Innovations in Wayfinding: Using Signage for People Living with Dementia Authors: Jocelyn Hunt, BA, Barb McCoy, RN, BA, GNC(c), Gail Elliot, BSc, MA, Kate Ducak, MA,CPG, PhD(c)

A Study Supported by a New Horizons Grant and The Alzheimer Society of Hamilton, Halton, Haldimand Norfolk and Brant

People with dementia experience an altered sensitivity to

environmental conditions, which can lead to responsive

behaviours if needs are not properly addressed. This further

adds to the stress and burden of care on family members,

consequently leading to institutionalization (van Hoof, et al.,

2010).

Environmental cueing and support supports declarative mem-ory loss. By supporting memory loss with external memory cues, such as placing information in the environment at the time of information retrieval, individuals with dementia will be more successful at finding things and locations (Charness and Holley, 2001; Elliot, 2014).

Environmental strategies can help decrease responsive behaviours (Kincaid and Peacock, 2003).

Some solutions to support these memory deficits include ensuring the use of wayfinding and environmental cueing is simple and can successfully trigger well-learned behaviours that are supported in the procedural memory (Fleming et al., 2003; Rainville, et al., 2010).

Use of pictorial signage accompanied by text will further aid people with dementia to find things and locations (Fleming et al., 2003).

Wayfinding needs to be connected to the abilities of those who will use the cueing (Rainville, et al., 2010).

BACKGROUND

Wayfinding can be defined as… “The system of navigation that enables individuals to find their way quickly and easily within a built environment consists of designed elements (such as pictograms, words and colours) to support an individual’s wayfinding abilities”

(Marquardt, et al., 2009)

To focus on discovering whether environmental cues such as

directional arrows that point to rooms ( e.g.— “ living room”)

and templates that look like glass-covered cupboard doors,

aimed at helping a person find things, will help persons with

dementia.

Hypothesis: The implementation of wayfinding signage, direc-

tional arrows and environmental cues will help people with de-

mentia more effectively find things and locations. Also, sign-

age will help decrease responsive behaviour(s) and contribute

to increased functional capacity, independence and enhance

self-esteem and quality of life.

Research Questions:

A. Will the use of wayfinding signage and environmental cues

within the home help support memory, and promote inde-pendence for those living with dementia?

B. Will the use of wayfinding signage and environmental cues help lessen the burden on family/informal caregivers?

C. Will the use of wayfinding signage and environmental cues positively impact responsive behaviour(s)?

This research consisted of a one-way dyad study, where two populations were studied. The primary participant in this study was the family member/informal caregiver (FM/IC), where the family member with dementia was the second population stud-ied, indirectly, through observations made by the FM/IC. A series of quantitative research questions, in the form of pre-study and post-study questionnaires, were conducted to examine changes in behaviour related to wayfinding signage, directional arrows and other environmental cues that were implemented in the per-son’s home.

Total # of Participants: 9 families (initially 17 families were in-cluded but 8 families had to drop out for various reasons).

Participants were recruited through posters & presentations delivered by the researchers at education sessions held at he Alzheimer Society of Hamilton, Halton, Haldimand and Brant.

A series of quantitative research questions, in the form of pre-study and post-study paper questionnaires were con-ducted to examine changes in behaviour related to wayfinding.

The details from the questionnaires were complimented by qualitative observations recorded by the FM/IC

Volunteer visitors also collected observational details regard-ing how the cues were being used in the home.

PURPOSE AND HYPOTHESIS

METHODOLOGY

Ethical Considerations:

This research received ethical clearance. All participants were in-

formed in writing of their rights as a participant, potential

benefits and risks of this study, confidentiality and their right to

withdraw. To respect the choice of the participant with dementia, a

letter of information and assent was provided prior to participating

in the study. There are no conflicts of interest present in this study.

Themes

The cues enhance independence

Templates help persons with dementia as well as others,

such as visiting staff support

Demonstration and teaching the person with dementia to

use the signs is important as well as consistent reinforce-

ment to ensure they continue to be used.

Resistance to signs ( especially for the toilet)

“Less is more” philosophy, with all signs tailored to needs.

Some need pictures, words or words and pictures. No other

markings should interfere with what is being seen/used.

Positive outcomes for formal care partners and for persons

with dementia.

Important Design Features in Environmental Cueing:

Compensating for age-related sensory changes (colour &

contrast).

Specific wording and language as per needs of individual.

Visibility and physical placement of signs (vision assess-

ments prior to implementing signs).

Important Considerations in using Artwork

Vision and the older adult: Avoid glare, no clutter (on cues/

templates), colour contrast (so images are clearly seen), im-

ages are familiar.

