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What if we could predict stress levels by paying attention to the environment around us? New research from Belgium offers groundbreaking insights into how our surroundings, specifically lighting and sound, can trigger different types of agitation.
What Did the Researchers Discover?
Researchers worked alongside 37 people living with dementia in a specialised hospital ward, partnering with them over the course of one week each. Using environmental sensors, the team continuously measured three environmental factors: light levels, sound levels, and temperature. Throughout the study, nurses observed and documented moments when people expressed signs of distress or changes in behaviour, noting what types of responses occurred. This careful monitoring created a detailed picture of how the physical environment influences how people express themselves and experience their surroundings moment by moment. What they discovered was genuinely surprising and important. Different expressions of distress respond to different environmental triggers. This is crucial because it means that creating a supportive environment isn't just about making spaces generally "calmer" or "quieter" for everyone. Instead, it requires understanding the specific relationship between environmental conditions and how different people respond. Some individuals may find certain sounds or lighting conditions challenging, while others may experience the same environment quite differently. The key insight is that we need to listen to and understand each person's unique needs and responses
The Key Findings
Let's break down what this research actually means in everyday terms, starting with the most striking discoveries.
The first major finding relates to light and physical agitation. When light levels were lower than usual, people were more likely to show physical signs of agitation like pacing, wandering, or restlessness. The researchers found this relationship was strongest in the 12 to 33 minutes before agitation occurred, which is fascinating because it gives care partners/givers a potential window to intervene. Imagine being able to notice that the light is getting dim and gently increasing it before someone becomes distressed rather than trying to manage their agitation after the fact. The second key finding involves sound and verbal agitation. When sound levels varied a lot, think of sudden noises, voices rising and falling, or inconsistent background noise, people were more likely to show verbal signs of agitation like calling out, repeating words, or verbal aggression. Just like with the light findings, these sound patterns appeared 12 to 33 minutes before the agitation started. This pattern suggests that the human nervous system is picking up on environmental stress signals before they manifest as behavioral responses.
Time of day emerged as another important factor. Agitation increased as the day went on, peaking in the late afternoon and early evening, a phenomenon many care partners/givers recognise as "sundowning." This was particularly true for physical agitation. While we've long known that sundowning is real, understanding its connection to environmental factors like light and circadian rhythms gives us new tools to address it. Location on the ward also made a measurable difference. People showed more agitation in hallways compared to living rooms, possibly because hallways can be more stimulating or confusing spaces. There's something about those in-between spaces that seems to increase distress in people with dementia, whether because they're less defined, more exposed, or simply lack the comfort and familiarity of primary living spaces.
Why Does This Matter for Dementia Inclusive Design?
This research is genuinely a game-changer for how we think about designing spaces for people with dementia. The implications go far beyond academic interest. They fundamentally shift how we approach creating supportive environments.
For years, dementia care has emphasised creating "calm environments," but this research gives us specific, measurable targets. We now know that consistent, adequate lighting and stable sound environments aren't just nice-to-haves. They're essential design features that can prevent distress and unnecessary behavioral episodes. This distinction matters enormously because it means environmental design becomes a core component of care strategy, not an afterthought. The finding that different types of agitation have different triggers is particularly important because it challenges the idea of one-size-fits-all design. A quiet, dimly-lit space might reduce verbal agitation but could actually increase wandering and restlessness. This means effective dementia-inclusive design must balance multiple environmental factors simultaneously. There's no simple solution like "make it quieter" or "dim the lights." Instead, designers and caregivers need to think systematically about how multiple environmental elements work together. What's particularly exciting is that prevention becomes possible with this knowledge. With a 12 to 33 minute warning window, there's time for intervention. Environmental sensors could alert caregivers to problematic conditions before someone becomes distressed, allowing for proactive adjustments like turning on lights, closing doors to reduce sound fluctuations, or redirecting someone away from overstimulating hallways. This moves us from a reactive model of care, where we respond after problems occur, to a proactive model where we prevent problems from developing.
