Everyone navigates the built environment differently, with abilities changing across a person’s lifespan. One billion people, or 15 percent of the global population, experience some form of disability. The global population of people over 65 years of age is expected to double by 2050, totaling 1.6 billion people. Universal design means that everyone, regardless of ability or age, can access and participate in public life.
ASLA’s guide provides a comprehensive view of which communities are underserved by the built environment. It also offers a set of new universal design principles that address the needs of deaf or hard of hearing, blind or low vision, autistic, neurodevelopmentally and/or intellectually disabled, and mobility-disabled adults and children, as well as concerns for older adults. These include: accessible, comfortable, participatory, ecological, legible, multi-sensory, predictable, and walkable/traversable.
“This guide serves as an entry point into Universal Design, asking designers to assess our existing design models and projects, and to include disabled folks as stakeholders and experts in the design process,” said Alexa Vaughn, Associate ASLA, a landscape designer at OLIN. “As a Deaf landscape designer, I am elated that landscape architects, designers, planners, elected officials, and beyond have started to think about Universal Design.”
Landscape architects, urban planners, elected officials, and community advocates can implement these real-world solutions in their communities to ensure that the built environment is accessible to all.
“As our society ages, those of us involved in creating public places must understand the unique challenges that accessing public spaces has for older adults,” said landscape architect Brian Bainnson, ASLA, founder of Quatrefoil, Inc. “The simple concepts captured in this guide provide clear, achievable steps that will make our public spaces safer and more accommodating for everyone.”
More About the Guide
The ASLA Guide includes hundreds of freely-available case studies, research studies, articles, and resources from non-profit organizations around the world.
Projects and solutions are organized around different types of public space that landscape architects and planners design: neighborhoods, streets, parks and plazas, playgrounds, and public gardens.
New design principles identified ensure that public spaces are:
Walkable / Traversable
The guide was developed with the assistance of an advisory group that includes disabled landscape architects, designers, and experts: Danielle Arigoni, director of livable communities, AARP; Brian Bainnson, ASLA, founder, Quatrefoil Inc.; Melissa Erikson, ASLA, principal, director of community design services, MIG, Inc.; Emily O’Mahoney, FASLA, partner, Gentile Glas Holloway O’Mahoney & Associates; Clare Cooper Marcus, Hon. ASLA, professor emerita of architecture and landscape architecture and environmental planning, University of California, Berkeley; Danielle Toronyi, OLIN; Alexa Vaughn, Associate ASLA, Deaf landscape designer at OLIN.
The guide was written by Ian Dillon, master’s of landscape architecture candidate at the University of Pennsylvania, and Jared Green, senior communications manager at ASLA.
AARP knows that working to create more livable communities is not an optional endeavor – rather, it is central to our mission of supporting people to live their best lives at every age. Increasingly, communities are realizing that the flipside is true, too –ensuring that communities work for people of all ages is essential to their own community’s ability to thrive economically, socially, and culturally. And that realization is coming not a moment too soon: currently one in three people is over the age of 50, and by 2035, there will be more people over the age of 65 in the United States than under the age of 18. Any community that isn’t already asking, “Are we ready?” is going to be in for a surprise.
So, what does “ready” look like? Ultimately, it looks a place that offers diverse choices in housing, a range of viable transportation options, and well-designed parks and public spaces that invite interaction and activity. “Ready” means that communities are crafted to engage older adults in the community – as volunteers, as entrepreneurs, and as local leaders – and to harness their insights to drive better public investments and policy. The good news is these attributes don’t just deliver benefits to a single age group – they meet the needs of all.
AARP works closely with communities through our Livable Communities initiative to help examine their needs from an “age-friendly” lens in ways that can create a fruitful context for change. To date, more than 330 communities – and three states – have joined AARP’s Network of Age Friendly States and Communities. As a result of AARP’s efforts, more than 25 states reported local and/or state policy wins in 2018 that deliver better housing and transportation choices for older adults, and by extension, for all.
Inherent to our Livable Communities approach is the ability to help communities demonstrate the “proof of concept” for change – whether that change means a temporary roundabout, or a short-lived demonstration bike lane, or a model approach to adapting tiny homes to increase their accessibility. Since 2017, we have funded nearly 220 such models through our Community Challenge Grant program – which this year will give awards to communities for small-scale, quick-action demonstration projects.
If past grantees are any indicator, our 2019 awardees will help advance real impact in communities across the US – in cities, towns, and on tribal lands — through small, tactical investments in placemaking, housing, and transportation that spark broader conversation and community change.
Past Community Challenge projects include:
City Heights, San Diego, California – The eastern San Diego neighborhood of City Heights is an enclave for refugees from Somalia and other East African countries. The Challenge grant supported the construction of permanent seating and landscaping along University Avenue – home to shops, markets and mosques and a popular area for local residents (especially ones 50 or older) to gather (see image above).
Kenaitze Indian Tribe, Alaska – The Old Town Kenai campus is home to the Dena’ina Wellness Center as well as the Tyotkas Elders Center. Medicinal plants are an important tradition for the Dean’ina people, who have inhabited this region for more than 1000 years. The AARP Challenge grant funded the construction of six raised-bed garden boxes containing 12 native Alaskan medicinal plants which enabled tribal elders to grow the plants without stooping over. Walking tour maps and informational signs describe the medicinal properties of each plant and how they address specific ailments.
