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“What’s in it for me?” The importance of the ‘built environment’ for living well with dementia



built environments

Strangely enough, with the focus of drugs, drugs, and yet more drugs, there’s been relatively scant attention for the environment in which a person living with dementia finds himself or herself in.

Improving wellbeing for a person is essentially about understanding the past and present of that person, and building on that person’s beliefs, concerns and expectations about the future. But the idea that you can ignore the environment is simply science-fiction.

The design of care homes maters. The design of hospital wards matter. The design of towns including pavings and signs matters.

Such an approach sounds ambitious and joined up, but not impossible. There’s been a long and proud history in England of understanding the social determinants of health, including housing.

The Attlee Government also extended the powers of local authorities to requisition houses and parts of houses, and made the acquisition of land less difficult than before. In 1949, local authorities were empowered to provide people suffering from poor health with public housing at subsidised rents. That very same year, unemployment, sickness and maternity benefits were exempted from tax.

Recent research suggests that wellbeing in later life is closely related to the physical environment, which is an important mediator of ageing experiences and opportunities. The physical character of the built environments or neighbourhood in particular seems to have a significant impact on the mobility, independence and quality of life of older people living in the local community.

According to a “Greenspace Scotland” report from 2008, “Trust for Nature” is a community-based conservation organisation that focuses on the protection of private land of high conservation value in the state of Victoria, Australia.

In recent research by Inclusive Design for Getting Outdoors (ID’GO), 15% of questionnaire respondents (a large sample, nearing 1000 in sample size) had stumbled or fallen outside within the last 12 months. The real figure is likely to be higher, since past-year falls are often under-reported. Many of the environmental risk factors associated with outdoor falls appear to be preventable through better design and maintenance; factors including pavement quality, dilapidation and kerb height.

Abstract experiential qualities such as perceptions of ‘safety’ and ‘attractiveness’ have been identified as important factors in stated preferences for parks and green spaces and there has been much written over many years on landscape aesthetics  and how this might influence preference and use.

By contrast with research on environment and health, arguably this is a domain rich in theoretical concepts for the mechanisms behind engagement with the environment but poor in terms of tools to measure the detailed spatial and structural qualities of different landscapes in relation to how people actually use and experience them. For landscape designers, this is of crucial interest. There have been, historically, attempts to develop guidance based on general principles, but few tools actually to measure the dynamic spatial experience in practice.

A built environment for all ages is conceptualised as one that has been designed so that people can access and enjoy it over the course of their lifetime, regardless of ability or circumstance. Such environments are said to be designed “inclusively”. The I’DGO (Inclusive Design for Getting Outdoors) consortium was launched in 2004 to investigate how outdoor environments affect older people’s wellbeing and to identify what aspects of design help or hinder older people in using the outdoors. Their focus is on identifying the most effective ways of shaping outdoor environments inclusively. They support the needs and preferences of older people and disabled people, always seeking to improve their independence and overall quality of life.

I’DGO was set up to explore the ways in which being able to get out into one’s local neighbourhood impacts on older people’s wellbeing and what barriers there are to achieving this, day-to-day. The project asked the crucial question: why do we need a built environment for all ages? The first phase of research, which finished in 2006, involved over 770 people aged 65 or above. Participants were asked about their wellbeing and quality of life, how often and why they went outdoors and what features of their local neighbourhood helped or hindered their activity. Researchers also physically audited 200 residential neighbourhoods to look for barriers and benefits to getting around as a pedestrian.

The I’DGO research found quickly that older people went outdoors very frequently to socialise, exercise, get fresh air and experience nature. If they lived in a supportive environment – one that made it easy and enjoyable for them to get outdoors – they were more likely to be physically active, healthy and satisfied with life. Walking was by far the most common way that people spent their time outdoors, whether for recreation or transport (‘getting from A to B’). Participants in the I’DGO study who lived within 10 minutes’walk of an open space were twice as likely to achieve the recommended levels of healthy walking (2.5 hours/week) as those whose nearest open space was not local.

