The Effect of Seoul Dementia Healing Design Project on Cognition and Social Engagement

Demographic changes in South Korea over the years highlight the importance of a paradigm shift in the national health-care policy. The rapid growth of the elderly population in South Korea has brought population aging and socioeconomic problems related to caregiving for dementia patients. According to the Korean Dementia Observatory 2019 on the outlook of the dementia population, the prevalence of dementia in people 65 or older is 9.8%, with a projected 2 fold increase every 20 years, so that the dementia population of 788,035 in 2019 is expected to rise to 3,200,000 by 2060.1 Consensus on the need for a change in the current health-care policy to adequately address the severity of the socioeconomic burden is spreading.

One area warranting policy consideration is creating a dementia-friendly environment for both therapeutic and preventive purposes. Sixty percent of dementia caregivers are family members, and related social issues such as murder-suicide involving caregivers have been increasingly reported in the media.2, 3 Thus, given that it is difficult to manage the rapidly increasing dementia patients collectively and that most patients receive care at home, there is an absolute need for a “dementia-friendly” environmental design that meets the specific needs of dementia patients at home. These efforts to create a dementia-friendly residential environment will ensure the safety of dementia patients receiving in-home care and reduce the burden of family caregivers.

The importance of environmental design in the care of patients with dementia has long been emphasized.4 Many previous studies have been done on dementia-care design guidance to reduce potential risks to demented elderly.5, 6, 7 These results showed that proper environmental modification could improve functional daily activity and independence in dementia patients. However, these recommendations were proposed for high-income countries and could not be applied directly to Korean society and cultural elements; so their effect is unclear.

The Seoul Dementia Healing Design Project (S-DHDP) was conducted by the Department of Design Policy of the Cultural Division of the Seoul Metropolitan Government to develop a dementia-friendly design that can be applied to Korean society in cooperation with the Yangcheon-gu Dementia Center. Our pilot study investigated the effect of S-DHDP In-House design (S-DHDP-IHD) on mild cognitive impairment (MCI) and early-stage vascular dementia (VD) households by investigating residential patterns and satisfaction levels and S-DHDP Environmental Design (S-DHDP-ED) on dementia caregivers and non-demented older adults by using survey research.

The S-DHDP by the Department of Design Policy of the Cultural Headquarters of the Seoul Metropolitan Government was conducted between November 2014 and March 2016. It was designed to obtain safety for dementia patients and alleviate the burden on the family members, as the need for the development of a dementia-friendly environment has increased in Korean society. The project consisted of 2 parts: 1) S-DHDP-IHD to improve the vulnerable indoor environments of dementia families and improve the quality of life (QoL) of patients with cognitive impairment and their family members, as well as to increase cognitive activity in MCI by modifying the indoor environment based on analyses of the residential patterns of the dementia family; and 2) S-DHDP-ED to promote outdoor activities not only of dementia patients and caregivers, but also of healthy community elderly. A comprehensive flowchart of the study is shown in Supplementary Fig. 1.

We selected Yangcheon-gu, Sinwol 1-dong for the study site because of the high rate of aged population and the high ratio of residents with dementia compared to that in other districts. We did pre-test/post-test surveys to evaluate the effectiveness of S-DHDP.

S-DHDP-IHD

Subjects of S-DHDP-IHD

To assess effect of S-DHDP-IHD, we recruited 10 households of residents who were 70 or older living in Sinwol 1-dong and had cognitive impairments from Yangcheon-gu Dementia Center. We selected 2 household settings after site visits and evaluations conducted between November 2014 and March 2015, using the following criteria: 1) ability to understand the project and cooperate, 2) home conditions in need of improved services, 3) family arrangements with residents either living alone or living with one caregiver.

We chose 2 households among 10 candidates to undergo renovation for S-DHDP-IHD. Since this study was about the environmental effects of preventing dementia, an MCI patient without daily activity problems and an early-stage dementia patient who had mild difficulties in daily life were selected. The first of the 2 households consisted of a 70-year-old MCI woman living alone and engaging in social activities 2 or 3 times a week. She complained of mild anxiety, depression, and fatigue but was otherwise generally healthy for her age. The other household consisted of a 77-year-old early-stage VD patient and his 78-year-old spouse, who was the main caregiver. The patient had almost no outdoor activities because of deteriorating physical health, and the caregiver had limited social life, lacking empathizing friends and other family members.

