Nature Prescription: The Missing Link in Dementia Treatment
Student Scholarship – First Place Research Review
Cayla M. Bronicheski, MSc
Cyndi Gilbert, ND
The intrinsic and instinctive need for humans to affiliate and connect with nature is a notion that has been present as far back as paintings inside the pyramids of Egypt. Nowadays, we see biophilia – the instinctive bond between humans and other living things – represented in parks and other spaces, where trees and other plants are part of urban and suburban planning. Nature is woven into meditation, music, gift-giving in the form of flowers or through the enjoyment of a scenic landscape. There is no denying that plants possess an intangible power, a power which is reflected in the naturopathic principle vis medicatrix naturae. A salient part of creating a healing environment and treatment plan for many different health conditions, there is increasing evidence that the healing power of nature in the form of therapeutic gardens may prove particularly effective in improving the health outcomes of patients with dementia.
Plants in a Medical Setting
The introduction of plants in the design of a medical system is not a new concept, as access to the natural world was once considered integral to healthcare settings. Historical accounts from the Middle Ages demonstrated that hospitals within European monastic communities incorporated gardens as an essential component of their facilities to support healing, where patients’ rooms typically surrounded courtyards filled with sunlight, grassy lawns, and seasonal plants. As nature was thought to have an innate ability to heal, sanatoriums in Europe as far back as the 1850s featured intricately constructed flowerbeds, trees, and man-made ponds within the grounds. Extending to the 15th century, hospice courtyards incorporated natural light and fresh air, in support of a holistic connectedness to nature.1 Benedict Lust, one of the founding fathers of naturopathic medicine, also stressed the importance of designing healing spaces to nurture the vis medicatrix naturae,2 incorporating sun therapy, dew-walking, and wide outdoor spaces. Although hospitals and physicians’ offices have been designed for some time as architecturally sterile and concrete structures, with little attention to landscaping, more recent research and guidelines are once again supporting the inclusion of healing landscapes in their designs.
Modern-day evidence suggests that gardens may have a positive effect on healing, along with improvements in health outcome.3 In some hospitals, gardens are incorporated into their design and planning. For example, St Michael’s Hospital in Texarkana, Texas, noted that rehabilitation patients were returning home within 2-3 weeks, rather than 6 or more weeks when garden accessibility was granted.4 At a children’s hospital and health center in San Diego, California, physicians commented that recovery and attitudes were positively influenced among patients who interacted with gardens.5 And at the Danderyd Hospital in Sweden, doctors noted that horticulture therapy had a positive influence on brain damage rehabilitation.6
Exposure to nature, and gardening, in particular, has also been associated with the prevention of a variety of chronic diseases. In a prospective cohort study, people over age 65 without cognitive impairment, who engaged in daily gardening at baseline, had a significantly reduced risk of developing dementia over the following 16 years, compared to those who rarely gardened (HR = 0.64; 95% CI: 0.50-0.83, p<0.001).7 While regular gardening may reduce the risk of developing dementia, the presence of therapeutic gardens and the activity of gardening, itself, has also been shown to have positive effects for people already diagnosed with the condition.
