On a press tour of Appleby Blue, a new social housing scheme (or almshouse) for older people in South London, U.K., many of us journalists ask when we can move in. And we’re only half-joking. There’s a roof terrace replete with seating nooks; generous use of warm timber and brick; a sun-filled central courtyard with gingko trees and a serene water feature; and a glazed, terracotta-tiled walkway on each floor that features seating, plants and windows that open to let in sun and fresh air. In fact, apart from the walk-in showers, wheelchair access and alarm service — all designed to ensure it can safely cater to residents’ changing physical and cognitive needs — Appleby Blue is not only the opposite of an institutional building but also a genuinely intimate and elegant one. “You have to set out with [good design] as a key ambition,” explains Stephen Witherford, a co-founder and director at Witherford Watson Mann, the architecture practice behind the design, “and find that balance between keeping everybody safe and fighting for joy in people’s lives.”

Though Appleby Blue (a joint venture among local charity United St Saviour’s, Southwark Council and developer JTRE) doesn’t cater specifically to dementia, it does have some residents experiencing early-onset cognitive decline. It’s part of a growing movement to deinstitutionalize elderly and dementia care away from the exclusive domain of medicalized senior homes: Around the world, new models for housing and comforting the aging are emerging, including intergenerational homes and even entire villages for those with dementia. The latter, whether rendered in nostalgic or sophisticated form, are designed to allow residents to be active, mobile and socially engaged with each other within the safety of an enclosed community.

Altogether, these nascent options represent a paradigm shift in providing better care — as well as the possibility for entirely new architectural typologies to facilitate that care — at a time when we’re living longer and becoming more susceptible to neurodegenerative illness. From 55 million in 2020, the number of people with dementia globally is expected to reach 78 million by 2030 and 139 million by 2050.

Among the first (and perhaps still most widely discussed) examples of a dementia village is De Hogeweyk, located some 32 kilometres south of Amsterdam in a little town called Weesp. Opened in 2009, and based on a concept that grew out of a pilot project in an existing care home, it focuses on small-scale living and includes village-style amenities such as a supermarket, a café, a hair salon, a restaurant, physiotherapy and a theatre. Its 27 houses each accommodate six or seven inhabitants alongside live-in and external care staff. The houses come in four lifestyle categories — traditional, urban, formal and cosmopolitan — so that residents ideally end up with like-minded housemates. They can participate in the running of the household and help with  cooking, should they wish to, or have meals at different hours.

De Hogeweyk went on to influence many subsequent projects around the world. One of the best, architecturally, is the Village Landais Alzheimer in Dax in southwestern France, which opened in 2020. It was inspired by De Hogeweyk, says Morten Rask Gregersen, a partner at Copenhagen-based NORD Architects and lead designer on the project, but the setting is less dense and urban, and the client decided against an obvious theme for the housing. “The emphasis was instead on vernacular architecture,” he explains. “We started by looking at local materials, climate and traditions to make the architectural component work as a means of dialogue between the place and the person with dementia. The idea was that as you lose your cognitive abilities, you should be in an environment where you are able to read the physical context as easily as possible.”

In practice, this meant creating four neighbourhoods with houses for seven or eight residents each, connected by an “urban street” that leads to a central square reminiscent of the medieval bastides or villages in the region. Here, residents can find a grocery store, a hair salon, a restaurant, a media library, an auditorium (open to outside visitors, too) and healthcare facilities. There’s a major emphasis on nature at Village Landais: Five hectares of landscaped park unfurl with shaded patios and concrete colonnades designed to allow residents to enjoy the outdoors whatever the weather and move “seamlessly from inside to outside.”

NORD has honed its design methodology in multiple elderly care projects and outlined it in a study called “Healthy Ageing.” For Furuset Hageby, an Alzheimer’s and dementia village in Oslo that the firm just completed in collaboration with Norwegian practice 3RW Arkitekter, the architects adapted to a more confined and sloping site and much colder climate by designing a cluster of buildings linked to each other and to two rooftop gardens by a green circular trail. “Instead of the individual homes we have in Dax, it’s a kind of continuous building subdivided into two loops but still with a row-house typology. Each loop has a courtyard.” Here, too, shared amenities abound at the heart of the village, both for residents and visitors from the local community.

As the dementia village typology gains traction, critics have weighed in on what they perceive as the artificiality of these settings and their “pretend” amenities. Some are modelled after old-fashioned town squares, with clapboard facades, front porches and street lights that come on in the evening; some villages have shops that use fake money, others have faux post offices. An e-flux article from 2021 likened De Hogeweyk to The Truman Show, arguing that it represented “an urge to camouflage serious illness” and “illustrated the ongoing power of the ‘village’ trope as a caring environment.”

For Eloy van Hal, one of the three founders of De Hogeweyk, many critics harbour generalized or even misinformed notions about these places a d haven’t actually visited them. They are unfamiliar with how different villages may diverge in terms of medical care models, philosophies and oversight. “Moreover, they don’t seem to ask themselves how artificial traditional nursing homes are,” he says. De Hogeweyk, for the record, has no fake bus stop, post office or sets; a rebuttal on the village website states that all the people who work there — be it the nurse, the hairdresser or the handyman — are using “their professional skills to actually support the residents and are, therefore, certainly not actors.”

Gregersen argues that what might seem artificial to the non-resident can make sense and even help the person with dementia. The props and prompts, also known as “simulated presence therapy” and used to evoke “reminiscence” worlds, are in fact designed to soothe residents and reassure them life is as it once was. NORD is envisioning the Willow Valley Memory Care Center in Lancaster, Pennsylvania, a 2.86-hectare village for people with dementia that will have a town square, a mix of indoor and outdoor spaces and a brain technology centre where visitors can learn about dementia and the healthy eating and lifestyle habits that can reduce the risk.

