Design touches to make the SCU a "home." (designing Alzheimer's Special Care Unit of nursing homes)

"Make the building work for you" is a motto for facility designers, and Alzheimer's SCUs are no exception

For nursing homes deciding to include an Alzheimer's Special Care Unit in their facilities, the most valuable approach in designing it is to assume the residents' perspective. Consider it as the resident's "haven," designed specifically for his or her special needs. This point of view is particularly critical because Alzheimer's residents are generally mobile and conscious. It follows that, with the exception of specialized medical equipment, the most valuable design elements are not necessarily expensive, but rather, responsive. The following concepts may be applied to either a new or renovated facility.

Ideal Layout

In a newly constructed facility, the ideal layout would feature a continuous loop which enabled residents to wander without confronting a "dead end." Observation, conference and nurses' rooms would be centrally located within the loop, while residents' bedrooms and activity rooms would be at its periphery. While renovating facilities seldom have the luxury of such extensive new construction, it is possible to improve the existing layout by re-configuring space to locate a living room or cul de sac at the end of a corridor.

Special Requirements

Most Special Care Units require more staff than other units, additional space and, generally, special equipment. Space planning should take these requirements into account and not overlook the space required for both medical charting and special activities aimed at "resident management." While current regulations allow a maximum of 45-60 beds per nursing station, many facilities find that smaller Alzheimer's units foster a more nurturing atmosphere.

Also of note, within an Alzheimer's SCU there is generally a need to accommodate more residents in gerichairs and wheelchairs than there is in a typical assisted living center.

In an Alzheimer's SCU, the nursing station should be enclosed with glass to discourage residents from climbing onto or over the desk or appropriating materials from it. As a visual cue for patient-nurse conference areas, define a portion of the station with accent lighting or a different wall color, and equip it for both ambulatory and wheelchair patients. Reverse magnet locks, which are activated by metal disk rather than keys, can greatly contribute to the sanity of the staff.

Throughout the unit all furniture should be weighted down or secured. Fabrics should be vinyl or vinyl-coated and rounded corners should be the rule. Carpets should also be antimicrobial. The use of contrasting edging can assist the visually-impaired in finding the edge of a table.

Color and Pattern

A wide range of color schemes is suitable for the Alzheimer's SCU, although pastels tend to work best. Within any palette, avoid harsh contrasts or patterns. Many elderly patients often lack depth perception. To an Alzheimer's patient, a dark stripe can be interpreted as a message possibly suggesting "barrier", and he or she can become confused in approaching it. Similarly, a floor pattern of contrasting tiles can cause residents to fixate and "step on" only tiles of one color.

Because Alzheimer's patients become deeply engrossed in touching objects, non-glare surfaces are preferred for both maintenance and their visual quality. Objects should have a quality that is pleasant and tactile, rather than abrasive. Three-dimensional, smooth relief sculptures can serve a dual purpose as therapeutic artwork. They should offer a variety of simple images, and, of course, must be secured to the wall.

Visual Cues

Visual cues designed into a project provide two important benefits: they add ambiance and they can help a patient remain independent longer. One cost-effective approach uses signage boards with photo insets that cue location. For example, a bowl of fruit or a group of people eating might signal "dining"; a picture of a loved relative or pet, "home."

Applied in a corridor, different patterns in coordinated colors can signal destination. For example, one wall leading to a dining room might be patterned in leaves; the opposite wall, leading back to the bedroom, might be patterned in a coordinated stripe.

Dining

Food and dining often present challenges for both patient and caregiver. For many reasons, regularly scheduled meal times do not suit all residents. Some residents may be in an agitated state at designated meal times. Others may be sleeping or simply not hungry. Conversely, those who can't sleep are often comforted by a light snack.

One approach to meeting around-the-clock meal needs is a small pantry/cafe consisting of a kitchen space with a dining area large enough to accommodate 10-15 people. The kitchen should be separated from the care with a table-height wall opening. In this way residents are protected from the dangers of cooking but can interact with caregivers. These spaces also offer "friendly" sites for family visits, and are wonderful venues for both "occupational therapy," such as cooking or baking and "social activities," such as a Brunch Club. Because these spaces count as a multi-feature, they also qualify for reimbursement.

Regular dining facilities need to be equipped with some tables suitable for feeding, and others set at wheelchair height. Artwork featuring images or scenes that encourage residents to eat is helpful, as are comforting smells of home, such as cinnamon potpourri or baking apples. When possible, it is preferable to contain emergency medical supplies, such as suction machines, within an inconspicuous hutch or built-in cabinet.