A major research goal has been to examine the specific attribute of neighbourhood streets – tactile paving at steps and crossings – and asks how this affects the biomechanics of walking and risk of falling in older people (the project run by the SURFACE Inclusive Design Research Centre and their colleagues in Health, Sport and Rehabilitation Sciences at the University of Salford). The benefits of tactile paving for blind and visually impaired people have been well established yet the system is not without its issues.

Tactile paving is not a policy area without its concerns, and a few in particular emerge from a report by the UK Health and Safety Executive. This report suggested that there is a need better to understand the extent and implications of incorrectly designed and laid tactile paving, and the toe clearance of an individual in negotiating paving ‘blisters’ and potential slip hazards. These factors appear to be crucial to older people, since many of the first phase ID’GO interviewees expressed concerns about falling?or feeling unstable on tactile surfaces and fall-related injuries are associated with loss of independence, morbidity and death in older people.

If we are to understand what qualities of the environment are important to an ability of individuals to ‘live well’, we need perhaps to acknowledge the diversity that exists in people’s capabilities, experience, desires and needs. This overall is a huge challenge for designers; the response conventionally has been to look for factors in the environment that matter to most people, or to a defined group of people, and to address those factors as if they were equally important. Yet for any individual, different qualities and elements in the environment may be a matter of indifference (e.g. certain colours if you are visually impaired) or vitally important (e.g. proximity of an accessible toilet if you have a weak bladder).

Such an approach builds on the concept of “affordance” and the reciprocal relationship between perceiver and environment. The concept of affordance links environment and human behaviour, or opportunities for action, and is therefore of particular interest in understanding how the environment might encourage or support people to be more active—a primary goal of public health policy. This is an insight of key relevance to investigating human behaviour in the landscape. As Appleton has put it, more succinctly, for any individual considering their landscape context, it helps us understand “what’s in it for me?” (Appleton, 1975).

Key text

Appleton, J. (1975) The experience of landscape, New York, NY: John Wiley.

Preface to my book: “Living well with dementia: where the person meets the environment”



Volumetric MRI dementia

Volumetric MRI dementia

 Introduction

According to the Department of Health’s “Improving care for people with dementia” (2013), there are around 800,000 people with dementia in the UK, and the disease costs the economy £23 billion a year. By 2040, the number of people affected is expected to double – and the costs are likely to treble. There is no doubt therefore about the scale of the problem, and it needs the finest minds in showing leadership on how to enable individuals with dementia to live better, and indeed live well.  The Prime Minister’s Challenge on dementia (“Challenge”) (2012) set out a renewed ambition to go further and faster, building on progress made through the National Dementia Strategy, so that people with dementia, their carers and families get the services and support they need. This Challenge wished to address in particular certain issues, such as the observation that the number of people with dementia is increasing, that currently the diagnosis rates are thought to be low, and there is sadly a lack of awareness and skills needed to support people with dementia and their carers. Whilst it is possibly difficult to find a ‘miracle cure’ for dementia, it is a reasonable aspiration for individuals with dementia (and their immediates) to have as best a quality-of-life as possible, and it is not necessarily the case that subtle but significant improvements in quality-of-life will “cost the earth”.

It is intended that this book should not just of interest in the UK, as the problems in healthcare are relevant to all jurisdictions. Thinking about how society should respond does pose some jurisdiction-specific issues; for example, this book refers to legislation in the UK such as the Equality Act (2010) or the Mental Capacity Act (2005), or regulations in health and safety relevant to building design in the UK. However, a consideration of the global issues in public health leads one quickly to appreciate the complexity of the economic case for improving wellbeing in individuals in dementia and their immediates, and that there are many people who are genuinely interested. Whilst indeed there has been a lead through the Prime Minister’s Dementia Challenge (2012), it is clear that previous administrations in England have latterly decided to prioritise dementia as a public health priority (for example, the National Dementia Strategy, “Living well with dementia” (2009)).

The ‘ecosystem’ of interested parties is large, and it is striking that there are so many passionate ‘#dementiachallengers’ on Twitter daily for example who are always a source of contemporary information, enthusiasm and innovation. There are currently huge advances being made in research and policy, and it is only possible through dementia communities ‘working together’ to keep abreast of them all. For that reason, this book has necessarily had to include electronic references, and I have tried to maintain links as correct as up-to-date at the time of publication. However, please feel free to look for any related information anywhere, and please do not use this book as an authoritative source of information to rely on necessarily. This book is intended simply as an introduction to a vibrant field, and certainly please be guided by healthcare professionals regarding individual care. The text of this book provides general principles, which I hope you might find interesting.

