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26 Quality in Ageing – Policy, practice and research Volume 7 Issue 1 March 2006 © Pavilion Publishing 2006
ABSTRACT
Design for dementia has, to date, focused on the internal, generally institutional environment
of carehomes and dementia carefacilities. Yet the majority of older people with dementia
live at home, around one third of these on their own. Unless outdoor environments are
designed to help older people with dementia continue to use their local neighbourhoods they
will become effectively housebound.This paper presents the findings of a three-year research
project conducted bythe WISE (Wellbeing in Sustainable Environments) research unit of the
OxfordInstitute for Sustainable Development at Oxford Brookes University. The researchers
were funded by the EPSRC EQUAL initiative to examine how the outside environment could
be made dementia friendly. This unprecedented research investigated the perceptions,
experiences and use of the outdoor environment by older people with dementia and
identified design factors that influence their ability to successfully use and negotiate their
local neighbourhoods. The research found that dementia-friendly outdoor environments are
places that arefamiliar, legible, distinctive, accessible, comfortable and safe.The findings
have enabled the researchers to provide some preliminary recommendations for designers, at
all scales from urban design to the design of street furniture, on the criteria to consider in
developing dementia-friendly urban areas.
KEY WORDS
older people quality of life dementia
outdoor environments wayfinding neighbourhoods for life
Neighbourhoods for life:
Designing dementia-friendly outdoor
environments
Lynne Mitchell and Elizabeth Burton
Lynne Mitchell is a postdoctoral researcher and associate research tutor at OISD: WISE, Department of
Architecture, School of the Built Environment, Oxford Brookes University.
Elizabeth Burton is a reader and research tutor at OISD: WISE, Department of Architecture, School of the
Built Environment, Oxford Brookes University.
Both Dr Lynne Mitchell’s and Dr Elizabeth Burton’s interests are in social sustainability and how the built
environment influences people’s quality of life and mental and physical health and well-being.
Quality in Ageing – Policy,practice and research Volume 7 Issue 1 March 2006 © Pavilion Publishing 2006 27
Neighbourhoods for life
BACKGROUND
Current statistics on the ageing of the
population are remarkable. The World Health
Organisation predicts that the number of
people aged sixty and over worldwide is
expected to double by 2025 (WHO, 2004). The
UK Census 2001 found that, for the first time,
there are more people over the age of 60 than
there are children, with the greatest increase in
the age group of 85 and over (National
Statistics Online (NSO), 2002).
As they progress through old age, people
experience a number of challenges, such as
reduced financial income, frailty, ill-health and
reduced capabilities and age discrimination
(Help the Aged, 2004). The recent launch of
the UK government’s Excluded Older People
project demonstrates that policymakers are
beginning to acknowledge the negative affects
that these challenges have on well-being and
quality of life (ODPM, 2005). Developing
dementia is one of the biggest and most feared
challenges of old age yet the needs of people
with dementia continue to receive scant
attention. The likelihood of developing
dementia increases with age, from one in 50
between the ages of 65 and 70 to one in five –
in other words, a twenty per cent chance – over
the age of 80 (Alzheimer’sSociety, 2004a).
With the UK population trend expected to
continue in the same pattern identified by the
2001 Census the number of people with
dementia will increase dramatically. However,
the recent attempt to stop NHS provision of
drugs that delay the progression of dementia
on the grounds of cost demonstrates a lack of
understanding and concern about the needs of
people with dementia among policy makers
(Revill, 2005).
Policyand practice relating to the design of
the outside built environment is no exception.
Traditionally, the design of the built
environment has been based on the
stereotypical needs of young fit adults. In the
past, when people with disabilities were
considered, research mainly focused on the
accessibility needs of people with physical
disabilities, particularlywheelchair users. The
1995 Disability Discrimination Act constituted
amajor step forward by defining disability as
encompassing physical, sensory and cognitive
impairments. Much research is required,
however, before the concept of ‘inclusive
design’ – designing places, buildings and
products that everyone, regardless of physical,
sensory or cognitive needs and capabilities,
can equally understand, use and enjoy –
becomes a reality.
The majority of people with dementia in
the UK live at home, around one third on their
own (Alzheimer’s Society, 2004b). Unless the
provision of dementia care facilities increases
greatly in the near future most will continue to
live at home until they reach the severe stage
of the illness. Research has shown that people
with dementia generally prefer to stay at home
for as long as possible and that they tend to
cope better with the physical and mental
effects of dementia in the familiar
surroundings of home and the local
neighbourhood (Goldsmith, 1996;
Baragwanath, 1997).
