2006 Workshop Aging/Alzheimer’s Design: Links to the Neurosciences

“What if?” is a provocative question, and an essential way to view the future of architecture, suggested Leslie Moldow, AIA, member of the Advisory Group (AG) of AIA’s Design for Aging Knowledge Community (DFA KC) and a principal of Mithum, as she convened a workshop, Aging/Alzheimer’s Design: Links to the Neurosciences, held in Washington, D.C., on November 30 and December 1, 2006.

The groundwork had been laid for this workshop more than a year before at a DFA KC meeting at which Dr. John Zeisel commented that he had started reviewing postoccupancy projects that sought to validate assumptions about the care of Alzheimer’s patients. His comment led the group to speculate about how this kind of information could be used to improve the architecture of Alzheimer’s facilities. To explore this concept, the DFA KC created a partnership with the Academy of Neuroscience for Architecture (ANFA) and proposed the idea of offering a workshop of leaders from the scientific and architecture communities.

“What if?” became a central theme of the workshop. It is the nature of the architect to ask this question, explained Moldow, often with no idea of the answer. In the past they have relied on intuition and previous experience. The time has come to begin finding the answers to the questions that surround the architecture of Alzheimer’s facilities and how to best serve the people who live there.

The following summary will illustrate the first steps toward finding those answers.

Taking the First Steps
Using the example of a staircase, John Zeisel, PhD, board member of ANFA and president of Hearthstone Alzheimer’s Family Foundation and Hearthstone Alzheimer Care, explained how even the most simple architectural assumption must be examined. It is accepted that staircases remind people of home and make them feel at ease. For this reason it is a common architectural element in retirement facilities, but no one knows why this feeling is evoked or if it is a universal response.

We must begin to examine why, said Dr. Zeisel. To know why people behave as they do in specific environments, the neurosciences must be employed. If we want to deeply affect the interaction of people with the environment, we must develop a robust body of knowledge that makes these linkages explicit and study them.

Two types of research must be incorporated. Applied research is immediately useful. It is the low-hanging fruit that is based on existing knowledge. While this research is valuable and necessary, it must be incorporated with basic research. This is the research that stretches the mind and will have long-term benefits.

The impact on both the practice of architecture and neuroscience research will be profound. Architects will gain greater expertise with clients and will raise the bar in outcomes management. Ultimately, it will result in greater personal and professional responsibility in every decision.

Neuroscientists will be able to incorporate a built environment as a variable in their research. In addition, this new avenue of study will create more graduate studies programs and grants in neuroscience as it pertains to architecture and the environment. As a result, more professional links will be created to the architecture and design professions.

Challenges for Architects
Stefani Danes, member of the workshop planning committee and principal of Perkins Eastman, spoke eloquently about how greater scientific understanding and new models of aging will affect the architecture of facilities designed for those who live with Alzheimer’s disease.

She stressed the need for more answers as we move forward. “We can’t presume,” she said.

The architectural model, she explained, is different than the engineering model, where the goal is to solve a problem with a fixed answer by breaking down every question and answering it objectively. In the architectural model, answers are uncertain and unstable because there is never enough information. This model begins with “what if?” and works backward.

According to John Zeisel's research, the design process for architects is a spiral that employs three parts: imaging or envisioning a solution, presenting or communicating that solution, and testing by comparing the presented solution with the goals and constraints of the project as they apply to each other. Throughout the process, we gain knowledge and reconceptualize in response to new information and insights.

We now rely on design principles during the “what if?” process. Some are well-grounded; others are anecdotal or intuitive. Through research the architectural model will improve. In closing, Ms. Danes noted that as designers, architects won't ever find definitive answers to whatever design problem they are working on. Architects tend to rely on general concepts (such as, "people with cognitive impairments should live in small groups") rather than situation-specific information. Through the collaboration of neuroscientists and architects, the hope is to develop better design principles to replace the inadequate ones we use today.

Linking Neuroscience and Architecture
The research conducted by Russell Epstein, PhD, assistant professor at the University of Pennsylvania, on the mechanisms that support spatial representation will have profound impact on the design of Alzheimer’s facilities in the future.

