Recent statistics cited by Alzheimer’s Australia show that there are more than 353,800 Australians currently living with dementia, with that number expected to increase to over 400,000 over the next five years. Whilst there are 25,100 individuals in Australia with Younger Onset Dementia, the overwhelming number of suffers are older Australians aged over 65. In this age bracket, dementia is the single greatest cause of disability and, sadly, there is no cure or effective medical treatment for the disease.
Dementia is defined by Medical Dictionary as a loss of mental ability severe enough to interfere with normal activities of daily living, lasting more than six months, not present since birth, and not associated with a loss or alteration of consciousness.
Alzheimer’s disease is the most common form of dementia. It usually occurs in old age and is marked by a decline in cognitive functions such as remembering, reasoning and planning.
The Alzheimer’s Association has listed some of the early symptoms of dementia. These include:
- Memory loss that disrupts daily life
- Challenges in planning or solving problems
- Difficulty completing familiar tasks at home, work or leisure
- Confusion with time or place
- Trouble understanding visual images and spatial relationships
- New problems with words in speaking or writing
- Misplacing things and losing the ability to retrace steps
- Decreased or poor judgement
- Withdrawal from work or social activities
- Changes in mood and personality.
The symptoms of Alzheimer’s disease worsen over time, although the rate of deterioration varies. The average person lives for 4-8 years following diagnosis but sufferers can live as long as 20 years, depending on a range of factors.
In the early stages of dementia and Alzheimer’s, a person may function independently. He or she may still drive, work and be part of social activities. Despite this, the person may feel as if he or she is having memory lapses, such as forgetting familiar words or the location of everyday objects.
Examples of typical behaviour in the early stages include:
- Problems coming up with the right word or name
- Trouble remembering names when introduced to new people
- Having greater difficulty performing tasks in work or social settings
- Forgetting material that one has just read
- Losing or misplacing a valuable object
- Increasing trouble with planning or organising.
The middle stage of Alzheimer’s, or Moderate Alzheimer’s, is typically the longest stage and can last for many years. The person will require a greater level of care and you may notice frustration, anger or unexpected behaviour as the damage to the brain’s nerve cells progresses.
Examples of typical behaviour in the middle stage include:
- Forgetfulness of events or about one’s own personal history
- Feeling moody or withdrawn, especially in socially or mentally challenging situations
- Confusion about where they are or what day it is
- The need for help in choosing proper clothing for the season or occasion
- Changes in sleep patterns – eg sleeping during the day and becoming restless at night
- Some individuals encounter difficulty with controlling bowel or bladder
- Increased wandering and becoming lost
- Personality and behavioural changes including suspiciousness, delusions or compulsive repetitive behaviour.
Late-stage or Severe Alzheimer’s is the final stage of the disease and is characterised by a strong deterioration in mental functioning. The individual often loses the ability to respond to their environment, carry on a conversation and eventually, lose control of their movement. Individuals at this stage of Alzheimer’s will usually require full-time care and assistance with daily tasks.
Examples of typical behaviour in the late stage include:
- Loss of awareness of recent experiences and surroundings
- Changes in physical abilities such as walking, sitting and even swallowing
- Increased difficulty communicating
- Becoming vulnerable to infections, especially pneumonia.
Definition and purpose of a dementia gardens
Dementia gardens are gardens designed to specifically meet the needs of dementia patients. The gardens are usually located in aged-care facilities and they should take into account both the physical and mental symptoms of individuals at each stage of the disease, as listed in the previous section.
The goal of treatment gardens for Alzheimer patients according to Zeisel and Yson, is ‘to create a well-designed environment with good planning and medical and social management to reduce symptoms and ease the burdens on family members or caregivers.’
But why create gardens for dementia patients in the first place? What do they offer and how should this best be achieved? What are the principles of a well-designed garden for dementia patients?
Advantages of dementia gardens
According to Kaplan (1995), nature is restorative and has healing powers.
This is true for both those afflicted by dementia, but also for well individuals who seek to escape the pressures of everyday life by interacting with nature.
