Introduction
Can miniature towns help make dementia care more humane?
Script
Narrator: At first glance, The Hogeweyk looks a lot like any other neighborhood in the Netherlands. It’s got a restaurant, barber shop, theater, grocery store, and open green space. You can see people walking around, getting groceries and having coffee. The difference is that this neighborhood is a facility for people with severe dementia. And everyone else in it from grocery store cashiers to barbers to waiters are trained in dementia care. This model of care has been dubbed a “dementia village”.
As people continue to live longer around the world, the proportion of older people in the population will continue to rise and that means a steep increase in the number of people with dementia. Caring for that population will require designing environments that help people feel safe and free even as they lose the ability to recognize the world around them. And the architects behind dementia villages think they might have figured out the formula to do it.
Eloy van Hal, Founder, The Hogeweyk: So this is The Hogeweyk. Social life is happening there so you can see it now.
Narrator: That’s Eloy van Hal, one of The Hogeweyk’s founders.
van Hal: Dementia, it’s — of course — a brain disease. If you look at your life as a photo album you forget the last pictures. The last pictures, they fall out of the album and so you remember the past better when you were younger. And that’s a daily challenge for the individuals: how to live with memory loss.
Narrator: In early stages, people with dementia can live at home, looked after by family, friends or home care, but they eventually need full-time care. Often, that care comes from traditional nursing homes. But those settings can be sterile and clinical.
van Hal: You all dine together in a big dining area. You all have to listen to the same music at the same time. Where you’re forced as a person into a program of the institution. There’s not that much attention to who are you really, what is my life’s story, who am I, what do I prefer to do during the whole day.
Narrator: In any setting, the goal of good dementia care should be to preserve quality of life as dementia progresses. In traditional settings, like nursing homes, surface-level changes are a good place to start:
- Since people with dementia might perceive dark tiles as holes, floors should be visually consistent, without contrasting patterns.
- Brightly colored doors and handrails help residents navigate around and bright dishware has been shown to help people with Alzheimer’s eat more food.
- Acoustic ceiling tiles, carpeted floors, and soft furniture can absorb noises that trigger disorientation.
- Glass-fronted cabinets help residents have a clear line-of-sight to what’s stored inside.
- And lighting fixtures that mimic natural light strengthen residents’ circadian rhythms, which helps mitigate sundowning where people with dementia become confused in the evening and night.
van Hal: Some of the advice about lighting, clear lines, surface patterns, and so on, are based on institutions instead of normalizing the environments. All those elements are essential, but sometimes they are the solution for an institution.
Narrator: But The Hogeweyk’s design solution is different. Instead of changing surface-level design to preserve quality of life for people with dementia, they took a structural approach and designed their facility to look as much like the outside world as possible.
van Hal: Our guiding principle here is normalcy. It’s the vision of a normal life for people living with dementia.
Narrator: That starts with lodging. Traditional nursing homes keep all their residents under one roof, but real households don’t typically consist of dozens of people. So, The Hogeweyk split its residents up into small groups of 6 or 7 recreating the scale of a single family home. Inside, each resident has a private room furnished with personal belongings. The units are split up into different neighborhoods to mimic Dutch cities that residents are used to.
van Hal: The public space, the gardens, the streets, the squares. They are equally important if you want to build a community where people live.
Narrator: Each neighborhood’s public space was given distinct landscapes and unique landmarks so people could easily find their way around. And destinations like the theater, barber shop, and grocery store were put in separate buildings encouraging intentional movement and intermingling in that public space.
These different areas provide multiple scales of experience and residents are given the autonomy to safely wander along that spectrum from very private to very public space. That autonomy helps further preserve quality of life.
van Hal: People stay in their own bedroom. Many people socialize in the living room, but you can also decide to leave the house, because the front door is open, and to walk to your own private outdoor space, your terrace or balcony or your own garden. Or you walk further into the neighbor(hood) where you can mingle. So, it’s about choice, choice, choice: where you want to be during the whole day and with whom.
Narrator: Crucially, The Hogeweyk’s design allows for a balance of safe design and controlled risk. Walkways, for example, don’t have super high walls to guarantee no one falls over.
van Hal: You see handrails everywhere in institutions. The question is, do you need a handrail everywhere or do you want to provide a walker where you can walk with two hands on the walker and make it accessible for the walker?
Narrator: Since The Hogeweyk opened in 2009 dozens of other dementia villages have opened across the globe. But without ample government funding, they can be prohibitively expensive. And there isn’t enough evidence yet to say whether the dementia village model is better than traditional models of care. The Hogeweyk claims that since they transitioned from a traditional model to the village the number of residents on antipsychotic medication decreased from 50 percent in 1993 to just 8-10 percent today.
And there have been studies backing up different features that dementia villages use. One review of the evidence found that uncrowded, small-scale living resulted in fewer psychiatric symptoms and behavioral issues among residents with dementia and that increased daylight lighting reduced their behavioral issues and improved spatial orientation.
Another review found that outdoor gardens can reduce agitation and improve quality of life for people with dementia. But by creating an environment specifically for people with cognitive and physical impairments, dementia villages are a fascinating practice in universal design: design that works for as many people as possible, regardless of their ability. And they can teach us something about where the outside world falls short.
van Hal: If you design well for normal people without dementia, you design also well for people with dementia. We forgot that people with dementia are human beings with a lot of aspirations and we forgot that people with dementia are not patients where you can put them in a chair and wait until they die. They are people who want to do certain things during the day. And they know and they’re happy to have this freedom.
Quiz
1. At first ________, The Hogeweyk looks a lot like any other neighborhood in the Netherlands. Discussion
- Are you familiar with the magnitude of the elderly population and it’s continued projected growth for the next several decades?
- What are some of the significant challenges presented in caring for such a large elderly population?
- What are some of the innovative medical technologies and approaches to elder care that are currently in use and being developed?