Social life, travelling, housekeeping, shopping. The past few decades have seen the rise of dementia models centered on the “living experience” of those affected, with the aim of improving their autonomy and comfort. One key to this approach is the creation of “dementia-friendly environments”: inviting, easy to navigate and safe spaces suited to the needs and challenges of people with dementia.
Dementia-friendly environments are one subject covered in my module “Language and Communication in Dementia”, which is optional to students of several programmes at UCL’s Division of Psychology and Language Sciences. As a means of exploring the topic, we visit a public space and evaluate its dementia friendliness. The aim is not only the reflection on environment design principles; we also want to train a change in perspective as we traverse a familiar place while considering the experience of a person with memory, navigation, executive function, or perception difficulties. In the first term of 22/23, we visited a large local supermarket.
We report the experience as a case study for a dementia-friendly space, but also to show how real-world issues that demand action can be approached in education.
According to a survey by the Alzheimer’s Society, 80% of people with dementia list shopping as their favourite activity. At the same time, two thirds believe that shops are not dementia-friendly enough. For someone following this subject, these issues are not that surprising. Care environments and private households have received the greatest priority in the design of dementia-friendly spaces. Attempts to turn public spaces, or even entire cities, dementia-friendly, are largely in early stages. And as we found out through our exercise, and as the students explain below, in the case of supermarkets one reason may be that dementia-friendly design principles may clash with business priorities.
However, our goal was not to shame and blame, but rather to understand the issues. Students used the “Dementia-friendly environment checklist” provided by the National Dementia Action Alliance. It has 21 questions about environmental features and focuses broadly on ease of navigation, clarity of information, and comfort. Students went through the checklist on site, and we discussed the results afterwards in the seminar room.
Artemis Bekiari, Hafsa Qureshi, Lidia Slominski, James Taylor-Anton, students:
We start with factors which negatively affected dementia-friendliness. Signage was a big issue. Many signs were above eye level, and some were confusing – for instance, a single sign mentioned soups, beef and vegetables, and someone with dementia may struggle to understand that this refers to the collective items in the aisle, as signs indicating single product categories were in a different format. Limited edition and discount signs were much bigger than regular signs, and printed on red paper which was more visually striking. On price labels, the larger numbers often showed money “saved” (often as a percentage) rather than the actual price. Other highlighted values referred to prices for deals or club members.
There were also issues with navigation within the shop. At the time of the exercise, large Christmas offers were advertised in the middle of the aisles, dominating as navigational landmarks. Placement of wares was not helpful. For example, fruits and vegetables were near the shop’s entrance, while bread, milk and eggs were in separate locations on the opposite end of the store. Shelves also contained possibly confusing combinations of items, with signage containing illogical semantic contrasts, such as one sign listing “Fresh Pizza” and “Vegan & Vegetarian”.
There were two checkout areas towards the front of the store, but no signs informing that one was a self-service station and the other was a cashier-serviced station. Another checkout was present at the rear of the store but was not working, and again there was no signage to indicate this. We found no quiet places or seating, and there were no toilets for customers. Transparent entry/exit doors were a potential source of confusion.
Other features were more supportive. The lighting was even, and the flooring was of a consistent design and level throughout the shop. Therefore, there were no large pools of bright sunlight or shadow or changes in floor surface, which could cause confusion in someone with perceptual difficulties. Font size was mostly large enough and most signs used strong colour contrast.
Our observations are in line with findings from focus group interviews by Anna Brorsson (Karolinska Institute) and colleagues. People with dementia reported that difficulties start with finding the way to a grocery shop. Once there, the space is often considered cluttered, with too many products and too much information on display, while the layout was criticized as “illogical”. Background music feels like a distractor, while glass doors and mirrored surfaces add confusion and can cause visual illusions. Aisles can be perceived as too narrow.
Some of these issues might be easily addressed with increased awareness of the challenges of people with dementia. The dementia-friendly retail guide from the Alzheimer’s Society and previous research suggests some ways to improve a supermarket. These include clear signage for store facilities, contrast between sign wording and the surface, a map of the store, logical layout of checkout stations, a warning sign next to hazardous products, fewer changes of store layout, additional seating, a quiet hour with decreased traffic and no background music, and staff training, for example via the “Dementia Friends” programme. This initiative has already been taken by Iceland UK, who was the first food retailer ever to train all their 30,000 employees. Marks & Spencer have now committed their 80,000 employees to do the same. We urge other big supermarket retailers to follow suit in this endeavour.
However, other necessary changes appear to go against the principle of supermarket design profiting from the impulsivity of the customers. Essentials are often not near the entrance, and popular products are placed at opposite ends of the supermarket, because this makes customers walk through the whole shop and carry out unplanned impulse purchases. For the same reason, inessential signage, such as for savings or seasonal offers, is displayed bigger than more crucial information.
Research on consumer behaviour has helped increase the effectiveness of these designs, which were introduced with neurotypical customers in mind. However, people with dementia are particularly vulnerable because of impaired memory and increased impulsivity, particularly in individuals with frontotemporal dementia or Alzheimer’s disease. This means that impulsivity-based designs risk severely disrupting their shopping experience. While current research investigates the potential of “healthy nudging”, with the aim of helping customers make better choices, we have not seen evidence of this in our observations. We need to consider whether supermarkets and other providers have a social responsibility to cater for vulnerable customers.
It makes sense to look at approaches outside the UK. Taiwan’s Dementia Friendly Store project was launched in 2013 and makes prior arrangements with families to enable people with dementia to continue to use their services. There is also an advance payment for products the person with dementia plans to buy – any unwanted items picked up can be returned. In Bruges, Belgium, shops displaying a red knotted handkerchief logo indicate that they are dementia-friendly. The effect of technical solutions also needs to be explored. No-checkout shopping may avoid queue stress. Augmented reality may help identify products faster, map the easiest route based on a shopping list, provide price matching or highlight information such as sell by dates.
Rethinking supermarket layouts can enable people with dementia to stay independent and reduce social isolation. Increased accessibility would also enable other parts of the population, such as autistic and other neurodiverse individuals, and may overall provide a better customer experience. Some studies have shown that accessibility programmes benefit staff as well by building pride in their workplace.
We found this an interesting exercise as we were able to view retail environments in the context of finding solutions to help dementia affected individuals. In our experience, it was a very different approach to teaching which allowed us to gain practical experience in the field of ethical people-centered design.
Undergraduate Students, Artemis Bekiari, Hafsa Qureshi, Lidia Slominski, James Taylor-Anton.
Dr Vitor Zimmerer is a Lecturer is the Department of Language and Cognition, University College London. Vitor studied linguistics at Heinrich-Heine-University in Düsseldorf, and has a PhD in Human Communication Sciences from the University of Sheffield. He is very interested in the effects of neurological damage and atypical development on language and study a range of populations including dementia and aphasia, also how language can be used as a marker of cognitive change.