dementia. Green Houses were inspired by the ‘Eden Alternative’, a concept that emerged in the early 1990’s, where homelike long-term care facilities are encouraged. This philosophy didn’t create much change initially, which sparked the founder to bring the concept to life with the creation of ‘Green Houses’. Green Houses are small homes for those in need of 24 hour nursing care, with no more than 12 persons per home.

The houses contain furniture and décor selected by the residents, with plenty of outdoor space and high levels of sunlight in each room. Preferences and privacy of residents are honoured, with nurses ringing the house’s doorbell before entering. Green Houses do not have the following items that would be typically be found in institutionalized nursing homes, such as nurses’ stations, medication carts and public address systems.

A beige single level, aged care or senior facility exterior with an American flag hanging on the entry post.

In addition to homelike aesthetics, smaller units appear to have numerous positive benefits, such as higher motor functioning, greater friendship formation, reduced anxiety and depression, and greater mobility.

Reducing resident falls

Resident falls are one of the leading causes of resident injuries and liability claims in LTC. Research identified lighting, furniture, flooring, wander gardens and assistive or restrictive devices as the key environmental design elements impacting resident falls. The review conducted by Xiaobo Quan, PhD, EDAC, is research associate for The Center for Health Design. Anjali Joseph, PhD, EDAC, is the director of research at The Center for Health Design found:

● High lighting level and light glare reduction were associated with reduced fall risk.

● Selecting low-height furniture, positioning furniture (e.g., beds) against walls and allowing more maneuvering space between furniture pieces were found to prevent residents from accidentally falling from beds or chairs and reduce fall-related injuries.

● Flooring surface materials with small motifs and lowest contrast as well as soft sub-floor improved walking and reduced falls and fall-related injuries.

● Residents with dementia who had access to wander gardens tended to experience fewer falls than those without access.

● Appropriate configuration of grab bars in the bath and toilet areas may contribute to a reduction in resident falls in bathrooms.

● Some restrictive devices, such as bedrails, were related to more severe injuries and should be avoided.

Dementia enabling environments

Refenced from Fleming, R., Zeisel, J. & Bennett, K. (THE DIGNITY MANIFESTO OF DESIGN FOR PEOPLE LIVING WITH DEMENTIA). Their are 10 dementia enabling environment principles based on evidence based research.

1. Unobtrusively reduce risks

People with dementia require an internal and external environment that is safe and easy to move around if they are to continue to pursue their way of life and make the most of their abilities. Potential risks such as steps must be removed. All safety features must be unobtrusive as obvious safety features, such as fences or locked doors, can lead to frustration, agitation and anger or apathy and depression.

2. Provide human scale

The scale of a building can affect the behaviour and feelings of a person with dementia. The experience of scale is influenced by three key factors; the number of people that the person encounters, the overall size of the building and the size of the individual components (such as doors, rooms and corridors). A person should not be intimidated by the size of the surroundings or confronted with a multitude of interactions and choices. Rather the scale should encourage a sense of wellbeing and enhance the competence of a person.

3. Allow people to see and be seen

The provision of an easily understood environment will help to minimise confusion. It is particularly important for people with dementia to be able to recognise where they are, where they have come from and where they can go. When a person can see key places, such as a lounge room, dining room, their bedroom, kitchen and an outdoor area they are more able to make choices and see where they want to go. Buildings that provide these opportunities are said to have good visual access. Good visual access opens up opportunities for engagement and gives the person with dementia the confidence to explore their environment. It can also enable staff to see residents. This reduces staff anxiety about the residents’ welfare and reassures the residents.

4. Manage levels of stimulation- reduce unhelpful stimulation

Because dementia reduces the ability to filter stimulation and attend to only those things that are important, a person with dementia becomes stressed by prolonged exposure to large amounts of stimulation. The environment should be designed to minimize exposure to stimuli that are not specifically helpful to the resident, such as unnecessary or competing noises and the sight of signs, posters, places and clutter that are of no use to the resident. The full range of senses must be considered. Too much visual stimulation is as stressful as too much auditory stimulation.

