Trends in Senior Living - March 2012

By Ruth Simon McRae

In eight years, there will be 55 million people over the age of 65 in the U.S. And by the same year, 2020, the population of people age 85 and older will grow to 6.6 million, according to senior healthcare professional Anthony Cirillo. By definition, all of these individuals will be in senior housing. What will these homes look like? And what kind of flooring will be used in them?

We can begin to predict the future by looking at the present. Currently, there are four major types of senior housing, with a constellation of spaces and functions within.

SENIOR LIVING: A MICROCOSM OF SOCIETY
A senior living community is not just a collection of corridors, apartments and public spaces, all geared to levels of care needed; it is a microcosm of society. Consider the current categories of senior living facilities: independent living apartments, assisted living with and without memory care, skilled nursing, and continuing care retirement communities that include all of the above. There are also senior centers and senior day care facilities. And that is just today, or possibly yesterday.

Senior living communities contain as many types of areas as you would find on a college campus or in a small city: dining rooms (formal, casual, bistros and cafes, possibly a pub), gift shops, beauty salons, spas and wellness centers, physical therapy facilities, fitness areas, and spaces for fun activities such as billiards, arts & crafts, and often an auditorium or atrium for concerts and speakers. Staff areas are also part of the mix, including nursing offices and stations, administration areas, meeting rooms and training rooms.

The options for senior living are not just growing but they’re also changing; new forms of senior housing and community will be part of our future.

The Culture Change movement was started 13 years ago with a goal of improving the quality of life for residents in all settings where aging services are delivered. The initial mission was to de-institutionalize long-term care and make these facilities more like home. In Culture Change, quality of care and quality of life are inseparable and equally important.

In addition, Culture Change puts more focus on the wellness aspect of health. Residents are encouraged to have a full life with care, programming and space design. Functions such as meditation gardens and other outdoor areas are routinely included. College courses are often available.

Many skilled nursing facilities have rearranged from much larger units that share a common dining area to households of a small group of residents who have their own dining and living spaces; this is termed the Household Approach. Open “country kitchens” are used in many of these facilities to provide the ambience of home.

The Green House Project is a de-institutionalization effort designed to restore individuals to a home in the community by combining small homes with six to ten residents living as a family. Each home has a small number of dedicated caregivers. The Green House concept has spread to over 100 Green House homes operating on 43 campuses in 27 states. This same style of housing is called by other names, Small Houses, for example. Currently in Georgia, there is a Small House being built in Columbus, and a Green House in the planning stages for Augusta.

People nearing retirement seem to be considering two directions as they look at the options. One would be to enter a retirement early, possibly with friends, and enjoy the amenities, community and security. The other direction, appealing to a somewhat larger group, would be to age in place with the help of universal design.

One viable way to age in place is to become part of a Naturally Occurring Retirement Community (NORC). A NORC is a community or neighborhood where residents remain for years and age as neighbors. This designation may refer to a specific apartment building or a street of single-family homes. Some 27% of seniors live in NORCs.

Seniors who age in NORCs may eventually need care. The result of the trend towards aging in place is that assisted living with memory care or possibly skilled nursing levels will be the entry points into senior living facilities for many people. The average age for entering a facility is late 80s to early 90s.

FLOORING IN SENIOR LIVING
Senior living does not just mean one product type. Many flooring products will be needed to address all the types of communities and spaces involved. And with the trend toward aging in place, there will be opportunities for new types of flooring for residential settings as well.

It is important to develop an understanding of the issues of aging to create products appropriate for elders. To begin, the product designer must listen to the customer. It is a truism to say that great design comes from listening to the customers’ needs. This is key in the senior living market. All stakeholders have important input into the process.

The most successful projects are ones where the design process is a conduit to express the mission of the organization. Responding to positive feedback on the Willson Hospice House, an award winning respite center in Albany, Georgia, architect Ila Burdette of Perkins+Will put it this way: “The staff did a great job. Our job is to give them an environment to do what they do well.”

By the same token, caregivers are increasingly listening to residents’ fundamental needs: to be heard, to feel safe, to be in an environment with a home-like rather than institutional feel.

So where does a designer start the design process? Function is the starting point, indicates Melinda Avila-Torio of THW. The first requirement is to research products that will meet the level of safety needed for all people in the space, most importantly the residents.

Facility designers go through a process of discovery by interviewing all stakeholders: owners, administrators and caregivers. The operators and nursing staff all come from different backgrounds and have different issues to be addressed. After detailed discussions concerning maintenance schedule, types of cleaners, and previous experience with products (good and bad), the designers are ready to proceed. And of course, they must also factor in budget requirements and lifecycle costs.

