Key Characteristics of Dementia-Friendly Environments: An Observational Study in Hungarian Nursing Homes
Bálint Balázs1,2, Barbara Fogarasi1,2, Emőke Bukovenszki1,2, Attila Kurucz1,2, Violetta Toth-Varga2, Andrea Dúll2,3
1 ELTE Eötvös Loránd University, Doctoral School of Psychology, Budapest, Hungary
2 ELTE Eötvös Loránd University, Institute of People–Environment Transaction, Budapest, Hungary
3 Budapest University of Technology and Economics, Department of Sociology and Communication, Budapest, Hungary
Keywords:
dementia-friendly environment, nursing home, environmental psychology, field observation
One of the significant challenges contemporary societies face is ensuring the living conditions and the psychological well-being of the aging population. Additionally, it is crucial to develop an institutional and social safety net that can effectively mitigate the impact of age-related diseases. In pursuit of these objectives, it is essential to integrate scientific frameworks grounded in empirical data collection, initiate transdisciplinary research projects, and promote international collaboration among diverse countries and regions. Our research investigates the environmental characteristics observable within nursing care institutions in Hungary, with a specific focus on dementia-friendly architectural practices. This exploration encompasses a detailed analysis of spatial design, organizational structures, and the socio-physical environment at large.
Our research, supported by environmental psychology and space morphology methods, employs expert observation alongside space syntax analysis. It aims to understand the fundamental elements of dementia-friendly environments within nursing care homes in Hungary. Focusing on how the built environment of elderly care institutes supports the well-being of its residents, the main research question is how security, privacy, and the possibility of social interaction are achieved in the socio-physical context of patients living with dementia.
Given that all institutionalized nursing environments are regarded as a ‘home’ for the residents, the concept of ‘homeness’ in such settings is particularly significant in the examination of these institutions. There is an emotional and meaningful connection between residents and their ‘homes’ (Dovey, 1985), therefor in the interactions between individuals and their surroundings, homes ought to be “conceived as a dynamic confluence of people, places, and psychological processes” (Werner et al., 1985 p. 2). Furthermore, ‘home’ signifies personal accomplishment, functions as a center for significant relationships, and embodies an individual’s character. These elements contribute to the maintenance of a sense of identity and self-esteem (Lawton, 1990).
Previous research indicates that older individuals residing in institutionalized elderly care facilities experience lower self-esteem, a negative self-concept, and a more limited sense of interpersonal self in comparison to those living in home environments (Antonelli et al., 2000). Interviews with elderly care home residents reveal that understanding the concept of ‘home’ is vital for addressing the negative perceptions of nursing homes as distant and undesirable (Groger, 1995).
Natural ageing is associated with a decline in perceptual performance across visual and auditory perception, thermoception, as well as touch, smell, taste, vestibular and proprioceptive processes. For individuals living with dementia the ability to process information from the outside world is greatly reduced, and they are unable to cope and respond optimally to the environment because of its overwhelming or complex sensory demands. The impairments include a narrow field of vision, reduced visual-spatial orientation, lack of shape recognition, hallucinations, loss of depth perception and misinterpretation of complex visual scenes or visual images such as shadows, reflected images and mirrors. These are often accompanied by cognitive decline, including memory impairment, the inability to express oneself, impairment in executive functions, difficulty in initiating tasks, poor judgments about safety, uncertainty, fear of failure, and misrecognition of objects (agnosia). Dementia-friendly spatial design should incorporate strategies that effectively compensate for perceptual impairment (Orfield, 2015). Considering the socio-physical environment, it is crucial to emphasize that the perceptual challenges associated with dementia can make it difficult for individuals to perceive and navigate their surroundings, even in well-designed spaces. Therefore, the social environment, including caregivers and family members, plays a vital role in supporting individuals with dementia. This support can involve guiding them during walks or reinforcing auditory and visual information to help them adapt to and better perceive their environment. This support is essential because the difficulty in orienting oneself to the physical environment can lead to frustration, potentially discouraging the individual from trying again, which may in time lead to a complete disengagement from the environment.
Research Methodology
During the initial investigation phase we collected data through structured and semi-structured observational methods to evaluate the physical and spatial attributes of interior and exterior spaces. We documented our findings with notes and photographs to capture the intricate characteristics of the spaces and their usage. We focused on both the tangible and intangible elements of nursing homes, including space utilization options, variations across different areas, material and design features of dementia-friendly architecture, the influence of ambience (such as noise, smells, lighting, and colors), environmental stressors (like congestion and disturbances), social interactions, and the observation of people's movements.
The semi-structured data collection method was conducted with the assistance of the caretakers of the institution. Our focus was on the characteristics and spatial utilization of environments, addressing aspects such as security, privacy, social relationships, and socio-physical space. This also included exploring elements promoting water intake, as well as design features and material characteristics associated with dementia-friendly architectural practices. We also evaluated ambient factors, including noise, odors, lighting, and colors, while identifying environmental stressors, such as congestion and disturbances. Additionally, we observed spaces designed to foster social interaction.