Personal Care

Because many Alzheimer's residents tend to be fearful of anything abrupt, bathing can often be frightening. A hand-held shower unit puts the control of the water in the hand of the caregiver and, because it is out of sight, reduces the fear of bathing. The temperature of bath and shower rooms should be warm. If the existing HVAC system is inadequate for this, a simple alternative is to install heat lamps in the ceiling.

As another method of visual cueing, toilets within lavatories should be immediately visible. Alzheimer's SCUs should also have their own supervised "personal care centers" furnished minimally with brushes, combs, wall-mounted mirrors and chairs. They should also include counters, some at wheelchair height.

Family Activities

Special Care Unit residents typically receive more frequent visits from relatives and friends, rendering lounges more of a necessity than a luxury. Several small, intimate lounges are preferable to fewer, larger units. Ideally, lounges should be equipped with seating for six to eight people, a desk and a chair, a small coffee table, and a small convenience counter for preparing beverages.

Alzheimer's disease can affect even young people, and for these residents in particular (although not exclusively), sexual activity may remain a viable component of their lives. Providing a secluded spot with a pull-out sofa incorporated into the seating will provide both comfort and privacy.

In general, making life comfortable and natural for both residents and their visitors is, basically, a good marketing tool.

Home Base

The ideal semi-private room configuration for Alzheimer's residents allows each occupant to have equal access to both window and wardrobe without going into the roommate's space. Patterns and colors should be calming rather than vibrant.

To foster continued independence, it is helpful for Alzheimer's patients to continue dressing themselves. However, left with unlimited choices, many Alzheimer's patients would continue "dressing" until their wardrobe was exhausted. When economically feasible, a double wardrobe system helps facilitate independence, with the resident's full wardrobe placed under lock and key. The patient's clothes for the day are placed in a small closet in the order in which they are to be put on.

"Feeding the Soul"

Several features that respond to compulsive behavior and nurture the Alzheimer's resident's "soul" can be easily and economically designed into a Special Care Unit.

Rummage Boxes

A rummage box contained within a built-in cabinet located in an activity or living room and filled with a variety of objects can address the Alzheimer's resident's need to explore. The box should contain a variety of items - for example, picture books, articles of clothing, or calendars might help a resident cope with agnosia. These containers need to be inspected periodically by staff, of course, as a variety of objects - sandwiches, missing beepers, etc. - might be added by residents.

Gliding Rockers

The recognizable swaying motion of these rockers can be very comforting to an Alzheimer's resident. Gliding rockers are safer than typical rockers and can be effective in helping to "settle down" those who are non-ambulatory or who have difficulty walking.

Children's Toys

Over-sized implements, such as a giant abacus or clock, can keep residents occupied for hours. Placing a large strand of beads in a resident's hand may arouse other senses.

Display Cases and Fish Tanks

Filled with different objects, display cases can provide an opportunity for viewing delicate objects and create an opportunity for discussing "happy memories." Displays might be changed seasonally and feature holiday ornaments, birdhouses, doll collections, model cars, figurines, etc. For almost everyone, fish tanks provide a calming sensation. For safety sake, all units should be recessed into the wall. Ideal height is above the handrail.

Recreation Areas

Living rooms and lounges need comfortable seating, as well as tables suitable for a variety of activities including therapeutic training and stimulation. Several types of secured lighting - bolted table lamps, wall sconces, ceiling fixtures - are ideal, as they allow the caregiver to vary the "mood" of the space. Both music and lighting have been found to have positive effects in Special Care Units, and music can even overlay sound in TV lounges in the SCU.

Locked Doors

Locked doors are very frustrating to Alzheimer's residents. The typical facility renovated to accommodate an Alzheimer's SCU will have many more dead ends, fire doors, and locked doors than a unit specifically designed for this use. A large poster of a painted landscape scene can significantly ease the frustration these obstacles pose. A scene painted on the door and incorporating texture can provide the resident with an additional sensory experience.

Outdoor Activities

When economically feasible, two separate outdoor recreational areas are ideal. One, located adjacent to a care or food service facility, might be dedicated to dining and relaxation and should include tables and chairs. A second, in a different location, could be used for activities such as gardening. For security, both areas should be equipped with "wander guards" which are not "climbable." Both areas should also offer protection from the sun through table umbrellas and/or awnings. Wander guards that play music rather than beep can enhance quality of life.

In sum, these often modest design "touches" can help make the Special Care Unit a "home" for these difficult-to-manage residents.

Annemarie Kretschmann is principal of Annemarie Kretschmann Interior Design (AMKID). Based in Westport, CT, AMKID specializes in the interior design of health-related facilities. Ms. Kretschmann has designed several Alzheimer's Special Care Units and a wide range of other health care facilities, including medical offices, hospitals, skilled nursing facilities and long-term living centers.