Chicago, Illinois – “People Spots” are temporary platforms that turn an existing parking spot into an outdoor space for public enjoyment. AARP grant funding enabled the City of Chicago to offer a People Spot prototype for installation on a rotating basis in areas of high economic hardship, or those designated “retail thrive zones” on Chicago’s south, southwest, and west sides.
Jackson, Mississippi – Jackson’s first pedestrian-aimed project is a pilot for its Open Streets program to transform its auto-centric downtown streets into vibrant social spaces. The AARP grant funded the transformation of a block of Congress Street to including outdoor furniture, a parklet, bike infrastructure and programmed events such as PARK(ing) Day Friday on September 21, 2018.
Manning, Iowa – Manning’s brick-paved Main Street is a popular gathering spot for neighbors of all ages, including residents of the nearby Plaza Nursing Home. AARP funding helped add ambience and new design elements to the area with the purchase and installation of 12 lighting fixtures created by students from the Iowa State University College of Design.
Gardner, Kansas – The citizens of Gardner want to maintain the traditions of their small but fast-growing community while creating new public spaces to meet the changing needs of residents and visitors. AARP funding helped create a portable parklet in the heart of the community, offering a place to rest in the shade near many facilities. Guided by more than 500 responses to a public input survey, the accessible parklet was equipped with shade canopies, comfortable seating, plants, lighting and is helping build awareness about larger green spaces planned for the area.
Woodbridge, Virginia – In this two-part project at the Woodbridge Senior Center, AARP funding was used to develop a vegetable garden that supplements the meals provided to residents and creates an opportunity for physical activity. The second part of the project involved improvements in an outdoor area that lacked sufficient seating and landscaping, encouraging more social activity.
The task of preparing communities for a future in which older adults are able to live their best lives calls for broad engagement about how to improve housing, transportation and public spaces. Efforts like AARP’s Community Challenge Grant program provide a clear opportunity for landscape architects, planners, community members, and local leaders to come together to craft and deliver real solutions in communities. Little by little, working hand in hand, together we’ll prepare our communities – and our country – for the age-friendly future that awaits us.
The Senses: Design Beyond Vision, a new book from designers and curators Ellen Lupton and Andrea Lipps, is a compelling survey of the emerging field of sensory design. The book accompanies an interactive exhibit of the same name by the authors on display at the Cooper Hewitt Design Museum through October 28th. While The Senses is not quite the manifesto for multi-sensory design practice its authors claim it to be, the book captures the poetics and science of sensory design and in doing so conveys some useful lessons for landscape architects.
Sensory design’s historically-narrow application has broadened as our own understanding of the senses has gained sophistication. Add to that the potential of emerging technologies to create and augment sensory experiences, along with the urgent need for more inclusive design, and you have the swell in popular attention the field is currently experiencing.
It’s worthwhile to ask whether, as landscape architects, we are guilty of treating hearing, taste, scent, and touch as second-class senses. Put to any landscape architect that the senses other than sight are important and you’re likely get a nod of agreement. What isn’t as clear is whether this acknowledgment commonly manifests in our design work.
Sensory experience commands greater consideration in landscape architecture than most design fields, and so landscape architects are better attuned to their designs’ effect on the senses. But we often conceive of and deploy landscape architecture as a palliative to harsher environments than rich sensory environments in and of themselves. As to how we might improve and innovate in this regard, The Senses offers some inspiration.
The first step is to bring to sensory design the same level of critical thought brought to visual and spatial design. What are the qualities of an environment where all five senses have been weighted equally in the design process, not simply manufactured under “the tyranny of the eye”?
The Senses features an interesting case study in San Francisco’s LightHouse for the Blind and Visually impaired. There, light and space are maximized, materials are chosen for their acoustic properties over their appearance, and details such as tapered handrails and textured steps are integral elements, not tacked-on details.
One recurring practice among The Senses’ featured designers that has an application for landscape is layering. Layering allows for the creation of environments rich with hierarchy and nuance.
Snarkitecture’s undulating wallpaper, Topographies, is one example, as is the Rich Willing Brilliant Studio’s attitude towards lighting. According to these designers, sound, smell, light, flavors, and texture can be layered to form thresholds and barriers, ceilings and corridors. If this seems architectural, that’s intentional. Perfumer Christophe Laudamiel stresses the multi-dimensional quality scents take on when layered and allowed to develop volume. Laudamiel is a master of evoking landscapes with his scents, such as meadows dense with wildflowers and the Bosporus Strait.
If there’s one project in the book the offers a more grounded idea of how landscape architecture and sensory design can interface, it is Tactile City. Expanding on existing tactile paving systems, Tactile City illustrates how streetscapes can be designed to benefit the visually impaired. Highly-textured paving tiles can signal features of the environment to someone relying on a walking stick. Indications of street furniture, bus stops, or construction can be imprinted in the landscape. “Sensory design can shape the beauty and function of a place – and address dangers and obstacles,” the authors write.
