Editor’s Pick | Free to All – The times they are a-changin’ – The case for low arousal care home environments
Stokes, G. (2025) ‘The times are a changin’. The case for low arousal care home environments’, Journal of Dementia Care, 33(5) 26-29.
Over the years, care homes have incorporated a number of design features such as signage, the use of contrasting colours, and images intended to make it easier for people with dementia to find their way around and feel more comfortable. In this article, Professor Graham Stokes challenges the thinking behind this. He argues that these features can actually add to residents’ confusion and cause distress, and proposes a different approach to ‘dementia friendly’ design.
Enter most care home communities supporting people living with dementia and you are invariably faced with a cacophony of bold colours, a variety of symbols and signs, and murals so perfectly detailed to be experienced as misleadingly real. These features are intended to help residents navigate themselves around the building, understand the purpose of rooms and create interest. However, when these ideas were popularised in the 1980s and 1990s, people living with dementia who resided in care homes were more intellectually able than those who do so nowadays (Barker et al. 2020; Matthews et al. 2021). Bignall (1996) describes a resident standing in the lounge of a care home asking, “where is the toilet” and being informed by another resident: “It’s there where the red door is.” Nowadays this is an unlikely scenario.
People in care homes today are living with more severe dementia than ever before; a trend that experience suggests has accelerated since the COVID pandemic, Wittenberg et al. (2020) project that the numbers living with dementia in England in 2040 will total 1,351,000, of whom 909,00 will have severe dementia. In 2015, 251,000 older people with dementia lived in care homes or hospitals, of whom 80% had severe dementia (ibid). The projected number in care homes will rise to 667,000 in 2040, an increase of 166% over this 25-year period. This means that the proportion of the older population with dementia (at any stage of the condition) living in care homes is estimated to rise from 39% in 2015 to 49% in 2040. This is because of the projected sharp rise, nearly a three-fold increase, in the numbers with severe dementia.
Summary
Over a third of people living with dementia reside in care homes, but within fifteen years the proportion will be nearly 50%. This is partly because of the projected increase in the numbers of people with dementia by 2040. It is also caused by the increasing proportion of those living with severe dementia, a severity that exhausts the capacity of families to cope and eventually overwhelms the capability of domiciliary support services to provide the care required.
This article reflects on whether care home environments today are dementia-friendly and supportive for a population of people who are more intellectually impaired compared to those who lived in care homes 40 years ago, when the first attempts to create dementia-friendly living environments embraced signage, pictorial symbols and colour coding to orientate people with dementia to their environments. The article challenges these approaches to dementia-friendly design.
It’s a welcome development that the severity of dementia is being addressed by considering the benefits of low arousal care environments that minimise sensory input that cause overstimulation. This is done in part by removing stimuli that are not helpful to residents, such as signs, symbols and information boards that are of no use to them, as well as removing images that can be baffling as well as being a source of frustration. We no longer relate to people living with dementia as we did in the 1980s, so the question is asked, why should it be any different when considering the contemporary design of dementia care settings.
Compensatory design
Signage to orientate was originally advocated when the resident population was not only less cognitively impaired, but when care settings were predominantly anonymous institutions (e.g. Hanley and Hodge, 1984; Stokes and Goudie, 1990). Hanley and Hodge built on the therapeutic concept of ‘reality orientation’, and the view that people with dementia could not remember what they were told, by recommending people living with dementia could be oriented to their environment through cues such as signage and directional information. However, for people with severe dementia the compensatory value of cues may never be acquired. For this reason, the results of orientation cues in counteracting the disabling consequences of dementia have been generally disappointing (Barnes et al. 2002; Stokes, 2011a).
Author Details
Professor Graham Stokes, Director of Dementia and Specialist Services Innovation, HC-One and Honorary Visiting Professor of Person-Centred Dementia Care, University of Bradford, specialises in the support of people living with dementia who experience distress and present with behaviours of concern.
It is not being argued that signage, symbols and colour coding doors have no value in supporting independence and orientation in the care of people living with dementia, even though a review of research studies reported that there is currently insufficient evidence on which to draw conclusions about the impact of physical environment design changes, including way‐finding cues, on the quality of life for older people with dementia in residential care (Harrison et al. 2022).
