Abstract
Objective
Design
Methods
Results
Conclusion
Keywords
- (1)What is the impact of gardens and outdoor spaces on the mental and physical well-being of people with dementia who are resident in care homes?
- (2)What are the views of people with dementia, their carers, and care home staff on the value of gardens and outdoor spaces?
Methods
Literature Search and Eligibility Criteria
Data Extraction
Risk of Bias
Data Synthesis
Results

Study Characteristics
Study Quality
Quantitative Synthesis
Dementia-related behaviors
Emotional outcomes
Physical outcomes
Medication
Qualitative Synthesis
- -Nature of activity: descriptive information about activities the residents did in the garden (eg, sitting, gardening, writing letters).
- -Interaction: who or what the residents interacted with in the gardens and how that interaction was affected by being in the garden.
- -Impact: how the experience of using the garden affected residents, staff, or visitors (eg, quality of life, happiness, contentment, anxiety).
- -Mechanism: attempts to explore or explain the processes through which the garden may or may not be having an effect.
- -Negatives: limitations to the intervention or its implementation, such as safety barriers and staff capacity.
Nature of activity
Member of staff – “….We can bring them out here just to relax… It is more fun to come to work as well. They're happier and so are we.” (Edwards et al17, p. 13, reviewer edit)
Member of staff – “On a nice day like today, we can take them out there to see the flowers and to sit outside and just enjoy them. And then there are a few residents that we know they love flowers. They used to like gardening (before) and used to like growing things and stuff….” (Hernandez25, p. 137, reviewer edit)
Member of staff – “… what they normally do there is to go out and have a picnic type of thing. Drinks and ice cream, snacks and that type of thing. And I've seen some family members joining the group. I think this is a very good courtyard.” (Hernandez25, p. 139, reviewer edit)
Family member – “He can't concentrate on anything for very long. So, television is not effective for him because he can't follow the story line. He doesn't read stories or books. These are activities he did before but he's not able to continue them because of the progression of the dementia. But gardening is something that he can still do and enjoy very much.” (Raske27, p. 343, edits in the original)
Interaction
Family member – “There are days when my mom can't even tell me who I am. When she comes out in this garden I see my mom because she lights up. I've had her out front when we had visitors from out of state and she just sits there. But when I bring her out here, she turns her head and is looking at things in the garden. It's different. You can tell she really likes being out here.” (Raske27, p. 344, edits in the original)
Resident – “I like it all. The fountain, the fish, the memory boxes – everything. The table and chairs in the sunroom came from my lounge room at home, you know. We all sit around it and talk.” (Edwards et al17, p. 13, edits in the original)
Family member – “Well, mother loves looking out her window at the new tulip tree we planted there for the ‘memory garden.’ She goes outdoors and walks around on a regular basis, but she also spends some time in her room … and she has a little bit of a view. I got her a little snowman birdfeeder which she asked me for last Christmas when we were at the store shopping. I think it's tacky, but she just loves it, and it brings her such joy to look out at it in the garden. The director said it was OK and I was so glad to do it for her. Now, I'm not sure if she realizes that it's hers today, but she smiles when she sees it and comments on it….” (Hernandez25, p. 132, reviewer edit)
Member of staff – “You know, we have flowers, plants outside. And here (in this house), like, Sam … Some days when he remembers, he says, ‘Oh, it's time now, I want to go take care of my flowers.’ He'll say something like that. And once outside, he'll say, ‘It's time, you know, to water,’ or something like that. He's aware that gardening is part of his life and enjoys it.” (Hernandez25, p. 140, edits in the original)
Member of staff – “It calms them to be outside and away from whatever was agitating them. They see something different or feel the breeze against their skin and then they forget why they were upset. They have something else to focus on.” (Hernandez25, p. 135, edits in the original)
Member of staff – “The staff gets such a kick seeing the residents in the garden. They tell one another stories about residents doing things out in the garden.” (p. 346)
Volunteer – “This whole idea about volunteering to help create the garden. Through these stories and shared walks with residents in the garden, I believe it's the residents who are giving to us.” (p. 346)
