Outdoor Environments for People with Dementia

Susan Rodiek, Benyamin Schwarz

• Publisher: Routledge
• Year: 2013
• ISBN:
  9781135805753
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Learn how gardens and parks can be beneficial to residents Mounting evidence reveals that nature and outdoor environments provide individuals with dementia greater enjoyment in life, lower stress levels, and positive changes to physical well-being. Outdoor Environments for People with Dementia explores how fulfilling the fundamental genetically based need of human relationships with nature can improve the health and well-being of people with dementia. Top experts analyze current research and comprehensively examine how the design processes of gardens and parks can be closely connected to effective interventions. Evaluation tools for those with dementia are discussed, including studies of the impact of plants and outdoor activities on this population. Outdoor Environments for People with Dementia discusses in detail practical approaches that can significantly improve the quality of life for dementia victims. Research is discussed revealing important aspects and issues needing to be addressed when creating better outdoor environments that are effective in helping residents of long term care facilities and residential care homes. The text is extensively referenced and provides several tables, figures, and photographs to clearly illustrate concepts. Topics discussed in Outdoor Environments for People with Dementia include:

• the impact of outdoor wandering parks and therapeutic gardens on people with dementia
• empirical studies on how access to and participation in nature-related activities can benefit people with dementia
• interventions to restore people with dementia having directed-attention fatigue
• evaluation tools for gardens for people with dementia
• research-based design recommendations for future gardens
• theories and empirical studies about healing gardens
• training staff to increase their knowledge about horticulture and encouraging them to involve residents in outdoor activities
• general guidelines for developing an outdoor space
• examination of the attributes for the superior outdoor space found in Grand Rapids, Michigan, with design recommendations for the future

Outdoor Environments for People with Dementia is a valuable resource for scholars, policymakers, legislators, architects and urban planners, lending institutions, developers, landscape architects, and the lay public in general who have an interest in the subjectpersonal, professional, or civic.

PART I

Introduction:
Outdoor Environments
for People with Dementia

Benyamin Schwarz

Susan Rodiek

This volume is about people who are afflicted with dementia, about nature and outdoor environments, and about the relationship between them. There are special problems associated with providing care for cognitively impaired persons and support to their families; these problems are recognized by researchers, funding agencies and care providers. We view this collection of articles as a contribution to the task of expanding the knowledge base for the design of outdoor environments for people with Alzheimer's disease and other kinds of dementia. While we consider the outdoors to be essential component in the intervention efforts in dementia care, we have a complementary task to set limits on what are believed to be achievable goals in the care for this population. As Lawton and Rubinstein have cautioned us: “For a condition whose biological substratum is irreversible, it is tempting to foster unrealistic hope that is good for neither science nor families with an impaired person” (2000, p. xiv).

The first objective of the volume is to maintain the position in which empirical studies and direct observations constitute the foundation on which hope is kept alive. A second objective is to provide a basis for hope that recognizes the significance of connection to nature in any stage of dementia, and looks for favorable outcomes of intervention in the interactions between people with dementia and their outdoor environments.

ABOUT PEOPLE WITH DEMENTIA

According to a report released in March 2007 by the Alzheimer's Association, there has been a 10 percent increase in the number of people afflicted with dementia since 2002. The number of Americans with Alzheimer's disease is now more than 5 million, which supports the long-forecast dementia epidemic as the American population ages. One in eight people 65 and older have this mind-devastating disease, and nearly one in two people over 85 has it. Unless scientists discover a way to delay the onset of the illness, some 7.7 million people are expected to have the disease by 2030, the report says. By 2050, that toll could reach 16 million.

“The fundamental pathology of Alzheimer's disease is the progressive degeneration and loss of vast numbers of nerve cells in those portions of the brain's cortex that are associated with the so-called higher functions, such as memory, learning and judgment. The severity and nature of the patient's dementia at any given time are proportional to the number and location of cells that have been affected.” At the same time there is “a marked decrease in acetylcholine, the chemical used by these cells to transmit messages” (Nuland, 1993, p. 91). Patients with Alzheimer's disease experience high rates of non-cognitive, behavioral, and psychiatric symptoms that may include hallucinations, delusions, depression, physical aggression, pacing, wandering, and sleep disorders. The cause of the disease is still unknown and there is no known cure for it. Today's available pharmacological treatments alleviate symptoms only temporarily, and there is no evidence that non-pharmacological therapies can improve cognitive performance. At this point there are nine drugs in late-stage clinical trials, including a few that aim to slow Alzheimer's worsening (Associated Press, 2007).

Central to the ethics of dementia care is enhancing well-being and making the most of the strengths that are still present within the person. Stephen G. Post has suggested that “above all, we must recognize that the quality of life for the person with dementia is always partly subjective and is somewhat a matter of emotional adjustment facilitated by interactions and environment” (Post, 2000, p. 94). Compelling advice to caregivers was presented by Nancy L. Mace and Peter V. Rabins: “Since dementing illnesses develop slowly, they often leave intact the impaired person's ability to enjoy life and to enjoy other people. When things go badly, remind yourself that, no matter how bad the other person's memory is or how strange his behavior, he is still a unique and special human being. We can continue to love a person even after he changed drastically, even when we are deeply troubled by his present state” (1999, p. 12).