This research also validates what many family and professional care partners/givers have long observed. Many people who care for someone with dementia have noticed that their loved one appear to be much more stressed in certain environments or at certain times of day. This research provides scientific backing for those observations and empowers care partners/givers to make evidence-based environmental modifications rather than just following intuition or tradition. When research confirms what caregivers already know, it strengthens their confidence in their own judgment.
What Can You Take Away? Implementation and Action
Whether you're a family caregiver, healthcare professional, architect, or policy maker, here are practical actions you can take based on this research. These aren't theoretical recommendations but concrete steps grounded in the study's findings.
If you're caring for someone living with dementia at home or in a family setting, there are several environmental adjustments you can make based on this research. Start by thinking about lighting. Keep lights bright and consistent during the day, especially in areas where someone living with dementia spends time. Use natural daylight whenever possible by opening curtains and blinds during daytime hours. Avoid dim lighting in afternoon and evening hours when sundowning is most likely. Pay attention to whether low lighting might be contributing to wandering or restlessness. Many older homes are simply not lit brightly enough for someone with dementia to feel secure and oriented. Sound management is equally important. Work to minimise sudden noises and loud, unpredictable sounds that can jolt someone into distress. Keep background noise like the TV or radio at consistent, moderate levels rather than fluctuating volumes that create an unstable acoustic environment. If possible, create quiet zones in the home where someone can retreat from stimulation. Be mindful that conversation volume in common areas can affect someone's agitation levels. Sometimes simply training family members to speak more quietly and consistently can make a real difference. Time of day awareness should inform how you structure activities and support. Plan stimulating activities for morning hours when agitation is typically lower. Increase environmental monitoring in late afternoon and evening. Establish calming routines as the day progresses rather than maintaining the same level of activity throughout. Consider light therapy interventions to help regulate sleep-wake cycles, which research shows can help with sundowning. Spatial design within the home also matters. Create clear, well-defined spaces that reduce confusion. Minimize time spent in transitional spaces like hallways. Ensure living areas are well-lit and have stable acoustics. Use visual cues and landmarks to support orientation. Think about making paths through your home clear and predictable rather than confusing or maze-like.
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Strategies for Healthcare Facilities and Aged Care Providers
If you work in a healthcare facility or aged care setting, the implications of this research suggest several important changes. Start with environmental monitoring. Install sensors to track light and sound levels throughout facilities. Use data to identify problem areas and times. Develop protocols for environmental adjustment when triggers are detected. Train staff to recognise environmental factors in agitation episodes rather than attributing all agitation to internal factors or assuming it's simply part of dementia progression. Consider conducting a comprehensive assessment of your existing lighting systems. The median light levels in this research were quite low, less than 100 lux in most rooms, suggesting that many facilities may actually be under-lit for optimal functioning. This is particularly striking because most people assume dementia facilities are properly designed for lighting, but the data suggests otherwise. Design acoustically stable environments with sound-absorbing materials. Create multiple zones with different sensory profiles to meet varying needs. Minimize long, featureless hallways that can contribute to agitation. Staff training is fundamental to implementing these insights. Educate teams about the 12 to 33 minute prediction window. This changes how staff approach their work because they understand that environmental monitoring is preventive medicine, not just creating comfort. Develop environmental checklists for agitation prevention. Implement non-pharmacological intervention protocols based on agitation type. Document environmental conditions when agitation occurs to identify patterns unique to your facility. Over time, this data becomes invaluable for tailoring your environment to your specific population.
