ORIGINAL ARTICLE

Gardening activities for nursing home residents with dementia

VERUS B. THELANDER1, TARJA-BRITA ROBINS WAHLIN1,2, LOTTA OLOFSSON1,

KRISTIINA HEIKKILA1,3 & LARS SONDE1,2

1KC-Kompetenscentrum, Research and Development Center in Elderly Care, 2Department of Neurobiology, Health Care

Sciences and Society, Division of Geriatric Medicine, Karolinska Institutet, Stockholm, Sweden, and 3School of Health

Sciences and Social Work, Vaxjo ‘University, Vaxjo, Sweden

AbstractActivity is recommended for persons with dementia based on the assumption that human abilities and functions must beexercised in order to be retained. The aim of the study is to describe and evaluate gardening activities for persons withdementia. Eight nursing home residents with a diagnosis of dementia were selected. The participants were activated in anoutdoor environment three times a week during an intervention period of 6 weeks. The activities used were gardeningactivities (i.e. watering, weeding, raking, and planting), walks, and social activities. The ability to carry out activitiesindependently was assessed with an independence scale devised for this study. All residents were able to participate, but thedegree of independence varied. Factors such as impaired balance and falls risk seemed to be more important than degree ofdementia. Activation and rehabilitation in outdoor environments are suitable in the care for demented persons but should beseen as an individual treatment.

Key words: Dementia, gardening activities, intervention, physiological effects, rehabilitation

Introduction

It is difficult to find rehabilitative and activating

methods that are suitable for demented persons,

given their marked cognitive impairment. Standard

rehabilitation methods often require participants to

follow instructions and to understand the purpose of

the exercise, i.e. requirements that people with

dementia often fail to meet. To be effective and

meaningful, intervention should be based on the

participant’s own interests and experiences (1�5). It

is therefore vital to practice what the elderly them-

selves want to do and find meaningful.

Activity theory (6,7) claims that older people who

are active in various occupations and in contact with

other people become more satisfied and better

adapted in later life than those who are less active.

This is held to be true even for persons suffering

from dementia. One aim of activities for people with

dementia would thus be to maintain functions;

another aim to improve or restore functions, for

example, training after injury. Procedural memory is

fairly well preserved in persons with Alzheimer’s

disease (AD), so they can often still perform various

motor activities learned in the past. In fact, the

ability to learn new motor skills is to some extent

preserved in persons with AD (8).

Rehabilitation in dementia care is mainly carried

out indoors. However, the outdoor environment

around a nursing home can be a supplementary

environment for treatment, rehabilitation and in-

creasing quality of life for older persons (9,10). The

present study attempts to evaluate whether the

outdoor environment can be beneficial as an integral

part of rehabilitation and care.

Methods

Eight nursing home residents with dementia were

recruited for this study. The selection took place in

cooperation with the nurses responsible for the

residents. The following inclusion and exclusion

criteria were used: residents with a diagnosis of

Correspondence: Lars Sonde, KC-Kompetenscentrum, Research and Development Center in Elderly Care, Box 189, SE�125 24 Alvsjo, Sweden. E-mail:

lars.sonde@sll.se

Advances in Physiotherapy. 2008; 10: 53�56

(Received 24 August 2006; accepted 31 January 2007)

ISSN 1403-8196 print/ISSN 1651-1948 online # 2008 Taylor & Francis

DOI: 10.1080/14038190701256469

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dementia, with a documented history of agitated and

restless behavior and who were interested in outdoor

activities were included. Residents who were con-

fined to wheelchairs and had hindering communica-

tion problems were excluded. Finally, residents

suffering from any disease that contraindicated

physical activity were excluded.

The participants took part in activities in the park

during an intervention period of 6 weeks during

summer. Activities consisted of gardening (e.g.

watering, weeding, raking, and planting), walks

and social activities. The choice of activity was

adapted to the residents’ wishes, daily routines and

to weather conditions.

Intervention

The intervention was carried out in a park located

adjacent to the nursing home. The park can be

described as in the style of nature romanticism, with

full-grown trees, a brook that runs under a little

bridge and gravel paths. There is a large, open, grass

lawn and a pond with a fountain at a paved entrance

area. The beds for perennials and annual summer

flowers are at ground level, but have been supple-

mented with four wooden planters for bedding

plants in two places in the park. Several benches

and settees are set out in the park.

