Explore 15 (2019) 352 362

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Explore
journal homepage: www.elsevier.com/locate/jsch

Review Article

Therapeutic gardens as a design approach for optimising the healing

environment of patients with Alzheimer’s disease and other dementias:
A narrative review
Patrick Chukwuemeke Uwajeha, Timothy Onosahwo Iyendob,*, Mukaddes Polaya
a
Department of Architecture, Eastern Mediterranean University, Faculty of Architecture, Mersin 10, Gazimag
usa, North Cyprus, Turkey
b
European University of Lefke, Via Mersin 10, Lefke, North Cyprus, Turkey

A R T I C L E I N F O Purpose: The first half of this paper documents the role of nature in healthcare environments and its impact on
wellness, with a particular focus on gardens. The second half presents a scientific evaluation of the role of gar-
Keywords: dens as a therapeutic intervention to optimise the clinical outcomes in patients with Alzheimer’s disease (AD)
Alzheimer’s disease and dementia, including a review of the innovative application of technologies alongside nature to promote
Dementia cognitive rehabilitation in this particular patient population.
Horticultural therapy Methods: Using search engines such as the Institute for Scientific Information (ISI) Web of Science, PubMed,
Stress recovery ProQuest Central, MEDLINE, Scopus and Google Scholar, a relevant literature search on the positive health
Therapeutic garden
implications of therapeutic gardens (TG) on AD and dementia patients in the healthcare milieu was
Virtual reality
conducted.
Results: The health implications of TG for AD and dementia patients span physical, social, psychological and
cognitive effects. Virtual reality (VR) technologies that display natural environments also offer positive cogni-
tive outcomes for AD and dementia patients.
Conclusion: TG should be used to improve the health and wellbeing of AD and dementia patients, and its
application should be extended to other patient populations to promote quicker recovery. Future directions
in the design of TG, with a focus on patients with AD and other dementias, is also discussed.
© 2019 Elsevier Inc. All rights reserved.

Introduction and background 1860s.6 This concept was extended in the practice of evidence-
based design (EBD), a healthcare design movement that supports
Research shows that almost every country in the world will healing spaces that promote family involvement, improve staff
experience a growth in the population of older adults—the global performance, relieve stress7 and improve healthcare manage-
population of people aged 85 years and above is projected to ment.8 Several disciplines, including horticultural therapy (HT),9
grow at an alarming rate between 2000 and 2050.1 As 6% of indi- ecological psychology,10 environmental psychology11 and medical
viduals aged 65 years and above are likely to suffer from demen- geography12 have supported the significance of views of natural
tia, the projected growth rate of the older population will also scenery and landscapes, seeking to discover how and why they
increase the burden of this disease, particularly in developing may alter people’s moods, reduce stress and improve cognitive
countries with large populations.2,3 Therefore, creating age- functioning.
friendly environments that are accessible, equitable, inclusive, A physical healthcare environment that incorporates gardens
secure and supportive is important to promote health and prevent may provide pleasant views of nature, producing a calming effect,
the onset of disease and functional decline in older people.4 facilitating both social support and privacy, and contributing to
Adopting more holistic medical practices that provide therapeutic stress reduction. As such, conducting more research on therapeutic
advantages through a variety of interventions—particularly those gardens (TG) in care settings is key for harnessing all the benefits
that incorporate nature—may prove to be beneficial for optimising of such spaces, which, among AD and dementia patients, increase
the healthcare experience of patients with Alzheimer’s disease their ability to exercise and be mobile; minimise feelings of isola-
(AD) or dementia.5 tion, vulnerability, and the loss of abilities; and improve depres-
The concept of designing a healing environment to improve sion, self-esteem and cognitive decline.13 Particularly because
patients’ recuperation process and staff satisfaction began in the there is currently no fully effective therapy for the treatment of
AD or mild cognitive impairment,14 considering potentially suc-
cessful therapeutic developments is vital to improve patients’, just
* Corresponding author. as it is for patients with other chronic illnesses, such as cancer or
E-mail addresses: tiyendo@eul.edu.tr, t.iyendo@gmail.com (T.O. Iyendo).

https://doi.org/10.1016/j.explore.2019.05.002
1550-8307/© 2019 Elsevier Inc. All rights reserved.
 P.C. Uwajeh et al. / Explore 15 (2019) 352 362 353

Fig. 1. The structure and main themes of the literature review.

