Designing therapeutic environments

Nursing Homes, July-August, 1996 by Paul S. Stevens

A new trend in the design of environments for "frail elderly," a "therapeutic model" of care, is replacing the old "medical model." In these new environments, design and program work in concert to create a more supportive setting. Design, both indoors and out, is directed at affirming residents' dignity, self-esteem and happiness by continuing their past life patterns through socialization and meaningful activities.

These design principles are formulated to create non-institutional residential spaces that preserve privacy and provide a variety of spaces that promote positive feelings of wellness. They use the traditional design tools of arrangement, size and proportion, decor and color, and lighting. Positive outdoor spaces that provide opportunity for stimulation in a natural setting are a key ingredient. These principles are being applied to the creation of assisted living and nursing settings for both alert and cognitively impaired residents.

Recently professors Uriel Cohen and Gerry Weisman at the University of Wisconsin-Milwaukee's Institute on Aging and Environment developed therapeutic goals for the design of dementia facilities. This work was based on analysis of early successful facilities, such as the Weiss Institute in Philadelphia, the Corinne Dolan Center in Ohio and the Alzheimer's Care Center of Gardiner, Maine. They described these design goals in Holding On To Home, the first comprehensive book on design for dementia based on the therapeutic model. Soon after this, Victor Regnier's book, Assisted Living Housing for the Elderly, formulated similar principles based on his analysis of successful European and American assisted living models.

Based on this work, therapeutic goals for design can be described as promoting:

* A safe, secure environment - both actually and perceptually.

* Improved resident awareness and orientation via a visually apparent environment.

* Maximum use of remaining functional ability.

* Control of the quantity and quality of stimulation - enhancing therapeutic and minimizing harmful stimulation.

* Enhanced social interactions.

* Privacy via resident control of intrusion.

* More opportunities for personal control, based on individual choice.

* Maintenance of links to past residential environments and life patterns.

Though some of these goals were developed in direct response to needs of elderly residents with dementia, all apply to the frail elderly in general. Of course, each provider's program will have its own goals, which the designer should identify early in a project. Among specific provider goals that have guided our firm in recent projects are:

* Smaller groups of residents;

* Residential plan organization and image - i.e., non-institutional

* Personalized private resident rooms;

* Intimate dining;

* Domestic kitchen for activities/socializing;

* Varied activity spaces;

* Incorporating objects from the past;

* Controlled environmental stimulation;

* Places for visiting;

* Meaningful wandering;

* Positive outdoor spaces;

* Space for staff retreat.

Two projects are illustrative:

The Alzheimer's Care Center of Viera, to be located in the new town of Viera, Florida, emphasizes the preservation of resident dignity by encouraging participation in activities of daily living. Two 26-resident units are subdivided into two 13-resident houses, each with living and dining areas and both organized around a shared activity kitchen and secure courtyard garden. Paths for circulation end in activity areas, and offer choices concerning movement through the unit and garden.

A variety of intimate and public rooms, transparency of common space partitions and orientation and grouping of openings encourage residents to interact according to individual needs. Homelike organization and detailing cue past experiences to assist in making appropriate choices.

Major design principles and responses included:

* Support and Sustain Functional Abilities: The houses are spatially organized, constructively detailed, furnished and equipped to cue the long-term aspects of memory most common and longest available to Alzheimer's residents.

* Provide a Habitable, Accessible Environment: The entrance doors to the houses and gardens orient residents to an environment entirely accessible to them at will. Built-in shelving at beds to display personal items, signage with personal photos and an environment spatially and materially similar to home allow residents to transfer personal habits and comfortable routine to their new setting.

* Encourage Communication and Interaction: A family-sized table in a functioning kitchen greets residents entering the houses. From here, opportunities for participation in a variety of indoor and outdoor activities are visually apparent. Transparency of interior common space partitions, orientation and grouping of openings and adjacency of path and place allow residents to observe and interact according to individual needs.

* Provide Choice Within a Safe, Secure Environment: The houses embrace a range of opportunities for activity and experience within their boundaries. Anxiety about boundary limits is reduced by visually-concealed exit points. Flush doors at the house exit blend with adjacent wall finishes. Garden gates continue the pattern and rhythm of adjacent fences [ILLUSTRATION FOR FIGURES 1 AND 2 OMITTED].