Interior Designer Resources Directory :: Interior Design Article

Insights and Strategies for the Design Professional: The Cognitively Challenged and Interior Design

Everyday, we walk through crowds of people, greeting and smiling at them as we go. They appear 'normal,' yet statistics indicate that any one of them could be someone who is either cognitively challenged or is a caregiver of someone who is. Whether a child who is a near drowning victim, a teenager with Asperger Syndrome, an executive recovering from traumatic brain injury or an individual suffering from Alzheimer's disease, all need special consideration when planning and designing spaces.

Understanding the different causes and resulting behaviors of brain injury or dis-ease, helps the design professional apply the researched best practices to create environments that will not cause agitation and will increase the quality of life of their clients. What are the main condi-tions causing cognitive dysfunction and the statistics associated with them? Let us examine some of them.

Tommy is a four year old near drowning victim. Near drowning is considered to be an acquired brain injury and in Tommy’s age group (0-4), there are 596,000 near-drowning cases per year in the U.S. Of those 596,000 cases, approximately one third of the victims are comatose on admission to the hospital and will suffer significant neurological damage. The cost is approximately $100K per year for severe cases. (American Academy of Pediatrics, Center for Disease Control, 2000) While on the outside, he appears normal; his brain injury can be complex and cause cognitive dysfunction as he matures. (Foundation for Responsible Television/Bond-Chapman, 2003)

Our next victim is Mary, a successful executive with a local bank and a traumatic brain injury victim resulting from an automobile accident. Her injury is considered to be moderate, so she will recover or will successfully learn to compensate for the resulting deficiencies. The statistical com-parison of more publicized conditions is staggering. There are 1.5 million incidences of traumatic brain injury annually as compared to 10,400 incidences of Multiple Sclerosis, 11,000 incidences of Spinal Cord Injuries, 43,681 cases of HIV/AIDS or 176,300 cases of Breast Cancer!(Brain Injury As-sociation of America, 2000)

Adam is a teenager with Asperger Syndrome. He is intelligent (genius IQ), very mechanical and has great language skills. When he was in the 9th grade, he stopped learning and could not be stimulated. His difficulty relating to people and social environments increased, however by main-streaming him in a school based on empathy and acceptance of individual needs, his success has greatly improved. Those with Asperger Syndrome do not like change. It took over a year to convince Adam to allow his room to be updated from that of a five year old to that of a teenager. (Leigh, 2004; Online Asperger Syndrome Information and Support, http://www.udel.edu/bkirby/asperger/aswhatisit.html)

Robert is our recently retired golfer who was looking forward to many relaxing hours on the golf course. Unfortunately, he recently suffered a series of mini strokes (TIAs) and has become a victim of Multi-Infarct Dementia. Robert’s dream of an active and independent retirement has dimin-ished and chances are he has only to look forward to the eventuality of Senile Dementia of the Alz-heimer’s Type (technical term for Alzheimer’s Disease or AD) Statistics show that 62% of women have Alzheimer’s Disease versus 32% of men and that 85% of the victims are white. Because of the “Age Wave,” the demographic prediction of future cases increases from 4 million Americans in 2000 to 14.3 million in 2050. (Alzheimer’s Association, 1990)

With statistics such as these, perhaps it is now easier to understand why design professions need to understand how to increase the quality of life of these individuals through the environment. What about the brain itself and the previously mentioned conditions? Let us take a moment to learn about the brain and the conditions that can cause cognitive dysfunction.

