By: Margaret P. Calkins, Ph.D. President, I.D.E.A.S., Inc. Kirtland,
John P.Marsden, Ph.D., Assistant Professor, Auburn University, Alabama
The physical environment plays an important role in creating an
atmosphere of home. Too seldom, however, are the deeper meanings
of home fully incorporated into the design of dementia care settings.
In this article, "home" is considered at three levels:
as a psychological state, as an expression of self, and as a physical
structure. Successful design must address all three levels, and
must integrate the physical environment with operational and programmatic
aspects of the setting.
The information contained in this article was supported by research
funded by the National Institute on Aging (grants AG15249-01 and
"Mid pleasures and palaces though we may roam,
Be it ever so humble, there's no place like home"1
Close your eyes, and take a "walk" through your home,
either your current home, or a favored one of the past. As you come
in the door, scan the room, and think about what it smells like.
Is there something baking? Or does the aroma of flowering trees
outside come wafting in an open window? Where do your eyes linger
as you scan the room--on a favorite photograph, or momento from
your parents? Is there a favorite chair, where you--or your mother
or father--used to sit in to watch the ongoing activities? Spend
a minute "walking" around the house, and pay attention
to your feelings.
Now, let's walk into a nursing home. If you've been in many nursing
homes, you may have a composite picture of lots of different places.
What are your first images like? Walk onto one of the units. Are
there long hallways, and a single day room or shared social space?
Think about the nursing station--is it a fortress behind which staff
sit and passively monitor the residents? Or is it more like a concierge
desk at a hotel? What is the lighting like? What does it smell like?
How does it feel to be in this space? Again, pay attention to your
This exercise demonstrates the power of home. The images and feelings
summoned by thinking about home were probably quite different than
those evoked when thinking about the nursing home. Even the word
home evokes positive, comfortable feelings. Thus, it is not surprising
that many care facilities are trying to be less nursing home, and
more nursing home--particularly for those individuals who will be
long term residents in this setting.
"This is the true nature of home--it is the place of Peace;
the shelter, not only from all injury,
but from all terror, doubt and division."2
But these exercises also demonstrate that home
is much more than a few simple decorating techniques. "Home"
needs to be distinguished from "house." As Dovey3 put
it, "Although a house is an object, a part of the environment,
home is best conceived of as an emotionally based and meaningful
relationship between dwellers and their dwelling places."
For the purposes of this article, there are three levels at which
"home" needs to be considered: as a psychological state,
as an expression of self, and as a physical structure. All three
are important and intertwined, although the majority of this article
will focus on the last level--physical structure.
Home as psychological state
"Ah, what is more blessed than to put cares away,
when the mind lays by its burden, and tired with labor and far travel
we have come to our own home and rest on the couch we longed for?
This it is which is worth all these toils."4
Home has been defined in many ways: a place of
refuge or a secure place (Rainwater5), a place where one has control,
a place of certainty and stability (Dovey6), a sacred place (Eliade7).
Dovey8, who has conducted substantial research on home, suggests
that "being at home is a mode of being whereby we are oriented
within a spatial, temporal and sociocultural order that we understand."
"To be at home is to know where you are; it means to inhabit a secure
center and to be oriented in space."9
Attempting to recreate this experience-this state
of being home-for people with dementia can be challenging. Often
when a resident says "I want to go home" they are not
necessarily referring to the house they came from, but rather to
a state of being that was comfortable, ordered, and fundamentally
orienting. They want to return to a place that makes sense, where
they can feel comfortable and not threatened by myriad things they
cannot understand. This is the underlying principal behind both
validation therapy10 and agenda behavior11--the importance of understanding
the emotional state behind the overt actions. But, as will be seen
below, the physical environment plays an important role in helping
people feel either comfortable and at home or out of place and uncertain
in a given setting.
Home as an expression of self
"Be thou thine own home, and in thy self dwell."12
What makes people interesting is that they are all very different.
As unique individuals, people have specific tastes, preferences
and identities. This is noticeable if you look at the clothes people
choose to wear, the cars they drive, the jobs they take. It's also
noticeable through the houses people choose, and the changes they
make to those houses through additions, decorations, and furniture.
For the vast majority of people, the home is also an expression
of personality, taste, lived experiences, socio-economic status,
and ethnicity or culture. Whether it's modern or classical, humble
or grandiose, urban, suburban or rural, people's homes represent
a unique aspect of personality that is readily understood by others..
