Dementia-friendly environments: guidance for assessors

Dementia is an umbrella term used to describe a range of symptoms that people experience when the brain is affected by certain diseases or conditions. Research shows there are more than 850,000 people in the UK who have dementia. One in 14 people over the age of 65 have dementia and the condition affects 1 in 6 people over 80. The number of people with dementia is increasing because people are living longer. It is estimated that by 2025, the number of people with dementia in the UK will be more than 1 million.

It is therefore important that healthcare premises are designed in a less alienating way for people with dementia, creating a safe and secure environment for them to move around.

According to Age UK, there are over 100 types of dementia, although they do not all have the same symptoms or combination of symptoms. Dementia symptoms may include problems with:

• memory loss
• thinking speed
• mental sharpness and quickness
• language, such as using words incorrectly, or trouble speaking
• understanding
• judgement
• mood
• movement
• doing daily activities

While there are many types of dementia, they often have things in common such as memory loss, difficulty learning and retaining new information, cognitive functions including visual and spatial abilities getting worse than they would normally be expected to with age, and confusion. People with dementia may find it difficult to see things if they are the same colour as the background, for example handrails that are the same colour as the wall. Highly polished floors can look wet and slippery, and shadows may be misinterpreted as a change in floor level.

Everyday things that were familiar may become unfamiliar. Seeing something such as a toilet and remembering what it is for can become two unconnected processes which do not necessarily work together. 

These things and the other ways that dementia can affect a person mean that ‘normal’ environments can become difficult, confusing, or unsafe places. There are things which can be done, or not done, to reduce this. The questions in the assessment try to assess what is in place to help make the environment more dementia friendly.

It should be noted that patients with dementia can be in hospital for clinical issues directly related to their dementia, but also owing to issues not related to their dementia. This should therefore be considered as part of the assessments.

The questions in PLACE are designed to assess how well the healthcare setting already supports people with dementia, and what needs to improve to help them stay as independent as possible for as long as possible. Without the right things the environment could contribute to people being and feeling less safe, more confused or anxious or less independent. There are some simple things that help, such as keeping things consistent, for example all toilet doors being painted in yellow; or all signs being the same size and colour and having the same type of lettering.

It is generally accepted that if you improve the environment for those with dementia you will probably improve it for others and will not do anything that has a negative impact. 

The correct answer to the question in the assessment should usually be obvious and unambiguous. However, these conflicting needs or recommendations do mean that an organisation sometimes has to make decisions based on their judgement of what is in the best interest of the majority of patients. 

The questions in the assessment look at a selection of the issues that can affect how dementia friendly an environment is. However, this is not a comprehensive/full assessment of all the issues, and it is recommended that organisations carry out a fuller assessment of their environment using a recognised toolkit.

Good flooring supports stability, encourages safe walking and reduces falls. Poor flooring can cause injury, anxiety, loss of independence and increased reliance on staff. Getting it right is important. Put simply, a good floor looks and acts like a floor – and nothing else.

Flooring should:

• not look like a step because of a sudden change of colour
• not look like an obstacle or barrier because there is a line or pattern across it, because this can make people hesitate or try to step over it
• not look like it might be wet (for example, highly polished or reflective) because this might not register with a person with dementia
• not have a pattern which is busy or big. Patterns can make it look as if there are things that need to be picked up, pushed to one side or stepped over making a fall more likely. Contrast is important as a small pattern which contrasts is worse than a large pattern which is inconspicuous
• be clear where the floor ends, and the walls begin, by good colour contrast with skirting
• not be noisy to walk on and, ideally should absorb other noise

For these reasons consistency, matt and non-reflective surfaces, size of patterns and contrast become important. When assessing the flooring, PLACE assessors should think about whether it meets the criteria listed above.

We all use signs to guide us through life. People with dementia, and particularly those entering a new environment are no different, but the impairments to their cognitive functions and decision-making abilities may mean that signs need to be much clearer.

Consistency is very important. Signage should always be clear, visible, easily recognisable and have good colour contrast.

Using both pictures and words is also important as people with dementia will lose cognitive function in different ways. Some will lose the ability to recognise words, while others may not be able to recognise pictures, so both are important.

Signs should be fixed at a height that makes viewing easy (recommended height 4ft/1.21 metres) where possible or appropriate.

Making sure there is a good colour contrast between fixtures and the area around them is important. It makes it more likely that people with dementia can use them without help and be more independent. Having a white toilet with a white seat against a white background could make it very difficult for someone to know where to sit or aim. Adding a coloured seat and contrasting hand rails is not usually difficult or expensive. Sometimes simple changes can make a big difference.

You will need to use your judgement when assessing fixtures and fittings, but it is important to be accurate, and if you think something might cause confusion or be unfamiliar then you should say so in the assessment. You should not take an over-positive approach and suggest things are better than they are.