DSDC centred

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By Katie Wallace

September 21st, 2020

Dementia Design Principles Review

There are several dementia design evaluation tools available across the world, that can be used to rate the built environment and its suitability to provide a dementia inclusive setting. The Dementia Services Development Centre’s Dementia Design Audit Tool [i](DDAT) is one of the most in-depth, containing almost 350 assessment items.  

Since its first publication in 2008, the dementia design standards set by the DDAT has been considered the highest international benchmark of dementia design quality for residential aged care settings. Underpinning these dementia design standards are a set of dementia design principles that were first adopted from Professor Mary Marshall’s Schema[ii], published in 2001, as follows: 

  1. ‘Compensate for disability’

  1. ’Maximise independence, reinforce personal identity, and enhance self-esteem/confidence’

  1. ‘Demonstrate care for staff’

  1. ‘Be orienting and understandable’

  1. ‘Welcome relatives and the local community’

  1. ‘Control and balance stimuli’


And when summarising international consensus up to 2001, Mary Marshall recommended design features that would enhance dementia-specific residential facilities:  

  1. ‘Be small in size’ 

  1. ‘Control stimuli, especially noise’ 

  1. ‘Enhance visual access, i.e. ensure that the resident can see what they need to see from wherever they spend most of their time’ 

  1. ‘Include unobtrusive safety features’ 

  1. ‘Have rooms for different functions with furniture and fittings familiar to the age and generation of the residents’ 

  1. ‘Have single rooms big enough for a reasonable amount of personal belongings’

  1. ‘Be domestic and home-like’ 

  1. ‘Have scope for ordinary activities (unit kitchens, washing lines, garden sheds)’ 

  1. ‘Provide a safe outside space’ 

  1. ‘Provide good signage and multiple cues where possible, e.g. sight, smell, sound’ 

  1. ‘Use objects rather than colour for orientation’ 


As we progress with the development of a new audit tool, it is only rational that we look at the current evidence base to ensure our design principles and related features are a reflection of the best available knowledge on how to improve the lives of people with dementia and other age-related impairment. And as the interest in dementia design increases amongst the wider public, and as dementia design is now being seriously considered in all types of spaces across our communities, we consider how, where, and by whom, a dementia design audit tool might be used. As part of this expansion of environment types being assessed we have naturally found ourselves reviewing and revising the features that Marshall advocated whilst focussed on care settings. 

However, we believe it is at least equally important that we re-visit the established dementia design principles to consider how these might need to be adapted to improve their suitability for use in the design of the many other types of physical environments likely to be experienced by people with dementia living in our wider community.  

Therefore, for the purpose of this comparison, Van Hoof’s study on environmental interventions [iii] (2010) played a key role in pinpointing design principles which have been adopted to ‘assist with activities of daily living and functions’, with these presenting a clear emphasis on the wellbeing of the individual. Further environmental tools also included in this analysis comprised TESS-NH[iv] (Sloane et al, 2002), EAT[v] (Fleming, Bennett and Forbes, 2013) EHE[vi] (The King’s Fund, 2014) and Design Smart (Cunningham and McIntosh, 2015) and thus focussed more on the built environment and its impact. 

A common feature of well-established dementia design guidelines, including our own, has been the tendency to promote principles and features that relate better to residential care settings than other types of physical environment. Of course, this is not surprising when we know that research to date has favoured this type of environment. However, as an increasing majority of people living with dementia remain living at home within the community, it is important that we seek to develop design principles that are encompassing of all environments. With an aim for a more inclusive future, the path our principles will take should be a more holistic one, taking into account any building typology or public space.  

To achieve ‘dementia inclusivity’ we have to think about designing for dementia as a united entity, moving away from current societal attitudes and towards inclusive design as a whole. The overarching approach to disability is the Equality Act (2010) which protects all individuals in Great Britain from discrimination and unfair treatment, and therefore our principles should aspire to attain this too. 

