397

Copyright 2000 by
The Gerontological Society of America
The Gerontologist
Vol. 40, No. 4, 397416

Vol. 40, No. 4, 2000

Design of the physical environment is increasingly recognized as an important aid in caring
for people with dementia. This article reviews the empirical research on design and
dementia, including research concerning facility planning (relocation, respite and day care,
special care units, group size), research on environmental attributes (noninstitutional
character, sensory stimulation, lighting, safety), studies concerning building organization
(orientation, outdoor space), and research on specific rooms and activity spaces (bathrooms,
toilet rooms, dining rooms, kitchens, and resident rooms). The analysis reveals major themes
in research and characterizes strengths and shortcomings in methodology, theoretical
conceptualization, and applicability of findings.
Key Words: Architecture, Alzheimers disease, Nursing homes, Assisted living

The Therapeutic Design of Environments for
People With Dementia: A Review of the
Empirical Research

Kristen Day, PhD,

1

Daisy Carreon, BA,

2

and Cheryl Stump, BA

3

Design of the physical environment is increasingly
recognized as an important aid in the care of people
with Alzheimers disease and other dementias. Facil-
ity administrators and designers now view the design
of long-term care, assisted living, and other environ-
ments as more than simply decorative. Design is re-
garded as a therapeutic resource to promote well-
being and functionality among people with demen-
tia. This article reviews and analyzes findings from
empirical research on the therapeutic impacts of de-
sign in dementia care settings.
Since the early 1980s, numerous design guides
books and articles offering planning, architectural,
and interior design recommendationshave been
written to instruct architects and care providers on
how to enhance safety, homelikeness, and so forth in
dementia care facilities. At least four books of design
guidance for dementia environments have been pub-
lished to date (see Brawley, 1997; Calkins, 1988; Co-
hen & Day, 1993; Cohen & Weisman, 1991), along
with numerous articles in scholarly and professional
books and journals (see Appendix A, Note 1). Design
recommendations for dementia environments are or-
ganized on a continuum by scale, as follows (after
Cohen & Weisman, 1991): (a) planning principles
broad decisions made when developing a dementia
care facility (e.g., facility planning should accommo-
date a continuum of care); (b) general attributes
desired qualities of the overall environment of the fa-
cility (e.g., facility design should promote noninstitu-
tional character); (c) building organizationdesired
arrangement of spaces within the facility (e.g., build-
ing design should support residents sense of orienta-
tion); and (d) specific rooms and activity spacesthe
design of particular rooms within the facility (e.g., de-
sign of bathrooms should preserve residents dignity
and privacy).
Design guides typically offer hypotheses for how
the spatial organization and appointment of the phys-
ical environment may promote well-being for people
with dementia. For example, to minimize the sensory
overstimulation that afflicts many people with de-
mentia, design guides recommend modifications such
as designation of quiet rooms with soft colors, elimi-
nation of unnecessary clutter, and removal of paging
systems (cf. Brawley, 1997; Cohen & Weisman, 1991).
Frequently, design guidance is based on the practical
experience of designers or facility administrators; other
times, design guidance is research based, applying
findings from clinical research on dementia in the
form of design solutions (Weisman, Calkins, & Sloane,
1994).
Not all design guidance requires empirical re-
search findings to justify its recommendations. For in-
stance, design guides frequently call for enhanced
quality of life in institutional settings (e.g., design
strategies to increase homelikeness and autonomy for
residents). Such valuesessential qualities of dignity,
privacy, and so forthare arguably inalienable
rights (Lawton, 1981, p. 245) that do not require
empirical research for validation.

1

Address correspondence to Dr. Kristen Day, Department of Urban and
Regional Planning, School of Social Ecology, University of California, Irvine,
CA 92967. E-mail: kday@uci.edu

2

Department of Sociology, University of California, Irvine.

3

Department of Psychology and Social Behavior, University of Califor-
nia, Irvine.

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398 The Gerontologist

Other design guidance does demand verification
through empirical research, however. Empirical re-
search is needed to resolve situations in which con-
flicting design recommendations are offered. Re-
search is also warranted when recommended design
solutions are of unknown effectiveness or when de-
sign recommendations have major or controversial
impacts for cost or quality of life. Research on design
and dementia has been conducted in earnest since at
least 1980, yet findings of many studies remain un-
known among designers and facility administrators.
In the following sections, we review and analyze ex-
isting studies of design and well-being for people
with dementia to enhance the design of dementia fa-
cilities and to provide direction for future research.

Methods

Several strategies were used to identify potential
studies for review. The first involved a key-word
search of four major databases: Psych Abstracts,
Medline, MAGS, and CAT (see Appendix A, Note 2).
Potential studies were also identified by reviewing all
issues (1980 or later) of several journals in gerontol-
ogy and environment-design research (see Appendix
A, Note 3). Finally, reference lists were inspected for
all studies included in this review. In each case, arti-
cles, books, and chapters identified as potentially rel-
evant (by title and by abstract if available) were col-
lected and assessed for appropriateness.
Studies included in this review met the following
criteria: a report of empirical research (see Appendix
A, Note 4), published 1980 or later (see Appendix A,
Note 5), written in English, with an emphasis on peo-
ple with dementia or their families or staff caregivers,
and with a substantial (though sometimes secondary)
emphasis on the relationship between

the design of
the physical environment

and the

well-being of peo-
ple with dementia, their families, and/or staff.

For this
review, the physical environment was loosely de-
fined as the domain of relevance to architects, inte-
rior designers, facility managers, and/or administra-
tors or caregivers undertaking environmental design
or renovation. Thus, research on issues such as light-
ing, furnishings, and outdoor space was included.
Research on microscale product design (e.g., pros-
thetic devices to facilitate eating) or on the sensory or
social environment outside the purview of designers
(e.g., incorporation of music and pets) was excluded, as
were studies that did not examine actual environments
or actual impacts. Well-being was defined broadly, to
include factors such as residents activities of daily liv-
ing (ADL), physical well-being, cognitive function, and
problem behaviors; family members well-being; and
staff well-being and job performance. Seventy-one re-
search reports were included in the review. Because of
this selective search strategy, we may have overlooked
some relevant material in the review.

Research Design and Sample Size

Much research on design and dementia comprises
small size samples. For example, more than 30% of
the studies reviewed used samples of fewer than 30
participants; many included less than 10 participants.
Sample sizes reflect the limited populations of resi-
dents at the single facility in which many studies
were conducted, the high rates of resident mortality,
and facilities limited populations of residents in
comparable stages of dementia. Although they raise
concern for the validity and generalizability of find-
ings, studies with small samples were included so as
not to severely restrict the scope of this review. Re-
search designs and samples are described in Table 1.

Results

The rate of research on design and dementia is in-
creasing: from 6 research reports from 19811985, to
17 research reports from 19861990, to 26 research
reports from 19911995, and to 21 research reports
already published since 1996 (see Table 1). This sec-
tion summarizes findings from the research reports
reviewed, according to the organizational framework
presented earlier (i.e., planning principles, general at-
tributes of the environment, building organization,
and specific rooms and activity spaces). The sum-
mary is followed by a discussion and analysis of ex-
isting research on design and dementia.

Planning Principles

These studies examine broad decisions regarding
the development of dementia care settings. Studies
examined impacts for well-being following reloca-
tion of people with dementia to new environments,
use of respite and day care environments and of spe-
cial care units (SCUs), and exposure to various group
sizes of residents.

