Memory Care Architecture and Design: A Human-Centered Approach

Over the past 30 years, researchers and architects have collaborated to create memory care facilities based on a human-centered design approach, which considers how the interior space of a structure affects a person’s thinking, behavior, and emotions. The result: Communities have moved away from the outdated image of a sterile, hospital-like institution filled with medical equipment, where routines are standardized and individuality can be lost.

“What we’ve changed to is trying to design a space that feels like home,” says Casey Franklin, assistant professor of interior architecture at the University of Kansas (KU). Franklin, who specializes in environmental psychology and human factors, is a member of the Smart Cities Research Institute at KU, where she helped integrate caregiver apps into a smart home for seniors.

“Research shows that residents have an easier time transitioning and forming bonds in a new facility when they can make it feel like their own space,” Franklin explains.

Much more than simple forgetfulness, dementia can take away a person’s ability to regulate emotions. Minor daily obstacles — such as not getting to eat the same meal you’re used to — may lead to anger, aggression, and depression.

To study how an interior environment can affect a person’s emotions, the architecture field has moved toward evidence-based design, which means taking research and data and “translating it into new design solutions aimed at giving patients a better quality of care,” Franklin says.

Healing gardens — sometimes called therapy gardens — are outdoor green spaces, usually in a health care setting, intended to improve a person’s overall well-being.

At Memphis’s Trezevant Terrace, an assisted living community with a memory care unit, the roof garden heals by creating a sense of nostalgia. Residents step out onto the roof, and a screen door slams shut behind them as they follow a path leading to an old Cadillac convertible.

“It doesn’t run,” says Lee Askew of Askew Nixon Ferguson Architects, which designed Trezevant Terrace. “But it has nice seats.”

Askew acquired the Cadillac and installed the screen door on the advice of John Zeisel, president and co-founder of Hearthstone Alzheimer Care. Zeisel, who has a background in sociology and architectural design, was the principal investigator of a three-year study that found a balanced combination of medication with behavioral and environmental approaches is likely to be the most effective treatment for dementia symptoms. The key finding, he says, was that environmental factors are equally as important as behavioral approaches and medication.

Star fixtures at each of Hearthstone’s seven memory care facilities in New York and Massachusetts, healing gardens are popular in memory care throughout the country — and for good reason. Studies show these spaces help reduce agitation, isolation, depression, and aggressive behaviors in people with Alzheimer’s and other types of dementia.

For residents and their caregivers at Hogewey dementia village in Weesp, Netherlands, the line between therapy and everyday experience has blurred. They roam the four-acre campus — which resembles a miniature city more than a senior living community — and drop into the post office, movie theater, and grocery store. Offices and residential units form the village’s perimeter, creating a secure enclosure around a network of walkways, courtyards, and other public spaces including a café and art gallery.

Dementia villages like Hogewey may be the next stage in the evolution of memory care. Taking more into consideration than evoking fond memories through sight and sound, these communities allow a resident to move beyond the walls of their room and toward interaction with the outside world — or at least a safe, contained, small-scale version of it.

“The question is: How can we push image-based nostalgia to other senses, and also to physical actions and actually engaging people in tasks rather than just looking at an image?” says Max Winters, co-host of the Shaping Dementia Environments podcast, and senior designer at RLPS Architects, an architecture firm specializing in senior living and student housing.

Winters and Jennifer Sodo authored “Missing Main Street: Reconnecting Older Adults with Dementia to the Fabric of Authentic Living,” a 2019 report detailing the innovative, effective environmental design features demonstrated at Hogewey.

“At its core, Hogewey works because of its total commitment to the vision of normalcy for older adults with dementia,” Winters and Sodo note in “Missing Main Street.”

Is memory care the right fit?

Reminiscence drives design

Studies on reminiscence therapy suggest that when people physically engage in an action, especially if it’s a task they used to perform regularly when they were younger, there’s a better chance of triggering or even restoring memories. Interconnectivity is a crucial part of that, because when a resident has to leave a single, designated space to participate in an activity, chance encounters with neighbors occur, and familiar routines resurface. In short, life happens.

“The grocery store in Hogewey is not just an activity,” Winters explains.

“It’s not like you take the can of tomatoes off, put it in your cart, and then eventually somebody just puts it back on the shelf for you to do again. For the meals that get cooked in the houses at Hogewey, the ingredients come from the supermarket — if you want to make food, you need to go buy groceries.”

Rather than a one-size-fits-all approach, where staff keep everyone on the same schedule of daily routines like group meals and outings, Winters says memory care communities should look at the Hogewey model for ways to recreate the world residents once knew.

Read more:What Do Dementia Patients Think About?

For some seniors with dementia, stress and fear can lead to wandering, where a person goes in search of familiarity with no clear destination in sight. All of the potential causes of wandering have design implications, and designers of memory care facilities can implement different strategies to help prevent accidents resulting from wandering.

Wayfinding

An entire field of study on its own, wayfinding guides humans through spaces via basic concepts like signage, iconography, carpet design, and lighting. But it’s more strategic than simple arrows and room names.

