A neurological and philosophical perspective on the design of environments and technology for older people with dementia

3.1 Historical overview

The British neurologist Jackson (1835–1911) was one of the first researchers to characterize information processing in the brain as a step by step process in which increasingly complex parts of the brain are involved (Meares, 1999). In the 1960s, Luria proposed that the brain is hierarchically organised (Luria, 1973). In his view, there is a hierarchy in the brain that consists of an increasing complexity of neurons combined with a “higher” location in the anatomical and functional brain that ranges from the brainstem to the frontal lobe. Subsequently, Powers (1973) distinguished different hierarchical levels of which the highest levels have the most sophisticated information-processing capacity. All these levels are actively part of the information processing within the brain (Cools, 1985). At present, over twenty hierarchical levels can be differentiated in the brain, which may be summarised into four groups (van der Plaats and Verbraeck, 2008) (Figure 2):

• level 1: maintaining homoeostasis, pain, hunger, primitive reflexes, reflex behaviour, waking, sleeping, sorting and arranging incoming stimuli, and so on (brainstem and formatio reticularis);

• level 2: concrete representation of context with a welling up of primary emotions (especially fear, fight or flight, pleasure and displeasure), automatic movement and language patterns and so on (amygdalae and hippocampus);

• level 3: consider own behaviour by consciously using key stimuli, memory, emotions, movement patterns, mental inhibition and so on (nucleus caudatus and nucleus accumbens); and

• level 4: planning tasks, start, keep up, adjust and stop, self-knowledge, awareness of others, awareness of time, choosing, generalisation and so on (dorsolateral and ventromedial prefrontal).

Levels 1 and 2 develop in the first years of our lives, and levels 3 and 4 develop until approximately 24 years of age. It is argued that, after the age of 24, the brain starts to (slowly) deteriorate again. The onset of dementia impacts these levels in due course (van Hooren et al., 2005).

Simple information can be processed by the lower brain (levels 1 and 2); complex information requires actions from the upper brain (levels 3 and 4). With the use of the higher levels functions, possibilities that are offered in life or by the environment are explored and choices are made based on these possibilities. These higher levels functions include for exampling, planning, reasoning and problem solving. At the lower levels, the options for behavioural action are more restricted. These include more basic, physiological functions such as breathing, which are important for surviving of the individual.

3.2 Neurological processes and behaviour

Cools (1985, 2014) provided a detailed description of the relation between information processing in the different levels of the brain and behaviour. According to his theory, behaviour is always the result of how a person perceives the environment (i.e. situation) around him. This process is called perception. Consequently, certain behaviour may emerge in case of misunderstanding a situation. This behaviour may be perceived as inadequate by others.

Our brain is hierarchically organised in lower and higher levels (). According to Cools (2013a, b), the various levels in the brain process different information. Dynamic stimuli (everything that moves or produces sound or light) may be processed by the lower levels and static stimuli (everything that does not move or does not produce sound or light) may be processed by the higher levels. Cools (2013a, b) also suggested that stimuli are sorted and ordered, and reflexes are being generated at the lowest level of the brain. At level 2, an image is created on the basis of dynamic stimuli (movement, sound), which is also processed in terms of safety. Spontaneous, unchecked emotions find their origins here. If these emotions are not managed by the higher levels they may result into fight or flight behaviour (Cools, 2013a, b). Another important function of these higher levels is mental inhibition. Impulses are constantly being slowed down and disruptive stimuli are being disposed of in order to obtain adequate behaviour-under-control (Goldberg, 2005).

The perception process occurs by means of so-called neural representations (Ratey, 2003). They are like vivid images (concrete or abstract) of the situation. In the lower levels relatively simple, concrete and less complex neural representations are formed. In the higher levels, the information send through by the lower levels can be processed into sophisticated, well-chosen and abstract plans of action with possible alternatives. The higher levels consciously supervise some of the lower levels, such as postponing needs and inhibition of impulses. In general, human interactions are so complex that higher levels are needed to process the input. According to this theory damage to these levels of the brain may lead to inadequate behaviour which may be labelled as “problem behaviour” or, more generically, behavioural symptoms.

