Improving Care Effective Design: Person-Centered Through

GE N E R ATIONS Journal of the American Society on Aging
By John Zeisel
Improving Person-Centered
Care Through Effective Design
Addressing eight areas of design criteria in
community living settings allows people with
dementia to be more themselves, leading to
better relationships with staff and family.
erson-centered care is a primary goal of

designing for dementia. Every environmental characteristic that helps people with dementia be more themselves helps unleash hardwired brain capacities that reinforce a persons
sense of self, which improves reciprocal relationships between the person and their partners
and caregivers. As such, the two reasons for
designing for dementia are to enable the person
to be all he or she can be, and to support the
most enriching relationships possible.
Achieving these goals is the definition of
person-centered care, as originally described
by Tom Kitwood in his groundbreaking book,
Dementia Reconsidered: The Person Comes First
(Kitwood, 1997). He writes:
Identity remains intact, because others
hold it in place; feelings are expressed and
meet a validating response; and if there is a
spirituality, it will most likely be of the kind
that Buber describes, where the divine is
encountered in the depth of I-Thou relating.
Recognized dementia design experts Maggie
Calkins, Jerry Weisman, Uriel Cohen, M. Powell
Lawton, and Loraine Hyatt each generated
design guidelines, which when analyzed and
combined, lead to a set of eight key user-needs
design performance criteria (Zeisel, Hyde, and

Levkoff, 1994): exit control, walking paths,
common spaces, privacy and personalization,
garden access, residential-ness, sensory comprehension, and support for capacity.
In 2003, a two-year clinical trial funded by
the National Institutes of Health and the National Institute on Aging, for which I was the
principle investigator, evaluated the impact of
these design characteristics on the behaviors of
people with dementia residing in special assisted
living residences or nursing home special care
units. Our data indicated that most of these
design elements correlated with reduced
behavioral dysfunctions among residents,
specifically in anxiety, agitation, aggression,
and apathythe four As of Alzheimersas
well as in social withdrawal and psychotic
symptoms (Zeisel et al., 2003).
Since that clinical trial, I have become more
mindful of the neuroscience basis of healthy
dementia design and dementia relationships.
Neuroscience has shown that a host of hardwired skills and abilities in the brain do not
diminish, even with dementia, and can be
accessed through design to improve each
persons sense of self.
Copyright 2013 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org. For information about ASAs publications
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Fall 2013 Vol. 37. No. 3 | 45
GE NER ATIO NS Journal of the American Society on Aging
Pages 4552
This article explains the

eight types of design guidelines
listed above, emphasizing the
effects design can have on the
personhood of residents and on
opportunities for relationships
that such effects can havethe
link to person-centered care
(Zeisel, 2009).
Controlled Exits Allow

for Independence
The human brain is naturally
curious. What lies beyond the
seas? What is around the corner? How does that machine
work? The natural curiosity of
people with dementia attracts
them to inviting doors leading
to dangerous places, fences that
are low and climbable, and
people who can be seen coming and going outside.
Doors that attract in this
way need to be made less inviting and as invisible as possible, or camouflaged. They
should be made difficult to
open, using a keypad with a
hard-to-remember code or
other complex memory
mechanism. The same is true
(Top) A door, easily camouflaged by being painted the same color as the
for windows whose openings
surrounding walls, with no hardware to grab, also has a keypad around a corner
need to be controlled and
requiring multiple memory steps. (Bottom) An eight-foot garden fence provides
fences around gardens to
absolute security outdoors.
which residents have access.
used for people leaving a residence unattended).
At the same time, doors to places that are safe,
The door communicates please come through
such as a door from the inside to a safe garden
while the rule says dont. Even signs that say
or an interior courtyard, need to be as inviting
Way Out or Dont Open attract attention and
as possible.
when they do, residents with dementia who are
Doors with see-through panes that invite
curious and naturally walk through the door
those nearby to look out of and pass through are
are often blamed by caregivers for consciously
one reason people with dementia are accused
wanting to leave. They are not escaping; they are
by caregivers and others of wanting to leave, or
elope, from a residence (the term elope is often searching for a more interesting place. Well-
46 | Fall 2013 Vol. 37. No. 3
Pages 4552
Person-Centered Care for People with Dementia
designed exit controls on doors,

