Colour perception in old age With implications in the caring environment Helle wijk Helle Wijk, Ph.D. Dr. Helle W jk is lecturer and registered nurse (RN) in the field of Geriatric Medicine at the Department of Geriatric Medicine at the Sablgrenska University Hospital in Gothenburg Swveden. She is a-member of the board of the Swedish Society in Gerontology and Geriatrics and is irvalved in seve- ral national projects concerning improvement « ernie care ther PhD. “Color peeption olf age (2001)” at the Medical faculty of Gothenburg University concerned color’ discrimination, color naming, color preferences and color as support for recognition in old age and during Alzheimer's disease, The results of the thesis is implemented in rursing homes far the elderly as well as at geriatric departments at the Sablgrenska University hospital in order to improve orientation and understanding of the encironment for the elder Colours are of great importance for most people in most environments for the detection and iden- tification of objects, for information, and for the aesthetic point of view. Normally the perceptual information of the environment is sufficient, but visual and cognitive deterioration accompanying old age can have a negative impact on how we perceive and act in the environment. Although studies of the elderly indicate that a majority of older people remain in good physi- cal and mental condition over the years, its still a fact that chronic disease and disability beeome more frequent as we grow older (Heikkinen et al, 1997). Those common changes in, for example, sensory acuity, psychomotor speed, mobility, social roles with age and cognitive 167 deterioration, make the older person more reli- ant on the physical environment. This could be expressed as difficulties to acquire and retain spatial-bound information and to recognize fea- tures (Lawton 1986). However, even though old age is related to an increasing risk of cognitive decline (Skoog et al.1993) and visual disturbances (Bergman et al, 1999) it does not necessarily mean a negati- ve change in performance. On the contrary, it has been shown that it is the personality and the ability to use different coping strategies to overcome difficulties in daily life and to main- tain a high degree of activity level that is the major determinants of well-being among the oldest old (Agren 1995, Hilleris 2000). It has also been assumed that a supportive environ- mental layout could have a positive impact on the behaviour of the individual despite loss of functions (Lawton & Nahemow 1973, Lawton 982,1984, Lawton 1994). In addition, lifestyle, social network and the living ronment are factors among others that have been suggested as important for the capa- city of survival instead of chronological age itself (Ljungqvist et al. 1995). ‘The focus in this study was on colour percep- tion in old age. For this reason it seemed par- ticularly important to be aware of the influence of various perceptual components, and to acqui- re more knowledge about the role of colour in this context, The use of colour contrasts, codes and cues should be based on systematic obser- vations as to how colours are perceived, recog- cd and preferred in old age despite Sensory deterioration and memory disturbance. ‘This study was intended as a contribution to this knowledge.Fundamental concepts of the studies. ‘The fundamental concepts in the study were colour perception and ageing. Colour percep- tion is defined as to how the colours are percei- ved by the individual in the specific situation. It is implied that the perception of a certain colour can be influenced by many factors despite a standardised external condition. ‘The pre- understanding, knowledge and expectation of the individual in the particular situation are all factors that could have an impact on the percei- ved colour (Anter 2000). It is therefore propo- sed that perception of a colour is more related toa colour area rather than to a specific colour. ‘The concept of ageing refers to the heterogene- ity and homogeneity of elderly. individuals regarding health, function and coping strategi- es. In this study the special focus regarding colour perception and ageing refers to similari- ties and differences in performance between age groups and the influence of visual and cognitive function on the results of the colour tests. Seeking for more knowledge regarding how aspects of colour perception is preserved in old age groups could be related to a more salutoge- nic way of caring for the elderly. ‘This approach inspired by Antonovsky (1987) advocate that the health of various degree always present within the individual should be the focus of ear- ing instead of the disease. In connection with that Antonovsky emphasised that caring should take into account what other measures beside medical care that could promote health for the patient, This focus on health and preserved fun- tions instead of disease and lost functions is also in line with the concept of patient empo- werment