They take these first steps before even setting foot into the resource library. Then it is on to the next step—product, pattern and color.

Bethany Harris, also a designer at THW, starts with the flooring selection. “There is such a wide variety of material available. We create a plan to develop a hierarchy of spaces, and then select the appropriate flooring material for each. Flooring is one of the largest canvases available on a project; it can make it or break it, both aesthetically and from a functional standpoint. The flooring will be touched and worn every day. In this way it is one of the designer’s biggest responsibilities.”

SELECTION OF FLOORING TYPE
Avila-Torio mentioned just some of the issues that should be addressed concerning flooring during the planning process. The design team should inquire about preferred flooring product manufacturers or flooring types.

They should also ask about building infrastructure conditions that have compromised the performance of the previous flooring product or that may occur in the future, such as moisture levels, as well as adhesives that have reacted to or may react to moisture levels related to the concrete slab.

Designers also need to request information on the current rate of incidents associated with falls, incontinence and injuries, just to name a few. The team should identify where these incidences have occurred within the community.

Acoustic issues can interfere with the caregiver’s ability to provide quality care. Designers must inquire about whether these sound levels enhance or deter the residents’ daily quality of living. Where are the undesired levels of sound occurring? At what times?

In addition, designers must look into any physical therapy regimens occurring outside the typical physical therapy suite. For example, a community may be providing a self-propelling wheelchair therapy program in the corridors. In this case, it is important to provide flooring options that help ease resistance as residents maneuver down the hall.

Lastly, the designer must inquire about slip and fall issues relative to flooring. The aging experience a change in their gait and often begin to shuffle their feet more. Shoe sole designs are engineered for better traction, potentially producing more resistance for seniors when they are walking across cut-pile carpet. If a resident comes to a complete halt, they may lose their balance, resulting in a fall. Carpet products with backing designed to soften an individual’s fall are a plus. However, they may also be a big adjustment for staff accustomed to walking or maneuvering heavy loaded carts on a hard surface like VCT. Whenever possible, educate the community, especially the staff, that there will be a change in the floorcoverings, and provide a large sample so that it can be tested prior to final selections. The test should include pushing an individual in a wheelchair, geriatric day chair, mobile bariatric chair, fully loaded medicine cart, and food cart—at a minimum.

The information gleaned from all these inquiries will help the designer determine what types of flooring materials are appropriate for the space.

DESIGN CONSIDERATIONS FOR FLOORING
The key aging issues to be considered in flooring selection are mobility, vision, and the special requirements of dementia. According to designers interviewed, there are a few ways that they can address vision and perceptual changes. First, keep color contrast minimal, so that a value change is not perceived as a hole or a barrier. Awareness of color contrast is key. If something reads like a change in depth, it will stop an older person from moving forward.

Second, use color to promote safe visual navigation or to deter residents from going in a certain area. Next, choose a palette of clear yet soothing colors in order to minimize combative behavior.

Review color palettes through yellow glasses to see the interior from the residents’ perspective. Avila-Torio comments, “Looking through the film allows the designer to see if contrast may be too high and may cause visual cliffing or cause the carpet pattern to ‘move.’ For some with dementia, there may be more critical stages where the brain can no longer interpret color but can see pattern. Even if they can no longer see color, they can still enjoy seeing pattern.”

Lastly, use color to help residents understand their environment by selecting contrasting colors that differentiate floors from walls and making sure there is some color contrast on window and door frames.

Designers also have to address mobility issues, especially in relation to glare, which impacts both vision and mobility. Glare is a significant issue because the floor may appear to the resident to be wet and therefore dangerous. A matte finish on flooring is preferred, even though the facilities workers may be accustomed to maintaining a high wax finish.

Designers should think carefully about transitions. Alison Faecher of TRO Jung|Brannen says, “Any change in level is a hazard, so the designer must to be cognizant of aligning details. In order to create flush transitions, we may use feathering or a leveling compound beneath flooring. If at all possible we prefer not to use transition strips.”

Avila-Torio adds, “Transitions between floor materials, thickness and finish need to be addressed where residents move from space to space. Designers also consider how the transition of floor material can provide cueing, whether it’s to help notify a change of direction or to alert the person of the direction, etc. There are flooring products now that are incorporating Braille in the floor finish and photoluminescence in floor guiding accessories. Products are also available for the visually impaired that have photoluminescent properties to help navigation on stairs.”

In addition to these considerations, there are several key attributes of flooring for senior living. Products must have bleach resistance and be easy to clean. In selecting carpet, this does not always mean 100% solution dyed products, as other products may be treated with effective bleach resistant finishes.

