Talking Design: Why it can ‘provoke’ behaviour

Colm Cunningham: 0:12

Hello to you and welcome again to The Dementia Podcast. I'm your host, Colm Cunningham and it's great to have you with us. Today in this episode we're exploring how design influences behavior for those living with dementia. And to do that, I'm going to be in conversation firstly with Liz Fuggle. This is a UK registered architect who specializes in design for those living with dementia. And then I'm also lucky to have her in our dementia centre consulting team and Dr. Meredith Gresham, an OT and researcher at the University of New South Wales here in Sydney in the field of aged care, and somebody who's done a lot of work in the importance of design, one of the first papers I ever read was her work on the design of kitchens. Thank you so much, Liz and Meredith, for joining us today. Why does an OT get into design and dementia? because probably people don't think that way.

Meredith Gresham: 1:07

Thanks, Colm. OTs are very much about encouraging, supporting, and assisting people to live as well as they possibly can. OTs are about helping people adapt to disability adapt when they can't function as they would like. And part of our toolbox as an OT, is about adapting the environment, and adapting tasks that will enable people to do stuff that they want to do. So coming from that frame of reference, as an OT, design is incredibly important. If you get the design wrong, you're actually inhibiting indeed even excluding people. So I come with real passion, that it's particularly important to get the environment right, to enable people to live as well as they possibly can.

Colm Cunningham: 2:06

Liz. Now I have jumped to the OT and said, not all OT's are created in the same way. So why did you get passionate about design and dementia? And not all architects I reckon are so why for you? Is dementia design important?

Liz Fuggle: 2:22

Yeah, very true. Thanks. Yeah, I think for me, I come from a medical background, my family are all medical. And I was always interested in health and health spaces and environments. I, at university was really interested in how particularly the person occupying the building was affected by the environment and how really uncertain environmental psychology. And so when I left uni, and got my first job, actually, with Ricky Pollack, and his firm, and that you'll have, if you've heard Mary Marshall's podcast, you'll have heard her reference him. And he obviously was doing some really pioneering work with buildings for people with dementia. And I just, it just felt like such a natural fit for me that this was an opportunity to create environments that were really making a difference in people's lives where the the design was critical to well being and health for the person. Yeah, so I think that's, that's probably the main thing.

Colm Cunningham: 3:24

Liz, I'm conscious of your story, also, that, you know, the importance of designing for people whose vision is impacted. Yeah, there's something that personal as well.

Liz Fuggle: 3:35

Yeah, that's right. My mom had a significant visual impairment. And when I was growing up, she had cataracts in both eyes. And so as a child and a young adult, a teenager, I was very aware of the impact of a poor environment on her ability to engage and enjoy spaces you even the simple things like going to a restaurant and the poor lighting being really affecting her enjoyment, so the glare from Windows or from candles, and just being able to find find her way, and how that impacted her confidence and sense of, I guess, self esteem, I think was also important and when I when she then was able to have surgery, and the cataracts were removed sometime later, the dramatic impacts on her quality of life was just amazing for me to see. And I think my whole family were just so amazed and delighted with how that changed her life. It being able to go back to work and be able to drive but also from a personal level having more confidence and yeah, real quality in her life. Yeah, just didn't that's just vision.

Colm Cunningham: 4:47

Yeah, exactly. But what you hit at thank you for sharing that is at the heart of what we're trying to talk about here which is how do you ensure that you are providing people with the comfort confidence and providing them with the information that allows them to make the decisions, they want to make. Design principles and features. were part of a previous podcast with Professor Mary Marshall. But I really want to take advantage of having you both here to talk again, about the importance of those principles and how they guide the decision making in good dimension design.

Meredith Gresham: 5:19

I think principles are really important. But I think principles need to be placed in the context of a real understanding of who is the end user of your actual space. And I've seen a lot of confusion, I think, over my time in this area with who are the end users. For me, front and center is the person with dementia, we have to keep that front of mind, I think it's really important to say that everything within environment cues, the way we act, and interact with the environment, both physical and social. So you got to really examine what the building is saying to the people who are in it.

