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UK/Europe and the rest of the world
Effects of garden visits on
people with dementia: A
pilot study
Man-Li Liao
Department of Landscape Architecture, University of Illinois at Urbana-
Champaign, USA
Sheng-Jung Ou
Department of Landscape and Urban Design, Chaoyang University of
Technology, Taichung City, Taiwan (R.O.C.)
Chung Heng Hsieh
Department of Landscape Architecture, Fu Jen Catholic University,
New Taipei City, Taiwan (R.O.C.)
Zhelin Li
College of Landscape Architecture and Arts, Northwest A&F
University, Shaanxi, China
Chia-Chun Ko
Department of Leisure and Recreation Management, National
Kaohsiung University of Hospitality and Tourism, Kaohsiung, Taiwan
(R.O.C.)
Abstract
The number of people with dementia is increasing rapidly worldwide. Developing strategies to
improve quality of life for those with dementia is crucial and is receiving more attention. Natural
environments are known for their healing effects on most people. This pilot study aimed to
understand the benefits that natural environments, such as gardens, can provide for people with
dementia. In total, 42 staff members in nine dementia care facilities were recruited as participants
in this study and answered a semistructured questionnaire. One-way analysis of variance with
Corresponding author:
Sheng-Jung Ou, Department of Landscape and Urban Design, Chaoyang University of Technology, No. 168, Jifeng E. Rd.,
Wufeng District, Taichung, 41349 Taiwan (R.O.C.).
Email: sjou@cyut.edu.tw
Dementia
0(0) 1–20
!The Author(s) 2018
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/1471301218793319
journals.sagepub.com/home/dem
repeated measures and the Mann–Whitney Utest were used to compare the effects of garden
visits on evaluated characteristics and the differences in evaluated characteristics between free
garden use and unfree garden use groups. Data from open-ended questions underwent text
analysis to obtain the principal beliefs of the participants. The staff members reported that
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.
Of the evaluated cognitive characteristics, attention and orientation to time were improved the
most after residents with dementia had spent time in a garden. Additionally, staff members in the
free garden use group scored the effects of garden visits on the mood, long-term memory,
language abilities, spatial ability, aggression, and agitation of patients with dementia as significantly
higher than staff members in the unfree garden use group. Recommendations for future studies
are discussed.
Keywords
dementia, gardens, mood, social interaction, cognitive abilities, behavioral problems
Introduction
The number of people with dementia is rapidly increasing worldwide. According to the
World Health Organization (WHO, 2012), the annual number of new cases of dementia
is approaching 7.7 million, implying a new case every 4 seconds. The total estimated world-
wide cost of dementia was US$604 billion in 2010 (WHO, 2012) and US$818 billion in 2015
(Wimo et al., 2017), a 35% increase in five years. Therefore, identifying the type of environ-
ments that benefit people with dementia and the manner in which they benefit them is a
question of interest worldwide.
Dementia is a syndrome caused by various brain illnesses that affect cognitive abilities
and is accompanied by several behavioral problems (Alzheimer’s Association, 2015; Perrin,
May, & Anderson, 2008). Worsening cognition affects the ability of patients to perform
everyday activities (Perrin et al., 2008; WHO, 2012). The symptoms of dementia include
memory impairment, lapses of judgment, difficulties with abstract thinking and language,
faulty reasoning, disorientation to time and place, and behavioral problems, such as agita-
tion, aggression, hallucinations, depression, wandering, suspicion, delusions, and emotional,
financial, and sexual abuse (Alzheimer’s Association, 2015; Perrin et al., 2008). The symp-
toms of dementia place a substantial burden on caregivers (Etters, Goodall, & Harrison,
2008) and must be treated properly and harmlessly.
Natural environments have healing effects for most people, as investigated and proven in
numerous studies (Kaplan, 1995; Ulrich et al., 1991). A natural environment can alleviate
depression, anxiety, and stress (Beyer et al., 2014; Ulrich et al., 1991); facilitate recovery
from mental fatigue (Kjellgren & Buhrkall, 2010; Sonntag-
€
Ostr€
om et al., 2014); and encour-
age physical activity and social interaction (Holtan, Dieterlen, & Sullivan, 2015; Kuo,
Sullivan, Coley, & Brunson, 1998). Thus, green space should be considered the “vitamin
G” that enhances or maintains human physiological, psychological, and social health
(Groenewegen, van den Berg, de Vries, & Verheij, 2006).
2Dementia 0(0)
Gardens appear to be irreplaceable healing environments for people with dementia living
in care facilities, but research on the healing effects of gardens and outdoor spaces on people
with dementia is scant. Edwards, McDonnell, and Merl (2013) reported that the quality of
residents’ life was significantly improved after a garden was opened at a dementia care unit.
Gardens and outdoor environments have positive effects on the quality of life of people with
dementia, particularly in terms of redirection, stress relief, access to fresh air, meaningful
daily activities, enjoyment of daily life, interpersonal relationships, and independent func-
tioning (Cohen-Mansfield & Werner, 1998; Cox, Burns, & Savage, 2004; Duggan,
Blackman, Martyr, & Van Schaik, 2008; Edwards et al., 2013; Hernandez, 2007; Raske,
2010). In addition, some studies have suggested that garden visits can improve mood and
decrease depression in people with dementia (Detweiler, Murphy, Myers, & Kim, 2008;
Edwards et al., 2013; Rappe & Topo, 2007).