Healing Gardens & Dementia
Agitation & Behavior
While nature has been shown to positively influence stress and well-being in the elderly, recent research has also examined the effects of exposure to nature on dementia.8 This disease is pervasive in today’s society, affecting over 24 million people worldwide. Establishing a good quality of life is the main goal of dementia care.9 Cholinesterase inhibitors are the only drugs used as first-line treatment for dementia, and while they may slow or minimize the progression of dementia symptoms, there is no known treatment or therapy that can lead to remission or cure.10 The disease course itself, as well as confinement in a hospital environment, can result in increased frustration, agitation, and even aggression.11 Since dementia patients often have limited ability to communicate their needs and feelings, inappropriate behaviors may be interpreted as anxiety and depression, thus potentially increasing the likelihood of psychotropic and antidepressant medications. Therapeutic gardens and access to outdoor areas have been shown to reduce the incidence of inappropriate behaviors in these patients.12
In a randomized controlled trial (RCT)13 examining the differences between Cohen-Mansfield Agitation Inventory (CMAI) scores in dementia patients after 30 minutes of horticultural activity compared to 30 minutes of non-horticultural activities (puzzles, origami, collages, art) for 6 weeks, a few trends were noted. For example, horticultural activity decreased the frequency of agitated behaviors in patients who had low Mini-Mental State Examination (MMSE) scores, but increased agitation in patients with higher MMSE scores. When examining the CMAI change and MMSE scores pre- and post-intervention, there was a positive correlation (r=0.809, p=0.028) in the experimental group, but a negative correlation (r=-0.975, p=0.005) in the control group, indicating that horticultural activities can improve agitation outcomes in patients with lower MMSE scores.13
Another RCT examined the efficacy of indoor gardening activities (planting beans, touching, watering, harvesting, or cleaning plants) on sleep, agitation, and cognition in institutionalized dementia patients. Results showed statistically significant improvements in nap time (p=0.000), nocturnal sleep efficacy (p=0.006), nocturnal sleep time (p=0.002), wake-up time (p=0.002), agitation (p=0.001), and cognition (p=0.000). The literature appears to demonstrate qualitative and quantitative symptom improvements in dementia patients when they engage in activities that utilize nature.14
Several additional studies using the CMAI assessment have also shown a correlation between increased time spent outdoors and decreases in the dementia behaviors of pacing, violence and escape-seeking.15-17 Based on these studies and more, current dementia guidelines advise that the physical environment where dementia patients live should include access to gardens.18
Fall Risk & Medication Usage
Each year, medical costs rise in relation to fall injuries for people 65 years and older, with a predicted increase to about $55 billion by 2020.19 In dementia patients, fall risk is a serious danger to their livelihoods, which can be compounded by side effects of medications used to treat comorbid conditions. For example, psychotropic medications are the most common class of drugs used to treat agitation or behavioral problems in dementia patients; these drugs alone have been shown to increase the risk of falling.20 A cohort study examined the effectiveness of a wander-garden on fall frequency and severity, as well as the ability to reduce psychiatric medications.21 Results revealed a statistically significant decrease in the need for high-dose antipsychotics, and a 30% decrease in the number and severity of falls after garden time was implemented; the total number of falls decreased by 38.7% in frequent garden-users, compared to 7.9% in infrequent users.21
Another study followed dementia facility residents for 1 year before and after adding a garden to the facility.22 Results demonstrated that garden usage improved CMAI scores from baseline, also that the percentage of residents not needing PRN antidepressants and antipsychotic drugs for behavioral issues increased from 35.4% to 55.9%. Family members reported that the gardens mitigated mood and improved quality of life in the individuals with dementia. Additionally, high garden-users were prescribed significantly fewer antidepressants (p<0.005) and antipsychotics (p<0.001) compared to dementia patients who used the garden less often.22 Decreasing the usage of adjunctive medications in dementia patients can have a profound effect on reducing the mental and physical adverse effects associated with these drugs.
Social Connection & Empowerment
Several studies with qualitative data have explored garden exposure time on psychosocial well-being. In one study, garden experiences were subjectively reported as “raised spirits” and offered passive enjoyment.23 Hospital and resident staff members noted that dementia patients were easier to manage when they had exposure to the outdoor sun, particularly if the patient was “sundowning” – a term used to describe the tendency of dementia patients to become further agitated or confused as the day progresses, as a result of reduced exposure to light.23 Garden environments are also sources of meaningful activities for dementia patients that, by engaging them and invoking memories from childhood, can increase self-confidence and keep them involved in their lives.24
In several studies, garden interaction time improved dementia patients’ social interactions with visitors and staff.25, 26 For example, an RCT examining 129 individuals with diagnosed dementia were split into 2 groups, 1 receiving a 6-week horticulture-based activity program (sowing seeds or clipping foliage of plants), and the second group receiving standard care.14 Using the Menorah Park Engagement Scale, horticultural therapy participants demonstrated significantly higher levels of active (p=0.00) and passive (p=0.01) engagement and lower levels of maladaptive behaviors including self-engagement, compared to standard care (p=0.00). The findings suggested that horticultural activities are valuable for sustaining attention, empowering exercise, stimulating cognition, and enhancing social connection.14
Observational data has suggested that individuals residing in a nursing home have limited exposure to adequate light conditions for regulating circadian rhythm and sleep patterns.27 An RCT comparing bright to dim light exposure in Alzheimer’s patients demonstrated that morning or evening light exposure lengthened sleep time at night.28 Another pilot study randomly assigned dementia residents into 2 intervention groups, encouraging either indoor or outdoor activities for 10 days.29 The outdoor activity group experienced an increase in sleep duration, along with a significant decrease in verbal agitation, according to CMAI scores.29 Since dementia patients commonly present with sleep onset and sleep quality disturbances (as a result of medications, depression, or daytime napping), natural light exposure through access to outdoor gardens may help to regulate their sleep patterns.28, 30
Overall, the available evidence suggests that incorporating therapeutic garden designs leads to improvements in the lives of people with dementia, improvements in caregiver and/or staff experiences, and improvements in the overall visiting experiences of family members and loved ones.25 Therapeutic gardens should include a variety of plants to promote visual, olfactory, and tactile stimulation for dementia patients. Walking paths should be designed to encourage contact with plants, and paths should be continuous, with no dead-ends, to promote cardiovascular exercise.
