Biophilic Design Strategies in Long-Term Residential Care Environments for Persons with Dementia

Abstract

The number of persons living with dementia and related cognitive disorders is predicted to increase dramatically in the coming years. As a consequence, the need is increasing for appropriately designed long-term care (LTC) environments and design guidelines for these settings. This investigation presents the findings of a broad literature review on biophilic design and its application to a set of LTC architectural case studies selected for the degree to which each variously expresses key attributes of a set of ten biophilic patterns particularly rooted in the day to day experience of the aged in these care settings: visual connections with nature, non-visual connection with nature, non-rhythmic sensory stimuli, thermal and airflow variability, presence of water, dynamic and diffused light, complexity and order, prospect, refuge, and mystery. The three methodological aims are to conduct an in-depth literature review, to distill the aforementioned subset of biophilic patterns with respect to how the aged experience their built surroundings, and third, to examine these in light of their various expression in recently built state-of-the art LTC settings for persons with dementia and related cognitive disorders. Residents’ engagement with and proximity to nature and landscape, and transactions with biophilia-inspired artifacts was the principal focus. The case studies are further examined in relation to the planning and design of LTC environments in the context of the COVID-19 pandemic. Future biophilic-inspired directions for evidence-based research and design for persons with dementia and related cognitive disorders are discussed.

Full text

Biophilic Design Strategies in Long-Term Residential
Care Environments for Persons with Dementia
Terri Peters
a
and Stephen Verderber
b
a
Department of Architectural Science, Ryerson University, Toronto, Canada;
b
John H Daniels
Faculty of Architecture, Landscape and Design, Dalla Lana School of Public Health, University of
Toronto, Toronto, Canada
ABSTRACT
The number of persons living with dementia and related cog-
nitive disorders is predicted to increase dramatically in the
coming years. As a consequence, the need is increasing for
appropriately designed long-term care (LTC) environments
and design guidelines for these settings. This investigation
presents the findings of a broad literature review on biophilic
design and its application to a set of LTC architectural case
studies selected for the degree to which each variously
expresses key attributes of a set of ten biophilic patterns par-
ticularly rooted in the day to day experience of the aged in
these care settings: visual connections with nature, non-visual
connection with nature, non-rhythmic sensory stimuli, thermal
and airflow variability, presence of water, dynamic and
diffused light, complexity and order, prospect, refuge, and
mystery. The three methodological aims are to conduct an in-
depth literature review, to distill the aforementioned subset of
biophilic patterns with respect to how the aged experience
their built surroundings, and third, to examine these in light
of their various expression in recently built state-of-the art LTC
settings for persons with dementia and related cognitive dis-
orders. Residents’engagement with and proximity to nature
and landscape, and transactions with biophilia-inspired arti-
facts was the principal focus. The case studies are further
examined in relation to the planning and design of LTC envi-
ronments in the context of the COVID-19 pandemic. Future
biophilic-inspired directions for evidence-based research and
design for persons with dementia and related cognitive disor-
ders are discussed.
KEYWORDS
Architectural design;
biophilic design; long term
care (LTC); housing;
aging; dementia
Introduction
The quality of the everyday living environment greatly impacts our moods,
health and wellbeing. Its quality influences our ability to communicate
effectively with others, to heal, and recover from stressful conditions and
situations. It stands to reason that long-term care (LTC) environments for
CONTACT Terri Peters Terri.Peters@Ryerson.ca 350 Victoria Street, Toronto, Ontario, M5B 2K3, Canada.
Supplemental data for this article can be accessed at www.tandfonline.com/wjhe.
ß2021 Taylor & Francis Group, LLC
JOURNAL OF AGING AND ENVIRONMENT
https://doi.org/10.1080/26892618.2021.1918815

the aged, including those designed for persons with dementia, a condition
that results in significantly diminished cognitive and physical functioning,
should be planned, designed and built to promote occupants’wellbeing and
enjoyment of this stage of life to the fullest extent. In the U.S. alone, 5.7
million individuals live with dementia with Alzheimer’s disease accounting
for approximately 60–70% of these cases. This is followed by vascular
dementia (Alzheimer’s Association, 2018). Worldwide, an estimated fifty
million are living with dementia and these numbers are projected to
reach 82 million by the year 2030 and 152 million by 2050 with the major-
ity living in low-to-middle-income countries. Globally, the annual number
of new cases as of 2020 was 9.9 million (World Health
Organization, 2020).
In North America, the majority of the aged continue to be cared for by
the family, with a small percentage residing in LTC settings. Individuals
who do enter LTC settings are increasingly older and more frail than a dec-
ade ago (Canadian Association for Long Term Care, 2017). The majority of
LTC environments are not explicitly designed from the standpoint of facili-
tating meaningful person-nature connectivity. This paper illustrates how
biophilic design strategies can be effectively implemented in these residen-
tial care settings. Biophilia is defined as people’s innate affinity to other
forms of life, and the natural world; its theoretical tenets have been
explored in psychology and sociology since the 1980s (Kellert & Wilson,
1993; Wilson, 1984). In architecture and design, there is increasing focus
on the impacts of nature and landscape on people in buildings, including a
growing body of evidence-based research (Gillis & Gatersleben, 2015;
Kellert, 2008; Ryan et al., 2014; Yin et al., 2018). Interest has increased sub-
stantially since the Ulrich et al., 2008 comprehensive review of the state of
the art in evidence-based research on healthcare environments, where the
role of biophilia was not directly reviewed (Ulrich et al., 2008).
Literature review
The role and function of meaningful connectivity with nature and landscape
in LTC has yet to receive the level of evidence-based research and design
attention warranted. This inattention is especially acute given the growing
numbers of persons in LTC environments globally who live with dementia
and related cognitive disorders and the growing body of evidence that expos-
ure to nature improves cognitive functioning. In a comprehensive 2014
report “14 Patterns of Biophilic Design,”Browning et al. (2014) conceptual-
ized biophilia for human health and wellbeing in buildings as comprised of
three principal categories: Nature in Space Patterns (specifically visual con-
nection with nature, non-visual connection with nature, non-rhythmic
2 T. PETERS AND S. VERDERBER