Relocation to New Environments.

Findings are
mixed regarding the impacts of relocating people
with dementia to new environments (Robertson,
Warrington, & Eagles, 1993; Seltzer et al., 1988; see
Appendix A, Note 6). When moved together as intact
units of residents and staff, people with dementia ap-
pear to suffer few or no adverse impacts from reloca-
tion (Anthony, Procter, Silverman, & Murphy, 1987;
McAuslane & Sperlinger, 1994; Robertson et al.,
1993). The more pleasant environment of a new fa-
cility may partially explain the lack of negative im-
pact for relocated residents (according to McAuslane
& Sperlinger, 1994). In contrast, residents with de-
mentia who are moved individually appear to suffer
higher rates of depression and mortality following re-
location (Anthony et al., 1987; Robertson et al.,
1993). This effect holds when residents undergo ori-
entation to ease relocation. Staff members also report
decreased job satisfaction (attributed to anxiety) prior
to moving, which returns to premove levels of satis-
faction following relocation (McAuslane & Sper-
linger, 1994).

Respite Environments.

Respite environments of-
fer temporary care for people with dementia and pro-
vide relief to families. The impacts of respite environ-

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399 Vol. 40, No. 4, 2000

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,

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n
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l
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e
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n

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t

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s
,

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,

a
n
d

w
a
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.

F
a
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a
n
d

s
t
a
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f

w
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r
e

s
a
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S
C
U
.
C
o
h
e
n
-
M
a
n
s
f
i
e
l
d

&

W
e
r
n
e
r

(
1
9
9
8
)
D
i
s
c
r
e
t
e
;
P
r
o
b
l
e
m

b
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h
a
v
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a
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x
p
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r
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m
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t
2
7

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s
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n

n
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h
o
m
e
2
3

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2
9

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m
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s

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n

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h
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m
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R
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p
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1
1
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2
0
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o
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o
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f
r
o
m

400 The Gerontologist

T
a
b
l
e

1
.

S
u
m
m
a
r
y

o
f

K
e
y

I
n
f
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o
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t
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R
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o
n

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a
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m
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a

(

C
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)

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C
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o
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a

;
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f
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(
s
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l
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W
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n
e
r
,

&

M
a
r
x

(
1
9
9
0
)
D
i
s
c
r
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t
e
;
P
r
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b
l
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m

b
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h
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S
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r
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y
2
4

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l
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c
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f
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w
a
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a
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w
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l
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u
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c
k
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n
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M
c
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a
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-
K
a
r
k
,

&

M
a
r
s
h
a
l
l
-
B
a
k
e
r

(
1
9
9
5
)
D
i
s
c
r
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t
e
;

D
e
s
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g
n

f
e
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t
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s
O
n
e

g
r
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u
p

p
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t
/
p
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t
7

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S
C
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R
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d
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s
,

w
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c
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m
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o
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w
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w
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,

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c
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p
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b
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.
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l
m
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t

h
l
,

A
n
n
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r
s
t
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d
t
,

&

h
l
u
n
d

(
1
9
9
7
)
D
i
s
c
r
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t
e
;

D
e
s
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g
n

f
e
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t
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Q
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x
p
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m
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t
1
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5

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p

l
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R
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c
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B
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p
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,

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,

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R
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g
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f
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p
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w
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h
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c
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c
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m
m
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c
a
t
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n

a
r
e
a
.

t
e
s
t
a
m

&

M
e
l
i
n

(
1
9
8
7
)
D
i
s
c
r
e
t
e
:

D
e
s
i
g
n

f
e
a
t
u
r
e
s
E
x
p
e
r
i
m
e
n
t
2
1

r
e
s
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d
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n
t
s

i
n

p
s
y
c
h
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g
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r
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a
t
r
i
c

w
a
r
d

(
1
9

w
i
t
h

d
e
m
e
n
t
i
a
)
R
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s
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d
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n
t
s

e
a
t
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n
g

b
e
h
a
v
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o
r
,

c
o
m
m
u
n
i
c
a
t
i
o
n
,

a
c
t
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v
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t
y

l
e
v
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l
s
N
o
n
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n
s
t
i
t
u
t
i
o
n
a
l

d
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n
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g

a
r
r
a
n
g
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m
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t
s

(
d
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n
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g

i
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c
o
f
f
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r
o
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m

a
t

s
m
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t
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b
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w
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f
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t
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s
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v
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b
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t

l
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)
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a
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d
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m
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m
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v
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b
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h
a
v
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a
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c
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m
m
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c
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n

a
m
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r
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s
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d
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n
t
s
.
G
r
e
e
n
e
,

A
s
p
,

&

C
r
a
n
e

(
1
9
8
5
)
G
l
o
b
a
l
;

E
n
v
i
r
o
n
m
e
n
t
a
l
c
o
m
p
a
r
i
s
o
n
O
n
e

g
r
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u
p

p
r
e
t
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s
t
/
p
o
s
t
t
e
s
t
1
2

r
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s
i
d
e
n
t
s

i
n

S
C
U
R
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s
i
d
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n
t
s

h
o
s
t
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l
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t
y
,

a
g
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t
a
t
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n
,

a
p
p
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t
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t
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,

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f
-
f
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d
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g
,

c
o
m
b
a
t
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s
s
,

a
m
b
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l
a
t
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o
n
,

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n
c
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n
c
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,

d
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e
s
s
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g
,

c
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g
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v
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s
k
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l
l
s
,

w
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t
h
d
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a
w
a
l
,

h
a
l
l
u
c
i
n
a
t
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n
s
S
C
U
:

s
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n
g
l
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a
n
d

d
o
u
b
l
e

r
o
o
m
s
,

l
o
c
k
e
d

d
o
o
r
s
,

p
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r
s
o
n
a
l
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z
a
t
i
o
n
,

m
u
s
i
c
,

d
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g

a
r
e
a
S
C
U

w
a
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

i
m
p
r
o
v
e
m
e
n
t
s

i
n

r
e
s
i
d
e
n
t
s

b
e
h
a
v
i
o
r
,

c
o
g
n
i
t
i
v
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s
k
i
l
l
s
,

a
n
d

a
f
f
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c
t
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v
e

r
e
s
p
o
n
s
e
s
.
H
a
n
l
e
y

(
1
9
8
1
)
D
i
s
c
r
e
t
e
;
P
r
o
b
l
e
m

b
e
h
a
v
i
o
r
s
E
x
p
e
r
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m
e
n
t

a
n
d

q
u
a
s
i
-
e
x
p
e
r
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m
e
n
t
6

r
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s
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d
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n
t
s

i
n

p
s
y
c
h
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g
e
r
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a
t
r
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c

w
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d
2

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s

i
n

o
l
d

p
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o
p
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s

h
o
m
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R
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d
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t
s

o
r
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a
b
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l
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L
a
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g
e
,

3
-
D

w
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d

s
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s

a
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d

l
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p
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401 Vol. 40, No. 4, 2000

T
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1
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K
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1
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1
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1
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8
9
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&

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(
1
9
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(
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&

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(
1
9
9
2
)
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s
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3
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(
1
9
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2
c
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p
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1
1
,

2
0
1
1
g
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.
o
x
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a
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s
.
o
r
g
D
o
w
n
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a
d
e
d

f
r
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m

403 Vol. 40, No. 4, 2000

T
a
b
l
e

1
.

