Aged care and dementia: why aren’t we building better?

Our knowledge about how to design buildings that support people with dementia has never been greater, but it’s being ignored by too many providers, says Professor Mary Marshall.

Given all we know about how the environment supports or hinders the person with dementia, why do so many new aged care projects ignore this, asks Mary Marhsall
Given all we know about how the environment supports or hinders the person with dementia, why do so many new aged care projects ignore this, asks Mary Marshall.

Our knowledge about how to design buildings that support people with dementia has never been greater, but it’s being ignored by too many providers, writes Mary Marshall.

In the 1990s, I sat in a mental health unit for people with dementia, being served tea by a very tall, distinguished man with dementia.

The dining/sitting room was the heart of the 10-bed unit in which he lived. He agreed to show me his bedroom which he found immediately since it faced into the sitting room. It was also easy to identify because it had a football poster covering half the door and the room itself was full of football memorabilia.

Only three months before this man had been living in a 24-bed unit with one dark central corridor, a big day-room and most beds in bays. He had been intimidating staff and other patients, and was constantly aggressive, which included smearing his faeces.

Not in use today

Mary Marshall
Mary Marshall

There were many units in Scotland like the one this man was currently living in, built in the 1990s, some in rural areas away from the main hospitals. Yet none of them are in use today.

The one I had tea in is now an office. Some have been joined up to make bigger units and others have simply closed.

Far too few hospital, residential and nursing home units for people with dementia are really small these days, yet we know that small scale works. We know that corridors – unless they are short and wide – are confusing. We know that way-finding is improved if people can see where they want to go. Our knowledge about the design features that are helpful for people with dementia is much better known than it was in the 1990s. This knowledge is based on research and a very strong international consensus.

An international issue

This lack of determination to build what we know is best for people with dementia is not simply a British phenomenon. At the HammondCare International Dementia Conference in Sydney in June there were several sessions reflecting on this issue. All of these presentations came to the same conclusion: that the known best building designs for people with dementia are not universally required or provided.

There are, of course, a great many providers that remain resolute about doing it right including, HammondCare itself. Many used to do it well and are slipping backwards, and a great many are barely trying. Neither commissioners nor regulators are requiring the best.

Cheaper to do it right

It would be useful to know why this is happening. The knee-jerk answer is that it is more expensive to do it right. We need more evidence for this. HammondCare CEO Dr Stephen Judd asserts that if we take every aspect of care including staff turnover and the drugs bill into consideration, it is cheaper to do it right – certainly over the medium term.

When we talk about the cost of a building, we tend to talk about its immediate expense not the longer term, and we often consider only the building rather than including those living and working in it.

In the UK we are experts at budget shunting, by which I mean that providers do not meet all the costs. Some buildings are built and sold; others are built and rented, the NHS pays for the drugs bill, and so on. This makes taking all costs into consideration very tricky.

Another possible explanation is that doing it right is no longer seemingly new and exciting? Or is it a lack of design champions? These people have always needed to be very determined to stop the wrong compromises being made and to keep all parties together and sometimes to take on regulators.

Some suggest that it is about the priority given to other regulatory requirements. Others feel that there is an inability in cultures such as ours, to see buildings themselves as part of ‘treatment’? Everyone has different answers to this important question.

The crucial question remains – what are we going to do about it? How are we going to reignite widespread enthusiasm for therapeutic building design for people with dementia?

We know that design makes thing possible, it does not make things happen. But there are already far too many buildings where optimal care will be a real struggle, and there will be more of them unless we can do something.

Mary Marshall is an emeritus professor at the University of Stirling.

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Tags: accommodation, aged-care, architecture, dementia, design, hammondcare, mary-marshall, new building, refurbishment,

3 thoughts on “Aged care and dementia: why aren’t we building better?

  1. I had listened to Mary at the HammondCare conference, and I have to say her enthusiasm, dedication and hilarious banter was excellent. Thank you for providing such an honest, and straight-down-the-line talk about dementia and design. It is my hope – and wish – that one day it will be done right across all facilities and that it will be an expectation rather than the exception to providing quality, evidence-based care.

  2. Absolutely agree!
    I see ‘hotel’ like buildings almost every day where people strugggle to find their way around. And yes Kate, this is a human rights issue! We need prosthetic enviroments where people are enabled to function independently.
    The Uni of Wollongong with Kirsty Bennett and Richard Fleming offer a wonderful education service through Dementia Training Australia on the principles related to design for people with dementia. See also

  3. It’s extremely simple. Accomodation for folks with dementia are simply built by builders. For whatever reason, extremely few of those people whose funding will cover building a building ever even consider actually paying attention to what dementia folks feel comfortable in. Canada has made good progress in this — everyone else, not so much.

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