sensory stimuli, thermal and airflow variability, presence of water, dynamic
and diffuse light, connection with natural systems); Natural Analogue
Patterns (specifically biomorphic forms and patterns, material connection
with nature, complexity and order); and Nature of the Space Patterns (pro-
spect, refuge, mystery, risk/peril). Browning et al., put forth evidence in sup-
port of how these “patterns”can foster stress reduction, enhance cognitive
performance, emotional-mood, and overall human physiology (2014, p. 12).
Another leading researcher in this field, Kellert (2008), defined the main ten-
ets of biophilic design as having two primary dimensions: Organic or
Naturalistic; and Place-based or Vernacular. Within these, six biophilic design
elements are further defined: environmental features; natural shapes and forms;
natural patterns and processes; light and space; place-based relationships; and
evolved human-nature relationships. Each of these biophilic design elements is
then variably examined in relation to a compendium of seventy design attrib-
utes. Both Browning, Ryan and Clancy’s patterns, and Kellert’s later dimen-
sions, elements or attributes, are intentionally presented as general
descriptions, or observations. As such they are presented without the added
specificity, or reinforcement, that would have accrued had they been connected
to, for example, case studies of specific sites, building orientations, cost/trade-
off ramifications, climatic determinants, the ramifications of new construction
versus renovation/addition scenarios, or multiple functional program type var-
iants—all of which are significant drivers of architectural design outcomes for
the aged or any user group constituency, for that matter.
To extend this theoretical framework, and relevance to LTC administra-
tors and their commissioned architects and allied designers, this paper’s
overarching goals are: to examine the literature on this topic with particular
attention accorded LTC environments, and second, to connect the afore-
mentioned conceptualization of biophilic design patterns to specific build-
ings and specific places. This is accomplished through the systematic
review of built examples.
A growing evidence-based literature focuses on the health-promoting
application of biophilic design patterns in LTC environments.
Typologically, this set of facilities broadly includes assisted living facilities,
continuing care retirement communities, and residential hospices—care set-
tings premised from the outset, presumably, on incorporating health-pro-
moting design strategies including an inhabitant’s stress level, sleep quality
and patterns, and mental health status (Golembiewski, 2017).
Methodology
First, an in-depth literature review was conducted biophilic design strat-
egies in the planning and design of LTC settings for aged residents with
JOURNAL OF AGING AND ENVIRONMENT 3

dementia and related cognitive disorders. This search of scholarly journals,
conference papers, and reports uncovered more than one hundred relevant
sources. This compendium was first utilized in an examination of the role/
non-role of biophilic design in LEED-certified LTC built environments in
North America (Peters & Verderber, 2019; Verderber & Peters, 2019).
Second, the most pertinent biophilic design patterns identified by
Browning et al. (2014) were identified. Third, the resultant ten patterns are
examined in terms of their various expressions of the state-of-the-art. This
involved a search of architect’s websites, architecture award sites, scholarly
journals, conference papers and web searches with selected examples pre-
sented in some detail. Some of the ten concepts manifest robustly within
and across the LTC typology while others remain in a more nascent state
of development at this time. The ten selected themselves warrant closer
examination on the assumption that each possesses meritorious affordan-
ces. These were selected for further analysis due to their relevance to this
user constituency. The following patterns were not analyzed: connection
with natural systems; biomorphic forms and patterns, material connection
with nature, and risk/peril. In the literature review, these four were least
published in the context of LTC environments. The resultant ten patterns
are not presented hierarchically so as to not pre-bias their interpretation-
application by others. As such, their ordering remains identical to the
Browning et al. (2014) list. This was based on the underlying assumption
that no two LTC built environments for the aged are exactly alike. While a
given case study may express more than one (or many, in fact) of the ten
patterns no on-site post-occupancy investigations were conducted due to
logistical restraints. Table 1 presents a categorized summarization of the
most germane, recent, evidence-based research investigations with direct
implications for this building type and specific user constituency.
Findings and discussion: interpreted biophilic patterns—case studies
Drawing from the evidence-based biophilic design literature, key aspects of
this theoretical conceptualization considered to be most relevant to the pro-
grammatic challenges of LTC environments for dementia care are high-
lighted below. Here, the subset of ten of Browning et al. (2014) larger
compendium of biophilic design patterns are examined in the specific con-
text of the LTC typology. Each of the ten patterns are briefly defined, and
associated peer reviewed research investigations cited, specific to numerous
built LTC case studies. Each case study selected for analysis vis-
a-vis the lit-
erature review is recognized for its design excellence, i.e. design awards,
publications received, to date. An additional benefit of focusing on these
particular ten patterns is to spark discussion of how they (as well as other
4 T. PETERS AND S. VERDERBER

Table 1. Summary of recent relevant research relating to biophilic design and long term care environments.
Patterns Researchers/Setting Research design, sample, setting and results Measures of wellbeing Key environmental features
1. Biophilic Design Pattern: Visual
Connection with Nature
Pattern identified by Browning
et al., (2014)as“A view to
elements of nature, living
systems and natural processes.”
Rappe & Lindén, 2004.
Helsinki, Finland.
Study based on survey of 65 staff from 10 dementia
care homes. Results showed plants can contribute
significantly to the well-being of individuals
with dementia.
Effect of plants on sensory
deterioration
Indoor and Outdoor plants
Kaplan, 2001.
Michigan, USA
Study of apartment residents using a survey with
both verbal and visual material. Results showed
that natural elements in a view from the window
contributes to well-being.
Influence of natural views from
windows on restoration
Viewing environmental and built
content from windows
Yin et al., 2018.
Boston, USA
Comparison of blood pressure, and reported
emotions, of people in real and Virtual Reality
(VR) environments with and without biophilic
design elements. Results showed benefits in
biophilic environments
Health benefits of real and virtual
biophilic environments
Indoor biophilic environment and
VR biophilic environments
2. Biophilic Connection with Nature
Pattern identified by Browning
et al., (2014) design pattern:
non-visual as “Auditory, haptic,
olfactory, or gustatory stimuli
that engender a deliberate and
positive reference to nature,
living systems or
natural processes.”
Whear et al., 2014
a
Systematic review of databases and organizations,
data screened in a 2-stage process. Results
showed spending time in gardens to reduce
agitation in care home residents with dementia
Effects of multisensory engagement
on dementia residents
Outdoor gardens with auditory,
haptic and olfactory stimuli
Detweiler et al., 2012.
b
Literature review reported benefits of horticultural
therapy and garden settings in reduction of pain,
improvement in attention, lessening of stress,
modulation of agitation, lowering of medications
and reduction of falls.
Benefits of touch and horticulture
therapy in improving well-being
of aging residents
Literature review
Ratcliffe et al., 2013.
South East England, UK
Semi-structured interviews with 20 adults aged
22–74 years. Results showed birdsong most
commonly associated with restorative experiences,
although perceptions varied between bird species
Positive influence of auditory
natural stimuli on stress and
attention fatigue.
Interview transcripts with choice
questions on natural
preferences
3. Biophilic design pattern: non-
rhythmic connection with
nature
Pattern identified by Browning
et al., (2014)as“Stochastic and
ephemeral connections with
nature that may be analyzed
statistically but may not be
predicted precisely.”
Tappen et al., 2008.
Florida, USA
Study of 65 participants with dementia randomly
assigned to the treatment group in a nursing
home. Results showed assisted walking with
conversation contributed to functional mobility.
Effects of walking-conversation and
mobility in residents.
30 Minute either walking, talking,
and walking-talking
Ottosson and Grahn, 2005.
Lund, Sweden.
Study of 15 geriatric home residents with
concentration, blood pressure, and heart rate
measured before and after rest in a garden or in
their favorite indoor room. Results showed greater
benefits in gardens.
Influence of nature and green
space on cognitive ability of
elderly populations
Resting in an outdoor garden
versus resting indoors
Jonveaux et al., 2013.
Nancy, France.
Study of 68 Alzheimer's patients, visitors, and health
care workers in a hospital healing garden.
Findings showed sensory elements such as varied
scents, colors, textures, and sounds helps fight
against sensory deprivation
The role of sensory stimuli in
improving mental and physical
well-being in healthcare
environments.
Pre and post evaluation of a
healing garden
(continued)
JOURNAL OF AGING AND ENVIRONMENT 5