Much of the exhibition and book is concerned with new technologies: The Scent Player, emitting smells instead of music, or a device that converts reverberations against the skin into dialogue for the deaf. These technologies, while not immediately translatable to landscape architecture, underscore the fluid nature of our senses. The authors do an excellent job of conveying how senses feed and play off of one another. Sights can trigger smells can trigger tastes, with past experience setting some of the rules for these exchanges.
Experience of the landscape should engage all of our senses. Sensory design is about maximizing that experience and making sure others of differing abilities can as well. The Senses is a worthwhile read for landscape architects wanting to pursue these goals.
“By 2030, there will be more than 75 million older Americans aged 65 and up,” said Danielle Arigoni, director of livable communities at AARP, in a session at the Congress for New Urbanism (CNU) in Savannah, Georgia. This older population will need more livable, age-friendly communities that can meet their needs by offering affordable housing where they can age in place, accessible mass transit and walkable neighborhoods, and daily sources of civic and social engagement and meaning.
AARP recently released comprehensive new survey data, the first major data set in four years. They found that 8 out of 10 older adults want to stay in their home as they age. However, only 46 percent believe they can actually age in place because of accessibility, affordability, and lifestyle issues.
Arigoni thinks communities need to work much harder to keep older residents in their communities. “Older adults are an asset — they are the ‘experienced class’ who add value with their purchasing and voting power. They volunteer their expertise and are entrepreneurial.”
So what can communities do to better keep older adults? Arigoni said diversifying the housing stock is important.
In too many places, when an older person can no longer drive, it’s like a “receiving a serious medical sentence.” Being stuck at home means isolation, which has the health impact of “smoking about 15 cigarettes a day.” The health impacts are particularly acute for older adults.
Home sharing is a way to solve this problem. Some 15 percent of older adults already do this in order to get help with transportation, but also for companionship or economic reasons.
Accessory dwelling units (ADUs), sometimes described as “granny flats or mother-in-law suites,” which are independent units on the lot of a single family detached home, are another way to provide nearby support. Some one-third of older adults would consider building an ADU or living in one, but only 7 percent do, in part because “lots of regulations prevent them.”
8 out of 10 older adults want safe streets, which is why AARP has been supporting walkability audits and pursuing complete street policies at the state and local levels.
84 percent of older adults drive themselves, while 38 percent walk and 10 percent use ride share. Some 43 percent have used Uber, Zipcar, Lyft, and the like; some 55 percent are not likely to use. “What’s preventing them? 50 percent cited safety and privacy issues. Another cohort lacked the technology or knowledge. And 17 percent had disability concerns.”
Arigoni thinks the vast majority of accessibility issue with ride sharing can be resolved. “We have to solve the disability component — the last few feet of ride sharing.”
To promote livable communities, particularly for older adults, AARP has put its considerable advocacy muscle behind Measure M in California, a $120 billion bond for public transit, which subsequently passed.
And they partnered with the World Health Organization (WHO) to create the AARP Network of Age-friendly States and Communities, which 246 communities and two states have joined. In 2017, AARP gave 90 communities grants to undertake a 5-year age-friendly community planning process designed to result in a concrete action plan.
In Macon-Bibb, Georgia, which was the first city to sign onto the network, the age-friendly planning process was a “catalyst for things we wanted to accomplish,” said Myrtle Habersham, a consultant and AARP executive committee member.
Macon-Bibb assembled a 28-person age-friendly council, went out into the community, and identified priorities, like redesigning the city’s 2nd street corridor, creating new bus routes and mixed-income housing. The team also invested in revitalizing decrepit parks. “At the beginning of the process, we started with 30 volunteers and now there are 200,” said David Pilgrem, with AARP who was involved in the effort.
In China, traditional Confucian values dictate that children take care of their parents in their old age. It’s taboo to put your parents in a home. But from 1979 to 2015, Chinese parents could only have one child, which means there’s a whole generation of Chinese with four grandparents and two parents to take care of. To get around the taboo, China Senior Care, a company based in Shanghai and Hangzhou, launched a Western-style senior residential care facility. The idea seems to be if a facility doesn’t seem typically Chinese, perhaps the stigma associated with placing an elder in a home will be avoided.
At the Environments for Aging conference in Las Vegas, Jane Rohde, principal with Baltimore-based architecture firm JSR Associates and Jerry Smith, FASLA, design principal at SMITH | GreenHealth Consulting, walked us through the brand-new Cypress Gardens, in Fuyang, a suburb of Hangzhou. The project, which took eight years, is a private, 5-star senior care center, with just 64 beds, some for assisted living and some for memory care for patients with neuro-cognitive disorders. Each room rents for about $5,000 per month. There are community spaces, restaurants, a library, a theater for both relaxation and entertainment. In fact, it replicates a traditional American senior care facility model: the car-dependent, self-contained suburban facility.
China, like the West is rapidly aging. According to the Brookings Institution, there will be nearly 250 million people 65 and older in China by 2030. Today, Chinese seniors are essentially cared for during “extended hospital stays,” said Rohde. “It’s OK if it’s called VIP care. But it’s really out of the 1950s,” with rows of beds packed into one room. It will be interesting to see how the culture and current senior care models evolves as the country ages.
