On a recent visit to a memory care community, Perkins Eastman Senior Associate Max Winters saw a resident with dementia attempting to go outside.
But as the resident tried to open the door, they were gently stopped by an associate who insisted that it was too hot to go outside. To the untrained eye, such an interaction might seem ordinary. But for Winters, the experience was “horrifying.”
“The idea that a resident needs to be babysat at all times, regardless of who they are and what their ability level is just to go outside is pretty sad,” he said at the inaugural Senior Housing News BRAIN conference in Chicago.
Winters’ point was that the industry too often treats all memory care residents as though they must live behind lock and key, even when it means they have to forgo things they like to do.
“To me, as a designer, the biggest problem with how we develop and design dementia environments today starts with a fundamental assumption,” Winters said. “And that fundamental assumption is that the primary and overarching goal of a physical environment for dementia is to protect residents from themselves and to mitigate risk for the operator.”
But Winters sees it another way. To him, the primary role of any memory care community isn’t to keep residents safe and mitigate risk, but instead to provide social integration and purpose for residents.
And while it’s true some safeguards are needed in any memory care community, he also believes that architecture and design can play a larger role in keeping residents safe while also allowing them to live with purpose and agency.
He is joined in that way of thinking by Mark McBride, vice president and general manager for ProMedica’s Arden Courts memory care brand. Like Winters, he believes that memory care engagement doesn’t only relate to programming and amenities. Instead, it all starts with design.
“Our residents live in a different world than we do,” McBride said during the panel at BRAIN. “So, we have to create a world that is supportive for them.”
Moving away from locked doors
Some of the big current trends in memory care architecture and design are related to giving residents more choice and autonomy. First and foremost, both panelists see a need to do away with restrictions such as locked doors.
Locked doors have long been a staple in memory care communities — and with good intention, given that residents wandering away from their community and getting hurt is a real risk. But that doesn’t mean locked doors are the solution to those risks, either.
McBride used an analogy of being unexpectedly locked inside of a mall to illustrate why such restrictions might trigger consternation and alarm in memory care residents.
“Imagine you’re in a mall and you go to the exit and the door is locked. What would you do?” he said. “Would you bang on the door, would you yell?”
Though that is a common response in memory care residents, it is one that can lead to a “slippery slope” of more prescribed medicines and potentially a cascade of negative health events. But that could have been prevented with the right design, McBride added.
For example, ProMedica’s more than 60 Arden Court communities are designed with unlocked doors leading to outdoor courtyards. Though residents can and do walk through those doors on occasion, they are not in danger.
Some of the communities are also built with “city centers” that might include a beach, park, nursery or a flower shop so that residents can wander and self-engage if they choose.
“The slippery slope we go down — all of this can be avoided by building a supportive environment for the residents where there aren’t barriers for them,” he said.
Winters echoed that sentiment and noted that there are a few relatively simple design touches that can aid residents.
One approach is to “lower the barrier” for information and access. For example, spaces can be designed with storage that residents can easily see inside.
It takes a village
Winters’ guiding light when designing a memory care community is that “the primary role of a physical environment for dementia is to provide social integration and a sense of purpose for the residents.”
He takes particular inspiration from the Hogeweyk Dementia Village in The Netherlands, which is famous for its hands-off approach to memory care and resident engagement. In fact, Winters and Perkins Eastman are working on a project in New Jersey with a nonprofit that visited Hogeweyk in an attempt to create the same kind of village-like environment.
During their visit, the developers asked how the famous memory care community could achieve such a hands-off approach to residents with a staffing ratio that is similar to many U.S.-based memory care communities. The community can pull this off by using real-time location sensors and artificial intelligence to learn and monitor resident behavior.
Memory care operators across the Atlantic should take note of these and other approaches, Winters said.
“Not everybody is going to build a dementia village, but I think there are principles there about how care is delivered,” he said.
Winters is also big on the concepts of biophilic design, which is meant to connect humans with the natural world. Though a common way to incorporate biophilic concepts into a community design is by giving residents lots of access to the outdoors, operators can also find ways to connect residents to nature inside of their four walls, such as by filling a space with greenery.
“Those types of intrinsic human experiences become so crucial for a memory care population because they are struggling to retain experiences,” he said. “To the extent that the environment can tap into those things… that’s a key element of design,” Winters said.
Middle market still unmet challenge
Although both Winters and McBride see many solutions for making memory care more accessible and engaging through design, they see fewer options in the design process to make such care more affordable for the middle-market.
“This is a much bigger issue than just what finishes you pick and what grade of lumber is used,” Winters said.
Many of the millions of adults with dementia who can’t afford to receive care at a memory care community end up in skilled nursing care because it is funded by Medicaid, according to McBride. He added that most states have yet to realize that assisted living is cheaper than skilled nursing.
“At some point, we have to look at where the needs can best be met,” he said. “And in reality, [those needs] can best be metin an assisted living community at a fraction of the cost.”
But to that end, memory care designers and operators may draw inspiration outside the borders of the U.S.
Winters mentioned Perkins Eastman client in Canada, United Active Living, that uses a transitional care model called United Minds that allows residents to live in independent or assisted living while experiencing cognitive decline.
“It is not a separate piece of real estate, it is not a separate product, it’s an add-on service,” he said. “They can tailor the engagement places to go during the day to engage.”
But even that solution amounts to a drop in the bucket for a product type that is prohibitively expensive for many middle-income Americans.
“Are we ever going to make 24 hour residential dementia care affordable for the average person? I’m really skeptical about that,” Winters said.
McBride agreed, and added that staffing is the most expensive component of memory care. Until operators can solve that, he thinks middle-market memory care will continue to be a tough nut to crack. But technology may play a role there, too, he said.
“We are going to have to start looking at different ways to do some tasks that really don’t enhance the quality of life of the residents in an engagement sense,” he said. “And utilize the technology to accomplish that.”