“Think of it like environmental cueing,” Franklin says. “You want to provide physical signals that help people get to identifiable destinations.”

Wayfinding considerations may be something obvious, like a restroom marked clearly with legible text and a recognizable symbol. Sometimes it’s more subtle: A high-traffic room’s doorway with painted woodwork should be clearly outlined, while a doorway for a room residents should avoid should be camouflaged with a mural like a painted bookshelf.

According to Winters, people with dementia retain their ability to recognize objects better than colors, especially as their vision begins to deteriorate, so placing distinctive markers, like an antique sewing machine or a grandfather clock, at hallway intersections is an effective way to help residents navigate.

Zeisel suggests wayfinding can involve many human senses.

“Design the entire environment so what people see, hear, touch, and smell all give them the same information about the environment,” Zeisel says. “If the kitchen is meant to be the social hub of the setting, make sure it looks, feels, sounds, and smells like a social hub.”

As part of a wayfinding solution, healing gardens can serve as a safe, natural endpoint for residents who wander. In a carefully designed memory care facility, strategically placed hallways may lead a disoriented, wandering resident to a peaceful, centrally located garden surrounded by fences.

“If a garden is to be used frequently, make it highly visible through a window and accessible through an easily located and unlocked door,” Zeisel explains.

Designers often use wayfinding to offset the confusion caused by double-loaded corridors, which are long hallways with doors on both sides, as you see in most hotels. This repetitive design can be disorienting for people with dementia, as every hallway and room appear basically the same.

Ideally, architects who specialize in memory care interior design would organize residents’ rooms in smaller, more identifiable clusters. But because double-loaded corridors are so common in existing facilities, designers often must use personalization strategies to reduce confusion in long hallways.

Maintaining privacy

Some loss of privacy is often unavoidable when an elderly person moves into senior living — particularly if they’re living with a condition like Alzheimer’s and require daily care. They may feel a lost sense of freedom or control as they try to adapt to a new routine or when someone comes into their room every day to help with daily tasks. That negative feeling can be amplified when there are too many residents in memory care units.

“The general rule of thumb is that less crowded is better,” Franklin says. But even if a resident doesn’t have a private room, there are other ways to create privacy, such as visual barriers and separate shared spaces for visiting with relatives.

Memory care questions? Get expert help

It’s a balance, though, because too much privacy can lead to senior isolation. A design solution could be a window in the resident’s room that looks out into a hallway, or barn doors where top and bottom halves open separately. This allows residents to feel some sense of connection while maintaining distance and control.

Social support to avoid isolation

An elderly person moving into senior living may have lost a spouse and may not have a strong network of support, so to avoid isolation, it’s important to create opportunities for residents to make new friends and meet regularly. If a resident has friends outside of the facility, there should be a place for the resident to entertain guests. This could be a kitchen and living area in private rooms or a common area for residents to reserve.

Another social consideration is sleeping accommodations for residents’ family members or close friends. Sometimes, facilities may provide space for overnight guest stays. In some cases, senior living furniture is designed with guests in mind: Seating in private rooms can convert into beds.

In “Missing Main Street,” Winters and Sodo write, “When visiting their loved ones in dementia care environments, one of the most dreaded statements for friends and family members to hear is ‘I want to go home!’ But for those living with dementia, this verbal longing for home is not always a literal request, but sometimes a cry for reaffirmation of a sense of ‘self’ — a sense of self previously supported by the feelings of safety, control, and love wrapped up in the memory of home.”

Memory care facility designers should continually think about the environment as a healing space, according to Franklin. The goal is for the interior and exterior spaces to have a positive effect on dementia symptoms by targeting several basic human needs, including a sense of self-esteem, belonging, and safety. Addressing these needs helps reestablish place attachment, which is the feeling of connection and comfort a person associates with their home.

“What makes a home a home? That’s a big question,” Franklin says. “When people are moving, it’s an emotional process as well as a physical one, so this is about providing opportunities for that same type of emotional attachment to occur in a new space.”

While North America still awaits its first Hogewey-like village, communities continue to incorporate forward-thinking, human-centered design features into their environments — and it’s only a matter of time before consumer demand brings more personal choice and social activism to senior living.

These articles explain the types of therapies and activities typically offered in dementia care, plus how memory care communities compare to other types of senior living:

• Memory Care vs. In-Home Care for Dementia: What’s the Difference?
• Assisted Living vs. Memory Care: What’s the Difference?
• Memory Care vs. Nursing Homes: What’s the Difference?

A Place for Mom’s Senior Living Advisors can share information about all types of senior care options in your area. They can also help assess your family’s specific situation — all at no cost to you.

Sources:

Franklin, C. (2020, June 1). Personal communication [Personal interview].

Sodo, J. & Winters, M. (2019). Missing main street: Reconnecting older adults with dementia to the fabric of authentic living. Perkins Eastman.

Winters, M. (2022, March 8). Personal communication. [Personal interview].