Dr. Epstein shared his recent findings on the retrieval of spatial information. There are two kinds of representation in the brain, he explained, large-scale and local scene. Using functional magnetic resonance imaging (fMRI), he was able to discern how local scene is represented in the brain.

Subjects were asked questions about a specific location on the University of Pennsylvania campus while their brain activity was measured by an fMRI. Is the location east or west on campus? Is it facing east or west? Is it on the campus?

It was found that the parahippocampal place area (PPA) responded equally strongly in all scene conditions and that the retroplenial cortex (RSC) response is affected by location, orientation, and familiarity. PPA responds to category location (a storefront) and RSC to specific location (a specific store) using memory retrieval.

A previous study found that when there was RSC damage after a stroke, patients could identify a building or landscape, but couldn’t use it to orient themselves. If these findings transfer to Alzheimer’s patients, they will lead to greater understanding of how to design Alzheimer’s facilities to help residents effectively navigate in their surroundings.

Science in Practice
Cameron Camp, PhD, provided insight into the micro-environmental level ability of a person with Alzheimer’s to engage at a social and environmental level. As the director and senior research scientist of Myers Research Foundation, a division of Menorah Park Center for Senior Living, Dr. Camp offers the unique perspective of a scientist who is intimately involved with the residents of a facility for the elderly.

There is a danger in embracing a paradigm focused on negatives, not positives, he explained. In doing so, facilities work to preserve abilities that are there, but his research indicates that many people with Alzheimer’s are able to learn.

Dr. Camp's research has shown that (much to everyone's surprise) classical conditioning is a good tool for enabling people with Alzheimer's disease to learn. He demonstrated that residents are able to learn skills that allow them to have greater autonomy and rely less on staff.

To optimize classical conditioning ask, “Why is this happening?” Feelings related to a location and micro-clues about how to use a location happen whether we want them to or not. They can and should be identified and used to achieve positive results.

People with Alzheimer’s are normal people with memory function issues. If we can create cognitive procedures to work around these deficits, we can create a normal person. When the environment and person “fit,” the result is normalization. This reduces staff turnover, as well as resident stress and behavior issues.

The largest challenge is how to create community. We must create not only places, but people and places that fit.

Breakout Sessions
Attendees then broke into five small groups representing memory, physiological and physical ability, sensory perception, cognitive mapping, and environmental press. Each group included a mix of neuroscientists, architects, aging/Alzheimer’s experts, facility managers, and funding agency representatives.

The task of each group was to create hypotheses that would lead to meaningful biochemical research that would have a positive affect on the architecture of Alzheimer’s facilities. Later in the afternoon, the groups gathered together and reported on their progress.

Preliminary Group Reports

Memory

Group Defined
With age the brain experiences changes in the ability to embed new experiences into short-term and long-term memory and to recall these experiences later on. How might the environment better provide effective memory cueing for those aging with and without Alzheimer’s?

Preliminary Report
The group first focused on type of memory and established two types of memory to be discussed; declarative and procedural. Declarative memory is conscious recollection of past activities and procedural memory is the long-term memory of skills. In Alzheimer’s patients, procedural memory tends to stay intact, while declarative, especially short-term memory, is affected.

The goal is to assist memory for more than memory’s sake. Memory should create personal or cultural meaning. When applied to architecture, this means that if we want to create an environment that conjures feelings of “home” we must first define home by asking questions like: “What is home?” “Whose home?” “Is home a look or is it an activity, like getting coffee in the morning?”

They discussed the meaningful parts of memory they want the studies they propose to evoke and began to discern whether environment evokes memory and what behaviors are testable in the studies.

Physiological and Physical Ability

Group Defined
As the human body ages, it undergoes many changes with regard to physical ability. This group was asked to explore how architecture can employ neuroscience and other physiological knowledge of how the brain processes and sends out messages in the body to support and enhance the physical function of elderly people in their environment.