windows, and garden fences
allow residents their independence. If the doors do not invite
eloping, and if boundaries are
secure, residents can use the
environment freely and not
continually try to walk away.
When meaningful and creative
activities define life within this
circumscribed world, and when
residents regularly visit community cultural events away from
the residence, there is even
less reason for them to search
elsewhere for something to do.
Freedom to move around a
Familiar museum portraits, a memory box next to the apartment door, rocking chairs,
residential setting and garden
and an open door to an activity spacea destinationsupport finding ones way.
not only gives the person living
We find our way in the world by identifying
there independence, but also, more importantly
for person-centered care, it enables a sense that
landmarks that mark a place to start a journey, to
the place belongs to him or her; this grants a
make a turn, to indicate a new situation along a
sense of personal control. With the prison guard path, and ultimately to arrive at a destination. If
you are asked to find your way from where you
responsibility removed, caregivers can focus on
are now to your car or home, you will begin to
the person rather than on safety and security,
leading to a more intimate and informed person- think in terms of landmarks.
centered relationship.
Purposeful walking replaces aimless wandering in places that enable people with dementia to
Clear Walking Paths Clarify Destinations
have a purpose. Walking paths with place-definWhen they know where they are and can see
ing landmarks and meaningful destinations
where they are going, people with dementia
enhance the persons sense of place and thus
walk with purpose. Curves and corners, as in a
their sense of selfelements essential for
continuous circular wandering path, prevent
person-centered care. Someone wandering
seeing a destination, confuse the person, and
elicits a sense of loss from onlookersfamily
invite wandering. People with dementia know
members, caregivers, visitorsand leads the
where they are when they are in a place they
onlooker to ignore the person or misinterpret his
recognize or see a familiar object that is meanor her actions. When a person appears to have
ingful to them, such as a photograph they have
purpose, the potential for person-to-person
chosen to hang on the wall. They know where
relationships increases.
they are going when they see the next object or
place. And they know where they were headed
Common Spaces: Room Purpose
when they reach an evident destination. WanIndicators Improve Behavior
dering loops built with the false impression that Common spaces in dementia residences are
they enable people with dementia to be more
places where people are expected to behave
themselves actually reduce their sense of place.
socially and appropriately. Design of dining
Fall 2013 Vol. 37. No. 3 | 47
Pages 4552
rooms, music rooms, and other