What is being contended is that when advocating any therapeutic support, the basic premise involves questions such as: who does the intervention benefit, in what way, for how long, and at what point on the spectrum of progressive cognitive impairment is it no longer of value and should be stopped (Stokes, 2011b)? To do otherwise means supportive care becomes simply another feature of institutionalised practice, albeit dressed in more contemporary clothing.
Residents living with severe dementia in care homes can rarely learn from experience, including exposure to orientation information, whether that be signage or colour coding. Serendipity therefore is often the only means by which they may find themselves in the proximity of the room a sign is identifying. Impaired learning capacity inevitably means a blue door is simply a blue door, not the colour that identifies, for example, ‘this is the toilet’.
In response to the progressive language impairment observed in advanced dementia that results in difficulty understanding even the simplest of words, pictorial symbols were considered the type of visual communication that could be helpful for people living with dementia. However, severe dementia is more than a memory and communication disability; it is also characterised by a reasoning deficit. Hence, seeing for example, a picture of an armchair assumes that a person with dementia can reason that what is being communicated is that behind or through the door is a lounge. Similarly, it is assumed that a knife, fork and plate symbol can be successfully interpreted as ‘I’m being told by this symbol that this is the room where I eat’. The probability is that this vastly over-estimates people’ reasoning ability. Signage was designed to be a memory cue (Schiff, 1990), not a reasoning cue, and therefore it is easy to see how signage loses its purpose and hence its value as cognitive impairment increases. Habell (2013) reported that room names and numbers are increasingly ineffective for advanced dementia, whilst symbols could be indecipherable and confusing.
The report ‘Inclusive Symbols for People Living with Dementia. Feasibility Research’ (Wilkinson, 2016) examined the support offered by symbols in daily life. The results were based on a sample of people with dementia predominantly living in their own homes, and hence in all probability more cognitively able than residents accommodated in dementia care settings. There was an inconsistency in responses to a variety of symbols presented. Hesitancy, perplexity and varied interpretations were evident for some everyday signs. A literal translation of symbols was often observed, such as interpreting a lift icon as people in a box. These findings have implications for using signage in care homes.
Not solely about redundant design
Minimising the use of signage and colour coding in dementia care communities, given the absence of navigation benefits, is not simply about dispensing with environmental features that have no compensatory value. Signs, symbols and colour coding can contribute to an institutional feel when best practice consensus recommends domestic-style homeliness (Cantley and Wilson, 2002). They also contribute to ‘environmental noise’. Bennett et al. (2020) argue that orientation cues risk adding to ‘environmental clutter’ and as such become over-stimulating.
In dementia, the brain’s ability to filter out irrelevant stimuli and focus only on those things that are important is impaired. As a result, a person living with dementia can become stressed by prolonged exposure to large amounts of stimulation. The living environment should therefore be designed to minimise exposure to stimuli that are not specifically helpful to residents, such as the sight of signs and posters that are of no use to them (Fleming et al, 2020).
Yet, it is not only signage that has the potential to stress people living with severe dementia. Wall murals can also be psychologically overwhelming and perplexing, whilst some are best described as ‘environmental lies’. For example, the image of a window used to brighten a hallway depicting a sun that is always shining and night never falls; the painted shop fronts so lifelike that the fruit and vegetables appear real; and the fake bookshelf that causes frustration as no books can be removed. And what is a resident living with dementia to make of lift doors disguised as a waterfall, or a seascape that dominates a hallway end?
Key points
- Care home providers, designers and the UK’s regulators of dementia care services need to reflect on what constitutes dementia-friendly
- design.
- The numbers of people with dementia living in care homes is set to rise dramatically over the next fifteen years.
- Since the mid-1980s dementia-friendly designs have promoted the need to support people live as independently as possible in environments that no longer present as barren institutions.
- Traditionally these designs have included signage, symbols and colour coding in the expectation that people with dementia will learn the meaning of orientation information.
- A contemporary approach to dementia-friendly design is to create low arousal care settings that minimise sensory input that can cause overstimulation.
- When it comes to designing living environments there’s a need to understand what works, what doesn’t and the reasons why.
