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BOOK REVIEW |
Board Chair and President IDEAS Institute Kirtland OH 44094
Design Innovations for Aging and Alzheimer's: Creating Caring Environments, by Elizabeth C. Brawley. John Wiley & Sons, Hoboken, NJ, 2006, 350 pp., $85.00 (cloth).
Humanistic Design of Assisted Living, by John P. Marsden. Johns Hopkins University Press, Baltimore, MD, 2005, 119 pp., $49.95 (paper).
The quest for knowledge about and application of key design principles to enhance and maintain quality of life for elderly individuals continues in these two books. They seek to explore, examine and explain the importance of the built environment in supporting the physical, psychosocial and emotional needs of older adults.
Despite this commonality, the books reflect radically different approaches, both in terms of the scope and scale of what they cover and how their information was derived. Elizabeth Brawley's book touches on a range of settings from homes in the community to day care, shared residential and acute care settings. It is drawn from both her extensive personal experience in a vast array of settings and a broad range of literature sources. John Marsden's book is narrowly focused on essentially four spatial areas of assisted living, and the information is based on systematic research with elders and family members.
These books also reflect some of the struggles taking place in the long-term care industry—particularly between assisted living and nursing homes. Traditionally, nursing homes have been staff-centric: organized for the convenience of staff with operational systems designed to support the medical needs, not the quality of life, of the residents. This traditional model has been challenged in two ways. Thirty years ago, assisted living began emerging as a response to what was seen as the dismal life nursing homes offered. At the same time, the development of special care units (SCUs) based on a social model was prompted by increasing recognition that nursing home residents with Alzheimer's disease (AD) and other forms of dementia often didn't have significant medical needs that required a medical model of care. (The development of SCUs was also spurred by the intent of nursing homes to increase market share and maintain census.)
The assisted living movement has argued that care could be delivered in ways that respected the needs, desires, and preferences of the older individuals who lived there, and still be financially feasible for the provider. According to Kane and Wilson (1985), the three guiding principles of assisted living are privacy, autonomy, and dignity. It is a mark of the degree of success of the assisted living movement that 20 and even 10 years ago, assisted living communities were being designed and built to nursing home standards so that they could be converted if necessary, while today, nursing homes are being built to be able to be easily converted to assisted living if the market shifts in the future.
Assisted living is an amorphous entity—not just a new level of care on a continuum between independent living and nursing homes, but increasingly an alternative to nursing homes. Regulations in some states specifically allow assisted living communities to care for an individual through end of life. Nursing homes (well, if we're going to be honest, some nursing homes) are working on reinventing themselves to reflect the same priorities as assisted living, with the full support of the federal government's Centers for Medicare and Medicaid Services and the state Quality Improvement Organizations. But if nursing homes reinvent themselves to reflect the same elder-centric principles as assisted living, what is the difference between them? In most states the answer to this might be the source of payments. Assisted living communities are, for the most part, still privately funded. Yet when their residents need assistance from Medicaid they are forced to relocate to a nursing home. But in states with Medicaid waiver programs that allow Medicaid to help fund assisted living, the differences are less apparent.
The evolution of SCUs has had a different type of impact on nursing homes. Recognizing that care for people with dementia shouldn't be structured around the provision of medical care, facilities (supported by research) began to evolve other criteria for structuring care settings. Issues of orientation, regulating stimulation, providing opportunities for both privacy and appropriate social interaction, and supporting functional independence became known as the hallmarks of good dementia care. These are remarkably similar to the principles of assisted living (c.f., Cohen & Weisman, 1991). As nursing homes became more experienced with providing good dementia care, some began to realize that each of these issues is equally important to cognitively intact individuals who need a significant amount of nursing support. Increasingly, as nursing homes are applying these principles to all of their care units/households/areas, dementia care settings are becoming less distinctive, less "special" or unique, and are simply a place where people with similar needs and abilities can be clustered together.
In light of these developments, one can question how similar or different these different settings are, should be, or could be. Assisted living continues to work to hold on to the public images that they are fundamentally different from nursing homes. Nursing homes, however, are trying their best to be more like assisted living. The explosive interest in the Green House model is a clear indication of this. While the Green House concept is remarkably similar to many board and care homes and a number of assisted living communities with clusters of group homes served by some centralized staff, the application of this model to nursing home level care reflects another example of the shift from an focus on quality of care to increased emphasis on quality of life. Any book that deals with environments for aging must, at some level, deal with this set of issues. Both these books do, though in indirect ways.