S
u
m
m
a
r
y

o
f

K
e
y

I
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f
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m
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S
t
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d
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(
1
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9
7
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l
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b
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n
v
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(
1
9
9
1
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s
c
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(
1
9
9
3
)
G
l
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b
a
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(
1
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9
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(
1
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9
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l
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b
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(
1
9
9
5
)
D
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s
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;
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(
1
9
8
8
)
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l
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b
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n
v
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3
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D
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405 Vol. 40, No. 4, 2000

T
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406 The Gerontologist

ments on people with dementia appear to be related
to individuals functional levels and to the type of en-
vironment. In an examination of 37 clients of respite
services, Seltzer and colleagues (1988) found that,
following a 2-week respite stay, lower functioning in-
dividuals showed small improvements in ADLs, whereas
higher functioning individuals showed a small de-
cline in ADLs. Both effects were minor, and neither
group revealed any changes in cognitive status fol-
lowing respite. In a study of 85 people with demen-
tia, use of respite environments for approximately 2
weeks was associated with little deterioration and
with improvements in cognitive function and mood
(Ulla, Johanna, & Raimo, 1998). Improvements were
attributed to the therapeutic philosophy and care
plan of the SCUs, and to the SCUs homelike envi-
ronments. Thus, findings largely support the use of
respite as an alternative to home care alone, because
negative impacts of respite are limited.

SCUs.

Generally, SCUs are segregated units that
accommodate only cognitively impaired individuals,
such as those with dementia. SCUs distinguish them-
selves by offering one or more special features, in-
cluding dementia-appropriate activities, small groups
of residents, special staff selection and training, fam-
ily involvement, and specialized design (see also
Berg et al., 1991). According to a survey of 31 SCUs
in five states, the most typical, distinguishing envi-
ronmental features of SCUs (compared to nonspecial-
ized units) include smaller size units, fewer resident
rooms, and more designated private rooms (Mathew
& Sloane, 1991). SCUs are further characterized by
the presence of private dining rooms, separate and
larger activity rooms, and access to the outdoors
(Mathew & Sloane, 1991).
The effectiveness of SCUs for people with demen-
tia has been subject to debate. A complete review of
this multifaceted research is beyond the scope of this
article, in which we focus on the physical environ-
ment only (for reviews, see Maslow, 1994; Teresi,
Grant, Holmes, & Ory, 1998; Weisman et al., 1994).
General information on the impacts of SCUs warrant
mention, however. Studies show associations be-
tween SCU environments and improvement or
slowed decline in residents communication skills,
self-care skills, social function, mobility, and affec-
tive responses (Benson, Cameron, Humbach, Servino,
& Gambert, 1987; Greene, Asp, & Crane, 1985; Mc-
Cracken & Fitzwater, 1989; Skea & Lindesay, 1996).
Additionally, SCUs are associated with reductions in
behavior disturbances, abnormal motor activity, apa-
thy, and hallucinations among residents (Annerstedt,
1993; Bellelli et al., 1998; Benson et al., 1987;
Greene et al., 1985; McCracken & Fitzwater, 1989;
Swanson, Maas, & Buckwalter, 1993).
Other positive impacts of SCUs reported in these
studies include reduced emotional strain among rela-
tives and increased competence and satisfaction
among staff (Annerstedt, 1993; Wells & Jorm, 1987;
see Appendix A, Note 7). Segregation of dementia
residents into special units also appears to benefit
residents without cognitive impairments. Cogni-
tively intact residents are found to suffer declines in
mental and emotional status when living in close
residential proximity to people with dementia (Ter-
esi, Holmes, & Monaco, 1993; Wiltzius, Gambert,
& Duthie, 1981).
Alternately, SCUs are reported to have little or no
positive effect on residents wandering, cognition,
functionality, and behavior, or on staff job satisfac-
tion or job pressure (Bellelli et al., 1998; Chafetz,
1991; Holmes et al., 1990; Ramrez, Teresi, Holmes,
& Fairchild, 1998; Saxton, Silverman, Rica, Keane, &
Deeley, 1998; Skea & Lindesay, 1996; Swanson et
al., 1993; Webber, Breuer, & Lindeman, 1995). Re-
ports of findings do not distinguish between SCUs
with and without special environmental features. Many
studies of SCUs include small sample sizes and lack
comparison groups (see Table 1 for details.)
It is difficult to assess whether specialized design
features in SCUs have any impact on people with de-
mentia. First, SCUs are not comparable, because what
is considered an SCU varies enormously (Maslow,
1994; Teresi, Holmes, Ramrez, & Kong, 1998). Sec-
ond, most SCUs do not use extensive specialized de-
sign features (U.S. Office of Technology Assessment,
1992, in Maslow, 1994). Further, special features used
in SCUs (staffing, activities, design, etc.) are frequently
treated by researchers as one global intervention
(Weisman et al., 1994; see Appendix A, Note 8). Thus,
potential impacts from individual design features (pri-
vate rooms, minimal sensory stimulation, etc.) are ob-
scured by simultaneous modifications in other arenas.
When used, design features may not be identified by
researchers as highly significant aspects of the special
intervention (cf. Skea & Lindesay, 1996; Swanson et
al., 1993). For these reasons, the impact of specialized
design cannot be easily distinguished in much existing
research on the effectiveness of SCUs.

Day Care Centers.

Only one study was identified
that specifically examined the design of day care cen-
ters in terms of therapeutic impacts. In this research,
relocation of a day care center to an enhanced facility
(including safety and surveillance features, an en-
closed garden, and more space for day health pro-
grams and activities) was associated with positive and
negative changes in staff stress and quality of care (Ly-
man, 1989). Following the move, staff stress shifted
from that prompted by space shortages to (lower)
stress associated with specific spatial configurations
(e.g., difficulty involving clients in activities in new,
larger activity areas). Negative impacts on quality of
care associated with limited space (e.g., insufficient
space for clients to conduct specific activities as long
as desired) were also reduced following relocation.

Group Size and Clusters of Residents.

Design guides
suggest that units with fewer residents may reduce
overstimulation among people with dementia by
controlling noise and by limiting the number of peo-
ple each resident encounters. This recommendation
is supported by research findings, including those of

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f
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407 Vol. 40, No. 4, 2000

a major survey of 53 SCUs in four states (Sloane et
al., 1998). According to this study and others, larger
unit sizes are associated with higher resident agita-
tion levels and with increased intellectual deteriora-
tion and emotional disturbances (Annerstedt, 1994;
Sloane et al., 1998). Further, residents in larger units
exhibit more frequent territorial conflicts, space inva-
sions, and aggressiveness toward other residents (Mor-
gan & Stewart, 1998). In contrast, people with de-
mentia residing in smaller units experience less anxiety
and depression and more mobility (Annerstedt, 1997;
Skea & Lindesay, 1996). Small group sizes are also
positively associated with increased supervision and
interaction between staff and residents (McCracken &
Fitzwater, 1989) and with social interaction and
friendship formation among residents (McAllister &
Silverman, 1999; Moore, 1999; Netten, 1993). No
consistent numbers are offered for what constitutes a
large or a small unit.
Smaller facilities offer additional benefits for resi-
dents and staff. In a comparison of 28 residents of
group living facilities (see Appendix A, Note 9) and
31 residents of traditional nursing homes, residents of
group living displayed higher motor functions and
slightly improved or maintained ADLs and required
less usage of antibiotics and psychotropic drugs (An-
nerstedt, 1993; see Appendix A, Note 10). In the
same study, relatives with family members in group
living units reported lower levels of strain and better
attitudes toward dementia care than relatives of resi-
dents in nursing homes. Staff members also experi-
enced benefits associated with group living facilities.
Staff in group living units reported greater compe-
tence, more knowledge in dealing with dementia,
and greater job satisfaction than did their counter-
parts in nursing homes (Annerstedt, 1993).