human immunodeficiency virus (HIV). In doing so, there is a need presents the five-phase iterative process applied in this research
to place greater emphasis on environment-based interventions, to method.
include diverse sample populations at different stages of multiple
types of dementia15 and to apply integrative medicine that Literature review results
involves patient-centred and healing-oriented approaches16 to
improve cognitive functioning. Describing the therapeutic environment
This paper documents the role of TG in healing and evaluates the
extent to which research has postulated the benefit of these interven- Hospitals are often perceived as stressful places for patients, their
tions to achieve positive outcomes for patients with AD or other relatives and staff; however, they can be therapeutic if they are
dementias. The main themes discussed in this paper are structured in designed to foster positive physiological, psychological, social and
two sections as described in (see Fig. 1). behavioural outcomes (see Fig. 3).17,18 This idea is supported by pre-
vious studies that documented the need to design of healing environ-
ments that improve user experience,19 21 especially through
Literature review search method interventions including art therapy,22 music therapy,23 music medi-
cine,24 forest therapy and HT.9 While the benefits of healing environ-
Study selection and search procedure ments have been discussed, there is a need to explore the specific
aspects of these environments in greater depth.
For this literature review, seven databases were searched for rele-
vant studies: Scopus, Google Scholar, the Web of Science index, MED-
LINE, PubMed, ProQuest Central and Google. There was no restriction HG and TG as environmental design constructs
on the article publication dates. Book reviews, monographs, dupli-
cates, encyclopaedia articles, non-English publications and editorials HG and TG have often been used interchangeably in studies.25
were excluded. Generally, HG describes a space designed to provide certain thera-
peutic benefits to its users.26 HG aims at achieving a general set of
goals, while TG focuses on one or more specific patient groups.27
Inclusion criteria However, horticultural therapists often refer to HG and TG as envi-
ronments that provide gardening and other physical activities that
As of February 2019, the initial search results yielded 784 promote wellness.
references. After a closer look at the retrieved papers, 91 articles
were selected for use in this review. The inclusion criteria were Therapeutic dimensions of nature views and access to gardens
that the papers must highlight therapeutic environments, heal- Living near green spaces or viewing nature through a window can
ing gardens (HG), TG or non-invasive technological interventions promote positive health benefits,28 reduce healthcare costs and stim-
with nature. Of the 91 references identified, 29 met the inclu- ulate mental stress recovery,29 suggesting that the exposure to nature
sion criteria and were included in the final dataset. Fig. 2 is beneficial for health and wellness.30,31 Outdoor gardens that
354 P.C. Uwajeh et al. / Explore 15 (2019) 352 362

Fig. 2. Review search procedure.

incorporate aquatic elements, seating elements, play areas and exten- Patients’ visitors and family members find comfort in the beauty of
sive greenery have shown similar effects32,33 in reducing stress- gardens in hospital environments, often referring to them as peaceful
related negative outcomes.34 Similarly, the application of TG has places that provide a sense of privacy and refuge that enables them
been shown to reduce behavioural problems (e.g., fear and anxiety) to experience solitary restoration.33,37,38 These gardens also provide
during post-stroke rehabilitation procedures,35 improve ambulation, an opportunity for low-level activities (e.g., sitting indoors and look-
promote positive reminiscences, stabilise sleep wake cycles and ing out to the garden), mid-level activities (e.g., sitting outdoors) and
reduce stress,9 suggesting this treatment option as a complementary high-level activities (e.g., picking flowers, planting and gardening).36
therapy for dementia patients dwelling in aged-care facilities.36 Nursing staff, too, appreciate and have recommended the use of
Table 1
Highlights the impact of natural views, access to healing and TG

Reference(s)/medical specialty Design Participant size Design Intervention Results on health outcome(s)

