Entrances and exits
Good design of entrances and exits is important for people with sight loss and dementia. With good design of both internal and external entrances and exits, people with dementia and sight loss will be able to move easily between rooms and to enter and leave buildings freely. Some guidelines in this section relate mainly to care homes, e.g. advice about emergency exits, but most are applicable to both individual homes and shared residential accommodation.
What do the ticks mean?
helps or is of benefit to most people
helps or is of benefit to some people
helps or is of benefit in specific circumstances
means that this aspect of design needs to be considered carefully before being adopted
Where house alarm systems are fitted, control panels which have tactile markings and audible confirmation when keys are depressed are easier for people to use.
Intercoms that allow entrance doors to be answered from anywhere in the house can be helpful. Colour, contrast and lighting can help external intercom panels to be seen.
Some people may find it helpful to have equipment fitted to exterior doors which provides an audible warning whenever the door is opened to let them know when others have entered their homes.
Accessibility of entrances and exits
Whether in people’s own homes or in care homes, all doorways should be wide enough to be easily accessible for people with different levels of mobility. Additionally, external entrances and exits should be designed to provide easy access to outdoor spaces.
Door thresholds should be as low as possible because thresholds which are not flush to the floor can be trip hazards.
Handrails help people to use steps safely. Where steps lead up to front doors or to entrances to buildings, handrails should be provided. Handrails should extend beyond the first and last steps so that people can grip them before starting to go up or down.
Larger landings at stairs are helpful to people with sight loss.
Sliding doors may help some people and may reduce the hazard of people walking into door edges. However, it is important to be aware that they may cause confusion for others and to base choices on people’s individual needs and preferences.
In some circumstances, to prevent injury from accidental collisions, it might be appropriate to replace standard door handles with recessed door handles. However, this will depend on individual preferences as some people may find recessed handles harder to locate or confusing and difficult to operate.
Visibility of entrances and exits
Colour coded doors and/or door frames draw attention to the doorway and assist people to identify their front doors or doors to specific rooms. For example, front doors painted in colours that contrast strongly with the front of the building are more easily spotted from a distance, and coloured bathroom and bedroom doors can help people identify these rooms. Colour and contrast can also be used to highlight key features such as: door handles; keyholes; letterboxes; bells, buzzers or door knockers. It can be useful to supplement interior doors with appropriate signage or pictures, as some people may find it difficult to remember what the colours signify.
There may be circumstances where going through a particular door would expose a person to risk of harm, for example where doorways lead directly to steps down to cellars or to rooms with unguarded machinery or exposed heat sources. In such circumstances, visual barriers such as dividers, cloths, and blinds which obscure all or part of a doorway can disguise a doorway and/or deflect attention from it.
Sometimes people will repeatedly try to use doors which are designed only to be used in emergencies. Whilst it is possible to use visual barriers to disguise emergency exits, this has implications for safety and many consider this to be inappropriate. If this is a problem it is better to use other ways of diverting the person’s attention away from the door, e.g. providing other activities.
Lighting at entrances and exits
Additional interior and exterior lighting at entrances and exits makes them easier for people to use. Entering through a front door can be made easier by providing motion or sound-activated exterior lighting which comes on as people approach their doors. Illuminating key parts of the door can also be helpful, for example by using lighted key holes and lighted doorbells.
Points for reflection and further consideration
The information about door security used to create these guidelines came primarily from the findings of research on the needs of people with sight loss, rather than on studies which looked at people with both sight loss and dementia. People with dementia who are not familiar with their use might find intercoms or audible warnings alarming or confusing. Users of these guidelines should give due consideration to this when thinking about potential changes.
Careful consideration needs to be given to the ethical and safety implications of disguising entrances and exits. In particular, it is important to recognise people’s right of free movement, to try to understand why a person is repeatedly trying to leave their home, and look for solutions which address the cause of this. Nevertheless for safety reasons there might be some instances where disguising access may be deemed necessary.
We conducted a structured literature review which involved systematic searches of a wide range of electronic databases, complemented by consultation with expert informants who were asked to recommend materials (such as reports) that the searches might not have identified. The searches yielded 14,616 ‘hits’. 14,043 were discarded as either duplicates or not relevant, and the remaining 573 were scored for relevance on the basis of title and abstract. In total 33 publications were included for full text review: 28 based on relevance scores, and 5 items recommended by expert informants.
These were systematically evaluated using a proforma which enabled assessment of the quality of the research reported, and assembled key information regarding the subject matter, results and conclusions of each item. The quality criteria used to assess different types of research were drawn from standard protocols including Centre for Research and Development (CRD) Report No 4, Cochrane Effective Practice and Organisation of Care (EPOC) checklists and, as appropriate, Critical Appraisal Skills Programme (CASP) assessment criteria (NHS CRD 2001; Cochrane EPOC 2002; CASP undated). Each publication was rated as being of High, Medium or Low quality, based the extent to which the research as reported in the publication meets the relevant quality criteria, and an overall rating was provided for each of the sections within the guidelines. Publications rated as being of lower quality are still of evidential value, but should be regarded as providing suggestive rather than definitively evidenced findings.
