Design for the Elderly – Designing for People with Alzheimer's

By Nina Hollender, SAP User Experience, SAP AG & , AG Gerontopsychiatrie, Goethe-Universität Frankfurt am Main – June 1, 2011

Alzheimer's disease is the most frequent form of dementia. It progresses gradually and displays increasingly severe symptoms. Initially, people suffering from Alzheimer's are unable to remember new information. In the latter stages of the disease, they find it increasingly difficult to function, to orientate themselves, and even to remember their own biographic information.

However, Professor Carolyn Baum from the University of Washington stated that two people with the same level of severity of Alzheimer's disease (as assessed with standardized cognitive tests) may show an entirely different degree of independence in their familiar environment (Baum, 2000). How can this be?

It is because a suitably designed environment can support cognitive processes, and such environmental structures may enable a person with Alzheimer's to show greater independence than their medical assessment would have assumed.

In the following, we start by expanding on the fact that environmental structures can support cognitive processes. We then describe some examples of how the purposeful design of artifacts supports persons with Alzheimer's. The last paragraph deals with the specifics of the design in this particular context, pointing out that supporting cognition is just one design goal, and that it is a goal with limits. However, there are other important goals, including enabling people with Alzheimer's and their caregivers to share meaningful activities and reducing stress for caregivers.

 

Environmental Structures Support Cognitive Processes

We constantly make use of our physical and social environment to support our cognitive processes. For example, children learn to tie their shoe laces by following verbal instructions from their parents. People write shopping lists to remember what to buy, and professional chefs arrange ingredients in a row so that they know which order to use them in “without thinking” (for these and more examples, see Clark, 1997, or Kirsh, 1995).

For a long time, such phenomena were neglected in mainstream research related to cognitive science. Cognition was researched in artificial laboratory settings. It was only in the 1980s and 1990s that people like Ed Hutchins studied cognitive processes “in the wild”, for example, in ethnographic studies of ship navigation. These studies showed that cognition is a complex and dynamic interplay between internal processes in the brain and interaction with the physical and social environments.

Hence, if healthy people can make use of social and physical environmental structures to support cognitive processes, then the hope would be that people suffering from dementia can make use of them, too, and that such structures or artifacts could also be purposefully designed for them by others.

 

Design to Support People Suffering from Alzheimer's

Since no medical cure has yet been developed for Alzheimer's, a major goal is to support patients and their caregivers in their everyday lives. One way in which practitioners in the field of dementia have tackled this goal is to design artifacts that support the cognition of people suffering from Alzheimer's. Some of these are presented in the following:

Electronic Memory Aids

In order to help people with dementia keep to time-linked activities - such as taking medication or meeting people - various devices have been developed as electronic memory aids. For example, MemoJog is a mobile device connected to the Internet. Important activities or dates can be entered into the device both directly and remotely. At the relevant point in time, these dates are shown on screen and an acoustic signal sounds. Family or professional caregivers receive feedback about whether an activity was accepted or not. Lou and colleagues (2010) state that the role of caregivers in the implementation of such memory aids is crucial, since they can motivate the person suffering from dementia to use the aid. Caregivers also benefit from the aid, because it can reduce their feelings of anxiety.

Paper-Based and Digital Memory Books

Memory wallets are small folders that contain photos and facts from the life of the patient. They are created by the patient's family or by professional caregivers (Bourgeois & Mason, 1996). Michelle Bourgeois evaluated memory wallets under different conditions. It appeared that the wallets increased the number of topic-centered statements in conversations and reduced the number of erroneous or indefinite statements made by the person suffering from dementia. If professional caregivers in an institution create the wallets, they learn a lot about their patients by conducting interviews with family members, which in turn allows for more personal and high-quality caregiving.