Preliminary Report
As the group focused on the challenges presented by aging and Alzheimer’s, particularly in facilities, a spirited discussion resulted in a breadth of issues that might bear further investigation.

Specific issues that enter into the design of facilities include

• Light—The need for large amounts of light and high contrast to see adequately might make people less inclined to participate in group social activities and eating.
• Exercise—The inability to move around can breed frustration. In the future there will be less supervision so an environment needs to encourage safe movement.
• Navigation—What navigation might be preserved and what is most damaged in people with Alzheimer’s? Is there a desire to explore that is diminished by a decreased ability to map the environment?
• Sleep—Alzheimer’s patients have disturbed sleep, so it is essential to reduce noise and create quiet spaces.
• Sundowning—Is the increased agitation that is observed as light diminishes caused by the disruption created by staff shift changes or because there are fewer activities at the end of the day? Light absorption may affect individual or artificial lighting may have a negative affect. Circadian rhythms may lead someone to go “home” at the end of the day. We may be hardwired to return home.The need for improved navigation for indoor and outdoor environments was discussed. There are often many barriers to the outside environment, such as protected gardens. Means of incorporating freedom of movement, navigation, and ways to offer residents a choice to go in and out should be devised that do not put residents at risk of danger.

Ways of creating opportunities to socialize and decreasing separation from community were explored. Suggested solutions ranged from introducing children and pets into facilities to incorporating a concept successfully used in Chicago that integrated into the community coffee cafes with exercise areas designed for seniors.

Sensory Perception

Group Defined
With age, changes in ability to sense the world around us affects our enjoyment and quality of life. Senses such as the ability to see, hear, taste, smell, and perceive movement and spatial orientation may lessen. Neurologically, what is being diminished, and are there ways to combat or better understand these losses?

Preliminary Report
Two hypotheses introducing research logistics were discussed by the group.

Existing studies indicate that the perception of time is influenced by the size of the space. In a small room time goes faster, while in a small room it seems to slow down. Therefore, it may be beneficial to have residents participate in enjoyable activities in large rooms where time seems to pass more slowly and less enjoyable tasks in smaller rooms where time is compressed.

The second hypothesis discussed was to create a prototypical room that telegraphs its use to residents through visual cues. For example, a kitchen would have a sink, dishes, a dish towel, etc. The most effective visual cues would be established through testing. In this way, only the things that are associated with a specific room would be used in that room to decrease confusion and build familiarity.

Cognitive Mapping

Group Defined
Wayfinding, knowing where we want to go and having a clear ability to get there, is key in the ability of elderly people to feel comfortable moving around their communities. This skill is particularly compromised among those living with Alzheimer’s.

Although people with Alzheimer's Disease are an extreme population, our observation has been that what is good for people with Alzheimer's tends to be good for everybody. The working group believes that the cuing and wayfinding ideas we are discussing could apply to places for the general population, such as recreation centers, schools, and other facilities.

Preliminary Report
The following ine hypotheses were established by the group for further discussion.

• Environments that support the learning of cognitive maps that are legible are where social interaction is heightened and behavioral disorders are diminished.
• Alzheimer’s residents have not lost capacity to learn.
• Individuals are more successful in wayfinding with companions.
• Redundant cueing is beneficial in both wayfinding and cognitive mapping.
• Industry relevant outcome majors are affected by environmental cueing
• Cognitive mapping can be learned by manipulation of the entire environment, not just the physical environment.
• Cognitive mapping requires generalization and that generalization can be learned by procedural learning.
• Research can be used by architects more effectively if outcomes are expressed in architectural principles.
• Designing an environment with landmarks rather than other types of cues is more effective for residents with Alzheimer’s.

Environmental Press

Group Defined
The relationship between the challenges and opportunities an environment offers its users and their individual abilities changes radically as people age. Environmental press holds that the optimum environment, especially for those who are older, represents a balance between the challenges an environment presents to its users and the user’s abilities.

Preliminary Report
The group focused on the aspects of the environment that relate to home life, safety, and socialization.

