Gregor Timlin

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The ability of care home residents is extremely diverse. Two factors account for this. The first is that disability rises with age and greatly increases the probability that residents will have a concurrence of different disabilities. The second is simply that care homes by their very nature exist to cater for those with high levels of disability who need help with day-to-day tasks.

In the UK the current average age of a care home resident is 83. 40% of people aged 85 and over are disabled by frailty, disease or sensory loss. 29% of people aged 85 have Alzheimer’s disease and either cancer, heart disease or a respiratory disease. (2)

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(1) Adapted form national disability follow up survey appearing in: Paterns of functional loss among older people: a prospective analysis, David Seidel, Human Factors, Vol. 51, No. 5, Oct 2009, pp. 669-680
(2) Fact finding interview: Dr Graham Stokes, ARUP, February 2011

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Although factors such as depression, the absence of a partner or family members are contributing factors that necessitate people needing to enter care, the main cause is disability.

Even though is difficult to predict what impact medical advances our current lifestyles will have on future health, emerging evidence suggests that as we live longer, we also spend longer in poor health. The expected number of years spent in poor health in Great Britain rose from 6.4 to 8.8 for men between 1981 and 2002, and from 10.1 to 10.6 for women. (1)

The number of disabled older people in the UK is projected to double from approximately 2.3 million in 2002 to approximately 4.6 million in 2041. (2) Based on current prevalence rates, the number of older people with dementia could rise from 684,000 to 1.7 million by 2051, an increase of 154 percent. (3)

In 2000 research from the Department of Health suggested that, “if nothing changed in the current housing situation, occupied places in care homes and hospitals would need to rise by 151 per cent, from around 450,000 to around 1,130,000 by 2051, and some estimates project long-term care expenditure as rising by around 325 per cent in real terms between 2002 and 2041.” (4)

The current National Dementia Strategy understandably encourages people to live independently at home for longer. However given the severity of disability that conditions like dementia create for people in their later stages many living at home will still need to enter care at some point. Current trends among care home providers suggest that they are seeing progressively higher levels of disability in new residents. (5)

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(1) Lifetime Homes, Lifetime Neighborhoods, A National Strategy for Housing in an Aging Society, A green paper form The Department of Health and The Department of Work and Pensions, 2008, p34

(2) Wittenberg et al (2006)

(3) Personal Social Services Research Unit, PSSRU (2007).

(4) Lifetime Homes, Lifetime Neighborhoods, A National Strategy for Housing in an Aging Society, A green paper form The Department of Health and The Department of Work and Pensions, 2008, p35

(5) Fact Finding Interview: Dr Graham Stokes, commenting on Bupa’s internal census. ARUP, February 2011

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At present, it is estimated that 700,000 people in the UK have dementia (1). The likelihood of developing dementia becomes greater the older a person is: 1.3 percent of people in the UK aged 65-69 have dementia, rising to 20 per cent of those over 85 (1). As population in both developed and developing countries are aging rapidly, the number of people with dementia will increase. It is forecast that the number of individuals with dementia could more than double to 1.7 million by 2051. (1)

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(1) Knapp M and Prince M, Kings College London and London School of Economics, 2007, Dementia UK (London Alzheimer’s Society), pxii.

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The following descriptions are taken from the Alzheimer’s Society Fact sheet 458 and concisely describe the differences in progression of the four leading causes of dementia:

Alzheimer’s Disease: “Alzheimer’s is often described using three stages. In the early stages, the person is likely to experience memory loss, difficulty learning new things or making decisions, some degree of disorientation and bewilderment, and social withdrawal. The middle stages are associated with more serious disorientation, for example getting muddled about day and night, getting lost, and putting themselves at risk by forgetting to turn off household appliances; with increasing difficulty recognising family and friends; and also problems with visual perception which may have a very significant effect on their ability to function independently. Finally, in the later stages, the person is likely to have difficulties with swallowing and eating, lose control over bodily functions and lose all, or virtually all, of their speech.” (1)

Vascular Dementia: “People with vascular dementia will experience a gradual decline in their abilities, while others find that they may remain steady for some considerable time and then suddenly decline as the result of another stroke.” (1)

Frontotemporal: “Those with frontotemporal dementia tend to first to experience behavioural changes associated with damage to the front part of the brain, including, uncharacteristic rudeness and selfishness, along with loss of inhibition and the development of obsessive behaviour and then later develop symptoms more similar to those of Alzheimer’s disease.” (1)

Lewy Bodies: “A person with dementia with Lewy bodies; on the other hand, is more likely in the earlier stages to experience visual hallucinations, have difficulty judging distances (leading to falls) and experience some of the symptoms of Parkinson’s disease such as slowness of movement and tremors. Later, again, the symptoms are likely to develop on a similar basis to Alzheimer’s disease.” (1)

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(1) Alzheimer’s Society (2008) The Progression of Dementia, Factsheet 458, (London: Alzheimer’s Society) available at: www.alzheimers.org.uk/factsheet/458.

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There are many reasons why a person enters care. Severe dementia is only one cause. Others include the lack of family support to stay at home, social circumstances such as not having the necessary life experience to look after oneself or simply having a lack of available choice. The study below shows that there are people in all stages of dementia living in care. Designers need to take a broad view of ability and ensure environments offer appropriate opportunities for residents to enjoy life regardless of the stage of dementia they are experiencing.

Proportion of care home residents in the UK with different levels of cognitive impairment 2005 by MDS Cognitive Performance Scale; Intact 15%, Mild Impairment 8%, Moderate Impairment 21%, Moderately Severe Impairment 13%, Severe Impairment 27%, Very Severe Impairment 5%. (1)

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(1) Visualized from: Darton, R., Forder, J., Beddington, A. et al. (2006) Analysis to support the Development of the Relative Needs Formula for Older People: Final report. PSSRU Discussion paper 2265/3, University of Kent: Canterbury

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1A. Memory loss: “He had difficulties taking messages. He would answer the phone and forget what it was about 20 minutes later. On one occasion he forgot he had already taken medication and took an almost fatal overdose.”

1B. Awareness of difficulties: “He began to have trouble driving. He had difficulty judging distances and had a number of crashes. The neurologist politely encouraged him to give up. He found the loss of independence really hard and would ask if he could continue every time he had an appointment. He wasn’t aware of his own difficulty.”

1C. Calculation: “I (his carer) had to do the tax returns. He could no longer handle numbers”

1D. Reading: “He lost the ability to read music but continued to improvise creating the most beautiful and complex pieces.”

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Ref: Insights from patient & carer interviews

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2A. Poor Judgment: “He burnt a hole in the counter top with a pot and almost started a fire. From then on he no longer cooked. He had lost confidence. From then on we did things together. When preparing meals I’d cook and he’d chop. As time passed he would need gentle reminding but he would participate and he enjoyed it.”

2B. Social Isolation: “He became socially isolated. People stopped addressing him. It was as though he didn't exist. Some people are afraid of dementia. Dues to problems in fluency in language many of his friends dropped off, a lot of them were archenemies, the relationship changed. Social norms are kicked and longevity compromised.”

2C. Sequencing: “Dressing became difficult. He would put his arms in wrong sleeves. No physical problems it was perceptual. As time moved on I would have to make more hands-on intervention.”

2D. Challenging Behavior: “I had to distract him when washing; he could no longer do it properly and would get upset if he thought we were doing it for him. I always wonder if I took over too early. If you don’t use it you lose it.”

2E. Way finding: He couldn't find the toilet in his own hall. I started to leave the door open so he could see it.”

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Ref: Insights from patient & carer interviews

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3A. Loss of balance: “He would bump into objects and take short steps. He began to fall a lot when getting in and out of chairs. Eventually he needed a standing hoist.”

3B. Shared Activity: “He continued being pushed in his wheelchair for walks with three faithful friends.”

3C. Dignity: “Very important to get up and dress despite being dependent. This was about dignity and orientation, the importance of not looking at the same piece of wall.”

