3.1. The Concept of Dementia Sensitivity
Earlier biomedical approaches to dementia focused largely on dysfunction and brain pathology. The social model of disability in the 1980s brought along a paradigm shift, turning away from a focus on dysfunction and towards the responsibility of society [85
]. Additionally, the United Nations’ Convention on the Rights of Persons with Disabilities (2008) emphasized that the design of an inclusive built environment must allow equal opportunities and, hence, unrestricted access to built space [87
]. Furthermore, the development of Universal Design brought progress in establishing barrier-free accessibility, security, privacy, orientation, and safety principles, with the aim of achieving universal usability (e.g., of an environment) for the largest possible number of people [88
The characteristics of a supportive built environment have also been discussed in terms of a person–environment fit [89
], wherein the environmental docility hypothesis assumes that people with reduced competences are more dependent on a supportive environment [90
]. People living with a dementia syndrome are more dependent due to their limited ability to adapt to or change their environment according to their personal needs or aspirations. This emphasizes the need to specifically develop dementia-sensitive environments that respond to their increasing dependency and to support residual abilities to foster autonomy, for as long as possible. An environment that does not fit the abilities, needs, and perspective of people with dementia can easily distract, fatigue, or overwhelm.
Furthermore, practicing a person-centered dementia care approach follows the idea that a person with a dementia syndrome can live well, even with the disease progressing [91
]. Thus, while the pathology eventually causes a loss of spatial orientation, a person with DAT might still be able to cope with other everyday tasks and situations, if dementia-sensitive support structures are provided. Following such a salutogenic approach [92
], planners of built space might focus on preventive and supportive factors, e.g., identifying resources and capacities that contribute to health and well-being, rather than on the impairment due to the disease. For instance, removing overstimulation to ease agitation is considered a pathogenic approach; and creating supportive design elements is a salutogenic approach [34
]. A salutogenic design of built space tackles environmental design factors that enable a person to make sense of their situation, to be supported in their everyday tasks and needs, and to experience a sense of coherence, i.e., personal meaningfulness [34
In sum, for dementia-sensitive environments, the impairments (e.g., processing environmental information; potentially being distracted by environmental cues that are irrelevant to solving a wayfinding task; or having a low threshold for sensory stimulation) in terms of the design of built space might be translated to simply relying on simplified geometries, landmarks, and spatial functions. However, in its full potential, built space would equally address a personal sense of coherence/meaningfulness, and an optimized ambience, while also offering dementia-sensitive engagement, and while supporting spatial orientation and wayfinding.
For the discussions in the next sections, we distinguish between environmental design principles
.) (often implemented before
the construction or the redesign of built space), and environmental interventions
(3.3.) or evaluation tools and strategies
(3.4.) (often implemented after
the construction of a space, e.g., translating design principles to a care context to test their effectiveness and feasibility).
3.2. Environmental Design Principles
A plethora of research in the past decades already investigated environmental design factors that might contribute to dementia-sensitive indoor
built environments. For instance, in personal home environments or hospitals, night lights can support orientation [82
]. In care facilities, areas that are not well-lit or look too similar, as well as signage with low contrast, may hinder wayfinding [95
]. Especially people living with moderate or severe dementia progressively may benefit from on geometrically simple, small-scale floor plan layouts; whereas changes of direction can be linked to disorientation [33
]. Visual accessibility to relevant places supports spatial orientation [96
]. Yet, in late, severe stages of DAT, people might not be able to rely on compensatory wayfinding strategies anymore, even if supportive cues are present [71
]. Hence, while supporting all stages is important, the built environment might best support people in early stages of the disease; thereby potentially supporting the use of residual abilities, and fostering sustained autonomy and social inclusion.
