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Wandering: repaving the way you think. (Cover story).

No doubt wandering is one of the most common problems encountered with people with dementia or Alzheimer's disease. Experts estimate that the behavior occurs in up to 40 percent of cognitively impaired nursing facility residents and up to 70 percent of cognitively impaired community dwellers.(1)

If you search the medical literature, you'll be hard pressed to find many scientific articles evaluating wandering and even harder pressed to find studies evaluating the usefulness of behavioral interventions. But many in the field anecdotally and intuitively know that certain design elements do work to either lessen the agitation that can promote wandering or accommodate the behavior, making it less problematic.

Many experts now say that what requires change is not the behavior of wandering, but rather our way of thinking about it. Caregivers have tended to view wandering as aimless, non-goal-directed walking or pacing. But Maggie Calkins, PhD, president of I.D.E.A.S. Inc. (Innovative Designs in Environment for an Aging Society), a Kirkland, Ohio-based consulting firm and research institute, and author of the book Design for Dementia: Planning Environments for the Elderly and Confused (National Health Publishing, Owings Mills, Md., 1988), says that the very term "wandering" represents an outdated way of thinking. "It assumes purposelessness," she says. "Caregivers may not always understand the purpose, but there usually is a reason for the behavior."

Calkins prefers to call the behavior whatever term best describes the underlying motivation.

For example, if a resident is looking for something--even if it is something that cannot be found in the residence--then that resident is wayfinding or searching. If the resident is anxious or agitated about a recent occurrence, then that resident may be pacing or venting frustration. Perhaps the resident is bored or in need of exercise; then that resident is walking or exercising. The resident may be trying to escape a noisy, overstimulating, or aggravating environment. And if the resident goes out for a stroll, as we all sometimes like to do, then the resident is simply strolling. Calkins points out that if we leave a crowded, noisy room in which people have been telling us what to do or taking to us incessantly, we're not accused of eloping or wandering--so why should residents of long term care facilities be accused of doing so?

Calkins says it is of utmost importance to consider what residents did in their lives before they arrived at a facility. Perhaps a resident used to rise each morning and walk three miles for exercise. Such a resident might be termed a morning wanderer when he is simply engaging in a behavior that is routine for him.

Linda Erickson, social worker at Bethany Hearten House in LaCrosse, Wis., agrees. She recalls a resident who every night would stroll the halls of the facility, checking the door of every resident's room. It wasn't until the staff discovered from the resident's family that he used to be a night watchman that the behavior made sense.

There's no place like home

Calkins offers a variety of simple strategies to address the wandering behavior. For example, if a resident is walking in search of home, increase the number of personal possessions that resident has in her private space as well as in common areas. Find out more about what the resident did at home. If she used to hang laundry out to dry each morning, add a clothesline, pins, and a laundry basket full of old towels and sheets to your outdoor space. For someone who used to clip coupons, have a small table in a common area equipped with the daily newspaper and blunt-edge scissors. If she used to knit, have a basket of yarns available so that even if she can't actually form stitches, she can at least feel the familiarity of the yarn and perhaps wind the skeins into balls. If a resident was a handyman, have a toolbox and an old phone or radio available that he can take apart and put back together. (See "Putting the resident first," May 2001 CLTC, page 24.) Many solutions don't require a lot of money--just interes t, creativity, and motivation.

According to Calkins, the more a facility resembles a resident's home, the less likely the resident is to wander aimlessly. Homes generally do not have long corridors terminating with locked doors or dead space. As much as possible, eliminate these elements from designs. Calkins also recommends having plenty to do and explains that this doesn't necessarily entail staff to organize and attend activities. Having activity space where residents can engage in independent, unattended activities is equally important.

