HEALING THROUGH DESIGN: THE PSYCHOLOGICAL EFFECTS OF DESIGN ON THE ELDERLY A DARCH PROJECT SUBMITTED TO THE GRADUATE DIVISION OF THE UNIVERSITY OF HAWAI‘I AT MĀNOA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF ARCHITECTURE DECEMBER 2016 By Kellene Kehau DeMello DArch Committee: Sara Carr, Chairperson Andy Kaufman Beverly Hoversland Keywords: Environmental Psychology, Elderly, Biophilic ABSTRACT The purpose of this dissertation is to document and explore how the built environment impacts elderly individuals dealing with various forms of dementia. The human population within the United States is not only increasing, but the number of those over the age of 65 is also increasing. As U.S. citizens age, the number of individuals with dementia will increase accordingly, which will increase the demand for senior care facilities that focus on treating individuals with dementia-related diseases. When continuing to live at home or with loved ones is no longer an option, family members will look for an appropriate senior care facility where their loved one can live and receive healthcare. Given the medical realities involved in the aging process, design elements must be created in a way that allow residents to physically, psychologically, and emotionally flourish. However, creating such a senior care facility that addresses all of these needs for residents on an individual basis can be challenging when the range and ability of each individual can vary greatly. This dissertation proposes to investigate current senior care facilities from three different locations around the world and three locations on the island of O’ahu to determine the ideal senior care residential design for a modern facility in Hawai’i. This dissertation will also be drawing from growing research on environmental psychology, nature’s effect on health, and contemporary advances in senior care for residents with dementia. Native Hawaiians have a strong connection to and respect for the land along with their ancestral lineage as this element, too, connects each individual to past generations and the places upon which Hawaiians lived and thrived for centuries. These cultural elements are deeply embedded in an understanding of nature’s healing powers and the importance of family and one’s larger familial community. This dissertation will show how modern conceptualizations of the therapeutic qualities of nature, specifically connected to traditional Hawaiian cultural practice, and the need for human connections within the growing aging population can be interwoven to create a unique architectural design solution for a senior care facility focused on care for individuals dealing with dementia. i TABLE OF CONTENTS ABSTRACT ........................................................................................................ i LIST OF FIGURES ............................................................................................ iv LIST OF TABLES ............................................................................................. vii INTRODUCTION ............................................................................................... 1 1.0 RESEARCH IMPERATIVE ........................................................................... 3 1.1 The Aging Population in the Nation ......................................................... 4 1.2 The Aging Population in Hawaii .............................................................. 5 1.3 Needs for the Elderly in Hawaii .............................................................. 6 1.4 Aging in Place ...................................................................................... 8 2.0 HOW THE BUILT ENVRIONMENT IMPACTS THE ELDERLY ............................ 12 2.1 The Human-Environment Relationship and Its Impacts ........................... 14 2.2 Importance of Environmental Psychology .............................................. 16 2.3 The Benefits of Nature on the Elderly.................................................... 17 2.4 How Planning Plays a Role ................................................................... 22 3.0 ALIMENTS PARTICULAR TO THE ELDERLY ................................................ 27 3.1 Physical Aliments ............................................................................... 27 3.2 Psychological Aliments ........................................................................ 31 4.0 DESIGN ELEMENTS ............................................................................... 33 4.1 Spatial Organization ........................................................................... 33 4.2 Sensory Experience ............................................................................ 38 4.3 Natural Environment and Landscape ..................................................... 45 4.4 Sense of Place ................................................................................... 55 5.0 CASE STUDIES ..................................................................................... 59 5.1 Introduction ...................................................................................... 59 5.2 Dementia Village Advisers (DVA) - De Hogeweyk, Amsterdam Location .... 60 5.3 Cohen Rosen House ........................................................................... 69 5.4 Custead Care Center–Haven Hospice .................................................... 76 5.5 Case Study Conclusions ...................................................................... 82 6.0 SITE VISITS TO EXISTING SENIOR CARE FACILITES ................................. 