Residential Care Facilities for Users with Alzheimer’s Disease: Characterisation of Their Architectural Typology

Abstract

The design and construction of residences for persons with Alzheimer’s disease (AD) have been based on the recommendations of design guides, the results of empirical tests with samples of the population, and the experience of architects and planners. The reiteration of certain patterns, criteria, and guidelines has given rise to a new type of building that has not yet been explicitly described. The aim of this paper is to determine the main characteristics of this typology. This research is based on a critical review methodology, analysing 30 care homes built over the last four decades across various global contexts. Detailed surveys of plans, projects, and buildings were carried out, allowing a comparative analysis of the architectural attributes to determine the most influential parameters for these buildings. The results indicate that environments designed with safety, accessibility, and opportunities for social interaction in mind—and, above all, those that are personalised to the needs of this collective—significantly enhance the behaviour, emotional state, and cognitive state of their residents. The main theoretical contributions include identifying and stating the key features of this type, such as small scale, basic cell housing, comprehensible organisation, and sensory stimulation of spaces, among others. The breakthrough of this study that differentiates it from other works in this field is that it provides concrete guidelines to approach the planning, design, and construction of these kinds of residences. The significance of this research lies in the definition of this unique typology, which is not characterised by its morphology, shape, or formal composition but rather focused on promoting an adequate cognitive and physiological reception of the space by the users. This building concept has important management implications, as its construction must provide for and integrate specific care services in a residential setting for people with AD.

1. Introduction

Today’s society faces the ambitious challenge of responding to the problems caused by the progressive increase in the ageing of the population [1]. Ageing is a risk factor directly linked to dementia [2], and Alzheimer’s disease (AD) accounts for between 60% and 70% of diagnosed cases [3]. This disease is a multifactorial syndrome characterised by a progressive alteration of brain function that increases significantly from the age of 65 onwards. It also has a high incidence and prevalence in developed countries, becoming not only a medical but also a social, economic, and architectural problem [4].

Traditional models of care, often characterised by institutional settings that prioritise efficiency over residents’ well-being, have proven inadequate in addressing the complex needs of those living with dementia [5]. This inadequacy has sparked a growing interest in the role of architectural design in enhancing the quality of life for individuals with cognitive impairments. As with tuberculosis and cholera at the beginning of the 20th century, architecture is now also being used as an important aid to alleviate some of the symptoms of a disease for which there is still no cure [6]. Although there are great methodological difficulties, which constitute some of the greatest problems in this field, there is a growing body of evidence supporting the positive effects caused by the appropriate adaptation of a space or environment to the needs of Alzheimer’s sufferers (see Table A1) [7,8].

The importance of AD has influenced some architectural practices that, for the last forty years, have been used to improve the environmental conditions of people with Alzheimer’s dementia, focusing their efforts on providing qualities and services. During this period, there has been a shift from an inpatient hospital model to a new paradigm based on caring for these patients in a residential environment with care facilities adapted to their needs [9]. This change of model has generated a new residential architectural typology specialised for people with AD, which has been the embryo and genesis of the current models of geriatric residences. It is possible to maintain the hypothesis that this unique type of residential-care building, dedicated to users with AD dementia, has ended up being applied and extended to all nursing homes for the elderly, with or without dementia. This has been due to the undoubted advantages and benefits that the implementation of this innovative residential model has brought to all groups of people over 65 years of age.

Research has shown that the built environment in hospitals, residences, day care centres, and homes can profoundly influence the cognitive and emotional experiences of people with dementia [5]. Factors such as spatial orientation, sensory stimulation, small scale, and social interaction play critical roles in shaping their daily lives. However, the existing literature often lacks a complete exploration of how specific architectural features can evoke positive feelings and support cognitive function. On the other hand, some of the solutions applied in residences incorporate criteria and guidelines expressed in specialised design manuals and guides. Other times, these solutions are based on results obtained in empirical research intended to find out how certain spatial and environmental variables influence people with dementia [10,11]. However, most of the buildings constructed in recent decades are based on the experience of the architects’ or designers’ teams, who have been testing various practical measures as part of a trial-and-error process.

The milestones achieved with these buildings have not been analysed and compared in depth. There has been no methodical review of this type of architecture, nor has there been a rigorous evaluation, from an architectural point of view, of the main contributions that have contributed to the genesis of this typology of residential facilities for AD. This gap in knowledge highlights the need for a systematic approach to the design of residential facilities that cater specifically to the needs of users with Alzheimer’s disease.

This paper aims to address these gaps by defining a new architectural typology tailored for residential care facilities serving users with AD. By synthesising insights from various disciplines—including architecture, psychology, gerontology, and health sciences—this study advocates for a multidisciplinary approach that considers the diverse factors influencing residents’ well-being. The proposed typology emphasises the importance of creating environments that not only meet the functional requirements of care but also enhance residents’ cognitive and emotional experiences.

In addition to establishing a theoretical framework, this research employs a robust methodological approach that combines qualitative analysis with observational data. This research has been carried out by performing a critical review of a significant sample of 30 care homes for AD sufferers in various parts of the world. The method involves studying the facilities built in the last 40 years that have made some kind of progress in improving these residents’ quality of life. This research has found that, in these buildings, certain patterns are repeated that apply architectural attributes or parameters and employ similar organisational and functional aspects. This reiteration of elements has produced the decantation of a new type of building, the characteristics of which have not yet been explicitly stated. By identifying key characteristics, this study provides empirical validation for the proposed architectural attributes. This empirical foundation strengthens the theoretical framework and demonstrates how specific design features can lead to improved outcomes for individuals with Alzheimer’s disease.

The novelty of this work lies in the analysis and review of a set of residential architectures intended for people with AD, with the aim of establishing their main patterns and common elements. The main contributions of this research consist of defining the features of an architectural typology for a residential building for people with AD, establishing the functional programme that these types of residences must have, empirically validating design guidelines, and providing evidence supporting specific design principles that enhance the quality of life for this collective. This research highlights the importance of user experience in architectural design, focusing on how the physical environment can enhance residents’ cognitive and emotional well-being. It explores the interplay between design and the lived experiences of residents, carers, and family members, recognising that a holistic approach to design must consider the needs of all stakeholders involved in the care ecosystem.

This knowledge is essential for investors, developers, and managers of these facilities as a prior step to their planning, and it is very useful for architects, interior designers, and technicians who undertake the design, construction, and environmental renovation of these residences. This study is intended to contribute to a paradigm shift in architectural practice, emphasising the necessity of creating residential environments that foster dignity, autonomy, and a sense of belonging for individuals living with dementia. By laying the groundwork for future research and practice, this study invites ongoing dialogue about the impact of design on health and well-being, encouraging architects and planners to embrace innovative solutions that address the evolving needs of ageing populations. Through this comprehensive exploration of architectural design for Alzheimer’s care facilities, this paper aims to enhance our understanding of how they should be built.

2. Background and State of the Art

In 1945, 45% of admissions to mental hospitals had a diagnosis of neurodegenerative disorder associated with dementia [12]. Until the late 1950s, people with dementia were usually admitted to institutional psychiatric hospitals. The first examples of architectures for users with dementia begin to emerge in the United States. The approval of the social action programmes ‘Medicare’ and ‘Medicaid’ in 1965 were key to the changes introduced to the social and healthcare models aimed at these people. These programmes provided the financial support necessary for many people with cognitive disabilities to be eligible to reside in specialised facilities with more developmental and stage-based care [9].

This change in the American healthcare system led to the development of new initiatives for this group of people between 1955 and 1980, with hospitals losing 75% of dementia patients to what were initially known as nursing homes. From that moment on, a model dedicated to care for the elderly called the Green House Project proliferated (Figure 1). These were residential homes located in peripheral or rural environments that, with a controlled size and scale, grouped residents into small groups of people who could thus have constant and personalised care. The main aim was to provoke memories of home and stimulate the memory of the residents. Thus, the first dementia care units emerged, accommodating a limited number of users, from six to fifteen people, and introducing places for social interaction with family and others [13].

Alongside this, a model of dementia care known as Gentle Care emerged in Canada. This programme was based on the assumption that Alzheimer’s disease should be approached with the aim of treating its symptoms in order to improve the patient’s quality of life, maintaining residual abilities and supporting those that are deteriorating. It was thought that it could be useful to design an environment dedicated to the specific needs of these users, trying to make up for their cognitive deficits and facilitate the implementation of therapeutic rehabilitation programmes. The need to build an external prosthesis to support the patient in relation to their environment arose, which would be proportionally more complex the more severe the cognitive loss. The definition of prosthetic environment thus appeared to describe a spatial context of support for the person with Alzheimer’s dementia.

Moyra Jones, programme sponsor and director of Moyra Jones Resources, an international consultancy specialising in Alzheimer’s dementia care, maintains that there is a need for designs or projects aimed at adapting the living environment, as dementia patients are among those most affected by the quality of the place in which they live [14]. This approach led to the idea that the patient should be accommodated in an environment free of obstacles and restrictions, with intimate and familiar features, much more like a home than a hospital, and in which technological aids, necessary for control and safety, are transparent and invisible to the person in order not to restrict their freedom.

Senior living communities progressed rapidly in North America from the early 1980s onwards, as they provided optimal and specialised care, especially for people with cognitive impairment. Their intentions were focused on creating friendly environments that would bring spatial quality to the living conditions of this group. This type of accommodation differed substantially from the typology of aseptic sanitary or hospital facilities. The main novelty was that they had domestic characteristics with communal living areas, thus facilitating the maintenance of the user’s social ties. In the places where these units were created, the positive results of this person-centred care became evident.

Lawton stated in 1984 that a building for these people had to meet the requirements of safety, orientation, functionality, integration, and personalisation. These concepts were reflected in the construction of The Abram and Helen Weiss Institute [15,16]. This institute reduced the number of people indoors and incorporated outdoor areas, with the aim of reducing disorientation and memory loss in residents [17]. In this building, it became clear that many of the problems experienced by people with dementia and their caregivers are directly related to the planning and design of the environment [18].

2.1. Design Guidelines, Manuals, and Principles

As a result of these early experiences, various manuals for the design of buildings for people with dementia began to be published in the mid-1980s. The design guidelines offer recommendations for planning, spatial organisation and guidelines focused on safety, accessibility, homelikeness and, in general, on improving quality of life in dementia care facilities (Figure 2). Managers and developers of these facilities are starting to see the importance of the architectural project as an essential resource to promote, in the long-term, well-being and functionality among people with dementia, beyond applying solutions based on purely decorative aspects.

In 1987, Fleming and Bowles [19] published some initial design principles, later expanded in 2003, which were incorporated in the first specific building for people with dementia, built in the Australian city of Sydney, called The Meadows. This work was followed by other manuals such as that of M. Calkins [12], which establishes the following as basic criteria for these buildings: attention to safety, orientation, privacy, and personalisation of space.

Shortly afterwards, Cohen and Weisman [18] developed new criteria, highlighting the influence and importance of environmental design to maintain the functional capacities of users with dementia. These authors established the following as central elements for designing this type of building: safety, orientation, support for functional abilities, stimulation, autonomy, privacy, and the family social link. They also proposed a classification in which it was established that the design of these buildings should take into account certain planning principles, the attributes or qualities of the building, the organisation and layout of the different spaces, and, finally, the provision of specific rooms and spaces for activities that preserve the dignity and privacy of the residents. Shortly afterwards, two other manuals appeared, that of Cohen and Day [20] and that of E.C. Brawley [21], which also emphasised the need to support functional abilities and provide opportunities for stimulation and socialisation.

