When is a door not a door?

Associate Professor Colm Cunningham discusses the practice of disguising doors in residential facilities with Professor Mary Marshall.


Door painted the same colour as the wall

Associate Professor Colm Cunningham discusses the practice of disguising doors in residential facilities with Professor Mary Marshall.

Disguising a door to stop a person with dementia leaving is commonly used in residential facilities. I could discuss at length the importance of first and foremost ensuring we understand the reasons and triggers that lead someone with, or indeed without, dementia to want to leave a building.

Boredom, noise intrusion, lack of open spaces in a residential facility are just some of the reasons one could provide.

Whatever the cause, investigating and seeking to understand why this is happening is essential. We need to avoid labels and assumptions being placed upon the person with dementia about their actions and to not routinely define these as a ‘behaviour’ of their dementia.

I do, however, want to focus on and call into question a couple of solutions in common practice to disguise these doors. These include: the use of mirrors on the face of the door or disguising the door with an image of a bookshelf, welsh dresser, or in a most recent example, a café scene with chairs.

Hallucinations can occur for at least 25 per cent of people with dementia and are typically auditory and/or visual. Sensory impairments such as hearing loss or poor eyesight that increase with age tend to exacerbate hallucinations in the older person with dementia.

Certain types of dementia, for example dementia with Lewy Bodies, increase the possibility of visual hallucinations. There are also a significant number of older people at risk of delirium and associated visual hallucinations. Residential facilities who define their service as not for people with a diagnosis of dementia are therefore not exempt from the challenges created by a confusing environment. All of these factors mean that people living in residential facilities are at risk of visual misidentification of their environment.

Why, then, would the answer to stopping a person leaving through a door be to create a solution that can add to their confusion? In the example of the image of the café scene with a chair being used on the door, this could put the person at risk of trying to sit on the chair with an outcome as serious as fracturing their hip in the process.

An inconspicuous door in the bathroom
An inconspicuous door in the bathroom

Research-based evidence is lacking in this area. Cumulatively, the evidence about the changes in the ageing eye from visual impairment experts and the confusion that occurs to people with dementia are strong arguments in themselves. I have also observed the problems these strategies can create, for example a person with dementia trying to reach for a book on a bookshelf image.

Looking to expertise and experience in the area of design, I asked Emeritus Professor Mary Marshall, University of Stirling, for her view on using an image to disguise a door.

She told me: “It concerns me that we have to use trickery in buildings for people with dementia. Life must be bewildering enough with dementia, especially since many people are in a very unfamiliar environment.

“Often they have no idea what a modern care home or hospital looks like, so have no notion where they are.”

Mary also says that “while there is no research to support this, we need to treat people with dementia properly as adults.”

So what’s the alternative? Mary’s starting point is “it depends where the door is.”

She says:  “There are many problems with fire doors, especially if they are at the end of a corridor and have a window. The light attracts people and the bar sometimes says ‘PUSH BAR TO OPEN’ – what do we expect people to do? It is often made worse because there is no easy access to fresh air and outdoor spaces, and few activities to keep people engaged. The answer to this one is to avoid putting fire doors at the end of corridors, put them at the side. If they are there anyway, then the sign on the bar needs to be removed (this is allowed in the UK if there is a green sign above the door). Making the window look more like a window helps, as do distractions on the wall at either side. Surely this is better than a fake bookcase?”

Mary continues: “If it is the main door to the unit and it has been designed to be highly conspicuous, then it needs to be painted out. The door needs to be the same colour as the walls, the handrail needs to go across the door and there needs to be some well-lit and attractive area nearby to distract people. Bored people with dementia will be attracted to where there is action and this is often around the entrance/exit. This can be upsetting for everyone. We have seen sideboards stuck on these doors which must be very worrying – why are people coming through a sideboard?”

Mary concludes by stating: “Ideally entrance/exit doors are very inconspicuous indeed and there is a lot going on elsewhere, including open access to an outside space.”

In the example of the café image mentioned above, it was observed that residents with dementia stated people were walking through the chairs. What residents were actually seeing was staff entering through the doors and the image of the café then being split open. A redesign of the environment and/or staff practices of where or when they enter the facility could help.

The potential for the words of the person with dementia in this context to be assessed by a doctor or relative as further evidence of confusion and hallucinations is very real.

The NSW Dementia Behaviour Management Advisory Services identifies environmental triggers as a significant factor in the referrals they receive.

It is incumbent on residential facilities to ensure that they are not adding to a person’s confusion or indeed unnecessarily frustrating them. In my view, painted or printed images to disguise a door do not fit with what we know about changes to the ageing eye, problems interpreting 3D images and the risks of hallucination that are associated with having dementia. I’m with Professor Marshall that we need to pick up our paint brushes and paint these types of doors the colour of the wall.

That is the easy part, the hard yard is what we do to change our care models and adapt our environments to enable people with dementia and create spaces they want to live in.

Associate Professor Colm Cunningham is director of The Dementia Centre, HammondCare.

Images courtesy of The Dementia Centre

Tags: colm-cunningham, dementia-centre, dementia-design, mary-marshall,

1 thought on “When is a door not a door?

  1. We have recently disguised a contentious door in the DSU with timber look wallpaper which runs the length of a wall and over the door, blending it right into the wall.
    As there is outdoor access to a secure garden just nearby it has in this case solved the problem of residents trying to open the door and becoming agitated when it would not open, causing all sorts of behavioural ripple effects through the unit.

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