As mentioned in our highlights from the Environments for Aging Conference post, 72 million Americans will be 65 or older in the next 10 years, the highest number ever, and by 2032 there will be more Americans over the age of 65 than under 18, for the first time in the history of the US. As the demographic anomaly of the baby boom continues to age, the need for Memory Care will dramatically increase. Read on to see how we are designing continuing care retirement communities and senior lifestyle communities accordingly.
A few months ago, Jennifer Schlimgen, AIA, Vice President, Kahler Slater and Gary Selmeczi, MHSA, President and CEO, Westminster Canterbury of the Blue Ridge co-presented Research Based Design Practices in Memory Care at the Virginia Society of Hospital Engineers Annual Conference.
Jennifer on Why Designing Experiences for Aging Adults is Meaningful:
As an architect with a passion for design for aging, the idea of creating a compelling Memory Care experience has recently taken on new meaning for me personally. Longevity seems to run in my family. That’s the good news. On the other side of that opportunity, all of the elders in my family have developed some form of dementia in their later years, which is one of the major challenges of living into your mid 90’s and beyond. The idea of learning what we can do to make life more meaningful when we are (as elders or their loved ones) living with those challenges has become very important to me. I now think, why wouldn’t we design all of our living environments with these guidelines to support aging in place?
Gary on Why Designing Experiences for Aging Adults is Meaningful:
As a provider, the President and Chief Executive Officer of Westminster Canterbury of the Blue Ridge (WCBR) in Charlottesville, VA, I see the challenges of caring for seniors across our Continuing Care Retirement Community (CCRC), as residents begin to face memory and cognitive challenges and the stress that creates for their spouses and families. Starting my education as a psychology major, my degree took me in to a nursing home and a geriatric assessment clinic, where I learned I could not be a clinician, because I could not “fix” what was happening to these elders. This is when I decided I could, however, make a meaningful impact by pursuing a Master of Health Services Administration degree with a concentration in long-term care.
Statistics on Dementia
Statistics tell us that nearly 30% of Americans will have some form of dementia underway by the age of 70. These statistics are frightening and staggering—every 65 seconds someone in the U.S. develops dementia. As the number of older Americans grows, so too will the number of new and existing cases of Alzheimer's and Related Dementias. By 2050, the number of people age 65 and older with some form of dementia is projected to reach 13.8 million people. Today, that number is 5.8 million people affected with dementia (Alzheimer’s Association, 2019). The real personal and economic impact on individuals, both those individuals with dementia and those who love them, are almost incomprehensible.
How Evidence-Based Design Concepts Can Improve Senior Lifestyle Communities
As providers and designers, it becomes imperative that we create the best conditions around people with memory and cognitive function loss to enable them to live their life by maximizing their abilities, to actively continue to be part of society, and to enhance their self-esteem and independence. Research includes not only pharmacological therapies but also the effects of the built environment and best practice approaches to caring for persons with dementia.
The evidence-based design concepts we have identified should have application for any senior living environment. While not every person in this environment will need memory care, embedding these ideas in senior lifestyle communities, especially those designed for Memory Care, will contribute to a life that is less confusing and less anxiety-filled for everyone, allowing more people to age in place.
How This is Impacting WCBR
WCBR’s Vision is to be a world-class model of best practices in wellness, hospitality and care-giving, and a leader in the field of aging. WCBR is a not for profit, Lifecare, CCRC serving 450 residents on a beautiful 56-acre campus with views of the blue ridge mountains. The community has 276 independent living apartments and cottages, 52 private nursing care rooms, 45 assisted living residences and 12 private assisted living memory care rooms. The organizations commitment is to provide the best services and care for people it serves.
As we began planning for a new Memory Care Center, we found ourselves asking “How will we know what we’re designing is correlating to positive outcomes, not just a pretty picture?” Those of us who have been working in senior living for a number of years will recognize there has been cyclical thinking in design for dementia care. For example, evolving from larger to smaller floor plans or neighborhoods, to a hybrid approach with single-loaded or double-loaded corridors. Thoughts on what works best keep changing. Is there a right answer based on evidence? What creates the best outcomes for residents? Fortunately, Memory Care research shows evidence of how the built environment impacts the psychosocial and emotional well-being of residents living in these environments (Marquardt & Schmieg, 2009; Sloane et al 2002, Nolan 2007).
Research Findings and Evidence Based Design
An increasing amount of research exists today which shows making modifications to the interior environment results in a positive impact on outcomes such as behavior, cognitive performance, function, well-being, social abilities, orientation, and care outcomes. There are specific design interventions which are beneficial to the outcomes for people with dementia (Marquardt, 2014; Ziesel, Silverstein, Hyde, Levkoff, 2013; Pati, 2011; Stichler, 2010).
