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Enhancing wellness: Maximize use of indoor / outdoor environments


By thinking creatively and making some simple changes, organizations can boost health and wellness benefits for their constituents

by Marilynn Larkin, MA
Reposted from: The Journal on Active Aging March/April 2017 – pp 76-83 –

Individuals can participate in outdoor exercise programs or just walk around the safe, enclosed garden at Ruby Pardue Blackburn Adult Day Health Care Center in Wilkesboro, North Carolina. Image courtesy of Design for Generations, LLC

A card table that sits vacant most of the day … long empty corridors … a patch of land lying fallow outside a residence … These are common sights in settings that serve older adults—yet, those unused and often unsightly indoor and outdoor spaces can be transformed into inviting venues that motivate members or residents to increase physical activity, socialization, and emotional and spiritual wellness.

Recognizing that environments contribute vitally to overall health and wellness, the International Council on Active Aging ® (ICAA) added this dimension to its wellness model in 2010. ICAA believes that all kinds of spaces, both built and natural, offer possibilities. For industry professionals who seek to enhance older-adult wellness, exploring use of space is an avenue that can yield results.

The Journal on Active Aging® (JAA) recently interviewed two experts whose presentations at ICAA annual conferences gained praise for providing practical strategies and tips on making the most of your environment. Kim Eichinger, executive director of fitness at Country Meadows Retirement Communities in Pennsylvania and Maryland, presented “How to use your space creatively” at the 2015 ICAA Conference and was featured in a webinar on the topic. Here, she shares and expands on ways to turn indoor spaces into settings for physical activities.

Landscape architect Jack Carman, president of Design for Generations in Medford, New Jersey, copresented “The importance of exercise in nature for older adults” at the 2016 ICAA Conference. In this article, Carman discusses how communities (and, by extension, other older-adult settings) can ensure constituents enjoy the many benefits of access to nature and the outdoors by converting outdoor spaces into esthetically pleasing multipurpose sites.

Both longtime supporters of ICAA and its mission, Eichinger and Carman have years of practice and expertise in supporting multidimensional wellness for older adults. Offered below are their ideas and advice to help JAA readers maximize use of their environments—and enjoy the outcomes that go along with it.

The great indoors

“With clever use of space, making the most of the resources you have available and possessing a positive attitude, you can create a successful physical-activity experience anytime, anywhere,” enthuses Country Meadows’ Kim Eichinger. JAA asked about specific ways to accomplish this.

ML: How can providers take a fresh look at their indoor space?

KE: The first thing is not to think, “Oh, we have no space.” Even at Country Meadows, where we have plenty of space, I often hear, “I don’t have the right space for that,” or “If only I had the right space.” Instead, start by thinking, “What can I do with the spaces I have?”

ML: Are you saying we have stereotypes of what a fitness room is, for example, and people need to get rid of those stereotypes?

KE: The success of any activity, no matter where it’s held, is the person facilitating it. Some of our fitness directors bring such personality, fun and purpose to everything that the residents will do whatever is asked of them no matter where they are. Much of the success of physical activity programs is in the delivery, the talent—not the space and equipment.

ML: That said, you still need a place to hold the activity.

KE: Right. If someone has a particular activity in mind, they may look at a room and think, “It’s full of tables and chairs; in order to do an exercise program, I would need to move all of that.” But you can turn those obstacles into opportunities, and use what you consider to be items in the way as actual tools for your exercise class.

For instance, we have an area where residents typically gather to play cards, and we use that space a couple of ways. We looked at the table surface and the chairs, and recognized that many of these folks need to practice the physical skills of getting up and down from a chair at a table—pulling a chair out and sliding themselves back in while they’re in the chair. So, we put together an exercise routine that took that basic function and made it fun.

We started everybody at the table, had them work on moving their bodies in the chair—to the front of the chair, to the back of the chair—and then pushing the chair back from the table, standing up and walking around behind the chair. It may sound simplistic, but for someone who’s starting to have mobility challenges, those are purposeful activities.

We track falls and know that very frequently, they happen in relationship to a chair, or when individuals are in the act of pulling that chair out and about to sit down into it. They may have difficulties not only with arthritis or muscle weakness, but also with sensory systems and their proprioception—knowing where their rear end is in relation to the edge of the chair.

