“I” wrote, “you” died. Words mattered, and terms could be slippery. You may have seen this body of text between two big air quotes. It was written by a “normal” weight brain with two hands and ten fingers. It was visible, readable, and exposable. It was constructed inside. Yet, it was about the invisible edge that created the dichotomy in the first place. It was about the ones that would never be able again. The human beings that could not remigrate to the center, that were not being advocated for, while slowly falling off the bittersweet margins, pushed aside, slipping into eternal silence. Therefore, this text was by no means aphoristic. Rather, this exploration offered a petite peeking hole from inside. Like that old beard Plato, who stumbled, and tumbled into his own cave.¹ A place that one day might became mine.

The public health domain is a place we all share. In the light of our current situation, human interdependency is becoming more tangible. While this ecosystem of health reveals itself, national lockdowns and self-isolation policies are implemented as acts of care. Acts that often seem to trace out a reality of boundaries and borders. Yet this also triggered a counter reaction of independency and individualism. In the same breath, Bolsonaro promoted gun possession while abandoning COVID-19 as an innocent flu.³ Sudden manifestations of our fragile co-existence seem to ignite misinformation, and a misleading portrayal of individual liberties.⁴ Health has become the subject of political controversy. Phenomena like Brexit and Trump show isolationist tendencies on the global stage. But their campaigns also tap into a sentiment of self-containment: The strong man can do it himself. These sentiments of neoliberal ableism may sound catchy to some, yet they automatically enable division.⁵

(Not) Surprisingly this doesn’t only stay in the medical domain. It’s treacherous how quickly the sentiment of medical ableism finds its way as a tool of othering. “Health intersects with sexuality, ethnicity, gender, class and coloniality - ultimately revealing the interdependence our entangled existence” (Munoz). An existence that is bodily and (battle)grounded. The disability justice framework, developed in 2005 by the Disability Justice Collective, examines ableism in relation to other forms of oppression. It theorizes disability as a cultural, political, and social phenomenon, instead of an individualized, medical matter attached to the body.⁷

It is no coincidence that the word asylum refers to institutionalized places for both refugees, and people suffering from a mental disorder.⁸ Both are invisible places far from home and enclose precarious, docile bodies. Both institutions exercise a disciplinary force on the individual.⁹ Analyzing society’s view on mental illness inevitably leads to insights concerning other labels of otherness. But perhaps their most profound similarity is their paradoxical relationship with accessibility. At the orthopedic clinic, accessibility is everything. Wheelchair ramps and elevators make sure patients can easily enter and move freely through the building. At the mental asylum, inaccessibility is everything. It’s a one-way in and a one-way out, a buffer zone in order to protect "both sides" of the wall.

Fortunately, the mental asylum as we once knew it does not really exist anymore. As part of a “global” deinstitutionalization process during the 20th century, the asylum made way for less isolated mental health services.¹⁰ Figures like Franco Basaglia and Ervin Goffman pleaded for a more existential approach, countering the ‘total institution’. Complete isolation and psychopathological treatments were slowly reformed into less "penetrating" health services and provided "more freedom" and agency to patients. This didn’t mean that the psychiatric domain suddenly became a place for freedom and equality. With the discovery of psychiatric drugs, the architectural confinement was substituted by medicinal prescriptions. The healthcare environment became more specialized and ramified into different types of care facilities. Formats such as assisted living, therapy groups, halfway houses and inpatient clinics all originated from that time. The stigma remains.

The current setting in which mental care is provided differs drastically around the world. Generational care is still the most common practice on a global level. Some countries, like Japan, did not follow a program of deinstitutionalization and the number of hospital beds in the country has increased over the last few decades. In Uganda it’s estimated that 90% of mentally ill people never gets a treatment.¹¹ Being aware of these differences, this thesis mainly focuses on the contemporary architectures encircling dementia care in The Netherlands. A densely populated, industrialized, neoliberal country that has one of the most institutionalized elderly care systems in the world. In the Netherlands, about 115.000 people live in elderly homes.¹² Roughly half of this group is afflicted by dementia. There are currently about 290.000 people experiencing dementia in the Netherlands and it this number is likely to double by 2050 because of an increasing life expectancy.¹³

Like a boomerang. Dementia is where the advancements in health science are confronted with a dead end. It’s a psychogeriatric condition that is currently not considered to be medically curable. For people with dementia this often means that the elderly home is their last resort. It requires palliative care, which means that the well-being is more important than the caregiving. This demands a huge responsibility from the care environment itself. With an already urgent shortage in caregivers and a market full of cuts, and insufficient policies, the setting surrounding people experiencing dementia is the absolute bearer of their well-being.