Cypress Gardens sits on a steep suburban site in the side of a mountain, which meant major grading challenges for Smith, and his design-build partner, Yumin Li, ASLA, with POD Design, Shanghai. To deal with the slopes, Smith built in layers of stone retaining walls in the form of step terraces.
A winding drive leads visitors up to the upper level entry. Smith said working with multiple Chinese contractors (two for the building and interior and one for the landscape) was a new learning experience — “just getting the drive and entrance to meet each other was a challenge.”
Many of the rooms have their own terraces. And surrounding the base of the 6-story building are a series of “outdoor rooms,” both public and private, where residents can be alone or socialize, or engage in physical activities like Tai Chi.
Smith said the owners “didn’t want the character of the space to be Chinese. They wanted all new, all Western.” A water fountain on the south wall cascades into a pool, in an effort to achieve the “Bellagio Wow!,” the owners said they wanted.
Still, Smith delivered a tasteful landscape that manages to be packed with a mix of Chinese and Western landscape elements, from pagodas, to a bosque of gingko trees, and a labyrinth.
The pagodas mark the transition from the larger public spaces to the quiet memory care spaces, and can be “closed off for privacy and security as needed.”
Chinese children paying to have their parents stay at Cypress Gardens will see a “wonderful place with very high-end amenities,” Smith said. The facility opens in next month and it’s already mostly booked.
When an older person loses their cognitive and motor functions, how do they maintain a connection to nature? This is the central question for Dr. Lori Reynolds, a clinical professor of occupational therapy, and landscape architect Brad Smith, ASLA. For a senior care facility in Phoenix, Arizona, with some 80 beds for assisted living and 30 for memory care, which involves helping those with advanced neuro-cognitive disorders, Reynolds and Smith together came up with new approaches to redo their courtyard in order to better maintain that connection. At the Environments for Aging conference in Las Vegas, they presented two options — one geared towards the assisted living residents and one for the memory care residents.
Reynolds made the case for investing in gardens in senior care facilities. “For 100 percent of older adults, nature is important.” As Jack Carman, FASLA, a landscape architect who works on senior care facilities, said: “our interaction with nature doesn’t end when we age.”
Reynolds found studies that show “access to nature increases resident satisfaction. And residents are most satisfied when there is ample seating, a variety of nature elements, walking paths, and adequate shade.”
Furthermore, the presence of a garden in a senior care facility influences those family members making the decision about where to put their parent or grandparent. “Nearly 50 percent report the availability of a garden influenced facility choice.”
Other surveys show that “outdoor activity space is among the top desired features,” and “the second most-important feature after the location.” So, if gardens make residents and families happy, and happy residents recommend a facility to others, than functional garden spaces seem like a no-brainer.
After explaining the many physiological benefits of nature for all people, she focused in on the benefits for those in memory care, explaining how exposure to nature can “reduce agitation and aggression among Alzheimer’s patients.” For these patients, “plants can become like people.” They are a presence that can take on “significant meaning,” Reynolds explained. Plants can also represent a legacy: A plant that has been in someone’s life for many years “is a past-life experience, and adds coherence.” The plant of a loved-one who has passed away can help sustain memory of that person.
Facilities can design ways to maintain this elemental connection — for both those who still have an active relationship with nature and those with a mostly passive relationship. For those able, an active relationship, which involves going out and spending time in the garden, is preferable. For those who cannot, a view out a window of a garden or even indoor potted plants are important. For some, “engagement outdoors may be too difficult — it may be too windy or too far from the bathroom.” But still, this doesn’t mean that accessible, aesthetically-pleasing gardens should be jettisoned from budgets.
The current state of garden design for senior care facilities is more focused on the internal than the external, “despite the acknowledged value of these outdoor spaces,” Reynolds said. If there are outdoor spaces, they are too often ornamental, not functional. More need to be accessible and provide healthy doses of nature.
To that end, Brad Smith worked with Reynolds and a senior care facility in Phoenix, Arizona, which they prefer to leave anonymous, to create garden designs that enable both more active and passive interactions with nature in an interior courtyard (see image at top). There are opportunities for transforming the space, which has a required access lane for a fire truck, into a more dynamic, therapeutic place that enables “inside out and outside in” connections.
The option geared more towards assisted living patients, offers a meandering path, an expanded covered patio and outdoor seating areas with rocking chairs, and a water feature surrounded by trees and plants. There are also bird and butterfly feeders patients can bring nectar and seeds to. For this option, Smith envisions caregivers bringing out wheelchair-bound residents so they can enjoy classes in the morning or early evening when it’s cooler.
For the variation designed for memory care residents, there are “vignettes designed to spark connections to the past.” Smith proposes making the space “as familiar as a backyard,” by designing a space for clothes lines and a gardening shed. “Women of a certain generation spent much of their time drying clothes; just letting memory care patients hang stuff up may make them feel better.” There’s already an old 1940s-era car parked in the courtyard, which he imagines male residents enjoy seeing and exploring. A loop walking path, inspired by the memory garden in Portland, Oregon, would enable chaperoned pacing. And the garden is also designed to provide pleasing views from inside the memory care residences of soothing water features.