Design can help to provide a safe and
comfortable environment in which people with
dementia can maintain a good quality of life
and a sense of independence. Much attention
has recently been paid to the design of the
internal environment of care homes and
dementia care facilities. Early findings show
that small-scale, legible non-institutional
layouts with domestic-style furnishings and
fittings can help to reduce the level of
disorientation, confusion and distress of
residents (for a comprehensiveliterature
review of internal design for dementia
guidance see Mitchell et al,2003). In recent
years, smarthomes have been created with
electronic aids to alertacontrol centre if, for
example, the dweller falls or fails to turn off
the bath or gas tap (ASTRID, 2000). The
Gloucester Smart House goes a step further by
incorporating both internal dementia-friendly
guidelines and assistivetechnology to create a
calm, legible and safe home environment for
people with dementia (Dementia Voice, 2005).
Advances have, therefore, been made in
creating dementia-friendlyinternal
environments but unless people with dementia
are expected to stay indoors for the rest of
their lives, the outdoor environment – of
streets, spaces and places – also needs to be
dementia-friendly.Prior to this research project
little research existed on the design needs of
older people in the outdoor environment and
none on the requirements of people with
dementia.
Neighbourhoods for life
28 Quality in Ageing – Policy,practice and research Volume 7 Issue 1 March 2006 © Pavilion Publishing 2006
AIMS OF THE STUDY
The main aim of the research was to
investigate how to create dementia-friendly
neighbourhoods that enhance and extend the
active participation of older people with
dementia in their local communities. By doing
this the quality of life and well-being of both
people with dementia and their carers could be
improved. The objectives of the research were
as follows:
• to investigate how older people with
dementia interact with the outdoor
environment
• to investigate the nature and quality of their
experiences and understanding of the
outdoor environment
• to identify design factors that help older
people with dementia to use and enjoy the
outdoor environment
• to offer preliminary guidance (at all scales,
from urban design to the design of street
furniture) for designing dementia-friendly
outdoor environments.
THE STUDY SAMPLE
The researchers felt it was crucial to talk to
people with dementia themselves about their
feelings and experiences rather than relying on
the proxy views of professionals and carers.
Twenty older people, with a Mini-Mental State
Examination (MMSE) score showing that they
were in the mild or moderate stages of
dementia, were interviewed. Twenty-five older
people without dementia were also interviewed
as a control group. Participants were aged
sixty or over, ambulant, used the outdoor
environment and lived at home or in sheltered
accommodation in the towns and larger
villages of Oxfordshire and Berkshire. More
people with dementia were sought but
recruiting willing participants who met all the
criteria, especially the essential validation of
an MMSE score, proved to be extremely
problematic. This was despite the invaluable
help of the Oxford Project to Investigate
Memory and Ageing, Oxford University’s
Department of Old Age Psychiatry,the
Berkshire National Health Service Trust
Department of Old Age Psychiatry,
Oxfordshire Social Services, the Alzheimer’s
Society, Age Concern and Anchor Housing
Trust. Recruitment of people with dementia
appears to be a common problem in research.
In this case, it was mainly due to carers who
understandably felt the need to act as
protective ‘gatekeepers’. Many explained that
both they and the people they cared for were
struggling to cope with the challenges and
changes that dementia was inflicting on their
lives and they did not have the strength or
inclination to cope with anything else.
To ensure informed consent participants
and carers, where relevant, were provided in
advance with information leaflets specifically
written for people with dementia and for carers
and asked to sign a consent form. When
telephoning to make arrangements the
researchers asked participants and carers
whether they were still happy to take part and
reminded them that they were free to withdraw
at any time. This was repeated when the
researchers telephoned on the day to see if the
meeting time was still convenient, and again
on arrival at the participant’s home. The
research instruments were also designed to be
flexible enough to meet the individual
capabilities and anxiety levels of each
participant.
THE FIELDWORK
The fieldwork consisted of interviews,
accompanied walks and an environmental
assessment of each participant’
slocal
environment. Each method was guided by a
research instrument developed and informed
by a literature review and focus groups of day
centre clients, and tested and validated in pilot
interviews.
Interviews
Participants were asked about their interaction
with the outdoor environment and their
experiences and feelings about their local
neighbourhood in semi-structured
conversational interviews, guided by a
questionnaire. Aided by a book of photographs
they were also asked to identify environmental
features, such as street layouts, architectural
features and street furniture that help or hinder
their understanding, enjoyment and use of their
local neighbourhood. Carers were interviewed
Neighbourhoods for life
Quality in Ageing – Policy,practice and research Volume 7 Issue 1 March 2006 © Pavilion Publishing 2006 29
atthe same time in a separate room so that
background information, such as the length of
time they had resided in their current home,
could be clarified and also to prevent them
from influencing the answers of the
participants.