Yet, few studies exist on dementia-sensitive outdoor
built environments, such as districts—with exceptions of, e.g., [84
] who advocate inclusive neighborhoods, but do not specifically address spatial orientation or wayfinding. The few studies on outdoor wayfinding indicated, e.g., that people with mild to moderate dementia identified visual distinctiveness and memorability of outdoor landmarks (e.g., the size, shape, texture, color) but also the meaningfulness (e.g., a subjective personal significance or familiarity) as important [100
]. Wayfinding cues, e.g., signage and the presence of other people, support them to navigate independently; whereas they avoid large-scale, crowded, and noisy environments [100
]. Crossings, junctions, overstimulation, and unfamiliar spaces reportedly contribute to spatial disorientation [30
]. People with dementia seek to stay engaged in outdoor spaces and connected to their community [84
]. Thus, examining landmarks and other wayfinding cues, in terms of visual attention processes and behavior, is a potential avenue for further research; especially when considering the adaptation of outdoor spaces from the perspective of people with early stages of DAT.
At the same time, any single environmental design factor can also have negative effects, if not designed with the principle of dementia sensitivity and the perspective of the person in mind. For instance, stimulation involving more than one sense can easily overwhelm attentional resources, even if this factor is designed as wayfinding support. Yet, too many wayfinding cues can result in visual clutter and may be overwhelming, rather than supportive.
In sum, the core component of dementia-sensitive indoor and outdoor environments is spatial legibility, the degree to which an environment facilitates spatial information-processing. In this context, simplicity and safety are key planning principles in current approaches. In the view of the authors, a dementia-sensitive built space must be tailored specifically to the needs and perspective of a person with dementia (e.g., via appropriate dementia-sensitive levels of stimulation and supportive orientation cues), whilst also offering factors that support positive, meaningful experiences (e.g., dementia-sensitive ambiences or sensory interaction that involves more than one sense). This requires evaluating planned and existing built environments from the perspective of people with dementia.
With regard to the characteristics of a dementia-sensitive built environment, the authors identify the following challenges:
A first challenge is acquiring informed consent, as the person may forget having agreed to participation, while already participating in the study. Researchers can use proxy consents by caregivers or relatives, or ongoing consent where the person is informed, and asked whether they like to continue, both at the beginning of the study, as well as continuously throughout the data collection [101
A second challenge is to refine participatory dementia-sensitive methods. To more closely integrate the perspective of people with dementia in research and planning processes, researchers may need to develop alternative measures [102
] and creative analytic formats [103
]. On a content level, this includes developing methods that do not overwhelm but support people with DAT to, from their perspective, identify useful wayfinding cues. For instance, they could identify wayfinding cues involving more than one sense, rather than landmarks/geometries that appeal mainly to the visual sense. In each case, we deem it important that the research revolves more closely around their perspective, even if it may be challenging to develop sensitive methods.
A third challenge is that the plethora of studies about dementia-sensitive indoor (and to a lesser degree outdoor) environments makes it harder for non-researchers (i.e., planners of built space or dementia caregivers) to identify which studies are methodologically sound (e.g., simple geometries) and, hence, provide evidence for guidelines; and which ones show interesting directions, but contain study limitations and, hence, remain to be tested further (e.g., color recommendations). This also brings along the question how to translate research insights into practice (e.g., into an environmental design or intervention). Translation, in itself, is a complex endeavor [104
] with many barriers (such as interpreting heterogeneous research outcomes) and practical issues (such as financial or organizational barriers).
In addition, different research disciplines, e.g., psychological research and architectural planning, typically rely on different methods, paradigms, and expertise (e.g., [106
]). Here, developing a shared terminology between disciplines may facilitate a more nuanced perspective taking [107
]. In our view, structuring participatory research approaches, and reaching a common terminology of concepts might be valuable for fostering interdisciplinary collaborations. Also, researchers and planners, in a combined effort, could collaborate to reach their shared aim of supporting wayfinding via a dementia-sensitive built environment.