So, we took this challenge of table and chairs in a space, and figured out a way to turn it into a beneficial opportunity for people to exercise.

We also transformed that space into a place for tabletop activities using gliding disks and small balls. By pressing down on the disk or ball and moving it around the tabletop, the residents had a workout for their whole upper torso, arms and shoulders.

Here again, instead of thinking that the table was in the way, we were able to use it productively. Because the act of sitting around a table is familiar and comforting to people, you may have more success in bringing residents to the tabletop to be active than you would in bringing them to a conventional group-exercise setting.

Another option: Instead of playing a seated-exercise video in a common room, look at the sitting area itself. There may be a high-back chair, a loveseat, another type of chair and a bench. You can have residents practice sit-to-stand exercises on these different surfaces, and get them to move around and try the different surfaces.

The bottom line is to look at what you have and think, “How can I make movement happen here?”

ML: What about getting more of a totalbody activity, especially if you can’t get individuals to an exercise room?

KE: We have some long hallways with railings that we transformed into spaces where we can do agility and balance exercises with the residents. We placed stacking cones similar to those used in physical therapy in different locations so that in order to move down the corridor, individuals have to look and move sidetoside, instead of just walking or pushing their walker straight ahead. That lets them practice with the added challenges of direction change and head turning and spotting.

We also use foam noodles. The residents use these noodles to tap on the cones, which requires that they bend down and reach low. And we ask them to pick up the cones and change hands to set the cones aside—again, all with a functional purpose. For example, tapping the cones helps residents with looking down while moving, a skill they need if they step onto the curb when leaving one of our vans. If they’re going shopping, they need to be able to weave back and forth in the aisle, reach down to the bottom shelf and up to the top shelf. A goal of all these drills is to help individuals function in a larger environment outside the community.

ML: Are people reluctant to adapt space for those exercises because of the possibility of falls?

KE: Fear of falling is a huge concern for everybody, not just the older adults who themselves are at risk, but also for coworkers and family members. No one wants to see somebody fall. But the reality is, we set people up for an increased risk of falling by not motivating them to get up and move. So, we need to encourage people to move in a safe environment.

As we’re working in the hallway, for example, we know there’s a railing people can touch or hold onto, or use to bring the walker along, so they’re working with the walker at a higher level.

We educate staff on how to spot appropriately, and how to grade the activity so that we’re challenging individuals at the right level, where they can be successful and safe. When we let people sit all the time, we’re giving them a message that sitting is all they can do. And that in itself increases their risk of falling.

ML: When you work in a common space or hallway that’s been transformed into a multipurpose space, how is it transformed back so it’s ready for a different type of use?

KE: That’s an issue we need to deal with. We know that our organizations expect those common spaces to have a certain look to them, so if a tour or a family member comes through, the spaces look like their labels—that is, if it’s a sitting room or relaxation room, it should look that way. That takes communication across the departments.

We also have different types of activities taking place throughout the day that may not be delivered by the same individual. The same space may need to accommodate a program by a chaplain, an associate who’s doing an art program, someone doing a music program and someone else doing a fitness program. The staff needs to coordinate, to decide whether it’s easier to do the art program then move chairs and tables out of the way for fitness or vice versa. And everyone needs to help set up for the program that’s coming in next.

ML: Do other issues need to be worked out among staff ?

KE: Yes. We’ve found the biggest challenge to implementing these ideas doesn’t come from residents. If they understand the purpose behind what you’re asking them to do, and they trust and respect you, you will get their buy-in.

But other staff members may have some of the concerns we mentioned earlier, like residents falling when they try to weave through the hallway. Or they wonder if they’ll be able to sell this new idea of doing exercises around the card table. It’s more about bringing staff along and helping everyone see the possibilities and understand how to execute new ideas.

We do staff trainings so everyone understands how they can use space to introduce more physical activity, how they can be safe with what they’re doing, and again, how to sell these programs to residents.

ML: Any lessons learned from going through this process?

KE: First, you need buy-in from the top to make it happen. At Country Meadows, our CEO gives me license for creativity and exploring some of these new ideas. Having that buy-in, not just from a lateral aspect of your company, but also from the top down, is huge.

Next is to start small. Don’t try to change an entire room. Don’t try to change an entire program. If you’ve got a group of folks sitting around for, let’s say, happy hour, and you want to introduce some of those movement ideas and they’re at a table, bring a deck of cards, put some cards on the table and have them work on some movements, sliding those cards around.