5.1 Information processing in the impaired brain

Maintaining a high quality of life in older age requires advantageous decision making in domains such as finances, health care, use of technology and housing situations (Zamarian et al., 2010; Kazak et al., 2017). Hence, decision making is an important ability for independent living. OPD are confronted with extreme difficulties in decision making, especially when decision making is complicated by means of time-pressure or poorly structured situations.

Complex situations, in which decision making is required, are processed in the damaged upper brain, and may create a state of chaos in the minds of OPD (Cools, 2011, 2013a, b). The subsequent behaviours may be dictated by feelings of anxiety and anger. These behaviours affect the well-being of OPD, and are difficult to handle and are usually not well understood by carers. All the input to the brain should be fitting for the cognitive abilities of OPD in order for them to cope with the situation at hand. In conclusion, OPD slowly lose their capacity to organise their behaviour “voluntarily” and become increasingly dependent on the environment (Cools, 2012).

The amygdalae were originally “intended” to recognise danger by way of a quick screening of the environment. It determines behaviour programmed in level 2 (Jablonski et al., 2011). The activation of the amygdalae generates fight (aggression), flight (run) or freeze behaviour in stressful situations. Without the moderating qualities of the higher level systems this behaviour is non-reflective, impulsive and reactive (Phelps and Anderson, 1997). Neuroanatomical changes to the amygdala therefore also alter behaviour in OPD (Wachinger et al., 2016). It is, therefore, essential to present every situations as safe and pleasant. This means we need to create environments that feel secure and offer a protective atmosphere.

5.2 The environment as key determinant of behaviour

In normal brain-functioning there is a mutual interaction between a person and the environment (Perry, 2002). Research shows that the impaired brain becomes increasingly dependent on the environment at hand (Goldberg, 2010). In other words, the person-environment relationship is damaged and the environment becomes a key determinant for behaviour (Cools and Ellenbroek, 2002; Cools, 2012; Colombo et al., 2017). An important part of understanding the environment around onself, are stimuli. Stimuli are defined as “something that incites to action or exertion or quickens action, feeling or thought”. Especially for OPD, the environment should incorporate a perfect balance in stimuli (Cohen-Mansfield et al., 2010). In order to prevent inadequate behaviour, a “balance” in stimuli has to be present.

Two types of imbalance in the amount of available stimuli might occur: an overload and an underload. In case of an underload of stimuli, the brain may switch to a state of dismay. The result is that the person with dementia may create his or her own stimuli by making obsessive sounds or movements like shouting, plucking, walking or obsessive sleeping (van der Plaats and Verbraeck, 2008). These behaviours may occur in situations without dynamic stimuli, such as in quiet private rooms, in a chronic bedfast situation, and at night alone in bed (van der Plaats and Verbraeck, 2008). These behaviours may act as stressors for professional caregivers and relatives. In order to avoid such behaviours, sources of dynamic stimuli, like moving coloured led-lights (in private sleeping rooms), appealing DVDs (in silent living rooms) and the so-called experience areas in corridors (in order to stop obsessive wandering) are created in practice (de Koning, 2012). In contrast, an overload of dynamic stimuli may arise, for example, when several carers are talking with each other while the television is on, and people are walking in and out. As a result, OPD may become restless and scared, which may result in shouting or behaving angrily or hostile

Consequently, a perfect balance regarding stimuli has to be found for people with dementia. We would like to coin the idea of designing for a balance of stimuli as “designing for a favourable state”. In order to acquire such an equilibrium, there are several considerations. First, one should consider all stimuli that are not in the person’s immediate field of vision. These stimuli may cause unwanted distractions (van der Plaats and Verbraeck, 2008). For example, when a OPD hears a noise, but may not know where the noise comes from and as a consequence, may get frightened. When designing housing and supporting technologies for OPD it is of utmost importance to prevent such unwanted stimuli. So, one should design rooms when nursing aides or paid carers cannot walk behind OPD or engage in conversations with them or other people when the OPD cannot see them. Furthermore, floor covering should be used in order to prevent the transfer of noise from hard soled shoes, and other sources of distracting noise from entrance-doors, kitchen equipment and the TV coming from behind should be limited. Seats should be backed to the walls and the OPD should be able to see all the emerging dynamic stimuli in the room.

