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.

Reading time approx. 11 minutes Published: August 24, 2021 Publication type:

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.

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Published: August 24, 2021 Report no: ut202119 Registration no: SBU 2020/74

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

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.
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.

Literature search

PubMed via NLM 2021-07-14

Outdoor rehabilitation for dementia
	Search terms	Items found
The search result, usually found at the end of the documentation, forms the list of abstracts [MeSH] = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; [MeSH:NoExp] = Does not include terms found below this term in the MeSH hierarchy; [MAJR] = MeSH Major Topic; [TIAB] = Title or abstract; [TI] = Title; [AU] = Author; [TW] = Text Word; Systematic[SB] = Filter for retrieving systematic reviews; * = Truncation
Population:
1.	"Cognition Disorders"[MeSH] OR cognitive disorder[tiab] OR cognitive failure[tiab] OR cognitive impairment[tiab] OR cognitive decline[tiab] OR memory impairment[tiab] OR cognition disorder*[tiab] OR mild cognitive[tiab] OR Dementia[tiab] OR Dementias[tiab] OR Amentia[tiab] OR Amentias[tiab] OR Senile[tiab] OR "Dementia"[Mesh] OR “Alzheimer's disease”[tiab] OR “Alzheimer Disease”[tiab] OR BPSD[tiab]	376 784
Intervention:
2.	"Horticultural Therapy"[Mesh] OR "nature based"[tiab] OR "nature supported"[tiab] OR "nature assisted"[tiab] OR "nature-based"[tiab] OR "nature-supported"[tiab] OR "nature-assisted"[tiab] OR gardening[tiab] OR garden[tiab] OR gardens[tiab] OR horticultural[tiab] OR horticulture[tiab] OR "natural environment"[tiab] OR "green space"[tiab] OR "green spaces"[tiab] OR "natural environments"[tiab] OR "urban forest"[tiab] OR "urban forests"[tiab] OR (Outdoor[tiab] AND (physiotherapy[tiab] OR rehabilitation[tiab] OR activity[tiab] OR activities[tiab] OR walk*[tiab] OR therapy[tiab] OR “sitting”[tiab] OR relaxing[tiab] OR resting[tiab] OR “sensory stimulation”[tiab] OR exercise[tiab])) OR "Green Care"[tiab] OR "Green exercise"[tiab]	36 350
Combined sets:
3.	1 AND 2	371
Final	3	371

Cochrane Library via Wiley 2021-07-14

Outdoor rehabilitation for dementia
	Search terms	Items found
The search result, usually found at the end of the documentation, forms the list of abstracts au = Author;& MeSH = Term from the Medline controlled vocabulary, including terms found below this term in the MeSH hierarchy; this term only = Does not include terms found below this term in the MeSH hierarchy; :ti = Title; :ab = Abstract; :kw = Keyword; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Population:
1.	[mh "Cognition Disorders"] OR cognitive disorder:ti,ab,kw OR cognitive failure:ti,ab,kw OR cognitive impairment:ti,ab,kw OR cognitive decline:ti,ab,kw OR memory impairment:ti,ab,kw OR cognition disorder*:ti,ab,kw OR mild cognitive:ti,ab,kw OR Dementia:ti,ab,kw OR Dementias:ti,ab,kw OR Amentia:ti,ab,kw OR Amentias:ti,ab,kw OR Senile:ti,ab,kw OR [mh "Dementia"] OR “Alzheimer's disease”:ti,ab,kw OR “Alzheimer Disease”:ti,ab,kw OR BPSD:ti,ab,kw	60 182
Intervention:
2.	[mh "Horticultural Therapy"] OR (("nature based":ti,ab,kw OR "nature supported":ti,ab,kw OR "nature assisted":ti,ab,kw OR "nature-based":ti,ab,kw OR "nature-supported":ti,ab,kw OR "nature-assisted":ti,ab,kw OR gardening:ti,ab,kw OR garden:ti,ab,kw OR gardens:ti,ab,kw OR horticultural:ti,ab,kw OR horticulture:ti,ab,kw OR "natural environment":ti,ab,kw OR "green space":ti,ab,kw OR "green spaces":ti,ab,kw OR "natural environments":ti,ab,kw OR "urban forest":ti,ab,kw OR "urban forests":ti,ab,kw OR Outdoor:ti,ab,kw) AND (physiotherapy:ti,ab,kw OR rehabilitation:ti,ab,kw OR activity:ti,ab,kw OR activities:ti,ab,kw OR walk*:ti,ab,kw OR therapy:ti,ab,kw OR “sitting”:ti,ab,kw OR relaxing:ti,ab,kw OR resting:ti,ab,kw OR “sensory stimulation”:ti,ab,kw OR exercise:ti,ab,kw)) OR "Green Care":ti,ab,kw OR "Green exercise":ti,ab,kw	1 366
Combined sets:
3.	1 AND 2	124
Final	3	124