Images have clear connection to purpose and are positioned

at eye level.

This study was limited to measuring wayfinding for finding lo-cations and things. It did not include assessing cueing for task completion. Future research should focus on the bene-fits of cueing related to task completion, including sequencing cueing.

Aspects from assessment tools, such as the Wayfinding Effectiveness Scale (WES) and the Home Environmental Assessment Protocol (HEAP) have been recognized in some sections of this study. However, these tools apply to institutionalized settings and/or do not adequately account for wayfinding strategies and environmental cueing in their assessment.

Conclusion

Wayfinding strategies and supportive environmental solutions need to incorporate smart and appropriate elements of design. By doing so, we are one step closer in helping people with dementia live with the disease, and lead more independent lives that en-hance function and self-esteem and promote quality

of life.

Statistically significant effects ( when excluding the person with severe dementia) , where the program:

1. Improved ability to find their way around the home

2. Decreased feelings of frustration, anger, confusion and anxiety when forgetfulness occurs.

3. Improved the level of independence

4. Improved the ability to find commonly used items

Family members have reported that the use of templates have helped in decreasing responsive behaviours for the PWD, by helping them find things more easily and independently,

With the use of templates in the home, families report a change in improved mood and self-esteem in the person living with de-mentia

Care providers have noted the person with dementia ,with the use of templates, exercises more independence and allow more personal time for the caregiver

The use of the templates in the home have also assisted home support workers, and family friends, in locating items.

The directional arrows have been used to help divert from dangerous areas for the PWD, such as stairs and falling hazards, increasing the safety for PWD and their families.

The directional arrows have also been used to help the PWD find specific spaces around their homes, such as exit hallways in apartments and bedroom recognition.

Quotes from Individuals Living with Dementia:

“It helps me think”

“I wouldn’t know unless I have these signs”

“I can find (things) without having to ask for help.”

Behavioural and Psychological Symptoms of Dementia and Causes

(Aberdeen et al., 2010; Elliot, 2010)

Design Elements & Purpose in Supportive Living Environments for Dementia

(adapted from van Hoof et al., 2010; Marquadt and Schmeig, 2009; Cioffi et al., 2007; Pynoos et al., 1989; Giltin et al., 2002; Davis et al., 2009)

Behavioural Symptoms Psychological Symptoms Causes of BPSD

Wandering Restlessness Hyperactivity Agitation Aggression (verbal and

physical) Appetite and eating disorders Socially unacceptable

behaviour Disturbed sleeping and waking

cycle

Irritability Anxiety Depression Emotional liability Apathy Delusions and

misidentification problems (paranoia, suspicion, abandonment, betrayal)

Hallucinations (visual, olfactory, touch, auditory)

Psychological co-morbidities Unmet need or situation Over and under-stimulation Presence of pain Overwhelming stressors or event(s)

made unmanageable by cognitive deficit

Lack of meaningful activity Unsupportive environment Social and cultural differences between

individuals

Design Element Purpose

Structured, simple, and stable environment Familiar and home-like Support functional ability through meaningful activity Use of familiar furnishings (such as artwork,

furniture, memorabilia, pictures) Use of warm, soft colours Floor finishes and use of lighting

Defining spaces through use of colour and spatial

contrast Barrier-free, compensating environment; safety and

security

Promote dignity and independent functioning Serve as a cue to memory Reduce agitation, confusion or other responsive

behaviours Maintain competence and self-esteem Promote social interaction Support wayfinding and orientation

Encourage eating, create home-like atmosphere Non-glare finishes on floors and non-intrusive

lighting will support vision sensitivities; decrease like-lihood of falls

Support space orientation and purpose Promote and preserve autonomy

DISCUSSIONS

“Dad used to get frustrated when he wanted to get things himself, not

remembering where things are.

He would settle for things that would be easy to see—not what he wanted. He now can go directly to the cupboard and get

the item that he wants”

“Cues they give him independence. His independence is what builds his self esteem.”

“He has not gone into the wrong room since signs were posted.”

“More self reliant, less frustrated.

More independent.

Family Caregiver

Image of templates used in participant’s home

Meaning, purpose & independence . . .

Family caregiver comments

“Dad comments to all that come in about the signs ,

about how well they work

and he is very proud of them.”

“He feels more effective in his own kitchen.”

“More confident about self care.”

“She likes to feel helpful and useful.”

“Where she helps she feels less of a bur-den.”

“Calls me less often for assistance or to find misplaced things.”

Image of templates used in participant’s home.

RESULTS

LIMITATIONS AND RECOMMENDATIONS FOR FU-TURE RESEARCH

*

g

G