Memari et al.37 Restorative natural environments in care Photo-questionnaire 124 Therapeutic natural  Perceived sensory dimensions affect restoration.
settings. environment  Serene, nature and refuge improved restorative qualities.
Reeve et al.33 LCCH Children’s’ Hospital Subjective comments N/A HG  Natural elements including fresh air, gardens and nature views pro-
vided a sense of normalcy and positive distraction, substantial seat-
ing, places for play and extensive greenery were appreciated by
users.
van der Riet et al.40 ; van der Riet et al.41 Pediatric ward Narrative inquiry 8 + 8 (N = 16) Access to garden  Enhanced psycho-social and physical engagement was reported by
children, parents and caregivers.
 Promoted holistic care for children with chronic illness.
Pasha and Shepley,43 Pediatric Hospital. Exploratory 184 Physical activity in gardens  Physical activity in pediatrics was improved.
 Gardens with substantial planting, properly designed layout, path-
ways and amenities improved behavioural culture
children.
 HG had valuable therapeutic benefit for hospital visitors, patients
and staff.
Davis,44 Surgery center POE 20 Access to a garden  Provided indoor escape for users.
Detweiler et al.46 Dementia unit. Observational 28 Wander Garden  Reduced patients fall, psychiatric medications and high and inter-
mediate-dose antipsychotics drugs were reported.

P.C. Uwajeh et al. / Explore 15 (2019) 352 362

 Decreased in agitation and improved quality of life.
Naderi and Shin,39 Health Care Center Traditional landscape architec- 61 Healing Garden  Features including archetypal landscape, thresholds, contemplative
ture data-base design method. paths, benches, symbolic creeks and sacred springs enhanced the
restorative spatial experiences in nursing.
Hernandez,36 Dementia Special Care Units. Multi-method qualitative 45 TG  Provided relief activities, including low-level, mid-level and high-
research and POE level activities for staff and family members.
 Music therapy, picnics and ritual activities restored old memories.
Ottosson and Grahn,47 Geriatric Home. Intervention 15 Access to gardens  Increased concentration was found in elderly people who visited
garden outside the geriatric home, when compared to those that
did not. No effects found on blood pressure/heart rate.
Sherman et al.38 Pediatric cancer centres. Behavioural observations and 1400 Access to HG  Gardens that provided socialization and relaxing, soothing sounds
POE of running water and path ways increased usage.
Whitehouse et al.42 Children's Hospital Garden POE 105 Garden use and activity.  Well-designed gardens, including greenery, shades, water sounds
and adequate seating facilitated a sense of emotional well-being in
chronically ill and handicapped children.

Note. N/A, indicates Not Applicable; POE, Post-Occupancy Evaluation.

355
356 P.C. Uwajeh et al. / Explore 15 (2019) 352 362

Table 2
Summarizes the health effects of TG and HT on AD and dementia patients

Theme(s) References Measured outcome Result on health outcome(s)

TG impact on AD and Dementia Goto et al.63 ; Edwards et al.62; Physical, Social, Psychological  Reduced agitation, isolation and vulnerability, and improved
patients Wang and MacMillan,65; Det- and Cognitive effects depression, aggressive behaviours and self-esteem.
weiler et al. 9; Murphy et  Provided opportunity for walking, physical activities, sociali-
al.61; Detweiler et al.35; D’An- zation and ambulation, including positive reminiscences, sta-
drea et al.66; Ottosson and bilized sleep-wake cycles and reduced stress.
Grahn,47; Sloane et al.60;  Reduced heart rate, improved short-term and long-term
Cohen-Mansfield,45 memories and behavioural symptoms.
HT impact on AD and dementia Wang and MacMillan,65 ; Brown Physical, Social, Psychological  Improved strength and stamina, mobility, flexibility and
patients et al.73; Gonzalez et al.72; and Cognitive effects endurance.
D’Andrea et al.66; So€ derback,  Enhanced coordination and social interaction, coping skills
€derstro
So €m and Scha€lander,53 and motivation.
 Reduced depression and anxiety, increased confidence and
hope, reward nurturing behaviour and stimulates the senses
(touching, tasting and smelling) of plants.
 Improved concentration and focus, problem-solving and
planning skills and positive thinking.