Cynthia L. Senke, CPM, vice president of Harbour Village in Milwaukee, a 44-suite community devoted exclusively to the needs of people with dementia, agrees with the importance of a homelike environment. Harbour village is made up of four "households" made up of five to six suites surrounding a living room and common country kitchen, which opens to a covered patio, screened porch, and therapeutic gardens. Each household also has its own entrance and foyer, a laundry room, and a nursery nook. All corridors and activity spaces are linked to provide an interesting walk for residents. Along the way are places to stop and attend to activities or objects. Corridors are short passages lined with nooks and alcoves. Every corridor terminates in a turnaround or destination point, which helps to provide residents' walking with a sense of purpose.

Senke says that when they were designing the facility, they recognized that certain approaches to cueing can be almost infantile and can unintentionally demean residents. At the same time, they were faced with households of similar geography and layout and the desire to promote purposeful wandering and exploration between households and throughout the hub areas. The goal became distinguishing "my house" from "your house" so residents could find their way "home."

Two distinctly different garden settings-the therapeutic activity garden and the passive reminiscence garden-provide programming opportunities for staff and residents while advancing the idea that gardens properly planned for residents with dementia reduce stress and encourage a sense of wellbeing. A pathway leads residents through herbs, aromatic plants, colorful flowerbeds, shrubs, and cutting gardens, providing options for people with varying sensory abilities, sunlight sensitivity, and degrees of awareness and orientation.

Harbour Village also contains life-skills lounges. These are areas of the facility that are adapted according to resident interests. Currently they have an office, a schoolroom, a quilting/ sewing lounge, and a workshop. Reminiscence lounges include a gardening lounge, a sports/games lounge, a fishing lounge, and a pet shop. The built-in flexibility of these spaces not only allows staff to modify programs in the face of new research and development, but to have the lounges reflect the current resident population and to evolve with future populations.

Ron Traupane, vice president of Design and Architecture for HCR ManorCare, Toledo, Ohio, which manages close to 400 assisted living and skilled nursing facilities, says that some recent research is showing that "many of the things we in architecture have always placed a greater value on may not be as important as we thought."

For example, he explains that traditionally "facilities were often lamped with parabolic-lens light fixtures because it was thought that this type of lighting minimized glare, but we've discovered it also casts shadows, which may be more of a negative in terms of safety."

Another example of a potential shift in thinking concerns the ubiquitous cue boxes placed by each resident's door. Traupane explains, "Many of us have long believed that these boxes needed to contain anything other than printed material, such as photos, mementos, colors, etc., but we're finding that having names in large, printed letters may be equally important and that many residents with dementia or early Alzheimer's disease may be able to process more printed material than we thought."

Dan Dokken, vice president of Law/Kingdon, a Wichita Kan.-based architectural firm that has designed facilities for HCR ManorCare, Somerford Corp., and other long term can facilities, says that his firm doesn't design to prevent wandering. "We design to accommodate it," he says. The focus is or eliminating frustrations-such as locked doors at ends of corridors- and on providing security so that residents can wander all they like in safety.

In search of

John Zeisel, Columbia University-trained sociologist, president of Hearthstone (a group of assisted living centers for people with Alzheimer's disease), and professor at the Harvard Graduate School of Design, says, "Many people tend to think of wandering as a symptom of Alzheimer's disease; it isn't. We just haven't learned to care for it properly."

Zeisel explains that what is a true symptom of the disease is not knowing how to find one's way. "We lose our cognitive mapping capability with Alzheimer's," he says, adding that very often patients wander because they are looking for something-tangible or intangible-that is lost. He says the answer is to put what residents might like to find at the end and along every pathway so that even if they don't find what they set out for, they find something else that interests them.

Each corridor in Zeisel's facilities leads to something to do-a kitchen, a sitting area, an activity, a garden, a player piano. He strives "to make every hallway a museum"-every corridor wall is covered with photographs, paintings, lithographs, shadowboxes, musical instruments, old albums, and activity boxes. Zeisel asks, "Would you want to walk through the Guggenheim Museum in New York City if there wasn't anything on the walls?" He reports that staff and residents sometimes even use the hallways for bowling. Bulletin boards with pictures of staff and residents enable residents to see themselves engaged in activities,

"The answer is not to stop people from wandering, but for the rest of us to stop calling it wandering," Zeisel says with conviction. "Just as we wouldn't say, 'Bring that broken arm in here,' we shouldn't refer to residents as wanderers; it's dehumanizing."