General Attributes of the Environment

These studies investigate desired qualities of the
overall facility environment. Studies have examined
effects on well-being associated with noninstitutional
character, levels of sensory stimulation, lighting lev-
els, and design modifications for safety.

Noninstitutional Character.

Design guides frequently
endorse the use of noninstitutional design features,
such as homelike furnishings and personalization, to
promote well-being among residents. This endorse-
ment is supported by research findings, though stud-
ies often compare facilities in which many features
vary (e.g., staff training, activity programming), in ad-
dition to environmental design. Noninstitutional en-
vironments characterized as having homelike or
enhanced ambiance (personalized rooms, domes-
tic furnishings, natural elements, etc.) are associated
with improved intellectual and emotional well-being,
enhanced social interaction, reduced agitation, re-
duced trespassing and exit seeking, greater prefer-
ence and pleasure, and improved functionality of
older adults with dementia and other mental illnesses
(Annerstedt, 1994; Cohen-Mansfield & Werner, 1998;
Kihlgren et al., 1992; McAllister & Silverman, 1999;
Sloane et al., 1998). Compared with those in tradi-
tional nursing homes and hospitals, residents in non-
institutional settings are less aggressive, preserve
better motor functions, require lower usage of tran-
quilizing drugs, and have less anxiety. Relatives re-
ported greater satisfaction and less burden associated
with noninstitutional facilities (Annerstedt, 1997; Co-
hen-Mansfield & Werner, 1998; Kihlgren et al., 1992).
Staff also prefer less institutional, enhanced environ-
ments (Cohen-Mansfield & Werner, 1998).
Noninstitutional environments are not entirely bene-
ficial, however. A higher degree of homelikeness is
associated with greater restlessness, more distur-
bances (tied to greater assertion of independence),
and increased disorientation and deterioration of diet
(Elmsthl, Annerstedt, & hlund, 1997; Kihlgren et al.,
1992; Wimo, Nelvig, Adolfsson, Mattsson, & Sand-
man, 1993). Studies also show that mortality and de-
cline rates for residents do not significantly improve
in noninstitutional units when compared with tradi-
tional settings (Annerstedt, 1994; Phillips, Sloane,
Howes, & Koch, 1997; Wimo et al., 1993). Further,
noninstitutional design requires supportive caregiv-
ing to be effective. In an ethnographic study of one
facility, institutional caregiving practices (charac-
terized as inflexible and formal) were described as
undermining the therapeutic potential of the home-
like environment (Moore, 1999).

Sensory Stimulation.

Residents face difficulties
with sensory overstimulation, which may increase
the distraction, agitation, and confusion associated
with dementia. Sensory overstimulation may be ex-
acerbated by the normal hearing loss that accompa-
nies aging and the further hearing loss associated
with dementia, both of which may increase confu-
sion and reduce social interaction and self-esteem
(Brawley, 1997; see Appendix A, Note 11). (Visual
deficits, discussed later, further increase overstimula-
tion.) At the same time, sensory deprivation has been
identified as a potential problem in many dementia
care environments (Cohen & Weisman, 1991).
Design guides call for appropriate levels of sensory
stimulation, striking a careful balance between envi-
ronmental overstimulation and deprivation. Recom-
mendations include removing unnecessary clutter,
providing tactile stimulation in surfaces and wall
hangings, and eliminating overstimulation from tele-
visions, alarms, and so forth (cf. Evans, 1989; Hall,
Kirschling, & Todd, 1986).
Researchers have identified characteristics and lo-
cations linked with high levels of sensory stimulation
in environments for people with dementia. In an eth-
nographic study of one skilled nursing facility, over-
stimulation is associated with loud noises (loud talk-
ing, singing and clapping, etc.), with crowding and
disruptive behavior from other residents, and with
frightening experiences (e.g., scary movies, costumes;
Nelson, 1995). High stimulationas measured by
agitation levelswas found to occur in elevators,
corridors, nursing stations, bathing rooms, and other

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s
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d

f
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o
m

408 The Gerontologist

residents rooms, whereas low stimulation has been
observed in activity and dining rooms (Cohen-Mans-
field, Werner, & Marx, 1990; Negley & Manley, 1990).
Detailed descriptions of these spaces were not pro-
vided by researchers.
Overstimulation may impair residents ability to
concentrate. Limited stimulation activity areas
made by hanging cloth partitions to eliminate views
to ongoing activityreduce distractions among resi-
dents by up to two-thirds (Namazi & Johnson,
1992b). Use of partitions increased the ability to fo-
cus on a task among residents in all stages of demen-
tia by eliminating some visual and especially audi-
tory distractions (e.g., noise, talking).
Findings on the effects of low stimulation units are
mixed. Use of a neutral design and color scheme,
elimination of stimulation, and consistent daily rou-
tines have been shown to reduce behavioral distur-
bances, curtail use of physical and chemical restraints,
and encourage weight gain (Bianchetti, Benvenuti,
Ghisla, Frisoni, & Trabucchi, 1997; Cleary, Clamon,
Price, & Shullaw, 1988). Similarly, in one quasi-
experiment, 13 residents of an SCU that incorporated
structured resident routines and reduced stimulation
displayed fewer catastrophic reactions and more pos-
itive interactions, compared with nine residents in
long-term care (Swanson et al., 1993). Reduced stim-
ulation units have had little effect in regulating sleep
patterns, decreasing urinary incontinence, or dis-
couraging wandering, however (Bianchetti et al.,
1997; Cleary et al., 1988; Swanson et al., 1993; see
Appendix A, Note 12).
Design guidance argues that certain levels of sen-
sory stimulation may be required to promote engage-
ment in activities and interaction and to minimize
withdrawal among people with dementia (cf. Calkins,
1988). The positive impacts of sensory stimulation
have received limited research. The experimental
Weiss Institute of the Philadelphia Geriatric Center
was designed to maximize positive sensory stimula-
tion; this facility featured resident rooms opening di-
rectly to a central open space. The spatial configura-
tion was intended to enhance residents orientation
and engagement in activities (Lawton, Fulcomer, &
Kleban, 1984). Indeed, in a postoccupancy evalua-
tion of the Weiss Institute, residents were found to
spend less time in their rooms and were more atten-
tive to activity following relocation to this facility
(Lawton et al., 1984). In a related study, a high stimu-
lation environment (including orientation aids, recre-
ational materials, and extensive reality orientation
programs) was associated with increased morale
among 16 staff members in one unit, compared with
morale among 13 staff members in a traditional de-
mentia unit (Jones, 1988). The focus on increasing
structure and resident orientation in the high stimula-
tion unit suggests other possible explanations for en-
hanced staff morale in this unit.

Lighting and Visual Contrast.