3D. Helping Him Eat: “Helping him eat could to take 40 minutes to an hour for just two small bowls and a thickened drink. You can’t rush it. You have to work at their pace.”

3E. Palliative Care: “Cognition and physical function had been almost chewed away. That’s when sensory, psychological and spiritual needs became so important. He still needed time and attention, smiling faces, eye contact, handholding and the feeling of being loved.”

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Ref: Insights from patient & carer interviews

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All memory starts with our perception of information taken in through our senses. The brain processes this information into sounds, objects and surfaces, leading to our understanding of the current environment. (1)

With short-term memory we manipulate and rearrange information within the span of attention. We draw information into our working memory from both our long-term memory banks and our current perception. A person can usually hold information for about 20 seconds before it starts to decay. (2)

In dementia a person’s short-term memory is affected very early on. Damage to the Hippocampus and other areas can affect short-term memory meaning new information is more rapidly lost and storage to long-term memory banks becomes more hit and miss. (3) This difficulty can progress to the point where short-term memory is almost non-existent.

This problem changes the way we have to think about activity and service provision. Watching TV becomes about the sound, visuals or the long-term memories of the particular program when a person can no longer follow a current story. Offering an appropriate choice in what a person eats means showing people two options of real meals directly in front of the person before they dine.

In our interviews, working memory problems brought up basic issues such as not being able to remember phone messages shortly after they were taken and an almost fatal overdose when one individual forgot they had already taken medication that day. As dementia progresses, short term memory impairment becomes much more profound. (3)

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(1) The brain book, Rita Carter, Dorling Kindersley Limited, Great Britain, 2009, p158-159

(2) Inclusive Design Toolkit, John Clarkson, Roger Coleman, Ian Hosking and Sam Waller, Kall Kwik Cambridge, 2007, p72-99

(3) Understanding dementia, 2006. [DVD] Suzanne Cahill, Robert Coen, Ireland: DSIDC

(4) Interview: Several interviews where carried out with life long carers who cared for a person with dementia intimately in their own homes over the entire duration of their life with dementia.

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Visual Perception:

Include storage in private rooms that allows residents to see where they have left important objects such as reading glasses. Layout buildings to ensure important facilities such as the toilet and the outside can be seen. Namazi and Johnson have shown good supporting evidence of this idea. In their study, when a toilet was made visible, residents with dementia used it eight times more than when it was hidden by a curtain.(5)

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(5) Namazi, K. H. and B. D. Johnson (1991a). “Environmental effects on incontinence problems in Alzheimer’s disease patients.” American Journal of Alzheimer’s Disease and Other Dementias 6(6): 16-21.

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Controls of levels of stimulation by environmental manipulation and staff practices have become defining features of Special Care Units for people with dementia (1)(2). Evidence suggests that residents are less verbally aggressive when sensory input is more understandable and such input is more controlled (3)

In our interviews it was clear that a person could be overwhelmed when too many things were going on at once. This could often lead to situations where the person would incorrectly respond to sensory information they where receiving. (4)

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(1) Grant, L. A., R. A. Kane, et al. (1995). “Beyond labels: nusing home care for Alzheimer’s disease in and out of special care units.” Journal of the American Geriatrics Society 43(5): 569-76

(2) Morgan, D. G., N. J. Stewart, et al. (2004). “Evaluating rural nursing home environments: dementia special care units versus integrated facilities.” Aging & Mental Health 8(3): 256-65.

(3) Zeisel, J., N. M. Silverstien, et al. (2003). “Environmental correlates to behavioural health outcomes in Alzheimer’s special care units.” The Gerontologist 43(5): 697.

(4) Interview: Several interviews where carried out with life long carers who cared for a person with dementia intimately in their own homes over the entire duration of their life with dementia.

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Archetypical single function rooms:

Including normal activity rooms such as kitchens, TV rooms or gardens allows the two working memory inputs of long-term memory and perceptual information to match up. Avoid multi-use spaces. Common rooms should have one function in which there is no competing sensory input distracting the person from the activity that is taking place. (1)

Meaningful sensory input:

Allow meaningful sensory input including sounds, smells, lighting, colours, heat and touch that reinforces the memories associated with the activity that is taking place. (1) Minimize distractions that disrupt a person’s ability to concentrate such as busy viable entry doors. Minimising the presence of P.A. systems (2)(3), alarms, loud televisions (4), corridors and crowding (5) have been shown to be beneficial to people with dementia.

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(1) Zeisel, J., N. M. Silverstien, et al. (2003). “Environmental correlates to behavioural health outcomes in Alzheimer’s special care units.” The Gerontologist 43(5): 697.

(2) Cohen U., & Weisman, G.D. (1991.). “Holding on to home : Designing environments for people with dementia.” Baltimore: Johns Hopkins University Press,.

(3) Brawley, E. C. (1997). “Designing for Alzheimer’s disease. Strategies for creating better care environments.” New York: Wiley

(4) Hall, G., Kirschling, M.V., & Todd, S. (1986). “Sheltered freedom – An Alzheimer’s unit in an ICF.” Geriatric Nursing, 7,:132-137.

(5) Nelson, J. (1995) “The influence of environmental factors in incidents of disruptive behaviour.” Journal of Gerontological Nursing, 21,(5): 19-24

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Long-term memory involves a widespread network of brain areas, including the sights, sounds, words or emotions that were associated with the memory when it was first experienced. (1).

Long-term memory includes the recollection of your personal past. In the early stages of dementia, autobiographical memory, particularly older memory or memories in which the person has self-interest, are maintained better (2).

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(1) The Brain Book, Rita Carter, Dorling Kindersley Limited, Great Britain, 2009, p158-159

(2) Understanding Dementia, 2006. [DVD] Suzanne Cahill, Robert Coen, Ireland: DSIDC

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Morgan and Stewart have pointed out that single bedrooms offer opportunities for personalisation, familiarity and continuity with the past, supporting a sense of security and individual identity (4). Even though there can be a loss of sense of self, memories can be primed through the environment (3). Zeisel, Silverstein et al. have shown residents to have fewer instances of anxiety and aggression when given individual personal spaces and opportunities for personalization (5).

Privacy:

Include one person bedrooms with en-suite and showering facilities. Ensure bedrooms have entrances independent of common spaces(5).

Personalization:

Ensure residents can easily personalise their rooms. Provide adequate space to bring in one’s own furniture (5). Ensure the room is of a size and shape to allow easy rearrangement and natural customisation of the space.

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(4) Morgan, D. G. and N. J. Stewart (1998). Multiple occupancy versus private rooms on dementia care units.” Environment and Behaviour 30(4): 487-503.

(3) John Zeisel, Inquiry by Design: Environmental / Behavior / Neuroscience in Architecture, Interiors, landscape, and planning, Cambridge University Press, US, Revised Addition, 2006, P372

(5) Zeisel, J., N. M. Silverstien, et al. (2003). “Environmental correlates to behavioural health outcomes in Alzheimer’s special care units.” The Gerontologist 43(5): 697.

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Designing environments, which tap into a person’s long-term memory strength, can also help provide recognition and continuity for the individual. It can help the person use existing memory to function without having to learn the new patterns of living or social rules associated with more institutional care models.

Home-like settings have been shown by Reimer, Slaughter, et al. to improve quality of life for adults with middle to late-stage dementia when compared to traditional institutional facilities (1). Their study showed residents had reduced anxiety and increased in interest in their surroundings. Zeisel, Silverstein et al. have shown lower levels of overall aggression amongst residents living in home-like settings. (2) Wells and Jorm showed no difference in the rate of deterioration when comparing groups of people living in home-like care with matched groups of people living at home with dementia who accessed community services such as respite care. (3)

Home-like philosophy:

Design the interior and gardens to reflect a domestic atmosphere (3). Use non-institutional qualities in staff clothing, décor, linens, wall accessories, furniture and lighting. Include several living and activity areas where people can engage in normal activities (3). Include daily activities that take place in a typical home such as helping in the kitchen, sweeping the floor and sitting by the fireplace (1).

