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DOI: 10.21005/pif.2016.25.D-01
THERAPEUTIC GARDEN DESIGN FOR PATIENTS
WITH NEURODEGENERATIVE DISEASES
OGRODY TERAPEUTYCZNE DLA PACJENTOW
Z CHOROBAMI NEURODEGRADACYJNYMI
Agnieszka Anna Olszewska
dr inż. arch. kraj.
University of Porto, Portugal
Faculty of Science
Department of Geosciences, Environment and Spatial Planning
Jakub S. Bil
dr inż. arch.
Andrzej Frycz Modrzewski Kraków University
Faculty Architecture and Fine Arts
STRESZCZENIE
Niniejszy artykuł omawia koncepcję ogrodów terapeutycznych przy ośrodkach opieki dla
pacjentów z chorobami neurodegeneracyjnymi, takimi jak choroba Alzheimera
i demencje. Opisano sposób, w jaki projektowanie takich przestrzeni może wyjść na
przeciw specyficznym potrzebom mieszkańców i opisuje najnowsze badania dotyczące
wytycznych dla projektowania ogrodów w pobliżu szpitali, ośrodków medycznych i do-
mów spokojnej starości. Przegląd literatury zestawiono z wynikami najnowszych badań
na temat wpływu różnych rozwiązań zaprojektowanych w krajobrazie na aktywność mó-
zgu. Zgodnie z tymi badaniami, przestrzenie charakteryzujące się zgodnością projektu,
przejrzystym systemem komunikacji i sygnalizacji, wprowadzeniem elementów archety-
powych oraz nacisk na szereg wizualnych niuansów, mogą być szczególnie korzystne dla
pacjentów z chorobami neurodegeneracyjnymi.
Słowa kluczowe: Alzheimer, architektura, demencja, krajobrazu, neurodegeneracyjne,
ogrody, projektowanie, terapeutyczne.
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ABSTRACT
This paper explores the concept of therapeutic gardens surrounding healthcare institu-
tions treating neurodegenerative diseases, such as Alzheimer’s and Dementias. It fo-
cuses on how the design of such spaces can address the specific needs of residents, and
describes the recent studies concerning the most relevant guidelines for therapeutic gar-
den design near hospitals, medical centers, and retirement homes. The literature study is
compared with results of our recent study on the brain response to different landscape-
design features. According to which an outdoor space with a high level of design com-
patibility, inward space composition, a clear communication and signage system, while
introducing archetypal elements and factoring several visual nuances, can be especially
beneficial for patients with neurodegenerative diseases.
Keywords: Alzheimer’s, architecture, dementia, design, garden, landscape, neurodegen-
erative, therapeutic.
1. INTRODUCTION
Neurodegenerative diseases are characterized by molecular changes in nerve cells that
lead to the loss of functions of neurons, progressive loss of neurons, and their death [22].
A variety of symptoms lead to neural dysfunction, resulting in emotional, cognitive, and
social behavior impairment [34][23]. The patient’s behavioral patterns are represented by
a set of symptoms that are, in many cases, the same for mental disorders. For this rea-
son, the patient might often be misdiagnosed [30]. Usually patients are delusional, hallu-
cinating, while exhibiting strange, destructive and aggressive behaviors and, for example,
suffer from sleep cycle deprivation and wandering [26].
Environment plays a crucial role in the treatment of patients with neurodegenerative dis-
eases as well as other mental health disorders. The quality of space as a system of inter-
connected features is determined by the functional arrangement of elements, materials,
and strategies utilized by a designer. Depending on the type of disease, different thera-
peutic priorities should be considered and addressed through the design. The specificity
of spatial solutions for patients suffering from neurodegenerative diseases requires vari-
ous structures, in terms of the scale of the entire space as well as individual wards, interi-
ors, and their equipment. Both patient stress management and improvement of the quality
of life are the basic aims that can be achieved through the design of the indoor as well as
the outdoor environment. A properly designed outdoor environment can have a tremen-
dous contribution to alleviating the effects of diseases through stress reduction and im-
provement of the sense of well-being for patients and staff of healthcare units.
