Dementia-Friendly “Design”: Impact on COVID-19 Death Rates in Long-Term Care Facilities Around the World

The pre-COVID-19 dementia resident

PWD represent 50%or more of the LTC population globally. The vast majority of families would prefer to keep their loved ones at home until their end of life; however, this is not always possible. The type and location of LTC facility PWD are placed into, and the timing of that placement can vary depending on who is involved with the decision (spouse, child, grandchild, other relative) [22], as well as family dynamics, cultural behavior, and accessibility to medical services; however the reasons for that placement are often similar around the world and include:

The pre-COVID-19 dementia caregiver (staff)

Job descriptions for LTC staff vary around the world, but may include doctors, nursing directors, LTC facility directors, floor nurses, nurse practitioners, gerontology specialists, healthcare aides, nursing assistants, nurses’ aides, medication aides/technicians, personal care or support workers, orderlies, social workers, physiotherapists, recreational therapists, occupational therapists, as well as kitchen, laundry, maintenance, and housekeeping staff [34, 35]. For direct care providers, educational and training requirements can range broadly from minimal requirements to extensive training. In the U.S., the federal government mandates that all direct caregivers receive 75 hours of training before being certified to work in Medicaid/Medicare certified Nursing Homes, whereas Germany requires at least 50%of all care staff are Registered Nurses who have had a three-year geriatric training program [5]. In Canada, however, unregulated workers (no independent accountability, no recognized education and training standards) provide up to 90%of direct patient care, more than 90%are women, 70%are over 40, and 60%speak English as a second language [2, 34]. In China, where LTC is an emerging concept, 70%of Nursing Home administrators only had junior high school degrees, and for direct caregivers, 76%of them were illiterate or only had primary school education [5]. Common staffing problems in LTC worldwide include poor dementia-specific training, relegation of most jobs to women (often immigrant women), low pay, poor benefits, stressful working conditions, high rates of on-the-job injury, and fewer opportunities for advancement and development, which leads to job dissatisfaction and high turnover [2, 4, 29, 34–36]. Gaps in training have been identified in many countries and policies are now being developed to provide training unique to dementia care. In the U.K., nurses often felt frustrated and overwhelmed by dementia care and felt they did not possess the practical skills to implement the necessary psychosocial interventions required to care for PWD [37]. In other instances, poor training was found to impact the way staff behaved towards residents [35].

It is estimated that only 10%of residents’ symptoms in LTC are caused by the dementia itself with the other 90%resulting from the quality of care PWD receive [12]. In 1991, Dr. Bill Thomas, a Harvard-educated physician, defined the “three plagues” of nursing homes: boredom, loneliness, and helplessness [34]. Dementia residents often feel neglected by LTC staff who are over-worked and unable to provide the type of targeted care required. Although basic food and accommodation needs are met in LTC, unmet needs reported by dementia patients include lack of stimulating daytime activities and social company, lack of support to help cope with psychological distress (depression and anxiety), and poor assistance with memory, eyesight, and hearing problems [12]. When PWD were interviewed in Norwegian LTC facilities about their QoL, they often complained that staff walked into their rooms without knocking (lack of privacy), they were not treated by some staff in a way they approved (i.e., treated as a brat, over-handled), and staff disappeared and left residents alone in living rooms and corridors [38].

The pre-COVID-19 LTC building

The Institutional-based “environment of care” (EOC) has contributed to resident’s agitation and restlessness [39]. LTC facilities are not designed with PWD in mind and are often crowded, have shared bedroom and bathroom facilities, and allow gathering in common areas [40]. Building standards in current facilities may be decades old, and can include four-person shared wards and communal dining rooms where hundreds of residents are brought down to dine together [40]. For-profit homes tend to have a lower proportion of single-occupancy rooms and older design standards than not-for-profit homes [41]. The larger the LTC facility (>30 residents), the more agitation, aggression, intellectual deterioration, and emotional disturbance and the more frequent territorial conflicts/space invasion issues arise in PWD [42]. Spatial design, unnatural lighting, high noise levels, long dead-end hallways, poor color contrasts, lack of privacy, glare off floors, lack of access to outdoor spaces, and the lack of homelike décor and visual cues, all affect the long-term QoL for PWD [42, 43].

