One sunflower painting looks like another here, each numberless door is identical and I am hopelessly disoriented; desperate to find an exit, a shaft of light, even. I turn right, up another featureless corridor, and then left and then right again – but is this really the way I came?
It’s a relief when a researcher removes my virtual reality headset, but it takes a few moments for my heart rate to return to baseline. I am at Bournemouth University’s department of psychology, where Jan Wiener and his team are researching the difficulties people with dementia have with wayfinding (orienting oneself in physical space). I have just briefly experienced the spatial disorientation that characterises Alzheimer’s, but for Wendy Mitchell, who lives near Hull in Yorkshire, it’s a perpetual experience. Diagnosed with the condition almost four years ago, when she was 58, she now travels around the country raising awareness of dementia. Her journeys demand precision planning. “I have a pink file that’s stuffed with information,” she says. “Walking maps to and from venues, pictures of venues, so they look familiar. My phone with Google maps talking to me. The occasional venue has a video walking map – these are wonderful. It’s important not to panic. I look for the first smiley face to come along and ask them the way or where I am.”
Her difficulties happen closer to home, too, compounded by memory loss: “When I moved to my new house, I hadn’t appreciated how difficult it would be to learn where I lived. The main issue was the four houses looking the same, nothing to differentiate one from another except a number and, of course, I couldn’t remember my number. So I put two forget-me-not tiles, one on each side of my door, to tell me that was my house. And inside the house, I removed two doors as I couldn’t remember where they led.”
Of all forms of dementia, Alzheimer’s especially is associated with a severe decline in navigational skills. “There’s an overlap between the brain regions affected in the early stages of Alzheimer’s and the areas important for spatial navigation, including the entorhinal cortex of the temporal lobe,” says Wiener. These difficulties could emerge decades before Alzheimer’s is diagnosed. In another virtual reality experiment, German and Dutch researchers detected impaired navigation (as measured by the function of grid cells in this location) in young adults who were at genetic risk of developing the condition, but potentially wouldn’t until many years later.
For 15 years, Wiener has been building on psychology and neuroscientific wayfinding research to redesign environments. Virtual reality is ideal for this work, he says. It is impractical to build a care or residential setting, measure how people with dementia fare and then redesign it a few months later. “But VR enables us to simulate unfamiliar home environments and then simply change features and structures systematically, whether it’s the layout of corridors, the number of intersections or the types of landmark.”
Virtual reality next transports me from Bournemouth to Virtual Tübingen, the university town near Stuttgart, in Germany, where Wiener did his PhD. After that, it is on to a virtual care home where PhD student Chris Hilton has run his most recent experiments with people without dementia. Here, older participants are slower at learning routes than young adults: they make more errors and need more repetitions to succeed; unsurprising, since information processing speed declines with age. But what also might be happening is that older adults use different strategies when they learn new routes, pointing out salient landmarks more than turns and intersections – which younger people tend to rely on.
Gaze behaviour experiments are shedding further insights on these differences between young and old, particularly how each distinguishes between the location of objects. “Older healthy adults tend to make more use of external information, for instance windows and walls,” says Vladislava Segen, another member of the Bournemouth team. “But younger participants tend to look at the spatial arrangements of objects within a room, as well as flicking back and forth to external cues.”
Segen thinks we could capitalise on these differences, drawing specifically upon cues that older adults prioritise. So paintings or different wall colours may be more helpful at intersections or room entrances, rather than yet another pot plant or a blank wall. Memory for landmarks also seems to be preserved in older adults, but they tend to have impaired memory of the sequence in which they are encountered. So switching the order of a pot plant or lampshade might impair navigation while, conversely, Hilton says, keeping these sequences consistent could avert spatial disorientation.
Several of these findings apply to older people rather than those with dementia, however, and emphatically, dementia is not simply a consequence of ageing. But the strategies could be crucial for older people who either stay in their own homes or move to retirement housing. “If all environments were more dementia-friendly,” Wiener says, “we may be able to extend the time people can live independently.”
As for VR testing in those with established Alzheimer’s, he acknowledges this has been difficult and so his experiments are shifting towards people with early signs of atypical Alzheimer’s, where working with residual capacities is vital: “I think what we can do – by designing environments to compensate for declining navigation abilities – is to smooth the transition from living in a well-known environment to moving into a care environment.”
Ultimately, Wiener’s work depends upon collaboration and he regularly meets with architects, designers, care commissioning bodies and policymakers among others. And, crucially, people with dementia themselves. It’s the sort of collaboration that has evolved at Trinity College Dublin, where researchers from TrinityHaus at the school of engineering has joined forces with the dementia services information and development centre’s Living with Dementia research programme at the school of social work and social policy. They are drawing upon Universal Design guidelines to create dementia-friendly dwellings – homes (new or retrofitted) that are integrated into the neighbourhood. As 80% of people living with dementia will move into assisted living or care-home environments, the guidelines can also be adapted.
Discussing some of their recommendations with Mitchell, it becomes clear that they speak to her experience. Reflective surfaces and glare are especially problematic, she says. “I only have one small mirror in the house, which I rarely use as it’s disconcerting, especially when you live alone, to suddenly see a reflection. I find shiny floors look like water. There’s a new shopping arcade in Leeds where the floor is not only shiny but swirly and I have to look up when walking through it or I feel sick and very wobbly.”
There are other unnerving experiences associated with dementia that could be diminished by design. For some, a black doormat appears as a hole. Or a kitchen floor develops a series of treacherous steps. Depth perception issues mean that abrupt changes in colour or tonal contrast of flooring are unsettling. Meanwhile, Mitchell has found that contrasting colours can help: “I painted a blue border around light switches to make them easier to see,” she explains, “and luminous yellow stripes on the steps outside – there are often simple cheap solutions, it’s just about having some imagination.”
The architect Thomas Grey, a research fellow at TrinityHaus, believes many of the recommendations can be realised on a small budget, with minimum disruption. “But it is important to say that Universal Design and dementia-friendly housing is about helping a person to remain living at home for as long as possible and the value of this is hard to overestimate, both in terms of wellbeing and financial cost. Our home is so much more than a roof over our head – it is the place where most of our lives unfold.”
Design for dementia may simply be design for everybody. Grey explains that Universal Design aims to provide an inclusive environment for people of all ages, sizes, abilities and disabilities – rather than designing exclusively for a distinct set of needs. “The conditions that support a person with dementia – a calm, coherent, orientating and gently stimulating environment – are good for all of us,” he says.
These design ideas yield specific power though, in combatting confusion and disorientation in dementia. And, in the absence of a medical cure or transformative treatments, for some at least, design might just outdo drugs.