It is also common for ‘design principles’ and ‘design features’ to be confused with one another. Though when comparing both environmental features and person-centred principles, common themes could be seen between the two, with the same six themes clearly seen as important: 

  1. Control Stimuli (to increase helpful and reduce unwanted stimuli)

  1. Familiarity (mainly in the domestic/ home like sense)

  1. Safe and Secure

  1. Individual to Social (providing spaces for choice, from private to social interaction and connections with the wider community)

  1. Activities of Daily Living (providing engagement and independence)

  1. Orientation


Table to show correlation between DSDC 2001 principles and findings from comparing multiple tools


2001 DSDC Principles


Relation to Top 6 Common Themes

Compensate for disability



Maximise independence, reinforce personal identity, and enhance self-esteem/confidence


Activities of Daily Living (providing engagement and independence)


Demonstrate care for staff



Be orienting and understandable




Welcome relatives and the local community


Individual to Social (Providing spaces for choice, from private to social interaction and connections with the wider community)


Control and balance stimuli


Control Stimuli


Familiarity (mainly in the domestic/ home like sense)



Safe and Secure



Although ‘Familiarity’ and ‘Safe & Secure’ could not be linked directly to a current DSDC principle, they can in fact be found within the DSDC design features, and therefore signifies the need to distinguish further between principle and feature

So how should we define each? 

Design Principle

    An overarching theme 

Design Feature

    An attribute which contributes to achieving the principle. 


The most recent systematic literature review undertaken by Bowes & Dawson[vii] (2019), found that although the evidence base is growing, further research is needed in a number of areas. Themes such as visibility, familiarity, wayfinding and orientation, were seen to have the largest amount of research, with safety and personalisation following thereafter. When considering stimuli, the evidence base is broken down into the senses, where sight (53%) has been shown to be considered more than hearing (24%), touch (14%), smell (12%) and taste (5%). The principles however, acknowledge stimuli as a whole. 

The literature has been closely evidenced against room typology, following the current structure of the DDAT assessment process, but not in explicit relation to the design principles. It does confirm, however, that two sections, ‘Meaningful Activity’ (27%) and ‘General Principles’ (51%) are both clearly represented in the literature, and this corresponds more readily to the identified ‘common themes’ noted above. Two thirds of the literature is also closely related to residential environments with ‘emotional health-related outcomes the most frequently considered in the included literature’, comprising 53% of the evidence base. 

When developing an environmental audit tool, it is easy to remove the human and emotional aspect of design which is perhaps harder to measure and focus solely on the tangible built structure. As the environment has a causal effect on the emotional aspect this should perhaps be seen in the principles with environmental elements addressing the features to achieve this. One cannot be without the other. Supporting people to live well into older age is the common goal and therefore human wellbeing needs to be the primary objective. 

There are many challenges facing the team during this development, and with a commercial need to drive things. Unfortunately, we do not have all the answers, which makes the journey a slower process, and what may appear a simple development of the tool includes debates around the influence on past and future principles. 


[i] Cunningham, C. et al. (2008) Dementia Design Audit Tool. 1st Edition, Dementia Design Series. 1st Edition. Greenwich, NSW: University of Stirling.
[ii] Marshall, M. (2001) ‘How it helps to see dementia as a disability’, Care Homes and Dementia: Journal of Dementia Care. Edited by S. Benson. London: Hawker Publications, 6, pp. 15–17.
[iii] van Hoof, J., Kort, H. S. M. S. M., van Waarde, H. and Blom, M. M. M. (2010) ‘Environmental Interventions and the Design of Homes for Older Adults With Dementia: An Overview’, American Journal of Alzheimer’s Disease and Other Dementias, 25(3), pp. 202–232. doi: 10.1177/1533317509358885.
[iv] Sloane, P. D. et al. (2002) ‘Therapeutic Environment Screening survey of nuring homes (TESS-NH)’, The Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 57(2), pp. S69–S78. doi: 10.1093/geronb/57.2.S69.
[v] Fleming, R., Bennett, K. A. and Forbes, I. (2013) The Environmental Audit Tool Handbook. Wollongong: Dementia Training Australia (formerly Dementia Training Study Centres). Available at: https://www.enablingenvironments.com.au/uploads/5/0/4/5/50459523/eat_handbook_july_13.pdf
[vi] The King’s Fund (2014) ‘Is Your Care Home Dementia Friendly? : the EHE environmental assessment tool’, The King’s Fund, p. 11. Available at: https://www.kingsfund.org.uk/sites/files/kf/field/field_pdf/is-your-care-home- dementia-friendly-ehe-tool-kingsfund-mar13.pdf.
[vii] Bowes, A & Dawson, A (2019) ‘Designing Environments for People with Dementia: A Systematic Literature Review’. Available at: https://www.emeraldinsight.com/doi/full/10.1108/978-1-78769-971-720191004


Categories: Dementia Design