Member of staff – “I very rarely, in all the years that I have been here, ever went out there, and now I probably go out two or three times a day. I can't wait to go out when they start again this spring.” (p. 346, edits in the original)
Impact
Member of staff – “We are taking residents from the dementia unit out into the garden in the afternoon and this is preventing them becoming agitated later in the day.” (Raske27, p. 344, edits in the original)
Member of staff – “Some of them … when they get agitated and stuff … you know, you can ask them, ‘Would you like to go outside for a little while?’ And for some of them it really cools them down. It calms them to be outside and away from whatever was agitating them.” (Hernandez25, p. 135, reviewer edit)
Member of staff – “We walk them. Well, depending on the weather, we try to walk them at least twice a week around the garden they have out there. Sometimes … I know in Pod One [Pod One being the highest functioning of the three pods], when the residents come back they're more … um, happy. You notice a difference in them. You know, it might not be very drastic, but there's something noticed that's different. They're not as they were before they went walking outside.” (Hernandez25, p. 138, edits in the original)
Member of staff – “Residents are easier to manage, especially if they are sun downing [‘Sundowning’ is where people with dementia become more confused or agitated later in the day. The cause of this syndrome is unclear but it may be due to reduced levels of light or increased tiredness.]. We can bring them out here just to relax…They're happier and so are we.” (Edwards et al17, p. 13, edits in the original)
Member of staff – “When I take residents out into the garden, especially those from the dementia care unit who don't speak, they make a deep sigh, as if they are at peace.” (Raske27, p. 346, edits in the original)
Member of staff – “The fact that it (the outdoor space) might help not medicate somebody, that it means putting someone in a better mood when you're not in the mood to eat … that means feeling better about themselves and eating … that's pretty beneficial. And you know, you go on and forget your troubles. It takes you outside, it takes you in another dimension of life. There's a real world out there beyond the walls.” (Hernandez25, p. 136, reviewer edit)
Family member – “I can't say how much of a difference the garden has made for [name]. Today I have taken her up on the viewing platform and we wrote a letter, she talked about the birds, she loves animals. It's relaxing for us both to be out here. It has definitely improved [name's] quality of life and I enjoy coming more too.” (Edwards et al17, p. 12, edits in original)
Mechanisms
Social Worker – “I think because gardening it keeps their senses alive. Dementia folks cannot learn new things for the most part, unless you are extraordinarily repetitive. But, by any kind of physical therapy, and gardening is one of those, we can help maintain where they are at right now…” (Hernandez25, p. 141, reviewer edit, emphasis added by reviewers)
Member of staff – “They see something different or feel the breeze against their skin and then they forget why they were upset.” (Hernandez25, p. 135, reviewer edit)
Member of staff – “They often come at other times to water the garden or look at the fish, smell the herbs, pick the cherry tomatoes. There is a lot more for them to do.” (Edwards et al17, p. 13, reviewer edit)
Social worker – “And the beautiful smells that come from the garden, and color identification that they may forget without the garden. So, I think it's just one part of their therapy, but it's a necessary part in my opinion.” (Hernandez25, p. 141, edits in original)
Member of staff – “It really depends on the resident. For example [name] spends a lot of time in the tinka car and I think perhaps he liked to drive when he was younger. [name] spends some of every day looking at the memory boxes and talks about parts of her own life that relate to what she sees in the boxes. She says ‘I have a teapot like that, you know.’ Quite a few of the residents enjoy feeding the birds every day or watering the garden.” (Edwards et al17, p. 13, edits in original)
Member of staff – “…And it brings back memories for them. If they were flower people or outdoor people, or had flower gardens … or garden gardens (vegetables) and so forth. It brings back memories. Many of them it might bring back memories from childhood and they'll talk about it.” (Hernandez25, p. 136, edits in the original)