When people change their environment to suit their
tastes and to express their unique individuality, they are engaging
in personalization. Even in places, such as rental apartment buildings
where they may be strict rules governing personalization options
(no holes in the walls, can not paint the apartment, etc.), most
people still find subtle ways to express themselves or mark out
their own territory. A small wreath of flowers on the front door,
or a pot of flowers are simple examples of ways people personalize
the entrance to their homes.
Personalization of homes in an overt statement
of what is important to that person. Someone who loves cooking has
a well-tended and obviously loved kitchen. For readers, the library
will be embued with comfort and good lighting. Travelers may display
photos and mementos of favored locations. The selection and placement
of furniture can indicate whether conversations or the TV are more.
For a facility to be truly like home, it must
accommodate these different patterns, by providing options to personalize
their space in different ways. But it goes beyond simple personalization.
People vary in how they show their priorities. Some may spend a
great deal of time taking care of their home and garden--maintaining
and renewing it--as if to convey loving respect. Others may make
very few changes over the years, as if to suggest contentment and
stability. Some people enjoy spending time in the kitchen, puttering
around, planning the menu, preparing and cleaning up from meals,
reading the paper, visiting with neighbors, and have kitchens that
reflect the love and care it receives daily. Others, who view the
kitchen as functional space to be used as little as possible, would
much rather spend time elsewhere in the house-and these areas show
the attention given to them. Regardless of the ways people choose
to personalize their space, it is practically universal to want
to identify a space as yours, in one way or another. And this need
does not change simply because one has aged. For a facility to be
truly like home, it must accommodate these different patterns, by
providing options to engage in these familiar maintenance and domestic
chores, without necessarily requiring residents to participate in
Expressing the self through personalization or
patterns of daily activities is linked to the issue of control (which
also impacts the psychological state, as mentioned above). In individual
homes, people generally control what and where furniture and belongings
are displayed. They also have control of when they engage in different
activities. These options and decisions are more possible in individual
homes than in group residential settings (nursing homes and assisted
living settings) which have a broad range of subtle and not so subtle
constraints. For example, it would not be considered appropriate
behavior for a resident to tap a nap in the middle of the dining
room during a meal, yet this could be done at home.
There is another aspect of control that is particularly
important for this population. Due to cognitive deficits, it is
recognized that it may not be appropriate for people with dementia
to have complete control over what they do and where they go. Many
facilities create secure or semi-secure units, so residents with
dementia can not walk away and become lost. Often these units are
on upper floors, making it even more difficult for people to leave
the building inappropriately or unattended. While this goal of safety
is laudable, its execution must be reconsidered. The ethics of locking
people up, giving them virtually no access to outdoor space, needs
to be examined. When these secure units are on upper floors of multi-level
buildings, getting outside becomes a rare event. Staff are understandably
busy with many caregiving tasks and the extra steps it requires
just to get people outside may be more than they can manage. And
this is considered acceptable. By contrast, in many states, prisoners--people
who have committed crimes--are required to be allowed one hour in
every 24 outside. It is the position of these authors that no secure
unit should be considered acceptable unless it has direct, and at
least partially unrestricted (during clement weather) access to
a (secure) outdoor space. Research has demonstrated that there may
be a correlation between some anxious behaviors (pacing, standing
at doors, rattling the door handles) and having secured doors13.
In this research, when the doors to the courtyard were unlocked,
several residents would walk to the door and open it, then walk
away. They didn't want to go outside, they wanted to know they could
While this is just one example of control, it
highlights the challenges of creating a place that supports both
the abilities and the disabilities of people with dementia. These
are ethical challenges which caregivers face everyday, which need
to be addressed more consciously. One way to address these issues
is to give residents as much autonomy and control as possible over
aspects of their lives that do not affect their ultimate safety
Home as Structure
"For a man's house is his castle
One's home is the safest refuge to everyone"14
Beyond all the psychological and emotional levels
of the meaning of home, there is also a very concrete, structural
level that needs to be considered. In addition, it must be recognized
and accepted that most long-term care facilities are not homes;
they are larger, congregate residential settings with many unrelated
people living together and sharing some amenities. Therefore, it
is not realistic to assume that facilities will be able to actually
recreate the complete expression of house or home. Nevertheless,
the physical environment can be considered at several different
levels: exterior elements, connection with neighborhood, scale,
types of spaces, arrangement of spaces, and decor. Each of these
topics will be considered separately.