Intervention of S-DHDP-IHD

For S-DHDP-IHD, the intervention consisted of renovations of various home areas. In the MCI household (Fig. 1), there were replacements of a storage closet, toilet seat covers, storage shelves, wall-socket safety covers in the bathroom, a shoe shelf at the entrance, window shades in the bedroom, and sink bowls in the kitchen and dining area. Two storage closets and a clothes rack were set for a second room. In the early-stage VD household (Fig. 2), there were replacements of sidesteps and application of handrails, tissue holders, non-slip tapes in the bathroom, replacements of sink bowls in the kitchen and dining area, curtains in the bedroom, and application of handrails and a storage closet in the living room. Also, handrails were applied to the porch stairs. Three storage closets and a clothes rack were set for a second room. In both households, light switch, wallpaper, and door handles were replaced, and name tags on storage closets and labels for cold/hot water were applied in common living areas.

Fig. 1
Pre- and post-intervention in renovations of various home areas in the mild cognitive impairment household (top: before; bottom: after). (A) Replacement of storage closet, toilet seat covers, storage shelves, and wall-socket safety cover. (B) Replacement of shoe shelf at entrance. (C) Replacement of sink bowl at kitchen and dining area. (D) Appliance of 2 storage closets and clothes rack in second room.

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Fig. 2
Pre- and post-intervention in renovations of various home areas in the early-stage vascular dementia household (top: before; bottom: after). (A) Replacement of sidesteps and appliance handrail, tissue holder, non-slip tapes in bathroom. (B) Replacement of sink bowl in kitchen and dining area. (C) Appliance handrail at porch stairs. (D) Appliance of 3 storage closets and clothes rack in second room.

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Measurement of S-DHDP-IHD

We carried out pre- and post-intervention studies by surveys, used video monitoring to measure task performance improvement, and completed a comprehensive neuropsychological battery. We defined the effectiveness of the S-DHDP-IHD as being evidenced by improvements in facility satisfaction with the home environment and in functioning of everyday activities.

First of all, we evaluated the study subjects' cognition, mood, and neuropsychological symptoms using the following clinical tools before and after the project.

• • Korean Mini-Mental State Examination (K-MMSE), Clinical Dementia Rating (CDR), CDR-Sum of Boxes

• • Seoul Neuropsychological Screening Battery8 to assess cognitive impairments in memory, executive functioning, visuospatial function, language, and attention

• • Short Geriatric Depression Scale (SGDS)9 to assess depression in the elderly

• • Barthel Activities of Daily Living scale (ADL)10 to measure degree of independence in everyday activities, and the Seoul-Instrumental Activities of Daily Living scale11 to assess complex functional tasks of the elderly in daily living

• • Caregiver-Administered Neuropsychiatric Inventory12 to assess neuropsychiatric symptoms

• • Zarit Burden Interview (ZBI)13, 14 to measure subjective caregiver burden

• • Positive and Negative Affect Schedule (PANAS)15 to assess mood and emotion

Second, we evaluated the indoor facility satisfaction levels by surveys conducted between April 14 and April 30, 2015, before intervention and between July 14, 2015, and August 28, 2015, after intervention. We used a Five Evaluation Framework (Supportiveness, Safety, Accessibility, Efficiency in Perception, Amenity) and the 10 Point Scale Bar.

The Five Evaluation Framework Questionnaire was derived from the concepts of Universal Design. According to this theory, supportiveness provides convenience to the user by reducing physical effort, such as by handrails and door handles. Safety is a characteristic that prevents accidents and minimizes obstacles, such as by using anti-slip tapes, handrails, and gas insulator or hot-water labels. Accessibility offers easy access regardless of the user's activities; examples include removal of pulleys and appropriateness of the height and size of sinks. Efficiency in perception heightens awareness and necessary information for switches. outlets, and storage labels. Last, amenity promotes comfort and emotional welfare by adequate environmental stimulations; examples include satisfaction with lighting, wallpaper, curtains, and storage.