Size:

Design each unit to house between 7-15 residents (2). Ensure there is low perceived crowding. Decreased density 10 people, self contained units (1). Enhanced staffing ratios - enable - personal care – leisure - rehabilitation activity (1).

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(1) Reimer, M., A. , S. Slaughter, et al. (2004) “Special Care Facilities Compared with Traditional Environments for Dementia Care: A Longitudinal Study of Quality of Life.” Journal of the American Geriatrics Society 52(7): 1085

(2) Zeisel, J., N. M. Silverstien, et al. (2003). “Environmental correlates to behavioural health outcomes in Alzheimer’s special care units.” The Gerontologist 43(5): 697.

(3) Wells, Y. and A. F. Jorm (1987). “Evaluation of a special nursing home unit for dementia sufferers: a randomised controlled comparison with community care.” Australian & New Zealand Journal of Psychiatry 21(4): 524-31

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The difficulty of not being able to recognizing an objects use is called an agnosia. Damage to the parietal lobes and temporal neocortex cause agnosia by disrupting the semantic memory system. Agnosia can also affect the ability to recognize a person who was previously well known. A person with dementia may fail to recognize a spouse or mistake them for someone else. (1)

Recognition of what an object is and how an object should be used is more likely to happen if the person has strong memories of using similar objects regularly during their lifetime. Unfamiliar objects are more challenging because they require a person to learn new information that they then have to store and then recall. (2)

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(1) Understanding dementia, 2006. [DVD] Suzanne Cahill, Robert Coen, Ireland: DSIDC

(2) Inclusive Design Toolkit, John Clarkson, Roger Coleman, Ian Hosking and Sam Waller, Cambridge, 2007, p72-99

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Archetypical Furnishing

Use screw taps instead of mixers taps in bathrooms and kitchens. Use Georgian style front doors with archetypical panelling to enter bedrooms to reinforce the idea that this is the entrance to a person’s private space. Include objects such as sewing machines, pianos and domestic hanging lights that are familiar and reinforce the aesthetic of the home.

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In interviews with users, wayfinding problems were cited as being particularly unsettling. Problems started with wayfinding at an urban scale such as getting lost while driving home but progressively worsened to the point where finding the toilet in the person’s own home became a serious issue. (1)

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(1) Interview: Several interviews where carried out with life long carers who supported people with dementia in their own homes over the entire duration of their life with dementia.

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One of the most common problems associated with caring for people in a particular environment is keeping them safe from danger of wandering away, getting lost or being run over (1).

Although a person might no longer hold a cognitive map of the space around them, they can be tempted through doors or to follow the traffic of people moving in and out of the space. Providing secure environments was one of the central characteristics of the special nursing home unit evaluated by Wells and Jorme (2). Zeisel, Silverstein et al, also found residents were less depressed in secure environments (3). Evidence from Namazi (4) and Dickinson, McLain-Kark et al, (5) suggests that hiding the door and door handles makes exit doors less tempting.

Camouflaging Techniques:

Locate doors along sidewalls of corridor. Use smaller exit signs. Include exit doors that resemble non-exit doors. Ensure there is no visible door hardware such as handles that attract attention. Use solid opaque doors. Include doors that open into safe locations such as gardens so residents can be free to roam. (3)

Immediacy of controls:

Use window locks and electric locking devices that keep doors closed. Ensure the design of the building minimises the chance of elopement so that this does not require staff action. (3)

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(1) Rosewarne, R., J. Opie et al. (1997). “Care Needs of People with Dementia and Challenging Behaviour Living in Residential Facilities”, Australian Government Publishing Service.

(2) Wells, Y. and A. F. Jorm (1987). “Evaluation of a special nursing home unit for dementia sufferers: a randomised controlled comparison with community care.” Australian & New Zealand Journal of Psychiatry 21(4): 524-31

(3) Zeisel, J., N. M. Silverstien, et al. (2003). “Environmental correlates to behavioural health outcomes in Alzheimer’s special care units.” The Gerontologist 43(5): 697.

(4) Namazi, K. H., Rosner, T. T., & Calkins, M.P. (1989). “Visual barriers to prevent ambulatory Alzheimer’s patients from exiting though an emergency door.” The Gerontologist 29,: 669-702

(5) Dickson, J. I., J McLain-Kark, et al. (1995). “The effects of visual barriers on exiting behaviour in a dementia care unit.” Gerentologist 35(1): 127-30.

There is currently no evidence to suggest that signs are helpful to aid wayfinding for people with dementia living in care. What little evidence we do have is that wayfinding cues can be helpful. Early evidence supports the idea that personal memorabilia next to private rooms can help people with mild to moderate dementia locate their room. (1)(2)

Continuous layouts with destinations:

Design layouts to include clear destinations in corridors with an absence of dead ends. Design activity spaces at ends of pathways. Make sure bedrooms are not located in dead ends to reduce intrusion (3). Ensure hallways are wide to allow easy two-way walking to reduce confrontation.

Wayfinding cues:

Include wayfinding cues along walking routes. Use biographies and resident memorabilia next to bedroom doors to improve identification. Use windows along pathways with views. Design frequent orientating devices, activity places and visible landmarks along each path. (3)

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(1) Namazi, K. H., T. T. Rosner, et al. (1991c). “Long-term memory cuing to reduce visuo-spatial deterioration in Alzheimer’s disease patients in a special care unit.” American Journal of Alzeimer’s Disease and Other Dementias 6(6): 10-15.

(2) Nolan, B., R. Mathews, et al. (2002). “Evaluation of the effect of orientation cues on wayfinding in persons with dementia.” Alzheimer’s Care Quarterly 3(1): 46-49

(3) Zeisel, J., N. M. Silverstien, et al. (2003). “Environmental correlates to behavioural health outcomes in Alzheimer’s special care units.” The Gerontologist 43(5): 697.

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Damage to the parietal lobes can cause Apraxia, the ability to carry out intended purposeful movements, though motor strength is adequate. Left parietal damage can interfere with the sequencing of movements i.e. knowing what actions to do one after another. Simple tasks such as cooking and dressing can be difficult because they require a series of steps for successful completion. (1)

During interviews with users, this difficulty was particularly distressing for people with dementia because they were aware they could no longer complete tasks they had known how to do all their lives. A good compensatory strategy was to keep active by completing tasks alongside other people. (2)

The reason to include activities in care homes is to ensure residents are not passive recipients of service but are afforded the opportunity of making a contribution. They should be viewed as competent partners . (3) An Alzheimer’s Society survey found “that the typical person in a home spent only two minutes interacting with staff or other residents over a six hour period of observation, excluding time spent on care tasks.” (4)

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(1) Understanding dementia, 2006. [DVD] Suzanne Cahill, Robert Coen, Ireland: DSIDC

(2) Interview: Several interviews where carried out with life long carers who supported people with dementia in their own homes over the entire duration of their life with dementia.

(3) Kihlgren, M., A. Hallgren, et al. (1994). “Integrity promoting care of demented patients: Patterns of interaction during morning care.” International Journal of Aging and Human Development 39(4): 303-319.

(4) Samantha Sharp, (2007). “Home from home: A report highlighting opportunities for improving standards of dementia care in care homes.” Alzheimer’s Society, Great Britain, 14

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In a comparison of traditional care facilities and special care units, Reimer and Slaughter showed that residents had an increased ability to carry out activities of daily living, less anxiety and increased interest in the environment. Daily activities, which were arranged to resemble those in a typical home, included a kitchen where residents could help, a fireplace that residents could sit by and a small enclosed garden area that they could access. (1)

Uniqueness of common spaces:

Include a kitchen, living room, dining room and activity room. Ensure there are a variety of common areas to evoke different moods and emotions. (2) This will allow residents to be able to choose the activities they want to participate in.

Appropriate number of common spaces:

Provide 3-5 common rooms and ensure there are a minimal amount of multi-use spaces. It is important that each home has an adequate amount of total common space for the number of residents it houses. (2)

Reduced complexity:

Reduce the complexity of independent and group activities in each room type. Most tasks involve a series of steps, which can be broken up to give people responsibilities in the running of the household. For example, cooking a meal can present opportunities for people to peel potatoes, stir cake mixtures, help measure ingredients or wash up. When designing out risk ensure the opportunity for involvement is not also designed out.