Natural and outdoor environments can also mitigate behavioral problems in people with
dementia. Mooney and Nicell (1992) conducted longitudinal research in five dementia care
facilities over two years and reported that using exterior environments reduced incidents of
aggression among residents. By adding visual, auditory, and olfactory stimuli to the indoor
environment to simulate an outdoor natural environment, Cohen-Mansfield and Werner
(1998) discovered a trend toward less trespassing, exit-seeking, and other agitated behaviors
among residents with dementia. Other studies have suggested that being outdoors, such as in
a therapeutic garden, substantially decreases agitation (Edwards et al., 2013; Mather,
Nemecek, & Oliver, 1997) and improves sleep quality for people with dementia (Calkins,
Szmerekovsky, & Biddle, 2007; Mather et al., 1997).
Agitation and psychosis prevalences are approximately 50% and 70%, respectively, in
the moderate to advanced stages of Alzheimer’s disease and related dementia conditions
(Detweiler et al., 2008; Sunderland, 1995). When several medications are concurrently used
to treat psychiatric problems in patients with dementia, some side effects, such as increased
fall risk, may occur (Detweiler et al., 2008; Zagaria, 2001). This appears to imply that if the
agitation and psychosis of patients with dementia can be improved, the patients’ fall risk will
decrease because of lower usage of psychiatric medicine. Detweiler, Murphy, Kim, Myers,
and Ashai (2009) classified the 28 participating residents of a dementia unit into high and
low wander garden user groups and recorded the two groups’ number and severity of falls.
The type and dose of scheduled psychiatric medications were monitored for 12 months
before and after a wander garden was opened. The results showed that there was an approx-
imately 30% decrease in the raw number of falls and fall severity scores. The high wander
garden user group required fewer scheduled medications and as-needed antipsychotics,
experienced fewer falls, and had lower fall morbidity than did the low wander garden
user group. Thus, access to a garden may not only improve the quality of life of people
with dementia but also make long-term financial savings for a nursing home’s management
(Detweiler et al., 2009).
Although these studies have revealed that people with dementia receive some physical,
psychological, and social advantages from garden visits or engagement with a natural envi-
ronment, some of the behavioral problems of residents with dementia—such as hallucina-
tions, repetition, suspicion, delusion, and physical, emotional, verbal, or sexual abuse—have
yet to be evaluated after the prolonged exposure of residents to a natural environment.
Furthermore, whether garden visits help people with dementia maintain their cognitive
abilities, such as orientation to time and place, short-term and long-term memory, and
Liao et al. 3
attention, has been rarely discussed. Therefore, the purpose of this pilot study was to eval-
uate the effects of garden visits on mood, social interaction, cognition, and behavioral
problems and determine what type of behavioral problems and cognitive abilities among
patients with dementia may be improved after visiting a garden. Effects were evaluated from
staff members’ points of view. The results obtained from this pilot study can be a reference
when designing a research framework for further study on the benefits of garden visits for
people with dementia.
Methods
Approval was obtained from the Office for the Protection of Research Subjects of the
University of Illinois at Urbana-Champaign. Thirty dementia care facilities with gardens
in Illinois were approached to participate in this pilot study, of which nine agreed. The
dementia care facility staff members are familiar with residents and must continually eval-
uate residents’ cognitive states and behavioral problems; therefore, staff members’ opinions
are valuable. In total, 55 staff members who had worked in a dementia care facility for more
than one year were recruited as participants in this pilot study; ultimately, 42 samples were
valid. The nine dementia care facilities analyzed in this study, along with their respective
gardens, are described in the following subsections.
Facility A
Located in the suburbs of Champaign in Illinois, facility A features general care and demen-
tia units. The dementia unit can accommodate up to 24 patients with mild, moderate, or
severe dementia. The unit contains a rectangular garden that is 24.5 m long and 12.5 m wide.
Two adjacent sides of the garden are surrounded by the facility’s buildings, whereas the
other two are bordered by a metal fence that can be seen through. The garden is simply
designed; along its edges is an elliptical loop formed by a nearby walkway, and sparse, small
deciduous trees and shrubs grow along the garden’s edges. Most garden tables and chairs
are placed near the gate; benches also line the walkway. A raised flowerbed is located at the
center of the lawn. The dementia unit does not regularly host activities related to gardening
or horticultural therapy. However, in spring and summer, staff and residents occasionally
grow flowers and herbs in the garden together. The staff is tasked with maintaining the
garden. The garden has only one entrance, which is normally locked, and residents must
enter with a companion.
Facility B
Facility B, located in Mahomet in Illinois, is an assisted and supportive living facility; its
dementia unit can accommodate up to 30 patients with mild or moderate dementia. The
garden in the dementia unit is 16.4 m long and 9.3 m wide. Three sides of the garden are
surrounded by the facility’s buildings, whereas the remaining side is bordered by a wooden
fence that cannot be seen through. A circular walkway encloses a gazebo at the center of the
garden. The garden contains several small deciduous trees, low-lying shrubs, and movable
pots and hanging baskets with annual flowers. Bird feeders and benches are installed along
the walkway. On fine days, the staff at facility B typically takes residents out for strolls in the
garden and to sit under the gazebo. The facility does not organize gardening activities for its
4Dementia 0(0)
residents. The staff maintains the garden. The garden features only one entrance, which is
normally locked, and residents must enter the garden with a companion.
Facility C
Facility C, a dementia care facility located in Urbana in Illinois, can accommodate up to 66
patients with mild, moderate, or severe dementia. The center encompasses a square garden
that is surrounded by single-story buildings, with an area of approximately 576 m
2
. Inside
these buildings, spacious corridors ring the garden and feature expansive windows that
overlook it. Residents can walk along the corridors or sit on cozy sofas placed along
them to view the garden. The garden can be accessed through four gates. Residents are
allowed to enter and exit the garden independently in their free time when the weather is
favorable. Along the edges of the garden is a walkway that connects the corridors in the
buildings, allowing residents to enter and exit. Several movable tables and chairs are located
near the main gates of the garden. The flowerbed in the garden contains a tiny pond in
which fish are kept in summer. Facility C engages residents with garden-based activities,
such as gardening and relaxing. The residents of the facility also help to water the garden. In
summer, some group activities are hosted there. The gates to the garden are locked only
when the weather is unsuitable for going outside.
