The Dementia Enabling Environment Principles are based on the work of Prof. Richard Fleming and Kirsty Bennett, University of Wollongong. These principles have an evidence base and have been constructed from reviewing the 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, secure and easy to move around if they are to make the best of their remaining abilities. However, obvious safety features and barriers will lead to frustration, agitation and anger and so potential risks need to be reduced unobtrusively.
2. Provide a human scale
The scale of a building will have an effect on the behaviour and feelings of a person with dementia. The experience of scale is determined by three 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 help the person feel in control.
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 what they will find if they head in a certain direction. When they 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 find their way to 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 from where they spend most of their time. This reduces their anxiety and the anxiety of the residents.
4. 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 helpful. The full range of senses must be considered. Too much visual stimulation is as stressful as too much auditory stimulation.
5. Optimise helpful 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 ie providing a number of cues to the same thing, recognizing that what is meaningful to one person will not necessarily be meaningful to another. A person may recognize their bedroom, for example, because of a view, the presence of furniture, the colour of the walls, the light fitting and/or the bedspread. Cues need to be carefully designed so that they do not add to unhelpful stimulation.
6. Support movement and engagement
Aimless wandering can be minimised 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 space
The person with dementia is more able to use and enjoy spaces and objects that were familiar to them in 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. This will involve an understanding of the personal background of the people living in the environment.The involvement of the person with dementia in personalising the environment with their familiar objects should be encouraged.
8. Provide opportunities to be alone or with others
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 spaces, some for quiet conversation with one or two others and some for larger groups, as well as spaces where people can be by themselves. These internal and external spaces should have a variety of characters, e.g. a place for reading, looking out of the window or talking, to cue the person to what is available and stimulate different emotional responses.
9. Provide links to the community
Without constant reminders of who they were, a person with dementia will lose their sense of identity. Frequent Interaction with friends and relatives can help to maintain that identity. This is made easier when the person is admitted from the local community as friends and relatives are able to drop in easily. The environment must include spaces for the resident and their visitors to use within the unit and in its immediate surrounds. These need to be attractive and comfortable to encourage visitors to come and spend time. Stigma remains a problem for people with dementia so the unit should be designed to blend with the existing buildings and not stand out as a ‘special’ unit. Where possible a ‘bridge’ should be built between the unit and the community by providing a space that is used by both the community and people with dementia. 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. Respond to a vision for way of life
The environment should support the person with dementia to lead a life that has meaning and value to them. The choice of this 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 becomes 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.
1. Fleming R, Bowles J. Units for the confused and disturbed elderly: Development, Design, Programmimg and Evaluation. Australian Journal on Ageing. 1987 November;6(4):25-8.
2. Fleming R, Forbes I, Bennett K. Adapting the ward for people with dementia. Sydney: NSW Department of Health; 2003.