NICE quality standard 30 on ‘supporting people to live well with dementia’

In April 2013, NICE published its quality standard 30 on ‘supporting people to live well with dementia’. This quality standard was intended to cover the care and support of people with dementia. It applies to all social care settings and services working with and caring for people with dementia.

NICE quality standards are supposed to describe high-priority areas for quality improvement in a defined care or service area. Each standard consists of a prioritised set of specific, concise and measurable statements. NICE quality standards draw on existing guidance, which provide an underpinning, comprehensive set of recommendations, and are designed to support the measurement of improvement.

The areas covered in this ‘quality standard’ includes:

Statement 1. People worried about possible dementia in themselves or someone they know can discuss their concerns, and the options of seeking a diagnosis, with someone with knowledge and expertise.

Statement 2. People with dementia, with the involvement of their carers, have choice and control in decisions affecting their care and support.

Statement 3. People with dementia participate, with the involvement of their carers, in a review of their needs and preferences when their circumstances change

Statement 4. People with dementia are enabled, with the involvement of their carers, to take part in leisure activities during their day based on individual interest and choice.

Statement 5. People with dementia are enabled, with the involvement of their carers, to maintain and develop relationships.

Statement 6. People with dementia are enabled, with the involvement of their carers, to access services that help maintain their physical and mental health and wellbeing.

Statement 7. People with dementia live in housing that meets their specific needs.

Statement 8. People with dementia have opportunities, with the involvement of their carers, to participate in and influence the design, planning, evaluation and delivery of services.

Statement 9. People with dementia are enabled, with the involvement of their carers, to access independent advocacy services.

Statement 10. People with dementia are enabled, with the involvement of their carers, to maintain and develop their involvement in and contribution to their community.

 Overview

The aim of this book was not to provide a prescriptive text for this quality standard. I hope the book will be useful for a ‘diverse audience’, in other words anyone interested in the diagnosis, investigation or management of dementia, with especial emphasis on improving wellbeing; such interested people might particularly include the general public, psychologists, innovation specialists,, psychiatrists, neurologists, geriatricians, general medical physicians, nurses, public health physicians, medical students, engineers, economists, psychologists, commissioners and hospital managers. It is therefore extremely hard to find all this information ‘in one place’, and it is hoped that this book will help to provide a much needed overview and to build bridges between different ‘silos’ of thinking.

The approach of the National Dementia Strategy: Living well with dementia (from the Department of Health) (2009) devotes the whole of its chapter 5 to the issue of living well with dementia. In the preceding chapter to this Strategy, chapter 4on ‘early diagnosis’, the approach described is obviously inclusive:

 “From our consultation, and based on a successful DH pilot and the DH cost- effectiveness case, it appears that new specialist services need to be commissioned to deliver good-quality early diagnosis and intervention. Such services would need to provide a simple single focus for referrals from primary care, and would work locally to stimulate understanding of dementia and referrals to the service. They would provide an inclusive service, working for people of all ages and from all ethnic backgrounds.”

A ‘timely diagnosis’ is only of benefit, it is felt if there is a ‘useful’ intervention in dementia: this is described in chapter 4 has having three essential components: making the diagnosis well, breaking the news of the diagnosis well to the individual with dementia and their immediates, and providing directly appropriate treatment, information, care and support for such individuals. This timely book is part of a drive to dispel the notion that ‘nothing can be done’ in the context of management of dementia, even if current pharmacological therapies might have limited efficacy. The book is an overview of the field, describing what ‘wellbeing’ actually means, and why it is important in the context of national policy. The book quickly establishes the importance of the ‘person’ in discussing dementia care, including independence, leisure and other activities, and, in the final stages, end-of-life care, which is a discussion which should not be avoided. No individual with dementia should be abandoned in relation to his or her environment, and indeed there is much evidence to support the idea that the environment can be optimised to improve the wellbeing of an individual with dementia and his/her immediates. Considerations include home and ward design, the use of assistive technologies and telecare, and the ‘built environment’. A constructive interaction of an individual with his or her environment is clearly vital, and this includes understanding communication issues, how to champion the rights of an individual living well with dementia through independent advocacy, and the way in which ‘dementia friendly communities’ can be supported.