This results in countless tayloristic rituals, captured in Excel sheets, about the right amount of light, the ideal television volume, and the average length of walks through the courtyard. But these heterotopias of crisis often don’t just provide daily routine.¹⁴ Design interventions offer a lighting consolation for an architectural reality in which the walls are closing in. They effectively tap into a brain condition in which reality is already wavering. If we can’t play God, we can at least simulate God: murals, decors, music, and innovative simulators tend to bring residents back to the brighter days of tactile autonomy. From high to low art: the credibility of these escapist mediation moments depends on the pockets of the pensionado, in a country that has little room for the ill.

1. Plato. The Republic Book VII. Ed. Rouse, W.H.D. Penguin Group Inc, 1999. 365–40.
2. Sontag, Susan. llness As Metaphor. 1st ed., Farrar, Straus and Giroux, 1978. 3. Muggah, Robert.
  Jair Bolsonaro Wants Every Brazilian to Have a Gun. The Economist, 15 April 2021. .
4. Munoz, Barbara Rodriguez. “Health”. Health, ed. Barbara Rodriguez Munoz, Cambridge, Massachusetts, The MIT Press, 2020, p. 13.
5. Goodley, Dan, and Rebecca Lawthom. Critical disability studies, Brexit and Trump: a time of
  neoliberal ableism, Rethinking History, 2019. 233-251.
6. Munoz, Barbara Rodriguez. “Health”. Health, ed. Barbara Rodriguez Munoz, Cambridge, Massachusetts,
  The MIT Press, 2020, back cover.
7. Piepzna-Samarasinha, Leah Lakshmi. Care Work: Dreaming Disability Justice. Arsenal Pulp Press, 2018.
8. “Asylum Definition: 1. Protection or safety, especially that given by a government to people who have
  been forced to leave their own countries for their safety or because of war. Asylum Definition: 2. a
  hospital for people with mental disorders.” Cambridge Dictionary, 2022.
9. Foucault, Michel, e.a. Discipline and Punish. 2de ed., Adfo Books, 1995. Monoskop.
10. “Deinstitutionalisation”. Wikipedia, 6 February 2022. .
11. BBC News. “Breaking the Stigma around Mental Illness in Uganda”. BBC News, BBC, 21 februari 2015, .
12. Centraal Bureau voor de Statistiek. ‘115 duizend mensen in verzorgings- of verpleeghuis’.
  Centraal Bureau voor de Statistiek, 25 March 2020.
13. “Neemt het aantal mensen met dementie toe of af?” Alzheimer Nederland, 19 februari 2021, .
14. Foucault, Michel, and Jay Miskowiec. Of Other Spaces. Diacritics, vol. 16, no. 1, Johns Hopkins
  University Press, 1986. 22–27.

My grandma called me Wouter instead of Jules and offered me a biscuit each ten minutes. Every two weeks on a Sunday we would drive from Eindhoven to the nursing home in Bergen. We always stayed for two hours. I used to draw armless people in her room after which she would ask if I was left-handed. “Wouter is left-handed, isn’t he?” “Wouter is left-handed, isn’t he?” She passed away in October 2010. We never visited the nursing home in which she lived again. Thinking about it now, makes me remember how I used to run laps through the unit. It felt like an infinite corridor, like an endless world. The building was circular, had vinyl floors and semi-automatic push bar doors. In the middle was a little park with an artificial lake. All residents of the unit suffered from dementia.

Isolation derives from the Latin word isola, meaning island.² The closed character of the memory care institution seems to be born out of protective necessity. The cortex of the human brain is humanly divided in different islands that all have different functions: forming memories, processing sound, speech production, all that jazz.³ The logic of everyday rationale is often based on similar mappings. Money, clothes, and the way in which your home is ordered. It’s exactly in these taxonomical circumstances that things start to get lost. In an overly-calculated country like the Netherlands, daily life with dementia is less bearable. These factors seem to reinforce each other: more systems demand more care demand more systems. .

Cell derives from the Latin word cellula, meaning “small room”.⁴ Trapped in the boundaries of protocol, only a tiny fragment of personal belongings makes it into the dementia unit. The dementia care environment may serve as an analogy between the brain and the building. A healthy brain probably weighs about 1300 to 1400 kilograms. In an Alzheimer brain, abnormal buildups of proteins block the cell transport system resulting in a dysfunctional cell transport system.⁵ Nutrients and other essential supplies can no longer move through the cells. Neurons and cells die. In the last stage of Alzheimer, a brain weighs 1170 – 1260 grams.⁶ When you are in the process of depersonalizing, the space surrounding you may do the same.

