Learning from Dementia Villages Examining End-of-life Care Spaces as XXI Century Collective Living Types

1 / STRUCTURE

The Ph.D. research illustrated here began in November 2019 and will be completed by 2023. A partial representation of the status of the study at this stage, this paper extends and revises my contribution on the same subject to the November 2020 CA2RE Milan conference and the 2021 CA2RE Hamburg conference.

The structure of the research develops in three interlinked phases. The first phase focuses on studying selected historical test cases and provides the necessary context for the approach to a recent case study. The second phase consists of the in-depth investigation of the current case study: the Dementia Village, a recently developed end-of-life care facility type. The third phase consists of producing a qualitative handbook for dementia-driven architecture. The research develops gradually from a reflective to a projective moment through each step of the study. With the first and second stages primarily completed, the research is now entering the third phase.

The research aims at critically evaluating and examining the controversial phenomenon of dementia villages. For this reason, the study borrows the “learning from” approach developed by Venturi, Scott Brown, and Izenour in the contexts of Levittown and Las Vegas.

A set of distinct investigation methods characterizes each phase. Each determines a set of interlocking tools. Descriptive writing and compiling illustrate the first and second phases, while interpretive drawing and argumentative essays mark the second and third phases. Physical model making becomes a tool leading to the third and last phase.

2 / CONTEXT

A recurring aspect of recent architectural literature is attention to the body - human or other - and its relations with the space surrounding it. In the introduction to Warped Space, published in 2000, Anthony Vidler writes: “ever more often space has been defined as the product of subjective projection and introjection, thus the opposite of a stable container for objects and bodies.”1

As expressed here by Vidler, the relationship between architectural space and the human body has become progressively more central in the disciplinary debate. Architectural theory progressively interprets the human body as a malleable entity that can deform and be deformed by architectural space. If “design always represents itself as serving the human, but its real ambition is to redesign the human,”2 the creation of end-of-life care facilities puts architecture in a situation of extreme stress that allows for a reconsideration of its effectiveness in this domain.

As reported by Beatriz Colomina in her 2019 book X-Ray Architecture, Robert Musil wrote in The Man Without Qualities that “Modern Man is born in a hospital and dies in hospital - hence he should also live in a place like a hospital.”3 Colomina sees this sentence as a representative statement of how healthcare architecture contributed to developing the modernist imagination. In the same way, recent developments in healthcare architecture, set in an interdisciplinary realm, can drive the architectural discipline in new directions.

Yet, as Fabiola Lopez-Duran exposed, medical discourse is often materialized in architecture imperfectly, distorted through an ideological lens.4 Thus, this research is not limited to detecting medical influence on architectural spaces but instead considers end-of-life facilities as examples of collective living. Following the categorization illustrated by ETH Wohnforum in their History of Collective Living5, end-of-life facilities are, in fact, cases of sharing based on social intentions.

Locating these facilities within this realm also allows for the contextualization of end-of-life facilities as intentional communities, or “self-contained, planned communities that attempt to pursue a peaceful ideal instead of a community created and run without an organizing principle.”6 This notion positions this work within the disciplinary platform of architectural literature on the subject, particularly of publications such as Kommunen in der Neuen Welt by Liselotte and Oswald Mathias Ungers and, more recently, Young-Old: Urban Utopias for an Ageing Society by Diane Simpson.

Looking at this topic through this lens enables a genealogy that links a series of reform movements with the development of assisted living facilities, materializing therapeutic practices into distinctive architectural types. Assisted living facilities often stem from religious or otherwise spiritual or idealistic organizations dedicated to philanthropic work and the care of vulnerable population strata.

