Designing A Better Environment For Those Living With Dementia
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Florida Gulf Coast University, Department of Psychology
The physical design of an environment can significantly influence a person’s behavior, mood, perception, and overall quality of life. This is especially true for people living with dementia and memory issues. After reading chapter 14 of Environmental Psychology and Human Well-Being Effects of Built and Natural Setting by Ann Sloan Devlin, I have determined the most important factors needed in order to design better environments for Alzheimer's patients.
In the context of dementia, well-being and quality of life can be particularly difficult to pinpoint. When we typically think about well-being, we usually associate it with concepts like satisfaction, happiness, and wellness. Yet, because we are dealing with individuals with a deteriorating mind, not all of these terms are applicable. Thus, we have to rework our idea of well-being to properly tailor it to patients living with Alzheimer's and dementia.
According to page 370 of the textbook, Eden Alternative (2012) defined well-being as having seven domains. These include; identity, development, autonomy, security, connectedness, meaning, and joy. When you combine all of these concepts together, they allow people to have a firm understanding of their sense of place, resulting in a better quality of life. Although this theory may apply to everyone, this particular perspective on well-being is especially relevant to the elders in our community. It is critical that we keep this framework in mind when we are developing long-term care facilities and special care units.
Another key element that we need to be aware of for individuals living with dementia is the idea of press. In 1973, Lawton and Nahemow developed the Competence-Press Model, which represents the range of pressure and demands a person can tolerate from their environment while still being able to function (Devlin, 2020. p. 366). Too much press results in the person being overwhelmed and overstimulated while too little press leads to boredom and an apathetic lifestyle. In order for an individual to successfully function in their environment, they need to find a healthy balance somewhere in the middle.
In 1987, Hall and Buckwalter further built on this model, specifically tailoring it for individuals living with dementia, and called it the Progressively Lowered Stress Threshold. According to page 367 of the textbook, Hall and Buckwalter found that individuals with dementia can only manage a small range of lower environmental press before moving into more negative behaviors. This means that it is very easy for people living with dementia to get both overstimulated and understimulated by their environment. So, although it is best to keep things simple in Alzheimer's units and memory care facilities, there still needs to be a level of cognitive effort and interaction between them and their environment.
The demand for nursing homes, long-term memory care facilities, and Alzheimer's units largely stems from how drastically society has changed over the past 100 years. Advancements in medicine have led to people living longer lives and advancements in technology have led to people moving farther away from home. For centuries, families would stay close together and take care of each other when members got sick or old. Now, the macrosystem we relied on for generations has changed and we are not able to responsibly look after or support our elders like we once could.
The macrosystem refers to our culture as a whole. Societal norms, social norms, values, traditions, and beliefs are all a part of the macrosystem. It is important to recognize that America’s current macrosystem tends to value hard-working, able-bodied individuals that can contribute a lot to society and often dismisses the elderly, viewing them as a burden. All of these factors have directly led to our current situation where we rely on these long-term care facilities to look after the older members of our society.
The fact of the matter is that our society needs to change the way we view memory-loss problems like dementia and Alzheimer's. We have created a stigma around the topic that has become inadvertently harmful. Too often we focus on the negatives, labeling certain behaviors as “challenging”, “difficult”, or “need-driven” when in reality, it is just how we are framing it. We need to start focusing on the more positive aspects, not just trying to manage the negative ones.
The first book on this topic was written in 1988 by Calkins and listed the “five ‘Environment and Behavior Issues’ that could support individuals living with dementia: wayfinding and orientation, privacy and socialization, personalization, safety and security, and competence in daily activities” (Devlin, 2020. p. 374). This was a revolutionary publication because it restructured the way many viewed dementia by shining a positive light on it. Then in 1991, Cohen & Weissman continued to expand on Calkins's list and included, “opportunities for stimulation and change, maximize autonomy and control, adapt to changing needs, establish links to the healthy and familiar (Cohen & Weisman, 1991)” (Devlin, 2020. p 374). Focusing on ways to improve well-being and quality of life helped make a difference for those living with dementia and Alzheimer's.
In regards to the overall organization and design of long-term memory care facilities that we have developed for dementia patients, I believe we should invest in unit models just like the Green House/small house movement. In my opinion, traditional institutional-style designs are outdated, unwelcoming, unfamiliar, and isolating. Elements like hospital lighting, tight quarters, and long narrow corridors would not seem appealing to most. As I discussed in the well-being section, it is important to feel like you are at home, have autonomy, and are part of a community. That is why I think the Green House/small house movement is the gold standard
The Green House/small house movement is an example of an exosystem, which are systems or settings in place that affect an individual regardless of their involvement. The Green House/small house movement is a community specifically designed for people living with dementia. It is made up of free-standing homes that are tightly clustered together where a dozen or so full-time residents can safely participate in normal activities with little environmental press. This is a humane, ethical, and natural setting that ensures an individual's quality of life and allows them to actually enjoy it.
References
Calkins MP. Design for dementia: Planning environments for the elderly and the confused Owings Mills, MD: National Health Publishing; 1988.
Cohen U, Weisman J. Holding on to home: Designing environments for people with dementia Baltimore, MD: Johns Hopkins University Press; 1991.
Devlin, A. S. (2020). Environmental psychology and human well-being effects of built and natural settings. Academic Press, an imprint of Elsevier.
Eden Alternative. (2012). The Eden alternative domains of well-being. Rochester, NY. http://www.edenalt.org/about-the-eden-alternative/the-eden-alternative-domains-of-well-being/
Hall G, Buckwalter K. Progressively lowered stress threshold: A conceptual model for care of adults with Alzheimer’s Disease. Archives or Psychiatric Nursing. 1987;1(6):399–406.
Lawton MP, Nahemow L. Ecology and the aging process. In: Eisdorfer C, Lawton MP, eds. Psychology of adult development and aging. Washington, DC: American Psychological Association; 1973;619–674.