During the 1990s, The Dementia Services Development Centre was set up at the University of Stirling (UK) to research designs aimed at people with dementia. Its director, Professor M. Marshall, published the guide Working with Dementia: Guidelines for Professionals, which is still a benchmark for the design of buildings aimed at this group [22]. In 1993, R. Pollock applied some of these design principles in a pilot example of a housing project called St. Leonard’s Initiative, built for the Places for People Housing Association in Edinburgh. Gradually, certain design guidelines and criteria were consolidated at facilities for people with dementia, producing residential buildings equipped with care areas, which provided direct and personalised assistance to the user. The results obtained in some of these experiences were evaluated and assessed by M. Kelly in 1995. One of the main conclusions of his study was the confirmation that it was necessary to promote a safe and accessible design that would facilitate the autonomy of the residents [23].

Another important contribution was made by J. Zeisel, director of Alzheimer’s in the United States, together with J. Hyde and S. Levkoff, geriatricians from Boston [24]. In a paper published in 1994, these authors propose a building organisation model called Environmental-Behaviour (E-B). Its aim is to identify the special needs of these patients, motivated by the behavioural deficits caused by the disease. The results pointed out some of the characteristics that these facilities should have in order to be congruent with the requirements of the user frequenting them. A series of critical performance criteria were identified, that is, the specific requirements that a space intended for this group must meet in order to respond to the user’s behavioural model and, on this basis, to be able to apply certain intervention strategies. The criteria of the E-B model are summarised into eight environmental characteristics, each with two parameters that define them quantitatively. These characteristics are:

1. Exit control; its parameters are immediacy of control and not seeing the exits.

2. Wandering paths; their parameters are continuity and localisation/orientation.

3. User rooms: their parameters are privacy and personalisation.

4. Communal spaces: their parameters are quantity and variability.

5. External freedom: its parameters are availability and assistance.

6. Residential: its parameters are familiarity and size.

7. Autonomy support: its parameters are safety and external prostheses.

8. Sensory comprehension: its parameters are noise management and comprehensibility.

Later, J. Zeisel and his team investigated the correlation between optimal environmental conditions and the health of people with Alzheimer’s dementia. In a new article, published in 2003, they set out several design principles, emphasising aspects such as safety control, enhancing autonomy, sensory stimulation, spatial comprehension, and open-air spaces [25].

In the early years of this century, these concepts on the importance of adequately designing spaces and environments inhabited by this group of people spread throughout Europe. Various guides and manuals began to appear in different places. In Spain, the Guía de arquitectura. Adaptación y habilitación de la vivienda para personas con Alzheimer y deficiencias de movilidad was published in 2002, which contains a series of recommendations aimed at organising, planning and adapting a home inhabited by a person with Alzheimer’s disease [26]. Shortly afterwards, in 2010, J. van Hoof’s team reviewed different studies and works related to domestic interventions for the elderly [11].

In Italy, the book Architettura per l’Alzheimer. Il malato di Alzheimer e l’ambiente was published, which maintains that the environments experienced and lived in by these patients must be conceived, designed, structured, and built taking into account their reduced capabilities and their daily discomfort; this is an essential prerequisite to avoid reactive and depressive states that greatly compromise therapeutic treatments [27]. The physical space, its morphological dimension, its functions, and its environmental connotations can contain fear, reactivate memory, facilitate orientation, and reduce the feeling of frustration through the generation of a security that the patient must perceive. To this end, during the process of designing the space, the perceptual-sensory component must take precedence over functionality.

The design principles culminate in the World Alzheimer Report 2020 [28], which contains a set of recommendations to be observed when designing spaces for people with dementia. This series of criteria are summarised in the following points:

• Reduce risk. Prioritise safety and avoid elements that could lead to increased agitation, anger, or apathy.

• Provide a human scale, through three key factors: the number of people, the physical size of the space, and the size of the elements in it.

• Allow the user to see and be seen. An environment that is easy to understand and recognise helps to minimise confusion. Visual relationships give people the opportunity and confidence to explore their environment.

• Reduce unnecessary stimulation, both visual and auditory. The environment must be designed to minimise exposure to stimuli that are not useful to the person with dementia.

• Optimise useful stimulation. Allow the person living with dementia to see, hear, touch, or smell elements present in the space that give them clues as to where they are and what they can do.

• Support movement and participation. Design and propose well-defined, unobstructed internal and external pathways and avoid complex decision points. Create points of interest and opportunities for activity and social interaction.

• Create a friendly place by using familiar and personal elements that are recognisable in the living environment.

• Provide the opportunity to be alone or in company, which requires a variety of spaces, some for tranquillity, others for personal interaction, activity, or relaxation for users.

• Allow interaction with the community, as well as friends and family, to maintain a sense of identity; to this end, the building should provide meeting spaces.

• Facilitate various life options, allowing the focus to be on ordinary or instrumental activities of daily living, leisure, and recreational lifestyles, healthy lifestyles with exercise and walks, etc.

A summary of the main authors and theoretical contributions which have been made over the last thirty-six years, is presented in Table 1.

All the criteria set out in the different guides, manuals, and design principles consist of a series of very useful recommendations. The problem lies in the fact that they are somewhat generic and do not specify, with specific ranges and values, how they should be applied during the process of planning, designing, and building these facilities. Likewise, none of the aforementioned works define the architectural characteristics that a residential typology intended for these users should contemplate. This information is very useful for tackling, practically and with guarantees, the challenge posed by the planning of this type of building.

2.2. Empirical and Experimental Tests

There are essential values and attributes involving security, accessibility, privacy, autonomy, etc. that are inalienable and therefore do not require specific research for their validation [40]. Therefore, not all design guidelines are required to incorporate findings from patient trials to justify their recommendations for implementation.

Design guidelines often offer hypotheses on how a building can improve the quality of life and well-being of people with Alzheimer’s disease. Some of the solutions proposed, both in these manuals and in the construction of buildings, are the result of research findings and studies with people which assess and verify how certain environmental and spatial variables influence people with dementia. These tests are necessary to properly understand and know the impact that certain design decisions may have on people. Table A2, in Appendix A, is a summary of some of the main studies carried out to determine the impact of certain environmental variables and architectural factors on people with dementia.

These validations are also necessary when the proposed solutions are of unknown effectiveness, when they involve controversial and important impacts, or when situations that provoke certain conflicts in the behaviour of these people need to be resolved. Another value of these research studies is that they serve to discriminate and find out which architectural attributes or parameters have the greatest impact on these people.

The disadvantage of incorporating these tests on design and dementia into the projects of these buildings is that, as they are experimental, they usually address a very specific problem and do so punctually and partially. Furthermore, they generally fail to assess the inevitable interactions that the variables under investigation have with the other spatial components comprising a building. Another limitation is that most of these research studies are conducted on a population sample that tends to be small and variable in size, which raises problems about the validity and generalisability of the results obtained [8]. Another important aspect to consider is that these trials tend to focus on patients in the mild or intermediate stages of the disease, but do not address the unavoidable impact of living spaces as the disease progresses.

Due to the ageing of the population, there has been a proliferation of therapeutic models aimed at the retired population and the elderly, with the aim of improving their quality of life, preventing their cognitive deterioration, and reducing their possible dependence. In recent years, knowledge of cognitive functioning in the elderly has improved enormously through specific techniques for training their cognitive skills [41,42]. The starting point for interventions aimed at promoting therapeutic action in the field of brain ageing has a proven scientific basis in the plastic capacity of the brain. Neuroplasticity is the brain’s ability to restore disturbed equilibrium and adapt to new situations. Neuronal plasticity is regulated by two types of factors: intrinsic factors, which refer to the physiological characteristics of the human being, and extrinsic stimuli, which include environmental and socio-economic influences, but also the physical environment, such as the domestic or living space in which these users live. These factors can be addressed with pharmacological and non-pharmacological treatments, both with their respective limitations [43].

Furthermore, two causes of cognitive deficit coexist: organic and functional. The first is caused by the onset of the degenerative pathological process; in the case of Alzheimer’s disease, this is neuronal death, loss of synapses, and alterations in neurotransmitters. The second cause would result from the continued absence of the exercise of a certain function, be it cognitive, physical, or social. This decline in function is often brought about by the sufferer themselves and sometimes by their relatives. This withdrawal from daily activities can be prevented by psychosocial interventions, but also by cognitive, physical, and sensory stimulation through an appropriately designed environment [43]. The latest trends have a holistic, person-centred approach and address the need to support the person’s permanence in their own environment, with a special emphasis on maintaining the autonomy of people with dementia [44].

These fundamentals support the concept on which the particularised designs of environments and physical spaces for people affected by Alzheimer’s disease are based. It is a matter of designing and building environments that facilitate effective psychostimulation and that are also as accessible, safe, and comfortable as possible. Sensory stimulation is understood as a set of stimuli generated by the physical environment, with the aim of preventing functional losses, as well as maintaining the skills and activities of daily living [45]. With this approach, the spaces inhabited and used by those affected by this disease can be used as effective tools to improve their cognitive aspects, optimising and improving their quality of life and that of their family environment.

2.3. Residential Homes for People with Alzheimer’s Disease

Alongside the publication of the different design guides and the conducting of studies and tests on the environmental variables that influence people with dementia, buildings specifically designed for this group have also been constructed over the last forty years. One of the main objectives of this work is to review and evaluate the experiences obtained from these residential facilities, in order to know what results have been obtained with the practical application of the recommendations and design principles previously established theoretically and experimentally.

The first institution designed with specific criteria for people with Alzheimer’s dementia was the Corinne Dolan Alzheimer Center, designed by Taliesin Associated Architects and built in 1985 in Heather Hill (Cleveland) (Figure 3).

This is a nursing home with medical assistance, which arose as an architectural experiment with the aim of finding out which environmental design features could keep Alzheimer’s patients relaxed, safe, independent, and active for as long as possible [46]. The building proposes a spatial organisation model whose main contribution is the elimination of long paths, the creation of communal relationship areas, the design of open spaces with visuals to and from the residents’ bedrooms, and the use of warm materials to create specific atmospheres.

In 1991, the Woodside Place residential complex was built in Oakmont, Pennsylvania, USA, designed by the architectural firm Perkins Eastman (Figure 4). This building was an important milestone in residential homes for this group of people. With this facility, designed for 36 residents, the development of a new residential model for Alzheimer’s patients began, which is still in force today and has been extended to all homes for the elderly. The main innovation introduced by this centre is its spatial organisation, based on the grouping of rooms into cohabitation units or dwellings, each with a kitchen, living room, and eight bedrooms. These housing units are distributed into three modules, with a floor plan in the shape of a comb or inverted E, in which each of the arms is a housing unit. The design of each of these modules allows the residents to maintain close social relations, as well as permanent contact with the outside spaces, thus changing the secrecy and control that had hitherto existed over the patient. The user with dementia can go out independently to the garden areas, encouraging independence in some daily activities, and thus using the environment as a therapeutic mechanism for the resident. The architectural language of the building proposes space as an important factor of reminiscence, using archetypal forms linked to the concept of the house, such as gable roofs. Moreover, reduced proportions and dimensions are used in the volumes, or adornments and furnishings are incorporated into the rooms, allowing residents to reminisce about their homes.

The residential models, tested in the United States, in which the housing unit, similar to a dwelling, is the generating and structuring element of the residence, are also starting to be introduced in Asia and Europe. One example is the Kompetenzzentrum Demenz in Nuremberg (Germany), designed by Feddersen Architeckten in 2006. The contribution of this building was that it developed the extensive single-storey residential model, common in the USA, over several floors. Another interesting case is the Hogeweyk Dementia Village, a residence built in the city of Wees (Holland), which opened in 2009. A one-hectare enclosed complex for 150 residents with twenty-three homes for six to eight inhabitants each, which recreates a kind of urban centre of a small town. This building, with a closed block morphology, develops a type of residence in which a traditional urban environment is recreated with restaurants, a supermarket, a post office, shops, and another urban services. The idea is for its inhabitants to develop a daily life that maintains their daily routines prior to the disease as far as possible.

