Dementia-friendly Environments Research Articles

Dementia Friendly Buildings—Approach on Architectures

Dementia’s escalating incidence, coupled with its economic burden, highlights the need for architectural designs and forms that benefit people living with dementia. This research explores strategies and design principles that focus on establishing supportive spaces for the prolonged autonomy, well-being, and safety of dementia patients. Contemporary research emphasizes the implementation of effective navigational techniques, via visual cues, familiar landmarks, and simplified layouts. For greater navigational signage, the intentional use of contrasting colors, textures, and lighting are recommended to demarcate functional areas within a structure. Incorporating familiar objects in personalized areas enhances treatment outcomes, e.g., reminiscence therapy leverages familiar objects, environmental cues, scents, sounds, and tactile features to trigger and retain memory. Integrating safety precautions such as slip-resistant flooring, handrails, and accessible bathrooms helps mitigate falls for the cognitively impaired. From a therapeutic perspective, this study draws attention towards incorporating gardens and outdoor spaces, which offers sensory stimulation, encourages physical activity, and fosters social engagement. Additionally, the integration of scents, sounds, and tactile features enriches the sensory experience for individuals with dementia. Through comprehensive consideration of design elements, this research highlights how intentionally crafted, dementia-friendly environments can convert spaces into empowering therapeutic settings tailored to address the unique need of this vulnerable group. This architectural approach acts as a valuable complement to the medical and therapeutic interventions in the treatment and care of people living with dementia and their families.

Effects of Route Complexity and Lighting on Route Following in Alzheimer's Disease and Posterior Cortical Atrophy.

Visual processing deficits arising in dementia are associated with particular functional disability. This study aimed to investigate the effects of the built environment on mobility and navigation in people with dementia-related visual loss. Participants with posterior cortical atrophy (PCA; "visual-variant Alzheimer's"; n = 11), typical Alzheimer's disease (tAD; N = 10), and controls (n = 13) repeatedly walked down routes within a simplified real-world setting. Participant groups were of comparable age and gender. Routes were of different complexity (straight, U-shaped, and S-shaped), overhead lighting levels (low and high) and with or without a dynamic LED (light-emitting diode) cue (trial n = 24). Ratios of walking times for each experimental condition (each complex route vs the straight route, high lighting vs low, and LED cue vs no cue) were compared between participant groups. Kinematic measures were produced from a total of 10,813 steps using wearable inertial measurement units (IMUs). The walking time ratios relating to route complexity were higher in the PCA group than in controls: 30.3% (95% CI [13.5%, 49.5%] higher for U-shaped vs straight and 31.9% [21.1%, 55.3%] for S-shaped vs straight, averaged over other conditions). The analogous results relating to route complexity for the tAD group were intermediate between those for the PCA and control groups. There was no evidence that walking time ratios differed according to lighting level or the presence of the LED cue. Findings contribute to evidence-based design for dementia-friendly environments, emphasizing consequences of environmental complexity for functional independence and mobility in people with dementia-related visual loss. Findings inform recommendations for environmental design to support the independence of individuals with dementia.

Home Through Their Eyes: A Qualitative Exploration of the Meaning of Home for Persons With Dementia and Impact of Physical Environment During Meaning-Making.

This study aimed to examine the meaning of home for persons with dementia and the role of the physical environment during their meaning-making process. In response to a growing number of persons with dementia, there has been a strong advocacy for prioritizing the development of dementia-friendly environments within design practice and research agendas, for which "home" has become one of the important loci. However, of the limited studies on the meaning of home from the perspective of those individuals who continue to live in their own homes after developing dementia, even fewer addressed this issue within the Chinese context. Five dyads, persons with dementia and their family caregivers, participated in the qualitative phenomenology study. Ten home visits-2 visits per dyad-were conducted, during which interview data, photographs, and field notes were collected. Phenomenological analysis was applied within and across the data sets. Three key themes emerged-"Three Dimensions of Home" revealed that "home" goes beyond physical residence and immediate family connections, including meaningful objects and places, enduring relationships, self-identity, and lived experiences.; "The Impact of Physical Environment" and "The Impact of Cognitive Impairment" showed the complex interactions between the environment, cognitive impairment, and meaning-making. An exploration of the essence of meaning of home within the Chinese context, in person-environment relationships with dementia progression, and implications for future research and practice on dementia-related environments and care were further discussed. This study contributes insights into enhancing the well-being of persons with dementia and benefiting their caregivers.

