Do elderly people with dementia and Alzheimer loose their quality of life and autonomy as they move out of their homes and into nursing facilities? This article explores a concept that bridges the transition between living at home, and in an institution, namely the Dementia Village.
Ingrid Elizabeth Haraldseid, Student By-og regionplanlegging NMBU, Nettredasjonen
Dementia is a neurological condition that causes intellectual and cognitive impairment, forgetfulness, disorientation and decreased lack of judgement(SNL 2009). This is normally seen among elderly and appears often, as the person gets older. When a person is diagnosed with dementia, it is crucial that the surroundings are safe and provide a feeling of home in order to avoid stress. However, it is just as important that the surroundings are stimulating, but provide a “soft fascination” that doesn’t demand too much(Krisch 2014).
In a traditional nursing home, many of the qualities and functions a person use or benefit from in their everyday life is no longer accessible, such as a kitchen, a garden or even the ability to walk around freely – and still be safe. One can ask if a complete loss of autonomy – like in a nursing home - generates well-being, and dignity for a person who might be still somewhat conscious and functioning? Some claim that the loss of autonomy and dignity worsen dementia rather than to relieve it. Therefore, we see more and more alternative solutions to dementia care. The Netherlands has pioneered one solution to dementia care; a solution that is both celebrated and contested, namely the dementia village.
Hogeweyk dementia village is a concept that started up in the Netherlands, just outside Amsterdam. The village is an alternative nursing home containing all the functions of a traditional nursing home, such as medical competent staff around clock, dining rooms, kitchens, bedrooms and living rooms, but it looks and functions differently like a tiny village. The concept is that the patients, or the users live in small apartments together with people who share equal backgrounds as themselves and live “normal lives” together within the safe borders of the village. Doctors and nurses work around the clock at the village in order to facilitate for a life similar to one previous to being diagnosed with dementia.
How can living in dementia village improve the patient’s quality of life?
Not only do patients shop and cook their own food, but also live in separate homes, together in groups with individuals of the same background as themselves. These factors might seem minor and somewhat unimportant according to how most people live their lives. Hogeweyk’s approach is to divide the users into lifestyle groups, where the residents share the same either cultural or social background. This is because dementia is a condition that causes parts of the brain to degenerate and the patients tend to forget things in their most recent memory. People with dementia tend to have their long time memory intact, while usually forgetting what happened yesterday, or the same day. These factors combined makes it easier for patients to live with people sharing more or less equal background from when they were young, to easier facilitate for a healthy social life when living in the village.
However, we must not forget the importance of an individual’s own autonomy of controlling their own day and their own life – which is crucial for a good mental health. The aim is that the users live their lives as normal as possible. It is seen among elderly and especially people with dementia or Alzheimer that they tend to be depressed.
Medication and institutionalization vs. activity and autonomy
One way to handle depression is medication, probably the most common way of treating it among elderly and care needing. However, studies show that there are more efficient ways of handling depression – physical activity. (Kraus 2006) A research done by psychologist Mirka Kraus, show that physical activity combined with medication and socializing show good results among people with depression where behavioural and psychological symptoms are present. Furthermore, the research indicates that this treatment could be even more efficient if the physical
activity is connected to socializing and group activity, which will increase the subjective experience of life quality and increase the patient’s self esteem. (Kraus 2006) This supports the more recent research that also shows that an increase of physical activity reduces the need for medication and improves physical and mental health for the patient. In Hogeweyk they focus on living life as normal, and execute daily habits and doings such as activities. This keeps the patients moving throughout the day.
To maintain both physical and mental health, it is important to avoid premature institutionalization of the patient and too quick development of dementia. Dementia and depression are two conditions that often walk hand in hand. (Bystad et al. 2014) To maintain a person’s autonomy and provide the users the opportunity to live as normal as possible while socialize with others is a great way to avoid this. There has also been done a research study to see how residents of a traditional nursing home reacted after being involved in a trial where they were to move more frequently, and do more of their everyday habits by themselves, in the beginning of this research the patients found it to be an effort moving around. However, after a while it increased their self-esteem and gave them a sense of empowerment in their life (Formholt Olsen et al. 2015).
Green environments and dementia
A problem with traditional nursing homes is that they sometimes don’t provide sufficient, user-friendly, quality outdoor spaces. Studies show that elderly who spend more time outdoors are less stressed and tend to be happier. (Bengtsson 2015) Thus, a high quality green environment is crucial for best taking care of patients at nursing facilities; a feature that has been important in Hogeweyk, designed by landscape architect Niek Roozen from Niek Roozen Tuinen Landschapsarchitecten.
By using their body, rather than sitting inside in a chair, people with dementia don’t only improve their physical health, but also reduce their need for sleeping medication, as they would naturally feel more tired when the evening comes(Haugseng 2009). In Hogeweyk dementia village there has been paid a lot of attention in the creation of outdoor space. As mentioned earlier the users of Hogeweyk are free to roam around as they please and still be inside the safe borders of the village. The spaces between
the buildings are designed carefully to fulfil a variation of different needs. Some are for entertainment and activities, while others for walking or purely relaxation and restoration. As studies have shown, green environments tend to have a relaxing effect and reduce mental fatigue(Krisch 2014), a feature Hogeweyk has addressed to its fullest.
Designing dementia-friendly space
It is common among dementia patients to feel disoriented. Thus, it is important to create a calm and easily legible environment to avoid dead ends when carrying out their lifestyle in the village. Hogeweyk has created such an environment, which makes it difficult to get disoriented when manoeuvring around. Important features to keep in mind when designing care gardens for people with dementia are accessibility, which includes physical-, social- and visual accessibility. (Zeisel & Tyson 1999) Green qualities are considered as restorative qualities, and Kaplan and Kaplan write this in their book The experience of nature;
“A preferred environment is thus more likely to be a restorative environment. And since nature plays such a powerful role in what is preferred, in general terms, there is a theoretical basis for expecting natural environments to be restorative.” (Kaplan & Kaplan 1989) The theory of ART – Attention Restoration Theory is built on this. This is done in Hogeweyk by dividing the outdoor spaces into different zones to fulfil different needs – active zones and calmer zones.
We are in the coming years facing a massive growth of elderly people in Europe and worldwide, and they will be in need of better quality and more accommodating environments than the urban environment can offer us today (Kraus 2006). As this project first noticed, a common problem with elderly is that as soon as they are in need of care, they loose their autonomy and possibility to make decisions about their everyday life. What has been done in designing Hogeweyk is quite extraordinary, by providing patients the right to control their day and giving up the traditional model of a nursing home where the users often sit in a chair most of the day.
Hogeweyk is a great inspiration to designing future care-facilities, and most certainly a pioneer in institutional design. Yet it is still is an institution. The challenge therefore, in designing for an older population, is that we can enable people to function and participate in society as long as possible. Hence, if we can transfer many of the good design principles of the dementia village to our public spaces, we are enriching our environments, communities, and enable quality of life at all stages of life.
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