Things that spoke for themselves, slowly don’t speak for themselves any longer. Forgetting a name or coming up with the right word are the first appearances of a downwards fall into a semantic mush. While these “language errors” are still relatively insignificant, in the last stage, verbal communication becomes difficult or impossible. This also goes for the interpretation of images. As with many institutions, standardized spaces have standardized decorations to appeal to a wide audience. For the dementia care environment, that’s no different. Yet it requires some additional deliberations. The trick here is to find a dialect that is outspoken but not too specific. It should balance between individuation and collectivity, often ending up in a sort of archaic local vernacularity.

The wall sized language through which residents banter is greatly influenced by the way in which disease affects memory. Writing a few words about it feels almost sarcastic. Those with Alzheimer’s disease may have impairments in short-term memory, however remote memory can be left relatively intact. So, they’re able to remember public and personal events many decades ago, but unable to recall what happened earlier that day.⁷ Sometimes—like a blind person having a better hearing than an abled person— an individual might suddenly recall a memory that she/he/they couldn’t before.⁸ Reminisce therapy response to this by helping “individuals retain a sense of self-worth, identity, and individuality” (Dempsey, 1). Making use of the still in-tact memory, it is the process of recalling personal events or experiences from one’s past that are memorable to the person. Nostalgic artefacts such as photographs, music, familiar items, and historical architecture, are used to bring residents back to a time that still exists in their brain.¹⁰

I’ve never happened to know my great grandmother. She grew up in the late 19th century in Cologne. Raised in a catholic environment, she never talked about sexually explicit topics. It was a taboo. But at the time she started to experience dementia, she suddenly became relaxed and flirty. While her daughter visited the nursery home, my grandmother told her how she had a crush on the doctor, who happened to be thirty years younger. In Dutch this type of behavior is called decorumverlies, which literally means loss of décor. It is characterized by behavior that is conceived as “inappropriate” in the social environment of that specific moment. This has to do with the decline of abilities a person learnt specifically when growing up as an adult. An emotion such as shame is learnt along the way of growing up, as one explores what’s acceptable behavior and what is not. From an abled perspective this might be perceived as childish.

All of the aforementioned gives us the feeling as if dementia sets back the clock into the years of being a child. Like a flower losing its leaves. The Theory of Retrogenesis theory suggests that brain decline mirrors brain development from birth. Stages of Alzheimer are compared with the cognitive and motor abilities of a child of certain age, e.g. a person in the early stages of dementia will have the skill level of a 5 to 7 year old.¹¹ While this theory is still a theory, the average abled eye will perceive the effects of senile dementia as child-like behavior. This corresponds with the day-care aesthetic that a lot of therapeutic mediation devices have. It confronts us with a flaw in our pathological view of expandable growth.

Touch is a crucial facet within dementia therapy. It’s the first sense to develop when coming alive. The sense of tactility is the first sense to develop in the fetus.¹³ “A new-born baby is not aware of the fact that sounds, movement, sight and touch are different things. All impressions melt in a single experience or feeling together” (Goddard, 2005). It’s a deeply expressive, receptive sense of communication, a mental experience that is largely ignored in western culture until present day. Presented by Plato and compounded in the enlightenment: vision remains predominant in media culture and so does the mind body dual continue. The lowly position of touch in the hierarchy belies in its complex constitution, being a singular sense that corresponds with no singular organ.¹⁵