To understand which key design interventions have been proven in research to have a positive impact on outcomes, Kahler Slater performed a systematic review of 125 articles published between 2000 and 2019. Twenty articles that had strong merit were evaluated using a meta-analysis. The following matrix highlights the organization aspect of this analysis.
The greatest environmental interventions of outcomes in dementia care are: lighting, noise, air-quality, color contrast and patterns, furniture arrangement, creating a personalized more homelike environment, and providing ample environmental cues. Let’s dive in deeper.
Lighting design is the most important and promising for improving health and fall prevention (the third highest cause of death in the US.) It is clear from the research evidence that guidance on lighting design for people with dementia should not be limited to consideration of visual tasks and compensation for deteriorating eyesight. The well-being of those who are physically and cognitively frail is affected by their overall exposure to the cycle of day and night, to sunlight and view. Their freedom from anxiety and the extent to which they can continue the activities they enjoy depends on their perception of the whole place, as well as on the physical support that the building provides.
Multiple studies have shown that it is important to ensure that residents have sufficient daylight exposure, and that they experience a 24-hour Diurnal daylight cycle of light and dark, to minimize the risk of Seasonal Affective Disorder (SAD) and Sundown Syndrome.
Residential buildings used by dementia sufferers should have freely accessible internal areas with strong daylight. In high latitude climates these areas should receive direct sunlight penetration wherever possible, but there should be blinds or other means of control. The daylit areas should be useable for normal daytime activities. Intermediate indoor-outdoor spaces such as conservatories satisfy these requirements. Electric lighting at night should be controlled to provide dark sleeping conditions.
Research shows that bright light therapy in public areas improves sleeping patterns and circadian rhythms and creates less agitated behaviors. Two studies explored increasing the amount of ambient light to around 2500 lux (roughly 250 foot-candles) and found improvements in sleep and a 47% to 55% reduction in disruptive behaviors.
Lighting for people with dementia resources:
JM Torrington BA BArch RIBA and PR Tregenza BArch MBdgSc PhD RIBA MCIBSE CEng
School of Architecture, The University of Sheffield, Western Bank, Sheffield, UK
Received 16 May 2006; revised 4 September 2006; accepted 10 October 2006
Hearing has the most significant impact on quality of life. There is a correlation between high noise levels and increased alterations in memory and other cognitive functions, less tolerance for pain, feelings of isolation and unwanted behavior. Alternatively, pleasant sounds of music (recorded bird song or other small animals, sounds of babbling brooks, for example) have been found to be positively stimulating.
Our sense of smell has a strong hold on human emotions and memory. Olfactory cues can serve as orientation aids and improve wayfinding (for example, locating the kitchen by following cooking aromas.) Exposure to positive cooking smells correlates to improved appetite and food intake. And, no surprise, providing comfortable room temperature and humidity are associated with less agitation and disruptive behavior.
(Torrington & Tregenza, 2006, Sloane et al 2007, Ancoli-Israel et al 1991, Okawa et al 1991, Satlin et al 1992, Mishima et al 1994, Mishima et al 1995, van Someren et al 1996, Okumoto et al 1998, Thorpe et al 2000, Bakker 2003, Hoof, van, J., et al 2010.)
Research studies have found that learning new routes was a slow process for newly admitted residents with dementia. Residents who could not identify paths to desired locations exhibited anxiety, confusion, mutism, and even panic.
Some residents perceived high contrast patterns on the floor as a barrier. They also noted that the typical location of signs (at heights specified by the Americans with Disabilities Act guidelines) is often not seen by residents whose visual field is low to the ground.
Clear distinction between private, semi-private, and public spaces can enhance personal orientation and independence. Placing landmarks such as artwork, plants, ornaments, and photographs at strategic locations can attract attention and provide clues for orientation.
Home-Like Environment and Views
Providing a home-like environment aids in orientation by increasing the sense of familiarity towards everyday life. The information given by all the senses must be consistent and there must also be consistency between the perceived nature of a room and people’s behavior within it. The clues to the nature of the room should fit with a commonsense understanding of the building.
More ‘homelike’ gradation of space may provide small private places for receiving visitors other than the residents’ own bedroom, for example a conservatory or small, quiet lounge. Positive features include a fireplace to recreate social rituals, large windows with interesting views of outdoor activities and soft furnishings that absorb noise.