The brain is one of the, if not the most complicated organs in the body. It contains over 10,000 million nerve cells and has no pain sensing nerves. For this reason it doesn’t know when there is something wrong until the problem manifests itself in another part of the body. (Foundation for Responsible Television, 2003). The challenge occurs when cells are damaged due to trauma and do not re-generate or a condition causes them to die. When there is an injury or the presence of a degenerative disease, the result can be thinking changes, physical changes or personality and be-havior changes. These changes alter the way the victim sees and experiences their environment. (Brain Injury Resource Center, 1998; Headway Essex)

There are several possible causes of cognitive and/or physical challenges. They include Learning Disabilities, Traumatic Brain Injury (TBI), Acquired Brain Injury (ABI), Genetic Diseases and Degenerative Diseases. Learning disabilities such as Attention-deficit Hyperactivity Disorder (AD/HD) affect peoples ability to hear and see and often are caused by chemical disconnects. Trau-matic Brain Injury is damage to brain tissue caused by external force such as motor vehicle acci-dents, acts of violence, falls, sports, and blows to the head or lightening strikes. The types of Trau-matic Brain Injury include Diffuse Axonal Injury, Concussion, Contusion, Coup-Contrecoup Injury, Second Impact Syndrome (Recurrent Traumatic Brain Injury), Penetration Injury or Shaken Baby Syndrome. Acquired Brain Injury (ABI) is internal damage to the brain caused by strokes, tumors, anoxia, hypoxia, toxins, and near-drowning.

Now that we have discussed Acquired Brain Injury let us look at Genetic Diseases which include Autism and Asperger Syndrome. These diseases are characterized by the sufferer living in their own world, high intelligence and disruptive behavior when their world is disrupted. Degenerative Diseases are diseases that affect brain function and progressively worsen rather than improve until death occurs. The most common of these diseases is Senile Dementia of the Alzheimer’s Type (DAT or Alzheimer’s Disease). Other diseases include HIV/AIDS, Parkinson’s Disease, Huntington’s Disease, Pick’s Disease and Creutzfeldt-Jakob Disease. All three of these causes of cognitive dys-function can result in various forms of dementia. (Brain Injury Resource Center and Headway Essex)

Dementia is a mental state characterized by a loss of intellectual ability that is long lasting and displays a decline in memory and other intellectual functions. It is NOT a disease, but a group of symptoms, which include: agitation, depression, memory loss, fearfulness, and difficulty with new learning. The term senility is gradually being replaced with the term dementia and research has shown that aging does not necessarily include dementia. The cognitive challenge brought on by de-mentia can manifest itself in physical dysfunction, memory dysfunction, learning dysfunction and rea-soning dysfunction. All of these dysfunctions can result in stress, functioning difficulties and behavior problems for victims. It is through these different dysfunctions that design strategies can be organ-ized to help these victims interact in a more positive way with their environment.

One of the best strategies for the design professional to use when working on a design pro-ject involving someone with a cognitive challenge is to employ the concept of “Designing In the 4th Dimension.” This concept is one of empathic design or one where the design professional places himself or herself in the place of a client with cognitive dysfunction. The designer asks, “What do they see, …. how do they feel, ….what is their world like? Designing in the 4th dimension can help the client compensate for their dysfunction, therefore increasing the quality of their life. (Malkin, 1992) To maximize this process, there are therapeutic goals that should be employed. They are to: 1)ensure safety and security; 2) support functional ability through meaningful activity; 3) maximize awareness and orientation; 4) provide opportunities for stimulation and change; 5) maximize auton-omy and control; 6) adapt to changing needs; 7)establish links to the healthy and familiar; 8) provide opportunities for socialization; 9) protect the need for privacy. (Cohen, et.al., 1991) To continue the strategy, we can examine design opportunities and physical dysfunction.

