United Kingdom

United Kingdom


The D - Word

Guest blog by Paul Allison, Director, HPDA Architecture.

Let's be honest from the start and equally contentious. The word Dementia and Alzheimer’s sends shock waves through the lives of those it affects, not just those that have the condition, but for the family and friends that are part of their lives. To me, the attitude and social understanding of this condition is virtually equal to that of HIV in the 1980s in that there is a psychological recoil at the mere mention of the word and, as such, it is avoided – that is until we as individuals have to front-line this personally , whether in our work or family life.

As architects specialising in healthcare design, myself and Peter Dammeyer have, over the past couple of years, heard the word dementia used quite often, suffixed with the word 'friendly'. This loose term describes something incredibly complex. As with autism, it is defined as being 'on a spectrum' in that the condition and its effects are unique to the individual, and to understand the way they are perceiving their world, is something which has to be addressed if we are to generate designs for this condition correctly, but let's be clear from the start ; we cannot design the condition 'out'.

Through investigation of the information available to us and by listening to front line staff and medical professionals at the time of generating a brief, we listen to their personal observations and sense check this with the academic and medical information available to us at the time. We already recognise that, whilst there is validated information to refer to, compiled by academic institutions, which is evolving into a recognised standard, the richest vein of information to inform us for our designs is found in those who engage with people with the condition on a daily basis in the healthcare environment. Additionally, with the Disability Discrimination Act (DDA) and the Equality Act, there are already recognised standards to apply where certain conditions involving cognitive impairment and limited mobility require sensitive consideration to aid spatial recognition. In considering the requirements for dementia it only gives, in my opinion, a rough baseline.

There is a wide spectrum of views out there to filter and consider amongst medical and academic circles. We find contradictions along the way that conflict and cause seemingly endless discussions amongst those who become directly involved in design development, where facts and anecdotal examples are given to add support to their input. In short, as with any design, my conclusion so far, is that there is no 'one-size-fits-all' solution. This state of flux is frustrating but equally encouraging as it provides us with an opportunity to 'pioneer' the thinking behind designing for dementia. Pioneering may sound extreme so...let me put this into context. 25 years ago I had never heard of dementia, let alone Alzheimer’s. In 1994, I had just started a combined diploma / MSc Course in architecture and had decided to get involved in computers and their 3D capabilities for designing. A chance flick of the remote control for the TV tuned me into a lecture by Susan Greenfield, a research scientist in Parkinson's Disease and Alzheimer’s. The series of lectures was titled ‘Journey to the Centre of the Brain’. To illustrate the storage capacity of the brain in terms of information, she trundled into the auditorium a goods trolley laden with CDs to illustrate that the brain could hold far more information than all the discs on the trolley and then went on to do a lecture about memory – how it works and the physiology it has.

I was hooked for two reasons – I had seen her lectures before and they were extremely enlightening, second, she referenced in the technology that was used to do brain scans and create 3 dimensional models to study how the brain functioned by picking up information using the 3D read out of blood flow and oxygen consumption on memory recall. I contacted a hospital in London to ask about these scanners and asked if I could visit to have a look at the computers and visualisation methods that they used to read brain function; they said yes. I was met by a clinical psychologist who gave me a great introduction to the technology involved, how it worked and what they were doing in terms of researching Alzheimer’s and whether or not there was a way in which a treatment could be found; I was intrigued. I didn't acknowledge it at the time, but these were the first steps of me taking a very wide orbit from the built environment during my diploma course as an area of study, instead wanting to have a better understanding of how our brains perceived space. My thought at the time was how will my designs affect someone's psychological perception of their world? What levels of consciousness were operating when I design, and can I qualify my decisions and associative choices? It was a chance statement by a lecturer in architecture on my degree who told us that we were never 'innocent' of the decisions we make when we design and this statement has always stuck with me as a result and keeps me in check!

I was invited to take part in a memory test on the day, but that it would take a few weeks to organise. They wanted to perform tests on people without the condition in order to see which areas of the brain were working and compare that to scans of people who had already been diagnosed. By overlaying the images of both, they could identify which areas of the brain were affected and how memory recall functioned. So, two months later I popped along to the hospital and had two hours of memory tests, 'encoding' information with the use of letters, sentences and images and then reviewing the same number of examples again to engage 'recall' of the most recent information I had absorbed. At the point of recall, a radioactive isotope was released into my blood stream which indicated oxygen levels in the brain when memory was being used to recognise information – the most active areas of the brain had high concentrations of oxygen 'burn', thus locating where the brain activity was most concentrated. The researchers were quite surprised at my results, but I was a little put out at the stifled laughter I witnessed, so I asked what was amusing them, had they not been able to locate my brain? I was reassured that they had and that I had given them the highest reading so far on their tests; somewhere in the upper 90%. I was asked how I had done this, and said I had consciously created my own images to help reinforce the encoding part of the test, and that this had helped me to remember things I was being 'tested' on, a technique I had used for myself when revising for exams 20 years earlier at school. We all do it, it's not unique to me. We are just not always conscious of the fact that we do.

