Living Better With Alzheimer’s Thanks to a Village Square, a Garden and Autonomy

Specially designed spaces allow people with dementia to live freely—and could slow their decline.

When Therese Jeffs used to visit her mother’s nursing home, she often found her once-loving and adventurous parent with her face screwed up and her body rigid with tension. Because her mother, in her 80s, had lived with dementia for years, she was no longer able to verbalize her emotions or even her pain.

But when she moved to a new facility built to resemble a small village, her demeanor changed dramatically. At the Care Village, a campus of white clapboard houses on the shores of New Zealand’s Lake Rotorua, her body language visibly relaxed as she spent hours in her shared cottage’s living room, listening to opera or Vivaldi’s Four Seasons. “They played the music she liked, and she would sit there, foot tapping and hands flowing,” Jeffs says. “She wasn’t able to articulate how she felt, except when you looked at her and you saw how she was, you knew she was happier.”

Jeffs’s interest in her mom’s well-being wasn’t only personal. As the village’s chief executive officer, she’s been involved in every detail of the residence, which is designed to care for people suffering from various stages of dementia. The facility is one in a growing number of communities around the world experimenting with models of care that encourage a sense of autonomy and accomplishment. The concept is resonating as societies grapple with aging populations, raising fundamental questions about what care for Alzheimer’s disease and other degenerative disorders should look like and whether the traditional nursing home model is outdated.

“We said, ‘What do we have to change to make this more a home?’” says Jannette Spiering, one of the founders of the village concept, first conceived in the Netherlands. “How could we create a community where you can go on with your life?

The answers can’t come soon enough. By 2050 the number of people living with Alzheimer’s will almost triple to an estimated 153 million. Japan, a country where the elderly already make up almost a third of the population, is working to ensure people can stay at home as long as possible by training social workers, as well as store employees and ordinary citizens, to engage with and talk to people with the disease.

The village concept takes that further by re-creating the real world within a safely enclosed space. In New Zealand, six or seven residents share a house. They can shop for groceries, cook with others and do their laundry with support from staff taught to empower them, rather than do chores in their place. They can also meet friends at the cafe, stroll along the lakeshore or do some gardening.

Another village in the South of France, outside the old spa town of Dax, is conducting research into whether such liberties can lessen some Alzheimer’s symptoms and, if so, how. If scientists at Village Landais succeed in demonstrating that the holistic model can slow cognitive decline, it could lead to a different approach for dementia care at a time when much of the medical community and public have pinned their hopes—and financial investments—on new but so far largely ineffective drugs. “Here you are making people better not by giving them medication but simply because the environment is nicer,” says Paola Barbarino, the CEO of Alzheimer’s Disease International, an umbrella organization of dementia associations with no financial ties to any of the villages.

The concept isn’t without its detractors. The main criticism is that residents are trapped in a make-believe environment. (The village creators argue that they had to come up with a way to replicate the freedom residents can no longer safely enjoy in the outside world.) Nor are they cheap to build, but proponents say they are less expensive to operate than nursing homes.

The French village, with 120 residents, cost $30 million (28.8 million euros) to construct. Building a nursing home in the same region with a similar number of beds is about $10 million less, according to Mathilde Charon-Burnel, a spokeswoman for the local region, Les Landes. The maximum monthly price for village residents without any state or regional financial aid is about $2,000. With subsidies, that can go as low as $250 a month. A private room in a US nursing home, meanwhile, costs about $9,000 a month, according to the Alzheimer’s Association.

Jeffs says the New Zealand village cost less to run than the residence it replaced because it’s more flexible and there’s less staff turnover. “We’re able to be more responsive to residents’ needs,” she says. “If someone became unwell during the day, and the house needed more care, we could easily bring in someone and people will do it. If you’re running an institution, you’re running a roster that’s very set. You give everybody breakfast at half past seven, you make every bed at 8 o’clock and everybody gets showered at half past eight.”

The pilot project in France launched in the middle of the pandemic. People mill about the town square and stroll down walkways covered by vaulted arches, or they stop to chat in front of the supermarket. Others play Scrabble outside the cafe. A few people in the village ride bikes, but it isn’t clear if they are patients, doctors or volunteers because staff don’t wear uniforms. They may even be visitors, because locals are welcome to enter the village to have lunch at the restaurant or get a haircut at the salon.