Embase via embase.com 2021-08-14

Outdoor rehabilitation for dementia
	Search terms	Items found
/de = Term from the EMTREE controlled vocabulary; /exp = Includes terms found below this term in the EMTREE hierarchy; /mj = Major Topic; :ab = Abstract; :au = Author; :ti = Article Title; :ti,ab = Title or abstract; * = Truncation; ’ ’ = Citation Marks; searches for an exact phrase
Population:
1.	'cognitive defect'/exp OR 'cognitive disorder':ti,ab,kw OR 'cognitive failure':ti,ab,kw OR 'cognitive impairement':ti,ab,kw OR 'cognitive disorders':ti,ab,kw OR 'cognitive failures':ti,ab,kw OR 'cognitive impairements':ti,ab,kw OR 'cognitive decline':ti,ab,kw OR 'memory impairement':ti,ab,kw OR 'cognition disorders':ti,ab,kw OR 'memory impairements':ti,ab,kw OR 'cognition disorder':ti,ab,kw OR 'mild cognitive':ti,ab,kw OR dementia:ti,ab,kw OR dementias:ti,ab,kw OR amentia:ti,ab,kw OR amentias:ti,ab,kw OR senile:ti,ab,kw OR 'alzheimer disease':ti,ab,kw OR bpsd:ti,ab,kw OR 'alzheimers disease':ti,ab,kw	578 123
Intervention:
2.	'horticultural therapy'/exp OR 'nature based':ti,ab,kw OR 'nature supported':ti,ab,kw OR 'nature assisted':ti,ab,kw OR 'nature-based':ti,ab,kw OR 'nature-supported':ti,ab,kw OR 'nature-assisted':ti,ab,kw OR gardening:ti,ab,kw OR garden:ti,ab,kw OR gardens:ti,ab,kw OR horticultural:ti,ab,kw OR horticulture:ti,ab,kw OR 'natural environment':ti,ab,kw OR 'green space':ti,ab,kw OR 'green spaces':ti,ab,kw OR 'natural environments':ti,ab,kw OR 'urban forest':ti,ab,kw OR 'urban forests':ti,ab,kw OR (outdoor:ti,ab,kw AND (physiotherapy:ti,ab,kw OR rehabilitation:ti,ab,kw OR activity:ti,ab,kw OR activities:ti,ab,kw OR walk*:ti,ab,kw OR therapy:ti,ab,kw OR 'sitting':ti,ab,kw OR relaxing:ti,ab,kw OR resting:ti,ab,kw OR 'sensory stimulation':ti,ab,kw OR exercise:ti,ab,kw)) OR 'green care':ti,ab,kw OR 'green exercise':ti,ab,kw	41 593
Combined sets:
3.	1 AND 2	577
Final	3	577

Cinahl via ebsco.com 2021-07-14

Outdoor rehabilitation for dementia
	Search terms	Items found
The search result, usually found at the end of the documentation, forms the list of abstracts AB = Abstract; AU = Author; DE = Term from the thesaurus; MM = Major Concept; TI = Title; TX = All Text. Performs a keyword search of all the database's searchable fields; ZC = Methodology Index; * = Truncation; “ “ = Citation Marks; searches for an exact phrase
Population:
1.	(MH "Dementia+") OR (MH "Cognition Disorders+") OR TI ("cognitive disorder" OR "cognitive failure" OR "cognitive impairment" OR "cognitive disorders" OR "cognitive failures" OR "cognitive impairments" OR "cognitive decline" OR "memory impairment" OR "cognition disorders" OR "memory impairments" OR "cognition disorder" OR "mild cognitive" OR Dementia OR Dementias OR Amentia OR Amentias OR Senile OR “Alzheimer Disease” OR BPSD OR “Alzheimers Disease”) OR AB ("cognitive disorder" OR "cognitive failure" OR "cognitive impairment" OR "cognitive disorders" OR "cognitive failures" OR "cognitive impairments" OR "cognitive decline" OR "memory impairment" OR "cognition disorders" OR "memory impairments" OR "cognition disorder" OR "mild cognitive" OR Dementia OR Dementias OR Amentia OR Amentias OR Senile OR “Alzheimer Disease” OR BPSD OR “Alzheimers Disease”)	130 042
Intervention:
2.	TI ("nature based" OR "nature supported" OR "nature assisted" OR "nature-based" OR "nature-supported" OR "nature-assisted" OR gardening OR garden OR gardens OR horticultural OR horticulture OR "natural environment" OR "green space" OR "green spaces" OR "natural environments" OR "urban forest" OR "urban forests" OR (Outdoor AND (physiotherapy OR rehabilitation OR activity OR activities OR walk* OR therapy OR “sitting” OR relaxing OR resting OR “sensory stimulation” OR exercise)) OR "Green Care" OR "Green exercise") OR AB ("nature based" OR "nature supported" OR "nature assisted" OR "nature-based" OR "nature-supported" OR "nature-assisted" OR gardening OR garden OR gardens OR horticultural OR horticulture OR "natural environment" OR "green space" OR "green spaces" OR "natural environments" OR "urban forest" OR "urban forests" OR (Outdoor AND (physiotherapy OR rehabilitation OR activity OR activities OR walk* OR therapy OR “sitting” OR relaxing OR resting OR “sensory stimulation” OR exercise)) OR "Green Care" OR "Green exercise")	7 980
Combined sets:
3.	1 AND 2	328
Final	3	328

Page published August 24, 2021

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