During the structured field observation, we concentrated on four key spatial elements within the institution: private rooms, corridors, designated social areas (such as the chapel, dining room, and lobby), and the surrounding park. The observation criteria included the following aspects: visual elements of the spaces; general architectural descriptions of the environments; the degree of differentiation within the surroundings; opportunities for room personalization; the promotion of hydration through the physical environment; the use of pictograms, maps, and other visual signs and landmarks; the assessment of ambient stimuli; the presence of objects that hinder spatial orientation; surfaces and features that suggest affordances; and the behavioral patterns of elderly residents and caregivers.
Additionally, we employed space syntax analysis to reveal the spatial features of the elderly care institute. Space Syntax is a set of analytical techniques used to examine the connections of spaces in a spatial system of a building, and how these connections influence movement patterns and the various activities of people (Hillier, 1996; Hillier and Hanson, 1984). In this study we utilized measurements of integration to assess the proximity of a space in relation to all other spaces within the spatial system. Additionally, we analyzed the permeable and visible relations of spaces in the nursing homes. The spatial integrations revealed the most accessible areas within the spatial system of the buildings. This information is particularly important for caregivers, as it identifies the most central spaces that allow them easy access to residents’ rooms. These measurements also highlighted the most segregated rooms within the nursing homes. The visual integration analysis identified the most visible spaces within the system, from which most areas could be monitored by caregivers. These findings also showed us how easily elderly residents could find their way within the analyzed buildings. In buildings where spaces are both spatially and visually highly integrated, wayfinding tends to be easier. As Passini and colleagues (Passini et al., 2000) noted, elderly residents are better able to make wayfinding decisions when most of the necessary information is readily available within the spatial system. This means that spaces that are accessible both visually and spatially can support successful navigation. Conversely, dark and closed spaces - in our terminology: segregated spaces - can act as obstacles, causing confusion and anxiety for residents during wayfinding.
Results
Regarding the spatial integration of spaces, the corridors and staircases were identified as the most integrated spaces (red, orange). In contrast, the restrooms and basement offices were found to be the least integrated spaces (green, blue) within the institution. The ground floor and first floor displays the highest levels of integration, whereas the basement exhibits the lowest degree of spatial integration. Our visual integration analysis revealed that all areas are visually segregated, except for the corridors, which represent visually cohesive elements within the institution.
By comparing the field observations with the integration analyses, the following preliminary conclusions can be drawn about the private rooms, corridors, designated social areas (chapel, dining room, and lobby) and the surrounding park. From the field observation, it is clear that the rooms are ‘extremely overcrowded with furniture’ and ‘too many people live together in one room’.
Only the ‘(childish) drawings on the door’ differentiate the rooms with symbols. Furthermore, these areas are not easily visible from the corridor, which may contribute to a sense of privacy and intimacy. In terms of spatial integration, the rooms are moderately integrated within the institution; however, visually, these spaces are less visible and harder to perceive from other parts of the building.
Based on the field observations, the corridors are relatively short and provide clear accessibility to other spaces within the institution. The color contrast between the flooring and the paneling assists in wayfinding, while the conveniently located nurses' desk serves as a point of reference. Additionally, a gate has been installed in the dementia unit to prevent patients from wandering. It was also noted that the corridor experiences significant overcrowding due to the placement of various types of furniture. Overall, these areas represent spatially and visually integrated components of the institution on each floor, with specific emphasis on the nurses’ desks as key focal points.
The designated social spaces (chapel, dining room, and lobby) are welcoming yet challenging to access without caregiver assistance. Although these areas are spatially separated, their usage has the potential to transform the character and function of these spaces.
Although the garden, as a green space attached to the institution, is intended for leisure activities such as walking, sitting, relaxing, socializing, observing natural phenomena, or engaging in sports, it poses significant accessibility challenges without assistance. This is not surprising, as the garden is solely accessible from the basement and the ground floor (main entrance).
Conclusion
The existing environmental conditions are considered inadequate from a person-environment transaction perspective. Consequently, it is essential to strenghten human capacity to address the personal needs of the elderly. Certain areas are overly congested, such as rooms accommodating three or four patients, while others require a reassessment regarding their usability and accessibility, including designated social spaces and parks. Although what was formerly a pilgrimage house has been repurposed as an elderly care facility, this change in use has not substantially impacted the spatial characteristics of the premises.
Acknowledgments:
We would like to thank our project partner, Máté Paksy (Université Catholique de Lille) and the staff of the elderly care institute.
The research project called ‘Tempora et mores - Transdisciplinary knowledge transfer and experience exchange between Eötvös Loránd University, Institute of People-Environment Transaction, Budapest and Université Catholique, Lille’ is supported by the 2021-1.2.4-TÉT program of The National Research, Development, and Innovation Fund
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