shared common spaces that
reflect their intended use
encourages appropriate behavior in these settings. The scale
of the space, the furniture,
the built-in features, and the
fixtures can all contribute. At
least two or three such places
are needed in a common residence for residents to have
an authentic choice between
common areas rather than
having to spend all day unnaturally in one common place
even if the activities change in
the one common place. More
Kitchen dcor indicate that it is appropriate to wash dishes and set the table there.
than two or three common
rooms can be confusing. When
more likely the person is to feel that he or she is
the physical settings and the activities taking
personally involved in the setting; this reinforces
place both communicate to residents what is
appropriate behavior in that place, the person is both the I and the we.
Simply put, if a person is behaving approprimore likely to behave appropriately.
ately, others relate to her or him as a regular perWhile knowing who I am clearly is part of
son and less as a sick person. The more this haphaving a sense of self, so is being aware of the
pens in a dementia residence, the more awareness
meaningful groups we are part ofacademic
there is among staff that residents are people first
groups, work groups, social groupsthe we.
and people with a disabling condition second,
Both I and we are hard-wired senses. All
and the more the person is treated and related to
such groups have their established norms,
as a person. Mutual positive perceptions create a
which, when people accept them and behave
accordingly, create bonds reinforcing the related virtuous circle of improved relations.
hard-wired need to belong.
The more that people can read environmen- The Bedroom Needs to Be a Sanctuary
tal cues as to what is expected of them, the more Bedrooms need to be private or, at most, shared
with one other persona choice that adds to the
they behave accordingly and become solid
persons well-being. If a bedroom is shared by
members of the group. And the more a person
two people, which essentially means they use a
with dementia behaves as expected in any
common bathroom, it is important for personsituation, the less sick others consider that
centered care to create a territory with visual
person to be. The more the person behaves
and audio privacy for each persons sleeping area
appropriately in a situation and is made aware
that is under the residents control. Personalizaof this from the way people react to him or her,
tion, the invitation to use ones own furniture
the more the persons self-image is enhanced.
and display ones own personal objects and
At the same time, merely making a choice to
mementos in ones bedroom or bed area, is as
be in one social setting or anotherthe dining
important as privacy.
room, for example, rather than the gardenthe
48 | Fall 2013 Vol. 37. No. 3
Pages 4552
people with dementiathe more they are surrounded by photos of family, mementos from
trips, or artwork they have created, the more they
remember the people and events involved.
Our brains are hard-wired to create and
support our sense of self. Surrounded by
personal cues and hints as to their past, their
achievements, and their social roles, people with
dementia know better who they are. With a
sense of self in hand, residents are more likely to
express their wishes and desires directly, rather
than by shouting or otherwise attracting attention in impersonal ways. In turn, others, as well
as caregivers and partners, are more likely to
address the person as a person, rather than as a
sick person, and tend to behave more normally
toward them.
Gardens Must Be Safe and Easily Accessible

In order to be therapeutic, outdoor areas for
people with dementia must be safe, have engaging elements, have a clear, direct walking path,
Our memories are not perfect. We often use
and be secure from potential public dangers
cues in our environment to remind us of what we beyond the garden. Gardens fundamentally
want to remember. Papers on the desk remind us are another common area. Being outdoors in
to work on something. Leaving our umbrella near sunshine for an hour in the morning aligns ones
the front door reminds us to take it when it rains. internal clock, reducing time disturbances and
Mementos we display sharpen our memories of
evening sundowning. The more that gardens
the events they come from. The same is true for
are safe and accessible, the more people with
dementia get outside, and the
more they have a sense of time
and seasons.
Garden design and enclosure
decisions are intimately linked
to the gardens governance,
which also has to be carefully
planned, including decisions
such as when the door to the
garden is unlocked, who
controls the key, and whether
residents plant the flowers and
vegetables. Decisions like these,
more than ramps for wheelchairs, constitute accessibility
Landmarks, self-evident walking path, and patio furniture all help to define
therapeutic gardens.
for people with dementia.
Memory shadow boxes outside residents rooms, and personal
furniture, photos, and mementos in bedrooms give residents
and visitors a sense of the person as a whole person.
Fall 2013 Vol. 37. No. 3 | 49
For many people with dementia, gardens

serve as the only outside place to which they
have access. If a garden is secure, its the only
place outdoors a person can use independently
without a caregiver present. Security is essential
for staff to feel comfortable leaving a door open
and providing access, because if the security is
not 100 percentfences too low, views out to
busy streetsstaff members understandably will
not provide access to residents except under the
control of a staff member. The more the garden
is designed therapeutically, the more the person
will feel comfortable and in control in that space
(Zeisel and Tyson, 1999).
Our brains are hard-wired to respond
positively to nature and a daily dose of sunlight
helps align our internal clocksour chiasmatic
nuclei. Therefore, being able to visit a garden
easily enables people with dementia to soothe
themselves if they are bored or anxious. Whenever a person with dementia behaves in a way
others consider more normal, the others treat
that person more normally and with hope that
the relationship can be rewardingand it usually
is. Gardens provide places where residents and
visitors can together experience flowers, sun-
Pages 4552
light, snow, sitting on a bencheach employing