Colm Cunningham: 6:08

Can you help our audience understand some of the behaviors that you might see, and tracking back the way might actually be the root cause of that. And I'd love also to hear from a design point of view Liz site, you'll have seen some features that really disable rather than enable.

Meredith Gresham: 6:26

Let me tell you a little story. I was at a particular nursing home quite some years ago now. And the staff I was speaking to was talking about one particular man who was a real and in inverted commas a problem. He had frequent falls in his room, he would fall from the bed, he would also go into the bathroom, but urinate on the floor. I had my suspicions already, as soon as she started talking about that. So we went up to his room to have a look. I took one look around the white floor or the white linoleum floor, the white blanket, the white bed, the white pillowcase, the bathroom. Similarly, everything tended to be white. So I asked this particular staff member to scrunch her eyes up and peer at the environment in the bathroom. And what was the most prominent thing she could see when she was squinting? And she pointed to the floor waste. And I said is that where you tend to find the puddles on the floor? And she said, Yes. And I said, This poor man probably can't see the toilet. Because we know that the ability to perceive similar colors really diminishes with age and the aging eye finds it particularly difficult. You add dementia, which actually affects the vision processes within the brain. This poor man is in a state of whiteout. He can't see the edge of the bed. That's probably why he's falling off the bed when he tries to sit on it. That's why he's probably lying the wrong way around because he can actually see where the pillow end is. Well, I was very pleased to say that. By that afternoon, they had sent the handyman out to go and buy a contrast toilet seat of black toilet significant, they had actually looked around to try and find a colored blanket, and a contrasting pillow slip. I did actually follow up a few days later. And virtually the weeing on the floor had stopped. And he was able to get in the right way round into bed by himself. A prime example of just the lack of understanding of how visual changes actually affect people's ability to interact with their environment. And it is so disabling.

Colm Cunningham: 8:48

Do you think Liz that you know it's funny, people are probably not expecting us to be talking about color. And contrast here and total contrast? Oh, gosh, we could have a whole podcast on this. But the I guess one of the things is, if we look at the customer point of view, of course today, we see white and clean exactly what Meredith has described as Who are you selling to? White would suggest to me this is a lovely clean environment. We keep our environment well. And it's also on trend. But there's a challenge for somebody like yourself designing well for the people who live there.

Liz Fuggle: 9:26

Yeah, absolutely. And I think what you were saying earlier, Meredith about, the provider potentially selling or thinking about that the person who's going to be paying for the room as being the person that they're designing for as opposed to the the resident, but if that person knew the impact that would have on their family member, then their priorities would change. And I think certainly with something like the bathroom environment, there are ways to really make the bathroom look very beautiful, and also be visually accessible. I think those two things don't need to be in conflict at all, but it just takes a little bit of pause. A little bit of consideration as to what are their basic rules around total contrast. And there are plenty of finish options that will make make it work. So the two things don't need to be in conflict at all.

Colm Cunningham: 10:13

And, of course, it's a palette so everything needs to complement Have you got any tips on you know, I know I use my iPhone and turn it to that one. But if you've got any tips on that, for people listening?

Liz Fuggle: 10:24

Yes, I mean, I think the scrunching your eyes tip is is one I use a lot. So because by doing that, you're really reducing the amount of light that's coming into your eyes. And so it's a very good simulation for if you're looking at, you know, a series of finishes together to just quickly tell if something's going to stand out or not. And using your phone to to change and the image to Black and White, then you're removing the hue and the saturation from the colors, you're just looking at the tone itself. And so that's that, you know, that's clearly the best way to ensure you have a vision, visual accessibility in terms of in terms of tips for design in those spaces. I think the first thing you need to think about is the floor and the floor being a sacred space really, that you should have really nothing on the floor that is going to cause someone to consider that it's a step or something to pick up. I mean, I saw just last week, a gentleman very frail gentleman, but walking, bending over to pick up part of a pattern that was on the carpet, and you just think ah so, so annoying that the designer and the client of that home, decided to put that carpet in you know, very expensive carpets a very luxurious carpet. But yet so downright dangerous. Really,

Colm Cunningham: 11:38

Meredith, are there myths we've talked about? We've talked about tone and everything is our myths about color and dementia because I have heard everything from use this color for this and use this color for that. And I know that because we have talked about toilets that red toilet seats will be that. Could you help us with our myths around color?

