4.2 History and fundamentals of Dementia Friendly Environments.
4.2.1 Short History of Environmental Design
We live immersed in a stage where all the demographic and social changes described are leading us to rethink the system or model of social health care for the elderly and people with disabilities or dementia, gradually abandoning the traditional systems based on family and residential care to use, and moving towards new innovative systems combining very different factors, where people are regaining the prominence of their own destiny and research is advancing at very different levels.
This idea is framed within the philosophy of “person-centred care”, where the person himself is at the centre and centre of the planning of the social health care model, taking into account his wishes and preferences and counting on his participation in the process of making all the decisions that concern you. The person-centred care model requires changes not only in organization and in services or programs, but also in professional roles and in physical environments, where all services and programs will be developed, and where that person will live. (Martínez, 2011).
Person-centred care must promote from all angles that the person who receives it is capable (with the necessary support in each case) of being able to develop their personal autonomy to the maximum to continue controlling their own life project, minimizing as much as possible their dependence.
This model therefore focuses on the part of the capabilities and desires of the beneficiary who, in addition, will be the one who controls and chooses the services and the way to provide them, which will be designed in a way that optimizes the possibilities of achieving the life project of the elderly person (Bermejo, 2009), which applies equally to the person living with dementia. The design of accommodation systems will also assume this conceptual framework, bringing therapeutic interventions and the residential model closer to daily life, in a way that increases the quality of life of the users of this accommodation.
The World Health Organization emphasizes this subjective dimension of the Quality of Life concept: «the perception that an individual has of his place in existence, in the context of the culture and the value system in which he lives and in relation to his objectives, your expectations, your standards, your concerns. It is a very broad concept that is influenced in a complex way by the physical health of the subject, their psychological state, their level of independence, their social relationships, as well as their relationship with the essential elements of their environment.
Within these essential elements, the importance of the environment is recognized: People are more independent and we exercise greater control over our affairs if the environment that surrounds us (both the physical and social environment) makes it possible and facilitates it. For this, it will be necessary to adapt and organize the environment according to those who enjoy it and what it is intended to achieve. That is why environmental intervention is considered as one of the main proposals for improving care in centres (Martínez, 2011).
The environment, the home where we live is a basic necessity, but many homes do not adapt to the needs of the users, or to the changes that they undergo throughout their lives, which in the best of cases causes the need to undertake works of great cost and inconvenience, or to have to move to a new home or environment in the worst of them. Therefore, it can be affirmed that many times it is the environments themselves that contribute or limit people’s capacities, and it can be stated as stated in the Stockholm Declaration of the EIDD (European Institute for Design and Disability): “Good design enables. Bad design disables”.
When we speak of “environment”, we have to understand the word as the sum of the following concepts:
(Size of spaces, lengths, visual connections etc ..)
(Size and type of furniture, signage, flooring, colours, etc.)
(Smells, temperature, sound, lighting, reflections, etc.)
(Interpersonal relationships, communication, etc.)
According to the environmental competence model (Lawton 1984), the environment-person relationship is determined by the relationship between the level of personal competence and environmental demand (figure 9): the lower the competence of a person, the influence of the environment on its capacities is greater, reducing them to be able to carry out any activity.
It follows that the physical environment has a special influence on people in a situation of dependency, and on people who suffer from cognitive impairment. It is necessary to design environments that promote maximum autonomy and integration, as well as physical and psychological well-being and maximize people’s capacities that is facilitating environments.
Personal competence depends on factors such as health, sensory abilities, cognitive and motor skills. Environmental demand, on the other hand, is determined by the real physical characteristics of the surroundings, and by the subjective ones.
There are several environmental factors and characteristics that are related to objective and subjective well-being, for example: accessibility, security, light, noise, type of access, view to the outside, decoration, privacy, spaces of socialization, the size of the rooms, their organization or vision, etc.