Table 1. Continued.
Patterns Researchers/Setting Research design, sample, setting and results Measures of wellbeing Key environmental features
4. Biophilic design pattern: thermal
and airflow variability
Pattern identified by Browning
et al., (2014)as“Subtle changes
in air temperature, relative
humidity, airflow across the
skin, and surface temperatures
that mimic natural
environments.”
Weuve et al., 2012.
Boston, USA
Study of 19,409 US women aged 70–81 years. GIS
used to estimate recent and long-term exposures
to particulate air pollution. Findings showed
higher levels of long-term exposure was
associated with faster cognitive decline.
Effect of air pollution on cognitive
capabilities of older women
Analytical study of data
Wong et al., 2014.
Hong Kong, China
Focus group study of staff, nurses, caregivers and
architects about behavioral problems of dementia
residents. Results showed acoustics, lighting and
thermal conditions most important factors
influencing cognitive behavior
Influence of indoor care home
environments on the onset and
progression of dementia
Indoor architectural and
environmental features of
care homes
Tartarini et al., 2017.
New South Wales, Australia
Study of agitated behaviors of 21 nursing home
residents assessed using the Cohen- Mansfield
Agitation Inventory (CMAI). Findings showed
agitated behaviors may be reduced by limiting
range of indoor air temperature variations.
Effect of indoor air temperature on
agitated behaviors in residents
with dementia
Indoor air quality and temperature
5. Biophilic design pattern:
presence of water
Pattern identified by Browning
et al., (2014)as“A condition
that enhances the experience of
a place through seeing, hearing
or touching water.”
Crouse et al., 2018.
30 large cities in Canada
Study of adults living in the 30 largest Canadian
cities. Study found a link between living within
250 m of blue space and benefits to health.
Influence of viewing water on the
rate or mortality
Proximity to water
Jo et al., 2019.
a
Systematic review of 37 papers on the physiological
effects of visual stimulation from either nature or
representations of nature indoors. Findings
showed that studies that used real nature stimuli
had positive effects on cerebral and autonomic
nervous activities
Restorative effects of viewing
natural landscapes on stress
and attention
Reviewing and analyzing peer-
reviewed articles
Tang et al., 2017.
Taipei, Taiwan
Study compared restorative values of urban,
mountain, forest, and water environments using
questionnaires and by measuring the different
environments and brain region activity by means
of fMRI. The findings show the brain reacts
differently and supports a more restorative
experience in water and mountain environments
and least in the urban setting.
Influence of landscape visualization
(primarily water) on
brain activity
Questionnaires, visual aid and the
use of fMRI to map
brain activity
6. Biophilic design pattern: dynamic
and diffuse light
Pattern identified by Browning
et al., (2014)as“Leverages
varying intensities of light and
shadow that change over time
to create conditions that occur
in nature.”
Konis et al., 2018.
California, USA
Study of 77 participants with Dementia in eight
facilities over 12 weeks. Results showed that
increased exposure to daylight can reduce
depression in people living with dementia.
Effect of daylight exposure on
socialization behaviors.
Daylight exposure versus artificial
lighting exposure
Klauber et al., 1997.
California, USA
Study of 24-hour circadian-rhythm patterns of activity
and sleep/wake were measured in nursing home
patients with a mean age of 85.7 years. Results
showed participants have fragmented sleep and
spend very little time in bright light. There were
significant correlations between mental status and
light exposure.
Influence of light exposure on
sleep patterns in
nursing homes.
Sleep/wake activity was recorded
with an Actillume
portable recorder
6 T. PETERS AND S. VERDERBER

Shochat et al., 2000.
California, USA
Study of 66 nursing home residents monitored for
activity and light exposure over a 3-day period.
Data was collected about light levels, minutes
spent over 1000 and over 2000 lux, time asleep
and awake, and daytime naps. Results showed
that daytime light exposure impacts night time
sleep and timing of peak activity level.
Effect of low light exposure on
activity levels in
institutionalized adults
Exposure to 1000–2000 lux of light
7. Biophilic design pattern:
complexity and order
Pattern identified by Browning
et al., (2014)as“Rich sensory
information that adheres to a
spatial hierarchy similar to those
encountered in nature.”
Balan et al., 2001.
Be'er Ya'akov, Israel
Retrospective study reviewing medical records of
5218 patients aged 65 years and older to
understand Delirium incidence and seasonality.
Statistical analysis revealed higher rates in the
winter months.
Influence of seasonal complexity on
delirium incidence
Analytical study
Hagerhall et al., 2004.
b
Study of preferences for fractal dimensions from
silhouettes of natural environments.
Findings show relationships between preference and
the fractal dimension, and this could relate to
well-documented connection between preference
and naturalness.
Effect of fractal dimension on
esthetic experiences
Literature review and state of the
art study of silhouettes of
natural environments and
fractal dimensions
8/9. Biophilic design pattern:
prospect and refuge
The prospect pattern identified by
Browning et al., (2014)as“An
unimpeded view over a
distance, for surveillance and
planning. It is “A place for
withdrawal from environmental
conditions or the main flow of
activity, in which the individual
is protected from behind
and overhead.”
Dosen and Ostwald, 2016.
a
Study provides overview of concepts of prospect,
refuge, mystery, complexity and how they are
desirable in natural, urban or interior
environments. Studies on natural spaces provided
evidence for both prospect and refuge, which has
been linked to comfort, but also included
evidence against and a neutral finding.
Significance of prospect and refuge
in promoting comfort
Critical meta-analysis
Senoglu et al., 2018.
Tokyo, Japan
On site survey study of 129 people about
preferences for eight garden environments. Data
collected on degree of openness, perceived safety,
and ratio of background buildings. Results
showed predefined, open-protected sites
preferred; and that prospect was an important
indicator of the preferences, whereas the refuge-
related symbols of the gardens were not
perceived differently between the sites.
Influence of prospect and refuge
on preferences in gardens
Elements of prospect and refuge in
an outdoor garden
10. Biophilic design pattern:
mystery
Pattern identified by Browning
et al., (2014)as“The promise of
more information, achieved
through partially obscured
views or other sensory devices
that entice the individual to
Szolosi et al., 2014.
Ohio, USA
Study of 144 participants using Recognition Memory
Task (RMT) about presence of mystery and its
duration in spaces. Results showed that with
additional viewing time, images perceived high in
mystery achieved greater improvements in
recognition performance when compared to those
images perceived low in mystery.
Effects of mystery on natural
preferences
Images with an element of mystery
versus images without
Ikemi, 2005.
Saitama, Japan.
Study presented participants with photomontages of
a housing facade and they rated their preference
Influence of mystery on the
preference of housing facades.
Images of facades with elements of
mystery and without
(continued)
JOURNAL OF AGING AND ENVIRONMENT 7