landscape features such as thresholds, contemplative paths and gar- The efficacy of nature-based therapy on behavioural and physiological
den benches, as well as symbolic creeks and sacred springs for restor- indicators
ative experiences.39 Nature-based interventions, including HT, TG and forest bathing,
Exposure to beautiful gardens has the potential to heal, elevate are vital in the future of complementary medicine.54 Recent investi-
clinical outcomes and improve wellness in children and their rela- gations assessing physiological indicators, such as brain, autonomic
tives.40,41 Garden activities, including planting trees and greenery, nervous, endocrine and immune activities, in relation to such thera-
have resulted in perceived restoration and increased consumer satis- pies have been conducted, both in situ and though laboratory tests.55
faction.42 Similarly, garden facilities with seating elements, water The introduction of biological markers in the clinical management of
fountains, natural plants, wall murals, play equipment and other AD has improved both the early detection and diagnosis of neuropa-
areas in which to play have been shown to support positive experien- thology and the tools for the assessment of objective treatment bene-
ces in children.40,43 Additionally, patients with access to a rooftop fits.56 For instance, forest bathing has been shown to stimulate
garden had higher satisfaction levels when compared with staff who immune functions after an increase in natural killer (NK) cell activity;
had less time for use of the garden.44 Likewise, exposure to natural the increase in the number of NK cells was mediated by the levels of
environments improved inappropriate behaviours in patients with intracellular anti-cancer proteins and phytoncides released from
dementia.45 Research has shown that wander garden resulted in trees.57
increased feelings of freedom, improved quality of life and reduced Research into forest bathing and stress recovery has shown that
agitation,35 including the number of falls and the need for high doses negative mood states, anxiety levels and systolic blood pressure were
of antipsychotics in dementia patients.46 Table 1 provides detailed significantly reduced after patients visited forests.58 A study on the
information about these findings. benefits of forest bathing for elderly patients with chronic heart fail-
ure (CHF) revealed that it induced the reduction of brain natriuretic
Physiological and psychological perspectives of HT and TG peptide (BNP), inflammatory cytokines and oxidative stress levels in
the participants. This study also found that cardiovascular disease-
Interactions among the brain, stress physiology and nature related pathological factors—including endothelin-1 (ET-1) and con-
Stress has been associated with the biological reactions of corticoste- stituents of the renin-angiotensin system (RAS), angiotensinogen
rone, a hormone with multiple effects on memory, including emotional (AGT), angiotensin II (ANGII) and ANGII receptor type 1 or 2 (AT1 or
long-term memory, and on fear and cognitive ability. Corticosterone is AT2)—in subjects exposed to a forest environment were lower than
released in a diurnal rhythm after an experience of stress and appears they were in subjects of the urban control group.54 The Effects of
to have a wide range of effects on the hippocampus, an area of the Stress on Cognitive Aging, Physiology and Emotion (ESCAPE) proj-
brain that plays a central role in memory formation.48 Studies have ect has evaluated the short- and long-term impact of stress-
established that the inadequate control of stress responses can present related unconstructive repetitive thoughts (URT) on cognitive
a severe threat to health and wellbeing, especially for the elderly. This health using psychological and physiological mediators. Specifi-
is partly because the loss of hippocampal cells is associated with norma- cally, a multivariable approach was used to simultaneously assess
tive aging in most cases.9 Physiological and psychological dysfunctions C-reactive protein (CRP) in blood plasma and biomarkers includ-
associated with the excessive secretion of glucocorticoids has been ing interleukin (IL) 1b, IL-2, IL-4, IL-5, IL-6, IL-8, IL-10, tumour
implicated in the pathogenesis of depression and post-traumatic stress necrosis factor (TNF)-a, interferon (IFN)-g and granulocyte mac-
disorder.49 A hallmark of the pathology of stress responses is the activa- rophage colony-stimulating factor (GM-CSF).59
tion of the hypothalamic pituitary adrenocortical (HPA) axis, which
mobilises the energy required by an organism to respond to psychologi- Health effects of TG and HT on AD and dementia patients
cal stressors.50
While stress responses can harm a variety of physiological and Effects of TG on AD and dementia patients
psychological functions, access to natural environments has been Research has demonstrated that integrating TG in a healthcare
linked with mental restoration among older adults.51 For example, environment can induce a profound effect on the agitation, behav-
HT may be effective in accelerating the improvement of activities in iour, ambulation and stress levels of AD and dementia patients.60 62
the brain including cognitive and psychosocial functioning,52 emo- Similarly, older adults with AD derive benefits from exposure to gar-
tion, sensory motor functioning, stress tolerance, wellbeing and men- dens in that they foster walking, socialisation and higher self-esteem
tal and physical illness in older adults with dementia.53 while reducing depression and aggressive behaviours, including
 P.C. Uwajeh et al. / Explore 15 (2019) 352 362 357