An example of an extensive residence located in a peri-urban environment is the interesting experience of Boswijk, built in 2010 by EGM Architecten in the Dutch city of Vught. Another case is the Village Landais Alzheimer built in 2020 in the French town of Dax, designed by the French-Danish team of architects Champagnat and Grégoire (Landes) and Nord Architects (Copenhagen). This extensive complex is prepared to accommodate 120 inhabitants affected by this disease and other dementias. The complex recreates a population centre, whose life is organised around a garden with a central lake, around which the buildings are located. The buildings are small in scale, with shapes and materials that favour and guarantee a functioning in accordance with the needs of these patients.

3. Materials and Methods: Case Studies and Parameter Analysis

In order to draw solid and solvent conclusions about the contributions of this typology and its genesis and evolution, this paper is focused on the review, analysis, and comparison of 30 of these residences built over the last four decades. Due to their configuration and characteristics, these residences have contributed significant advances in the design of spaces and environments for patients with AD and have formed a specific architectural typology (Figure 5).

This research adopts the methodology of critical review, using an analytical framework with a search, assessment, synthesis, and analysis process. The methodology used in the review of the residential homes for individuals with Alzheimer’s disease included an exhaustive review, selection of facilities, comparative observational process, data collection, and identification of patterns. These steps are described in the following:

1. Exhaustive review:

An extensive review of design principles proposed in various specialized guides and the scientific literature was conducted to provide a complete and objective view of what has been published to date on this subject. Moreover, a compilation of the existing information about facilities for people with AD from the first initial examples, during the last quarter of the last century, and in the present day provided knowledge and understanding of the chronological evolution of the solutions that have been adopted in the construction of these facilities.

To define the sample for this critical review, the main database literature used comprised books published in 2018 and 2019 by the Healthy Architecture & City research group, representing 28 residences designed for users with AD [47,48]. Additionally, the World Alzheimer Report 2020, Volume 2, presents a compilation of 84 buildings for people with AD in 27 countries [28]: twenty day care centres, fifty-eight residential homes, five public facilities and gardens, and one hospital. This list of buildings is based on self-reports sent to Alzheimer’s Disease International following an initial survey carried out by this institution. The document does not provide any specific critical assessment of these buildings, so no conclusions can be drawn from this compilation as to what value they add to knowledge on improving the quality of life of AD patients.

• 2.. Selection of residential facilities for people with AD:

The criteria for the initial selection included buildings primarily intended for this collective; a representative global sample incorporating countries with a significant incidence of dementia was sought. No geographical limitation was envisaged, which is why the initial selection of buildings was broad. It also needed to be a diverse and varied sample in terms of the buildings’ surroundings, covering those found in urban, peri-urban, and rural environments.

Buildings were selected through a screening process. Initially, the duplicate buildings from different databases were excluded. The criterion for inclusion was centres with long-term care units exclusively for the use of Alzheimer’s patients or, failing this, with a separate area in their formal and functional structure. Moreover, these buildings needed to have facilities, care services, and uses complementary to residential ones, which provide users various types of services focused on socio-health or care aspects. Buildings that, despite being care and assistance centres for people with dementia, did not have residential areas for this population of patients in their spatial organisation or formal configuration were excluded. For the final selection, quality and architectural uniqueness criteria were established, considering the projects carried out by reputable architectural firms or by those with experience in developing facilities for people with dementia. Buildings that have received quality awards or recognitions were also included, as well as buildings that serve as a reference in their closest geographical setting due to their social impact and/or significance in their contributions, as they have become a landmark in this type of construction.

• 3.. Comparative observational process:

This step involved analysing several aspects of the selected buildings, including:

• (a). Locations of the residences;

• (b). Organisation and functional programme of the building;

• (c). Presence of architectural attributes or parameters;

• (d). Integration of new technologies.

This process made it possible to obtain useful quantifiable data to compare and identify the patterns that are repeated in them, and thus determine the structure and organisation of these buildings. The results of this study make it possible to establish the main characteristics forming this typology, which has been shaped and decanted over time.

By applying the above criteria, an initial selection of facilities was obtained, the global distribution of which corresponds to the following percentages: America (35%), Europe (21%), Oceania (6%), and Asia (3%). Based on this initial compilation of buildings, a significant group of buildings was selected to analyse the ways in which people with AD live in residences in various parts of the world, distributed across 11 countries. The final sample comprised 30 buildings which, due to their quality, contributions, and architectural characteristics, form a reference for determining the common patterns and rules in this typology (Table A2). The process is shown in Figure 6.

• 4.. Data collection:

After obtaining the sample, we first proceeded to carry out a detailed and rigorous survey of all the floors of these buildings at a scale of 1:200 and 1:300 so as to properly compare them with each other. With the detailed analysis of these buildings, results were extracted that provided the main architectural characteristics comprising these residential facilities. From here, we determined which common spatial conditions were repeated and the architectural attributes or parameters that influence the well-being and quality of life of this group. With the aim of collecting data in each building, a data sheet (Figure A1) was drawn up that included the various aspects to be analysed and evaluated (Table A3). To prepare this file, a review of the existing empirical tests from design guides and the scientific literature was considered, making it possible to evaluate and compare the various solutions. It was also analysed whether the buildings have specific architectural measures aimed at alleviating some of the specific symptoms of AD, such as memory loss, difficulty in performing daily tasks, disorientation in time and place, mood swings, problems with abstract thinking, misplacement of items, anxiety, and stress.

• 5.. Identification of patterns:

The methodology allowed for the identification of common patterns and characteristics that have come to define the architectural typology of these residential facilities over time.

4. Results

The results obtained in the research are presented in this section in four different parts: (a) Planning related to the location of the facility, (b) organisation of the building and its functional programme, (c) built-in architectural attributes or parameters, and (d) integration of information and communication technologies.

4.1. Location of the Residence and Its Relationship with the Surroundings

It should be noted that familiarity with the place in which these patients live is key to enhancing their daily activities, maintaining a sense of autonomous living and maintaining their social and spatial relationships [49]. The relationship with the surroundings is directly linked to the location of the building, its contact with the close space and its relationship with urban centres. Direct connection with outdoor spaces full of vegetation is a crucial aspect, which has become one of the priority elements to be taken into account in the planning of these buildings.

The first facilities, built for this group, are usually located in rural or peri-urban environments, proposing occupancy solutions on extensive plots, with low density and low height. One example is White Oak Cottages in Colorado, built in 2006, a building located in contact with large green and wooded spaces. Another similar example in Europe is the Boswijk complex, built in 2010 in the city of Vught (Holland), an interesting example that combines a central area with collective services to which a series of housing units are attached, directly connected to the outdoor green space (Figure 7). In other places, determined by the availability of land and the urban situation of the facilities, it is necessary for a residential development to be a high-rise. In this case, the facilities also have a functional organisation based on housing as the basic cell but incorporate green spaces on terraces or rooftops. An example would be the Kompetenzzentrum Demenz in Nuremberg (Germany), built in 2006, designed by Feddersen Architeckten (Figure 7).

The proximity or closeness to services, considered as everyday or basic necessities outside the home, depends on the environment in which the building is located. In the buildings analysed, 47.6% of them are located in a rural or peri-urban environment. The distance to urban areas with services such as shops, cultural, and other facilities is 1.1 km on average. In these residences, the relationship established with the natural environment and open spaces allows users to maintain direct contact with landscaped outdoor areas. Table 2 shows the average distances between the residences in the sample and service facilities, as well as the average distances to outdoor green or natural spaces.

4.2. Organisation of the Building

4.2.1. Size, Scale, and Number of Residents

The results of an investigation of fifty-three special respite units in four US states indicated that units with few residents reduce the overstimulation of people with dementia, mainly due to noise control [50]. Therefore, the reduction of the number of residents to be served and the provision of specialised care has been a constant since the first buildings were constructed in the 1980s.

A total of 73% of the buildings analysed in this research have an average number of users that is between 80 and 120 residents per residence, distributed in independent group-living units or households, the number of which in a residence varies between nine and twelve units (Table A4). Within each household, also referred to as a special care units (SCUs), the spaces shared by its inhabitants occupy 50–55% of the total surface area of the unit. These are areas where the user spends most of the time outside their room and are usually equipped with a living room, kitchen, dining room, or rooms for other uses shared with other patients or family members (Figure 8). In 87% of the buildings in the sample, the rooms are usually single, with an average size of 17.68 m². The average number of residents per household ranges from eight to twelve residents (Table 3).

The above characteristics have a direct and notable influence on the design of this type of building, since the concept of a housing or living unit is inescapably associated with the way in which residents are grouped in these modules and their relationship with the common use or care spaces. This requirement entails a particular determining factor in the composition of these facilities, because it is necessary to design them not as hospital accommodation with rooms in a row, but as a grouping of large dwellings equipped with care services. Moreover, closely linked to the number of residents are the size and scale of the buildings that, in 86% of the cases analysed, tend to have a very controlled size, both in terms of height and floor plan.

4.2.2. Distribution of the Functional Programme

Another decisive element in these residential facilities is their functional programme. The organisational structure of these buildings has evolved from the first buildings to the present day. Nowadays, services, facilities, and rooms are incorporated that complement the residential area and favour the daily activities of these users. Currently, the spaces that users use and require in these facilities are not limited to the private space of their bedrooms, but also include other places of coexistence existing in the centre.

From the analysis of the buildings in the sample, it can be seen that the spatial organisation of these facilities corresponds to three types of areas, ranging from a more public use to the private rooms of the patient (Table 4). The area that brings together the collective or common uses aims to provide the necessary support so that users can develop activities during the day, providing social interaction, psychomotor skills, cognitive stimulation, etc. These functions are generally located in the central areas of the buildings, where the user can interact with the other residents. This area also incorporates the management and administration areas of the centre and is complemented by places for interaction with family members, as well as rooms for carers or healthcare staff.

The semi-private and private areas correspond to those existing in the households or group-living units, in which their functional and organisational programme corresponds to the layout of an autonomous or independent house. The shared or semi-private uses incorporated in these units are the usual ones in a large dwelling, such as kitchens, dining rooms, living rooms, and cleaning or laundry areas, among others (Figure 9).

• Residential area

As mentioned in the previous section, the number of residents per household is between nine and twelve people. A dwelling or group-living unit of nine users usually has a surface area of approximately 425 m². Below is a summary table with the average surface areas of the different rooms obtained from the analysis of the sample of buildings (Table 5).

• Care area with communal uses and daytime activities

In recent decades, the spatial model of care for users with dementia has generated various profound changes in the organisational structure of these facilities, especially determined by the need to provide the building not only with a residential structure but also with complementary services that attend to the symptoms and evolution of the disease. According to A. Casares, the hospitalisation area corresponding to the surface area used by the patient accounts for 21.54% of the total surface area in a hospital, compared to 86.3% of the surface area used by a person with dementia in this new residential typology [51]. Thus, there is a move towards a mixed model that includes care services in residential accommodation.

This paradigm shift is reflected in the typology of these architectural structures, which now have controlled areas that regulate all the patient’s daily activities, while also integrating services such as medical care areas and special care or specific healthcare. In 76% of the cases studied in the sample, residential use is associated with a functional programme dedicated to services and facilities for social, therapeutic or medical care (Table 6).

A paradigmatic example of this new mixed typology is the Reina Sofía Foundation centre in Madrid (Spin), built in 2007 (Figure 10), a complex for 156 residents subdivided into several modules, six of which are residential, which have care areas according to the different degrees of their disease. It also has research areas, a day care centre, and a respite unit. The building is located in a congested urban environment, which leads to the construction of the group-living units with interior courtyards that allow an adequate relationship with the light and the outside air, as well as a suitable orientation of the dwellings.