The COVID-19 dementia resident

Co-morbidities such as diabetes, cardiovascular disease, chronic respiratory disease, cerebrovascular disease, malignancy, and dementia were proved to independently increase the risk of COVID-19 progression, severe outcomes, and death [45]. Early on in the COVID-19 outbreak, evidence showed a high prevalence of dementia among COVID-19 patients with the rate of dementia in hospitalized cases of COVID-19 ranging from 6.8–13.1%, and, in addition, case fatality of COVID-19 was significantly higher in the elderly with dementia [1, 46]. In Italy early in the pandemic, the mortality rate in dementia patients with COVID-19 was 62.2%compared to 26.2%in patients without dementia [1, 46]. In South Korea, AD and chronic lung disease were predictive factors for death from COVID-19, especially after the age of 70 [22].

This high rate of COVID-19 infection among PWD could be partially explained by frailty, aging, and chronic comorbidities, particularly cardio- or cerebrovascular diseases [1]. In addition, the APOE ɛ4 allele (a gene affiliated with dementia) is associated with severe COVID-19 infection [1, 47]. APOE ɛ4, which is known to exacerbate microglia-mediated neuroinflammation and neurodegeneration and increase macrophage production of cytokine, may augment COVID-19 severity by impacting the host immune response [47]. Individuals with dementia are more likely to have cardiovascular disease, diabetes, and pneumonia, all of which put them at higher risk of acquiring COVID-19 in LTC [18, 45]. In China early in the pandemic, 90%of COVID-19 patients had pneumonia, and mortality from pneumonia has been reported to be twice higher in individuals with dementia compared to those without dementia, even prior to the pandemic [18, 48]. Even with multiple co-morbidities, however, one of the reasons given for a high death rate in PWD with COVID-19 included early “asymptomatic” carriage or a lack of typical symptoms. COVID-19 patients with dementia often presented with non-respiratory symptoms such as delirium (particularly the hypoactive form) or isolated functional decline in the absence of any obvious physical symptoms, along with pyrexia and diarrhea [1, 47, 49]. During the pandemic, PWD have faced a “double burden” due to their increased morbidity and mortality and the breakdown of their social supports [1, 50]. One of the first responses to COVID-19 in LTC was to “shut the doors” and eliminate all family visits. This loss of familiar contact has caused much stress in the dementia population. While social distancing, isolation, and safeguard procedures are the most effective approach to COVID-19 infection in LTC, this approach can endanger the safety of dementia residents and increase the risk of cardiovascular disease, obesity, and stroke, and correlates with anxiety, depression, and cognitive decline [50]. A lack of physical closeness has increased the level of loneliness, depression, and stress, reduced the amount of exercise, disrupted sleep patterns, increased delirium, and have caused trauma which may lead to further cognitive decline, all of which have increased the risk of morbidity and mortality in PWD in LTC [18]. Lack of formal and informal support during COVID-19 may further endanger the lives of PWD due to risk of falls, aspiration pneumonia, and even suicide [1]. Loneliness was already more prevalent in LTC institutions than the community prior to COVID-19 (22–42%versus 10%), and loneliness has been associated with deleterious consequences, including depression, alcoholism, suicidal thoughts, aggressive behaviors, anxiety, and impulsivity [51]. Since COVID-19, some LTC residents have had more symptoms of depression and suicidal thoughts, and more have complained of weakness and muscle atrophy and had more falls [52, 53]. All of these factors increase their susceptibility to infectious agents such as COVID-19.