3.3. Environmental Interventions
If the built environment is already constructed, environmental interventions can additionally contribute to optimizing dementia-sensitive spaces. Guidelines for people with severe dementia may target several aspects at once, e.g., ensuring a supportive, dementia-sensitive environment, but also sustained training for caregivers (focusing on their interaction with people with dementia and on self-care), as well as psychosocial interventions [108
]. Psychosocial interventions target, e.g., the stimulation of physical activity [109
]. Environmental interventions target, e.g., improving safety, or supporting various everyday tasks, such as toileting, dressing, or cooking [111
The few environmental interventions specifically designed for supporting spatial orientation have largely focused on evaluating compensatory wayfinding cues, such as landmarks: studies evaluated installing residents’ younger-aged portraits or names [112
], images with familiar local content [95
], or images along with personalized familiar objects placed close to the resident’s room [113
]. Researchers also emphasized the need for a good quality of these cues, such as using large-size and contrast, and proper illumination; as well as installing cues on an adjusted height and at relevant locations [81
Recent studies also started debating how theory and evidence from neuropsychology and environmental psychology might inform principles and guidelines for dementia-sensitive environments and landmarks [114
]. For instance, landmark design should consider both the saliency (e.g., arising from unique colors and landmark placement at relevant locations), as well as their semantic differentiation (e.g., arising from verbally and visually differentiated landmarks). Additionally, dementia-sensitive levels of lighting, a meaningful personalization of space, and planning few decision points and small-scale units might minimize spatial disorientation [114
In sum, research about the perspective of people with dementia is beneficial to guide future environmental intervention approaches, e.g., by providing both the scientific knowledge as well as the evaluation methods for assessing dementia-sensitive environments.
With regard to environmental interventions, the authors identify the following challenges:
One challenge in the aforementioned context is that, based on the subjective individual perspective, needs, and abilities, researchers, planners, and caregivers often need to generalize insights to develop design principles or environmental interventions that accommodate the needs of a largest possible number of people. Yet, averaging individual backgrounds, e.g., cultural aspects, if applied without deeper reflection, may cause a design that is functional, but misses its full potential. In the view of the authors, this is where research could measure wayfinding challenges in field settings, and optimize spatial legibility and lived experience based on the perspective of people with DAT.
Another challenge is that, while numerous discussions of how environmental factors can support people with dementia exist, few focus specifically on evaluating spatial orientation and wayfinding from the perspective of people with DAT. In our view, it is worthwhile to identify, in a more nuanced way, how to integrate the perspective of people with dementia in design and planning processes. For instance, from the perspective of a person with dementia, space is not only related to physical and social environments, but in itself may become an existential experience, where a sense of continuity, self-identity, sense of place-attachment, familiarity, and autonomy remain relevant existential concepts that need to be preserved [79
3.4. Environmental Evaluation Tools and Strategies
First, regarding environmental evaluation tools, we refer to the Environmental Audit Tool [98
] as one example of such tools, to discuss potential challenges that are also inherent in other tools. Environmental evaluation tools often have a preventive character, focusing on actions to reduce negative factors:
A walkthrough and survey method, the Environmental Audit Tool addresses design factors such as: competence-oriented design and human scale; dementia-sensitive stimulation; unobtrusively placed safety features; familiarity with the space; spaces for both retreat/privacy as well as social inclusion; appropriate stimulation of meaningful activities; visual accessibility between locations; and opportunities for movement [34
]. The concept of spatial orientation and wayfinding is evaluated by judging whether a certain design factor is present, or not. For instance, spatial orientation is evaluated by the presence or absence of tactile or acoustic stimuli that “offer a variety of experiences and support orientation,” e.g., represented in floor materials, water, or soundscapes [98
]. Spatial orientation, hence, is not regarded as an independent principle, but integrated within the larger principle of “positive stimulation.” As spatial cognition and wayfinding play a minor role, it may remain unclear for practitioners (e.g., planners and caregivers) how they can best reduce wayfinding challenges.
Second, regarding strategies to reach dementia sensitivity, we refer to the recent World Alzheimer Report 2020 [34
] and the German National Dementia Strategy 2020 [35
], as two selected examples:
The international World Alzheimer Report 2020 [34
], emphasizes out-of-home participation. This is important, as recent studies indeed indicate that people with dementia engage less than others in public places [116
]. The report mentions so-called “easily seen wayfinding cues” as essential design elements. In the report, suggestions for practitioners are driven by research (e.g., concepts for adapting signage, colors, lighting, or furniture to the needs of people living with dementia). Yet, spatial orientation and wayfinding are, again, placed within other design principles, such as supporting movement, optimizing stimulation, or ensuring visual and physical accessibility. Wayfinding is not recognized as independent principle.