People with demen-
tia face particular visual deficits, including difficulty
with color discrimination, depth perception, and sen-
sitivity to contrast (Cronin-Golumb, 1995). These def-
icits exacerbate normal changes in vision that ac-
company aging, such as irritation from glare and
changes in color perception (Brawley, 1997). Design
guides for dementia environments recommend strate-
gies to reduce glare, increase contrast where appro-
priate, and minimize confusion concerning depth
perception. Design guides also recommend increas-
ing overall light levels and exposure to bright light
(cf. Brawley, 1997).
Compared with other older adults, people with de-
mentia are exposed to inadequate levels of bright
light (described as light exceeding 2,000 lux; Camp-
bell, Kripke, Gillin, & Hrubovcak, 1988). In findings
from two studies involving 24 and 10 residents, re-
spectively, bright light treatment consistently regu-
lated circadian rhythms and improved sleep patterns
among people with dementia (Mishima et al., 1994;
Satlin, Volicer, Ross, Herz, & Campbell, 1992; see
Appendix A, Note 13). Results are mixed concerning
the impact of bright light on agitation (Lovell, Ancoli-
Israel, & Gevirtz, 1995; Mishima et al., 1994; Satlin
et al., 1992).
Most often, research on the effects of bright light
is conducted under laboratory conditions, requiring
special equipment and the restraint of residents. The
effects of bright light as a regular environmental fea-
ture have received limited attention. One quasi-
experimental study was identified in which researchers
examined the effect of ceiling-mounted light fixtures
that provided high intensity illumination (7902,190
lux; Van Someren, Kessler, Mirmiran, & Swaab, 1997).
Bright light administered in this fashion fostered be-
havioral improvements and increased circadian rest
activity rhythms among 22 people with severe de-
mentia. Residents in facilities with low overall light
displayed higher agitation levels (Sloane et al., 1998).
Residents in units with inadequate lighting showed
no difference in psychiatric symptoms compared with
residents in units with ample lighting, however (Elm-
sthl et al., 1997).
Little research on the impacts of visual contrast in
dementia care environments was identified, though
this strategy is frequently recommended to enhance
legibility or clarity of the environment. In one quasi-
experiment, 13 residents with dementia ate more and
displayed less agitation when dining arrangements
incorporated brighter light and heightened color
contrast (i.e., high contrast tablecloths, place mats,
dishes; Koss & Gilmore, 1998).

Safety.

Residents attempts to leave facilities or
homes present a major safety concern for staff and
family caregivers. Design solutions to prevent un-
wanted exiting often do so by exploiting residents
cognitive deficits. For instance, in a study involving
nine residents of a psychogeriatric ward, a full length
mirror placed in front of the exit door reduced resi-
dents exit attempts by half (Mayer & Darby, 1991). A
reverse mirror had a similar, but less significant ef-

a
t

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i
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s
i
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a
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D
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d

f
r
o
m

409 Vol. 40, No. 4, 2000

fect. Impacts were attributed to residents loss of
memory of personal identities; accordingly, residents
may have been distracted from exiting when engaged
or frightened by the image of an approaching stranger
in a mirror (Mayer & Darby, 1991).
Another design strategy capitalized on the likeli-
hood that, because of problems with depth percep-
tion, people with dementia may interpret two-dimen-
sional patterns on the floor as three-dimensional
barriers. In a quasi-experiment with eight residents,
such two-dimensional grids successfully eliminated
most exit attempts for some residents (Hussian &
Brown, 1987). In other studies, two-dimensional grids
either increased or failed to decrease residents exit
attempts (Chafetz, 1990; Namazi, Rosner, & Calkins,
1989). Failure to reduce exiting was attributed to the
presence of glass doors and adjacent large windows,
which offered views to attractive, nearby outdoor
spaces (see also Morgan & Stewart, 1999). Attractive
views were hypothesized to distract residents from
two-dimensional grids or to entice residents to over-
come their aversion to these optical illusions. In a
study involving seven SCU residents, installation of
closed, matching miniblinds that restricted light and
views through exit door windows decreased exit at-
tempts by half (Dickinson, McLain-Kark, & Marshall-
Baker, 1995).
Other design strategies also created optical illu-
sions that reduced unwanted exiting. The addition of
a cloth panel to camouflage a door knob or panic
bar eliminated exit attempts for most residents
(Dickinson et al., 1995; Namazi et al., 1989). (Both
of these studies used fewer than 10 residents.) This
effect held irrespective of the color or pattern of the
cloth cover (Namazi et al., 1989) and with and with-
out the use of miniblinds to cover windows (Dickin-
son et al., 1995). Disguising the door knob itself (with
a knob cover or by painting the knob to blend with
the door) reduced exit attempts to a lesser extent
(Dickinson et al., 1995; Namazi et al., 1989).
Finally, conditioning residents to respond to atten-
tion-getting signage also reduced exit attempts. Three
residents with dementia who were conditioned to de-
velop negative associations with supernormal stim-
uliin this case, large, colored, cardboard geometric
shapes placed near exits (Hussian, 198283; see Ap-
pendix A, Note 14)wandered less into doors and
stairways bearing those images.
Accommodating residents exit attempts, rather
than discouraging them, also generated positive out-
comes. Unlocking doors to allow access into secure
outdoor areas was associated with significant de-
creases in agitation in a quasi-experiment involving
12 residents (Namazi & Johnson, 1992d). Reduced
agitation was tied to increased autonomy as well as
to outdoor usage.
Surveillance is considered essential by staff for
maintaining safety in environments for people with
dementia (Morgan & Stewart, 1999). Design inter-
ventions may have unintended consequences for staff
surveillance opportunities. In interviews with nine
staff members and nine relatives associated with a
newly designed SCU, staff reported that the new fa-
cilitys low density, private resident rooms, enclosed
charting spaces, and secluded outdoor area and ac-
tivity spaces impeded staff surveillance and increased
time spent locating and monitoring residents (Morgan
& Stewart, 1999). Ease of surveillance also has nega-
tive consequences. In an evaluation of the Weiss In-
stitute, staff interaction with residents was found to
decrease following occupation of this new facility
(Lawton et al., 1984; see also Liebowitz, Lawton, &
Waldman, 1979). Because the facilitys open design
accommodated staff surveillance from the nurses
station, direct staff contact with residents may have
been minimized.
Preventing falls among residents is another key
safety concern (cf. Morgan & Stewart, 1999; Pynoos
& Ohta, 1991; Scandura, 1995). Design interventions
have demonstrated some success in reducing resi-
dents falls. A significant reduction in falls was re-
ported in one SCU with the introduction of alterna-
tive furnishings that put residents closer to the ground
(i.e., bean bag chairs, futons, and mattresses placed
on the floor; Scandura, 1995; see Appendix A, Note
15). In other research, environmental modifications
introduced into home environments to reduce falls
were judged effective by 12 dementia caregivers at a
7-month follow-up (Pynoos & Ohta, 1991). These
modifications included tub and stair rails, a nonskid
bath mat, and a bath chair.

Building Organization

Studies of building organization examine the de-
sirable arrangement of spaces within facilities. Issues
investigated include residents orientation and way-
finding, and the impact of providing outdoor spaces
in dementia care facilities.

Orientation.