Resident – “Yes, quiet time, like at break time … mmm hmm … I do use the garden for when I'm by myself. You know … the garden … in general, garden is life. Garden is … Is life! I don't know how to explain (laughs) … It's so therapeutic to me. You reflect. You know, it gives you a little time for your meditation, you see … it is very positive. To give them … some space. The topography here is very good. Nursing home is kind of … you know … confined and institutional … you see the differences between here and there. Here there is so much more freedom. And the staff has so much more freedom by having a nice large yard to walk around in.” (Hernandez25, p. 140, edits in the original)
Member of staff – “It gives them a sense of purpose and ownership and I also think they enjoy the feeling of looking after the birds and plants instead of being the ones to be looked after all the time; after all most of them were nurturers of some description in their former lives.” (Edwards et al17, p. 13, edits in original)
“In green environments, no demanding cognitive appraisals are needed to understand how to act successfully. The environment is easy to interpret even with a diminishing cognitive capability, because it provides abundant information and cues about time, place and purpose, helping orientation toward reality. In addition, green environments provide meaningful activities in which people with dementia are interested in engaging and can consolidate self-esteem.” (Rappe and Topo16, p. 224, author interpretation)
Negatives
Member of staff – “We all have concerns at this point in time about the environment outside – we have nice walkways, nice shrubs, nice trees – with stakes at the moment – and we kind of wondered whether a level ground would have been better, just grass. We're kind of concerned that they're walking over the bushes and might trip and fall.” (Morgan and Stewart29, p. 110, edits in the original)
Field note – “Mrs Kuusela with mild dementia is walking in the corridor with a walking aid and asks the caregiver if she could go out for a walk alone. The caregiver: ‘I wouldn't like you to do it. You can fall. What do you say if we go together tomorrow?’ Mrs Kuusela: ‘It is always the next day …’ They decided to go outdoors tomorrow afternoon. The caregiver opens the door to the balcony for Mrs Kuusela, which was in the shade. She pops out for some minutes only.” (Rappe and Topo16, p. 242, reviewer edit)
“…safety of the outdoor patio area of the new ground floor SCUs was a concern when it first opened. Shrubs, sprinkler systems, stakes and wires supporting new trees and uneven surfaces were identified as potential hazards…” (Morgan and Stewart29, p. 110, author interpretation, reviewer edit)
Member of staff – “I do appreciate the fact that they allowed them the freedom to be able to go outside… [but] it creates quite a havoc for us to be watching them when we don't have the staff to do that.” (Morgan and Stewart29, p. 110, edits in the original)
Member of staff – “I usually take my breaks inside. I don't go outside … because I'm not a smoker. It's a nice garden space, so you would think I'd want to go outside, but I don't, because I don't smoke. Other employees use it because they go out there to smoke.” (Hernandez25, p. 137, edits in original)
Discussion
Conclusion
Supplementary Data
- Supplementary Appendix A
- Supplementary Appendix B
- Supplementary Appendix C
- Supplementary Table 1
- Supplementary Table 2
- Supplementary Table 3
- Supplementary Table 4
References
- Dementia: A Public Health Priority.World Health Organization, Geneva2012
- Interventions for decreasing agitation behaviors in persons with dementia.J Gerontol Nurs. 1995; 21: 34-40
- Behavioral and Psychological Symptoms of Dementia (BPSD) Educational Pack.International Psychogeriatric Association, Northfield, IL2002
- Case-controlled study of nursing home residents referred for treatment of vocally disruptive behavior.Int Psychogeriatr. 2000; 12: 333-344
- Dementia: Information for Carers, Families and Friends of People with Severe and End-Stage Dementia.University of Western Sydney, Penrith South, Australia2007
- Snoezelen for dementia.Cochrane Database Syst Rev. 2002; (Review): CD003152
- Music therapy for people with dementia.Cochrane Database Syst Rev. 2003; : CD003477
- Reminiscence therapy for dementia.Cochrane Database Syst Rev. 2005; : CD001120
- Green Care: A Conceptual Framework. A Report of the Working Group on the Health Benefits of Green Care, COST Action 866.Centre for Child and Family Research, Loughborough University, Loughborough, UK2010
- What is the evidence to support the use of therapeutic gardens for the elderly?.Psychiatry Investig. 2012; 9: 100-110
- Greening Dementia: A Literature Review of the Benefits and Barriers Facing Individuals Living With Dementia in Accessing the Natural Environment and Local Green Space.Natural England, Sheffield, UK2013
- Dementia: Supporting People With Dementia and Their Carers in Health and Social Care.National Institute for Health and Clinical Excellence, London2006
- Systematic Reviews: CRD's Guidance for Undertaking Reviews in Healthcare.Centre for Reviews and Dissemination, York, UK2009
