Salutogenesis for dementia patients; the potentials of a healing environment

Marloes Pieper, 4006194maus.pieper@gmail.comThe Healthy Environment: User Centered Research (Spring 2015)Irene Cieraad Research Seminar AR3Ai155May 2015

Dementia is the general term for the decline in mental abilities. The decline has to be severe enough to interfere with daily life in order for it to be recognized as a type of dementia disease. The most common type is Alzheimer’s disease. This concerns foremost the loss of a person’s (short) term memory. Over time this becomes worse and progresses in the end to the loss of emotional expression, social contact and speech. Vascular dementia often occurs after having a stroke and it is the second most common form of dementia. It shows mainly in a decline in thinking skills as a reduced blood flow to the brain deprives the brain cells of vital oxygen and nutrients. All types of dementia are based around the effects of brain cells coming to the end of their life and slowly dying off.

Right now there is no cure to stop this process. Many of its sufferers will eventually die from the symptoms. Yet people with diagnosed dementia are not to be treated the same as terminal patients who’ve only got months to live. As research and technology keeps on developing, many people diagnosed with a dementia disease will live anywhere between 5 to 20 years.1 Their inability to live at home without the assistance of medical staff will result in an increase of facilities that deal with severely demented patients. The quality of life within these facilities will largely depend on the design positions that designers from today take stand in. One of which includes the use of the healing environment gardens and more general outdoor space.

Healing environments

Large white hospitals, your local dentist, a sterilised emergency room, healthcare institutions are not known for their welcoming and comfortable atmospheres. They are places often associated with fear, anxiety and stress, for both patients as well as families. However in the last few years many new initiatives have been developing for making a change within this accepted standard. Instead of focusing on the most cost-efficient and care/technology based design decisions, it is the patients themselves, their families and the staff who are the focus of a design. Supporting the needs of these users so-called healing environments are created which try to make an impact on the patients’, their families’ and staffs’, well-being and health.2

However new these spaces are for healthcare facilities, the concept of healing environments has been used many times before. They have been a part of complementary and holistic healthcare for a very long time. When you think of what makes a healing environment, there is a global intuitive idea about what they look and feel like among people.3 Nature and all its elements play a large role in this basic understanding of a healing environment. Aspects such as daylight and fresh air or the quietness or calmness are usually the focus. The use of these holistic health principles can be traced back to as far as the very first hospital (or care facility), the Asklepieion in ancient Greece.Here the dormitories, the abaton, were situated inside a long and narrow building strip with an open facade facing south. Patients would be able to sleep and live inside a space that is well-ventilated and filled with warm sunlight. Just outside of the Asclepieia patients had access to forests which held both hot and

1 Alzheimer Nederland 2013

2 Berg 2005

3 Huelat 1998

Fig. 1, 2: Images of the remains of the Asklepieion on the island of Kos, Greece. Upper image shows a healer and patient, below the long open facade of the abaton.

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cold springs. The nearness of nature, especially in the form of water, was thought to have oracular and visionary influences.4

Today, these aspects from complementary healthcare are receiving more and more scientific support. This is most likely caused by a shift in the way we think about healthcare. Traditionally, care is given in order to reach the ultimate goal, curing. In healthcare this is referred to as Pathogenesis, where ‘pathos’ is the Greek word for ‘suffering’ and ‘genesis’ that for ‘origin’. The starting point for this framework of thought is the problem, in this case an illness, and it searches for its causes. What can be seen however with the re-appreciation of healing environments is that our healthcare framework shifts to a Salutogenesis thought framework, where ‘saluto’ stems from latin ‘salus’ which means ‘health’.5 This means that the starting point changes from looking at the already existing problem, to looking at the potential still to gain. It focusses on what is possible rather than on what is impossble. Assumptions will be based on causes of health, instead of causes of illness. The concept of healing environments has been defined as the environment where an individual’s inner strengths are empowered and stimulated, especially of somebody who’s ill.6 They therefore fit perfectly within the latter framework of healthcare thinking. The scientific reports have been supporting the claims that the contact with nature through healing environments can for example reduce anxiety, lower blood pressure and decrease the notion of pain.7 As dementia patients often find themselves confused, stressed and aggressive, healing environment would be ideal for integrating in a dementia facilitating clinic.