Research indicates that physical and visual access to nature can have the following positive impacts in individuals with and without dementia:
- Helps people recover from illness quicker
- Reduces stress and lowers blood pressure
- Helps a person maintain circadian rhythms
- Aids in the natural absorption of vitamin D when exposed to sunlight for brief periods of time, which is important for maintaining strong bones.
In addition to this, the benefits of a garden as a place of quiet beauty and mental rejuvenation have been shown to increase with age and have been established for people with dementia specifically.
Gardens and outdoor environments are being increasingly reintroduced as important support tools in the care, management and contribute to the quality of life of people with dementia.
Some of the benefits to dementia suffers include:
- Enjoyable form of exercise
- Increases levels of activity and maintains mobility and flexibility
- Encourages use of motor skills – walking, reaching, bending, planting seeds and taking cuttings
- Improves endurance and strength
- Helps prevent diseases such as osteoporosis
- Reduces stress levels and promotes relaxation
- Provides stimulation and interest in nature and the outdoors
- Improves the sense of wellbeing due to increased social interaction.
There are many different types of dementia gardens, such as healing gardens, sensory gardens and meditation gardens, as well as mobility gardens, rehabilitation gardens and community gardens. Each of these types of gardens can be useful for dementia patients and you should consider the therapy goals and daily therapeutic programs, such as physiotherapy, occupational therapy and horticultural therapy, when you design your garden.
Whichever type of space you are trying to create, the principles and tips below can be a great guide to helping you achieve a wonderful design that meets the needs of the patients.
The following design principles have been specifically developed with the needs of individuals and groups with dementia in mind. They have been written to help you to consider the variety of decisions that should be made at the planning stage of your garden and will help to maximise the use and benefits of dementia gardens.
We are developing a list of tips that can help you to achieve these principles and you will be able to use these 2 resources, together with the list of plant suggestions to create a warm and inviting space. If you would like us to notify you of this and other updates you can subscribe to our blog by completing the “subscribe” form on the right side of the page.
For any garden, especially dementia gardens, it is important for the design and upkeep to be sustainable. If the garden falls into disrepair it will become under-utilised and unsafe for both users and staff.
The staff should not be expected to maintain the space, their focus should be on caring for their patients and it is also unlikely that they will have the time to ensure the facility is well kept. Depending on the size and complexity of the space, make sure that you hire a regular maintenance contractor or specialised staff member to care for outdoor spaces.
Gardens will be more sustainable if they are carefully planned from the outset.
As mentioned above, dementia patients have a number of symptoms that need to be catered for in a garden. Providing a well-laid-out garden that is properly planned from the beginning can assist users to feel comfortable in using the space and minimise the potential for disorientation and distress in navigating their way in the garden.
Gardens that have areas with clearly defined roles and include indicators for direction and location allow users to behave and use the space more independently. For example, designing your garden to have paths that loop back to the beginning will still allow patients to journey through the landscape without risk of becoming lost.
Gardens need to be accessible for both patients and staff if they are to receive regular use. Dementia patients frequently have health issues associated with ageing, as well as other issues of mobility to consider.
Careful thought, planning, design and implementation will help users to maximise their independence in the landscape, encourage physical activity and allow the users to decide how they would like to interact with the outdoor space.
Considering issues associated with climate and weather can also make a garden more accessible. Create covered outdoor spaces for enjoyment of the garden in inclement weather. Use screens to help reduce the effects of wind and sun. Create transitional spaces between indoors and outdoors to give patient’s eyes time to adjust. Plant carefully placed canopies in parts of the garden to allow for dappled sunshine or times of full shade and cool relaxation.
Socialisation and solitude
One of the main benefits of gardens for dementia patients is the increased socialisation opportunities they create. Users can have greater opportunities for enjoying relaxed, regular, social interaction in an outdoor setting with other patients and staff, as well as with family and friends.
Gardening lends itself easily to interacting with communicatively challenged individuals. It can help to promote teamwork, self-esteem and self-confidence, particularly through regular social interaction. It is also helpful for decision-making skills and providing a feeling of self-determination and control.