The 10 Point Scale Bar assigns 0 to 10 points to images to measure satisfaction level. Five points is the baseline score, which is the satisfaction level before intervention. Increase in the satisfaction level is reflected by a shift of the score to the right, whereas a decrease in the satisfaction level is reflected by a shift to the left.

Third, we evaluated daily activity by means of video recordings and observations of task performances. Security cameras were placed in selected residential spaces from April 14, 2015, to May 9, 2015, for pre-intervention assessment and from July 7 to July 22, 2015, for post-intervention assessment. We compared video recordings of daily living before and after intervention. The monitored task performances in a specific home space were cleaning and washing clothes in the bathroom, finding lotion or favorite pants in the bedroom, and making bean sprout or seaweed soup in the kitchen. We measured the time spent in daily life, such as in taking a bath, finding winter hats and coats, and cooking, and evaluated each subject's ADL scales.

S-DHDP-ED

Subjects of S-DHDP-ED

For S-DHDP-ED, we recruited 255 residents of Sinwol 1-dong who are 40 or older and without dementia (‘non-demented residents’) by random selection to participate in pre- and post-intervention studies. We initially recruited 32 residents who were high-risk or early-stage dementia (‘demented elderly’) to participate in the first pre-intervention studies in June 2015. Only 30 of the demented elderly participated in the second pre-intervention studies, because 2 subjects dropped out, but subsequently, one additional demented elderly was recruited, and a total of 31 subjects completed the post-intervention study. We conducted pre-intervention studies between May and June 2015; neighborhood renovations were done between June and July 2015; post-intervention studies were done from October 12 to December 20, 2015; and a reassessment study was done until December 29, 2015.

Intervention of S-DHDP-ED

For S-DHDP-ED, the intervention consisted of renovations of various areas in the town, such as safe passage named helpful service facilities named Gil Ban Jang, exercise picture board, 7 rest areas, the 100-m trail bulletin board, and intersection marks along the Cognitive Health Walking Course (Fig. 3).

Fig. 3
Seoul Dementia Healing Design Project-Environmental Design facilities. (A) Pre- and post-installation of helpful service facilities named Gil Ban Jang (top: before; bottom: after). (B) Pre- and post-intervention in Cognitive Health Walking Course with 100-m trail marks on the road (left: before; right: after). (C) Pre- and post-intervention in one of the 7 rest areas (left: before; right: after). (D) 100-m trail bulletin board and exercise picture board along the Cognitive Health Walking Course.

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Measurement of S-DHDP-ED

To measure the effectiveness of the S-DHDP-ED, we conducted pre- and post-intervention surveys to: 1) evaluate the changes in the outdoor and social activity patterns of residents and 2) evaluate the satisfaction of residents in the project itself. To investigate changes in outdoor activities, we measured the number of outdoor activities per week, daily practice of taking a walk, and the number of social activities per week. These were surveyed in both pre- and post-intervention studies. Awareness of and experience with the renovated facilities of S-DHDP-ED, as well as satisfaction with their function and design, were surveyed in the post-intervention studies to evaluate the effect of the project itself.

Our study was done to assess the effectiveness of the S-DHDP conducted by the Department of Design Policy of the Cultural Headquarters of the Seoul Metropolitan Government between November 2014 and March 2016. This pilot study investigated the effect of S-DHDP-IHD on MCI and early-stage VD households based on analyses of the residential patterns and satisfaction level and S-DHDP-ED on dementia caregivers and non-demented community older adults based on survey research. We found some positive changes of S-DHDP-IHD on detailed neuropsychological tests, satisfaction-level surveys, and video analysis for monitoring of time to task and ADL. Also, we identified positive effects of S-DHDP-ED on the frequency of outdoor activity and social activity.

The S-DHDP was conducted to develop a dementia-friendly design that is directly applicable to Korean society. It was designed to consider the cognitively impaired patients and their caregivers in order to reduce the burden of dementia care, to promote external activities and cognitive activities of dementia patients, family members, and healthy community elderly. As a result, we expect to reduce the socio-economic burden of the dementia population and aging in Korean society, which is moving toward being a super-aging society.

S-DHDP-IHD increased the satisfaction level using the Five Evaluation Framework Questionnaire and 10 Point Scale Bar in both MCI and early-stage VD patients. They were satisfied with all components of safety, accessibility, efficiency in perception, supportiveness, and amenity, which are the main 5 elements of universal design.

