Group Living for Elderly with Alzheimer's Disease: The Importance of Environmental Design

During the 1990's, within different fields of research, great pains have been taken to improve and develop understanding of people's relationship to the environment. The whole relationship issue is manysided and complicated, and innumerable attempts have been made in order to accurately measure these relations.

A theoretical approach which has proved to be particularly suitable in the area of the "elderly and their environment" has been developed by the American gerontologist Powell Lawton at Philadelphia Geriatric Clinic. His starting point is in the relationship between the individual's functional ability and environmental pressure.

In the last ten years of development of housing for the elderly in Sweden, it has been mostly group living for dementia patients which has received the greatest attention. Understanding the effects that this form of care has in an overall care-chain is still lacking. Despite this, there is great expansion of group living in Sweden.

During early stages of the development of dementia, patients can usually continue to live in their own homes. As a rule this is possible because of the considerable support given by relatives. As a complement to the care given by relatives, and especially if the dementia patient lives alone, assistance from a home helper will be required at an early stage.

At a later stage in the development of dementia, daycare centres with different forms of group activities may be available in some places. When care in the patient's own home becomes unsatisfactory or the burden on the relatives becomes too great, relocation to group living or a nursing home becomes necessary.

The Group Living Concept

In the past dementia patients who could not be cared for in the home were cared for in nursing homes or hospitals. Planning for group living as an alternative to hospitalization began in Sweden in 1983 to deal with the large groups of patients with the most common dementia diseases.

In 1985 three group living units were completed, by knocking together and converting conventional apartments. These were evaluated as a pilot project. The benefits of the small-scale, familiar and homely environment were taken advantage of. Staff were directed and trained to deal with a group of patients with limited comprehension, sharing similar symptoms.

Based on the pilot project, as well as experience from subsequent similar projects by other hospital authorities, the Swedish Board of Social Health and Welfare published recommendations on the expansion of group living. The development of the group living concept has been very rapid. In 1987 there were 60 units with a total of 500 residents. By 1992 there were 830 units with 6,700 elderly residents and in 1999 there are 2,100 units with 19,000 residents. In order to further stimulate expansion, the State introduced a subsidy of 500,000 SEK for every new group living unit created between 1992 and 1996. The political goal was 25,000 demented individuals in group living by the Year 2000.

From the beginning the Government gave financial support to group living units for six elderly with dementia [see example 1], but today they have changed their minds and are supporting units with 8 - 10 residents [see example 2].

Example 1: Group living for six residents

This group living is one of the first built in Sweden. It is planned for six elderly demented persons and is situated in an ordinary block of flats three kilometers from the center of the city. The basic design criteria were:

• all six flats must be fully equipped with a room, a kitchen with a special dining area and a private hygiene room.
• the common area in the middle of the unit must give the residents opportunities to meet each other, eat together, ADL activities etc.

At the same rate as the understanding of dementia increases, greater demands are made on how the group living units ought to be designed. Mostly we know all too little about whether the activities which take place in the unit conform with the needs of the dementia patients. In the same way we know very little about how group living works in practice.

In 1993-95 we studied 18 group living units in Malmö (Åhlund et al, 1995). The aim was to improve understanding of the group living environment. In order to do that we also tried to measure characteristics of the physical environment. Based on the results we made recommendations on what should be considered when designing and planning group living for dementia patients.

The main data collection instrument was the TESS +2 scale (Therapeutic Screening Scale) developed by Sloane and Mathew (1990). Eight areas were studied: general design features, maintenance, inventory of spatial amenities and seating capacity, lighting, noise on the unit, amenities in residents' rooms, programming orientation and global environmental ratings.

The scale is supplemented with unstructured discussions with the staff who are given the opportunity to express their opinions on how the individual unit worked.

The results of the study allowed us to make the following recommendations about group living for elderly with dementia:

Location

In the past, the location of many units lacked any overall planning. Initially group living units were placed on the outskirts of Malmö, often on housing estates, which in the middle of the 1980's had many vacant apartments. The analogy to the location of Medieval leper colonies and later mental hospitals on the outskirts of the community is striking. It is also impossible not to compare leprosy in the Middle Ages, insanity in the last century and the dementia patients of today as society's outcasts.

Individual Dwelling

Regarding the individual dwelling, the following results are worthy to note:

• The flat should not have a kitchenette.
• one room is enough in the individual dwelling. It is appropriate to design the room with a bed alcove so that a sleeping area and a living area can be maintained.
• The door to the hygiene room should be placed near the entrance door.
• The door to the apartment should not be designed as an outside door with, for example, letterbox, an expensive lock etc.
• The shower should be provided with a temperature controlled mixer tap.
• The dwelling should be equipped with a lockable cupboard for valuables and a medicine cabinet.

