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The Accessibility of Public Spaces for

People with Dementia: A new priority
for the 'open city'
a
TIM BLACKMAN , LYNNE MITCHELL , ELIZABETH BURTON , MIKE

b
JENKS , MARIA PARSONS , SHIBU RAMAN & KATIE WILLIAMS
School of Social Sciences and Law , University of Teesside ,

Middlesbrough, TS1 3BA
b
Oxford Brookes University , London Rd, Headington, Oxford, UK

Published online: 01 Jul 2010.
To cite this article: TIM BLACKMAN , LYNNE MITCHELL , ELIZABETH BURTON , MIKE JENKS ,
MARIA PARSONS , SHIBU RAMAN & KATIE WILLIAMS (2003) The Accessibility of Public Spaces for
People with Dementia: A new priority for the 'open city', Disability & Society, 18:3, 357-371, DOI:
10.1080/0968759032000052914
To link to this article: http://dx.doi.org/10.1080/0968759032000052914
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Disability & Society, Vol. 18, No. 3, 2003, pp. 357371
The Accessibility of Public Spaces

for People with Dementia: a new
priority for the open city
TIM BLACKMAN*, LYNNE MITCHELL, ELIZABETH

BURTON, MIKE JENKS, MARIA PARSONS, SHIBU
RAMAN AND KATIE WILLIAMS
*School of Social Sciences and Law, University of Teesside, Middlesbrough, TS1 3BA,
and Oxford Brookes University, London Rd, Headington, Oxford, UK
ABSTRACT The social model of disability de-medicalises disability and politicises it as an

issue of universal rights. However, the rights of people with dementia have been less strongly
advocated than those of people with physical disabilities. This is particularly the case with
environmental planning and design. The needs of people with dementia are now informing
the design of residential homes and day centres, but the issue of accessibility to public spaces
and amenities has been almost completely neglected. Many outdoor environments such as
shopping centres or parks may be inhospitable for people with dementia because they are
disorientating, difficult to interpret and navigate, threatening or distressing. The article
reviews the literature on indoor design for dementia, reports on research investigating the
accessibility of outdoor environments, and describes a new approach using virtual reality
technology to enable people with dementia to identify and test outdoor design and planning
improvements themselves.
Introduction
Since the social model of disability was elaborated and formalised in the 1980s it has
become increasingly influential as an alternative to the traditional view of disability
as a personal medical tragedy (Oliver, 1990). The social model is based on the
principle that disability is a denial of civil rights caused by exclusionary practices in
all spheres of society from employment to design. This principle separates impairment caused by disease or injury from disability caused by personal, social and
environmental barriers that, if removed, could enable capacities to be re-gained.
Indeed, impairment itself is questioned as a meaningful concept when there is so
much variation in physical and cognitive characteristics across human populations.
The social model thus de-medicalises disability and politicises it as a social issue
about universal rights.
ISSN 0968-7599 (print)/ISSN 1360-0508 (online)/03/030357-15
2003 Taylor & Francis Ltd
DOI: 10.1080/0968759032000052914
358 T. Blackman et al.