Ad Hoc Modifications to a High Dependency Psychiatric Unit for People With Dementia During the COVID-19 Period.

The COVID-19 pandemic led to behavioral exacerbations in people with dementia. Increased hospitalizations and lack of bed availability in specialized dementia wards at a tertiary psychiatric hospital in Singapore resulted in lodging people with dementia in the High Dependency Psychiatric Unit (HDPCU). Customizations to create a dementia-friendly environment at the HDPCU included: (1) environmental modifications to facilitate orientation and engender familiarity; (2) person-centered care to promote attachment, inclusion, identity, occupation, and comfort; (3) risk management for delirium; and (4) training core competencies. Such practical solutions can also be implemented elsewhere to help overcome resource constraints and repurpose services to accommodate increasing populations of people living with dementia.

Exploring Dementia-Friendly Environments in Long-Term Care Facilities: Perspectives from Multiple Stakeholders in Portugal

Current evidence suggests the importance of dementia-friendly environments in enhancing the well-being and quality-of-life of people living with dementia, particularly when they need to move out, either permanently or temporarily, of their own homes (e.g., long-term care facilities or hospitals). As dementia-specific regulations are currently absent in Portugal, most long-term care facilities are not designed to meet the needs of persons living with dementia. Also, this topic has not been the focus of attention by policymakers and researchers in Portugal and there is no recent scientific literature useful for planning new responses for dementia. To address this need, this study examines stakeholders’ perspectives on dementia-friendly environments in Portuguese long-term care facilities. Five stakeholder groups participated, including people living with dementia, caregivers, clinical and non-clinical staff, and experts. Through focus groups and interviews, participants discussed elements of a dementia-friendly environment considering autonomy, independence, mobility, stimulation, orientation, socialization, safety, and care assistance. Thematic analysis identified ten categories, emphasizing indoor (e.g. architectural elements, privacy, ambience, socialization, and safety) and outdoor components (e.g. surroundings, social spaces, and safety). These findings highlight collaborative design’s significance in enhancing the lives of people living with dementia and caregivers, providing comprehensive insights into creating purposeful long-term care environments.

HOME TRIAD: A NEW WAY TO UNDERSTAND THE MEANING OF HOME FOR PEOPLE LIVING WITH DEMENTIA

Abstract Highlighted by the frequent stating “I want to go home,” understanding the meaning of home for people living with dementia (PLWD) is crucial to provide them better care and environment. Our novel theoretical framework, termed ’home triad’, abstracts “home” into three interconnected pillars: conceived, perceived, and lived home. We conducted in-depth interviews with five PLWD, who were over 65 years old with MMSE scores between 11-24, received home care, and could understand and consent to the study. Their caregivers were also consulted for member-checking. The findings showed that the early memories of home were more vivid. The lived home experience held paramount significance; while stable housing was vital, family was of utmost importance to PLWD. Additionally, a gender-based distinction in lived home was evident. It was also found that PLWD’s perceived daily activities and lived memories expanded their home beyond their immediate residence, encompassing neighborhoods, villages, and cities. Within home triad, we noticed that the conceived home, focusing on the discourses of power and knowledge, could easily be overlooked. Yet, focusing on this pillar revealed the pivotal roles of design and caregivers in shaping PLWD’s home, which in turn influenced perceived and lived experiences. Through home triad, we can better appreciate profound home memories for PLWD. This could bolster reminiscence therapy and enable more effective home modifications, or even improve institutional homelike environments. Our future direction aims to refine and apply home triad with more home stories, thereby informing research and practice to enhance dementia-friendly environment and PLWD’s well-being.

Using Simulation-Based Learning (Gamified Educational Network) to Provide Micro-credentialing for Dementia Care Workers