Meredith Gresham: 11:59

Sure. Look, I'll gravitate back to the toilet seat. I know that there was a myth in the UK. Around red was the color for the toilet seat in the UK. We interestingly had the same thing but oh no dementia, toilet seats in Australia were blue, royal blue seats. And in in making inquiries with a sanitary supply company I was inquiring about colors of toilet seats. And I was informed by the salesman that all dementia dementia, you definitely want a blue toilet seat. Look, I don't know where this myth started. But I can absolutely assure that I think it's the lack of understanding that people know that you need a brightly colored toilet seat. But they don't understand it's actually the tonal contrast you want. Not the color per se. So Liz was talking about, there are plenty of rules about what the color contrast difference should be the light reflective light reflectance values should be, we know it's around about 30 degrees of LRVs. It doesn't so much matter what the color is. But you've got to use contrast, well, you've got to use it judiciously in order that people can perceive items to be able to use them. I want to pick up on what Liz was saying earlier about floors. Because another design, I don't know whether we can actually call it a myth. But another very commonplace design feature, which stems from the interior design circuit is that people designers love carpet inserts. They appear everywhere. Carpet insert. By that I mean there's a slight contrast of carpet color, or design or pattern to actually then create a seating grouping to define the space. And yes, I do understand where interior designers are coming from. But if they think about the effect that then that has on people living with dementia, the actual change from pattern to plane of slight variation in color is perceived or can be perceived as a step or dip or some sort of change. We know that people with dementia will fall more, they often have more problems with balance. I just think there is absolutely no place for carpet inserts with any sort of an environment in which people with dementia are going to live.

Colm Cunningham: 14:29

So what Liz is the issue of size and scale of an environment?

Liz Fuggle: 14:34

If you consider where nursing homes as a building type came from they were originally intended to be flow-ons from hospital buildings. So they were traditionally very large buildings. And somehow we've still got that mindset that a care home needs to be needs to be big, and it just has huge problems really in terms of how a person can Manage in that in a large environment. So I'm not saying that you have to have very small buildings, you can have small households within a larger building. But it's it's critical that the environment is small. And the reason for that is because it's much, much harder for a person with dementia to cope with, for example, the more complex layout, as Meredith was talking about, and cope with larger volumes of space, because of the impact on acoustics, and also the number of people that might be in that space. So if there are many other residents of the many other members of staff visitors, that all contributes to a hugely overwhelming experience for the person, and that just adds on cognitive load to them and reduces their ability to cope there, they will be using more of their resources to cope with this additional information, you could consider that more spaces gives people more choice, but actually more choice can be really disabling can actually cause the person not to choose anything at all. And so giving the the ability of the person just to have a reduced number of choices, simple choices, and a sort of progressive revelation of an option options is is actually more enabling for the person and gives them confidence and security in their environment, Gesine Marquardt her her work on Wayfinding has been really interesting in terms of, you know, collating all the evidence that they're that they that it has been around, the the format and layout of buildings and what is actually the most helpful, and that really the simplest layout is the most, most enabling. So literally a single corridor A to B is the most likely to be successful for the person for Wayfinding come out of your bedroom, you look one way, and there's a positive destination, you look the other way. And there's another positive destination

Colm Cunningham: 16:50

Now to call out. Some of the solid evidence is underpinning our discussion today. Three that I would include, and we'll link is the world Alzheimer's report of 2020, which focused in a two parter on design, dignity and dementia, a fantastic look at the literature and thinking and will inform our thinking for decades to come. privileged to have Meredith with us. So we must absolutely talk about the pre and post occupancy evaluation of a new dementia cottage. That was research Meredith was involved in. And then the Flinders research work on small domestic cottage models led by Suzanne Dyer, and to be found in the mga all of these will link and others important research to in the form of decision making. Now Meredith, when it comes to all of that research, what about the issue of accessibility and queuing and the legibility of areas your work on kitchens will all have been about people finding things, and being able to use them and be empowered to do so.