The design of environment for patients with neurodegenerative diseases should be ad-
justed to their behavioral patterns and focused on stress reduction. The pace of develop-
ment of the disease plays an important role as well. Neurodegenerative diseases mostly
develop slowly, across decades, and lead to impairment in numerous aspects of life of an
individual, and finally to death. However, sometimes the development of the disease is
much faster, and its intensity not equally severe. That is why the space should be pre-
pared in a way that would be suitable for patients representing all different stages of de-
velopment of neurodegenerative diseases, i.e., those whose disease is in the early stage
and those who need to be assisted in their everyday life.
The following pages explain how the values of the outdoor space and their proper use by
the designer can, directly or indirectly, contribute to the mental health and well-being of
the residents of healthcare units. All the described physical attributes of space have been
supported by scientific evidence and fall under the concept of evidence-based design [7].
AGNIESZKA ANNA OLSZEWSKA, JAKUB S. BIL 261
2. NEURODEGENERATIVE DISEASES - BASIC STATS
The most common factor of neurodegenerative diseases is aging. It is the main risk factor
[13] especially for neurodegenerative diseases of the Central Nervous System that often
cause dementia [8][24]. Dementia is a leading cause of mortality and morbidity, especially
in developing countries, and about 66% of all deaths every day are related to conditions
of dementia [16][11][18]. More than 50% of people over 85 years of age suffer from de-
mentia, between 75 and 84 years of age - 19% and between 65–74 nearly 3%. The spec-
trum of dementia includes several conditions such as: Alzheimer’s Disease - AD - 50%-
70% of all cases [10], Vascular Dementia - VD - 25%, Dementia with Levi bodies -DLB -
15%, and others [12] [9]. In DSM V, dementia is classified as a neurocognitive disease [1]
and in ICD-10 classified as F00 - F09 (ICD-10/F: Mental and behavioral disorders). Neu-
rodegenerative diseases are classified in ICD-10 as G30-G32: Other degenerative dis-
eases of the nervous system [31].
The most widely applied pharmacotherapy has shown limited benefits in longer term
treatment [3]. Moreover, concerns are growing over their serious side effects, which in-
clude stroke and death. Therefore, providing a possibility of a non-pharmacological ap-
proach to alleviate the symptoms of neurodegenerative diseases is very important. There
is increasing evidence in support of alternative therapies, such as exposure to therapeutic
gardens.
3. GENERAL OBJECTIVES OF HEALING GARDENS
Charm of natural scenery is an influence of the highest curative value; highest, if for no
other reason, because it acts directly upon the highest functions of the system, and
through them upon all below, tending, more than any single form of medication we can
use, to establish sound minds in sound bodies [6].
Ryc. 1. Widok na strefę wypoczynku, Naumkaeg Estate, Berkshires, Massachusetts / USA. Projekt Fletcher
Steele, Źródło: fotografia A.A. Olszewska wykonana w czerwcu 2014 r.
Fig. 1. A view over the resting area at the Naumkaeg Estate, Berkshires, Massachusetts / USA. Design by Fle-
tcher Steele. Source: photo by A.A. Olszewska, June, 2014.
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It is clear that the environment around us affects behavior as long as we can perceive it.
Disciplines such as environmental psychology, architecture, and landscape architecture
are increasingly interested in using scientific tools in order to explore the relationship be-
tween different elements of the designed space and our behavioral-psychological re-
sponse. Fletcher Steele’s project (Fig. 1) presents an example of a space that, according
to recent studies on contemplative landscapes, was ranked by experts as the highest in
contemplative values5.13 points in 1-6 Likert scale [21]. The evaluated factors included
the contribution of the following key-components to the overall contemplativeness of the
photograph: Landscape Layers, Landform, Vegetation, Compatibility, Color and Light,
Archetypal Elements, and Character of Peace and Silence. The garden view from the
Figure 1, in a later EEG experiment, induced in the brain activity of observers patterns
associated with positive emotions and attention restoration, compared with the landscape
images classified as non-contemplative [21]. The Naumkaeg Estate in Berkshires, Mas-
sachusetts is a good example of what quality of design would be recommended in order
to achieve mental restoration in the people exposed to it.
