Boredom is a killer. Ask any preschool teacher or any retirement facility manager and they’ll tell you that the worst thing they can do is let their charges get bored. And that goes for dementia patients, too – possibly even more so.
To care and protect
Obviously, the most urgent and essential aspect of care is to ensure the safety of the people being cared for. But an emphasis on safety and security can ‘coerce those people living “in care” into becoming passive participants in daily routines that are out of their direct control,’ as William G McMorran of Architectonicus says in his 2017 study of the relationship of architecture to the care of dementia patients: The architecture of care – a new approach.
This resonates with the main argument in the 2006 book1* by Judith Torrington (School of Architecture, University of Sheffield), who says:
Quality of life was shown to be poorer in buildings that prioritise safety and health [over wellbeing]. Buildings that positively support activity by providing good assistive devices, giving people control of their environment, and affording good links with the community have a positive association with wellbeing.
Care vs control
McMorran explains that the physical structures and spaces in which care takes place largely dictate how much interaction is possible between carers and residents, and between residents. Most care facilities, he continues, are based on a long-standing default design of lots of rooms leading off long corridors – structures he describes as ‘essentially the most basic people storage; effectively a giant human filing system’. On the surface, this design might seem efficient but, McMorran explains, it is stressful for all parties:
The opportunity for independent expression of personhood is substantially limited and a culture of dependence is consequently the basis of most care provision. Care staff become so fully preoccupied by the pressures this dependence imposes that they are unable to create for themselves the empathetic, shared oneto-one care that would increase wellbeing in those they care for and reduce the frustration and exhaustion generally experienced by carers.
Continuing with the obvious similarities (despite the equally obvious immense differences) in caring for children and caring for people with dementia, everyone acknowledges that nurturing potential, allowing for creativity and meaningful social interaction, is an essential part of caring for children, and recent research shows that older people – including and especially people with dementia – need that too. Old age, and even dotage, should be a time of consolidation, a time to creatively bring one’s life to a close, but the generally held, knee-jerk, default assumption is that – especially for people with dementia – it’s just an interim arrangement of killing time until you die.
Spaces for care
Early reactions to the obvious ineffectiveness of the corridor style of building in caring for older people and/or people with dementia involved creating spaces that replicated traditional households. It was certainly an improvement, but they failed to take into account the difference in social and care interactions in a family setup as opposed to a residential care setup. So, while the inclusion of sitting rooms and the clustering of bedrooms did away with the institutional feel of single-room models, these initiatives were only partly successful for two reasons, according to McMorran. The first is that many still rely on the corridor system between the units, and the second is because:
despite being considered a home-from-home, activities are generally segregated in exactly the same way as in one’s own home. All the same problems of social disconnection remain. Without substantial assistance, independent access to daily routine and activity remains as difficult as in one’s own home. Consequently the necessary high ratio of staff to residents (two to five or six) creates an unsustainably labour-intensive care model. But, most fundamentally, the social structure is exactly not like one’s own home, for in this model each resident shares “their” home with the other residents.
Echoing the inevitable comparison between children and older people (starting to see where the term ‘second childhood’ originated), McMorran discusses playground design:
Playgrounds are an excellent example: opportunity for a child to independently choose their preferred activity is made abundantly possible by the layout of a wide range of safe spaces containing different play equipment. While playing, it is possible for each young person to scan across and see what other playmates are enjoying, and make further independent decisions about what – or what not – to do next. Learning by participation leads to confidence building; trusting friendships are established. Significantly, family and friends – “the carers” – are able to easily and passively supervise the playground because generally sightlines are clear. The need for intervention and intrusion is minimised, and anticipated difficulties can be pre-emptively handled before a crisis develops. This whole scenario would be ridiculously impossible were the playground and each play zone accessed by corridors and surrounded by high walls.
It’s a case of ‘out of sight, out of mind’. If people (children, older people, dementia sufferers, you and me) are kept confined to one space from which we can’t see other people, and can’t identify opportunities for interacting, we will just wither away. We’ll get bored, and, to misquote Yoda: ‘Boredom is the path to the dark side. Boredom leads to frustration. Frustration leads to anger. Anger leads to suffering.
Creating caring spaces
The simple take-home message from all this is that the best possible designs for social interaction – regardless of who the residents are – utilise a central courtyard with rooms and/or units facing inwards and facing each other. And, while these courtyards may be square or rectangular, they don’t have to be (in fact, triangular courtyards have some advantages), particularly in terms of creating access and flow to gardens and other outdoor areas.
From Architectonicus’s work in designing dedicated dementia care facilities in the UK, Australia, Canada and Europe, McMorran has distilled some basic principles for ensuring more effective, efficient and caring care, and – most importantly – better quality of life for residents (and consequently, also for staff).
• Arrange bedroom/apartment accommodation to directly embrace the main activity area without resort to corridors – opportunity for immediate engagement is imperative.
• The main activity area should allow direct lines of sight for residents and staff – enabling way-finding for residents, and maximising ability for unobtrusive visibility of residents by staff.
• Ensure direct integration of inside and outside spaces, i.e. a small garden area to be in wide and full view from the interior.
• Each resident’s personal identity is expressed by a ‘threshold’ area immediately outside their private space to act as:
» a transition zone between private and public areas
» a place for expression of self by use of personal objects
» a safe place of one’s own in which to sit and observe, and meet and greet.
• The main activity area should provide sufficient space for social groups of between 10 and 12 residents, with – optimally – a maximum of two professional skilled dementia care staff (plus volunteers). A wide variety of permanently available activities should be possible within this space throughout the day.
• The communal space should be well ventilated, naturally lit as far as possible, and contain facilities for interaction, making simple meals, and making tea or coffee. It should also have a view of an accessible garden. The garden space should be designed for easy access and active participation by residents – possibly with some raised beds in which residents can grow flowers or even veggies that can be used in the kitchen.
The above are almost all based on increased visibility and access. While this may seem to be in conflict with our Western need for privacy, it doesn’t need to be. The designs allow for increased visibility, but there is always the option of retreating to one’s private space and closing the door. So, really, it’s not about privacy vs accessibility, it’s about choice.
“Boredom is the path to the dark side. Boredom leads to frustration. Frustration leads to anger. Anger leads to suffering.” Apologies to Yoda and George Lucas