With memory care, Reynolds said facility owners should use light furniture that’s easy for caregivers to move around. Also, pergolas should be avoided, as they throw shadows that will “wig out” residents. In Phoenix, the gardens will be really hot much of the day, with lots of glare, so use would be limited to mornings or evenings.
Smith and Reynolds estimated the senior care residence had spent about $57,000 on what they have now, which doesn’t do much. For $155,000 they could have the assisted living landscape, or for $96,000, the one for memory care. For just a little bit more, “they could have a killer garden space that boost marketing, creates positive first impressions and a sense of perceived value” while also providing many of the health benefits of nature, Smith explained. Bringing in volunteers — local Habitat for Humanity or other groups — to help plant could further reduce the costs. But they also noted a need for a maintenance budget up front.
Senior living communities can either be car-dependent and isolated, or an urban or suburban “destination for experiences,” with proximity to transportation, services, arts and culture, restaurants, shopping, and personal development opportunities. Which community would you want to live in? The answer was clear in a session at Environments for Aging in Las Vegas.
According to Michael Hass, managing partner, Drive Development Partners, who is also a member of the Urban Land Institute’s senior housing council, from 1990-2009, senior living communities, mostly geared towards the World War I-era “silent” generation, were all about providing “a sense of security, peace of mind, ‘safety in numbers,’ and belonging.”
But in 2009, occupancy across the senior living industry dropped. This was a key year, the first year baby boomers (those born between 1946 and 1964) became consumers of these places themselves, not just shoppers of these facilities for their parents. Their views on the traditional places could be summed up with: “I’ll never live in a place like that.”
Starting in 2009, senior living developers saw new demand among some of the oldest baby boomers for communities with “flexibility, choice, a unique variety of experiences, and spending opportunities.” They don’t want the self-contained campus, “35 acres in a cornfield.” Hass said: “They want an individualized experience, not the same formal dining room every day.”
Sean Thomson, senior living director, CR Architects, said a new model is needed to reach the 75-million-strong boomers, and walkable urban communities could be it. Walkable urbanism is in demand among all age groups, but is particularly appropriate for seniors.
A report from the George Washington University school of business found that “walkable urbanism is gaining market share.” Furthermore, there is a 90 percent premium for walkable office space, 71 percent premium for retail, and 66 percent premium for multi-family housing.
A 2013 report from Fannie Mae found senior communities with a WalkScore above 80, which means they are walkable, had a “relative risk of default that is 60 percent lower.” Those communities with a WalkScore below 8, which deemed them totally car-dependent, had a “risk 121 percent higher.” As Thomson explained, “walkable communities have a real human impact, but they also have real financial results.” Places with WalkScores in the 60 and 70s have some services in walking distance, but those with scores of 90-plus are ideal.
The ideal walkable senior community is basically found in dense European and Asian cities, or New York City. Imagine an apartment complex in a highly walkable environment, open to the surrounding neighborhood, with ground floor shops, cafes, and restaurants, and close to multi-modal transit opportunities, parks, plazas, self-storage facilities, and co-working spaces. Instead of all these services provided within an isolated campus, they are distributed through the surrounding neighborhood.
Thomson said an urban environment can provide better quality and a higher range of restaurants than any isolated senior community can. Embedding a senior community in a neighborhood also enables that inter-generational contact, social integration, and intellectual engagement so critical to “successful aging.”
Thomson summed up the benefits of walkable urbanism for seniors: “you don’t have to build the amenities; they are already there.”
To make these kinds of communities happen will take some creative housing development strategies. Senior housing developers can partner with medical groups, physicians networks, hospital districts, religious institutions, fitness or wellness companies, or become parts of existing mixed-use developments. “Senior living developers are almost never the top bidders so they need to be part of mixed-use projects, attach themselves to bigger projects.”
In revitalizing second-tier cities, senior housing developers have a real chance, particularly if they piggy-back on mixed-use developments where it’s advantageous to have a set of new fixed-income resident buyers all in one place. “Senior living communities can become an asset to a community.”
Senior housing developers can remake under-performing hotels or extended-stay hotels, or B and C class multi-family housing. “They can partner instead of acquire.”
Also, Thomson can even see universities and colleges building nearby housing for retired alumni who want to return to the area.
They created a vision of a 2.5-acre urban senior development with medical facilities, spa, club, street-facing “fast, fresh” restaurants, shops, a playground, grocery store, and housing for 100-200 residents. “It wouldn’t be adult daycare, but a place where people enjoy themselves.” Perhaps this model could be deemed senior or grey urbanism?
When asked where this comprehensive vision is actually happening in the U.S., both Thomson and Haas said “some elements are happening incrementally, but not all together.”
“Dementia used to be viewed as a psychological problem, a mental illness. There was a stigma associated. Now, we know it’s an organic problem related to cell death in the brain. It’s a medical condition,” said P.K. Beville, founder of Second Wind Dreams, at the Environments for Aging conference in Las Vegas. Dementia, which includes diseases like Alzheimer’s, some forms of Parkinson’s, Lewy body disorders, and others, is now called a neuro-cognitive disorder. It affects more than 5 million Americans and their families.