Second, a great deal of the visual stimuli gets lost in the lower brain and is not processed. Therefore, the environment may be perceived only vaguely. OPD need higher light levels in terms of daylight and illumination, and bright and contrasting colours (Day et al., 2000; van Hoof, Kort, van Waarde and Blom, 2010). Examples of non-supporting design include furnishing in only one basic colour, bathrooms all in white, and walls in pastel (Brawley, 1997).

Third, the memory in dementia reverses to the neural representations of youth and early adulthood. Modern contexts, technologies, objects, words, noises and food are often unrecognised as the dementia progresses. This has an enormous impact on how things have to be designed. The environment has to be in tune with what interior designs and technology looked like when still young and when the brain was still developing. This has ever evolving consequences for the layout of buildings and the choice of furniture and technology, as styles and technological styles succeed each other with ever greater speeds.

These abovementioned considerations regarding OPD, stimuli and design, provide insights in the manner in which environments for OPD can best be designed. In conclusion, an institutional setting aimed at caring for OPD, can be improved by simply looking at how the brain of OPD handles stimuli in the near environment (Cohen-Mansfield et al., 2010).

5.3 Beautiful moments

In the foregoing section it was shown that both an underload and an overload of stimuli can result in aberrant behavioural responses. On the other hand, the right “dosing” of stimuli might create the perfect condition that OPD may function at the higher brain levels. We have coined the term “beautiful moments” to describe these.

Beautiful moments can be evoked spontaneously by (dynamic) stimuli from the environment that are adapted to level 2. The creation of an old-fashioned context can facilitate purposeful behaviour. For instance, in an old-fashioned church or chapel, people with dementia can sing psalms, make the sign of the cross, and talk about God. In a similarly old-fashioned cinema, people can sit down and enjoy a black and white movie.

5.4 The power of the environment

OPD may experience a reduced quality of life when the environment does not match their sensory needs. So-called “stimuli in context” are needed in a fitting environment, which “seduce” the person to conduct the expected action. These contextual stimuli include the characteristics of category vii of the overview of Van der Plaats (2010) described at Step 2. Various design guidelines can help designers and architects to create such environments (Brawley, 1997; Day et al., 2000; Calkins, 2009; van Hoof et al., 2009; van Hoof, Kort, van Waarde and Blom, 2010; Marquardt et al., 2014), for instance, the design of familiar taps in kitchens and bathroom that can be recognised and used as such (Boger et al., 2013) or the use of pictures for environmental orientation (Motzek et al., 2017).

6.1. Design for ageing people

OPD are ageing people themselves. In Section 3 we have investigated the neurological processes in brains of OPD. In Section 4 we have related these insights to the experience and the behaviour of OPD. It was argued that OPD have difficulties in taking initiatives, handling complexity, making up their mind, and interacting with the environment. Both an overload and an underload of dynamic stimuli might result in inadequate behaviour. A balance of stimuli prevents inadequate behaviour and supports meaningful behaviour. The idea of designing for a balance of stimuli as “designing for a favourable state” was coined (section 5.2). It has to be noted that all OPD have their personal characteristics and thresholds. Apart from these design aspects, designers should always consider the needs for safety and security when designing for OPD (van Hoof, Kort, van Waarde and Blom, 2010). The second principle for designing housing and technology for OPD is.

6.2. Design for a favourable state

OPD need an environment with a controlled level of stimuli. OPD can achieve a higher level of functioning including having social contact, enjoying beauty and experiencing spirituality. Such a state only can be realised when there is no excessive stress that induces a fight or flight response. Therefore, these higher functions only can be activated when the OPD are in a favourable state and when the environment offers the right stimuli at the right time and place in order to initiate and to support these higher functions: “designing for beautiful moments” (section 5.3). These stimuli depend strongly on personal characteristics and should be a research topic for future studies.

6.3. Design for beautiful moments

OPD may function on higher brain levels when the environment offers the right stimuli at the right place and the right time. Overall, this leads to a three-stage design model describing the general design principles for OPD (Figure 3).