1. “De Zorggroep - Maasduinen Staete”. De Zorggroep. 14 February 2022 .
  www.dezorggroep.nl/maasduinen-staete.
2. “Isola - Wiktionary”. Wiktionary. 3 February 2022.
  en.wiktionary.org/wiki/isola.
3. “Brain Tour”. Alzheimer’s Association. 9 February 2022.
  www.alz.org/alzheimers-dementia/what-is-alzheimers/brain_tour.
4. “Cèl·lula”. Wiktionary. 2 February 2022. en.wiktionary.org/wiki/c%C3%A8l%C2%B7lula.
  5. “Brain Tour”. Alzheimer’s Association. 9 February 2022.
  www.alz.org/alzheimers-dementia/what-is-alzheimers/brain_tour_2.
6. “Neuropathological changes in Alzheimer’s disease linked to four key proteins”. Research Outreach,
  nr. 129, 2022. Crossref, https://doi.org/10.32907/ro-129-2405138985.
7. Keage, Hannah and Tobias Loetscher. “Passage of Time: Why People with Dementia Switch Back to the Past”. The Conversation. 15 February 2022.
8. Goth, Ursula S. en Benedicte S. Strøm. “Language disintegration: communication ability in elderly
  immigrants with dementia”. The Lancet Public Health, vol. 3, nr. 12, 2018, p. e563. Crossref,
  https://doi.org/10.1016/s2468-2667(18)30184-1.
9. Dempsey L, Murphy K, Cooney A, et al. Reminiscence in dementia: A concept analysis. Dementia.
  2014;13(2):176-192. https://doi.org/10.1177/1471301212456277
10. Dempsey L, Murphy K, Cooney A, et al. Reminiscence in dementia: A concept analysis. Dementia.
  2014;13(2):176-192. https://doi.org/10.1177/1471301212456277
11 Kaur, Amandeep & Venigalla, Hema & Ayub, Shahana & Brainch, Navjot & Ahmed,
  Saeed & Hassan, Mudasar. (2017). The Retrogenesis model in Alzheimer’s disease:
  Evidence and practical applications. Current Psychiatry Reviews. 13. 1-1.
  https://doi.org/10.2174/1573400513666170127093925.
12 Braden BA, Gaspar PM. Implementation of a baby doll therapy protocol for people with dementia:
  Innovative practice. Dementia (London). 2015;14(5):696-706. https://doi.org/10.1177/1471301214561532
13 Chen, Jack S. C. The Agency of Touch: Engaging Alzheimer’s Patients. Amsterdam, Master of Interior
  Architecture Sandberg Instituut, 2012.
14. Goddard, John, (2005), Regression models for forecasting goals and match results in association
  football, International Journal of Forecasting, 21, issue 2, p. 331-340.
15. Chen, Jack S. C. The Agency of Touch: Engaging Alzheimer’s Patients. Amsterdam, Master of Interior
  Architecture Sandberg Instituut, 2012.
  Systematic Reviews, 2003. Crossref, https://doi.org/10.1002/14651858.cd001394.

When thinking of the healthcare environment, you might think of a giant ‘H’, sealed white workers, and other standardized systems of sameness. A medical space, dominated by an aura that helps us believe that we will be cured. Not the environment to stick around for fun. Yet, healthcare architecture tried to shift away from this horror trope since the fifties. The ‘Form follows function’ credo slowly made way for Postmodernism and its escapades. During the postwar economic boom, health architecture aimed at normalizing, or better said, capitalizing the healthcare environment: instead of focusing on physicians, architects focused on patients and families. It was purposely anti-medical.¹ With the advent of New Urbanism during the 80s, hospitals started to look like malls or airports, offering retail, dining, and healing gardens. Landmarks helped to find patient-consumers find their way and distracted patients from being seriously ill. Sometimes the hospital-as-city metaphor was so explicit, with corridors as streets, as if outside, with ‘street’ lighting and benches, giving the hospital an aura of being public.²

A growing part of healthcare architecture seems to eagerly underline a view of salutogenesis. It focuses on the positive impact of human health instead of only curing disease. But what does health mean in this context? “Health is not the absence of disease. It’s a state in which we know that life is manageable and meaningful: it’s how we retain our ability to keep going when facing changes internally and externally. These therapies are an extensional device to enhance your present state, to help you find your sweet spot” (Reyes). You may think of an open environment with great views on the outdoors, fresh air, and natural light.

For the dementia care environment this “sweet spot” creates — even if there would be the infrastructure and the financial capacity — a paradox. On the one hand the function of the program is to protect residents from the real world with all its risks, while on the other hand everybody agrees that the environment should be meaningful, manageable, and comprehensible. “In the designers’ hyperbole salutogenesis now rarely means more than fuzzy intentions to create restorative environments by providing views that represent nature: whether it be designed parkland, grassy areas, views of the sky or even video representations of these things. The term is thus bleached of meaning” (Golembiewski, intro).

Yet that meaning may also be created from within the institution. Let’s not forget, the elderly home also provides a community. If the outside is arguably too dangerous, it might as well be pulled inside. There are a lot of examples in, especially the United States, where the interior has gone “wild”. With a private health care system, a love for neoclassism and an extremely rich upper-class, some Las Vegas-like dementia care facilities reminds us of that sort of type of Disney monumentalism that we know from postmodern architects like Michael Graves and Bob Stern.⁵ In the end, decorating only parts is not the most convincing? Hence a sort of hyper real 1:1 parody for the 1% hyper rich.⁶ This concept of holistic decoration approach is called the dementia village, or Truman care.