But, the starting point, the fundamental axis of environmental design must always be the user, the person. Each person has different tastes or preferences, but in addition, certain cognitive, psychological and behavioural characteristics, and this means that their relationship with the space that surrounds them is different, they perceive it differently, more markedly even if they suffer from some type of cognitive impairment.
The environments must respond to the realization of the activities of daily life, leisure, socialization and in short the day-to-day in them. They must give a specific response to the particular needs of each person, allowing them to be able to use the skills they maintain and reducing their frustration, so that they achieve the highest quality of life.
There are certain key aspects that will be developed below that promote the objectives pursued: family sensation, social interaction, personalization or sensory stimulation are essential for a person in a situation of dependency to make use of their capacities, to be able to orient themselves within a space or remain calm and collected.
The characteristics of people are therefore particular, their relationship with the surrounding space as well, and therefore, the response that this environment must give and the way to evaluate the effect that this space has on people must also be particular.
In this sense, the environmental adaptation of the spaces must be part of a complete care process to be able to adapt to the needs of the people and improve their quality of life, which should cover all the areas that determine a new model of care: organizational, structural, environmental, functional, professional, etc.
In the case of environmental adjustments, the cycle could be represented as follows:
Therefore, it starts with the people themselves, their needs at the time of the evaluation, their preferences, their hobbies, their family, etc. Of what has been called his “life story.” This will determine many of the environmental actions to be carried out, because although the psychological and behavioural symptoms of people may be common (especially in the case of suffering from some type of dementia), the responses to the stimuli that the environment can cause they are not always the same. For example, music may not have the same effect for everyone, a bathroom may be less stressful than a shower, or they may recognize a traditional tap but not a mixer. It is therefore necessary to know people well to be able to select the most appropriate measures for them. In this sense, it seems evident, therefore, the necessary participation in each phase of the cycle of evaluation and / or action by the people themselves, the family members and the caregivers, who are the ones who know the person who suffers from dementia best .
Likewise, and given that dementias are persistent and progressive syndromes, it will be necessary for the protocol to be considered as a continuous evaluation to be able to certify the incidence of the proposed environmental changes, and to adapt and modify them as the disease progresses in each person. In the same direction, as the person may gradually lose the ability to communicate, the observation of their reactions, gestures, etc., will be an important part and basis of the analysis and obtaining information for this continuous evaluation, in addition to the caregivers themselves and relatives.
From all these data, the need to move towards the constitution of multidisciplinary teams is extracted that complement their knowledge and provide all the necessary knowledge to advance in the direction marked towards the improvement of the integral quality of life of people: gerontologists, psychologists, assistants, relatives, architects, managers and above all and in the central point, the people themselves and their relatives from the initial stages in case of suffering from any disease.
4.2.2 Dementia and environments
As you have already seen, dementia is a clinical syndrome characterized by a persistent and progressive deterioration of higher brain functions (memory, language, orientation, calculation or spatial perception, among others).
This deterioration entails a loss of the autonomy of the patient, who becomes increasingly dependent on others, as well as a detriment to the social, work and leisure activity of the patient and the caregivers of him.
Therefore, a dementia is a syndrome, a set of symptoms that usually appear together and that produce a whole series of consequences in the people who suffer from them.
We can classify the symptoms into three large groups:
- Cognitive symptoms.
- Psychological and behavioural symptoms.
- Functional alterations.
All of these symptoms are related in some way to the environments around people. Let’s see some examples.
Memory loss is the main and most characteristic symptom of this disease. There are several types of memory:
-Immediate memory. It is what we use to retain important or necessary information for a certain time (a few seconds).
-Recent or short-term memory. Data storage ranges from a few days to several weeks. The loss of this type of memory implies that the person will not be able to remember events that have occurred recently. At first, you will forget events that happened a few days ago and that time will gradually shorten until, in advanced phases, you will not remember what you did a few hours or a few minutes ago.
-Remote or long-term memory. This type of memory is capable of storing large amounts of data from our biography until we remember distant events, who we are, what we have done, how our life has happened.
In the person suffering from Alzheimer’s, remote memory lasts longer, with short-term memory and closer events being lost earlier.