The COVID-19 dementia caregiver (staff)

LTC staff worldwide were overwhelmed when COVID-19 swept through their facilities. Some of the reasons for this included a rapid spread of positive cases due to high patient density, as well as poor ventilation and communal living conditions (shared bedrooms and bathrooms, common eating areas, single elevators). Other reasons included a lack of infection control and dementia-specific knowledge and training, lack of pandemic and crisis preparedness and strategic planning, poor COVID-19 testing and surveillance guidelines, poor working conditions including insufficient staffing levels and staffing mix, a lack of personal protective equipment (PPE) such as oxygen, ventilators, masks, and eye shields, a lack of screening resources for symptoms, travel history and contacts, and the poor physical design of their facilities [2, 40, 41, 54–61]. These conditions exacerbated an already stressful situation, and many staff got infected or stayed home to prevent getting infected, threatened to quit, or quit outright [1, 2]. Even when Infection Prevention and Control (IPC) guidelines for respiratory infections were in place, staff found them complicated and constantly changing, and felt a lack of communication and support from managers as well as a lack of IPC training, lack of physical space for isolation and lack of access to and trust in PPE [62]. Pandemic and disaster contingency planning in LTC (which should involve political commitment and strict monitoring processes) was found to be lacking in China and Italy early in the pandemic [63]. Staff themselves were often the vectors of infection, due to working part-time in multiple facilities due to poor pay and lack of benefits (e.g., sick time), increasing the likelihood of spread of infection to residents and staff [2, 14, 18, 47, 60, 64]. In the U.K., each resident receives between 3.1 and 4.8 h of direct care per day normally, dependent on most residents spending significant time in common areas [49]. Managing residents in isolation in bedrooms during COVID-19 presented challenges to staff and placed residents at risk of falls and injury due to lack of supervision [49]. Staffing shortages, lack of training, and lack of resources during COIVD-19 led to restrictive interventions and placed all residents at increased risk of falls, injury, stroke, deconditioning, skin breakdown, blood clots, and death [65]. In one case study in Canada, a dementia patient who tested negative for COVID-19 was told to isolate for 14 days in her room; math problems, coloring pages, and movies and music on a tablet were provided to keep the resident occupied. However, because the door could be opened from the inside, and the resident was strong and of large size, staff could not keep her contained to her room, and often ended up confronting the individual without time to don proper PPE. In this case, pharmacological measures (use of a more sedating agent) and physical restraints (a geriatric recliner using a pelvic holder) were used, although this is not a preferred option [65]. This case demonstrates the unique challenges to staff during COVID-19, who had to deal with both sick and healthy residents while short staffed, under extreme conditions of stress, facing the loss of residents on a daily basis, and concerned for the wellbeing of themselves and their loved ones at home.

The COVID-19 LTC building

COVID-19 can remain stable in airborne aerosols for at least 3 h and persist on some surfaces for days [58]. Most LTC facilities do not have airborne infection isolation rooms, which are under slight negative pressure with respect to adjacent rooms and hallways and thus are not designed for infection control practices [2, 58]. Forced flow air ventilation systems are found in most institutional LTC facilities [39]. In these systems, both cold and hot air are pushed through ceiling grills, which often creates breezes on residents, and despite exchange rates which follows building codes, the air is circulated throughout the entire building so if one resident is sick, their germs can spread through the entire ventilation system [39]. In one European study, the effect of air quality and ventilation in 50 nursing homes in seven countries was evaluated in 600 elderly nursing home residents [66]. Only 19%of the residents had adequate ventilation, and poor air quality and exposure to indoor air pollutants in these LTC facilities exacerbated respiratory symptoms in elderly residents, with frailty increasing with age [66]. Recommendations during COVID-19 included placing patients in isolation alone or having them share rooms with known COVID-19 positive patients and leaving the door closed [58]. This is difficult to accomplish with PWD who are prone to open doors and wander (commonly called “walk with purpose”) [54]. Crowding, shared bathroom facilities, and gathering in common areas are a result of design flaws that have been linked to the rapid spread of COVID-19 in LTC facilities [67]. In Canada, most LTC buildings were built between 1950 and 1990 and many of these facilities remain at 1972 building standards (called C standard) and still include four-person shared wards and large communal dining rooms [2, 40]. The oldest buildings tend to be larger (200–400 residents), with narrow hallways, crowded nursing stations, lack of outdoor spaces, and limited areas for staff and families away from resident rooms, all of which contributed to the challenges of dealing with COVID-19 [2]. Sharing a washroom means more opportunity to spread the virus among residents, and make staff less likely to wash their hands between patients [40]. Overall, the institutionalized design of older LTC facilities around the world have had a direct impact on the spread of COVID-19 and subsequent death rate and have placed the emphasis on what the design of future dementia care and housing should look like.