Meredith Gresham: 17:54

Being able to see something means that somebody can find something. If you can actually have very simple choices that are visible to you, it takes the the anxiety, of making decisions away. So being able to actually see if you want to be inside, or have a door to the outside, so you can actually leave the space and go into an outside space is highly empowering.

Colm Cunningham: 18:25

So how do you find the outside space? What do you think's important as we design spaces? Is it simply that when you look one direction, you can see access to open space and the other access to the cozy living room? What is it?

Meredith Gresham: 18:40

I think, as Liz said, I think if you turn your head, you should have two positive choices. So if I want to be with a bunch of people, I can see where the people are, I can see where I can go to to ask questions, I can see where I can be with someone. But if I want to be out of my room, and I want to have a bit of space to myself, but not be alone in my room, I can actually see another maybe quiet space to go or an outside space to go. So I think having choices just as Liz was saying choice one, choice two, it takes away the complexity of decision making. I think when you're in say for example, a living space to have a choice to understand I can be in a cozy living environment, or I can actually have the opportunity to go outside. That also brings up the issue of locked doors.

Colm Cunningham: 19:35

And provoking people yeah,

Meredith Gresham: 19:39

as soon as we actually have dead ends, no access, doors that are in accessible locked areas. It sends a very powerful message of I am somehow being contained. One of the things I was thinking about as we came into this podcast, very much was about size and scale. And that idea that I think residential care homes need to be just that they need to give a sense of home. But this concept of home is a very difficult one to actually pin down what is home, because home means something different to us all. I did however, write down two words when I was thinking about the first one is freedom. And that's freedom of movement, we are not barred from anywhere within our own homes. The second one is a sense of ownership, which for me is you can do things that you want to do in that space. And if we have freedom and that sense of ownership, that to me gives a sense of belongingness. And belongingness means psychological comfort, comfortable in that space. Or we can design places that give that psychological comfort, I think we're gonna have much happier people living there.

Liz Fuggle: 20:58

Well, just linking to what Meredith was talking about earlier, in terms of access to the garden, one thing that really frustrates me is when you have a really beautiful garden that is actually quite close to the dining or living space, and in a curious care home environment, but the door itself is invisible. So it's one thing, or you actually have to press a button, which is off to the side to open the door. And that's something we see not infrequently, and it's really frustrating, because it's like, it's so close, but there's no cigar, you know, you can't actually get into the outdoor space and reducing the number of steps that the person has to take to to get to to get to the result that they want. So whether that's getting into the garden or finding the toilet, is really important to just reducing the number of, you know, contact process of the person has to go through.

Colm Cunningham: 21:50

Speaking of steps, does that mean and talking about Gesine's research? So is there an ideal length of a corridor?

Liz Fuggle: 21:59

Oh, well, there's been some research on this. One recommendation is, is that less than 20 meters is, is is better. But I suppose the shorter and wider the corridors are, really the better. So we know that corridor spaces are places that can be a source of conflict. Even in student accommodation, it's the is the corridor spaces that where you, you have fights happening in, there's research on that in student accommodation. And but if you if you think of coming down a corridor, and you you've made a decision to go one way, and you come across somebody else, who you maybe don't like the look of, what do you do, you're immediately in a bit of a conflict situation. So making the making sure there's enough space that there's wide as well lit, and that it's really quite short, is probably a good way to manage that. Yeah, and I totally agree. And I think so many of

Meredith Gresham: 22:52

Picking up on that point. I guess a fairly little known aspect of vision is called optic flow. And it's the ability that we all tend to have, but never really think about that we judge speed and distance away from us. Now, if you think about it, you use it all the time when you're moving around in a crowded street, when you're driving. And that is actually a visual skill, or visual perceptual skill that tends to get lost in dementia. So the next time you're in a care home environment, and you watch somebody coming down the corridor, many times you will actually see the person trailing their fingers down the wall, they're actually using that sensory input to try and judge the distance, the length. If you the behavior that we see is coming from a place of anxiety. watch that person, more often than not, if somebody is walking towards them, they may actually stop. The reason being that they have no cues to judge how fast or what the trajectory is of that person. So are we going to have a collision, or are we not? And that must be incredibly anxiety provoking. So while Li you're mentioning that corrid rs are conflict spaces, I wo ld argue that rather than think ng that of, Oh, I don't like he look of that person, I'm go ng to beat them up. It's very m ch provoked. Again, there's t at provoked by anxiety by he inability to judge where t at person is? And are we going And another area, which I think is really important is the lack to collide? Yeah, so I may put my hand out to push that per on away. So they don't knock me over. that then gets interpre ed as Mrs. So and so actually b ing aggressive. of privacy that people have in care home environments and, and a large scale is it countering that so if you have a big building lots of rooms, then the present sense of privacy is going to be significantly diminished. And if you have less personal space, then you're going to be more anxious and moremore stressed in the environment.

