Dementia-friendly architecture: Reducing Spatial Disorientation in Dementia Care Homes

Lead Research Organisation: Bournemouth University
Department Name: Faculty of Science and Technology

Abstract

Knowing where we are and how to get to places are fundamental features of successful everyday living. Although most of us rely automatically and unquestioningly on our wayfinding abilities, they are markedly impaired in people with Alzheimer's disease (AD), the most prevalent form of dementia. This project will identify the features of buildings that make them relatively harder or easier for people with AD to navigate. The knowledge gained will allow us to create dementia-friendly architectural guidelines for use in the design of residences for people with AD.

Many people with AD eventually move from their familiar home environments into unfamiliar care homes. Unfortunately, the dramatic reduction in wayfinding skills commonly seen at the onset of AD is particularly marked when it comes to learning unfamiliar environments. Thus, people with AD would have an easier transition to new residences if these larger - and often more institutional - environments were designed to be dementia-friendly in terms of wayfinding. A psychological understanding of orientation and navigation could play a major role here but, unfortunately, current design-guidelines are mainly based on custom and practice, not theory and research. This project aims to improve matters through a series of experiments on navigation in people with AD.

Our research is innovative in several ways: We will use Virtual Reality (VR) technology to simulate unfamiliar care home environments. VR lets us change environmental features and structures systematically, to monitor how these changes impact on learning to way-find over a period of several weeks. This would be impractical in real world settings. Additionally, by using state-of-the-art eye tracking technology to record gaze direction, we can pinpoint the types of cues people use to find their way through unfamiliar environments (www.spatial-cognition.org). Finally, our experiments will allow us not only to measure the way in which navigation abilities decline in people with AD, but also to identify the mechanisms underlying these declines.

Successful navigation depends on learning to recognise places by identifying and remembering landmarks, environmental cues that are unique to each location. We will investigate this process in more detail. Our experiments will examine how AD impacts on landmark selection by comparing the performance of people with AD and healthy adults of a similar age (age-matched controls). Our participants will learn routes through virtual residences that include multiple intersections. We will systematically vary the features present at the intersections to determine whether people with AD have particular difficulties when the same distractor cues are present at more than one intersection, and/or when uninformative cues are nevertheless particularly noticeable (salient).

Next, we will use VR to simulate what happens when people move into unfamiliar residences. Over several weeks, we will (a) teach people with AD and age-matched controls to navigate a number of different routes through the same environment, and (b) compare their ability to discover new routes through the same environment, based on knowledge of the routes they have just learned. VR allows for systematic comparisons of different floor plans, so we will be able to establish the kinds of architectural structure that either help or hinder wayfinding in people with AD.

A key output of the research will be a set of empirically validated design guidelines that support effective wayfinding in people with AD. Because these principles will be widely applicable, we will work with architects, building standards agencies and care commissioning bodies to ensure that they are used to develop national standards for residential care home design. Our research will thus help to increase or preserve the independence and well-being of people with AD, avoiding a further loss of autonomy, dignity and control that is, in theory, preventable.

Planned Impact

Who will benefit from this research?
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The primary beneficiaries of this research are people with Alzheimer's Disease (AD) and other forms of dementia, and their families and carers. Currently 800,000 people in the UK, including 80% of care home residents, live with dementia. This figure, which is expected to double within 30 years as longevity is extended through improved medical care, is reflected throughout much of the developed world. In 2012, the Prime Minister launched a dementia challenge to improve dementia awareness, care quality, and research by 2015 (https://www.gov.uk/government/publications/prime-ministers-challenge-on-dementia/).

One of the earliest signs of AD is spatial disorientation. This has a devastating effect on independence, wellbeing, and quality of life. It is therefore crucial that the design of care homes is sensitive to the problems experienced by residents and, whenever possible, capitalises on their residual navigational abilities. Current guidelines for dementia-friendly design reflect awareness of these issues, but they rely on architectural custom and practice, or intuition, to guide construction and furnishing (e.g., http://dementia.stir.ac.uk/design/design-guides). Not surprisingly, the resulting solutions are not well integrated with the neuropsychological wayfinding theory on which our research builds, nor with empirical evidence of the kind that we will gather.