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(1) Reimer, M., A. , S. Slaughter, et al. (2004) “Special Care Facilities Compared with Traditional Environments for Dementia Care: A Longitudinal Study of Quality of Life.” Journal of the American Geriatrics Society 52(7): 1085

(2) Zeisel, J., N. M. Silverstien, et al. (2003). “Environmental correlates to behavioural health outcomes in Alzheimer’s special care units.” The Gerontologist 43(5): 697.

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A secure outdoor area has been shown to be one of the defining features of care homes for people with dementia (1). The beneficial effects on levels of agitation of being able to get outside have been well demonstrated. (2) Opportunities to access natural light have also been shown to be beneficial to consolidating sleep and strengthen circadian rhythms in severe Alzheimer’s disease patients. (3)

Accessibility of outdoor space:

Make sure each home has safe access to an outdoor space for which is adjacent to and visually accessible from the care home. Ensure the policy and rules support full access to the space. Provide activities and opportunities for garden use. (4)

Appropriate plan and design of outdoor space:

Ensure the garden is designed to be appropriate for the residents’ abilities and that it is free from hazards. Use an eight foot high solid fence to provide a good level of safety and increase staff confidence for people to use the space without supervision. (4)

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(1) Grant, L. A., R. A. Kane, et al. (1995). “Beyond labels: nusing home care for Alzheimer’s disease in and out of special care units.” Journal of the American Geriatrics Society 43(5): 569-76

(2) Namazi, K. H., Johnson, B.D., (1992a) “The effects of environmental barriers on attention span of Alzheimer’s disease patients” American Journal of Alzhiemer’s disease and related Dementias 7(1): 9-15

(3) Ancoli-Israel, S., P. Gehrman, et al. (2003). “Increased light exposure consolidates sleep and strengthens circadian rhythms in severe Alzheimer’s disease patients.” Behavioral Sleep Medicine 1(1): 22-36

(4) Zeisel, J., N. M. Silverstien, et al. (2003). “Environmental correlates to behavioural health outcomes in Alzheimer’s special care units.” The Gerontologist 43(5): 697.

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The temporal neocortex is a critical for storage and retrieval from memory. As Alzheimer’s spreads to the temporal neocortex there is a breakdown in the semantic memory system which houses our accumulated knowledge of the world. This area also includes language. (1)

In early stages this is first evident as language disturbance rather than memory. A characteristic problem is Anomia, the difficulty of not being able to find names and words. A person’s speech might be fluent but hesitant due to word finding difficulties and the person may talk around the missing words replacing inaccurate ones for more accurate ones. (1) Damage to the left parietal lobes can also cause Anomia. As pathology spreads to parietal lobes the individual is doubly disadvantaged. (1) As Alzheimer’s progresses language becomes more and more broken both as a result of loss of train of thought and increasing difficulties assessing semantic memory. (1)

In interview with users, it was clear that language became a real problem for a person with dementia. It was cited as one of the main causes of social isolation as “people stop addressing the person.” As dementia progresses, social norms are "kicked" and friendships “tested”. (2) People stated that having slower conversations on topics that the person knew from their past, personal history was less challenging and more rewarding. They also said that non-verbal communication became more and more useful. The most successful examples included shared events such as concerts of walks in the park. Taking the person out of the home was important because they felt they where achieving something with their day. (2)

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(1) Understanding dementia, 2006. [DVD] Suzanne Cahill, Robert Coen, Ireland: DSIDC

(2) Interview: Several interviews where carried out with life long carers who supported people with dementia in their own homes over the entire duration of their life with dementia.

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Availability of shared tasks:

Include gardens that allow people to take walks together, opportunities to make tea together, facilities to watch a sporting event or enjoy music. Create opportunities to play with children, have a picnic, do a barbeque or make food together.

Location:

Locate care homes in good transport areas and provide resources for interaction between the outside community and residents. Locate near significant community resources such as parks, shops, coffee shops, music venues, galleries, schools or forests. If there are no facilities nearby include them as a community space in the home.

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One of our interviewees gave a very poignant description of the later stages of dementia, “Cognition and physical function had been almost chewed away. That’s when sensory, psychological and spiritual needs became so important. He still needed time and attention. Smiling faces. Eye contact. Holding a hand. Stroking a face. His face had become very mask-like. The brain had lost control over the minor muscles. You’re not born knowing how to smile – it has to be learnt. A small frown became really significant. Keeping on talking was really important. He wouldn’t talk back. I think that the physical stuff unravels and is seen to regress. But there is an adult in there and that’s the dichotomy. One of the first things a baby hears in the world is its mother speak and there is incredible comfort in that. That is why is it so important to keep talking to the person. You communicate anyway you still can. We used taste by experimenting with exciting flavors in his food. We used sound by talking to him and playing music. We used touch by softly stroking his hand. I would encourage the carers to wear bright tops to stimulate his vision. We used smell in aromatherapy sessions. There wasn’t expression but you could see he was enjoying himself.” (1)

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(1) Interview: Several interviews where carried out with life long carers who supported people with dementia in their own homes over the entire duration of their life with dementia.

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An individual who is calm, engaged and happy can be considered to have a high level of psychological wellbeing. (3) Calkins has suggested five ways to improve the environments for late-stage dementia in her 2005 paper (2):

1) Tactile Stimulation:

Positive interpersonal touch, a soft hug, or a gentle massage with essential oils has been shown to have a calming impact on residents in distress. (4) Design of furniture particularly beds and chairs to be comfortable with appropriate support and flexibility for different body types. Use beds with automatic pressure variance.

2) Olfactory Stimulation:

It has been hypothesized that the smell of coffee brewing or food baking does not only act as an orientation cue for meal time, but can also stimulate salivary glands, and thereby possibly increase caloric intake. (5) Aromatherapy has proven calming and enjoyable for some people.

3) Acoustic Stimulation and Control:

Create opportunities to enjoy music. Norberg et al. found a more positive response to music versus therapeutic touch (massage) and object presentation directed at multiple senses. (6) Reduce of noise sources that cause disturbance.

4) Visual Stimulation:

Remove overhead lights from bedroom settings as bed-bound residents can look directly at them causing discomfort. (2) Lighting levels should be easily changed to suit different purposes and moods. Opportunities to be in natural light can improve circadian rhythms and the wake-sleep cycle. Manage direct sunlight to reduce visual discomfort.

5) Thermal Environment:

Relative immobility and the inability to pull up or take off layers of clothing or coverings can reduce the person’s ability to control their thermal environment. Ensure forced air systems are not creating drafts where residents are likely to be sitting or lying. Warm bath towels or a lightweight blanket that is heated can be an enjoyable experience straight after a shower.

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(1) Volicer L. (1997) “Goals of care in advanced dementia: Comfort, dignity and psychological well-being”. American Journal of Alzheimer’s Disease and Other Dementias 12 196-197

(2) Calkins M. (2005), “Environments for Late-Stage Dementia”, Alzheimer’s Care Quarterly, 4(1): 71-75

(3) Norberg A, Melin E, Asplund K. (1986) “Reactions to music, touch and object presentation in the final stage of dementia: An exploratory study”. International Journal of Nursing Studies 23(4) 315-323

(4) Calkins, M. P. (1988). Design for dementia: Planning environments for the elderly and the confused. Owings Mills, MD: National Health Publishing.

