Making the outside World Dementia-Friendly: Design Issues and Considerations

Abstract

Design guidelines for dementia care homes have, in recent years, acknowledged the important role the internal environment plays in influencing the functional capabilities and emotional well-being of people with dementia. However, although the majority of people with dementia live in the community, similar guidance does not exist in relation to the outdoor environment. To identify aspects of design that should be considered in making the outside world dementia-friendly an analysis of the literature on the needs of older people with dementia and on current knowledge of best practice for internal environments was carried out. By drawing parallels with the outside environment this paper demonstrates that design solutions do potentially exist which would enable older people with dementia to continue to negotiate and use their local neighbourhoods. Familiarity, legibility, distinctiveness, accessibility, comfort, and safety all appear to have a major influence. Small street blocks with direct, connected routes and good visual access, varied urban form, and architectural features, and distinctive, unambiguous environmental cues could enhance successful orientation and wayfinding. Services and facilities within walking distance with adequate seating, lighting, shelter, and well-maintained, smooth, level, plain paving would ameliorate attending problems of physical frailty. The authors are now empirically testing these initial findings.

Full text

1 Background
The number of people over the age of 65 years in the United Kingdom is predicted to
increase to around 12 million by 2021 and nearly 16 million by 2041 (Government
Statistical Service, 1999; Russell, 1999). The ageing of the population has major
design implications, as the ability to access, negotiate, and utilise the outside
environment is essential for the successful performance of activities of daily living.
Traditionally, design of the urban environment has focused on the needs of a much
younger demographic group with little attention, above the basic legal minimum,
paid to the requirements of people who do not fit into the average stereotype.
Research into designing the built environment to meet the needs of people with
disabilities has, hitherto, concentrated mainly on the accessibility requirements of the
physically disabled, particularly wheelchair users, with a focus on the disability rather
than on environmental barriers and social attitudes. The literature suggests that this
has been relatively unsuccessful: wheelchair accessibility is still not universal, the vast
ranges of age and ability of wheelchair users are frequently ignored, and fixtures and
fittings are still often designed to meet the universal standard of the average white male
Making the outside world dementia-friendly: design issues
and considerations
Lynne Mitchell, Elizabeth Burton, Shibu Raman
Oxford Centre for Sustainable Development, School of the Built Environment, Oxford
Brookes University, Gipsy Lane Campus, Headington, Oxford OX3 0BP, England;
e-mail: lmitchell@brookes.ac.uk,ejburton@brookes.ac.uk,skraman@brookes.ac.uk
Tim Blackman
Department of Social Sciences and the Law, University of Teesside, Middlesbrough TS1 3BA,
England; e-mail: t.j.blackman@tees.ac.uk
Mike Jenks, Katie Williams
Oxford Centre for Sustainable Development, School of the Built Environment, Oxford
Brookes University, Gipsy Lane Campus, Headington, Oxford OX3 0BP, England;
e-mail: mjenks@brookes.ac.uk,kwilliams@brookes.ac.uk
Received 5 November 2002; in revised form 14 February 2003
Environment and Planning B: Planning and Design 2003, volume 30, pages 605 ^ 632
Abstract. Design guidelines for dementia care homes have, in recent years, acknowledged the
important role the internal environment plays in influencing the functional capabilities and
emotional well-being of people with dementia. However, although the majority of people with
dementia live in the community, similar guidance does not exist in relation to the outdoor environ-
ment. To identify aspects of design that should be considered in making the outside world
dementia-friendly an analysis of the literature on the needs of older people with dementia and on
current knowledge of best practice for internal environments was carried out. By drawing parallels
with the outside environment this paper demonstrates that design solutions do potentially exist
which would enable older people with dementia to continue to negotiate and use their local
neighbourhoods. Familiarity, legibility, distinctiveness, accessibility, comfort, and safety all appear
to have a major influence. Small street blocks with direct, connected routes and good visual access,
varied urban form, and architectural features, and distinctive, unambiguous environmental cues
could enhance successful orientation and wayfinding. Services and facilities within walking distance
with adequate seating, lighting, shelter, and well-maintained, smooth, level, plain paving would
ameliorate attending problems of physical frailty. The authors are now empirically testing these
initial findings.
DOI:10.106 8/ b2 9100

and the developer's profit margin (Imrie and Kumar, 1998; Manley, 1998). This is
evidenced by the reluctance of many property owners to meet the accessibility regula-
tions stipulated in the Disability Discrimination Act 1995 before the deadline of
October 2004 (Imrie and Kumar, 1998). Until the rights of all users with their diverse
range of needs are addressed, disabilities of any kind or scale will continue to be
perceived by many as an abnormal, irrelevant, and constraining design issue (Imrie,
2000; Manley, 1998). As Hall and Imrie (1999, page 424) state:
``The design and development of buildings and the built environment have the
capacity to facilitate or to hinder people's movement and mobility, and particular
designs ... are infused with powers of demarcation and exclusion.''
Physical accessibility is only one aspect of an inclusive environment. To focus on
physical disabilities alone is to ignore the disabling effects of the built environment
on people with cognitive impairment despite the definition of disability by the
Disability Discrimination Act 1995 as a physical, sensory, or mental condition. All
three conditions are affected by the ageing process and, while not necessarily becoming
severe enough to be declared a disability, will affect the ability of many older people to
function successfully in the outside world. Rather than building segregated environ-
ments for those struggling to live independently there is a growing conviction that the
outdoor environment should be designed to meet the needs of all generations and
dis/abilities (Greenberg, 1982; Laws, 1994). As Lavery et al (1996, page 189) note, this
will not be an easy task:
``Designers must be aware of the fact that designing for the `average' person is a
thing of the past. The challenge of designing the `Friendly Street' is a formidable
one. The end product must not present a hazard to anyone: young or old, fit or
frail.''
It may be thanks to this `formidable challenge' that research on designing the outside
environment to meet the needs of older people is scarce compared with that for
younger people with physical disabilities and nonexistent for people with dementia. It
is probable, however, that this failure is also a result of the perceived low status of
older people in our society and a misconception that those with dementia do not
venture outside (Goldsmith, 1996; Laws, 1994). This may account for the fact that
recent design guidelines acknowledge the influential role of the environment on the
quality of life of older people with dementia in segregated indoor settings but not in
the outside environment.
The overall aim of this paper is to identify the needs of older people with dementia
when using the outdoor environment, and to suggest aspects of design that should
be considered in making it dementia-friendly. The research on which the paper is
based was a preliminary study for an on-going three-year, EPSRC-funded project
(http://www.brookes.ac.uk/schools/arch/dementia/index.html). This was an innovative
piece of work that addressed, for the first time, dementia-friendly design from the
perspective of the outdoor environment. An extensive review of literature and existing
research was undertaken to inform the development of the methodology and research
instruments used in the main project fieldwork. The paper begins with examination of
the importance of creating dementia-friendly outdoor environments. Then we review
existing design-for-dementia literature to examine the focus of the design guides and
their limitations with respect to the design of the outdoor environment (table 1).
Finally, a synthesis of the advice provided by these internal design guides is presented
in table 2. By drawing parallels between internal and outdoor environments, we iden-
tify aspects and features of urban form that may be influential in the ability of older
people with dementia to use and enjoy the outdoor environment.
606 L Mitchell, E Burton, S Raman, and coworkers

