Therapeutic or restorative gardens have been part of the landscape of healing since medieval times. Such gardens have been parts of hospitals, hospices, rehabilitation centers and more recently nursing homes for elderly and infirm people. In the late twentieth century the ever-present psychological possibilities of gardens have sometimes been neglected or even denied. Today the therapeutic effects of gardens in health care settings are again questioned as a part of the patient’s treatment. In this article, design guidelines for planning therapeutic gardens for people with dementia are presented.

Because of the distortion of perception, sapping of identity and loss of connectedness to the external world, patients in health care settings often feel disoriented and terrified. The aims of a therapeutic garden are to create supportive outdoor environments in connection to different health care settings. For example, the possibility for people with dementia to be in a garden can reduce behavioral problems, psychotic symptoms, slow down the inexorable decline of the functional abilities and diminish the causes of stress.

Dementia

Due to the expected increase in the number of elderly in the western world, the number of people with dementia is expected to increase dramatically in the twenty-first century. In Norway there are around 60 000 people suffering from dementia today against an expected number of 120 000 in 2050 (ENGEDAL & HAUGEN, 1996). The same numbers for America is 4,5 millions today against 14 millions in 2050 (BRAWLEY, 1997).

Dementia is a degenerative, neurological process, at present incurable. It involves brain areas controlling memory, speech, perception and time-space knowledge. These are the human faculties through which the central nervous system controls the relationship between a person and his or her environment. The evolution of the condition leads to a gradual and serious estrangement from the environment and progressive loss of consciousness of the person’s body. This makes it very difficult for people with dementia to recognize and use space and objects within the environment.
Design guidelines

The physical environment for people with dementia should attempt to compensate for the sensorial and perceptive deficits caused by this condition. The designer’s task is to incorporate suitable design elements and to plan an outdoor environment that responds to the persons remaining abilities. A major difficulty is that people with dementia are unable to clearly communicate their experiences, therefore it is not known how they perceive their surroundings. In addition, knowledge about gardens suitable for people with dementia is limited because there are few build projects and those that do exist are too recently established to provide data to guide the designers.

The guidelines presented in this article are based on literature regarding the clinical picture of dementia and descriptions of a few therapeutic gardens in the USA and Scandinavia. Research done by Ulrich (1999) shows that it is possible to create therapeutic, restorative gardens which improve the quality of life for individuals with severe cognitive impairment, as well as the lives of relatives and the medical staff.
Seven important issues for a therapeutic garden design
Grandma’s garden – garden typology
– Hedges and stone walls – the external garden boundaries
– Tracks and pathways – way-finding
– Stops and breathing places – private or social places
– Ferns and peonies – plantings
– Tractor and clotheslines – symbolic cues
– Apple trees and wood cutting – activities
Grandma’s garden

The garden is a recognized outdoor situation for most people. This makes the garden ideal as typology for a therapeutic outdoor setting. Most activities done in a garden are well known and homelike, moreover the assume familiar actions with little planning.
The garden could be fenced on grade, an enclosed atrium garden or a rooftop garden. Views into, within and from the garden impact its use and the effect the garden has on its residents. Views into the garden from interior rooms entice residents outdoors; if they are not aware of the garden they will not use it. Window views from inside also integrate life indoors with the outdoor life of the garden. Distant view connects people with the surrounding landscapes. A calm, rural landscape view does not stress people with dementia. Views to adjacent streets with high activity of people and/or cars coming and going may cause problems for some residents and should be avoided.

Hedges and stone walls

Elements that enclose the garden provide security. Edges of paths and of places orient people with dementia by identifying and clarifying where these elements begin and end. Enclosures such as hedges or walls should be used if the building edge does not fully enclose the outdoor area.
The more secure the garden is, the more often the resident will be free to use it without being accompanied by a caregiver, allowing for spontaneous use and relieving staff of the constant concern for the residents safety. Research has shown that caregivers restrict garden access to residents when enclosures do not present absolute security (ZEISEL & TYSON, 1999).

Logging tracks

People with dementia seem to have a tendency to just wander around without any specific goal. The reason could be that they are confused, bored or have need to exercise. It is important for the freedom and the life quality of the elderly that they are allowed to move around in a secure garden. Pathways are a fundamental design element to orient and support walking outdoors for people with dementia.

Paths need a distinct beginning and end. They should lead clearly from one place to another and from there to the next place and back home again with series of goals and landmarks along the way. Dead-end paths, crossroads, shortcuts and too many choices along the pathways should be avoided. If a shortcut is really needed, they should be narrower and placed at a 90-degree angle to walking paths with another material and lead to an end destination.
The walking paths should lead to different activities and destinations stimulate people walking around them to watch, smell, feel and interact with interesting features of the garden. Destinations provide a sense of purpose to the walking experience.

Walking paths need to be wide enough for three people to walk side by side comfortably. This allows for a wheelchair to pass but is not so wide that the paths appears to be a small street. The material on the pathway should be nonreflecting and not too smooth to avoid sliding. Illuminated pathways stimulate use allaround the year.

Places to stop and breath

A therapeutic garden for people with dementia should have distinct and recognizable places within the enclosure of the garden. Places cue and encourage appropriate behaviors, increasing physical and social interaction with the garden elements and people in the garden. Gathering places, away places, and symbolic places are the three important types of places.