To provide potentially therapeutic views and enhance opportunities for social interaction, the extent and quality of views from the site should be a factor in the choice of a location for residential facilities. Preferred views are of natural scenes rather than the built environment; people confined within a building enjoy seeing the activities of people outside. The building design itself should ensure that residents receive the benefit of these views. Seating and areas for social interaction should be provided beside view windows.
The choice of surface finishes within the building should enhance the ability of the ageing eye, especially by emphasizing contrast differences. High contrast helps visually distinguish between many elements in a visual field, from doors and walls to the dinner plate and the place setting to the table, which yields more independence with mobility and meals. (Calkins, 2009). Changes of level should be emphasized by increasing contrast between surfaces in different planes, for example: at entrances, between seats and floor, in showers and bathrooms.
According to the Dementia Training Study Centre in Australia, a pioneering organization focused on dementia education and training worldwide, ten key principles that define an appropriate physical environment for people with dementia for their help with psychosocial/ emotional wellbeing are seen in the following graphic.
We also scoured additional research and design guidelines published in other parts of the world. Some commonalities emerged as synopsized in these design drivers:
- Provide unobtrusive inclusion of safety features
- Provide multiple cues through the senses (sight, smell, sound)
- Use objects rather than color for orientation
- Control stimuli, especially noise, but also smell
A Key to WCBR’s Evidence-Based Design Strategy
Following a search for research-based design guidelines, WCBR partnered with renowned expert on dementia care, John Zeisel, PhD Hon D.Sc., President of Hearthstone Institute and the I'm Still Here Foundation, a PhD sociologist who studied the effect of built environment on human behavior and taught at Harvard Graduate School of Design. In the fall of 2018, WCBR was fortunate to sponsor the debut of the PBS documentary film, “Revolutionizing Dementia Care” at the annual Virginia Film Festival held in Charlottesville. The film opens with statistics on dementia around the world, and then introduces Dr. John Zeisel, who became key to the specific evidence-based design strategy in the WCBR Memory Care project we will share with you in this article.
Dr. Zeisel founded Hearthstone Institute, which has received the largest non-pharmacological research funding in the United States from NIH and also developed an approach to Alzheimer’s Care called “I’m Still Here”, which recognizes what a person can do, versus what they can’t do and embraces a hope versus a despair model. Essentially this model says:
If you do this:
- Be in the present
- Be sad but live with it
- See the person
- Appreciate abilities
- Do things together
Then this happens:
- Feel less lonely
- Less apathy
- Less depressed
- Less anxious
- Less agitated
- Less aggressive
- Better relationships
Dr. Zeisel’s following eight design principles inform design for Memory Care as follows:
- Camouflage and control dangerous exits (reduces “elopement”)
- Provide “walking” paths with destinations (reduces “wandering”)
- Provide private and personal places (increases sense of self)
- Decorate distinct common spaces (increases appropriate behavior)
- Provide a safe therapeutic garden (reduces sundowning)
- Keep scale residential and like extended family (decreases agitation)
- Maximize autonomy and independence (increases identity)
- Make sure sensory input is understandable (reduces anxiety)
(Zeisel, Hearthstone Alzheimer Care)
WCBR Memory Care Design
We began our project collaboration by engaging residents in a visioning session, introducing them to Dr. Zeisel and his research. Kahler Slater facilitated a series of creative exercises around a day in the life of several different participants: those who would live in this new environment, their loved ones who would visit and those who would work there. What was our collective vision for what life should be like for all stakeholders? Residents worked in teams to describe ideal experiences given the circumstances, then prioritized what was most important to them. Those goals became our project drivers. We prioritized these project drivers in order of importance from top to bottom on the following matrix and scored where we are today on a horizontal scale of one to five.
Notice that the residents’ top two project drivers are essentially about creating an attractive and supportive environment for caregivers, knowing their own experience often hinges on staff skills, behaviors and attitudes, so this is a critical success factor. Fortunately, part of Dr. Zeisel’s engagement is to train staff in the Hope Model of dementia care, based on his both his research and personal experience as an operator of multiple memory care environments. This caregiver training will positively contribute to a key component of the staff experience and as a result, the resident and family experience.
We ended with brainstorming what it would take to make what is less than ideal today, better in the new environment. This conversation yielded many ideas that influenced the WCBR Memory Care design and even better, many others that might be able to be put in place well before the new design is built.
The WCBR campus is a beautiful 56-acre property with long views to the Blue Ridge Mountains. The outer ring road is lined with independent cottages. The lower half of the campus in this aerial view is skilled care and assisted living. The upper half of the site houses independent apartments. The center of the campus houses dining and other resources, such as large gathering facilities and a Wellness Center. We were working with a steeply sloped site, the last buildable land on campus.