Throughout the conference, perhaps the major focus was how to orchestrate a shift to more empathetic or patient-centric care for those with neuro-cognitive disorders. Just like with autism, it’s now understood there is a spectrum of neuro-cognitive disorders. One person with the disorder is really one person with the disorder. Designers, physicians, and researchers are partnering to better understand what it’s like to have a neuro-cognitive disorder and then create more sensitive processes and empathetic spaces that can help alleviate the pain these patients experience while institutionalized in memory-care facilities.
With these disorders, there is a loss of cognitive abilities. Our ability to hear, speak, read, and understand come from different parts of our brain. If there is cell death in these areas, then forging understanding connections with others becomes much more challenging. For many of these patients, long-term memory may be intact, but not short-term episodic memory. Also, semantic memory, which deals with abstract concepts, and procedural memory, which helps people remember how to get from point A to B, may be damaged. With the loss of abstract memory, “the goals or intentions of life is lost,” explained Terry Zborowsky, a researcher with HGA architects and engineers in one session, which is why they need “so many cues from the environment.” The loss of procedural memory means those care environments become incredibly confusing, so designers must be really thoughtful to make them more legible.
In her keynote, P.K. Beville said she wants caregivers to better understand why patients with neuro-cognitive disorders behave the way they do. When this is achieved, we can create spaces to better meet their needs. For example, Alzheimers patients in advanced stages “don’t get warning signals when they have to go to the bathroom.” All of the sudden it just comes on and they have to go. If the bathroom is far away, they may miss it and then be labeled incontinent and placed in briefs. “That’s a horrible threat to their dignity. How can we get them to their bathroom faster?” Some ideas: make the bathrooms more easily accessible via hallways, instead of hiding them, and put them in direct line of sight from beds.
Patients with neuro-cognitive disorders often have macular degeneration, which will put a large black spot in the middle of their vision. Their peripheral vision will also be significantly degraded. Their field of view is then limited to just a few feet, which is why they often look down to see where they are going. Beville said, knowing this, “it’s really silly that caregivers are still sitting to the sides of patients when they feed them. Imagine this fork flying out of space into your mouth.” When a patient balks or refuse to eat, they are then labeled difficult and that behavior gets “charted.” It makes much more sense to sit directly in front of the patient and create dining spaces that enable this.
In neuro-cognitive patients, degeneration of the reticular activating system is “what’s causing all the mess. It removes what’s important, causing a loss of focus. When this area of the brain is damaged, the brain picks up all sensory input, relevant or irrelevant.” These patients will hear everything — a door being slammed, a vacuum cleaner, a TV, and even the HVAC system. A dog barking or baby crying will be incredibly painful. When these patients are overwhelmed, they will begin to rock or become agitated. It’s important that memory care facilities then eliminate all sounds that can cause an annoyance. “The dining room can become a cacophony of sound. No wonder the residents don’t want to eat.”
Beville has created an amazing virtual reality tour that demonstrates what it’s like to have a neuro-cognitive disorder like Alzheimer’s. Working with leading medical professionals, researchers at Georgia Tech, and patients, she modeled the effects using goggles, which layers the effects of macular degeneration on whatever you are looking at; gloves that reduce fine motor skills; and headphones that mimic the aural sensory overload these patients can experience. Some two million caregivers in senior facilities have taken the tour.
At the conference, she modeled the newest iteration of the tour using Samsung Gear virtual reality (VR) headsets, instead of goggles, which augment a user’s field of view. The woman who tested it said it was a “terrifying experience.” She said she had “no perception of depth or peripheral vision; it was very hard to hear. I was very, very anxious.”
Studying the responses of the caregivers who have taken the tour, Beville found they exhibit the same behavior as those with Alzheimer’s and other neuro-cognitive disorders. They mumbled or hummed in an attempt to focus and block out the extraneous noises. They were agitated, wandered, rummaged, made negative statements that indicated they felt overwhelmed or depressed. Just 8-10 minutes in the headset caused some to have “strange or bizarre behavior.” Now imagine someone struggling with this condition for years.
Through the tours, Beville found older patients with this condition need “three times the light to see than younger people.” So facilities and their landscapes need to be well lit. The reaction time of the pupil is also delayed, so any changes in lighting causes major issues and should be avoided. Noise needs to be reduced to eliminate distractions. And patients want clear guidance — “something to do” — to help them focus.
After taking the tour, more caregivers agreed with the statement that neuro-cognitive disorder patients “don’t get the care they need.” The tours then help facilities begin to institute performance-based systems to improve quality of care. After taking the VR tour, caregivers say they will be “more patient and understanding with patients, will take more time and provide more attention, and communicate better.” Beville and her group are measuring the changes before and after sensitivity training to demonstrate improvements, which can be measured in adaptive behaviors among patients (engagement, communication, wayfinding, and social integration) and maladaptive behaviors (aggression, confusion, disorientation).