Dementia and gardens

The user group of dementia patients are truly a unique group of users for a garden. They have challenges like no other and are in need of very specific design decisions when it comes to a healing environment. A couple of factors that determine their well-being parallels with those for people generally aging. These factors include measures taking for comfort, security, visual appeal, visual contact, easy access, safety, accessibility of elements, sensory qualities, activity potential and transition zones.8 These factors influence both the mental as well as the physical effect the garden space has on a patient. As dementia patients have especially difficulties with numb senses which are not properly triggered a garden space tackling these factors could be very beneficial.Suffering from dementia patients can have a wide range of changes in their behaviour. As for the physical state these concern wandering and intrusiveness, repetitive actions or questions, verbal disruptions, aggression and other types of socially inappropriate behaviour. The results of these actions cause the well-being of the patient to decrease as they account for many negative health outcomes. A decline in functional status, social engagement and effectively physical inactivity are examples of this.9 Thus one of the main primary focuses of a dementia healing environment is creating an enjoyable space for simple physical movement. Two distinctive types of gardens are associated with this goal; horticultural therapy gardens and therapeutic landscapes. The garden setting and design of

4 Risse 1999

5 Becker et al. 2010

6 Jonas et al. 2003

7 Ulrich 1999

8 Chalfont et al. 2005

9Cochrane 2010

Fig. 3, 4: Optical Glass House by Hiroshi Nakamura, images show the creation of a tranquil garden space. By using semi-transparant glass blocks and trees/shrubs with a moderate coverage, the sun and shadows play a large role in the experience of this space. Especially for dementia patient, the contrasting playfully moving shapes can hold their attention. This space is not meant for healthcare and therefore would not be considered safe (open water, no wayfind, etc) but the calm atmosphere is something to strive for.

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outdoor space is in both cases aimed at creating opportunities where staff professionals can create an interaction between patient and garden. Examples that belong to these gardens are raised planting beds so patients can easily join in taking care of the (vegetable) garden, a long pathway leading along several elements of orientation points for exploring, and small fences or bridges to either push open or cross. Looking at what the patient is still able to do, they are encouraged to join in as much as possible. Active healing is promoted and can significantly reduce stress related heart problems, high blood pressure and stiffness of joints and muscles.10

Parallel to the physical well-being of a patient, the mental state is where real improvement can be made. Dementia often causes a depressed and withdrawn mood, sleep disturbances, stress, anxiety and hallucinations and false ideas. By aiming for the highest quality of life for these patients the environment should trigger their attention and support the maintaining of semi-normal functioning as long as possible.11 Evidence shows that the restoring of attention within patients for their surroundings can simply be derived from looking at nature. The natural environment can help foster inner peace and strengthen mental energy.12 The awareness of growth and decay within nature can aid in the same way to a sense of time for patients. Losing memory and a frame of time creates the largest point of confusion; the experience of changing seasons can act as a natural clock. Because dementia patients find it hard to feel in control of their own actions, it is equally important to make them aware of possible decisions to be made inside a garden. These decisions can be basic questions as to what path to take, where to sit, who to talk to and what to look at. By giving people options and possibilities their confidence can be increased. Another important benefit surrounding dementia patients with nature is that nature does not require any form of traditional communication. Gardening activities themselves are easily taken over by individuals and can encourage social interaction while still staying on a relatively primitive, or non-existing, level of communication.13 The healing environments addressing the mental well-being of patients have the characteristics of being calming and peaceful; it is a place where the patient can, as it were, escape to. The healing approach is passive here and the design often specifically diverse in sight, sound, smell, taste and touch. It is a place to emotionally regenerate from the confusion, sometimes judging, and everyday life.14 As so beautifully expressed by a retired professor, Richard Taylor, 65 years old, living in Texas and diagnosed with dementia three years ago;

“Who or what makes the ‘best’ companion for someone with Alzheimer disease? Actually what is needed is something I can feel I am still taking care of. Something that returns unrequited love, that gives itself away without expecting anything back, that wants to please me…all the time! Something that never ever judges me, just accepts me for whom and what I am at that particular moment. Something that is not hung up about who I was, who I am, or who I will be. Something that is more concerned with where am I going to get water and food for today, rather than will I be around in 5 or 6 years. Something that is happy to be with me