Environmental planning and design have been an important focus of this
demand for universal rights (Shakespeare & Watson, 1997). The geography of towns
and cities is often experienced as oppressive for many people not just because their
needs for accessibility are neglected, but because ablelist values are positively
asserted in the socio-spatial patterns created by planners and designers. Imrie (2001,
p. 232) describes the outcome as an architectural apartheid:
Thus, the absence of lifts into underground stations makes them into
no-go areas for mobility-impaired people. Likewise, the use of moving
stairways in public buildings inhibits usage by many vision-impaired and
frail and elderly people with diminished categories to judge distance and
speed.
Similarly, Freund (2001, p. 699) describes the risks presented by contemporary city
environments:
Here, there is a constant, complex flow of traffic to be navigatedwith
signals, pedestrians, cyclists and other vehicles. Self-control and a state of
vigilance are essential. A loss of self-control can be lethal. Certain states of
consciousness and the ability to utilise ones body in particular ways for
moving through space, come to be taken for granted and expected of
anyone using public spaces.
Accessibility has become a major issue because of campaigning by disabled people,
the political influence of growing numbers of older people and more positive
attitudes towards disability in general. A recent UK Government Green Paper
describes the creation of barrier-free urban environments as a mainstream concern
for planning policy and practice (Department for Transport, Local Government and
the Regions, 2001). Certain planning guidelines and building regulations aim to
prevent or reduce the inaccessibility of buildings and transport for people regarded
as having physical or sensory impairments. However, there remain extensive problems with the scope, effectiveness and enforcement of these measures (Imrie &
Kumar, 1998). Gant (1997), for example, documents the extent to which pedestrianisation over recent decades has positively transformed the accessibility of shopping
centres for disabled people, but important shortcomings are evident such as the
inadequacy of toilet facilities and a lack of signposting. Imrie and Kumar (1998)
draw upon the accounts of disabled people themselves to demonstrate the extent to
which the built environment compounds their experiences of social and economic
marginalisation. A common theme in the informants accounts was to divide places
between those that are safe and secure, and those that are harmful and dangerous.
It was often the home that was regarded as safe and secure, while the environment
beyond the home was often perceived as harmful and dangerous. Humiliation was
a frequent experience outside the home, such as having to access buildings by side
or back doors or face high counters in offices and shops. A typical comment was, no
one really gives a care about our needs and we feel this everytime we go outside (Imrie
& Kumar, 1998, p. 366; emphasis added).
The aim of this article is to extend consideration of disabling environments and
Accessibility of Public Spaces
359
the open city concept to people with dementia and the outdoor environment. It
reviews the literature on indoor design for dementia, reports on research investigating the accessibility of outdoor environments, and describes a new approach using
virtual reality technology to enable people with dementia to identify ways environments should be planned and organised so that they are both accessible and
comfortable.
Dementia and the Social Model of Disability

The studies by Gant (1997) and Imrie and Kumar (1998) are typical of research on
accessibility in focusing on physical impairment and ignoring cognitive impairment.
Gant draws attention to the increasing prevalence of disability associated with an
ageing population, but no mention is made of the growing occurrence of dementia
also associated with this demographic trend. Although both physical impairment
and dementia are increasing in ageing societies, far more emphasis has been given
to the poor fit between psychomotor capacities and the organisation of space than
between psychological capacities and the organisation of space. This neglect cannot
be put down to the number of people experiencing cognitive impairments being
small. In the UK there is currently estimated to be over 700,000 people with
dementia and this is projected to rise to over 1.2 million by 2040 (Cox, 1999). In
addition, given the limited changes that built environments undergo over time,
much larger numbers of people with dementia will experience a given environment
than are present in the population at a particular time.
However, the case for enabling environments is not just one of special needs.
While it is possible to estimate numbers in a category such as dementiaand its
separate disease typesmany other people will share experiences of forgetfulness
and confusion at times, but not have a diagnosis of dementia. There is, therefore, a
wider interest in designs that aid navigation and comfort in all environments. This
kind of argument is frequently made in respect of the general diversity of bodily
forms and gaits, but there is less recognition of cognitive difference as a feature of
the normal conditions of humanity (Freund, 2001, p. 693). When a difference is
defined as impairment it becomes exceptional despite the fact that, in the case of
dementia of the Alzheimers type, it may be emerging as a normal feature of ageing
as longevity increases in many societies. Alzheimers disease might represent an
accelerated form of ageing, with the implication that everyone could develop a
dementia if they lived long enough (Whitehouse, 2000).
The progression of dementia is often described in stages. The early stage of
mild dementia is not especially disabling, but is typically associated with social or
work life difficulties due to poor memory and occasional confusion and disorientation. At a more moderate level of severity, dementia usually means that living
independently becomes more hazardous because of greater disorientation, difficulty
reasoning and understanding, and sometimes incontinence and emotional
difficulties. For many individuals, these symptoms become more severe and are
compounded by personality and behavioural changes, affecting the ability of carers
to continue their care or increasing the isolation of those living alone. High levels of

