Welcome to the next installment of our biweekly series on the many different kinds of nature therapy. This week’s topic is gardening for dementia.
So what is gardening for dementia? Unlike some of the other topics we’ve covered, this one is a little easier to guess the meaning behind; gardening for dementia is all about using the natural world—specifically gardens and the act of gardening—to help mitigate some of the medical, behavioral and emotional issues that adults with dementia deal with.
Also known as dementia green care or therapeutic dementia care, gardening for dementia is a subset of therapeutic horticulture, wherein the therapeutic interventions are specifically targeted towards the unique needs of those living with dementia. Just like other kinds of therapeutic horticulture, it involves specific programming and trained staff.
And its benefits, as you’ll see below, are wide-ranging: it enables engagement, exercise and movement, relaxation, purpose and meaning. It helps improve appetite, blood pressure, focus, verbal expression, sleep, mood, memory, strength, agility and balance. It can diminish pain, apathy, agitation and aggression in patients. And it provides sensory stimulation, distraction, and pleasure—not to mention a healthy dose of Vitamin D!
Healing without a cure
Dementia is a long-term condition that can have a substantial impact on a person’s health and life—and as of now, dementia, Alzheimer’s, and related memory diseases have no cure. Gardening for dementia, then, is not necessarily about healing in the same way that other types of nature therapy can be; there is no reversing dementia (although The End of Alzheimer’s by Dale Bredesen, MD, describes fantastic cases in which this might be possible); so no gardening it away. The goal is not to stop or cure dementia; the goal of gardening for dementia is to improve the quality of life for people with dementia.
A comprehensive literature review from 2012 in Psychiatry Investigation by Detweiler et al from Virginia investigated the evidence to support therapeutic gardens for the elderly, especially those in assisted living or dementia care facilities. It makes the case that “constructing…dementia residence gardens that encourage autonomy and sensory stimulation is an economically sound, non-pharmacological strategy for improving the quality of life for persons needing these types of residences.” Gardens cited provide strategies that reduce reliance on medication while at the same time provide benefits like autonomy and mental stimulation.
The authors write: “Exposure to nature has been associated with reduction in pain, improvement in attention and modulation of stress responses. In addition, some studies have reported that having free access to an outdoor area may reduce some agitated behaviors, medications and falls in dementia residents.” Gardening in nature promotes exercise, stimulates the senses, and can “promote ambulation, positive reminiscences, decreased stress and stabilized sleep wake cycles.”
The authors also compare assisted living homes which include a gardening component with a more modern, institutional style of nursing home you and I might be more familiar with—what they call the “sterile modern medical complex.” They conclude that this more institutional setting is not just neutral—it can actually be quite harmful to people with dementia. To be in one of these “sterile complexes…often without the sight of or access to gardens or natural settings…may increase resident anxiety and fear as evidenced by elevated vital signs.”
This suggests that allowing people with dementia to be in natural environments is not just a nice perk or an added bonus—it’s actually essential to the patients’ well-being and can go a long way in reducing the negative emotions patients feel in a more sterile, traditionally medical environment. Though patients cannot be cured in the traditional sense, their quality of life and severity of their symptoms can be greatly improved.
What does the dementia garden research say?
There’s a surprising amount of research about dementia gardens—the myriad effects of gardening on those with dementia, the different types of dementia gardens, and even the effect of VR on those with dementia.
A 2019 literature review from Turkish investigators identified therapeutic gardens as a potential design approach to “optimize the healing of patients…with dementia” found that they had “a profound impact on the physical, social, psychological and cognitive health of Alzheimer’s and dementia patients.” They also looked specifically at the use of virtual reality (VR) that displayed natural environments and found that “VR may be used to simulate or recreate a boundless range of environments, including positive setting for patient’s recuperation.” The researchers suggested that “future studies should inquire into the positive aspects of non-invasive applications of VR technologies to create a greater understanding of this new application in healthcare.”
Another 2019 article from the Netherlands identified five different kinds of nature-based adult day services (referred to in the article as ADSs) in urban areas for those with dementia, hoping to look specifically at the characteristics and challenges that were in common and unique to each kind. They found that all five types suffered from common problems—namely, lack of green space and lack of funding—but that each variation of the program also faced unique challenges.
For example, the success of services offered by social entrepreneurs depended strongly on their commitment; challenges for nursing homes included lack of commitment from nursing staff and lack of interaction with the neighborhood; services offered by social care organizations of community gardens depended hugely on volunteers but struggled to find ones who knew enough about gardening and care. By identifying the myriad different forms of dementia gardens, as well as the specific challenges each different kind faces, the researchers have greatly aided those who might be interested in starting their own dementia garden (or getting involved with an existing one) and don’t yet know where to start or what they can contribute.