Just as dementia patients can have the need for greater social interaction, they can also be living in close quarters with many other people and often feel the need for some private time alone. Achieving an appropriate garden layout that allows for staff supervision for safety, balanced with quieter places for solitude can help to meet this need.
There are many, many ways that gardens can help dementia patients to increase the meaningful activity in their lives.
Planning a garden that caters to the therapy needs of patients will help regular care staff and other staff, such as therapists, to make use of the outdoor spaces you design. Providing well maintained, accessible spaces creates ready-made opportunities for staff to tap into when caring for patients. This can be as simple as, ‘Why don’t we take a stroll and look at the changing colours of the leaves in the garden?’, but it can also provide opportunities for more structured activities associated with horticultural therapy, for example.
Planting an array of flowers that can be used for flower arranging or providing pine trees with cones can allow patients to make and decorate bird feeders.
Consulting with the range of staff who use the facility can make sure that outdoor spaces can be designed in a way that will maximise their use. It can help to determine many key aspects from plant selection to ensuring that storage is organised, accessible and adequate for the equipment that will be used. This will also help to ensure the garden is well-maintained and that patients and visitors can access and care for their own equipment. Explaining the garden design layout and features to staff will also help them to access all its spaces and features and allow them to develop or adapt appropriate activities.
Speaking and consulting with the dementia patients is also a critical part of the design process. It helps to better cater to their individual needs and desired usage for garden and it also fosters a sense of ownership and control. In this way, you can provide opportunities for more meaningful activity in the garden. Gardens have usually been a place of meaningful, everyday activity for most dementia patients and offering a range of normal activities can make the garden feel comfortable and home-like. Examples of this are regular gardening activities such as raking leaves, as well as home duties such as hanging out the washing.
This kind of careful planning will also help to make sure that the garden is used frequently and maximum benefit achieved.
Stimulating reminiscence in dementia patients can be an excellent way to help maintain mental acuity. Choose garden styles and plants that are familiar and recognisable to dementia patients and reminiscent of an appropriate era. Selecting the right plants and styles can also assist with interaction with staff and visitors as they provide an opportunity for suffers to share their life memories and experiences with others.
Sensory stimulation can be a wonderful way for dementia patients to really enjoy nature and the outdoor spaces you create, whilst for other patients sensory stimulation can lead to sensory overload. Providing anumber of different spaces within a garden is a good way to balance this dichotomy. Keep some areas of your garden tranquil with subdued colours and very familiar plant choices but also create spaces that are stimulating to each of the five senses: sight, sound, touch, taste and smell. The sense of smell can also be particularly effective in provoking memories for all people, but especially for individuals with dementia. Select plants with a variety of foliage colours and flowers, plants with different textures, scrumptious herbs, vegetables and fruits for smell and taste, as well as grasses and trees that rustle or crunch. Your plant selections could also reflect the change in seasons.
Including plants and other features that attract wildlife can also help to stimulate the senses. You could try bird baths and feeders, as well as certain plants to attract bird life but you can also consider other kinds of wildlife such as butterflies, earthworms, bees or small marsupials.
Safety balanced with independence
Whilst safety must always be of paramount concern, it is important to the quality of life of dementia suffers for this principle to be balanced with opportunities for independence.
Try to make sure that your garden design and inclusions allow people to use the garden as freely as possible whilst still giving staff adequate ability to supervise patients. Try to make the garden as easily accessible to living spaces as possible to encourage regular movement between indoor and outdoor spaces. Provide a range of activities and different kinds of spaces to allow individuals to choose the different ways they would like to use the space and interact with their natural surroundings.
Case studies and examples
Alzheimer’s Australia SA Inc, Gardens that care: Planning outdoor environments for people with dementia
Sempick et al, 2003, Social and therapeutic horticulture: Evidence and messages from research, Thrive in association with The Centre for Child and Family Research, Loughborough University.
Kaplan, S (1995) ‘The restorative benefits of nature: Toward and integrative Framework’, Journal of Environmental Psychology, 15, 169-182
Marcus, CC and Barnes, M (1999) Healing Gardens, John Wiley
Medical Dictionary – Alzheimer’s disease
Medical Dictionary – Dementia