Ageing-in-place : the integrated design of housing facilities for people with dementia

J. Hoof, van

Research output: ThesisPhd Thesis 1 (Research TU/e / Graduation TU/e)

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Ageing-in-place is the preferred way of living for older persons in an ageing society and can be facilitated through support for (instrumental) activities of daily living and support for physical activity. In addition, home in which older adults dwell can be modified in terms of architectural and technological solutions. Dementia syndrome poses additional challenges when designing, constructing or retrofitting housing facilities that support ageing-in-place. For instance, this is evident in relation to the support of (instrumental) activities of daily living, the creation of safe and secure living conditions, the optimisation of well-being, and the execution of care tasks.At present, there is a quantitative and qualitative shortage in the number of modified dwellings that support ageing-in-place in general, and for people with dementia, in particular. In order to solve the apparent gap between demand (i.e., the needs of people with dementia related to ageing-in-place) and supply (i.e., the supply of architectural and technological solutions to facilitate ageing-in-place), the domains of building and health care should cooperate more in the creation of such modified dwellings. Also, more research is needed on how housing facilities for people with dementia should be designed and built. This dissertation provides solutions to these challenges based on a theoretical and practical framework, which integrates the domains of building and health care.The research sets out to investigate the contribution of various aspects of housing facilities in relation to the needs of older adults with dementia and their family carers, in order to support ageing-in-place. Second, an integrated design for a home for people with dementia is proposed. In this dissertation housing facilities comprise architectural solutions, including the indoor environment and related building services, and emerging technological solutions, including ambient intelligence.MethodologyAn integrated approach, combining the domains of building and health care, was chosen for the research. This is reflected in the way the studies are structured and in the way that demand and supply are taken into account. A combined framework of the International Classification of Functioning, Disability and Health (ICF) by the World Health Organization, and the Model of Integrated Building Design (MIBD) by Rutten is used for structuring and retrieving information.Moreover, to investigate demand and supply, a combination of research methodologies has been chosen. Apart from literature study, these approaches include qualitative and quantitative research methodologies, such as interviews using topic lists, focus group sessions, observations of existing homes, behavioural observations using numerical scales and physiological measurements.Summary of investigationsThe first step in research was to examine more closely the type of housing facilities in which people with dementia live in the various countries of the European Union and how family care is related to the type of housing facilities for older adults, and for people with dementia in particular. The applicability and implementation of research findings, of which the majority stems from Anglo-Saxon countries, as well as a person’s living career, may differ from country to country in accordance with traditions and culture. Furthermore, political choices on a national level regarding ageing in place, dementia and ensuing legislation may also vary in this way.Thereafter, architectural and technological solutions were investigated. An overview was made of existing design principles and design goals, as well as environmental interventions implemented in the home. These environmental interventions included home modifications, assistive devices, object modifications and task simplifications. Each of these environmental interventions was studied in relation to a specific activity of daily living or a general function it supports.Existing research on dementia and housing facilities has no specific focus on the indoor environment and related building systems, whereas this domain is germane to ageing-in-place. Thus in this dissertation, the indoor environment and related building systems were studied in relation to the hindrance or support these environmental factors have on people with dementia and their family carers. Special focus was on the effects of the indoor climate and lighting systems on well-being and behaviour, as these two areas of research are most promising for future interventions in order to positively influence behavioural problems. At the same time, promising applications within the domain of lighting are not fully understood. Therefore, two clinical-controlled trials were conducted in a group setting to study the effects of ambient bright light and high colour temperature dim light on behaviour and circadian rhythmicity.Apart from architectural solutions, there are numerous technological solutions available to support ageing-in-place. Aspects of ambient intelligence technologies were explored in the context of daily living and care support, as the application of such technologies is relevant to concerns about privacy, ethics, and the inclusion of people with dementia. The contribution of ambient intelligence technology was also studied in the field among community-dwelling users of the Unattended Autonomous Surveillance system. This system is applied as a means to support ageing-in-place by improving safety and security and supporting carers.The studies on architectural and technological solutions were followed up with a design study of a conceptual dwelling for people with dementia, which incorporates the integrated view on the demand in relation to ageing-in-place and the supply of adequate housing facilities. This conceptual dwelling is an example of how the combined framework of ICF-MIBD may be used. The design is based on the most important and succinct architectural and technological solutions identified in this dissertation.Main findingsIn the European Union, living in the community is the most