Studies on the etiology of Alzheimer suggest that the built environment, including contact
with nature through the exposition to gardens, can play an important role in alleviating the
effects of the disease [33]. The direct aims to achieve are connected with the health
benefits of patients, including the diminishment of behavioral disorders, such as agitation,
aggressive behavior and aimless wandering, better sleep, improved general health and
nutritional status. These indirectly lead to improvements in the well-being of staff mem-
bers and savings for the management of the institution (e.g., limiting the number of su-
pervising staff employees).
While it may be difficult to predict patient response to the specific event or space, it is
possible to set up preliminary conditions for a therapeutic environment. The outdoor
space linked with the health-care unit, where patients have contact with fresh air, sun-
shine, and vegetation, seems to be a very promising area to implement design solutions
that enhance people’s mental capacities by including some contemplative design strate-
gies. However, in the literature, those gardens prepared specifically for improving the
well-being of patients are called therapeutic or healing gardens.
Their main objectives besides contact with nature, with all its restorative benefits, is to
stimulate physical exercise in a pleasant, familiar and secure environment, and encour-
agement of self-managed exploration, while being stimulating and challenging to increase
mental alertness. They also promote a sense of independence and provide reduction of
stressors.
4. PRESENCE AND ACCESSIBILITY
The most obvious and most important way for the therapeutic garden to benefit patients
is, of course, its presence as a space attached to the institution where they reside. Most
of the retreats provide some outdoor space, however rarely, designed to meet special
therapeutic criteria. Due to the lack of a proper design, and lack of constant staff-
supervision, the outdoor space is accessible for patients only according to a certain
schedule, which limits their independence. The study from Marlborough Alzheimer’s heal-
ing garden [33] (Fig. 2) showed the therapeutic effect of the mere fact that the residents
have the opportunity to come and go to the garden as they please. In the proper design
of such spaces, it is very important for it to be safe and fully accessible at least during the
daytime.
5. COMPATIBILITY OF DESIGN AS A THERAPEUTICAL ELEMENT
In any landscape design, compatibility plays a vital role, and according to the recent
study, it contributed most significantly to the overall contemplativeness of tested views
AGNIESZKA ANNA OLSZEWSKA, JAKUB S. BIL 263
(Item-Total Corr. =.831). It is identical to the Adjacent Scenery feature of the VRM model
[29]. It is about the quality of the design in terms of balance and harmony. Basic premises
of compatibility are:
− explicit spatial order, keeping the design in balance;
− absence of disturbing elements;
− openings and closings of views worked out well;
− harmonious physical and visual relations between the elements;
− a clear communication system and hierarchical relations between signage elements
Ryc. 2. Ogród terapeutyczny przy ośrodek opieki nad osobami z chorobą Alzheimera Hearthstone, Marlbor-
ough, Massachusetts, Źródło: fotografia, Naomi Sachs [27]
Fig. 2. Therapeutic garden at theHearthstone Alzheimer’s Care, Marlborough, MA. Photo by Naomi Sachs [27].
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As to ensure the high level of compatibility in the enclosed space, inward composition is
recommended, where all elements are organized around one clear center. The example
presented in Fig. 3 shows the enclosed space with an inward composition, which also
scored high in terms of compatibility in the Contemplative Landscapes Expert evaluation -
4,8 points in 1-6 Likert scale [21]. This inward composition of space can also be mani-
fested through a clear signage system, which is very important for avoiding the feeling of
being lost in space.
Ryc. 3. Trawnik otoczony nasadzeniami, Ogrody Biskupie przy katedrze w Waszyntonie, Washington D.C, USA
Źródło: fotografia A.A. Olszewska wykonana w lipcu 2014
Fig. 3. Large lawn area in Bishop’s Garden with an inward orientation of space composition. National Cathedral,
Washington D.C., USA. Photo by A.A. Olszewska, July 2014.
