Last Updated: April 4, 2013
Read this interview with Lee Askew, representative from an
architectural firm that designed a memory care home in Memphis, TN,
and John Xeisel, president and co-founder of Hearthstone Alzheimer
Care, in Woburn, Massachusetts. Discover what Margaret Calkins,
leading designer of dementia care facilities, has to say about
environment's role in treating Alzheimer's disease.
The old Cadillac convertible parked comfortably in a small
enclosure of Trezevant Terrace's garden in Memphis, Tennessee, is
not out of place. Neither is the screen door that in summer slams
each time a resident exits for a refreshing walk in the garden.
Whatispeculiar, though not readily apparent to the residents of
this dementia care home, is that both the garden and the Cadillac
are on the roof of a building.
"It doesn't run," says Lee Askew of Memphis's Askew Nixon
Ferguson Architects. "But it has nice seats."
Askew, whose firm designed Trezevant Terrace, an assisted living
community with a resident Alzheimer's care home, also known as
dementia care or memory care home, acquired the Cadillac and
installed the screen door on the advice of John Zeisel, president
and co-founder of Hearthstone Alzheimer Care. Zeisel's background
includes degrees in sociology and architectural design from
Columbia and Harvard universities.
Gardens a Key Element in Memory Care Design
"We had the Alzheimer's residents on the ground floor," recalls
Askew, who hired Zeisel for his renown expertise in designing
memory care facilities, "but John said very quickly that it was no
good-too accessible, too much going on." So Askew and his team
moved the 30-resident Alzheimer's special care unit (SCU) to the
third floor. "We started thinking about the roof of the adjacent
building as the garden," Askew comments.
Gardens, according to Zeisel, are crucial in helping dementia
care residents feel less trapped and more attuned to the natural
rhythms of day and night. An easily accessible garden comprising a
simple circular path is a star feature in Hearthstone's seven
Alzheimer's care facilities in New York and Massachusetts.
Environment as Medicine
To Zeisel and his colleagues around the country, medication is
not the only treatment for
Alzheimer's disease. While medication can slow the progression
of Alzheimer's-related symptoms, another equally effective
treatment is the environment itself. For the last 15 years,
Hearthstone has specialized in creating environments in memory care
facilities that have qualitatively improved their residents' lives
when measured in terms of fewer injuries, less medications
required, less sleep disturbances and less wandering.
"We're a leader in this movement," Zeisel says of his company's
holistic approach to treating Alzheimer's. "In the design and in
the use of arts and, generally, in non-pharmacological approaches.
Before we look for a medical solution, we look for a
Proof that Place Matters in Dementia Care
Zeisel was the principal investigator of a three-year National
Institute on Aging study, published inThe Gerontologistin 2003.This
study found that a balanced combination of medication, behavioral
and environmental approaches is likely to be the most effective
treatment of dementia and Alzheimer's symptoms. The key finding was
that environmental factors are equally as important as behavioral
approaches and medication. "We have done the empirical work to know
that we reduce anxiety, depression, social withdrawal,
hallucinations and agitation," Zeisel says. "The only way to reduce
those is to affect people's brains."
After two decades of research into how environment affects the
brains of people with dementia in general, and residents of memory
care facilities in particular, Zeisel and his Hearthstone
colleagues have developed a set of guiding principles for designing
Alzheimer's care homes.
Putting theHomeinto Memory Care Homes
At Hearthstone homes and in others sensitive to the functional
needs of Alzheimer's residents, home is more than a place. It is,
as leading designer of Alzheimer's care
facilities Margaret Calkins says,as much a way of being as it
is a location. Following this principle, Hearthstone makes sure its
homes look like homes, not institutions. Nursing stations are
absent. The staff does not wear uniforms and every room is at a
residential scale so that a few people-not too many, not too
few-can congregate together. Shared spaces are clearly defined and
private bedrooms, complete with doors that look like front doors,
surround well-placed kitchens, living rooms and dining rooms with
working hearths. Sometimes a home will contain more than one
kitchen, living room and dining room, depending on the number of
Privacy is paramount, so that residents can surround themselves
with personal and memorable objects to enhance feelings of safety.
Free access to open outdoor spaces creates a feeling of autonomy,
while discreet fences keep residents safe.
Wandering can be a particularly dangerous symptom of Alzheimer's
disease. To prevent wandering without "imprisoning" residents,
Zeisel recommends camouflaging exit doors and using unobtrusive or
keypad locks. Exit doors can also be placed off to the left, or
right of hallways so they are not conveyed as destinations. Knowing
that residents are not going to disappear if left alone, staff can
feel safer about their care-also increases a level of autonomy in
At Hearthstone Alzheimer's care
facilities, paths are very clear with wholesome destinations.
"John is a proponent that every vista must have a destination,"
says Askew of Zeisel. For example, one hallway may lead to a
painting, while another may lead to a toilet, and yet another, to a
In sensory elements often decorate the hallways, such as
pictures, that are cohesive with the destination and era of the
residents. In gardens, simple unilateral paths prevent residents
from feeling lost, which is the feeling, in general, that leads to
wandering. Beside rooms, "memory boxes" contain personal
memorabilia so that residents don't have to remember room numbers
or locations but can rely on recognition of iconic images from
The Importance of "Sensing Home" in Dementia Care
Because Alzheimer's tends to destroy the brain's cognitive maps
of the environment, it is important, according to Zeisel, to
"triangulate" the senses of residents to their location in a
setting. "Design the entire environment so that what people see,
hear, touch, and smell, all give them the same information about
the environment," he writes in a 2005 edition of Alzheimer's Care
Quarterly. "If the country kitchen is meant to be the social hub of
the setting, make sure it looks, feels, sounds, and smells like a
social hub. If a garden is to be used frequently, make it highly
visible through a window and accessible through an easily located
and unlocked door."
At Hearthstone, a sense of "residentiality," as Zeisel calls it,
is conveyed as much by the way the staff encourages residents to
experience the environment through their own realities as it is by
the absence of traditional institutional touchstones such as
nursing stations and uniforms.
"Create a home that is residential," Zeisel concludes, "then
people feel at home and people don't feel anxious."
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