All designers interviewed recommend a moisture barrier backing on carpet to address incontinence and spillage issues. Carpet must pass 10,000 cycles of Moisture Impact Penetration Dynamic Test as well as the British Spill test. Manufacturers are now all providing results for these tests.

Bathrooms present challenges for both slip and fall and moisture issues. One option is a safety floor that integrates mineral grains to create a non-slip surface. Moisture issues can be addressed with flash coving or integral base on resilient flooring.

FLOORING TYPE BY END USE FACILITY
The focus in independent living is to create a hospitality feel in corridors and public spaces. Typically this means carpet, although it depends largely on design vernacular and regional preference. THW often uses printed carpet in public space. They also typically use broadloom carpet in rooms. The texture may be cut pile or Berber, either glued down or over double set carpet pad.

Dining areas may be soft or hard surface, resilient flooring or ceramic tiles. Acoustical values need to be considered, taking the effect of all interior materials into account as well as interior architecture. Flooring selection will vary by dining type. For example, dining rooms tend to be either wood look vinyl or carpet, and bistros or cafes may be luxury vinyl tile, ceramic or porcelain.

Rubber flooring and cushioned sheet vinyl sports flooring are good options for fitness areas due to underfoot comfort, cleanability and acoustical properties. Fitness/exercise centers are typically available for use by independent and assisted living and as appropriate to skilled nursing residents.

Similar in many aspects to independent living, assisted living spaces need to have a residential ambience. Many facilities have soft floorcovering in the corridor; if carpet is used, it should be all loop or a dense cut/loop texture and have moisture barrier backing.

Carpets selected for apartments tend toward loop pile constructions, often with a moisture barrier backing. The look and underfoot softness of a tight sisal is one flooring option that can offer a home-like feel. Residents use more assistance devices in these situations, and the carpet generally gets more day-to-day abuse.

Many facilities have residents with some level of dementia, so it is important to design for the highest need. This makes pattern selection and color contrast critical, particularly in public spaces.

Burdette expresses a broader perspective on memory care units, “Alzheimer units are places where architects and designers can really make a difference in residents’ lives. These memory care patients live in the here-and-now, and the design of the facility greatly effects their experience and quality of life.”

Skilled nursing tends to use more resilient flooring than carpet. Whatever type of floorcovering is deemed appropriate, changes in perception and mobility must be factors in pattern and color selection. Rooms are often wood-look sheet vinyl, giving a residential feel. Corridors also tend to be resilient flooring. Vinyl or rubber millwork profile base can add a residential feel and provide warmth to the interior.

Carpet tile is one additional flooring option for senior living. However, during our interviews there was no consensus on the best ways to incorporate carpet tile into senior facilities. There are areas where the inherent flexibility of carpet tile provides a good solution, as long as the facility has provisions for managing attic stock. Subflooring options, such as sealing the concrete, may increase the opportunity to use carpet tile in higher levels of care.

SUSTAINABILITY
Sustainability is a key issue in all product selection for senior living. Regarding sustainability, Perkins+Will says, “Sustainability is always a very important part of our projects. We do not use vinyl. The Wilson House used natural materials: bamboo, cork and MCT modular linoleum flooring.”

And THW comments, “I would like to think we always take the approach of being good stewards in protecting our natural resources while finding a balance for function, durability and aesthetics. More importantly, we design for a very sensitive demographic whose well being can be compromised at varying degrees.”

Designers must look at the adhesive systems that are associated with the floor systems being considered. They should make certain that both the adhesive and flooring material together do not infringe on daily living. This includes understanding how it affects indoor air quality, which is of the utmost concern for all stakeholders. It is imperative to understand what the flooring maintenance program entails.

Designers have the responsibility to have upfront discussions with the housekeeping staff regarding what is on their cleaning cart. If chlorine bleach is one of the cleaning solutions, then shielding surfaces that cannot withstand chlorine bleach spills is crucial in protecting the capital investment of high dollar items such as carpet. The question should be asked if the community is considering changing their regimen to include zero/low VOC cleaning agents. This is an important fact-finding mission that will enable the design team to develop early on the best floorcovering solutions.

In designing for projects that are pursuing LEED or other certifications, designers are challenged with providing the best solution that will provide a safe and visually appealing product, yet enables the staff to fulfill their philosophy of resident centered care.

So what will senior living look like in 2020? A wonderful question was posed by a designer at HOK: Will the Grateful Dead be playing in the elder housing of the future?

Whatever the forms, we can be certain that the flooring industry will rise to the creative challenge of providing effective and elegant solutions to the needs of senior communities.