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Unpacking - Design for Dementia: 'recall'

Pamela Topping School of Art and Design, University of Ulster, York Street, Belfast BT15 1ED, UK

Abstract In seeking an Innovative solution, this paper seeks to deliver how the built environment will serve as a holistic therapeutic resource for the ageing population. The design will embrace a holistic societal space, - a modular Memory Bank Café, Reminiscence and Information Centre for people in the early stages of dementia. Research has shown that the direct impact of elements in the physical environment has an influence of behavioral and functional abilities of people with dementia. This space as well as being a highly functional place will also become a type of cognitive prosthesis. Keywords: dementia, social Inclusion, reminiscence, digital technology Unpacking - Design for Dementia The objective of this paper is to translate extensive practice led research into actionable insights, providing a positive user experience for people with dementia. Presented here are some of the facts, statistics, government proposals and strategies that have influenced decisions made during the design process of 'recall' -the proposed design concept. Dementia is one of the greatest major public health problems of our time, it is a term used to describe various different brain disorders that have in common a loss of brain function that is usually progressive and eventually severe (1). The changes that occur affect cognitive, emotional and social aspects of functioning, this includes memory loss, impaired judgement and the ability to learn and recall new information. Dementia is defined by the official medical classification of diseases that states:

'Dementia is a syndrome due to the disease of the brain, usually of a chronic or progressive nature in which there is impairment of multiple higher cortical functions, including memory, thinking, orientation, comprehension, calculation, learning capacity, language and judgement. Consciousness is not clouded. The cognitive impairments are commonly accompanied, and occasionally preceded, by deterioration in emotional control, social behaviour, or motivation. This occurs in Alzheimer's disease, in cerebrovascular disease, and in other conditions primarily or secondarily affecting the brain'. (2)

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Globally, the United Nations research agenda on Ageing for the 21st Century (2007), seeks to prioritise the relationship between population ageing and socio-economic development. This information appears problematic in an ageist society that stereotypes people with dementia, the fact that society in the 21st Century is ever more risk-averse, adds a layer of difficulty, leading the family, carers and staff under more pressure to protect rather than enable. National Strategy The publication of the first National Dementia Strategy was launched in February 2009; this strategy outlines the three key steps, which will improve the quality of life for people with dementia and their carers, this strategy provided the blue print that is necessary for cultural change. The first step is to remove the stigma attached to dementia, ensuring that better knowledge becomes available. The second step addresses a proper diagnosis, and the third step seeks to deliver a range of services, which must be developed for people with dementia and their carers. (3) The aim of the strategy is to put people first, ensuring that all people with dementia and their carers live well. Neurological deterioration inevitably occurs in persons with dementia, however people gradually develop a sense of their own personal uniqueness by recalling their life story, reminding them of their singular identity and value as an individual. Global Perspective

Designers now have the freedom and cultural autonomy to work and understand all cultures. As cultural differences disappear - engaging, observing, perceiving and contributing becomes second nature. In 1968 Charles and Ray Eames delivered one of the most influential documentaries with iconic relevance 'The Power of Ten', ascending to another realm the constant search for opacity and spatial coherence in design thinking. It is these principles that have influenced the methodologies of scale, space, light and materials in this proposed design for dementia. Adaptability has permitted designers to embrace progress, translating technological and scientific innovations into practice. However being able to negotiate change especially in the field of design for dementia, equips the designer with a visual translation exploring the spatial narrative, informing an appropriate response to the functional and technical needs in a holistic manner. Abandoning the traditional institutionalised authority, this spatial transformation of a free flowing space may just capture the emotional and personal liberation required, to escape the life sentence of a diagnosis of dementia. The hallmark of this design is the uniformity that is neither rigid nor fixed; in fact its strength lies in its flexibility.

Design Thinking

The design process of this design concept has been informed by qualitative research undertaken, influenced in particular by Juhani Pallasmaa, and Alvar Aalto both architects from Finland, these innovators have influenced the principles and design thinking. Pallasmaa and Aalto share common ground in that both celebrate humanism and the spirit of the individual place; both practitioners demonstrate how design can deliver a process of 'whole life sustainability' that puts people first; proving that a people centred space is possible. Nordic countries are among the most humane, affluent and democratic in the world, the reason for this is that in Scandinavia well designed and executed objects are seen as a vital enrichment of daily living rather than status symbols.

