3. Biomedical Therapy.
Biomedical therapy includes Psychopharmacology, Electroconvulsive Treatment (ECT), and Psychosurgery.
Psychopharmacology involves the use of medication to treat disorders. It is the most common form of biomedical therapy. It is used for emotional, behavioral and mental disorders and benefits many patients. Drug treatment is often combined with psychotherapy.
Physicians prescribe different drugs based on the nature of the problem and the patient's medical history. Drug types include Antipsychotic drugs (such as Thorazine), Antianxiety drugs (Valium, alcohol), and Antidepressent Drugs (Tofranil, prozac, lithium).
Electroconvulsive treatment (ECT) is used only for cases of major depression, delusions and hallucinations, or life-threatening sleep and eating disorders that cannot be effectively treated with drugs. Modern methods of administering ECT employ low "doses" of electric shock to the brain along with sedatives and relaxants to minimize the unpleasantness to patients. 60-90% of ECT patients show rapid improvement.
Psychosurgery is a rare, last resort treatment when psychotherapy and psychopharmacology have failed. This surgery consists of surgical destruction of neural pathways in the brain. One example of this type of surgery is a cingulotomy, which involves severing the pathway from the frontal lobe to the basal ganglia regions, called the cingulate pathway, of the brain.
4. Milieu/Community Therapy.
Milieu therapy can be defined as the type of treatment...... in which the patient's social environment is manipulated for his benefit.
One type of this treatment is the therapeutic community, in which patients stay at a residence where they lead a highly structured life. This approach can be used for substance abusers, or people with severe disorders that impair their ability to function in normal living.
The Origins and Beliefs of Milieu:
Milieu work has its primary roots in the therapeutic community movement, which emphasized the role of social and societal relationships in developing, maintaining and ameliorating mental illness and its symptoms. Malcolm Pines, in his paper Forgotten Pioneers: The unwritten history of the therapeutic community movement (Therapeutic Communities, 20:1, 1999), traces the 20th century, pre-WWII development of milieu therapy. During this period, diverse practitioners began to apply Freuds insights into intrapsychic life to the group and social arenas, and extend the thinking and understanding of the role of the community in the life of the individual.
David Kennard, in his book An Introduction To Therapeutic Communities (Jessica Kingsley Publishers, 1998, London), picks up the story as the pioneering work of Wilfred Bion and others in rehabilitating traumatized war victims initiated dramatic developments in this approach to treating mental illness. Development continued with the evolution of therapeutic community treatment for individuals with a broader range of psychiatric diagnoses, including severe personality disorders, psychotic disorders and substance abuse.
The therapeutic community movement and milieu therapy share several common values and beliefs. First is that the clients difficulties are both expressed in, and arise in, relationships with other people. The milieu allows for highly sensitive and attuned understanding of how a clients relationships are derailed. It is also the arena where the client is offered many opportunities to find better ways of relating.
A second belief is that therapy is essentially a learning process that involves both clients and staff. To be effective in the milieu, the therapist must be available to be affected and changed by his or her interactions with the client. This self-reflective teaching model rests on the understanding that clients and staff share the same psychological processes, while recognizing the difference in the roles they play in the clinical situation.
The Methods of the Milieu:
The milieu therapist program plays a central role in the treatment of the client. The therapist meets the client in the client's home, in a consulting room, at the beach during a client outing, in the hospital during an acute episode, in the hallway, the parking lot and pretty much anywhere in between. The milieu is where the concepts and insights of the "in-office" therapies meet the reality of the client's daily life.
In all of their work with clients, milieu therapists draw upon a psychodynamic understanding of client experience and behavior. For example, in response to a client who is persistently disruptive in therapy groups, the milieu therapist might offer an interpretation, set a limit or ask the client to leave, encourage other group members to give the client feedback on the effect of the behavior on the group, and/or call upon the rest of the staff to consider what is being expressed for the client group through this behavior. Similarly, when a client refuses to apply for a job, after agreeing to do so as part of his or her treatment plan, the milieu therapist must determine the most effective intervention.