Dementia-friendly communities (DFC) (non-nursing model)

The term “dementia friendly” (which differs from “age-friendly”) may vary, but generally refers to the “social” health of PWD versus their “medical” health [69, 70]. Defining attributes of dementia friendly include empowerment, aspiration, self-confidence, contribution, participation, meaningful activities, wayfinding ability, sense of safety, accessibility to local facilities, social acceptance and human rights [69]. Alzheimer’s Disease International (ADI) states that Dementia Friendly Communities (DFC) “not only seek to preserve the safety and well-being of those living with dementia, but also empower all the members of the community to celebrate the capabilities of persons with dementia, and view them as valuable members of the towns, cities, villages and countries in which they reside.” [70].

Across the world, 70%of PWD live in the community (not LTC institutions) and must alone face the stigma and social and cultural isolation that accompany such a diagnosis [71]. The vast majority of PWD globally have no formal diagnosis, and thus have no access to information, support, care, and treatment [71]. Increased awareness and understanding of dementia, increased social and cultural engagement, legal protection of PWD, increased capability of health and care services to respond to PWD needs, and improvements in physical environments (homes, residential care, hospitals, LTC, public places) are required for the DFC model to work [71, 72]. The most successful models internationally use two layers of networks/consultations: 1) A “bottoms-up” approach in which the PWD are directly involved in decision-making and design, and directly engage with their community; and 2) A “top-down” approach where governments and institutions (banks, healthcare organizations) help design and fund a DFC [34, 71–73]. DFC involve the following: 1) People (PWD, paid or unpaid caregivers); 2) Communities (social environment, physical environment); 3) Organizations (e.g., Alzheimer’s and dementia-specific societies, healthcare organizations); and 4) Partnerships (ministers, government, businesses, consumer groups, social organizations) [69, 71]. Dementia Alliance International, a non-profit organization run effectively by PWD, states that “being dementia friendly is less about being ‘friendly’ and more about accessible communities and human rights” [71]. Following are examples of DFC initiatives around the world that have focused on “home” and “community” as the central component and have worked within the available infrastructure.

Dementia-friendly LTC (nursing model)

If PWD can no longer remain in their home or community, their institutionalization should not have to include old, large, sterile, over-crowded buildings with poor design and layout, poor air quality, shared bedrooms and bathrooms, and lack of color, poor lighting, and unfriendly surfaces. Small-scale dementia-friendly care models have emerged the world over that address the unique needs and challenges of dementia residents, and consider the long-term mental, physical and psychological health of both the resident and the caregiver/staff. In Table 1, we summarize how each LTC nursing model described below relates to the triad described previously (dementia resident, caregiver/staff and building).

De Hogeweyk, The Netherlands (the “Dementia Village” Model)

This world-renowned, mainly publicly funded dementia village was built on 4 acres of land in Weesp, The Netherlands in December 2009 at a cost of € 19.3 million (U.S. $27 million) [81–84]. It contains 27 homes with 6–7 residents per home, 17 designs, ∼170 residents with severe dementia and 250 full- and part-time staff (geriatric nurses, specialists) who work in the village and hold a myriad of occupations (grocery-store attendees, cooks, and waiters).

Fig. 1

A day in the life of the De Hogeweyk Dementia Village in Weesp, The Netherlands. Reprinted with permission from the Hogeweyk^® Care Concept.

Fig. 2

Glenner Town Square: A typical dining room at home and Rosie’s Diner. Reprinted with permission from the George G. Glenner Alzheimer’s Family Centers, Inc^®.