Accompanied walks
Anumber of participants with and without
dementia were accompanied on short walks
from home to a destination of their choice. An
observation schedule was used to record their
reactions to the outside environment,
wayfinding techniques and the environmental
features that appeared to help or hinder them.
One researcher walked with the participant to
ask questions relating to their strategies and
reactions. A second researcher followed behind
to map the route taken and to record the
environmental features used by the participant.
To make the walks as natural as possible and
to help the participant feel confident and at
ease the questions were inserted into casual
conversation about the local area. Most
participants appeared to quicklyforget that
they were being recorded and observed.
Environmental assessment
The home street and route taken on the
accompanied walks were also measured and
evaluated using a checklist of environmental
characteristics. Features recorded included:
• location, land use, density and built form
• street pattern, use and hierarchy
• pedestrian/traffic segregation, number/type
of road junctions
• permeability, legibility and accessibility
(level of ease with which pedestrians can
move around, find their way around and
enter the streets, spaces and places).
FINDINGS
How older people with dementia
interact with the outdoor
environment
Most of the participants with dementia and all
of those without dementia went out alone, over
half in each group daily. All went shopping
and about half also regularly visited the local
post office, park or took walks around their
local neighbourhood. Participants with
dementia tended to avoid socially demanding
situations, such as visiting friends or attending
church, preferring less challenging activities
such as going to the corner shop or posting a
letter.
None of the participants with dementia
now drove or used public transport
unaccompanied so their choice of destination
was restricted to within walking distance of
home. Participants with dementia were also
significantly less likely than those without
dementia to visit more than one place in a
single trip. They were, therefore, far more
physically restricted in their independent use
of the outdoor environment than those without
dementia.
The nature and quality of
experiences of older people with
dementia in the outdoor
environment
Just as most participants with dementia tried to
avoid socially exigent situations they also
often felt intimidated in formal places, such as
historic public squares with imposing
architecture, and open spaces such as botanical
or historic gardens. This was in direct contrast
to the participants without dementia who
generallypreferred the more formal settings.
Similarly, rather than choosing the quiet
retreats chosen by those without dementia,
participants with dementia tended to prefer
vibrant spaces full of activity, such as urban
squares surrounded by shops, offices and cafes
and parks providing a range of facilities such
as a children’s playground, tennis courts,
boating lake and so on. For people fearful that
theyare losing the ability to always understand
what is expected of them in particular
environments the more informal, lively, mixed-
use settings were seen as more welcoming and
safe than the sometimes forbidding formal
spaces. Theyalso provided the interest and
environmental cues theyneed to find their way
around.
When interviewed, participants without
dementia talked about a number of physical
barriers that they faced when they went out,
Neighbourhoods for life
30 Quality in Ageing – Policy,practice and research Volume 7 Issue 1 March 2006 © Pavilion Publishing 2006
including uneven paving, poor seating,
bicycles on footways and steep inclines. They
also discussed social and psychological
problems, such as the closure of local shops,
poor bus services and the fear of attack or of
getting lost. In comparison, participants with
dementia were far less likely to say that they
faced any problems when they were out and
those who did focused on their own physical
ailments, such as poor eyesight or an unsteady
gait. However, during the accompanied walks
it became clear that people with dementia face
similar problems to those described by
participants without dementia but are less
aware of them as they walk along.
Participants described many different
emotions about using the outdoor environment,
from feeling happy or comfortable to boredom
or anxiety. The majority, both with and without
dementia, said that they enjoy going out,
although many are anxious about being out
after dark or in unfamiliar places. Comments
such as ‘I rejoice’, ‘I always feel better for
getting out and getting a bit of fresh air’ and ‘I
get claustrophobic if I don’t go out’ show the
positive effects that being outside can have on
well-being. Remarks such as ‘the world
belongs to me for that time’ and ‘I feel in
charge of myself’ demonstrate how being able
to successfullynegotiate and use the outdoor
environment can enhance a sense of self-worth
and independence. This enjoyment was
generally evident during the accompanied
walks. None of the participants without
dementia showed signs of anxiety, confusion
or fear. However, around half of those with
dementia seemed temporarily anxious or
confused when they were unsure of the route
or distracted by sudden noises.
How older people with dementia
understand the outdoor
environment
When interviewed, fewer people with dementia
said that they sometimes lose their way than
those without dementia. Common responses
such as ‘I’m just used to the area – I’ve got to
knowit and I goto the same places moreor
less each time’ and ‘I just know where I’m
going – I’ve lived here all my life’ demonstrate
areliance on familiar, regularly used routes.