2 The importance of dementia-friendly outdoor environments
Although not necessarily part of the normal ageing process, the prevalence of dementia
is expected to escalate progressively in the future because of the population's increasing
longevity and the greater likelihood of developing dementia as one ages (Goldsmith,
1996; Perrin and May, 2000). There are currently about 750 000 people with dementia in
the United Kingdom, a figure that is predicted to rise to around 900 000 by 2021 and
over 1.2 million by 2040 (Alzheimer's Society, 2000; Cream, 1998; Keady, 1996).
Although only one person in fifty will have dementia between the ages of 65 and 70
years, the likelihood of having dementia increases dramatically to one in five over the
age of 80 years (Alzheimer's Society, 2000).
Dementia is not a disease in itself but rather a set of symptoms caused by a number
of illnesses, with Alzheimer's disease being the most common form.Vascular dementia,
Lewy body disease, Pick's disease, and frontal lobe dementia are among the other more
common types (Alzheimer's Society, 2000). Although arising from different causes,
which create a variety of cognitive limitations and personality changes, ``for design,
the differences are not as important as the similarities'' (Calkins, 1988, page 4). As yet
incurable and irreversible, dementia does not result in a sudden global diminution of
abilities and memory but rather a gradual and incremental loss over many years.
As the dementia progresses through the mild to moderate stages, people experi-
ence a number of interrelated impairments that reduce the ability to cope with
current environmental barriers. For the majority, major symptoms will be related
to cognitive changes including spatial disorientation and short-term memory loss
which, in turn, lead to confusion, agitation, and anxiety (Alzheimer's Association,
2000; Dementia Services Development Centre, 1995; McGowin, 1993). Recent
advances in medications to reduce the severity of the symptoms of dementia now
enable some people to retain relatively `normal' functions for a longer period of time
although eventual and incapacitating decline is inevitable (Alzheimer's Society, 2001).
As the number of people with dementia increases, the provision of appropriate
residential care environments may fall far short of demand. Current government policy
in the United Kingdom aims to provide for the needs of older people primarily through
domiciliary care and has placed the provision of residential care in the hands of the private
sector. Over the past few years, the number of residential care homes for older people that
have closed down has greatly exceeded the number of new homes that have been
established. In 2001 alone, 827 private and voluntary care homes closed with a loss of
16 600 places, yet only 117 new homes opened with the combined ability to care for a
maximum of 3800 people (Laing and Buisson, 2002). Therefore, it is essential to focus on
the design of private housing and its local environment to enable older people to remain
successfully in situ for as long as is possible. As Burley and Pollock (1992, page 2) reflect:
``... we can expect that during the next decade about four out of five people with
dementia will continue to be living at home. This being the case should we not be
doing far more to organise and plan the house and its environment to be more
comprehensible to people who suffer from disorientation?''
Even when it is available, the majority of older people with dementia prefer not to
move into a residential care setting until absolutely necessary (Fogel, 1992; Goldsmith,
1996). Around 80% of people with dementia currently live at home, roughly a third of
whom have severe dementia, and about a quarter live alone (Audit Commission, 2000;
Dementia Services Development Centre, 1995). Research demonstrates that, as people
age, remaining in a familiar home and neighbourhood becomes increasingly important
(Axia et al, 1991; Greenberg, 1982; Laws, 1994). This is particularly the case for those
with dementia, as removing them from a familiar environment tends to compound their
confusion and further reduce their ability to cope (Burley and Pollock, 1992; Fogel, 1992;
Making the outside world dementia-friendly 607

Goldsmith, 1996). For example, Baragwanath (1997) discovered that people with
dementia are more likely to injure themselves in unfamiliar environments, such as
respite homes or hospitals, because of the increased anxiety and disorientation caused
by having to cope with unfamiliar places, people, and objects. Conversely, a familiar
environment presents a predictable and reliable setting that is less likely to create
stressful new situations that a person with dementia is unable to understand or contend
with (Calkins, 1988; Golant, 1984). Regardless of the inherent difficulties, living at
home with adequate services and support allows people with dementia to maintain
some sense of autonomy and privacy in a familiar setting which may be ``the one
constant in an emotional world threatened by losses'' (Fogel, 1992, page 16).
The recent innovation of `Smart Homes', equipped with `assistive technology', such
as gas, fire, and fall detectors, now provides the opportunity for a safer home environ-
ment for people with dementia (ASTRID, 2000; Adlam, 2001). Yet similar advances do
not exist in relation to the outdoor environment, apart from some embryonic research
into the use of electronic tracking devices using radio transmitters or global positioning
satellite technology (Levine, 2001; McShane et al, 1998). During the mild to moderate
stages of dementia, people generally retain the ability to cope independently, although
assistance is increasingly required over time until, in the severe stage, continual
support is usually necessary (Alzheimer's Association, 2000; Kitwood, 1997; Twining,
1991). Thus, as capabilities decline and frailty increases, people experience a growing
restriction of independence and lifestyle. This is sometimes self-inflicted but is often
imposed by others who fear that the person with dementia may come to harm if
`allowed' to act autonomously. The resulting sense of social isolation, low self-esteem,
and loss of control over one's own life can be debilitating (Cotrell and Schulz, 1993;
Norman, 1987). Thus, the physical, psychological, and social benefits of continued
functional activity within the local community, whether regular lengthy visits or simply
an occasional trip to the local newsagent or a walk around the block, are considerable.
As Robson (1982, page 265) explains:
``Even if it [going outdoors] is only routine activity, it may be vital for their quality of
life, and even for them to maintain any independence and self-respect.''
Facilitating their ability to access the outside world for as long as is possible will not
only help to ameliorate overwhelming social and psychological impacts but will also
reduce the burden of those caring for older people with dementia (Fogel, 1992; Golant,
1984; Norman, 1987). This may necessitate a certain degree of risk taking but, as
Clarke and Heyman (1998, page 228) state:
``A risk-management strategy which might be dismissed, at first glance, as rash,
makes sense when put in the context of attempts to preserve life quality, and to
lead as normal a life as possible, in the face of serious health problems.''
The ability to lead a `normal' life is, however, restricted by the incapacity of the
environment to accommodate changing needs, such as cognitive or sensory impair-
ment, reduced perception, increased reaction times, poor mobility, or reduced strength
and stamina (AIA, 1985; Skelton, 1982). Many studies have found that, faced with an
inflexible environment, older people tend to lower their expectations and desires by
restricting their activities to destinations within walking distance, regardless of the
availability or suitability of local services and facilities (see, for example, Peace, 1982;
Robson, 1982). Greenberg (1982, page 405) also finds that:
``Age does not obviate the desire or necessity to go shopping, see the doctor, visit
friends, and undertake other everyday activities but it may alter the method and
frequency with which they are done.''
The majority of older people today will have been car owners. At the very time when
the physical effects of the ageing process can make walking and using public transport
608 L Mitchell, E Burton, S Raman, and coworkers

onerous, impaired sensory perception, increased reaction times, and, for those with
dementia, cognitive impairment can eventually necessitate the cessation of driving
(Greenberg, 1982; Skelton, 1982). Studies have found that older car users make around
25% more journeys than older people without access to a car. This suggests that
the latter do not stay at home through choice but because of the problems they
encounter as pedestrians in the outdoor environment (Greenberg, 1982). As Lavery
et al (1996, page 183) note, ``It is no exaggeration to say that the `average street' can be a
very unfriendly place for older people'' with many barriers such as uneven or steep
footpaths, inadequate lighting, inaccessible bus stops, or insufficient seating or shelter.
Ongoing research by the authors has found that, despite the many restrictions, a
significant number of older people with dementia do venture out of doors on their
own, whether through choice or necessity. A diminution of capabilities, at least in the
mild to moderate stages, should not prevent them from getting out and about and from
performing basic activities of daily life. Many more would be able to do so if the
outside environment were more accommodating to their particular needs (Gant,
1997a; Imrie and Kumar, 1998; Twining, 1991). As the American Institute of Architects
(AIA, 1985, page 7) states:
``Design can do a great deal to diminish that sense of disorientation and vulnerability
by providing the appropriate forms of physical support and behavioural cues.''
3 Design-for-dementia literature
Having established the importance of improving the design of the outdoor environment
for people with dementia, in this section we review the current design-for-dementia
literature shown in table 1 (see over). The design guidelines were selected through library
and Internet searches, publication lists, and expert advice from organisations including
the Stirling Dementia Services Development Centre, the Oxford Dementia Centre,
and the Alzheimer's Society. Design guides were selected that focus entirely, or have
a substantial section, on the particular design needs of people with dementia. Design
guides addressing physical impairments, such as visual or hearing loss, have not been
included for, although many people with dementia also experience physical impair-
ments, such guidance does not take into account the additional impact of cognitive
impairment.
This is not an exhaustive study because of the unavailability of some publications,
but provides a clear picture of the types and patterns of focus of existing guides. The
first two columns of table 1 show the author, year, and title. The third column gives
the type of publication, such as book, journal article, or research report and lists the
main aim of the publication, such as to provide overall design advice for dementia care
facilities or to address specific needs (for example, wayfinding or accident prevention).
The fourth column provides some general information on the content and focus of
each publication followed, in the fifth column, by a reference to whether design of the
care homes' grounds and gardens is addressed. The final column demonstrates whether
advice is also given on the design of the public outdoor environment beyond the
boundaries of the dementia care facilities.
All but two of the publications focus on the design of institutional settings rather
than private homes, apart from one that refers to both. Just over a third are research
based. The majority are books giving guidance on the design-of-dementia care homes.
There are also a number of design-for-dementia chapters from books that cover
the design of residential homes for older people in general and a chapter from an
inclusive design book. The other publications are mainly journal articles that either
present an overview of general design principles or have a specific focus, usually
wayfinding.
Making the outside world dementia-friendly 609

