Silver Book II: Frailty-friendly building design

Good practice guide
Good practices guides focus on providing information on a clinical topic.
(Section editors)
Andrew Price
Efthimia Panzartis
Date Published:
22 February 2021
Last updated: 
22 February 2021

The Silver Book II was written to address the care needs of older people, specifically older people living with frailty, during the first 72 hours of an urgent care episode. This chapter, by Efthimia Panzartis and Andrew Price, looks at the impact of the physical environment and how this can be optimised to help provide safe and effective care.

The built environment in which the care is delivered plays a critical role in ensuring older people experience the smoothest possible journey through their care pathway, which directly benefits their individual needs, and supports staff and carers.

Following an extensive literature review in addition to the evidence and findings from the English Department for Health’s Dementia Capital Programme, 12 design principles for dementia-friendly environments were identified. Recommendations have also been provided for each principle in terms what dementia-friendly health and social care environments should, and should not, do. The rationale behind the development of the principles has been linked to dementia-related sensory, cognitive and physical impairments. These principles have been tailored in this section to suit the urgent and emergency care needs.

To complement these 12 principles, subsequent sections discuss the importance of environmental design features, dementia type, early diagnosis, carer engagement, integration and technology to the care pathway. All the principles apart from Principle 1 have been grouped under three dementia-related categories: sensory; cognitive; and physical.

Dementia can reduce the ability to see, hear, taste, smell and touch. People with dementia can also find it difficult to distinguish and differentiate between simultaneous sensory stimulations, leading to confusion and disorientation.

Difficulties in hearing, remembering and communicating can contribute to the person living with dementia experiencing difficulties in navigating and engaging with their environment and the people in it. The consequence is reduced ability to communicate effectively and interact in social settings. Dementia-friendly environments need to promote provide a non-institutional scale and environment, to support orientation, wayfinding and navigation. These should also aim to provide access to nature and the outdoors and promote engagement with friends, relatives and staff.

Day-to-day functions such as walking, standing and sitting become increasingly difficult as the disease progresses. The person with dementia can also experience problems eating as the ability to chew and swallow is impaired. Dementia-friendly environments therefore need to provide good visibility and visual access, promote privacy, dignity and independence, promote physical and meaningful activities, and support diet, nutrition and hydration.

The design of ceilings and ceiling finishes should reduce sound transmission, glare and shadows from ceiling lights. Use ceilings that provide points of interest or locational and directional information at the line of sight and with identifiable size of fonts and pictograms.

The design and specification of doors should enable independent orientation. Door closure systems should be designed to ensure smooth and quiet closures, to avoid unintended noise that could cause distress and anxiety to patients and residents when doors are operated, especially at night.

Flooring design and selection should be consistent, matt, non-reflective and non-patterned throughout the building to avoid confusion and encourage movement. Internal flooring should have non-slip and non-shiny textures to reduce slips, trips and reduce injurious falls without causing confusion due to sudden and unexpected changes in flooring type and/or feel.

The design of walls and wall finishes should be non-patterned, matt and anti-glare, with colour accents and feature walls used to promote calm and safe environments. The design and installation of windows and transparent panels should not compromise privacy and dignity. External glazing solutions should maximise views of natural outdoors and the skyline. Window openings should provide: fresh air, which can improve wellbeing; and suitable illumination and ventilation of all main areas. The use of windows and transparent panels can reduce distress and anxiety as they can enhance sight of activities in adjacent spaces.

Elements that can enrich the built environment include artwork, decoration, furniture and fittings, reminiscence hardware and software, and signage.

Traditional pieces of artwork and more modern elements of artistic representation (e.g. digital photography and photo-frames, projectors with sensory animated scenes) can ensure people with dementia spend time in settings as close as possible to how they were living prior to the onset of dementia (e.g. eat, sleep, dress and do activities). Artwork selection should consider culture, as different types of art may have different connotations for people from different cultural backgrounds, but allow personalised artwork in any space aimed at promoting self-esteem and personal identity.

Decoration can enhance lighting and provide good colour contrast and a non-institutional homely environment, with elements of soothing décor to help people living with dementia to orientate in and navigate around the building. Themes for decorative finishes should flow through all areas and across all spaces to avoid confusion and distress and enhance the journey and personal experience whilst navigating the built environment, avoiding excessive use of patterns and clutter.

Colour-coordinated furniture and fittings can support recognition and orientation, however, traditional and/or familiar shapes and sizes should be used to facilitate recognition and identification. Bright, simple and non-institutional furnishings should be used where possible, with due consideration given to softness and brightness. Fittings should be adjustable and flexible to the needs of people living with dementia. Sharp edges should be avoided in furniture and fittings to minimise risks of harm for people with dementia and the choice of layout should reduce space clutter.

Reminiscence hardware and reminiscence software embedded within the built environment can be used to enhance sensory perceptions and enable people living with dementia to collect, promote and organise information in an individual and personal way. Staff and carers might be required to operate them while friends and relatives should be actively engaged and provide material to develop life stories aimed at prompting recall of positive personal life events, experiences and achievements to inform carers and enable person-centred care delivery. However, this will be more challenging in settings where patients stay for a relatively short time.

Signage should be purposefully designed to promote independence, orientation, wayfinding and ensure inclusive access for everyone, avoiding clutter and information overload. Clear contrast and consistency should guide the design and choice of signage. Directional and locational signage should use clear symbols for people who do not read or are unable to read or decipher words, while tactile signage can help those with visual impairments.

Technical elements include acoustics, colour and lighting, that could potentially be applied cross-construction element and to other elements.

Dementia-friendly acoustics should consider locations where clear speech is important and where noise (i.e. unwanted sound) needs to be reduced or absorbed to ensure that distress and anxiety are minimised. Sound-absorbent construction materials and finishes should be used for surfaces, fixtures and fittings whenever possible as they can contribute to quieter, peaceful and restful environments. Noise reducing design solutions and sound-effect technologies should be integrated within the built environment during the early design stages.

Colour design is a fundamental element in dementia-friendly environments, as contrast sensitivity is the most consistent visual deficit in people living with dementia, and people with particular types of dementia may have to rely on their conceptual knowledge to identify individual items and thus use size and orientation in combination with colour. High-level contrast between the different elements of the built environment should also be used to support orientation, wayfinding and creation of calm environments.

Dementia-friendly lighting should be designed to provide control, create different moods and create calming environments, and to help regulate the human circadian system on to a 24-hour light-dark pattern. Type of light, colour of light, level of luminance, direction of lighting sources, reflection and diffusion, glare, system operability, flexibility of switching between different uses, fixtures, maintenance and upgrades, and energy consumption are all elements against which an effective and efficient design solution should be determined.

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