Fig. 3. A model for understanding a therapeutic environment. Adapted from.11,17

isolation and vulnerability.45 One study showed that late-stage AD depression or a lack of self-identity,72 which is consistent with the
patients who viewed an indoor Japanese garden reported a reduced findings of another study,73 which concluded that HT can affect the
heart rate, improved behavioural symptoms and improved short- physical, social, psychological and cognitive functioning of dementia
and long-term memory.63 patients. Table 2 presents a summary of these findings.
A recent study also revealed that plant cultivation-based HT pro-
grams may improve the stress levels and physical functional abilities Current options in the treatment of AD and dementia
of elderly patients with mental health problems.64 For example, gar-
dening may facilitate reminiscence65 and improve the activity partic- The pathology of AD and dementia
ipation of patients with dementia,66 suggesting an overall AD is a neurodegenerative disease linked to progressive memory
improvement in the wellbeing and healthcare experience of older loss and is pathologically diagnosed by the presence of amyloid-beta
adults with dementia. (Ab) peptides and neurofibrillary tangles (NFT).74 Several hypotheses
that may explain this pathogenesis have been proposed (see Fig. 4).75
Effects of gardening and HT on AD and dementia patients However, a weak correlation between Ab deposition, neuronal atrophy
Studies have revealed that gardening and HT may promote gen- and cognitive impairment has been reported. 76
eral health, quality of life and cognitive functioning in AD and demen- The presence of Ab has been considered the major cause of AD,
tia patients,67,68 encompassing such attributes as physical strength, meaning it is likely that the disease develops as a result of the accumu-
flexibility and socialisation.65 Gardening and HT have been shown to lation and deposition of Ab peptide aggregates in the brain and a con-
modulate the central nervous, endocrine and immune systems,69 as tinuous imbalance between the production and clearance of Ab40 42
well as promote coping and skill development in older adults.70 HT is fragments by b- and g -secretases; this leads to the accumulation of
often considered to include any program that encourages active and Ab peptide monomers and oligomers and, finally, to the significant
passive involvement in activities such as gardening and imagining accumulation of Ab plaque in the brain.77 In contrast, however,
and viewing nature in a hospital environment.53 One study showed another study has reported that the main factor causing the progres-
that incorporating HT programs into long-term care homes by having sion of AD is Tau, not Ab.78
patients participate in HT for about five to ten minutes helped to
maintain patients’ cognitive functioning and encouraged further par- The failure of monotherapeutic interventions and future directions for
ticipation in horticultural activities, which promoted a sense of self- the treatment of AD and dementia
worth and the expression of feelings.66 Additionally, a recent study The lack of effective treatment options for AD has raised concerns
showed that a 10-session HT program revealed a significant improve- about the potential bankruptcy of Medicare systems.79 Recent phase
ment in the clinical symptoms of patients with schizophrenia.71 III clinical trials aimed at eliminating the most predominant patholo-
Active participation in gardening was shown to have positive gies of AD—amyloid plaques and neurofibrillary tangles—have failed,
health effects for middle-aged women who suffer from anxiety, indicating that once symptoms appear, the brain is already affected
358 P.C. Uwajeh et al. / Explore 15 (2019) 352 362

Fig. 4. Pathogenic hypotheses of synaptic and neural toxicity in AD. Adapted from75

by neuronal death, limiting the efficacy of drugs.80 This pitfall may environments, have been used to reduce anxiety and agitation in
also be due to the choice of biomarkers and the interaction of the AD patients.84-86 For example, the application of a VR headset with
drug-targeted molecules.81 However, research into the early detec- visual and auditory features showing peaceful beach scenes, forests
tion and treatment of AD is still developing.82 For example, a compre- and animals, underwater coral reefs and dolphins improved
hensive and personalised therapeutic program based on the patients’ moods and overall experiences (see Fig. 5).87
underlying pathogenesis of AD using multiple modalities to achieve Applying 3D simulation to patients while they are in the hospital
metabolic enhancement for neurodegeneration (MEND) has been has been used as a mock-up tool to compare patients’ emotional
developed in two studies. The first study results showed improve- responses to natural stimuli in a real-world design.88,89 VR tests
ment in patients’ cognition and performance within 3 to 6 months,79 revealed high satisfaction, including relieved discomfort, anxiety and
while the second study showed significant improvement in patients fatigue, as well as improved mild cognitive impairment90 and mem-
with cognitive decline within 5 to 24 months.83 These studies con- ory performance, in dementia patients.91 Table 3 provides a sum-
cluded that the early detection of cognitive decline may be treated mary of the selected studies.
using metabolic processes, offering a potential successful treatment
therapy for AD and dementia.79,83
Summary of the literature review findings
Non-invasive technological interventions for improving the clinical
outcomes of AD and dementia patients Hospital environments that integrate TG or HG and HT have a pro-
found effect on the physical, social, psychological and mental status
Technological advancements, including virtual reality (VR), of AD and dementia patients. These settings use nature to foster
three-dimensional (3D) simulation technologies and intelligent social support, a sense of control, the opportunity for physical activity

