Aim of This Study scale from clinical practice,15 which was developed
on the basis of the Global Deterioration Scale.16
Architectural features that support the resident’s To systematically analyze the orientational
residual spatial abilities and promote their mobility abilities of people with dementia, measurable vari-
and independence were to be identified through an ables are required—in this study, the finding of
empirical study in selected nursing homes. To imple- places relevant to the residents. Those who felt com-
ment the results into the design of new or remodeling pelled to wander and walk around all the places of
of the existing facilities, a publication on design the home were not included in this study.
criteria would be developed. The data collections were carried out in 30
German nursing homes, and 450 residents (mild
dementia n ¼ 91, moderate dementia n ¼ 183,
Design and Methods severe dementia n ¼ 176) were rated. From these
data, the average orientational indices were calcu-
The impact of the characteristics of the architectural
lated separately for each of the 5 routes, and also
structure of a nursing home on a resident’s wayfind-
as a sum of routes 1 to 3 as the overall orientational
ing abilities can be measured by the destinations they
index of the home (here routes 4 and 5 remained out
were able to reach independently. Therefore, 5 char-
of consideration because those destinations were not
acteristic routes within the living areas of the home
existent in all the analyzed homes).
were chosen. To contribute to the resident’s inde-
Through an empiric-qualitative exploration,
pendence, the routes had to be a part of the activities
architectural features of the floor-plan structure
of daily living:
were graphically analyzed and quantified. The layout
(1) To go to the live-in kitchen (in all homes these were
of the circulation system was the most distinctive
open-plan kitchens, featuring a kitchen unit and a variation, and 3 major typologies were identified:
dining table). straight circulation systems (n ¼ 14), layouts that
(2) To identify and go to the resident’s individual featured one shift in direction (eg, L-shaped circula-
bedroom. tion systems, n ¼ 9), and continuous paths around
(3) To go to the toilet (either in the resident’s own an inside courtyard (n ¼ 7). Within these 3 typolo-
bathroom or to an additional bathroom within the gies, differences in the shape of the walls of the
living area, if provided). corridors were identified: 40% featured smooth
(4) To go outside (into the garden or to a balcony). walls, 60% featured several wall recesses and
(5) To go to the common room. alcoves. Within the straight circulation systems, the
possibility to overview the whole living unit was ana-
If, or how, the residents were able to find those
lyzed, which was given in 42% of these homes. The
destinations, was rated by the head of nurses and/
other distinctive features of the nursing homes
or a gerontopsychiatric trained nurse as shown here:
included the number of live-in kitchens within the
0 Point resident does not find the way.
residential living unit, the availability of an addi-
1 Point resident needs some reminder or direction to tional toilet outside the bathrooms of the resident’s
reach the destination. rooms, and the way the access to the outdoor space
2 Points resident reaches the destination independently. was designed.
According to their architectural features, the
The stage of dementia (mild, moderate, or severe) nursing homes were divided into groups and subse-
that the resident was in was identified by using a quently ranked on the basis of the orientational
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Dementia-Friendly Architecture / Marquardt, Schmieg 335
Straight circulation routes (str) provide better orientation than str n ¼ 11 str n ¼ 12
typologies featuring one change in direction, eg, L-shapes (cd) cd n ¼ 16 cd n ¼ 13
Route 1–3 P ¼ .040a P ¼ .001c str x ¼ 5.15 0.88 str x ¼ 2.93 1.45
cd x ¼ 4.27 cd x ¼ 1.48
A continuous path (cp) causes lower orientation than all cp n¼7 cp n¼7
other considered typologies (oth) oth n ¼ 20 oth n ¼ 18
Route 1–3 P ¼ .048a P ¼ .002b cp x ¼ 3.78 1.15 cp x ¼ 1.15 1.43
oth x ¼ 4.93 oth x ¼ 2.58
Typologies featuring one change in direction (cd) provide better cd n¼9 cd n¼6
orientation than typologies featuring a continuous path (cp) cp n¼7 cp n¼7
Route 1–3 P ¼ .122 P ¼ .058 cd x ¼ 4.65 0.87 cd x ¼ 1.88 0.73
cp x ¼ 3.78 cp x ¼ 1.15
Straight circulation routes (str) provide better orientation than all str n¼8 str n¼9
other typologies considered (oth) oth n ¼ 19 oth n ¼ 16
Routes 1–3 P ¼ .050a P ¼ .001c str x ¼ 5.22 0.84 str x ¼ 3.12 1.47
oth x ¼ 4.38 oth x ¼ 1.65
Overview on the whole circulation system (ov) provides better ov n¼5 ov n¼6
orientation than all other typologies considered (oth) oth n ¼ 22 oth n ¼ 19
Routes 1–3 P ¼ .049a P ¼ .006b ov x ¼ 5.32 0.86 ov x ¼ 3.20 1.34
oth x ¼ 4.46 oth x ¼ 1.86
Corridors with smooth walls (smw) provide better orientation alc n ¼ 16 alc n ¼ 14
than corridors with alcoves and wall recesses (alc) smw n ¼ 11 smw n ¼ 11
Route 1–3 P ¼ .156 P ¼ .292 alc x ¼ 4.45 0.43 alc x ¼ 2.02 0.35
smw x ¼ 4.88 smw x ¼ 2.37
Living areas with only one live-in kitchen (one) provide better one n ¼ 16 one n ¼ 15
locating of this place than units with several (sev) sev n ¼ 11 sev n ¼ 10
Routes 1–3 P ¼ .010b P ¼ .001c one x ¼ 5.01 0.93 one x ¼ 2.89 1.77
sev x ¼ 4.08 sev x ¼ 1.12
Formation of the live-in kitchen to a spatial anchor point (ap) ap n¼4 ap n¼3
provides better locating of this place than other designs (oth) oth n¼9 oth n¼9
Route 1 P ¼ .045a P ¼ .026a ap x ¼ 1.76 0.45 ap x ¼ 1.13 0.65
oth x ¼ 1.31 oth x ¼ 0.48
A shared toilet within the living area (tl), additional to the residents tl n¼8 tl n¼7
en suite bathrooms, increases the locating of a toilet (none) none n ¼ 19 none n ¼ 18
Route 3 none > tl, ns none > tl, ns tl x ¼ 1.23 0.28 tl x ¼ 0.45 0.13
none x ¼ 1.51 none x ¼ 0.58
Access to the outdoors from the live-in kitchen (lik) provides better locating lik n ¼ 13 lik N ¼ 11
than access from any point on the circulation system (cs) cs n¼8 cs N¼8
Route 4 P ¼ .245 P ¼ .160 lik x ¼ 1.06 0.18 lik x ¼ 0.79 0.26
cs x ¼ 0.88 cs x ¼ 0.53
An outside sitting area (sa) close to the exit from the living area sa n¼9 sa N¼8
provides better locating of the outdoor space than none (none) none n¼3 none N¼3
Route 4 P ¼ .322 P ¼ .041a sa x ¼ 1.04 0.25 sa x ¼ 0.88 0.57
none x ¼ 0.79 none x ¼ 0.31
a
Significant.