Other facilities resolve the incorporation of care services by recreating a traditional urban environment inside with supermarkets, pharmacies, shops, etc., similar to the original neighbourhood or town, with the aim of making the residents feel like they are living in an environment they recognise, as in the case of Dementia Village in Hogeweyk (Holland), built in 2009.

4.2.3. Paths and Wayfinding

Spatial disorientation in these patients is generated by the existence of an unrecognisable space, by confusion regarding the reference of the time in which they live, aggravated by the loss of personal identity [18]. Paths and wayfinding support movement and participation, and are also closely associated with the size of the building. A simple and clear layout, with explicit environmental information in the building, generates a good orientation for the resident [52]. It is important to design and propose well-defined, unobstructed internal and external pathways, avoiding complex decision points. This means providing points of interest, clear visuals, and opportunities for activities and social interaction [53].

In the facilities analysed, as they are predominantly residential and small in scale, the paths tend to be short, with low to medium distances between rooms and other essential spaces, excluding long corridors where there are no visual references or landmarks that allow the user to orientate themselves in the best possible way. In 42% of the cases in the sample, the paths are arranged around communal areas or rooms, allowing the user to quickly identify the services of the dwelling that are independent of their room. A total of 68% of the buildings have circular or concentric circuits. The average distance travelled by a person from their room to the communal services of the residence is 18.10 m. The average distance travelled by the user in the outdoor areas is around 142 m (Table 7).

Some of the creative practices recently used by architecture allow the patient to recognise certain spaces and orient themselves. At Woodside Place Pennsylvania, built in 1995 or at the Alzheimer’s Respite Centre, built in 2011 in Dublin (Figure 11), memory boxes, photographs of rooms, or the chromatic identification on the doors of the rooms are used, among other resources. In 81% of the projects analysed in this research, furniture or ornamental aspects of the house in which the residents lived are incorporated into the rooms, with the aim of generating a reminiscence of their own home in the inhabitant. Some buildings, such as Abe’s Garden, built 2015 in Nashville, create a fictitious outdoor environment that reproduces the environment in which the users have lived, so that they maintain a link with environments that are familiar to them.

4.3. Architectural and Environmental Attributes or Parameters

4.3.1. Lighting and Visual Contrast

People with AD often have sleep disorders, so exposure to light during the day may improve their night-time sleep and reduce daytime sleepiness. Lighting is an essential attribute in the care of people with Alzheimer’s dementia, as it has a particular impact on circadian rhythm, reduction of agitation and anxiety, and improved safety, orientation, and cognitive stimulation, all of which are critical to the well-being and quality of life of people with dementia. It is beneficial to use natural lighting whenever possible, as its influence on people with AD has been demonstrated by different scientific evidence, as shown in Table A2. Artificial lighting systems should avoid glare, shadows, and dark areas, as these can cause disorientation or anxiety. Adequate lighting helps people with AD to move around more confidently and safely, as well as preventing falls and accidents. Moreover, good lighting, which makes it possible to perceive changes in the intensity and type of light throughout the day, helps residents to orient themselves in time and space (Table 8).

It is therefore important to design and maintain a well-lit environment, adapted to the specific needs of these patients. Designing and building interiors with adequate light, both natural and artificial, has a very positive influence on people’s moods. In this sense, the orientation of the building and, in particular, of the rooms comprising it, is closely linked to this parameter.

Providing adequate levels of light in interior environments is also achieved through the design of façades, as well as windows, atriums, skylights, or courtyards, all of which are elements used in the buildings in the sample to incorporate daylight into specific spaces. The interior layout and organisation of the space also influences the exposure to natural light that users receive. The use of significant contrasts, both with the correct lighting and with the use of colours, generates identification benefits in the memory of these users.

Generally, the buildings analysed in this study are located in the northern hemisphere, so their rooms are usually oriented towards the south-east, meaning that their users are in direct contact with natural light during most of their daytime activities. The importance of natural light is evident in 92% of the buildings studied.

4.3.2. Thermal and Climatic Comfort

Thermal comfort is essential for general well-being. A well-designed and maintained climate control system can significantly improve the quality of life of residents, facilitating their care and contributing to their physical and emotional well-being. However, climate control in buildings for people with Alzheimer’s is not only a matter of comfort, but also an integral component of a safe and healthy environment. It contributes to their safety, for example, in the prevention of falls, as falls may increase in Alzheimer’s patients if they feel cold or if there is condensation on surfaces due to poor ventilation. It is also important to control air quality, in aspects such as eliminating dust, pollen, or other allergens or maintaining the relevant humidity, preventing environments that are too dry or too humid, which can favour the proliferation of mould and bacteria [54].

On the other hand, people with Alzheimer’s dementia may have difficulty regulating their body temperature due to symptoms of the disease that affect thermoregulation, and sudden changes in temperature can cause stress and confusion. A constant and appropriate room temperature environment contributes to a more stable daily routine, reducing anxiety, but also helps to avoid problems such as hypothermia or hyperthermia, which increase the risk of dehydration and heat stroke. Equally, good climate control can help to regulate the circadian rhythm of residents, maintaining appropriate temperatures at night to improve the quality of sleep.

Thermal conditioning in the buildings analysed is influenced by a number of elements including building orientation, local location, organisational structure, occupant density, ventilation strategy, and mode of operation. These combined variables influence and interact in the comfort and thermal sensation of the users, which are basically achieved with an adequate combination of outdoor temperature and humidity, both of which influence people’s well-being.

When the air temperature is within a comfortable range for the occupants, the effects of humidity do not play a role. However, in warm temperature environments, humidity can influence the human body’s ability to release heat through evaporation and the level of discomfort from excessive sweating. Conversely, cold and dry spaces can cause discomfort and irritation of the respiratory tract, skin, eyes, and throat. This is why the operating temperature is useful for the assessment of thermal comfort, as it reliably represents the temperature felt by a person in an indoor environment. This temperature is the mean value between the air temperature and the average radiant temperature and is variable depending on the geography and location of the building.

In this research, buildings located in the northern temperate climate zone have been studied, where the appropriate humidity level should be between 50% and 60%. Maintaining humidity within this range helps to ensure a comfortable and healthy environment, reducing respiratory problems and ensuring the general well-being of residents [36] (Table 9).

4.3.3. Sensory or Environmental Stimulation

One of the innovations introduced since the first experiences of these architectures has been the personalisation of the surroundings or environment as a mechanism of spatial stimulation for the resident. The parameter of sensory or environmental stimulation is what differentiates this typology from other types of residences or facilities for the elderly. It is also one of the most important in providing quality of life for people with dementia. The use of this attribute consists of managing and balancing a series of environmental stimuli in such a way as to have a significant impact on the perceptions, feelings, and behaviours of users.

The use of certain materials and their corresponding textures, the use of colours, the control of noise, or the smells themselves are stimuli that have a direct impact on the well-being of the person with AD, as they report to a certain extent a reduction in their stress, anxiety, or agitation. Over time, certain measures that influence patients’ senses have been incorporated into the different nursing homes. Elements that favour sensory or environmental stimulation have been introduced, such as those described below (Table 10):

• Materials: A total of 78% of the buildings studied use warm materials such as wood or similar in their interiors. As opposed to colder materials such as marble or porcelain elements, 69% of the buildings use warm flooring such as floorboards/parquet/carpets; these are materials that also cushion the effects of possible falls.

• Textures: There is a tendency to use smooth textures or surfaces, without excessively greyed drawings, so that they do not generate uneasiness, fear, stress, or situations of apathy on the part of the user when they see or touch them. In 32% of the case studies, the use of textures related to materials that allow the user to use them comfortably is identified, as opposed to cold metal elements that normally cause rejection.

• Colours: A total of 78% of the case studies analysed use light colours in both vertical and horizontal surfaces. A total of 22% use differentiating colour elements to increase contrast and identify a colour with a use or room. Contrasts are used between different rooms and places, as well as between different walls, in order to identify different zones or areas. As a general rule, warm colours predominate in night-time spaces or in spaces associated with tranquillity and relaxation.

• Smells: The presence of smells inside spaces is produced with the incorporation of certain plant elements, among other resources. Some studies show that certain fragrances can have a favourable effect on factors such as sleep. These smells can be achieved through the presence of jasmine, lavender, or other pleasant scents. A total of 72% of the buildings analysed have a direct relationship with outdoor spaces that incorporate natural vegetation with its associated smells, thus allowing the presence of certain smells at different times of the year.

• Climate control: Today’s ability to adjust the climate control differently in different areas of the building allows the creation of personalised environments to the different needs of people, such as warmer areas for residents with greater sensitivity to cold or rooms with more ventilation for physical activities.

The proposals for the most recent buildings do not forget proposing contemporary architectural languages. This is the case at the Etablissement d’hébergement pour les personnes âgées dépendantes, built in 2012, in Paris and the Foyer la Grange Alzheimer’s residence, built in 2014, in Nantes, which include exposed concrete or prefabricated panels on their façade so as to sift the light according to the time of day and the needs of their residents.

4.4. Integration of New Emerging Technologies

Alongside the development of this type of building, in recent decades, contemporary society has been immersed in a digital revolution that is also transforming living spaces and environments. Architecture designed for people with AD has been gradually integrating the new emerging information and communication technologies. Its objective has been, first and foremost, to provide these buildings with maximum safety, comfort, and well-being for their inhabitants. Recently, the new paradigm being established by new technologies is that the habitat and environments can interact proactively with the Alzheimer’s sufferer.

With the architectural integration of new technologies, it is possible to build a prosthesis, which becomes proportionally more complex the more complex the cognitive loss. In this way, the living space can become a kind of ‘exo-brain’ that actively supports the affected person in their daily relationship with the physical environment. The current development of technology makes it possible to create assisted environments and spaces that interact with the person, making up for and complementing some of their cognitive or sensory deficiencies, and also helping them to preserve their cognitive capacity in the early stages of the disease. A degree of technological development has been reached in which it is possible to build a prosthetic environment where, after assessing the patient’s condition, deficits, and capabilities, the environment can provide a prosthetic response, providing the possibility of maintaining their capabilities and slowing down those that are deteriorating.

In the design of these new spaces, the emergence of new paradigms such as Active and Assisted Living (AAL) plays a fundamental role, an innovative assistance model that, using the Internet of Things (IoT), Ambient Intelligence (AmI), and generative Artificial Intelligence (AI), introduces intelligent assistance systems embedded in furniture, objects, and domestic spaces. These systems are made up of different devices that communicate with each other and interact invisibly and proactively with the inhabitant, making it possible to generate assisted environments that facilitate a healthier, safer, and more comfortable life for people with physical, sensory, or cognitive functional diversity, as well as greater personal autonomy [55].

Through the use of technologies such as facial or biometric readers, smart mirrors, voice control, contact or presence locks, location, movement and presence sensors, and alarm systems in kitchens and bathrooms, it is possible to improve the instrumental activities of daily living of people with cognitive impairment, improving their orientation, motivation, or mood. It is possible, for example, that a person may not remember where the bathroom is but can be shown the way to it by automatically activating LED lights to lead them to that room. Likewise, position sensors are used linked to the switching on and off of directed paths, the control of air-conditioning units that provide comfortable aspects to the domestic environment. These are techniques that make up the new residential care space for these inhabitants and have a significant influence on aspects such as stress and anxiety control.

5. Definition of a New Architectural Typology, Characteristics

What is common to all the examples analysed in this research is that they repeat patterns that frequently use the elements described in the previous section. The application and repetition of these architectural measures gives rise to the main characteristics that define the typology of residential care facilities for patients with Alzheimer’s dementia. The peculiarities comprising this type of architecture are adapted to the circumstances and determining factors of the different places where the buildings are located, as well as to the specific requirements of the developers and planners.