Guidance for Architects and Designers
For professionals designing new spaces or renovating existing ones, this research provides specific technical guidance. When thinking about lighting design, aim for consistent, adequate lighting of more than 100 lux in all occupied spaces. Incorporate circadian lighting systems that support natural sleep-wake rhythms, not just adequate brightness. Ensure hallways and transitional spaces are well-lit because these are areas where agitation tends to increase. Provide access to natural light throughout the day because the research suggests that time-of-day effects are partially mediated through light exposure. Acoustic design deserves serious attention in dementia environments. Use sound-absorbing materials to reduce noise fluctuations. Design spaces that minimize echoes and sudden sound amplification. Create acoustic separation between high-activity and rest areas so that noise in one space doesn't disrupt calm spaces. Consider sound masking systems to maintain consistent background ambiance rather than allowing unpredictable fluctuations. When organizing spatial layouts, design destinations rather than long corridors. Create clear sightlines and visual connections. Ensure living and activity spaces are the most appealing, well-designed areas rather than concentrating resources on back-of-house spaces. Minimize confusion through clear wayfinding and familiar design cues. Think about how someone with dementia actually moves through and experiences the space, not just how the space looks on floor plans.
The Critical Messages
Several core messages emerge from this research that should shape how we think about dementia care going forward. Here I have broken it down to 5 key points.
1. Environment is not neutral. It actively influences behaviour and wellbeing in people with dementia. What surrounds us matters profoundly. This might seem obvious in retrospect, but it's often overlooked in practice, where behavioral issues are treated as purely medical or psychological problems requiring pharmaceutical intervention rather than environmental solutions.
2. Specificity matters greatly. Different environmental factors trigger different types of agitation. Effective design requires understanding these nuances, not applying blanket "calm environment" approaches. The days of assuming that all agitation requires the same environmental intervention are over. We now know that we need to think more carefully about what specific behaviours we're trying to prevent and what specific environmental triggers might be involved.
3. Prevention is possible. With the right monitoring and knowledge, we can intervene before agitation occurs, improving quality of life for everyone involved. This shifts the goal from managing crisis to preventing crisis, a fundamental change in approach that benefits both individuals with dementia and their caregivers who often experience significant stress.
4. Design is care. Thoughtful environmental design is not a luxury or an afterthought but a fundamental component of person-centred dementia care that can reduce distress and the need for pharmacological interventions. When we elevate environmental design to the level of importance it deserves, we're saying that how we create physical space is as important as medical treatment in supporting quality of life.
5. Context is crucial. Time of day, location, and individual differences all play roles in how environments affect behaviour. Flexible, adaptable environments that can respond to changing needs throughout the day are essential. A one-time design solution isn't enough. Environments need to be dynamic and responsive.
Looking Forward
This research opens exciting possibilities for technology-enabled care that could transform dementia support. Imagine homes or care facilities with smart sensors that detect concerning environmental patterns and automatically adjust lighting or alert caregivers, all before someone becomes distressed. We could move from reactive care, where we respond after agitation occurs, to proactive care where we prevent it from happening in the first place. The findings also support a more holistic view of dementia care that extends beyond medication and interpersonal care to encompass the physical environment itself. When we design and maintain spaces with this level of environmental awareness, we create settings that enable people with dementia to thrive, maintain independence longer, and experience greater dignity in daily life. For those of us working to create more dementia-inclusive communities, this research provides the evidence base we need to advocate for better design standards, environmental monitoring, and caregiver education. It reminds us that small changes, like better lighting or more stable sound environments, can have profound impacts on the lived experience of dementia. The path forward involves collaboration across many disciplines. Architects need to talk to caregivers. Healthcare providers need to work with sensor technologists. Researchers need to partner with people living with dementia and their families to understand how these findings work in real-world settings. When we bring all these perspectives together, guided by rigorous research like this study, we can create environments that are truly supportive, enabling, and person-cantered.
This is the promise of understanding how environment affects agitation in dementia: not just better behavioral management, but better lives for people living with dementia and those who support them.
Reference
Davidoff, H., Van Kraaij, A., Lutin, E., Van den Bulcke, L., Vandenbulcke, M., Van Helleputte, N., De Vos, M., Van Hoof, C., & Van Den Bossche, M. (2025). Environmental triggers of specific subtypes of agitation in people with dementia: Observational study. JMIR Formative Research, 9, e60274. https://doi.org/10.2196/60274
Want to learn more about dementia-inclusive environmental design? Explore our Resource Hub for practical examples and current research on creating supportive home and care environments: https://design.dementia.utas.edu.au/page/512/for-educators