Universal design and addressing the victim’s five senses are two ways to compensate for physical dysfunction that might occur due to their altered cognitive state. Embracing a universal de-sign philosophy will enable all people to interact to the fullest extent with their environment. Univer-sal design is the design of products and environment to be useable by all people to the greatest ex-tent possible without the need for adaptation or specialized design and it incorporates seven princi-ples: 1) equitable use; 2) flexibility in use; 3) simple and intuitive use; 4) perceptible information; 5) tolerance for error; 6) low physical effort; 7) size and space for approach and use. (Center for Univer-sal Design) The five senses include vision, hearing, taste, smell, and touch. Vision and hearing defi-ciencies seem to cause most frustrations, therefore problem behavior where smell and touch are used as comfort and security interventions. (Center for Universal Design)

When our vision is affected, frustration occurs even when we are thinking clearly. Add the dimension of cognitive challenges and the result is sure to be agitation and disruptive behavior. The following are several strategies that can be used by design professionals. Provide exposure to natu-ral light. Edwin Babbit, MD, a noted physician said, “ . . . put the pale, withering plant or human be-ing into the sun, and if they are not too far gone, each will recover health and spirit.” (Brawley, 1997) Avoid surfaces that produce glare both on vertical and horizontal surfaces. When one has dementia, visual cliffing (misinterpretation of changes in colors as differences in depth, elevation or plane changes) becomes a challenge when floor types, textures or colors are changed or there is the pres-ence of glare or shadows. Stalling which is the inexplicable action of walking and then suddenly stop-ping, is often the result of visual cliffing. Stalling is a major reason for falls and interestingly enough, the result of not wanting to fall in the first place.

Another visual challenge is the subject matter in art. A simple carved tablet with a face may appear that a person is trapped to a person with an altered cognitive state. This can easily create fear, concern, and then agitation. Painting subjects can also elicit the same response, so care in choosing art should be taken. (Brawley, 1997 and Warner, 2000) Color can be a challenge especially for those with vision problems due to a chronic condition or age. Pastel colors, especially toward the cool end of the spectrum (blues, greens or purples) are harder to see. They can appear gray. This can cause frustration when color alone is used as a way finding cue. Research has shown that the use of full spectrum color theory can positively influence ones psychological, physical and social well being. This would certainly be true for victims of cognitive dysfunction. There must be a presence of green, yellow, orange, red, violet indigo and blue meet the criteria for full spectrum color. (Brawley, 1997 and Marberry, 1995)

We see using contrast, so when our vision is affected and our cognitive state is altered, cre-ating contrast can decrease frustration and reduce the number of falls. Examples of contrast appli-cation would be to create contrast between: walls and floors, the toilet and wall and floor, furniture and wall and floor, stair treads and counter tops. Pattern creates interest in the environment, but certain patterns are problematic for those with cognitive problems. Patterns creating movement such as a flame stitch or geometric can cause a mobility or balance problem for some. Stripes can resem-ble bars and symbolize imprisonment. Agitation is soon to follow. Patterns that are very realistic such as an apple wallpaper border may cause the cognitively challenged person to try to “pick that apple” until they destroy the paper, not to mention the agitation that will be caused due to increased hunger. (Brawley, 1997; Warner, 2000; Namazi, 1993)

Lighting is another vision related issue. Evenly distributed light, without glare or shadows, is desired. Task lighting in the rehabilitation setting or home environment must be adequate for the task to prevent frustration. By providing gradual lighting transitions between interior spaces and the inside to outside, the person with cognitive dysfunction will react more favorably to their environment. As one recovers from brain surgery, intense light is greatly intensified. Any light is like a “headlight in the night” to them until the brain heals. Therefore, these transitions, as well as flexibility of lighting control are essential. This lighting control can be accomplished using adjustable window treatments and dimming devices on all lighting controls. After lighting, the auditory quality of an environment is the next crucial area of concern for the design professional. (Brawley, 1997 and Warner, 2000)

We all know that when we are stressed, the wrong auditory stimulation can greatly increase our stress level. Just imagine the same environment and the confusion and frustration that are ex-perienced by the cognitively challenged! Designing spaces to minimize the wrong auditory stimula-tion is the goal of the design professional. Quite simply, minimize the use of hard, reflective surfaces and balance the combination of absorbent surfaces with reflective surfaces. Using rugs, fully uphol-stered furniture, draperies and acoustic ceiling tiles can help create the desired balance.