Table 3
Summary of selected studies on VR Technology

Theme(s) References Design Participant Measured outcome Result on health outcome(s)

size

Doniger et al.84 Randomized controlled 55 Cognitive and  Improved cognitive functioning was
trial neurobiological reported.
Manera et al. 90
Questionnaire 57 Cognitive and behaviour  Patients reported high satisfaction and
impairment feelings of security, reduced discom-
fort, anxiety and fatigue.
VR Technology Riley-Doucet Quantitative pilot study 12 Agitation  MSE reduced anxiety and agitation in
and Dunn,85 participants with BPSD.
Man et al.91 Pre and post test 24 Multifactorial Memory  Greater improvement in objective
memory performance was reported.

Note. BPSD indicates Behavioural and Psychological Symptoms of Dementia; MSE, Multisensory Environment; MCI; Mild Cognitive Impairment; N/A, Not Applicable.
Table 4
Summary of the findings adapted from existing literature

Design intervention Design parameters Sub-design parameters Health benefits for improved user experience

Healing Gardens TG, HG and HT.  The health impact of HT, TG and HG interventions in AD and dementia patients, cuts across their physical, social, psychological and cognitive
environments status, presenting positive outcomes including reduced agitation and anxiety, increased cognitive functioning, emotional recovery and physi-
cal activity.
Colours.  Integrating appealing colours for signage on floors and pathways can improve wayfinding in gardens.
 Colours and well-chosen hues on furniture and floors in a garden may have a positive or negative effect on a health and wellbeing.
 Overdosing spaces with too much or ominous colours such as black can increase anxiety levels and depression.
Views, Positive distraction  Properly designed gardens in the healthcare physical environment provide pleasant nature views and calming effects on users.
and  Nature scenes provide pleasant distractions to reduce worrisome and stressful thoughts, and may improve cognition.
Nature scenes.  Visibility of garden spaces from hospital interior spaces by both staff and residents is critical to its use.
Sunlight.  Adequate exposure to sunlight is required for vitamin D synthesis and calcium metabolism especially for the elderly group in nursing homes.
Sound.  Pleasant sound from water fountains, nature and bird sounds may be introduced as a positive distraction in gardens to improve postoperative
patient sleep and physiological recovery.
 Gardens that promote social support for patient’s family members and close friends accelerates psychological rehabilitation and emotional

P.C. Uwajeh et al. / Explore 15 (2019) 352 362

Social support.
healing.
 Respite spaces in gardens can reduce the anxiety of family members, improve staff-patients communication and promote better care in clinical
environments.
Sense of control.  Gardens should increase a sense of control and intimacy through features including flexible seating arrangements to reduce frustration and
promote a sense of togetherness among users.
Art work.  Nature themed murals and art works in gardens evoke positive memories, and elicits feelings that sustains attention and interest.
Art therapy.  Art therapy programs reduce ambient environmental stressors, provide positive distractions, increase cognitive functioning and promotes
comfort level.
Architectural design factor.  Phenomenological considerations in the design of gardens can improve the sensory experience and evoke positive of emotions.
 The design of garden spaces can enhance wellbeing if it addresses all the senses simultaneously and combines our image of self with our expe-
rience of the world.
 Garden designs should consider spaces for activities that can meet the experiences of the target patient group.
 An optimal design of TG should integrate a mix of architecture that is not alienating and domesticity that is practical to its users.
Physiological and HT and TG Biological indices.  The physiological and behavioural reactions to environmental settings involves a bi-directional communication of the brain, with multiple sys-
psychological tems including endocrine, cardiovascular and immune systems.
perspectives on  Biological, interleukin, and immunological markers have been regarded as the Gold standard model to investigate HT and TG outcomes in
AD aging/neuro cognitively impaired.
 HT and TG activities reduces plasma IL-6, prevents inflammatory disorders, while maintaining plasma CXCL12 (SDF-1) and hematopoietic sup-
port to the brain.
 Changes in neurobiological markers and magnetic resonance imaging (MRI), volumetric changes in brain including hippocampus, amygdala
and caudate nucleus are current new standards in therapeutic intervention research.
Non-invasive VR and intelligent  VR provides a visual and auditory experience through high-tech gadgets such as 3D headsets which incorporate simulated nature environ-
technologies environments. ments for improving cognitive gains in AD and dementia patients.
 VR technologies have been applied with 3D simulation in the hospital environment as mock-up tools to evaluate patient responses in real-
world design.
 3D interactive walls create intelligent environments in geriatric homes that provides activities including playing familiar music and views of
images that improves emotional responses, reduces wandering, as well as restlessness and agitation in dementia patients.