Those who did refer to losing their way talked
about the shock of discovering that they no
longer knew where they were; as one
participant with dementia said ‘It was
extremely spooky to me – my hair went on end
because I was actually lost’.
Carers confirmed that a higher number of
participants with dementia sometimes got lost
than those who talked about losing the way
when interviewed. On the accompanied walks,
although none of the participants without
dementia lost the way, one third of those with
dementia did. Again, familiarity and regular
use was mentioned by many participants.
Those who lost their way all lived in
neighbourhoods with complex street layouts
and few connecting streets, such as areas with
anumber of cul-de-sacs. Some lost their way
at road junctions or when trying to follow a
less familiar route. Others lost their way when
they lost concentration. Participants with
dementia were often startled by sudden noises,
such as people shouting, heavy vehicles
passing by or emergency vehicle sirens, which
left them disoriented and confused. With
gentle encouragement and reassurance all but
one were quickly able to recover their
equilibrium but may possibly not havebeen
able to do so had they been on their own.
People with dementia often struggle to
interpret the cues that signal the use of
buildings, the location of entrances, the
behaviour that is expected of them or the
intentions of people around them. The
important role that familiarity and regularity of
use playin helping people with dementia to
understand the outdoor environment has
already been mentioned. The participants with
dementia were able to understand places,
streets, buildings and features that were in
designs recognisable to older people. This does
not necessarilymean that dementia-friendly
outdoor environments should be traditional in
design. Clarity of use and function appeared to
be the overriding positive factor rather than
style, whether traditional or modern.
Design factors that help older
people with dementia use and
enjoy their local neighbourhoods
Most participants preferred mixed use,
compact local neighbourhoods with
welcoming open spaces and a variety of
Neighbourhoods for life
Quality in Ageing – Policy,practice and research Volume 7 Issue 1 March 2006 © Pavilion Publishing 2006 31
historic and civic buildings, distinctive
structures and places of activity. They also
tended to find simple, well-connected street
layouts with uncomplicated road junctions the
easiest to use and understand. Short, narrow
and gently winding streets were generally
considered more interesting than long, wide or
straight streets and therefore helpful in
maintaining the concentration people with
dementia need to avoid losing the way. The
opening up of views while walking along
winding streets and being able to see the end
of short streets also had a positive effect on
wayfinding.
Most participants preferred the familiarity
of long established places and buildings, where
any change was small scale and incremental.
Participants with dementia were more likely to
state in the interviews that they do not use
wayfinding techniques as the local
neighbourhood is so familiar to them.
However, on the accompanied walks, they
regularly looked for landmarks and other
environmental features to help them to clarify
their location and route. There were four types
of commonlyused landmarks:
• historic or civic edifices, such as war
memorials, churches and town halls
• distinctive structures, such as clock and
water towers and public art
• places of activity, including mixed-use
squares, parks and playgrounds
• places or buildings of personal
significance, such as a previous workplace,
general practitioner’s surgery, favourite
public house and so on.
Streets with a variety of building styles,
shapes, colours and sizes were seen as more
interesting to walk along and,therefore,
helpful for maintaining concentration.
Different architectural features, such as
varying roof tiles, chimney pots, front doors,
windows and gardens were also useful
wayfinding cues. In addition to architectural
features, two further groups of latent cues
along the street were often used, especially
when located at decision points and where
visual access ended,such as junctions and
corners:
• aesthetic features, including green areas,
trees, flower tubs and hanging baskets
• practical features, such as street furniture,
including telephone and letter boxes, public
seating and bus shelters.
These landmarks and environmental features
had four things in common: they were
noticeable and interesting, in a variety of form
and styles, in designs familiar or easily
understood by older people and were
remembered if regularly encountered.
Too much visual stimuli however, such as a
clutter of street furniture and signage, had a
negative effect causing confusion and a lack of
concentration. Simple, plain signs with large,
dark lettering on a light background were the
easiest to read and to understand. The post
office sign, which is a well-established and
familiar sight, was recognised by everyone.
Positioned perpendicular to the wall they are
also useful wayfinding cues as they can be
viewed from a distance. The post office
red/orange colour scheme is also more visually
accessible for the many older people who
experience colour agnosia, a condition where it
is difficult to distinguish colours. While
colours on the blue–green spectrum are the
hardest for people with colour agnosia to
distinguish, they tend to retain some ability to
differentiate those on the red–orange spectrum.
Signs full of information appeared to be too
complicated and confusing and those with
multiple pointers too ambiguous. Advertising
boards and a-frames were also of little
practical use but often quite hazardous to
walking along. Participants with dementia only
recognised symbols, such as those painted on
bicycle tracks, when they were very realistic
and regularly encountered.