The “Model” is based on 7 pillars: 1) favorable surroundings, which include a house with front door, living room, kitchen, bedroom, homey furniture, outdoor space, daily activities, and access to a supermarket, restaurant, café, hairdresser, theatre as well as gardens, squares, alleys, streets, and lanes; 2) life’s pleasures and meaning of life, which in-volves a social life, including access to 35 different clubs, walks, daily shopping, day trips, and theatre; 3) health, which focuses on QoL, well-being, and social-relational, rather than medical, programs; 4) lifestyle, which is defined as surrounding, environment, interior design, social behavior, daily routines, preparation of meals, and norms and values; 5) employees, volunteers, and family, who understand the vision and apply it to their work. Employees consist of professional caregivers and assistants who provide 24/7 care and volunteers who work under a direct supervisor; 6) the organization, where policy is centered on the resident and living a normal life, and health; and 7) emancipation and inclusion, a recently added pillar which involves freedom from stigma and inclusion, along with being understood, respected, and supported [82, 85]. Staff aim to enable people to “live until they die” and there is no sign of dementia as a form of “social death” [81]. The 17 designs assigned to the homes are based on which lifestyle the residents of that home adopt. Residents with similar personalities and interests live and eat together in the same home, to reduce stress and anxiety. The four most recent lifestyles assigned to the residents include Urban, Traditional, Cosmopolitan, and Formal [82, 84]. This model of care has won multiple awards for innovation and design and stands as a role model for other countries. There have been some ethical arguments against this model including the use of “deception” and the creation of a false reality, as well as stigma and separation of residents from the real world [85]. The “Dementia Village” concept has been replicated to some degree in Denmark (Bryghust-Svendborg Dementia Town; 2015), Switzerland (Weidlisbach; 2017), Ireland, Germany, France, New Zealand, Australia, and Canada (Comox, Langley, and Vancouver in British Columbia; Saskatoon in Saskatchewan) [85, 86]. In some “Dementia Villages”, residents are not matched for cultural background, lifestyle, or shared interest, but they do follow the basic De Hogeweyk “Dementia Village” concept [85]. Although “Dementia Villages” have not yet been replicated in the U.S., a “retro” day village concept has emerged [87]. One example is Glenner Town Square in Chula Vista, California that mimics a Main Street, U.S. style of 1953–1961 and uses props such as fire hydrants, era furniture. and old movie houses to create a community atmosphere [87]. The company behind this concept (George G. Glenner Alzheimer’s Family Centers) plan to construct 100 “retro” day villages within the next 20 years, including in Baltimore, Maryland and Louisville, Kentucky [87].

Lighting

The average 75-year-old requires four times the light than their 25-year-old counterpart [100, 101]. As a person ages, their eyeballs thicken and become yellow, which filters out blue light, required to generate melatonin in the body [101]. Melatonin is a natural hormone secreted by the pineal gland in response to darkness and is controlled by the suprachiasmatic nucleus (SCN) located in the hypothalamus [102]. PWD may have abnormalities in this part of the brain, which lead to lower melatonin levels and disruption in the circadian rhythm (i.e., the body’s natural clock) [103, 104]. This disruption can present itself as “sundowning” (SD), “sundown syndrome”, or “nocturnal delirium” in which PWD exhibit worsening neuropsychiatric symptoms (anxiety, agitation, irritability, nighttime disturbances) in the late afternoon and evening, a phenomena not given a formal psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM) and yet recognized in PWD for over 60 years [102–104]. Sundowning can affect 10–25%of institutionalized PWD and 66%of community-dwelling PWD and may be caused in part by a lack of exposure to natural light during the day [100, 102–107]. Exposure to natural light is known to produce vitamin D, increase productivity, protect vision, and improve sleep and mood [100]. Other eye problems in PWD include blurring and increased sensitivity to glare, inability to distinguish contrast (e.g., between floor and carpet) and a requirement for higher light levels [68]. Many LTC institutions have standard lighting levels without consideration to the color temperature [39]. It is believed that both light intensity (lux) and spectral wavelengths (k) are important to maintain circadian rhythms [39]. Early morning exposure to natural light for at least 2–3 h at 1000 lux minimum has been shown to improve sleep and reduce agitation in PWD [100, 105, 106, 108] and exposure to brighter artificial light in the blue wavelength has also proven to be therapeutic [102, 105]. Exposure to higher lighting levels using a bright light box (2,500 to 10,000 lux) is associated with improved circadian rhythm quality and mood, increased consolidation of night-time sleep, increased daytime wakefulness, alertness, and Mini-Mental State Exam scores, and decreased agitation and disruptive behavior [42]. Design elements that improve lighting and reduce confusing shadows and glare include installation of anti-glare, non-reflective glass throughout the building including bedrooms, bathrooms, and kitchens, brighter ambient light in the blue spectrum in common areas, access to outdoor spaces, yellow amber night lights to aid in night care, removal of bright lights over beds, strip lighting around doors and on floors leading to the bathroom, window coverings to reduce glare and bright moonlight at night, use of Light Emitting Diodes (LED), skylights with diffusers to reduce glare, and avoidance of shiny floors and surfaces [10, 39, 101, 109–112].