359
360 P.C. Uwajeh et al. / Explore 15 (2019) 352 362

Fig. 5. A VR headset for Dementia Patients at St Peter’s Hospital, Ashford and St Peter’s Hospitals NHS Foundation.87

and positive distractions, to improve health outcomes. Table 4 pro- health status of these patients. It was as well established that TG should
vides a summary of these findings. be employed as a non-pharmacological intervention in the day-to-day
care of AD and dementia patients for stress reduction, pain manage-
Suggestions for garden design ment and the improvement of cognitive ability. Furthermore, the
results from the literature showed that nature-based interventions
The healthcare ecosystem should consider design features such as (including forest bathing) reduced blood pressure, improved stress and
ease of access; movement and orientation; sensory stimuli, positive dis- anxiety levels, and reduced cognitive decline and negative moods.
tractions and mental mapping; shelter and shade; and safety and main- As a result of the literature review, the current study suggests that
tenance, to create user-centred environments that can help patients, VR can be utilised to simulate or recreate many different natural envi-
relatives and healthcare providers cope with stress and other health- ronments and multi-sensory conditions to enhance mood, cognition
related issues that often accompany illness (see Table 5). and overall experience in AD and dementia patients. Furthermore, as
Conclusion this knowledge is explored further, designers and healthcare collabo-
rators will face the challenge of creating more therapeutic environ-
This paper provides an overview of the research that has been con- ments that accommodate and improve the experience of people living
ducted on the role of TG as a design intervention for improving the with AD and dementia. This approach can then be extended to other
physical and mental health of AD and dementia patients. Based on the patient populations as well. Therefore, future studies should inquire
research findings, TG and HT have been predominantly used as alterna- into the positive aspects of non-invasive applications, including VR
tive treatments for AD and dementia and were shown to have pro- technologies, to maximise the treatment options for AD and dementia
found impacts on the physical, social, psychological and cognitive patients.

Table 5
Summary of garden design recommendations in healthcare settings

Design consideration(s) Design recommendations

Ease of Access, Movement and  Integrate views to provide visible outdoor spaces to help staff monitor residents.
Orientation.  Provide clear, legible routes and entrances.
 Provide level plane access from communal rooms or private patios to gardens.
 Introduce ‘circular’ walking routes that returns resident to their starting point.
 Provide obvious and clearly signposted footpaths.
 Provide seats with adequate space for wheelchairs access.
Sensory Stimulus, positive distraction  Garden designs should provide Sense of being; Sense of belonging; Sense of purpose; Sense of imagination; Sense of humour;
and Mental Mapping. Sense of discovery and Sense of spiritual connectedness. It should also evoke the senses of touch and proprioception.
 Provide adequate sunlight required for vitamin D synthesis and calcium metabolism.
 Patterns and floor texture usage to change the dynamics in larger surface area.
 Allow the residents/clients an opportunity to identify and suggest plant types that can evoke memories of familiar environ-
ments.
 Avoid abstract sculptures or art works that can evoke a negative response.
 Include nectar-producing plants that lure birds into your garden.
 Introduce seasonal plants to stimulate reminiscing.
 Incorporate wall murals of nature scenes to evoke positive stimuli.
 Select textured paths that produce sounds to aid people with sight impairment.
 Install water feature to provide a cooling effect, positive distraction, visual appeal and mask noises.
Shelter and Shade.  Introduce pergolas, appropriate seating, climbing plants and trees to in shelters to create comfort and light shade.
Safety Considerations and Maintenance.  Adopt perimeter fences or other physical boundaries to increase safety.
 Avoid steps or sudden changes in level.
 Provide handrails for support.
 Avoid planting toxic or thorny plant species.
 Consider observation and surveillance of the space from the building.
 Educate staff to maximize garden use.
 P.C. Uwajeh et al. / Explore 15 (2019) 352 362 361

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