Surroundings symposium

It's not every day you can lock down three of the field's most intriguing and expert sources on aging environments and design to debate best practices in long-term care installations. When you get that opportunity, you make the best of it.

The editors of Long-Term Living proudly present this designer roundtable, featuring:

Elizabeth C. Brawley, AAHID, IIDA, CID, is president of Design Concepts Unlimited and one of the preeminent authorities on lighting for senior environments. With more than 30 years of experience, Brawley specializes in designing therapeutic environments for Alzheimer's special care and was awarded the 1998 Polsky Prize for research in this area. She is a founding member of the American Academy of Healthcare Interior Designers and holds an advisory position with the Illuminating Engineering Society of North America.

Mitchell S. Elliott, AIA, is chief development officer at Vetter Health Services, and serves as vice-president of the Society for the Advancement of Gerontological Environments. A 28-year member of the American Institute of Architects, Elliott oversees the planning, design, construction and property management of all 33 Vetter-owned nursing facilities and retirement communities throughout the Midwest. Elliott's work reinforces resident-centered care, and he has been a member of the American Health Care Association Life Safety Committee since 2009.

Lisa M. Cini, ASID, IIDA, is founder and president of Mosaic Design Studio in Columbus, Ohio. Cini's work has been recognized by the American Society of Interior Designers with the First Place designation in its Chapter 32 Design Awards every year since 2007, and she has received several local business awards in her home city of Columbus. Cini regularly participates in national speaking engagements on design and is a blogger for Long-Term Living ( www.iadvanceseniorcare.com/CiniBlog).

And without further ado…

SOLID SURFACE FLOORING VS CARPET IN LONG-TERM CARE AND SENIOR LIVING ENVIRONMENTS—WHAT ARE THE PROS AND CONS TO INSTALLING EITHER OPTION?

Elliott: The functional and programmatic expectations of the space should drive the floor selection. We begin with the question, “What is best for the resident waithin this space?” Considerations include safety, aesthetics, acoustical control, comfort and the level of self-ambulation by the residents. Second to the needs of the resident are the needs of the caregiving staff. You also have to look at the initial and long-term maintenance costs of the material, and we can't be specifying materials without gathering input from the environmental workers taking care of these surfaces. And in our organization, if the material that is better for the staff compromises quality care or quality life for the residents, the residents always win.

Brawley: With the advancements in technology and construction methods in soft surface floorcovering, there are more options today for LTC and senior living environments. The color palettes are greater than ever and are aesthetically pleasing.

Carpet is an excellent choice for senior living dining rooms, social rooms, corridors and resident rooms. Not only does it control the number of transitions, but it also helps with acoustics by softening floor noise generated on hard surfaces. Because many elders in these settings have vision issues, using a mid-range color palette for flooring makes the color more visible. Lighter hues show stains, requiring diligent cleaning. If excessive maintenance is needed, carpet would not be a good choice.

I would also like to see tasteful monochromatic patterns developed—it's one solution for providing pattern and interest without introducing multiple colors and confusion underfoot. Large patterns incorporating multiple high contrast and bright colors are confusing, disorienting and dangerous for older adults with vision impairment or dementia.

Cini: I completely agree with Betsy regarding the importance of selecting the right hue of color for flooring, which in high traffic areas should have a varied pattern with multiple complementary colors to add visual interest, hide difficult stains and reduce the appearance of traffic patterns. Betsy mentions monochromatic colors, but I find that if the colors are complementary and of the same value, the intensity is lessened but stain and soil hiding are increased.

Having said all this about carpet, I still feel there is a place for hard flooring. I do love the feel of a sunroom, arts and crafts space or small dining area with vinyl flooring that looks like wood. It feels fresh and homey, is easy to clean and creates visual warmth. I also find that if residents can identify that a space is different than the rest of the home, it helps with wayfinding and memory loss.

Brawley: Using a rubber, vinyl or wood wall base to match the lighter color of the wall surface provides strong contrast with the floor surface. This contrast provides a distinction between the vertical and horizontal surfaces. It is this small detail that unconsciously sends a powerful message affecting balance and contributes to keeping residents mobile for a much longer time.

Elliott: Wood-look hard surface flooring brings an interesting point to the “homelike” discussion. Many of our elders grew up in an era where they had wood floors only when they couldn't afford carpet. A resident shared an interesting perspective with me that a wood floor actually sends a message of lesser quality compared to a carpeted floor.

Brawley: That's a strong indicator that we might want to incorporate design planning sessions as a new activity with residents—not because we are planning a renovation but as an activity program. Think of what we might learn that could be explored and used in future planning—and I bet the residents would love the new activity.