Designs with a high level of compatibility can provide a soothing experience to the person
exposed to them. The lack of distracting stimuli, intruding the tranquility of the space, can
create a ground for restoring one’s attention capacities and reduce the level of stress
[16].
6. WAY FINDING AND LANDMARKS
Being lost can be terrifying. Fears of getting lost can contribute to people’s decisions to
avoid unfamiliar natural settings. By contrast, feeling reassured that one will be able to
find one’s way can increase the quality and potential benefits of nature experiences [16,
p. 49].
Neurodegenerative conditions often cause patients to get lost even in familiar places.
This is due to visuospatial disorientation with impaired optic flow perception, and is one of
the earliest clinical manifestations of a disease. Getting lost can cause anxiety and agita-
tion, diminish the effectiveness of applied therapy, and put people’s safety at risk [28].
The environmental features associated with both reduced aggressive and agitated behav-
ior include the ambient environment that residents can understand [32 p. 709].
Simplicity and clarity of the landscape design can significantly facilitate patients’ spatial
orientation and navigation skills. Spaces with a clear, intuitive design, where it is very dif-
AGNIESZKA ANNA OLSZEWSKA, JAKUB S. BIL 265
ficult to get lost, can also be called naturally-mapped environments [20]. These spaces
are characterized by very few pathways visible from anywhere around the space with
clear entrances and exits, and with well-considered accessibility expressed through the
ground cover. Fig. 4 presents an example of distinction of the area that should not be ac-
cessed by covering it with stones.
Ryc. 4. Ogród terapeutyczny przy szpitalu Overlake, Bellevue, Washington, USA Źródło: fotografia John Souza
[27].
Fig. 4. Therapeutic garden at the Overlake Hospital, Bellevue, WA, USA, Photo by John Souza [27].
An important part of way finding is associated with introducing landmarks in the space.
Landmarks are the reference points singled out from other elements in a setting. They
play a central role in how people develop their cognitive maps [19, p. 48]. The landmarks
in the therapeutic gardens can be architectural elements, such as a wooden shelter,
bridge or tower, or elements originating from nature, for example, a single old tree, water
feature or big stone. The studies about landscapes of contemplation showed that the
scarce elements in the landscape, originating from nature, play the role of archetypal
elements that are familiar to everyone on a deep psychological level. They can be power-
ful, meaningful and symbolically-charged elements, evoking memories, (both personal
and more general), eliciting recognition, and inducing contemplation [14, p. 61].
According to Jungian dream analysis, archetypal elements can evoke a strong, uncon-
scious, emotionally-charged response and attraction [15]. For example, one seeing a hill
wants to climb it, seeing a water mirror or an old branched oak, one wants to be closer to
it. Utilizing natural archetypal elements in therapeutic gardens is important for two major
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reasons: to help enhance the naturally-mapped environments with landmarks and to
make patients feel even more familiar with the space (on a deeper, unconscious level).
7. VISUAL ASPECT
One of the bases of Attention Restoration Theory (ART) is that natural environments pro-
vide the involuntary type of attention:
in involuntary attention… attention is captured by inherently intriguing or important stimuli,
and in voluntary or directed attention, … attention is directed by cognitive-control proc-
esses [5, p. 16].
Landscapes classified by environmental psychologists as “natural” do not demand con-
centration or focus on details, therefore they enable a decrease of stress level as well as
regulate emotions, anxiety and mental fatigue.
An important aspect of the visual character of the therapeutic garden are views in the dif-
ferent distance zones that it provides (see Fig. 5).
Ryc. 5. Trzy główne strefy widokowe,
zaadaptowane z Yeomans’ 1983.
Fig. 5. Three main distance zones,
Adapted from Yeomans’.