Fig. 3

An example of color contrast for a toilet seat and the use of natural lighting and color contrast to define a space. Reprinted from Google Free Images.

Color and contrast

PWD are prone to visual impairment, which may include a reduction in contrast perception (ability to differentiate subtle changes in environment, such as carpets, floors, walls, and steps), a reduction in perceived saturation or vividness of colors (e.g., reds become pink), and a progressive reduction in the ability to perceive the blue end of the spectrum [68]. For some PWD, things may be blurred, moving, less three-dimensional or just unrecognizable [113]. The selective use of colors and tonal contrast can help differentiate objects, define borders, assist wayfinding, prevent trips and falls, reduce anxiety, and encourage independence [39, 68, 113, 114]. The blue end of the spectrum contains the “cool” colors: Blue can create a sense of calm and make a room seem larger in size and cooler in temperature; green is associated with nature, can reduce central nervous activity, calm and relax someone, and can also makes a room seem larger and cooler [114, 115]. The red end of the spectrum contains the “warm” colors: Red and orange increase brain activity, can stimulate the production of adrenalin, and make a room feel smaller and warmer [114, 115]. Although PWD can show a marked decrease in color naming ability, they prefer blue, red, and green in that order when given color cues [114–116]. The lightness of the color (tint and shade) can impact the ability to recognize a color [114]. Design elements that can improve color contrast and wayfinding and reduce falls and confusion include painting of doors, light switches and wall mounted fittings a different color from the background, avoidance of very dark or pastel colors, use of non-glossy matte finishes, simple solid floor patterns and colors with no black lines, swirls or circles which could be confused for holes or water, and a clear delineation between objects (e.g., toilets, furniture, grabrails, dining plates, shelves, cupboards) and their surroundings [10, 39, 68, 110]. Colors with a Light Reflective Value (LRV) of >65%should be used on all surfaces. LRV measures the percentage of light a paint color reflects, and high LRV paint will “bounce” daylight deeper into spaces improving orientation and visual acuity for residents [39].

