By the National Council of Certified Dementia Practitioners
As a corporate dementia unit consultant, I worked with a facility that had an underused court yard. It was mostly used for the residents who were smokers. This very large space lacked shade, comfortable places to sit, flowers and plants. There were large trees that were planted along the walls of the building but provided no shade. It was about as attractive as a prison court yard. Because there was no shade, residents did not want to venture out in the summer time. Because it was so unattractive, no one wanted to use this space any time of the year and no one did. The facility had no outdoor programs or walking programs.
We worked with the maintenance director who with the help of his staff worked the weekend and turned this ugly space into a gorgeous fragrant and colorful oasis. The space already had sidewalks that were even with the grass. This was an enclosed court yard bordered on all four sides by the building so a fence and gate was not required. The Maintenance Director purchased four large awnings from Home Depot. Placed tables and chairs under the awnings, set up park benches and additional very large umbrellas to provide shade along the path. The Maintenance Director built flower beds using rail road ties and purchased raised planters. He planted many flats of fragrant colorful flowers and bushes. He additionally planted butterfly bushes that attracted humming birds and butterflies. He hung numerous large flower baskets. All beds were heavily mulched. He added, wind chimes and bird baths and finch bird feeders that attracted bright yellow birds. He added water features and a water fall using a kit. By Monday morning he transformed the barren and cold court yard into a warm, inviting, magical and gorgeous place that was packed with visitors and residents. It is now the favorite destination for families to visit with loved ones. From that point on, residents were taking outside walks. Talking with each other about the different birds they saw or flowers that were blooming. The dementia unit manager now was able to schedule daily walks and a cool soothing place for the residents to sit and relax. Because of the investment in this project resident and family satisfaction scores increased.
According to Elizabeth Brawley, “Designing the outside environment has been an overlooked opportunity to create meaningful places that are rich in association, encourage good health and exercise, and are responsive to the magic of the changing seasons”
If you take the time to develop an attractive outside environment it will encourage your residents to go outside, walk and utilize this area.
The benefits of daily: emotional benefits, reminiscing, lifting the mood and spirit, relaxation, physical benefits, improving sleep and increase self esteem.
Unfortunately, many of our residents are not taken outside on a regular basis. This is sure to be a focus during your next survey by the state surveyors. Because of culture change, this is an area that the Administrator, Director of Nursing and Activity Director should put thought, planning and development into. Outdoor walks and events must be planned and implemented for all residents at a minimum of several times a week.
Even where we have seen courtyards that egress directly from the dementia unit but we don’t see frequently scheduled outdoor programs and walking programs. The court yards often times are under utilized by residents and their family. Sometimes this is due to poor scheduling and others times due to lack of staff to participate in the walking programs. Some facilities may keep the dementia gardens or outside court yards doors locked for fear of having residents outside or risk of falls. Facilities must meet the challenge of staffing nursing assistants to participate in outside walks and outside programs. A great time to schedule the nursing assistants to participate in walks might be at 3:15 P.M. and involve the 2nd shift. This is an important and necessary program. The Activity Director should provide a daily list of names who are participating in the outside programs so the Unit Manager can assign the Nursing Assistants to transport their residents. The Activity Department, Unit Managers and Director of Nursing Must work together to insure that outside programs are included in the residents plan of care.
If facilities are afraid of residents being unsupervised when outside but want to unlock the doors than consider scheduling specific times when the court yard is open and supervised.
Take the time to educate your staff on the benefits of outdoor exercise programs. If they understand the benefits of the programs and the impact this will have for the resident, they are more apt to participate willingly. Facilities need to be more sophisticated in getting this message across not only to the staff but to the family members as well.
The Activity Director and the Nurse Manager should work together to set up a detailed schedule that would indicate which residents are going out, what day and what time. The Nurse Manager should be responsible to insure that this becomes part of the nursing assistant’s daily routine and assignment. For some resident’s, the time of day for a walk may be determined by when the behavior concern is the greatest.
The Activity Director and the Activity staff should be tracking which residents went outside and their response to going outside. For those residents with care plans, outside walks should be added to the care plans, especially for those residents who have care plans for behaviors such as aggression, agitation, NPO, self isolators, depression, hospice, pain, low self esteem or experiencing loneliness. This is a valuable program to implement for those residents who receive room visits and are not participating in other planned activities. This will insure that all residents are provided the opportunity to go outside for daily walks. In addition, the Activity Director should be noting the outside walk schedule on the monthly calendar as well as scheduling group walking programs.