Facility D
Facility D, which is located in Decatur in Illinois, features both general care and dementia
units. The dementia unit at facility D provides 20 beds for patients with mild or moderate
dementia. Two gardens are situated in the dementia unit. One is rectangular, spanning an
area of 348.27 m
2
—24.7 m in length and 14.1 m in width—and is surrounded by residents’
rooms, a restaurant, and living rooms. The walkway of the garden is shaped like the number
eight and lined with shrubs and vegetation. The garden can be accessed through four gates,
and movable tables and chairs are located near them. The other garden is adjacent to the
building and measures 25.2 m in length and 16.6 m in width. One side of the garden borders
the building, whereas the other three sides are enclosed by wooden fences. The garden
contains raised garden beds in which residents can grow plants. Every year from May to
July, gardening activities are held twice a week that allow residents to grow vegetables, such
as tomatoes and cucumbers. Residents can enter and exit the gardens independently except
during inclement weather.
Facility E
Located in Forsyth in Illinois, facility E provides independent living, assisted living, skilled
nursing, and memory care. The dementia unit in the facility E has a total of 18 beds and
mainly admits patients with mild or moderate dementia. The garden in the dementia unit is
15.1 m long and 12.3 m wide. Two adjacent sides of the garden face the facility’s buildings,
whereas the other two are enclosed by a white wooden fence. Several movable garden tables
and chairs are located near the gate of the garden. The garden has a looped walkway lined
by benches and bird feeders. Gardening activities are hosted occasionally. In spring and
summer, residents grow tomatoes and flowers in the raised garden beds. The garden features
only one entrance that is normally locked and inaccessible to residents unless they are
accompanied by a staff member.
Liao et al. 5
Facility F
Located in Kankakee in Illinois, facility F caters to different care communities, featuring
independent living and assisted living, with memory care and skilled nursing provided. The
dementia unit can accommodate up to 20 patients with mild, moderate, or severe dementia.
Dementia unit residents share a garden with assisted living community residents but use
their own separate entrance. The garden is spacious, spanning an area of 1107.6 m
2
—35.5 m
long and 31.2 m wide; it is enclosed by the buildings of the four care communities. The
garden features an expansive lawn. The entrances to the garden from the four buildings are
connected to walkways that lead to a recreational area called the Butterfly Garden at the
center of the garden. This area features tall deciduous trees, shrubs, benches, and bird
feeders. The gate from the dementia unit to the garden is typically locked; residents must
enter the garden with a staff member. Several garden tables and chairs are situated in
proximity to the entrance from the dementia unit. Group activities are occasionally under-
taken by the unit’s residents with the aid of staff members on fine days.
Facility G
Located in Chrisman in Illinois, facility G provides independent living and assisted living in
addition to skilled nursing and memory care. The dementia unit can accommodate up to
23 patients with mild, moderate, or severe dementia. The garden in the dementia unit is
rectangular and measures 25.0 m in length and 15.1 m in width. Three sides of the garden are
surrounded by buildings, whereas the remaining side is bordered by a metal fence that can
be seen through. Only one entrance provides access to the garden; the walkway into the
garden starts from the entrance and forks into two paths: one leading to a recreational
wooden platform in the corner of the garden and the other leading through the center of the
garden to a gazebo. Trees grow on the lawn, and benches are installed only on the wooden
platform and inside the gazebo. Events are occasionally held in the garden during summer.
Residents who enjoy growing flowers are provided with the outdoor space to do so; they
may also grow flowers in pots indoors and later take the pots outdoors. The residents help to
water the flowers. The entrance to the garden is locked; residents must enter the garden with
a companion.
Facility H
Located in Paris in Illinois, facility H is a care facility for patients with Alzheimer’s disease
and other types of dementia. It can accommodate up to 19 patients with mild or moderate
dementia. The rectangular garden in the facility is 34.6 m long and 6.5 m wide. One long side
of the garden is contiguous to the buildings of the facility, whereas the other three sides are
enclosed by a white wooden fence. A walkway encircles the garden, which is lined with
benches and bird feeders. Near the gate of the garden is a gazebo where staff members and
residents can rest and eat snacks on fine days. Several movable garden tables and chairs are
located near the entrance to the building, opposite the gazebo. The garden comprises lawns
and several small shrubs and is adorned with flowerpots. Gardening activities occasionally
take place in the garden. The garden has only one entrance that is normally locked and
inaccessible to residents without a companion.
6Dementia 0(0)
Facility I
Located in Decatur in Illinois, facility I is an assisted living facility with a capacity of up to
40 patients with mild, moderate, or severe dementia. The garden in the facility measures 31.4
m in length and 24.3 m in width. Three sides of the garden are surrounded by the facility’s
buildings, whereas the remaining side is bordered by a white wrought-iron fence that can be
seen through. Spacious, flat walkways are located along the four sides and lead to the center
of the garden. The walkways divide the grassy area into three sections in which some small
deciduous trees and flowering shrubs are located. Movable garden tables and chairs are
placed near the gate of the garden. Benches have also been installed along the walkways. On
fine days, staff members often accompany residents for a walk. The garden sometimes hosts
group activities. Next to the garden is a room named the Potting Shed, an indoor space in
which flowerpots, soil, trowels, and several rectangular workbenches and chairs are stored.