Synthesizing all of the studies examined, it is suggested that 150 minutes of outdoor garden activity (equating to 30 minutes of outdoor activity per day) for at least 5 days per week will benefit dementia patients by normalizing sleep patterns, decreasing medication usage and falls, and improving social interactions. These segments can be broken up into 3 short 10-minute sessions throughout the day. Naturopathic doctors should encourage gardening activities (including walking in a garden, planting, sowing, watering, or harvesting plants), either individually or communally, as therapeutic activities for patients with mild dementia. An individualized approach to these treatment recommendations is warranted, as some patients may need the assistance or supervision of either a family member or staff care worker.
Additionally, naturopathic clinics might well consider incorporating indoor plants within their clinic rooms, or outdoor gardens surrounding their offices. Unconventional methods of patient visits and treatments is ultimately what sets naturopathic doctors apart from our conventional medical system. With the research supporting therapeutic benefits from being in proximity to plants, this is a simple concept that can be implemented with even a single indoor plant of interest. Naturopathic doctors can truly exemplify the vis medicatrix naturae by incorporating nature into their tool kit of resources to help support the healing process in their patients with dementia.
Cayla M. Bronicheski, MSc, is a 3rd-year student at the Canadian College of Naturopathic Medicine and has a passion for research and writing. She is excited to be working towards helping people care for their health when she becomes an intern at the Robert Schad Naturopathic Clinic, in Toronto, ON, in May of 2016. In her spare time, Cayla enjoys distance running and yoga. To contact Cayla personally or to learn more, visit her at: www.caylabronicheski.com.
Cyndi Gilbert, ND, is a naturopathic doctor, faculty member at the Canadian College of Naturopathic Medicine, and author. She has a special interest in the sociocultural aspects of health and the praxis of naturopathic principles. She maintains a clinical practice in Toronto, ON, that includes a medicinal herb garden outside her office. Her new book, The Essential Guide to Women’s Herbal Medicine, was published earlier this year. Learn more at: www.cyndigilbert.ca.
- Warner SB. The periodic rediscoveries of restorative gardens: 1100 to the present. In: Francis M, Lindsey P, Rice JS, eds. The Healing Dimensions of People-Plant Relations: Proceedings of a Research Symposium. University of California, Davis: Center for Design Research; 1995.
- Kirchfeld F, Boyle W. Nature Doctors: Pioneers in Naturopathic Medicine. Portland, OR: Medicina Biologica; 1994.
- Ulrich RS. Health Benefits of Gardens in Hospitals [presentation]. Plants for People Symposium, Reducing Health Complaints at Work. Amsterdam, Netherlands; June 2002.
- Raver A. Healing Power of Gardens. The Saturday Evening Post. 1995;267(2):90-100.
- Yang B. A Cross-Cultural Comparison of Preference for Korean, Japanese and Western Landscape Styles [dissertation]. Ann Arbor, MI; University of Michigan; 1988.
- Soderback I, Soderstrom M, Schalander E. Horticultural therapy: the ‘healing garden’ and gardening in rehabilitation measures at Danderyd Hospital Rehabilitation Clinic, Sweden. Pediatr Rehabil. 2004;7(4):245-260.
- Simons LA, Simons J, McCallum J, Friedlander Y. Lifestyle factors and risk of dementia: Dubbo Study of the elderly. Med J Aust. 2006;184(2):68-70.
