Using ecological theory to manage behaviour and symptoms in people living with dementia: a transdisciplinary approach to design

Introduction

Design (of all types and at all scales) is largely an attempt to manipulate the way we react to our surroundings. Design has functional concerns – architecture is naturally preoccupied with shelter and how it’s to be built, how it flows and what it looks like. Architecture is usually designed to assist users with such things as way-finding, critical adjacencies and conveniences, but nowadays rarely with behaviour in mind (Horayangkura 2012). Graphic design is preoccupied with telegraphing messages (Ambrose, Harris, and Ball 2020). But along with the functional concerns, there are also critical decisions every designer will make that influence behaviour and health. Normatively designers are oblivious – thinking, with good reason that health is the domain of clinicians, not designers. But in this space, it’s unusual to find anybody to offer more than hackneyed advice (good as it may be) about things like the importance of views of nature or the importance of natural sunlight (Beauchemin and Hays 1996; 1998; Dijkstra, Pieterse, and Pruyn 2006; Ulrich et al. 2008). Clinicians sometimes have a sensitivity to the ways architecture affects such things as disruptive behaviour and cognitive decline, but rarely have the understanding to be prescriptive about what’s needed. If there are few clinicians who understand the nexus between clinical sciences and architecture, there are still fewer architects who have the competency to make claims about how design can affect things like pathology (Horayangkura 2012). The effect of design generally (and architecture specifically) on the symptomatology of dementia is, therefore, a problem that spans the disciplines and gets lost in the gaps. Without disciplinary ownership of the problem, complex solutions are hard to realize. The people who should be most concerned – that is the PLWD are only occasionally consulted about their preferences and solutions because carers typically make decisions for them (Niedderer et al. 2020). But how PLWD feel about the environment is critically important because valence (the hedonic and affective quality of things) can radically change perception and with it, behaviour and even symptoms, and how people feel is deeply personal (Francis and Murtha 2021). A good key to draw the disciplines to work together to enable wellbeing, reduce symptomatology and stimulate desirable behaviour, are the overlapping yet independent ecological theories of Gibson (1979), Bronfenbrenner (1979) and Barker and Wright (1949; 1954). While all these theories originally emerged from sociology, none are now particularly well-known and are rarely more than footnotes of a lecture. The theories have apparently become boundary objects. No discipline claims authority on the theories, yet they draw together very diverse interests including creativity (Glăveanu 2016; 2020), neuroscience (de Wit et al. 2017; de Wit, van der Kamp, and Withagen 2015), architecture (Salingaros 2017), clinical psychology (Loveland 2001), or an interdisciplinary admixture of all the above (Golembiewski 2019a).

What is dementia, and how does it relate to the milieu?