dependence on others, particularly for personal care, are strongly correlated with
nursing home admission (Audit Commission, 2000).
Although dementia is frequently described in these general terms of progressive
stages, the individual experience is often far from linear. A feature of dementia is
good days and bad days, and it can be difficult to regard a particular individual as
being at a particular stage in the disease (Cheston & Bender, 1999). The diminished
capacities that accompany dementia are not experienced uniformly and, as with
physical impairment, apparently similar cognitive impairment is not necessarily
reflected in the same levels of reduced functional ability or general well-being across
individuals (Faletti, 1984). The existence of a specific underlying disease state does
not determine the individuals experience of dementia, which depends greatly on
personal, biographical and environmental factors (Cheston & Bender, 1999).
Given Burys (2001) observation that the growing impact of degenerative and
chronic illnesses has reduced the influence of the bio-medical model because of the
importance of social care and quality of life, it is surprising that the social model is
not applied to dementia more often. Indeed, Goodley (2001) argues that people
with cognitive impairment have felt discriminated against within the mainstream
disability movement, with their impairment tacitly conceived of as a biological
deficit (p. 211). Such medicalisation enables a range of behaviours to be labelled as
abnormal and the spatial segregation of people with cognitive impairments to be
regarded as acceptable (Bracken & Thomas, 2001). This neglect has started to be
corrected in recent years. Kitwood (1997) has been especially influential with his
argument that much dementia care is oppressive because carers fail to establish
relationships of respect and trust that engender in the person they care for a sense
of personal worth, agency, social confidence and reassurance. Instead of being
regarded as autonomous individuals making decisions and expressing dis/satisfaction, people with dementia are vulnerable to disempowerment through decisions
made for them. As Parker and Penhale (1998, p. 203) comment, For people with
dementia, it is often not only the illness and disability which leads to a lack of control
and influence, but the attitude of others The views of people with dementia are
often overlooked, ignored or assumed not to exist.
This focus on the individual with dementia challenges those formulations of the
social model in which the individual hardly figures at all because of a concern with
structures and macro-processes. The recent re-discovery of narratives and biographical methods is bringing the individual back into the picture but in a way that
recognises both the uniqueness of individual experience and the contextual ways in
which disease and impairment are experienced (Greenhalgh, 1999). Diseases do not
exist as entities in themselves, but as relational and emergent outcomes of genetic,
infectious, metabolic, psychological, social and environmental conditions and interactions (Engelhardt, 1981). Disease is a concept that seeks to capture this emergence, and is operationalised in the case of dementia and many other conditions by
observations agreed to be in the upper tail of an empirical distribution, defining the
presence of an illness or impairment as opposed to its absence (Dillmann, 2000).
While this is useful for the purpose of organising knowledge about causes and
treatments, binary categories of this nature, typical of the bio-medical model, set up
361
divisions with implications that go well beyond medicine. An example of such a

division is that between the clinical or care environment appropriate for a person
with a disease or impairment and the normal environments appropriate for ordinary people (Sibley, 2001). In the case of people with dementia, their needs for an
enabling environment are beginning to be recognised within indoor care settings,
but the public outdoor world is rarely conceived of as a dementia setting. If it is, the
setting is an outdoor space bounded to create a garden or green safe area attached
to a nursing home or special housing project, enclosed and excluding.
All individuals, whether classified as diseased, impaired or normal, are embedded in networks of social relations. The world is experienced and acted upon
through these relations, so no individual experience, such as the experience of
dementia, can be understood separately from the relationships of the individual with
others (Emirbayer, 1997). Goodley (2001) discusses how the relations of people
with learning difficulties with their carers can construct a negative dependency:
doing for the person with learning difficulties, rather than working with what they
can do. For a person with dementia, their individuality as constituted through
interactions with others in possibly unconnected moments of time is of heightened
importance.
Recent work by a number of dementia researchers has extended the social
model to cognitive impairment by highlighting the relational nature of the individual
experience of dementia. Recognition of people with dementia as service users (even
customers) who should be actively involved in shaping their care has been an
important aspect of this (Reid et al., 2001). The new culture of dementia care has
encouraged positive personal interaction with people with dementia, encouraging
expression of individual feelings, needs and preferences, and working to hold in
place individual identities through a knowledge of personal biographies (Kitwood,
1997). However, with its origins in psychology, this approach tends to individualise
the experience of dementia, and the social context in which this re-formulation is
applied is the care setting: generally the institutional setting of a nursing home or day
care centre.
There is, therefore, a need to extend the new thinking about dementia to society
in general. Around 80% of people with dementia continue to live in their own
homes, including a third of people with severe dementia, and it is estimated that
almost a quarter live alone (Audit Commission, 2000; Dementia Services Development Centre, 1995; Gilhooly, 1986). Personal care is a very significant issue for
those who continue to live at home, but there is the same danger as with physical
impairment of creating a negative dependency. For example, the inability of a person
to undertake a task themselves because of an impairment may be removed by a
suitable adaptation to their environment. For people with dementia, spatial disorientation and loss of wayfinding ability are major reasons why the environment
constrains their autonomy (Passini, et al. 1998). Perceptual skills are often impaired
so that there may be difficulty telling right from left or differentiating between shapes
and sizes, while loss of higher cognitive skills impairs decision-making, spatial
memory, spatial planning and mental mapping. Functional spatial skills are also
affected so that people with dementia find difficulty using unfamiliar environmental