5. Manage levels of stimulation- optimise stimulation

Enabling the person with dementia to see, hear and smell things that give them cues about where they are and what they can do, can help to minimize their confusion and uncertainty. Consideration needs to be given to providing redundant cueing i.e. providing a number of cues to the same thing, recognizing that what is meaningful to one person will not necessarily be meaningful to another. Using text and image in signs is a simple way to do this. Encouraging a person to recognize their bedroom through the presence of furniture, the colour of the walls, the design of a light fitting and/or the bedspread is a more complex one. Cues need to be carefully designed so that they do not add to clutter and become over stimulating.

6. Support movement and engagement

Purposeful movement can increase engagement and maintain a person’s health and wellbeing. It is encouraged by providing a well defined pathway, free of obstacles and complex decision points, that guides people past points of interest and opportunities to engage in activities or social interaction. The pathway should be both internal and external, providing an opportunity and reason to go outside when the weather permits.

7. Create a familiar place

A person with dementia is more able to use and enjoy places and objects that are familiar to them from their early life. The environment should afford them the opportunity to maintain their competence through the use of familiar building design (internal and external), furniture, fittings and colours. The personal backgrounds of the residents need to be reflected in the environment. The involvement of the person with dementia in personalising the environment with their familiar objects should be encouraged.

8. Provide a variety of places to be alone with others- in the unit

People with dementia need to be able to choose to be on their own or spend time with others. This requires the provision of a variety of places in the unit, some for quiet conversation and some for larger groups, as well as places where people can be by themselves. These internal and external places should have a variety of characters, e.g. a place for reading, looking out of the window or talking, to cue the person to engage in relevant activity and stimulate different emotional responses.

9. Provide a variety of places to be alone with others- in the community

Without constant reminders of who they are, a person with dementia will lose their sense of identity. Frequent interaction with friends and relatives can help to maintain that identity and visitors should be able to drop in easily and enjoy being in places that encourage interaction.

Stigma remains a problem for people with dementia so the unit should be designed to blend with the existing community and not stand out as a ‘special’ unit. Where possible a ‘bridge’ should be built between the unit and the community by providing a place that is shared by the community and people with dementia. A coffee shop near the unit, for example, may enable a person with dementia to go there easily without needing assistance. Where the unit is a part of a larger site, there should be easy access around the site so people with dementia, their families and friends can interact with other people who live there.

10. Design in response to vision for way of life

The choice of life style, or philosophy of care, will vary between facilities. Some will choose to focus on engagement with the ordinary activities of daily living and have fully functioning kitchens. Others will focus on the ideas of full service and recreation, while still others will emphasise a healthy life style or, perhaps, spiritual reflection. The way of life offered needs to be clearly stated and the building designed both to support it and to make it evident to the residents and staff. The building should be the embodiment of the philosophy of care, constantly reminding the staff of the values and practices that are required while providing them with the tools they need to do their job.

11. Colour and patterns

Inappropriate colours and patterns can be confusing for a person living with dementia.

  • Avoid patterns which are overly bold or prominent because of their large sized motifs or striking colour contrast. Bold patterns such as stripes and zig-zags can be perceived as moving objects. Subtle patterns which are low in contrast are a better choice.

  • People living with dementia may perceive patterns and motifs as actual objects. For example in a kitchen, a laminate benchtop with a pattern of white specks on a dark background may be perceived as crumbs which the person may attempt to clean or pick up. In this instance, a solid colour surface may be more appropriate.

  • Highly contrasting patterns on the floor (such as a checker-board pattern or wood flooring with an overly prominent grain) may be perceived to be changes in floor level or ‘holes’ in the ground.

  • Similarly, highly contrasting patterns on vertical surfaces may be perceived to be changes in depth, and so should be avoided.

12. Sensory materials

Embedding sensory stimulation into the environment is an important aspect of enabling design. It provides points of interest, encourages exploration or can be used to help zone spaces.

  • Natural materials can be included in a space through the use of wooden elements, plants or natural fabrics. These textural elements can add variety to a space and contribute to the domestic style of the home.

  • Surrounding the person’s space with sensory items that are familiar to them. It can also help someone feel more comfortable in the space. It can also reinforce that person’s sense of identity.

  • Sensory preferences are personal and individual. Having a mix of textures (for example knitted wool blanket, suede cushion, lace tablecloth) available in communal areas allows people to find and engage with what they find enjoyable or comfortable.

An older light skinned woman clasping her hands looking at a box filled with mementos and photographs.

Thanks for reading my, blog and if you have any questions, please do not hesitate to contact me.

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