One of the main conclusions drawn from this paper is that, unlike traditional residences or hospital architecture where the space used by the patient is confined solely to the room and bed, the innovative nature of this new typology is its functional programme and organisational structure. In this new type, the residential component has been complemented by care services and areas that complement the living area and seek to favour the daily activities of these users. The building has to respond not only to the geographical, climatic, and cultural characteristics of the place, but also, to a certain extent, to propose a continuation of the customs and ways of life of the people who live there.

The analysis conducted during the research has identified a series of eight characteristics (Figure 12) that define the main aspects of this new typology, which are set out below:

1. Close and familiar location with large outdoor areas with vegetation.

   The surface area available for gardens, terraces or walkways in the residences should be between 55–60% of the total plot. This means that the occupation of the built-up area should be between 40% and 45%, always considering it as a single-storey development. In order to maintain the person’s sense of identity, it is necessary to maintain interaction with the territory, the climate, and the community with which they have lived. The location must be linked to the ways of life of the resident user, so that the location of the residence facilitates maintaining the social and spatial relationship with the environment they have known. In other words, it is important that the locations of these residential centres ensure, as far as possible, that their residents do not abandon the traditional habitat where they have lived their lives. Sites should provide a welcoming, safe, and stimulating environment with meeting places. The location needs to provide a variety of living options, allowing a focus on ordinary activities or leisure and recreational modes of living, healthy lifestyles with exercise and walking, encouraging social interaction and providing constant emotional support, and better managing the symptoms of the disease.

2. Residential scale with non-institutional character, reduced size, and dimension.

   The appropriate maximum number of residents is usually between 80 and 120 people, grouped into several group-living units, household, or dwellings. A building for these patients needs to be on a human scale, with a small number of residents, small spaces and controlled environments. As far as possible, a building with few storeys in height and extensive development is preferable, so that the building allows the user to visually and immediately recognise the volumes comprising it. The size of the interior spaces should have characteristics and dimensions similar to those of a home. Instead of proposing institutional or hospital environments, it is necessary to design environments that are reminiscent of the home through the use of familiar elements and that allow the user to easily recognise the environment in which they live. The patient must be given the opportunity to be alone or accompanied, which requires a variety of spaces. To this end, it is necessary to provide welcoming spaces in which to be at ease and others for shared use, with communal living areas and kitchens that encourage and facilitate interaction and coexistence. These communal areas are large, accessible spaces with uses that are not restricted to resident users.

3. The dwelling as a basic cell in the building distribution.

   The grouping of the residents’ rooms in these residences is by dwellings or households, with a variable number of rooms that varies between five and twelve rooms per group-living unit. The number of dwellings per residence varies from nine to twelve units. These units are equipped with the usual spaces in a dwelling such as kitchens, living rooms, launderettes, etc. and which, as far as possible, have a relationship with outdoor spaces such as terraces, gardens, courtyards, etc. The layout should be orderly with short paths, avoiding right angles and blind spots; the design of the routes should make it easy for residents to walk without encountering barriers or dead ends. Elements that could lead to increased agitation, anger, or apathy should be avoided.

4. Mixed functional programme: residential and care services, with comprehensible organization.

   The programme of uses should incorporate a mixed organisation chart that integrates both residential and care services. It must also take into account the temporary needs of the user and the state or phase of the disease. The spatial organisation of these facilities consists of different areas with private, semi-private, and public uses. Semi-private areas favour socialisation and generally have an open design so that they are visible to the patients themselves and also to carers. Public care spaces incorporate services and facilities with areas for medical care, special care, specific healthcare, visiting spaces, or multifunctional activity rooms. The orientation of the building should be clear and understandable, with cross visuals and a unitary perception of space, and clear and understandable visual signs are used to help residents find their way around. These visual relationships give people the opportunity and confidence to explore their environment. An environment that is easy to understand and recognise helps to minimise confusion, so it is important to establish visual landmarks or direct connections to outdoor spaces through windows or access to gardens.

5. Safety and mobility adapted to cognitive accessibility and universal design.

   As far as possible, compliance with the seven principles of universal design or design for all should be taken into account, so that the environment always facilitates the movement, well-being, and comfort of the residents. On the other hand, one of the priorities in this type of building is to minimise risk. A safe building is more accessible and promotes greater freedom in decision-making for users. To achieve this, it is necessary to implement cognitive accessibility measures in buildings, complemented by technical solutions for access control, with security systems that prevent residents from wandering outside designated areas. Ramps, handrails, and adapted toilets should be provided, as well as avoiding open stairways, balconies without secure handrails, or any other element that could pose a risk of falls or accidents.

6. Personalisation of spaces through sensory stimulation.

   Spaces should be designed to minimise exposure to stimuli that are not useful to the person with dementia, so unnecessary stimulation, both visual and auditory, should be reduced. On the other hand, it is necessary to optimise useful stimulation and allow the person living with dementia to see, hear, touch, or smell elements present in the space that give them clues as to where they are and what they can do. To do this, materials, colours, and textures that are stimulating to the senses should be used in a controlled way, creating a calm environment that does not cause anxiety, confusion or counterproductive effects due to a high presence of stimuli. It is important to implement construction techniques and solutions that minimise noise to create a calm and relaxing environment. In private rooms, which are the places where residents can maintain some autonomy, independence, and privacy, it is important to allow them to be personalised with furniture, personal objects, and decorations that are familiar and comforting to them. In public areas of the building, furnishings should be comfortable and safe for people with reduced mobility. It is important that outdoor areas have areas with greenery or water features arranged to stimulate the senses and provide a tranquil environment that provides relaxation and well-being.

7. Conditioning for well-being: lighting and climatic comfort.

   Proper environmental conditioning is essential for the well-being and comfort of Alzheimer’s patients. Two parameters are important in this typological feature: natural lighting and climate control. Adequate lighting improves sleep cycles, reduces agitation, improves safety and supports temporal and spatial orientation. On the other hand, well-managed climate control ensures a comfortable temperature, reduces heat stress, controls humidity, and maintains good ventilation. Both factors combined create a safer, more comfortable, and more therapeutic environment, which is crucial for the quality of life of people with AD.

8. Integration of emerging information and communication technologies.

   The integration of technologies, as one of the main characteristics of this new architectural typology, is a fait accompli in new residential buildings. The application of new information and telecommunication technologies makes it possible to ensure the well-being of residents by monitoring them in a non-invasive way. Care management systems, consisting of software and digital tools for daily care management and monitoring of the health status of residents, must be integrated. On the other hand, it is possible to design and build an intelligent or exo-brain environment that, through the use of various types of assistance devices, sensors, and monitoring systems, can make up for some of the shortcomings of these people with cognitive impairment. Internal communication systems can also be implemented to facilitate staff coordination and immediate attention to the needs of the residents.

6. Discussion

The findings of this research underscore the importance of creating environments that are not only functional but also supportive of the cognitive and emotional needs of residents. This discussion explores the implications of this study’s theoretical contributions, the weaknesses of the research, a comparative analysis between the results obtained in this work and the findings of the existing literature, and the potential for future research and practice in this area.

The establishment of a concrete architectural typology for Alzheimer’s care facilities is a significant advancement in the field. By defining this typology, this study challenges traditional notions of architectural design, which often prioritise composition, aesthetics, or functionality over the cognitive, emotional, or memory needs of this collective of persons. The emphasis on the individual’s cognitive and emotional well-being as central to design principles represents a paradigm shift that aligns with contemporary understandings of health and wellness in built environments. This research not only enriches the theoretical discourse but also provides a practical framework for architects, planners, and investors to follow. The results demonstrate that effective design for Alzheimer’s inhabitants requires a comprehensive understanding of how environmental factors influence behaviour and well-being. This approach encourages architects to engage with psychologists, gerontologists, and healthcare professionals, fostering a holistic understanding of the challenges faced by persons with AD. Such collaboration can lead to more innovative and effective design solutions that address the complex needs of this population.

One of the main limitations of this work has been the lack of a previously established methodology, a circumstance that constituted a major barrier at the beginning of the work. However, this lack of methodology made it necessary to design an innovative method that has allowed us to tackle the problem under study with certainty. This new methodology can serve as a basis for future research and studies on this subject, and it is one of the main contributions of this work.

The results of this study present several advances compared to existing literature findings regarding the design of residential facilities for persons with AD. The paper defines a new architectural typology specifically for residential facilities catering to AD patients, detailing characteristics that have not been explicitly stated in the previous literature. Additionally, while the existing literature proposes various general design principles, this paper synthesises these into eight concrete architectural features that emphasise cognitive and physiological receptions of space for these people. Previous studies may not have systematically reviewed such a wide range of residential facilities for people with AD, limiting their applicability to current architectural practices.

The existing literature may address user experience, but it frequently lacks a detailed exploration of how specific and architectural design features can evoke positive feelings in residents. This research highlights the importance of user experience in architectural design, focusing on how architectural attributes can enhance residents’ cognitive and emotional well-being. Many previous studies have relied on less systematic approaches, which can limit the generalisability of their findings. This paper employs a robust methodological framework that combines qualitative analysis with observational data, allowing for a more comprehensive understanding of design impacts.

In summary, the research advances the field by providing a well-defined architectural typology, a contemporary review of facilities, a holistic design approach, a focus on user experience, and methodological rigour, all of which enhance the understanding of effective residential environments for individuals with Alzheimer’s disease.

This study opens several avenues for future research that can further improve the architectural design in the context of Alzheimer’s care. Longitudinal studies examining the impact of specific design features on residents’ cognitive and emotional outcomes would provide valuable empirical data to support the characteristics of this typology. Additionally, exploring the role of technology in enhancing the design of these facilities could yield insights into how smart environments can further support residents’ needs. Furthermore, future research could investigate the experiences of carers and family members within these environments, as their well-being is also crucial to the overall care ecosystem. Understanding how design can facilitate family engagement and support carer needs could lead to more comprehensive care models that benefit all stakeholders involved.

This research represents a significant step forward in the theoretical understanding of architectural design for residential facilities serving persons with AD. By establishing a new typology, the research contributes to a more nuanced understanding of how built environments can enhance residents’ quality of life. However, challenges in implementation and the need for further research highlight the complexities of translating theory into practice. As the population of users with Alzheimer’s continues to grow, the importance of evidence-based design in residential care settings will only become more critical.

7. Conclusions

The main contribution of this work is the definition of the main architectural characteristics that a typology of residential care facilities for people with Alzheimer’s dementia should have. Residences for people with AD dementia must attend to aspects such as spatial and temporal orientation, control of scale, relationships with exterior spaces and interior paths, participation in daily activities, the use of forgotten skills, and improvement in behavioural changes or in the well-being of the people affected. Additionally, these aspects need to be integrated with consideration for the necessary provision and adaptation of spaces for the family and the carer. The theoretical contributions of this study are significant and contribute to the broader discourse in architectural design, particularly in the context of residential care for individuals with AD. Key theoretical implications include the following:

1. Establishment of an architectural typology: This research defines a unique architectural typology specifically tailored for Alzheimer’s care facilities. By focusing on the interplay between design and residents’ cognitive and emotional needs, it challenges existing paradigms that often treat architectural design as a purely aesthetic or functional endeavour. This typology emphasises the importance of creating environments that actively support cognitive function and emotional well-being, thus expanding the theoretical framework for designing spaces for vulnerable populations.