cues and navigating (Liu et al., 1991). Overall, dementia is associated with progressively decreasing abilities to plan a route, to remember or try different options, to
recall previous mistakes, and to remember or use mental maps, spatial information
and signs.
Imrie and Kumars (1998) finding that many disabled people distinguish
between the safety and security of their home and the danger and inhospitableness
of the environment out-of-doors is especially relevant to dementia. It is not only
disorientation and loss of wayfinding ability that keeps people with dementia
indoors, but also the social stigma associated with many of the behavioural symptoms, such as aimless wandering or aggression, which risks causing embarrassment or shame in public settings (Bond & Corner, 2001). Often, however, this
behaviour represents attempts to communicate distress or discomfort caused by the
environment, rather than unavoidable symptoms of brain damage (Kitwood, 1997;
Parker & Penhale, 1998).
Dementia-friendly Environments
The increasing prevalence of dementia is a specific aspect of the more general ageing
of the population. Most people want to stay in their own home as they age and, if
they develop dementia or other disability, want to be supported in their own home
(Marshall, 1998; Walker & Warren, 1996). Ageing increases the importance of
home and familiar neighbourhoods for most older people and having to abandon
them can mean losing self-respect as well as independence (Greenberg, 1982;
Robson, 1982; Golant, 1984; Axia et al., 1991; Laws, 1994). Living at home affords
privacy, a sense of control, a link with the past and often continuing membership of
a social network and may be the one constant in an emotional world threatened by
losses (Fogel, 1992, p. 16).
Older people may have to leave their home for residential or nursing home care
not because this is a positive choice, but because the level of care services in the
community is insufficient or the home is not suitably adapted (Royal Commission
on Long Term Care, 1999). This is the case even though the loss of a familiar
environment has been found to compound disorientation and further reduce coping
abilities (Fogel, 1992; Goldsmith, 1996; Newton, 1997). A study by Baragwanath
(1997) demonstrates that people with dementia are more likely to injure themselves
in unfamiliar settings, such as a respite home or hospital, due to increased anxiety
and disorientation. A familiar environment is felt to be predictable, reliable and
unlikely to involve stressful new situations which cannot be understood or managed
(Calkins, 1988; Golant, 1984).
Community care policy in the UK recognises an important role for supported
housing in the care of older people, and for people with dementia ordinary housing
with appropriate support is an alternative that can be provided at a cost comparable
to residential care (Cox, 1999). A range of innovatory housing and care projects
demonstrate that staying in your own home is a feasible option for many people with
moderate or even severe dementia (Cox, 1999; Sandford, 2000). These projects
include flexible home support schemes, memory and personal safety aids, such as
363
sensors that stop baths overflowing and gas cut-off switches, and adaptations to
create barrier-free home environments. However, although staying put in your own
home is more likely to support independence it is no guarantee against exclusion
because it does not necessarily mean that an older person can get out and about to
use and enjoy local amenities (Blackman et al., 2001). The home may begin to feel
like a prison if the world beyond the front door is inaccessible or inhospitable.
People with dementia have short-term memory problems, may be unable to
learn or understand new information, and have difficulties in utilising and enhancing
the cognitive mapping skills, which people unaffected by dementia can deploy to
navigate the outdoor world. Dementia may not only cause disorientation and
memory loss, but also exacerbate the effects of physical impairment. If the environment is not to be disabling, appropriate environmental features and behavioural cues
need to be designed-in, enabling the person to understand what to do in a particular
context and how to find their way around (Cohen & Day, 1991; Kirasic, 2000). It
is especially important to support emotional well-being and spatial orientation to
avoid unnecessary frustration and anxiety. Dementia-friendly environments are
calm, familiar and welcoming (Calkins, 1998; Weisman et al., 1991; Brawley, 1992;
Dementia Services Development Centre, 1999). However, even indoor care settings
have rarely been designed to provide appropriate physical support and behavioural
cues.
Guidelines for the design or refurbishment of residential and nursing homes
now mean that this is changing. They emphasise the importance of unambiguous
and familiar surroundings for residents with dementia, especially the re-creation of
domestic environments (Axia et al., 1991; Kuller, 1991; Judd et al., 1998). If
bedrooms, bathrooms and living rooms in residential and nursing homes resemble
those of ordinary private residences, people with dementia are more likely to be able
to understand what is expected in each setting and to find their way around (Cohen
& Day, 1991; Kirasic, 2000). Design guidelines also advocate using traditional
designs for those environmental features intended for use by residents, while those
for staff only are designed in ways that give few indications as to their purpose to
avoid misleading or confusing residents (Bell, 1992).
Environmental cues are important for people with dementia so that they can
recognise and respond to them depending on their disability. For some it might be
helpful to follow a sequence of cues. Short corridors with uninterrupted visual access
and frequent environmental cues have been found to be more navigable than long,
uniform corridors with repetitive elements, fixtures and fittings (American Institute
of Architects, 1985; Bell, 1992; Goldsmith, 1996; Brawley, 1997; Judd et al., 1998;
Passini et al., 2000). Locational and directional information must take account of
sensory impairment, while recognising that people with dementia may be confused
and disorientated by an over-abundance of information. Wayfinding information,
systematically located at decision points, needs to be well lit, at eye level and take
account of the stooped posture of many older people. Signs should be simple and
explicit with large, dark text on a light background and graphics in clear colours
(American Institute of Architects, 1985; Bell, 1992; Calkins, 1998; Judd et al., 1998;
Passini et al., 1998; Dementia Services Development Centre, 1999).