(5) Norberg A, Melin E, Asplund K. (1986) “Reactions to music, touch and object presentation in the final stage of dementia: An exploratory study”. International Journal of Nursing Studies 23(4) 315-323

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Sight and ageing

Although our eyes change when we get older, most people lose their sight due to an eye condition or disease. (2)

Age-related changes include the need for more light as the cornea becomes more opaque. There can also be changes in colour perception, a yellowing of vision, and a tendency towards long sightedness as the lens becomes thicker, stiffer, denser and moves forward in the eye. (2)

The main causes of visual impairment in the UK are refractive error (31.6%), AMD (36.2%), cataract (24.5%), glaucoma (7.9%) and diabetic eye disease (2.3%). Other conditions included vascular occlusions and myopic degeneration. (1)

Lead causes of sight loss with ageing

The four most common conditions causing sight loss for older people are cataracts, macular degeneration, glaucoma and diabetic retinopathy. In care facilities. normal surgical procedures to treat eye conditions can become prohibitive as other difficulties such as late stage dementia influence the decision to move the person into a hospital setting.

1 Cataracts
Cataracts are a very common eye condition. As we get older the lens inside our eye gradually changes and becomes misty or cloudy. This condition worsens with time. (3)

2 Age-related macular degeneration (AMD)
Age-related macular degeneration affects the macula, a tiny part of the retina. AMD causes problems with central vision but not total blindness. Reading, looking at photos or watching TV can be problematic. Initially starting with blurred vision the center of your vision can become blank. (4)

3 Glaucoma
Glaucoma is the name given to different conditions that cause optic nerve damage and affect peripheral vision. (5) Glaucoma progresses gradually. Once detected, further damage can often be minimised if a resident is able to communicate the problem. (6)

4 Diabetic retinopathy.
Diabetes can affects tiny blood vessels in the eye causing them to become blocked or to leak. When this happens the retina and consequently vision is affected. The extent of sight loss depends on the type of diabetic retinopathy you have. (7)

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(1) Astrid Fletcher, Dr Jennifer Evans, Mr Richard Wormald and Dr Liam Smeeth. Thomas Pocklington Trust. Occasional paper, June 2006 number 8. P7

(2) Sarah J Butler, Hearing and Sight loss, London: Age Concern, 2004. P22

(3) Royal National Institute for the Blind. Cataracts. [online] (Last updated: 15 June 2011). Available at: <http://www.rnib.org.uk/eyehealth/eyeconditions/conditionsac/Pages/cataract.aspx> [Accessed 4 August 2011].

(4) Royal National Institute for the Blind. Age-related macular degeneration (AMD) [online] (Last updated: 16 May 2011). Available at: <http://www.rnib.org.uk/eyehealth/eyeconditions/conditionsac/pages/amd.aspx#H2Heading1 > [Accessed 4 August 2011].

(5) Royal National Institute for the Blind. Glaucoma. [online] (Last updated: 8 June 2011). Available at: <http://www.rnib.org.uk/eyehealth/eyeconditions/eyeconditionsdn/pages/glaucoma.aspx#H2Heading1> [Accessed 4 August 2011].

(6) Inclusive Design Toolkit. Inclusive design tools. Impairment simulator software. [online] (Last updated: 2011). Available at: <http://www.inclusivedesigntoolkit.com/betterdesign2/simsoftware/simsoftware.html> [Accessed 4 August 2011].

(7) Royal National Institute for the Blind. Diabetes-related eye conditions. [online] (Last updated: 16 May 2011). Available at: < http://www.rnib.org.uk/eyehealth/eyeconditions/eyeconditionsdn/Pages/diabetes.aspx> [Accessed 4 August 2011].

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Hearing loss

Hearing loss can be hereditary, or caused by disease, infection, medications, trauma or prolonged exposure to loud noise. (5) Most people who are deaf or hard-of-hearing in care homes in the UK have lost their hearing due to age.

Age-related hearing loss

Hearing loss progresses with age. Only 2% of young adults do not have full use of their hearing, this rises to over 55% of people over 60. (1) The cochlea, which is the part of the ear that processes sounds for the brain to interpret, there are tiny hair cells that begin to die as we age. This means sounds are heard with less clarity. (4)

Age-related hearing loss usually starts at the age of 40. About a third of people aged 60 complain of some degree of hearing impairment. This rises to over half of those aged 80. (3)

Most hearing loss does not dramatically change a person’s abilities for day-to-day living. The first difficulty a person with hearing loss usually experiences is the ability to hear the high-frequency sounds. (4) This can affect the ability to hear speech or enjoy music. It can create a sensitivity to changes in the intensity of sound making loud noises such as the slamming a door may be quite distressing. Background noise is particularly problematic for those with hearing loss, as the person will find it more difficult to distinguish between it and the sounds they are trying to hear. (4) Noise also interferes with the effectiveness of hearing aids.

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(1) Sarah J Butler, Hearing and Sight loss, London: Age Concern, 2004. P36-37

(2) Kenneth Lysons, Understanding Hearing Loss. Jessica Kingsley Publishers. London and Bristol, Pennsylvania. 1996. P7

(3) Christine Craggs-Hinton. Coping with hearing loss. London: Sheldon, 2007 P1

(4) Sarah J Butler, Hearing and Sight loss, London: Age Concern, 2004. P38-39

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Activities: “I did a lot of sowing and painting. After I got cataracts, it was hard to identify colours and choose colour combinations.” “I’m not able to do things as quickly as people who can see.” “I read less and find it hard to watch TV, I listen to the radio a lot.”

Mobility: “I walk more slowly and with less confidence. I can’t see clearly. It’s also because I am weaker. I need to catch my breath. I can get very tired. I need two grab rails when I going down stairs.”

Locating objects: “It’s more difficult identify objects which look similar. I keep things in the specific places. Sometimes I find it hard to be accurate about where I place things. I put the odd dirty cup away by accident sometimes.”

Lighting and glare: “I need a light above the mirror to see my face.” “Brightness is very important. Needing more light for reading and other activities.” “I need to be careful of the light’s angle. I use the lamp bent over to avoid glare. Being able to adjust the situation is best for me.” “I find it hard to cope with glare. I need hat or sunglasses when go out.”

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Other senses: “I do not read Braille. I prefer big print and audio.” “I use audio and touch material. “ “Other sensory abilities are more important to me. Sound can help memory.” “I can see black and white. Colour is important, highlight the contrast.” “I have problems looking at pictures. “

Using objects: “I have to use equipment to enlarge things.” “I need to learn how to use a keyboard, not just a mouse.”

Mobility: “I listen to hear what is coming or what is happening, the sound of a bus or the sound of conversation down the hall.” “Crossing the road at night is hard.”

Locating objects: “I always keep my clothes simple. Every piece of clothing is kept in a specific position.” “ I get mad with my wife because she moves things and I have no idea where they are.” “Memory is important”

Lighting and contrast: “Lighting and contrast is very important for me. In the bathroom, the toilet and bath are white, and floor is grey.” “Light is very important. In the morning I can see more clearly. The daylight is better. “

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(Communication: “Sometimes before conversation, I tell people I have a hearing impairment this makes the conversation more efficient” “I ask people to repeat things frequently.” “I find it hard to keep up with the conversation when talking in a group.” “I sometimes misunderstand what people are saying.” “ When people talk to me, they have to make their voice louder and be more patient.”

Awareness of Environment: “Difficult to notice someone knock the door. And in the room, when someone enters, I can be unaware.” “I don’t hear cars coming.”

Noise: “I don't use a hearing aid because it will twist the sound and make the noise louder.” “I find nearly impossible to talk to people when there is a lot of sound in the background”

Using products: “I understand someone talking over a normal telephone in a quiet room.” “I follow TV programmes at a volume that others find unacceptable.”

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When applying colour to help people to use the environment it is best to think of colour tone as not every colour will be perceived in the same way by everyone. Some people will might be colour blind and others will can have cataracts, which, reduces colour sensitivity and perception.

Depth of contrast, for example the lightness and darkness of a colour, can often be used effectively in place of two distinctly contrasting colours. (1) This avoids interiors taking on unnecessary garish, institutional or child-like appearances. The use of maximum contrast, white on black, can be useful in signage or other appropriate situations. Contrast can help bring important objects to the attention of people with limited visual acuity.

Designers should aim to create a consistent tonal contrast throughout all aspects of the building. (2) The easiest way to assess tonal contrast is to look through a red transparency. This will remove colour and highlight tonal differences in the environment.