3 / TEST CASE: DESIGNING FOR LATER LIFE FROM THE 1960s

An article titled “The Elderly” appears in the May 1967 issue of Progressive Architecture. It consists of an atlas of architecture for the elderly, which was an emerging subject in the architectural debate of the 1960s. Its incipit states:

Until fairly recently, the average urban American devoted himself so mercilessly to work, and spent the larger part of his life-span so frenetically engaged in the pursuit of his livelihood, that the problem of retirement and growing old were always farthest from his mind. Today, however, the problem has become a national one. The elderly population has increased significantly. As statisticians are fond of reminding us, one out of eleven persons in the U.S. is 65 or older: the projected total for the year 2000 is 28,500,000. Until the 50’s the problem of housing the elderly remained largely untouched.7

The emerging issue of an aging population in the 1960s spurred the development of new public policies and therapeutic concepts. These materialized into new housing types that replaced facilities such as almshouses and sanatoria. Contemporary assisted living facilities for the elderly emerged in the 1960s, a defined architectural typology underpinned by dedicated regulations.8

The issue of housing the elderly generated an important disciplinary debate, which mirrored advancements in gerontology, as described by Deane Simpson in his article Gerotopias9. Most iconically, this discussion was employed by Robert Venturi to illustrate his position towards modernism in Learning from Las Vegas, where he pitted his own Guild House against Paul Rudolph’s Crawford Manor. Both buildings are examples of independent living facilities for the elderly appearing in the Progressive Architecture issue mentioned earlier.

Here Venturi elevates the use of “the ugly and the ordinary” in the Guild House design as a whole design theory. While he does not make the connection between the use of the building and the design strategy explicit, it is clear that such a position represents a particular sensibility towards the building’s specific user. Referencing the windows of the Guild House, Venturi writes:

The windows look familiar; they look like, as well as they are, windows, and in this respect, their use is explicitly symbolic. But like all effective symbolic images, they are intended to look familiar and unfamiliar. They are the conventional element used slightly unconventionally.10

Aiming to promote a deliberately contradictory and complex architecture Venturi consciously expressed the will of creating “inclusion, inconsistency, compromise, accommodation, adaptation, super adjacency.”11 As housing for the elderly, the Guild house constituted the ideal testing ground.

The disciplinary discussion on elderly housing in this era constitutes a benchmark for studying comparable current phenomena. The use of vernacular, ordinariness, mundanity, and inclusivity remains a crucial aspect of the discussion. Yet, for this research, the central recurring element in the debate on the subject remains the attempt at creating quasi-urban conditions within assisted living facilities, aiming to support community life. This tendency, originating in the 1960s12, has evolved over the decades and has been translated recently in creating so-called “villages”13 dedicated to elderly residents in various age brackets and physical conditions.

4 / DEMENTIA VILLAGES, A CASE STUDY FOR CONTEMPORARY END-OF-LIFE CARE FACILITIES

The research focuses on contemporary manifestations of the previously discussed debate, focusing on emerging assisted living facilities and dementia treatment centers known as “Dementia Villages.”

As discussed in the following paragraph, these facilities are selected for their instrumental use of architecture in a therapeutic environment and consequent spatial layout and construction innovations. These aspects, this thesis argues, qualify Dementia Villages as an emerging architectural collective living type.

Dementia Villages are nursing homes dedicated to the specific treatment of dementia. Despite their high specialization, Dementia Villages are end-of-life facilities as they primarily host patients affected by an advanced and often terminal disease.14

Dementia Villages replicate community life in a controlled setting. Their nature as simulated environments leads some to define them as Truman Show-Esque.15 The dementia village model appeared in the Netherlands in 2008, the first example being De Hogeweyk in Amsterdam’s suburbs. Since then, the model has spread all over the world.

Today there are numerous active Dementia Villages in Europe. They are located in Germany, Italy, France, Netherlands, Denmark, Ireland, and Norway, while similar facilities exist in Singapore, India, Canada, and the U.S.A. Their number is growing as more villages are to initiate construction in Switzerland, and U.K. Dementia Villages take the shape of gated communities, most often located in the outskirts of cities or the countryside. Architecturally, Dementia Villages consist of low-rise buildings organized around one or more open spaces. These open spaces define neighborhoods within the village, each composed of a series of houses containing 6 to 8 individual rooms, in line with recent guidelines and practices regarding assisted living facilities.16 Yet, in addition to the housing units, specific village sections have shared services that include restaurants, barbershops, and other amenities situated in open spaces that mimic urban environments. The thesis argues that this specific innovative aspect qualifies Dementia Villages as an emerging collective living type.