Dementia-friendly design guidelines for care homes include advice on colours,
materials and textures for floor and wall coverings. People with dementia can find
coarse-textured floor coverings difficult to walk on because their gait may be
shuffling and poorly balanced. Impaired depth perception can cause sharp colour or
pattern contrasts to be misinterpreted as differences in level and reflective floors as
wet and slippery. Busy patterns, such as chessboard squares or repetitive lines, and
poor colour or textural contrasts between walls and floors, can cause dizziness or
confusion. Colour coding tends not to be a useful navigation tool for people with
dementia because it is too complex to understand, but a distinctive change in floor
colour can be useful in discouraging access to hazardous areas. The utility and
navigability of interior environments have also been found to be enhanced by tactile
wayfinding cues, good lighting and windows that provide plenty of daylight and
visual access to external landmarks (Brawley, 1992; Harrington, 1993; Goldsmith,
1996; Calkins, 1998; Passini et al., 1998; 2000; Dementia Services Development
Centre, 1999).
Although much progress has been made with guidelines for the design of
residential homes and other care settings, by introducing dementia-friendly design
into formal care settings the inhospitableness of other environments is all the more
apparent. It creates segregated spaces that reinforce exclusion from ordinary
environments, and does little to enable the wider population to share in the general
benefits that may arise from dementia-friendly design.
The Open City: design and planning for dementia
As yet there are few studies that address how to include dementia in the aspiration
of creating the open citya concept which is meant to be inclusive, but as
commonly formulated is silent about cognitive impairment (Gleeson, 2001). The
open city concept is especially relevant to ageing societies: continued functional
activity outdoors is associated with significant psychological, social and physical
benefits for older people in general (Robson, 1982). However, faced with an
environment that presents obstacles to outdoor activity, older people tend to lower
their aspirations and restrict their activities to very short walking distances regardless
of the quality of local amenities (Peace, 1982; Robson, 1982; Warnes, 1992).
Among the many impediments are uneven or steep pavements, poor lighting, heavy
traffic, no shelter or seating, and inaccessible bus stops: the average street can be
a very unfriendly place for older people (Lavery et al., 1996, p. 183). For older
people with dementia, the unfriendliness of external environments is likely to be
even greater.
There are no published guidelines for the design of outdoor environments for
people with dementia. This neglect seems to reflect a presumption that their lives are
home-based, as well as the greater technical difficulties presented by controlling
environmental features, such as noise or lighting levels outdoors compared with
indoor environments. It is likely that people with dementia experience the same
confusion, frustration and anxiety in the external environment as indoors when
design does not reflect their needs. They will find even familiar and explicit places
365
problematic if they are noisy and crowded (American Institute of Architects, 1985;
Harrington, 1993). Indeed, their needs may not be that special: studies of older
people in general in the outdoor environment have found that preferred destinations
are most likely to be familiar, legible, accessible, convenient, safe and comfortable
(Golant, 1984; Garling & Evans, 1991; Kaplan, 1991; Kuller, 1991). The pedestrianisation of town centre streets is a positive example because it not only protects
pedestrians from traffic danger and fumes, it also creates a quieter and calmer
environment that can reduce the likelihood of confusion and disorientation.
One of the lessons of the research on internal design is that urban design
outdoors should enable older people to read their external surroundings so that they
can establish where they are and make appropriate decisions to reach their destination. Well-articulated environments, with orientation cues and directional information, are needed both indoors and outdoors. Familiar, meaningful and stable
environmental cues for wayfinding should enable a person who has lived for some
time in one neighbourhood to use the local area effectively after the onset of
dementia (Liu et al., 1991; Twining, 1991; Alzheimers Disease Society, 1997;
Royal College of Psychiatrists, 1998).
Findings about the disorientating effect of long uniform corridors suggest that
in outdoor environments long uniform and repetitious streets and building frontages
could have a similar effect. Short, direct routes without dead ends and small explicit
spaces without sharp corners are likely to be less disabling. Grid street patterns,
sometimes regarded by urban designers to be the most legible street pattern, may be
the most disorientating for people with dementia, especially if each street looks the
same as the next (Bovy & Stern, 1990). The most beneficial urban design is likely
to be a visual hierarchy of wider streets for main routes, narrower streets for
secondary routes, and a variety of street frontages that define formal and informal
spaces, buildings and uses (Gehl, 1996; Passini et al., 1998; Tiesdell & Oc, 1998;
Cornell & Heth, 2000; Department of Environment, Transport and the Regions,
2000). Plain, smooth, level, non-slip and non-reflective paving is likely to be the
most effective surfacing for older people in general and people with dementia in
particular. Poor maintenance, inadequate street lighting, uneven surfaces, high
friction materials such as gravel or cobbles, and paved areas of complicated or mixed
patterns, colours or materials are all likely to contribute to unsteadiness and
disorientation.
Participation in Planning and Design