And remember to explain the functional purpose of what you’re asking residents or members to do. So it’s not just fun; there’s a serious side, too.

The great outdoors

Jack Carman believes that outdoor environments may provide “even more opportunities and flexibility for communities [and organizations],” he says, “because you’re not confined by four walls.” JAA asked him about ways of expanding the use of outdoor space, regardless of the amount of space currently available.

ML: How can staff and management start making the most of their outdoor spaces?

JC: There are two ways to answer that question. First is to see how programs that traditionally operate indoors might also work outdoors. You might want to run a yoga class outdoors, for example, and so you need to know, as a starting point, how much space you need to do it. After that, you’ll need to take other factors into consideration, such as whether shade is available, what the ground is like, and so forth.

The other way is to look at the outdoor space you have and ask yourself what you can do with it. You might not be able to run a yoga class, but you might be able to create a patio area where people can do seated exercises, or a walking space.

Importantly, you’ll need to consider how to make the space inviting so people want to come out, participate, and then stay and socialize. It’s one thing to ask individuals to take a class, but if there’s nothing to hold them there, they’ll want to leave right after the class or maybe not even go the next time.

ML: What specifically can people do to make an outdoor area more inviting?

JC: A simple thing is to have plantings that can create interest year-round, so you have something blooming in the spring, perennials blooming in the summer, and something to create color in the fall.

You can bring nature into the space with certain plants. During a class, for example, there may be birds feeding off echinacea or black-eyed Susans, or hummingbirds coming in to drink the nectar out of fuchsia in hanging baskets. You might add a birdbath or a birdhouse. All those things create a passive kind of enjoyment that is part of an inviting space.

It’s also important to have shade. So trees or a pergola are a good addition. Some pergolas have retractable canvas drapes that you can pull back manually; you can close them when it’s too hot, or if it’s an early spring day, you can run a class there and it would be warm enough because it’s open to the sun. Tables with umbrellas are a good option as well, especially if there are no trees nearby.

Comfortable places to sit are a priority, whether you’re making a more permanent seated area or if, for example, you’re thinking of creating a walking trail. Many existing benches aren’t appropriately specified, unfortunately. For comfort and safety, the seat should be at least 18 inches high and have a relatively flat bottom. It shouldn’t slope back, like an Adirondack chair, because individuals probably won’t be able to get out of them. You might consider placing cushions on benches to make them more comfortable.

A water feature is also a plus. It doesn’t have to be big—there are plenty of premanufactured fountains that are relatively inexpensive and easy to install and that have auto-fill devices and a timer, so someone doesn’t have to turn them on every day. These water features are soothing to watch and listen to.

Pavement surfaces can influence how much time people spend in an outdoor space, as well as what they feel comfortable doing there. If you have an opportunity to install new pavement, consider a rubber-surface material that’s softer under the feet than concrete, or the kind of material used under play equipment that’s not spongy but still has a bit of resiliency, so someone is less likely to get hurt in the event of a fall.

ML: Are there situations in which people have outdoor space but simply are not utilizing it?

JC: The simple answer is yes. I think many times these individuals may not understand what to do with the outdoor space; they’re not as familiar with it as they are with indoor spaces. That’s when getting together and discussing ideas becomes important.

Sometimes cost is an issue. People don’t realize that they don’t have to do everything at once. A garden, for example, can be created in phases, as funding becomes available.

I’m also finding more and more that donors are helping out. For one project I’m working on right now, someone donated half-a-million dollars to build a courtyard in a continuing care retirement community (CCRC). For another project, a foundation is underwriting the cost of a dementia garden.

ML: How do you work with organizations to decide the best ways to use available funds?

JC: The CCRC realized that to attract new residents, they needed to offer some of the amenities that nearby high-end resorts offer. So, they will have a pool with retractable glass walls, an outdoor patio with a fire pit, tables and chairs with shade umbrellas and a pergola. At the perimeter of the patio, they’ll have a small pond with a waterfall. Adjacent to that is an outdoor recreation area with a rubber-surface patio.

Near the pool will be an open kitchen area, and the culinary staff has requested that we grow mint in the garden to use for mojitos. In addition, physical and occupational therapists will use the garden and courtyard to work with residents on exercises and rehabilitation.