In the work of case management, milieu therapists encourage clients to practice new ways of engaging with others and the world. Essentially, the clinician consults to the client's project of pursuing treatment and life. For example, Sarah joined our program in the throes of an extended psychotic episode. In the early stages of her treatment, her milieu work focused on managing her medication, preparing to join a client household and making a commitment to a sobriety management program. Later, she emphasized learning to communicate with housemates, friends, family and others in ways that built relationships, rather than creating havoc. In the final months of her treatment, she worked with her milieu therapist to develop and execute a plan for the next stage in her life including a living situation, a social network, a vocation and ongoing support.
Milieu therapists also help clients to recognize existing ego resources and then to expand and strengthen them. A client who copes with stress by cutting herself would work to identify and use alternative means for managing distressing feelings. The clinician would also help her to develop a strategy for her life that would help her to modify or avoid overwhelming situations and seek out more positive experiences.
In working in their role as team members, milieu therapists contribute to the team's overall understanding of, and approach to working with, the individual client and the client community. They work with the team to share, understand, and contain the difficult emotional experiences of the team's clinical work. This occurs within the context of the supervisory and team settings: individual supervision (managerial and clinical), milieu team meetings, milieu consultation group, treatment team meetings, and the staff group as a whole.
In all of these settings, the milieu therapist is working to translate his or her psychodynamic understanding and emotional experience of the client and the team into clinical interventions that have a practical, positive and measurable effect on the client's ability to plan and pursue his or her life.
There are a variety of treatment modalities or forms available to meet each patient's individual needs. The modality chosen will depend on factors such as diagnosis, age of the patient, family support, financial constraints and patient preference.
Individual Psychotherapy is the modality with one patient and one therapist. This form offers the most attention to the patients individual concerns however it can be limited in that it cannot directly study family or social relationships. There are many different styles or theoretical orientations of therapists such as psychodynamic, cognitive and behavioral.
Family Psychotherapy is conducted with all or as many members as possible of a family. The work may all be done with the entire group or involve various combinations of family members. The process helps identify and modify maladaptive or destructive interaction patterns as well as foster group communication and problem solving skills.
Group Psychotherapy....... is conducted with at least three and up to fifteen patients together. This modality offers the patient the opportunity to interact with others and learn from them as well as study their own relationship style. Patients usually encounter some social anxiety in beginning group therapy, however it offers an ideal environment in which to challenge such anxieties.
Homogeneous groups are made up of individuals with similar concerns such as chemical dependency or women's issues. These groups offer support and understanding and the feeling that one is not the only one struggling with a given set of concerns.
Heterogeneous groups have a more varied membership and more closely approximate the world at large.
Stress Management training is a process of identifying stressors, learning ones physiological and cognitive responses to stress and developing techniques to manage those responses. Common stress management techniques are systematic desensitization, relaxation training, and cognitive therapy.
Medication Management is the use of psychotropic medications to manage emotional, cognitive, and behavioral symptoms. The medication is prescribed by psychiatrists after thorough evaluation and with ongoing monitoring. Medication management is usually implemented in conjunction with other therapies aimed at treating the underlying causes of the condition
3) TOPIC: AGORAPHOBIA.
What is agoraphobia?
Agoraphobia is the fear of being in a situation where one might experience anxiety or panic and where escape from the situation might be difficult or embarrassing. People with agoraphobia may feel anxious about such things as loss of bladder or bowel control or choking on food in the presence of others. They also might feel anxious about being home alone, leaving home, or being in a crowded place, such as on public transportation or in an elevator, where it might be difficult or embarrassing to find a way out. To avoid the anxiety associated with these situations they refrain from putting themselves into such situations.
The severity of agoraphobia is quite variable. Some people with agoraphobia live essentially normal lives as they avoid potentially anxiety-provoking situations. However, in severe cases of agoraphobia, people are homebound. These people work very hard to avoid any and all situations that might cause them to become anxious.What characteristics are associated with agoraphobia?
Two major characteristics are associated with agoraphobia:
- People develop anxiety when thinking about being in a situation out of their comfort zone. They fear feeling trapped in a situation where they judge it would be difficult or embarrassing for them to leave the situation.
- People avoid those situations which bring them anxiety or panic. It is the fear of the anxiety that leads to the agoraphobia.
Does agoraphobia affect males, females or both?
About twice as many women than men report that they experience agoraphobia. Frequently, people report that the onset of their agoraphobia followed a stressful or traumatic event in their lives.
At what age does agoraphobia begin?
The most common age for agoraphobia to begin is when a person is in his/her mid to late 20s.
How often is agoraphobia seen in our society?