610 L Mitchell, E Burton, S Raman, and coworkers n:/pdf-prep/
Table 1. Review of design for dementia literature.
Author(s) Title Type Content Design of on-site Design of off-site
outdoor areas outdoor environment
AIA (1985) Design for
Aging: An
Architect's
Guide
Design guide for
residential care
settings for older
people, including
those with dementia.
Three sections:
1. Aging and the environment
ö
physical,
psychological, and social needs of older
people.
2. Facility types
ö
different design
requirements for a variety of specialised
housing facilities from low-dependency
sheltered housing through to high-
dependency nursing homes.
3. A design for aging glossary
ö
detailed
reference list of design advice to meet the
needs of older people. Covers range of
aspects from site analysis to de
¨cor, fixtures,
and fittings.
Design of gardens,
patios, footpaths,
and parking areas.
No, although
stresses importance
of locating
facilities in local
neighbourhoods
near shops and
services.
Bell (1992) Pink Doors and
Door Knockers
Design guide based
on observational
findings by staff in
five dementia care
units and a day
hospital.
Recommendations on the design of doors and
door furniture, including materials, colours,
signs, and fixtures, to improve wayfinding and
orientation.
No No
Brawley
(1997)
Designing for
Alzheimer's
Disease:
Strategies for
Creating Better
Care
Environments
Design guide for
residential care
settings for people
with Alzheimer's
disease.
Five sections:
1. Aging and Alzheimer's disease
ö
the nature
and effects of Alzheimer's disease, and
the objectives of design for dementia.
2. Sensory environment
ö
the use of lighting,
acoustics, colour, de
¨cor, and materials.
3. Special care settings
ö
creating familiar and
therapeutic environments.
4. Implementing effective interior design
ö
furniture, fixtures, fitting, fabrics, and de
¨cor.
5. The design process
ö
a step-by-step guide to
designing a dementia care home.
Section 3 includes
a chapter on the
design of
therapeutic
gardens and
outdoor areas,
covering issues
such as comfort,
safety, legibility,
and stimulation.
No

Making the outside world dementia-friendly 611
Brawley
(2001)
``Environmental
design for
Alzheimer's
disease: a
quality of life
issue''
Journal article on
the benefits of
design for people
with Alzheimer's
disease.
Focuses on environmental aids to mobility,
particularly those provided by appropriate levels
and types of artificial and natural lighting.
No, although
refers to
therapeutic effects
of gardens and
outdoor spaces.
No
Calkins
(1988)
Design for
Dementia:
Plan ning
Environments
for the Elderly
and the
Confused
Design guide for
residential care
settings for older
people with
dementia.
Two sections:
1. Understanding the problem
ö
information on
dementia and how it affects people physically,
mentally, and behaviourally.
2. Designing the solution
ö
design issues, including
lighting, wayfinding cues, and the use of
colours and materials.
No No
Carstens
(1985)
Site Planning
and Design for
the Elderly:
Issues,
Guidelines and
Alternatives
Design guide for
outdoor areas of
residential facilities
for older people.
Four sections:
1. Defining the issues
ö
effects of ageing,
including cognitive impairment, types of
facility, design needs of older p eople.
2. Site planning and design
ö
location of facilities,
building configuration and content, examples
of types of facility, detailed road, parking, and
exit/entry specifications.
3. Designing for outdoor use
ö
design of gardens
and other outdoor recreational areas;
examples from existing facilities.
4. Summary and conclusion
ö
reference tables
listing design needs and recommendations
from size of building and development
patterns to seating and drinking fountains.
Yes, see previous
column.
No, although
stresses importance
of locating
facilities in well-
established
neighbourhoods to
enable access to
local services and
facilities,
community
involvement, and
visual stimulation.
Charness
and Holley
(2001)
``Human factors
and environ-
mental support
in Alzheimer's
disease''
Journal article
reviewing design
guidance for private
housing and
residential care
settings for people
with Alzheimer's
disease.
Reviews design literature aimed at ameliorating
the effects of memory problems. Stresses
importance of further research from the user
perspective of residents, relatives, and staff.
No No

612 L Mitchell, E Burton, S Raman, and coworkers
Table 1 (continued).
Author(s) Title Type Content Design of on-site Design of off-site
outdoor areas outdoor environment
Day et al
(2000)
``The
therapeutic
design of
environments
for people with
dementia: a
review of the
empirical
literature''
Journal article
reviewing design
guidance for
residential care
settings for people
with dementia.
Describes different types of dementia care
facilities, presents an extensive table of key
information from the research reports, and gives
a synopsis of findings on the form and layout of
facilities, the design of individual rooms and
spaces, and the sensory and safety needs of
residents.
No, although
comments on
benefits of
providing access
to outdoor areas.
No
Glasgow
(1999)
``Just another
disability:
making design
dementia
friendly''
Research-based
information pack
advising on good
practice in design
for people with
dementia at home
and in residential
care settings.
Four sections:
1. Explaining the project
2. Making design dementia friendly
ö
the needs of
people with dementia and the design aims,
principles, and features.
3. Different living situations
ö
design advice for
private homes, residential homes, and
dementia care facilities.
4. Design in detail: taking a closer look
ö
behavioural, orientation, and wayfinding cues,
and links to relevant organisations and
publications.
Section 2 includes
design advice to
ensure gardens are
familiar,
interesting,
comfortable,
and safe.
No
Goldsmith
(1996)
Hearing the
Voice of People
with Dementia:
Opportunities
and Obstacles
Research-based
book for carers
of people with
dementia
Includes a chapter on how the internal
environment can affect communication, including
the layout of facilities, the problems of noise, and
the use of light and colour.
No, but stresses
the importance of
access to gardens,
experiencing
weather, and
passing seasons.
No

Making the outside world dementia-friendly 613
Harrington
(1993)
``Perception and
physiological
psychology in
designing for
older people
with cognitive
and affective
disorders''
Conference paper
giving design
recommendations to
improve the safety
and comfort of older
people.
Includes effects on the physical and cognitive
abilities of older people of particular
environmental features, such as flooring, stairs,
lighting, signage, and the use of textures and
colours.
No No, although notes
dangers of older
people becoming
unsteady or
confused in crowds
or heavy traffic.
Judd et al
(1998 )
Design for
Dementia
Design guide
providing synopsis
of design for
dementia principles
illustrated by twenty
examples of best
practice.
Presents the needs of people with dementia, a
synopsis of the main design for dementia
principles, and a more detailed design checklist.
Also provides twenty examples of best practice
worldwide and two matrices of design details.
Design of gardens
and outdoor
activity areas and
therapeutic
benefits of
accessible, well-
designed, safe
outdoor areas.
No, although
stresses impor-
tance of locating
facility within
established
community, close
to local services
and facilities. Also,
importance of
external features of
the facility
blending in with
surrounding
properties to lessen
institutional image.
Kuller
(1991)
``Familiar
design helps
dementia
patients cope''
Research-based
Chapter in Design
Intervention: Toward
a More Humane
Architecture
Presents comparative research on an institutional
group home for people with dementia and one
newly designed in a domestic style.
No No