We assessed the overall quality of published evidence for guidelines in this section as Low. We based the guidelines on evidence contained in the following publications:
- Best R. and Porteus J. (2012) ‘Housing our Ageing Population: Plan for Implementation. HAPPI2’, Report of the All Party Parliamentary Group on Housing and Care for Older People [document on the internet]. November 2012 [cited 2013 Nov 29]. Available here.
- Edgerton, E. A., & Richie, L. (2010) ‘Improving physical environments for dementia care: making minimal changes for maximum effect’, Annals of Long Term Care, 18(5), 43-45.
- Goodman, C. and Watson, L. (2010) ‘Design guidance for people with dementia and for people with sight loss’, Thomas Pocklington Trust Research Findings Number 35 [document on the internet]. December 2010 [cited 2013 Nov 29]. Available here (and full report available on request from Thomas Pocklington Trust).
- Kelly, F., Innes, A. and Dincarslan, O. (2011) ‘Improving care home design for people with dementia’, Journal of Care Services Management, 5(3), 147- 155.
- Letts, L., Minezes, J., Edwards, M., Berenyi, J., Moros, K., O'Neill, C. and O'Toole, C. (2011) ‘Effectiveness of Interventions Designed to Modify and Maintain Perceptual Abilities in People With Alzheimer's Disease and Related Dementias’, The American Journal of Occupational Therapy, 65(5), 505-513.
- Long, R.G. (1995) ‘Housing design and persons with visual impairment: Report of focus-group discussions’, Journal of Visual Impairment & Blindness, 89(1), 59-69.
- Unwin, B.K., Andrews, C.M., Andrews, P.M., & Hanson, J.L. (2009) ‘Therapeutic home adaptations for older adults with disabilities’, American Family Physician, 80(9), 963.
Our expert interviewees said
- People with sight loss and dementia might benefit from high contrast door frames
- In care homes, different coloured bedroom doors might replicate those of previous home doors and help people to find their way around
People with dementia and with sight loss and their carers
taking part in interviews and focus groups told us
- Using contrasting colours for doors and door frames can help these features stand out
- Yellow bathroom doors can be seen more easily
- In rooms with insufficient light, it can be difficult to see where the doors are
- Motion sensor lighting outdoors can be infuriating if sensors are too sensitive and set off by wildlife
The survey found
- Out of 86 people who answered questions on this section, 77% thought that guidelines on lighting would be ‘very helpful’ and a further 22% thought they would be ‘helpful’
- When people were asked to either agree, disagree or say that they were unsure about a series of statements, the highest levels of agreement were in relation to: need to have door thresholds flush to the floor (99% agreed); having entrances and exits accessible to wheelchairs (98% agreed); importance of having handrails at entrance stairs or steps (98% agreed); providing easy access to outdoor spaces (98% agreed); use of colour coded doors and door frames (91% agreed)
- The highest levels of disagreement or uncertainty were in relation to: use of recessed door handles (35% disagreed, 45% not sure); disguising emergency exits to reduce attempts to use the exit (33% disagreed, 33% not sure); use of sliding doors (16% disagreed, 41% not sure)
Selected quotes from people completing the survey
- ‘I feel that it is particularly difficult for individuals who do not have a visual impairment to understand the complexities of everyday things for those who do.’
- ‘Sliding doors can cause finger injuries if they are slid across too quickly, such as when a user's spatial awareness is impaired. Also, if glass, there is a danger of a user not seeing whether the door is open or not - or becoming confused by any decorative markings (like coloured spots) used on the glass as a safety measure. Stairs should have deep enough treads to fit the user's foot comfortably, risers that are not too high for the user's leg to raise easily and the stair should not be too steep. My mother has difficulty walking, as well as dementia & she ended up at home shuffling up/downstairs on her bottom because she couldn't manage the stairs. I don't know how much this was physical discomfort and how much an inability to see clearly which step was which (particularly coming down), so good lighting and step markings are required. The homes I've visited have electronic doors, with security codes and alarms which seem to work well, though it's not been unusual to see residents hovering by the door in the hope they can slip out when it's opened!’
- ‘Not at all sure about ‘disguising' entrances/exits - and certainly should not compromise safety. However we must recognise the tension between discouraging access/egress for safety reasons and the confusion and anxiety that can be caused by doing this.’
- ‘Fixtures and fittings would need to be installed with the needs of the individuals taken into account and may therefore be different within different settings.’