What was explained to me, is that the back part of the brain referred to as the 'semantic zone' held the motor skills information and in impaired patients, spatial recognition and the ability to read new space was reduced. They introduced me to the word 'hippocampus’, a kind of Central Processing Unit in the brain for taking in or 'encoding' new information. This was key to new information becoming part of a person’s memory and spatial repertoire. My analogy for this was to imagine a cassette recorder (remember those?) not being able to record new sounds anymore, but you could play all the tracks you already had! The overlay method showed less oxygen concentrations at the back of the brain of impaired patients where ' blocks' had formed in the neural circuitry, thus breaking down the links between the synaptic activity that needed to activate for a memory to be fully recalled – a bit like a fairy light bulb becoming corroded on a wired 'series' of lights and causing the whole chain to malfunction.

The cassette recorder and fairy light analogies are simplistic illustrations obviously but have become a way of understanding the physiology and processes the brain employs to understand how spatial recognition formulates and maps our environment. Architecture is about engaging the senses, creating points of eminence for those individuals who take the time and live in the now – a particular on-trend reference to encourage people to live in the present, not the past, nor the future. But what if an individual does not perceive a 'present'? What if we change their environment after the record button fails and their spatial experience is unfamiliar, unrecognisable and isolating? Added to which, how many of us sense the same emotional response to what surrounds us when we are on unfamiliar territory or simply get lost when we misinterpret directions through poor signage and wayfinding or misunderstand map directions? We get confused! So, what is, if at all, the 'dementia aesthetic’?

Wayfinding is particularly relevant, especially in terms of colour recognition and simple forms that we can read spatially. We already know that there are colours which don't work and those that do. Vision impairment can distort the reality of a true colour and equally I do think that we observe colours in a subjective way and can recognise them through the experience of that colour and what it might mean in terms of that experience, even before we know what that colour is called or what it may represent. The acoustic qualities of a space require adequate dB ratings to reduce reverberation so the ear can distinguish sound more clearly to those with hearing impairment. Wall and floor surfaces need to be compliant to current standards and make movement easy and clear of perceived visual obstacles, lighting adequate and appropriately placed, but when safety, infection control and durable materials are employed in designs for dementia, what kind of aesthetic is being squeezed out at the other end of the design process? Invariably, depending on the client it can become instantly recognisable as institutional at best and pastiche at worst. Images of global iconic landmarks, local views and artefacts are displayed to add visual interest and become cues to sooth and calm and obviously way-find for those less impaired to process new spatial territory. One question that I do keep asking myself is, will we have to change our designs to suit each generation. Currently, I have observed many instances of decoration and details which reflect the 1930s, 1940s and 1950s......... when will the 1960s and 1970s start to emerge, and should they?

Having followed medical articles and architectural ones too, and the occasional academic paper or press release about designing for dementia since then, it was a few years ago that our practice was approached, after we released our 'Memorable Spaces' brochure, by the manager of a school for children and young adults with autism and we were told that the ideas, themes and spatial cues we integrated into our designs would be helpful to those who have this condition – both being on a 'spectrum' . When I hear the term 'designing for dementia', there are many ideas out there which feed into the design process, but quite often these can conflict with each other – for instance, ‘memory rooms’. Vintage-styled rooms with artefacts to recreate spatial experiences of the 1940s, 1950s and 1960s, are not something that is encouraged by some well-known organisations that deal with Alzheimer’s or dementia. Having asked why, I was told it is perceived to be more important for those with the condition to have a sense of NOW, and that certain visual cues from the past, artefacts and images, are sufficiently present to provide comfort to anyone that feels disorientated and in distress about being in an unfamiliar space, and that it is not about creating a spatial experience that replicates an authentic representation of a space from a particular decade or an individual’s past; that would be impossible. For instance, I was engaged in conversation with someone many years ago in the film industry and was surprised when they asked if I was a production designer or involved in set design and continuity. My interest in vintage artefacts and garb goes back 40 years and I often find myself 'snagging' period-set programmes on TV, so I fully understand the connections and the reasoning of not creating 'sets'.

So how do we design a spatial Rosetta Stone? In short, we don't …. or rather can't – can we? I have to put my hands up and confess to finding the 'kindergarten' aesthetic that is evolving in some dementia settings disconcerting in some instances. I immediately associate this with the term 'their second childhood' and recall the cloakroom in my infants’ school with primary colours and little pictures above the coat hooks to indicate 'your' space; mine was a red yacht on a blue sea with a white sail and about two inches square. Granted, you will find this in many public spaces, particularly healthcare settings but it's not the reaction of the patient’s level of engagement that captures my attention, but that of their visitors. For some reason, I feel a sense of displacement and that this kind of visual language forces me to acknowledge something I find spatially alien, but I go along with it as it is the current accepted style of visual cue that is becoming universal. Conversely, I have seen in some articles in the architectural press quite inspiring way-finding and signage techniques that are refreshingly contemporary, but instantly readable without being reductive in its psychological meaning and, for me, we have to extend that level of thinking into every aspect of design for dementia. We have to continue to understand and pioneer and to question what we are developing as a 'new' spatial language and challenge the thinking and understanding of what dementia does to our spatial recognition. There is so much more to learn and like any other client, or end user, designing for those who have no real input in the process is always going to be challenge.

About Paul Allison:

Paul became a mature student at 28 after 10 years working for the British Civil Service. He spent 13 years in London studying and working in the Department of Education, branded design companies and various architectural practices covering retail, commercial, residential and educational design before concentrating on Healthcare Design for the last 18 years. The range and scale of projects he has been involved in has been comprehensive. With Peter Dammeyer, Paul set up HPDA Architecture Ltd 9 years ago to continue their mutual interest in the advancement of Healthcare design into the 21st Century.