2. Integration of multidisciplinary perspectives: This study synthesises insights from architecture, psychology, gerontology, and health sciences, promoting a multidisciplinary approach to design. This integration underscores the necessity of considering various factors—such as safety, accessibility, and social interaction—when designing for persons with cognitive impairments. It encourages future research to adopt similar interdisciplinary methodologies, fostering collaboration across fields to enhance the understanding of how built environments impact health and well-being through thoughtful design. This contribution broadens the theoretical landscape by promoting collaboration across disciplines, emphasising that effective design for Alzheimer’s care requires a comprehensive understanding of the interplay between environment and human behaviour.

3. Empirical validation of design guidelines: Through a critical review of 30 residential homes, this study provides evidence that supports the proposed design principles. This empirical foundation strengthens the theoretical framework by demonstrating how specific architectural attributes can lead to improved outcomes for residents with AD. It encourages future researches to adopt similar empirical approaches, thereby enhancing the applicability of architectural guidelines in dementia care.

4. Framework for future research and practice: This study lays the groundwork for future research by identifying key characteristics and design principles that can be further explored and refined. This framework not only guides architects and planners in their practice but also invites ongoing investigation into the evolving needs of ageing populations and the role of architecture in addressing these needs. It encourages a continuous dialogue in the field about the influence of design on health and well-being.

In summary, the theoretical contributions of this paper significantly enhance the understanding of how architectural design can serve to meet the specific needs of persons with AD, promoting a paradigm shift in the design of residential care facilities. This work not only informs current practices but also sets the stage for future innovations in the field.

We can conclude that designing a residence for Alzheimer’s patients requires a deep understanding of the disease and designing with a holistic and comprehensive approach that includes aspects such as safety, accessibility, and emotional well-being, as well as social, family, and community interaction. One of the fundamental novelties of this typology is that it is configured by means of an organisation made up of households or dwellings, which recreate the atmosphere of a home, provoking reminiscences in their inhabitants. These residential facilities also incorporate care services for users and places for carers, and in some cases, they are complemented by day care centres and/or respite units. The peculiarity of this architectural typology is the sensorial personalisation of the spaces for the users for whom it is intended.

This typology is not defined by the morphology or composition of the building but focuses on achieving an adequate cognitive and physiological reception of the space by the people who inhabit it, which is why it is essential to use certain architectural parameters that stimulate all the senses. Its purpose is to stimulate the physical–neurological relations between the human body and the environment to naturally improve residents’ comfort and well-being. The understanding and inclusion of the physical–chemical mechanisms that govern spaces for people with dementia implies a change in the way of thinking and understanding these environments, consequently influencing the ways of designing to make them more habitable, healthy, and inclusive for this group.

In this new type of architecture, conventional forms of representation (analogical, aesthetic, or rhetorical) are overcome in favour of other design mechanisms that encourage the relationship between environment and organism. These residences are designed using not only semantic, cultural, or plastic means, but using alternative architectural attributes that promote and favour the existing stimuli between space and body. As a result, these spaces and environments become an effective element to physically, sensorially, and emotionally stimulate people with dementia, improving the conditions of comfort and habitability, and increasing their well-being and quality of life.

Author Contributions

Conceptualization, S.Q.-G.; methodology, S.Q.-G. and P.V.-F.; validation, S.Q.-G.; formal analysis, M.L.-G.; investigation, S.Q.-G. and P.V.-F.; data curation, P.V.-F. and M.L.-G.; writing—original draft preparation, S.Q.-G.; writing—review and editing, M.L.-G.; visualization, S.Q.-G. and M.L.-G.; supervision, S.Q.-G.; funding acquisition, S.Q.-G. All authors have read and agreed to the published version of the manuscript.

Data Availability Statement

The datasets below are part of the analysis process carried out at 30 residential facilities for people with Alzheimer’s disease. They are presented in several data sheets, one per building. Each dataset provides data on the buildings analysed, including location, functional programme, organisation, characteristics, photographs, drawings and diagrams, among other aspects. All of them are open access data and, in accordance with FAIR principles, are stored in the institutional repository of the University of Seville (iDUS). The list of data relating to the research covered by this publication is as follows: Characteristics and data of residential facility for people with Alzheimer’s disease. 01. Waveny Care Centre. 1975 [56]. Characteristics and data of residential facility for people with Alzheimer’s disease. 02. Corinne Dolan Alzheimer Center. 1985 [57]. Characteristics and data of residential facility for people with Alzheimer’s disease. 03. Alzheimer Woodside Place. 1991 [58]. Characteristics and data of residential facility for people with Alzheimer’s disease. 04. White Oak Cottages. 1994 [59]. Characteristics and data of residential facility for people with Alzheimer’s disease. 05. Wilhelmiina. 1995 [60]. Characteristics and data of residential facility for people with Alzheimer’s disease. 06. De Naber. 1995 [61]. Characteristics and data of residential facility for people with Alzheimer’s disease. 07. Laurens De Hofstee. 2000 [62]. Characteristics and data of residential facility for people with Alzheimer’s disease. 08. Gradmann Haus. 2001 [63]. Characteristics and data of residential facility for people with Alzheimer’s disease. 09. Kattrumpstullen. 2003 [64]. Characteristics and data of residential facility for people with Alzheimer’s disease. 10. Sun City Ginza East. 2006 [65]. Characteristics and data of residential facility for people with Alzheimer’s disease. 11. Kompetenzzentrum Demenz Nürnberg. 2006 [66]. Characteristics and data of residential facility for people with Alzheimer’s disease. 12. Fundación Reina Sofía, Centro de Alzheimer. 2007 [67]. Characteristics and data of residential facility for people with Alzheimer’s disease. 13. Norra Vram Nursing Home. 2008 [68]. Characteristics and data of residential facility for people with Alzheimer’s disease. 14. Il Paese Ritrovato. 2008 [69]. Characteristics and data of residential facility for people with Alzheimer’s disease. 15. Proyecto Villafal. 2008 [70]. Characteristics and data of residential facility for people with Alzheimer’s disease. 16. Hogeweyk. 2009 [71]. Characteristics and data of residential facility for people with Alzheimer’s disease. 17. Fürstlich Fürstenbergisches Altenpflegeheim. 2009 [72]. Characteristics and data of residential facility for people with Alzheimer’s disease. 18. Alzheimer’s Respite Centre. 2009 [73]. Characteristics and data of residential facility for people with Alzheimer’s disease. 19. Leonard Florence Center for Living. 2010 [74]. Characteristics and data of residential facility for people with Alzheimer’s disease. 20. Boswijk. 2010 [75]. Characteristics and data of residential facility for people with Alzheimer’s disease. 21. Hanna Reemstma House. 2011 [76]. Characteristics and data of residential facility for people with Alzheimer’s disease. 22. EHPAD Etablissement d’Hébergement pour les Personnes Àgées Dépendantes. 2012 [77]. Characteristics and data of residential facility for people with Alzheimer’s disease. 23. Alzheimer Residence for the “Foyer la Grange”. 2014 [78]. Characteristics and data of residential facility for people with Alzheimer’s disease. 24. Kompetenzzentrum Demenz München. 2014 [79]. Characteristics and data of residential facility for people with Alzheimer’s disease. 25. Kompetenzzentrum Beraten Wohnen Pflegen. 2014 [80]. Characteristics and data of residential facility for people with Alzheimer’s disease. 26. The Abe’s Garden Campus. 2015 [81]. Characteristics and data of residential facility for people with Alzheimer’s disease. 27. Abbeyfield Winnersh Society. 2016 [82]. Characteristics and data of residential facility for people with Alzheimer’s disease. 28. Lantern of Chagrin Valley. 2016 [83]. Characteristics and data of residential facility for people with Alzheimer’s disease. 29. Rosemount Gardens. 2016 [84]. Characteristics and data of residential facility for people with Alzheimer’s disease. 30. Village Landais Alzheimer. 2018 [85].

Acknowledgments

This paper has been possible thanks to funding obtained competitively from grant PID2020-115790RB-I00 funded by MICIU/AEI/10.13039/501100011033.

Conflicts of Interest

The authors declare no conflicts of interest.

Footnotes

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Figures and Tables

Figure 1. Green House Project. Photo of The Green House Homes at Green Hill. Bottom left, the general plan of the Green House Project for the 2008 National Design Competition. Bottom right, the group-living unit of the same Green House. (Source: Prepared by the authors and adapted from NKArchitects).

Figure 2. Main contributions of various authors over the last forty years to design principles for environments for people with dementia. (Source: Prepared by the authors).

Figure 3. Corinne Dolan Alzheimer Center, designed by Taliesin Associated Architects and built in 1985 in Heather Hill (Cleveland). (Source: Prepared by the authors and adapted from photography by Pete Guerrero and Daniel Ruark).

Figure 4. Woodside Place, designed by the architectural firm Perkins Eastman, built in 1991 in Oakmont (Pennsylvania, USA). (Source: prepared by the authors and adapted from photography by Robert Ruschak).

Figure 5. Chronology of the Alzheimer’s residential facilities reviewed and analysed in this research. (Source: Prepared by the authors).

Figure 6. Sample selection flow diagram of the Alzheimer’s residential facilities reviewed and analysed in this research. (Source: Prepared by the authors).

Figure 7. On the left, the Boswijk Residence, built in 2010 in Vught (Holland), an extensive single-storey building designed by EGM Architecten. On the right, the Kompetenzzentrum Demenz Nürnberg residence, designed by Feddersen Architeckten, built in 2006 in Nuremberg (Germany), an example of a high-rise development of this residential model. (Source: Prepared by the authors).

Figure 8. Norra Vram Nursing Home, designed by Marge Architeckten, built in 2008, in Billesholm (Sweden), with homely environment and domestic scale. (Source: Prepared by the authors and adapted from photography by Johan Fowelin).

Figure 9. Functional programme and zoning of the Woodside Place residence. (Source: Prepared by the authors).

Figure 10. Reina Sofía Foundation, Alzheimer’s Centre, designed by Estudio Lamela, built in 2007 in Madrid (Spain). (Source: Prepared by the authors and adapted from Estudio Lamela Arquitectos).

Figure 11. Alzheimer’s Respite Centre, designed by Niall McLaughlin, built in 2011, in Dublin (Ireland). (Source: Prepared by the authors and adapted from Niall McLaughlin Architects and photography by Nick Kane).

Figure 12. Characteristics of the typology of residential facilities for Alzheimer’s patients. (Source: Prepared by the authors).

Table 1

Design principles for people with dementia according to different authors.

