Dementia Gateway: The environment

Creating a relaxing environment

Key messages

Having dementia is very stressful and exhausting.
All the problems of dementia – including agitation, sleeplessness, wandering and aggression – are made worse by stress.
Stress can be reduced with environmental changes.
Each person with dementia is different, so work at finding solutions that suit the individual.
Remember to draw on all the senses and avoid overstimulation.

Rest is a good thing, but boredom is its brother.
Voltaire

Explore the links below now to read a range of practical suggestions on how to make the most of gardens and outdoor spaces:

1. Get moving and get out!Open

Exercise is one of the best things we can do to help reduce stress. In a care setting, it is important to include places where people with dementia can get out into the open air and move about, such as a garden or balcony. If a person with dementia can have regular time out in the daylight this will also help to set the body clock and establish a natural rhythm for the day. They are more likely to eat and sleep better, and this will also help reduce stress (see the 'Gardens' feature in this section).

Having a garden does not mean just growing areas or a patio. You could place an old car out there for people to tinker with or a washing line for people to hang up tea towels. If you have a patch of lawn, some residents may be able to get good exercise by using a manual lawn mower to cut the grass. Ask residents to dig over a rough patch with a view to planting vegetables. You may or may not get to actually do the planting, but it is often the process – being outdoors and the digging – that matters, more than the outcome.

Design or adjust outside spaces so people can move about safely on their own. Have gates that residents can open and shut and lead to another safe space.
2. Let there be lightOpen

As we age, our eyes get less efficient. Most people with dementia are older and will get frustrated and stressed by not being able to see things. It is difficult not being able to see what is going on or what you are trying to do. People with dementia get confused and mistake what they are looking at easily. They may mistake a shadow for a strange person or think that the pattern in the wallpaper or the reflection in the windows is someone looking in at them. For these reasons, it is important to have good lighting. While young and middle aged people generally find low lighting relaxing, it is different if your vision and cognition are impaired. Not being able to see does cause stress.

A well-designed building will try to bring in as much daylight as possible, but be careful about reflections on shiny surfaces or glare. If you use low-energy lights, make them a higher wattage or use more of them. Arrange curtain rails to stretch beyond the window frame so that you can push the curtains right back, bringing in as much light as possible. The increase in light can really help to reduce disturbing behaviour (see the 'Lighting' feature in this section).
3. Put out that light!Open

After the above, it may seem contradictory to say this, but there is a time when it is better to cut out as much light as possible. In a care home at night, when residents are trying to sleep, typically there is quite a lot of light about. Even if the corridor lights are dimmed, often there is enough light to see that people are moving around. To a person with dementia this might feel unexpected and strange.

Of course there are times when the light is needed, like going to the toilet, but with a passive infrared beam you can have the light switch itself on only when the person moves to get out of bed. And it can go off again after (see the 'Lighting' feature in this section). A glass panel in a bedroom door can look like a TV screen, and what is going on outside the room might look like something that needs to be investigated.

Again everyone is different. Some like complete darkness and others need to have a night light. If you are designing a sleeping space, consult the user and try to work out solutions that work for the individual.

A movement sensitive outside light might be unhelpful, particularly if the person is not accustomed to it in earlier life. If the person notices it at night, they may get stressed and go outside to investigate, causing even more stress for everyone else.
4. Noise: stressful or helpful?Open

Everyone who lives near an airport complains about the noise, but if the planes stop flying, they often find it strangely disturbing. Keeping noise down is generally a good idea for avoiding stress but silence too can be worrying. Reduce noise by having double glazed windows and keeping them shut. Floor coverings and curtains can help reduce and soften noise, and ceiling tiles can help.

In a care home, be careful about the use of radios or televisions. Although having favourite music playing in the background can help to screen unhelpful noise, make sure your area is designed so that everyone does not have to listen to one person's taste. Even if the majority prefer one thing, it can be stressful for one person to have to put up with it. A stressed person might cause everyone else to be disturbed. Radio music with frequent news or advertising is less helpful for staying calm.

Staff may think a care home is quiet at night, but what about the nurse call system that flashes and buzzes or the tumble dryer that is on all night – all these make for potentially disturbing noises.
5. Watch out for mirrors and reflections and colour contrastOpen

People with dementia don't always immediately recognise their own face in a mirror, and the logical conclusion if you see a strange face is to think that there is a stranger staring back at you through a window. This can be very stressful as the person thinks they are being observed by someone who looks a bit suspicious, hostile or frightened. There are simple solutions for mirrors, such as putting a roller blind over the top of the mirror to cover it when it is not in use, or placing mirrors behind a door (see the features on 'Bedrooms' and 'Toilets and bathrooms' in this section). If you have garden lights, put them on after dark or close the curtains to avoid the mirror effect of windows at night. In general, having contrast between floors and walls and doors does help people avoid falling or getting lost – both very stressful experiences.
6. Have a hideawayOpen

For a person with dementia who lives in a care home, being forced to choose between a big communal sitting area and your own bedroom is rather limiting, especially if you are stressed. Consider creating a small sitting area in a corridor or a corner where a person can sit on their own and watch everyone else and what they are doing. Or they could be accompanied by a staff member or friend if this helps. If a sofa can fit in the quiet place the person could have a snooze there or at least put their feet up.

In a person's own home, try to create something similar. This can be a place where the person can retreat to – a nook, a den, even a shed – with a DVD, a paper, a window to look out of and even the dog to talk to, and get away from everything.
7. SmellsOpen

Smells can do a lot to help people relax. Scented candles are fashionable, but if this feels risky, there are lots of plug-in equivalents. Make sure that the ventilation in any building is sufficient to remove unpleasant odours. In an open plan kitchen, cooking smells can drift towards living areas and stimulate appetite (as long as the food is delicious, of course!). Eating and drinking is very important and people will not enjoy mealtimes if the eating area smells bad. The smell of coffee, toasting bread, frying onions: all of these can be mouth watering.
8. Make it easier to find thingsOpen

Most of us know that it can be really helpful to get rid of clutter, and this is especially so for people with dementia. In a care setting, try to put things that are notvalued or are only used occasionally out of site. This can help the person with dementia to find what they need for themselves, because everything that is used and needed will be clear to see and access. Place labels on cupboards, or have cupboards that have a glass window on them, making it obvious what is inside. If a resident can find things, they are less likely to be frustrated and stressed.

Bathrooms in care homes can be strange and stressful places, in particular if they are used as store rooms for boxes of incontinence products, shiny metal equipment and washing machines. The stress of having a bath in a place that feels like a laundrette can give rise to disturbing behaviour (see the 'Toilets and bathrooms' feature in this section).

In a person's own home, to avoid stress change as little as possible, apart from increasing the light levels. If they forget that you have moved or changed anything significant, a person with dementia may get stressed and start to look for it or accuse someone of stealing it. Glass fronted cupboards can make things easier to find if stored.

Finding things that you may need urgently, like the toilet, is really important for reducing stress. Wayfinding support can include signs and objects.

Over to you!

Click here to do a quick activity that will deepen your understanding of this topic. The activity can be done alone or with colleagues and you can also download a copy. Trainer's notes have also been provided.