Gardening activities are conducted sporadically at facility I. Residents can grow plants in
the raised garden beds in the garden or in the pots in the Potting Shed, and subsequently
place them in the garden. The garden features three entrances, which are normally locked,
and the garden is inaccessible to residents without a companion.
A semistructured questionnaire, completed by staff members, was used to evaluate the
benefits of garden visits on people with dementia. The 20 evaluated characteristics com-
prised seven regarding cognitive abilities, nine regarding behavioral problems, and one each
regarding activities of daily living (ADL), appetite, mood, and social interaction. The seven
evaluated cognition characteristics were orientation to time, orientation to place, short-term
memory, long-term memory, attention, language ability, and spatial ability, which are
addressed by the Mini Mental State Exam, the most commonly used instrument worldwide
for screening cognitive function (Edwards et al., 2013; Folstein, Folstein, & McHugh, 1975).
The nine evaluated behavioral problems were aggression/anger, anxiety/agitation, depres-
sion, hallucinations, repetition, sleep issues, suspicion/delusions, wandering, and abuse
(physical, emotional, verbal, and sexual abuse) behaviors that are suggested as common
among people with dementia by the Alzheimer’s Association (2015). Staff members were
asked the following question: “After residents visit your care facility’s garden and for 1 hour
or so afterwards, what changes do you observe in the following characteristics? (1 = much
worse than usual; 2 = slightly worse than usual; 3 = the same as usual; 4 = slightly better
than usual; 5 = much better than usual).” An open-ended question followed—“Can you
please explain?”—for each evaluated characteristic.
The data from the five-point Likert-type scale questions underwent one-way analysis of
variance (ANOVA) with repeated measures to compare the garden visits’ effects on mood,
social interaction, cognitive characteristics, and behavioral problems in people with demen-
tia. The Mann–Whitney Utest was employed to compare the effect of garden visits on the
evaluated characteristics between the free garden use group (n = 7) and unfree garden use
group (n = 35). The data from the open-ended questions underwent text analysis to obtain
the prevailing beliefs of the participants.
Results
Demographic characteristics of participants
In total, 42 staff members from nine dementia care facilities participated in this pilot study.
All participants were women. Most participants were in the age group 21–60 years and had
Liao et al. 7
a high school/general equivalency development diploma (50.0%) or associate’s degree
(38.1%). Staff members with between 1 and 10 years of service constituted 92.9% of the
total participants (Table 1).
Effects of garden visits on dementia residents’ mood, social interaction,
cognitive ability, and behavioral problems
Staff members who participated in the current study indicated that, of the evaluated char-
acteristics, the most common effect of garden visits was improving the residents’ moods
(mean = 3.81, standard deviation [SD] = .59), followed by reducing depression (mean =
3.76, SD = .62), enhancing social interaction (mean = 3.71, SD = .64), and reducing
agitation (mean = 3.69, SD = .74) (Table 2). However, the differences for mood, depres-
sion, social interaction, and agitation were not significant (Table 3). Participants reported
that garden visits had less effect on improving dementia residents’ spatial ability (mean =
3.12, SD = .33) among the evaluated characteristics (Table 2).
Mood
Staff members reported that after residents with dementia had spent time in the garden, their
most obviously improved characteristic was mood (mean = 3.81, SD = .59). Furthermore,
7.84%, 66.67%, and 25.49% of the participants reported that after residents had spent time
in the garden, their mood became “much better than usual,” “better than usual,” and “the
same as usual,” respectively. They thought that garden visits allowed the residents to feel
independent and made them happier. Looking at pretty flowers, experiencing the sunshine,
and talking about the blue sky improved their mood. Their stress was relieved, and they felt
refreshed and calm.
Table 1. Demographic characteristics of participants (n = 42).
Demographic factors Participants Frequency Percentage
Gender Male 0 0
Female 42 100
Age 19–30 11 26.2
31–50 18 42.8
51–70 13 30.9
Education High school/GED 21 50.0
Associate’s degree 16 38.1
Bachelor’s degree 4 9.5
Master’s degree 1 2.4
Length of service 1–5 years 28 66.7
6–10 years 11 26.2
11–15 years 1 2.4
16–20 years 1 2.4
More than 20 years 1 2.4
GED: General equivalency diploma.
8Dementia 0(0)
Social interaction
The mean score for social interaction was the second highest (mean = 3.71, SD = .64). In
total, 10.20%, 53.06%, and 36.73% of the participants thought garden visits made residents’
social interaction “much better than usual,” “better than usual,” and “the same as usual,”
respectively. The participants reported that the principal reason was that the garden visits
offered residents many topics for discussion, such as weather, sunshine, and flowers. When
the residents visited the gardens, they were reminded of incidents from their pasts. They
enjoyed recounting such anecdotes to their peers.
Behavioral problems
Among the evaluated behavioral problems, staff members reported that garden visits
reduced dementia residents’ depression, anxiety/agitation, and aggression/anger significant-
ly more than other behavioral problems such as hallucinations, repetition, sleep issues,
suspicion/delusion, wandering, and abuse (one-way ANOVA repeated measures, F=
10.087, p<.001; Figure 1). Depression had the highest mean score (mean = 3.76, SD =
.62) for improved effect after garden visits, followed by anxiety/agitation (mean = 3.69, SD
= .74), and aggression/anger (mean = 3.57, SD = .77).
Depression. In total, 7.84% and 58.85% of participants reported that residents’ depression
was “much better than usual” and “better than usual,” respectively. They reported that
Table 2. Means and standard deviations of the evaluated characteristics of garden visit effects on people
with dementia.