A crucial aspect of the Dementia Village is the instrumental use of the architectural language in fostering patients’ well-being. Developed by nurses and architects, Dementia Villages are designed to promote a sense of comfort in people affected by neurodegenerative diseases.

From an architectural perspective, this intention materializes through the extensive use of the vernacular register. Despite being entirely newly built due to technological and economic concerns, Dementia Villages often mimic a simplified version of traditional architectural languages, which provides their distinctive “fake”17 quality.

In the case of the Hogeweyk (the first dementia village, built in the Netherlands), a strategy of comprehensive design is employed to provide specifically crafted interior environments:

Unique interior decoration is intended to make residents feel at home in familiar surroundings. The residential areas are divided into different lifestyles allocated to the elderly based on their past preferences. An opinion research institute analyzed the seven most common environments in the Netherlands for this purpose, resulting in the following categories: traditional, city, wealthy, cultural, Christian, Indian and homely.18

This architectural agenda advances under the auspices of empirical observations by the nursing personnel. Part of this work is aimed at critically understanding and evaluating this transdisciplinary influence. While numerous sources have critically analyzed dementia Villages, most of the existing literature focuses on the case study’s efficacy as a treatment center, thus focusing on the patient. This thesis aims to examine the potential relevance of the Dementia Village for the architectural discipline, therefore concentrating specifically on the learning process that architects and developers undergo in the design and construction of these facilities.

5 / A QUALITATIVE HANDBOOK

Since architects have realized that the perception of space isn’t objective, immutable, or universal. As described by Antony Vidler, architecture can now be seen as a phenomenon imbricated with the instruments that allow humans to perceive it. As clearly pictured by Peter Zumthor in his book Thinking Architecture, inhabiting is a sensory experience in which space relates to the brain through the senses and, crucially, through memory. The process of reminiscence, in particular, is described here by Zumthor as unconscious:

There was a time when I experienced architecture without thinking about it. Sometimes I can almost feel a particular door handle in my hand, a piece of metal shaped like the back of a spoon.19

The act of reminiscing is an uncanny sensorial journey that leads Zumthor back to a familiar place: in this case, a doorway in his aunt’s house. The design of facilities dedicated to dementia care puts the architectural project under extreme stress that forces it to reconsider a series of established disciplinary practices. Paraphrasing Colomina and Wigley: dementia’s real ambition is to redesign human space. At the core lies a debate around the therapeutic role of reminiscence that pushes architects to produce familiar, reassuring spaces tailored to the needs of people with impaired intellectual capacities. It constitutes an architecture no longer founded on the quantitative ratios of ergonomics but qualitative assessments of perception and memory in a state of dementia. Phenomenologist Dylan Trigg writes in his book “The Memory of place”:

Over time, those places define and structure our sense of self, such that being displaced can have a dramatic consequence on our experience of who we are and even leave us with a feeling of being homeless in the world. Equally, the memories we acquire of the places we inhabit assume a value that is both immeasurable and vital. Without the memory of places, memory itself would no longer have a role to play in our conscious lives.20

The proposed design approach aims to structure instances from the phenomenology of memory into the architectural project, mainly through the graphical tool. The thesis’s outcome will consist of a qualitative handbook synthesizing models regarding the connection between memory, place, and the creation of a therapeutic architecture. Following the steps of Venturi, Scott Brown, and Izenour, the final chapter will consist of an ironically intended addendum to the Neufert: Architect’s Data manual, which will focus on the vocabulary of familiarity that constitutes the architectural atmosphere of dementia villages.