A central goal of our impact strategy is therefore to ensure that our research findings be disseminated effectively to potential users of research. Foremost amongst these are policy-makers at international, national and local levels and care commissioning bodies, who are in a position to influence dementia care through legislation or regulation. Likewise, the architects who design care homes, the care organisation managers who commission them (working either for companies and their shareholders, or public services), and the residential care providers who manage the staff teams that service them are important potential consumers of our research. Access to these groups will be facilitated through existing contacts of the Bournemouth University Dementia Institute (BUDI).

How will they benefit from this research?
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The research can bring about improvements in the health and quality of life of people with dementia by informing design-principles for environments that promote independence, access to outside spaces thus reducing agitation and frustration through difficulties in navigating the physical spaces where they live. The families of people with dementia will benefit from the reassurance that their loved ones live in environments designed to meet their needs, ensure their safety, and protect their independence as far as possible. These benefits will come about because we will work with policy-makers, architects, and representatives of the care provision industry to ensure our guidelines are adopted in future design of care homes and, wherever possible, incorporated into the refurbishment of existing facilities.

BUDI (Bournemouth University Dementia Institute) has many contacts with stakeholder to whom our research will be of immediate interest. We would expect the successful completion of the project to coincide with further applied or translational research to evaluate the impact of our dementia-friendly guidelines to the design of residential facilities. For example, we would seek KTP funding with a major care provider and/or architectural studio to ensure that this work proceeds seamlessly. Wider adoption of our design principles would then follow, supported by further research and dissemination. The likely timescale for such implementation in the UK would be around 5 years from the start of the project. We would expect to then see widespread major changes in practice with corresponding benefits to people with AD living in care homes and their families within 5-10 years of the design implementation process.

Publications

10 25 50
 
Description With other experts in the field, the PI has published a comprehensive review on the "Aging Navigational System" in a high-impact journal (Neuron). The article provides an overview of behavioural and neuroscientific findings and outlines the state-of-the-art knowledge about the cognitive functions and mechanisms that involved in navigation are affected by (a)typical ageing.
We ran a series of experiments exploring the role of (visual) attention on people's ability to learn novel routes through unfamiliar environments and investigating the role of landmark placement on their ability to learn to navigate unfamiliar environments.
Findings from the first project part showed that our older participants' route learning performance was worse than younger participants. Importantly, older participants showed significantly higher variability, while there was substantial overlap between age groups, with many older adults performing similar to our younger participants. These findings suggests that ageing does not affect all participants equally, but that some older participants were less protected from age-related cognitive decline than others. Interestingly, these individual performance differences were strongly associated with declining verbal and episodic memory abilities, suggesting that these measures could be sensitive indicators for declining navigation abilities. The eye-movement data revealed further systematic differences between age groups. Specifically, older adults spent less time looking at navigationally relevant landmark objects, highlighting a specific age-related difference in the control of attention that is likely to contribute to declining route learning abilities.
We also investigated whether age-related declines in executive control of attention contribute to navigation deficits. The results highlight that directing attentional resources to the navigationally relevant situations is an important factor contributing to successful route learning, and that older adults only did so efficiently much later during route learning than younger participants.
In the second part of the project we manipulated the positions of landmarks to investigate the effect of landmark placement on the ability to learn unfamiliar environments. Results demonstrate that older participants had substantially more difficulties than our younger adults to form a 'cognitive map' of the environment. The careful placement of landmarks in our care home-like environment, however, did help older participants substantially to navigate novel environment. These findings have important implications for the interior design of care environments.
We have started a new collaboration with Dr Laczo (Charles University in Prague). We have shared experimental software paradigms and Dr Laczo's group has collected data from participants with MCI, participants with Alzheimer's Disease, and control participants. Preliminary data analysis suggests that our paradigms reliably distinguish cognitively normal population from individuals with early clinical Alzheimer's Disease, which has important implications for the development of sensitive assessment tools for the early diagnosis of AD.
An important aim was to develop improved dementia-friendly design guidelines for care environments, as current guidelines do not target wayfinding specifically, are not well integrated with (neuro-)psychological theories and are often not evidence-based. On basis of our literature review and our own findings, we have now created improved dementia-friendly design guidelines and run first workshops training care home managers and architects on how to improve the interior design of their care environments to reduce spatial disorientation.
Exploitation Route Key findings have been and will be published in several journal publications. We also will make all data available once we have published it, so it can be used by other researchers.
Based on our findings and under guidance of an advisory board with relevant stakeholders, we developed improved design guidelines for dementia-friendly environments. A first draft of these has now been made available at: https://microsites.bournemouth.ac.uk/wayfinding/consultancy/ . Once the design guidelines have been finalised they will be widely disseminated using different media (online website, app for devices like phones or tablet PC's, printed as a handbook). The design guidelines are meant to be accessed by architects, interior designers, care home developers among others who are involved in planning and developing environments for older people and people with memory complaints.
Sectors Communities and Social Services/Policy,Construction,Environment,Healthcare