And on a recent trip to the U.S., Gregersen heard about a real train being used in a memory care unit. People with dementia, after sitting inside it, started speaking for the first time in months. At his Village Landais in France, the library also features a single train car with luggage racks and a screen that displays the view from a train as it makes its way through a forest. Some of the residents who have gone on this simulated journey have articulated specific worries that they were previously unable to. “At that point, I don’t care if it’s an artificial train and not a real one, because that person experienced something that allowed them to communicate again. How can I be opposed to that?”

The greatest weakness in any criticism of these places is the inability of the critic, presumably at the height of their mental capacity, to put themselves in the mind of someone with a neurodegenerative disorder — someone whose tethers to time, loved ones and the physical world at large are becoming increasingly frayed. Typical care scenarios are aimed at constraining their movements so they don’t run off or otherwise inadvertently hurt themselves; the wall or fence, and its connotation of isolation, that so many critics decry in dementia villages, exists in traditional settings in the form of often exhausted caregivers who must control their loved ones’ unpredictable behaviours 24/7, and facilities where automatically locked doors preclude any notion of liberty for patients.

Many architects and experts working in this area speak about breaking the stereotypes and stigma of dementia and creating places that offer freedom of choice and decision-making, opportunities for socializing and the ability to move around freely and safely. Van Hal puts it this way: “Yes, people living with dementia need professional support to live their lives as normally as possible, but they are still able to do a lot if we allow them to.”

This approach is backed up by research and the experiences of people on the ground. Sebastian Crutch, a neuropsychologist and a professor at the Dementia Research Centre at the Institute of Neurology at University College London, specializes in rare and early-onset dementias, especially posterior cortical atrophy (or PCA). The condition can often be misdiagnosed, as it presents in visual ways that people don’t associate with the disease. The experiences of people with PCA, who can still communicate clearly, can help to understand some of the visual challenges that someone with the more typical memory-led dementia will likely experience later in their condition as the disease spreads to other parts of the brain. And they demonstrate that cognitive function is part of life — not all of it. “Patients are left with many abilities,” says Crutch. “The focus is shifting from ‘These are people who need to be cared for’ to ‘These are people who can be involved in their life, in their care and in supporting each other.’ ” If you apply this understanding to designing spaces for people with dementia, it means foregrounding the sensory abilities people still retain in order to help them move around and interact with the world.

To this end, the Rare Dementia Support service, where Crutch is the clinical lead, is fundraising alongside the National Brain Appeal charity to build a rare-dementia support centre in two existing townhouses in Central London. Its ethos will be similar to the renowned Maggie’s Centres, which support people with cancer, and likewise feature a large central “kitchen” table, as well as meeting rooms and lounges. “We want it to be somewhere that’s homey, where we can provide support but also carry out education and research,” says Crutch.

Down to the level of detail, the support centre will cater to people with different types of dementia. “For example, a shadow across one’s path, something that may not bother you or me, can be perceived by someone with PCA as a step or a hole. So, thinking about things like lighting, and not just the amount of light but the positioning of that light against other objects in the space, will be really important for us.” Colour contrast is also critical. “The partner of someone we were working with changed the toilet seat in an all-white bathroom to red and it literally made the difference between their partner being able to use the loo on their own and not.” But it’s not all about perceptual acuity. For people with language-led dementias, it may be difficult to hear speech in a noisy environment or understand where it’s coming from. “We are thinking about how to design rooms in which eight or 10 people can have meaningful conversations.” If completed on schedule, the townhouse support centre will open in 2025.

In the meantime, the dementia village model has made its way to North America. Elroy Jespersen, a former senior home living executive, opened Village Langley in British Columbia, Canada’s first dementia village, in 2019. It will be followed by Crossmount, in Saskatoon, by Duncan McKercher and Heike Heimann, a pair of local developers championing a  deinstitutionalized model to give seniors the best of what living in largely rural Saskatchewan has to offer. Crossmount’s first neighbourhood, which will have 80 independent homes, is in its final stages; the site has municipal approval for 300 independent homes in total, plus approximately 500 additional multi-family-style units (condos, apartments, and supportive and care facilities).

While they don’t yet provide dementia-specific accommodation — they’re working on it — the houses are all equipped with built-in safety features that will come in handy as residents’ health needs change, including the onset of dementia. Monthly fees for living in a dementia village are higher than traditional care-home fees, so McKercher and Heimann had applied for a government offset that would help extend access to those of lower economic means (and in order to de-risk the project). After 18 months of trying, the pair have all but given up and are now pivoting the concept to be able to move forward regardless of government support. “Presenting anything new and innovative to government has its own challenges,” says McKercher. “The tendency is to fall back on old-style methodology.”

An important feature of Crossmount, like the models aforementioned, is its social element. There are outdoor community garden spaces, an events venue and the Arts Barn, which houses a small country restaurant, prairie market and cheese production facility. Both this space and the on-site cidery — with its indoor tasting room and outdoor patios with views to pear and apple orchards — have proven popular with local seniors and residents. A care and living facility needs to tread that fine line between safety and joy.

This and what NORD’s Gregersen describes as “trying to keep it as real as possible for as long as possible” are the twin tasks of the designer working in the realm of a dynamic and constantly changing disease. Van Hal, the De Hogeweyk co-founder who started it all, concurs. “Too much of looking after older people with dementia focuses on the things that could go wrong, but things can go wrong for the rest of us too. If we as care providers and regulators try to remove all risk, we also take away life.” These newer housing and care models for dementia aim to give a great deal of that life back.