Marie Höglund from Malmo University created a digital photo album for a patient suffering from Alzheimer's (Höglund, 2002). Höglund applied a participatory design approach and involved both the patient and her caregiving husband in the design process. With the help of diaries, interviews, and digital photos, an individual digital photo album was created. It contained photos relating to different areas and biographical phases, such as childhood, family, and profession, with additional commentaries by the couple. The photo album aimed to help the patient remember, but also to enable the couple to communicate and share a meaningful activity. At a later stage, it also aimed to inform professional caregivers about the needs and characteristics of their patient. Höglund pointed out that, when designing such an artifact, it is not only important to take into account the individual characteristics of a patient, but also to bear in mind that the symptoms of dementia will worsen over time. Hence, artifacts have to be adaptable in a way that makes them useful for patients in the latter stages of the disease.

Special Wardrobe

Namazi and Johnson (1992) developed a special wardrobe for people suffering from Alzheimer's. It contains several horizontal bars that are adjusted one after another, with one set of bars in the upper part, and one set of bars in the lower part of the wardrobe. Thus, clothes can be arranged according to the sequence in which they are put on. For example, underwear is placed upfront, followed by tights and a skirt. The wardrobe aims to make decisions easier by presenting clothes in the right order, and by reducing the range of clothes to choose from.

The furniture was tested in a nursing home with eight patients suffering from moderate or advanced stages of dementia. Every evening, the patients chose their clothes together with their caregivers, and the caregivers then arranged the clothes in the wardrobe. The following day, a record was made of how much assistance the patients required to get dressed. On the one hand, it appeared that most patients required less physical assistance, such as guiding an arm through a sleeve. On the other hand, verbal assistance increased. However, the authors concluded that verbal assistance was a minor intervention compared with physical assistance. Nevertheless, the wardrobe was not effective for all patients: Namazi and Johnson state that it was only effective for patients suffering from mild or moderate dementia who were able to make decisions.

 

Conclusion: Specifics About Designing for People with Alzheimer's

This article focuses on artifacts that offer cognitive support and increase patients' independence. However, the examples show that this is only possible to a limited extent. In the mild or moderate stages of Alzheimer's, specially designed artifacts may indeed be able to support sufferers cognitively; in the latter stages, however, this becomes more and more difficult. The examples also show that the artifacts serve other important goals, such as offering a feeling of safety, allowing for meaningful activities to be shared by the person with dementia and their family, and reducing challenging behavior by the person with dementia, which in turn decreases stress for caregivers.

When designing for people with dementia, we should apply a user-centered design process that involves the person with dementia and his or her social environment (Robinson and colleagues, 2009). Family and professional caregivers play an important role in the usage of such artifacts. Firstly, they motivate and support people with dementia to use the artifacts. Secondly, they may profit from the artifacts if they reduce challenging behavior from the person with dementia and enable meaningful shared activities. In the case of the memory books, professional caregivers can learn about the care receivers, which may allow for a better quality of care.

The individual characteristics of a person with dementia need to be taken into account, as well as the fact that the disease progresses gradually and that a specific artifact may become useless at a later stage, or serve a different goal.

 

Literature

  • Baum, C. (2000). Measuring Function in Alzheimer's Disease. Alzheimer's Care Quarterly. 1(3), 44-61.
  • Bourgeois, M., & Mason, L. A. (1996). Memory Wallet Intervention in an Adult Day Care Setting. Behavioral Interventions: Theory and Practice in Residential and Community-based Clinical Programs, 11, 3-18.
  • Clark, A. (1997). Being There. Putting Brain, Body and World Together Again. Cambridge MA: MIT Press.
  • Höglund, M. (2002) Ingegärd och den groan brevlådan. En designprocess för och med människor med demens. Examensarbete, Malmö Högskola. Retrieved on May 24, 2011 from http://www.trollreda.vgregion.se/np/dokument/foto.pdf
  • Kirsh, D. (1995). The Intelligent Use of Space. Artificial Intelligence, 73 (1-2), 31-68.
  • Namazi, K.H. & Johnson, B.D. (1992). Dressing Independently: A Closet Modification Model for Alzheimer's Disease Patients. The American Journal of Alzheimer's Disease and Related Disorders & Research, 22-28.
  • Robinson, L., Brittain, K., Lindsay, S., Jackson, D. & Olivier, P. (2009). Keeping In Touch Everyday (KITE) Project: Developing Assistive Technologies with People with Dementia and their Carers to Promote Independence. International Psychogeriatrics, 1-9.

 

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