The Principles of good signage design

Use of colour

A constant question asked is what is the most dementia-friendly colour? A decade ago, the consensus (including that of academics) was that primary colours worked best. These days, we are more focused on ensuring a good colour contrast. This can either be achieved by using shades of colours (i.e., light blue and dark blue), which is quite straight forward, or by combining colours using light reflectance values (LRVs) which is more complicated.

All colours are on the LRV scale (Low Reflectance Values) and for a person with sight impairment to successfully differentiate between two contrasting colours, there must be at least thirty points of difference. For example, a shade of red with an LRV of 40% would look the same as a shade of green with an LRV of 40%. A shade of red with an LRV of 30% with a shade of green with an LRV of 70% should provide a marked contrast.

The only exception to the use of colour contrast is when deciding on the colour to use for toilet door signage. Unlike other areas of a care setting, if a person with dementia needs to use these facilities, time is of the essence and therefore the signage should be bold, extremely easy to see and different for all other signs.

It is therefore a recommendation to use red or yellow, based on scientific evidence, as these are the colours we recognise for longer and the ones we see from farthest away. Red is also the first colour that we learn in life and the last colour that we lose in life, and therefore many opticians and audiologists are designing glasses and hearing aids in red. In a care home setting, red works very well, but in an acute hospital setting for example, yellow would be a preferable colour as fewer people using the facilities will have dementia and may be confused using red. Yellow is an accepted colour for signage in general but also widely used to support the blind and partially sighted.

Shape

Shape can be another good clue in helping to identify a specific sign, which is particularly important for ones such as the Toilet. For those with sight impairment the shape, along with use of a primary colour can make a significant difference.

Font

We learn to read and write using upper- and lower-case letters and scan rather than read every word. Could you imagine how long it would take to read a novel if we had to read every single word? Capital letters have no shape and therefore have no recognisable features. THIS IS SOMETHING THAT IS OFTEN OVERLOOKED WHEN TYPING NOTICES AND PEOPLE DO NOT READ THEM AS THEY GET BORED AND LOSE TRACK OF THE MESSAGE “HIDDEN” WITHIN IT

Images

Dementia affects people in different ways and at different times along their pathway.  Some people can read, some identify with colour and others need images to identify the purpose of rooms and maintain their independence. The use of images is also very useful for people where English is a second language, for those who have reading difficulties, for some with learning disabilities and for some younger children.  Whereas using only an image could appear patronising, when used with all other prompts, they help create a user-friendly orientation aid.

Materials

This is often where there needs to be compromise between the need of the service user and the aesthetically pleasing look some care providers wish to achieve. Many “signs” have a gloss finish, which may look upmarket and give a more “hotel” feel to the environment, however it can also cause issues with vision and perception. Light reflecting on glossy surfaces can make wording difficult to read and images difficult to identify. This can cause confusion, agitation and potentially distress. To take it even further and give you a clear understanding of the need to get this right, increased levels of distress have proven to increase the risk of falls and incontinence episodes and therefore the need for more pain management, medications, hospitalisation and ultimately a reduction in life expectancy.

Positioning

Finally, the best sign in the world will not work if it is positioned incorrectly. The ideal height for a sign is 1.2m-1.4m above the ground. Higher than this will be out of the line of sight of most people with dementia and therefore give no orientation support at all. If necessary, position signs at a lower level so that residents that are frail will be more likely to be looking down towards where they are walking so will still see them.

Looking at the “signage” rather the “sign,” what can you expect to achieve by putting the right messages in place?

  • A reduction in agitation and distressed behaviours (as the environment is easy to navigate and recognise)
  • A reduction in slips, trips, and falls (easier to navigate to a destination and reduced agitation leads to fewer lapses in concentration and subsequent incidents)
  • A reduction in incontinence episodes (the toilets are easy to find – and use)
  • Promotion of independence (less reliant on others)
  • Promotion of confidence (more likely to engage with the environment and socially interact with other people if they can navigate familiar surroundings)
  • Promotion of independence and dignity (opportunity to live well, making own choices, which is, after all, a human right – something too often not considered in care settings)
  • Increased nutrition and hydration (increased activity improves appetite and reduces the risk of UTIs)

Developing your full signage strategy

It is often easier to think about your strategy in sections:

Toilet areas

Ensure all toilet door signs display the same sign that is highly visible. If the facilities are located down long corridors and not easy to see, I would also recommend the use of Toilet flag signs

Once a person can find and use the toilet, they are less likely to have incontinence episodes, become agitated or be at an increased risk of falls. they are also more likely to have a good appetite and therefore maintain good levels of hydration and nutrition, meaning they can engage more safely with the environment.

For a person living at home with mild symptoms of dementia, all closed doors will look the same and it can be incredibly frustrating from someone trying to find the toilet. The agitation and distressed behaviours that can result from not feeling in control in this situation can be misinterpreted as a symptom of the dementia taking its course and lead to the use of unnecessary medications to calm a person down. However, it is more likely to be fear of losing control, feeling lost in their own home, and needing help that has prompted the strong reaction. A simple sign can enable a person to find the toilet unaided and manage their own personal care and hygiene for longer.

If you have bathrooms and shower rooms that include toilets, it is the toilet sign that should be used as it is highly unlikely that a resident would be taking a bath or shower unaided. Bathrooms and shower rooms that do not include a toilet should be in a totally different colour to avoid confusion and unnecessary agitation.

