Dementia Enabling Environment Principles

The Dementia Enabling Environment Principles are based on the work of Professor Richard Fleming and Kirsty Bennett, University of Wollongong. These principles are evidence based, and have been constructed from reviewing research literature of studies looking at maximising enablement and wellbeing for people living with dementia through physical design.

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 a 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 minimise 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 minimise their confusion and uncertainty. Consideration needs to be given to providing redundant cueing i.e. providing a number of cues to the same thing, recognising 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 recognise 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 or 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 or 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.

References:

1. Fleming, R., Zeisel, J. & Bennett, K.
   THE DIGNITY MANIFESTO OF DESIGN FOR PEOPLE LIVING WITH DEMENTIA
   https://designdignitydementia.com/manifesto-2​​

For further information, read the literature review undertaken as part of this principle development. These principles are an extension of work first published in 1987 (1) and continued in 2003 (2).

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