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Quirke, M.; Bennett, K.; Chau, H.; Preece, T.; Jamei, E. Environmental Design for People Living with Dementia. Encyclopedia. Available online: https://encyclopedia.pub/entry/48632 (accessed on 27 July 2024).
Quirke M, Bennett K, Chau H, Preece T, Jamei E. Environmental Design for People Living with Dementia. Encyclopedia. Available at: https://encyclopedia.pub/entry/48632. Accessed July 27, 2024.
Quirke, Martin, Kirsty Bennett, Hing-Wah Chau, Terri Preece, Elmira Jamei. "Environmental Design for People Living with Dementia" Encyclopedia, https://encyclopedia.pub/entry/48632 (accessed July 27, 2024).
Quirke, M., Bennett, K., Chau, H., Preece, T., & Jamei, E. (2023, August 30). Environmental Design for People Living with Dementia. In Encyclopedia. https://encyclopedia.pub/entry/48632
Quirke, Martin, et al. "Environmental Design for People Living with Dementia." Encyclopedia. Web. 30 August, 2023.
Peer Reviewed
Environmental Design for People Living with Dementia
This is a peer-reviewed entry published in Encyclopedia Journal, full entry can be found at 10.3390/encyclopedia3030076

The term ‘environmental design for dementia’ relates to both the process and outcomes of designing to support or improve cognitive accessibility in physical environments. Environmental design for dementia is evidenced as an effective nonpharmacological intervention for treatment of the symptoms of dementia and is associated with higher levels of independence and wellbeing for people living with a variety of age-related cognitive, physical, and sensory impairments. Evidence-based dementia design principles have been established as a means of supporting both the design and evaluation of environmental design for dementia.

cognitive access dementia design environmental design independence therapeutic environment evidence-based design assessment tools supportive built environment

1.1. Background

Dementia is a widely misunderstood condition, leading to widespread stereotyping, stigmatisation, and mistreatment of people who live with it. Accordingly, before discussing environmental design for dementia, it is important to develop an understanding of dementia, how it manifests, and how this, in turn, impacts the abilities and experiences of people living with dementia.

1.1.1. Dementia

Dementia is a collective term for a range of symptoms that are caused by disorders affecting the brain and have impacts on memory, emotion, behaviour, and thinking. The most common type of dementia, Alzheimer’s disease, represents around two-thirds of diagnoses [1][2]. Other common types include frontotemporal, vascular, and Lewy body dementias. While dementia is most associated with a loss of memory, this is only one of many potential cognitive impairments that a person living with dementia can experience. Dementia can also affect mood, sensory perception, language, learning, problem-solving, and more based on the type of dementia, the specific affected areas of the brain, and the relative stage of disease progression being experienced. Accordingly, social and environmental support needs can vary widely from one individual to the next. More than 55 million people worldwide are now estimated to be living with dementia [2]. This figure is forecast to reach 152.8 million by 2050, with the largest increases expected in developing countries [3].
Dementia is not considered to be a normal process of ageing [4], and an increasing number of younger people under the age of 65 are being diagnosed with ‘early onset’ dementia [5]. Nonetheless, the incidence of dementia increases with age. In the US, for example, the incidence of dementia among people aged 70 to 74 years is around 3%, but the incidence rises to around 22% among those aged 85 to 89 years [6].