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(1) Tomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. P11

(2) Sarah J Butler, Hearing and Sight loss, London: Age Concern, 2004. P182

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Floors and Surfaces:

Colour contrast and good lighting can greatly increase the ability to ‘read’ the surroundings for people with sight loss, enabling safer navigation around the home and identification of features. (1) Ensure floor surfaces contrast adjacent walls. Doors should contrast the surrounding walls. Avoid busy patterns on floor surfaces and use consistent colours.

Changes in colour can make it appear as though there is a change in surface height causing people with sight loss, and particularly those with sight loss and dementia, to misjudge their step leading to falls. Surfaces should be plain or have small patterns only. Prominent or large-scale patterns should be avoided. This will assist in locating objects on the surface. (2)

Furniture, Fixtures and fittings:

Contrast the colour of the furniture with the room décor e.g. colored cushions that contrast with the chairs, napkins that contrast with the tablecloth. Handles and door fittings should be clearly identifiable using contrasting materials. Ensure grab rails contrast with the wall surface. (3)

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(1) Tomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. P80

(2) Tomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. P81

(3) Best Practice Access Guidelines: Designing Accessible Environments. Irish Wheelchair Association. [online] (Last updated: July 2010). Available at: <www.iwa.ie/Docs/publications/IWA-Access-Guidelines2010-Edition-2.pdf> [Accessed 13 August 2011].

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Older people have been shown to need three times as much light as that of a younger person to obtain the same amount of light on the retina. (1) They may experience reduced visual acuity and increased sensitivity to glare. This means it takes longer to adapt to sudden changes in lighting levels. (2) Poor lighting has also been shown to be a contributing factor in the risk of falling. (3) Improved lighting can effectively reduce the amount of people who are seens as visually impaired. (4)

Increased lighting levels are good for health. Low vision has been found to have a significant influence on quality of life. (5)(6) Light deprivation is associated with sleep disorders and depression. (7) Inadequate exposure to daylight has been linked to sleepiness. (8)(9) Increased exposure to natural light has been shown to consolidate sleep patterns in those with Alzheimer’s disease. (10)

It is important to note that there are conditions where some visually impaired people will need less light and where normal light levels are uncomfortable or disabling. (11) It is essential that lighting levels are controllable and that rooms can be tailored to individual preference.

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(1) Tomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. P75

(2) Boyce PR (2003) Lighting for the elderly. Technology and Disability, 15(3): 165-180.

(3) Tinetti M and Speechley M (1989) Prevention of falls among the elderly. The New England Journal of Medicine, 320: 1055-9.

(4) Cullinan T, Silver J, Gould E, Irvine D (1979) Visual disability and home lighting. The Lancet, 1: 642-644.

(5) Stevenson M, Hart P, Montgomery A-M, McCulloch D (2004) Reduced vision in older adults with age related macular degeneration interferes with ability to care for self and impairs role as carer. Br J Ophthalmol. 2004 Sep; 88(9): 1125–1130.

(6) Palmer S (2005) Factors which influence the use of low vision aids. Visibility Publishers.

(7) IESNA (Illuminating Engineering Society of North America) (1998) Recommended practice for lighting and the visual environment for senior living. New York: IESNA.

(8) Lockley SW, Brainard GC, Czeisler C (2003) High sensitivity of the human circadian melatonin rhythm to resetting by short wavelength light. The Journal of Clinical Endocrinology & Metabolism, 88: 4502-4505.

(9) Brainard GC, Hanifin JP, Rollag MD, Greeson J, Byrne B, Glickman G, Gerner E, Sanford B (2001) Human melatonin regulation is not mediated by the three cone photopic visual system. The Journal of Clinical Endocrinology & Metabolism, 86: 433-436.

(10) Ancoli-Israel, S., P. Gehrman, et al. (2003). “Increased light exposure consolidates sleep and strengthens circadian rhythms in severe Alzheimer’s disease patients.” Behavioral Sleep Medicine 1(1): 22-36

(11) CIE (Commission Internationale de l’Eclairage) (1997) Technical report: low vision- lighting needs of the partially sighted. Vienna: Commission Internationale de L’Eclairage.

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Higher Levels:

Designers should provide higher levels of controllable lighting consistently throughout the building. Additional lighting should also be provided in areas, which require high levels of visual acuity e.g. a pull-down light over dining tables or task lights on a desk. (1) Natural light is the best form of light for individuals with sight loss. People with severe sight loss still perceive and enjoy the changes in level natural light brings. Care homes should bring the maximum amount of natural daylight in as possible without making rooms too hot. (2) South facing windows may need to be covered with blind or architectural features to reduce direct sunlight.

Control:

All lighting within a building, including natural light, should be controllable and adjustable so that environments can be tailored to suit individuals. (3) Flexibility and controllability should be maximized. Provide a range of internal lighting fittings and ample sockets for portable task lighting. (2) Night lights can be used to help eyes adjust gradually and help alleviate night blindness.

Graduation and consistency:

Lighting needs to be consistent, as older people cannot adjust rapidly to varying lighting. (4) Lighting should be managed to ensure a gradual change between rooms or when exiting a building. (5)

Shadow and Silhouette:

Lighting can be a great asset to help express and accentuate texture, color and shape in interiors for people with sight loss. Indirect lighting should be used. Wall and floor surfaces can be lighted. Avoid lighting that creates shadow hazards on steps or floors. Shadows may appear to look like obstacles which need to be stepped over. Avoid light sources that put objects or people in silhouette. (5)

Reflection and glare:

Illuminate in a way that does not dazzle people. Natural and artificial light sources can create glare. Ensure artificial lighting is shielded or diffused from a person’s line of sight. In care homes, this includes residents who have reduced mobility and often in a reclined position looking up towards the ceiling. Natural light can be obscured using blinds. (2)

Glare can also be reflected. Large areas of highly polished surfaces should be avoided. (6) Glare ‘hotspots’ can occur where windows or open doorways harshly illuminate darker areas such as hallways. (4) Ensure light sources are positioned behind people unless they need to look clearly at something. (1)

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(1) Sarah J Butler, Hearing and Sight loss, London: Age Concern, 2004. p180

(2) Tomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. p12

(3) Best Practice Access Guidelines: Designing Accessible Environments. Irish Wheelchair Association. [online] (Last updated: June 2010). Available at: <www.iwa.ie/Docs/publications/IWA-Access-Guidelines2010-Edition-2.pdf> [Accessed 13 August 2011].

(4) Rosemary Oddy - Promoting Mobility for People with Dementia 2003

(5) Building for Everyone, National Disability Authority. [online] (Last updated: June 2011). Available at: <www.nda.ie/cntmgmtnew.nsf/0/EBD4FB92816E8B

B480256C830060F761> [Accessed 13 August 2011].

(6) Tomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. p11

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People with a visual impairment can take longer to recognise new environments. Low visual acuity and contrast sensitivity make it harder to detect key visual markers that help a person form mental pictures of the world.

People with sight loss compensate for this difficulty by gathering remaining visual information, tactile information, audio information and olfactory information. They also rely heavily on memory to navigate and use architecture.

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Layout:

Interior and exterior site layouts should be simple and logical. (1) Long distances between frequently used services should be avoided. (2) Important amenities such as toilets, social spaces, exits to outside and nursing stations should be placed conspicuously, to permit easy location. (3) Changes in height and volume of a space can also aid wayfinding as it changes the airflow and sound of the space giving the user additional information to remember.

Distinctive Visual Features:

Distinctive features which contrast their backgrounds such as furniture or plants can be used in rooms and corridors to aid way finding. (4) Repeat features should be avoided. Opposite sides of corridors should contain unique features to aid directional orientation.

Tactile information:

Handrails are a good direction finder. Tactile information can be included on handrails to warn of coming hazards or provide information about adjacent room type. (4) Varying the texture underfoot to provide a clue to location, including the presence of a feature or edge of a route. (5) Door numbers and other information can be tactile. Different types of door handle and indicate room types. (4) Changes in air movement can inform a location within a building.