Disorientationconfusion regarding
place, time, personal identity, or social situationis
common among people with dementia (Cohen &
Weisman, 1991). Design guides suggest numerous
strategies to enhance orientation, including improve-
ments for wayfinding (e.g., landmarks, signage) and
provision of information from the environment (e.g.,
allowing views to accessible outdoor areas to increase
residents orientation to time of day and season).
Research confirms that residents orientation de-
pends, in part, on the physical environment. In a
study of 79 dementia residents at 13 long-term care
facilities, higher levels of orientation were associated
with quiet environments (Netten, 1993). Researchers
theorized that disorientation followed residents at-
tempts to shut out noisy environments. Not surpris-
ingly, wayfinding among residents was judged less
successful in facilities with low lighting levels in pub-
lic areas (Netten, 1989).
Design strategies intended to enhance orientation
appeared to aid at least some residents. Staff mem-
bers reported that orientation among residents was
supported by design modifications that included
room numbers and use of distinguishing colors for

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410 The Gerontologist

resident rooms and doors (Lawton et al., 1984). In
studies with eight residents, large signs improved res-
ident orientation, when incorporated with orientation
training (Hanley, 1981); signs alone had minimal ef-
fect on residents orientation, however.
The type of orientation device may make a differ-
ence, though research on this question is limited to
one experiment involving 10 SCU residents. When
displayed in cases outside resident rooms, personally
significant memorabilia were somewhat more likely
to help residents find their rooms than were displays
without personal significance (Namazi, Rosner, &
Rechlin, 1991). Personally significant memorabilia
were most useful for those with moderate dementia;
higher functioning residents were able to orient with
nonsignificant memorabilia as well, and lower func-
tioning residents were aided by neither.
Orientation is further impacted by building config-
uration. Simple building configuration is associated
with resident orientation, when residents are also
provided with explicit environmental information
(Passini, Rainville, Marchand, & Joanette, 1998). In a
quasi-experiment with 105 residents in several group
living facilities, residents were found to experience
greater spatial orientation in facilities designed around
L-, H-, or square-shaped corridors, compared with fa-
cilities with corridor designs (Elmsthl et al., 1997).
Corridor designs were also associated with higher de-
grees of restlessness and dyspraxia and with reduced
vitality and identity (Elmsthl et al., 1997). Residents
in facilities with more hallway space demonstrated
less disorientation and less lack of vitality (Elmsthl et
al., 1997).
In survey research with 104 residents in several
homes, higher levels of orientation were identified in
cluster facilities (comprised of small units of resi-
dent rooms and associated common spaces), com-
pared with larger scale communal facilities (com-
mon spaces separated from resident rooms and shared
by larger groups of residents; Netten, 1989). In clus-
ter facilities, higher levels of orientation were associ-
ated with complex decision points and longer corri-
dors, which allowed meaningful choices between
places residents used (Netten, 1989). In communal
facilities, heightened orientation was associated with
short corridors and simple decision points, which al-
lowed residents to travel only short distances without
prompts and did not force residents to choose be-
tween spaces they did not use (Netten, 1989).

Provision of Outdoor Areas.

Design guides rec-
ommend access to the outdoors to maintain home-
likeness, to accommodate activities, and to increase
residents exposure to light and sun. Limited research
findings support the value of outdoor spaces to re-
duce aggression among people with dementia. In a
longitudinal study of five facilities with and without
outdoor spaces, researchers found that violent epi-
sodes among residents decreased over time in facili-
ties with outdoor environments, whereas violent epi-
sodes increased during the same time period in
facilities without outdoor environments (Mooney &
Nicell, 1992). Residents walked outdoors more often
(for short periods of time) in a facility with a special
therapeutic garden (Mooney & Nicell, 1992).

Specific Rooms and Activity Spaces

This research investigates the design of particular
rooms within the facility. Studies examine the design
of bathrooms, toilet rooms, dining rooms, kitchens,
and resident rooms, as these impact well-being among
people with dementia and others.

Bathrooms.

For people with dementia, bathing is
an experience that frequently compromises dignity
and autonomy. Design recommendations emphasize
increasing independence and control in bathing (e.g.,
choice of shower or tub bath), promoting a more
homelike bathing experience (e.g., less institutional
design), and assisting caregivers during bathing (addi-
tional space, grab bars, etc.).
Bathing is regarded as among the most stressful
tasks in caring for people with dementia (Kovach &
Meyer-Arnold, 1996; Pynoos & Ohta, 1991; Sloane
et al., 1995). Several studies examine aspects of bath-
ing associated with high stress. Negative resident
reactions are associated with unfamiliar or fearful
equipment or procedures (bath tub lifts, specialized
tubs, getting in and out of the water, high water levels
in whirlpool baths), cold tub rooms (cold air or water
temperature, chills from slow tub filling or draining),
design features that impede bathing (poor lighting,
inadequate mats or handrails), and distractions (noisy
equipment, running water, or distracting activities
outside the bathroom; Kovach & Meyer-Arnold, 1996;
Lawton et al., 1984; Namazi & Johnson, 1996; Sloane
et al., 1995). Some evidence suggests that baths may
be less upsetting than showers for residents, though
findings are mixed (Kovach & Meyer-Arnold, 1996).
Perhaps because of their long-term positive associ-
ation, natural elements had a calming effect when in-
troduced during bathing in an experiment with 31
residents in five nursing homes (Whall et al., 1997).
Nature sounds (e.g., animal and water noises) and
pictures (e.g., birds), when provided along with fa-
vorite foods and distracting conversation, significantly
decreased agitation during shower baths among resi-
dents with late stage dementia (Whall et al., 1997).

Toilet Rooms.

Incontinence is a major problem
among people with dementia (Namazi & Johnson,
1991b). Design guides emphasize the importance of
maintaining independence in toileting whenever pos-
sible, such as by making toilets easy to locate and to
identify (signage, visible locations, etc.). In some in-
stances, the design of toilet rooms may exacerbate
toileting problems. Staff report that small toilet rooms
make assisting with toileting difficult and that wheel-
chair users are more likely to have accidents when
the toilet room is occupied, preventing access (Hutch-
inson, Leger-Krall, & Wilson, 1996).
Research findings, though limited, support the ef-
fectiveness of design interventions to facilitate toilet-

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411 Vol. 40, No. 4, 2000

ing. One quasi-experiment involving 44 residents in
two SCUs compared residents responses to various
forms of directional signage for toilet rooms, includ-
ing the word rest-room, toilet, or a graphic of a
familiar household toilet (Namazi & Johnson, 1991b).
Early and moderate stage dementia residents were
most likely to locate and use public toilets in re-
sponse to primary color signage affixed to the floor
(responding to residents typically downcast gaze)
comprising a series of arrows and the word toilet
(Namazi & Johnson, 1991b). Further, frequency of
toilet use increased dramatically when toilets were
visibly accessible to residents (Namazi & Johnson,
1991a), though this experiment included only 14 res-
idents. Residents use of toilets increased by over
800% when curtains surrounding toilets (in lieu of
doors) were left open, making public and private toi-
lets clearly visible when not in use (Namazi & John-
son, 1991a). In particular, visibility increased toilet
use among residents with more advanced dementia.

Dining Rooms and Kitchens.