Alzheimer’s facilities offer both family- and restaurant-style dining. To establish which style of dining is more beneficial for this population, the group discussed using nutrition to measure the effectiveness of each method. Also important to consider is the effect of auditory noise and whether the room is used exclusively for eating or is a multiuse room.

Methods of assisting navigation were also discussed. In group facilities, corridors can look alike and methods must be established that will help Alzheimer’s residents differentiate between them. Use of color, landmarks, objects, and room shape were examined.

Final Reports from the Groups
The second day began with the small groups reconvening to complete their hypotheses and recommendations for research projects. Mid-morning, the groups gathered together to present their reports.

Memory
The types of memory were expanded to five types from the two that were discerned in the previous day’s report. For purposes of the group’s discussion, they now include episodic, working, seismic, autobiographical, and emotional.

During the course of their discussion, the group compiled a series of questions that they considered worth investigating separately from the hypotheses they presented.

• How does the environment support meaningful engagement?
• How can we best provide settings for meaningful interaction?
• Which memories are collectively known and which are private?
• Does approximating environments trigger memory?
• Does adrenalin still work at the same level to consolidate emotional memory?
• What are the effects of classical conditioning?

Hypothesis 1
Performing certain orienting activities will help people know who and where they are in an environment.

Some examples would be installing a window to provide clues to what time of day it is or placing a toilet in the direct line of vision to assist in continence.

Hypothesis 2
Engagement in quality of life will be enhanced by providing culturally relevant activities and spaces.

The basis for this hypothesis is that life-long activities are hardwired.

Hypothesis 3
Specific cues that differentiate personal space from public space will enhance memory for room location and personal activities.

Hypothesis 4
Environments that rely on tapping into autobiographical memory will improve normative activities.

This would provide support for allowing residents to bring personal items like their own furniture to ensure that there are things in their environment that are usual and customary.

Hypothesis 5
Independent functioning can be enhanced by encouraging use of traditional scripts rather than novel and nontraditional approaches to daily living.

Hypothesis 6
Lifelong activities are hardwired; therefore, they should be integrated into the design of a project as catalysts for meaningful activities.

Hypothesis 7
Exposure to daylight improves memory.

Is this because sunlight improves mood and as a result improves memory?

At the end of the presentation a concern was raised that programs were being presented that respond to certain activities with a warning that we shouldn’t assume a “tight fit,” but rather aim for a loose fit of design. An example was given that picking berries might evoke memories in a person raised in the country, but would not in a person raised in the city. It was suggested that there is sufficient demand to allow segmenting rather than a one-size-fits-all solution.

Psychological and Physical Ability

Hypothesis 1
Higher contrast afforded by more light will allow people to see food and other people better and will improve both nutrition and caloric increase. Results can be tested either behaviorally or with fMRI. (Increase lighting levels in dining rooms).

Hypothesis 2
Greater physical activity is assumed to increase health and life expectancy, but outdoor spaces are often not used in facilities. (Provide free access to outdoor environment to increase activity.)

While many facilities have outdoor gardens, if residents can’t see outside, it is unlikely that they will self-initiate to go outside.

It was also suggested that we don’t know if the desire to explore outdoors declines as Alzheimer’s progresses. This can be tested at various stages in Alzheimer’s progression to find out.

Hypothesis 3
The presence of pets and plants promotes faster healing. (Introduce places and spaces for children and/or pets to increase health.)

There is some research to support this hypothesis. This study could build on that information. It is recommended that physiological factors indicating stress could be measured.

Hypothesis 4
There is an optimal group size for Alzheimer's patients. (Groups of nine Alzheimer’s residents are better than groups of 15 or more).

This research would help discern if there is an optimal group size. There is speculation that larger groups may be confusing.

Sensory Perception

Hypothesis 1
A basic assumption of neuropsychology is that multi-sensory cues aid performance. However, since there is a degeneration of the senses in Alzheimer’s patients, a greater combination of sensory input may not be optimal.

There is a tension between desire to minimize architectural complexity and the potential benefit of multiple cues. We must discern if multiple destination cues are more helpful than individual cues in wayfinding, which cues are effective, and how they should be combined.