People with Alzheimer’s will have difficulty remembering and organizing events that occurred in their lives. At first, distant memories will remain intact, while more recent events will be lost early.
Sometimes, the patient remembers his past life as if it were a current event and therefore may forget that he has grandchildren, children or they believe that they still live in the town.
RELATIONSHIP WITH THE ENVIRONMENT
These memory deficits impair the learning capacity of people with dementia, which can lead to problems such as great disorientation in new places, forgetting where certain rooms are or where things are stored, as well as difficulties in learning new routines or using objects not relatives.
All of these problems are aggravated when the person with dementia is institutionalized and thus introduced to a new environment. One way to alleviate the effect of a new environment is by introducing nostalgic elements that encourage the reminiscence of vital events (photo albums, memory boxes, etc.).
-Temporary orientation: you begin to lose track of the date you are on, not recognize the exact day, month and year, etc.
-Spatial orientation: begins to become disoriented in spaces that are not very familiar or known and gets lost. Later it will be lost in more well-known places. Finally, they lose their orientation within their own home and do not know how to locate the different rooms.
-Personal orientation: the dementia patient, already in moderate stages, ceases to have knowledge of his self and does not know who he is: nor his likes and hobbies, what he has worked on or by which members the environment is composed and his family.
People with dementia lose their temporal orientation first, later their spatial orientation, and finally their personal orientation.
RELATIONSHIP WITH THE ENVIRONMENT
When the environment of a person with dementia is simple and hardly changes, the feeling of security increases, and therefore orientation difficulties are alleviated.
In this sense, visual signals, indications, and posters – drawings, words, arrows, etc. – they will favour not only the orientation in the usual environment, but also they will remind the function of for example the cabinets.
In addition to these considerations, it is important that the main roads are clear of obstacles.
Anxiety is an unpleasant emotion of anguish that arises in the face of certain events or situations that we feel overcome or threaten us.
The causes or events that produce anxiety can be very varied and we all look for a way to avoid this state of anxiety, all except dementia patients, who are disoriented in time and space, without the ability to remember why he or she is in that place, without recognizing it, without being able to understand or communicate their anxiety or what causes it, etc.
RELATIONSHIP WITH THE ENVIRONMENT
The environment must therefore be simple, clear, and easy to perceive and understand, with tools to help compensate for disorientation.
The impersonal, cold, unrecognizable spaces, with a hospitable character, without stimuli, etc. alarmingly increase the anxiety of people with dementia.
When a person with dementia can still walk or support himself, another possible form of expression of the anxiety described is through erratic walking or wandering.
People walk and walk without a specific destination, moving from one place to another without any purpose. This erratic ambulation has an added risk such as the risk of falls or flight and loss.
RELATIONSHIP WITH THE ENVIRONMENT
The actions against this behaviour are directed towards three key aspects:
-The need to establish safe itineraries where they can wander erratically.
-The necessary removal of obstacles and barriers in these areas.
-The control of the risk of leakage.
An environment free of hazards must be created, where the person can move freely and safely, and prevent the person from leaving through doors that allow the exit of the residential centre or into dangerous places, either with appropriate supervision, through surveillance or other strategies such as conceal the doors so that they look like part of the wall.
In the same way, adequate planning of the spaces must be carried out, clearing the line of sight of obstacles, with spatial continuity, which in turn will facilitate the orientation of the person with dementia. The ideal solution is usually loop-shaped circuits.
5-ALTERATION OF THE APPETITE:
Appetite can be another parameter where people with Alzheimer’s have difficulties: not being able to concentrate on an activity, losing the ability to perform tasks, etc. appetite and the amount of food eaten tends to drop significantly.
RELATIONSHIP WITH THE ENVIRONMENT
It has been proven how spaces designed to avoid agitation – smaller dining rooms or with fewer people – or the introduction of other elements – an aquarium in the dining room, or music at the appropriate level – make people with dementia maintain better nutrition and show less upset during meals.