Because of their cognitive challenge, victims of brain injury or degenerative diseases often retreat into their own world. It can be said that they retreat into their soul. The sense of touch and smell help them when they are in their own world. Tactile changes comfort us and is said to afford stimulation for those living in their own world. Research indicates that texture stimulates thinking and responsiveness and helps recall memories. It is especially useful in the rehabilitation process. De-signers should plan for tactile luxury through the use of quilts, soft surface wall hangings, textured wall coverings and pillows of all shapes, sizes colors and textures. Specifying zippered covers facili-tates keeping the pillows clean. Lorraine Hyatt, a pioneer in the study of environment, aging and long term care sums up the design professionals responsibility when she said, “Our task is to replen-ish that which has been inadvertently removed, to provide human and inanimate sources of stimula-tion within each individual’s needs, and to consider texture and human contact as a resource in our overall program of care and environmental design.(Brawley, 1997) Research on peoples ability to smell indicates that smells travel to our brains faster than even sight and sound. It is attached to our emotions primarily because the olfactory system (smell) is connected to the limbic system which con-trols emotional memory processing. Pleasant scents and aromas should be facilitated by the de-signer because they are stress reducing. While too much stimulation of the senses can be over-whelming for the cognitively challenged, sensory deprivation must also be avoided. M.D. Vernon, a noted British psychologist sums up the need for sensory stimulation when he said, “When there is not change, a state of sensory deprivation occurs; the capacity of adults to concentrate deteriorates, attention fluctuates and lapses and normal perception fades.” (Brawley, 1997)

From physical dysfunction let us look at learning dysfunction. The design professional’s main challenges in this area are space planning, safety and wandering. The key to wandering is to make it safe and non-disruptive with paths that flow continuously. They can be in the shape of a cir-cle, square, rectangle or triangle. Straight line paths with barriers at each end only produce agitation for those suffering from dementia. Night wandering can be reduced or controlled by creating the only exit through the staff or caregiver’s space or through the use of a Dutch door. With a Dutch door, they can see out, but cannot get out to wander. Furniture arrangement can simplify the environment for those who are not thinking clearly by eliminating as many paths of travel as possible. Keep any changes to existing arrangement to minimum, yet simplify the arrangement. (Cohen, et.al., 1991)

Another space planning tool is to create views into adjoining spaces or to see out of spaces. The Dutch door allows the cognitively challenged person to see out, while vistas to adjoining spaces allow them to see in to eliminate fear of the unknown and to encourage socialization. (Cohen, et.al., 1991)

When we think of safety, designers should consider “eliminating dangerous options” by plan-ning openings into enclosed gardens to invite exploration, but not escape. Doors for exit or those protecting dangerous options can be disguised and locking devices that eliminate frustration on the part of the person with cognitive dysfunction can be used. non-evasive and silent wandering alarm systems can also be specified by the design professional. Dangerous objects must be stored out of sight in visually integrated locked spaces and appliances can be equipped with control lockout de-vices and magnetic induction cook tops. (Leibrock, 2000)

From learning dysfunction, we now turn to memory dysfunction. Wayfinding, incontinence intervention and dressing are three key memory dysfunction challenges to be overcome by the de-signer. The basic premise for wayfinding in any environment is for the occupant to be able to read the surroundings, know where they are, make appropriate decisions and reach their destination. When dealing with those with mild to moderate brain injury, their rehabilitation process includes “re-learning.” However, for those with degenerative diseases such as Alzheimer’s Disease, there is no new learning. For both parties, the use of cues such as landmarks, architectural detail or historic references are helpful, but for those with no new learning capacity, they are essential. The designer can use doors of similar design and color to their front door at home to help them know their room or apartment. Shadow boxes or built-in shelf niches with significant items they recognize can be useful as well. Use a combination of color, pattern and landmarks to help mark the way from public spaces to private spaces. Clear colors, simple patterns and landmarks such as clocks or historically or re-gionally significant paintings or prints also help eliminate confusion. (Brawley, 1997 and Warner, 2000) Next, let us talk about the sensitive issue of incontinence