Similarly, in the German National Dementia Strategy (2020) [35
], spatial orientation also is not defined as independent principle, and solutions for a supportive environment in terms of wayfinding remain vague. For instance, the development of color principles is seen as possible method to support spatial orientation. Yet, color codes have in some studies been ineffective [69
], despite being conceptually discussed as relevant [43
]. While colors can become relevant when establishing contrast and marking edges [81
], or can be used creating zones between areas, researchers are often hesitant to provide “golden rules”: the use of colors is context and target-group dependent, and other design variables, such as geometries, visual and physical accessibility, are harder to change once a place is constructed. For planners, colors are also subordinate to other design factors, such as geometry [117
]. The strategy also identifies an urgent need for district development, to foster mobility and social inclusion of people with dementia. For instance, it advises that people working in public transport systems need to be further trained. This could be extended towards developing, additionally, a spatially legible built environment.
In sum, the key source for informing evaluation tools and strategies for dementia-sensitive environments is the perspective of people living with dementia. In particular, the use of contradicting information in dementia-sensitive strategies may indicate a need for identifying ways to continuously integrate research results into planning, and to translate research knowledge into support tools and interventions for planners. Such efforts could also distinguish results that are reliable, yet still falsifiable, from innovative pilot-studies that need follow-up studies. Thus, while, undoubtedly, such existing efforts are both timely and needed, they might benefit from further refinements based on research theory and experimental insights (also cf. [34
With regard to environmental evaluation tools and strategies for dementia-sensitive environments, the authors identify the following challenges:
A first challenge is that it currently remains unclear how
the perspective of people with dementia could be further translated into early design and planning stages. We propose refining participatory methods and co-research, as Section 4
Additionally, it is unclear whether existing principles would work similarly both for indoor (care institutions) and outdoor environments (districts, public buildings). Broad design principles are useful as they raise awareness and sensitivity. Yet, if research results are applied without further reflection on the changing stages and needs in dementia and across generations, these principles might not reach their full potential.
Additionally, in terms of advancing dementia-sensitive design and planning guidelines, one research avenue is to measure wayfinding challenges in a more nuanced way, and potentially over an extended period of time, to identify more responsive, dynamic solutions that respond to individual backgrounds and changing stages of the disease and aging.
3.5. Design and Planning Processes of Built Space
Design and planning processes of built space, by nature, require anticipating how the future users of a planned environment interact with the space. In the context of wayfinding, this means anticipating how different groups of users of the space, such as people with DAT, process and use spatial and non-spatial information to orient themselves and to decide where to go. During the design and planning process, planners iteratively immerse themselves into different spatial perspectives within a floor plan, using sketching, simulations, or physical- and virtual models [119
While planners are trained by their education and experience to anticipate behaviors in terms of a perspective shift (i.e., anticipating what a user can see in a specific spatial configuration), they might yet face challenges with perspective taking (i.e., anticipating the informational situation of a user of the space, and how they would process, experience, and behave in the environment) [54
]. Perspective shifting in this context is the anticipation of what the users of an environment can perceive from their viewpoint [54
], e.g., that a room is open or closed based on its spatial configuration being wide or narrow. Perspective taking is a more holistic, metaphorical concept than perspective shifting: it means imagining how another person experiences the world from their perspective, and developing a positive concern for the person [56
]. Both are needed to take the perspective of a future user of the space, and to develop optimized design outcomes.
Yet, it may be challenging for planners to take the perspective of a person who perceives and processes environmental information differently [53
]; e.g., with limited attentional, emotional, or physical resources. Indeed, some professionals do report a lack of knowledge and methods to better integrate the perspective of people living with dementia into their design and planning processes [120
]. Here, reflecting conceptually about another person’s point of view and their difficulties based on impaired brain functions might require additional information. Furthermore, planners and designers are often focused on visual senses, whereas wayfinding design outcomes can potentially involve more than one sense, as long as it is not overwhelming people [81
Additionally, there are other barriers for integrating the perspective of people living with dementia into planning and design processes: while planners have a high interest in developing dementia-sensitive concepts for built space, the interactions between built design and behavioral outcomes cannot be entirely objectified [117
]. Planners long for knowledge about how several environmental design factors are linked to specific behavioral or experiential outcomes. Research, to ensure experimental control, may yet focus on isolated details, such as colors or furniture. Yet, these are not the main focus in planning processes [117
] that need to consider design factors more holistically.