- A process for systematically reviewing the literature: Providing the research evidence for public health nursing interventions.Worldviews Evid Based Nurs. 2004; 1: 176-184
- Meeting the challenge: Developing systematic reviewing in social policy.Policy and Politics. 2004; 32: 455-470
- Contact with outdoor greenery can support competence among people with dementia.J Hous Elderly. 2007; 21: 229-248
- An evaluation of a therapeutic garden's influence on the quality of life of aged care residents with dementia.Dementia (London). 2013; 12: 494-510
- Effect of increased time spent outdoors on individuals with dementia residing in nursing homes.J Hous Elderly. 2007; 21: 211-228
- Visits to an outdoor garden: Impact on behavior and mood of nursing home residents who pace.in: Vellas B. Fitten J. Frisoni G. Research and Practice in Alzheimer's Disease. Serdi, Paris1998: 419-436
- The effect of a walled garden on behavior of individuals with Alzheimer's.Am J Alzheimers Dis Other Demen. 1997; 12: 252-257
- The importance of exterior environment for Alzheimer residents: Effective care and risk management.Healthc Manage Forum. 1992; 5: 23-29
- Outdoor environments at three nursing homes: Focus on interviews with staff.J Hous Elderly. 2006; 19: 49-69
- Scheduled medications and falls in dementia patients utilizing a wander garden.Am J Alzheimers Dis Other Demen. 2009; 24: 322-332
- Does a wander garden influence inappropriate behaviors in dementia residents?.Am J Alzheimers Dis Other Demen. 2008; 23: 31-45
- Effects of therapeutic gardens in special care units for people with dementia: Two case studies.J Hous Elderly. 2007; 21: 117-152
- Care home design for people with dementia: What do people with dementia and their family carers value?.Aging Ment Health. 2011; 15: 548-556
- Nursing home quality of life: Study of an enabling garden.J Gerontol Soc Work. 2010; 53: 336-351
- Horticulture therapy in dementia care impact on behavioral symptoms, physical and cognitive activities.Elant At Goshen, Goshen, NY2003
- The physical environment of special care units: Needs of residents with dementia from the perspective of staff and family caregivers.Qual Health Res. 1999; 9: 105-118
- Therapeutic effects of an outdoor activity program on nursing home residents with dementia.in: Rodiek S. Schwarz B. Outdoor environments for people with dementia. Haworth Press, Philadelphia, Pennsylvania2007
- Multisensory environments for leisure: Promoting well-being in nursing home residents with dementia.J Gerontol Nurs. 2004; 30: 37-45
- The effect of horticultural activities on agitation in nursing home residents with dementia.Int J Geriatr Psychiatry. 2011; 26: 435-436
- Observed affect in nursing home residents with Alzheimer's disease.J Gerontol B Psychol Sci Soc Sci. 1996; 51: 3-14
- Sundowning.Dementia Now. 2009; 6: 1-13
- Stress recovery during exposure to natural and urban environments.J Environ Psychol. 1991; 11: 201-230
- Physical activity and risk of cognitive decline: A meta-analysis of prospective studies.J Intern Med. 2011; 269: 107-117
- Implementing the evidence for preventing falls among community-dwelling older people: A systematic review.J Safety Res. 2011; 42: 443-451
- Instruction manual for the Cohen-Mansfield Agitation Inventory (CMAI). Manual of the Research Institute of the Hebrew Home of Greater Washington.1991
- EuroQol—a new facility for the measurement of health related quality of life.Health Policy. 1990; 16: 199-208
- Measurement of health-related quality of life for people with dementia: Development of a new instrument (DEMQOL) and an evaluation of current methodology.Health Technol Assess. 2005; 9 (iii–iv): 1-93
- The dementia care garden: Innovation in design and practice.Journal of Dementia Care. 2008; 16: 18-20
Article info
Publication history
Footnotes
The authors declare no conflicts of interest.
This systematic review was funded by the National Institute for Health Research (NIHR) through Peninsula CLAHRC. This review presents independent research commissioned by the National Institute for Health Research. The views expressed in this publication are those of the author(s) and not necessarily those of the National Health Service (NHS), the NIHR, or the Department of Health, UK. R.G.'s salary is also supported by investment from the European Regional Development Fund and the European Social Fund Convergence Programme for Cornwall and the Isles of Scilly, UK.
Identification
Copyright
User license
Creative Commons Attribution - NonCommercial - NoDerivs |
Permitted
For non-commercial purposes:
- Read, print & download
- Redistribute or republish the final article
Not Permitted
- Text & data mine
- Translate the article
- Reuse portions or extracts from the article in other works (except for the author)
- Sell or re-use for commercial purposes
Elsevier's open access license policy