Innovative Design for Long-Term Care
Design Innovations for Aging and Alzheimer's: Creating Caring Environments, is by Elizabeth Brawley, a noted expert in interior environments for older adults, especially those with dementia. This 2006 book is a substantial revision of the first edition of her well received design guide. The volume is divided into six sections, which helps to organize the substantial amount of information she seeks to provide the reader. The first section provides an overview of aging, dementia and environment as a treatment modality.
Chapter 1 presents an overview of aging in the 21st century, with both demographic trends and physiological changes and conditions that are common among older persons. The descriptions of the conditions, in particular, seem short and somewhat shallow, and there is no clear picture for the reader of what is meant to be covered in this chapter versus the later, more detailed chapters. Nor is there explicit information on how these conditions relate to the design of the environment, which would provide more justification for their inclusion. Chapter 2, however, provides a cogent description of AD and its onset. Brawley also details many of the new and developing treatments, though the focus seems to be solely on pharmacological treatment, with no mention of environmental or psychosocial treatments in this chapter. More information, beyond a single sentence, of the other conditions that cause dementia and how they differ in presentation from Alzheimer's disease would have been welcome, especially since few care settings specifically differentiate or separate people based on different forms of dementia. Providers and designers often don't understand the distinct presentations of the different diseases. Chapter 3 introduces the environment as a form of treatment. Brawley reviews a broad array of research from multiple fields, which makes the information relevant to a broader audience. Virtually all of the research reported focuses on people with dementia, not elders without cognitive impairment. Yet there is a wealth of evidence-based information on the interaction of older adults with their environments, so it's not clear why this wasn't chosen for inclusion, especially since the book is about aging as well as Alzheimer's disease.
The second section of the book tackles the basic elements that constitute good design, broadening the focus from aging and dementia to issues affecting persons of all ages and conditions. Both chapters 4 and 5 deal with light for vision and health. The description of how light is absorbed and used by the body for more than vision (e.g. circadian rhythms and maintaining mood) is an important point that is not generally acknowledged, and she handles it well. She also provides the best description and differentiation of clerestory windows versus skylights I've read. Skylights can be glazed with translucent materials which can distribute the lighting more evenly, while clerestory windows, with clear glass, provide more dramatic lighting effects but also tend to cause more glare.
Chapter 6, on hearing, has logical organization of material by design element (e.g., floor, wall, ceiling). She mentions that the average recommended sound level for a residential community is 50 decibels, but doesn't say whether this is measured in several places at one time, in one place over time, or a combination of both. This makes it hard for providers to assess their existing acoustic environment. She also does not address the sometimes significant noise generated by call systems and overhead pagers.
The chapter on Mobility pays a great deal of attention to on exercise-based interventions (yoga, tai chi, walking, strength training) and insufficient attention (a bullet list of 14 items) to environmental correlates of mobility. The discussion of handrails that is in Chapter 14 might be better addressed in this chapter. Occasionally, there are ambiguous or vague recommendations that would be hard to interpret, such as suggesting that older people need to "wear appropriate shoes" without describing what makes a shoe appropriate for a specific type of flooring. This chapter also reflects the tension between trying to address recommendations for both group residential environments and homes in the community—it's difficult to do both in one resource because some of the issues are so different.
The next two chapters address color and floor covering. It is surprising, given the depth of information on physical conditions, that Brawley does not mention the contrast perception deficit that is associated with Alzheimer's disease, as this has significant implications for appropriate use of contrast as a design principle.
Another chapter addresses Sustainability and Green Design. It suggests that designers and providers should pay attention to using highly efficient systems and consider life-cycle costs, not just initial purchase cost. For instance, paying more for a high grade carpet that will last twice as long as a lower grade carpet is not only less expensive in the long run, but better for the environment. While I don't deny this is an important consideration, it is unclear what this has to do with design for aging and Alzheimer's, and simply dilutes the important relevant messages contained in the book.
The next two sections of the book move into "culture change," which reflects the industry's movement away from medical or institutional models to settings that reflect welcoming and comfortable places in which to live. It is in Chapter 11 that Brawley formally introduces the framework of organizational/social/physical aspects of settings that are inherent throughout the book, and also introduces the reader to some of the models of culture change. She moves from this more operationally-focused chapter back to the physical environment when she discusses gathering spaces in Chapter 12 and shared living spaces in Chapter 14 (although the difference between these is not made clear). There is a very interesting presentation of eight "generations" of plans, although a more detailed analysis of the benefits and challenges of each plan, in terms of culture change principles, would be have been a useful addition. Section 4 describes different care models—Green House, Planetree (which is an acute hospital-based model, not aging related), adult day care, and Hospice/end-of-life care—in more detail than was provided in Chapter 11.
