It is increasingly recognized that the built environment serves as a therapeutic resource. Research over the past several decades has demonstrated convincingly that certain elements of the physical environment can have a direct impact on the behavior and functional abilities of individuals with dementia. It is important to recognize that what many caregivers now consider "basic knowledge" was, as little as 15 years ago, cutting edge and radical. For example, the vast majority of dementia specific care units now have some type of personalized orientation cue at the bedroom entrance. Whether this be a few photos, a shadow box with a few small trinkets, or a larger curio cabinet that can hold a whole china doll collection or awards from a distinguished military career, it is now widely accepted that incorporating this type of personalized cue is an important part of a therapeutic environment. Yet, as little as 15 years ago, this was a new concept. Wesley Hall, in Chelsea Michigan, was one of the first care settings to use a photo (current) and some other personalized cue on the bedroom door to help its eleven residents find their rooms more independently. The Corinne Dolan Center expanded this concept and built large, well lighted display cases at each bedroom entrance, which allowed for more personal items to be displayed. Systematic research demonstrated that items that had greater personal significance-whether it be photos or trinkets-did indeed help most residents find their rooms more independently (Namazi, Rosner, & Rechlin, 1991). The research, along with significant dissemination of information about the Corinne Dolan center, helped make this concept of personalized bedroom cues an industry standard.

Not all concepts that were developed as therapeutic interventions worked as successfully. The wandering path is a perfect example of an intervention that has received significant amounts of attention, although no clear best practice solution has yet emerged. Early caregivers noted that many people with dementia spent significant amounts of time "wandering" the hallways, sometimes going into rooms and disturbing others or their belongings, and sometimes getting "stuck" at the ends of hallways where the path ended. The proposed "solution" was to develop wandering loops or paths, sometimes referred to as racetrack designs. When facilities were built based on this premise, they often found it didn't solve the problem. This is in large part because the original "problem" it was meant to solve was never well defined. Was the goal to simply encourage residents to continue to walk around in circles? Or was the goal to discourage them from entering others' private spaces? Or to be able to circle around and eventually find their own room? How do these goals relate to another common goal of trying to find ways to engage residents in more meaningful activities? At the Corinne Dolan Center, whose design included a "racetrack" layout, the proposed research on continuous versus dead-end paths had to be cancelled because residents were sufficiently engaged in the programming that few spent any significant amount of time walking around the building. This example clearly shows that when the desired outcome is not well defined, it's hard to develop a solution that's likely to be effective. And yet, this "solution" of creating a continuous loop is often still applied without understanding the complexity of the issues. In many facilities, it appears that the creation of a walking loop is the end goal, with little or no consideration for what the desired therapeutic benefits for the residents are.

Enlightened caregivers and researchers understand the importance of creating opportunities for meaning and pleasure in the daily experiences of the people with dementia they care for. Simply "wandering" around a circular path, be it inside or outside, that has no intrinsic opportunities for meaning or pleasure is not considered therapeutic. And yet, even today a significant number of facilities are built and courtyards created with "circular" paths that have no places to sit and rest, nothing of interest to look at or watch, nothing to encourage either an activity or dialogue with others. To be fair, there are also facilities and courtyards that do pay attention to these important considerations, that create places that are ripe with opportunities for residents to experience the pleasures of smelling fresh flowers, watch birds or squirrels at play, sit and chat with a friend, watch others engaged in work or play, or pick up a magazine or catalogue to leaf through while resting along the path. These facilities have taken a hard look at what goals they want to accomplish (e.g., increased pleasure, more meaningful interactions with others, and reduced frustration associated with being confronted by barriers or dead ends), and developed multi-faceted solutions that address these goals through both the physical and social environments.

The various aspects of the built environment are not yet clearly understood. For instance, while many people assume there are significant benefits to spending time outdoors, there is almost no clinical evidence of potential benefits for people with dementia. Can it impact depression, improve circadian rhythm and sleeping patterns, reduce agitation? Are there specific elements of outdoor space that are necessary to achieve these goals, or is it simply enough to be outside? Assuming there are some benefits, there is the related question of what features or elements encourage people to spend time outdoors. We have all seen courtyards in long-term care settings that are almost always empty and unused. How much is use of outdoor space related to the physical design, and how much is use tied to staff-either their commitment to use outdoor spaces or their fear that they are unsafe for residents to use on their own. This example demonstrates the confluence of physical and social/organizational dimensions of the setting-and the need to always consider them together. I have seen facilities with wonderfully designed outdoor spaces, secure with level paths and delightful plantings and both quiet and active areas, that were never used because the staff kept the door to the courtyard locked. When asked about it, they replied that they feared for the residents' safety because there were roses in the garden that had been donated by a prominent family. While you and I can come up with several potential solutions to resolve this issue, the point is that organizational and social factors had a direct influence on the potential impact (or lack of impact, since the residents were unable to use the courtyard) on the physical environment.

Thus, while the concept of the physical environment as a therapeutic resource in long term care settings has been given increasing recognition over the past several decades, we need to move into the next level of sophistication in learning about how it impacts residents and staff. More and more care providers are looking to the built setting to serve as an active partner in the caregiving environment. In fact, many seem to believe that making a change in the physical environment can "solve the problems" of their particular situation. Unfortunately, it's almost never that simple. Environments are as complex as the people who inhabit them, and there are almost never simple solutions to complex questions. The settings we experience are a confluence of physical, social, personal and organizational factors, all perceived through our own experiences. And when the challenges of dementia, and the myriad ways it affects how people interpret what they perceive, the situation becomes even more complex.

Reference
Namazi, K. H., Rosner, T. T., & Rechlin, L. (1991). Long-term memory cuing to reduce visuo-spatial disorientation in Alzheimer's disease patients in a special care unit. American Journal of Alzheimer's Care and Related Disorders and Research, 6(6), 10-15.

Additional References
Calkins, M. P.(Producer) (2001) Creating Successful Dementia Care Settings, Vol. 1-4. Baltimore MD: Health Professions Press.

Day K., & Calkins, M. P. (2001). Design and Dementia. In R. Bechtel (Ed) Handbook for Environmental Psychology. John Wiley & Sons.

Brawley, E. (1997). Designing for Alzheimer's disease: Strategies for creating better care environments. New York: John Wiley

Reprinted with permission from Aspen Publishers, Inc., Alzheimer's Care Quarterly (ACQ), Volume 2, Issue 4. Order by calling 1-800-638-8437 or on-line at www.aspenpublishers.com/journals/acq.