The exterior of a building
is the first impression we receive. A place that looks like a hospital
or a hotel is unlikely to be considered a desirable housing choice.
Obviously, it is easier to create a small, residential exterior
appearance if the building is, actually, smaller (see Scale for
more on this). But there are ways of breaking up the apparent mass
of a building, through placement on the site, use of landscape features,
and articulation of the exterior facade. Marsden15 using photographs
of different building entrances and exterior elements (porches,
building materials, roof articulations, landscaping, etc.) was able
to demonstrate that people have distinct impressions of what make
a place look more "home-like." Family members and elderly
residents of retirement communities were asked to evaluate the photographs
and showed remarkable agreement, although there were also some areas
where they disagreed.
Porches and porticos were viewed more favorably
than long driveways with porte-cocheres by both residents and family
members. The scale of porte-cocheres as well as wide driveways with
signage indicating clearance heights suggested the entrance could
accommodate a truck or an ambulance, which evoked more images of
institutional building types such as hospitals, hotels and funeral
homes15. Residents did favor certain covered walkways at the entrance
to provide protection from the weather even if it included an unfamiliar
housing cue such as a canopy. In contrast, family members viewed
familiar housing cues (porches and porticos) as more important than
sheltered covering. With respect to exterior elements, residents
and family members felt that attention to maintenance and small
details such as picnic benches and seating at the entrance and decorative
features were positive. Natural building materials such as wood
and to some degree brick were viewed as more home-like than synthetic
materials such as stucco. In addition, residents tended to view
one-story buildings more favorable than two or three story ones,
whereas building height was not particularly salient in the family
Connection with neighborhood
People live in varied
settings: dense urban neighborhoods filled with many apartment buildings
and houses very close together; suburban lots of identical size
with similar set backs and overall design; rural communities with
varied houses on multi-acre lots, and many other options in between.
While a discussion of setting at this scale may not seem relevant
to the overall goal of this article on long-term care settings,
it actually is quite relevant. As facilities move away from an institutional
model and toward something that is more reflective of home, what
that home is, and how it is related to its neighbors must be considered
at a fundamental level. Consider these two options. In one scenario,
the old "nursing unit"--a cluster of bedrooms with shared
bathing and social spaces--is reconceptualized as a "household"
and the shared spaces become the living room and dining room, and
the bedrooms remain the bedrooms. In another scenario, the bedroom
is considered the apartment, and the shared spaces become more like
neighborhood spaces--the corner deli or cafe, the library or lobby
or game room of the apartment building. This latter scenario may
actually be more appropriate for facilities with existing bedrooms
arranged along a double loaded corridor. It is critical for facilities
to decide which approach they are taking, as it fundamentally alters
how different spaces are handled. It is, however, a complicated
decision which has many implications, and therefore will be addressed
in several of the subsequent sections.
One key feature that makes a place feel
institutional is the scale of the spaces. Large-scale spaces, or
rooms that hold over 25 people, are not common in residential environments.
Most living rooms comfortably hold 5 to 10 people, and are rarely
more than 300 square feet. And few people have a dining room that
will easily seat more than 10 people. Most residential ceilings
are from eight to ten feet high (with the exception of recently
popular cathedral ceilings). In contrast, many long term care facilities
have large shared spaces (which some refer to as living rooms, others
as day rooms) that are two stories in height, and which have large
expanses of glass. Dining rooms may easily accommodate 30, 40, even
60 people. While many of these differences reflect the fact that
long-term care facilities are designed to provide service to a large
number of people, if the goal or intent is to create a setting that
feels like home, it is imperative to break-down the scale of the
spaces. This can be challenging--particularly so in existing facilities.
But there are things that can be done to help.
The first level at which this must be considered
is the scale of what has traditionally been referred to as the "unit."