10 Chalfont et al. 2005

11 Cochrane 2010

12 Hartig et al. 1991

13 Cochrane 2010

14 Chalfont et al. 2005

15 Taylor 2005

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no matter where I live, or am forced to live (for my own good or course). Something that remembers little or nothing of yesterday, but does its best to make today the best day of its life, and quite unintended the best of my life. I vote for plants!”15

Limitations and disadvantages

Although the shifting to a Salutogenesis framework of thought within healthcare has given space to the quickly developing knowledge and usage of gardens as healing environments, there are still some disadvantages to be explored. Of which the main one is actually right where a garden environment ends, the edge. The edge is supposed to be clear and obvious. The patients are not to leave the grounds of the facility, anyway not on their own. The use of fences or strict visible borders will give the patients a feeling of being imprisoned; obviously this needs to be avoided. Yet some type of access, whether a gate or simple friendly fence, will have to be closed for patients somewhere. Giving people a feeling of freedom while still restraining them from leaving creates a paradox attitude towards the healing environment. Giving patients a view on a natural site they cannot even enter is most likely even worse.16

When you think of the most ideal garden, one imagines a lush planted array of flowers, grasses, trees and meadows, maybe even a little water. But even the really well-designed gardens would not be ideal for demented patients, simply because it is outside. Unfortunately we live in a climate where we experience not too many sunny days. Patients would not be able to use the space all year round, and be limited to visitors or caretakers for them to be taken outside. However beneficial the awareness of seasons and changes in weather might be, in practical everyday life nobody would want to go outside when it is pouring down. Creating a garden for a facility which is built on a tight budget might not be favourable. Scares resources are already the reason that less staff is being hired and rooms are smaller. As well as the priorities of doctors and nurses who can have a very different focus points then those of a designer. Why spend money on a garden when a update to the technological systems could lead to a faster and more efficient workflow?17 The garden will need another member of specialised staff to maintain it as the patients are not a reliable group of caretakers. When working and helping in the garden the patients will also need to be assisted which calls for the hiring of more people. The role of the garden in the daily life of a patient must be encouraged by an active role of the staff. This might require additional learning and a new appreciation of garden spaces. The patients with severe dementia will most likely not consciously decide to take a stroll or interact with the garden. The neglect in staff involvement with the garden will result in an empty healing environment.

The garden itself will naturally grow and decay over time, offering a much less attractive view during winter then during the lush flowering summers. The enjoyment that comes with the bright green en flowering plants cannot be experienced in winter and may offer little aid to patients then. Also the garden

16 Chalfont 2006

17 Hartig et al. 2006

18 Hartig et al. 2006

Fig. 5, 6: The Nest House by UID Architects, the upper image shows the entrance of the house, the lower one the section. Although it might not come across as a good example for dementia friendly environment I think it has some major benefical architectural elements. The lowering of pathways to experience nature on different levels can be beneficial for patients, as the physical movement that requires interaction is minimal. Plants can be reached standing up or from wheelchair level. Also the embedment of the pathway suggets a safe and intimate atmosphere that creates a feeling of privacy. This is an inside space, but it would also work great outdoors. The windows and doors open directly onto the garden and maximise the interior view on them.

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is naturally subject to the weather changes, which can heavily influence the overall look of the garden. On a grey and rainy day, it might seem like a blunt and dreary space. In order for people with dementia to enjoy the garden individually or maybe in the company of a family member, the garden must be public, yet also private. The interventions to prevent over-crowing are usually absent but could become important in large shared gardens. Over-crowed garden spaces minimize the feeling of safety and will add to the confusion of the patient. Noise can trigger aggression and inward behaviour, both of which are to be avoided.18

Conclusion

As the life expectancy for elderly with dementia is increasing the need for facilities where their quality of life can be the best possible, is high. Healing environments are a vital part of this. There is no type of interior space that can trigger as much positive progress with a dementia patient as a garden. The time spend outside is vital for good mental and physical health, both being aided towards with elements in the garden. It is one of the only spaces, when designed well and save, that gives them many points of decisions and lets them be free in making up their own mind. Through this the easy agitation and aggression is reduced, their independence promoted and sometimes it might even create memory recall. The garden must give patients the opportunity to enter at all times, and thus be a safe place with walking circuits with easy understandable wayfinding and orientation points. Activities done within the garden can range from hanging out washing to feeding birds, from playing with children to gardening. These simple things create physical activity, social interaction and a feeling of being useful. Most importantly, a garden accepts them for not who they used to be, not who they want to be, but for who they are at that exact moment.