Less than one percent (1%) of the population of the United States is thought to have agoraphobia.
How is agoraphobia diagnosed?
People suffering from agoraphobia sometimes fear that they are "losing" their mind or "going crazy" because of their fears and anxiety. Consequently, they might seek advice from a mental health professional.
Also, it is common for a friend or family member to notice that another person is reluctant to leave home without a companion. For instance, a spouse might notice that his/her mate finds reasons not to leave home. In these cases, the friend or family member often urges the agoraphobic to seek professional help.
A mental health professional arrives at the diagnosis of agoraphobia by taking a careful personal history from the client/patient. There are no laboratory tests required to confirm a diagnosis of agoraphobia nor are there any physical conditions that must be met. However, it is very important for the therapist not to overlook a physical illness that might mimic or contribute to a psychological disorder. If there is any doubt about a medical problem, the mental health professional should refer to a physician who will perform a complete physical examination and request any necessary laboratory tests.
Terms You Need to Know
Dementia is a medical condition that interferes with the way the brain works. Symptoms include anxiety, paranoia, personality changes, lack of initiative, and difficulty acquiring new skills. Besides Alzheimer's disease, some other types or causes of dementia include alcoholic dementia, depression, delirium, HIV/AIDS-related dementia, Huntington's disease (a disorder of the nervous system), inflammatory disease (for example, syphilis), vascular dementia (blood vessel disease in the brain), tumors, and Parkinson's disease.
Alzheimer's disease is the most common form of dementia. It proceeds in stages over months or years and gradually destroys memory, reason, judgment, language, and eventually the ability to carry out even simple tasks.
Delirium is a state of temporary but acute mental confusion that comes on suddenly. Symptoms may include anxiety, disorientation, tremors, hallucinations, delusions, and incoherence. Delirium can occur in older persons who have short-term illnesses, heart or lung disease, long-term infections, poor nutrition, or hormone disorders. Alcohol or drugs (including medications) also may cause confusion.
Depression can occur in older persons, especially those with physical problems. Symptoms include sadness, inactivity, difficulty thinking and concentrating, and feelings of despair. Depressed persons often have trouble sleeping, changes in appetite, fatigue, and agitation. Depression usually can be treated successfully.
Delirium may be life-threatening and requires immediate medical attention.
Purpose of this BookletThis booklet is about Alzheimer's disease and other types of dementia. It presents information for patients, family members, and other caregivers. It talks about the effects Alzheimer's disease can have on you, your family members, and your friends.
The booklet describes the early signs and symptoms of Alzheimer's disease. Sources of medical, social, and financial support are listed in the back of the booklet. This booklet is not about treating Alzheimer's disease.
What Is Alzheimer's Disease?
In Alzheimer's disease and other dementias, problems with memory, judgment, and thought processes make it hard for a person to work and take part in day-to-day family and social life. Changes in mood and personality also may occur. These changes can result in loss of self-control and other problems.
Some 2 to 4 million persons have dementia associated with aging. Of these individuals, as many as two-thirds have Alzheimer's disease.
Although there is no cure for Alzheimer's disease at this time, it may be possible to relieve some of the symptoms, such as wandering and incontinence.
The earlier the diagnosis, the more likely your symptoms will respond to treatment. Talk to your doctor as soon as possible if you think you or a family member may have signs of Alzheimer's disease.
Research is under way to find better ways to treat Alzheimer's disease. Ask your doctor if there are any new developments that might help you.
Who Is Affected?
The chances of getting Alzheimer's disease increase with age. It usually occurs after age 65. Most people are not affected even at advanced ages. There are only two definite factors that increase the risk for Alzheimer's disease: a family history of dementia and Down syndrome.
Family History of Dementia
Some forms of Alzheimer's disease are inherited. If Alzheimer's disease has occurred in your family members, other members are more likely to develop it. Discuss any family history of dementia with your family doctor.
Persons with Down syndrome have a higher chance of getting Alzheimer's disease. Close relatives of persons with Down syndrome also may be at risk.
What Are the Signs of Alzheimer's Disease?
The classic sign of early Alzheimer's disease is gradual loss of short-term memory. Other signs include:
- Problems finding or speaking the right word.
- Inability to recognize objects.
- Forgetting how to use simple, ordinary things, such as a pencil.
- Forgetting to turn off the stove, close windows, or lock doors.