Categories Evaluated characteristics Mean
a
SD
Cognitive abilities Orientation to time 3.52 .55
Orientation to place 3.26 .54
Short-term memory 3.19 .51
Long-term memory 3.23 .48
Attention 3.60 .66
Language abilities 3.21 .42
Spatial ability 3.12 .33
Activities of daily life Activities of daily life 3.19 .40
Behavioral problems Aggression/anger 3.57 .77
Anxiety/agitation 3.69 .74
Depression 3.76 .62
Hallucinations/delusions 3.19 .45
Repetition (words/question/activity) 3.19 .45
Sleep 3.31 .47
Suspicion 3.21 .47
Wandering 3.29 .83
Abuse (physical/emotional/verbal/sexual) 3.26 .50
Appetite Appetite 3.40 .50
Mood Mood 3.81 .59
Social interaction Social interaction 3.71 .64
a
1 = much worse than usual; 2 = slightly worse than usual; 3 = the same as usual; 4 = slightly better than usual; 5 = much
better than usual.
Liao et al. 9
natural elements in the gardens, such as fresh air, sunshine, and plants, reduced residents’
depression. Their stress was relieved in the gardens. Residents could enter and leave the
garden or courtyard independently, which provided a sense of independence, reducing
depression. The garden visits made the residents happier.
Anxiety/agitation. In total, 68.75% of participants reported that garden visits improved resi-
dents’ anxiety/agitation, and this might be attributable to the fresh air in the garden and
residents enjoying the fine weather. Residents with dementia became calm. Most residents
had been farmers, so spending time in the garden provoked recall of pleasant memories.
Residents were permitted to enter and leave the garden or courtyard independently, which
allowed them to feel independent, which in turn reduced agitation.
However, two participants reported that whether a positive or negative outcome occurred
from the garden visits depended on the individual. In total, 6.25% of participants reported
that residents’ anxiety levels became “slightly worse than usual” or “much worse than
usual.” Residents may have been anxious that they could not leave the facility.
Furthermore, gardens may overstimulate and confuse residents.
Table 3. One-way repeated measures ANOVA of different effects of garden visits on people with dementia.
Source SS df
a
MS F p Post hoc
b
Between
groups
40.756 8.004 5.092 10.079 .000 1 >2; 1 >3; 1 >4; 1 >6; 1 >7; 1 >8; 1 >12;
1>13; 1 >14; 1 >15; 1 >17; 1 <19; 2 <5;
2<9; 2 <10; 2 <11; 2 <19; 2 <20; 3 <5;
3<9; 3 <10; 3 <11; 3 <18; 3 <19; 3 <20;
4<5; 4 <9; 4 <10; 4 <11; 4 <19; 4,20;
5>6; 5 >7; 5 >8; 5 >12; 5 >13; 5 >14;
5>15; 5 >16; 5 >17; 5 <19; 6 >7; 6 <9;
6<10; 6 <11; 6 <18; 6 <19; 6 <20; 7 <9;
7<10; 7 <11; 7 <14; 7 <18; 7 <19; 7 <20;
8<9; 8 <10; 8 <11; 8 <18; 8 <19; 8 <20;
9<10; 9 <11; 9 >12; 9 >13; 9 >14; 9 >15;
9>16; 7 >17; 9 <19; 10 >12; 10 >13;
10 >14; 10 >15; 10 >16; 10 >17; 10 >18;
11 >12; 11 >13; 11 >14; 11 >15; 11 >16;
11 >17; 11 >18; 12 <18; 12 <19; 12 <20;
13 <18; 13 <19; 13 <20; 14 <19; 14 <20;
15 <19; 15 <20; 16 <19; 16 <20; 17 <19;
17 <20; 18 <19; 18 <20;
Within
groups
258.500 369.155 2.766
Total 299.256 377.159
ANOVA: analysis of variance; SS: sum of squares; MS: mean squares.
a
Degrees of freedom (df) were corrected using Greenhouse–Geisser estimates because of violation of sphericity.
b
1 = orientation to time; 2 = orientation to place; 3 = short-term memory; 4 = long-term memory; 5 = attention; 6 =
language ability; 7 = spatial ability; 8 = activities of daily life (ADL); 9 = aggression/anger; 10 = anxiety/agitation; 11 =
depression; 12 = hallucinations; 13 = repetition; 14 = sleep issues; 15 = suspicion/delusions; 16 = wandering; 17 = abuse;
18 = appetite; 19 = mood; 20 = social interaction.
10 Dementia 0(0)
Aggression/anger. In total, 56.25% of participants reported that garden visits reduced resi-
dents’ aggression and anger levels. The fresh air and agreeable weather were therapeutic,
and the positive ambience of the gardens cheered residents. They felt less stressed, happier,
more content, and calmer in the gardens. Residents could move enter and leave the garden
or courtyard independently, allowing them to feel independent, which in turn
reduced aggression.
As in the case of the effect of garden visits on anxiety/agitation, two participants reported
that whether a positive or negative outcome occurred from the garden visits depended on
the individual. In total, 4.16% of participants reported that garden visits might make
residents angrier because, after the garden session, they wanted to return outside or
return home.
Sleep. Some participants (31.0%) believed that garden visits helped residents with dementia
achieve a higher sleep quality because residents felt more relaxed. They noted that a happy
spirit led to more restful sleep and calmer bed rituals. Fresh air and warm weather also
improved sleep quality. However, other participants (69.0%) reported that the sleep quality
of residents with dementia did not change after they visited the garden.
Cognitive ability
Although the average score for cognitive ability was significantly lower than those for mood
and social interaction, many participants reported that the garden visits had a positive
impact on residents’ cognition. Among all the evaluated cognitive characteristics, attention
and orientation to time were found to have benefited the most after residents had spent time
in the gardens (one-way ANOVA repeated measures, F= 8.244, p<.001; Figure 2).