A common criticism of design made by physically disabled people is that they are
not consulted by planners and designers (Imrie & Kumar, 1998). Accessibility can
be perceived by planning and design professionals as a matter of applying appropriate technical standards and this can lead to a neglect of the user-friendliness of
accessible environments and important detail such as the type of walking surface.
In starting to fill the gap in knowledge about how the outdoor world can be made
more accessible and comfortable for people with dementia, it is important that they

are involved in research as active participants rather than passive end-users of design
modifications.
Much of the research on the experience of dementia has drawn upon the
accounts of carers. This experience is often recounted as personal stories and there
is an increasing awareness that, while these accounts can access the inner worlds of
experience, they will also be cast in the carers preferred terms and own framework
of personal needs, biography and understanding (Gubrium, 2000). In recent years,
there has been a small but significant research effort to enable people with dementia
to speak for themselves about their experiences (Goldsmith, 1996). Much of this
work has been based on conversational approaches using gentle prompts to explore
themes and issues. Methods include semi-structured interviews and group discussions using loose interview protocols. It is important to avoid normative preconceptions, such as that it is impossible to be forgetful and intelligent at the same time,
or that a person with dementia cannot speak for themselves, but is best understood
by talking to their caregiver. The principle that informs this new emphasis on
communicating directly with people with dementia is that they are the experts of
their own experience (Reid et al., 2001, p. 390).
This type of research needs a different approach to one-off surveys or focus
groups. It needs to be conducted informally and over a period of time because of the
importance of empathy and close relationships in accessing the world of people with
dementia (Bond & Croner, 2001). Dementia research calls for a collaborative style
in which the person with dementia, carers and researchers explore difficulties and
options for their resolution together.
The authors of this article are currently working on a research project investigating cognition and use of the external environment by older people with dementia, aiming to identify with them the design and environmental factors which
influence ability to access, negotiate and utilise the environment. Older people with
dementia are being interviewed about their perceptions and experiences, and
accompanied on short walks to enable the researchers to observe wayfinding
techniques used and problems faced as they negotiate the environment. One of the
authors is taking this work further with colleagues at the University of Teesside by
enabling people with dementia not only to identify barriers and facilitators in the
environment but also to try out planning and design modifications themselves. This
would be very difficult to do in real-world environments as they are not easily
changed for research purposes, so the research is being undertaken in virtual
environments using the universitys Innovation and Virtual Reality Centre. Dynamic three-dimensional images with sound are projected onto a curved cinema
screen, giving the participant the impression of being in an environment such as a
town centre or urban park. The project is currently at the feasibility stage but
early results demonstrate that people with dementia are able to navigate in the
virtual environments using a joystick. They report that the experience is very close
to the real-life experience of, for example, walking along a pavement and across a
road to a bus stop, or taking a walk through a park. To date, the virtual reality