- Milligan C, Gatrell A, Bingley A. “Cultivating health”: therapeutic landscapes and older people in northern England. Soc Sci Med. 2004;58(9):1781-1793.
- Ballard C, Gauthier A, Corbett A, et al. Alzheimer’s disease. Lancet. 2004;377(9770):1019-1031.
- Norwrangi MA, Rao V, Lyketsos CG. Epidemiology, assessment and treatment of dementia. Psychiatr Clin North Am. 2011;34(2):275-294.
- McMinn BG, Hinton L. Confined to barracks: The effects of indoor confinement on aggressive behavior among inpatients of an acute psychogeriatric unit. Am J Alzheimers Dis Other Demen. 2000;15:36-41.
- Maller C, Townsend M, Pryor A, et al. Healthy nature healthy people: ‘contact with nature’ as an upstream health promotion intervention for populations. Health Promot Int. 2006;21(1):45-54.
- Luk KY, Lai KY, Li CC, et al. The effect of horticultural activities on agitation in nursing home residents with dementia. Int J Geriatr Psychiatry. 2011;26(4):435-436.
- Jarrott SE, Gigliotti CM. Comparing Responses to Horticultural- Based and Traditional Activities in Dementia Care Programs. Am J Alzheimers Dis Other Demen. 2010;25(8):657-665.
- Cohen-Mansfield J, Werner P. Visits to an outdoor garden: Impact on behavior and mood of nursing home residents who pace. In: Vellas B, Fitten J, Frisoni G, eds. Research and Practice in Alzheimer’s Disease. Paris, France: Serdi; 1998: 419-436.
- Mather JA, Nemecek D, Oliver K. The effect of a walled garden on behavior of individuals with Alzheimer’s. Am J Alzheimers Dis Other Demen. 1997;12(6):252-257.
- Calkins M, Szmerekovsky JG, Biddle S. Effect of increased time spent outdoors on individuals with dementia residing in nursing homes. J Hous Elderly. 2007;21(3-4):211-228.
- National Institute for Health and Care Excellence. Dementia: Supporting People With Dementia and Their Carers in Health and Social Care. November 2006. Social Care Institute for Excellence Web site. http://tinyurl.com/gtqmrkp. Accessed November 1, 2015.
- Rizzo JA, Friedkin R, Williams CS, et al. Health care utilization and costs in a Medicare population by fall status. Med Care. 1998;36(8):1174-1188.
- Sleeper R, Bond CA, Rojas-Fernandez C. Psychotropic drugs and falls: new evidence pertaining to serotonin reuptake inhibitors. Pharmacotherapy. 2000;20(3):308-317.
- Detweiler MB, Murphy PF, Kim KY, et al. Scheduled medications and falls in dementia patients utilizing a wander garden. Am J Alzheimers Dis Other Demen. 2009;24(4):322-332.
- Detweiler MB, Murphy PF, Myers LC, Kim KY. Does a wander garden influence inappropriate behaviors in dementia residents? Am J Alzheimers Dis. 2008;23(1):31–45.
- The Dementia Services Development Centre. Sundowning. Dementia Now. 2009;6:1-13.
- Rappe E, Topo P. Contact with outdoor greenery can support competence among people with dementia. J Hous Elderly. 2007;21(3-4):229-248.
- Edwards CA, McDonnell C, Merl H. An evaluation of a therapeutic garden’s influence on the quality of life of aged care residents with dementia. Dementia. 2013;12(4):494-510.
- Hernandez RO. Effects of therapeutic gardens in special care units for people with dementia: Two case studies. J Hous Elderly. 2007;21(1-2):117-152.
- Ancoli-Israel S, Gehrman P, Martin JL, et al. Increased light exposure consolidates sleep and strengthens circadian rhythms in severe Alzheimer’s Disease patients. Behav Sleep Med. 2003;1(1):22-36.
- Czeisler CA. The effect of light on the human circadian pacemaker. Ciba Found Symp. 1995;183:254-290.
- Connell BR, Sanford JA, Lewis D. Therapeutic effects of an outdoor activity program on nursing home residents with dementia. J Hous Elderly. 2007;21(3-4):194-209.
- McMinn BG, Hinton L. Confined to barracks: The effects of indoor confinement on aggressive behavior among inpatients of an acute psychogeriatric unit. Am J Alzheimers Dis Other Demen. 2000;15(1):36-41.