In another session, we heard how to take empathetic design to the next level. Architect Alana Carter, with HGA architects and engineers, explained how she checked herself into a healthcare facility she was redesigning, pretending to be a stroke victim with degraded capabilities on her entire left side. She was fed, washed, and helped in the bathroom. She called the experience “extremely humbling,” but it gave her insights into what needed to be done better from a patient point of view.
Carter and her colleague Zborowsky called for “walking in the footsteps” of patients first, using a comprehensive design methodology to uncover design solutions that will improve environments for aging. Their teams put GPS tracking devices on staff and patients and apply sensors that generate heat maps to understand the flow and popularity of areas in a facility. This kind of analysis can reduce inefficiencies in layout and help discover what features patients feel most comfortable around. Using VR headsets, HGA then prototypes Revit designs of new spaces in real-time, working with caregivers to optimize layouts and features. Finally, they test implemented designs through comprehensive pre- and post-occupancy reviews.
Carter concluded: “We need to move design for seniors out of the care facilities and into museums, galleries, movie theaters, and the home. We need to bring empathetic design to all places. We need to design for the outliers.”
The world is rapidly aging. According to Foreign Policy magazine, the share of the population 60 and older will nearly double to 21.5 percent by 2050, from 12.3 percent today. Aging populations will surge in Japan, South Korea, Germany, China, and the United States. The “‘grey tsunami’ will the defining feature of the 21st century.” By 2050, the median age in the U.S. it will be 42, while the global median will be 36. And the number of dependent people in America will also skyrocket from 49 for every 100 people of working age to 66.
At the Environments for Aging (EFA) conference in Las Vegas, which brought together senior living developers, architects, and landscape architects, along with physicians and caregivers, Debra Levin, president of the Center for Health Design, said 10,000 baby boomers (those born between 1946 and 1964) will turn 65 every day for the next decade. And these boomers have “different expectations about how and where they will age” than their parents, the World War I-era “silent” generation. Furthermore, these boomers are now living longer and want more control over their last years. They want more affordable solutions than increasingly expensive residential home care. The entire senior care industry will need to change to meet their needs and demands.
Dr. Roger Landry, author of Live Long, Die Short: A Guide to Authentic Health and Successful Aging, said “we can’t afford to make mistakes as the baby boomers age.” It’s important to promote “successful aging” strategies that can stave off long, slow declines due to illness, in favor of maintaining high levels of performance before a quick drop off at the end. The goal is to “die young as late as possible.”
He said all our cognitive performance will eventually drop after a long plateau that lasts from our 30s through out 60s. That decline is usually a “painful, degrading, and expensive experience.” But we can dramatically shorten the decline by using some smart approaches. About 70 percent of our ability to avoid the awful extended decline is tied to lifestyle choices, “the choices we make every day.”
First off, it’s important that older people not put themselves out to pasture. They must actively combat the low expectations our societies have for them. In rapid fire, he issued a set of maxims: “Maintain physical and cognitive function. Continue engagement with life. Minimize risk of diseases and disabilities. Don’t be isolated in your home.”
Specifically, he called on older people to move a lot; engage in quick learning — “not coasting or settling” — to stimulate new neural pathways; maintain a strong social network in order to reduce the risk of major diseases like cancer, diabetes, and dementia; find a role and higher purpose — it can be small or big thing, but we “wither without purpose”; take on a slower pace, avoid clocks, and practice mindfulness to reduce chronic stress; eat a Mediterranean diet; create inter-generational connections, particularly with young kids; laugh a lot, which boosts the immune system; engage in creative pursuits in order to “be in the moment”; and be close to nature.
Many of these life-preserving behaviors have been documented in Dan Buettner’s book Blue Zones: 9 Lessons for Living Longer from the People Who Have Lived the Longest about the “living labs,” the unique communities around the world that have high numbers of incredibly vital 90 and 100-year olds. These communities maintain important features of the lifestyles of our prehistoric hunter-gatherer ancestors. Landry said we make mistakes when we veer too far from ancient wisdom.
As the boomers retire, a new approach, rooted in a less-ageist mindset, is needed. “Can we make acting your age a bad thing? As a society, we must change how we see aging. Age should be irrelevant.”
In the past, there has been “too much human capital warehoused in facilities.” We can’t waste the potential contributions of 76 million aging baby boomers and many millions more around the globe.
The senior population is growing. By 2050, a third of the U.S. will be 65 and older. The World Health Organization, AARP, and other organizations have called for more age-friendly communities, with parks and open space that offer what seniors needs to feel safe, but not enough are heeding their call. One question that came up in a session at the American Planning Association (APA) conference in Seattle is whether future parks need to be designed to be inter-generational, or designed specifically for the elderly. Two academics and a landscape architect argued the research shows seniors do better when they are around all age groups, but they need specific things to feel safe and comfortable in parks and other open spaces. If they don’t have them, they are far less likely to venture into these places.
Lia Marshall, a PhD student at the Luskin School of Public Health, University of California Los Angeles (UCLA), said older adults have a preference for “aging in place,” meaning staying in their community. They need independence. This group — like any other broad category — is amazingly diverse, both socially and culturally. Walking is their most common physical activity, so “distance to the park affects use.” But many older people are also at the risk of isolation, which can result in mental health problems. This group is also among the least active, which can also lead to physical health issues.