Author(s)	Main Contributions
Calkins, 1988 [12]	Signage/orientationSafety and protectionCompetence in daily activitiesSpaces for groupsControl stimuliCompensate for sensory losses	PersonalisationNatural outletsPrivacy and socialisationFamily interactionCompetence in daily activities
Pynoos et al., 1989 [29]	Adequate sensory stimulationPromote dignity and autonomyProvide securityProvide a homely and familiar environmentGenerate an appropriate level of activity/taskProvide individual control and privacy	Create opportunities for socialisingEmphasise well-being and maintain a connection to health and familyFlexibility and adaptability in supporting the person’s physical and behavioural needs
Zgola, 1990 [30]	Stable and structured environmentProvide environmental routines (associating activities with certain locations)	Serve as a memory cuePromote memoriesFacilitate orientationProvide security
Schiff, 1990 [31]	Stable and familiar environmentClear and well-structured environment	Serve as a memory aidServes as a behavioural cueSupport orientation to reality
Cohen and Weisman,1991 [18]	Ensure safety and securityMaximise autonomy and controlAdapt to needs	Establish linksProtect the need for privacyProvide opportunities for stimulation and change
Cohen and Day,1993 [20]	Contemporary design of environments Safety and protectionAutonomy and control	Opportunities for stimulationEndow and provide privacy
Brawley, 1997 [21]	Ensure safetyMaximise autonomy and controlAdapt to needsEstablish linksProtect privacy	OrientationSupport functional ability with activityOpportunities for stimulation.Opportunities for socialisation
Marshall, 1998 [32]	Maximise independenceImprove self-esteem and confidenceStrengthen personal identityImprove visual access	Control stimuliGuiding and comprehensibleStrengthen personal identityWelcome family members and local community
Regnier, 2002 [33]	Control, choice/autonomySafetyAccessibility and functioningAdaptabilityFamiliarityAesthetics and appearance	OrientationSensory aspectsStimulation/challengePersonalisationPrivacySocial interaction
Fleming et al., 2003 [34]	Ensure safetyReduce group sizeHighlight useful stimuliReduce unwanted and unnecessary stimuliSimple environment with good visual accessProvide wandering paths	Make the environment as familiar as possible and the atmosphere homelike Provide spaces for visitors to interact with the communityProvide both privacy and community opportunities
Moore et al., 2006 [35]	Safety and protectionFunctional independenceSignificant activityContinuity of selfOrientation	Sensory stimulationPersonal controlPrivacySocial interaction
Burton and Torrington,2007 [36]	FamiliarDistinctiveLegible	SecureAccessibleComfortable
Marquardt and Schmieg,2009 [37]	AutonomyLegibilityFamiliarity	Sensory stimulationSocial interaction
Chaudbury, 2017 [38]	Safety and protectionSupport functional skillsProvision of privacyMaximise orientation	Regulation and quality of stimulationControl opportunitiesFacilitation of social contact
Calkins, 2018 [39]	Support securityCreate a sense of communityImprove comfort and dignity	Opportunities for meaningful engagementProvide opportunities for choice
Fleming et al., 2020 [28]	Environmental design principles from Alzheimer’s Disease International

Table 2

Average distances between residences to urban centres and to green or natural spaces.

Parameter	Units	Range of Optimal Values
Relationshipwith the surroundings	Distance (km)	Average distance to services
		Large cities 1.5 ± 0.5 kmSmall cities 1 ± 0.25 kmRural environment 0.5 ± 0.25 km
		Average distance to green/natural spaces
		Large cities 1 ± 0.25 kmSmall cities 0.5 ± 0.25 km

Table 3

Number of residents and households or group-living unit in a residence or nursing home.

Number of total residents:	80–120 people
Number of residents per household:	8–12 people
Average number of households:	9–12 units per residence
Number of rooms per unit:	5–12 rooms/dwelling
Average surface areas of a 12 group-living units with 9 persons per unit
Average floor area of the residence	7160 m2 (average value of floor area)
Average living area of the residence	5812 m2 (average value of usable area)
Surface area of outdoor spaces	9760 m2
Plot occupancy	43%
Building height	One floor

Table 4

Zoning, functions, and uses of a residence for people with AD.

Areas		Classification	Uses
1. Public area:Collective area dedicated to care activities and uses (22–25% of the total usable area of the residence)	1.1	Main areas	Access/reception—waiting room
			Workshops/multipurpose activity rooms
			Evaluation rooms and other services
			Auxiliary room for carers—staff
			Medical—nursing assistance room
			Administration—offices
			Living area—cafeteria
			Outdoor areas—gardens—terraces
	1.2.	Complementary areas	Relaxation room—library
			Physiotherapy room—gym/swimming pool
			Psychomotor stimulation room
			Geriatric bathrooms for collective use
			Resting area—lounge area for care staff
2. Semi-private areas: Residential area of the dwelling or household (30–35% of the total useful area of the residence)	2.1	Main rooms	Kitchen
			Dining hall
			Living room—communal rooms
			Multipurpose room—small groups
	2.2	Complementary rooms	Laundry—cleaning room
			Facilities—storage
3. Private areas: Residential area of the dwelling or household. (42–45% of the total usable area of the residence)	3.1	Main rooms	Rooms for users—patients
			Bathrooms for private use
	3.2	Secondary areas	Private outdoor spaces—terraces—gardens
			Living area

Table 5

Functional programme of semi-private and private areas with the calculated usable areas for a nine-user group-living unit or household.

	Classification	Length of Stay	Surface Area m2	Surface Area (m2/User)
Semi-private areas
2.1	Main rooms	Kitchen	22.86	2.54
		Dining hall	36.27	4.03
		Living room—communal rooms	31.32	3.48
		Multipurpose room—small group	35.30	3.92
		Laundry—cleaning room	16.35	1.82
		Facilities—storage	23.75	2.64
Total surface area of semi-private areas:1 group-living unit with 9 users			165.87 m2	18.43 m2/user
Total surface area of semi-private areas:12 group-living units with 108 users			1990.44 m2	18.43 m2/user
Private areas
3.1	Main rooms	9 single bedrooms	159.12	17.68
		Bathrooms for private use	50.49	5.61
		Bedrooms (Single)	16–18 m2
		Bedrooms (Double)	26–28 m2
		Bathroom size	4–6 m2
		Outdoor areas associated with the bedrooms (terraces, gardens, courtyard) per user	3–4 m2 (min)
		Average clear height of rooms	2.70 m/3.23 m
Total surface area of private areas 1 group-living unit with 9 users			209.61 m2	23.29 m2/user
Total surface area of private areas 12 group-living units with 108 users			2515.32 m2	23.29 m2/user

Table 6

Functional programme of the public area, with usable areas calculated for a residence with 12 households or group-living units and a total of 108 users.

	Classification	Length of Stay	Surface Area m2	Surface Area (m2/user)
Public area
1.1	Main areas	Access/reception—waiting room	21.60	0.20
		Multipurpose activity workshops (4 units) 1	179.28	1.66
		Evaluation rooms (2 units) 2	32.40	0.30
		Geriatric bathrooms (2 units)	23.76	0.22
		Administration, management and offices	45.36	0.42
		Cafeteria area	108.00	1.00
		Outdoor area for physical activities	324.00	3.00
		Psychological care room 2	16.20	0.15
		Occupational therapy care room 2	16.20	0.15
		Family interaction room (4 units)	54.00	0.50
		Group activity room	108.00	1.00
1.2	Secondary areas	Group relaxation room (2 units) 3	41.04	0.38
		Physiotherapy room—gym	108.00	1.00
		Psychomotor stimulation room 3	41.04	0.38
		Swimming pool (sheet of water) 4	79.92	0.74
		Changing rooms and toilets	54.00	0.50
		Rest area—lounge area for staff	54.00	0.50
Total (public area)			1306.80 m2	12.10 m2/user

¹ Workshops of 45 m²/unit, for small groups of 15 users (3 m²/user). ² Room for individualised use for user + assistance/healthcare staff. ³ Rooms of 21 m²/unit, for small groups of seven users (3 m²/user). ⁴ Swimming pool with capacity for 40 users (2 m²/user).

Table 7

Average values of the paths in the buildings studied.

Parameter	Units	Range of Optimal Values
Paths	Distance (lm)	Interior paths
		Bedroom—service area: 10 ± 2 lm (max)Bedroom—secondary rooms:15 ± 3 lm
		Paths of private outdoor spaces.
		Outdoor areas 142 ± 10 lm

Table 8

Average lighting values.

Parameters	Units	Range of Optimal Values
Lighting	Illuminance (lux)	Predominant light source
		Natural light, in day + night rooms.
		Illuminance, by areas
		Communal areas: 300–500 luxActivities and therapy areas: 500–1000 luxOutdoor areas: 100–200 lux Bedrooms: 300–500 luxBathrooms: 300–500 lux

Table 9

Optimal residential temperature values in the northern temperate climate zone, where most of the case studies in the sample are located.

Parameter	Units	Range of Optimal Values
Thermalcomfort	Temperature (°C/°F)	Operating temperature
		Daytime temperature: 20–25 °C; 68–77 °F Night-time temperature: 18–21 °C; 65–70 °F Bedrooms in winter: 21 ± 2 °C; 70 °FBedrooms in summer: 22 ± 1 °C; 71.6 °FDaytime areas in winter: 22 ± 2 °C; 71.6 °FDaytime areas in summer: 24 ± 2 °C; 75.2 °F

Table 10

Adequate values for sensory stimulation.

Parameter	Categories	Optimal Characteristics
Sensorystimulation	Touch	Warm, naturally sourced, medium-elasticity, high-strength materials
		Smooth, soft, and uniform textures
		Customised climatic conditioning
	Appearance	Colours with light tones, high saturation to generate contrasts and medium brightness
	Smell	Aromas of plant origin, preferably from plants or vegetation
	Noise	Noise levels < 80 dB, natural sounds from animals, such as birds singing

Appendix A

Table A1

Studies on the influence on people with AD of environmental and spatial variables that affect planning, organisation, or architectural attributes/parameters.

Variables Related to Planning (P)/Organisation (O)/Attributes (A)	Author(s)/Year	Results of Studies and Trials
(P) Non-institutional	Annersted, 1994 [86]; Kihlgren et al., 1992 [87]; Slone et al., 1998 [50];Cohen-Mansfield and Werner, 1998 [88]	Home environments are associated with improved emotional well-being, reduced agitation, increased social interaction, and improved functioning.
	Cohen-Mansfield et al., 1990 [89]	In non-institutional settings, compared to institutional settings such as nursing homes and hospitals, residents are less aggressive and have less anxiety
(P) Provision of outdoor areas	Mooney and Nicell, 1992 [90]	Violent episodes between residents decrease at facilities with outdoor environments compared to those without such outdoor spaces.
(P) Dimension and scale	Sloane et al., 1998 [50]	Larger sized spaces are associated with higher levels of agitation and emotional disturbance.
	Morgan and Stewart, 1998 [91]	Larger units exhibit more frequent territorial conflicts, spatial invasions and aggression towards other users.
	McAllister and Silverman, 1999 [92], Moore, 1999 [93]; Netten, 1993 [94]	Small units experience less anxiety and depression and more mobility. Small groups are positively associated with increased supervision and interaction among users.
	Annerstedt, 1993 [95]	Residents living in groups show higher motor functions and slightly improved performance in activities of daily living.
	Skea and Lindesay, 1996 [96]; Annerstedt, 1997 [97]	People with dementia living in small units experience less depression and anxiety, and are more mobile.
(O) Paths and wayfinding	Netten, 1993 [94]	Higher levels of orientation were associated with calm environments.
	Elmsthal et al., 1997 [98]	Corridor design is associated with higher degrees of restlessness and dyspraxia. Residents show more orientation in places with shorter corridors, with more space and with L, H, or square shapes.
	Passini et al., 1998 [52]	The orientation depends on the configuration of the building.
	Marquardt and Schmieg, 2009 [37]	Paths with interconnected visuals and avoiding longitudinal and back-and-forth corridors were conducive to greater orientation.
	Chaudbury et al., 2017 [38]Orfield, 2015 [99]	The environment should maximise clarity of perception and reduce optical perceptual noise such as visual clutter.
(O) Private and semi-private rooms and activity spaces: bathrooms, dining rooms, kitchens, resident bedrooms	Pynoos and Ohta, 1991 [100]; Sloane et al., 1995 [101]; Kovach and Meyer-Arnold, 1996 [102]; Namazi and Johnson, 1996 [103]	The bathroom is one of the spaces associated with the greatest degree of stress in people with dementia. With aspects of design involving lighting, mirrors, bathtubs, etc. Natural elements such as water or animal sounds have a calming effect.
	Namazi and Johnson, 1991 [104]	The accessible location and visualisation of the toilet is important to avoid accidents and incontinence problems. It is important that they are visible through glass or windows preserving privacy when occupied.
	Gotestam and Melin, 1987 [105]	Need to locate dining and kitchen activity areas within each housing unit so that meals are at small tables and “non-institutional”.
	Lawton et al., 1970 [106]	The number of residents and the design of rooms can affect levels of social interaction. In single rooms grouped around a communal space, residents spent less time indoors and increased their interactions.
(A) Lighting and visual contrast	Brawley, 1997 [21]	Increase overall light levels and reduce glare. Increase contrast to minimise confusion over depth perception.
	Mishima et al., 1994 [107]	Bright light treatment consistently regulates circadian rhythms and improves sleep patterns among people with dementia.
	Sloane et al., 1998 [50]	Residents in facilities with low overall lighting showed higher levels of agitation.
(A) Thermal and climatic comfort	Linares et al., 2017 [108]	The AD population is a group at risk to thermal extremes and temperature variations, especially heat waves.
	Jung et al., 2022 [109]	Environmental temperature is linked to the body temperature of patients with AD being significantly higher than that of other elderly people.
(A) Sensory stimulation	Calkins, 1988 [12]	Certain levels of sensory stimulation may be necessary to elicit participation in activities and social interaction.
	Brawley, 1997 [21]; Cohen and Weisman, 1991 [18]; Evans, 1989 [110]	Sensory overstimulation must be reduced as it can increase confusion and reduce social interaction and self-esteem. Therefore, a balance must be maintained between overstimulation and that needed to motivate participation.
	Evans 1989 [81]; Hall et al., 1986 [111]	Provide tactile stimulation on surfaces and walls and eliminate overstimulation of dispensable elements
	Heller, 2004 [112]; Reginald, [113] 2008	The use and classification of colours based on the psychology of colour according to what each colour conveys and the influence they can cause.
	Cohen-Mansfield et al., 1990 [89]Negley and Manley, 1990 [114]	High stimulation, as measured by agitation levels, generally occurs in lifts, corridors, bathrooms, and other residents’ bedrooms or shared bedrooms.
(A) Safety	Mayer and Darby, 1991 [115]	Placement of a full-length mirror on the exit door reduces exit attempts by half.
	Morgan and Steward, 1999 [91]; Pynoos and Ohta, 1991 [100]	Increase vigilance and supervision by facility staff, as well as prevention of falls for residents.
	Dickinson et al., 1996 [116]; Namazi et al., 1989 [117]	Create optical illusions on doors by disguising door handles and knobs.
	Hussian and Brown, 1987 [118]	Due to depth perception problems, people with AD may interpret certain elements placed on the floor as three-dimensional. The use of grids or two-dimensional elements reduced exit attempts.

