Give me a sign: Concrete symbols facilitate orientation in Alzheimer’s disease dementia

Why does this study matter?
People living with dementia frequently become disoriented in unfamiliar environments despite signage. Signage systems are the primary navigational and wayfinding approach used within healthcare settings. While previous studies generally support using pictorial signage with high contrast, the optimization of signage for people living with dementia would benefit from more empirical studies.

How was the study done?
The researchers conducted a controlled comparative study, designed to assess the impact of different types of signage on the speed and accuracy of sign interpretation by people with Alzheimer’s disease dementia (ADD). In addition to vision, extensive neuropsychological testing was performed to control for subjects’ global cognition, episodic memory, semantic memory, attention, executive functioning, working memory, and spatial comprehension abilities. The research team used an experimental “real-life environment” setting where subjects could simultaneously view three identical dummy doors fitted into a neutral wall from a distance of approximately 17 feet. Distractor signage was placed on two doors and restroom signage was placed on a target door at eye level using magnetic strips. Restroom type signage was selected as the target signage because it was deemed the most commonly used signage in public and clinical environments. Target signage symbols included one pictogram recommended by the International Organization of Standardization (ISO) and three pictograms that were adapted for dementia: a 2D frontal view, a 2D profile view that included a person, and a 3D view. These single-coded pictogram signs were compared with double-coded signs that included the same pictograms plus written information. The eight target signs and sixteen distractor signs all used black wayfinding information on a white back ground. Participants were instructed to “find the sanitary facilities as fast and accurately as possible.” Speed was measured by the time it took to open the door divided by the baseline speed under consideration of distance to target door. Accuracy was measured by the correct or incorrect door opening.

What do we learn from the study?
The effects on reaction times and errors were quantitatively evaluated to describe the interaction effects as well as the relationship between sign comprehension speed and accuracy and neuropsychological test performances for each group separately. Persons with Alzheimer’s disease dementia showed statistically significant increased speed with the optimized signage that included a profile view and person. Persons with Alzheimer’s disease dementia had significantly higher error rates than the control group in the single-coded condition, but the comparison groups did not differ in the double-coded condition.

Can we say the results are definitive?
By virtue of the study being conducted in an experimental setting, there are inherent limitations, such as the size, color or distance of signage being different in practical applications. There is also the possibility that non-restroom signage could be more complex to understand. As with any study with a small sample size that focuses on a single sample type, it can be difficult to make broad generalizations. I would, however, like to note that the number and types of neuropsychological tests that were performed should serve as a model for other research investigating the visual interpretation and comprehension of individuals living with Alzheimer’s disease and other dementias.       

What’s the takeaway?
We know that built features within healthcare environments can positively influence infection control, recovery, activity levels, well-being and overall satisfaction. This study demonstrates that by actively engaging individuals with Alzheimer’s disease dementia, orientation and wayfinding can also be improved through dementia-supportive signage.

Summary of:
Boedeker, S., Driessen, M., Schulz, P., Beblo, T., Kreisel, S., & Toepper, M. (2023). Give me a sign: Concrete symbols facilitate orientation in Alzheimer’s disease dementia. The Journals of Gerontology: Series B, Volume 78, Pages 1269-1277. https://doi.org/10.1093/geronb/gbad041

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