614 L Mitchell, E Burton, S Raman, and coworkers
Table 1 (continued).
Author(s) Title Type Content Design of on-site Design of off-site
outdoor areas outdoor environment
Marshall
et al (1999)
Just Another
Disability:
Making Design
Dementia
Friendly: Tools
for the Future
A strategic brief and
audit tool to guide
and test the design
of care homes for
people with
dementia. Part of
the Glasgow 1999
research project.
Three sections:
1. Introduction
ö
the needs of people with
dementia.
2. Strategic brief
ö
principles and features to be
considered when designing homes for people
with dementia.
3. Audit tool
ö
design checklist for testing the
quality of home environments for people with
dementia from the user's perspective.
Design advice to
ensure gardens are
familiar,
interesting,
comfortable, and
safe.
Recommendations
for location of
facilities and
choice of site. Also
design advice on
external
appearance of
buildings.
Netten
(1993)
A Positive
Environment?
Physical and
Social
Influences on
People with
Senile Dementia
in Residential
Care
Research-based
book examining the
effects of the social
and physical aspects
of different care
environments on
people with
dementia.
Seven sections:
1. Issues in the residential care of people with
senile
dementia
ö
the care needs of people with
dementia.
2. The research questions and study design
ö
research objectives and methodology.
3. The social environment: caring regimes
ö
how
the care facilities in the study met residents'
social needs.
4. The social environment: social climate and
regime classification
ö
the different types of
dementia care facilities and policies.
5. The physical environment
ö
design issues and
features.
6. The effect of the environment of residential
homes on demented residents
ö
influences and
effects of different social and physical
environments on residents and staff.
7. Policy implication and future research
ö
relating social and environmental design
to policy
No, although
refers to the
positive effects
of having
independent
access to the
grounds.
No, although
recommends
locating facilities
within the
catchment area.

Making the outside world dementia-friendly 615
Passini
et al (1998)
``Wayfinding
and dementia:
some research
findings and a
new look at
design''
Research-based
journal article
examining the
effects of the
internal design of
institutional settings
on the wayfinding
abilities of people
with dementia.
Findings and design recommendations focusing
on unambiguous architectural design, the design
and use of relevant signage, and the reduction of
unnecessary information.
No Recommends that
building entrances
should be clearly
defined and
visually accessible
from the street.
Passini
et al (2000)
``Wayfinding in
a nursing home
for advanced
dementia of the
Alzheimer
type''
Research-based
journal article
examining the
effects of the
internal design of
nursing homes on
the wayfinding
abilities of people
with Alzheimer's
disease.
Findings and design recommendations, including
layout, visual access, architectural features,
signage, and other wayfinding cues, furniture,
flooring, furnishings, and de
¨cor.
No, although
refers to the
importance of
access to outdoor
areas.
No
Pollock
(2001)
Designing
Gardens for
People with
Dementia
Design guide for
private and
institutional
gardens.
Detailed advice on the layout and elements of
a dementia-friendly garden and suitable plants,
features, and materials.
Yes, see previous
column
No
Shroyer
(1994)
``Recommen-
dations for
environmental
design research
correlating falls
and the physical
environment''
Journal article
reviewing design
guidance for the
prevention of falls
by older people in
their own homes
and institutional
settings.
Includes flooring, lighting, stairs, the type and
positioning of furniture, and safety features, such
as handrails.
No No

616 L Mitchell, E Burton, S Raman, and coworkers
Table 1 (continued).
Author(s) Title Type Content Design of on-site Design of off-site
outdoor areas outdoor environment
Skaarer
(2001)
``The garden: an
outdoor place
for safety and
experience''
Research-based
journal article on
the design of a
therapeutic garden
for people with
dementia.
Information on pathways, paving, planting,
fencing, landmarks, and other points of interest.
Yes, see previous
columns.
No
Torrington
(1996)
Care Homes for
Older People: A
Briefing and
Design Guide
Design guide for
residential care
homes for older
people including
those with dementia.
Four sections:
1. The people
ö
physical and cognitive needs of
older people in care settings; types of care
facilities.
2. Building design guide
ö
detailed design
specifications, from layout patterns to
doorknobs, both for ambulant residents and
for wheelchair users.
3. Management of the building process
ö
building
regulations and process.
4. Technical supplements
ö
further technical
information, including lists of agencies and of
dangerous and poisonous plants.
Siting of visitors'
car park near
main entrance.
Importance of
easy access to
gardens and other
outdoor spaces.
Orientation and
layout of outdoor
areas, pathways,
seating, wandering
paths, activities,
planting.
Provides pre
¨cis of
Highway Authority
requirements,
including building
location, access
drives, and pedes-
trian footpaths.
Refers to need for
good-quality
paving, street
lighting, pedestrian
crossings, and
seating but does
not provide design
guidance.
Stresses impor-
tance of locating
facilities in
established neigh-
bourhoods with
community links
and easy access
services and
facilities for
residents, relatives,
and staff

Making the outside world dementia-friendly 617
Wa r ne r
(1998 )
The Complete
Guide to
Alzheimer's-
proofing your
Home
Design guide for
improving the safety
and wellbeing of
people with
Alzheimer's disease
living at home.
Presents straightforward design solutions within
the home to ease the physical, behavioural, and
cognitive problems experienced by people with
Alzheimer's disease.
Garden design. No
Wei s m an
et al (1991)
``Architectural
planning and
design for
dementia care
units''
Chapter in
Specialised
Dementia Care
Units, providing a
literature review of
planning and design
guidance.
Stresses the importance of planning dementia
care units as holistic organisational, social, and
physical therapeutic environments that are safe,
supportive, legible, gently stimulating physically
and socially, respectful, adaptable, and familiar.
Presents existing guidance relevant to achieving
these aims, illustrated by a new dementia care
unit and a redeveloped existing facility designed
to meet these criteria.
Includes advice on
garden layout to
ensure legibility,
safety, and
comfort. Also
suggests activity
features and
wayfinding cues.
No, although
recommends siting
dementia care units
within residential
areas and close to
medical facilities.

The design guides typically begin with information on dementia, the physical,
behavioural, and cognitive effects of the illness, and the needs of people with dementia.
This is generally followed by an examination of the types of residential care available
and a presentation of specific design details ranging from the orientation and size of the
building to types of door levers. The majority of the guides concentrate on the design of
the physical environment although a few stress that environmental design, the manage-
ment of dementia care homes, and their care policies should be addressed holistically.
Only three of the publications look exclusively at the outdoor environment, two
relating to the grounds or gardens of institutional settings, and the third addressing
the design of gardens belonging to private homes and institutions. Over half the inter-
nal design guides do not give any advice on the design of outdoor areas and gardens
within the boundaries of the care facilities despite some reference to the therapeutic
benefits of access to the grounds. However, those that do give design suggestions for
outdoor areas provide some useful advice that is potentially significant for the design
of urban environments for people with dementia, such as the layout of footpaths and
suitable types of paving materials, planting, and wayfinding cues. None of the guides
gives advice on the design of the outdoor environment beyond the boundaries of
dementia care homes although one includes UK highway regulations for approach
roads and footpaths leading to the facilities.
Reviewing the design-for-dementia literature shows that guidance concentrates
on the internal design of institutions and that the design of the outdoor areas of
dementia care facilities is largely neglected. Even more importantly it demonstrates
that guidance on the design of the outdoor environment beyond the boundaries of
facilities is nonexistent. The literature, however, suggests that the internal design
principles are having a positive effect on the functional and cognitive abilities of
residents. In the next section we examine the design principles and features of the
design guides to determine whether a similar effect could be achieved in the outdoor
environment.
4 Design principles for outdoor environments
All the design guides address one or more of a number of principles. Most of these are
relevant to the outdoor environment:
(1) Ensure environment is familiar.
(2) Ensure environment is legible.
(3) Ensure environment is distinctive.
(4) Ensure environment is accessible.
(5) Ensure environment is comfortable.
(6) Ensure environment is safe.
By drawing out information from the literature relevant to each design principle,
we present potential equivalent design suggestions that may help towards creating
dementia-friendly outdoor environments. Some of these suggestions are direct transla-
tions and others propose corresponding features; for example, the design guidance for
corridors has informed suggestions for the design of streets. In addition to the litera-
ture review, this process was greatly informed by preliminary interviews held with older
people with dementia in local day centres and expert advice gained through steering
group and team meetings.
4.1 Ensure environment is familiar
Familiar surroundings play an important role in preventing and alleviating spatial
disorientation, confusion, and impaired memory problems. These impairments
reduce people's ability to understand their surroundings, to plan or follow a route,
618 L Mitchell, E Burton, S Raman, and coworkers