84 6.1 Site 1 ............................................................................................... 85 6.1.1 Location of Site ............................................................................... 85 6.1.2 General Interior Layout and Design .................................................... 86 6.1.3 Exterior Configuration and Features ................................................... 90 6.1.4 Interview ........................................................................................ 90 6.2 Site 2 – The Plaza Mililani.................................................................... 91 6.2.1 Location of Site ............................................................................... 91 ii 6.2.2 General Interior Layout and Design .................................................... 92 6.2.3 Exterior Configuration and Features ................................................... 95 6.2.4 Interview ........................................................................................ 95 6.3 Site 3 – Ka’amilo Hale ........................................................................ 96 6.3.1 Location of Site ............................................................................... 96 6.3.2 General Interior Layout and Design .................................................... 97 6.3.3 Exterior Configuration and Features ................................................... 98 6.3.4 Interview ........................................................................................ 99 6.4 Site Visits Conclusion.......................................................................... 99 7.0 DESIGN: Site Selection and Analysis ..................................................... 103 7.1 Senior Population Distribution on Oahu ............................................... 104 7.2 Senior Care Facility Distribution on Oahu ............................................ 105 7.3 Hawaiian Population Distribution on Oahu ........................................... 106 7.4 Hawaiian Homestead Lands on Oahu .................................................. 107 7.5 Climatic .......................................................................................... 108 7.6 Geographical ................................................................................... 109 8.0 Design Implementation ........................................................................ 111 8.1 Spatial Organization ......................................................................... 111 8.2 Sensory Experience .......................................................................... 120 8.3 Natural Environment and Landscape ................................................... 122 8.4 Sense of Place ................................................................................. 135 9.0 CONCLUSION ......................................................................................... 141 Bibliography ................................................................................................ 143 iii LIST OF FIGURES Figure 1.1 Image of apartment at The Karmel, Deerfield, Illinois. ........................... 8 Figure 1.2 Floor plan of The House for Betty, Asbury Methodist Village, Gaithersburg, Maryland ....................................................................................................... 10 Figure 4.1 Floor Plan of Woodside Place, Oakmont, Pennsylvania ......................... 34 Figure 4.2 Living area in Warroad Senior Living Center in Warroad, Minnesota ....... 42 Figure 4.3 Enclosed patio in Warroad Senior Living Center in Warroad, Minnesota .. 42 Figure 4.4 Public space in Massachusetts General Hospital .................................. 46 Figure 4.5 Patient room at Massachusetts General Hospital ................................. 47 Figure 4.6 Horticulture Therapy........................................................................ 49 Figure 4.7 Gardening ...................................................................................... 52 Figure 4.8 Horticulture therapy ........................................................................ 52 Figure 5.1 De Hogeweyk: Site Plan showing the various courtyards. ..................... 60 Figure 5.2 De Hogeweyk Supermarket .............................................................. 61 Figure 5.3 De Hogeweyk: Restaurant in De Hogeweyk. ....................................... 62 Figure 5.4 De Hogeweyk: Theatre in De Hogeweyk ............................................. 63 Figure 5.5 De Hogeweyk: Employees Assisting Residents .................................... 64 Figure 5.6 De Hogeweyk: Floor Plan of Second Level .......................................... 66 Figure 5.7 De Hogeweyk: Various Lifestyles ....................................................... 67 Figure 5.8 De Hogeweyk: Courtyards ................................................................ 68 Figure 5.9 Cohen Rosen House: Site Plan .......................................................... 69 Figure 5.10 Cohen Rosen House: Residential Rooms ........................................... 71 Figure 5.11Cohen Rosen House: Zones ............................................................. 71 Figure 5.12 Cohen Rosen House: Daylighting ..................................................... 72 Figure 5.13 Cohen Rosen House: Living Room ................................................... 72 Figure 5.14 Cohen Rosen House: Public Spaces.................................................. 73 Figure 5.15 Cohen Rosen House: Site Line Study ............................................... 74 Figure 5.16 Cohen Rosen House: Memory Garden Concepts ................................ 