Figure 1. Effects of garden visits (mean SD) on the different behavioral problems of residents
with dementia.
Liao et al. 11
Attention. In total, 66.67% of the participants reported that garden visits made residents’
attention “better than usual” or “much better than usual.” Participants reported that when
activities were held outdoors, residents with dementia focused more on the tasks that they
were assigned and their attention was sharpened. This increased attention might have been
caused by the fresh air, agreeable weather, ambience in the gardens, or variation in their
monotonous daily routine.
However, 5.88% of the participants reported that residents’ attention became “slightly
worse than usual” after they had spent time in the gardens. The worse attention was caused
by residents wanting to return outdoors after the garden session rather than concentrating
on their assigned indoor activities or their seeking exit routes relatively more frequently
than usual.
Orientation to time. In total, 50.98% of the participants reported that after spending time
outdoors, residents were more orientated to time because in the gardens, they could track
the changes in leaves, trees, and flowers through the seasons and perceive different weather
conditions or temperatures. These changes helped the residents with dementia to track the
seasons. Seeing sunrise and sunset also helped the people with dementia to orient themselves
to time.
However, 49.02% of the participants reported that residents’ cognition of orientation
to time was the “same as usual” even after they had spent time in the gardens. One
participant reported that some residents could not determine whether the weather was
hot or cold.
Impact of freedom to move in and out of gardens
Residents were forbidden from independently moving in and out of the gardens in all
facilities except two in this pilot study. The participants were thus divided into unfree
garden use (n = 35) and free garden use (n = 7) groups to test for any significant differences
Figure 2. Effects of garden visits (mean SD) on the cognitive abilities of residents with dementia.
12 Dementia 0(0)
that existed for all evaluated characteristics between the two groups; such differences were
evaluated using nonparametric testing.
The Mann–Whitney Utest revealed a significant difference in mood (Mann–Whitney U
= 64.500, p<.05), namely that the free garden use group gave higher scores than the unfree
garden use group (Table 4). Additionally, staff members in the free garden use group
reported that the effects of garden visits on improving dementia residents’ long-term
memory, language abilities, spatial ability, aggression/anger, and anxiety/agitation were
significantly better than those in the unfree garden use group. No significant differences
were observed for orientation to time, orientation to place, short-term memory, ADL,
depression, hallucination, repetition, sleep issues, suspicion, wandering, and abuse between
the free and unfree garden use groups (Table 4).
Discussion
Mood, social interaction, and behavioral problems
The results of this pilot study suggest that staff members believed the most positive effects of
garden visits for residents with dementia were improvements in mood, less depression,
higher social interaction, and less agitation (Table 3) and were a result of the harmless,
gentle features of the natural environment, including the sunshine, breeze, flowers, fresh air,
and blue skies and having a common topic (i.e., aspects of the gardens) with which to initiate
conversations with peers.
The prevalence of depression among residents with Alzheimer’s disease is approximately
50% (Benoit et al., 2012; Chi, Yu, Tan, & Tan, 2014; Engedal, Barca, Laks, & Selbaek,
2011; Knapskog, Barca, & Engedal, 2014). Additionally, in the moderate and advanced
stages of Alzheimer’s disease, at least 50% and 70% of residents exhibit agitation and
psychosis, respectively, during the first six to seven years of the disease (Detweiler et al.,
2008; Sunderland, 1995). Agitation and other inappropriate behaviors of residents with
dementia place a burden on caregivers and are often treated using medication (Cohen-
Mansfield, Marx, & Rosenthal, 1989; Detweiler et al., 2009; McMinn & Hinton, 2000).
However, medications may have side effects, such as increased fall risk, and result in
impaired quality of life (Katz, Rupnow, Kozma, & Schneider, 2004).
Fortunately, some nonpharmacological interventions, such as cognitive stimulation ther-
apy and multisensory stimulation, have been approved for reducing neuropsychiatric prob-
lems in people with Alzheimer’s disease (Cox et al., 2004; Mapelli, Di Rosa, Nocita, & Sava,
2013; Niu, Tan, Guan, Zhang, & Wang, 2010; Ozdemir & Akdemir, 2009). Natural environ-
ments are endowed with fascinating and delightful elements, such as clouds, sunshine, trees,
flowers, and birds. These elements offer multisensory stimulation, including visual, auditory,
tactile, and olfactory stimulations, for residents with dementia. Moreover, studies have
demonstrated that garden use can reduce agitation, aggression, and depression levels in
people with dementia (Calkins et al., 2007; Cohen-Mansfield et al., 1989; Detweiler et al.,
2008; Edwards et al., 2013; Hernandez, 2007; Mooney & Nicell, 1992; Rappe & Topo, 2007).
Using fall severity score records, Detweiler et al. (2009) determined that greater garden use
was related to lower fall morbidity.
The results of this and similar studies are valuable for people with dementia and their
caregivers. A natural environment enhances mood and social interaction among people with
dementia and reduces caregivers’ burdens by reducing behavioral problems, such as
Liao et al. 13
Table 4. Differences for evaluated items between the unfree and free garden use groups.