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Scandinavian design is distilled in humanism, embracing human needs but adopting a fine balance with innovative developments and technology. Aalto's philosophy draws upon the democratic architecture called for by John Ruskin and William Morris.

'But above all, accustom yourselves to look for, and to love, all nobleness of gesture and feature in the human form; and remember that all nobleness is usually among the aged, the poor and the infirm; you will find in the end, it is not the strong arm of the soldier, nor the laugh of the young beauty, that are the best studies. Look at them and look at them reverently; but be assured that endurance is nobler than strength, and patience than beauty. (4)

Aalto was a functionalist with a dedicated humanitarian approach, examining and analysing how design could be developed to provide comfort, and support man at his weakest, stating 'what is the purpose of new form if there is no new content', (5). Pallasmaa states how the dominance of our consumer culture has led to an impoverished environment leaving a feeling of alienation and detachment, requiring all designers to acquire a deep understanding of nature and the fundamental needs of human beings, (6). The proposed design is not prescriptive but generic, the infrastructure requirements and acceptability of changes to care pathways is necessary, as each person can take with them the information necessary for their needs. Self-management is encouraged achieving goals that people with dementia identify for themselves, developing participative methods that identify unmet needs.

Design Research

It is discussed in (Building for Dementia, A Matter of Design, 1998) (7), that a shift from the medical model of care is welcomed, embracing the more social and physical model of care, permitting the experience of a person with dementia to contribute to an active everyday life, instead of doomed institutionalised daily routines. It is accepted that good design within the built environment should not depend on peoples memory, learning or reasoning, in fact a well designed building should produce a conducive result to those with the least ability. Design for persons with dementia must relate and engage on a personal level, expressing social, cultural and economic history - ensuring human experiences and interactions between people and the physical environment are meaningful. It is through recall and remembering, that we reconstruct our imagination, for people with dementia this process encourages self-identity and confidence. The distinct lack of knowledge, particularly on what can be offered to people with an early diagnosis of dementia and their carers requires radical change, the stigma attached to receiving a diagnosis of dementia remains, this not only effects the person with dementia, but also the family carers and supporters resulting in a 'care gap' developing after diagnosis. I realised that by creating similar 'safe environments' that I was in fact producing bland homogeneity, totally obliterating the demographic, cultural and social changes that emerged throughout recent research. A health care system that offers a solution through design and that turns a traumatic experience into a soothing experience creates a positive user experience.

Design Concept Six recycled shipping containers will wrap around the design concept - a modular Memory Bank Café, reminiscence and Information Centre for people with early on-set dementia, (Fig.1), equally the design concept may be placed into an existing

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building or a new build. Statistics show that 38,000 shipping containers leave the United States every day, it is more expensive for them to return empty than it is to abandon them on the shores. Shipping containers are an ideal social and spatial construction, as we delve into the deep motivations and implications of the concept, it is found that the design references significantly more complex thoughts and ideas.

Figure 1. Shipping Containers

The User Experience

The qualities of the user experience in visiting 'recall', suggest spatial continuity embracing the physical and psychological thresholds of internal and external. At the turn of the last century, the emphasis of Universal Design was hygiene and shelter, then in the post war years Universal Design was applied to mass production and distribution. The focus on Universal Design in the current digital age is global interconnectivity and along with it a newly discovered accessibility. The idea of an undifferentiated neutral space, permitting affordability and global interconnectivity, suggests a clear distinction between containers and contained. This modular design (Fig.2) shall empower people with dementia helping them to feel in control, helping to support and make decisions about their health, when in fact they are at their most vulnerable, embracing all-inclusive design, including emotional, physical and human values. New materials within the space inspire a new language, a sensual language developing an organic relationship between the person and an object, throughout the space polarisation of materials will be experienced as the outside becomes inside adhering to complimentary opposites. Sustainable designs are relatively new influences in healthcare design, informing the synergy between the outdoor and indoor environment providing more energy efficient positive distractions, providing open spaces, lighting, acoustics and economic benefits. The space proposed will include a sensitive interface of design and nature, a biomorphic design expressing the biological nature of all existence inspired by nature.