Colm Cunningham: 25:01

Meredith, for you, What is there something that you commonly see I mean, you've talked about nurses stations, and I've said yet totally agree with you. Is there any other ones that you go? Why do we keep designing this way, because it just causes problems for the people who actually live there?

Meredith Gresham: 25:18

Why, in this day and age, do we need audible nurse call systems, we can have pagers, we have the technology to make it silent, we can put things on vibrate if we want. But comes back to this idea that in an environment that has a lot of noise, it has people moving around in it, it means that the person with dementia doesn't have any sort of sense of control over their environment, that this is something that they cannot control. If they can't control things, I think that for many people, it is incredibly frustrating, they may not be able to tell you that the constant noise this, this constant alert of the nurse call system is probably actually putting adrenaline into their system on an ongoing basis, they get startled every time it happens. And if you've got a hyper, vigilant, startled person, you come up and try and interact with them on a on a human, normal conversational interaction, they may be rather short with you, because they're in that hyper alert state. It's an environmental thing. It's an environmental problem that that we are sort of subjecting people to and somehow expecting that they can live with this 24 hours a day.

Colm Cunningham: 26:34

And absolutely, you're really illustrating the fact that people would be thinking we were talking about design, and then it's the walls and the doors. Whereas actually what you're saying is it's the whole palette, because how it all sits together impacts on the people who live there. Liz any pet design things that you see?

Liz Fuggle: 26:52

I would echo the nurse call system. I mean, I think acoustics is one of these things, which is kind of ethereal, it's difficult to really get a grasp of just by looking at some drawings. And I think it's really thinking about the building as a living, breathing entity. When you're designing to think how is this actually going to play out in reality on day to day? What are all the noises coming together like nurse call like the staff processes, which are going to accumulate to create a noisy space and then trying to engineer those out.

Colm Cunningham: 27:25

We've all had the privilege of traveling internationally, I know I did a field trip with your self Liz to Germany a while back, and Meredith you've seen many other places in the world, is there any examples that you'd like to call out that you really love?

Meredith Gresham: 27:42

In the work that I did on kitchens quite a long time ago, I actually had 11 different nursing homes. And I examined their accident incident records over the previous two years to my visit to the area in which they had kitchen, I found two accidents in kitchens, that is two accidents in kitchens, both were involving staff, and both involve the use of regethermic equipment, the idea of risk, I think, is poorly managed in the variety of our settings and services, that the worry about risk is far greater. And the protective way that we tend to manage risk, I think is highly detrimental. Again, it is depriving people over control over their environment. And once we do that, we create very anxious, very agitated people. So I think that looking at having environments that support staff to deliver care in which they can take risks in intelligent and measured ways, is incredibly important. So it's not only helping residents feel more in control, and residents feeling that sense of belongingness it's also helping the staff that work in those facilities to feel supported to deliver the sort of care that will help the residents feel in control.

Colm Cunningham: 29:13

Liz is there any environment that you've gone? I love this architect, I wish I designed this building, you know, so you again, you got to see places all across the world.

Liz Fuggle: 29:23

Yeah, I mean, I think it was less about the architecture and more about I think the model of care really, about what impressed me because it's what it allowed to happen in the building and this was a care home that was in England in Swadlincote. And it was partly funded by Swadling county council, city council, but it was a beautiful home because they had such an amazing connection with the local community. I think that's what really impressed me. So they had a lovely restaurant and they had a bar and they had a town hall. And these facilities were used hugely by just the local community. And in addition, they had extra care housing and dementia specific care home attached to the building. So it was just a really nice picture of how, you know, everybody could use the building, irrespective of their, their needs and their background. You know, there were things within the environment that weren't ideal maybe for people with dementia in terms of like the lighting and the restaurant, I could have, you know, could have been better, but but they really had attempted to do something very powerful. And, and for the benefit of the whole community.