Contents

  1. Introduction
  2. What is “living well with dementia”?
  3. Measuring living well with dementia
  4. Socio-economic arguments for promoting living well with dementia
  5. A public health perspective on living well in dementia, and the debate over screening
  6. The relevance of the person for living well with dementia
  7. Leisure activities and living well with dementia
  8. Maintaining wellbeing in end-of-life care for living well with dementia
  9. Living well with specific types of dementia: a cognitive neurology perspective
  10. General activities which encourage wellbeing.
  11. Decision-making and an introduction to advocacy in living well with dementia
  12. Communication and living well with dementia
  13. Home and ward design to promote living well with dementia
  14. Assistive technology and living well with dementia
  15. Ambient-assisted living well with dementia
  16. The importance of built environments for living well with dementia
  17. Dementia-friendly communities and living well with dementia
  18. Conclusion

Chapter synopses

It is possible to read each chapter in this book independently, and indeed each chapter is independently referenced.

Chapter 2 is an introduction to the whole book. Introduces the concept of what is like to ‘live well with dementia’. Investigating wellbeing has broadened the scope of previously overly narrow approaches to healthcare, in measuring outcomes. This chapter also introduces the idea that it is grossly unfair to consider ‘dementia’ as an unitary diagnosis, as in fact the term is a portmanteau of hundreds of different conditions at least. There has been a growing trend that ‘dementia’ and ‘memory problems’ are entirely synonymous, and this has added unnecessary noise to the debate. Dementia care is currently done in a number of different settings, and assisted living may be of increasing relevance in a drive to encourage individuals to live well independently with dementia.

Chapter 3 presents the formidable challenges of how ‘living well’ might be measured in general. There are issues about how quality of life measures change as a dementia progresses, what the relationship might be between wellbeing and physical health, and how wellbeing in dementia should be measured accurately at all.

Chapter 4 looks at the current socio-economic arguments for promoting a wellbeing approach in dementia. There are a number of converging cases for considering wellbeing, such as the economic case, the ethical case and a case based on social equality. While resources are limited, serious considerations have to be made as to which interventions are truly cost-effective, including of course the assistive technologies.

Chapter 5 presents the background for dementia as a public health issue in the UK. There is also a very active debate as to whether one should ‘screen’ for dementia. A core aim of the National Dementia Strategy (1999) is therefore to ensure that effective services for early diagnosis and intervention are available for all on a nationwide basis. It is argued, in this Strategy, that “the evidence available also points strongly to the value of early diagnosis and intervention to improve quality of life and to delay or prevent unnecessary admissions into care homes.”

Chapter 6 considers how and why being a ‘person’ has become so central to living well with dementia in academic and practitioner circles. In a way, the approach of ‘person-centred care’ is a historic one, but it has been a consistent strand of English health policy developing into contemporaneous views of integrated and whole-person care. This chapter also introduces ‘personhood’, and the approach of ‘dementia care approach’.

Chapter 7 addresses the specific rôle of leisure activities for an individual with dementia. Leisure activities are generally considered for many to be beneficial for the mental and physical wellbeing of individuals with dementia, and there are specific problems to be addressed such as the reported levels of relative inactivity in care homes.

Chapter 8 details how wellbeing is relevant also to end-of-life in dementia. This chapter considers the importance of support for carers, for the wellbeing of individuals with dementia and their carers. This chapter considers where optimal care could be given for individuals with dementia, the contribution of medication, but how it is vital to address specific issues in advanced dementia which have a direct impact on wellbeing (such as pain control).

Chapter 9 identifies that it is in fact it is impossible to consider dementia as a unitary diagnosis, and that specific forms of dementia can present their own formidable demands and issues. This chapter considers in detail how and why memory problems can be a presenting feature of dementia of the Alzheimer type, and the implications for interventions in wayfinding which could rationally improve wellbeing in such patients. The chapter also includes recent elegant work about the neural networks which are hypothesised to be important in behavioural variant frontotemporal dementia, and how this “social context network model” fundamentally affects our notion of wellbeing in such individuals.