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Figure 2. Modular Space - Social and Cultural Changes

Almost like fabric, architectural materials also speak a language that refers to history, and to a particular period of time. We can clearly see in (Architecture from the Inside Out, 2007) (8) that architectural materials embody qualities of a particular era; each relating to an individuals experience and perceptions, as each material carries its own particular character and voice, intimately related to our own. Materials are a few of the intimate things that we interact with throughout our lives, materials that provide us with protection and shelter, holds memories of our laughter and tears, our sweat and our labour over the years carrying evidence of who we are, revealing identity and memories of our past. This tactile sense of touch therefore connects us with time and memory, as the body knows and remembers, as materials have a uniquely intimate and personal relationship with the human body.

We experience spaces not only by smell, sight and touch but also by listening. The audible attributes of physical space have always contributed to human culture, as the ability to sense space and explore auditory spatial awareness implies that the listener is conscious of sound. This cognitive process of interpreting sound is highly complex, transforming feelings into an awareness that has meaning. Capturing physical memory is explored in (The Eyes Of The Skin, 2007) (9), as memory, perception and imagination are in constant interaction, along with muscle and skin, as the body constantly recognises the plasticity of hearing, touch, smell, vision and taste, which is hidden in the unconscious mind. Therefore it is not only materials that come into intimate bodily contact, but also furniture and objects encountered throughout daily living, it is this encounter with the object that permeates equally with all the senses.

'It is our responsibility to be magicians, to be jesters, to be alchemists, to create hope where there is only illusion, to create reality where there are only dreams'(10).

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The Relationship of Colour

Some of the facts that emerged from my research were the communicative values of colour, including the psychological effects and the visual ergonomics. It is important to remember that this environment is tailored to peoples needs, displaying the functional and emotional requirements, active in a holistic space. 'Colour exists in itself, it connects things with each other and connects things with people,' (Colour Communication in Architectural Space, 2007) (11). The use of colour constitutes our visual perception, influencing our visual communication and interaction. In interacting with people who have memory problems, it is vital to try and enter their world facilitating social relationships and inclusion. This exchange of information includes colour in way finding, geographic markers and symbols in the environment. The emotional and cultural associations of the memorability of the colour red, created a powerful emotion associated with red roses, a reminder that there are many ways in which colour can play a part in enriching the lives of those with dementia. This informs the need to be sensitive to emotional meanings and associations, as colour governs our cognitive reactions, including spiritual, health and well - being. I think as human beings we identify and manipulate colour in many ways, however when designing for people with dementia, conversation and interaction within the built environment becomes relevant, accessing memories that link 'now with then'. The appropriate use of contrasting colours rather than specific colours is important and poor colour contrasts include those colours that are similar in shade. The balance between under and over stimulation plays a vital role in human interaction, highly saturated colours can wrongly inform the senses, leading to irritating and aggressive behaviour. Information from the built environment requires plain and clear signals - no patterns or shiny surfaces, as people with dementia remain highly dependant of cognitive signals from their surroundings.

Lighting Perspective

As an aspect of our sensory functioning, light is one of the most important influences, directly affecting our well - being and health. As age progresses a different perception of colours is interpreted, less blue light reaches the retina, resulting in yellowing of the eye. This designed space acknowledges human dependency on light, as light is the most important time regulator of the human biorhythm, in fact recent studies have found that the circadian rhythm influences our sense of time much more than social factors such as eating and working. Daylight is emitted by all sides of the sun, which is made up of two components, sunlight and skylight. People feel more alert and positive in sunshine, however by providing brightness, an environment may be created that has the attributes of a sunny day. The difference between a dull space and a bright space is the quality of light.

The entrance is the most important characteristic of the building, as visitors are received to 'recall' they will be greeted by a member of staff, an illuminated reception desk and a grand chandelier will hang over the desk. The glass entrance will throw warm light to those arriving, as the transparent Memory Bank reveals itself on the outside. The lighting design aims at providing a pleasant welcoming atmosphere; artificial light will compliment and enhance the primary use of daylight, (fig.3).