Background:Dementia care is a critical area of need in the community and institutional settings, with estimated one-third of seniors younger than 80 years of age with dementia living in institutional settings and this proportion increases to 42% for those 80 years and older in Canada. It is of critical importance to promote excellence and best practices in dementia care by preparing for well-trained dementia workforce through capacity building.Methods:This project developed a dementia care micro-credential education to enable competency development of new graduates and upskilling of workers through simulation-based learning. This micro-credential program leveraged interdisciplinary partnership, to develop nine core modules related to best practices in dementia care, facilitated with a Gamified Educational Network (GEN). GEN is an evidence-based learning management platform that provides learners with a simulated and immersive experience to engage them in a virtual learning environment that allows for rich experiential interaction with other users and its content.Outcome:Face and content validity was established by an inter-professional committee including geriatric psychiatry, nursing, social work, occupational therapy, behavioral therapy, knowledge mobilization and simulation education experts. Next phase will begin to establish construct validity. It is expected that GEN will have a positive impact on increasing learner’s motivation and engagement in the educational tasks, as well as improving learner’s competencies and outcomes through its multi-modal approaches, including gamification (usage of game-based elements in a non-game context to engage learners and promote learning), active observational practice, independent hands-on practice, case-based discussion, peer-to-peer assessment, expert facilitated feedback, skills debriefing and reflective practice.Conclusion:This micro-credential program will provide an enhanced dementia care curriculum for building capacity of existing workers, and those entering into the workforce to promote a dementia-friendly environment for older adults.

Can I Hold That Thought for You? Dementia and Shared Relational Agency.

Agency is talked about by many as something that people living with dementia lose, once they've lost much else-autonomy, identity, and privacy, among other things. While the language of loss may capture some of what transpires in dementia, it can obscure how people living with dementia and their loved ones share agency through sharing capacities for memory, language, and decision-making. We suggest that one consequence of adopting a framework of loss is that it makes the default response to changes in agency the substitution of a family member's agency for the purported lost agency of someone living with dementia. We argue for an alternative framework in which sharing agency is recognized as a central feature of living with dementia. Building on the work of relational theorists, we argue for the value of thinking about agency in dementia as fundamentally shared, and explore potential implications for treatment, caregiver support, and building dementia-friendly environments.

Perception of designers of an enabling environment for dementia care in Thailand

This paper explores the perception of designers towards an enabling environment for dementia care in Thailand. The global number of people living with dementia has increased, and the number is growing in developing countries with the decline in the quality of care and the high turnover rates of formal caregivers. A dementia-friendly environment can support the challenging dementia symptoms, employing a specialised environment for quality care that is a significant therapeutic resource for supporting residents’ well-being, such as comfort, familiarity, and organised space. Thus, the salutogenic design approach becomes vital in supporting personalised narratives related to personality, lifestyles, and a decision-making process to enable the person-centred care to enrich their quality of life. The concept of salutogenic design has become a trend for people with dementia to live in small-scale and home-like care settings to enhance meaningful daily activities in familiar domestic settings. This study thematically analyses 15 semi-structured interviews of architects and therapists in Thailand about their perception towards the dementia environment and its relation towards salutogenic design and capabilities approach. Based on such analysis, an enabling environment for dementia care should balance functions and aesthetics for the positive affordances between users and the environment. Instead of perceiving design as a physical environment, the design of an enabling environment should have contextual factors of politics, urban-rural gaps, and education for the whole community.

Media discourses on the socio-spatial rights of older people living with dementia and their carers.

Media discourses about people living with dementia and carers contribute to the ways in which public, social spaces are designed, planned, and used. Negative media discourses play an important role in the socio-spatial exclusion of people living with dementia and stigmatising and dehumanising language prevents the achievement of genuine, rights-based dementia-friendly environments. Because the media plays a powerful role in shaping public attitudes, there is a need to understand media constructions of people living with dementia and carers in relation to their socio-spatial rights, which is the aim of this paper. A Foucauldian-inspired discourse analysis (FDA) was conducted on the public news media texts of one regional Australian city, to identify discourses relating to the socio-spatial rights of people living with dementia and carers. Lefebvre's (1996) 'right to the city' concept was used as a conceptual framework, to define socio-spatial rights. Analysis revealed discourses relating to the right to urban citizenship, the right to difference and socio-spatial justice. Representations of participatory democracy, important to urban citizenship, are absent, as are the voices of people living with dementia. Through advocacy from others and a lens of citizenship, socio-spatial rights for people living with dementia, and in one instance carers, are recognised, in the context of dementia-awareness and dementia-friendly initiatives. While a lens of personhood constructs people living with dementia as historical and relational beings, a citizenship lens adds a spatial dimension. Advocacy and the lenses of personhood and citizenship are important in creating positive constructions of people living with dementia, however, their participation in decision-making processes would confer an active citizenship status, and the inclusion of their authentic voices in media discourse would contribute to raising awareness towards rights-based dementia-friendly communities.