Wayfinding and orientation

Spatial disorientation is one of the prime reasons for institutionalization of PWD [117]. Internal representation of the environment in one’s mind are called “cognitive maps”, which are also referred to as the mind’s eye (precuneus) [117]. As dementia progresses, the cognitive map deforms and breaks apart, causing deteriorating orientation. Unsafe wayfinding can lead to falls, which leads to poor health outcomes, including the ability to recover from infections such as COVID-19. Wayfinding (orientation) involves the following components: knowing where you are, knowing where you are going (destination), knowing how to get somewhere (mental map), recognizing when you’ve arrived and knowing how to get back [39, 118]. Barrett et al. (2019) states that wayfinding requires: 1) a manageable cognitive load; 2) clear sequencing; and 3) appropriate level of stimulation [98]. Most institutions lack the visual cues required to accommodate safe wayfinding, with long double-loaded corridors with equally spaced doors, a lack of distinctiveness of different areas, and poor environmental cues [119]. Orientation involves both building design (size of scale, spatial anchor points, places with different and legible function and meaning) and environmental design (signage, labels, art, pictures, use of color, personal items on doors) [118]. PWD use allocentric navigation in their environments (i.e., use landmarks and external cues for orientation, rather than rely on self). Architectural design details that can improve wayfinding include use of small scale “cluster” design (10–12 residents per “home”), spatial layout that provides a continuous circuitous route (L-shaped or circular routes around a central courtyard, rather than long dead-end hallways), visual cues at each change of direction, elimination of corridors where possible, a centralized kitchen/dining/living area that serves as a central orientation point, use of murals to hide exit doors from the inside, access to bathrooms from the bed, access to outdoor spaces, and use of surface materials, signage, labels, pictures, color, art, lighting, memory boxes on resident doors, and other “salient” (bright, distinctive) cues to aid in orientation within a space [39, 42, 43, 68, 93, 98, 110, 111, 118–122].

Fig. 4

A floor plan with central hearth area to aid in wayfinding. Reprinted from Google Free Images.

Outdoor spaces

Studies have shown that access to gardens and outdoor space can produce many stress-reducing, restorative benefits in PWD including improved mental health, improved QoL and mood, reduced agitation and aggression, reduction in blood pressure and muscle tension, reduction in falls, improved sleep efficiency and sleep duration (circadian rhythm), socialization, improvement in cognitive scores, and reduced use of behavioral medication [39, 42, 123]. In fact, a green view and access to external garden space can reduce the symptoms of dementia by 50%[68]. Benefits may be the result of two mechanisms: reminiscence and sensory stimulation [123]. For PWD in LTC, having unhindered access to an outdoor garden that loops naturally back to the main building allows PWD to wander independently without getting lost [107]. Physical activity, exposure to fresh air and sunlight, contact with plants and animals, and exposure to seasonal change that comes with outdoor spaces are therapeutic to PWD, can provide information about the time of day and aid in wayfinding [10]. Architectural design elements that aid in wayfinding and provide safe, calm outdoor environments include unhindered, unlocked, and safe access from inside (with signage to direct residents to the garden), non-slip, non-shiny wide level walkways with gentle grades, a circuitous loop design, elevated fences that prevent climbing, hidden gates and locks on fences to prevent elopement, textures and forms of materials that provide a tactile experience, and continuity of surfaces. Other elements include aromatic non-toxic seasonally interesting plants, low plantings near windows that do not hinder inside views of the space, potted plants placed near seating areas, safe water features to encourage calm, handrails, shade trees to sit under, furniture placed along paths and near beds and trees, features to attract birds or wildlife, raised beds to allow for gardening activities, adequate lighting for evening visits, and open spaces for picnics, barbeques, and activities [10, 39, 68, 124, 125].

Fig. 5

A looped pathway design in an outdoor garden. Reprinted from Google Free Images.

Other dementia-friendly design elements

Other design elements that can improve QoL for LTC residents and help reduce stress and provide a sense of independence, include reduction in loud noise (e.g., alarms and paging systems) to prevent over-stimulation but addition of pleasing noises that reduce boredom (e.g., background music), temperature controls and ventilation systems that reduce drafts and cold spots in a LTC facility and prevent the spread of respiratory viruses and other contaminants, a reduction in overall clutter, “home-like” décor including art, bedspreads, furniture, and personal items that provide familiar comfort, and “home-like” dining areas with non-institutionalized seating arrangements. Other friendly elements include private person-centered bedroom, shower and bath design, spaces for recreational activity (e.g., music therapy, arts and crafts, games, reading, exercise), improved sightlines, reduction of barriers to allow purposeful wandering, non-institutionalized ambiance and design elements, and the use of SMART technologies [39, 42, 68, 98, 102, 111, 113, 126].