A couple weeks ago, my mother walked by herself from her rest home to my house. It is about a mile as the crow flies. On foot, this route takes you down a long suburban street, around a corner, through a bustling village crammed with small shops, across the road, and up a steady incline to the top of a hill where you turn left onto my street.
There is nothing particularly exceptional about this occurrence, except that my mother has Alzheimer’s disease. Her short-term memory is badly affected, and she hasn’t walked to my house in about three years. Even more surprising is the fact that she did it all by herself. It’s important to note that she is not yet in the more severe stages of the disease, otherwise I would be very concerned about her leaving the rest home unattended. Currently, she is free to come and go as she pleases. As her condition progresses, we will determine next steps for a more secure living situation to prevent her from wandering and potentially getting lost.
So, how is it that my mother can find her way to my house, yet she is completely unable to draw a map of the exact same route or even give verbal directions for how to get here?
It is all about visual cues. As Mum walks out of the rest home gate, she sees something that triggers her memory. She walks a bit further, recognizes something else, and so on. At each of these points, her memory is being prompted and the unfolding series of cues enables her to find her way.
Creating Dementia-Friendly Environments
More than a decade ago, Lynne Mitchell and Elizabeth Burton of Oxford Brookes University undertook a fascinating piece of research. This three-year project entitled Neighbourhoods for Life: Designing Dementia-friendly Outdoor Environments set out to learn how the outdoor environment could be made dementia-friendly. Prior studies had only focused on adapting the interiors of senior living facilities like assisted living communities, memory care units and nursing homes to be more dementia-friendly, but the benefits of such measures are extremely limited since the majority of Alzheimer’s and dementia patients live at home, many independently.
The researchers, who have a particular interest in built environments, wanted to understand what influences people with dementia to successfully use and negotiate their local neighborhoods. Mitchell and Burton interviewed people with mild to moderate dementia, accompanied them on walks, and completed an environmental assessment of each participant’s local neighborhood. By examining the perceptions, experiences and activities of a group of older people living with dementia, they identified six factors that make neighborhoods dementia-friendly: familiarity, legibility, distinctiveness, accessibility, comfort and safety.
Thinking about my mother’s incredible journey from her place to mine, the researchers’ conclusions make perfect sense. The cottage-lined footpath that takes Mum down the bottom of the hill is familiar to her because she previously spent years walking this route. The road sign that tells her which street leads up to my place is perfectly legible. The street art mural of a cabbage tree just before the road turns the corner leading to the shops is extremely distinctive. These are exactly the kinds of visual cues that make “way-finding” possible for people with short-term memory problems
Then there’s the accessibility of the gate leading out of the rest home, the comfort of the seat where Mum rests on her way up the hill to my home, and the safety of the traffic-controlled pedestrian crossing that guides her across the busy street.
Applying the Six Tenets of Dementia-Friendly Environments
Since Mum’s amazing walk, I’ve been noticing how, even around the rest home, visual cues increase her independence and make life easier and more enjoyable.
Take Advantage of Familiarity
Clarity of purpose and regular use help make things feel familiar. Whenever she visits my house, Mum likes to help out by drying the dishes. She can’t remember where anything goes, but mostly she works it out through trial and error. However, there is one item she always struggles with: the pots. At my house they live in a drawer, but this is not a place where Mum would expect them to go. In her experience, pots live in cupboards. Nowadays when we are drying up, I start by putting a small pot in clear view on the counter. Mum gets it immediately. She carefully dries all the other pots and this visual cue prompts her to add them to the collection atop the counter. As we finish up, I put all the pots away in the correct drawer.
Here is another example: the gate at Mum’s rest home has a childproof catch that opens at the top. When Mum first moved to the rest home six years ago, she learned how to open it. Daily use means its operation has stayed familiar. It is important that when I’m with Mum, I let her open the gate herself. By doing things with her instead of for her, the familiarity of simple tasks like this one can be preserved for as long as possible. Otherwise, this familiarity would be lost.
Create Distinctiveness and Accessibility
Ensuring things are noticeable and interesting helps to make them distinctive. At least once a week, I go around de-cluttering Mum’s small room at the rest home. I’ve done this since she moved in because it helps her manage in the tiny space.
Recently, I’ve been much more strategic with my tidying. I have started setting things up so that Mum’s attention is drawn to particular activities. For instance, this week I cleared her table completely and replaced a large pile of magazines and notebooks with a single coloring book and a jar of pencils that are ready for action.
Decision-making can be extremely difficult for an individual with dementia. Limiting clutter, excessive choices and over-stimulation can help a patient easily decide on an activity, meal, article of clothing, you name it. Setting certain items or options at the forefront or in distinctive containers can assist in the decision-making process. Another example could be placing a brightly colored medication box alone in a specific spot on the kitchen counter. This object is distinctive and its placement minimizes competition for attention. This type of strategy could help a loved one remember to take their medications.
When it comes to dementia, making an item or option more distinctive can also make choices and activities more accessible.
With legibility, the problem for Mum is not the act of reading but connecting the individual words with actions. Written reminders and instructions do not work if you forget to look at them. I have taken to putting notes as close to the actual materials or activity as I can.
For instance, the dimensions for Mum’s peggy squares (granny squares) are detailed in a note pinned to each new piece of knitting. I have also posted a note about choosing cotton skirts and dresses on hot days right next to the handle of the wardrobe door. This reminder helps both Mum and her caregivers at the rest home. I keep all these notes as short and straightforward as possible to avoid provoking more confusion.
Prioritize Comfort and Safety
For dementia patients, comfort and safety are the two fundamental factors that determine their quality of life. Throughout the progression of this disease, patients typically lose their ability to clearly vocalize when something is causing them to feel uncomfortable or unsafe. A patient may have an outburst instead or simply stop engaging in related activities that cause pain or fear.
For example, a regular task like bathing can easily become overwhelming. Patients typically feel vulnerable or uncomfortable, especially if they need someone’s assistance. They may be cold during or after a bath or shower, and they can easily feel unsafe in a slippery and precarious bathroom setting. Utilizing a few tips, such as turning off the air conditioning or heating up towels for use after bathing, and proper equipment, like a step-in tub or a comfortable shower chair, can make all the difference. Caregivers can take this one step further by making the environment and any equipment look inviting and safe. Setting up the bathroom with everything you and/or your loved one will need and turning the faucet will help indicate that it is time for a bath or shower. You could also use towels that are their favorite color or provide a note with illustrations of the steps involved in bathing.
Familiarity, distinctiveness, accessibility, legibility, comfort and safety: these qualities—many of them involving visual cues—help us all throughout our lives, whether we realize it or not. Utilizing each of these cues both inside and outside the home can increase a dementia patient’s quality of life and ability to function more independently. Just be sure to provide appropriate supervision depending on the task at hand and the individual’s level of impairment. I do not anticipate that these cues will remain effective for Mum over the long term, but I will continue using and adapting them as long as I can to help her maintain a sense of independence and purpose.
Sources: Neighbourhoods for life: Designing dementia‐friendly outdoor environments (https://www.emerald.com/insight/content/doi/10.1108/14717794200600005/full/html); Care Settings and Clinical Characteristics of Older Adults with Moderately Severe Dementia (https://onlinelibrary.wiley.com/doi/abs/10.1111/jgs.16054)