7.1 Philosophical distinctions

The Dutch philosopher Dooyeweerd (1969) made a distinction between “aspects” and “wholes”. A whole is an entity with an own character and every whole functions in different aspects. Dooyeweerd (1969) describes in his theory of modal aspects that every whole or entity functions in different aspects or dimensions. For example, a human being needs food (biological aspect), thinks in a rational way (logical aspect), interacts with other people (social aspect), buys and sells products (economic aspect), and cares for others (moral aspects) (Verkerk et al., 2016, pp. 62-85). Dooyeweerd (1969) describes in his theory of individuality structures that every whole or entity has its own character or identity. For example, an enterprise is economically qualified, a court judicially, a piece of art aesthetically, and a church religiously.

7.2 Theory of modal aspects

The theory of modal aspects states that every whole functions in different aspects or dimensions (Verkerk et al., 2016, pp. 62-85). This theory is important to understand and to map the different modes of functioning of OPD and to define design requirements that have to support these different modes of functioning. Dooyeweerd (1969) distinguishes in total 15 different aspects of modes of being (Figure 4). By means of an in-depth analysis, Dooyeweerd argued that all these dimensions have their own character. For example, the nature of the biological aspect of a person with dementia is quite different from the nature of the psychic or sensory aspect. The dynamics of the social interaction for OPD are quite different from the subtleties of a spiritual experience. In other words, every dimension has its own dynamics, mechanisms, laws, and norms. Technological artefacts and long-term care facilities have to support the different modes of functioning of OPD. This means that specific specifications have to be developed to support the biological functioning, the psychological aspect, and the social and spiritual aspects. In conclusion, a multidimensional specification has to be developed in which all different aspects of the functioning of OPD have to be addressed.

7.3 Theory of individuality structures

The theory of individuality structures supports us to understand the identity of wholes, for instance, the identity of a long-term care facility. Dooyeweerd (1969) emphasised that human beings cannot be characterised by one aspect or dimension. Humans are not only social beings but also rational beings, not only moral beings but also spiritual beings. Consequently, it is the challenge of health care to support all different aspects or dimensions in which humans function. The identity of a long-term care facility can only be understood from its function to care for OPD. The design of the technology, private rooms and kitchen areas all (have to) reflect this basic function. So, the identity of a long-term care facility is determined by “caring for”, i.e. the moral dimension. In the Dooyeweerdian terminology: the different functions of a long-term care facility have to be disclosed by the objective of caring for OPD. This formulation has firm implications for the design of the whole facility. For example, the social room is not a “simple” social room (qualified by the social aspect) but a social room that supports the social behaviour of OPD. In other words, it is disclosed or marked by the moral aspect of caring for. Another example is the design of the chapel. The chapel in a long-term care facility is not a standard design that supports religious activities but it is a design that supports religious experiences of OPD.

7.4 Developing a multidimensional specification

The philosophical concepts presented in the previous sections support the translation of design principles into design specifications. There are two methods to develop a multidimensional specification. The first method is to take the design principles as a starting point and to explore the different aspects systematically. The second one works the other way around. In our view, the first method is more appropriate. This section presents some examples to show the power of the methodology. The starting point lies in the functioning of OPD, particularly the biological up to religious aspects are relevant (Figure 4).

8.1 Design of a living room

Most nursing homes have one or more living rooms. The identity or qualifying aspect of a living room is the social aspect: living together with co-residents, social contact with relatives, and interaction with staff (Rijnaard et al., 2016). Plate 1 presents a design of a living room. Windows are essential elements, but should not reach down to the floors, as OPD may not be able to tell the difference between inside and outside. People may actually try to step outside and hit the window pane, or experience cold sensations as they think a door has been left open. A solution to such design flaws could be the introduction of raised window sills or sticking foils to the windows to cover the lower part up. Windows that lead to the corridor should be covered by net curtains, so that people walking by do not form a source of distraction. If there are no curtains inside the room, people may think they are either moving out or having spring cleaning. In the evening, they may see their own mirror images in the window, faces they do not longer recognise and which leads to fear.

Ideally, the dining table is positioned next to a window, and residents can enjoy their breakfast there and sit around the table. Another solution that should be considered is having multiple smaller dining tables. It can be quite burdensome to be sitting around the table with multiple co-residents for a long time as one may be offended by someone else’s lack of decorum. Small square tables may do the trick, but one should be aware that in case of wheelchairs, the foot board should not touch the person sitting opposite. Based on intuition and character, people can choose their own table mates, and be together and interact. In a group with eight individuals, two tables are sufficient, and perhaps, a third small table should be considered for allowing additional guests or creating flexibility. In practice, however, there is no question of “one group of eight people” but “eight groups of one person” showing the complexity of the social interactions and its moral implications.