Dementia-friendly design should be supportive, not a potential source of agitation, exasperation and bewilderment. De-cluttering a hallway is not simply about removing unnecessary objects and bric-a-brac. It is also about ensuring walls are free from intrusive and what may be perceived as chaotic stimuli. Visual stimulation can be as stressful as too much auditory stimulation.
This is not to suggest the living environment becomes bland and devoid of interest. Wall features should be relatable to living at home. A well-designed dementia-friendly care community supports those living with dementia by being familiar. Zeisel et al. (2003) found that aggressive and agitated behaviours were reduced when the environment was one that residents with dementia could understand and relate to. Such findings help us understand that the statement ‘abnormal behaviour in an abnormal setting is normal behaviour’ came about for good reason.
If there is a desire to create interest in rooms and hallways by having murals, these can be situated where they can have real purpose by providing the backdrop to a café that serves tea and cake, or if it’s a greengrocer, has real fruit available to eat. In other words, the mural acts as a prompt, giving people a quality of life in the present.
Low arousal, supportive environments
Some time ago, Lawton and Simon (1968) argued that the more dependent and vulnerable a person is, the more they are affected by the environment that surrounds them. To avoid distressing sensory overload, environments should be thoughtfully designed to create low arousal care settings that minimise sensory input that can cause overstimulation. Low arousal design dispenses with brash colours and busy wallpaper, replacing them with calm soothing shades. Neutral pastel shades are low arousal colours, meaning they are not distracting to people with sensory processing difficulties. Distinguishing contrasts are used to identify spaces and doors that support independence, such as bedroom hallways and toilet doors, whilst contrasting shades that hold no meaningful relevance to people living with advanced dementia are dispensed with. Non-resident doors to offices, treatment rooms and store rooms are designed-out by being the same colour as adjacent walls and so possess no interest value.
By using neutral colour schemes as background, cues, such as everyday objects, furnishings and decoration, as well as natural textures, can be used to replace signs and symbols to support orientation (Cantley and Wilson, 2002). As a result, instead of adding unnecessary signage and symbols to the living environment, thereby creating environmental noise that has little or no utility, orientation cues are integrated into the interior design.
Acknowledging that familiar cues are better solutions to disorientation also encourages us to design environments that are meaningful, so a lounge looks like somewhere you would sit, rest and relax and a dining room looks like somewhere you would eat. You do not need a sign to tell you. However, there is one exception. Identifying a toilet by natural cueing is not possible because we preserve dignity and promote hygiene by the toilet door being closed. This means the only design-critical dementia-friendly symbol that is required to support independence is a toilet symbol. To give the toilet door prominence it is first defined by a bold, but not brash colour. Then one draws on the principles that in dementia what a person learns first stays the longest and what they experience most often throughout life is more resilient to memory loss. The symbol of choice, the traditional figure of a man and woman, is therefore used, although this can still be misunderstood by some people living with dementia (Wilkinson, 2016).
When used creatively and age-appropriately, the use of recognisable cues, including sound and smell, can give residents living with dementia pleasure as they walk down hallways, for we must never forget that the moments spent between rooms can be as important as the moments spent within rooms. A resident’s room is their home, a place that is theirs, where amid familiar things, they feel they belong and can be themselves. But to be outside their own room a resident finds themselves in a community, where the building is part of their wider world (Stokes, 2008). Somewhere to not only walk but where there are places to sit and linger, so hallways cease to be functional passages and become part of the living space of the building, supporting the rhythm of daily life (Stokes, 2000).
Residents living with dementia are also supported to walk without stress by good visual access, ‘the capacity of residents to see or sense where they are or want to go’ (Judd, 1998). Well-lit, uninterrupted lines of sight, especially if they benefit from natural light (helping people with dementia see clearly and understand their surroundings), allow a person to identify key places and destinations, enabling them to make intuitive choices. Harrison and Fleming (2020) note that signage may not be as efficient as visual access in supporting orientation and wayfinding. Visual access mitigates the distress of disorientation. It also supports ‘instinctive’ rather than ‘cognitive’ wayfinding. The latter is dependent on decision-making that in advanced dementia is severely impaired and a source of anxiety and was the reason for the introduction of what is now largely pointless directional signage.The places that are seen and found in a dementia care community should be familiar and act as cues for behaviour that is desired and typically expected. In a low arousal environment, spaces have a singular and unambiguous use, described as “organised space as orientation” (Pastalan, 1984). Compensating for impaired ability to recognise familiar objects, the design message uses as many sensory cues as possible (“organised space as stimulus” – ibid). Pastalan called this the ”empathic model”.
