Adapting Homes for Cognitive Impairment – Dementia-friendly design

I am a Senior Occupational Therapist of 28 years working for Stoke on Trent City Council. Along with my council colleague, Louise Hamilton (OT Assistant), we have worked for the last 3 years on a project to design level access shower schemes for Client’s with a Cognitive impairment. Both for Stoke on Trent City Council owned properties and privately-owned homes.

Background to the Project

We have worked with many Client’s with Dementia over the years and then my Father was diagnosed with Dementia approximately 6 years ago. Historically Client’s with a Dementia diagnosis have not necessarily been considered a priority unless there is an immediate risk. Therefore, adaptations are installed too late into their diagnosis whereby the person’s condition has advanced to an extent that they struggle to use the new adaptation as this is so unfamiliar. Through research and working with a local Dementia specialist charity we concluded that if a level access shower adaptation was in place earlier in their diagnosis that there is less burden on carers as the person is more independent and less supervision is required. “Appropriate housing (incl adaptations) can support older people to stay healthy and live independently for longer. This might reduce the need for Social Care” (House of Commons, 2018) and also picked up in the evidence presented by the Royal College of Occupational Therapists to the All-Partly Parliamentary Group on Housing and Care for Older People Inquiry report, Housing for people with dementia: Are we ready? Housing LIN, 2021).

What we did first

To develop the specific Cognitive Impairment specification, we carried out a great deal of research and worked with the local Dementia charity to identify aspects of a new level access shower bathroom adaptation that would allow someone to be more independent. Research identified how a person with a Dementia sees the world around them, which colours they can identify more easily and looking at light reflective values of anything we intended to trial. The local Dementia charity provided training to the whole team then Louise and myself provided further training on what aspects of a person’s Dementia journey we need to identify at the initial assessment stage.

Developing the specification

We broke down a standard level access shower specification into sections then researched each area to see if there are alternative fitments that could be installed to aid anyone with a cognitive impairment.

We specified a shower tray that is as large a possible covered with non-slip flooring that is lighter than the walls and is as plain as possible. If a person with Dementia sees flecks or shining pieces within the non-slip flooring they can think that they have dropped something and are more likely to bend and fall. The flooring needs to be lighter than the walls as a person with Dementia sees a dark flooring as if they are falling down a hole. A colour contrast drainage was also specified as a white drainage can be seen as a bar of soap dropped on the floor and can again lead to falls whilst bending.

We specified darker matt wall tiles so there is a contrast with the floor and no reflection, as a person with Dementia can become frightened when they see their own reflection thinking someone else is in the room. The shower unit specified is a matt surface again for the same reason with options of a button or lever control dependent on what the person is used to using. We worked with a company who were already looking to develop a shower of this type and this is now readily available on the market.

We also researched equipment that is available in different colours such as grab rails, shower chairs and toilet seats and frames so that a colour contrast with the floor or walls could be created.

We specified that wherever possible the sink, basin and new shower area remain in the same positions within the bathroom for familiarity. Same taps, in the same position, same type of toilet flush as is existing if required to be changed again for familiarity.

Directional lighting was specified if required so that instead of one light fitting in the ceiling there would be a light fitted above the sink, toilet and shower, to direct the person to the function they wanted to complete. Directional automatic lighting was specified above the person’s bedroom door and bathroom door so as to stop confusion at night time.

Consideration was given to heating as many people with Dementia tend to have a shuffling gait and can burn themselves on a standard radiator therefore we specify either a low surface temperature radiator or an automatic wall mounted heater.

Consideration for if a mirror is needed in the bathroom at all or if a small blind should be provided to cover the mirror when the person is home alone as a person’s reflection can be frightening to someone with Dementia.

Lastly, we considered the door opening to the bathroom, many times in the past we would have replaced a bathroom door for a sliding door but if this is unfamiliar to a person with Dementia they may become trapped in the bathroom not knowing how to get out. Door furniture such as the handles also remained the same. If the bathroom space is small we considered a two-way hinge so that the door could open either way.

Trialling the Adaptation

We worked with our council’s Housing Adaptations Team, who oversee Disabled Facilities Grants (DFG) and decided to pilot 4 level access shower adaptations using this specification to see if it met needs. We researched suitable flooring and tiles, sanitary ware, shower units and equipment.

We worked with the housing Adaptation Team Technical Officer and a Contractor to resolve any issues as the adaptation progressed and changed the original specification accordingly as we worked through these four adaptations.

The results

Client’s and their carers/ families reported that the person with Dementia needs less supervision and is therefore more independent. Reports of less falls in this area of the home.

Since the trial we have now had agreement that all of our local authority bathrooms will be adapted to a cognitive impairment design so that housing stock is future proofed. We use the Cognitive Impairment specification for private homes where a Dementia diagnosis has been identified.

We have agreed to use three walls tile colours and three non-slip flooring colours that are suitable for someone with a Dementia diagnosis as standard. Always using a darker matt wall tile and a lighter floor. Specific products identified such a shower unit are all uniformly installed.

We continue to research equipment and products that can be used in conjunction with this design and change the specification accordingly.

Future Projects

The next stage is to roll this research out to other areas of the home and looking into other ways we can adapt the home with a Dementia diagnosis in mind. We have found that this specification works with some Client’s with a visual impairment and other cognitive impairments also therefore more work is to be completed in these areas.

With the introduction of the new (DFG Legislation Dementia grants are now available which are small grants to fund modifications that would allow someone with a diagnosis of dementia to remain living safely in their home for longer. As a result, we are looking at how we can use signage, painting doorways a stronger colour to direct Client’s to a specific room and the use of technology to aid Client’s with a Dementia diagnosis. We look forward to sharing the lessons from this in a future Housing LIN blog.

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This guest blog is published to coincide with Dementia Action Week 2023. For more on dementia-friendly design, please visit Housing LIN’s dedicated webpages.

And for more on the work of Occupational Therapists and inputting into the design process, check out Housing LIN’s OT webpages.