Audio information:

A distinctive sound, near the entrance of a room can be used to indicate the particular room type such as the sound of ticking clocks, a small fountain, rustling plants or wind chimes. (4) Change the texture of flooring to indicate location through the sound of a footstep.

Olfactory information:

A distinctive smell can indicate a particular location e.g. raised flowerbeds, containing lavender or strong smelling herbs, potpourri or plug-in scent dispensers. (4)

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(1) Tomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. P7

(2) Best Practice Access Guidelines: Designing Accessible Environments. Irish Wheelchair Association. [online] (Last updated: June 2010). Available at: <www.iwa.ie/Docs/publications/IWA-Access-Guidelines2010-Edition-2.pdf> [Accessed 13 August 2011].

(3) Building for Everyone, National Disability Authority. [online] (Last updated: June 2011). Available at: <www.nda.ie/cntmgmtnew.nsf/0/EBD4FB92816E8B

B480256C830060F761> [Accessed 13 August 2011].

(4) Tomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. P11-12

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Mobility is affected when a person loses both their sight and hearing because the cues they might previously have used are reduced. (1)

People with little or no sight may be apprehensive about textures underfoot for example, carpets, grass or gravel. They may experience hills and slopes or changes in surface level more dramatically than people with ordinary vision.

Designers can increase a person’s confidence to navigate an environment by reducing the risk of hazards that may cause people to hurt themselves when moving.

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(1) Sarah J Butler, Hearing and Sight loss, London: Age Concern, 2004. p19

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Pedestrian travel:

All circulation routes should be short and uncomplicated. Include adequate space to enable simple and direct circulation routes within all rooms. Use even surfaces. Reduce trip hazards left out such as garden hoses, electric flexes, partly open doors and windows, refuse bags left in corridors, low furniture such as coffee tables, fire extinguishers and other belongings. (1)

Reduce impact hazards:

Include guardrails around hot fires or heaters. (2) Ensure furniture is sturdy enough to absorb the occasional knock. Avoid protruding objects such as noticeboards, shelves and anything that ‘sticks out’ at head or shoulder height. Doors should not open out onto corridors, passageways or hallways. Radiators, fire extinguishers and fire doors should be recessed to create an uninterrupted wall surface. (1) Floor hazards such as ramps or steps can be illuminated. (2) Use furniture with soft edges to reduce impact damage to person. Use impact absorbent floors to reduce injury if a person falls.

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(1) Tomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. P89

(2) Best Practice Access Guidelines: Designing Accessible Environments. Irish Wheelchair Association. [online] (Last updated: June 2010). Available at: <www.iwa.ie/Docs/publications/IWA-Access-Guidelines2010-Edition-2.pdf> [Accessed 13 August 2011].

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People with severe sight loss will rely heavily on memory to locate important items such as light switches and personal possessions. If an item is misplaced or architectural features have no discernable placement it will make it more difficult for a person to function independently.

In interview, those with severe sight loss stressed how important it was for them to be consistent about where they left personal possessions. Sharing space was cited as being particularly difficult when others moved items which where important to the person. (1) Having access to personal space where a person can control his or her own environment is an important feature of any care home.

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(1) Interview: Several interviews were carried out with a sample group of expert users from representative disability groups.

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Consistency:

Fixtures and fittings such as switches and sockets should be placed at the same height and in the same locations all rooms. Doors and window handles should be consistently positioned. Hot and cold taps should be arranged in the same manner in every room. (1) Dining tables should be arranged in a logical position and never be moved as a visually impaired person relies largely on their memory to avoid walking into things. Bedrooms should provide adequate storage to allow a resident to arrange personal items in areas where they can then relocate them.

Identification:

Design important objects and their locations to be easily identified. Distinctive form and colour contrast is important. Bathroom emergency cords need to look and feel different from the light pulls. Entrances to buildings should be prominent and identifiable on building exteriors. Furniture should have a distinctive form and contrast the background. (2)

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(1) Tomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. p10

(2) Best Practice Access Guidelines: Designing Accessible Environments. Irish Wheelchair Association. [online] (Last updated: June 2010). Available at: <www.iwa.ie/Docs/publications/IWA-Access-Guidelines2010-Edition-2.pdf> [Accessed 13 August 2011].

The most important factor that affects hearing is the presence of background noise. This is sound from the ambient environment that interferes with the sound of interest e.g. another person in the conversation or a television programme. Background noise introduces hearing demands so that the user has to struggle to separate the sound of interest from a mixture of other sounds.

Spaces that introduce have large areas of reflective surfaces and produce reverberation can cause problems with hearing. The sound becomes distorted and more difficult to discern. Most hearing aids are least effective in noisy environments, as they amplify the background noise indiscriminately.

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Sound Spaces:

Include small quiet rooms within the layout. Use narrow tables that enable people who are hard of hearing to sit close to those they would like to talk to, so that they can understand more of what their companions say, and be able to lip read more easily. Avoid multiuse rooms, which detract from quiet areas. Consider room adjacency and avoid social spaces, which transmit noise from street traffic, staff areas, entrance areas or appliances. (1)

Materials:

Minimize high gloss finishes and hard surfaces that amplify echo. High ceilings and many bare surfaces can produce echo, resonance and background noise. Balance non-reverberant materials such as carpets, tablecloths and curtains with hard surfaces. Overuse can create muffled sound. Under use can create noise. (2) Beware of noisy heating, air conditioning, plumbing or machinery. Locate noisy equipment in utility areas. Include sound absorbent materials in all rooms and use them to support conversational spaces.

Lighting:

Good lighting levels are also important to ensure that people can lip read or communicate using sign language. This becomes doubly important for those who are deaf blind as it allows people to more easily recognise those who are approaching them or to be able to participate in activities using their remaining visual ability. For information on lighting please see the previous section entitled ‘Light’.

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(1)Thomas Pocklington Trust, Housing for people with sight loss: A Thomas Pocklington Trust design guide. London: BRE Press. 2008. p6

(2) Sarah J Butler, Hearing and Sight loss, London: Age Concern, 2004. p176

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Disease/Illness:

Mobility issues can arise from early disorders of the nervous, skeletal and muscular systems such as cerebral palsy. Degenerative conditions such as arthritis, brittles bones and Parkinson’s disease also limit joint mobility and muscle control.

Temporary Loss:

Temporary loss of physical abilities can also occur due to injury. A fall or trip can cause a muscle strain or a broken bone. A sudden loss of physical ability can also occur because of limb amputation, immobilisation or a stroke. (1)

Age:

As a person ages they may become less active, leading to muscle wasting and weakness from lack of use. Bones that do not bear weight over time can deteriorate leading to osteoporosis. This condition can be very serious as it increases the risk of fractures. (2)

Dementia:

Most forms of dementia cause muscle coordination problems, balance difficulties or misperceptions that contribute to falls. (3) In some cases, mobility problems are actually the first symptoms that alert physicians that a neurological problem also may exist. (2) Difficulties with walking and accessing body position are common. The later stages of dementia are linked to high levels of physical difficulty and dependency.

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(1) John Clarkson, Roger Coleman, Ian Hosking and Sam Waller, Kall Kwik Cambridge, Inclusive Design Toolkit, 2007, p109-159

(2) Margaret Calkins, Creating Successful Dementia Care Settings: Maximizing cognitive and functional abilities, 2001, p45

(3) Louise Waite, G. Anthony Broe, David A. Grayson and Helen Creasey, Motor function and disability in the dementias, International Journal of Geriatric Psychiatry, (2000), 15, p897-930

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Balance: “I need even paths. Tripping can be a major problem and I have become very awareness of my fragility. I need to exercise to avoid becoming stiff. If there is something like snow outside I won’t go out. It’s too dangerous.”

Gait: “I tend to shuffle my feet along the floor to keep my balance. Mats and rugs are lethal. I don’t keep them in the house.”

Hazards: “The kitchen floor needs to be clean. Ideally it should be non-slip. Every now and again something like a potato peel falls, I step on it, then woosh! The fright of my life.”