This is a very important aspect to include when developing your volunteer program. Volunteers can be assigned to monitor the outside court yard, serve refreshments, and assist with transporting residents to and from the outside court yard, walking with residents who require supervision and gardening with the residents.
There are many benefits for your dementia residents who participate in an outside walking program.
1. Walking and spending time outside in the sunshine and fresh air is therapeutic.
2. Walking is fun and rewarding. You might be surprised at how much they smile when walking.
3. Walking can lighten the mood. We all know how much better we feel after a walk outside. One reason is that walking releases endorphins into the body which is a natural pain killer. Per the British Journal of Sports Medicine, 30 minutes of walking boosted the mood in a depressed patient.
4. Walking helps distract the resident from the stressors found inside the facility such as noise on a long term care unit. While they are outside the resident may be distracted by the lovely surroundings of your garden and begin to calm down.
5. Walking may calm agitation, as a non-pharmalogical approach. A second year medical student, Edris Aman from St. Louis School of Medicine conducted a study that showed 30 minutes of exercise reduced agitation in the dementia patient. This study involved patients with severe dementia.
6. Many studies show that walking may assist with insomnia. A walking program can happen at any time of the day but you might want to think of scheduling it late in the day when the 2nd shift staff arrives.
7. Walking is a distraction from pain.
8. Walking encourages residents to spend more time outdoors.
9. Walking contributes to weight loss for those needing to lose weight.
10. Walking contributes to digestion and increases appetite.
11. Walking offers opportunity for socialization and decrease loneliness.
12. Walking may increase self confidence and self sufficiency.
13. Walking can increase endurance and improved balance.
14. Walking creates opportunities for meaning.
15. Walking creates opportunities for pleasure.
Encourage your family to visit with their loved ones outside and participate in the walking program. Believe it or not, sometimes you have to offer this suggestion to the family. Some family members may not even be aware that you have a court yard. Facilities should set aside an area for a designated memorial garden for deceased residents, this could be way families and friends could honor their loved ones. Encourage families to donate trees, perennials, engraved paving stones and engraved benches to remember and honor their family members. Encourage family members to work in the gardens.
We now know that consistency is very important for the dementia patient. Plan the walking program the same time every day. Use the same door to egress to the courtyard and the same path through the facility to get to the outside door.
A well designed court yard with a wandering path will encourage high functioning and independent residents to utilize this space. Per World Health Design, a study was conducted with 68 randomly selected assisted living facilities to see how design encouraged or discouraged residents in utilizing outside courtyards, gardens and wandering paths. The study found several environmental features that influenced the use of the outdoor space such as safe paving, clear indoor and outdoor connections, round trip walkways, good maintenance, choice for comfortable sitting areas and appealing views. The implications of this study are that well designed outdoor environments can have a major impact on health related behaviors in health care settings which impacts health and well being.
Create opportunities for the residents to smell the flowers, watch the birds and butterflies, listen to nature sounds and water features, observe the beauty of the garden, watch seasons change and participate in the gardening duties. This includes raised flower beds that they can reach, flowers to plant and maintain, vegetable to plant and harvest, bird feeders to fill with finch bird seed and encourages bright colored birds such as yellow finch, water gardens with fish to feed, and wind chimes to listen to.
One word of caution before planting any flower or bush is to ask your local garden which plants and flowers are toxic and these should be avoided.
Be sure to have refreshments placed outside. Offer plenty of shaded areas. Have sunscreen available for those who can apply it independently. For those who need assistance be sure to apply the sun screen before going outside. Avoid coconut scented sun screen for those residents who may have allergies to coconut. In some states you may need a doctor’s order to apply sunscreen. Order sun hats for your dementia patients through www.activitytherapy.makesparties.com or ask the family to bring in sun hats. Have staffs assigned to court yard to supervise residents, watch for fatigue or overexertion and monitor for falls.
Implementing a daily walking program and designing an environment that encourages people to use the outdoor space has benefits for all concerned. Someone once said, “It’s the journey not the destination” but in this case, the destination is extremely important, if you are to have positive outcomes for your patients. The destination in fact has everything to do with what the end goal is and that is a successful outside walking program and dementia garden.
References and Resources
- Arthritis Today article: Mental Benefits of Walking
- Reuters article: Exercise Calms Agitation Associated with Dementia
- World Health Design article: Elderly Care Increasing Outdoor Usage
- Alzheimer’s Care Today article: Therapeutic Gardens for Individuals With Alzheimer’s Disease
- Cooperative Extension Service of University of Kentucky free hand out: Active Ideas for Dementia: Help for Caregivers
- Ideas Institute article: The building as a Therapeutic Invention
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