Common Areas

In a group living for dementia patients the common areas are the most important:

• Priority should be given to the design and planning of the common areas, rather than the individual dwellings.
• It is important to have an overview and the door to the individual apartments should preferably open onto the common space. Halls, if there are any, should be short and the common space should be centrally positioned in the unit.
• “Dead ends” should be avoided if possible. Short distances between the individual dwellings and the common areas are much more important.
• The common space should be planned so that it is possible to see out. This point is particularly worthy of notice. However, it can be considered important for elderly people, who perhaps have limited mobility, to see what is happening outside by, for example, having a good view.
• Most compact areas provide greater home-likeness, coziness, shorter distances and better visibility. It is very important for the patient to be close to other people.
• An open connection between the kitchen and the dining space is desirable. An important part of the activity in group living is the meals. The patient appreciates the smell of food and sometimes wants to help with the cooking.
• If at all possible, the unit should be placed so as to have direct access to the ground. If this is not possible, the unit needs a balcony or terrace which can accommodate all of the patients and staff.
• The group unit should have a separate desk/reception (with telephone). This can be placed in the common space or in the hall.
• There should be a guest room for relatives.
• At or near the entrance there should be storage space for outdoor wheelchairs and other technical equipment.
• The laundry in the unit should have a window.

The results of our research so far have provided an opportunity to implement knowledge about elderly with dementia in a small municipality where they decided to build a group living for elderly with Alzheimer’s disease.

Example 2: Group living for eight residents

To a very large extent this group living has been designed with regard to medical aspects. Special emphasis was laid on the fact that the premises should have a very clear layout. It must be easy for the patients/tenants to find their way about. Since activation and stimulation are key concepts in this context, our requirement was that the common parts of the building should predominate.

In summary

The two examples show a development of the group living concept during one decade. Example 2 helps us to understand that design can:

• compensate for disability
• maximize independency
• demonstrate care for the staff
• reinforce personal identity
• be orientating and understandable

By using the common areas in daytime as much as possible the aggressive behavior might be handled in an effective way and the residents are less aggressive already six months after they moved in. The kitchen is very important, allowing residents to maintain their ability to cook meals and be independent. At the end this improves their quality of life. A well designed environment and the efforts from the staff caring for the residents are two of the keypoints in a group living unit.

An International Outlook on Special Care: Units for Elderly with Dementia

The United States

In the USA a great variety of special care units for the demented elderly have been developed in nursing homes during the last two decades. Extensive research is going on to evaluate advantages and disadvantages of special care units. A special Work Group of the National Institute on Aging has taken a leading role in examining critical research and policy issues.

Guidelines for designing the physical environment have been presented by researchers at the School of Architecture of University of Wisconsin-Milwaukee (Cohen & Weisman, 1991; Cohen & Day, 1993) much according to the theories of Powell Lawton (1980).

Great Britain

In Britain a "Domus philosophy" for residential care of the elderly has been developed as part of an overall district plan for psychogeriatric services. It will improve quality of care by specifically addressing the staff anxieties and attitudes that lead to institutional maintenance and poor quality of life for residents.

Further perspective studies are however needed to establish this model of residential care (Lindesay et al 1992).

Japan

The need for special care units has grown enormously in the Japanese society. Influences come from examples developed in United States and Sweden. In 1999 the Japanese government decided to initiate development of group living units. Today there are about 500 units already built and the financial support from government and the municipalities guarantees rapid development.

France

In France an innovative form of communal nonmedical care, so-called "cantous", appeared in 1968 and these are now widespread. In cantous the physical environment is adapted especially to the demented individual's needs. The question of which type of structure of care is most beneficial for which type of pathology and at which stage of its evolution has been raised (Ritchie et al 1992).

Conclusions

Group living as a new model of care could be implemented based on the needs and prerequisites of the unique demented patient by increasing the knowledge of dementia conditions in different individuals.

The expansion of group living units for dementia patients has greatly increased in Sweden in the 1990's. One reason for this is the increased understanding of dementia diseases in combination with the idea of the importance of the designed environment for adequate care.

There is still considerable uncertainty as to how to plan and design group units for dementia patients. The needs and requirements of the individual have not been considered enough. Most of the Swedish examples are converted tenements with conventional flats being knocked together. Along with the system of financing, the physical framework has been too limiting for adequate care.

If we want to design good group living units, it is necessary to decide which of the patient's needs should be satisfied. Different dementia diseases probably require that the demands on the built environment must be formulated differently. Medical knowledge is the most important cornerstone. It is only when such a test is done that the importance of the group living unit as a form of care can be defined.

In conclusion, I would merely state the fact that group living is a good alternative for the care of dementia patients. A successful result requires collaboration between different factors: medical expertise, well trained staff, well-educated designers familiar with dementia care and the designed environment. A truly holistic perspective is necessary.