1.1.2. Misinformation, Language, and Stigma

Despite strong evidence to the contrary, a common misconception remains that people living with dementia lack the ability to live independently [7]. This, in turn, fuels the incorrect assumption that a diagnosis of dementia automatically results in the need for admission to residential care. This lack of awareness is also pervasive among health and care professionals, as indicated in a 2021 report suggesting that 33% of clinicians think of the diagnosis of dementia as a futile exercise, since they hold the belief that nothing can be done for the person [8].
The words used in reference to people living with dementia, such as ‘sufferers’, ‘senile’, or ‘demented’, have impacted how dementia is perceived. Not only can this type of language have a dehumanising effect on individuals living with dementia, but it can also add to stigma, contribute to fear of the condition, reinforce outdated stereotypes, and affect how people living with the condition are treated in the community.
Stigma is still identified as a major barrier to diagnosis by 46% of people living with dementia and their carers [9]. Dementia advocates believe this will change over time through community awareness and education, increasing recognition of the rights and experiences of individuals living with the condition, as well as changes in language. This is most notable in the evolution of terminology for describing the ‘behavioural and psychological symptoms of dementia’ (BPSD) [10]. Where ‘behavioural disturbances’ were once deemed to be direct and independent symptoms of dementia itself, they have come to be better understood as emotional or physical ‘expressions of unmet needs’ or ‘needs-driven behaviour’ [11]. They can also be thought of as a distressed reaction by the individual to an experience of a diminished sense of ‘choice and control’ over environmental conditions [12]. Accordingly, terms such as ‘challenging behaviour’ and ‘behaviours of concern’ are gradually being discouraged in favour of more informed and respectful terms, such as ‘changed behaviour’ or ‘responsive behaviour’ [13][14].
Consistent evidence from across the globe indicates that 61–70% of people living with dementia can remain living at home in their community when provided with appropriate practical and social support [15][16]. Many people living with dementia remain active, often taking on paid or voluntary roles in community organisations within their communities. Some even find new careers working as authors, researchers, or dementia rights advocates. Well-known examples in this area include Agnes Houston and Wendy Mitchell in the UK, Helen Rochford-Brennan and Stephen Kennedy in Ireland, Tomofumi Tano in Japan, Christine Thelker in Canada, and Kris McElroy in the US. An especially notable example is Kate Swaffer, an Australian who was diagnosed with younger-onset dementia just before her 50th birthday. She was advised after her diagnosis in 2008 that she needed to ‘give up work, give up study and go home and live for the time’ she had left [17]. Instead, Swaffer completed bachelor’s and master’s degrees and, in 2014, founded an international organisation, Dementia Alliance International (DAI), which gives a global voice to people living with dementia, demanding respect and inclusion for them. She remained chairperson of the DAI until 2022.

1.1.3. Environment and Wellbeing with Dementia

The traditional biomedical approach to health, with its focus on disease diagnosis and the amelioration of objective symptoms of physical and mental illness, has been criticised for largely ignoring the roles of the physical and social environments in supporting or undermining wellness [18]. In 2003, the alzheimerHealth Organisation (WHO) identified a multitude of nonbiomedical contributors to wellbeing, which they referred to collectively as ‘social determinants of health’ [19]. These contributing factors include social inclusion, discrimination, equitability in access to services and amenities, and the physical environment, including living conditions.
Huber et al. expanded part of this towards a dynamic understanding of social health, which was characterised by three dimensions: the ability to fulfil one’s obligations and potential, the ability to manage life with a certain degree of independence, and the ability to participate socially [20]. Under the notion of social health, a state of wellbeing can be achieved when people living with dementia are able to actualise opportunities to maintain or reclaim some of their abilities and make adaptations to their limitations [21].
The built environment has a significant impact on the independence and wellbeing of people living with dementia. It affects their behaviour, affective responses, and ability to engage in both basic activities of daily living (ADLs) and instrumental activities of daily living (IADLs) [22], whereas unsupportive or poorly designed physical environments can be a contributory cause of unwanted responsive behaviours, anxiety, agitation, and spatial disorientation [23]. Well-designed environments can provide affordances that allow the individual to remain at ease, optimising independence and compensating for physical, sensory, or cognitive impairments [24].
The experience of dementia and its associated cognitive challenges can be different from one individual to the next, meaning that the cognitive prosthesis or support required from the environment will differ from one person to the next. While it is important that the design of the built environment can respond to and support individuals’ specific needs, the application of broad evidence-based dementia design principles remains important due to their known universal benefits across a wide range of cognitive, physical, and sensory impairments.
The potential complexity of environmental design for dementia is further highlighted when we consider that people living with dementia are also more likely to experience a wide range of physical and sensory disabilities, such as hearing impairment, mobility impairment, and visuospatial perception issues [25]. This overlap of different impairments can further undermine the person’s ability to understand and then navigate their social and physical environments, compounding any barriers to autonomy. Designing for people living with dementia therefore requires architects and others to possess the knowledge and skills to design for all three types of impairment: cognitive, sensory, and physical.
In a care setting, a close relationship between the design of the environment and its operation is essential. A focus on person-centred care [26][27], for example, aligns well with the notion of creating supportive and therapeutic physical environments. This signifies a shift from task-oriented care concerned with symptoms and disability to a support-based approach that emphasises the capacities, preferences, and potential of the whole person [28].
The built environment plays supportive and therapeutic roles in supporting people living with dementia [29][30]. Such an interactive relationship acknowledges diverse lived experiences and sensory perceptions of space and place according to a person-centred understanding of the environment [31]. This person-centred approach to design also needs to address the diversity of roles, identities, and life experiences of different people coming from different cultures [32]. Culture serves as a therapeutic resource in caring for people living with dementia, in which sensitivity to different cultural environments is heightened [33]. Culturally appropriate interiors and outdoor spaces correlate with individual identities, personal experiences, and traditional practices, which are embedded in cultural contexts [34].
There is a significant, helpful cross-over between the principles of design for people living with dementia and other key movements in accessible environments, universal design, and salutogenesis. Universal design recognises that people have changing needs at different stages in their lives. It proposes the creation of environments that can be adapted and changed by factoring in design features that enhance quality of life [35]. Salutogenesis is an approach that focuses on motivation, strengths, and assets, to maintain and improve the movement towards health. It centres on creating a sense of coherence, which has three components: comprehensibility, manageability, and meaningfulness [36].
All three approaches build upon the moral and philosophical basis of the long-established disability rights movement, which, with the support of the United Nations, has led to widespread legislative grounds on the need to ensure equality in the provision of access to environments, goods, and services for people living with disability [37][38]. However, despite the addition of dementia as a recognised form of disability within the UN Convention on the Rights of Persons with Disabilities (CRPD) (2006), national-level policies and legislation of individual member countries rarely acknowledge this [39].