Interior design: re-visiting what is dementia-friendly
It is naïve to propose a cause and effect relationship between design and people’s wellbeing. As noted by Fleming et al (2020), such crude architectural determinism is flawed, for buildings and designs are only as important as the way they may or may not be used. However, there is no doubt that buildings can hinder or help people have a quality of life, and in extreme cases can prevent it, even if buildings by themselves cannot guarantee it.
However, in comparison with many other fields, designing for people living with dementia does not have a large knowledge base. Nevertheless, there are basic principles of designing for people with dementia (Department of Health, 2016), one of which is to reduce unhelpful stimulation and excessive ‘noise’ (Day et al, 2000). The arguments in favour of low arousal living environments are based on redundancy (i.e.de-cluttering) and a need to avoid overwhelming and over-stimulating visual stimuli. Serene and calming low arousal settings have demonstrated psychological and emotional benefits for many people, from young children to adults living with a learning disability and mental health needs (e.g. Ashokkumar & Krishnamurthy, 2023). There is now a need to reflect on what constitutes dementia-friendly design in care homes rather than being wedded to ideas that were first proposed over 40 years ago. We no longer relate to people living with dementia as we did in the 1980s. So why should it be any different when it comes to the design of contemporary care settings for people with dementia, a time when they are at their most vulnerable and their behaviour and emotional responses are too easily misunderstood? Are we seeing signs of increasingly severe dementia, or are we failing to acknowledge that their behaviours and distress may be reactions to unsupportive living environments, masquerading as dementia-friendly?
References
Ashokkumar, R. and Krishnamurthy, G. (2023) ‘Therapeutic architecture: Towards a low arousal sensory environment for people with challenging behaviours and intellectual disability’, Journal of Design and Built Environment, 23(1), pp 29–41. Available at: https://www.mdpi.com/2673-8945/4/3/29.
Barker, R., Hanratty, B., Kingston, A., Ramsay, S. and Matthews, F. (2020) ‘Changes in health and functioning of care home residents over two decades: what can we learn from population-based studies?’, Age and Ageing,17(50), pp. 921–927. Available at: https://doi.org/10.1093/ageing/afaa227.
Barnes, S. and Design in Caring Environments Study Group (2002) ‘The design of caring environments and the quality of life of older people’, Ageing and Society, 22(6), pp. 775-789. Available at: https://doi.org/10.1017/S0144686X02008899.
Bennett, K., Fleming, R. and Zeisel, J. (2020) ‘Environmental design principles and their use in this report’ in R. Fleming, J. Zeisel and K. Bennett (eds) World Alzheimer Report: Design Dignity Dementia: Dementia-related design and the built environment. Volume 1. Alzheimer’s Disease International. Available at: https://www.alzint.org/u/WorldAlzheimerReport2020Vol1.pdf.
Bignall, A. (1996) ‘Look and learn: designs on the care environment’, Journal of Dementia Care, 4, 3, pp. 12-13.
Cantley C. and Wilson, R. (2002) Designing and Managing Care Homes for People with Dementia, London: Jessica Kingsley Publishers.
Day, K., Carreon, D. and Stump, C. (2000) ‘The therapeutic design of environments for people with dementia: A review of the empirical research’, The Gerontologist, 40(4), pp. 397–416. Available at: https://doi.org/10.1093/geront/40.4.397.
Department of Health (2016) Health Building Note 08-02: Dementia-friendly health and social care environments. London: Department of Health.
Fleming, R., Bennett, K and Zeisel, J. (2020) ‘Design, Dignity, Dementia’, in R. Fleming, J. Zeisel and K. Bennett (eds) World Alzheimer Report: Design Dignity Dementia: Dementia-related design and the built environment. Volume 1. Alzheimer’s Disease International. Available at: https://www.alzint.org/u/WorldAlzheimerReport2020Vol1.pdf.