On a sunny autumn day, a group of residents quietly flows through their exercise class on park benches, under the curious gaze of Jasmine and Junon, two docile resident donkeys. Other villagers—no one uses the loaded word “patient” here—gather in the cafe’s back room for a singalong. Some of them can walk, a few require a wheelchair. Most of them move around the 4-acre campus with a remarkable degree of freedom. The residents have individual rooms in one of the 16 houses scattered on the campus, which they can furnish as they wish. The architecture is intended to reduce frustration and confusion: There are no dead-end corridors, few mirrors and signs are depicted with simple images rather than words.

Volunteers blend in, becoming essential to the life of the community. “The way the village is set up is very serene, very calming,” says Florence Laudouar, who’s in charge of coordinating the volunteers. Some have found creative ways to contribute beyond the original responsibilities of bringing residents to the grocery store or helping out in the cafe. One started a regular discussion of current events, and another on astronomy.

Every six months, Helene Amieva, the lead scientist on the project, and her team meet with patients to evaluate indicators that include cognitive function, depression, anxiety and social participation. The results of the research should be available next year. She’s also investigating the effect of the village on families, staff and neighbors. That work is revealing that people’s perception of dementia has changed in Dax since the village opened. Locals are now less likely to perceive Alzheimer’s negatively, Amieva says, compared with a control group in Villeneuve sur Lot, a similar-size town three hours to the north that’s home to a traditional nursing home.

“We can hypothesize that if the person is better adjusted to her environment, better supported, that there is a level of well-being that brings out less anxiety and behavioral disorders,” says Amieva, a psycho-epidemiologist at the University of Bordeaux’s Population Health Research Center. “That indeed could slow the disease evolution.”

Spiering and her team in the Netherlands, working for a local elderly-services company called the Vivium Care Group, oversaw building the original Alzheimer’s village, which entailed tearing down a nursing home over several years and building in its place a typical-looking Dutch downtown: Streets and narrow alleyways crisscross clusters of brick houses and converge on a central hub with a restaurant, pub, theater and supermarket. Today doctors, nurses and dementia specialists allow villagers to set the rhythm of their day rather than impose a rigid schedule.

The Dutch village, known as The Hogeweyk, inspired Jeffs’s New Zealand project, and she retained Spiering and her team as consultants. They’ve since helped introduce similar communities in Australia, Canada, Italy and Norway. There are also villages in planning stages in the US, including one in New Jersey, Spiering says. The Hogeweyk features a mix of furniture and architecture that purposely differs from house to house. Some have heavy curtains, dark wood furniture and antique chandeliers in the living room. Others are airy and loftlike. Families are involved in helping pick the house that best fits each resident’s background and preferences, ranging from food to music, because familiarity lessens the fear and anxiety stirred by the illness.

Jeffs observed these differences first-hand when she traveled to the Netherlands in search for a new model of care. Her mother was going through the early stages of dementia at the time, and when Spiering and a colleague took Jeffs around the village, “one house I went into I just immediately thought this is so my mother.”

Applying that approach to the New Zealand village has led to some unconventional thinking. Some long-married couples, for instance, are placed in different houses despite having spent decades under the same roof. That’s because dementia tends to bring people back in time, Jeffs says. So if the pair experienced different economic levels as children, the one with the far more modest upbringing, but who became wealthy in adulthood, is likely to feel more at ease in simpler surroundings. For one such couple, their routine includes the husband walking over from his house to his wife’s for lunch.

A scientist studying the New Zealand village found that people who moved there from a more traditional nursing home were generally less agitated and required fewer antipsychotic medications. The environment, says Kay Shannon, a senior lecturer at the Auckland University of Technology’s nursing department, has also altered staff practices and attitudes about dementia.

Jeffs cites the example of a Care Village resident who used to be an accountant and auditor, and who regularly shows up at the reception desk to check lists there. Now the staff have created lists for him to look over, and they thank him for his contribution. “We validate the residents’ reality, because their reality is not our reality,” Jeffs says. “I don’t believe that we are creating a false world. We are actually walking into their world.”