defined as giving the individual the opportunity to engage in and influence his care and rehabilitation (Baksi & Cradock 1998, Rappaport 1984). By focusing on preserved fun- ction, here as to colour perception, and by implementing this knowledge in the environ- ment and care of the old, itis assumed that the patients opportunity to behave independently arises. ‘This is in congruence with the central concept of nursing science i.e. person, environ- ment, health and nursing. The characteristic Rien International Academy for Design and Health 168 feature of nursing is the respect and dignity for the person as a whole in his environment with the overall goal to contribute to health and to support preserved functions (Barbosa da Silva & Andersson 1990). This is expressed in many nursing theories e.g. in Orem's (1995) model of nursing with its focus on compensation for the patient’ lack of self-care abilities. Based on the knowledge of how the elderly person perceives colour the nurse could contribute to an enhan- ced visibility of the environment in many ways. A more frequent use of contrasts, cues and codes would likely increase the possibility of independent functioning and decrease the bar- riers against it. Theoretical framework: The ecological model of ageing. In this study the framework used was the ecolo- gical model of ageing, developed by Lawton and Nahemow (1973). Characteristic features of this model are that it predicts behavioural outcomes by looking at an individual's compe- tence in relation to environmental pressure. ‘The model is built on the following equation: B=f(@ 5), where B stands for behaviour, f for function, P for person or competence and E for environ- ment, i.e. behaviour is a function of the person and the environment. According to Lawton, competence is only a part of the person (P) and includes a person's biological health, sensory perceptual capacity, motor skills, cognitive capacity and ego strength, Adaptation is predicted by examining the match between competence and the demands of the environment. Environmental (E) pressure encompasses the multiple demands of the environment upon the indivi dual, It includes aspects of the physical envi ronment (lighting, orientation cues, geograp- hic distance), the personal environment (family members, friends etc), supra-personal environment (characteristics of the residents in a person's neighbourhood), and the socialenvironment (norms, values in the individuals’ society) (Lawton et al.1982). Lawton and Nahemow (1973) classified envi- ronments on the basis of the "demand charac- ter” of the context in which the person acts. ‘The demand character could be either positive, neutral or negative. Outcomes for individuals are dependent upon the strength of environ- ‘mental pressure in relation to an individual's adaptation level and his or her competence. ‘The less competent the individual, the greater the impact of environmental factors on that individual. (Lawton and Nahemow (1973, Lawton et al.1982, Lawton 1986). Lawton and Nahemow held that the outcome, when a person of a given level of competence was acting in an environment with a given pressure level, could be placed on a continuum from positive to negative and was manifested on two levels, as behaviour and affect (Lawton 1986). Thereby it would be possible to predict behavioural outcomes by looking at an indivi- dual’s competence in relation to environmen- tal pressure (see figure 1). 169 Figure 1, Diagrammatic representation of the behavioural and affective outcomes of person- environment transactions, Source: Lawton MP, and Nahemow L. Ecology and the ageing pro- cess. In: C. Fisdorfer and MP. Lawton eds. The psychology of adult development and aging. Washington: American _ Psychological Association, 1973. Copyright * (1973) by the ‘American Psychological Association. Reprinted by permission. Population ageing. ‘The population of Sweden is ageing. An estima- te encompassing the increase of the elderly part of the population until the year of 2025 indicate that those aged 75-84 will increase with 45% and those 85 years or older will increase by 42% (Landstingsfrbundet 2000). Accordingly the remaining life expectancy at birth also show a continues increase, the last two centuries with more than 40 years. In 1995 the remaining life expectancy at age 65 was 16 years for men and 20 years for women (Statistical Yearbook of Sweden 1999). The normal age-related loss of functions mentioned above emphasises the importance of using a multifactorial approach when creating a supportive environment for the elderly. Alzheimer's disease With Alzheimer’s disease (AD) follows common problems with visuo-spatial disturbances and disorientation at an early stage of the disease. Knowledge of how colours are perceived despi- te their disease ought to be one of the prerequi- sites when planning for environment interven- tions for this group of patients. Dementia is common in old age with a preva~ lence of about 5% for those aged 65 years or more and with a clear