The last two sections, each with but one chapter, explore outdoor spaces (Chapter 19) and what success looks like (Chapter 20). The outdoor chapter does a wonderful job of linking physical design (logical layout, smooth paths, presence of sun and shade) with the other domains of the setting—social and organizational. It emphasizes that staff must be trained to understand the tremendous value for residents of spending time outside, that policies should encourage people to go outside on a regular basis, and that both structured and spontaneous activities for both individuals and groups of people outside need to be supported. The final chapter provides some glimpses into the processes that can be used to help create successful settings, including participatory design, post-occupancy evaluations, and evidence-based design. It is upbeat and sure to invigorate the reader to go forth and work on creating caring environments.
Overall, Brawley's book provides a wealth of information for the interested reader. Its focus is broad—possibly a little too broad. In places the book covers a broad continuum of settings from home, to day care, to long-term care and acute care. Yet none of the settings are addressed systematically in any real depth. Similarly, while the title of the book suggest the focus is on the physical environment (Design Innovations), in many places it crosses over to include the social and organizational environments. And while I would be the first to agree that all three domains of the environment are important, there is no clear roadmap for the reader to know to what extent these other domains are covered. The concepts aren't explicitly introduced until Chapter 11, though is it implicit earlier in the book. That said, the book provides a wealth of well-grounded information that is practical and understandable to a broad range of audiences. The book also implies that people with dementia don't need unique or different types of environmental characteristics—that the design principles Brawley describes apply to all older adults, regardless of setting or population characteristics.
A Focus on Assisted Living
Humanistic Design of Assisted Living by John Marsden translates the results of several research studies into consumer-based design guidelines. He begins the book by making the argument that "older people who live in assisted living and family members who periodically visit should have a say about the environment" (p. 1). This point is reinforced in Chapter 3, when he discusses the way architectural education is structured so that the ways architects and designers conceptualize and evaluate the built environment is often very different from the consumer perspective. This helps to explain the disconnect between what architects sometimes propose and "sell" the administrators of a facility, and what residents say when they move in and experience the environment. The research which forms the foundation of the book is well designed to elicit honest opinions unswayed by feeling the need to please facility operators, which gives it high credibility.
Marsden's book begins with an overview of the demographics and evaluation of assisted living, pointing out the diversity caused by widely varying state definitions and regulations. Because of this diversity, the definition of assisted living he provides is, necessarily, broad, and indeed could be applied to nursing homes: [assisted living] "offers a range of personal and health care services, delivered by professionally trained providers, to meet scheduled and unscheduled needs on a 24 hour basis" (p. 12). He continues with assisted living design being residential in character, and that care is based on a philosophy driven by the needs and preferences of the residents: independency and autonomy, dignity, privacy, and involvement of family members. The question of the extent to which these are unique to assisted living will be taken up later in this essay.
Chapter 2 presents an interesting model of knowledge by Hassell and King (in press). Marsden uses this model to justify why the information in his book, which is directly drawn from systematic research with consumers, provides higher quality information than many of the other resources and references that are available on the market, because they are based on clinical experience and literature reviews that vary in the reliability of the information they contain.
Chapter 3 explores several different methods for gathering direct input from users, from observations of patterns of use to structured interviews (with good tips for strategies for conducting successful interviews) to the use of images and action research. Marsden traces the history of housing construction from when the user was the builder utilizing materials from the site, to current construction practices where the designer may never even meet the users and relies on generically produced products. This, combined with the educational system that trains architects to view the built environment different than non-architects, supports why getting direct input from users is so necessary.
Chapter 4 presents the basic conceptual framework of six design goals that guide the discussion of specific design elements in the rest of the book: familiar housing cues, protective enclosure, caring cues, human scale, usability, and naturalness. Each design goal is justified in terms of the research.
Chapter 5 begins the section of the book that addresses four basic areas of the facility—exterior design, interior entries (lobbies), living spaces, and dining rooms. Within each space/area, Marsden drills down to more discrete elements. For instance, in the chapter on exterior design he addresses porte-cocheres, porticos, porches, ramps, layers of enclosure, roof and balcony elements, windows, and glazing elements in doorways. Chapter 6 addresses interior entries, with elements such as size and location of the information desk, scale of the space, and presence of plants. Living rooms are covered in Chapter 7, where size, placement and style of furniture, along with shelving and decorations were evaluated differently by family members and older adults. Chapter 8 focuses on dining rooms, and addresses elements such as the décor, furniture style and relationship with adjacent circulation spaces that impact the formality versus casualness of the room, and elders and family member perceptions of these dimensions. Throughout this section, each strategy is well articulated and suitably illustrated with photographs, mostly (though not exclusively) from his studies, highlighting both positive and negatively viewed elements. It is somewhat unfortunate that the images are all printed in black and white, rendering descriptions of "colorful carpeting and couches" less meaningful than they would be in color.