research closest to this work concerns rehabilitation, such as training in the use of
a wheelchair, street crossing, use of public transport and supermarket shopping
367
(Rizzo, 2001). Rather than adapting the person to the environment, however, the
Teesside project is investigating how to adapt the environment to the person.
Conclusion
The new culture of dementia care regards people with dementia as service users who
should be able to participate in shaping their care. People with dementia are also
users of environments. Just as the variable quality of care can affect the symptomatology of dementia for better or for worse, so can the quality of environmental
design. The medical model has focused attention on biological factors in its search
to find treatment, reduce risk and explore prevention. This has led to a neglect of
the environment and the way it can be adapted to the person with dementia. This
article has argued for shifting the focus from the disorientated, confused and
distressed person, and the private sphere of personal medical tragedy, to the issue of
disorientating, confusing and distressing environments, and the public sphere of
planning and design.
In particular, the article has emphasised the significance of the outdoor environment of public spaces and amenities. Given that continued functional activity
outdoors is associated with social and health benefits, if the outdoor world is avoided
by people with dementia this is likely to contribute to a loss of autonomy and health
status (Fogel, 1992; Warnes, 1982; Bond & Corner, 2001). Dementia need not be
an experience of unremitting decline and exclusion. There is evidence that a person
with dementias orientation to place, level of social disturbance and level of apathy
depend on the quality of care provided (Kitwood, 1997). There is also potential for
rementing as some powers that had apparently been lost are recovered, and for the
acquisition of new forms of feeling language (Gubrium, 2000). Indeed, virtual
reality may have a role in rehabilitation and stimulating interaction with the environment in a way that stimulates the latent plasticity of the brain (Johnson et al., 1998).
There are, in other words, capacities that can be worked with and which good
environmental design may be able to support and enhance.
Attempts to counter discrimination against disability with legislation have in
general focused on physical and sensory impairments, including the UKs 1995
Disability Discrimination Act. The principle which underlies this legislation is
that disabled people should not be treated less favourably for a reason that relates
to their disability, and that reasonable adjustments should be made to ensure
that disabled people are not put at a significant disadvantage compared to people
who are not disabled. On both these counts the outdoor world is likely to fall well
short of the reasonable adjustments that could make public spaces dementiafriendly. Confusion and forgetfulness are part of the human experience in general
and environmental designs that aid navigation, orientation and the peaceful enjoyment of public space will have benefits that extend well beyond people with
dementia alone. Work is only just beginning to establish the type of changes that are
needed, and to translate them into new planning and design requirements for the
open city.

Acknowledgements
This article draws on results from a project funded by the Engineering and Physical
Sciences Research Council EQUAL programme, Designing the External Physical
Environment to Improve the Quality of Life of Older People with Dementia (ref.
GR/M68985 OTH010RU). The Principal Investigator is Elizabeth Burton (ejburton@brookes.ac.uk). We are also grateful to Darren Flynn and Paul van Schaik at
the University of Teesside for their comments.
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