Habell., M. (2013) ‘Specialised design for dementia’. Perspectives in Public Health, 133(3), pp. 151-157. Available at: https://doi.org/10.1177/1757913912444803.
Hanley, I. and Hodge, J. (1984) Psychological Approaches to the Care of the Elderly. Beckenham, Kent: Croom Helm.
Harrison, S. and Fleming, R. (2020) Design and the built environment for people living with dementia in residential aged care. in R. Fleming, J. Zeisel and K. Bennett (eds) World Alzheimer Report: Design Dignity Dementia: Dementia-related design and the built environment. Volume 1. Alzheimer’s Disease International. Available at: https://www.alzint.org/u/WorldAlzheimerReport2020Vol1.pdf.
Harrison, S., Dyer, S., Laver, K., Milte, R., Fleming, R. and Crotty, M. (2022) ‘Physical environmental designs in residential care to improve quality of life of older people’, Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD012892. Available at: https://doi.org/10.1002/14651858.CD012892.pub2.
Judd, S. (1998) ‘Building for dementia: A matter of design’ in S. Judd, M. Marshall and P. Phippen (eds) Design for Dementia. London: Hawker Publications.
Lawton, M. and Simon, B. (1968) ‘The ecology of social relationships in housing for the elderly’, Gerontologist, 8, pp.108–115.
Matthews, F. Bennett, H. Wittenberg, R. Jagger, C. Dening, T. and Brayne, C. & Cognitive Function and Ageing Studies (CFAS) Collaboration (2021) ‘Who lives where and does it matter? Changes in the health profiles of older people living in long term care and the community over two decades in a high income country’, Age and Ageing, 50(3), pp. 921–926. Available at: https://doi.org/10.1093/ageing/afaa227.
Pastalan, L. (1984) ‘Architectural research and life-space changes’ in J. Snyder J (ed), Architectural Research, New York: Van Nostrand Reinhold.
Schiff, M. (1990) ‘Designing environments for individuals with Alzheimer’s disease: Some general principles’, American Journal of Alzheimer’s Disease and Other Dementias, 5(5), pp. 4–8. Available at: https://doi.org/10.1177/153331759000500303.
Stokes, G. and Goudie, F. (1990) Working with Dementia. Bicester: Winslow Press.
Stokes, G. (2000) Challenging Behaviour in Dementia: A Person-Centred Approach, Bicester: Speechmark, Bicester.
Stokes, G (2008) And Still The Music Plays, London: Hawker Publications.
Stokes, G. (2011a) ‘Psychosocial interventions in care homes’ in T. Dening and A. Milne (eds.) Mental Health and Care Homes, Oxford: Oxford University Press. Available at: https://doi.org/1.1093/med/9780199593637.001.0001.
Stokes, G. (2011b) ‘From psychological interventions to a psychology of dementia’ in J. Hughes, M. Lloyd Williams and G. Sachs (eds.) Supportive Care for the Person with Dementia, Oxford: Oxford University Press. Available at: https://doi.org/10.1093/acprof:oso/9780199554133.001.0001.
Wilkinson, H. (2016) Inclusive Symbols for People Living with Dementia. Feasibility Research Report. Commissioned by Life Changes Trust. School of Health in Social Science, Edinburgh Centre for Research on the Experience of Dementia, University of Edinburgh.
Wittenberg, R., Hu, B., Jagger, C., Kingston, A., Knapp, M., Comas-Herrera, A., King, D., Rehill, A. and Bannerjee, S. (2020) ‘Projections of care for older people with dementia in England: 2015 to 2040’, Age and Ageing, 49(2), pp, 264–269. Available at: https://doi.org/10.1093/ageing/afz154.
Zeisel, J., Silverstein, N., Hyde, J., Levkoff, S., Lawton, M. and Holmes, W. (2003) ‘Environmental Correlates to Behavioural Health Outcomes in Alzheimer’s Special Care Units’, The Gerontologist, 43(5), pp. 697-711. Available at: https://doi.org/10.1093/geron/43.5.697.