Finding one's way outside

Zeisel applies the same philosophies to outdoor spaces. He and Martha Tyson, MLA, senior associate at Douglas Hills Associates, a landscape architectural firm in Evanston, Ill., developed a system to accommodate wandering outdoors. It is described in their chapter, "Alzheimer's Treatment Gardens," in Marcus and Barne's book, The Healing Gardens (John Wiley and Sons, New York, N.Y., 1999). Zeisel and Tyson based their recommendations on the work of Kevin Lynch, which is described in his book Image of the City (MIT Press, Cambridge, Mass., 1960), which showed how people organize complex spaces in their minds to more easily find their way.

Lynch identified five elements that all people use for orientation and wayfinding. As applied to garden spaces, these elements include: paths (channels for moving people through the space); edges (boundaries, barriers, or seams that enclose the space or join parts together); districts (sections of the space that are recognizable as having a unique identifying character); nodes (junctions or foci to and from which people travel--they are usually places of intense activity); and landmarks (reference points, such as gazebos, fountains, etc.).

Incorporating Lynch's elements into garden design for people with dementia or Alzheimer's relieves users from having to organize a cognitive map and makes them more competent in their use of the garden. To these elements, Zeisel and Tyson added views (into, within, and from the garden), furnishings (benches, lighting, sculpture), plantings, and symbolic cues (anything evoking a symbolic or familiar purpose that helps to orient users to time and place, or that helps with memory recall) to further adapt a garden specifically to populations with Alzheimer's disease or dementia.

Zeisel says of Hearthstone, "We have clear walking paths through our gardens but with stopping points and things to do along the way as well as true destinations so that people aren't just walking aimlessly in a circle."

Even if you build it, they may not come

When planning outdoor spaces, Calkins reminds us that "A beautiful physical environment in and of itself doesn't work; it works only in conjunction with other aspects. In other words, you can build the most beautiful garden in the world, but if there's no reason for residents to go there, or if there's nothing to do once they get there, or if access is hindered, they won't come."

Judy Wengerd, RN and horticultural therapist at McGregor Home in Cleveland, agrees. She said they worked with Martha Tyson to create a spectacular garden space for their residents with dementia. Brick walking paths, water gardens, benches, a gazebo, potting areas, a music area complete with wooden xylophone, and an orchard along a promenade sat almost completely unused for about two years until Wengerd convinced the powers that be that the remotely located and awkward access door to the garden needed to be moved and replaced. Now the residents of McGregor Home enjoy their garden often and whenever they please.

Cynthia Longchamps, founder of the Family Life Center in Grand Rapids, Mich., a respite care facility for people with dementia and Alzheimer's disease, agrees that wandering is not bad in and of itself. "It's how we deal with it," she says. "Caregivers are afraid of people getting hurt, so we restrict and restrain in an effort to protect." She says the answer is to create environments in which people can wander and explore safely.

That was the thinking behind the center's $700,000 restorative therapeutic garden that took two years to complete and a planning board of approximately 35 people. Longehamps says that she doesn't need to see any scientific studies documenting the healing properties of garden spaces. She remarks, "The garden, by giving residents the freedom to get outdoors and breathe fresh air or get away from someone always being around, or the opportunity to just sit under a gazebo or by a waterfall, does nothing short of giving them life."

New York-based Lisa Maher is a regular contributor to CLTC.


(1.) Nasr, Samer, Tuck, Osterweil: Nonpharmacologic management of wandering behavior in the nursing home: A consensus Approach. Annals of Long Term Care (formerly known as Nursing Home Medicine). 1997;5(12):401-411.
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Title Annotation:Innovative Designs in Environment for an Aging Society designs gardens for nursing home residents; wandering behavior in Alzheimer's disease patients
Author:Mather, Lisa A.
Publication:Contemporary Long Term Care
Geographic Code:1USA
Date:Dec 1, 2001
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