Evolution of simulated versus mock-up testing may come into play in the design of this research. It must be determined if computer-simulated environments provide the same experimental results as mock-up tests in people with Alzheimer’s.

Hypothesis 2
Despite impairments in cognitive domains, people with Alzheimer’s retain relatively intact semantic memory; therefore, appropriate sensory cues can promote recognition.

By creating an environment with the proper sensory cues to bring out appropriate behavior, the often difficult transition to residential living can be eased. For example, we recognize a kitchen by certain sensory cues, but what are appropriate cues for a person with Alzheimer’s?

Within the context of this research, boundary features, such as walls, flooring changes, distance, and ambient condition changes would be tested to determine which best define an area and evoke context appropriate behavior. It would also be determined if overlapping spaces (such as kitchen, dining room, and bedroom) create confusion and methods would be examined to decrease confusion.

Cognitive Mapping

Hypothesis 1
Cognitive mapping can be learned through manipulation of representations of the environment.

The challenge inherent in this hypothesis is not to limit to testing to photos or three dimensional puzzles. We need to determine the best mapping techniques to manipulate landmarks and cues for testing.

Another challenge is how neuroscience can be integrated in this research. The use of high technology could be difficult because we want to see what happens to the brain during the exercise.

Hypothesis 2
Redundant cueing is beneficial to cognitive mapping.

Hypothesis 3
Legible environments will be characterized by more social engagement, less disruptive behavior, and a more positive effect.

During the discussion of this hypothesis, it was asked if we are talking about Alzheimer’s or aging. The response was that Alzheimer’s is an extreme group and that results of this research can be applied to recreation centers, schools, and other facilities.

Environmental Press

The group reported that their focus was on social interaction as the primary driver.

Hypothesis 1
Family-style dining promotes socialization, better eating habits, and leads to better health.

This research would compare the outcomes of people who ate in groups of two to four in a restaurant style environment to those who ate in groups of eight to 10 in a family-style environment. Initially, they would examine gross levels to see if there are any differences; then they would ease factors out to find what factors lend to the results. The emphasis would be on nutritional measures.

Hypothesis 2
Community settings with more social interactions on a larger group scale are associated with better health outcomes.

The concept of small living groups of eight to 10 individuals is popular, but do we lose because of lack of social interaction of a larger group? Does the presence of a space that fosters larger social interactions improve health outcomes? Specifically, this would examine a social model facility with a main street versus one without a main street with an emphasis on physical and psychological measures.

Changing Assumptions
Dr. Zeisel compared the growing awareness of the link between neuroscience research and architecture to the acknowledgement of the link between germs and disease. Before we knew about germs, there were epidemics of disease in wards where women were having babies. With the realization that germs exist, health care providers began washing their hands, and the incidence of disease decreased.

Today, decisions are being made every day about the best care for people with Alzheimer’s. Just as the discovery of germs changed the way health care was provided in the past, our growing understanding of neuroscience will help us in making the best decisions for the Alzheimer’s population in the future.

Moving Forward: The Next Steps
There is an urgent need to publicize this information. Many populations could benefit from knowing about the type of research and planning that is taking place between the neuroscience research and architectural communities.

A report on the first day of the workshop was posted on the Web site of the Dana Foundation, and the event was being covered for the Dana News. It was suggested that participants should make submissions for presentations at appropriate meetings and write articles for professional journals. Methods of reaching the mainstream media were also discussed.

Participants will explore inroads to the neurosciences, including creating grants and responding to requests for applications, requests for proposals, and research project grants. It is important that researchers understand the real-world applications of this work to encourage further investigation.

Word of mouth will be an important means of spreading information. Attendees were encouraged to return to their offices and talk about what took place at this workshop.

Just as a sense of community is important in senior living, this community must work together to take the “what ifs?” explored at this workshop into “next steps” by keeping account of each other as we dedicate ourselves to creating larger good out of what has happened here.

This event was made possible by the generous financial support of the American Institute of Architects, Dana Foundation, Alzheimer’s Association, Aging Research Institute, and Bovis Lend Lease.