Insider Knowledge – A Continuation in Memory Care

Every time I watch a movie and the title says “Sequel”, or “Part Two”, I cringe. I loved the first movie, I am sure the second movie will not be as good, but I am determined to watch it anyway hoping that I will not be disappointed. So when I started this article, a follow-up to Insider Knowledge in Senior Living Design, I was committed to not make it “Part Deux”, but instead just a continuation of the first. Think of it as a new chapter, not a new book or sequel.

In my initial article, I touched on some issues related to senior living design, including mobility, storage, service logistics and outdoor space. This was not an article to single out architects. In many cases, the architect is often just a translator, taking ideas from the developer, owner or investor, and then creating them digitally, all while trying to appease many different parties. No matter who is driving the design, I suggested there was a component missing in the design process - an insider’s knowledge obtained by spending significant time in an actual operating senior living community. It is hard to address building function in a design when you can only assume how the building will truly operate.

So let me touch on another area where common design issues can occur, the Memory Care wing.

The memory care section of the community houses residents with Alzheimer’s disease, dementia or other types of memory loss (or loss of cognitive abilities) that are serious enough to interfere with activities of daily life. Memory care requires a higher ratio of staff to residents, poses managerial challenges, and creates an increased level of risk for the owner or operator. During my time as an administrator, I had many memory care residents in my community. I also had the pleasure of working with some great psychologists and nurses who specialized in cognitively impaired residents. I learned that these residents do not typically remember recent events, but can remember parts of their distant past vividly.

I had a resident who I will call Mr. Peach. He was unable to remember his wife, his kids, the town he lived in, or even his last employer. Mr. Peach, however, was able to remember his time in the Army, 48 years earlier, including names, ranks and deployments of his entire squad. Mr. Peach was one of the better memory care residents. He was happy and sociable and was famous for telling everyone,

“I just love life!”

Unfortunately, residents like Mr. Peach comprised a small percentage of my total memory care population. Other residents who were more progressed with dementia could become easily agitated, with caregivers often being the target of this agitation. I also had memory care residents who were easily confused or disoriented.

Keep Your Design Simple

What does all this mean for design? It means Keep It Simple. Your project may have a high-end style with gorgeous finishes and unique design patterns. The impulse is to carry this same design, style and finish over to the memory care wing. In my career, I have reviewed many plans that make that same mistake. In addition to a high-end style and finish, I find memory care plans often have hallways with numerous turns, sharp angles, and dead-ends. Residents have to walk convoluted routes through dining rooms and activity rooms to get to their memory care units. The carpet patterns and finishes are usually intricate and busy, the resident rooms have recessed doors making them harder to find, and there is no clear flow or arrangement to resident recreational areas. All the above design features contribute to confusing memory care residents rather than guiding them.

Facilitate Wayfinding

Memory care design should help to facilitate residents being able to navigate easily to and from their rooms, and between dining and recreational areas. Hallways need to be wide, well lit and the path of travel easy to follow. Dead-ends confuse memory care residents, who tend to wander, so redesign to limit them. Sharp angles need softening. Additionally, resident rooms, activity rooms and dining rooms should be highly visible, easy to find, and not recessed or hidden behind other uses. If not, caregivers will be spending an inordinate amount of time redirecting residents or escorting them to and from their destination. Stimulate a memory care resident’s mind with colors, sounds, smells, and even art, but keep the overall design and finishes more simplistic.

Safety First

Another important aspect of memory care design is safety. As a designer, you are not just dealing with resident and building safety, but also family member, visitor, staff and vendor safety too. Due to the broadness of this topic, I will only focus on a few of the most common issues.

I mentioned previously Mr. Peach and his ability to recall his days in the Army. It is a common occurrence for a memory care resident to remember a place from their distant past. This place could be a family member’s home, a house they grew up in, a job site, or another location where they felt safe. The bad news, many of these residents will try to escape to go to this place from their past. Please note, I did not say Leave, I said Escape. Cognitive impediments do not necessarily mean lack of creativity. I have seen memory care residents disable their electronic tracking devices and door locks, wait patiently for power outages to unlock electronic security doors, and even sneak through security doors behind visiting families. For the owner or operator this means huge liability. There are two prime examples of this liability that come to mind. A few years ago, a memory care resident walked past a security device that was not functioning and made it out the front door. Sadly, police found her two days later drowned in a tidal marsh. In a second incident, a memory care resident walked out the door and passed away from falling into the community retention pond. To compound these tragic events, both facilities were temporary closed, fined by the state and now face numerous family lawsuits and low census.

Focus on Prevention

So how do you address this by design? The key is focusing on prevention. If you know residents are going to attempt to get out, then you want to plan for it, and carefully limit and manage egress to the minimum allowed by code. In a set of plans I reviewed recently, I counted nine points of egress in the memory care wing, which had only twenty-six units. While there was a dedicated main entrance to memory care, there were other doors with direct access to another wing, to the electrical room, to a service hallway that linked to the central community kitchen, a generator, a maintenance room, and to a garden area with a very low fence (minimum 8-foot fence recommended). Additionally, there were three unsecured doors to a small memory care kitchen and to the laundry rooms.

Reduce Access to Potential Hazards

You must reduce points of egress. Caregivers cannot be watching every resident every moment of every day, and security devices do not guarantee safety. You also want to remove direct access from memory care to potentially hazardous spaces. Injury or death can result from a cognitively impaired resident accessing an electrical room or maintenance office. You should always lock down other rooms that could be hazardous too, like kitchens and laundry rooms. In many cases, memory care patients have lost the ability to determine when a situation or item is potentially hazardous.

Rethink Your Main Entrance

The other area you will want to examine is the main entry to the memory care wing. A high percentage of memory care residents will try to exit here. A crowded lobby might shield a resident from staff view while an unknowing visitor holds open the exit door for the resident (who is trying to reach a place from his or her past). Typically, the main entry has direct access to the building grounds and parking lot. Consider placing your memory care main entry internal to the building. If a resident does get out of the memory care wing, they are still inside the building and not immediately wandering the grounds or points beyond.

Designing to accommodate memory care residents is a challenge. No two residents are alike. Differences can relate to health, age, culture (Southerner, Northerner, city dweller, etc.), sex, and race. You will have residents who will want to get out of the building, residents who will let curiously get the best of them, and residents who just love life. There will be some residents laughing, some crying, some agitated, and some sleeping. In reality, this is the nature of memory care. Your focus as a designer is to keep these residents safe. However, this is not a memory care prison or jail. You need to design a homelike environment that encourages functional independence, minimizes over stimulation, promotes wayfinding, reduces stress, and ensures safety and security so everyone can have peace of mind.

More Insider Knowledge to come…

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