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Outdoor programming for older adults who are frail.

The camp experience offers numerous physical, mental, social, emotional and spiritual benefits. Yet most research on this subject has focused only on the benefits of camp for youth.

However, adults over the age of 85 are a rapidly expanding segment of our population. Many suffer from pain, limited motion, and cognitive and sensory losses and may need adaptations to experience positive leisure in their lives. Unfortunately, programming for this group often does not produce much benefit, since it is based on passive, diversional activities.

It is recognized, however, that participation in outdoor programming can be rewarding for all who experience it, no matter what their individual characteristics (Johnson, 1991). One can reason, in fact, that older adults should benefit from camp for the same reasons youth do (Cosky, 1989). The key is to tailor outdoor programming to the specific needs of the participants.

This article reviews a study of participants in a "back to nature" experience conducted at a New York State psychiatric center. By addressing the patients' sensory and mobility needs, the hospital was able to develop a program of active, stimulating and therapeutic activities that produced measurable benefits. The study provides evidence that older, frail adults can benefit from an outdoor program.

Exploring the Needs of the Elderly

A review of literature concerning older adults reveals some commonalities between the needs of older, frail adults and the outcomes of the camp experience. In fact, the terms used to describe the needs of frail, older adults are quite similar to the terms used describe the benefits of camp. Exercise for maximizing mobility, spiritual development, sensory stimulation and social experiences are needs of the elderly that can be met through outdoor programming.

Exercise for Maximizing Mobility. Physical inactivity and the lack of sensory stimulation are prime causes of the boredom and atrophy in older adults who are frail. Research on the needs of older adults indicates that the therapeutic effects of exercise result in real gains in muscle strength and functional mobility (Larson, 1991).

The physical benefits of camping are mentioned throughout camping literature (Chenery, 1984; Coles, 1982; McSwegin, Parker, Pemberton, and Steen, 1991; Cosky, 1989; Sugerman, 1989). Specific recommendations for older adults who are frail include range of motion exercises accompanied by the description of movements and positions of body parts during these exercises. Ambulation on a variety of surfaces is recommended as a specific intervention for preventing falling by the elderly (Lewis, 1990). These surfaces would include grass, gravel, marsh area, meadow, and pine needles in the woods, as well as stairs, logs and other surfaces requiring the motion of stepping up and down. Larson (1991) believes that therapeutic exercise has unrealized potential in the design of institutional programs for at-risk elders.

Spiritual Development. The North American Nursing Diagnosis Association (NANDA) includes the category "spiritual distress" as a nursing diagnosis (Trice, 1990). While the diagnosis primarily refers to religion, many disciplines define spirituality in a much broader sense. The individual suffering from spiritual distress appears bored because he or she views no action as meaningful. Institutionalized older adults are particularly vulnerable to loss of the sense that life has meaning and purpose. Trice notes the importance of giving these individuals exciting and meaningful experiences that can bring about changes in the physical and emotional functioning of the patients.

It is this "quality of life" concept of spiritualism to which camp can contribute. Chenery (1984) refers to camp as a place for nurturing the human spirit. She defines this "spirit" or "religion" as a "hunger for life, the meaning in our lives, for intimacy and for community."

Sensory Stimulation. Sensory changes related to aging dramatically affect functional performance in programs and in activities of daily life. Sensory deprivation and social isolation are especially serious problems for the institutionalized elderly. One study suggests that agitation behaviors such as screaming may arise in older adults who are frail as a response to social isolation and sensory deprivation (Cohen-Mansfield, Werner, and Marx, 1990).

Furthermore, visual and auditory losses often result in social withdrawal, emotional lability, and symptoms of confusion or dementia. Mahoney (1987) notes the importance of identifying sensory loss and selecting appropriate compensatory strategies for use during programming and treatment.

At the very least, the outdoor setting provides a new or different environment for the institutionalized older adult. In addition, many nature awareness exercises were specifically designed to use the various senses (Cohen, 1989; Van Matre, 1972). Some of these include experiencing feelings, thoughts and actions such as warmth of the sun, motions, images, one's own breathing, or wind.

