Improving Person-Centered Care Through Effective Design

Addressing eight areas of design criteria in community living settings allows people with dementia to be more themselves, leading to better relationships with staff and family.Person-centered care is a primary goal of designing for dementia. Every environmen- tal characteristic that helps people with demen- tia be more "themselves" helps unleash hard- wired brain capacities that reinforce a person's sense of self, which improves reciprocal rela- tionships between the person and their partners and caregivers. As such, the two reasons for designing for dementia are to enable the person to be all he or she can be, and to support the most enriching relationships possible.Achieving these goals is the definition of person-centered care, as originally described by Tom Kitwood in his groundbreaking book, Dementia Reconsidered: The Person Comes First (Kitwood, 1997). He writes:Identity remains intact, because others hold it in place; . feelings are expressed and meet a validating response; and if there is a spirituality, it will most likely be of the kind that Buber describes, where the divine is encountered in the depth of I-Thou relating.Recognized dementia design experts Maggie Calkins, Jerry Weisman, Uriel Cohen, M. Powell Lawton, and Loraine Hyatt each generated design guidelines, which when analyzed and combined, lead to a set of eight key user-needs design performance criteria (Zeisel, Hyde, and Levkoff, 1994): exit control, walking paths, common spaces, privacy and personalization, garden access, residential-ness, sensory compre- hension, and support for capacity.In 2003, a two-year clinical trial funded by the National Institutes of Health and the Na- tional Institute on Aging, for which I was the principle investigator, evaluated the impact of these design characteristics on the behaviors of people with dementia residing in special assisted living residences or nursing home special care units. Our data indicated that most of these design elements correlated with reduced behavioral dysfunctions among residents, specifically in anxiety, agitation, aggression, and apathy-the four "A"s of Alzheimer's-as well as in social withdrawal and psychotic symptoms (Zeisel et al., 2003). Since that clinical trial, I have become more mindful of the neuroscience basis of healthy dementia design and dementia relationships. Neuroscience has shown that a host of hard- wired skills and abilities in the brain do not diminish, even with dementia, and can be accessed through design to improve each person's sense of self.This article explains the eight types of design guidelines listed above, emphasizing the effects design can have on the personhood of residents and on opportunities for relationships that such effects can have-the link to person-centered care (Zeisel, 2009). Controlled Exits Allow for IndependenceThe human brain is naturally curious. What lies beyond the seas? What is around the cor- ner? How does that machine work? The natural curiosity of people with dementia attracts them to inviting doors leading to dangerous places, fences that are low and climbable, and people who can be seen com- ing and going outside.Doors that attract in this way need to be made less in- viting and as invisible as poss- ible, or camouflaged. They should be made difficult to open, using a keypad with a hard-to-remember code or other complex memory mechanism. The same is true for windows whose openings need to be controlled and fences around gardens to which residents have access. At the same time, doors to places that are safe, such as a door from the inside to a safe garden or an interior courtyard, need to be as inviting as possible.Doors with see-through panes that invite those nearby to look out of and pass through are one reason people with dementia are accused by caregivers and others of wanting to leave, or elope, from a residence (the term "elope" is often used for people leaving a residence unattended). …