to recognise when they are lost or to relocate the correct route. Poor short-term
memory retrieval further increases the likelihood of becoming lost through a dimin-
ishing ability to remember places, alternative routes, and previous mistakes, or to
remember and use spatial and verbal information (Kitwood, 1997; Liu et al, 1991;
Perrin and May, 2000).
The guidance, listed in table 2 (see over), promotes the design of simple, small
domestic-style homes that provide a more familiar, understandable, and comforting
living environment than large-scale, institutional settings (Judd et al, 1998; Kuller, 1991;
Passini et al, 2000; Torrington, 1996; Weisman et al, 1991). Traditional-style bedrooms,
bathrooms, and living areas that resemble those found in older people's homes in terms
of architectural features, de
¨cor, furniture, and furnishings are recommended to help
residents to recognise where they are and what is expected of them in each setting (Day
et al, 2000; Judd et al, 1998; Kuller, 1991; Torrington, 1996). Modernistic styles are
generally not familiar enough for people with dementia who have often been found to
misinterpret their role; for example, not recognising a sliding door or mistaking a glass
door for a window (AIA, 1985).
Similarly, people with dementia should be better able to understand and feel
comfortable in public spaces of recognisable appearance, with familiar styles of street
furniture, public art, building facades, and paving. However, people with dementia
are likely to forget any changes that occur through redevelopment, infill, or regen-
eration and will become disoriented when surprised by such alterations to a familiar
area. It seems likely, therefore, that people with dementia who have lived for a long
time in one area, which has undergone little or only very gradual change, would be
better able to continue to find their way around than recent newcomers (Liu et al,
1991; Royal College of Psychiatrists, 1998; Twining, 1991). For people planning to
move to sheltered or residential accommodation, finding a suitable place in their
familiar local neighbourhood should, therefore, be an important consideration.
4.2 Ensure environment is legible
Poor concentration, communication, and reasoning skills can further aggravate the
problems caused by spatial orientation and memory impairments already mentioned
by creating difficulties in seeking help or following directions (Kitwood, 1997; Orrell
and Sahakian, 1995; Perrin and May, 2000). Memory techniques can sometimes be used
to replace lost information, but recall is unlikely to be automatic; for example, a person
who has forgotten the route to a specific place may be able to relearn this information
but will probably need to use reminders such as written notes. Remembering to use such
prompts is a further challenge (Clare et al, 2002; McGowin, 1993).
Lynch (1960, page 4) eloquently describes the psychological effects of being lost or
disoriented:
``To become completely lost is perhaps a rather rare experience for most people in the
modern city. We are supported by the presence of others and by special wayfinding
devices: maps, street numbers, route signs, bus placards. But let the mishap of
disorientation once occur, and the sense of anxiety and even terror that accom-
panies it reveals to us how closely it is linked to our sense of balance and well-being.''
For people unable to seek help or to follow directions the psychological effects of
spatial disorientation can be even more debilitating. Ensuring that dementia care
facilities are highly legible is, therefore, a major design principle.
The design guides highlight the negative effects of complicated building layouts
on wayfinding and orientation, especially those with numerous corners and turnings,
connecting corridors, blind bends, and/or dead ends. People with dementia are
most likely to become disoriented at decision points, such as junctions and corners.
Making the outside world dementia-friendly 619

620 L Mitchell, E Burton, S Raman, and coworkers
Table 2 . Potential design principles and solutions for dementia-friendly outdoor environments.
Internal design for dementia guidance Potential equivalent in outdoor environment
Ensure environment is familiar
Small, domestic-style buildings and gardens of a design familiar to older
people.
Small-scale street blocks with buildings and open spaces in designs
familiar to older people.
Furniture, furnishings, artwork, wall and floor coverings of similar
designs found in private homes.
Architectural facades and features in designs familiar and understandable
to older people.
Well-defined spaces: bedrooms, bathrooms, living rooms, and gardens
resembling those found in older peoples' private homes.
Clear and unambiguous design and/or appearance of buildings and open
spaces giving unequivocal representation of identity of place or building.
Ensure environment is legible
Facility to follow the building line, rather than recessed, and visible from
60 m along the street in both di rections.
Buildings to follow building line with good visual access along the street.
Simple layout with nonuniform, short, direct routes. Short streets laid out on a deformed grid based on an adapted perimeter
block pattern rather than on a uniform grid with 908junctions.
A minimum of corridors no longer than 22 m in length with no blind
bends.
Direct, connected routes with few nodes and junctions and no blind
bends.
Uninterrupted visual access to all areas, ideally with unobstructed view
of at least 6 ^ 30 m in both directions.
Visual access along streets of at least 6
ö
30 m.
Doors fronting directly onto corridor. Buildings facing the street with clearly visible and identifiable entrances.
Where a number of corridors are unavoidable, varying widths to delineate
hierarchy of corridors.
A visual hierarchy with wider streets for main routes/centres, narrower
streets for secondary/side streets.
Simple, explicit signs giving essential information only. Simple, explicit signs giving essential information only.
Signs fixed to walls at eye level (around 1400 ^ 1700 m above floor level). Signs fixed to walls at eye level (around 1400 ^ 1700 mm above floor level).
Messages on signs separated from each other. Messages on signs separated from each other.
Signs with nonglare lighting and nonreflective coverings. Signs with nonglare lighting and nonreflective coverings.
Realistic, unambiguous graphics with no abbreviations. Realistic, unambiguous graphics with no abbreviations.
5 ^ 7.5 c m high letteri ng in clear colour c ontrast to background and
70% colour contrast between wall and sign panel.
5 ^ 7.5 cm high lettering in clear colour contrast to background and 70%
colour contrast between wall and sign panel.
Ensure environment is distinctive
Variety of architectural features, such as doors and door furniture of
different styles, materials, colours.
Variety of styles, materials, and colours of architectural features and street
furniture.
Explicit, traditional designs for architectural features rather than
ambiguous, modernistic styles.
Explicit, traditional designs for architectural features rather than
ambiguous, modernistic styles.
Where complete visual access is not possible, distinctive wayfinding cues
positioned at point where visual access ends.
Wayfinding cues positioned where visual access ends, especially decision
points, such as junctions and turnings.

