The Walls, the Light, the Garden: What the Evidence Tells Us About Designing for Dementia Care

The Key Findings

A systematic meta-review has examined the evidence on how the physical environment of long-term care facilities affects the quality of life and day-to-day behaviour of people living with dementia. The research team, led by Arnout Siegelaar and colleagues at the University of Groningen, searched seven databases and analysed 11 high-quality systematic reviews, together representing findings from 250 individual studies. The results are wide-ranging. Higher lighting levels, particularly bright-light therapy in the range of 1,000 to 2,500 lux, reduced agitation and disruptive behaviour and improved daytime wakefulness. Smaller residential units of 5 to 15 people were linked to lower agitation and less intellectual deterioration over time. Homelike interior environments reduced restlessness, exit-seeking behaviour, and wandering. Outdoor and garden spaces improved mood and a sense of vitality, and reduced the use of psychotropic medications. Environmental cues such as distinctive landmarks, colour contrast, clear signage with both icons and text, and thoughtful corridor layouts supported orientation and wayfinding. The central conclusion is that providing variation in the ambiance of spaces can have meaningful benefits, but the design challenge lies in finding the right balance. Environments that are either overstimulating or understimulating can have negative consequences for people with dementia.

What Can You Take Away?

The evidence points to several specific features that consistently show benefit:

- Lighting is among the most robustly supported elements. Bright, natural-quality light during the day improves sleep, reduces agitation, and supports engagement in daily activities. Both indoor bright-light therapy and outdoor exposure contribute to these outcomes.

- Smaller living units are better. Facilities with 5 to 15 residents show lower rates of agitation and better preservation of cognitive function compared with larger ward environments. The social density of a space shapes behaviour, and this finding is consistent across many of the studies reviewed.

- Homelike environments, those that resemble domestic settings rather than institutional ones, reduce exit-seeking and restlessness. This applies to furnishings, familiar objects, domestic-scale rooms, and the overall character of the space.

- Access to outdoor and garden areas is particularly valuable. These spaces are linked to improved mood, reduced medication use, and better sleep quality.

- Orientation supports, including landmark features at decision points, colour and texture variation, and signage with both pictorial and written information, help residents navigate their environment and maintain a sense of place.

Implementation and Action

If you are working in or advising a long-term care facility, the findings from this review translate into several practical starting points:

• Audit the lighting in communal areas and bedrooms. If daytime light levels are below 1,000 lux, investigate low-cost interventions such as repositioning furniture near windows, adding supplementary lighting, or exploring bright-light therapy programs.
• Review the scale of living arrangements. If residents are housed in large, high-density environments, consider how spaces can be subdivided to create smaller, more domestic clusters.
• Walk the facility as a resident would. Note the points at which orientation becomes difficult. Add colour contrast, landmark objects, and clear signage at decision points and corridor junctions.
• Ensure all residents have daily access to outdoor or garden spaces where possible, particularly in the morning hours when light quality is highest and the benefits to sleep and mood are most pronounced.
• Involve care staff in design review processes. Those who observe residents day-to-day hold detailed knowledge about where distress occurs and which spaces feel most comfortable.

The Critical Messages