The old Cadillac convertible parked comfortably in a small enclosure of Trezevant Terrace’s garden in Memphis, Tenn., 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. What is peculiar, though not readily apparent to the residents of this Alzheimer’s 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 of the Cadillac. “But it has nice seats.”
Askew, whose firm designed Trezevant Terrace, an assisted living facility with a resident Alzheimer’s care home, acquired the Cadillac and installed the screen door on the advice of John Zeisel, president and co-founder of Hearthstone Alzheimer Care, Ltd., in Woburn, Massachusetts. Zeisel’s background includes degrees in sociology and architectural design from Columbia and Harvard universities.
“We had the Alzheimer’s residents on the ground floor,” recalls Askew, who hired Zeisel because of his renown as an expert in designing Alzheimer’s 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, and “We started thinking about the roof of the adjacent building as the garden.”
Gardens, according to Zeisel, are crucial in helping Alzheimer’s 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 is proven to 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 Alzheimer’s 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 qualitative 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 non-pharmacological one.”
Proof that Place Matters
Zeisel was the principal investigator of a three-year National Institute on Aging study, published in The Gerontologist in 2003, that found that a balanced combination of medication, behavioral, and environmental approaches is likely to be the most effective treatment of 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 Alzheimer’s care facilities in particular, Zeisel and his Hearthstone colleagues have developed a set of guiding principles for designing Alzheimer’s care homes.
Putting the Home into Alzheimer’s 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. Staff don’t 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, based on the number of residents.
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.
Finding A Way
Wandering can be a particularly dangerous symptom of Alzheimer’s. 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 and this also increases a level of autonomy in the residents.
At Hearthstone Alzheimer’s care facilities, paths are very clear and have clear, wholesome destinations. “John’s 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 kitchen.
In the hallways are often sensory elements, 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 their pasts.
Sensing Home
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 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.”