There are several types of incontinence including medical incontinence, environmental in-continence, incontinence due to poor judgment/balance and cognitive incontinence. (Ferrini, 1992) Medical incontinence is a programming or training issue. However, environmental incontinence is where the design professional can help mediate the problem through arranging the space to where the toilet is near and/or clearly visible to the person with the cognitive challenge. (Namazi, 1996) Specifying lift chairs that help conserve strength so they will make the effort to go to the bathroom can be a contribution by the design professional as can specifying higher toilets with automatic lift toilet seats. When there is cognitive dysfunction, dressing can be a major challenge for a person. Decisions are difficult, so simplicity and organization becomes the key for the designer. Designing closets with sliding doors limit choices because only one half of the closet is seen at a time and drawers in case furniture can be labeled with pictures of their contents. These help with finding items, but not with the order of dressing. A challenge for those who are re-learning the dressing process or for those who have forgotten and cannot re-learn the process is getting the order right. Special care wardrobes are available that have one lockable side for storage and the other that pro-vides organization capability for laying out clothes in the appropriate order. A built in niche or a multi-armed clothing display rack can also be used to organize the clothing in the appropriate order. (Brawley, 1997 and Warner, 2000)

Now, what about reasoning dysfunction? Some of the most common reasoning dysfunctions creating challenges for the design professional are: rummaging, reflections, catastrophic reactions, Sundowning, picking and bathing. Rummaging is usually associated with the need to search by those suffering from dementia. Once it is found, it is taken, then horded or hidden. This behavior is a major source of disruption. Key mediation tactics for the designer are to specify lockable spaces for valuables. Place things so that it is easy to determine when they are missing, therefore “a place for everything and everything in its place. Create a rummaging area. Create controlled hiding places and eliminate dangerous hiding places such as drains. Reflections are disturbing for those with de-mentia. If portable, remove mirrors and if permanent, cover them with fabric or paint them with water based paint. Catastrophic reactions are extreme emotional or physical outbursts due to agitation or frustration. When creating space and furniture plans, allow for the escape of care givers in the case of these types of reactions. As design professionals, it is our responsibility to protect everyone, not just the person who is cognitively challenged.

Sundowning syndrome is a phenomenon characterized by agitation, heightened confusion or unusual behavior during later afternoon or early evening. Case studies are indicating that the use of light, both natural and artificial, helping to mediate the agitation. Maintaining circadian rhythms through controlled sleep patterns clearly defined daytime and nighttime environments is also helpful. The designer should provide a means for adjusting light to create the day/night environment espe-cially on overcast days. Picking is another reasoning dysfunction and is an inexplicable fixation where the touching, handling or working to remove small items, bit by bit is practiced. Items of inter-est, such as fabrics resembling pieces of lint or realistically depicted fruit or flowers should be avoided in the design professional’s concept. (Alzheimer’s Association, 1999)

Bathing is the last, but probably the most challenging time of the day for those dealing with the cognitively challenged. Why? Because of a possible change in senses, the cognitively chal-lenged may not think they need to bathe. There is a loss of control on their part and bathing is a very private time. Fear and safety is another concern. To address these issues, the design professional can make the space small and intimate. Use accessorization through pictures and floral arrange-ments as well elements to create privacy. Control the acoustics of the space with curtains and other fabric applications. The temperature must be adjustable and the lighting evenly distributed. Non-skid floor surfaces and strategically placed grab bars must be specified to eliminate the fear of fal-ling. (Brawley, 1997)