Table 1. Continued.
Patterns Researchers/Setting Research design, sample, setting and results Measures of wellbeing Key environmental features
travel deeper into the
environment.”
as high-mystery, medium-mystery, low-mystery.
Results showed high-mystery was preferred.
Nasar & Cubukcu, 2011.
Ohio, USA and Izmir Turkey
Study of preferences of 37 American students and 40
Turkish students who viewed a desktop virtual
environment (VE) of 15 large-scale residential
streets. For each VE, participants encountered low
mystery (straight) or higher mystery (curved); and
street-pairs with low, medium and high levels of
surprise (based on differences between the street
qualities). Results showed that for both groups
preferences were for high mystery and surprise.
Effects on mystery on recognition
performance.
Images with an element of mystery
versus images without
a
Systematic review.
b
Meta-analysis.
8 T. PETERS AND S. VERDERBER

biophilic concepts) can be further interpreted and subsequently incorpo-
rated in built projects internationally. Note that many the case studies are
recognized for their ecological sustainability. It is assumed, for purposes of
this discussion, that biophilic design excellence and sustainable/ecological
design excellence need not be mutually exclusive.
Visual connection with nature
The occupants of long-term care environments can benefit significantly
from meaningful views of nature, often through sufficiently large and prop-
erly oriented window and frame apertures. This pattern is defined by
Browning et al. (2014) as the existence of “a view to elements of nature,
living systems and natural processes.”Other studies on applied biophilic
design strategies support the multiple psychological wellbeing benefits of
visual connectivity with nature. Kellert (2008) identified views and vistas as
important dimensions, arguing that people prefer views outside rather than
those looking into other interior spaces, and views should contain natural
feature attributes combined with a significant amount of natural vegetation
and that such views are often most satisfying when the scale is compatible
with human experience. For example, views that are not overly restricted
or confined, unfamiliar, out of scale or proportion, too large or too high
above the occupants’typical viewing plane (Kellert, 2008, p. 7). This is fur-
ther reinforced as interpreted through the attention restoration theoretical
perspective put forth by Stephen Kaplan (Kaplan, 1995,2001; Kaplan &
Berman, 2010; Ohly et al., 2016) and since expanded upon by others in
multiple built environment contexts ranging from roadside commercial ver-
nacular building to hospitals (Verderber, 2016).
Numerous studies across several scholarly disciplines have shown that
incorporating views, plants, and engagement with nature can improve resi-
dents’experience in LTC environments for dementia residents (Table 1).
This is a strongly supported biophilic pattern in the peer reviewed litera-
ture, substantiated in studies evaluating the psychological effects of plants
on nursing staff and residents’emotional well-being. The inclusion of
plants and opportunities for nature engagement in indoor and outdoor
environments contributes to reduced sensory deprivation and can contrib-
ute significantly to the wellbeing of individuals with dementia, as well as
their carers (Rappe & Lind
en, 2004). Further work is warranted, however,
to determine the specific types of windows and views residents in LTC set-
tings prefer most. For example, do residents prefer views of nature from
their bedroom, and urban views visible from living and social activity
areas? How important is maintaining a multiplicity of exterior view types
and context in the everyday environment? What is the relationship between
JOURNAL OF AGING AND ENVIRONMENT 9

building siting orientation, thermal comfort, and window aperture orienta-
tion? To what extent does personal privacy, window aperture placement,
and view orientation covary? Meaningful visual connectivity with nature-
landscape is demonstrated as an effective architectural design strategy;
empirical studies on this pattern in LTC contexts suggests these environ-
ments should be designed for viewing nature for extended periods as a
means to provide a restorative experience for residents (and caregiver staff).
Additional affordances include fostering therapeutic engagement with the
outdoors, and opportunities for health-promoting activity indoors
and outdoors.
An example of a LTC home designed to provide residents with meaning-
ful visual connections to nature is Kipling Acres, a 337-bed nursing home
in Toronto Canada (Montgomery Sisam, 2015). This project has a living
wall inside the main entrance affording access to indoor greenery, and a
landscaped exterior courtyard (Figures 1(a,b)). This courtyard is a place
where children from the on-site childcare center interact with residents.
Montgomery Sisam architects developed this project on a ten acre site in
2015. Views of nature, provision of exterior amenities, and landscaped
spaces foster socialization with daycare workers, children, and the
broader community.
Non-visual connection with nature
Non-visual connection to nature is also important in biophilic design.
Browning et al. (2014) define this biophilic pattern as “auditory, haptic,
olfactory, or gustatory stimuli that engender a deliberate and positive refer-
ence to nature, living systems or natural processes.”They cite examples of
biophilic interventions in spaces including adding potted plants, bird
feeders, courtyard gardens, green walls and vegetated (green) roofs.
Figure 1. (a, b) The benefits of visual connection with nature: Kipling Acres Long Term Care
Home, Toronto, Canada, 2015 by Montgomery Sisam Architects. The 182,900 sq. ft. facility is
located on a 10 acre site and the program includes art and music therapy suites, seniors’com-
munity center, children’s daycare, adult day center, and a large intergenerational courtyard.
Photos by Shai Gill.
10 T. PETERS AND S. VERDERBER

Other relevant studies support non-visual connection with nature as a key
part of biophilia, including the sensory benefits of involvement in caring
for plants. Similarly, Kellert (2008) argues that greenery affords far more
than mere visual amenity, and that strategic insertions of plants into the
built environment is a source of enhanced comfort, satisfaction, well-being
and performance levels. There are studies that demonstrate the benefits of
exposure to, and caring for, greenery in LTC environments. The import-
ance of caring for a potted plant was first investigated by Ellen Langer and
Judith Rodin in the late 1970s and early 1980s. The focus was to identify
determinants of personal control in LTC settings. In their early research,
residents at a nursing home were randomly assigned to two groups: Group
1 were told they could arrange their furnishings as they wished, go where
they wanted, spend time with whom they wished and so forth, and each
resident was given a plant to care for; Group 2 respondents were told the
staff were there to take care of and help them, including watering the plant
given to each of them. Eighteen months later, residents who had been
given control and personal responsibility had an improved health status,
and among those for whom self-control-autonomy had not changed, a
greater proportion had died (Mallers et al., 2013).
A review of the associated literature indicates the importance of views
and visual connections to nature (Table 1) with its affordances having been
studied in multiple environmental contexts, with particular relevance to
how the aged experience LTC settings. However, relating to non-visual
connection to nature, there are much fewer studies in LTC settings.
Nature’s sounds, smells and textures are repeatedly shown to be of thera-
peutic value, yet there remains a need for further research on best practice
methods of integrating this therapeutic content into these environments,
i.e. the therapeutic impact of outdoor gardens on the behavior and
well-being of the elderly with dementia. Cooper and Sachs (2014) wrote a
comprehensive guide to “healing garden”(therapeutic) design for the frail
elderly and persons with dementia, although more research is needed on
the effects of transporting this content into LTC interior spaces. The litera-
ture conducted to date supports the position that viewing nature, touching
nature and to a lesser extent, taking in sounds and smells of outdoor gar-
dens can improve the quality of life of aged residents.
The Erika Horn Residential Care Home in Graz Austria (Figure 2(a,b))
maximizes non-visual connections to nature. The project is certified with
the EU-green building program due to its special class of energy efficiency
and its ecological construction features (Mies van der Rohe, 2020).
Designed by Dietger Wissounig, it is arranged over two levels, with four
wings, housing seven residential units, each with fifteen residents
(Wissounig & Prack, 2020). This care home emphasizes theraserialized
JOURNAL OF AGING AND ENVIRONMENT 11

