Arch. Gerontol. Geriatr. suppl.

6 (1998) 369-372
0167-4943/98/$19.00 0 1998 Elsevier Science Ireland Ltd. All right reserved 369

THERAPEUTIC GARDENS

P.J. OUSSET, F. NOURHASHEMI, J.L. ALBAREDE and P.M. VELLASa

Department of Internal Medicine and Clinical Ceront$logy, Toulouse University

Hospital, Purpan-Casselardit, F-31300 Toulouse, and Department of Research on
Architecture and Aging, University of the Third Age, F-31000 Toulouse, France

SUMMARY
Since outdoor areas are becoming more common in nursing homes, the con-
cept of “therapeutic” garden is relatively new in long-term facilities. In direct
contact with the natural environment of trees, flowers and greenery, such a
garden should offer properly designed walks, facilities for other forms of exer-
cise, and the opportunity for relaxation, sheltered spots for individual and
places reserved for the social gatherings, whether in sunny or shaded areas,
according to the season. It would offer facilities that would encourage fitness as
well as prevent illness during aging in healthy residents in need of either phy-
sical exercise or relaxation. For those patients affected by loss of autonomy,
locomotor dysablements, sensorial defects, behavioral or mental problems, the
garden would also have a specially designed area to provide a sense of security,
safe walks and easy supervision. In addition, the garden would not only benefit
patients. Its facilities would be a valuable addition for visitors, relatives,
friends, children, institution staff, and more generally the neighborhood as a
whole.

Keywords: nursing homes, therapeutic garden, wandering behavior, environmen-

tal intervention

INTRODUCTION
A garden is a place for being happy in. Why not, therefore. make available
to elderly people areas in which garden art and architecture, combined with the
latest insights from gerontological research, would take their needs into account.
Such gardens would be open not only to the elderly, to relatives, friends and
institution staff, but also, where possible, to the neighboring community, with
playgrounds for the younger children.
Thanks to its different functions, the therapeutic garden can play a role in
improving a lot of many different kinds of people, whether they be those elderly
people who enjoy good health or those who tend to become disoriented.

PROPERTIES OF A THERAPEUTIC GARDEN

1. The therapeutic garden constitutes an outdoor zone in which one has
avenues and walks or strolls along planned routes, affording sunlit areas and
shaded zones depending on the season and the position of the sun. Straight
lines that reveal inviting views give way to curves that soften the the layout,
limit the area and bring the users back to their point of departure under the
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ever watchful eye of staff. From the supervision point of view, this is parti-
cularly valuable as there are many problematic “strollers” in most homes. Ac-
cording to Heim (1986), 4 % of the residents in old people’s homes show severe
difficulties. and manifest unsuitable behavior when out for exercise. In 1977. the
U.S. National Home Survey estimated the figure at 11.4 8 (NCHS, 1979).
Taking a walk has both a positive and negative side. It fosters a basic de-
gree of independence and a certain amount of physical exercise. It obviates the
complications of those condemned to remain bedridden. But it can also be the
cause of accidents. It tends to disturb the environment and requires extra su-
pervision, what the staff may not always be happy to provide.
According to Fennelly (1984). residents at risk are thought to be a source
of higher salary costs to the tune of about 2.500 Dollars a year. In fact, they
are often secured. This can be a source of further psychological trauma, aggra-
vating the sense of loss of independence and encouraging the invalid mentality
and a whole range of related suffering. In such a situation, the prescription of
sedatives only contributes to undernourishment, disorientation and falls.
For these reasons, Monsour and Robb (1982) advocate a range of solutions
that include giving residents full and repeated briefings so that they do not lose
their bearings, physical exercise, group activities, entertainment, the suppres-
sion of factors that may cause stress, photos of home in residents’ rooms, a
photo of the resident on his room-door, bracelet with telephone number (for
runaways), clear signposting, locking of doors.. . , and the therapeutic garden.
The therapeutic garden fullfils a special function for these patients. It
needs to have a particular architectural structure and composition in which al-
ternate landmarks (trees, bushes, flowers, decorative elements, benches) obviate
the risk of loss of bearings and a resulting feeling of helplessness. These land-
marks are completed with familiar signposting, identical to that used inside the
establishment so that there is a continuity indoors and out.
Such a specialized layout may be required for the whole of the therapeutic
garden where it caters for nothing but residents who are psychologically dis-
turbed. It may however be limited to a part of the garden, which is then divi-
ded into two quite distinct, clearly defined parts, by the use of screens of trees
and bushes, so that there is a zone for “strollers” and another one for the most
robust elderly residents, visitors, staff and neighbors. Cohen-Mansfield and
Werner (1995) underline the use of outdoor visits for improving the well-being of
nursing home residents who tent to pace and for decreasing disruptive behavior
such as trespassing.
2. For the healthy elderly person, the therapeutic garden encourages walk-