Gathering places can be porches, patios, and terraces; all familiar places to get together. If placed adjacent to indoor activity areas such as living rooms and activity rooms, everyday use will naturally occur.
Secluded places are created by garden benches and seating alcoves separate from gathering places yet still along the path. They should provide a clear choice for people who prefer a more remote or private place in the garden, to get away from activity, other people or life indoors. A bench under a nice smelling tree is a good example for a place of recreation.

Symbolic places have a distinct and familiar character reflecting culture, geography, and the context of the area where the health care setting is located. Such places are extremely important to evoke deep memories of those with memory impairment and cognitive loss, which most people with dementia have. For example, a tractor placed in a cornfield would be a symbolic and maybe also a gathering place for people from the rural parts of Norway. In the north of Norway where the climate is much rougher and colder a turf hut would remind the Lapps of activities with their reindeers.

Ferns and peonies

Plants set gardens apart from all other forms of built environments. Plants change with the season, respond to soil and sun conditions, grow and change in appearance, structure, and function. Each unique climate, culture, and setting encourages the use of particular plant combinations. Consideration of the life cycle, growth rate and structure of particular species is essential when selecting plants for this type of garden. Of particular importance is the issue of toxicity, since people with dementia may pick leaves, flowers or fruits and eat them without being aware of potential effects on their health. Framework plantings such as trees, large shrubs, massed plantings and perennial or annual gardens create the foundation of the garden. Just as structured seating provides the backbone for social places and circulation; framework plantings provide structure and composition of the garden as a whole.

Evolving small gardens with vegetables, herbs, annuals or flowers suited for cutting within the therapeutic garden, encourage residents to garden themselves and enable structured horticulture therapy programs. They create working and activity possibilities where residents, staff and family can participate in the care. The planting areas may also encourage family members to bring plants from their own garden or other plants familiar to the resident. The beds should be raised to provide good access for both, unstable people and for wheelchairs.

Tractor and clothes lines

Every social and physical feature of the garden is enhanced when it evokes a symbolic or familiar purpose. For example, a bench set alongside a path where lilacs form a grove, provides the opportunity to connect with springtime, with past memories of fragrances and with the momentary beauty of the blooms themselves. Orientation to time and place, and memory recall are essential functions of symbolic cues in the garden. It is important for the designer to incorporate elements appropriate to the cultural background of the residents. The elements should be symbolic cues placed as landmarks or focal points.

Plantings and garden features significant to particular times of the year, seasonal holidays, religious celebrations and ordinary or predictable changes in weather can aid orientation to time and place. Programming around these cues can be a highlight of garden activity and bring residents to a momentary awareness of the time of the year. Memory recall is aided by garden elements that reflect past culture and common activities for the residents, such as a clothesline, flagstaff, a characteristic three, a old fishing boat or a tractor. A rose blooming at the back door may bring back deep, otherwise forgotten memories.

Apple trees and wood cutting

Usually the quality of life and the
self-confidence of people with dementia increase if they spontaneous are able to do different activities by themselves in the garden (ZEISEL & TYSON, 1999). Often they will need inspiration from their immediate surroundings for activities. That is why familiar activities and symbolic cues as well as other people being in the garden are of high importance. The following list of activities put the elements from the other guidelines in a wider perspective.
Activities could be:
n Gardening, watering, weeding or cutting flowers and picking different fruits or berries
n Walking or hanging around in the garden
n Keeping animals like cackling hens, grazing sheep or meowing cats
n Bird tables to feed different birds or to watch the birds play or sing
n Wood piling or cutting, repairing a fishing net, hanging clothes on a clothesline or „driving“ a tractor or a boat
n A tool or garden shed with different tools for garden work
n Ball playing or similar activities that kids visiting could do with their relatives

Conclusion

To conclude, freedom to use a garden is best achieved by providing an outdoor space surrounded by a secure enclosure preventing residents from walking away. The garden should be visible to caregivers located inside the residence. Also, clear pathways for residents, plants and planting areas and clear choices of where to go and what to do outside is of great importance when planning a therapeutic garden for people with dementia.


References:
BRAWLEY, E. C. (1997). Designing for Alzheimer’s disease. Strategies for creating better care environments. Wiley & Sons, New York.
ENGEDAL, K. and P. K. HAUGEN (1996). Aldersdemens – fakta og utfordringer. INFO-banken [in Norwegian].
GREFSRØD, Ellen-Elisabeth (2000). Therapeutic Gardens for people with dementia with a proposal for a therapeutic garden in Rognan. MSc Thesis in Landscape Architecture at the Agricultural University of Norway, Department of Land Use and Landscape Planning [in Norwegian].
ULRICH, R. (1999). Effects of Gardens on Health Outcomes: Theory and Research. In: Marcus, C. L. and M. Barnes (red.) In Healing Gardens: Therapeutic Benefits and Design Recommendations. John Wiley & Sons, New York, 27-86.
ZEISEL, J. and M. M. TYSON (1999). Alzheimer’s Treatment Gardens. In: Marcus, C. L. and M. Barnes (red.) In Healing Gardens: Therapeutic Benefits and Design Recommendations. John Wiley & Sons, New York, 437-504.