 
Description Spatial disorientation, one of the earliest signs of Alzheimer's Disease (AD), has a devastating effect on people's independence, wellbeing, and quality of life. Given that 80% of care home residents have AD and other forms of dementia, it is crucial that the design of care homes supports residual navigation abilities, thus compensating for the loss of navigation skills where possible. While current design guidelines for dementia-friendly environments reflect awareness of these issues, they mostly rely on architectural custom and practice, or intuition, to guide construction and furnishing (e.g., http://dementia.stir.ac.uk/design/design-guides) rather than on experimental evidence. Accordingly, the design guidelines are not well integrated with the neuropsychological theories of wayfinding and navigation. The aim of this project was to address this issue. In order to do so, we: 1.Set up a "Research to Impact Advisory Board" to guide the process of translating findings from our fundamental research into design guidelines that are applicable in real residential environments. The board first met in January 2017 and further meetings were be held every 6-9 months to learn about the progress of our research and, in collaboration with the researchers, advice on future work. Members were also asked to advise on dissemination strategies. The Advisory Board brings together relevant key stakeholders (carers, care home managers and developers, architects and designers with a special interest in dementia, representatives of UK dementia charities and academics ) to facilitate the process developing improved guidelines and their dissemination. 2.We have reviewed existing (neuro-)psychological research that can be used to inform dementia-friendly design guidelines. We have now finalised this literature review and compiled it into an review/opinion paper that will be submitted to an international peer-reviewed journal shortly (autumn 2018). 3.On basis of the discussion with the advisory board (1), the literature review (2) and the results from our experiments carried out in this project, we have created novel dementia-friendly design guidelines that aim to minimise spatial disorientation in the built environment. We have published the first version of these guidelines here: https://microsites.bournemouth.ac.uk/wayfinding/consultancy/ . We continue to work on and improve these design guideline. 4.We have received additional internal funding to carry out an interview study with care home managers to assess their knowledge of "dementia-friendly design", how they assess information, and what their preferences are for receiving education or educational material. We are currently using this information to inform the development of educational material (see below). 5.On basis of the results from this project, the extensive literature review, our discussions with the Advisory Board, our interview study, and our dementia-friendly design guidelines, we have developed educational material for care home manager, care home staff, architects and interior designers. We have run first workshops in autumn 2018. Results from these workshops demonstrate that participants gained increased knowledge and confidence in changing environments to minimise spatial disorientation. 6.We are currently preparing case studies in which we will work with care homes to improve their interior design in order to minimise spatial disorientation. The effectiveness of these measures for residents ability to orient, and accordingly their independence and well-being will also be assessed. 7.We are in the process of evaluating a new scale to assess the navigability of built environments, specifically of residential developments and care homes. Once successfully validated, this assessment tool will be combined with the dementia friendly design guidelines and will allow staff of care homes to assess how well their environment is suited to support navigational deficits in people living with dementia.
First Year Of Impact 2017
Sector Communities and Social Services/Policy,Construction,Environment,Healthcare
Impact Types Societal

 
Description ARUK South Coast Network pump priming grants - Summer Studentship
Amount £2,177 (GBP)
Organisation Versus Arthritis 
Start 06/2018 
End 09/2018
 