There should be opportunity to observe the closest landscape elements, such as the pet-
als of the flowers, as well as the long distance elements. Even though long-distance
views are usually most difficult to achieve for designers, they can be very beneficial for
the patients with neurodegenerative diseases. Far views can:
stimulate in the observer a sense of personal freedom, mental pleasure and stress reduc-
tion. The need of distant view or in many cases it can be a desire, results from a human
nature of a hunter, consolidated in our genes. Fulfilling this desire can be done beyond
our will or completely consciously [25].
Another benefit of introducing long distance views is described in a broad study by Bates
[4]. This author of alternative therapy aimed at improving eyesight without the use of
glasses or lenses. He suggested that nearly all eye problems are caused by the habitual
strain of the eyes. Switching the visual attention between the close, middle and far dis-
tances, repeatedly and continuously, blinking and relaxing from time to time, may signifi-
cantly improve one’s eyesight quality. The mechanism of switching between the distance
zones seem to stress the importance of introducing far vistas in any type of therapeutic
garden.
Considering the eye disorders associated with aging, namely age-related degeneration
which can induce social withdrawal and avoidance of going outdoors, it is important to
minimize the reflectiveness of garden elements, and provide shaded zones as well as the
AGNIESZKA ANNA OLSZEWSKA, JAKUB S. BIL 267
transition zone where the brightness gradually intensifies as the patient walks outside.
Sitting areas and observation points should always be in shaded areas (the Fig. 1,
Fig. 2), as direct exposition to the sun may increase anxiety and induce panic.
8. PRELIMINARY GUIDELINES
The most important design guidelines for the therapeutic gardens for patients with NG
together with the expected benefits of their use are presented in Table 1. The further
benefits of those guidelines include the aforementioned general benefits.
Tab. 1. Guidelines for the designers of therapeutic gardens with the expected benefits.
Category Specific guideline Expected benefits
Accessibility Fully accessible in a daytime
Long-distance views (over 400m into the
landscape)
Increase sense of independence, per-
sonal freedom
Views
Switching between short and long distance
objects
Improving eyesight
Explicit spatial order, keeping the
design in balance
Absence of disturbing elements
Openings and closings of views worked out
well
Harmonious physical and visual relations
between the elements
Sense of tranquility, peace and silence,
limiting level of stress, anxiety and limita-
tion,
Attention restoration
Invites to rest and relax outdoors
Clear communication system and hierarchi-
cal relations between signage elements
Compatibility
Inward orientation of space
Small number of paths visible from every
point in space
Natural mapping
Managing accessibility with the ground cover
Dominant, scarce elements in the space
easy to relate to
Reduced risk of getting lost and better
orientation in space
Landmarks
Landmarks in a form of archetypal element
(e.g. single large tree, stone, water-pond,
circle)
Identification (felling familiar) with the
space on the deep unconscious level
Shade & Gradual intensification of brightness Alleviating eye irritation
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Limiting the reflectiveness of garden ele-
ments
Reflectiveness
Lack of direct exposition to sun in the resting
areas
Feeling of security, limiting overheating
9. CONCLUSIONS
As ne
w research approaches emerge, there is an increasing number of findings about
how the quality of the built environment can influence peoples’ behavior and how benefi-
cial it can be for inpatients of mental-health services. Simultaneously, there is a demand
for therapy approaches alternative to commonly used pharmaceuticals to reduce the
symptoms of neurodegenerative diseases. For any health-care unit, especially those
which deal with mentally ill patients, it is vital to design so-called therapeutic gardens and
the literature on this subject is extensive.
Due to that fact that neurodegenerative diseases have a chronic character, it is not ex-
pected that the treatment would ever allow patients a full recovery, returning to their
homes and day-to-day lives. The specificity of neurodegenerative disease care units is to
help alleviate the symptoms of those diseases and help reduce their impact on the pa-
tients’ caregivers and on their own well-being, in effect, prolonging their life.
Studies have shown that a poorly prepared space can reinforce aggressive and agitative
behaviors among patients and, thus, reduce the expected treatment effects which indi-
rectly leads to more resources being spent on their care and treatment. On the other
hand, the right design of the surrounding environment can help in limiting those factors.