connections with the outdoors (Verderber, 2010; Verderber et al., 2020).
This condition is defined as a seamless, transparent, graduated sequence of
indoor-to-outdoor space and vice versa. Its green, open spaces collectively
constitute a graduated spatial sequence of varying proportions, character,
and function all universally accessible by elderly residents with dementia.
Its outdoor-to indoor layered spaces are designed in support of acuity
adaptability, i.e. adaptable to changing physical and cognitive functioning
levels of residents. The aim was to emphasize varied, interconnected activ-
ities indoors and outdoors, simultaneously fostering meaningful connectiv-
ity with nature and landscape. Nature is incorporated throughout its
indoor spaces; wood is featured throughout the project, atriums are fur-
nished with raised garden beds serving as light wells and social activity
spaces. Two large gardens flank the residence itself together with a system
of loggias and adjacent protected activity spaces. A vineyard directly to the
east provides a transitional link to a civic park (Wissounig & Prack, 2020).
Non-rhythmic sensory stimuli
As with the previous two patterns, the provision of quality of outdoor
space is central to effective biophilic environmental design. Several patterns
identified by Browning et al. (2014) pertain to outdoor therapeutic gardens.
These include Visual Connection with Nature, the providing vegetated
views; Non-Visual Connection with Nature, incorporating sensory aspects
principally as sound and touch; Non-Rhythmic Sensory Stimuli, “stochastic
and ephemeral connections with nature that may be analyzed statistically
but may not be predicted precisely.”Examples of non-rhythmic sensory
stimuli include the sound of rustling leaves, swaying grasses in a field, rip-
pling water. For individuals with dementia, experiencing the outdoors over
Figure 2. (a, b) The benefits of non-visual connection with nature: Erika Horn Residential Care
Home, Austria, 2015 by Dietger Wissounig Architekten. The 148,000 sq. ft facility houses elderly
residents with dementia, Parkinson’s and cardiovascular diseases.
12 T. PETERS AND S. VERDERBER

time, and engaging with it vis-
a-vis social or individualistic activity, such as
meeting friends, birdwatching, and gardening.
The general evidence-based literature on this topic underscores the thera-
peutic benefits of non-rhythmic sensory stimuli, although scant research
attention has yet been specifically devoted to LTC settings. Restated, while
gardens and connected leisure spaces are of benefit to their occupants,
there remains the need for built case studies with an emphasis on the role
of architectural design as a support modality in this regard (Whear et al.,
2014). This biophilic pattern can be of therapeutic benefit to residents, their
families, and carers. As previously discussed, exposure to outdoor, non-
rhythmic sensory stimuli can be restorative. Browning et al. (2014) state
“the human response to stochastic movement of objects in nature and
momentary exposure to natural sounds and scents have shown to support
physiological restoration.”Nature-themed temporal variation can enhance
the perceived passage of time, allow quiet contemplation, and foster
socialization.
The Camphill Ghent Elders in Community facility in Florida by Perkins
Eastman (Perkins Eastman, 2020) integrates outdoor spaces in a natural
setting, providing opportunities for therapeutic, non-rhythmic sensory
stimuli (Figure 3(a,b)). This facility is comprised of ten independent-living
townhouses, three buildings of independent apartment co-houses,avillage
house for younger residents and caregivers, and three residences housing
twenty-nine assisted-living beds (DeGroff & Wood, 2016). The landscape
architecture firm Dirtworks’design minimized ecological site disturbances,
highlights views of Hudson Valley, and its network of pedestrian paths and
Figure 3. (a, b) The Benefits of Non-Rhythmic Sensory Stimuli: Camphill Ghent Nursing Home,
Chatham, New York, USA 2017 by Perkins Eastman. The 100,000 sq. ft LTC facility is located on
110 acres of land in Chatham, New York. It features independent living as well as assisted liv-
ing, integrated with senior residents who have dementia. It was awarded the AIA Design for
Aging Review Merit Award in 2013. Photo Credit: Dirtworks, PC.
JOURNAL OF AGING AND ENVIRONMENT 13

associated spaces facilitates engagement with nature (Dirtworks Landscape
Architecture, 2015).
Thermal and airflow variability
This pattern, as defined by Browning et al. (2014) centers on “subtle
changes in air temperature, relative humidity, airflow across the skin, and
surface temperatures that mimic natural environments.”Kellert (2008) also
refers to fresh air as of critical importance to biophilic environmental
design, identifying it as a primary attribute within an “environmental fea-
tures dimension.”He argues that natural ventilation rather than mechanical
ventilation should be used wherever feasible, as a best practice, because it
can afford enhanced air movement and directional flow, sensory stimula-
tion (principally feel and smell), and esthetic appeal despite its seeming
invisibility (Kellert, 2008, p.7). The evidence-based literature indicates occu-
pants of LTC settings prefer natural ventilation in consort with self-oper-
able temperature controls.
Indoor environmental quality (IEQ)—specifically, appropriate levels of
thermal, acoustic, visual and air quality in buildings, has long been linked
to occupants’satisfactory health, wellbeing, productivity and overall com-
fort. A therapeutically supportive thermal comfort level in an LTC setting
is central to its overall success, from an occupant standpoint. Poor quality
environments where people live and work have been proven to cause ser-
ious illness. The occurrence of sick building syndrome (SBS) has been
repeatedly linked with an array of healthcare building types including LTC
facilities (United States Environmental Protection Agency, 1991). A review
based on 529 investigations conducted from 1971 to 1988 by the US
National Institute of Occupational Safety and Health, found that inadequate
ventilation was the primary contributor to building-related problems and
the occurrence of SBS symptoms (Seitz, 1989). Moreover, the deleterious
physical impacts of poor ventilation on people in healthcare facilities can
be fatal. Operable windows, balconies, and access to outdoor spaces is
necessary for this reason. A 1996 study examined the role of indoor venti-
lation in nursing home residents and its link to the spread of influenza.
The researchers found that 100% fresh air and local filtration in each room
significantly reduced the spread of illness, with an 87.4% reduction in influ-
enza in these buildings compared to others with only 30–70% recirculated
air and central filtration only (Drinka et al., 1996).
Elderly persons with dementia and related cognitive disorders often have
limited functional capabilities to rapidly, adaptively relocate from one place
to another. Adequate indoor air quality (IAQ) and thermal level control-
lability is of critical importance to human health, behavior, and wellbeing.
14 T. PETERS AND S. VERDERBER