Based primarily on notions of staff efficiency, most traditional
nursing units have housed between 40 and 70 residents, often in
rooms shared with one, two or three other people. Increasingly facilities
are creating pods or clusters of 12 to 24 residents. Usually, several
pods are grouped together to allow for increased staff efficiencies
(sharing some support spaces, and reducing the number of staff at
night), but keeping them sufficiently separated that residents feel
they are living with a small group of others (anywhere from 6 to
16). . It is easier to break-down the scale of the unit when doing
new construction, than when renovating an existing facility. Yet
there are often ways to adjust the scale of existing buildings as
Obviously, this alternative of breaking up the
units into households is not possible, or easily feasible, in existing
facilities. Other alternatives must be considered. In facilities
with existing long hallways, the layout may suggest it is more appropriate
to consider the "unit" the neighborhood, and treat all
bedrooms like resident apartments in an apartment building. The
shared social spaces would then be treated either like community
spaces (e.g. the dining room would be like a restaurant that seats
20 or more). The down side to this approach is that in many apartment
buildings, this hallway space remains anonymous, public, and "unowned."
The alternative approach would be to consider
the unit more like a home, with the bedrooms simply reflecting a
person's bedroom in a larger home. In this case, a top priority
is to minimize the length of the corridors, since houses rarely
have hallways that are more than 15-25 feet long. Long hallways
not only appear institutional, they require a great deal of energy
for older people to walk down, and it can be hard to orient oneself
if identical sets of doorways line both walls. Several techniques
can be used to break up the appearance of long hallways. First,
consider treating different sections of the hallway differently.
The ideal solution would be to have multiple small living rooms
or parlors along the length of the hallway, so people do not have
to travel so far to get to activities.
A second technique to break-down the apparent
length of the hallways is to distinguish doorways from each other.
For example, essential doorways, such as the entrance to a bathroom
can look distinct, either with color, or with a three-dimensional
canopy over the entrance. If this canopy can be seen from down the
hall, it can also act as an orientation cue. Resident bedroom doors
can also be decorated, as they sometimes are in apartment buildings.
Although this is a great technique which supports orientation16
it must be recognized that display cases and signs at bedrooms are
not typically found in people's homes. You must decide whether your
priority lies with supporting orientation, or recreating a place
that feels like home. There are other alternatives besides the display
case: consider encouraging each resident to bring a favorite piece
of art from home to hang outside their bedroom entrance. While it
might not be the location where these pieces hung in their former
homes, and it can make the hallway quite busy with lots of different
styles, it is more common to have art on hallway walls than to have
display cabinets or curio cupboards. Research suggests these types
of personalized cues can have a positive impact on helping people
find their own rooms16.
Hallways are not the only large spaces in many
facilities. Many of the shared social spaces were designed for 30-50
residents to congregate in--clearly not a residential scale. It
is probably best--especially for people with dementia who are easily
overwhelmed in large and busy spaces--to have several smaller rooms
for 10-12 people. This can be hard to achieve in existing facilities.
If a space is primarily used for dining, for example, permanent
or semi-permanent barriers can be constructed. These could be attractive
half walls, with planters or lattice work above. It may be helpful
to look at the ways local restaurants create smaller feeling spaces
without completely dividing an area. The same is true for activity
rooms. As an alternative, especially for facilities that are short
on storage space, cabinets on locking castors can be useful, as
they can either be moved against the wall if larger space is needed
for a special event or holiday dinner, or pulled out to subdivide
a larger area. This is a great solution for facilities with large
dayrooms, in which residents often sit in chairs arranged around
the perimeter of the room. Using cabinets or other dividers sub-divides
the space allowing for several smaller groupings of furniture.
Types of Spaces
Related to the issue of scale,
it is also important to define the types of spaces. If the basic
grouping of residents is considered a "house" (and residents'
rooms are bedrooms), then the shared spaces for this group of 6-16
should reflect the spaces typically found in their homes in the
community: kitchen, living room, dining room, and sometimes library/den
or family room. In the future, it will be more common to also have
an office. If the basic group of residents rooms is considered a
"neighborhood," then the residents' apartments should
contain these basic living spaces (kitchen, dining and living rooms
in addition to bedroom and bathroom). The shared spaces should then
reflect more public, communal spaces, like a local restaurant, the
village green, an art gallery, the public library, and/or a senior
center. Some facilities (particularly those with larger numbers
of residents) have found that local, well-known restaurants are
interested in opening a small cafe/lunch counter right in the facility.
Others are including a pub or cocktail lounge, recognizing that
many people are used to having a drink before dinner. A nursing
home in Oregon not only has the only restaurant in town, but the
local bank and beauty shop also operate out of the facility. This
is a wonderful way to break-down the separation often found between
long-term care facilities and the communities they are located in;
it entices local residents to come into the building.