Description Internal funding for PhD project to work closely with ESRC project and to support dissemination of results
Amount £56,000 (GBP)
Organisation Bournemouth University 
Sector Academic/University
Country United Kingdom
Start 01/2016 
End 12/2020
 
Description Research Assistant to support dissemination of findings, development of ageing and dementia friendly design guidelines based on our work, organising of advisory board
Amount £2,000 (GBP)
Organisation Bournemouth University 
Sector Academic/University
Country United Kingdom
Start 03/2017 
End 07/2017
 
Title Development of new Research Tool 
Description During the project, we have developed new Virtual Environments (VE) and new experimental paradigms using these VEs that are now used in other projects (e.g., undergraduate as well as postgraduate research projects) to study cognitive mechanisms and strategies involved in route learning. 
Type Of Material Improvements to research infrastructure 
Year Produced 2017 
Provided To Others? No  
Impact The tool and the VEs are now widely used in our research group for a number of other projects. We plan to make these tools freely available once we have published first data. 
 
Title Open Access Database Hartmeyer et al 
Description Data of own research made available to access openly on UK DataService ReShare . Database title: Effects of cognitive aging on attentional engagement during route learning 
Type Of Material Database/Collection of data 
Year Produced 2016 
Provided To Others? Yes  
Impact Data has been submitted for publication in December 2016 (awaiting further status) to "Frontiers in Psychology". 
URL http://reshare.ukdataservice.ac.uk/852534/
 
Title Open access database - Grzeschik et al., 2019 
Description All data used in Grzeschik et al. (2019) has been made available. 
Type Of Material Database/Collection of data 
Year Produced 2019 
Provided To Others? Yes  
Impact Data has just been made available, no impact so far 
URL http://reshare.ukdataservice.ac.uk/853592/
 
Description Developing ageing- and dementia-friendly design guidelines 
Organisation Arts University Bournemouth
Country United Kingdom 
Sector Academic/University 
PI Contribution On basis of the project we started a new collaboration with the graphic design department at the Arts University Bournemouth. We provided knowledge about how (a)typical ageing affects navigation abilities and ideas of how environmental design can be used to compensate for declining navigation abilities.
Collaborator Contribution Colleagues from the Arts University and their students help us with creating explicit design suggestions for our improved dementia-friendly design guidelines that are suited to be implemented in real world scenarios.
Impact This is a multi-disciplinary collaboration in which we work with colleagues from a design department to develop improved design guidelines. Work is still ongoing and first tangible outcomes are expected later in the year.
Start Year 2018
 
Description The effect of MCI and Alzheimer's Disease on Navigation abilities 
Organisation Charles University
Country Czech Republic 
Sector Academic/University 
PI Contribution We have shared experimental paradigms (software) to investigate the effect of typical ageing, MCI and AD on navigation abilities with Dr Jan Laczo from the University of Prague. We have also contributed and are still contributing to the analysis of the data collected in Prague. This collaboration is a direct result of the presentation of data from this project at an international workshop and subsequent discussions with Dr Laczo.
Collaborator Contribution Dr Laczo and his team have used our experimental software and have collected data from participants. Data collection is nearly finished now.
Impact Data collection is nearly finished and the data will be presented by a member of Dr Laczo's team at the next iSCAN meeting in Magdeburg/Germany in November 2018 (https://events.dzne.de/event.php?vnr=f-10a). We will subsequently publish the results from this study in an international peer reviewed publication.
Start Year 2017
 
Description ADRC's Annual Open Public Meeting 2016 
Form Of Engagement Activity Participation in an open day or visit at my research institution
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact It was the most successful event of the Ageing and Dementia Research Centre (ADRC) yet with close to 100 people attending including academics, local practitioners, business, charity and care managers as well as people with dementia and their care partners. The event consisted of five presentations delivered by ADRC staff and PhD researchers. The post-presentation activities included a networking and poster session, and a Dementia Friends Awareness Session as part of ADRC's wider aim to ensure Bournemouth becomes a Dementia-Friendly University.
Year(s) Of Engagement Activity 2013,2014,2015,2016
URL http://blogs.bournemouth.ac.uk/dementia-institute/past-events/
 