Table A2

Buildings selected as case studies in the sample.

Cases	Building Name	Year	Architect(s) Author(s)	Location
C01	Corinne Dolan Alzheimer Center [56]	1985	Taliesin Associated Architects	Ohio, U.S.A.
C02	Alzheimer Woodside Place [57]	1991	Perkins Eastman	Pennsylvania, U.S.A.
C03	White Oak Cottages [58]	1994	EGA Architects	Massachusetts, U.S.A.
C04	Wilhelmina [59]	1995	Tuomo Siitonen	Helsinki, Finland
C05	De Naber [60]	1995	Massa Bureau	Rotterdam, Netherlands
C06	Laurens De Hofstee [61]	2000	ONS Architecten	Rotterdam, Netherlands
C07	Waveny Care Center [62]	2001	Reese Lower Patrick, Scott, Ltd.	Connecticut, U.S.A.
C08	Gradmann Haus [63]	2001	Sybille Heeg, Hermann + Bosch	Stuttgart, Germany
C09	Kattrumpstullen [64]	2003	White Arkitekter	Stockholm, Sweden
C10	Sun City Ginza East [65]	2006	Perkins Eastman	Tokyo, Japan
C11	Kompetenzzentrum Demenz Nürnberg [66]	2006	Feddersen Architeckten	Nuremberg, Germany
C12	Fundación Reina Sofía, centro Alzheimer [67]	2007	Estudio Lamela	Madrid, Spain
C13	Norra Vram Nursing Home [68]	2008	Marge Arkitekter	Billesholm, Sweden
C14	Il Paese Ritrovato [69]	2008	Studio Giovanni Ingrao	Monza, Italy
C15	Proyecto Villafal [70]	2008	Javier Sánchez Merino	Soria, Spain
C16	Dementia Village Hogeweyk/ [71]	2009	Molenaar, Bol y VanDillen	Wess, Netherlands
C17	Fürstlich Fürstenbergisches Altenpflegeheim [72]	2009	GSP architects-Volpp	Hüfingen, Germany
C18	Leonard Florence Center for Living [73]	2010	DiMella Shaffer	Massachusetts, U.S.A.
C19	Boswijk Dementia Care Centre [74]	2010	EGM architects	Vught, Netherlands
C20	Alzheimer’s Respite Centre [75]	2011	Niall McLaughlin	Dublin, Ireland
C21	Hanna Reemstma House [76]	2011	Schneekloth + Partners	Hamburg, Germany
C22	EHPAD. Alzheimer Rue Blanche à Paris [77]	2012	Philippon Kalt	Paris, France
C23	Alzheimer Residence for the “Foyer la Grange” [78]	2014	Mabire Reich	Nantes, France
C24	Kompetenzzentrum Demenz München [79]	2014	Feddersen Architeckten	Munich, Germany
C25	Kompetenzzentrum Forchheim Beraten [80]	2014	Feddersen Architeckten	Beraten, Germany
C26	The Abe’s Garden Campus [81]	2015	Manuel Zeitlin Architects	Tennessee, U.S.A.
C27	Abbeyfield Winnersh Society [82]	2016	Edmund Williams	Winnersh, U.K.
C28	Lantern of Chagrin Valley [83]	2016	TMA Architects	Ohio, U.S.A.
C29	Rosemount Gardens [84]	2016	Nicoll Russell Studios	Bathgate, U.K.
C30	Alzheimer’s village [85]	2018	Nord Architects	Dax, France

Figure A1. Data collection sheet for the selected buildings in the sample (Source: Prepared by the authors).

Table A3

Analysis parameters and measurers in residential facilities for people with Alzheimer’s disease. Quantitative and qualitative variables.

Identifying information	Name
	Architects		Year of construction
	Location	Site	City and Country	Context in the territory
		Environment	Type (rural, peri-urban, urban)	Nearby facilities
Categories	Subcategories	Quantitative analysis parameters		Unit of measurement
Functionalprogramme	No. of people	Residents—groups	Caregivers/service staff	No.
	Outdoor facilities	Type (garden, courtyard, paths…)		No.
	Paths	Distance of paths between rooms—common areas		lm
		Distance of outdoor paths
	No. of rooms	Number of single rooms/shared rooms		No.
		Number of communal rooms and contact with other people
	Size ofsurface area	Plot surface area	Floor area of building	m2
		Surface area of outdoor facilities	Usable area of communal areas
		Usable area of single room/double room	Usable area of single bathroom/shared bathroom
	Height dimension	Number of floors	Total building—interior ceiling	lm
	Other	Specific facilities for people with dementia (type)		No.
		Restricted use rooms for people with dementia (type)		No.
Parameters	Lighting	Light source	Predominant lighting	LuxN-S-E-W
		Type of light	Lighting control system
		Solar orientation	Amount of sunlight per area
	Climatic comfort	Average temperatures	Climate control units	°Cg/m3
		Specific temperature control system
	Acoustic control	Systems or elements for sound control or noise cancellation		dB
	New technologies	Existence, location, and use		No.
Categories	Qualitative analysis parameters
Sensorystimulation	Touch: materials—type/location		Textures—soft/delicate/smooth/rough/dry
	Smell: Smells—type/source		Vegetation—type/location
	Appearance: Colours—cool (blue/green/purple)/warm (red/orange/yellow)
	Noise: Quiet environment (0 to 20 dB)/low noise (40 to 80 dB)/very noisy (80 to 100 dB)
Safety	Accessibility—ramps/lifts/obstacle-free paths/adapted and assisted bathrooms
	Mobility—handrails/short paths/articulated beds/night safety light
	Access control—wide and sliding doors/remote assistance
Landmarks and spatial orientation	Exterior views		Cross visuals	Yes/No
	Recreation of environments		Homely environment
	Signs and markings on paths		Signs indicating spaces
	Change of wall textures		Colour-coded floors
	Personal furniture		Circular paths
	Display cabinets with souvenirs and photographs at the entrance to rooms (memory box)

Table A4

Average values in buildings for users with AD.

Cases	Number of Residents	Residential Group-Living Units byBuilding	Residents per Group-Living Unit
C01	24	2	12
C02	36	3	12
C03	24	2	12
C04	60	12	5
C05	71	1	71
C06	107	17	8 + 7 + 6 1
C07	52	4	13
C08	24	2	12
C09	97	9	8 + 13 2
C10	276	23	12
C11	80	8	10
C12	156	9	22 + 8 3
C13	36	2	18
C14	64	8	8
C15	28	1	28
C16	174	29	6
C17	36	3	12
C18	100	10	10
C19	120	12	10
C20	11	1	11
C21	100	5	20
C22	70	5	14
C23	118	4 + 11	20 + 3 4
C24	14	1	14
C25	91	8	11 + 12 5
C26	42	3	17 + 12 + 13
C27	63	6	10 + 11 6
C28	48	2	24
C29	48	2	24
C30	108	16	4 + 7 + 8 7

¹ 7 units of 8 persons + 5 units of 7 persons + 5 units of 6 persons. ² 4 units of 8 persons + 5 units of 13 persons. ³ 6 units of 22 persons + 3 units of 8 persons. ⁴ 4 units of 20 persons + 11 apartments for up to 3 persons. ⁵ 5 units of 11 persons + 3 units of 12 persons. ⁶ 3 units of 10 persons + 3 units of 11 persons. ⁷ 4 units of 4 persons + 4 units of 7 persons + 8 units of 8 persons.

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59. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 04. White Oak Cottages. 1994. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/151553]

60. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 05. Wilhelmiina. 1995. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/151557]

61. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 06. De Naber. 1995. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/153996]

62. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 07. Laurens De Hofstee. 2000. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/154056]

63. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 08. Gradmann Haus. 2001. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/154059]

64. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 09. Kattrumpstullen. 2003. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/154072]

65. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 10. Sun City Ginza East. 2006. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/152904]

66. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 11. Kompetenzzentrum Demenz Nürnberg. 2006. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/152986]

67. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 12. Fundación Reina Sofía, Centro de Alzheimer. 2007. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/153018]

68. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 13. Norra Vram Nursing Home. 2008. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/152627]

69. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 14. Il Paese Ritrovato. 2008. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/153155]

70. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 15. Proyecto Villafal. 2008. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/153160]

71. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 16. Hogeweyk. 2009. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/152629]

72. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 17. Fürstlich Fürstenbergisches Altenpflegeheim. 2009. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/152631]

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74. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 19. Leonard Florence Center for Living. 2010. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/152623]

75. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 20. Boswijk. 2010. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/152625]

76. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 21. Hanna Reemstma House. 2011. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/154079]

77. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 22. EHPAD Etablissement d’Hébergement pour les Personnes Àgées Dépendantes. 2012. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/153163]

78. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 23. Alzheimer Residence for the “Foyer la Grange”. 2014. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/153171]

79. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 24. Kompetenzzentrum Demenz München. 2014. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/153200]

80. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 25. Kompetenzzentrum Beraten Wohnen Pflegen. 2014. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/153211]

81. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 26. The Abe’s Garden Campus. 2015. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/154123]

82. Valero-Flores, P.; Lozano-Gómez, M.; Quesada-García, S. Characteristics and Data of Residential Facility for People with Alzheimer’s Disease. 27. Abbeyfield Winnersh Society. 2016. [Dataset]; idUS Depósito de Investigación de la Universidad de Sevilla: Sevilla, Spain, 2023; [DOI: https://dx.doi.org/10.12795/11441/153217]

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