prevalent type of living condition for people with dementia. The Netherlands is one of the countries in which national policies explicitly stimulate ageing-in-place for older adults in general, and where care support for family carers is facilitated at the municipal level. Unfortunately, this support does not sufficiently cover modifications to the home environment.This dissertation identified a large number of environmental interventions, which find their origin in design goals and principles for dementia, and conventional home modification practice. At the moment, environmental interventions for dementia are not offered in a structural way, which means that these solutions do not yet match the needs of people with dementia and their family carers.The studies in this dissertation on the indoor environment revealed that people with dementia may have an altered sensitivity for indoor environmental conditions compared to other older adults, which may be a cause of problematic behaviour and may have a negative effect on safety and security. There are a large number of building-related solutions, particularly within the domain of heating, ventilation, and air conditioning (HVAC) and lighting systems. These solutions can be implemented to decrease the incidence of problem behaviours, improve the comfort and well-being of people with dementia, and support with (instrumental) activities of daily living. The two lighting studies, which are part of this dissertation, showed that ambient bright light with a high colour temperature may lead to improvements in behavioural outcomes and circadian rhythmicity. These improvements are not seen in low colour temperature lighting conditions. Higher illuminance levels are a crucial factor in establishing successful light therapy. Increasing colour temperature may contribute to the effectiveness of lighting in improving behavioural outcomes and circadian rhythmicity.This dissertation shows that ambient intelligence technologies can contribute to an increase in safety and security among clients and their family carers. People with dementia may have difficulty understanding the technology, which has implications to the way technology is designed and installed. Moreover, the use of ambient intelligence technologies is not a substitute for adequate (care) support. Additional home modifications and assistive devices are also needed. In this dissertation, privacy-related issues and ethical dilemmas were not found to be a concern in practice.The design for the dwelling for people with dementia demonstrated that integration of architectural and technological solutions can be achieved. Such a dwelling can be an added value to family carers, as a spouse with dementia is (i) more independent and (ii) is being monitored and supported by technology, (iii) feels more comfortable and (iv) expresses fewer behavioural problems.Recommendations for research and practiceThe combined framework of ICF and MIBD, which can be used for analysis and evaluation, as well as for design purposes, was shown to be a valuable tool for structuring and retrieving information. It allows for both an integrated view and an integrated process for the design and construction of new homes or retrofitting existing dwellings. During the research, extensions to the combined framework have been incorporated and proposed, for instance, to include legislation and assistive technologies.Systematic and large-scale studies should be conducted on the efficacy of environmental interventions identified in this dissertation, as evidence is often based on small-scale and non-controlled studies. Additional research is also needed for the study of optimal indoor environmental conditions and related building systems. The application of ceiling-mounted lighting systems calls for more research on the details of the lighting equipment, in particular, threshold illuminance levels and spectral composition of the light. Future evaluation studies of technologies that are used to support ageing-in-place should focus on the integration of such systems within the context of family and professional care and a person’s home environment.Policies and legislation dealing with dementia and housing facilities should widen their scope to include ageing-in-place in the own home environment. This dissertation shows how demand and supply can brought closer to one another. In order to improve the current situation, it is essential that all people involved have access to relevant information. Family carers and people with dementia should have easy access to usable and understandable information about architectural and technological solutions, which can support ageing-in-place. The dissemination of knowledge should also address professional carers, professionals from the domain of building and technology, and policy makers and civil servants. This knowledge can help bridge the gap between demand and supply. Moreover, working with persons with dementia calls for a paradigm shift in the way designers and contractors operate. Civil servants at the municipal level should increase their skills and knowledge in order to adequately support people with dementia and their family carers in implementing architectural and technological solutions as people with dementia wish to age-in-place.Concluding remarksAgeing-in-place is possible for people with dementia by examining their care-based needs in relation to their home environments. To achieve this, architectural and technological solutions have been proposed in an integrated manner, which may also contribute to a lessened burden on family carers.Whether a modified dwelling is supportive in relation to ageing-in-place, and, if so, for how long, depends on the specific needs of people with dementia. There may come a time, as the dementia progresses, when architectural and technological solutions no longer offer support and institutionalisation becomes inevitable.
Original languageEnglish
QualificationDoctor of Philosophy
Awarding Institution
  • Built Environment
  • Rutten, Paul, Promotor
  • Duijnstee, M.S.H., Promotor, External person
  • Kort, Helianthe S.M., Copromotor
Award date8 Nov 2010
Place of PublicationEindhoven
Print ISBNs978-90-386-2326-9
Publication statusPublished - 2010

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