Description ARUK Southcoast Network Public Meeting 2018 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact In January 2018 Prof Jan Wiener presented his current ESRC project at the ARUK (Alzheimer's Research UK) Southcoast Network Public Meeting to the public.
Year(s) Of Engagement Activity 2018
 
Description ARUK meeting Southampton 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Supporters
Results and Impact On the 1st February 2017 Southampton University hosted an annual Alzheimer's Research UK (ARUK) public awareness event. The Ageing and Dementia Research Centre (ADRC) was invited to set up a display and provide information about ADRC's services and research. Jan Wiener from ADRC, along with scientists and clinicians from the local ARUK network demonstrated and provided information about Alzheimer's disease and other dementias, current treatments and the latest research. The event was attended by many members of the public, carers and students. ADRC was able to provide information about the services it can provide and insight from ongoing research. The day was very well received by the public and was said to be an 'excellent event".
Year(s) Of Engagement Activity 2017
URL http://www.alzheimersresearchuk.org/dementia-researchers-share-findings-public-southampton/
 
Description Article in newspaper (Guardian) reporting on our work to improve dementia friendly architecture 
Form Of Engagement Activity A press release, press conference or response to a media enquiry/interview
Part Of Official Scheme? No
Geographic Reach National
Primary Audience Public/other audiences
Results and Impact Article in the Guardian (both in print and online) reporting on our work to improve dementia friendly design/architecture.
Year(s) Of Engagement Activity 2018
URL https://www.theguardian.com/lifeandstyle/2018/jul/02/how-design-helping-people-with-dementia
 
Description Bournemouth University Festival of Learning 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact As part of the Festival of Learning the Ageing and Dementia Research Centre presented their work on Dementia Friendly Architecture to the public.
Year(s) Of Engagement Activity 2017
 
Description Dorset Wide Memory Advisers Group Meeting 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Professional Practitioners
Results and Impact We presented our work on Dementia Friendly Architecture at the meeting of the Dorset Wide Memory Advisers Group.
Year(s) Of Engagement Activity 2017
 
Description Invited talk at Lincoln University 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Postgraduate students
Results and Impact Jan Wiener gave a talk about "The effects of typical and atypical ageing on orientation and spatial navigation" at the weekly Research Seminars at the School of Psychology, Lincoln.
Year(s) Of Engagement Activity 2016
 
Description Mind body soul - Alzheimer's society event 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Patients, carers and/or patient groups
Results and Impact This was a 4 day event in which we presented our work on Dementia Friendly Architecture to patients and carers.
Year(s) Of Engagement Activity 2017
URL http://www.mindbodysoul.gallery/alzheimer-s-society.html
 
Description Public lecture on dementia-friendly architecture 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Public lecture about dementia-friendly-architecture attended by > 50 people from the public which sparked lively discussions and very positive feedback.
Year(s) Of Engagement Activity 2018
URL https://blogs.bournemouth.ac.uk/research/2018/04/12/adrc-presented-at-a-bu-public-lecture-day/
 
Description Residential Provider Forum 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact We presented our work on Dementia Friendly Architecture to the Residential Provider Forum organised by Bournemouth Council.
Year(s) Of Engagement Activity 2017
 
Description Residential Provider Forum March 2017 
Form Of Engagement Activity A formal working group, expert panel or dialogue
Part Of Official Scheme? No
Geographic Reach Local
Primary Audience Policymakers/politicians
Results and Impact Ramona Grzeschik will attend this forum on 30 March 2017. The forum is meant to discuss the Bournemouth Council's Commissioning priorities and their current view of the Care Home Market (Supply and Demand, Quality and Sustainability). There will be information sharing on a range of subjects, and an opportunity to network with other Care Home Proprietors and Managers. Also in attendance on the day: NHS Dorset, Skills For Care, Partners In Care, Bournemouth's Workforce Development Team, "Alive", Equipped For Living, and others.
Year(s) Of Engagement Activity 2017
 
Description Talk to the Bournemouth Natural Science Society 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Geographic Reach Regional
Primary Audience Public/other audiences
Results and Impact Invited public talk at the Bournemouth Natural Science Society describing our work around dementia-friendly architecture
Year(s) Of Engagement Activity 2018
URL http://bnss.org.uk/event/lecture-the-science-of-human-navigation/