Elliott: The transition between hard surface flooring and carpeting is the single most important safety factor we can address as designers. My team has gone to a wider vinyl transition strip in open areas between sheet vinyl flooring and carpeting. Although this minimized the “bump in the road” so to speak, it created other aesthetic and maintenance challenges. For instance, the wider transition strip shows marks from wheelchairs and walkers more prominently. The transition also has a more institutional feel and look. The best approach we have found involves floor feathering, which is the placement of a tapered, cementitious fill to bring the hard surface flooring to a plane level with the carpet. This requires an installer who is committed to the details.

Cini: Reducing the amount of “bump” for residents is important. Ideally, the flooring that needs to be higher would be feathered up as mentioned. However, this can be extremely difficult when renovating and in new construction requires skill during the installation.

Brawley: Excellent installation and maintenance is required no matter the flooring material. Installers trained and seasoned to work in healthcare settings can make the difference in how well the products selected hold up over time.

WHAT MUST TODAY'S SENIOR LIVING DESIGNERS CONSIDER WHEN CONTEMPLATING LIGHTING CHOICES FOR A COMMUNITY?

Brawley: Living in an appropriately lighted residence has been shown to improve social contact, appetite, mood, self-confidence and anxiety in seniors. Visual performance, ambience, safety and security all depend on lighting. An effective lighting solution requires raising light levels substantially, balancing natural light and electric light to achieve even light levels and eliminating glare to provide the necessary light for older eyes to see.

It's especially important to incorporate as much natural sunlight balanced with electric light as possible within the built environment. The best lighting solutions use abundant natural light, high levels of energy-efficient light and a strong cue as to the time of day. This means designing buildings with taller ceilings and window openings to help daylight penetrate through large skylights and windows. Skylights usually bring in more light and keep the brightness out of the field of view, reducing glare. As long as the light is evenly distributed, a few generous skylights are better than many small ones.

Cini: Natural light still needs to have quite a bit of help from artificial lighting in states with poor annual sunshine. The type of artificial lighting is key. And while I love natural light there are always complaints from staff regarding too much light or heat created from windows. This can be dealt with by placing a film on the window to lessen the heat transmitted.

Some residents complain about the hot spots from high windows that trail across the room at breakfast and dinner and can be blinding. Typically, a study will be done during day hours to see where the issues are occurring. This will need to be completed seasonally as the angle moves throughout the year.

Elliott: From a natural lighting standpoint, we must understand building orientation. We need much greater controls of daylight on the south- and west-oriented windows as compared to the east and the north—presuming we are all in the northern hemisphere. The low winter sun bouncing off of pavement into a resident room does not produce the quality, natural daylight that Betsy is promoting. We are finding that mini-blinds still provide our residents with adequate control of the natural daylighting.

Incorporating a “multiple switches to multiple lamps” strategy controls the amount of artificial light in a space. In Iowa, health regulations require 100 foot-candles of light over the bed. Surgeons could do a fine job of operating in those conditions. If we didn't incorporate a graduated light level approach to achieving that requirement, we would put our residents into shock. This multiple switch approach should also be incorporated into the public areas of our senior living environments, which can have a positive impact on the mood or ambience of the dining environment without sacrificing the necessary light levels needed for ADLs.

We are also experimenting with a movable wall sconce, or lamp, in resident rooms that will move with their beds, recliners or anywhere else that they need task lighting.

Brawley: Getting a lighting designer involved during the conceptual stage of a project ensures that lighting can be integrated with other systems and functions in the most cost-efficient ways. The client, architect, designer and lighting consultant must come to an agreement about how the space will be used, the transitions of light within the space, how color and finishes interact with light, and the physical opportunities or constraints the space offers, such as natural light, clearances and HVAC needs.

Cini: Color temperature is one of the largest concerns with artificial lighting. Decide if you want warm or cool colors and consider what this will do to how someone looks, how they will see the colors in the environment and the ambience it will create. Kelvins in the range from 3000 to 3500 tend to mimic natural sunlight but come off cool. Whereas a Kelvin temperature of 2700 will come off bright enough but be warmer to the eye and similar to the look of the incandescent we have in our homes.

On a compact fluorescent or tube we look for color corrective lamps or warm whites. The key is to make the lamping consistent throughout the building and spaces.

Elliott: The concept of light temperature is spot on. We have used the 2900K to 3100K temperature range for fluorescent lighting and it makes a world of difference from a quality of life standpoint. Skin tones are more natural and the color rendition of fabrics and materials is much better, as long as those materials are selected under the same lighting temperature conditions. The key to sustaining this strategy is to communicate these specifications to our maintenance team members who purchase the replacement lamps and bulbs.

Brawley: Designs must better utilize both daylighting and well-designed electric lighting systems to deliver the higher levels needed by older adults. If this seems like a less than subtle attempt to encourage healthcare providers, their architects and designers to use a qualified lighting designer as part of their team, make no mistake—it is! Lighting can and will make a greater difference in the success of a healthcare setting than any other single feature except the healthcare itself.