Many of the activities that Cohen (1989) suggests can be done without ever actually moving from a particular location. An example is an activity called "sharing nature." The leader acts as the nature guide and, without talking, leads his or her blindfolded partner through a sensory exploration of natural objects. Thoughts and feelings generated by this exercise included "I was able to sense color with my eyes closed" and "I could feel the warmth of the sun on my cheek" (Cohen, 1989).

Social Interaction. According to Johnson (1991), emotional benefits from camp include self acceptance, awareness and acceptance of others, and the development of relationships. Such benefits are achievable in programs for older adults, too. In a survey of 24 camp programs for the well elderly, Coles (1982) reported that benefits included fellowship and new friends, renewed self-esteem, and socialization.

Cohen (1989) provides an explanation for these benefits. He refers to natural sensations as "communicating connectors." These "connectors" can be used to facilitate social interaction through positive and appropriate expression of feelings. Thus, outdoor programming is particularly suited to addressing social interaction needs.

The Program

The program observed for this study was a five-day "back-to-nature" experience with 160 participants at a New York State psychiatric center. The hospital served 350 patients at the time of this event. All were diagnosed with major mental illness and 80 percent were geriatric. The patients in this program were considered the most frail and many were physically disabled as well. The "back-to-nature" program was set up so that the 160 patients would attend at least one event per day. A morning program, lunch-time cookout, and afternoon program were planned for the five days. The program was planned and staffed by recreation therapists, occupational therapists, and the nursing service.

The events took place right outside the ramp exit of the facility. In many cases, staff "brought nature" to the various programs so patients had access to moss, ferns, animals, buckets of earth and sand, flowers, lake stones, and shells. Activities focused on the therapeutic benefits of being close to nature. Small groups were established to experience the nature-oriented activities to foster learning and appreciation through hands-on study of natural objects. (See chart on page 42 for specific activities.)

Each of the outdoor activities was designed to produce the following outcomes as established by Ross (1990):

1. Patients participate in at least one activity task in

each session.

2. Each patient displays proper behavior (free from

disruptive and destructive incidents) in the sessions

they attend.

3. Patients leave each session in a calm, alert state.

Since this study was exploratory, comments from patients' charts were used to detect outcomes of the program. Of the 160 patients served in this program, three case studies were selected to represent a range of behavior changes. One case study is reviewed here; copies of the other two are available upon request from the authors.

While only three case studies were compiled, notable responses were observed in a majority of patients. Several patients who required total care reached and reacted to the environmental stimuli, five patients began to feed themselves again, and many displayed unusual calmness and awareness levels.

A Case Study

Mr. B is an 87-year-old immigrant. He spent many years as an in-patient in New York state psychiatric hospitals. Until recently Mr. B had spent the last five years in a family care home in the community. He had become depressed, stopped eating, and said that he "just wanted to die.' He had become very frail and socially withdrawn, refusing to get dressed or to leave his room. His physician referred him to therapeutic recreation services.

The referral was made during the planning process for the week-long outdoor recreation program. When asked if he would like to be in on the planning for this, Mr. B said "you'll have to have the meeting here," referring to his room. To his surprise, the staff brought coffee and did meet in his room. Mr. B told of the days he spent working outdoors clearing fields and caring for animals. He said "I skied everywhere when I was a boy; if only I could move like that again!"

Several days later, Mr. B was told there was a planning meeting upstairs in the recreation room. Surprisingly, he came. He soon began to look for the recreation staff daily, checking to find out when the next meeting was going to be held.

Two weeks later, the actual "back-to-nature" program was held. Mr. B brought his doctor out to show her around. He was excited that he helped plan the activities and spent more than four hours outdoors with the staff every day. At the end of the week Mr. B's nurse noted, "He was more relaxed and verbal, and had an improved appetite." His social worker documented he "discussed living in the community for ten minutes after weeks of no response." His doctor noted he was less depressed and felt needed and important."

For six weeks after the "back-to-nature" program, Mr. B remained active and more involved in his treatment. He was discharged back to family care 65 days after this program. He continues to do well.

Tailoring Outdoor Programming for the Elderly

While the "back-to-nature" program reviewed here does not resemble most camps, it was able to incorporate the three components that Chenery (1984) believes can lead to empowerment: 1) camper input in the planning process, 2) building projects, and 3) simple acknowledgment of the wonder of the natural world.

