New Methods to Support Wayfinding for Persons with Dementia

I recently served as Principle Investigator on a National Institutes of Health Small Business Innovative Research grant in partnership with the Center for Applied Research in Dementia. The purpose of our recent research was to develop and implement a signage system for long-term care that supports wayfinding for persons with dementia. Recognizing where one is and where one is going are critical aspects enabling persons with dementia to be self-sufficient. In unfamiliar situations people rely on environmental cues to find their way. When these cues are not easily interpreted due to cognitive impairment, autonomy gives way to dependency. The search for information to aid orientation may cause frustration, anger or agitation (Zgola and Bordillon, 2001). Poor wayfinding abilities have been found to impact resident safety, create conflict between residents (Rosswurm, et al., 1986), and cause unnecessary burden to nursing home staff (Everitt, et al., 1991). Residents who cannot identify paths to desired locations exhibit anxiety, confusion, mutism, and panic (Passini, et al., 2000). The stress caused by disorientation may result in feelings of helplessness, raised blood pressure, headaches, increased physical exertion, and fatigue (Carpman and Grant, 2001).

In dementia, the capacity for decision-making is reduced to decisions based on immediate and visually accessible information (Passini, et al., 2000). Since less visual information is taken in by persons with dementia (Koss and Gilmore, 1998), and they experience other visual challenges such as contrast and depth perception deficits, spatial disorientation, and difficulty judging certain colors, it is imperative that all cues in the environment are created using evidence-based design guidelines.

While the effectiveness of some cueing systems has been empirically tested, more research is needed to provide designers, care staff, and administrators with guidelines that can make a significant difference in environments for people with dementia. Thus, the purpose of this research study was two-fold:
1) gather information about the color, contrast and pictogram preferences of persons with dementia for dining room, activity room, bedroom, and restroom signs; and,
2) use this information for creating signs that increase wayfinding independence.

For this study, we used two methods to collect data. First, in the Human Factors phase, we had 28 persons with dementia identify the characteristics of the signage they preferred. Next, in Wayfinding Observations phase, 23 persons with dementia were observed walking to different locations in the care community pre- and post-intervention (i.e., before and after installing new signs designed based on resident preferences).

Phase 1 was carried out by having the persons with dementia view many different signs on easels placed out in front of them. Participants indicated which sign they preferred and their choices were recorded. From this process we were able to determine which combination of words, colors, and pictograms were the most favored.

Signage with a colored background were preferred over signs with a white background. The participants preferred bright green to dark green or white, bright magenta compared to dark purple or white, and bright royal blue compared to the dark navy blue or white.

In trials that assessed preference for the placement of words (before or after the pictograms), there was a trend to prefer the words to precede the pictogram on the sign, but not a strong preference. Participants were asked their preferences on eight pictograms. For activity room signage, the preference was for a pictogram of people seated playing a game compared to both the pictograms of a TV and people standing/waving. There was a trend to prefer the pictogram of a bowl of soup over a knife and fork or people seated at the table for the dining room signage. Participants preferred a pictogram of a toilet over a pictogram of a shape of the person (man standing) to indicate the restroom. Once we collected all of the data from the Phase 1, we used this data to develop a set of signs that were used during the wayfinding observations in Phase 2.

In the second phase, residents were accompanied on three different routes in the care community before and after installing the new signs. Time to walk to each location as well as the type and number of errors were noted. In general, a majority of participants showed improvement from baseline to post-test, especially with regard to time to navigate routes, though this showed variability across routes and locations. Overall, we found patterns of improvement in wayfinding in residents with dementia in two residential settings on a variety of outcomes. This was accomplished without any intervention other than placing the signage into these environments. Given the results of this study, we must consider that traditional approaches to signage in long-term care communities may not be adequate to support persons with cognitive impairment. There are still many aspects of signage that require in depth study, such as resident preference for other placement options, additional color choices, and the size and shape of signs. Regardless, if preferred designs of environmental cues are in place in dementia care
facilities, residents should be able to navigate more independently, thereby reducing their level of frustration and increasing their autonomy.

You can all of the details about the study in the full article:

Brush, J., Camp, C., Bohach, S., & Gertsberg, N. (2015). Creating supportive wayfinding for persons with dementia. Canadian Nursing Home, 26(1), 4-11.

©2015 Jennifer Brush, may not be reprinted or distributed without permission