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Figure 3. Light Modulation

Design Interaction

Interactions with social, material and psychological environments influence the self-identity of people with dementia, and whom they think they are influences how they behave in certain places. In reminiscence, people like to discuss their experiences of place, and many older people are able to achieve a better quality of life as they engage with their environment. A specific place should make a person feel good about themselves, they should look forward to being in that place, if social environments can become more visible they will facilitate new levels of social inclusion, engagement and creativity.

'Memory and Identity are inextricably linked, and each person's sense of identity provides a sense of continuity through time. Who we presently perceive ourselves to be is indisputably connected with a sense of who we perceive ourselves to have been in the past and will be in the future. Although we realise there have been changes over time, we are still the same person we always were in core ways and will be hereafter, for change and continuity go hand in hand'. (12)

Defined not Designed The space will include a multi touch visual media computer-based table for reminiscence, supporting memories for people with dementia and their carers. The table will contain a database of generic images, as the potential of technology to provide solutions to problems faced by older people is now receiving recognition, the inclusion of computer-based tables within the space will influence and inform the design of the project encouraging participation in creating social inclusion and interaction, this barrier free space will promote wellbeing, enhance communication and provide intergenerational activities.

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This paper discusses the analysis and reflection of evidenced based and practise led research undertaken throughout the design process, of the theoretical design concept 'recall'. Findings present functional, economic, social, cultural and political problems, suggesting that a paradigm shift is necessary in dementia. 'The true self, that is the self which is continuous throughout life, is revealed only at the moment of experiencing two fragments of time together, the present with the past'. (13)

CONCLUSION

'recall' - this special place will evolve as a natural setting, in which a sense of fellowship can develop for those who share the experience of an instinctive desire and ritual of wanting to return to the same place again, reminding us of previous visits, and somewhere in which we feel comfortable. This sense of place, at a time suggested a benign presence or a supernatural presence, however nowadays this experience varies in intensity, as atmosphere, mood and socio-economic influences affect how we behave. What brings together people, as a group is not the architecture, but the belonging of a significant special place, sharing the same observances, sharing a sense of time. This concept begins with the embodied process of delivering an intangible and invisible service to one of the most vulnerable groups in society; the proposal is an instigator of social change incorporating new forms, new materials, and embracing new technologies in the digital age. Through collaboration and interactions during my research, the strategies and end solutions that I propose will combine social inclusion, social relevance, interpretation and change. Basically I am proposing a catalyst for new beginnings (Fig.4), a holistic place for people with a diagnosis of dementia, collaboratively building a new agenda and shared ideology.

'We shall not cease from exploration And at the end of all our exploring Will be to arrive where we started, And know the place for the first time' (14)

Figure 4. Catalyst for New Beginnings

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References 1. www.alzheimers.org.uk /about dementia 2. Gibson, F. Internal Classification of Diseases, (World Health Organisation1992), in The Past in The Present, pp.203. Health Profession Press, London, 2004 3. Department of Health. Living well with Dementia: February 2009. A National Dementia Strategy 4. Ruskin J . 2004. The Two Paths, pp. 88. Parlour Press, Indiana 5. Ban Shigeru. 2008. Alvar Aalto. pp15. Black Dog publishing 6. Pallasmaa Juhani. 2007. The Eyes of the Skin. John Wiley, England 7. Judd. S, Marshall. M, and Phippen. P . 1998. Building for Dementia, A Matter for Design. Wiley Press, London 8. Frank. K.A and Lepori. B. R. 2007. Architecture from the Inside Out. Wiley-Academy, Great-Britain 9. Pallasmaa. J . 2007. The eyes of the skin. John Wiley & Sons. Great Britain 10. Wanders. M. 2009. in The Genius of Design. Sparke. P. p.p 227 11. Meerwein, Rodeck, Mahnke . 2007.Color Communication in Architectural Space. Birkhauser. Boston. Berlin 12. Warnock, M.Memory 1987. London. Faber & Faber, in The Past in The Present, pp 31. Gibson, F. Health Profession Press, London, 2004 13. Proust , M. 1981. Remembrance of things past, New York, Alfred A Knopf 14. El iot. T.S. 1969. The complete Poems and Plays. Faber & Faber

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Appendix 1. Figure 1. Shipping Containers Figure 2. Modular Space Figure 3. Light Modulation Figure 4. Catalyst for New Beginnings