It is also important to consider what rooms are
called. At the simplest level, having a living room or family room
is more familiar than having a day room or an activity room (which
sound more institutional or like a senior center). Language is also
important at the larger scale of the unit. Many facilities are moving
away from the term "unit" to calling these groupings of
residents clusters or pods. However, one could question how residential
these terms are. As one administrator17 put it, "Whales and
peas live in pods, and grapes come in clusters. People live in households..".
Language affects our thinking at a fundamental level, and should
be considered carefully. This may be why some facilities are giving
their units names, such as "Hill House" or "Beacon
Arrangement of Spaces
When you walk in the front
door of your house, or your neighbor's house, almost any house or
apartment, what do you come to first? It may be a foyer, or a hallway,
or the living room, but it's almost never the bedroom18. Yet, when
you enter most long term care units, what is the first space you
encounter? A hallway with bedrooms. This may be difficult to change
in existing facilities, but certainly any facility that is being
designed and newly constructed, that wants to create an atmosphere
of home, should consider the relative arrangement of spaces. Houses
and apartments, at least in most Western cultures, have a general
organization of shared, semi-public spaces at the front of the house
(living room and often dining room), followed by the kitchen (which
also often has a back door), and some transitional element (hallway
or stairs) before you reach the more private area with the bedroom(s).
There are exceptions: some bungalows and apartments have bedrooms
that open directly onto the living room or dining room, although
in many cases people have modified these rooms to be a TV room or
Overall, however, the structure of a typical house
should be used as the template for organizing the structure of a
care setting that is trying to create the feeling of home. The first
level of decision making has to do with the scale of the whole project.
The design and management team needs to decide whether multiple
households are connected together, or whether each household will
essentially be free-standing. Both models can work. In the former
case, the end result is a larger building, which is harder to make
look residential from the outside (see Exterior Appearance, above),
but may be viewed as more efficient. In the latter case, the end
result is something more like a neighborhood of small houses. Indeed,
several projects have been developed which look more like a residential
neighborhood of similar homes than a long term care facility.
The next decision is whether the "front door"
to the household connects to the rest of the building (assuming
there are several households being grouped together) or whether
it leads outdoors. Connecting the front door to the outdoors is
a more residential sequence, and works especially well if the households
are separate buildings. When households are combined into a larger
building, it is still possible to have the "front door"
open to the outside (e.g. courtyard), and have a "back door"
that connects to the rest of the building. In some facilities (e.g.
The Wealshire in Lincolnshire, IL), this back door opens into the
kitchen area--just as it does in many houses. In The Meadows, in
Hammond, Australia, there are three households that are connected
by a service corridor used only by staff. This corridor leads to
the kitchen pantry area and laundry room. The advantage of this
arrangement is that there is never an "institutional"
cart visible to the residents in the building.
In existing buildings, it is clearly not possible
to completely restructure the space. Therefore, the facility must
decide how much of a priority creating spaces that feel homelike
are, and what the options are. Existing spaces that are comprised
of long hallways with bedrooms on either side (commonly referred
to as "double loaded" corridors) may be more ideally suited
to the apartment style approach described above, rather than a household
approach. In the apartment approach, each resident's room is considered
their apartment, and the shared common spaces are either more like
what you would find in an apartment building (community rooms, maybe
a restaurant), or what you would find in the community (ice cream
parlor, deli or lunch counter, community center, etc.). Unfortunately,
this model may not be as supportive of the needs of people with
dementia who are moderately to severely impaired.
The alternative is to make the best of what you
have. First, try to define households in as small a group of bedrooms
and associated shared spaces as makes sense given your particular
plan. If possible, avoid having units that must serve as passage
ways to other units, because then you are doubling the amount of
traffic going through the "front" unit, which--again--is
not homelike. If it is not easy to create a living room and dining
room at the main entrance to the household, consider this entrance
to the rest of the facility as the back door, and create a front
door off the main living and dining rooms which leads to a secure
courtyard. This means residents can have largely unrestricted access
to a secure outdoor space--an important aspect of control discussed
above. This arrangement--having living and dining rooms at the center
of the unit--may be especially effective if you are trying to keep
residents away from the less secure exits of the unit.