1.2. Dementia Design Evidence Base

Several reviews of the dementia design research evidence base concur that the design of physical environments can have substantial impacts on people living with dementia [40][41][42][43][44]. Fleming et al. (2008 and 2010), for example, graded the reliability of preceding literature, confirming to designers that they may confidently employ ‘guiding principles’, such as providing unobtrusive safety, maximising visual access, and controlling levels of sensory stimulation [40][41]. More recently, Bowes and Dawson (2019) organised their assessment and discussion of the evidence base with respect to designing for specific uses of the environment (e.g., mealtimes and eating), room types (e.g., bathrooms), and building types (e.g., hospitals) [42]. Although they identified several specific gaps in the evidence base for various environment types beyond long term residential care settings, they concluded by stressing the need for designers to cater for a wide range of individual needs among occupants living with dementia. The World Alzheimer Report 2020 (WAR 2020) included a number of accessibly written literature reviews that are organised according to a set of dementia design principles [45]. They include, among others, a review of dementia design in residential aged care by Harrison and Fleming (2020) and a review focusing on home modifications for dementia by Osborne (2020) [46][47].
Building on the research evidence base, many authors have published lists of dementia design principles. Some notable examples include frameworks by Cohen and Weisman (1991), Calkins (1998), Judd et al. (1998), Marshall (1998), Regnier (2002), Marcus and Sach (2014), Grey et al. (2015), and Halsall and MacDonald (2015) [35][48][49][50][51][52][53][54]. However, the most sustained development and testing of dementia design principles over the past 35 years has been undertaken by Fleming, Bennett, and colleagues. Fleming and Bowles (1987) proposed eight design principles [55]. Bennett (2000), then Fleming, Forbes, and Bennett (2003) added further design principles [56][57]. These principles were further developed and refined over the next decade to become the Fleming and Bennett principles listed below [58]. Under Fleming and Bennett’s principles, environmental design for dementia should:
  • Unobtrusively reduce risks;
  • Provide a human scale;
  • Allow people to see and be seen;
  • Reduce unhelpful stimulation;
  • Optimise helpful stimulation;
  • Support movement and engagement;
  • Create a familiar place;
  • Provide a variety of places to be alone or with others;
  • Link to the community;
  • Design in response to a vision for way of life [58] pp. 32–33.
In WAR 2020, Bennett et al. evaluated, summarised, and mapped 15 different sets of dementia design principles against the ten Fleming and Bennett Principles (Table 6, pp. 41–44) [58]. Bennett et al. concluded that although other authors had approached the topic in a variety of ways with varying terminology, they had been consistent in their aim of providing a framework that would allow designers to respond to various needs, lifestyles, preferences, and socioeconomic and cultural backgrounds of occupants whilst taking local geography and climate into account. This exercise also showed that the Fleming and Bennett Principles encompassed the full combined range of design considerations covered by other sets of dementia design principles [58].
Since their earliest emergence, Fleming and Bennett’s principles have been used by state and national-level organisations to inform and evaluate environmental design for dementia in hospital and residential aged care settings [55][57]. For example, they are currently used by the Australian Aged Care Quality and Safety Commission to guide environmental assessments as part of their federal role in regulating quality aged care. The Fleming–Bennett principles form the foundation of a range of ‘Environmental Audit Tools’ (EAT) [55][56], which are now in use worldwide.

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Martin Quirke
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Terri Preece
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Elmira Jamei
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