The term healing environment is in itself a little misleading when it comes to dementia patients. The dementia illness is not a reversible process, it will only worsen over time and patients will never be ‘healed’. However I continue to use the term healing environment because I think it signifies the positive attitude and focus on small pleasures in life which can greatly increase the quality of life for a dementia patient. While they may never be truly healthy again, I see the reducing of stress, relief of anger and feeling of safety as the purest forms of healing. If that is what can be achieved, we must give it to them.

Figures 7, 8; Images of gardens by Piet Oudolf. His way of treating a garden is especially useful for dementia patients. Plants are arranged in such way that across all seasons the flowering and bloomings has the best coverage. Also Oudolf focuses on a varied and exciting compositions, creating an wonderful lookout for patients. By using higher plants and grasses he creates more private spaces inside the garden, but always keeping the pathway clear. The circular and winding paths are perfect for a good circulation of walk routes.

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References

Alzheimer Nederland 2013 Factsheet: Verloop van Ziekte. Amersfoort: Alzheimer Nederland

Becker, C. M., M.A. Glascoff and W. M. Felts 2010 Salutogenesis 30 Years Later: Where do we go from Here? Greenville: Health Education & Promotion East Carolina University

Berg, A. E. Van den, 2005 Health Impacts of Healing Environments: A review of Evidence for Benefits of Nature, Daylight, Fresh Air and Quiet in Healthcare Settings. Groningen: Foundation 200 years University Hospital Groningen

Chalfont, G. E. And S. Rodiek 2005 “Building Edge: An Ecological Approach to Research and Design of Environments for People With Dementia.” Alzheimer’s Care Quarterly 6, 3: 341-348

Chalfont, G. E. 2006 Connection to Nature at the Building Edge: Towards a Therapeutic Architecture for Dementia Care Environments. Sheffield: School of Architecture, University of Sheffield

Cochrane, T. G. 2010 Gardens that Care: Planning Outdoor Environments for People with Dementia. Australia: Australian Government Department of Health and Ageing

Hartig, T., M. Mang and G. Evans 1991 “Restorative effects on natural environmental experiences.” Environment and Behaviour 23, 1: 3-26

Hartig, T., and C.C. Marcus 2006 “Healing Gardens: Places for Nature in Healthcare.” Elsevier, 368, 1: 36-37

Huelat, B.J. 1998 “10 Myths of Healing Environments: A Healthy Space doesn’t have to be a Huge Headache.” Health Facilities Management 11, 2: 24-8

Jonas, B. J., R.A. Chez, B. Duffy and D. Strand 2003 “Investigating the impact of optimal healing environments.” Alternative Therapies 9, 6: 36-40

Risse, G. B. 1999 Mending Bodies, Saving Souls: A History of Hospitals. New York: Oxford University Press

Taylor R. 2005 “Alzheimer’s Disease Experienced: From the Inside Out.” Alzheimer’s Care Quarterly 6, 4: 265-272

Ulrich, R. S. 1999 “Effects of Gardens on Health Outcomes: Theory and Research.” In C. Cooper-Marcus and M. Barnes Healing Gardens: Therapeutic Benefits and Design Recommendations, pp. 27-86. New York: John Wiley

Images

All retrieved on 24.03.2015

Figure 1:Cultural & Experiental Traveling, http://somewhereweknow.com/portfolio-item/asclepieia-8-days/

Figure 2:A Pocket Full of Wanderlust, http://www.apocketfullofwanderlust.com/2013/10/the-ancient-healing-center-of.html

Figure 3;Speculaasblog, http://speculaasblog.nl/2013/01/optical-glass-house-hiroshi-nakamura/

Figure 4;Speculaasblog, http://speculaasblog.nl/2013/01/optical-glass-house-hiroshi-nakamura/

Figure 5;Arch Daily, http://www.archdaily.com/285221/nest-uid-architects/

Figure 6;Arch Daily, http://www.archdaily.com/285221/nest-uid-architects/

Figure 7;Living, http://living.corriere.it/tendenze/se-ne-parla/2011/giardino-piet-oudolf-30228053545.shtml

Figure 8;Timberpress, http://www.timberpress.com/blog/2013/04/signature-planting-piet-oudolf/

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