Hospitality in dementia-friendly environments is significant to caregivers during hospitalisation of their loved ones. Aqualitative study.

To explore what is meaningful to caregivers in relation to a dementia-friendly environment during hospitalisation of their loved ones with dementia or cognitive impairment. Implementation of dementia-friendly initiatives and person-centred care approach have shaped the political agenda within Danish society. Patients with dementia or cognitive impairment and their accompanying caregivers are challenged when admitted to hospital. During hospitalisation, caregivers find themselves in a vulnerable state of mind. Thus, the implementation of a dementia-friendly environment and adherence to person-centred care in hospital settings leaves room for improvement. This study was guided by a qualitative and explorative approach. Data were collected through 17 semi-structured interviews with caregivers at a subacute neurological ward. Thematic analysis was employed to interpret data. The study reports according to the COREQ checklist. The following three themes were identified: 1) Being a watchful bystander. 2) Visiting an undefined and foreign environment. 3) Longing for kindness. Hospitality expressed by staff towards caregivers is significant in allowing caregivers to experience hospital environments as "friendly." Dementia-friendly environments embrace existential aspects that go far beyond physical spaces; hence, experiences of kind acts shape caregivers' sense of safety and comfort during hospitalisation. Hospitality is an essential part of nursing in dementia care because caregivers are contextually vulnerable. Our study sheds new light on the provision of person-centred care to people with dementia and their families in healthcare. Nurses need to be aware that caregivers experience vulnerability and to involve caregivers in the care provided for patients with dementia. We recommend that a permanent contact person be appointed to follow patients throughout their admission period. Furthermore, systematic interventions focusing on phenomena such as hospitality and kindness may serve to form a person-centred clinical culture; an issue that warrants further investigation.

Small-Scale Living Environments' Impact on Positive Behaviors and Quality of Life for Residents with Dementia

This study explored the relationship of the environment in small-scaled nursing homes and positive behaviors on the residents' quality of life (QOL). The Environmental Assessment Tool-Higher Care was used to evaluate unit environments. Dementia Care Mapping was used to observe 113 residents' positive behaviors. Hierarchical linear modeling analysis showed that residents living in a dementia-friendly environment showed a significant correlation between their positive behaviors and QOL. In contrast, a non-dementia-friendly environment showed no notable impact upon their QOL despite the high/low frequency of positive behaviors. It is crucial to prioritize a comprehensive facility environment review to support residents' QOL.

The Impact of a Dementia-Friendly Garden Design on People With Dementia in a Residential Aged Care Facility: A Case Study.

There is a paucity of evidence on the efficacy of garden design based on dementia-friendly environment (DFE) characteristics on the level of agitation, apathy, and engagement of people with dementia in residential aged care facilities (RACFs). To investigate the effect of a garden improved according to DFE characteristics on agitation, apathy, and engagement of people with dementia in one RACF. A case study design with a mixed-method approach was used. There was no significant improvement in the level of participants' agitation following visits to the improved garden, χ2(2) = 5.167, p = .076. A high level of engagement was found in participants during the intervention (Week 1-1, p < .01; Week 1-2, p < .01; Week 2, p < .01; Week 3, p < .05; and Week 4, p < .05) when compared to before intervention (Week 0). A higher level of apathy was found in participants at Week 0 when compared to during the intervention (Week 1-1, p < .05; Week 1-2, p < .01; Week 2, p < .05; Week 3, p < .01; and Week 4, p < .01). Five themes emerged from participant interviews: the presence of sensory-provoking elements in the garden, meaningful engagement in the garden, accessibility of the garden, garden impacts, and garden experiences that demonstrated the effectiveness of the garden. The garden promoted engagement and decreased apathy of people with dementia living in the RACF with the researcher's partial facilitation of the intervention sessions. The qualitative findings indicated the effectiveness of the garden in reducing agitation.

Designing inclusive environments for people living with dementia: how much do we really know?