Comparison of some task times closely linked to everyday life and daily activity of the subjects before and after intervention showed a substantial improvement in both MCI and early-stage VD patients. In practice, we found the decrease in time for dressing, finding clothes and shoes, and washing dishes in both MCI and early-stage VD patients after renovation of S-DHDP-IHD. These findings suggest that the S-DHDP-IHD achieved the accessibility, efficiency in perception, and supportiveness as well as subjective satisfaction. Also, we observed the decrease in time despite the increase in number of uses of the cabinets by the MCI patient (Supplementary Table 2). This finding suggests that both patients used cabinets more efficiently with easier accessibility. A more important finding was that the amount of strolling increased and the time watching TV and lying down decreased in both patients. It suggests that the S-DHDP-IHD, which was developed as a dementia-friendly design, increases outdoor activity and leads to improvement of ADL and QoL in patients with dementia and their caregivers.

Many previous studies showed that a proper design for patients with dementia is good for their therapeutic perspective.6, 7 Some studies reported that patients' agitation and physical restraint use were reduced after environmental intervention,16 and the patients who received dementia-friendly design experienced fewer declines in ADL, more sustained interest in the environment, and less negative affect.17 Adequate design for patients with dementia led to their spending more time in the improved environments and showing increased pleasure in another study.18

In neuropsychological analysis and other investigation using some scales, cognition, affect, and instrumental ADL after the intervention either improved or did not change in either household. In addition, there was no change in disease status or functional ADL in either household. However, general satisfaction with life and the burden on caregivers improved slightly. Since dementia-friendly design does not relieve or reverse the underlying pathology, there is a limit to the improvement of cognitive function, and the short-term change arising from dementia-friendly design could not lead to improvement of objective cognitive function. However, ADL improvement and a decrease of the care burden would improve the QoL of patients and caregivers.

For the S-DHDP-ED, comparison of the frequency of use and satisfaction with project facilities by Sinwol 1-dong residents demonstrated positive changes. In particular, higher awareness, frequency of use, and satisfaction level with facilities were correlated with increasing age. After the S-DHDP-ED, the average satisfaction levels with the neighborhood showed an overall increase. Most of the non-demented residents who participated in the survey had decreased navigation time, better establishment of major hubs, a decrease in crossroad confusions, and an increase in use and awareness of facilities. Also, a notable point is that higher satisfaction was measured in older adults. This finding suggests that our design project is more suitable for older adults. Also, we could predict that these community changes of the project are an adequate plan for an aged society and aging people with slight aging-related cognitive impairment.

However, only a few residents living with dementia patients participated in pre- and post-intervention surveys, showed very low awareness of S-DHDP-ED, and had extremely limited outdoor activities, perhaps because of seasonal effects, since pre-intervention surveys were conducted around June and post-intervention surveys were conducted around October and December. The meager amount of outdoor activity may have been affected by the season in which the post-intervention studies were conducted, which is November. Furthermore, promotional efforts for the S-DHDP may have been heavily geared toward the non-demented population.

This study is meaningful in that it had a more positive effect on patients with milder stages of dementia and their caregivers than on conventional nursing-home-based dementia patients.

In conclusion, our study illustrates the need to improve both home and neighborhood in order to prevent dementia and provide suitable care for dementia patients. We conclude that a customized design approach that takes both residential and outdoor environments into consideration is essential for holistic, family-oriented dementia care.

Supplementary Table 1

Change in task time of MCI patient and early-stage VD patient between pre- and post-intervention

Supplementary Table 2

Change in activities of daily living scale of MCI patient and early-stage VD patient between pre- and post-intervention

Supplementary Fig. 1

Flowchart for evaluation of the effectiveness of (S-DHDP). The project consists of 2 main components: 1) S-DHDP-In-House Design was designed to improve the vulnerable indoor environment of patients with cognitive impairment and their family members for the quality of life and encouraging cognitive activity. 2) S-DHDP-Environmental Design was made to promote outdoor activities of not only dementia patients and caregivers, but also healthy community elderly. Both pre- and post-interventions were evaluated in both designs.