Parks are too often created for children or able-bodied adults. But they can be designed with a set of aging principles. Through a set of 8 focus groups conducted with elderly about their park use in Los Angeles, Marshall found that they all share “an enjoyment of natural beauty, with an appreciation for tranquility, plants, and fresh air.” Being in a park encouraged social interactions, which led to more physical activity. “Group activities — like Tai Chi in the park — lead to friendships and more exercise.”
But the elderly polled were also fearful, with their greatest fear being falling. “Breaking a hip can mean losing their homes and moving into a retirement facility.” For them, other primary threats were “disrespect by younger generation, robbery, drugs, and crime.” Environmental threats include: “uneven ground surfaces, trash caused by the homeless, a lack of visibility with walking paths, a lack of shade, and excess heat or cold.” Those with canes, walkers, and wheelchairs feel even more vulnerable outdoors. Marshall pointed to a park right next to a senior center in Los Angeles that wasn’t used by the elderly because “gang members are there.” Overall, “seniors are afraid of their communities but also want to be involved.”
Improve control: Provide orientation and way finding with large, visible fonts. “The park layout needs to be legible.” Signs should be 54 inches off the ground or lower, so people in wheelchairs can also see them.
Offer greater choice: “Everyone values options, such as passive or active recreation, sun or shade, single or multiple seating. Chairs should be movable.” Brozen emphasized that the group older than 65 is incredibly diverse, from “not old to advanced dementia,” so they have different needs.
Create a Sense of Security: “There should be shade but not too much so it feels enclosed.” Parks should enable “eyes on the street.” Isolated areas need good maintenance. Sidewalks should be wide and smooth. Check spaces between paved and unpaved areas to make sure there aren’t spots where a cane or wheelchair can get caught.
Accessibility: If a park is a good distance from a senior facility, add benches along the way so there are place to stop. Parks should have no more than a 2 percent grade for those in wheelchairs.
Social support: Design should facilitate interaction. Parks can feature bulletin boards, outdoor reading rooms, sculptures and fountains that help start conversations.
Physical activity: Parks should also feature mile markers for encouragement. “These kinds of things are low impact, high benefit.” Exercise machines should be under shaded areas.
Privacy: Use buffer plants to reduce street noise.
Nature: Bring in water features, which are relaxing and beautiful. Make sure they are wheelchair accessible. And lastly, parks should highlight natural beauty.
For Portland-based landscape architect Brian Bainnson, ASLA, Quatrefoil Inc, and ASLA Oregon Chapter Trustee, there is even more that can be done, beyond A.D.A. requirements — and, really, the guidelines listed above. “ADA is really just the bare minimum. It leaves out so many users.” Bainnson said when designing for seniors, “you are really designing for everyone, but there are other hazards you have to be aware of.” For example, contemporary parks often feature these sleek, backless, armless benches that are essentially useless for the elderly. “Without an armrest, they can’t lower themselves into the bench or get out of it, so they just won’t use it.”
Bainnson recommended the American Horticultural Therapy Association (AHTA) guidelines, which call for “scheduled, programed activities that create park use; access ramps; raised beds; a profusion of plant-people interactions; and benign and supportive conditions.”
Plants should appeal in all four seasons. Park and garden designers need to be aware of wind direction and the sun path to create both wind-free and shaded areas. He added that designers must reduce sharp differences between light and dark. “Hip fractures from falling can occur as the elderly navigate the transition from deep shadow to bright light. They think it’s a step and they can trip up. There should be a middle ground, a transition zone.”
Bainnson has designed more than 20 therapeutic landscapes, including the Portland Memory Garden and parts of the Legacy Emanuel Children’s Garden. The Portland Memory Garden, which is designed for users with Alzheimer’s or other forms of dementia as well as well as their care-givers and families, is an enclosed loop, with a central entrance and exit, which is not only soothing to those suffering from dementia but ensures they don’t wander off.
The single entrance and exit means nurses or family members can also keep an eye out from a central place. Built in 2002 with $750,000 in privately-raised funds, the Memory Garden has “no dead ends or choices. You just follow the curve.” Concrete pathways are tinted to reduce glare. Their outer edges have a different color. Raised curbs on the edge of the sidewalks help ensure users don’t fall into the lawns. Bathrooms are extra large in case nurses or family members need to go in with someone in their care.
For true open spaces, seniors also have special needs. Bainnson is now working with the U.S. Fish and Wildlife Service on national wildlife refuges near Portland to make them more accessible to seniors, by putting in trails, accessible paths, and readable signs. He said they may not be able to access the whole system — as the city wants to keep the trails as natural as possible — but these steps will make it easier.
Marshall, Brozen, and Bainnson all made the case: consider seniors when designing public spaces. Why exclude? “What works for seniors will work for everyone.” These spaces will also work for all those people with any other cognitive or physical challenge, like veterans dealing with PTSD, people with prosthetic legs, or anyone in a wheelchair.