Making the outside world dementia-friendly 621
Strategically placed cues of visual interest, such as potted plants, pictures,
and clocks to identify routes, areas, and uses.
Landmarks directly accessible from the street to identify places, to act as
cues to location and route, and to divide routes.
Distinctive ornaments and bright or scented plants and trees to act as cues
at main entrance and in garden areas.
Latent cues, such as familiar, traditional-style street furniture and
flowering/scented trees and shrubs, placed at decision points, such as
junctions/nodes.
Avoidance of colours on the blue^ green spectrum or those that fade or
are difficult to see in bright sunlight, for example yellow.
Avoidance of colours on the blue ^green spectrum or those that fade or
are difficult to see in bright sunlight, for example, yellow.
Ensure environment is accessible
Facilities cited in residential areas close to services and facilities. Services and facilities located no further than 5 to 10 minutes walking
distance of residential areas.
For unavoidable level changes, gentle slopes with a maximum gradient of
1 in 20 rather than steps.
For unavoidable level changes, gentle slopes with a maximum gradient of
1 to 20 rather than steps.
Slopes and steps clearly marked and lit, with guard and handrails on both
sides, smooth, nonslip, nonglare surfaces, and nearby seating.
Unavoidable level changes clearly marked and lit, with guard and handrails
on both sides, smooth, nonslip, nonglare surfaces, and nearby seating.
Ensure environment is comfortable
Doors with lever-type handles and no more than 2 kg of pressure to open. Doors and gates with lever-type handles and no more than 2 kg of pressure
to open.
Background noise kept to below 60 decibels. Pedestrianised areas to reduce traffic noise, fumes, and danger.
Use of sound absorbing materials, for example, acoustic ceiling tiles, wall
hangings, upholstery and curtain fabrics.
Acoustic barriers, such as planting and fencing, to reduce street and
background noises.
A balanced level of stimulation without clutter. No unnecessary street clutter, such as extraneous signs and advertising
hoardings.
Defined resting areas every 100 m. Seating or resting areas every 100m in a defined space with a choice of seating
in shade, sun, and under shelter.
Right-angle seating to enable those with poor hearing and/or vision to
converse, with a cle ar space (80 cm minimum width) next to seating for
wheelchair users.
Right-angle seating to enable those with poor hearing and/or vision to
converse, with a clear space (80 cm minimum width) next to seating for
wheelchair users.
Sturdy seating with soft coverings. Sturdy public seating in materials that do not conduct heat or cold, for
example, wood.
Seating with continuous backrests, protruding arm rests, nonprotruding legs,
and a rolled leading edge not more than 43 cm h igh.
Public seating with continuous backrests, protruding arm rests, nonprotruding
legs, and a rolled leading edge not more than 43 cm high.
Small, well-defined gardens with seating and shelter from the elements and
visual access to building entrance and/or toilets.
Small, well-defined open spaces with access to adequate facilities such as
toilets, seating, shelter, lighting, refreshments.

622 L Mitchell, E Burton, S Raman, and coworkers
Table 2 (continued).
Internal design for dementia guidance Potential equivalent in outdoor environment
Ensure environment is safe
Residents' areas domestic and nonambiguous in style to encourage
use. Dangerous or staff areas disguised or nondomestic in style
to discourage entry.
Familiar, unambiguous designs, building styles, and landmarks for
spaces open to the public. Disguised features for private or dangerous
areas.
2 ^ 5 times the level of standard illumin ation. Street lighting bright enough for older people that do not cause light pollu tion,
for example, high-pressure sodium lamps.
Indirect lighting for a good illumination level with reduced glare. Street lighting which illuminates pavement edge without creating glare or deep
shadows in movement areas.
No areas of deep shadow or glaring light. Design, orientation, and layout of spaces and buildings that avoid creating
areas of deep shadow or glaring sunlight.
Alarms/sirens/auditory cues on low frequency and at suitable pitch for
people with hearing impairments.
Alarms/sirens/auditory cues, for example, at road crossings, on low frequency,
and at suitable pitch for people with hearing impairments.
Provision for longer reaction time. Provision for longer reaction time, for example, at road crossings.
Corridors at least 2 m wide to enable less ambulant and wheelchair users
to safely pass oncoming people.
Wide footpaths.
Well-maintained, plain, smooth, level, nonslip, nonreflective floor
coverings.
Well-maintained, plain, smooth, level, nonslip, nonreflective paving.
Grates and drains flush with paving with openings smaller than walking stick
or shoe heel size.
Flooring in clear colour contrast and material to walls and furnishings. Paving in clear colour contrast and material to buildings and surrounding
greenery.
Changes in texture or colour of floor coverings to indicate potential
hazards.
Changes in texture or colour of paving to indicate potential hazards.
Coniferous or narrow-leafed trees, whose leaves do not stick to outdoor
paving when wet, nearest to paths.
Coniferous or narrow-leafed trees, whose leaves do not stick to outdoor
paving when wet, nearest to paths.

A legible layout, with a minimum of corridors, and uninterrupted visual access to all
areas and entrances is therefore recommended to enable people with dementia to
go from one decision point to the next without having to plan for future decisions
(AIA, 1985; Brawley, 1997; Calkins, 1988; Passini et al, 2000). Some newly designed
units have bedrooms clustered around the living and dining areas that in turn surround
a central kitchen with no corridors at all. Others are experimenting with Y-shaped or
U-shaped layouts affording corridors with visual access throughout (AIA, 1985; Day
et al, 2000; Judd et al, 1998). Many people with dementia have a compulsion to wander
and a continuous looping `wandering path' situated with unobstructed visual access has
also been a successful innovation in many care homes enabling residents to wander
safely and without impediment (Brawley, 1997; Passini et al, 2000; Weisman et al, 1991).
The use of simple, small-scale, and well-articulated internal building layouts has a
clear correlation with the urban design principles of permeability, clarity, and legibility
(Bentley et al, 1992; DETR, 2000; Punter, 1990). However, although the grid pattern,
which allows for a free flow of movement with a choice of direct routes and no dead
ends, is sometimes heralded as being the simplest urban layout to understand, this is
not the case for people with dementia (Bovy and Stern, 1990; Southworth, 1991).
Although dead ends should be avoided, the uniformity of the gridiron, the blind
corners, and the large number of routes at each junction will be problematic especially
if the streets, turnings, and junctions are identical or very similar to one another.
Alternatively, small, heterogeneous streets laid out on a deformed grid based on an
adapted perimeter block pattern with direct, connected routes, few nodes and junc-
tions, and visual access along routes would provide the legibility necessary for older
people with dementia (Gehl, 1996; Judd et al, 1998; McCluskey, 1992).
Although the design guides recognise that signs are useful tools by which to
identify, inform, or direct, they also note that an abundance of signs may increase
rather than alleviate confusion and disorientation, because the reduced ability of
people with dementia to cope with external stimuli. This can cause some people to
follow the instructions on signs regardless of where they actually want to go (Bell,
1992; Judd et al, 1998; Passini et al, 1998). The guides, therefore, recommend keeping
signs to a minimum. Where they are necessary (for example, at decision points such as
corridor junctions or outside lifts) they should be at eye level, well illuminated, and
contain simple explicit information with realistic symbols and large dark lettering on a
light background (Bell, 1992; Brawley, 1997).
Excessive signing in urban environments has also been criticised for being counter-
productive, intrusive and unattractive by the Urban Design Alliance (2000). Using a
minimum of signs that follow the design for dementia guidelines so that they are clear,
precise, and easy to read would be of benefit to all.
4.3 Ensure environment is distinctive
The design guides state that long, uniform corridors lined with repetitive architectural
elements, fixtures, and finishes lack the clarity required for successful orientation and
wayfinding and are therefore often festooned with signs. To reduce the need for signs,
short corridors with a variety of traditional architectural features, such as doors and
door furniture in different but familiar styles, materials, and colours, are therefore
recommended (AIA, 1985; Goldsmith, 1996; Passini et al, 2000). In addition, placing
distinctive latent cues at decision points or places along corridors where visual access
ends acts as a form of reference leading the person on to the next or final destination.
Items of personal significance to residents have been found to be highly effective in
capturing their attention and aiding understanding and orientation. For example,
placing pictures or ornaments belonging to residents outside their bedroom doors
Making the outside world dementia-friendly 623