Now that the design professional understands the need of those who are cognitively chal-lenged, they can better implement the project. Some of the most relevant design elements for effective spaces for the cognitively challenged are the specification of finishes, furniture and equipment (FF&E). When choosing paint finishes, they should be non-reflective, therefore an egg-shell finish for walls and semi-gloss for trim. Wall coverings placed in an institutional occupancy must be rated as a Class A or 1 rating with a type 2 or 3 weight rating for durability. Specify an-timicrobial backing and remember there is a pattern and color issue for those with cognitive dys-function. Be sure to specify corner guards in hallways with in a color as close as possible to the wall color to avoid distraction by residents. The use of a combination of simple crown molding, wall paper border and painted walls can create a value engineered residential ambiance. (Brawley, 1997)

Floors must be of a non-slip (= 0.5 slip resistance coefficient) and non-reflective finish. Car-pet helps with the acoustical control of the space but must be of durable, roller friendly construction that includes a moisture barrier back and an anti-microbial system. The enemy of the person with cognitive dysfunction in ceiling design is the hard, smooth, nonporous surface that reflects sound. Acoustical ceilings have sound absorption qualities that help design professionals create effective acoustical environments. (Brawley, 1997)

Case furniture must be designed for rigors of the cognitively challenged. Mechanical fastener systems where steel to steel connectors lock the furniture together rather than the typical glue joint construction enable the pieces of furniture to meet quality standards, yet to allow for the replacement of damaged components. This type of construction is essential where catastrophic reactions are prevalent. (Nemschoff Furniture) Specify case furniture that meets universal design requirements with regard to table heights and wheel chair clearances.

Seating provides its own set of challenges for the design professional. All chair construction must have strong back legs and stretchers if possible to accommodate the client’s tendency to fall into the chairs rather than sitting. This is especially true for those going through the rehabilitation process. Seat heights of 18 to 19 inches make getting into and out of the chair easier. Arm length should be even with the front of the chair or slightly longer if possible to help with the sitting and standing process. Where groupings of 10 or more fully upholstered seating pieces are used, con-struction specifications should meet California Technical Bulletin 133 for large scale applications. Other seating should meet criteria of California Technical Bulletin 117 for small scale applications. Newly developed fabrics such as Crypton fabrics are now being offered in tapestry, damasks, prints and solids. They are water and stain resistant, antimicrobial, antifungal, antibacterial, strong and breathe like natural upholstery and drapery fabrics. They are extremely durable, yet comfortable when seated. (Brawley, 1997)

Window treatments enable light and room temperature to be controlled while at the same time add to the residential character of the space. They too must be of sturdy construction and sim-ple to operate because those who are cognitively challenged find them extremely frustrating to oper-ate. If in an institutional setting, drapery fabrics must meet established vertical flame test ratings.

All of these design strategies can be used for those with dementia or Alzheimer’s disease as well as for those with other cognitive challenges. The statistics shared earlier in this paper reveal the prevalence of those suffering from these conditions. Interior environments are essential to those with cognitive challenges. Their world is not one of their choosing, so creating appropriate design solu-tions is the design professional’s gift for a richer quality of life. With knowledge and compassion, design professionals can make a difference in the lives of others.

Resources: American Academy of Pediatrics, [Online] Availiable: http://www.aap.org

Azheimers Association, [Online] Available: http://www.alzheimers.org.

Ashley, Mark J., Centre for Neuro Skills, [Online] Available: http://www.neuroskills.com.

Brawley, Elizabeth C., Designing For Alzheimer’s Disease, John Wiley & Sons, Inc., New York, 1997.

Brain Injury Resource Center, Learn About Brain Injury, [Online] Available, http;//www.headinjury.com.

Campbel, Amy, It’s All in the Details, Assisted Living Success, March 2001, [Online] Available: http://www.alsucces.com/articles/131feat1.html.

Center for Disease Control, [Online] Available: http://www.cdc.gov

Center for Universal Design, [Online] Available: http://www.design.ncsu.edu/cud/

Cohen, Uriel, Day, Kristen, Contemporary Environments For People With Dementia, The Johns Hopkins University Press, Baltimore, 1993.