In LTC residents, a non-supportive ambient indoor environment was iden-
tified as the principal source of behavioral disturbances among residents,
disturbances caused specifically by poor acoustics, lighting levels, and inad-
equate ambient air quality-thermal conditions (Wong et al., 2014).
The Fælledgården Nursing Home in Copenhagen, Denmark
(Figures 4(a,b)) is notable for the provision of accessible exterior space
adjacent to every apartment, and for its passive natural ventilation.
Architects JJW Arkitekter designed every unit with a balcony and operable
windows adjacent to communal courtyard spaces. The emphasis on natural
ventilation resonates with the biophilic pattern Thermal and Airflow
Variability. Evidence-based investigations on this issue summarized by
Loftness and Snyder (2008) highlight the relationships between health and
wellbeing in the design of views, daylight and natural air flow. Numerous
studies indicate residents prefer moderate levels of sensory variability
(Tartarini et al., 2017) including varied types of lighting and ambient illu-
mination levels (Shochat et al. 2000), modifiable ambient sounds and tem-
perature level (Rijnaard et al., 2016), and a personalizable space devoid of
unwanted sensory stimulation (VanHoof et al., 2015). Insufficient self-con-
trollability of these aspects of the residential setting resulted in feelings of
boredom and introvertedness.
The presence of water
This pattern is defined by Browning et al. (2014)as“a condition that
enhances the experience of a place through seeing, hearing or touching
water.”In biophilic environmental design rubric, water, together with light,
air, and plants, is an essential source of all life and human existence.
Figure 4. (a, b) The benefits of thermal and airflow variability: Faelledgården Nursing Home in
Copenhagen, Denmark 2010 by JJW Arkitekter. The 182,000 sqft assisted living facility is the
largest facility of its kind in Denmark, and was renovated to low energy standard, with balco-
nies and operable windows for all rooms.
JOURNAL OF AGING AND ENVIRONMENT 15

Kellert asserts the sight of water is visually appealing and capable of engag-
ing a wide variety of allied senses including sound, movement, touch, taste
and the olfactory sense (Kellert, 2018). Its multisensory, timeless appeal
makes water ideal to incorporate in outdoor gardens and landscapes, i.e.
fountains, ponds, reflecting pools, mist spays, rainwater spouts and water-
falls. Indoor water elements include waterwalls, reflecting pools, and recir-
culating “streams”(Kellert, 2018, p. 32).
The integration of water features and amenities in LTC settings remains
understudied although some research has been accorded the therapeutic
importance water in the context of attaining broader, multi-sensory design
attributes on LTC campuses. To a lesser extent, its role has been studied as
a general element of a “natural view”as experienced from the indoors or
from an outdoor vantage point. Table 1 lists the most relevant findings in
this regard, yet none specifically focus on LTC environments. Mador
(2008) has addressed design strategies integrating water, framing its thera-
peutic benefits around Kellert’s nine constructs of biophilic environments
(Kellert, 1997). Mador’s discussion does not specify any particular building
type, and the particularities of LTC architectural and landscape design
require further investigation. Water, within the context of a natural land-
scape, has been found to be of restorative benefit (Jo et al., 2019). There
remains the need for further research on water feature design attributes
most preferred in indoor and outdoor environmental LTC settings for resi-
dents with dementia and related cognitive disorders.
The Residence for the Sisters of St. Joseph Care Home in Toronto
Canada (Figure 5(a,b)) is a low-rise curvilinear building located between a
ravine edge and a landscaped open space (Frampton, 2014). Designed by
Shim-Sutcliffe Architects, the project successfully integrates water in the
exterior landscaping (Editors, 2015). Amenities include a chapel, dining
and kitchen facilities, meeting spaces and community rooms. A main fea-
ture is the connectedness with its natural setting; a reflecting pool functions
as the spiritual and physical center of campus, reflecting beams of light
throughout the day that bathe the interior natural wood-sheathed walls of
an adjacent chapel.
Dynamic and diffuse light
Browning et al. (2014) define this pattern as the ability to leverage varying
intensities of light and shadow that change over time, recreating conditions
occurring in nature. Similarly, Kellert identifies “Sunlight”as an important
attribute among his environmental features elements (2008), noting that
daylight rather than artificial light is consistently identified as a preferred
physical attribute in buildings; this preference for natural daylight reflects
16 T. PETERS AND S. VERDERBER

humans’diurnality, heavily reliant on the modality of sight as a means to
secure essential life-sustaining resources and to avoid the omnipresent haz-
ards inherent in the natural environment. Kellert connects this to the
importance of light in the fourth biophilic design element “Light and
Spaces.”Here, numerous design attributes are described pertaining to nat-
ural daylighting: filtered and diffuse light, light and shadow, reflected light,
light pools, warm light, and light as a scale- articulator of compositional
volume and form (Kellert, 2008, p. 11).
Multiple research studies highlight the significance of natural light in
LTC environments, typically as a reaction to the often poorly illuminated
conditions endured by building occupants for extended periods (Table 1).
Research on the effects of light therapy on seniors highlights the import-
ance of circadian rhythms in regulating vital bodily functions. Research has
found that built environments where people are chronically unsynchronized
with the body’s natural circadian predilections can negatively impact sleep
cycles, appetite, body temperature cycles, cardiovascular functions, mood
and emotions, levels of activity and cognitive functioning (Royer et al.,
2012). The provision of high-quality lighting in residential settings for per-
sons with dementia holds significant therapeutic promise.
The Wellcare Garden Fukasawa project in Tokyo, Japan is a seniors
housing facility with individualized levels of care (Archello, 2020).
Completed in 2017 by Nikken Housing System Inc, this project utilizes
innovative lighting strategies to minimize stress and promote wellbeing
(World Architecture Festival, 2018). Controlled daylighting, shading, mate-
rials, nature forms, and self-controllable lighting systems contribute to the
overall ambiance. Located in a busy urban setting, the building and front
plaza address the immediate neighborhood; a public forecourt is for use by
Figure 5. (a, b) The benefits of water: Residence for the Sisters of St. Joseph Care Home,
Toronto, Canada 2013 by Shim Sutcliffe Architects. The 96,000sq. ft project is the winner of the
2014 Governor General’s Medal in Architecture, the facility has fifty-eight residential suites
accommodating a variety of levels of care from independent living to skilled nursing care.
Photo credit: Scott Norsworthy.
JOURNAL OF AGING AND ENVIRONMENT 17

