By: Margaret Calkins, PhD
It is increasingly recognized that the built environment serves
as a therapeutic resource. Research over the past several decades
has demonstrated convincingly that certain elements of the physical
environment can have a direct impact on the behavior and functional
abilities of individuals with dementia. It is important to recognize
that what many caregivers now consider "basic knowledge"
was, as little as 15 years ago, cutting edge and radical. For example,
the vast majority of dementia specific care units now have some
type of personalized orientation cue at the bedroom entrance. Whether
this be a few photos, a shadow box with a few small trinkets, or
a larger curio cabinet that can hold a whole china doll collection
or awards from a distinguished military career, it is now widely
accepted that incorporating this type of personalized cue is an
important part of a therapeutic environment. Yet, as little as 15
years ago, this was a new concept. Wesley Hall, in Chelsea Michigan,
was one of the first care settings to use a photo (current) and
some other personalized cue on the bedroom door to help its eleven
residents find their rooms more independently. The Corinne Dolan
Center expanded this concept and built large, well lighted display
cases at each bedroom entrance, which allowed for more personal
items to be displayed. Systematic research demonstrated that items
that had greater personal significance-whether it be photos or trinkets-did
indeed help most residents find their rooms more independently (Namazi,
Rosner, & Rechlin, 1991). The research, along with significant
dissemination of information about the Corinne Dolan center, helped
make this concept of personalized bedroom cues an industry standard.
Not all concepts that were developed as therapeutic interventions
worked as successfully. The wandering path is a perfect example
of an intervention that has received significant amounts of attention,
although no clear best practice solution has yet emerged. Early
caregivers noted that many people with dementia spent significant
amounts of time "wandering" the hallways, sometimes going
into rooms and disturbing others or their belongings, and sometimes
getting "stuck" at the ends of hallways where the path
ended. The proposed "solution" was to develop wandering
loops or paths, sometimes referred to as racetrack designs. When
facilities were built based on this premise, they often found it
didn't solve the problem. This is in large part because the original
"problem" it was meant to solve was never well defined.
Was the goal to simply encourage residents to continue to walk around
in circles? Or was the goal to discourage them from entering others'
private spaces? Or to be able to circle around and eventually find
their own room? How do these goals relate to another common goal
of trying to find ways to engage residents in more meaningful activities?
At the Corinne Dolan Center, whose design included a "racetrack"
layout, the proposed research on continuous versus dead-end paths
had to be cancelled because residents were sufficiently engaged
in the programming that few spent any significant amount of time
walking around the building. This example clearly shows that when
the desired outcome is not well defined, it's hard to develop a
solution that's likely to be effective. And yet, this "solution"
of creating a continuous loop is often still applied without understanding
the complexity of the issues. In many facilities, it appears that
the creation of a walking loop is the end goal, with little or no
consideration for what the desired therapeutic benefits for the
Enlightened caregivers and researchers understand the importance
of creating opportunities for meaning and pleasure in the daily
experiences of the people with dementia they care for. Simply "wandering"
around a circular path, be it inside or outside, that has no intrinsic
opportunities for meaning or pleasure is not considered therapeutic.
And yet, even today a significant number of facilities are built
and courtyards created with "circular" paths that have
no places to sit and rest, nothing of interest to look at or watch,
nothing to encourage either an activity or dialogue with others.
To be fair, there are also facilities and courtyards that do pay
attention to these important considerations, that create places
that are ripe with opportunities for residents to experience the
pleasures of smelling fresh flowers, watch birds or squirrels at
play, sit and chat with a friend, watch others engaged in work or
play, or pick up a magazine or catalogue to leaf through while resting
along the path. These facilities have taken a hard look at what
goals they want to accomplish (e.g., increased pleasure, more meaningful
interactions with others, and reduced frustration associated with
being confronted by barriers or dead ends), and developed multi-faceted
solutions that address these goals through both the physical and
The various aspects of the built environment are not yet clearly
understood. For instance, while many people assume there are significant
benefits to spending time outdoors, there is almost no clinical
evidence of potential benefits for people with dementia. Can it
impact depression, improve circadian rhythm and sleeping patterns,
reduce agitation? Are there specific elements of outdoor space that
are necessary to achieve these goals, or is it simply enough to
be outside? Assuming there are some benefits, there is the related
question of what features or elements encourage people to spend
time outdoors. We have all seen courtyards in long-term care settings
that are almost always empty and unused. How much is use of outdoor
space related to the physical design, and how much is use tied to
staff-either their commitment to use outdoor spaces or their fear
that they are unsafe for residents to use on their own. This example
demonstrates the confluence of physical and social/organizational
dimensions of the setting-and the need to always consider them together.
I have seen facilities with wonderfully designed outdoor spaces,
secure with level paths and delightful plantings and both quiet
and active areas, that were never used because the staff kept the
door to the courtyard locked. When asked about it, they replied
that they feared for the residents' safety because there were roses
in the garden that had been donated by a prominent family. While
you and I can come up with several potential solutions to resolve
this issue, the point is that organizational and social factors
had a direct influence on the potential impact (or lack of impact,
since the residents were unable to use the courtyard) on the physical
Thus, while the concept of the physical environment as a therapeutic
resource in long term care settings has been given increasing recognition
over the past several decades, we need to move into the next level
of sophistication in learning about how it impacts residents and
staff. More and more care providers are looking to the built setting
to serve as an active partner in the caregiving environment. In
fact, many seem to believe that making a change in the physical
environment can "solve the problems" of their particular
situation. Unfortunately, it's almost never that simple. Environments
are as complex as the people who inhabit them, and there are almost
never simple solutions to complex questions. The settings we experience
are a confluence of physical, social, personal and organizational
factors, all perceived through our own experiences. And when the
challenges of dementia, and the myriad ways it affects how people
interpret what they perceive, the situation becomes even more complex.
Namazi, K. H., Rosner, T. T., & Rechlin, L. (1991). Long-term
memory cuing to reduce visuo-spatial disorientation in Alzheimer's
disease patients in a special care unit. American Journal of Alzheimer's
Care and Related Disorders and Research, 6(6), 10-15.
Calkins, M. P.(Producer) (2001) Creating Successful Dementia Care
Settings, Vol. 1-4. Baltimore MD: Health Professions Press.
Day K., & Calkins, M. P. (2001). Design and Dementia. In R.
Bechtel (Ed) Handbook for Environmental Psychology. John Wiley &
Brawley, E. (1997). Designing for Alzheimer's disease: Strategies
for creating better care environments. New York: John Wiley
Reprinted with permission from Aspen Publishers, Inc., Alzheimer's Care
Quarterly (ACQ), Volume 2, Issue 4. Order by calling 1-800-638-8437 or
on-line at www.aspenpublishers.com/journals/acq.