IN REGARDS TO FABRIC AND FURNITURE USED TO ADD DÉCOR AND FUNCTIONALITY IN SENIOR LIVING, HOW HAVE YOUR TASTES CHANGED WITH PRODUCT ADVANCEMENTS OVER THE YEARS?

Cini: The furniture needs of seniors vary as much as the range of senior living options and activities. In independent living, residents typically bring their own furniture and have residential desires that must be balanced in common areas. Furniture should be easy to get in and out of unaided but not be too hard as to be uncomfortable. Dining room chairs will typically be more formal, and accent pieces must have character.

In assisted living, furniture needs to be a bit denser in the foam but not too stiff. Dining room chairs will typically have front casters for ease of getting in and out from the table. Accent pieces create interest and aid in creating theme and wayfinding. Treated moisture-barrier backings are a must. Most vinyls are to be avoided.

And in skilled nursing, furniture has less detailing in most cases because it generally takes more abuse. Less detailing helps in the cleaning as wood carvings tend to hold food and fluids. Dining room chairs will typically have front casters when they are on carpet and no casters when they are on sheet vinyl. Very few accent pieces are used as wheelchairs and medication carts tend to do a number on them.

Elliott: As I walk through retirement communities and other multilevel care campuses, what Lisa describes is pretty accurate. I am amazed at the quality and level of finishes that are incorporated into the independent living environments as compared to the skilled nursing environments. The step down in furniture and the interiors is actually rather disappointing. As the cost of care goes up in the spectrum, it is my hope that the quality of the interior environment would not head the other direction.

I also agree with Lisa that ergonomics are important to how residents use furniture. Chairs and seating with arms are paramount. These arms must extend far enough to the front of the chair to give elders leverage to push themselves up. Ideally, if the vertical portion of the arm is continuous with the leg, the chair will be much more stable and can withstand side pulls.

Open space below the seat is also necessary to allow a resident to place their heels underneath them when transitioning from the seated position.

Brawley: I'm not sure why we have not in many cases upgraded skilled nursing units with a comparable residential feeling but most of what I see still remains rather institutional.

Mitch covered all my best points on seating and chairs—no armless chairs in senior living! Older adults rely on us as designers to specify seating that is not too low, too soft or too deep. Never use seating that is upholstered to the floor—it's fine for your children to jump on but an 80-year-old captured in a deep, soft, cushy sofa will have no leverage to get up and will be effectively restrained.

Elliott: Variety is also important. We encourage our interior designers to incorporate club chairs, sofas, benches and tables with chairs in a living area. This contributes to a much greater residential feel, while responding to the various life-enriching activities that residents participate in. The placement of furniture within the space must also encourage face-to-face interaction.

Cini: Mitch, your statement regarding variety in the furniture and décor is critical. Understanding the residents' background makes a huge difference in the interior. I have designed a NASCAR living room in Southern Ohio, a hunting and fishing room in Nebraska, explored the Native American tribes in Albuquerque and featured the formality of dinner at a retired military officer's home in D.C. A “one size fits all” approach never works for our various body types and certainly cannot be applied to the mind and soul.

Brawley: Residents come in many shapes and sizes and so should the seating. Wing chairs are more comfortable for men than women. Club chairs of varying sizes work well for both, remembering that “soft and cushy” ensures most will have difficulty getting up, providing a perfect opportunity for falls and hip fractures.

Cini: There has been little in the design of dining room chairs for senior living with the exception of grab areas on the arms, seat heights and cross braces for stability. The furniture industry has basically started with a restaurant chair and tweaked it. I would love to see industrial designers create something that meets all of the senior's needs, is beautiful and homelike and can be afforded by owners. One can dream.

Brawley: I have spent time with residents in assisted living and Alzheimer's care with baskets of fabrics and colors, listening to their memories that are stimulated from pieces of fabric—both patterns and textures. You can learn so much about these residents hearing their comments about the way a fabric feels. It's not so much to put together a design scheme but to get to know the people who will benefit from your design.

Elliott: At the end of the day, the furniture and the interior décor needs to enable independence while contributing to a sense of place for our elders. Beautiful furniture and finely appointed interiors are empty if we don't have a caregiving staff who compassionately turns the house into a home.

Long-Term Living 2011 July;60(7):34-39

I Advance Senior Care

I Advance Senior Care is the industry-leading source for practical, in-depth, business-building, and resident care information for owners, executives, administrators, and directors of nursing at assisted living communities, skilled nursing facilities, post-acute facilities, and continuing care retirement communities. The I Advance Senior Care editorial team and industry experts provide market analysis, strategic direction, policy commentary, clinical best-practices, business management, and technology breakthroughs.

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