74 Figure 5.17 Cohen Rosen House: Memory Garden .............................................. 75 Figure 5.18 Cohen Rosen House: Exterior Courtyards ......................................... 75 Figure 5.19 Haven Hospice Custead Care Center Main entrance ........................... 77 Figure 5.20 Haven Hospice Custead Care Center: Private Rooms .......................... 78 Figure 5.21 Haven Hospice Custead Care Center Floor Plan ................................. 80 Figure 5.22 Haven Hospice Custead Care Center: Chapel .................................... 80 Figure 5.23 Haven Hospice Custead Care Center: Courtyard ................................ 81 iv Figure 5.24 Haven Hospice Custead Care Center: Courtyard ................................ 81 Figure 5.25 Haven Hospice Custead Care Center: Enclosed Patio .......................... 82 Figure 5.26 Case Study Matrix ......................................................................... 83 Figure 6.1 Site 1: Front entrance ..................................................................... 85 Figure 6.2 Site 1: Public Area .......................................................................... 86 Figure 6.3 Site 1: Resident Kitchen................................................................... 87 Figure 6.4 Site 1: First Level Floor Plan ............................................................. 88 Figure 6.5 Site 1: Second Leve Floor Plan .......................................................... 89 Figure 6.6 The Plaza Mililani Street View ........................................................... 91 Figure 6.7 The Plaza Miliani: First Level lobby .................................................... 92 Figure 6.8 The Plaza Miliani: Ground Entry Level ................................................ 93 Figure 6.9 The Plaza Mililani: Memory Care Floor (5th Level) ................................ 94 Figure 6.10 The Plaza Miliani: Typical Floor Plan of Residential Rooms .................. 95 Figure 6.11 Ka’amilo Hale: Entry ...................................................................... 96 Figure 6.12 Ka’amilo Hale: First Level Floor Plan ................................................ 98 Figure 6.13 Matrix for Site Visits .................................................................... 102 Figure 7.1 Site Location: Nanakuli .................................................................. 103 Figure 7.2 Elderly Population Distribution ....................................................... 104 Figure 7.3 Senior Care Facilities ..................................................................... 105 Figure 7.4 Ethnicity Distribution ..................................................................... 106 Figure 7.5 DHHL Hawaiian Homestead Lands ................................................... 107 Figure 7.6 Climate ........................................................................................ 109 Figure 7.7 Nanakuli Master Plan ..................................................................... 110 Figure 8.1 Ground Level Floor Plan ................................................................. 111 Figure 8.2 Main Level Floor Plan ..................................................................... 112 Figure 8.3 Main Level Floor Plan: Public Areas .................................................. 113 Figure 8.4 Main Level Floor Plan: Main Circulation Area ..................................... 114 Figure 8.5 Main Level Floor Plan: Public Area Descriptions ................................. 115 Figure 8.6 Main Level Floor Plan: Back of House Areas ...................................... 116 Figure 8.7 Main Level Floor Plan: Private Areas ................................................ 118 Figure 8.8 Main Level Floor Plan: Private Residential Rooms .............................. 119 Figure 8.9 View looking from sitting area by the private residential rooms looking into the garden. ........................................................................................... 120 Figure 8.10 East West Building Section: Sunlight ............................................. 120 Figure 8.11 Main Level Floor Plan: Wind direction ............................................. 121 v Figure 8.12 East West Building Section: Natural Ventilation ............................... 121 Figure 8.13 Images of Ocean Views from Site .................................................. 123 Figure 8.14 View of Site from current neighborhood. ........................................ 124 Figure 8.15 Main Level Floor Plan: Landscape Elements .................................... 125 Figure 8.16 Main Level Floor Plan: Landscape Diagram ..................................... 126 Figure 8.17 Low Density Plant: Riviera Bermuda Grass ..................................... 127 Figure 8.18 Medium Density Plants ................................................................. 128 Figure 8.19 High Density Plants ..................................................................... 129 Figure 8.20 Diagram of Sitting Nook 1 ............................................................ 131 Figure 8.21 Plants of Sitting Nook 1 ................................................................ 131 Figure 8.22 Diagram of Sitting Nook 2 ............................................................ 132 Figure 8.23 Plants of Sitting Nook 2 ................................................................ 133 Figure 8.24 East West Section: Garden Terrace Elements .................................. 134 Figure 8.25 East West Section: Garden Terrace Plants ...................................... 