the same hard-wired capacity to experience and
enjoy nature. Mutual experience of this sort is
bonding, in part because few words have to be
spoken for the experience to be enjoyable.
A Sense of Home Is Key to Comfort

for Residents and Family
People feel an environment has a sense of home

when they can display their own objects and
mementos. Feeling at home is also achieved
when rooms are the scale of those in a house or
home, not an institution, and have homelike
furniture and fixtures, with residential (not
institutional) colors. Staff must reinforce the
sense of home by the way they behave and treat
each other and residents. Looking like a home
from the outsideeven a large homeis also
essential to family members often burdened by
the guilt of putting their relative into a home.
The many shifts in life associated with a progressive condition like dementia are disconcerting enough without the physical environment reminding us of these changes. One way
the environment can soothe transitions and
normalize new living situations is for it to look
like and feel like home
whenever possible.
A sense of home, hard-wired
even at birth, remains vibrant
in all of us until the end of life.
When you feel comfortable and
at home, you dont worry or
get angry as much. The more
people with dementia feel at
home, the less they exhibit
anxiety, agitation, aggression,
and apathy. In ones own home,
a person generally finds things
to do and is thus less apathetic.
Having a place that looks and
feels like home provides residents the opportunity to take
over the environment, care for
A central hearth and a companion animal can provide a strong and recognizable
it, and make it their own. The
sense of home.
50 | Fall 2013 Vol. 37. No. 3
Pages 4552
more they do this, the more

they develop a sense of self. The
more a person is himself or herself, the more caregivers and
family partners treat them as
a whole person and develop
respectful and reciprocal
person-centered relationships.
Residents Take Cues

from Sensory Details
They Comprehend
If residents are to feel comfortable in a setting, what residents
see, hear, smell, and touch must
be understandable to them.
This does not mean that such
Familiar dance music remains a coherent sensory experience for residents.
experiences have to be designed
the less anxiety they feel and express. The more
to match a childhood experience (long-term
the environment helps people develop a cohermemories are not the only memories left).
Instead, the messages sent by the colors, sounds, ent picture of their life that matches the view
held by others, the more others will relate to
smells, and textures must be coherent to all the
senses at once and be within the comprehension them as whole beings.
range of each person. Like all of us, people with
Supporting Independence Helps Retain It
dementia comprehend their environments by
Lean rails along corridor walls, toilets that are
triangulating all their senses concurrently. This
is more important for them because both old age high enough to rise up from without help, chairs
with arms to lift oneself up by, are among the
and dementia weaken the signals sent to the
environmental conditions that support each
brain by each sense individually.
individual to use whatever capacity they have
The interpretive part of each persons
brainthe left brain area studied by neuroscien- to remain independent as possible for as long
as possible. As people agewith and without
tist Michael Gazzaniga (1998)continues to
dementiathey do not lose all capacities but
make sense of the world around us until the
rather maintain certain physical and cognitive
end of life, even for people with dementia. The
abilities. When the physical environment is
particular explanation given to that coherent
planned to enable users to continue to use
whole may be different for different people,
whatever capacity remains, the person stays
and different for people with dementia than
independent from others and from intrusive
for people with no dementia. But the sense
technologies for longer.
of coherence itself is soothing.
Many places in the brain give us the feeling
The more that people hold a coherent picthat we can do something, that we can act
ture of the world around them, the greater the
successfully to meet our wishes and needs. Even
feelings of comprehension, the more they feel
like themselves, with their own understanding if the person with dementia fails at a task, he
and sense of control. All these feelings reinforce or she often thinks they can accomplish it the
next time. The parts of the brain that generate
their sense of self. The more they feel this way,
Fall 2013 Vol. 37. No. 3 | 51
Pages 4552
actionthe brains actors