Another important area to consider is the staff
space. In the traditional, institutional setting, a large, highly
visible nursing station was required. In many areas, codes may still
require that there be a place where staff can be easily located,
and where they can easily monitor residents. However, advances in
technology are making it less important to have a person simply
sitting behind a desk monitoring the call bell system. This is particularly
true in an area for people with dementia who may not know how to
properly use a call bell system. Call bells that are tied directly
to staff pagers allow staff to respond faster to residents who need
their assistance. Other systems rely on motion control sensors,
and do not require the person with dementia to know how to pull
the cord when needing or wanting assistance. With all these changes,
facilities are finding new ways to support staff needs, without
the large, institutional feature of the traditional nurse's station.
Some facilities have simply updated the nurse's station, making
it look more like a concierge desk (which would be more appropriate
in a resort model, "Defining Place-based Models of Care: Conceptualizing
Care Settings as Home, Resort or Hospital" in this issue).
Others are creating small, residential scaled desks, either in out
of the way corners or as part of a kitchen area. Many people have
a small desk area in their kitchen, so this can feel familiar. However,
these small desks may not be sufficient to meet the paper work requirements
of many regulatory agencies. Many facilities find it useful to have
a separate, enclosed work area for staff to do paper work and charting.
These spaces are often not visible to the unit, so staff are not
expected to both be doing paper work and supervising residents,
and thus can do the paper work more efficiently, and then get back
to spending time with the residents. This has the added benefit
of eliminating the nurse's station as the activity focal point of
the unit, which leads to residents sitting around the station all
Other support services also need to be considered.
Housekeeping carts, clean and (particularly soiled) linen carts
and large food carts are almost always institutional in style and
usage. If possible, design a kitchen for the unit that has a separate
entrance, so food can come onto the unit and trash can leave the
unit without crossing other spaces. Be sure there is a place where
the food cart can be placed so it is accessible, but not out in
the open and visible to all residents. Consider ways of storing
a clean set of sheets in a cabinet (secured, if necessary) in the
resident's room. Enclosed laundry hampers in each room that are
emptied regularly may be able to be substituted for large soiled
carts kept in the hallways all morning. Look around for other signs
of the old institution, and be creative about ways to eliminate
these non-residential features.
Finally, the overall decor of the household
will also have an impact on how it is perceived by residents and
family alike. There seem to be two current trends in décor:
hospitality style or quaint "Americana." As was mentioned
above, it's important to know your residents. Were they likely to
have decorator-designed interiors with matching fabrics and coordinating
prints? Did they fill every corner of their house with collectables,
bows and dolls? Or were they likely to have collected pieces over
a lifetime of living, an eclectic array of styles and colors and
patterns? Knowing what is familiar to the people who will be living
there is critical if you want to be like home. If possible, go (and
get your interior designer to go) out to visit the homes of prospective
residents and see how they decorated their houses.
In most homes, different rooms serve different
purposes, and are designed to look very different. Seldom does a
person have the same chair in the dining room as in their bedroom
and their living room. Institutions, on the other hand, are marked
by a uniformity of both furniture and design. All wall treatment
is the same, or so coordinated that it's hard to tell one space
from the next. When a well designed chair is found, it is used everywhere:
in the bedroom, in the dining room, in the activity room. But this
approach to interior design will not make a place feel like home.
Making rooms feel very different--light and airy versus warm, rich
earth tones--also gives residents a sense that the spaces available
to them are different. If there are three of four different shared
spaces, but they all look and feel alike, and are about the same
size, what does it matter if you are in one versus another? When
the rooms vary not only in size, but in overall decor, they add
to the feeling of choice.
Few facilities take sufficient advantage of letting
residents bring in their own possessions. We recognize that some
licensures restrict the amount or type of furniture residents are
allowed to bring, and some existing building designs are so restrictive
there is almost no opportunity for personal furniture. Nevertheless,
personal possessions--as described above--are incredibly important
for helping to define who we are. Look at a residential-style hotel,
one of the newer suites with a living room and a small kitchen in
addition to the bedroom and bathroom. It seems to have all the components
of a small apartment--yet would you ever mistake it for home? Probably
not. It's the lack of personal possessions--furniture, art, pictures
of your family--all those little things that help make a place feel
like home. It's not surprising many residents feel they are living
in a hotel. The furniture was already there when they moved in,
and it looks like the furniture in the room next door. It's not
arranged the way they would have it arranged at home. Rather than
a plaid bedspread, they would prefer the flowered quilt that their
grandmother made. As for all the knickknacks and memorabilia they've
picked up on their travels around the country, there's no mantel
place to display them on.
