8. Module 7 · Environmental design (milieu)

Milieu

The environment as ‘therapy’

The environment (the milieu) has a major influence on the wellbeing and behaviour of people living with dementia – this is referred to as milieu therapy/milieu design. Because people with dementia find it harder to understand and process their surroundings and are easily over- or under-stimulated, a dementia-friendly design is important. Aims: promote orientation, provide safety, design stimuli appropriately (neither overwhelming nor impoverished), create familiarity and homeliness, and enable movement. A good environment has a calming and orienting effect; a poor one (overstimulating, bare and clinical, confusing, unsafe) fosters anxiety, restlessness and disorientation.

Elements of dementia-friendly design: good lighting (bright, glare-free, avoiding shadows – shadows can trigger fear/misperceptions; orientation lighting at night), contrasts (e.g. high contrast between plate and food – Course 07; a coloured toilet seat so that it can be recognised), clear orientation aids (signage with pictures/symbols, names/photos on room doors), familiarity (personal/familiar objects, homely rather than clinical design), low-stimulus retreat spaces and stimulating areas (balanced), safe walking routes (circular routes, clear and safe corridors – enabling movement without dead ends/barriers), and the avoidance of hazards and overstimulation (noise, hectic bustle).

What this module is about. How light, contrast, familiarity, noise and layout shape the way a person with dementia feels and behaves, and how you can read a space and improve it with small, low-cost steps.

What you will be able to do afterwards. You can walk through a corridor or room with “dementia eyes”, name at least three triggers in it, suggest a change for each, and balance safety with freedom of movement without locking anyone in.

Think about it first. Mr Costa (fictitious), 81, has lived in a care home for three weeks. Each evening he stops at the entrance of the long corridor to the dining room, raises his hands and says, “I cannot go through there.” The floor is shiny, a large mirror hangs at the end, a dark mat lies in front of the door and a television runs in the lounge. What might Mr Costa see or hear? Write down two possible reasons and one change you would try. You will compare your ideas with Figure 7.1 and with the worked example on page 3.

Learning objectives of this module

  • You understand the influence of the environment (milieu).
  • You know the elements of dementia-friendly design.
  • You promote orientation, safety and familiarity.
  • You avoid overstimulation and hazards.
  • You can walk through a space with “dementia eyes” and list at least three environmental triggers with a suitable change (apply).
  • You can plan a low-cost change that balances stimulation, safety and freedom of movement (apply, analyse).

Designing for orientation and safety

Orientation can be supported by the environment: clear, highly visible signage (with symbols/pictures, not just text – e.g. a toilet pictogram), personal labelling of rooms (name, a photo of the person when younger, familiar objects on/in front of the door), seasonal/time orientation (calendars, seasonal decorations, daylight), and a clear, recognisable layout. Safety takes into account: avoiding fall hazards and barriers (Courses 08/18), securing dangerous areas/substances, but – very importantly – without restricting the person unnecessarily (no ‘locking in’; creating safe opportunities for movement instead of preventing movement). Circular walking routes (indoors/in the garden) are a fine concept that gives the urge to move (including exit-seeking, Module 8) a safe space – the person can walk without ending up in dead ends/at locked doors (which triggers frustration/restlessness). Managing stimuli is also important: too many stimuli (noise, commotion, garish patterns, a television left running) overwhelm and unsettle; too few (a bare, low-stimulus environment) lead to under-stimulation and withdrawal. The right balance – stimulating but not overwhelming – promotes wellbeing.

For care staff it is important to understand that the environment is a powerful, often underestimated factor: many behaviours and states (restlessness, anxiety, disorientation, risk of falling) are partly influenced by the environment. Care staff can contribute a great deal through attentive observation (What in the environment unsettles/calms the person?) and by suggesting design changes (to management/the team). A lot can be done on a small scale, too: ensuring good lighting, reducing noise, allowing familiar objects, labelling the room door, creating opportunities for retreat and movement. Milieu design links with mobility (Course 08, a movement-friendly environment), fall prevention (Course 18) and nutrition (Course 07, contrasts) – an expression of holistic dementia care. A dementia-friendly environment is ‘therapy’ in action: it works around the clock, entirely without medication, and promotes orientation, safety, movement and wellbeing.

Person and environment: a two-way fit

It helps to think of behaviour as the result of two things: what the person can still do and understand, and what the surroundings ask of them. When abilities shrink, the same room that once felt easy can become too demanding. The environment is then no longer neutral. It either carries the person or works against them.

Perception is the most practical starting point. Brain changes in dementia can affect how contrast, depth, brightness and reflections are processed, often on top of the ordinary changes of the ageing eye. The result is that people may misread what is in front of them without being confused about everyday things in general. Figure 7.1 lists five common traps. Each row has the same pattern: what staff see, what the person may see, and a simple response.

Five perception traps in a corridorFive perception traps in a corridor and what to tryWhat we seeWhat the person may seeWhat to tryDark doormatA hole in the floorRemove it or use a floor tone→→Shiny floor, glareWater, a slippery patchMatt floor, blinds, even light→→Strong shadowsFigures, something hidingEven light, night light→→Large mirrorA stranger in the hallwayMove, cover or hang elsewhere→→Bold wallpaperObjects, uneven surfacePlain, calm surfaces→→Check each point by looking from the person’s height, in evening light, and by asking the person what they see.
Figure 7.1: Five perception traps and design responses (general professional knowledge; examples, not a complete list). Source: own illustration.

Use Figure 7.1 as a checklist for a walk-through. Two points deserve emphasis. First, the person’s reaction is the best evidence: stopping, stepping over a line, avoiding a spot or startling at a mirror all tell you where a trap lies. Second, you do not need a building project. A mat that is removed, a lamp that is moved, or a mirror that is covered can solve a problem in minutes.