Dementia is a blanket term for a collection of neural disorders that cause cognitive decline typically affecting memory, reasoning and ability to undertake ordinary activities for daily life, behaviour and perception. The dementias are associated with ageing, but they sometimes occur in young people also and are not part of the natural ageing process (Alzheimer’s AssociationR 2021). Even so, because the frailties of age are common comorbidities, the pain points of ageing must be considered along with those exclusively for dementia – minimally design should be universal, compensating for losses of hearing, sight, strength, mobility, social networks and the immune system. Better still, it should be inclusive, which means they should not only compensate for losses and deficiencies but to amplify all abilities (Charras 2021). Beyond inclusive design, there’s more still that the design professions can do to positively impact quality of life (QOL), a sense of meaningfulness, perceptions and behaviour (Harison and Fleming 2021). Because dementia is largely diagnosed according to behaviour and ability (American Psychiatric Association 2013), non-pharmacological interventions such as environmental design can potentially address the very symptomatology used to define dementia in the first instance (Zeisel et al. 2016). Designing for health is more than designing for the functions and programmes of a care facility. Systematic meta-reviews identify positive aesthetic concerns (such things as views of nature, solar access, thermal comfort and access to animals) lead to better health (Eg. Dijkstra, Pieterse, and Pruyn 2006; Ulrich et al. 2008). The results are often impressive. For example, Beauchemin and Hays (1996; 1998) identified 30.8% faster recovery and 38% lower mortality when patients were given sunlit rooms for psychiatric disorders. If design can influence perception and behaviour through aesthetics, then we might employ the same means to designfor dementia, thereby relieving some of the burden of care from carers and some of the burden of cognitive decline in PLWD. But herein we find two problems: The first is the resistance that architects maintain for architectural determinism (as design for deliberate behavioural ends is called) because of its long reputation of failure (Gatt and Ingold 2020). The second problem is the opposite: A designer’s best intentions can miss the mark or be too forceful. In cases where people have severely reduced cognitive capacity (such as when they are living with dementia), they lose their independent capacity to resist the directions that are implied by the narratives of the environment, no matter how dangerous or bizarre (Lhermitte 1986). And again, in many cases, the behaviours that are triggered are undesirable, such as agitation, ‘sundowning’, absconding and other symptoms including interpersonal violence (Golembiewski and Zeisel 2022; Lhermitte 1986). Most architects simply don’t have the requisite knowledge to predict or identify the behavioural and health effects of design decisions, and how untested decisions may assist PLWD. Similarly, perceptual psychologists rarely know much about architecture or the clinical needs of PLWD. Carers and clinicians (including clinical psychologists) are similarly handicapped and are often concerned only that the architecture enables their routines (important concerns such as the handling of dirty linens, helping residents bathe, etc.). PLWD – the most important voices in the room, are unlikely to fully comprehend the potential of architecture (for good or bad), even as they offer important clues about their preferences and what bothers them (Francis and Murtha 2021). In essence, the involvement of PLWD does not guarantee a good result, but their exclusion virtually guarantees a poor one (Volker and Prins 2005). With no clear overarching scientific discipline to lean on, an empirical, cool-headed, transdisciplinary approach to the complex problem can be taken to inform design intended to stimulate desirable behaviour by amplifying evidence and drawing on robust theory. At a minimum, it can inform design to inhibit potentially undesirable effects wherever they can be predicted (Golembiewski and Zeisel 2022). The transdisciplinary space is at the edges of the disciplines where one merges with the next and all the disciplines work as one with no hierarchy. In place of core knowledge, there is a collective understanding that spans and intersects with all the knowledge present, even areas of knowing that aren’t academically enshrined, such as cultural knowledge, for instance (Yunkapurta 2019). In this space, the design team’s interventions (whether concerned with function or aesthetics) can come together to address complex problems, such as improving the residential settings for PLWD and reducing the burden of concurrent physical and cognitive loss that PLWD otherwise experience. This collective approach to co-design has the capacity to help with managing any problematic behaviour and even thought patterns associated with dementia, passively and without the need for carers to intervene. Already there’s work in this space – and much of it is multi-disciplinary, and it’s used to guide the design of residences today (Digby and Bloomer 2014; Eijkelenboom et al. 2017; Fleming, Kelly, and Stillfried 2015; Quirke et al. 2021). But a transdisciplinary approach takes another step. Rather than work on what’s held to be complete knowledge (multidisciplinary approaches nominally representing teams that collectively harness a jigsaw puzzle of deep expertise), the transdisciplinary team may employ safe-to-fail experiments – innovations that can be forgiven, and removed or reversed if they produce deleterious results (Nicolaides and Poell 2020), in other words, they don’t rely on existing evidence – they triangulate convergent thinking (Fielding 2012) and create it (Le Hunte 2023).

The motivational power of design

Once we remove design from an abstract discourse about it (Volker and Prins 2005), design is generally considered acceptable when it addresses functional concerns for which it’s designed (Cooke 2001). But to be considered successful, it does more than that: it must assist us with our actions and/or telegraph appropriate messages (Lang 1987). Design becomes extraordinary when it takes a rare step even further: when it compels us to undertake desirable actions – that is, it when embodies a motivational power to help people thrive. The undeniable contribution of design to the successes of many commercial ventures proves that architectural design has such a power, whether it be in Disneyland (Robert A. M. Stern Architects), Ikea (in-house interior architects), The Prada Epicentre in New York (OMA Architects) or the Plaza Athénée restaurant in Paris (Agence Jouin Manku). It has also been shown (as mentioned earlier) to improve health. This too is largely through subtle changes in behaviour: expressed behaviour, thinking patterns (brain activity) and autonomic activity as expressed in such markers as neural chemistry and blood pressure (Jo, Song, and Miyazaki 2019).

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