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"When an Alzheimer's patient dies," says Zeisel, "his or her brain typically weighs only 60 percent as much as a normal brain," so that Alzheimer's effects could be likened to the shriveling of an arm. Furthermore, it is possible to identify what parts of the brain have been lost, and to identify many of the corresponding functions that Alzheimer's patients must live without. One of the things that all Alzheimer's patients lose, at different points in their illness and in different intensities, is what Zeisel calls "the cognitive map." "The cognitive map is what you have in your mind when you close your eyes and say, 'I can get back to my car,"' he says. "A person with dementia could wander all over town trying to find their car."

John Zeisel in the garden at Hearthstone Alzheimer Care in Marlboro, Massachusetts. "We can treat the symptoms of the disease," he says.

To make up for this mental deficiency, Zeisel designs "naturally mapped environments," where the information about how to find your way is in the environment, not in your head. That does not mean putting up signs. "A naturally mapped environment doesn't have to be read, it speaks for itself," he says. "You always know exactly where you are going, either because you see it or you have only one choice." As a result, says Zeisel, "wandering is no longer a symptom of Alzheimer's for those people who live with us."

The garden at the Hearthstone residence in Marlboro, Massachusetts, commissioned by Zeisel and employing the principles of urban planner Kevin Lynch and architect Chris Alexander, is an example of a naturally mapped environment. An unlocked door opens onto a park-like area. To the right, a porch shades a patio, intended to suggest the rear of a house, so that the garden may be experienced as a backyard. A single path, which can be walked either clockwise or counterclockwise, runs around the perimeter of the garden, past flower beds and shrubs to a park bench under hemlocks at the far end. Because the garden itself is shaped like a triangle, and the farthest point lies at one of its vertices, the eye is naturally directed back towards the entrance to the building, a single door with a large portico centered on the wall forming the triangle's base. While Alzheimer's patients typically suffer from short-term memory loss, they remain able "to draw on deep memories of the distant past," says Zeisel. This is a facet of the disease he can take advantage of through careful design. At the center of each of his Alzheimer's care facilities are the hearth and the kitchen, consisting of a fireplace in an informal dining area adjacent to the food preparation area, where individual meals are prepared by the staff. In his New York City facility, which has an L-shaped floor plan, the hearth area is located at the center of the L. "This is a space that tells people they can feel comfortable," says Zeisel. "I believe what we are doing is tapping into archetypal feelings. You don't have to learn what a garden is, what a kitchen is, what a hearth is. They are deep-seated memories"

Because the emotions are among the last things to go in an Alzheimer's patient, Zeisel

designs environments according to eight principles that he describes as profound human needs: understanding what is expected in your community; withdrawing on occasion; feeling safe, secure, and free; knowing where you are going; enjoying nature; feeling comfortable; celebrating achievement; and understanding your surroundings.

The design of the fence around the outdoor garden is a good example of the balance Zeisel strikes between making the patients feel comfortable and keeping the facility secure. Because the door to the garden is unlocked, allowing residents to pass freely in and out, the surrounding fence must be high enough to prevent anyone from climbing over it. Zeisel's fence is eight feet high, but looks six feet; the top two feet, which one can see through, appear decorative, but because "some octogenarians can still scale a six-foot fence," he says, "those top two feet are the functional ones." Inside, the exit doors are as unobtrusive as possible, so residents aren't drawn to them. To critics who charge, "You are locking these people in," Zeisel responds that Hearthstone is in reality giving residents a life where they can do whatever they want, as opposed to having a totally open plan where residents must constantly be told "No," or "Don't go there." Zeisel has made the social spaces as clear as possible, and has tried to put feelings into them. Though Alzheimer's patients cannot remember each day cognitively, they retain emotional impressions of their daily lives. "You don't know what residents are feeling," he says, "but the theory is that the part of their brain that knows differences in moods and emotions will register at the end of the day that they have been in the garden, had a meal by the hearth, and participated in an activity." "We can treat this disease by getting rid of the symptoms," Zeisel says. He has just finished a three-year grant project from the National Institute on Aging on treatment programs for dementia, and says the data he has gathered confirm the validity of his approach. "We already know that the environment can have an impact on recuperation in hospital recovery rooms," he says. "Now, by combining environmental design, thoughtful communication, and activities, we can give our residents a higher quality of life."

Jonathan Shaw '89 is an associate editor of this magazine.

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