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Vision and awe: the missing ingredients in dementia care?

I have researched, presented on and used ten principles of design for people living with dementia for many years. Nine of these principles deal with what you might call ‘technical’ aspects of design, such as scale, visual access, stimulus control and familiarity. The application of these principles results in residential aged care facilities that support confused, anxious people by making it easy for them to find their way around, particularly to their bedroom, the lounge/dining room and to an outside space. The familiarity of the colours, fittings and furniture combined with an appropriate scale provides a comfortable and supportive feel to the place. Other principles about ensuring that there are links to the community and a variety of spaces so that residents can be alone, with one or two others or in larger groups, help to make the place attractive to visitors, so essential for the maintenance of the identity of the person who is having more and more trouble remembering who they are.

The combination of these principles reduces the number of obstacles experienced by people living with dementia and makes it much easier for staff to support them. So far so good but taking away obstacles is not enough.

The tenth principle is not about taking away obstacles, it is about adding something essential. It focuses on designing in response to a vision for a way of life. It calls on the designers, or more importantly, those who have commissioned the designers, to have a clear idea of how they want the people living and working in their building to spend their time. Or to put it another way, to be clear about the purpose of their service.

When the managers and designers have a clear purpose in mind the building can be designed to support the residents and staff as they live out that purpose. Indeed, the building can do even more, it can make the purpose of the building, and service, evident to those who live, work and visit in the building. The building can be the embodiment of the philosophy of care, constantly reminding the staff of the values and practices that are required while providing them with the tools they need to do their job.

If the managers and designers do not consciously and deliberately address the question of what the purpose of the building is, they will fall back on an intuitive belief that the building is to provide the support of care for the residents. In the worst-case scenario they will produce a hospital like environment, designed for the convenience of the staff. In a better scenario they will attend to the nine ‘technical’ principles of design and produce a building that is comfortable and obstacle free.

If they do engage with the question of what is the purpose of the building they will find themselves considering what is the purpose of the life of the people living in it. Is it to maintain their links with their memories, friends and families? Is it to enjoy a social life including fine wine and good food? Is it to engage in creative activities? Or perhaps it is to slow down the progression of dementia by keeping fit? All of these are worthwhile purposes and they all require the building to provide certain amenities.

Worthwhile though these purposes may be, are they missing a point? Is the purpose of the final months of our lives to enjoy good meals, good conversation and to stave off deterioration for as long as possible? Some would say that that is sufficient, and there is no doubt that if aged care homes were designed and staffed to support these activities, they would be better than they are now. But perhaps there is more that can be wished for.

A truly well-designed aged care home, for those with and without dementia, will give the residents access to a building, or space, that supports the ultimate purpose of the final stage of life, being ready to die.

What would such a space be like? Clearly, there is no one answer to this question but is there something common to all answers? Perhaps there is, perhaps it would be a space that leads us to think beyond concerns about food, wine, conversation and exercise and to feel that we fit in a much bigger picture. To experience a sense of awe that we have been, and are, part of something unimaginably immense.

This sounds like a tall order – building awe into aged care. But it’s not impossible. Some aged care homes have the good fortune to be associated with organisations that have a tradition of building with awe in mind and have access to existing awe-inspiring spaces. Other organisations deliberately design such spaces into their new aged care homes. The best and most recent example I have come across is the Village by Scalabrini. This purpose designed community for people with dementia includes a beautiful, calming chapel with a stained-glass window that blazes with the rays of the setting sun. And it’s not accidental. It came about because the managers and the designers were prepared to engage with all ten principles of design. Nine about technique and one about vision.

When I teach about applying the principles of design I always leave the vision principle until last. Paradoxically because it is the most important. I like people to be able to see how much improvement can be brought about by applying the technical principles and then to open their eyes to the huge difference between a technically excellent building and a building that has a heart as well. Reducing people’s confusion is a great thing to do but reducing people’s confusion and reminding them of where they belong in this great universe is something wonderful. Not always easy to do in the multi-cultural context of Australia. Perhaps the first step in achieving it would be to ask ‘What do spaces of awe look and feel like to the people you care for?’

Dr Richard Fleming

Professorial Fellow, University of Wollongong

Meaningful Ageing Australia Research Consultant