the home’s residents, visitors and family, as well as the local community. A
semi-private courtyard is viewable from the indoors, featuring highly glazed
facades and doors. Inside, a timer-controlled lighting system ensures interi-
ors are not automatically over-lit electronically whenever natural daylight is
simultaneously available. Additionally, a circadian lighting system combines
both natural and artificial lighting (World Architecture Festival, 2018).
Light fixtures allow for variable illuminance levels and color temperature
according to time of the day; this helps foster healthy sleep patterns and
promotes alertness during waking hours. Studies conducted on light levels
and light therapy with seniors highlight the salient role of circadian
rhythms in regulating vital bodily functions (Royer et al.,
2012)(Figure 6(a,b)).
Complexity and order
Browning et al. (2014) define this pattern as affording a multiplicity of sen-
sory information that nonetheless expresses clear spatial hierarchies similar
to those inherent in the natural environment. This translates to interesting,
comprehendible, identifiable, sequenced spaces and connecting paths navig-
able by an individual not dissimilar from how one would navigate a forest,
with its paths and multiple clearings. To date, no empirical research studies
directly address this pattern in LTC settings (Table 1). However, the con-
nection between delirium in patients in healthcare settings, seasonal
change, and circadian rhythms has been investigated (Balan et al., 2001). In
this respect, the typical LTC facility lacks spatial hierarchy. Nature ana-
logues—the indoor provision of nature-like forms, shapes, patterns and
Figure 6. (a, b) The benefits of dynamic and diffuse light in nursing homes: Wellcare Garden
Fukasawa project in Tokyo, Japan 2017 by Nikken Housing System Inc. The 96-bed facility for
seniors was shortlisted for the World Architecture Festival award in 2018 and incorporates a
range of natural and adaptable artificial lighting throughout the project and balances privacy
and urban life through various material and formal strategies.
18 T. PETERS AND S. VERDERBER

hierarchically sequential experiences—has been investigated as has the role
of fractal dynamics in esthetic experiences, and analogical relationships
between landscape preference and fractal properties (Hagerhall et al., 2004).
Interior spaces as well as exterior facades can express this pattern though
symmetries and fractal geometries configured within an overarching, per-
ceptible spatial hierarchy. Architecturally, the result can be visually stimu-
lating (Salingaros, 2012).
The Elderly Care Skarvet in Sweden (Figure 7(a,b)) features a striking
exterior facade and fenestration, with bold, diverse graphics evoking fractal
patterns found in nature (Fundaci
o Mies van der Rohe, 2019). Multiple vis-
ual conditions are achieved by incorporating more joints than facade ele-
ments and segmented tile patterns. Designed by Kjellander Sjoberg, the
overall effect thus resembles a textile pattern or a crocheted tablecloth
(Kjellander, 2020). Entrances, windows and roofs are accentuated by cop-
per-colored metal details, injecting natural tones and materiality (Kjellander
2020). Load bearing exterior prefabricated concrete panels, few load bearing
interior walls, and atypically high floor to ceiling heights (for this building
type), creating visual indeterminancy: an adaptable structure accommodat-
ing new functions as needed (Fundaci
o Mies van der Rohe, 2019).
Prospect-refuge
This pattern, as defined by Browning et al. (2014) is defined as an environ-
ment that provides “An unimpeded view over a distance, for surveillance
and planning. A place for withdrawal from environmental conditions or
the main flow of activity, in which the individual is protected from behind
and overhead.”This closely reinforces their Refuge pattern (2014). The
interrelated concepts of prospect and refuge are important to human well-
being and place attachment. In architecture, prospect might be a privileged
Figure 7. (a, b) Complexity and order in nursing homes: Elderly Care Skarvet in V€
axj€
o Sweden
2017 by Kjellander. The 59,200 sq. ft, L-shaped building was nominated for the prestigious
European Union Prize for Contemporary Architecture, the Mies van der Rohe Award (2019), and
1st. prize for the LEED Project of the Year (2019). Photographer: Max Plunger.
JOURNAL OF AGING AND ENVIRONMENT 19

perch from high above allowing one to look down to survey spaces below,
whereas refuge denotes a place to gravitate toward (in retreat from another
space) vis-
a-vis circulation spaces, allowing observation from afar or at least
from a once-removed (protected) vantage point. In landscapes, prospect is
afforded on hilltops and other types of vantage points, with refuge afforded
on the edges of a scene, with a view to the action without necessarily hav-
ing to engage with it directly or for sustained periods of exposure. Spatial
conditions aligned with prospect-refuge amenity provide a variety of spatial
experiences serving residents’differing functional abilities and predilections.
Balconies can be preferred spaces to survey activity below, and outward, as
protective, once-removed refuges (Dosen & Ostwald, 2016).
The Leonard Florence Center for Living Green House in Boston USA
houses residents in small group clusters, affording opportunities for pro-
spect-refuge behavior (Figure 8(a,b)). Bedrooms feature views looking onto
landscaped grounds. Each cluster of bedrooms has an entry zone with seat-
ing—a place to rest while visually surveying the outdoor milieu (Chelsea
Jewish Lifecare, 2020). This project was designed using the Green House
concept (NCB Capital Impact’s Community Solutions Group, 2010) which
fosters decentralization and enhanced connectivity with sunlight, greenery
and outdoor spaces (Cohen et al., 2016). It is the first urban Green House
V
R
case study, and its imagery projects a home-like ambiance with ten separate
“homes”each with common hearth, living room and open kitchen-dining
area. Residential scale is established and although six floors in height pro-
spect refuge opportunities underscore its non-institutionality. This case
study deftly balances refuge-seeking with prospect-seeking in the built
environment.
Similarly, the spatial configuration of the Ørestad Retirement Home in
Copenhagen, Denmark by JJW Architects (Figure 9(a,b)) balances pro-
spect-refuge opportunities. It is a residential village with eight residential
units interconnected by interior-exterior “streets and squares.”Private
Figure 8. (a, b) Prospect and refuge in nursing homes: Ørestad Retirement Home, Copenhagen,
Denmark, 2012, by JJW Arkitekter. The project is a 113,000 sq. ft. senior care facility with 114
residential apartments.
20 T. PETERS AND S. VERDERBER

apartments feature large windows, full views, private balconies, interiors
and natural daylight. The exterior color palette references recent contem-
porary architecture in Copenhagen (Prip, 2015). Its esthetic vocabulary is
strikingly atypical for a LTC facility with its fenestration and cube-like ele-
ments appearing to randomly extrude from the main envelope, thus pro-
viding individual expression to each apartment (Peters, 2014). Private
balconies provide fresh air and natural daylight while affording views to
the surrounding urban neighborhood from a protected perch (prospect),
once-removed (refuge) from the bustle of the city streets below.
Mystery
This pattern is defined by Browning et al. (2014) as the promise of more
information achieved through partially obscured views or other sensory
devices, enticing the individual to travel-ambulate further into the setting.
Table 1 shows few published research studies address the concept of mys-
tery in the context of biophilia or otherwise with even fewer related to bio-
philia-inspired LTC landscape and architectural design. The need exists for
evidence-based knowledge on the potential therapeutic benefits of the stra-
tegic incorporation of spatial variety, intrigue and intrinsically interesting
care settings for the aged and with dementia without causing informational
(sensory) overload, spatial disorientation, or similar deleterious behavioral
outcomes. Numerous studies have demonstrated how the strategic incorp-
oration of mystery can function as a sought-out attraction, including
nature-landscape features (Ikemi, 2005; Nasar & Cubukcu, 2011; Szolosi
et al., 2014).
The Santa Rita Geriatric Center in Menorca Spain is a single-level LTC
residence by Manuel Ocana Architects (2003). It is unconventional and
Figure 9. (a, b) Prospect and refuge in nursing homes: Leonard Florence Center for Living
Green House, Chelsea, Mass. USA 2010 by DiMella Shaffer Architects. The 93,000-square-foot
LTC facility offers short term rehabilitation, long term care and specialized support for residents
with ALS (Amyotrophic Lateral Sclerosis) and MS (Multiple Sclerosis). Photographer: Robert
Benson Photography.
JOURNAL OF AGING AND ENVIRONMENT 21