Chapter 10 introduces ‘general activities which encourage wellbeing’, in a first chapter on the possibility of “assistive technologies” in enabling individuals with dementia to live well. Certain memories can be particularly potent in the dementia of the Alzheimer Type, and, whilst the ‘jury is possibly out’ on the validity of reminiscence therapy, the chapter discusses the possible benefits of the CIRCA project on the wellbeing of individuals with dementia. Other activities are also considered; how they may help wellbeing, such as dancing, exercise, and music.

Chapter 11 takes up an important theme in living well with dementia; that is empowering the invididual to make decisions, the law relating to capacity, and how independent advocacy services have a beneficial rôle to play. Independent dementia advocacy is a critical area of a statement in NICE QS30, and this chapter reviews types of advocacy (and its relevance to wellbeing and person-centred care), the current mental capacity legislation, and the crucial importance of diversity and equality in policy.

Chapter 12 explains why good communication is so crucial in the setting of individuals living well with, but not simply restricted to healthcare professionals. This not only appears to be in terms of providing information about the condition locally, but also face-to-face communication with people living well with dementia. This chapter looks in detail at both verbal and non-verbal methods of communication, with a view to raising awareness of their impact on living well with dementia.

Chapter 13 analyses the importance of home and ward design for improving wellbeing in dementia. ‘Therapeutic design’ is a central philosophy of good design, and this chapter has as its focus a number of different setting. General principles are described as how to wellbeing can be improved through careful design of certain parts of the house (such as balconies, bathrooms, bedrooms, living rooms and dining rooms), and considers the neuroscience of sensory considerations at play (for example in lighting and vision, and sound and hearing.)

Chapter 14 is the first of two chapters on ‘assistive technologies’ in dementia, providing an overview of this important area for living well with dementia. This chapter explains what ‘assistive technology’ is, what its potential limitations are, the INDEPENDENT project, the importance of “telehealth” (and important ethical considerations), and the design of ‘smart homes’.

Chapter 15 is the second of two chapters on ‘assistive technologies’ in dementia, looking specifically at an approach called ‘ambient-assisted living’ (AAL). The rationale behind the use of AAL in improving wellbeing is explained, as well as the general issue of how to encourage adoption of innovations in an older population. Detailed examples of specific AAL projects in improving wellbeing are described including SOPRANO, COACH and NOCTURNAL.

Chapter 16 introduces the general emphasis on the ‘built environment’ setting, and how inclusivity still drives this area of work in living well with dementia. Ageing presents its own challenges including opportunities and threats, but this chapter focuses on the remarkable initiatives which have recently taken place in improving the outside environment for individuals with dementia. The chapter details the I’DGO project, and highlights the especial importance of inclusive design for furthering wellbeing in dementia outside environments.

Chapter 17 considers how an individual with dementia lives as part of the rest of a community and society, and policy initiatives which have sought to address this. The discussion is unexpectedly problematic about a need to define what a ‘community’ might be, but the chapter includes domestic and international approaches to the ‘dementia-friendly community’, including the RSA’s “Connected Communities” and WHO’s “age-friendly communities” initiatives. As a central policy plank which is thought to be critical for developing wellbeing in individuals with dementia and their immediates, this chapter considers why dementia-friendly communities are worth encouraging at all, why there is a societal need to involve individuals with dementia in their communities, what aspects individuals with dementia wish from such communities (including the “Four Cornerstones” model), and the benefits of “resilient communities”.

Further information

You are advised to look at specialty websites which are devoted to all the dementias (such as medical charities), which often have useful information factsheets and booklets. Also, the Department of Health and their ‘Dementia Challenge’ website is an impressive source of information. You are also advised to consult https://www.evidence.nhs.uk which has access to a number of useful contemporaneous clinical evidence sources. Online medical journals are also an excellent source of peer-reviewed research, such as the BMJ, the Lancet, and the New England Journal of Medicine.