Moreover, the described studies on the behavioral-physiological response to different
design strategies suggest that there may be some elements in the designed landscapes
that can actually enhance the sense of well-being in patients.
These landscape features (design guidelines) should not be treated as a set of universal
rules, as each design approach varies in terms of various factors, and also because there
is no one ideal design for any one space, but instead an infinite number of appropriate
ones [2]. Nevertheless, the presented design guidelines can successfully inform and in-
spire the landscape architectural and architectural practice as well as contribute to the
growth of the area of evidence-based design.
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AUTHOR’S NOTE
AGNIESZKA ANNA OLSZEWSKA, Master in Landscape Architecture from Warsaw Uni-
versity of Life Science, Founder of Terra-Landscape, PhD in Landscape Architecture and
Urban Ecology at University of Porto, Portugal. Research interest in application of neuro-
science methods in urban planning and landscape architecture practice. Successfully ran
a series of EEG experiments on different landscape settings, as a part of her 5-year-long
research project titled Contemplative Values of Urban Parks and Gardens, Applying Neu-
roscience to Landscape Architecture at the University of Porto, Faculty of Science and in
collaboration with the Laboratory of Neuro-Psychophysiology at the Faculty of Psychol-
ogy of the same university. Author’s Orcid number: ORCID: 0000-0002-5278-0374
JAKUB S. BIL, Phd Eng Arch, Licensed Arch.,IARP/MPOIA, PTPS, SHL, Adjunct at
Andrzej Frycz Modrzewski Kraków University, Faculty of Architecture and Fine Arts. Sci-
entific activity in the following fields: Architecture of psychiatric hospitals, Architecture
healthcare facilities, Evidence Based Design for healthcare facilities, Evidence Based
Design for mental healthcare, Therapeutic role of the built environment, general health-
care facilities, mental healthcare, Reduction of environmental hazards in hospitals
through the modernization of the built environment. Author’s Orcid number : 0000-0002-
2701-4475
O AUTORZE
AGNIESZKA ANNA OLSZEWSKA: Absolwentka Warszawskiej Szkoły Architektury Kra-
jobrazu (SGGW), założycielka studia projektowego Terra-Landscape. Doktorat na Uni-
wersytecie w trakcie którego z powodzeniem przeprowadziła serię doświadczeń na róż-
nych typach krajobrazu, jako część 5-letniego projektu badawczego zatytułowanego
"Wartości Kontemplacyjne Parków i Ogrodów miejskich, zastosowanie Neuropsychofizjo-
logii w Architekturze Krajobrazu" na na Wydziale Nauk Uniwersytetu w Porto oraz we
współpracy z Laboratorium NeuroPsychofizjologii na Wydziale Psychologii tejże uczelni.
Zainteresowania naukowe skupiają się wokół kontynuowania prac nad metodyką zasto-
sowania metod neuropsychofizjologicznych w praktyce urbanistycznej i architekturze kra-
jobrazu.
JAKUB S. BIL: Praktykujący architekt, adiunkt, zatrudniony na Wydziale Architektury
i Sztuk Pięknych Krakowskiej Akademii im. Andrzeja Frycza Modrzewskiego. Członek:
MOIA, PTPS i SHL. Prowadzi działalność naukową w zakresie: architektury szpitali psy-
chiatrycznych, architektury obiektów s
łużby zdrowia, Evidence Based Design – projekto-
wania opartego na dowodach naukowych, Evidence Based Design for mental healthcare
– projektowania lecznictwa psychiatrycznego opartego na dowodach naukowych, tera-
peutycznej roli środowiska zbudowanego obiektów służby zdrowia, szczególnie szpitali
psychiatrycznych, redukcji zagrożeń w obiektach szpitali poprzez modernizację środowi-
ska zbudowanego.
Kontakt | Contact: olszewska.agn@gmail.com, jacobbil@gmail.com