Design guides offer
many recommendations regarding dining and kitchen
areas (cf. Calkins, 1988; Cohen & Weisman, 1991).
Suggestions emphasize the importance of a familiar
and normal dining experience, the need to locate
dining and kitchen activity areas within each demen-
tia unit or household, and the value of reducing
sensory stimulation to encourage eating. Research
findings from an experiment with 22 residents sup-
port noninstitutional dining arrangements. Noninsti-
tutional diningin which residents dined family
style at small dining tables in a coffee room, instead
of from trays while seated in chairs in the corridor
was linked to increased social interaction and com-
munication during dining and to improved eating be-
havior among residents (Gtestam & Melin, 1987;
Melin & Gtestam, 1981). Institutional staff practices
(e.g., assigned seating, institutional food service) pro-
voked disruption and agitation in dining rooms with
homelike design features (Moore, 1999).
In an impact not anticipated by design guidance,
relocating dining to the dementia unit of an SCU
from a remote, centralized dining roomsignifi-
cantly decreased residents aggression (Negley &
Manley, 1990). Assaults were reduced by over 40%
when residents were no longer crowded into eleva-
tors to reach the centralized dining room (Negley &
Manley, 1990). (Elevators had been sites of frequent
violations of personal space, which caused alterca-
tions.) In this instance, assaults may have been fur-
ther reduced by designating two dining areas on the
dementia unit, thus separating higher functioning res-
idents, more likely to be assailants, from lower func-
tioning residents, more likely to be assault victims. In
the same quasi-experiment, staff reported less anxiety
and more time for assisting residents after moving
dining to the dementia unit.
In a study on the design of environments to en-
courage independent snacking, installation in kitch-
enettes of small, accessible refrigerators stocked with
snacks prompted only a minimal increase in resi-
dents independent snacking (Namazi & Johnson,
1992c). Transparent refrigerators, in which residents
could clearly see snacks inside, were only slightly
more effective than were conventional, dormitory-
style refrigerators. Both styles of refrigerators may
have been unfamiliar to residents. Staff provision of
snacks was suggested as a possible impediment to
residents independent snacking (Namazi & Johnson,
1992c).

Residents Rooms.

Design guidance emphasizes
the need for homelikeness, autonomy, and privacy in
residents rooms in dementia care facilities. The rela-
tive merits of private versus shared resident rooms is
a matter of debate (Cohen & Day, 1993); existing re-
search provides limited guidance on this issue. Com-
parisons of facilities with and without private rooms
typically incorporate other architectural and pro-
grammatic differences as well, thus obscuring the sig-
nificance of resident room type (cf. Annerstedt, 1994,
1997; Skea & Lindesay, 1996).
Lawton and colleagues (1970) presented findings
from a quasi-experiment involving 15 residents, which
suggest that number of residents and room design
may affect levels of social interaction. This study
evaluated the renovation of a long-term care unit
from two institutional-looking group rooms (four and
five residents, respectively), to six, less institutional-
looking single rooms clustered around a common
space. Following renovation, residents were found to
spend comparatively less time in their rooms and
more time in motion and to engage in less interac-
tion, compared with residents before the renovation.
Reduced interaction may reflect greater choice over
interaction in private versus group rooms (Lawton et
al., 1970).
Closet design was successfully used to enhance
residents independence in dressing. In a quasi-exper-
iment with eight SCU residents, specially designed
clothes closets were found to increase autonomy in
dressing for those with middle stage dementia
(Namazi & Johnson, 1992a). By presenting prese-
lected clothing in an appropriate sequential order
(undergarments first, followed by blouse, pants, etc.),
modified closets reduced staff members physical as-
sistance in dressing and enhanced residents inde-
pendence.

Discussion and Conclusions

From the research reviewed, four primary types of
studies on design and dementia emerge. Studies are
grouped according to their major focus (people/be-
havior vs. the physical environment) and their con-
ceptualization of the physical environment (global or
discrete).

Environmental comparison

studies com-
pare two or more facility types for impacts on resi-
dents, staff, and family (e.g., SCUs vs. skilled nursing
facilities.)

Design feature

studies assess the effects of
specific environmental interventions (e.g., door mod-
ifications to reduce exit attempts). Studies of

environ-
mental services and policies

examine organizational

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412 The Gerontologist

decisions and policies for dementia care environ-
ments (e.g., impacts of relocating residents to new
environments). Studies of

problem behaviors

investi-
gate resident conduct that creates difficulties in care-
giving (e.g., stressful aspects of bathing). One study
(Netten, 1993) fit more than one type (see Table 2).
Of these types, studies of design features (26 studies)
and of environmental comparisons (24 studies) pre-
dominate (compared with 15 studies of problem be-
haviors and 7 studies of environmental services and
policies). Studies should be evaluated according to
the type of research they represent. For example,
findings from studies of environmental comparisons
should indicate which type of environment is pre-
ferred and why.
The following sections analyze findings from exist-
ing studies with respect to their implications for ap-
plication and future research.

Recommendations to Enhance
Applicability of Findings

The focus of this article on design application de-
mands some recommendations (though tentative)
concerning the therapeutic design of environments
for people with dementia. On the basis of existing re-
search findings, dementia care environments should
consider the suggestions presented in Appendix B
among others.
Application of findings is often impeded by stud-
ies research design and/or methods. Confidence in
findings is impaired by the frequent use of small sam-
ples and the absence of comparison groups. Addi-
tionally, many studies use nonequivalent comparison
groups (e.g., residents in varying or unspecified
stages of dementia, or residents with and without de-
mentia who vary in other characteristics, such as mo-
bility.) Studies do not always adjust reports of find-
ings to account for baseline differences in severity of
cognitive, behavioral, or physical deficits. Of the 71
studies we reviewed, only 45 made reference to the
residents stage of dementia at baseline. Further, the
interrelations between design interventions has been
largely overlooked. For example, SCUs often encom-
pass multiple interventions (smaller unit size, home-
like design, low level simulation, etc.). In evaluating
the impact of SCUs, studies should consider both
which design features are most essential and how
various design features work together or detract from
each other. These issues must be addressed to im-
prove the validity and generalizability of future re-
search findings.
Applicability of findings would also be enhanced
by incorporating explicit hypotheses on the proposed
relationships between physical environments and
well-being to explain

why

design features are or are
not successful. Finally, the applicability of future
studies could be improved by thoroughly describing,
in research reports, the physical context of the de-
mentia environment and specific environmental modi-
fications tied to well-being. These last two qualities
are exemplified in research conducted by Namazi and
colleagues at the Corrine Dolan Center, in Chardon,
Ohio (see Appendix A, Note 16).

Recommendations for Future Research

Findings from existing studies substantiate the
need for more attention to the therapeutic use of de-
sign in dementia. Further research should be de-
signed to confirm findings from existing research, es-
pecially from small or exploratory studies. Future
research should also support the call for therapeutic
design of dementia environments and should eluci-
date the particular characteristics of effective design
interventions.

Focus on Multiple Populations and Diverse Envi-
ronments.

Of the 71 studies reviewed, 12 clearly
addressed staff well-being or job performance as out-
come measures of the design of dementia environ-
ments; only 7 studies investigated outcomes concern-
ing family members well-being or satisfaction. With
greater focus on impacts for staff and relatives, re-
search findings could provide a persuasive rationale
for design interventions that might otherwise be ne-
glected. For example, in addition to impacts for resi-
dent well-being, research should examine the im-
pacts of noninstitutional design on staff morale and
retention and on family visitation and satisfaction
with care (cf. Chapman & Carder, 1998; Hoglund,
DiMotta, Ledewitz, & Saxton, 1994; Regnier, 1997).
Improving staff and family well-being may also en-
hance caregiving.
In addition, studies should evaluate effective strat-
egies for the therapeutic design of environments
other than long-term care and SCUs. Environmental
alternatives such as day care and assisted living often
have resident populations, care practices and philos-
ophies, physical environments, and regulatory reali-
ties that differ dramatically from the more institu-
tional options that have been the focus of much
existing research. Such environmental alternatives
may present new opportunities and new challenges
for therapeutic design interventions.