aids orientation and wayfinding more successfully than a nameplate or door number
(Charness and Holley, 2001; Day et al, 2000; Judd et al, 1998). They also have the
benefit of being more home-like and familiar than signs or notices (Netten, 1993).
In outdoor areas it has been found that garden features, such as bright, flowering
or scented plants and trees, and items such as bird baths, water features, and benches
are generally more effective than signs in aiding orientation and wayfinding (Brawley,
1997; Pollock, 2001; Skaarer, 2001). Similar distinctive cues, which have the benefit of
being visible from a greater distance, are also recommended to identify the main
entrance to the facility in addition to the name plate (AIA, 1985; Glasgow 1999; Judd
et al, 1998).
The ageing process causes a yellowing of the lens of the eye, which is often
aggravated by dementia. Known as colour agnosia, this affects the ability to distin-
guish certain colours, particularly those on the blue ^ green spectrum, although colours
on the red ^ orange spectrum appear to be less problematic in comparison to other
colours. It also reduces the ability to differentiate between colours of similar dark or
light tones until, in severe dementia, people are often unable to see colours at all
(Brawley, 1997; Harrington, 1993). Coloured lines and other colour-coded wayfinding
cues often used in institutional settings, such as hospitals, have been found to be
ineffective for older people because of their reduced ability to differentiate colours.
They are even less useful for people with dementia who are also often unable to
understand the coding system (AIA, 1985; Brawley, 1997; Carstens, 1985; Netten,
1993). However, the design guides stress that ensuring clear contrasts between different
hues is the most important aim in compensating for reduced colour sensitivity and
impaired depth perception experienced by people with dementia (Bell, 1992; Brawley,
1992; Goldsmith, 1996; Harrington, 1993). This correlates with the findings of Project
Rainbow, which investigated the effects colour and luminance contrast have on people
with visual impairments (Bright et al, 1997).
As with corridors, it can be conjectured that an avoidance of uniform streets with
repetitive building frontages and architectural styles, features, and materials could
similarly reduce disorientation and aid wayfinding. Indeed, varied form and diverse
architectural designs and materials are also elements of urban design currently
promoted by the government, as are buildings directly accessible from the street
(DETR, 2000). For people with dementia, more traditional building facades and
architectural features will be more understandable than modernistic styles that provide
little visual information as to their role or features (for example, revolving doors).
Distinctive building frontages and gardens with cues, such as flowering trees and
garden ornaments, will help the returning person to differentiate their own house
from others on the street, particularly when the urban form is repetitively uniform
(Marshall et al, 1999; Skaarer, 2001; Warner, 1998).
Research into the wayfinding techniques of older people in general in the outdoor
environment has found that landmarks of personal or symbolic importance, that have
distinctive architectural characteristics, are in natural settings, or have direct visual
access are the most recognisable, identifiable, and meaningful (Golledge, 1999; Moore,
1991; Ramadier and Moser, 1998). The wayfinding studies also confirm the suggestions
in the internal design guides that older people rely more on visual cues, especially
those with long-established, familiar, distinctive, and recognisable identities (Axia et al,
1991; Evans et al, 1984; Kirasic, 2000; Moore; 1991).
Ensuring that urban areas provide wayfinding cues, such as visually distinctive and
accessible landmarks, for people unable to rely on mental maps or signs would not
only increase functional ability but also reduce feelings of disorientation, confusion,
and agitation. Latent cues in the outdoor environment are many and varied, including
624 L Mitchell, E Burton, S Raman, and coworkers

street furniture (for example, litter bins and public telephone boxes), public art, trees, and
planted areas. Provided these are of more traditional rather than modernistic designs,
in situ for a prolonged period of time, and do not overly clutter the streetscape they should
be useful and reliable orientation and wayfinding cues.
A reliance on visual cues, however, will not be beneficial to those who also have
problems with their sight. Furthermore, research has found that people with visual
impairments tend to keep a continuous note of their position along a mental map, a
strategy which may be difficult to maintain for people with dementia who are exper-
iencing concentration and short-term memory problems (Hull, 1990; Passini and
Proulx, 1988). For people experiencing a combination of dementia and visual impair-
ment, navigating the outdoor environment will continue to be problematic. However,
the smells and sounds that guide people with visual impairment, such as the aroma of
a local bakery, scented plants, and audible road-crossing signals, could also be helpful
to people with dementia providing they are familiar, regularly encountered experiences
(Hull, 1990; Skaarer, 2001). Recent research has found that people with developmental
disabilities are able to learn to use Talking Signs, which were developed to provide
verbal route-finding instructions for people with visual impairments (Crandall et al,
1998). Similar research into their usefulness for older people with dementia, especially
those who also have visual impairments, would be valuable. However, it seems likely
that, although people in the mild stage of dementia may be able to learn to use Talking
Signs, retaining the memory of their function and how to use them would require
constant reinforcement.
4.4 Ensure environment is accessible
People in their mid-seventies have, on average, approximately half the strength and
stamina of a thirty-year-old. Frailty is generally even greater for people with dementia
as cognitive symptoms are accompanied by a gradual and erratic physical deterioration
in which the normal effects of the ageing process tend to be exacerbated (Brawley, 1997;
Carstens, 1985). Siting dementia care facilities in close proximity to local services
encourages continued activity within the local community. For older people with
dementia living at home, those who live within walking distance of services and
facilities will be far more able to continue to use those services than those living further
away, particularly once the use of a car is no longer possible (Carstens, 1985; Gehl,
1996; Judd et al, 1998).
Urban design guidelines recommend that services and facilities be sited within
500 m ^1 km of residential areas. This is considered to be the average walking distance
for younger adults taking roughly 5 to 10 minutes in areas of relatively flat topography;
but, for older people, these same distances will take 10 to 20 minutes (DTLR, 2000).
Thus, older people with dementia should ideally live no further than around 500m
from the most relevant facilities, such as bus stops, food stores, health centres, and
post offices. This will be more feasible in dense urban areas. Unless the current trend is
reversed, the loss of post offices, bus, and other services from suburbs and villages will
continue most adversely to affect older people with or without dementia and others
with disabilities or low incomes.
The design guides recommend that level changes should be avoided whenever
possible because of a reduced sense of balance and shuffling gait. Where level changes
are unavoidable, gentle slopes are recommended as imperceptible level changes have
been found to cause stumbling and steep changes to be dangerous or onerous for frail
people (Brawley, 2001; Shroyer, 1994).
Making the outside world dementia-friendly 625

4.5 Ensure environment is comfortable
People with dementia struggle to cope with an abundance of external stimuli. A place
full of noise, crowds, or a plethora of audio or visual information can cause agitation
and anxiety, which further heightens disorientation and confusion and reduces well-
being and the ability to function successfully. Sudden, loud sounds and voices often
frighten people with dementia and background noise adversely affects their ability to
hear effectively (Day et al, 2000; Goldsmith, 1996; Passini et al, 1998). Consequently,
the design guides view calm, quiet, and ordered settings as ideal environments for older
people with dementia with plenty of suitably designed seating areas with wheelchair
access (Brawley, 2001; Goldsmith, 1996; Harrington, 1993; Judd et al, 1998).
In the outdoor environment, heavy traffic and noisy areas have been found to be
problematic for people with visual impairments in terms of both safety and wayfinding
(Passini and Proulx, 1988). It seems likely that such situations are particularly onerous
for people with dementia as well. The inclusion of spaces where people can avoid or
retreat from areas of heavy traffic or crowds, such as public squares and green open
spaces, is therefore another potentially influential outdoor design objective. Regular
seating areas and shelter from extremes of wind, rain, and direct sunlight would also be
necessary for the less mobile and active and to protect against disorientation and
agitation (Pollock, 2001). However, people with dementia may feel confused if there
is too much clutter; for example, a jumble of signs, litter bins, advertisement hoardings,
bollards, railings, and kiosks (Passini et al, 2000; Weisman et al, 1991). If badly
positioned, street furniture may also restrict visual and physical access along the route.
The planting of trees and shrubs as acoustic barriers alongside busy roads is already
common practice (Highways Agency, 1997). The pedestrianisation of town centres may
also provide more comfortable settings for people with dementia providing they are not
too crowded. A study in Kingston has found that pedestrianisation has enhanced the
ability of older people and people with disabilities to enter and use the town centre
because of the improved quality and safety of an environment protected from the noise,
danger, and fumes of motorised traffic (Gant, 1997b). However, to maintain familiarity,
it would also be important to ensure that the changes necessary to pedestrianise an area
do not radically alter the overall character or image of the place.
4.6 Ensure environment is safe
Routinely used elements such as doors and stairs can cause automatic behavioural
responses in people with dementia, encouraging some to enter a room unnecessarily
or go up a flight of stairs. To ensure that residents do not enter dangerous or staff areas
in facilities, the entrances to such places are often disguised; for example, by using a
nondomestic style of door, by wallpapering the door or by laying a textured or
reflective strip on the threshold (Brawley, 1997; Torrington, 1996). In the outdoor
environment, modernistic or camouflaged entrances to private or dangerous spaces
would similarly discourage inadvertent entry by people with dementia (Pollock, 2001).
Depending on age and level of visual acuity, older people require between two to
five times more lighting than younger adults. Diminishing visual acuity also makes it
difficult to focus in areas of glare or when moving between deep shadow and bright
light (Brawley, 2001; Day et al, 2000). Much importance is placed by design-for-
dementia guidelines on the provision and positioning of indirect lighting and windows
to guard against glare and dark shadowy areas (AIA, 1985; Calkins, 1988; Glasgow,
1999). In the outdoor environment, the same consideration should be given to the
configuration of buildings and spaces to avoid unsheltered areas in direct sunlight
and dark shadowy places. The transition between a dark entrance and a bright street
is especially difficult for those with diminished visual acuity; placing canopies over
626 L Mitchell, E Burton, S Raman, and coworkers