As our plan developed, we created a building form that embraces the sloping site, following the edge of the road to maintain as much space for a center therapeutic garden focal point as possible, similar in size to an existing Fountain Courtyard that residents and the leadership team were familiar with. Entry to the new memory care is on the southwest corner, roughly in the middle of the plan. The lowest level houses parking and support service areas.
We very much appreciated that John Zeisel is also an operator who understands staffing implications of planning decisions, which he shared in his design review as our concepts were developing and eventually refined. In the final plan, the second floor is the only floor of residential care, providing 32 rooms on one floor to maximize staffing efficiencies and flexibility.
Our original preconception was that we wanted to avoid the “institutional feel” of double loaded corridors, but we found we couldn’t design a plan that was workable and affordable within the defined square foot project budget parameters. Single loaded corridors also created amorphous spaces that were hard to define, a sprawling great room that would be confusing for memory care residents. We found that the use of double loaded corridors in the design made the activity spaces more definable and therefore recognizable for residents. This intentionally created spaces that would make sense to residents and would trigger memories. The kitchen looks like a kitchen. The Living Room has a fireplace and feels like a living room. These are not undefined multi-purpose rooms. A happy coincidence occurred when we designed a plan with double loaded corridors. The hinge points between wings became activity areas that will bring in a great deal of natural light from two directions, reducing the need for widespread use of artificial (electric) Circadian Rhythm lighting in public areas.
The kitchen is very purposefully placed in the middle of the plan. As the “heart of the home” it is the largest gathering area. The Memory Care unit entry is located nearby, but unobtrusively, to not draw attention from residents in the kitchen area, however, when someone arrives, staff in the kitchen area will see them. Opposite the kitchen is the library, a place for quieter activities, small family celebrations or queuing for meals. Staff is spread out in the major activity spaces during the day, (an economy of scale benefit of having 32 residents on one floor), hosting different activities throughout the day. The most active group spaces face the garden, a very desirable view because residents have access to the garden, and they can see it from multiple angles as they move through the facility. The garden becomes a familiar orienting device or landmark.
A key goal is to have no dead-end corridors. If a resident is wandering, they don’t need to wonder why they came this way, because no matter where they go, there’s something interesting going on. The Wellness Center, Salon and Spa are in the southwest end of the plan. The Living Room and Clubhouse (a place to play cards or watch sporting events) are to the east of the Kitchen and the Greenhouse terminates the east end, where residents might work with plants or do potentially messy art projects such as painting or sculpture. Throughout the new memory care facility design, activity spaces pierce the footprint with large expanses of glass on opposite sides of the plan to bring in as much daylight as possible, enhancing residents’ circadian rhythms and the physical functions dependent on them.
The centerpiece of the program is the Therapeutic Garden. Residents can enter the garden from the central Dining Terrace or from the Greenhouse. We partnered with Dirt Works Landscape Architecture on the design of the garden from the earliest design conversation, a firm with expertise in garden design for dementia care that also knows Dr. Zeisel’s work very well. The significant slope of the garden site is seen as beneficial; good for exercise for residents and visual clues, from previewing where you’re going, to overviewing from the top at the Woodland Terrace – where you’ve come from. Activity areas are programed for the Dining Terrace, Display Garden and Greenhouse Terrace. Smaller activities for a single or few people, can occur along the Woodland Path or sitting in a small alcove quietly. The Woodland Path is designed to replicate the feel of Charlottesville’s woodland hillsides, preserving legacy trees and adding native plantings.
To create community continuity and to keep the campus design context, the use of building forms and materials; sloped roofs with dark shingles, red brick and white trim will reflect the centuries old Charlottesville tradition. Preserving the view of the mountains from the existing central dining rooms in the distance, is very important to residents. Using Virtual Reality software, our design team was able to experience the arrival sequence, the challenges and opportunities of the slope of the property and massing of the facility. We will use this tool in the future to review interior architecture and advance design development opportunities in the same way.
Since we started working on the new memory care design for WCBR, it became apparent that it was time to find my 91-year-old mother a new home in Assisted Living in the Midwest. I was so relieved to find a new residential setting which also includes memory care that embeds many of these design principles. She’s just moved in and is acclimating to her new environment. It’s too soon to call it her new home, but we’re hopeful that will come with time. And, fun fact – did you know that many of the more senior elders enjoy bragging about their age? Now that’s something to look forward to.