Should you use images in dementia-friendly writing?
Introduction
When we’re talking about writing information that’s accessible to people living with dementia, it may seem obvious to include images. After all, use of images is generally thought to improve accessibility. It’s often recommended in Plain English and Easy-to-Read guidelines.
Images can definitely be helpful in many cases. BUT with dementia, it’s not always so straightforward. This is because various forms of dementia affect visual perception in a number of ways. It becomes harder to interpret what symbols mean. Some people can no longer remember the meaning of symbols that we might assume are very common.
In this article, I’m going to briefly explore the use of icons and symbols in creating dementia-friendly written information. I’ll outline some tips, consider some potential problems, and provide links for further reading.
Background
A lot of the research that has been done on icons, symbols and images relates to using symbols in everyday life, in the ‘lived environment’. There are some fascinating studies around dementia-friendly design. Chatting with people living with dementia suggests that similar issues, benefits and challenges exist when images, icons and symbols are used in written information.
In fact, here in the UK we do have a British ‘standard set’ of recommended Public Information symbols, known as BS8501:2002. But are they helpful for people living with dementia? A fascinating 2016 report by Studio LR on behalf of the Life Changes Trust, concluded that:
“There would appear to be a potential need to develop a ‘new and improved’ set of symbols that are ‘dementia friendly’. It was apparent that certain symbols were not easily comprehensible or recognisable for those living with dementia.”
(Inclusive symbols for people living with dementia, Life Changes Trust, 2016)
So, should we use images, icons and symbols in dementia-friendly information? Here are seven tips and things to consider:
1. Relevant, not just decorative
Diagrams and pictures can definitely be helpful, but they shouldn’t be used just for decoration. Having too much on the page can become confusing, so it’s best to stick to images that are clearly relevant to the written information.
2. Photographs not cartoons
Use photographs rather than cartoons. Cartoons can seem childish or patronising (and people living with dementia are already subject to plenty of that!) Cartoons can also be harder to interpret. A study participant quoted by the Alzheimer’s Society described it like this:
“[Using images] can be helpful - but not using cartoons. The classic one is the coffee cup for when we’re due to have a break in the meeting. I find myself wondering ‘is that a duck?!’. Photographs of actual places and things work much better for me than cartoons’”
(Tips for Dementia-friendly Documents, 2023)
3. Be aware of visual perception challenges
As the example above shows, dementia can affect visual perception. The occipital lobes at the back of the brain process visual information. If they become damaged, a person may find it harder to work out what they can see in front of them. The brain’s temporal and parietal lobes are involved in recognising faces and objects, and in judging distances. If those lobes become damaged, a person with dementia may find it harder to recognise faces or objects.
You can see how this would make it harder to recognise and work out what images and symbols are trying to convey.
4. Literal interpretation
British Standard symbol for a unisex toilet
Some people living with dementia find that their interpretations of the world become more literal. A symbol that most of us have known for many years is the male/female symbol representing a toilet.
The same Studio LR report mentioned above describes a study participant who interpreted this sign more literally as showing a woman and man with their heads knocked off. And that’s true – that’s actually what the sign shows. The symbols are no longer paired in the person’s mind with the idea of a public toilet, but are perceived more literally.
Another participant in the study commented on the well-known lift (elevator) symbol pictured below. “Only three people can get into that lift”, they said. Again, a totally logical interpretation.
British Standard symbol for a lift (elevator)
If that happens with symbols that we generally consider to be very familiar, you can imagine how difficult things become if we start using more stylised versions, such as those below, or simply using M and F on the toilet doors, for example!
5. Culturally appropriate examples
Using culturally relevant examples is a whole topic in itself and there are plenty of resources online for exploring this subject further. Many signs are now quite international, but not all. People living with dementia can find that over time images from their ‘home culture’ are more familiar and easier to interpret.
For example, in the nursing home where my mum lives here in South Wales, the appropriate sign on the dining room door is a picture of a plate full of food with a knife and fork on each side of the plate. My mum has travelled during her life and eaten many different kinds of food in various countries, but this is her ‘home culture’ recognised symbol and she can still interpret it.
Chatting with my friend Kimie, whose own mum lives in a care home near Yokohama in Japan, the comparable picture there shows a bowl of rice and a pair of chopsticks. Kimie’s mum has always preferred Western-style food, she tells me, but the rice bowl symbol is that one that she associates more readily with meals nowadays.
6. Images with text
Make sure that pictures or symbols are placed close to the text they’re describing. Always use images in addition to written text, not instead of it. People’s experience of living with dementia various enormously. By using both images AND text you’re making your information accessible to a wider group of people. Add clear labels to the images when you can to help people interpret them.
7. Don’t put text on top of images
Finally, don’t overlay pictures with text. Put down those complicated graphics templates! Although they may look visually interesting, laying text over images makes the pictures harder to interpret and the text harder to read. If you do need to put text over an image, set the text on a solid background.
Conclusion
This is by no means a comprehensive guide to using images in dementia-friendly written information. There is lots more work to be done in this area, particularly as it relates to on-screen reading and design. However, I hope it supplies some background to understanding the challenges involved and some useful tips to help you make your writing more accessible to all.
BIBLIOGRAPHY AND FURTHER READING
Inclusive symbols for people living with dementia (no date). StudioLR. Available at: https://static1.squarespace.com/static/5f58d174b8a3597ec9c2927e/t/5f86fefbecd3186dae226552/1602682625141/inclusive+symbols+report+(dementia_friendly)_12.16.pdf (Accessed: April 11, 2023).
Aikman, A. (2022) Signage & wayfinding, Dementia Services Development Centre. Dementia Services Development Centre. Available at: https://www.dementia.stir.ac.uk/newsblog/signage-and-wayfinding (Accessed: April 11, 2023).
Tips for dementia-friendly documents (2023) Alzheimer's Society. Available at: https://www.alzheimers.org.uk/dementia-professionals/dementia-experience-toolkit/real-life-examples/tips-dementia-friendly-documents (Accessed: April 11, 2023).
Trisnawati, S. and Sriwarno, A.B. (2018) Visual perception of the depiction of human figures in pictorial signage of public toilets, Visual perception of the depiction of human figures in pictorial signage of Public Toilets. Available at: https://www.tandfonline.com/doi/epdf/10.1080/23311983.2018.1553325?needAccess=true&role=button (Accessed: April 11, 2023).
Writing dementia-friendly information - deep (2013). The Dementia Engagement and Empowerment Project. Available at: https://dementiavoices.org.uk/wp-content/uploads/2013/11/DEEP-Guide-Writing-dementia-friendly-information.pdf (Accessed: April 11, 2023).