doorways would allow time to adjust between the two extremes (AIA, 1985; Brawley,
1992; Carstens, 1985; Glasgow, 1999). Street lighting is already being improved to
increase safety for pedestrians and road users, but problems of light pollution must
also be addressed if lighting is to be increased. For example, high-pressure sodium
lamps which direct most of the light downwards are thought to provide a brighter,
more natural light than low-pressure ones without adding to light spillage (DETR,
1998; Highways Agency, 1997).
Hearing tends to decline earlier than vision in older people, causing communication
problems and reducing the ability to understand what is going on. A decreased ability to
hear audible warnings, such as ambulance sirens, especially in noisy areas has the
potential to be life threatening in the outside environment. This is compounded by
the greater length of time it takes people with dementia to register and react to such
signals and their slower, unsteady walking pace (AIA, 1985; Brawley, 2001; Calkins,
1988; Harrington, 1993). Noise-attenuation measures and the pitch and timing of
audible cues, such as at pedestrian crossings would, therefore, also seem to be important
factors in the design of dementia-friendly environments.
People with dementia often walk with a slow, unsteady, shuffling gait and have
difficulty interpreting social signals, such as the direction or intention of people
coming towards them (Harrington, 1993). Impaired depth perception causes them to
misinterpret sharp colour contrasts or patterns in floor coverings as level differences or
holes, and diminishing visual acuity reduces the ability to see obstacles. Busy patterns,
such as chessboard squares or repetitive lines, can cause dizziness or may appear to
move and reflective or shiny surfaces will be perceived as wet and slippery (Goldsmith,
1996; Torrington, 1996).
All these problems create a high incidence of stumbling and falls, especially on
flooring which is badly maintained, uneven, high friction, or slippery (AIA, 1985;
Brawley, 2001; Calkins, 1988). The design guides, therefore, recommend wide corridors
with plain, smooth, level, nonslip and nonreflective floor coverings in clear contrast to
the colour and texture of the walls (AIA, 1985; Brawley, 2001, Carstens, 1985). In
outdoor areas, they further advise that broadleafed deciduous trees should not be
planted by footpaths because of the risk of slippery leaves underfoot (Carstens, 1985).
Applying the same footpath and paving recommendations to urban outdoor environ-
ments would aid a great proportion of the population, but especially those with
dementia, providing paths are regularly maintained and cleaned. The problems of
narrow pavements and cobbled, gravelled, and uneven paving for wheelchair users is
already well documented (Beale, 2002) but for people with visual impairments some
tactual roughness underfoot is beneficial (Hull, 1990). Finding the balance between
differing needs is a difficult problem for inclusive design, requiring further research
from the user perspective.
Negative experiences and an increased sense of vulnerability create a greater
sensitivity to environmental characteristics in older people with or without dementia
than in younger adults and heavily influence the use or avoidance of a place (Golledge,
1999; Kaplan et al, 1998). Thus, it seems likely that bright ^ dark transition areas,
excessive noise, street-lighting levels, and types of paving materials, colours and patterns
are all further relevant design issues.
5 Conclusion
The paper demonstrates that certain parallels can be made between the needs
addressed by design guidelines for internal environments and the requirements of
older people with dementia in the urban outdoor environment. There appear to be
many ways in which the outdoor environment can be designed to help older people
Making the outside world dementia-friendly 627

with dementia to identify and understand where they are, to make appropriate
behavioural and wayfinding decisions, to feel safe and comfortable and to access
and use their local neighbourhoods. The ability of older people with dementia to
enter and use the outdoor environment is more likely to be supported in familiar,
legible local neighbourhoods with well-established, distinctive and clearly visible
landmarks and environmental cues. There is also a connection between successful
orientation and wayfinding and simple, small-scale urban layouts with a minimum of
nodes and junctions and maximum visual access along routes. Services and facilities
within walking distance, with short quiet streets and small-scale open spaces provi-
sioned with adequate seating, lighting, shelter, and well-maintained, smooth, level,
plain paving, also appear to have the potential to provide a supportive outdoor
environment for people with dementia. Most notably, however, it is the combination
of the main design principles that together make an environment dementia-friendly.
For example, for people also experiencing visual impairment the familiarity and
legibility of their local neighbourhoods will be of utmost importance, but for those
with visual acuity the presence of suitable wayfinding cues will also be significant.
Dementia guidelines are infrequently based on empirical research from the user
perspective; postoccupancy studies are required to test the results of these guidelines in
practice (Calkins, 2001; Day et al, 2000). The development of a synthesis of internal
design-for-dementia guidelines has provided a valuable frame of reference. However,
empirical research is imperative to test the resulting extrapolations made in this paper
and to investigate effectively the feasibility of designing the outside environment to
extend and enhance the active participation of people with dementia in their local
neighbourhood. A greater understanding of the wayfinding abilities and requirements
of older people with dementia in the outside environment is also necessary. Research
on this subject appears to be nonexistent, but it has been shown that some insight can
be gained from studies on the spatial orientation and wayfinding abilities of older
people in general and those of people in internal dementia care settings.
Research into the consequences of `barrier-free' housing standards, which aim to
make living environments suitable for everyone regardless of impairments, found that
people with dementia would benefit in general from these design standards apart from
problems with familiarity (Smith, 1997). Similar research on the effects of barrier-free
features in the outside environment and, conversely, to ensure that outdoor design-for-
dementia guidelines complement rather than compromise design needs of others, such
as wheelchair users, is essential.
Examination of the literature and existing research has provided us with a theoretical
grounding with which to formulate research instruments and fieldwork methodology for
the project we are currently undertaking. The fieldwork entails interviews with older
people with mild to moderate dementia, accompanied short walks with participants
around their local neighbourhoods, and a survey of environmental characteristics in those
local areas. The empirical data will enable us to determine how well older people with
dementia perceive, navigate, and use their local outdoor environment and to identify
aspects and design features of urban form that help or hinder them in doing so. The final
report will include design advice, covering all scales from whole neighbourhoods to street
furniture, which will benefit older people with dementia in the external built environment.
Having addressed the influence certain design aspects can have in helping or
hindering older people with dementia, internal design is now progressing towards a
more holistic approach. `Placed-based models of care' aim to approach physical, social,
organisational, and operational components collectively to ensure that each constituent
works in harmony rather than in conflict with each other (Briller and Calkins, 2000;
Calkins, 2001). Day et al (2000), for example, note that the design of noninstitutional
628 L Mitchell, E Burton, S Raman, and coworkers

care environments will not have the required effects if an institutional type of care
system continues to be provided within that setting. Similarly, in the outdoor environ-
ment, design innovations will be less successful if social, cultural, and professional
attitudes continue to discourage people with dementia and others who do not conform
to society's perception of `normal' from venturing outdoors.
Our research focuses on the needs of a relatively small, but rapidly growing, section
of society, yet the design issues raised are also important for older people in general
and for many other people with sensory, cognitive, or physical impairments. Further-
more, improving the clarity, legibility, and accessibility of the urban environment will
be of benefit to society as a whole. The Disability Discrimination Act 1995 moves us
slightly closer to this goal, but a truly inclusive environment requires a far greater
commitment in terms of further research, funding, legislation, and implementation
from central and local government, design professionals, and the development industry.
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