Although physically active, many of our
participants were frail with reduced mobility
or the unsteady gait often experienced by
people with dementia, so walking to facilities
and services further than 500 metres from their
home was difficult. Changes in level were also
problematic so flat footways, wide enough to
pass oncoming pedestrians without being
jostled, were preferred. Where level changes
existed, being able to choose between steps or
aramp was appreciated and handrails
considered essential. Bus shelters and seating
at regular intervals along the street and a
ground level public toilet close to the shops
were also important for enabling participants
to continue to be able to use the local
Neighbourhoods for life
32 Quality in Ageing – Policy,practice and research Volume 7 Issue 1 March 2006 © Pavilion Publishing 2006
neighbourhood. Controlled crossings, such as
the pelican crossing, were considered the
safest means of crossing the road although it
was often difficult for them to hear the aural
signal or to cross in the time allowed.
In summary, our findings show that there
are six major requirements for outdoor
environments to be dementia friendly: they
should be familiar, legible, distinctive,
accessible, comfortable and safe. Preliminary
design recommendations for meeting these
requirements have been presented in a
findings leaflet: Neighbourhoods for Life:
designing dementia-friendly outdoor
environments,written for urban designers,
planners, architects, access officers and
highway engineers in both local government
and private practices. A similar leaflet,
Neighbourhoods for Life: a checklist of
recommendations for designing dementia-
friendly outdoor environments,was
commissioned bythe Housing Corporation
specifically for housing associations. Both
leaflets, which include a checklist of design
recommendations, can be obtained free from
the authors.
CONCLUSIONS
This is preliminaryresearch in an area that, to
date, has been neglected. Environments that
are easy for older people with dementia to
access, understand,use and enjoy would
contribute to a good quality of life in their own
homes and communities at least during the
mild to moderate stages of the illness. As the
findings were based on a relatively small
sample of older people with dementia, further
research was considered beneficial to improve
representativeness and to ensure that the
design suggestions do not conflict with the
needs of people with other impairments, such
as wheelchair users or those with visual
impairments.
In July 2004 the Oxford Centre for
Sustainable Development achieved Institute
status and the authors established a new
research unit called Wellbeing in Sustainable
Environments (WISE). OISD: WISE is
dedicated to research into how the built
environment (at all scales from buildings to
whole cities) affects people’s well-being,
health and quality of life. Building on the
research discussed in this paper OISD: WISE
is a member of the Inclusive Design for
Getting Outdoors (I’DGO) Consortium.
I’DGO is a three year project, also funded by
EPSRC EQUAL, investigating ways in which
the design of the outdoor environment affects
the quality of life of all older people. This is in
collaboration with OPENspace, a research
centre for inclusive access to outdoor
environments at Edinburgh College of
Art/Heriot-Watt University, and SURFACE, an
inclusive design research centre at the
University of Salford. In addition, there are
four non-academic consortium partners: the
Housing Corporation, Sensory Trust, Research
Institute for Consumer Affairs (RICAbility)
and Dementia Voice, and 12 collaborators
from central and local government,
professional design companies and support
groups representing the practitioner and users’
perspectives.
By holding a number of focus groups,
sending postal surveys to 300 older people and
interviewing 200 other older people a good
representative sample will be achieved
encompassing a broad spectrum of physical,
sensoryand mental needs and abilities. The
main outputs of the I’DGO project will be a
list of quality of life criteria for older people in
relation to outdoor environments and guidance
on designing outdoor environments that
enhance older people’s quality of life. These
will build on the preliminary recommendations
for designing dementia-friendlyoutdoor
environments to achieve inclusive outdoor
environments.
Regardless of increasing age and
diminishing capabilities, older people have the
right to a safe, dignified and healthy living
environment where theyare treated as equals.
Inclusiveurban design that incorporates the
recommendations of these projects has the
potential to provide ‘neighbourhoods for life’,
in other words, neighbourhoods where people
can enjoy a good quality of life throughout
their life-span. As a participant with dementia
declared during his accompanied walk, ‘I’m
still living,still living!’
Neighbourhoods for life
Quality in Ageing – Policy,practice and research Volume 7 Issue 1 March 2006 © Pavilion Publishing 2006 33
Address for correspondence
Lynne Mitchell
OISD: WISE
Department of Architecture
School of the Built Environment
Oxford Brookes University
Headington Campus
Gipsy Lane
Oxford OX3 0BP
Tel: 01865 484296
Email: lmitchell@brookes.ac.uk
Web: www.brookes.ac.uk/schools/be/oisd/sue/
wise/index.html
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