Mood and personality changes also may occur. Agitation, problems with memory, and poor judgment may cause unusual behavior. These symptoms vary from one person to the next.
Symptoms appear gradually in persons with Alzheimer's disease but may progress more slowly in some persons than in others. In other forms of dementia, symptoms may appear suddenly or may come and go.
If you have some of these signs, this does not mean you have Alzheimer's disease. Anyone can have a lapse of memory or show poor judgment now and then. When such lapses become frequent or dangerous, however, you should tell your doctor about them immediately.
Possible Signs of Alzheimer's Disease
Do you have problems with any of these activities?
- Learning and remembering new information. Do you repeat things that you say or do? Forget conversations or appointments? Forget where you put things?
- Handling complex tasks. Do you have trouble performing tasks that require many steps such as balancing a checkbook or cooking a meal?
- Reasoning ability. Do you have trouble solving everyday problems at work or home, such as knowing what to do if the bathroom is flooded?
- Spatial ability and orientation. Do you have trouble driving or finding your way around familiar places?
- Language. Do you have trouble finding the words to express what you want to say?
- Behavior. Do you have trouble paying attention? Are you more irritable or less trusting than usual?
Remember, everyone has occasional memory lapses. Just because you can't recall where you put the car keys doesn't mean you have Alzheimer's disease.
Consulting the Doctor
Identifying mild cases of Alzheimer's disease can be very difficult. Your doctor will review your health and mental status, both past and present. Changes from your previous, usual mental and physical functioning are especially important.
Persons with Alzheimer's disease may not realize the severity of their condition. Your doctor will probably want to talk with family members or a close friend about their impressions of your condition.
The doctor's first assessment for Alzheimer's disease should include a focused history, a physical examination, a functional status assessment, and a mental status assessment.
Medical and Family History
Questions the doctor may ask in taking your history include: How and when did problems begin? Have the symptoms progressed in steps or worsened steadily? Do they vary from day to day? How long have they lasted?
Your doctor will ask about past and current medical problems and whether other family members have had Alzheimer's disease or another form of dementia.
Education and other cultural factors can make a difference in how you will do on mental ability tests. Language problems (for example, difficulty speaking English) can cause misunderstanding. Be sure to tell the doctor about any language problems that could affect your test results.
It is important to tell the doctor about all the drugs you take and how long you have been taking them. Drug reactions can cause dementia. Bring all medication bottles and pills to the appointment with your doctor.
Do you take any medications? Even over-the-counter drugs, eye drops, and alcohol can cause a decline in mental ability. Tell your doctor about all the drugs you take. Ask if the drugs are safe when taken together.
A physical examination can determine whether medical problems may be causing symptoms of dementia. This is important because prompt treatment may relieve some symptoms.
Functional Status Assessment
The doctor may ask you questions about your ability to live alone. Sometimes, a family member or close friend may be asked how well you can do activities like these:
- Write checks, pay bills, or balance a checkbook.
- Shop alone for clothing, food, and household needs.
- Play a game of skill or work on a hobby.
- Heat water, make coffee, and turn off the stove.
- Pay attention to, understand, and discuss a TV show, book, or magazine.
- Remember appointments, family occasions, holidays, and medications.
- Travel out of the neighborhood, drive, or use public transportation.
Sometimes a family member or friend is not available to answer such questions. Then, the doctor may ask you to perform a series of tasks ("performance testing").
Mental Status Assessment
Several other tests may be used to assess your mental status. These tests usually have only a few simple questions. They test mental functioning, including orientation, attention, memory, and language skills. Age, educational level, and cultural influences may affect how you perform on mental status tests. Your doctor will consider these factors in interpreting test results.
Alzheimer's disease affects two major types of abilities:
- The ability to carry out everyday activities such as bathing, dressing, using the toilet, eating, and walking.
- The ability to perform more complex tasks such as using the telephone, managing finances, driving a car, planning meals, and working in a job. When a person has Alzheimer's disease, problems with complex tasks appear first and over time progress to more simple activities.
Treatable Causes of Dementia
Sometimes the physical examination reveals a condition that can be treated. Symptoms may respond to early treatment when they are caused by:
- Medication (including over-the- counter drugs).
- Problems with the heart, lungs, or blood vessels.
- Metabolic disorders (such as thyroid problems).
- Head injury.
