Course content – PFLEGE-16
The modules of this course – work through them in order.
8. Module 7 · Environmental design (milieu)
8.1. In depth: light, sound, safety and homeliness
Light, sound, safety and homeliness
Dementia-friendly environment
| Element | Effect |
|---|---|
| Good lighting, contrasts | Orientation, fewer misperceptions |
| Clear signage (pictures) | Orientation |
| Familiarity/homeliness | Safety, a sense of security |
| Safe circular routes | Movement without frustration |
Taking perception in dementia into account
Environmental design must take into account the altered perception in dementia. People with dementia often perceive their surroundings differently, which can lead to misunderstandings and fears. Examples: contrast vision is often impaired (light-coloured food on a white plate is not recognised – Course 07; a step/an obstacle without contrast is overlooked – risk of falling). Shadows and dark surfaces can be misinterpreted as holes, water or threatening objects (a dark floor covering is perceived as a ‘hole’ that one does not want to step into; shadows as threatening figures – especially in the evening, ‘sundowning’). Mirrors can confuse (the person does not recognise themselves and is frightened by the ‘stranger’). Patterns (on floors, wallpaper) can be misinterpreted as objects/uneven surfaces. Reflections/shiny floors can be perceived as wet/slippery (fear of walking). For environmental design this means: good, even lighting (avoiding shadows), using contrasts deliberately (where orientation is needed – e.g. toilet, handrail) and avoiding them (where confusion threatens – e.g. no confusing patterns, no ‘hole’ effects from dark surfaces), reducing/covering mirrors if necessary (if they unsettle), matt rather than shiny floors. For care staff it is important to know these perceptual particularities in order to understand the person’s behaviour (e.g. why they avoid a certain spot or are startled by something) and to adapt the environment accordingly or suggest changes. This knowledge links milieu design with understanding the inner world (Module 2): what looks harmless to us can be threatening or confusing for the person with dementia. Those who take altered perception into account create an environment that conveys safety rather than fear.
This shows: good dementia care means consistently viewing the world from the perspective of the person with dementia – including when designing the environment.
Light: the cheapest intervention
Light affects how well a person sees and also how well they sleep. Daylight during the day helps the body clock, and a room that is dim at noon but bright at midnight can add to day–night confusion (Module 8). Aim for even, glare-free brightness in the places where people walk, eat and wash, and use windows and the garden as often as the person can manage. At night, a low, warm orientation light on the way to the toilet is safer than a bright ceiling light, which wakes people fully and throws hard shadows. Curtains or blinds can reduce reflections from low evening sun, which is also when some people become more restless (“sundowning”, Module 8).
Sound and the feeling of the room
Noise is easy to overlook because staff get used to it. A television in the background, call bells, trolleys and several conversations at once can add up to more than a person with dementia can sort out. Ask in each room: is anyone actually watching the television? Can a quiet corner be created? Is there a place where a person can hear a familiar voice or a song without competing sounds? Soft materials, closed doors and a calm voice reduce noise at little cost. Figure 7.2 shows how too little and too much stimulation each show up in behaviour.
Read Figure 7.2 from the middle outwards. In the balanced column, the person chooses how much to join. In the other columns, the behaviour itself is the message, and the useful response is to adjust the environment before reaching for any other explanation (Module 4).
Safety without locking in
Safety measures and freedom of movement often seem to pull in opposite directions. The original text states the principle: secure what is dangerous, but do not restrict the person unnecessarily. In design terms this means that you secure the hazard, not the person. Examples are covering hot pipes, storing cleaning substances out of reach, removing loose cables and rugs, choosing non-slip but matt floors and fitting handrails with good contrast. Where a door must remain closed for reasons of safety, ask whether a visual solution, such as a door that looks like a wall or a bookcase, is possible, and discuss it in the team. Some solutions raise ethical and legal questions of their own, because they can mislead the person. Disguising a door is a measure that needs to be discussed, not simply installed (Module 11). The legal framework for deprivation of liberty is explained in the box at the end of this page.
Homeliness against the institution
Many care settings look like hospitals: long corridors, uniform doors, bright lights and no personal signs. A homely space is smaller, more varied and more personal. Familiar furniture, a favourite chair, photographs and everyday objects allow people to recognise “my place”. It is a mistake to equate homely with cluttered: familiar objects should be selected, within reach and not hidden among too many others.
Who decides what in your setting?
- Section 11(1) of the Social Code Book XI (SGB XI), the law on social long-term care insurance, requires care facilities to provide care that follows the generally recognised state of medical and nursing knowledge and that is humane and activating, with respect for human dignity (Bundesministerium der Justiz, n.d.-a). A calm, orienting environment is part of such care.
- Section 1831 of the German Civil Code (BGB), the law on legal custodianship (rechtliche Betreuung) in force since the 2023 reform, deals with deprivation of liberty. Paragraph 4 covers people living in a hospital, care home or other facility who are kept from leaving over a longer period or on a regular basis, for example by mechanical means or medication. Such measures need the approval of the custodianship court (Betreuungsgericht) (Bundesministerium der Justiz, n.d.-b). The text does not list locked doors by name, so ask in your organisation whether a door or a device falls under it.
- If a sensor, camera or tracking device records personal data, the General Data Protection Regulation (GDPR) applies. Article 5(1)(c) says that data must be adequate, relevant and limited to what is necessary for the purpose (European Union, 2016). Questions about such technology belong to management and the data protection officer.
Details of restrictions of freedom, consent and the court process are covered in Module 11. This course does not give legal advice for individual cases.