The participants were divided into three groups

with two or three residents in each group. Three

intervention leaders (IL) were each responsible for a

group, with one intervention session per resident per

day. Every intervention session lasted between 40

and 70 min. Every participant was taken out once a

day, three times per week over a 6-week period. Each

IL had only one participant at the time and he or she

had the same IL throughout the intervention period.

During the outdoor activity, the ILs took part in

activities in order to be available to help and support

the resident. On those occasions when residents

showed little need for help and great independence,

the ILs held back, and let the resident guide the

activity and decide what should be done. The

residents often got the tools they wanted to use out

of the park’s tool shed themselves. The ILs assisted

by fetching other tools when needed and sometimes

by preparing activities by taking out tools and

baskets out into the park before the residents came

out.

Instruments

The residents’ independence in various activities was

observed and assessed using a six-degree indepen-

dence scale that was prepared for this study accord-

ing to the following criteria:

1. Independent: Begins spontaneously and con-

tinues the activity independently;

2. With supervision: Carries out the activity by

self but needs supervision;

3. Minimal help: Needs verbal support, needs to

have the activity demonstrated or guided at

times;

4. Moderate help: Needs verbal support, needs to

have the activity demonstrated or guided on

repeated occasions;

5. Extensive need for help: Needs continuous

verbal support and needs to have the activity

demonstrated or to have practical help; and

6. Does not participate actively.

Field notes were written after each intervention

session, with focus on incidents or problems during

the activities as well as the residents’ mood.

Residents’ cognitive capacity was assessed with the

Mini-Mental State Examination (MMSE) (11). The

MMSE measures cognitive capacities such as mem-

ory, orientation, attention, speech and visuospatial

capacities. The maximum score is 30. Less than 24

suggest cognitive dysfunction (11,12).

Before the intervention period, background data

like information concerning personal background,

diagnosis, MMSE and previous illnesses were col-

lected from interviews with nurses responsible for

the residents. Independence in activity was assessed

during each outdoor activity.

Statistics

In the independence scale each resident were

assessed several times and in several activities during

the 6-week period. Independence data are presented

as individual median scores and range. MMSE

scores are presented at an individual level. The

interaction between MMSE and independence was

analyzed with Fisher’s Exact test. The study was

approved of the ethical committee at the Karolinska

University Hospital.

Results

All participants had been diagnosed with dementia,

ranging from severe (MMSE�5) to marked

(MMSE�18). Five residents had AD, two unspeci-

fied dementia and one vascular dementia. The

participants’ age ranged from 78 to 97 years (Table I).

Gardening activities

Maintenance of the park was the starting point for

the activities. Residents’ physical capacities, interest

in different gardening activities, and their own

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initiative and wishes about activities were provided

for in the first place, even if this sometimes resulted

in changes in the original plan. All residents did not

take part in all activities; rather, individual adjust-

ment meant that some activities were practiced more

often than others and not by all residents.

All residents were willing to participate and work

in garden activities. The most usual activities, apart

from walks, were spreading gravel on the paths,

raking the gravel paths, aerating and weeding the

flowerbeds, collecting weeds and taking them to the

compost, planting flowers, pinching off wilted flow-

ers in wooden planters and hanging flowerpots.

Independence in activity

A total of 104 outdoor sessions were recorded during

the 6-week-long intervention period. Every resident

was out 10�15 times and could be involved in up to

four activities during the same intervention session.

The usual participation was one to two different

activities. The total number of activities that every

resident carried out during the intervention period

varied between five and 18 activities. A total of 30

different activities were carried out and registered

during the intervention period.

On average, the independence of respective resi-

dents at the different activities was assessed at values

between 2 and 5 on the independence scale (Table

I). Half of the residents had a need for help that was

assessed at 4 or higher, i.e. they needed continuous

help and support in activities or constant supervision

because of the risk of falling. In many cases, the

remaining participants could manage activities with

supervision and verbal support and with help at

certain points. Viewed on the whole, residents’

independence in carrying out activities was constant

per activity and resident during the entire period.

Cognitive capacity had no significant influence

upon independence (p�0.50) although, with the

exception of one resident, the participants with lower

cognitive capacity had more need for help. Four of

the five residents with walking frames had an

extensive need for help.

Low independence scores (i.e. high level of

independence) were found in activities that the

residents initiated themselves, like picking flowers,

picking up trash, picking apples, raking grass,

spreading topsoil, sweeping the paving stones, wip-

ing off benches, gathering weeds, going to the

compost, and tending flowers in wooden planters

and hanging flowerpots. These activities appeared to

be natural to the residents.