Colm Cunningham: 30:32

It would seem strange to ask an architect about forgiveness Liz but tell me about that.

Liz Fuggle: 30:38

Yeah, so this is one that's something I'm I'm really quite keen on as a design principle. When you think about people actually, not just people with dementia, but just designing for anyone is creating an environment that's forgiving. So that it really a person is is enabled to do what they need what they want, and they're not put on the back seats. So the classic example of this is, I don't know if you've heard of the Norman door. But Don Norman was a gentleman who is a gentleman, he's an environmental psychologist, and he wrote a book on the sort of the design of everyday things. And the thing that he particularly wrote about it was this the door, and we've all experienced it, where you go to pull it, and it's a push door where you go to push it and as a pull door, it's so frustrating. My husband had this experience just two days ago, and he was trying to leave an architect's office, and he couldn't get out. And the receptionist had to tell him, it's a pull door, and he pulled it and then he left anyway, he was still mulling over that experience. Later in the day, they had to debrief with me. So it had really effectively felt felt pretty stupid. And I think that's, that's a common experience. We've all felt it where the design has let let you down. And there's no, there's no need for it. And so I think when we're designing for anyone, but particularly for people with dementia, who have additional sensitivity to the design of the environment, we need to be considering how, you know, no choice is a wrong choice, and things will just work the way they are supposed to work. So that's, that's something I'm pretty, pretty keen on as a basic principle.

Colm Cunningham: 32:15

And Meredith, I suppose therefore, the building needs to be legible?

Meredith Gresham: 32:18

Exactly. We could use the term legible, we could say understandable. But I also like thinking about elements of design or things that you put in the building are iconic. So let me tell you a story about taps. Again, this nursing home, I was commissioning, I looked at the tapware that had been selected. And it was this sort of hospital style wing tap where and I said Oh, we don't want that. We want something that looks like a tap. Oh said the architect to me, oh, but this is good for people with arthritis. And I said, we're not designing a nursing home for people with arthritis, we're designing nursing home for people with dementia, they may have arthritis, and we can address that as a secondary issue. But overall, we need taps that look like taps. So people can be independent in operating them. So thinking about making a taps looked like taps, a kettle look like a kettle, a light switch look like a light switch, a door handle look like a door handle, helps people function better in the environment. But the ability to personalize your space is extraordinarily important comes back to that idea of psychological comfort of a sense of belongingness. So I have been in situations where I've suggested that the person who's always been a great reader has a small bookcase with their favorite books in it. Oh, said one bright staff member to me, but that person can't read. I said it doesn't actually matter if they can't read. If they've been the sort of person who's always been surrounded by books, it gives you a sense of this is my space, I feel comfortable in this space.

Colm Cunningham: 34:10

Thank you so much Liz and Meredith for that fantastic insight in the importance of design and the impact if we don't think about it and do it well. And thank you also to Total Construction for their sponsorship of this particular episode, and their passion for good dementia design. As always, thanks to the dementia centre and podcast team for all of their hard work in research and putting together this podcast for you. And we've linked a number of papers through that work the world Alzheimer's report 2020 Meredith's paper on pre and post occupancy evaluation of a new dementia cottage and of course Flinders cluster domestic residential aged care in Australia paper which is all about the small domestic cottage model and validates a lot of the benefits of that and why we really need to be thinking about that as part of our strategies and policies in the needs of design for people with dementia in residential care. I encourage you to look at the show notes. There's a lot of great links, particularly in that world Alzheimer's report where a lot of fantastic research and evidence was gathered together as well as experience from so many countries. Finally, as always, we love to hear your thoughts on the podcast, and also on what you think would be important in future episodes. So as always, we'd love to hear from you on hello@dementiacentre.com. Thanks so much for listening and I look forward to you joining us again. Bye for now.