So, this CCRC will be taking full advantage of their outdoor space. But even if an organization can afford to do only one of these things, it’s worth doing it to give people the benefits of additional outdoor activities, and more opportunities for socialization. Every step contributes to multiple dimensions of wellness.

A key is to think a bit differently about what you already have. You may have a grill, for example. Can you add a small refrigerator and a hand sink? Then you have a full outdoor cooking area, where you can quickly set up a barbecue after an exercise class.

ML: Many outdoor ideas seem to involve different staff and departments—recreation, culinary, fitness and so on. What is your process for bringing them all together?

JC: It helps to engage a consultant such as a landscape architect who has experience working in senior living communities or other older-adult settings and understands the needs of these populations. Then, have a meeting with as many staff representing as many departments as possible to share what they are doing now and what they would like to see more of. Depending on the size of the community (or center) and the level of involvement, a resident committee or equivalent may also have representatives sitting in.

In these discussions, I often hear things like, “We want more opportunities for people to walk.” And, depending on the specific level of care, “We want to be able to see residents so we know they’re safe.” Or maybe the community has one bocce court and they want to know how to put in more. Or pickleball is becoming popular, and they want to know if that’s something they can do.

Many times we end up with a list of 20 items that can’t all fit in the available space or the budget won’t allow everything being done at once. Then it’s a question of prioritizing—sitting down again to say something like, “If you don’t need two more bocce courts, then maybe we put one in and we do a pickleball court.”

Communication is critical during these discussions. Go through all the details with everyone and understand that it’s not a one-time thing. While it might take as little as six months in some cases, I’ve had meetings over a period of two years for some communities. It depends on how involved the work is and how quickly people can make decisions.

ML: I understand the attendees at your ICAA Conference session with Missy Benson of Playworld Systems had an opportunity to do some of what you do when you come into a community to assess an outdoor space.

JC: Yes. We looked at three areas, but I’ll stay with the first courtyard to show the process. That courtyard had a flagpole, some benches and a paved area, and we asked, “If this were an area in your senior living community and you wanted to use it for specific activities, what works and what doesn’t?” Essentially, we had the attendees analyze the courtyard as if they were designers.

They said the benches didn’t work because they were too far away from each other, so socialization wasn’t possible. The pavement had cracks in it, which might be tripping hazards. The flagpole sat right in the middle and was an obstacle they felt shouldn’t have been placed there.

We then discussed how they would improve the space—for example, by putting in moveable seating so people could create their own places to sit, and by adding shade trees. We took a broader look and saw how far away the courtyard was from the building, and decided the courtyard itself needed to be closer in case people carried out mats or chairs or food, or simply wanted to bring out a cart with water to serve as a hydration station.

Next, we looked from the point of view of maintenance. Was there irrigation provided? What was the slope? Was the surface relatively level? Was there adequate lighting, so that the lighting would come on if you were doing something in the evening and people could find their way safely back to the building? And we talked about esthetics. How did the courtyard look at night?

This process brings us back to what we discussed at the beginning: What do you want to use the space for, and what elements will make your program as successful, comfortable and appealing as possible for the participants?

Ultimately, we want to enjoy where we are. And making that happen doesn’t always have to cost a lot of money. It doesn’t have to be a fire pit. It might be a birdfeeder; that’s easy enough to start with.

Maximizing the impact

Active-aging professionals can maximize the use of indoor or outdoor spaces for wellness by keeping an open mind and thinking creatively. As Kim Eichinger and Jack Carman have shown, simple changes are often all it takes to transform environments so they encourage older adults to join in physical activity, exercise and offerings across the wellness dimensions. By inviting participation and enhancing wellness, these spaces also maximize the impact—and the benefits—for everyone.

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Marilynn Larkin, MA, is an awardwinning medical writer and editor, an ACE-certified personal trainer and group fitness instructor, and originator of PosturAbility®, a program that boosts posture and self-esteem. She is also ICAA’s Communications Director and a regular contributor to the Journal on Active Aging®.

Eichinger, K. (2015). Using Your Space Creatively. Country Meadows Retirement Communities and Ecumenical Retirement Community. PowerPoint presentation for the ICAA Conference, November 19–21, 2015, New Orleans, Louisiana.

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