Dementia and the built environment

Dementia is a disease that comes to affect every aspect of a person’s life. It refers to a set of symptoms that may include memory loss and difficulties with thinking, problem solving or language and sensory impairments. There can also be changes in mood or behaviour and the disease can exacerbate the effects of physical impairments. All types of dementia are progressive and each person will experience dementia in their own way. There are well documented costs to the health and social care systems, and personal costs to the thousands of individual carers.

This is an issue that touches everyone. With an estimated 850,000 people living with dementia in the UK, we all have family and friends who have been affected by this most serious and debilitating illness, with its wide ranging symptoms. However, on a positive note, public interest in wanting to contribute to support and improve the lives of people living with dementia is evidenced by the 225 local communities that have already signed up to become Dementia Friendly Communities. This initiative, established by Alzheimer’s Society, galvanises local efforts and support.

But what does it mean for the built environment professions and is there a role for us all to play in combating the effect of the disease and helping people with dementia to live well for longer? I would argue that yes, there is.

Most people with dementia would prefer to stay in their own home for as long as possible, however they are going into residential care homes earlier, because their own homes are not designed to enable them to live independently and can be difficult to adapt to meet their needs. Staying in familiar surroundings with the right support can help people living with dementia continue to lead an active and independent life for longer. Therefore, the local environment can have a significant impact on someone’s ability to do this. This in turn reduces the costs for health and social care.

The RTPI’s practice advice Dementia and Town Planning highlights how appropriately designed local environments and housing can help people with dementia to live independently and well for longer. The advice is endorsed by Alzheimer’s Society with their Chief Executive, Jeremy Hughes saying, "I encourage all concerned to take the RTPI’s useful advice on board and support those with dementia to live the lives they want to."

Our advice argues that if you get an area right for people living with dementia, you get it right for older people, for young disabled people, for families with small children, and ultimately for everyone.

It is vital for their well-being that people with dementia stay as active as they can — physically, mentally and socially. However, Alzheimer’s Society have found that 35% of people with dementia only go out once a week or less, and 10% once a month or less. Having access to local amenities and shops, along with green space within safe and comfortable walking distances contribute to keeping people with dementia active and engaged, leading to better mood, memory and communication and improved concentration.

The design of the external local environment has an important role to play in allowing people with dementia to maintain their independence. Key urban design points to consider are:

Familiar environment: Functions of places and buildings are obvious, any changes are small scale and incremental.
Legible environment: Hierarchy of street types, which are short and fairly narrow. Clear signs at decision points.
Distinctive environment: A variety of landmarks, with architectural features in a variety of styles and materials.
Accessible environment: Mixed land uses with shops and services within a 5-10 minute walk from housing. Entrances to buildings conform to disabled access regulations.
Comfortable environment: Open space is well defined with toilets, seating, shelter and good lighting. Street clutter is minimised along with background and traffic noise through planting and fencing.
Safe environment: Footpaths are wide, flat and non-slip, development is orientated to avoid creating dark shadows or bright glare.

By thinking laterally, a scheme to improve the conservation area of the small town of Kirriemuir has had the added benefit of improving the town for its residents living with dementia. Angus Council worked with the Dementia Friendly Kirriemuir Project and gave planning permission for the change of use for a piece of derelict land to become a dementia friendly garden with a rent of £1.00 per year. The garden will be safe, friendly, outdoor space that people living with dementia and the local community can enjoy. As part of the project street clutter has been reduced to make it easier for older residents to move around, whilst sympathetically improving the appearance of the historic environment.

One of the best ways to understand the needs of someone living with dementia is to talk to them. ‘Walk the patch’ around the local area or buildings to find out what does and doesn’t work for them.

As part of Belfast’s successful application to become a World Health Organisation (WHO) age-friendly city it developed an assessment tool to gauge how accessible the built environment is for older people. It conducted walks with people with dementia living in supported housing to gain their opinions and use their experience of the walking environment in their area. In Bradford, the Face it Together group is wholly led by people with dementia. They have provided feedback on signage and accessibility, advised on a hospital refurbishment and input to the planning of a Westfield Shopping Centre.

This type of approach can be used for individual buildings. Age UK Enfield worked with Enfield Council to explore the potential for their Dementia Hub in Edmonton, North London. A workshop explored the current use of the building and how it can be improved to support a hub for dementia advice and services. It brought together diverse perspectives including Age UK staff, an occupational therapist, service users and carers.

Inside the home, whether this is a family home, extra care housing, residential care or nursing care there are more aspects of good design that can easily be incorporated to help someone living with dementia to be more independent by providing an environment that is clearly defined, easy to navigate, and feels safe. They include:

Safe environment: Avoid trip hazards, provide handrails and good lighting.
Visual clues: Clear signage, sight-lines and routes around the building; clearly defined rooms so the activities that take place there can be easily understood.
Interior design: Avoid reflective surfaces and confusing patterns. Use age and culturally appropriate designs.
Noise: Reduce noise through location of activities and soundproofing. Provide quiet areas as people with dementia can be hyper-sensitive to noise.
Natural light or stronger artificial light: Many people with dementia have visual impairment or problems interpreting what they see.
Outside space: Access to safe outside space, with good views from inside the building as daily exposure to daylight improves health.

These features of good design reflect the Housing our Ageing Population Panel for Innovation (HAPPI) principles, which are based on ten key design criteria. Many are recognisable from good design generally, but they have particular relevance to older persons’ housing which needs to be able to adapt over time to meet changing needs.

The design of specialist dementia care housing is improving. Limewood, in the town of Stafford, is a specialist dementia care home with 59 bedrooms. It includes an innovative dementia hub called the High Street - a 1950s internal street scene with a pub, cinema based on the local Stafford Picture house, and a hairdressers and barbers. It has been independently audited by the University of Stirling and accredited with a gold award for its design.

A more ambitious development that is internationally recognised as best practice in dementia care is in the Netherlands. Hogeweyk Village is home to 152 residents living with dementia. They live in groups in 23 specially designed houses. The village has streets, squares, gardens and a park where the residents move around independently, but in a safe environment. Just like any other village, Hogeweyk offers a selection of facilities, like a restaurant, supermarket and a theatre. These facilities can be used by both Hogeweyk residents and people from the surrounding area.

The types of local environments that work well for people living with dementia also work for all older people, for young disabled people, for families with small children, and ultimately everyone. For this ambition to happen it will require collaborative and innovative thinking between built environment professionals, who can work in partnership with health and social care professionals and really listening and learning from people living with dementia and their carers.

So my point is; if we create places that are suitable to meet the needs of people living with dementia, they will be that little bit kinder for all of us to use.

You can download Dementia and Town Planning here.

This article was originally published in AT ed. 122. It was written by Sarah Lewis MRTPI, Planning Practice Officer at the Royal Town Planning Institute.

--CIAT