ing. and the provision of physical exercise which plays an important preventive
role in many areas such as muscle trim, keeping articulations supple, psycho-
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physiological balance, the prevention, most notably, of cardiovascular, psychi-

atric and pulmonary pathologies (Rosen and Giacomo, 1978). A zone set aside for
physical exercise, games of various sorts, can also constitute a privileged meet-
ing point for the development of socializing.
The walks set in sundy areas but avoiding the full glare of the sun with a
provision for benches or seats mean that patients can expose their face, arms,
forearms and legs to the sun to encourage the metabolism of vitamin D, the lack
of which can be responsible for certain pathological conditions and brittleness of
the bone during the winter period.
Physical exercise combined with walking (given added impetus by the plea-
sant surroundings] constitute an efficient mean of preserving locomotor automa-
tisms, maintaining, keeping up or improving the sense of balance, and stimulat-
ing the appetite. In addition, undernutrition, so frequent in the elderly for
physiological and psychological reasons, can be prevented. At the same time, an
improved psycho-physiological balance is fostered, and this helps to ensure bet-
ter sleeping patterns at night (Young et al., 1988).
Easily accessible flower-beds planted out with aromatic plants, flowers,
bushes, fruit trees such as apple, pear, fig, and almonds, as well as black-
currant, raspberry, redcurrant and goosberry bushes, can provide activity and
natural physical exercise (gardening] and at the same time constitute elements in
a familiar landscape, integrated into the garden area just as they are in the tra-
ditional houses of the surrounding countryside complete with their vegetable gar-
dens, orchards and ornamental flowerbeds. Such a garden is felt to be part of
the external countryside.
The composition of the garden, with its trees, bushes, flowers, fruit trees,
grassy meadow areas, gravel, stone-lined avenues, varied contours of rises and
dips, is a reminder of the surrounding countryside. For the elderly who, for
various reasons, undergo acute mental deterioration, the remembered countryside
of their childhood is an anchor point that favors stability and equilibrium. This
childhood memory is recalled by means of the composition of the garden. It en-
ables a lost part of identify to be reconstituted and fosters a palpable relation-
ship in time and space between the subject and the familiar landscape seen and
walked. The garden also confers continuity and a sense of security at a time
when everything else recedes beyond the grasp and topples, whether it be rela-
tions, friends, projects or plans for the morrow.
Over and above the train of upheavals in socio-affective relationships, dis-
continuity in the living place, the image of the body, these well-known accompa-
niments of aging process, the perception of the garden renews the sense of con-
tinuity in time and place. Interrelationships are established with the color of
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the leaves and the flowers, the smell of the earth, the play of light filtering
through the branches.
The wind rustling in the trees, the water running out of a pond, the smell
of the damp soil, the heat of the sun warming the skin, face, hands and arms,
all this is an encouragement to natural relaxation and brings a feeling of phy-
sical and mental well-being. The physiological rhythm of movements made of
breathing is in harmony with the movement of the branches overhead and the
water in the pond nearby. It is a rhythm that reduces tension, stress and dis-
equilibrium. The composition of the garden’s forms, volumes and colors, and the
rhythm of these, assuages, tranquilizes, and soothes.
The garden should also be a friendly place, with clearly defined zones,
shaded area protected from the wind, lending themselves to social gatherings,
with provision for play areas for the younger children in the neighborhood, not
forgetting secluded spots for quiet contemplation. The structure, the architec-
tural composition and the functions of the therapeutic garden make it an essen-
tial element in the planning of centres for the elderly (Cohen-Mansfield and
Werner, 1998).

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