are hard-wired to make us at
least attempt to do what we
want and need to do.
Capacity-reinforcing elements in the physical environment enable residents naturally
to use their abilities on their
own. Even if they need help,
this is a task that falls to caregivers and partners to fill in, not
the environment to solve. The
more a persons environment
supports his or her capacities,
the more a person will act upon Lean rails along corridor walls provide sufficient support for many residents to
and feel a level of independence. walk independently.
The more a person acts successfully in their
community setting. The degree of personenvironment, the more they will continue to
centeredness reflects the degree to which the
do so. The more a person behaves indepenenvironment supports the person in feeling
dently and uses their capacities, the greater is
whole and having healthy relationships for as
their sense of self. The more caregivers and
long as possible.
partners see the person as independent, even
If a person or organization wants to reinforce
marginally, the more they treat the person as a
the capacities and personhood of a person with
person, not as a patient.
dementia, a good place to begin is to include in
their environmental design the eight design
performance criteria discussed in this article.
Meeting Design Criteria Can

Create Person-Centered Care
Ultimately the goal of design interventions is to
improve the person-centeredness of the persons
worldwhether he or she lives at home or in a
John Zeisel, Ph.D., is president, Hearthstone Alzheimer Care, Ltd., and the Im Still Here Foundation,
in Woburn, Massachusetts.
References
Gazzaniga, M. S. 1998. The Minds
Past. Berkeley, CA: University of
California Press.
Kitwood, T. 1997. Dementia
Reconsidered: The Person Comes
First. Buckingham, UK: Open
University Press.
Zeisel, J. 2009. Im Still Here: A
Breakthrough Approach to Understanding Someone Living with
Alzheimers. New York: Avery.
52 | Fall 2013 Vol. 37. No. 3
Zeisel, J., and Tyson, M. 1999.

Alzheimers Treatment Gardens.
In Marcus, C. C., and Barnes, M.,
eds., Healing Gardens: Therapeutic
Benefits and Design Recommendations. New York: John Wiley & Sons.
Zeisel, J., et al. 2003. Environmental Correlates to Behavioral

Outcomes in Alzheimers Special
Care Units. The Gerontologist
43(5): 697711.
Zeisel, J., Hyde, J., and Levkoff,

S. 1994. Best Practices: An
Environment-Behavior (E-B)
Model For Alzheimer Special
Care Units. American Journal
of Alzheimers Disease & Other
Dementias 9(2): 421.

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GE N E R ATIONS Journal of the American Society on Aging

erson-centered care is a primary goal of

design performance criteria (Zeisel, Hyde, and

Fall 2013 Vol. 37. No. 3 | 45

GE NER ATIO NS Journal of the American Society on Aging

This article explains the

Controlled Exits Allow

46 | Fall 2013 Vol. 37. No. 3

Person-Centered Care for People with Dementia

designed exit controls on doors,

Fall 2013 Vol. 37. No. 3 | 47

GE NER ATIO NS Journal of the American Society on Aging

rooms, music rooms, and other

48 | Fall 2013 Vol. 37. No. 3

Person-Centered Care for People with Dementia

Gardens Must Be Safe and Easily Accessible

Fall 2013 Vol. 37. No. 3 | 49

GE NER ATIO NS Journal of the American Society on Aging

For many people with dementia, gardens

light, snow, sitting on a bencheach employing

A Sense of Home Is Key to Comfort

People feel an environment has a sense of home

50 | Fall 2013 Vol. 37. No. 3

Person-Centered Care for People with Dementia

more they do this, the more

Residents Take Cues

Fall 2013 Vol. 37. No. 3 | 51

GE NER ATIO NS Journal of the American Society on Aging

actionthe brains actors

Meeting Design Criteria Can

52 | Fall 2013 Vol. 37. No. 3

Zeisel, J., and Tyson, M. 1999.

Zeisel, J., et al. 2003. Environmental Correlates to Behavioral

Zeisel, J., Hyde, J., and Levkoff,

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