Target Research and Application to Stage of De-
mentia.

Research findings on the effects of design
interventions reveal important differences in response
according to residents level of cognitive and behav-
ioral function (see also Columbo, Vitali, Molla, Gioia, &

Table 2. Primary Types of Studies on Design and Dementia

Conceptualiztion
of the Environment
Major Focus of Research
Environment People/Behavior
Global Studies of
environmental
comparisons
Studies of
environmental
services and
policies
Discrete Studies of design
features
Studies of problem
behavior

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413 Vol. 40, No. 4, 2000

Milani, 1998; Mirmiran, Van Gool, Van Haaren, &
Polak, 1986). For example, interventions targeted to
people in early or middle stages of dementia (e.g.,
closet design to promote independence in dressing;
Namazi & Johnson, 1992a) may prove useless for res-
idents in more advanced stages, and vice versa. In
developing research questions, researchers should
carefully consider the stages of dementia during
which design interventions are hypothesized to be of
value (see Appendix A, Note 17). When possible,
studies should include participants in different stages
of dementia, and research reports should specify the
stage of dementia for research participants.

Focus on Quality of Life, as Well as Problem Be-
haviors.

In the studies reviewed, impacts on prob-
lem behaviors were the most common outcome mea-
sure used (followed by impacts on resident ADLs,
cognitive function, and social function). Because
problem behaviors generate much caregiver burden,
caregivers and administrators may especially appre-
ciate this information. The emphasis on problem be-
haviors may also indicate, however, that many re-
searchers and administrators do not fully appreciate
the potential of environmental design to improve
quality of life, beyond simply minimizing undesirable
conduct. For greatest impact, design professionals and
researchers must continue to educate administrators
and families on the potential role of environmental
design for improving quality of life in a comprehen-
sive way. These recommendations, if implemented,
will ensure continued progress in the study and de-
sign of therapeutic environments for people with de-
mentia.

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Received May 19, 1999
Accepted January 19, 2000
Decision Editor: Vernon L. Greene, PhD
Appendix A
Notes
1. A small sample of design guidance includes Coons
(1987), Hiatt (1987), Hyde (1989), Lawton (1979), Pynoos,
Cohen, and Lucas (1988), Regnier (1997), and Zeisel, Hyde,
and Levkoff (1994).
2. MAGS is the magazine and journal article database of
over 1,500 scholarly and popular journals. CAT is the catalog
of the holdings of the entire University of California library
system. Search terms included dementia or Alzheimers
and the following: home, nursing home, special care unit,
SCU, day care, assisted living, design, environment, safety,
dignity, homelike, independence, security, wandering, activi-
ties, toilet, incontinence, kitchen, dining, resident room, pri-
vacy, bathing, continuum of care, aging in place, non-institu-
tional, and barrier. Searches generating more than 400
references were discarded as overly broad.
3. Journals reviewed systematically included Ageing and
Society, Environment and Behavior, The Gerontologist, Jour-
nal of Architectural and Planning Research, Journal of Envi-
ronmental Psychology, Journal of Gerontology: Psychological
Sciences, Journal of Gerontology: Social Sciences, and the
Journal of Mental Health and Aging.
4. Case studies and nonpeer-reviewed work, such as dis-
sertations, were excluded, as were articles that reported only
design guidance, or that had only minor reports of research, or
incomplete descriptions of research design.
5. This period was identified as the time of greatest produc-
tivity in research on dementia and design. An earlier article by
Lawton and colleagues (1970) was also included. This article
evaluates the impact of a renovation to the Weiss Institute of
the Philadelphia Geriatric Center, a premier, experimentally
designed dementia care facility.
6. See Borup (1983) for a review of the extensive research
literature on the effects of relocation on older adults in institu-
tional settings.
7. Wells & Jorm (1987) examine the use of an SCU for re-
spite versus permanent care. The authors found beneficial im-
pacts for family members associated with use of this SCU for
respite care.
8. Global studies of SCUs with special environmental
features include Annerstedt (1993), Bellelli et al. (1998), Ben-
son et al. (1987), Chafetz (1991), Greene, Asp, and Crane
(1985), Holmes et al. (1990), McCracken and Fitzwater
(1989), Phillips et al. (1997), Skea and Lindesay (1996), Swan-
son, Maas, and Buckwalter (1993), Webber, Breuer, and Lin-
deman (1995). Table 1 describes only those studies of SCUs
that specifically note environmental features.
9. Swedish group living facilities compare to both group
homes and SCUs in the United States. These residences for 810
people are tailoredin design and in care planto the needs
of people with dementia. Emphasis is placed on involving
families and on making care more affordable than institutional
alternatives (Annerstedt, 1993).
10. Group living units in this study differ from traditional
nursing homes in that group living units use noninstitutional
design features and specialized dementia caregiving, in addi-
tion to small group size.
11. Evidence suggests that the prevalence and severity of
hearing loss is greater among people with dementia; however,
the cause and effect relationship between dementia and hear-
ing loss is not well understood (cf. Gates et al., 1995; Rapcsak,
Kentros, & Rubens, 1989; Uhlman, Larson, & Koepsell, 1986;
Weinstein & Amsel, 1986).
12. Similar changes in other facilities are associated with
comparable results (cf. Hall, Kirschling, & Todd, 1986).
13. Circadian rhythms refer to daily activity cycles based
on 24-hr patterns.
14. Exaggerated, simple stimuli were hypothesized to be
most effective, since subtle or complex stimuli may be difficult
for people with dementia to comprehend (Hussian, 198283).
Conditioning occurred by reinforcing positive associations,
such as a favorite food, with one shape, and negative associa-
tions, such as loud clapping, with another.
15. Changes in furnishings were accompanied by changes
in care plans to reduce demanding tasks (e.g., bathing) in the
evenings, when most falls occurred. Full research methods are
not reported for this study.
16. Most of these studies are reported in a series published
in 199192 in the American Journal of Alzheimers Care and
Related Disorders and Research.
17. Calkins (1997) provides an excellent example of stage-
appropriate design guidance in her recommendations for de-
sign strategies to enhance care for people with late stage de-
mentia.

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416 The Gerontologist
Appendix B
Recommendations for the Therapeutic Design and Planning of
Dementia Environments
Incorporate small size units.
Separate noncognitively impaired residents from people
with dementia.
Offer respite care as a complement to home care.
Relocate residents, when necessary, in intact units rather
than individually.
Incorporate noninstutional design throughout the facility
and in dining rooms in particular.
Moderate levels of environmental stimulation.
Incorporate higher light levels, in general, and exposure
to bright light, in particular.
Use covers over panic bars and door knobs to reduce
unwanted exiting.
Incorporate outdoor areas with therapeutic design fea-
tures.
Consider making toilets more visible to potentially re-
duce incontinence.
Eliminate environmental factors that increase stress in
bathing.

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