Categories Variables Group
a
Mean Mean Rank Sum of Ranks Mann-Whitney U
b
Cognitive abilities Orientation to time 1 3.46 20.37 713.00 83.000
2 3.86 27.14 190.00
Orientation to place 1 3.26 21.26 744.00 114.000
2 3.29 22.71 159.00
Short-term memory 1 3.14 20.49 717.00 87.000
2 3.43 26.57 186.00
Long-term memory 1 3.14 19.57 685.00 55.000*
2 3.71 31.14 218.00
Attention 1 3.51 20.10 703.50 73.000
2 4.00 28.50 199.50
Language abilities 1 3.11 19.40 679.00 49.000*
2 3.71 32.00 224.00
Spatial ability 1 3.00 19.00 665.00 35.000**
2 3.71 34.00 238.00
Activities of daily life Activities of daily life 1 3.14 20.50 717.50 87.500
2 3.43 26.50 185.50
Behavioral problems Aggression/ anger 1 3.46 19.84 694.50 64.500*
2 4.14 29.79 208.50
Anxiety/ agitation 1 3.57 19.67 688.50 58.500*
2 4.29 30.64 214.50
Depression 1 3.69 20.17 706.00 76.000
2 4.14 28.14 197.00
Hallucination 1 3.14 20.54 719.00 89.000
2 3.43 26.29 184.00
Repetition 1 3.14 20.54 719.00 89.000
2 3.43 26.29 184.00
Sleep 1 3.26 20.40 714.00 84.000
2 3.57 27.00 189.00
Suspicion 1 3.17 20.54 719.00 89.000
2 3.43 26.29 184.00
Wandering 1 3.20 20.17 706.00 76.000
2 3.71 28.14 197.00
Abuse 1 3.23 20.84 729.50 99.500
2 3.43 24.79 173.50
Appetite Appetite 1 3.34 20.20 707.00 77.000
2 3.71 28.00 196.00
Mood Mood 1 3.71 19.84 694.50 64.500*
2 4.29 29.79 208.50
Social interaction Social interaction 1 3.63 19.93 697.50 67.500
2 4.14 29.36 205.50
a
Group 1 = unfree garden use group (n = 35); group 2 = free garden use group (n = 7).
b
*significant at p< .05; **significant at p< .005.
14 Dementia 0(0)
depression, agitation, and aggression. Moreover, if residents’ neuropsychiatric symptoms
are reduced by garden visits, antipsychotic medicine use by residents can be reduced or
stopped. Thus, the risk of falls for residents may decrease. Additionally, this results in
quality of life improvement for residents (Detweiler et al., 2008, 2009).
Sleep quality is also a crucial issue for people with dementia. Calkins et al. (2007) found
that increased time spent outdoors resulted in a mild improvement in the sleep of people
with dementia. Mather et al. (1997) reported that residents with dementia who spent more
time outdoors displayed less disruptive behavior and had less nighttime sleep disruption in
midsummer. In this study, 31.0% of participants believed that garden visits helped residents
with dementia achieve higher sleep quality, but 69.0% of participants reported that the sleep
quality of residents did not change after garden visits. The scores for sleep were significantly
higher only than those for spatial ability and were significantly lower than those for atten-
tion, aggression, agitation, depression, mood, social interaction, and orientation to time
(Table 3). This suggests that the effects of garden visits on the sleep quality of people
with dementia may be limited, and the effects were less pronounced than those on attention,
aggression, agitation, depression, mood, social interaction, and orientation to time.
The scores for hallucination, repetition, suspicion, and abuse (physical, emotional,
verbal, or sexual) were significantly lower than those for aggression, agitation, and depres-
sion (Table 3) and were not significantly different among groups. Results indicate that staff
members believed the positive effects of garden visits on aggression, agitation, and depres-
sion to be greater than those on hallucinations, repetition, suspicion, and abuse.
Cognitive abilities
Most studies exploring the effect of garden visits on people with dementia have focused on
the influences on mood or behavioral problems; few have concentrated on the impact of
garden visits on the cognition of residents with dementia. The results of this pilot study
suggest that residents’ orientation to time and attention were significantly more improved by
garden visits than were the other cognitive abilities of orientation to place, short-term
memory, long-term memory, language ability, and spatial ability. Furthermore, the differ-
ences among orientation to place, short-term memory, long-term memory, language ability,
and spatial ability were not significant (Table 3).
Orientation to time. Orientation to time is a cognitive ability essential to daily life. Because
temporal orientation is so fundamental, disorientation to time can indicate the presence and
severity of dementia or delirium in older hospital patients (O’Keeffe, Mukhtar, & O’Keeffe,
2011). Time in the garden observing nature helped people with dementia “know the time”
and maintain their temporal orientation. Rappe and Topo (2007) noted that green outdoor
environments can improve the orientation toward reality of people with dementia because
green environments provide information and cues about time, place, and purpose. In this
study, the effect of garden visits on orientation to time, as reported by staff members, was
significantly higher than that on orientation to place.
Attention. Natural environments facilitate attention restoration (Berto, 2005; Kaplan, 1995;
Sonntag-
€
Ostr€
om et al., 2014; Tennessen & Cimprich, 1995). Although it is unclear whether
the mechanisms of attention restoration in normal people and people with dementia are the
same, many staff members participating in this study reported that, similar to people
Liao et al. 15
without dementia, the attention of residents with dementia improved when they were in
the gardens.
Kaplan (1995) stated that the components of restorative environments were “being
away,” “fascination,” “extent,” and “compatibility.” Staff members in this study opined
that in the gardens, residents could “alleviate the monotony they experienced indoors.” That
is, garden visits offered an opportunity for residents with dementia to feel “away” from
normal life. Residents reportedly enjoyed sitting outdoors and the fine weather, fresh air,
gentle breeze, birdsong, colorful flowers, and seasonal color changes. This was the
“fascination” with the natural environment, which features rich, fascinating objects and
engrossing, natural processes (Kaplan, 1995). Residents felt relaxed in the gardens. They
could easily enjoy nature, and they were not obliged to make an effort to have fun.
Additionally, nature posed no threat to them. This is the “compatibility” of the restorative
environment. Being in the gardens allowed residents to recall familial and childhood mem-
ories. This is the conceptual “extent” of the restorative environment. Gardens facilitate
attention restoration in residents with dementia possibly because in gardens, all four
components of a restorative environment—being away, fascination, extent, and compatibil-
ity—are present.