b
Very significant.
c
Extremely significant.
supportive factor in this case is the straight layout of bedroom. The provision of an additional toilet within
the circulation system. the living area, which was not assigned to an individ-
This also relates to the finding of the toilets in the ual bedroom, did not affect the orientational indices
en suite bathrooms that belong to the resident’s of wayfinding to a toilet on this route (# 3). Here it
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Dementia-Friendly Architecture / Marquardt, Schmieg 337
great difficulties in retrieving a mental visual image geometrically simple structures to orient themselves
of a place which they cannot see, rendering them and to succeed in wayfinding. Guiding elements,
unable to generate, maintain, and use a cognitive such as a straight wall running though the whole
map. Concerning the layout of the circulation sys- living area, can be supportive features.
tem, the importance of a direct visual access to all It should be noted that changes in the direction
places relevant to the residents becomes evident. within the circulation system of a living area cannot
The absence of a cognitive map can be partially always be avoided, particularly, in terms of shape and
compensated by using other kinds of orientation size. They might already be in existing buildings, or
strategies. Residents then may orientate themselves they may become necessary owing to the local
allocentrically, from one decision point to the next. situation on a new plot.
In straight circulation systems, this orientation strat- Memorable reference points which can support a
egy can be efficiently and successfully used because resident’s allocentric orientation strategy are thus
only simple directional vectors between the point of needed. These can be architectural elements (such
origin and destination are required. To navigate as the live-in kitchen) or fixtures, fittings, and furni-
changes of direction within the corridor, several ture (such as objects with a biographic reference). It
subsequent vectors are required. This implies that is very important that these reference points are
allocentric orientation strategies cannot be used effi- carefully placed at the spot where the direction
ciently in more complex structures. Also, tracking changes, and that they are interpreted, remembered,
down a place takes longer and during that process and used by the residents in the designated way.
the aim of the trip undertaken may soon be forgotten. If living units with a large number of residents
A small number of spatial anchor points (eg, hav- are designed according to the findings of this study,
ing only one live-in kitchen) as a supportive design very long corridors leading to an institutional appear-
feature may also be ascribed to cognitive mapping: ance would be the outcome. Here reference points
a less detailed cognitive map that is easier to gener- can serve as an ‘‘intermediate element’’ to divide long
ate, maintain, and use would be the result. Further, corridors without interfering with the resident’s
differentiations between similar elements are no orientation.
longer necessary, which becomes increasingly diffi- Clearly visible endings of corridors provide a
cult with advancing dementia. good orientation. However, careful consideration is
needed in the architectural design of these points:
cul-de-sacs have to be avoided, and provision of
Recommendations for Architectural enough safe space for activities and exercise around
Design is advisable.
Spatial situations and places should not be
Not all the results from the statistical data evaluation repeated. The live-in kitchen, in particular, should
can directly be transformed into recommendations be designed in such a way that it becomes a unique
and guidelines for architectural design. Even though and memorable feature of the living area. Its func-
maintaining orientation is important to everyone, tion as a spatial anchor point can be intensified by
including older people and people with demen- the allocation of other functions, such as the exit to
tia,20,21 other factors that determine a resident’s the garden or balcony, or the duty room. In larger liv-
well-being have to be taken into account. The design ing areas, more than one live-in kitchen has to be
criteria shown in Table 1 remain valid. To integrate provided, because of the increased space require-
the results of this study, a design criteria catalogue ments and acoustic reasons. In this case, these places
of dementia-friendly architecture, which can be used should be allocated next to each other.
in the architectural practice, was developed.22 Con- The location of the resident’s rooms and toilets is
cerning the layout of the floor plans, the following mainly determined by the layout of the circulation
recommendations should be considered in future system. In addition, helpful elements such as door
designs. markings and signage, among others, can be
A smaller number of residents per living area included in the furnishing.
facilitate orientation and wayfinding. The current The access to the outdoor area or balcony should
development toward smaller units within the homes be located in a central area within the living area. A
may be judged positively from this viewpoint, too. sun-protected sitting area with enough tables and
Further, it is essential that people with moderate- chairs for all the residents should be placed in the
to-severe stages of dementia need well-defined, balcony or on the terrace. In this way, caregivers can
Downloaded from http://aja.sagepub.com at JOHNS HOPKINS UNIV on August 28, 2009
Dementia-Friendly Architecture / Marquardt, Schmieg 339
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