Making a home work for someone with dementia

Environment does a great deal of cognitive work for all of us. We find things because they are where they always are, we know what time it is because of light and routine, and we recognise a room by its function. Dementia degrades the internal machinery for all of that, which makes the external version disproportionately important.

The principles below come largely from the Dementia Services Development Centre at Stirling and from a substantial body of design research. Most cost very little.

Contrast, which does more than anything else

Visual processing changes markedly in dementia — reduced contrast sensitivity, narrowed visual field, impaired depth perception and difficulty distinguishing similar tones.

The practical consequence is that a white toilet against a white wall and a white floor may genuinely not be visible. A coloured toilet seat, or a contrasting wall behind it, solves a problem frequently misinterpreted as incontinence or refusal.

Apply the same principle throughout: contrasting crockery against the table, so a white plate on a white cloth does not disappear; a contrasting toilet seat, handrail, light switch and door handle; contrasting edges on steps and stair nosings.

Conversely, use low contrast to make things disappear where that helps: painting a door you would rather was not used the same colour as the surrounding wall reduces attempts to leave.

Light

Older eyes need considerably more light, and people with dementia more still. Poor lighting increases falls, worsens visual misperception, and contributes to hallucinations in dementia with Lewy bodies.

Aim for bright, even lighting with minimal shadows and glare, since shadows are readily misinterpreted. Avoid pools of light and dark, which create apparent obstacles. Increase daytime light exposure, which helps maintain circadian rhythm — sundowning, the late-afternoon agitation common in dementia, is partly a circadian phenomenon, and bright light during the day has some trial support for reducing it.

Night lights on the route to the bathroom, and a light within reach of the bed.

Reducing the demand on memory

The general principle: make things visible rather than remembered.

• Open shelving or glass-fronted cupboards so contents are visible. Out of sight genuinely becomes out of mind.
• Labels with words and pictures on cupboards and drawers. Pictures survive longer than reading ability.
• A large clock showing day, date and whether it is morning or afternoon. Disorientation in time is distressing and this addresses it directly.
• A visible written routine for the day.
• Toilet door left open and clearly signed, ideally visible from the bed.
• Familiar objects and photographs, particularly from earlier life, since older memories are retained longer.

Reducing noise and clutter

The ability to filter background stimulation degrades. A television in the background, a radio in another room, several conversations at once — these are exhausting and contribute to agitation.

Keep surfaces relatively clear, since visual clutter makes finding things harder. Reduce competing noise. Soft furnishings absorb sound and help in echoing rooms.

Safety, proportionately

Cooker isolation switches or automatic shut-off devices. Thermostatic mixing valves to prevent scalding. Removing or securing rugs. Safe storage of medicines, cleaning products and alcohol. Removing door locks that could trap someone inside a bathroom.

Assistive technology has a role but is easily over-applied. Simple works better: an analogue clock is often understood when a digital one is not; a corded telephone with large buttons and photographs beats a mobile; automatic pill dispensers help in the middle stages and confuse in the later ones.

GPS trackers and door sensors raise genuine ethical questions about autonomy and consent, and are worth discussing with the person while they can still express a view.

The instinct to reorganise

Worth resisting. Familiarity is itself a support, and a person who has navigated the same kitchen for forty years is drawing on procedural memory that survives longer than episodic memory.

Make changes gradually and one at a time. Do not rearrange furniture. Do not redecorate wholesale. A major reorganisation, even one that improves the environment on paper, can cause a marked and lasting deterioration in function.

This is also the strongest practical argument against moving house late in dementia unless it is unavoidable.

Getting an assessment

Occupational therapists with dementia experience can assess a home properly and are usually accessible through a GP or memory service referral. Alzheimer's associations in most countries publish detailed home-adaptation guidance and often run advice lines.

The changes that matter most are cheap, and the ones that get bought first — the gadgets — are usually the ones that matter least.