Field notes

The need for help increased when activities were

physically demanding, like lifting a heavy watering

can, or required the participant to be able to bend

down. Activities that included many elements also

necessitated more help. Activities that demanded

good sight and perception and the ability to distin-

guish figure and background resulted in less inde-

pendence in some of the residents. This could be the

case, for example, for weeding and aerating flower-

beds, or in order to distinguish which flowers were

wilted and need to be removed from wooden

planters or hanging flowerpots. Removing weeds

from among small perennials in flowerbeds had to

be entirely eliminated because it was difficult for

residents to distinguish what were weeds and what

should remain in the beds. Trimming around the

edge of the flowerbeds posed great difficulties, as

participants did not detect the delimitation between

the flowerbed and the path.

Table I. Demographic data and assessed independence in gardening activities.

Participants Sex Age Diagnosis MMSE Use of walking aid

Median independence

score in activitiesa (range)

1 Female 89 Vascular 18 Walking frame 4.0 (2�6)

2 Female 88 Alzheimer 16 � 3.0 (1�5)

3 Female 78 Alzheimer 14 � 2.0 (1�3)

4 Female 87 Unspecified 10 Walking frame 3.0 (1�4)

5 Male 84 Alzheimer 9 Walking frame 4.0 (3�6)

6 Male 85 Alzheimer 7 Walking frame 5.0 (2�6)

7 Female 79 Unspecified 5 � 3.0 (1�4)

8 Female 97 Alzheimer 5 Walking frame 4.0 (3�6)

Mean 86.8 10.5

aIndependence scale: (1) Independent: Begins spontaneously and continues the activity independently. (2) With supervision: Carries out the

activity by self but needs supervision. (3) Minimal help: Needs verbal support, needs to have the activity demonstrated or guided at times.

(4) Moderate help: Needs verbal support, needs to have the activity demonstrated or guided on repeated occasions. (5) Extensive need for

help: Needs continuous verbal support and needs to have the activity demonstrated or to have practical help. (6) Does not participate actively.

MMSE, Mini-Mental State Examination.

Gardening activities for persons with dementia 55

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Concerning walks, which were the most frequent

activity, independence varied quite a bit on different

occasions and with different residents, depending,

among other things, upon the residents’ present

condition, general physical condition, pain, tiredness

or impaired balance. Anxiety about being left by

themselves, not being able to find their way back or

risk of falling affected how much help and

supervision residents needed during the walks.

None of the residents was assessed as more inde-

pendent in carrying out activities after the interven-

tion period.

Discussion

The results indicate that activation and rehabilitation

in a park environment can be used as a complement

to other rehabilitation and activation activities to

retain or even improve functional capacity of resi-

dents with dementia. The park environment made it

possible to try a large number of activities that suited

individuals with marked to severe dementia and

different degrees of physical ability. Independence

in activities in the park was not naturally affected by

residents’ degree of dementia. More important

factors seemed to be impaired balance and risk of

falling, which affected the need for help and super-

vision to a great extent. Our results showed that it

was too difficult to take care of and support several

residents at the same time. Bartels et al. (13) argued

that dementia diseases are often complicated by

behavioral disturbances and require treatment stra-

tegies different from those of non-demented pa-

tients. Our results are in line with these findings and

show that gardening with residents with dementia

should be seen as an individual treatment or activa-

tion.

The independent scale prepared for the study was

inspired by Assessment of Motor and Process Skills

(AMPS), which is a widely used instrument in

clinical practice and research. AMPS is developed

for occupational therapists and is a client-centered

assessment of ADL performance based on evalua-

tion of the skills observed in the individual actions

performed as a person carries out ADL (14). The

AMPS has a battery of standardized ADL tasks (15),

but to fit our purpose we had to use tasks specific for

gardening activities, which are not included in the

AMPS. In the future, the independent scale needs to

be tested for both reliability and validity and on this

specific group.

Conclusions

It is generally known that physical capacity can be

improved far into old age, but that physical activity

of sufficient intensity and regularity is necessary for

this to occur. In conclusion, the study provides

suggestions about which activities are possible to

carry out in a park environment, and suggests that it

is possible to measure effects of these activities.

However, these activities need resources in the form

of staff members who can accompany residents on a

daily basis and help them individually according to

their functional ability.

Acknowledgements

This work was supported by funds from The Stock-

holm County (Kultur i varden), Movium-Centre for

the Urban Public Space and Swedish Brain Power.

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