Impact of freedom to move in and out of gardens
The results of the present study indicated that the effects of garden visits on the long-term
memory, language abilities, spatial ability, aggression/anger, anxiety/agitation, and mood of
residents in the free garden use group were significantly more favorable than those on
residents in the unfree garden use group. This implies that maintaining residents’ cognitive
abilities by allowing them to independently enter and leave gardens is beneficial. Learning
and memory require an external stimulus to trigger a subset of neurons to fire together
(Carter, 2014). When an individual faces the same situation or repeatedly practices a skill,
the neurons involved in the event fire together more easily, a tendency known as
“potentiation” (Carter, 2014). Therefore, the individual recalls the event more easily or
becomes more proficient at the skill. Dementia residents who enter and leave gardens inde-
pendently may exhibit slower progress in cognition abilities such as long-term memory,
language abilities, and spatial ability because they must trigger brain neurons to handle
the process of entering and leaving the gardens by themselves. Although neurons are
destroyed quickly in the brain, any delay in the rate of progression is meaningful and crucial
for residents with dementia (Dysken et al., 2014).
Some studies have revealed that garden visits benefit the quality of life of residents with
dementia (Calkins et al., 2007; Detweiler et al., 2009; Mather et al., 1997); however, most
dementia care facilities lock the doors to the garden to prevent residents from using the
garden independently. According to research, different levels of garden usage have resulted
in different fall risks and sleep quality of residents with dementia (Calkins et al., 2007;
Detweiler et al., 2009; Mather et al., 1997). Therefore, we hypothesized that garden usage
may affect the mood, cognitive abilities, and behavioral problems of residents with demen-
tia. The results of this pilot study show that entering and exiting the garden autonomously
may benefit residents with dementia by improving their mood and cognitive abilities (long-
term memory, language abilities, and spatial abilities), while reducing behavioral problems
(aggression and agitation) (Table 4). However, the sample size was small, and the evaluation
of the effects of garden visits may have been affected by unknown variables. The effects of
16 Dementia 0(0)
entering and exiting gardens independently on the mood, cognitive abilities, behavioral
problems, and ADL of residents with dementia merit further study.
Conclusions
Countries are facing the severe problem that the number of people with dementia conditions is
increasing quickly worldwide. Improving dementia residents’ quality of life, reducing the heavy
burdens on caregivers, and learning what environments benefit people with dementia are increas-
ingly investigated. The purpose of this pilot study was to evaluate the benefits of garden visits on
the psychological, cognitive, behavioral, and social characteristics of people with dementia.
The results highlight the crucial role of gardens in dementia care communities. From the
perspective of staff members working in dementia care communities, garden visits not only
improved residents’ mood and social interactions while reducing behavioral problems,
including depression, agitation, and aggression, but also enhanced their cognitive abilities,
such as attention and orientation to time, because of the rich, rhythmic, harmless, and
nonthreatening characteristics of the natural environment. The results of this pilot study
also suggest that whether patients with dementia are allowed independent use of gardens
affects their cognitive levels.
The principal recommendation of the present study for future research is to determine the
effect of allowing independent access to gardens on the rate of progression of cognitive
ability impairment, including long-term memory, language ability, spatial ability, aggres-
sion, agitation, and mood in patients with dementia through observation and medical record
analysis. A larger sample is recommended to verify the benefits of garden visits for patients
with dementia.
Acknowledgments
The authors thank Dr. William Sullivan, the head of and professor at the Department of Landscape
Architecture at the University of Illinois at Urbana-Champaign, Dr. Chun-Yen Chang, the head of and
professor at the Department of Horticulture and Landscape Architecture at National Taiwan University,
Dr. Dongying Li, the assistant professor at the Department of Landscape Architecture and Urban
Planning at Texas A&M University, and Dr. Yen-Cheng Chiang, the head of and associate professor
at the Department of Landscape Architecture at National Chiayi University, for their support. The
authors also thank the administrators and staff members working in the dementia care facilities who
participated in this study.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or
publication of this article: This study was supported by the Ministry of Science and Technology of
Taiwan (104–2917-I-005–002).
Liao et al. 17
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Man-Li Liao is an adjunct assistant professor in the Department of Landscape and Urban
Design at the Chaoyang University of Technology in Taiwan. She was a visiting scholar in
the Department of Landscape Architecture at the University of Illinois at Urbana-
Champaign from 2015 to 2016. Dr Liao is also a registered horticultural therapist of the
American Horticultural Therapy Association. Her research interests lie in the area of ther-
apeutic landscape and horticultural therapy for the elderly and people with dementia.
Sheng-Jung Ou is a professor and the dean of Design College at the Chaoyang University of
Technology in Taiwan. His major research field focuses on therapeutic landscape, horticul-
tural therapy, and aboriginal landscape typology. His research results have provided useful
guidelines for creating spaces with therapeutic functions and unique landscape style for local
areas in Taiwan.
Chung Heng Hsieh is an assistant professor in the Department of Landscape Architecture at
the Fu Jen Catholic University in Taiwan. He completed his PhD at National Chung Hsing
University in Taiwan. His research field focuses on the community garden and cultur-
al landscape.
Zhelin Li is a lecturer in the College of Landscape Architecture and Arts at Northwest A&F
University in China. Her research field focuses on the arts related to the landscape design for
the children, the elderly, and people with dementia.
Chia-Chun Ko is an assistant professor in the Department of Leisure and Recreation
Management at the National Kaohsiung University of Hospitality and Tourism in
Taiwan. Her research field focuses on recreational environments, ecotourism, and tourism
resource management.
20 Dementia 0(0)
