Outdoor rehabilitation for people with dementia

Outdoor rehabilitation and different forms of nature or garden therapies are being offered around Sweden to people with various conditions. For people with dementia outdoor time for rehabilitative purposes might preserve both mobility and muscle strength, but also stimulate different senses and affect mood and behaviour.

Question

What scientific studies are there on the effects of outdoor rehabilitation for people with dementia?

Identified literature

Table 1. Systematic reviews with low/medium high risk of bias
CI = Confidence interval; HT = Horticultural therapy; QES = Quasi-experimental studies; PWD = People with dementia; RCT = Randomised controlled trials; SMD = Standardised mean difference
Included studies
Zhao et al
2020
[1]
Medium risk of bias
14 studies:
4 RCT
10 quasi-experimental studies

A majority of the studies were performed in the USA (n = 7) and China/Hong Kong/Taiwan (n = 4). The rest performed in Korea, Japan and in the UK.
Population:
People with diagnosed dementia
n=411 (total)
Diagnosis according to ICD-11,
DSM-5 and Mini-Mental State
Examination (MMSE).

Intervention:
Horticultural therapy compared with usual dementia care or traditional activities.

Control:
Other non-pharmacological interventions (eg. cognitive stimulation activities and therapeutic recreation programmes) or usual dementia care (eg. viewing control display scenes, chatting with other PWD, cooking, current events discussions, puzzles).
Outcome:
Effectiveness of participatory HT on the total score of cognitive function (2 RCT, 4 QES):
Statistically significant difference: SMD = 0.97 (95% CI 0.11 to 1.83. p = 0.03)

Effectiveness of participatory HT on the total score of agitation (1 RCT, 2 QES):
Statistically significant difference: SMD = −0.55 (95% CI −0.88 to −0.21, p<0 .01)

Effectiveness of ornamental HT activities on the total score of agitation (1 RCT, 1 QES):
No statistically significant difference: SMD = 0.49
(95% CI −0.53 to 1.51, p= 0.35)

Effectiveness of participatory HT on the total score of positive emotion (4 QES):
Statistically significant difference: SMD = 1.00
(95% CI 0.39 to 1.61, p< 0.01)

Effectiveness of ornamental HT on the total score of positive emotion (1 QES):
No statistically significant difference: SMD = 0.31
(95% CI −0.44 to 1.06, p= 0.41)

Effectiveness of participatory HT on the total score of engagement (5 QES):
Statistically significant difference: SMD = 1.91
(95% CI 0.80 to 3.02, p< .01)
Authors' conclusion:
“In these meta-analyses, participatory HT yields positive outcomes on cognitive function, agitation, positive emotion and engagement, while ornamental HT yields negative outcomes on agitation and positive emotion. In order to determine the best practice guideline, more well-designed original studies in PWD are needed to clarify the impact of different types of HT on cognitive function, agitation, positive emotion and engagement.”
Jensen et al
2017
[2]
Medium risk of bias
2 studies on wander gardens

42 studies in total on environment-based interventions:
12 Level I Systematic reviews
10 Level I RCT
4 Level II studies
16 Level III studies
Population:
People with Alzheimer’s disease and related major neurocognitive disorders (formerly known as dementia) living at home or in other settings

Intervention:
Wander gardens
(among other environment-based interventions that address behaviour, perception and falls)

Control:
Different controls depending on which environment-based intervention being studied.
Outcome:
Evidence is insufficient to support the use of wander gardens to improve behaviour. Preliminary results showed a trend toward less agitation in a facility with unrestricted daytime wander garden access, with residents who visited the garden more frequently showing the largest effect.
(1 study, n=34, Level III evidence – one-group pretest-posttest study).

The evidence is insufficient to fully support the use of wander gardens for fall reduction. Preliminary results suggest that unrestricted daytime access to a wander garden decreased falls, as well as antidepressant and antipsychotic medication use for dementia unit residents, especially those who accessed the garden frequently.
(1 study, n=28 (subset of n=34 above), Level III – one-group, pretest-posttest study)
Authors' conclusion:
“The evidence is insufficient to support the use of wander gardens to improve behaviour. […] Limited or insufficient evidence was found for the use of wander gardens […] to reduce falls.

References

  1. Zhao Y, Liu Y, Wang Z. Effectiveness of horticultural therapy in people with dementia: A quantitative systematic review. Journal of clinical nursing. 2020. Available from: https://doi.org/10.1111/jocn.15204.
  2. Jensen L, Padilla R. Effectiveness of Environment-Based Interventions That Address Behavior, Perception, and Falls in People With Alzheimer's Disease and Related Major Neurocognitive Disorders: A Systematic Review. The American journal of occupational therapy : official publication of the American Occupational Therapy Association. 2017;71(5):7105180030p1-p10. Available from: https://doi.org/10.5014/ajot.2017.027409.

SBU Enquiry Service Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Published: 8/25/2021
Report no: ut202119
Registration no: SBU 2020/74