- Vision or hearing problems.
Drug reactions are the most common cause of treatable symptoms. Older persons may have reactions when they take certain medications. Some medications should not be taken together. Sometimes, adjusting the dose can improve symptoms.
Delirium and depression may be mistaken for or occur with Alzheimer's disease. These conditions require prompt treatment. See the inside front cover of this booklet for more information on delirium and depression.
Therapeutic Activities for People with Alzheimer's:
|How can therapeutic activities help manage the symptoms of Alzheimer's?|
Planning structured, individualized activities that involve and interest the person with Alzheimer's may reduce many of the more disturbing behavioral symptoms of AD, such as agitation, anger, frustration, depression, wandering or rummaging. Health professionals who work with Alzheimer's patients say therapeutic activities should focus on the person's previous interests, cue the person to old and recent memories and take advantage of the person's remaining skills while minimizing the impact of skills that may be compromised.
What kinds of therapeutic activities are best?
Successful activities support a person's sense of self - bringing out their skills, memories and habits - and reinforce the person's sense of being in a group, which can provide friendship, mutual support and spiritual connectedness.
Any number of activities may be beneficial depending on the individual, and different activities may affect certain symptoms but not others. (For example, music therapy may improve eating in some people but not others.) Any former hobby or interest of the person is a candidate, from gardening, cooking, painting and drawing, to singing, playing musical instruments or listening to music, etc. Routine is essential: Activities that are done regularly, perhaps even at the same time every day if possible, may help establish routine and increase the person's sense of stability.
Some of the therapeutic activities that have been shown in rigorous research studies to reduce certain problem behaviors in people with Alzheimer's are:
- playing music of the person's choosing;
- one-on-one interaction;
- playing videotapes of family members;
- walking and light exercise;
Several programs that combine various therapeutic activities have also shown favorable results in people with Alzheimer's. These include a multifaceted program of music, exercise, crafts and relaxation, and structured sessions combining meditation, relaxation, sensory awareness and guided imagery, so-called mind-over-body techniques designed to calm and soothe.
Click here to read a special feature on therapeutic gardens.
The Clinical Milieu
In this issue I will focus on the work of clinical milieu team. The milieu includes traditional case management services, vocational development, group therapy, household facilitation and many other activities that help the client make significant changes in his or her life. In using the word "milieu" we are speaking to the breadth of the interactions and factors that are included in this part of the clinical work, and the sense of the milieu as surrounding and interwoven with the rest of the treatment.
The essential effort in this work is to facilitate the patients engagement with the world. The milieu perspective emphasizes the effect of social relationships and ego capacities on the clients ability to get better, and addresses that arena where the client actually puts into practice his or her developing perspectives on life and love. In this work, the clinician draws on a remarkable diversity of therapeutic understandings and methods. He or she must be highly adaptable to new situations, quick to intuit and understand the behavioral implications of the clients emotional and psychological states, and able to shift sets quickly.
Milieu team members are also the front line in receiving and making sense of the primitive defensive maneuvers of the clients. They are the most exposed, in terms of the amount of time they spend with the clients, in the variety of roles they play, and their work as the emergency back-up system. The milieu therapist must be a person of many talents with the ability to think on his or her feet.
This is remarkably subtle, complex and varied work. The milieu therapist must, again and again, meet the complex challenges of making contact with another human being under very difficult circumstances in a way that leads to change.
What is a Psychotherapy Group?
Groups are everywhere. Our daily lives are filled with various groups of people, from families to work groups to church groups. What distinguishes these groups from one another is their purpose. The purpose of a psychotherapy group is to promote the personal growth and psychological health of its members. Although the composition, theme and length may vary, all psychotherapy groups have in common:
- A group psychotherapist, specially trained in the theory and technique of group psychotherapy. This distinguishes a psychotherapy group from groups that function without a psychotherapist, called self-help groups.
- A regular meeting time and place. Psychotherapy groups generally meet once weekly, but this can vary. Some groups are time limited (meet for a fixed number of sessions), others are open ended with members joining and leaving from time to time.
- A focus on self-examination and exploration of interpersonal relationships. This is the ultimate focus of most types of psychotherapy, although the particular methods and style varies depending on the therapists orientation. This distinguishes a psychotherapy group from a support group. In a support group, members generally share a common concern or issue and help one another adapt to difficult or challenging circumstances.
