A look through their eyes

Good interior design is an important part of creating safe places in which dementia residents can move about confidently, enjoy a sense of independence and stay safe. “Designing and planning helps enable the caregiving team to provide extraordinary care,” says Mitch Elliott, a licensed architect with RDG Planning and Design, a multistate firm that includes specialties in senior living. “The environment can have a very positive impact on enabling caregivers to do what they do best.”

He and colleague Kelley Hoffman, an interior designer at RDG, shared some thoughts on how facilities can use good design principles to help keep residents with dementia safe and engaged.

Listen to the staff

It’s important to employ best practices in dementia-friendly interior design, but design consultants should never underestimate the importance of staff input at a facility, Hoffman stresses.

“We should follow certain rules about the best ways to help people with cognitive disorders, but you need to marry that with the community’s needs,” she says. “We might go into a facility thinking we can’t use certain design elements or, we will think something is perfectly fine, but the staff may say it won’t work for their residents. We need to respect that.”

As an example, Elliott has seen caregiver feedback change the way bathrooms are designed. “We listened to a certified nursing assistant who said, ‘It would be helpful if you would move this toilet to the other wall, giving us better access.’ And we realized that was a great idea,” he says. “We, as designers, really have to drop our pride, drop any arrogance that might be there and know that we can learn a ton from the people that are really doing the work.”

What do your rooms look like to someone with cognitive decline? Everything from flooring patterns to lighting can help or hurt a resident’s ability to navigate safety and enjoy their surroundings. Elliott and Hoffman take a trip through the most commonly designed spaces to show how specific design elements are interpreted by the dementia-affected brain and how design can be used to encourage healthy behaviors in residents with cognitive decline.

Flooring

When it comes to choosing flooring for a senior living space that serves residents with dementia, Hoffman advises staying away from busy patterns and high-contrast finished materials. However, “You have to balance that with the practical side in terms of maintenance, making sure there is enough pattern that will be forgiving of some soil and staining and will wear well. It’s a fine line,” she says.

Avoid flooring that has a high gloss or a glare under the room’s lighting, since the shine can confuse residents with dementia. “In particular, don’t use anything that will create the illusion of wet floors and discourage a resident from walking across it,” Elliott advises.

This tile mosaic could look like broken glass to a person with dementia.

Carpeting can present visual and navigational issues, Hoffman notes. “We look for a short-pile carpet that is easy to navigate with a walker or wheelchair,” she says. “The texture may make it look like it isn’t [easy], which can be all it takes for a person to feel like they have a hard time getting from point A to point B,” she says.

Transitions between flooring surfaces also are crucial, both as a tripping hazard and a confusing change in surface feel. The age-old technique of using metal or wood transition strips to cover the edges of two different flooring materials creates a cumbersome bump on the floor that can be difficult for people with vision, gait or balance issues. The good news, Hoffman says, is flooring manufacturers have made great strides in creating fusible materials that allow smooth transitions between carpet and hard surfaces. Smooth flooring transitions also benefit staff members because they decrease falls risk and keep wheelchairs and walkers from getting stuck.

Flooring philosophies have changed over the years as the industry has learned more about dementia-related behavior, Elliott adds. For example, it was once thought that putting a solid dark patch of flooring in front of the exit doors would discourage residents with dementia from trying to leave, since it was believed they would perceive it as a “hole” they could not cross. “We thought we were tricking them, but when they see other people walk across that area and leave, they realize it’s the way out and try it for themselves,” he says.

Lighting

A better way to discourage residents from trying to leave or go into otherwise unsafe areas is the strategic use of increased lighting in places you want them to feel free to go and decreased lighting in other areas, Elliott says. “I think lighting is one of the exciting new frontiers that we as designers are going to be able to incorporate into spaces that will really make a difference in the lives of our residents.”

Spot lights and some track lighting can be harsh on elderly eyes and can confuse the circadian rhythm.

One of the most interesting technologies available today is tunable lighting, which changes the intensity and temperature of lighting to better emulate varying times of day and help residents maintain proper circadian rhythms. Warm yellow lighting may emulate a sunny morning, while cool blue lighting can mimic dusk.

“Studies are showing that it improves sleep patterns and reduces sundowning,” he says. “The more that lighting can be adjusted, in terms of temperature, throughout the day, the better it is for residents.”

Although tunable lighting is cost-prohibitive right now, the costs are coming down as the technology advances. In the meantime, some designers and operators are incorporating the idea in a manual way, dimming lights at different times of the day to give residents visual cues and to assist in maintaining circadian rhythms. This practice isn’t as effective as changing the color rendition/temperature of the light, but it helps, Elliott says.

As for night lighting—the tiny wall lights used to help residents navigate from bed to the bathroom, for example—the most important factor is to keep the lights low and out of eye level. Be sure to place the night lights so they aren’t visible to resident while in bed, since being exposed to a constant glow can disrupt sleep, Hoffman adds.

Having the right type of night lighting is important, too, Elliott says. “Amber light, or a warmer tone light fixture that really illuminates the floor, and not the space, won’t interrupt the night circadian rhythms.”

Some new lighting systems are connected to pressure-sensitive mats, so when the resident starts to get out of bed, the night lighting creates a glow that subtly highlights the perimeter of the bed. “If you think about it, that’s where residents need the light,” Elliott says. “Indirect floor lighting is a really good strategy.”

Wayfinding

Residents need ways to differentiate their living spaces from others.

Simplicity of design is key to dementia-friendly wayfinding, Elliott says. Avoid hidden corners and long hallways, and try to not require a resident to make multiple turns to get to a destination.

Color, imagery and shapes can also be used to provide wayfinding cues, Hoffman adds. These might include making the style, shape or color of a resident’s room door or doorway slightly different from others, putting a memorable piece of artwork or a memory box near their room door and creating differentiators for each residence corridor. “It’s best to mix up ideas because what works for one person doesn’t necessarily work for the next person,” she says.

When it comes to using good design to help residents with dementia navigate their environment, Elliott says the scale of a facility is an essential factor. “The distance between areas, whether it’s dining, life enrichment living rooms or the resident’s room, has to be short in order for it to be easy to navigate,” he says. “If they have to navigate the length of a football field to go eat, they are going to quickly become dependent on a team member and a wheelchair.”

Inclusion

This storage area is bright and cheery, but residents can't see any of the items inside the baskets.

Dementia is a devastatingly isolating disease, so providers have extra challenges when it comes to keeping residents with cognitive decline engaged all day long rather than just during activities and meal times. Creating inviting elements within the interior design can help attract attention to group spaces and entice residents to linger in common rooms and social spaces.

In dining areas, try an intimate table for four rather than longer, cafeteria-like tables. Smaller tables tend to encourage interactivity and socialization in a home-like setting. It also gives care teams the ability to group specific residents together during meal times if they haven’t chosen a seat themselves. Inclusion can be enhanced if residents with dementia sit with their friends or with those with similar communication abilities.

For common rooms, Hoffman says, the key is to keep items that encourage interaction—puzzles, games, pictures, stuffed animals and activities—visible and easy to reach without help. Open-shelving units are better choices than closed cupboards, which can look like a solid wall to those with dementia.

Although the industry trend is to give residents more personal space in the form of larger private rooms, it can have the unintended consequence of keeping them separate from the community at large. “The larger and more private rooms are, the less residents come out of them. We are almost creating an apartment rather than a sleeping room,” Elliott says. “We have to be careful that we don’t make them too large and include too many amenities because, at some point, we are encouraging isolation.”