The concept of the dementia village actually finds its origin in The Netherlands. Opened in 2009, De Hogeweyck in Weesp is a holistic reenactment of nostalgic familiarity. Here, architecture effectively taps into the phenomenological plausibility of dementia to validate their experience. An experience in which past and current life blur. This means nostalgic architecture, stores, restaurants, a theater and even a fake bus stop.⁷ Caregivers are not allowed to wear white medical clothes. In fact, they are often part of the reenactment: the caregiver may also be a cashier in the grocery store, or a barber in the barbershop. While from a birds-eye view it looks like a jail, inside it kind of looks like any other neighborhood. Normal so to say. The village therefore offers an escape from illness, as it affirms dementia and normalizes it. Illness becomes normal, illness becomes healthy.

I used to work as a designer at a wallpaper factory in Huizen, The Netherlands. We sold wallpapers to both consumers and companies. While having a wide range of products, Vincent van Gogh’s De Zonnenbloemen as a repeating motif was our most sold design. After that our own design Grand Safari and Cloudy Woods. Beautiful palm trees and blue skies: fertility at its best. They all seemed to signify nature or at least symbolize it in some way. Used by a Novotel next to a highway or a VINEX housing corporation, they often depicted quite the opposite of what was in reality behind the paper. Like the foundation for the building: it masks that it conceals, it inverts a space.

Often depicting an open window with an idyllic view, they trompe l’oeil the viewer into outside. This is supported by ‘Dan Muralman’ who wrote a blog about the ideal dementia wallpaper on www.magicmurals.com. “Stay away from any pattern that could make them feel closed in, like vertical stripes that resemble jail bars.” These kinds of design principles for people with dementia tell us something about the primal connotation of semiotics. He continues: “Most patients need both a décor that stimulates and a décor that soothes. In general, patients with minimal dementia or in the initial stages of Alzheimer’s are best served by environments that stimulate their cognitive functions. Give them plenty of things to do and look at while they’re walking along the hallways or staring at the walls (and perhaps they’ll spend less time just staring and more time interacting). Likewise, patients who are easily made anxious by too many distractions, by bold & loud colors, or by busy patterns and/or too many design elements are best served by warmer, homier, quieter colors. Use patterns to break up the monotony of flatly colored walls but keep them simple and familiar”. (Muralman)

Yet, these examples are embedded and fixated. It can be a costly activity to keep refreshing murals and wallpapers every five years. As time passes, so do memories of the past. Familiarity slowly corrodes into forlorn confusion. But most importantly, they only stimulate the senses of sight. With the technology of today, more and more travel simulators pop up in elderly homes. By combining décor building and the technologies of today, immersive multi-sensory travel experiences are breathed into life. Moving image, surround-sound, haptic feedback and even air supply support each other into a convincing “moving-through-time-and-space” experience. By doing so they bring back residents to an experience of spatial autonomy.

1. Peters, Terri.Design for Health. 1ste ed., vol. 87, Wiley, 2017.
2. Reyes, Pedro. “Sanatorium”. Pedro Reyes, 2011. 03 March, 2022.
  www.pedroreyes.net/sanatorium.php>
3. Borges, J. L. 1998.On exactitude in science. 325. (Trans. Hurley, H.) Penguin Books.
4. Golembiewski JA.lutogenic Architecture in Healthcare Settings.2016 Sep 3. In: Mittelmark MB, Sagy
  S, Eriksson M, et al., editors. The Handbook of Salutogenesis. Cham (CH): Springer; 2017. Chapter 26.
  https://www.ncbi.nlm.nih.gov/books/NBK435851/ doi: 10.1007/978-3-319-04600-6_26
5. Lauf, Stephen. “Learning from Las Vegas”. Quondam, Quondam, 14 oktober 2005,
  www.quondam.com/40/4015o.htm.
6. “Simulacrum”. College of Liberal Arts. 1 March 2022.
  cla.purdue.edu/academic/english/theory/postmodernism/terms/simulacrum.html.
7. Adams, Annmarie en Sally Chivers. “Deception and Design: The Rise of the Dementia Village -
  Architecture - e-Flux”. E-Flux, September 2021.'
  www.e-flux.com/architecture/treatment/410336/deception-and-design-the-rise-of-the-dementia-
  village.
8. Muralman, Dan. “Decorating for Alzheimer’s and Dementia Care with Wall Murals and Wall Art”.
  Magic Murals, 11 februari 2021,
  www.magicmurals.com/blog/decorating-for-alzheimers-and-dementia-care-with-wall-murals-and-
  wall-art.
9. Bas van Oerle. “Quo Vadis”. CODAworx, CODAworx, 1 april 2020.
  www.codaworx.com/projects/quo-vadis-nieuw-rijsenburgh-retirement-home>.