Who can benefit from Group Psychotherapy?
It is part of being human to experience some loneliness and sadness from time to time, but persistent anxiety or depression, or ongoing difficulties with relationships, may signal the need for consultation with a mental health professional.
The mental health field offers a confusing variety of practitioners, and it is often difficult to know what kind of professional to see. The partial list below may help you understand the training and qualifications of these mental health professionals. You have the right to ask about the credentials of the person you seek help from:
Psychiatrist (M.D.); a physician specializing in the treatment of emotional problems
Licensed Clinical Psychologist (Ph.D., Psy.D.); a doctoral degree in treatment of emotional problems
Social Work (M.S.W., A.C.P); a masters degree with advanced training and supervision
Licensed Professional Counselor (L.P.C.); a masters or doctoral degree, additional supervision, and a licensing examination
During the consultation, the consultant will determine the nature of your problems and what treatment approach may be most beneficial. If group psychotherapy is right for you and you are right for group psychotherapy, the consultant may arrange for you to join a group. Your plan of treatment may also include individual, family or marital psychotherapy as well as medication prescribed by a psychiatrist.
What happens during Group Psychotherapy?
It is not unusual to feel anxious and uneasy when first joining a psychotherapy group, but with time the anxiety will diminish and you will feel more comfortable about sharing your concerns. Group members are urged to be as honest as they can about their thoughts and feelings. Sometimes there are silent periods during group time, and other times everyone has something to share. It is the therapists responsibility to monitor the group, give feedback about what he or she may think is happening in the group, and help the group work through difficult periods. It is each group members responsibility to be on time for group, attend all sessions, talk honestly about the problems they are having, and to keep what happens during group time completely confidential.
How long does Group Psychotherapy take?
That depends on the nature and extent of your problems and on your capacity and motivation for self-examination. Group members generally remain in group for one to three years, and leave when the problems that brought them to group are resolved.
|What are therapeutic gardens?||
Therapeutic gardens, specially maintained gardening facilities that help people remain connected with nature, provide benefits for a wide variety of people who are ill or recovering from illness. They are used to help people recovering from surgery in healthcare facilities, for those who are undergoing physical rehabilitation and for individuals with Alzheimer's disease who are living in special care residences or who are living at home. Research indicates that physical as well as visual access to nature helps people recover from illness quicker, reduces stress and lowers blood pressure. Spending time outside helps a person maintain circadian rhythms (the sleep/wake cycle). There is also natural absorption of vitamin D when exposed to sunlight for brief periods of time, which is important for maintaining strong bones.
Why are they important and what role do they play in treatment?
Access to outdoor environments, in specially designed gardens can be beneficial to the physical, social, psychological and spiritual health of a person. A therapeutic garden can provide exercise to a patient through normal activities such as planting, weeding, walking and bending. Many of the same activities that occur inside a residence can be continued outdoors. For example, having access to a putting green is a good activity for people who have played golf throughout their lives. Adding play equipment to a garden will give visitors something to do with the resident while they visit. These are elements of a garden that help a person stay connected to the world around them. Therefore, everyone who uses the garden will benefit.
How do therapeutic gardens benefit people with Alzheimer's?
Gardening and bird watching are very popular activities for people of all ages. Watching a brilliant sunset, smelling the fragrance of a lilac tree and listening to the sounds of water cascading in a fountain are all wonderful ways to excite the senses in a positive way. These activities are very important because they help a person remain connected to the world around them. It is important for a person with Alzheimer's to be able to continue enjoying outdoor activities they have done throughout their lives. (Note: this outdoor area must be safe and secure.) Often, we do not know how to reach a person with Alzheimer's disease, and creating environments that support their needs will help us better understand who they are.
How do I find facilities with these gardens for my loved one?
Pictures in brochures can be misleading, so ask the staff of a facility if you can visit their community garden in order to determine whether a therapeutic garden has been created. The elements of a garden should include the following:
- Raised planters for people to use if they are in a wheelchair, walker or have other physical limitations;
- Birdfeeders, birdhouses and birdbaths;
- Plant materials should be nontoxic and not harmful;
- Walks and paths should be smooth level surfaces that are glare-free;
- Private sitting areas should be located throughout the garden;
- The garden should be enclosed to prevent a person from wandering away; and
- Furniture should be sturdy and designed specifically for the needs of older adults.