 Looking to the future

 There are, of course, no “right answers” to many issues, and a wise person is a person who knows where to find relevant information. However, the sense of optimism and goodwill is a genuine one in UK health policy, regarding dementia. Whilst there will often be difficult debates regarding dementia such as “How willing should a GP be to make a diagnosis of dementia when a patient has only gone to see his GP because of a sore throat?” or “Should we look to research a drug which can immunise people against dementia?”, the fact there are so many bright people in the UK working in areas relating to dementia is a real credit to English health policy as it faces formidable challenges of its own.

References

Department of Health (2009). Living well with dementia: A National Dementia Strategy: Putting people first. London: Her Majesty’s Stationery Office.  Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/168221/dh_094052.pdf.

Department of Health (2013) The Dementia Challenge. London: Her Majesty’s Stationery Office.  Available at: http://dementiachallenge.dh.gov.uk

Department of Health (2013) Improving care for people with dementia. London: Her Majesty’s Stationery Office. Available at: https://www.gov.uk/government/policies/improving-care-for-people-with-dementia

Department of Health (2012) The Prime Minister’s “Dementia Challenge”: Delivering major improvements in dementia care and research by 2015. London: Her Majesty’s Stationery Office. Available at: https://www.gov.uk/government/policies/improving-care-for-people-with-dementia

National Institute for Clinical Excellence (2013). Supporting people to live well with dementia (QS30). Available at: http://guidance.nice.org.uk/QS30.

UK government.  Mental Capacity Act (2005) http://www.legislation.gov.uk/ukpga/2005/9/contents

Last day of the RHS Chelsea Flower Show 24-28 May 2011



 

Today, the atmosphere was electric at the RHS Chelsea Flower Show 2011. My personal highlight was the exhibit of cactuses in the big tent, and the stall by the London College of Design explaining their work about inclusivity in garden design for the built environment.

 

 

Design in dementia : a blog viewpoint by Dr Shibley Rahman



This week, I attended a superb symposium on design principles in dementia care. Whilst I may have been in the land of the Trustefarians (those borne into trust funds), actually I was in a comfortable room in a community centre in Ladbroke Grove.

My doctoral thesis at Cambridge was in a minute area of neuroscience and academic neurology, relating to dementia. I would never have thought that 11 years later that I would end up interested in something seemingly rather different, the design of environments in dementia.

There are a number of reasons why I believe tackling the environment in dementia is important, but I think ultimately I believe in the best quality-of-life possible for patients with dementia. In a society driven by targets, it has become very untrendy to measure quality-of-life and happiness, yet it is clear to me that well-being and happiness can impact on physical health, in ways that are not yet fully understood. This may be due to discoveries which have not happened yet in neuroimmunology, but just because we may not understand the phenomenon, it doesn’t mean that the phenomenon does not exist. Anecdotes provide that transplanting an advanced patient with dementia to a totally unfamiliar surrounding can be very distressing and detrimental to their physical health; one might wonder why on earth you would do this, but unfortunately thousands of people make this journey everyday from their home to a nursing or care home everyday.

This course, run by senior people at the University of Stirling, such as Prof. Mary Marshall, did not get unreasonably bogged down in the scientific evidence. This put me much at ease, as well as making the designers, architects and artists comfortable that their creativity and common-sense were not jeopardised. We discussed everything from corridors to balconies, but the discussions were open-minded. We considered how patients with dementia perceived their outside environment. For example, I learnt that colour constancy was relatively intact in most stages of Alzheimer’s disease, despite there being many potential ‘lower-level’ visual problems. This phenomenon relates simply to how the human brain perceives the colour of something relative to the background colour. This colour constancy is well known to have been utilised to great effect in the art work of Pier Monde.

The course, and my discussions with several Professors and Readers in the UK, make me convinced that we can see a paradigm shift in the design of better environments for patients with dementia, including better use of assistive technology and planning of houses and built environments. It would be even better, if we could bridge this drive with the cognitive, behavioural and activities-of-daily-living challenges posed by patients in their day-to-day life, but I remain confident that this can happen one day.

Dr Shibley Rahman

QS, BA (1st), MA, MB, BChir, PhD, MRCP(UK), FRSA, LLB(Hons)

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