PurposeRecent years have seen a growing interest in and awareness of the importance of environmental design to the well-being of people living with dementia, in terms of both policy and practice. This trend has been accompanied by a plethora of advice, guidance and tools that aim to encourage and promote the development of inclusive environments. Not all of these are evidence-based, and even those that claim to be so are limited by a paucity of good quality, comprehensive research studies. This paper aims to consider the current state of knowledge in the field of dementia-friendly design and describes a project that refreshed and updated the suite of Environmental Assessment Tools originally developed by The Kings Fund and now managed by the Association for Dementia Studies.Design/methodology/approachThe mixed methods project reported on in this paper comprised a review of the literature, a survey of people who have used the five design assessment tools and an iterative process of updating the tools to make them as evidence-based and user-friendly as possible.FindingsThe suite of five assessment tools was refreshed and updated to reflect the latest evidence and the views of professionals and others who use the tools. The authors conclude that while a focus on dementia-friendly design is to be welcomed, there remains a need for relevant high-quality evidence to inform such work. In particular, there is a lack of research within people’s own homes and studies that include the perspectives of people living with dementia.Originality/valueFew assessment tools and guidelines for dementia-friendly environments are truly evidence-based. This paper reports on a project that combined a comprehensive literature review with the views of practitioners to update a widely used suite of tools that aim to make a range of settings more suitable for people living with dementia.

Are Analogue or Digital Clocks Friendlier for People Living with Dementia?

Background: In ageing population, it is desirable to reduce the impact of cognitive decline on daily life. While various types of dementia-friendly environments have been proposed, the question still remains regarding whether analogue or digital clocks are friendlier for people with dementia. Methods: In clinical practice, we normally use our original clock reading test (10 analogue and 10 digital clocks) to assess patients’ ability to read a clock. In the present study, a retrospective medical record survey was conducted. Fifty-five participants who had done the test were identified. The result of the test was compared between analogue and digital clocks. Additionally, to assess specific ability to read analogue clocks, an “analogue-digital gap” was defined as the difference between patients’ performance for analogue and digital clocks. Univariate and multivariate analyses were conducted to detect significant factors associated with reading ability specific to analogue clocks. Results: The analogue clock proved less readable than the digital clock, even after adjusting for MMSE total score (p = 0.003). Multivariate analysis revealed reading ability of the analogue clock was significantly associated with MMSE calculation and clock drawing test (p = 0.009 and 0.040, respectively). Conclusions: In the present study, the digital clock was friendlier than the analogue clock for patients with dementia. Compared to the digital clock, reading analogue clocks might require more widespread cognition, such as working memory and visuospatial processing. While our finding was a general tendency, and individual assessment is necessary, it might help the development of personalized environmental adjustments.

Dementia-Friendliness in Danish and International Contexts: A Critical Discourse Analysis.

Initiatives to create dementia-friendly environments are subject to political attention all over the world. As the interpretation of dementia-friendliness is influenced by current cultural trends, the concept is highly ambiguous. The present study aims to explore how discourses concerning dementia-friendliness are manifested in Danish and international policy documents and how they interact internationally. Inspired by Fairclough's critical discourse approach, 21 policy documents were analyzed to reveal how power is exerted through language and the discursive construction. We identified 5 types of discourses, namely, those concerning the domains of socioeconomy, rehabilitation, knowledge, responsibility, and a good life. Dementia-friendliness was found to be embedded in an overall ideology aimed toward supporting the individual's autonomy in life and health choices and their participation in society. Our analysis furthermore suggests that dementia-friendly initiatives are used collectively as a lever to achieve these policy aims to ultimately compensate for and protect people with dementia against the consequences of the loss of competencies, identity, and control. Thus, to develop and establish sustainable dementia-friendly environments and communities that meet the needs of people living with dementia, we need to be aware of and discuss the implications of the discourses constructing dementia-friendliness and their influence on the appearance of dementia-friendliness in society.

‘인간중심 돌봄’적인 측면에서의 치매친화환경지침 비교검토

Purpose: This study aims to examine how Person-Centered Care approach has affected the long-term elderly care facility design guidelines related to the dementia friendly environment, by examining the literature on ‘Person-Centered Care’ highlighted in research; to address the policy implications for dementia-friendly environment on basis of Person-centered approach. Method: The concept of Person-centered Care was defined, and the principles and the design features of Person-centered care were derived from literature review focused on person-centered Care and the design of environments for people with dementia highlighted in research. Based on the facts, this study examines how much Person-Centered Care approach affects the design guidelines for dementia-friendly environments by comparative review. Result: The result shows that the principles and design features of Person-centered Care influence on that of the selected design guidelines for dementia-friendly elderly care environments directly through comparative review. The viewpoint to dementia care environments has changed from person-centered care approach for dementia patients based on homelike environment to that expanded dementia patients’ families and staffs who take care of them, based on community. In Korea, the direction of dementia care policy is in the process of gradually changing from a medical approach to an expanded social and person-centered care approach. There is a strong need to establish the design guideline for dementia-friendly environments to apply the efficient change.

