Ashish Ranpura, MD, PhD
October 2021 There isn’t a lot of empirical research on how design features in clinical spaces affect patients with dementia and other forms of cognitive impairment. Likely this is because first, it would be difficult to conduct randomized controlled experiments on architectural features, and second, because patients vary widely in their capabilities and their cultural expectations surrounding design. In the absence of empirical evidence, the research literature offers expert opinion. The best work on this topic surveys a range of clinical specialists including doctors, nurses, occupational therapists and care workers to produce something like a professional consensus view on how design can be used to help patients. There are a few clear themes that emerge in this consensus view. First and foremost, familiar domesticity really helps patients navigate otherwise threatening clinical spaces. This means that those health and safety measures which are institutional rather than domestic tend to cause confusion. Torrington 2006 makes this explicit, writing that ‘quality of life was shown to be poorer in buildings that prioritise safety and health; buildings that support activity positively by providing good assistive devices, giving people control of their environment and affording good links with the community have a positive association with well-being.’ (Torrington, Judith, ‘What has architecture got to do with dementia care? Explorations of the relationship between quality of life and building design in two EQUAL projects,’ Quality in Ageing and Older Adults, March 2006). Safety is maximized when clincial environments evoke domestic spaces. Another theme emerging from the literature is the importance of light, colour and contrast. There is a conflict in the expert views here, because while patients with limited visual acuity need brighter lights and higher colour contrasts, those who are unwell or confused need restful visual environments which don’t clamour for their attention. The reliable conclusion is that unnecessary visual clutter, and in particular institutional visual clutter like staff notices and equipment storage, should be minimized, and that wherever possible natural light should be maximised. Again, safety emerges from familiarity and comfort rather than as an explicit design goal. It is striking that many of the papers in this field discuss the importance of gardens. From the perspective of low-level vision alone, a garden might be a chaotic and unpredictable space. However every paper which discusses gardens and green spaces concludes that patients navigate these spaces confidently and comfortably, and that the inclusion of significant green spaces improves the quality of life for patients with cognitive or sensory impairments, over and above nearly any other design feature of a building. Ultimately, though, clinical experts are not necessarily experts in architecture and design. Clinicians see their patients interact with health care facilities as they exist today, but they may not have the training required to re-imagine these spaces in the future. Furthermore, concepts like familiarity and domesticity are dependent on culture and social class. The role of clinicians and of clinical research should be to articulate problems that then require architects and designers with the training to create inclusive and flexible solutions. We shouldn’t be looking for prescriptive solutions in the research. Instead, our design should be led first and foremost by compassion and humanity. The challenge is to meet institutional design needs while absolutely prioritising human design preferences.