association between ine- reasing age and the risk of developing dementia. Ina Swedish epidemiological study the preva- lence of dementia disease was 30% at the age of 85 years and 40% at the age of 88 years (Skoog et al. 1993) which is in congruence with figures from preceding studies (Jorm et al.1987). Dementia encompasses as well cognitive, emotionalRien as personality disturbances where the characte- ristic feature is a declining memory according to orientation in time, personal circumstances, events or person (Gustafson 1996). During the progression of the disease an inte- raction with behavioural and daily living often occur such as deficient performance according to the complex and basie tasks of everyday life (decreased ability to dress, bathe, and toilet independently), In the severe stages of the disea- se ability to eat, move, speak and sit are lost. Studying aspects of colour perception in old age and in AD. ‘The definition used in this study is colour as a colour percept, that is to say the perceived colour is the colour seen and evaluated by an observer in a specific situation (Hird & Svedmyr 1995). To analyse the results there is a need for a colour terminology with clear colour categories, In this thesis the colour samples demonstrated for the observers are taken from the Natural Colour System (NCS), which offers an exact terminology and description of the colour samples used (SS 01 91 00 The Natural Colour Notation System 1990). “Most likely, aspects of colour perception such as colour naming, discrimination, preferences and colour/shape recognition would be affected by the typical degeneration of the brain caused by the dementia. But so far studies measuring those aspects of colour perception are often perfor- ‘med with young samples, and very little has been reported in a manner which allows these results to be applied in environmental studies. AIMS OF THE STUDY ‘The overall purpose of the studies reported here was to describe aspects of colour percep- tion and its relation to visual and cognitive fun- ction in 80-year-olds, 95-year-olds and among individuals suffering from Alzheimer’s disease. International Academy for Design and Health 170 The specific aims were: * To describe an approach to method develop- ‘ment regarding colour discrimination, colour naming, colour preference and colour/shape recognition and to use the tests in order to ‘measure the different aspects of colour perception. * ‘To describe colour discrimination, colour naming, colour preferences and_colour/shape recognition in representative samples of 80-year- olds and 95-year-olds. and among individuals with Alzheimer’ disease. * To describe differences and similarities of colour perception between 80-year-olds, 95- year-olds and individuals suffering from Alzheimer’ disease. * To study the association between visual and cog- nitive function and the results of colour percep- tion in 80-year-olds, 95-year-olds and among individuals suffering from AD. CONCLUSIONS * Patients with AD were able to undergo colour perception testing for colour naming, colour discrimination, colour preference and colour/form memory. * Despite great differences between the study populations included considering visual and cog- nitive function, age distribution and frequency of dementia, their results follow the same pattern in all four aspects of colour perception. * Discrimination of small variations between. colour samples was better in the red and yellow areas compared to blue and green in 80- and 95-years of age and for individuals suffering from AD. * Variation in lightness was the eritical factor in successful discrimination between colour samp- les despite the colour area.* Colour naming was better for elementary colours than for mixed colours both in 80- and 95-years of age and when suffering from AD. * Colour naming showed a gender difference in 80-year-olds but not in the other groups. * Ranking colours in order of preference was relatively stable both in 80- and 95-years of age and when suffering from AD and in congruence with reports of younger age-groups. * Chromatic colours supported immediate recognition in contrast to retained recognition that showed more support from shape. * The 80-year-olds had an overall better result on all tests than the other two groups. The AD group had an overall better result than the 95- year-olds except for the recognition test. * Visual function influenced the result on colour discrimination and colour naming to some extent. Visual function showed an associa- tion with cognitive function. * Cognitive function influenced the results on discrimination and naming within all groups. When only including cognitive intact 80- and 95-year-olds, their results improved and the dif- ferences between groups decreased. The signi- ficant better result for the AD-group over 95- year-olds disappeared. * Within the AD group dementia grading according to MMSE scores had a si influence on the results ofall tests. When exclu- ding subjects with dementia diagnosis among