Care of older people with Cognitive Impairment or Dementia Hospitalized in Traumatology Units (CARExDEM): a quasi-experiment

BackgroundIn our context, as in other European countries, care of patients with cognitive disorders or dementia still represents a major challenge in hospital settings. Thus, there is a need to ensure quality and continuity of care, avoiding preventable readmissions, which involve an increase in public expenses. Healthcare professionals need to acquire the necessary knowledge and skills to care for hospitalized patients with cognitive disorders and dementia.MethodsA quasi-experimental design with repeated observations, taken at baseline, post-intervention, and at one and three months post-intervention, in people hospitalized with cognitive disorders or dementia. The study will be carried out in four general hospitals in Spain and will include 430 PwD and their caregivers. The intervention was previously developed using the Balance of Care methodology where nurses, physicians, social workers and informal caregivers identified the best practices for this specific care situation. We aim to personalize the intervention, as recommended in the literature. The study has an innovative approach that includes new technologies and previous scientific evidence. Valid, reliable instruments will be used to measure the intervention outcomes. Quality of care and comorbidity will be analyzed based on the use of restraints and psychotropic medication, pain control, falls, functional capacity and days of hospitalization. Continuity of care will be measured based on post-discharge emergency hospital visits, visits to specialists, cost, and inter-sectorial communication among healthcare professionals and informal caregivers. Statistical analysis will be performed to analyze the effect of the intervention on quality of care, comorbidity and continuity of care for patients with dementia.DiscussionOur aim is to helping healthcare professionals to improve the management of cognitive disorders or dementia care during hospitalization and the quality of care, comorbidity and continuity of care in patients with dementia and their informal caregivers. Moving towards dementia-friendly environments is vital to achieving the optimum care outcomes.Trial registrationRegistered in Clinical Trials. ClinicalTrials.gov Identifier: NCT04048980 retrospectively registered on the 6th August 2019. https://clinicaltrials.gov/Protocol Record HCB/2017/0499.Sponsor: Hospital Clinic Barcelona.

Rationales and practices for dynamic stakeholder engagement and disengagement. Evidence from dementia-friendly health and social care environments

Latest developments in stakeholder management literature focus on dynamic stakeholder engagement and disengagement practices, and how these are facilitated towards reaching systemic outcomes. However, limited evidence support that this network-level approach can positively influence project success. The paper analyses this issue by considering the practices (how and when), rationales (why) and outcomes (so what) that evolve in the dynamic management of external stakeholders in dementia-friendly environments. This is a crucial area to explore as the ageing population and rising dementia prevalence has increased the need to engage external stakeholders, such as people living with dementia, to develop dementia-friendly health and social environments. The empirical study of the 2013/2014 Department of Health National Dementia Capital Investment Programme involved a statistical and qualitative analysis of 98 pilot projects’ final lessons learnt reports. The analysis advances the dynamic process of timely engaging and disengaging external stakeholders in a context not previously explored in the literature related to dementia-friendly environments. Eight recurring practices and six rationales, the latter characterized by their temporal dimension, are presented in a processual model of stakeholder management.

Creating a dementia-friendly environment through the use of outdoor natural landscape design intervention in long-term care facilities: A narrative review.

There is an increasing volume of literature on the positive effects of outdoor natural landscapes on health and well-being. However, to date, there is a paucity of research on the effect of outdoor natural landscapes designed for people with dementia living in long-term care (LTC) facilities, in particular, those which have incorporated the characteristics of a dementia-friendly environment (DFE). This narrative literature review synthesizes current knowledge on the effect of outdoor natural landscape design, which is aligned with the characteristics of a DFE, to improve agitation, apathy and engagement of people with dementia living in LTC facilities. The reviewed studies predominantly support the positive effects of outdoor natural landscapes on agitation, apathy and engagement of people with dementia. However, there are concerns about the methodological approaches, principles incorporated in the applied outdoor natural landscapes' designs, and the environmental assessment. Further rigorous research is required to understand the impact of the outdoor natural landscapes, with the application of DFE characteristics in the design, on agitation, apathy and engagement of people with dementia living in LTC facilities.