The first step to giving a feeling of home is
to provide as little furniture as possible. Encourage people to
bring their own furniture, and only supply what they are unwilling
or unable to bring. Second, be sure there are places to display
items, ideally places that are somewhat out of the way or are secured.
Many facilities are adding plate shelves 5 1/2 to 7 feet up the
wall--still visible without being too accessible. Others are providing
display space behind glass.
Finally, consider what furniture and display items
residents can provide in the shared living spaces. People don't
just live in their bedrooms at home; they have living rooms and
dining rooms full of important items. If you want residents to feel
at home, encourage them to bring some items for decorating these
public rooms. The decor may be somewhat eclectic, but it can also
promote the sense that this is their space. Some facilities have
had great success letting residents bring in their favorite chair
for the living room, while others have found this caused problems
when someone other than the "owner" sat in it. This may
need to be tried out on an individual basis. And there will be problems
with some chairs and fire regulations (which vary from state to
state). It is sometimes possible to have cushions treated sufficiently
to make them flame retardant and suitable for bringing into the
While the physical environment plays an important role in creating
an atmosphere of home, we must learn to look beyond the simple level
of interior décor and even the less frequently addressed
issue of spatial arrangements, and explore issues of the meaning
of home. The physical environment does not exist in a vacuum: it
must work in partnership with other dimensions of the setting. The
companion article by Weber begins to describe some operational aspects,
such as how meals are served, that also have an impact on how a
space feels. And ultimately, it is how all these different parts
of the setting are put together that gives rise to a setting that
feels like home. This was demonstrated in the research project described
in the article by Briller and Calkins. The goal is always to enhance
quality of life for your residents with dementia. Start by asking
them where they want to live, and get them involved in creating
a setting that they will want to live in.
1. Payne, J. "Clari, Maid of Milan." (1823).
2. Ruskin, J. "Sesame and Lilies." (1865).
3. Dovey, K. "Home and Homelessness." Home Environments
. In I. Altman & C. Werner (Eds.). New York: Plenum Press. (1985),
4. Catullus. "Odes. III." (50 BC).
5. Rainwater, L. "Fear and the house as haven in the lower
class." Journal of the American Institute of Planners, 32,
6. Dovey, K. "Home and Homelessness." Home Environments
. In I. Altman & C. Werner (Eds.). New York: Plenum Press. (1985).
7. Eliade, M. The Sacred and the Profane. New York: Harcourt Brace,
& World. (1959).
8. Dovey, K. "Home and Homelessness." Home Environments
. In I. Altman & C. Werner (Eds.). New York: Plenum Press. (1985).
9. Dovey, K. "Home and Homelessness." Home Environments
. In I. Altman & C. Werner (Eds.). New York: Plenum Press. (1985).
10. Feil, N. "Validation therapy helps staff reach confused
residents." Provider, 16, 12 (1990): 33-34.
11. Rader, J., Doan, J., & Schwab, M. "How to decrease
wandering: A form of agenda behavior." Geriatric Nursing, 6,
4. (1985): 196-199.
12. Donne, J. "Verse letter to Sir Henry Wotton" (1669).
13. Namazi, K. H., & Johnson, B. D. "Pertinent autonomy
for residents with dementias: Modification of the physical environment
to enhance independence." The American Journal of Alzheimer's
Care and Related Disorders & Research, 7, 1. (1992): 16-21.
14. Coke, E. "Third Institute." (1644).
15. Marsden, J. "Older persons' and famil members perceptions
of homeyness in assisted living." Environment and Behavior,
31,1 (1999): 84-106.
16. Namazi, K. H. "Effect of personalized cues at bedrooms
on wayfinding among institutionalized elders with Alzheimer's disease."
Paper presented at the American Psychological Association, Boston,
17. Oosterdorp, J. Personal Communication. Clark Retirement Community.
Grand Rapids, MI. (1996).
18. Calkins, M. "Home is more than carpeting and chintz."
Nursing Homes, 44, 6. (1997): 20-25.
Reprinted with permission from Aspen Publishers, Inc., Alzheimer's
Care Quarterly (ACQ), Volume 1, Issue 1. Order by calling 1-800-638-8437
or on-line at www.aspenpublishers.com/journals/acq.