Multiple requirements (e.g., resources and budgets; regulations and norms; capacity planning, etc.) and stakeholders (e.g., owners; developers; planners; facility managers; specialized consultants; structural engineers; technicians, etc.) influence the decision-making processes during planning. This results in competing interests. For instance, when re-designing a district, the perspective of people with dementia may be subordinate to other planning requirements or stakeholder interests, such as: federal and state laws; guidelines and statutes at various political and legal levels; mobility- and transport structures; climatic, ecological, and technical considerations; administrative, governmental, or budget-related concerns; topographical and historical aims; and the municipality’s land use and zoning plans that provide a framework for the city’s further development.
Moreover, the driving forces behind the design of public buildings (e.g., public libraries or shopping malls), private buildings (e.g., care facilities), and urban environments (e.g., districts) rely on different design considerations, processes, and interests. For instance, when planning a dementia care facility, the perspective and needs of people with dementia are usually the driving force for the design. For public buildings, however, planners may strive for a futuristic design and unconventional floor plan layout—even if there is a risk that building users may find this disorienting [42
]. Furthermore, many retail environments contain a sheer abundance of visually distinct shapes, materials, illumination, commercial displays, soundscapes (and so on): here, developers might even aim at triggering disorientation in time and space. Additionally, the redesign of a district needs to serve various functions and diverse user types at once, and often depends on manifold regulations. Efforts to renew an urban environment may improve a district on several aspects—but the changes can also bring along a loss of familiarity (e.g., removing or changing landmarks; or disrupting place-attachment; both of which may be particularly challenging for older persons and people with dementia).
As such, planning built space is a highly complex process, where anticipating the behavior and experiences of diverse groups of users of the space can easily fall by the wayside [55
]. Close cooperation and coordination between the involved stakeholders [12
], as well as a sustained collaboration with researchers who can provide scientific knowledge, could support, e.g.: managing the competing interests and expectations; exchanging and communicating information between disciplines; and deriving decisions, compromises, or trade-off solutions that benefit the users.
In sum, the complexity of the design and planning process may be a reason why perspective taking of a person with limited resources is challenging. While the needs of people with vulnerabilities might be represented in specific guidelines/norms, various design requirements and stakeholder interactions can influence the final planning decisions and design outcomes.
With regard to perspective taking in planning dementia-sensitive environments, the authors identify the following challenges:
One challenge is that the design and planning process is highly complex, with multiple requirements and stakeholders influencing decision-making. These requirements can draw attention away from designing from the perspective of a person with dementia. We envision iterative interventions for planners that inform early stages of planning that emphasize the perspective of people with dementia. In addition, wayfinding processes in people with dementia rely on highly complex interactions between the person, context, and the environment. It is worthwhile to examine how these complexities can be generalized and translated into interventions for planners, without oversimplifying the perspective of people with dementia.
A second challenge is that it can be hard for environmental planners to anticipate the perspective of a person with limited attentional, motivational, or physical resources. Additionally, research studies combining cognitive and behavioral measures in naturalistic tasks in the field are rare, and often contain low sample sizes. We envision that research using naturalistic tasks and in field settings can refine this perspective; while also translating this perspective into an appropriate format that can supplement existing design and planning processes. Furthermore, inclusive or participatory methods could be regarded as general requirement in future studies.
A third challenge depends on whether all involved stakeholders in a planning and design process are equally interested in supporting people with dementia; specifically, if built space needs to serve diverse groups of users and various competing interests (such as in the retail context). Raising awareness on the importance of dementia-sensitive built space is one step. Yet, it may be needed to mandate principles for dementia sensitivity as a general requirement for urban planning, with the goal of establishing demographically sustainable future cities.