Lawton (1983) described four components of quality of life: perceived quality of life, behavioral competence, objective environment, and psychological well being. Two of these components, perceived quality of life and behavioral competence, are crippled by Alzheimer's progressive brain degeneration. However, caregivers may impact the two remaining components of quality of life: appropriate physical and social environment; and accommodating conditions for psychological well being (Volicer, 2000). Clearly in addition to the physical needs such as safety, nutrition, and good health, people with dementia have the same psychosocial needs as other individuals. They need to feel secure, they need stimulation and companionship, and they need to be valued as unique individuals. Consequently the main caregiving goals for residents with advanced dementia are maintenance of quality of life and the preservation of dignity and comfort. Thus the experience of nature, which is perceived as a vital part of subjective quality of life, should be central to intervention programs for people with dementia. Because by eliminating interaction with natural elements from their daily lives, we “exclude people with dementia from the pleasurable sensory experiences most of us enjoy every day” (MacDonald, 2002).

ABOUT NATURE AND OUTDOOR ENVIRONMENTS

Human relationships with nature are a fundamental genetically based need. According to Wilson (1984) who coined the word Biophilia to describe the need, this instinct emerges unconsciously in human cognition and emotions, and is revealed “in the predictable fantasies and responses of individuals from early childhood onwards” (p. 85). Studies have shown that direct contact with nature benefits a wide range of people across cultures. In addition it can benefit prisoners, hospital patients, and autistic children, as well as adults with Alzheimer's disease (Kaplan & Kaplan, 1989; Tyson, 1998; Carstens, 1998; Marcus & Barnes, 1999; Ulrich, 1999; Kahn, 1999; Rodiek & Schwarz, 2005).

Kaplan and Kaplan (1989) noted that the “immediate outcomes of contacts with nearby nature include enjoyment, relaxation, and lowered stress levels. In addition, the research results indicate that physical well-being is affected by such contacts. People with access to nearby natural settings have been found to be healthier than other individuals. The long-term, indirect impacts also include increased levels of satisfaction with one's home, one's job, and with life in general” (p. 173). At the end of their book Kaplan and Kaplan (1989) reiterate their point: “Viewed as an amenity, nature may be readily replaced by some great technological achievements. Viewed as an essential bond between humans and other living things, the natural environment has no substitutions” (pp. 203–204).

If this essential cross-cultural human need has merit, it helps to form some normative principles such as “If you want to support your physical and psychological health, then affiliate with nature.” Or, in the context of this volume, “If we want to provide holistic care for people who suffer from dementia we need to maintain their affiliation with nature”.

ABOUT OUTDOOR ENVIRONMENTS FOR PEOPLE WITH DEMENTIA

In recent years, there has been a growing awareness that persons with dementia should have the necessary environmental support and freedom to access the outdoors, and a substantial crop of ‘wandering parks,’ ‘healing gardens,’ ‘treatment gardens,’ and ‘restorative gardens’ has sprung up as a result. However, even with wide scale endorsement of this concept, relatively little is known about how persons with dementia respond to specific environmental features, and how planned activities and environmental conditions can encourage usage and/or benefit residents. Even fewer studies have explored what beneficial health-related and behavior-related outcomes may result from having access to the outdoors, partly due to the complexity of measuring physical environment interventions, and pardy due to the difficulty of obtaining reliable and valid data on dementia resident outcomes.

Some of the potentially beneficial health outcomes for older persons with dementia may be similar to the potential benefits for older adults without a diagnosis of dementia: multiple physical and psychological benefits associated with increased physical activity; the hormonal balance associated with exposure to bright outdoor light; and psychological benefits from contact with nature elements. In addition to benefits that may be derived from actual usage of outdoor space, it is theorized that merely having access to the outdoors may in itself have substantial positive benefits, especially for persons with dementia, because of the potential impact on autonomy, independence, sense of freedom, and self-esteem.

The E-B inventory for dementia environments developed by Zeisel, Hyde and Levkoff (1994) used the term “outdoor freedom” to describe the benefits to residents. Their model attempts to support individual treatment goals with measurable positive outcomes on resident behavior, mood, social interaction, and active engagement in activities. This emphasis on the freedom engendered by nature contact is echoed by Tyson, who said the “ultimate goal of treatment gardens is to facilitate self-initiated and independent engagement in ordinary outdoor activities by providing residents access to supportive environment and the freedom to do so” (2002, p. 55).

Integrating insights from the nursing profession and landscape architecture, Randall and her colleagues (1990) proposed design solutions in the outdoor environment to specifically address symptoms of Alzheimer's disease such memory loss; apraxia (inability to perform motor acts); agnosia (the inability to understand or use sensory information); frailty; wandering; disorientation; plant ingestion; sundowning; and delusions and hallucinations. The authors caution that the proposed design solutions were not the only approaches to mitigate the symptoms of dementia but they tried to carefully address the issues necessary to achieve the goal of comfortable and secure outdoor environments for the patients.

ORIENTATION TO THE BOOK

In the opening chapter of this volume, John Zeisel explores the issue of therapeutic gardens for people with dementia. Drawing on the growing field of neuroscience and design, Zeisel (2006) describes the design process and links it to the specially designed therapeutic gardens. In the last section of his chapter the author provides eight basic design criteria for the review of these gardens. Zeisel stresses the synergy that can come from the holistic design approach to the indoor and the outdoor space of special care environments for people with dementia.

In the second chapter, Jiska Cohen-Mansfield provides a broad picture of the field of Outdoor Wandering Parks for Persons with Dementia. The article is based...

Table of contents

• Cover
• Half Title
• Full Title
• Copyright
• CONTENTS
• ABOUT THE EDITORS
• About the Contributors
• PART I
• PART II
• Index