Access: “Getting into bath can be a problem which is very irritating because a hot bath is excellent for relieving the constant pain in my joints.”

Rest: “It became difficult to balance when putting my clothes on. I have to sit while dressing.”

Assistance: “Eventually, in the later stages of dementia, he needed to be wheeled in and out of the shower. He was dependent for almost everything.”

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Body position: “In the kitchen I find drawers easier than shelves because it is easier to sort through things without having to lift them. Shelves are problematic because I don’t have the strength to lift things down from that height.”

Reach: “I have difficulty reaching around my body when dressing. So I tend to buy loose clothing which allows me to catch them with an aid.” “I need higher tables in my kitchen so the arms of my wheelchair go underneath. I need to be close to the vegetables to chop them.”

Bending: “Sockets and switches need to be higher up the wall for me to use them.”

Height: “The raised flower beds in the garden have helped me keep it gardening up. The cancer pain in my spine made reaching down painful. I have problems bending over to dig.”

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Weight: “I buy cups and bowls that are lightweight and have handles which require minimum grip.”

Grip: “My grip is very good when I need to grab something but I have issues with buttons, jewellery clasps and small wardrobe knobs.”

Pulling force: “Pulley style light switches are far easier than switches and dimmer knobs.”

Assistance: “I need assistance with dressing but it is important to put on my underwear alone.”

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Designers should ensure environments support the use of standard walking aids and wheelchairs to support good access and freedom to move within the space.

Dementia becomes particularly important when considering mobility in care. Loss of balance and shuffling gait cannot always be helped by standard assistive equipment as the person can often have a lack of awareness of their physical limitations. (1)(2)

This raises the importance of avoiding hazards such as uneven flooring and increases the need for prosthetic elements like rails, which allow residents to support themselves as they move through the space.

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(1) Interview: Several interviews where carried out with life long carers who supported people with dementia in their own homes over the entire duration of their life with dementia.

(2) Understanding dementia, 2006. [DVD] Suzanne Cahill, Robert Coen, Ireland: DSIDC

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Floor surfaces:

Design slip-resistant, smooth external surfaces using brushed concrete or textured stone. Paving joints should be filled and made flush. Provide level entrance access with flush thresholds, no door saddles and no lips. (1) Avoid loose mats and deep pile mats and finishes. (2) Avoid trailing cables and other hazardous objects left around. Use level entry shower trays or wet rooms. (3)

Room for independent motion:

Design wide corridors that allow wheelchair users to easily pass in opposite directions. Avoid objects that protrude into passageways. Use 1m/900mm wide doors that open against adjoining walls and not into circulation areas. (2) Allow space for wheelchairs users alongside seating. (1) Ensure there are clear floor areas on front of storage closets to allow for opening and clear routes through shared spaces.

Room for dependent motion:

Design a clear approach to showers with appropriate space for three people so that a person can be easily assisted. Ensure there is an adequate bedroom size that accommodates wheelchairs and hoist equipment with sufficient room to turn and transfer the person from one chair to another. (2) Consider the use of crash trolleys and design layouts to support easy access to all areas in the instance of emergencies.

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(1) Building for Everyone, National Disability Authority. [online] (Last updated: June 2011). Available at: <www.nda.ie/cntmgmtnew.nsf/0/EBD4FB92816E8B

B480256C830060F761> [Accessed 13 August 2011].

(2). Best Practice Access Guidelines: Designing Accessible Environments. Irish Wheelchair Association. [online] (Last updated: June 2010). Available at: <www.iwa.ie/Docs/publications/IWA-Access-Guidelines2010-Edition-2.pdf> [Accessed 13 August 2011].

(3). Rosemary Oddy, Promoting mobility for people with dementia: a problem-solving approach, Age Concern, England, 2003.

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Presence of surfaces and rails:

Design complete handrail systems on both sides of corridors whereever possible. Support rails can be added to beds to aid transfer. Include horizontal and vertical handrails on both sides of toilet pan and grab rails beside bath and shower. (1)

Furniture:

Use stable chairs with arm supports to help people easily rise and sit. (2) Provide multiple heights of chair to allow for different body types. Arrange furniture in the room to act as walking aids for people who need to steady themselves. Provide beds with adjustable height to help the person get in and out of it independently or to aid assistance when using a transfer hoist. (1) Beds can be lowered in the case of high risk residents with dementia to reduce falls at night.

Rest:

Include stable seating in lobbies and reception areas. (3) Provide seating areas that are set back along the length of corridors especially on lengths over 20 metres. Provide flip-up shower seats in the bathroom so people can shower while seated. Provide chairs for dressing. Provide regular seating intervals in outdoor areas or other walking routes. (2)

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(1) Building for Everyone, National Disability Authority. [online] (Last updated: June 2011). Available at: <www.nda.ie/cntmgmtnew.nsf/0/EBD4FB92816E8B

B480256C830060F761> [Accessed 13 August 2011].

(2) Rosemary Oddy, Promoting mobility for people with dementia: a problem-solving approach, Age Concern, England, 2003, p???

(3) Best Practice Access Guidelines: Designing Accessible Environments. Irish Wheelchair Association. [online] (Last updated: June 2010). Available at: <www.iwa.ie/Docs/publications/IWA-Access-Guidelines2010-Edition-2.pdf> [Accessed 13 August 2011]

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In interview participants overcame problems with reach by adapting and reorganising the home. Almost every item a person needed to access could be stored at a mid-range height to ensure easier access. People stated that fatigue from standing when carrying out tasks could be problematic. Many chose to sit down whilst carrying out tasks in order to conserve energy and strength. (1)

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(1) Interview: Several interviews where carried out with a sample group of expert users from the representative disability groups.

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Interior Specification

Place door handles, window handles, light switches and plugs at mid-range heights. Ensure tables, kitchen counters and reception desks allow wheelchair arms to slide underneath on all sides. (1) Avoid low storage at tables that prohibit knee space for wheelchair users. Place bedroom controls within reach of a person in bed or seated positions. Ensure bathroom toilet seat height is adjustable for short and tall users. Place the flush handle on the transfer side. Ensure mirrors are low enough to allow wheelchair users to see their reflection. Provide seating in bedrooms so that people can reach to put their socks on when dressing.

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(1) Best Practice Access Guidelines: Designing Accessible Environments. Irish Wheelchair Association. [online] (Last updated: June 2010). Available at: <www.iwa.ie/Docs/publications/IWA-Access-Guidelines2010-Edition-2.pdf> [Accessed 13 August 2011].

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In interview, participants mostly cited difficulties using products, as opposed to using fittings and fixtures included in standard buildings. This suggests that many of the issues arising from dexterity difficulties can be overcome by buying specific products that are specifically suited to the individual user. Difficulties with the building architecture can be related to the specification of fixtures and fittings. Fittings that worked best required low force, were easily grasped and had a high tolerance for error. (1)

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(1) Interview: Several interviews where carried out with a sample group of expert users from the representative disability groups.

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Fixtures

Handrails should allow for adequate grip and accommodate both left and right handed use. (1) Entrance doors should not require undue force to operate. Exterior exit doors from reception could be automatic. (2) All handles should be a push/pull down, lever type, easy to use and more than 30cm long. Avoid door hardware and locking mechanisms that require two-handed use. (2) Use D-shaped handles that are easy to pull. Avoid knobs on drawers and cabinet doors. (1) Use switches which require a light pressure to operate. Avoid switches that demand finger dexterity. Recessed controls should also be avoided. (2)

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(1) Best Practice Access Guidelines: Designing Accessible Environments. Irish Wheelchair Association. [online] (Last updated: June 2010). Available at: <www.iwa.ie/Docs/publications/IWA-Access-Guidelines2010-Edition-2.pdf> [Accessed 13 August 2011].

(2) Building for Everyone, National Disability Authority. [online] (Last updated: June 2011). Available at: <www.nda.ie/cntmgmtnew.nsf/0/EBD4FB92816E8BB480256C830060F761> [Accessed 13 August 2011].