135 vi LIST OF TABLES Table 3-1 Everyday activities that many individuals over age sixty find difficult to perform. ....................................................................................................... 28 Table 4-1 Good and Poor color choices .............................................................. 43 vii INTRODUCTION Over the past few decades, our nation’s population has been increasing at an accelerated rate. With the rise of population comes, accordingly, the increase of the senior population. As we age, all of our abilities—sensory detection, cognitive acuity, balance, and motor skills—begin to decline. Understanding this human differentiation has never been more important than now, given the steadily increasing senior population. Research exists regarding how more cognizant hospital and school designs could positively impact our respective healing and learning processes. However, with the growing senior population within the United States and, specifically, the Hawaiian Islands, it is important to look at how the built environment could impact the aging process and how senior care homes could be designed and crafted to improve the quality of life for our kūpuna. Thus, it is critical that we design environments that better serve the needs of the aging individual. Human-environment research suggests that our particular living spaces have a tremendous impact on how we feel, respond, and cope in daily life. Today, designers are shifting toward the idea that environmental modification can be a viable, more sustainable solution for some of our physical, psychological, and emotional problems, especially those increasingly present as we age. It is important that, as designers, we create spaces that allow an individual to physically, psychologically, and emotionally flourish. All three must be nurtured because one area cannot be present for overall good health if the other two are not. For example, if one is not able to physically flourish, it can negatively impact an individual’s psychological and emotional state and vice versa; if one is not psychologically and emotionally well, that individual will not physically flourish. The three key considerations when designing a senior care facility in a way that maintains commitment to aging individuals’ needs dictates that the design should promote independence, maintain a sense of community, and expose individuals to the healing powers of nature. As stated previously, when we age, our physical and mental abilities begin to decline making it difficult for some individuals to continue managing daily activities that were once able to be performed with ease, such as running errands and even cooking, cleaning, and bathing, Designing a living environment that helps our seniors maintain their independence for as long as possible is key for maintaining a high quality of life. Simply giving individuals the feeling that they still have their 1 independence is, in fact, critical, and this sense of self can be achieved through design by giving seniors the ability to make choices about their daily activities. Many seniors deal with feelings of isolation, which is why maintaining a sense of community and connection to society is also desirable for the aging population. No one wants to feel alone. This sense of community connection is especially prevalent in Hawaii because many cultures within these islands, especially the Hawaiian culture, embrace the importance of having a strong connection to their familial lineage. Significant to note is that this connection to one’s lineage is not only expressed by honoring one’s ancestors but also acknowledges a connection to future generations. Thus, for the sake of potential residents, it is essential that this sense of intergenerational connection be represented in the design of senior care facilities in the islands. Another key design element is the creation of spaces that encourage physical, psychological, and emotional health through incorporating the healing benefits of nature. Not only are there scientific studies that back the theory that gardens as living and growing outdoor spaces have healing capabilities, but there are also a number of cultural theories that support the positive impacts that nature can have on individuals. Native Hawaiians exist as a quintessential example of a culture that is uniquely connected to the land and the power it possesses. The creation of a strong connection to the land and nature through garden features within senior care facilities will not only offer healing benefits to the residents but could also benefit facility employees and even extend into the community as a place for peaceful retreat for all. In essence, understanding how population increases are impacting society on a national level will lead to the analysis of how the number of individuals over the age of 65 (i.e., seniors or the elderly) is also increasing. Accordingly, the aging population in Hawaii is growing and changing but, as such, this unique population should dictate the consideration of specific cultural elements within the design of an island senior care facility. Evaluating the current senior care facilities that exist in Hawaii and the changes that are occurring in the islands in regards to the increasing senior population, and, for the purposes of this dissertation, with a specific focus on designing facility for individuals dealing with dementia, designers will be able to create senior care facilities that offer transformative features to nurture a healthy and positive quality of life for our elderly island residents. 2