The concluding chapter summarizes the main sections of the book in four pages of bullet points, which I fear will be used as a "cheat sheet" without the benefit of the useful explanations found in the main body of the book. For instance, in a number of areas, older individuals' perceptions of an element differ from the evaluation of younger family members. This is particularly useful information, as often family members (or people their age) may be more involved in the design process than older adults, who are often treated in a more paternalistic way ("we know what is best for you").
Marsden's book is limited in scope in that it only deals with four areas of the building, and does not address the residential apartments, or building configuration (spatial adjacencies), outdoor areas, nor, as he acknowledges, many aspects of concepts such as privacy, autonomy, control, independence, dignity and decision making. Indeed, these are the very elements he suggests define assisted living, so their lack of inclusion is disappointing. However, it may be that the four rather discrete areas he does address lend themselves better to the type of methodology he used in his research, and that other strategies are needed to address these concepts in greater detail. I find it interesting that Marsden often appears to give equal weight to the input of family members who may only "periodically visit", possibly recognizing their role in marketing assisted living settings.
Finally, Marsden asserts that humanistic design entails consumer input. Yet he does not focus on information that would be useful to designers who actually meet with consumers and seek to get direct input. Although there is a level of research that requires specific skills of an individual trained in the conduct and interpretation of research data, there are also many ways to systematically gather information and input from user groups. Given the emphasis on consumer input, the book would have been stronger had it contained more information on processes for gathering valid and reliable data from users. The sample size in his research was still relatively small (546 elders and family members in Michigan, New York, Florida and Massachusetts), and thus the generalizability of his research to other groups of seniors is unknown.
Distinctive or Similar Designs?
These two books take different perspectives in addressing the issue of distinctiveness vs. similarity or overlap of assisted living and nursing homes. Brawley, for the most part, does not specify the setting for which her specific any given recommendation is targeted. For instance, changes in vision and principles for lighting are fairly consistent regardless of whether the person lives at home, in a nursing home or is in day care. On the other hand, two whole sections of the book are devoted to culture change, which she defines as "the process of moving from a traditional nursing home model, characterized as a system that is unintentionally designed to foster dependence by keep residents ‘well cared for, safe and powerless’ to a ‘regenerative’ model'" (p. 147), but does not link this to assisted living philosophy or models.
Marsden takes a different approach, possibly defining the topic more narrowly than is necessary or appropriate. He specifically identifies his book as being specific to assisted living; yet, in his description of the methods of his research projects, he indicates he told people they were going to look at images of "retirement housing" which could be any level of care. He chose to translate this specifically as assisted living, not as either independent living or nursing homes. Although his methodology allows for perhaps more specificity of detail in some of his recommendations, the latter are generally compatible with a range of other sets of design guides that are not specific to only assisted living (which is good, because it means we're all on the right track!). So why not suggest that the principles are equally applicable to a variety of settings, not just assisted living?
Both books have an underlying message that nursing homes are, inherently, undesirable places. Marsden seems to argue that assisted living is fundamentally different from the nursing home. Indeed, at one point he suggests assisted living can be considered as an alternative to rather than a point along the continuum from independent living to nursing home, thus potentially eliminating the need for nursing homes. This is reinforced by the fact that the book is specifically directed at assisted living, even though all of the design principles apply equally to any shared residential setting for older adults—including nursing homes. Brawley minimizes the differences across settings, at least from an environmental perspective. There are very few examples of a design feature or element that are identified as suitable in only one setting. However, she does address culture change (in relation to nursing homes), and occasionally reveals an underlying bias against nursing homes when she talks about the goal of certain treatments or therapies as ways to "delay institutionalization" (referring to nursing homes).
The issue of whether assisted living is inherently and by definition different from nursing homes—and thus whether there are also different environmental correlates of the two—is one the industry continues to explore. Factors such as reimbursement policies, regulations regarding level of service that can be provided, and the extent to which nursing homes can incorporate values related to quality of life—such as autonomy in decision making, dignity, and privacy—will all impact the future direction of both types of organizations. Implicit in this discussion is the issue of aging in place, and the extent to which current regulations and payment systems tend to link housing and services, instead of allowing service levels to vary for an individual who chooses not to relocate.
References
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