Cohen, Uriel, Holding On To Home: Designing Environments for People With Dementia., The Johns Hopkins University Press, Baltimore, .

Coons, Dorothy H., Specialized Dementia Care Units, Johns Hopkins University Press, Baltimore, MD, 1991.

Cooper, Barbara A., A Model for Implementing Color Contrast in the Environment of the Eld erly, The American Journal Of Occupational Therapy, 39,4, April 1985,253-257.

Cox, Sylvia, Keady, John, Younger People with Dementia: Planning, Practice and Develop ment, Jessica Kingsley Publishers, Philadelphia, PA, 1999.

Ferrini, Armeda F., Ferrini Rebecca L., Health In The Later Years, William C. Brown Communications, Inc., 1992.

Foundation for Responsible Television, The McCuistion Program: Discoveries and Hope for Brain Health, Foundation for Responsible Television, Dallas, TX, 2003.

Foundation for Responsible Television, The McCuistion Program: A Lifetime of Brain Build ing, Foundation for Responsible Television, Dallas, Tx 2003.

Headway Essex, Brain Facts, Headway Essex, [Online] Available: http://www.headwayessex.org.uk/facts/brain/

Hitzfelder, Nancy, Sensory integration Dysfunctions: Helping the Child at Home. Easter Seals of Greater Dallas, 2002.

Jones, Beth F., Key Lighting Elements for an Aging Population, Interior and Sources, [Online] Avail able: http://www.isdesignet.com/Magazine/Sep96/Lightelements.html.

Leibrock, Cynthia, Design Details for Health: Making the most of interior design’s healing potential, John Wiley & Sons, Inc., New York, 2000.

Leigh, Katherine, Creativeity and Innovation in Practice, Texas Chapter of ASID Annual Meeting, 2004

Marberry, Sara O., Zagon, Laurie, The Power of Color: Creating Health Interior Spaces, John Wiley & Sons, Inc., 1995.

Namazi, Kevan H. A Design for Enhancing Independence Despite Alzheimer’s Disease, Nursing Homes, September, 1993.

Namazi, Kevan H., Issues Related to Behavior and Physical Environment: Bathing Cognitively Impaired Patients, Geriatric Nursing, 17,5, September/October, 1996.

National Institute On Aging (2002) Resources, [Online] Online Asperger Syndrome Information and Support, [Available Online: http://www.udel.edu/bkirby/asperger/aswhatisit.html]

O’Neill Michael J., Effects of Signage and Floor Plan Configuration on Wayfinding Accuracy, Environment and Behavior, 23,5, September1991, 553-574.

PubMed, Search Service of the National Library of Medicine.

Rauma, Peter J., An Interior Wander Path, Nursing Homes, 46,6, June, 1997, 31.

Taira, Ellen D., Carlson, Jodi L., Aging in Place: Designing, Adapting, and Enhancing the The Haworth Press, Inc., New York, 1999.

Warner, Mark L., The Complete Guide to Alzheimer’s-Proofing Your Home, Purdue University Press, West Lafayette, Indiana, 2000.

Note: Bolded Items are Recommended Books or Web Sites for Design Professionals with spe-cial interests in this subject

Jim Marstiller received a BFA degree in interior design from Texas Tech University in 1975. For over 25 years, he has practiced interior design in several specialties including residential, corpo-rate, store planning, healthcare and facilities management. Because of his interest in healthcare design, he returned to school at the University of North Texas. In 1998, he received a MS degree in Applied Gerontology where his studies focused on environments for the aging. He is NCIDQ certified, is a Registered Interior Designer in the State of Texas and an ASID Fellow. As a leader in ASID, Jim has been trained as a presenter and trainer for the Society. Currently, he uses this training as an adjunct instructor at The Art Institute of Dallas and writes and presents continuing education programs in the areas of health, safety and welfare, aging and ethics. Jim currently practices design as the facilities designer and manager for the Texas market of Gabberts Furni-ture and Design Studio.