Healing gardens and cognitive behavioral units in the management of Alzheimer's disease patients: the Nancy experience.

The French Alzheimer Plan 2008-2012 anticipates the implementation of new Units specialized in cognitive rehabilitation and psycho-behavioral therapy of Alzheimer's disease (AD) patients. Conceived for AD and other dementia patients of all ages, their objectives are to propose a cognitive rehabilitation program, to prevent or treat psycho-behavioral crises, and to provide support and educational therapy to the family and professional caregivers, in order to ease the patient's return to his or her previous way of life. Studies on green spaces and healing gardens in health-care settings have revealed objective and measurable improvements in the patient's well-being. The Plan officially stipulates for the first time the need to make healing gardens an integral part of these Units, but it does not provide specific recommendations or criteria for implementing such gardens. Although green spaces and gardens are available in many French Care Units, they are rarely specifically adapted to the needs of AD patients. In Nancy, the Art, Memory and Life garden, a specific concept guided by a neuropsychological approach, was developed and complemented by an artistic vision based on cultural invariants. The main objective of this article is to describe the various steps of the process that led to the creation of this garden: the collection of experiences and information by a pilot group, surveys of patients, visitors, and caregivers before and after establishment of the garden, and implementation of a multi-professional group project. The specifications, the organizational criteria, the therapeutic project, and the criteria for the conception of such a garden stemming from our clinical experience with the Art, Memory and Life garden in Nancy, are described herein. We also present the first assessment following the implementation of the project.

[Healing gardens: recommendations and criteria for design]. / Les jardins thérapeutiques : recommandations et critères de conception.

The French Alzheimer plan anticipates new specialized structures for cognitive rehabilitation and psycho-behavioural therapy of Alzheimer's patients: the cognitive-behavioural units as follow-care units, the units of reinforced hospitalization inside the long term care units and the adapted activities units. this plan indicates the need to make healing gardens integral parts of these units. The benefits of green space in urban environments has been demonstrated with regards to physical, psychological and sociological effects and similarly studies in hospitals have revealed objective and measurable improvements of patients well being. Although green spaces and gardens are available in many French care units, they are rarely specifically adapted to the needs of Alzheimer's patients. For the garden "art, memory and life" a specific concept guided by a neuropsychological approach was developed, complemented by an artistic vision based on cultural invariants. It is already used in the frame of non-pharmacological therapies to improve symptoms such as deambulation, sleep disorders, apathy and aggressive behaviors. Based on the literature, and our experience and research, recommendations for the design of such gardens dedicated to Alzheimer's patients can be proposed. Beyond taking into account obvious aspects relating to security, allowing for free access, a careful design of walk-ways and a conscious choice of plants is needed. A systematic analysis of the existing green spaces or garden must be conducted in order to pinpoint the weakness of the space and identify the potential for developing it into a real healing garden. Evaluation of adapted questionnaires for users and professionals allow to establish a list of requirements combining both user requests and therapeutic needs as basis for the design of the garden as well as to evaluate during the course of the project, whether the needs of the various stakeholders have been met or if adjustments are necessary.

Risk factors of relative adrenocortical deficiency in intensive care patients needing mechanical ventilation.

OBJECTIVE: To study the factors associated with relative adrenocortical deficiency in mechanically ventilated, critically ill patients. DESIGN AND SETTING: Prospective observational study in a multidisciplinary ICU of a university-affiliated teaching hospital. PATIENTS: Sixty-two consecutive, acutely ill patients needing mechanical ventilation for more than 24 h. MEASUREMENTS AND RESULTS: A high-dose short corticotropin test 24 h after endotracheal intubation. Relative adrenocortical deficiency ("nonresponder" group of patients) was defined by a rise in cortisol less than 90 microg/l after stimulation. Twenty-seven patients were classified as nonresponders and 35 as responders. On univariate analysis nonresponders were more often men, had lower mean arterial pressure, required vasoactive agents more often, had lower creatinine clearance, higher SAPS II, higher organ dysfunction scores, and received etomidate as a single bolus for endotracheal intubation more often than responders. On multivariate analysis, only etomidate administration was related to relative adrenocortical deficiency (OR 12.21; 95% CI 2.99-49.74) while female gender was protective (OR 0.13; 95% CI 0.03-0.57). CONCLUSIONS: A single bolus infusion of etomidate could be a major risk factor for the development of relative adrenocortical deficiency in ICU patients for at least 24 h after administration. Female gender is an independent protective factor.