Several other research articles tackle the same subject: the specific positive effects that gardens can have on those with dementia. One article from 2018 looked at the effects of simply viewing a garden—not even being in it—and found that “garden observation not only relieved physiological stress, it improved qualitative measures such as verbalization and memory retrieval.” Their data suggested that “viewing the garden is a holistic experience rather a solely visual stimulus,” and the researchers recommended the technique readily to those involved in the care of dementia patients, saying that a garden’s “low cost and easy availability make it an economical adjunct to current pharmacological methods that has the potential to improve the quality of life of people with dementia.”
Another article from the same year looked at the effect of actually visiting a garden on patients with dementia and found “garden visits had positive effects on mood, social interaction, depression, and agitation in people with dementia because of the multisensory, gentle stimuli of the natural environment.” With regards to cognitive benefits, they found that “attention and orientation to time were improved the most after residents with dementia had spent time in a garden.” This study also looked at the difference between “free” and “unfree” gardens—meaning, those where patients could enter at will versus those where the gates were locked and only opened upon request—and found that those in the free garden group were scored significantly higher than those in the unfree group on things such as “mood, long-term memory, language abilities, spatial ability, aggression, and agitation.”
The research is clear: getting out into a dementia garden has a plethora of positive effects on mood, behavior, cognition, and physical health for seniors.
What makes a dementia garden special?
As we learned in the last blog on therapeutic horticulture, not all gardens are created equally; therapeutic gardens have specific qualities that define them as such, and as dementia gardens are a subset of therapeutic gardens with a very specific population, they have even more unique quirks, needs and specialties.
The design of the constructed environment where patients spend time is crucial to the kind and quality of healing that can take place there. One study analyzed and synthesized 169 different studies on the effect of the design of the built environment on people with dementia in long-term care settings. One finding: dementia gardens should be constructed to have wide paths with “defined edges to prevent falling, or to ease the fear from falling.”
In the classic book Healing Gardens, the Marcus and Barnes remind us that “remembering places and the connections between them is difficult for those with dementia,” and so creating landscape designs that are simple with easily identifiable districts, connecting nodes, and recognizable landmarks are crucial to allowing those with dementia to feel more competent and less fearful in the garden. It’s crucial that the environment feel safe and secure without making patients feel trapped.
This is being put into practice in many environments: here in California, Lakeside Manor shows that dementia gardens should also not use pesticides or herbicides, and all the plants should be edible and non-sharp. There should be no sharp and complicated gardening tools, no collapsible furniture, and no stakes, sprinklers or wires in the paths. Paths should be “quick-dry, non-slip, non-trip, well-lit, level [and] drainable,” and if possible, they should be designed round or in figure 8s; this encourages walking and makes gardens less confusing to navigate. It’s also important that staff should be able to monitor those walking the gardens while maintaining a private feel for the residents.
What happens in a dementia garden?
Dementia gardens serve multiple purposes: they provide space for peaceful walks and quiet contemplation, community gathering, physical activities, and for myriad benefits that increased autonomy brings the patients.
Residents can water plants, sit in the sun, listen to music, and talk a walk, either alone or with others. Outdoor exercise classes allow residents to stretch and move in the sunlight (which research suggests can actually reduce pain as well as the need for pain medication). Residents can be useful as they hang linens to dry, weed plants, help build planters, and mix seed for the bird feeders. Staff can organize outdoor social events where families can also participate. It provides “a milieu for socializing” as well as a place to find purpose, peace, joy, relief from pain, and so much more.
Another systematic literature review from 2018 looked specifically at how autonomy could be maintained for seniors with dementia and found that gardens were a vital part of this process. The importance of autonomy for patients with dementia is stressed: “Over the last decade … more attention has been given to preferences of residents in the provided care setting, [and] residential care facilities try to stimulate autonomy of their residents…to facilitate a more person-centered care approach.”
The authors amass research from over the course of decades, looking at all sorts of residential care facilities, and their results showed unequivocally the power of the dementia garden to increase resident’s sense of autonomy and, consequently, their wellbeing: “Specially designed spaces, for instance, therapeutic gardens, create activities for residents that remind them of themselves and contribute to their autonomy.” According to the researchers, by providing a space where residents can perform “an activity that reminds them of who they were or what they loved in the past,” dementia gardens can make patients “more comfortable and confident.”
Charnley Fold, a green dementia care facility in the UK, quotes a number of its residents in its pamphlet on green care, suggesting just how positive an experience the dementia patients find their experiences outside. “Are we gardening this afternoon? Oh lovely, I feel useful,” says one patient, while another remarks, “If I walk, it clears my head, it makes me feel free.” And my personal favorite: “We’ve done a good job—look at it! Amazing. A garden is such a good place to be.”
These sweet and sincere quotes elucidate just how healing being in a garden can be for mind, body and soul. By connecting to the earth, by experiencing the health benefits of Vitamin D and fresh soil, by being useful, by being social, by feeling autonomous, by helping to grow something that provides beauty or nourishment or both, patients with access to dementia gardens are finding healing in so many different and vital ways.