Modified camping activities can be an ageless way to activate older adults who are frail and institutionalized. Programs using nature are inherently stimulating to the senses and can promote thought and movement in even the most regressed clients. Such benefits can be achieved by using what nature offers right outside the back door, or even by bringing nature inside.

According to Curtin (1990), one of the most significant questions health care professionals should ask themselves is "do I serve the surviving or the living?" Outdoor programming for the elderly does indeed promote living - not just surviving.


Buettner, L.L. (1988). Utilizing developmental theory and adaptive equipment with regressed geriatric patients in therapeutic recreation. Therapeutic Recreation Journal, 22(3), 72-79. Clark, L. P., Dion, D. M., and Barker, W. H. (1990). Taking to bed: rapid functional decline in an independently mobile older population living in an intermediate-care facility. Journal of the American Geriatrics Society, 38(2), 967-972. Cohen, M. J. (1989). Connecting with nature: creating moments that let the earth teach. Eugene, Oregon: World Peace University. Cohen-Mansfield, J., Werner, P. and Marx, M. S. (1990). Screaming in nursing home residents. Journal of the American Geriatrics Society, 38(7), 785-792. Coles, R. (1982, September-October). Senior adult camping. Camping Magazine, pp. 26-27. Cosky, A. C. (1989, March). Graying America presents golden opportunities for camp directors. Camping Magazine, pp. 14-17. Curtin, L. L. (1990, December). Editorial opinion: Maria's choice. Nursing Management, pp. 7-8. DeGraaf, D. (1989, March). Camp in suburbs crosses age, racial barriers, Camping Magazine, pp. 22-26. Hupp, S. (1987, January). Camping in the third age. Camping Magazine, pp. 20-22. Johnson, R. C. (1991, May). The emotional benefits of camping. Camping Magazine, pp. 33-36. Larson, E. B. (1991). Exercise, functional decline and frailty. Journal of the American Geriatrics Society, 39(6), 635-636. Lewis, C. (1990). Changes in posture and voluntary control in the elderly. Geriatric Rehabilitation, 5(2), 1-11. Maciorowski, L. F., Munro, B. H., Dietrick-Gallagher, M., McNew, C. D., Sheppard-Hinket, E. Wanich, C. and Ragan, P. A. (1988). A review of the patient fall literature. Journal of Nursing Quality Assurance, 3(1), 18-27. McSwegin, P., Parker, M. A., Pemberton, C. and Steen, T. B. (1991, May). Healthy campers: the physical benefits of camp. Camping Magazine, pp. 28-32. Maloney, C. C. (1987). Identifying and treating the client with sensory loss. Physical and Occupational Therapy in Geriatrics, 5(4), 31-46. Morey, M. C., Cowper, P. A., Feussner, J. R., DiPasquale, R. C., Crowley, G. M. and Sullivan, R. J. (1991). Two-year trends in physical performance following supervised exercise among community-dwelling older veterans. Journal of the American Geriatrics Society, 39(6), 549-554. Reed, R. L., Pearlmutter, L., Yochum, K., Meredith, K. E., and Mooradian, A. D. (1991). The relationship between muscle mass and muscle strength in the elderly. Journal of the American Geriatrics Society, 39(6), 555-561. Ross, M. (1991). Integrative Group Therapy, 2nd Edition, Thorofare, New Jersey: Slack, Inc. Sugarman, D. A. (1989, March). A |wild' idea: adventure programs help seniors |age successfully.' Camping Magazine, pp. 18-21. Trice, L. B. (1990). Meaningful life experience to the elderly. IMAGE: Journal of Nursing Scholarship, 22(4), 248-251. Van Matre, S. (1972). Acclimatization: a sensory and conceptual approach to ecological involvement. Martinsville, Indiana: American Camping Association. Zemke, R. Knuth, S., and Chase, J. (1984). Change in self-concepts of children with learning difficulties during a residential camp experience. Occupational Therapy in Mental Health, 4(4), 1-12.
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Author:Kennison, Judith
Publication:Camping Magazine
Date:May 1, 1993
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