non-institutional, engaging residents with an environment to be explored
and traversed in varied ways (Manuel Ocana Architects, 2003). Bedrooms
are clustered around a landscaped courtyard with seating and gardens.
Inside, a polygonal perimeter corridor-path facilitates socialization opportu-
nities Individual spaces and circulation paths are non-prescriptive in the
sense that multiple routes can be taken indoors and outdoors. This pro-
motes individualized wayfinding through a palette of explorable spaces,
with differing intensities and types of natural daylight that allow occupants
to self-determine which path to take and how long to be there. Variable
lighting, materiality, and colors mark the different zones throughout the
building. For example, zones are color coordinated with colored stripes
running over ceilings and walls to facilitate wayfinding (Manuel Ocana
Architects, 2003). The perimeter circulation path creates opportunities for
self-discovery, encouraging further exploratory behavior (Figure 10(a,b)).
Conclusions and future priorities including COVID-19
This discussion has focused on the strategic identification of a subset of ten
biophilic design patterns considered highly apropos for consideration in
the functional planning, architectural and landscape design of LTC envi-
ronments. The patterns were chosen with particular emphasis on the needs
of residents with dementia and related cognitive disorders. The peer-
reviewed literature pertaining to this building type and its associated land-
scape settings was reviewed, distilled, then examined vis-
a-vis recently-built
case studies deemed exemplary from the standpoint of each one’s prior rec-
ognition garnered. Beyond, each case study presented above expresses one
or more of biophilic patterns as defined by Browning et al. (2014).
Figure 10. (a, b) The benefits of mystery in nursing homes: Santa Rita Geriatric Center,
Menorca, Spain, 2003, by Manuel Ocana Architects. The single level facility has large courtyard
and exterior gardens that can be experienced by residents as they walk along the perimeter of
the building. Photography: Miguel de Guzm
an.
22 T. PETERS AND S. VERDERBER

This has been the first published literature review specifically on bio-
philia in the context of long-term care environments for persons with
dementia and related cognitive disorders. Published studies relevant to LTC
environmental design span numerous disciplines including psychology,
education, sociology, philosophy, toxicology/public health, urban design,
landscape architecture, and architecture. That said, there is a growing inter-
est in biophilic design principles on the part of designers, LTC administra-
tors, and direct caregivers. Personal safety and security should be a priority
for persons with dementia and related cognitive disorders, however, institu-
tional design or policies that result in conditions devoid of nature and
landscape content are counterproductive if not outright countertherapeutic.
This applies to the design and furnishing of the indoor setting as well as
the design and furnishing of exterior spaces.
It was not possible to examine each case study comprehensively from the
standpoint of its biophilic built environment attributes. This would have
required time and fiscal resources unavailable to the authors. For example, a
case study included to illustrate a particular feature may not have extended
throughout the entire facility and its exterior environs. A given case study
might, for example, feature a therapeutic garden with a prescriptive wander-
ing path specifically for the cognitively impaired, although this same facility
may have not featured full views to this same garden from the main dining
room. In other words, the intent from the outset was not to conduct a com-
prehensive, full-facility post occupancy assessment on-site of either a given
facility’s total biophilic content nor the responses of its inhabitants to this
content. This is to be the subject of further investigation.
Several limitations encountered in this study warrant mention. First, ter-
minology differs across retirement homes around the world, making it dif-
ficult at times to pinpoint relevant case studies expressive of core biophilic
design principles and strategies. Second, not all built case studies are
equally well documented. Even if so, many lack critical information, i.e.
floor plans, pre/post occupancy study findings, photos of personal spaces
occupied by their residents, information about material palettes employed
in the project, and so on. Is this because LTC building typologies tend to
remain under-documented, generally, in architectural and landscape archi-
tectural media? Many old-school “nursing homes”built in the 1960s, “70s
and 80s”were site planned and designed to be efficient and inexpensive
above all, not salutogenic or biophilic per se. As a result, many still-used
facilities from this era neglect the therapeutic potentialities of the built
environment. Additional questions to be examined in future research on
this subject center on quality of life determinants for direct caregivers and
family members, because nursing burnout, diminished job satisfaction, and
family disengagement pose significant challenges.
JOURNAL OF AGING AND ENVIRONMENT 23

Finally, there remains the urgency of the COVID-19 global pandemic of
2020 and 2021 and its long-term ramifications for the biophilic-informed
planning and design of 24/7 care environments for the aged. The COVID-
19 pandemic has had catastrophic, disproportionate impacts on residents
and staff in long term care homes globally. These adverse outcomes have
been attributed to aging facilities in need of replacement. In particular,
older nursing homes have borne the brunt of this critique - with their nar-
row hallways, and overcrowded conditions with up to four residents occu-
pying a single bedroom with one communal washroom/shower. Many
coronavirus pandemic fatalities in the 2020–2021 period were attributed to
long term care facilities; in some countries the mortality rate that occurred
these settings reached as high as 80% or more of the total population
affected, at the height of the pandemic (Brean, 2020). Biophilic-inspired
design can lead to better quality of life for residents of LTC homes. This
literature review and the associated case studies yielded the following
conclusions:
1. Spaces that provide multisensory connections with the outdoor realm
are of therapeutic benefit as occupants’consistently express a preference
for visual and non-visual engagement with nature and landscape.
2. Natural ventilation mimicks nature’s rhythms. Operable windows allow
for self-determination of interior thermal conditions and auditory con-
nectivity with nature, thus reducing the potential for disease
transmission.
3. Natural daylighting can enhance occupants’well-being and satisfaction
in LTC residential environments by enlivening interior spaces while
affording views of nature-landscape and the broad exterior realm.
4. During the COVID-19 pandemic many residents in LTC settings
became hyper-isolated, with family visitations prohibited. Large-scale
facilities are to be eschewed in favor of smaller, decentralized residential
care settings that foster more direct interior-exterior connections.
The current pandemic has had a disproportionately adverse impact on
residential long-term care environments. That said, the effective integration
of biophilia-inspired design attributes and experiences with resident safety
and infection control remains a pressing design challenge at this time. This
can be best achieved if this duality is accorded high priority early on in the
planning and design process. Otherwise, biophilic architectural and land-
scape design strategies may be undervalued, or worse, dismissed outright.
The need is pronounced for evidence-based research on the potential thera-
peutic benefits of biophilia, together with resident safety and infection con-
trol (Anderson et al., 2020). Regardless, thousands of new residential care
24 T. PETERS AND S. VERDERBER

built environments for the aged will be renovated and constructed in the
coming decade. It is hoped this discussion will be of help in advocating for
architectural and environmental design excellence for persons with demen-
tia and related cognitive disorders.
Note: All permissions to reproduce photographic illustrations have been
obtained by the authors, with a few exceptions. In these cases, contact sour-
ces were unavailable or non-responsive to the authors’inquiries.
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