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Designing for Dementia: The Enablement Model

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Designing spaces and products for people with dementia has traditionally focused on impairment.  Protecting residents from injury was long hailed as the gold standard in dementia care.  Unfortunately, this disabilities-based approach did little to foster healthy interaction with the environment.  Design was focused on fall prevention and caregiver ease to better meet the needs of the caregiver: seat belts, lap buddies, congregate areas in front of nursing stations where the at-risk folks could be easily observed.

Recently, trends have shifted to more of a compensatory model, where the environment more closely aligns with the current abilities of the residents. People with dementia are less restricted than they used to be, and the independent ambulators are free to roam and access certain spaces that are designed to meet the urges and needs of the memory impaired.

We need to move from a compensatory model to an enablement model. Designing safe environments with potential hazards in mind is a good practice, but it shouldn’t limit the potential abilities of the person with dementia. The principle of potential is more than designing for a person’s needs and preparing for inevitable decline. It is designing for the best of who they may still become.

Instead of designing spaces that are intended to promote tranquil, home-like settings, dementia-friendly spaces should promote engagement and purpose. Most of us do not spend the most productive years of our lives sitting on the couch. We are working, caring for children, running households, and managing finances. We spend the majority of our lives in motion. Many people with memory impairment do not see themselves as sedentary couch potatoes; they live out their long term memories on a daily basis.  They remember being busy and needed, and without those opportunities present in their current environment, they can become more anxious and confused.

Do people with progressive, terminal conditions like Alzheimer’s disease actually have potential? Throughout the disease, the answer is generally yes on all fronts: cognitive, physical, and psychosocial. As Alzheimer’s disease progresses, and the ability to self-modulate and self-initiate actions that strive for improvement diminishes. The environment and the caregivers that manage the environment are responsible for providing the opportunities to realize that potential.

This is not achieved through a passive environment. Soft sofas and warm, crackling fireplaces  are lovely, but they do not address potential.  

The opportunities to fulfill potential lie in the sensory experiences and graded challenges that the environment has to offer.  As language declines, touch becomes the medium for expression and reception.  The vestibular and proprioceptive systems in the brain need the type of stimulation felt with changes in body position and movement- swinging, spinning, rolling.  A person can start to organize information better when he or she can feel objects and understand their position in the environment relative to their own.

Deconstruction is one way to provide a hands-on challenge that is a graded, organized sequence of manual actions.  So are changes in flooring surfaces with ample support mechanisms.  Visual interest/search and find activities placed above shoulder height on the walls of hallways and rooms forces people to look up and around- instead of down at the floor.  Remember that these stimulating environments are not passive experiences and sometimes require caregiver facilitation in order to be effective.

The Enablement Model is not intended to treat cognitive impairment for the sake of cognitive impairment.  It is meant to address cognitive and sensory-motor potential that will improve individual and social function and participation.  When designing environments for people with dementia, it is important to have to a big picture (functional) view of all that is possible versus a narrow view of disability impairment.

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