the 80- and 95-year-olds their results improved but the somewhat better result for AD over 95- year-olds remained. + Ivis suggested that AD per se does not have a conclusive impact on discrimination, naming and colour preferences in contrast to recognition. + In addition itis suggested that at 95-years of age the complexity of declining function as to vision, 171 cognition and psychomotor speed altogether have a strong impact on discrimination and naming. * Finally it is suggested that the aspects of colour perception measured in this study should be considered in the care of the elderly to enhance visibility of their environment. PRACTICAL IMPLICATIONS Reduction in environmental pressure by modi- fication of the environment It is essential that the whole team working with the patient is aware of the impact of the environment upon the quality of care for the elderly. By doing so they may be instrumental in reducing some of the harmful effects of a negative design of the environment. The focus is on how to maximise the use of elderly people's capacities in the envi- ronment with the aim of finding a means to compensate for normal and pathological speci- fic loss of function in the individual. For examp- Ie, collaboration between architecture and nur- sing could be expanded when planning for new ns s0 as to promote a better unders- tanding of the special needs of these patients. Evaluation of the individual's personal compe- tence should lead to different approaches in order to adapt the environmental pressure and promote independent functioning. Colour in the environment in old age Implementing the results ofthe present study in the environmentof elderly people with a decline of visu- al and cognitive functions could prevent differences betwen their level of adaptation and the demands posed by their surroundings in line with the model (Lawton 1973), A more frequent use of contrasting colours are proposed in order to accomplish visual distinction in the environment, to support depth and spatial perception and to simplify object recog nition, Colours similar in lightness could be justa posed when the purpose is to camouflage and mini- mise attention, Shades of different lightness within the red and yellow colour area on the wals of the room could support spatial distinction. Coding and cueing presuppose a communication between the carer and patient based upon acommon opinion of. the concept (Lawton 1986). Therefor a moreRien frequent use of the elementary colours (blue, red, green, yellow, black and white) for codes and cues in the environment could be recommended in contrast to some of the mixed colours causing problems for a majority of the participants (tur= quoise, pink, orange and purple). Because a decli- ne in vision is often following old age, very dark ot light colours should be avoided as codes and cues since they seem to be difficult. Even though it was indicated that colour prefe- rences remain more or less stable throughout life and that colour and colour design were highly appreciated among the elderly, itis not possible ‘on grounds of this study to make any recommen- dations of a colour scheme from the aesthetic point of view. What can be concluded is that a colour design in environments for the elderly should take into account the colour preferences of the inhabitants. Based on the results of this study it is suggested that colour could be used to attract attention of cues in the environment of the elderly. To support recognition in the long run, the shape of the cue and its associations seemed to be more important. From this follows, that in order to make the elderly be aware of the cues they have to be com- municated between carers and patients, and they have to be clearly visible in the environment. ‘The colour praferencesf te elderly showed the same order as have ben reported for younger populations. This indica te tha elder’ preferences sbould be considered when buil- ding institution for this target group. International Academy for Design and Health Elderly persons have good ability to discriminate betzeen diferent colour shades pecially acording to lightnes d.f- ferences, These results cold be used t either to bighlight ‘important features inthe caring environment ofthe elder- Jy ly juxtapose colours ith diferent lghtnes factors, or by ‘using colours with the some lightness fact in order to camouflage certain ol jects in the environment The colour concepts expecially concerning primary colours ‘ere still very well knoan despite dementia. This should be taken into consideration oben using colour codes.References Anter KE. What colour isthe red house ? Perceived colours of painted facades, Doctoral Thesis, The Royal Institute of Teclnology, Stockholm, 2000. Antonousky A. Unraveling the mystery f bealtb. How pecple manage stress and stay well. London: (Jossey-Bass Publishers, 1987. Baksi A, Cradock S. what is empowerment ? IDF Bulletin 1998; 3 (45): 29-31 Barbosa da Sifoa A, Andersson M. 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