The doors leading to en suite facilities should also be easily identifiable by the consistent use of the recognisable Toilet sign. Often the toilet door and door to the corridor look identical so residents need optimum opportunity of locating the facilities quickly to prevent incontinence, particularly at night.

When looking at toileting, we must ensure that we look from the person with dementia’s viewpoint rather than our own. As a person with dementia moves into a communal living area such as a care home, they will fall under the DOLS (Deprivation of Liberty Safeguards). This regulation is in place for their safety and unfortunately does means that most external doors and some internal doors will be locked. The person with dementia may start to associate every door as being locked whenever it is closed, and we must find ways of managing the increased levels of agitation and distress this can cause. The Toilet door sign is a clear navigation aid to get into the correct room, but for those affected by the fear of locked doors, it is important that we ensure the person can also identify the exit too. Research has shown that installing a Toilet exit sign can encourage independent use of the toilet, resulting in reduced incontinence episodes and reduced levels of distressed behaviours.

 

Communal areas

Ensure residents can identify each room and understand the purpose of it. The first step to achieving this is to install an appropriate sign on the door, i.e., a Dining Room sign should include an image of food. The colour of the signs is less important than I have stressed for the Toilet signs. Residents have time and are far less likely to become agitated when looking for a lounge or dining room. Depending upon the care facility, the recommendation would be either to use one colour for all communal doors or alternatively link the colour of the door to the décor inside the room. This can work particularly well if you have more than one Lounge. Either option will work well, but please ensure it is different to the Toilet to avoid confusion.

Staff doors and treatment areas do not need signage to stand out as this will draw attention to locked doors and in some facilities, they have been disguised or camouflaged to blend with the walls. However, using a low contrast coloured door sign helps staff with orientation and for those residents who are searching for somewhere and find a locked door, the sign helps them to understand it is not an area that holds any interest for them, and this can reduce agitation.

For someone living at home, a removeable sign attached to the back of the external door stating “Do not go out, it is night-time” with a picture of the moon could help. Of course this would need putting in place in the evening and removing early the next morning to ensure the person doesn’t feel trapped during the daytime.

In an ideal setting, kitchen units would have glass fronts and open shelves to enable a person with memory problems to find things easily. However, in a standard kitchen, cupboard and drawer signage can help maintain independence

Bedrooms

Although there are many ways of helping residents identify their own bedroom, a well-designed dementia sign is undoubtedly one of, if not, the best. These signs need to be personalised and always maintained to ensure that they are appropriate to the service user. Signs should of course say Bedroom and incorporate an image of a bed. There should be a space into which to insert the person’s name (using capital and lowercase letters) and ideally the name they recognise. The correct name is essential for both the resident who will recognise it, but also for carers who will know how to address the individual. As many care facilities use agency or bank staff, being able to use the correct name helps to build an immediate rapport.

The resident may not recognise the carer due to aphasia, but if they have a nice smile and use their correct name, have the right approach, then they will be more likely to feel safe.

Pictures are very important on the bedroom signs but must be used with care.  Remember as a person travels along their “dementia pathway,” memories change. The picture must be one they recognise and over the years may well need updating to match their timeline.

 At the age of forty you would not recognise yourself at aged sixty. Wedding photographs are extremely popular as “usually” hold lots of good memories. An unfamiliar photograph on a door could have the reverse effect of stopping someone feeling comfortable entering their own room. There is another benefit to using bespoke bedroom signs too. Some residents will go into other bedrooms and may take things that do not belong to them. Clear identification of personal bedroom spaces is proven to significantly reduce this, however as everyone is different and affected by dementia in diverse ways, there is never an absolute guarantee of privacy, so care is still required

Something as simple (but effective) as a bedroom sign can go a long with the changing the culture of some care facilities and choice (a human right) starts to play a larger part in someone’s care planning.

There is no specific colour that works better than others, again this is down to the décor and layout of a home. A small home may simply use one specific colour throughout, whereas a larger home with a maze of corridors may choose to colour coordinate areas

Directional signage

Keep this to a minimum as they could potentially cause confusion. People living with dementia may not recognise an arrow, but certainly when used they should be at the correct directional side of the sign. An alternative to an arrow would be a pointing finger. If a person were able to ask for directions, the chances are the person giving the directions would use their pointed index finger to help direct.

Traditional looking street signs are recognisable features and can certainly help residents find their bedrooms. These signs are unique to the setting and something that would need a separate discussion to ensure that they are correctly positioned.

Extra care should be taken with signage to help visitors leave the building or unit. Some residents will have the ability to read and signs stating Exit or Way Out that lead to a securely locked door can increase agitation and cause distress. If you do feel these signs are necessary, consider using alternative wording such as Entrance or Reception and as with staff signs, keep them low contrast. Way Out signs can be useful in confusion settings where there is more than one door. Communal toilets are an example, particularly in public areas there may be several cubicles, a storeroom, and the exit. In these cases, a clear sign to mark the way out can reduce agitation and distress.

 

For many residents who live with dementia, their ability to communicate verbally due to aphasia is very restricted. High quality signage that is designed specifically for the people that you support is essential to ensure their continued ability to live with independence, confidence, and dignity.

Good signage can empower people to take control of their daily routine, making their own appropriate choices and live with a degree of independence.

Continuous assessment of signage in someone’s own home is particularly important and should be changed or increased specifically in line with their needs. If a person feels safe and content in their own home, can manage their own care with minimum support and without becoming distressed, they are much more likely to remain at home and not need full time care.