When designing the living room, it is important to stress and define the two functionalities of the room: dining on the one hand, and relaxation on the other hand. Large armchairs and a fire place should be designed in overdrive: the stereotypical design may contribute to recognition and familiarity. The seating area should have a different colour from the dining area. This contributes to a spatial distinction between the two functionalities (so-called zoning). The use of sofas in the living room should be avoided, as people will use sofas as beds. A sofa can be qualified as a waste of space, because no one will sit down next to someone sleeping on a sofa unless they are friends.

In order to create visual borders, one could mount horizontal wooden elements onto the wall, as a sort of mock wainscoting or panelling. It allows people see where the borders of a room are, and if there are corners inside. A window sill can also be a horizontal element that defines the borders of a space. The wall surface below the window sill or wooden slat can be painted in a different colour.

8.2 Re-design of a part of a corridor

Many corridors nursing homes are dull and designed to support the transfer people and goods. However, there are various design solutions to transform corridors in places where OPD can experience beautiful moments. In this case the aesthetic aspect of human functioning is activated by transforming a dull alcove in a corridor into an indoor garden experience corner (Plate 2). This corner should be appealing for the emotional part of the brain. If OPD wander around in the corridor, they are drawn in by a green light shining down on the floor, coming through green sticky foils that were put on the window pane. When residents come near, they walk through an infrared beam from floor-mounted sensor. When this sensor is activated, bird songs start to play. The same birds can be found sitting on the branches of the artificial trees, as well as an owl. Some relatives stated that this corner provided topics for conversation, and they experienced this corner as a part of an adventurous route through the nursing home. Many variations on the theme can be made in practice.

8.3 Design of a baby room

Existing alcoves in corridors also can be used to enable OPD to enjoy beautiful moments by caring for others. In this case the moral aspect of human functioning is activated. A baby room was designed to offer an environment to initiate purposeful actions (Plate 3), which are related to doll therapy (Pezzati et al., 2014). At first glance this design appeared to be controversial. Regularly, family members asked critical questions suggesting that this room infantilises their beloved ones. After explaining the ideas behind this design, the criticism gradually ceased. However, this does not alter the fact that the question must be asked what a good design is to invite OPD to care for others.

In this baby room, the foil stuck onto the window pane is pink. Based on a sensor that is activated when walking by, a baby doll starts giggling and making baby sounds. These sounds are somewhat louder than normal, as older people should be able to hear well. The sounds only turn off when people leave the corner. Even though this corner is intended particularly for use by women, some men are attracted too. The intervention provides a number of stimuli that invites OPD to care. For example, the baby doll is placed on top of a chest of drawers, or inside a cradle. Baby clothes lie around. Some of the drawers of the chest of drawers are half-open, and clothes stick out. Some women start folding these clothes and put them back into the drawers neatly. Changing diapers is another activity that can be carried out in the experience corner.

8.4 Design of a chapel

The last example is related to the spiritual aspect of human functioning and concerns an alcove that was redesigned for worshipping. Many people have experienced support from religion throughout their lives and value religious rituals and festivities. It has to be noted that the choice of design elements is critical: for a Roman Catholic or Jewish chapel different symbols, images and architectural elements have to be applied. An alcove is a fitting space to redecorate as a religious space, as it resembles the type of space that people are used to from their previous church life. The existing window pane was turned into a stained glass window using paint. A slowly rotating light was placed behind, which makes a spectrum of colours shine onto the ceiling and the walls, just like a kaleidoscope. The colours of church are also applied on the walls of the corridor, as a means to draw in people or draw people towards the chapel. Two large candle sticks are placed in front of the alcove. The mock candles, which were battery-operated, burnt continuously. There is a sensor in the corridor which activated songs of worship or psalms. The room itself was large enough for three people, including the priest or religious worker. Inside the space was a large cross, and a small table that serves as the altar. There were two chairs for sitting.