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Outdoor spaces improve dementia care

Spending time outdoors can reduce symptoms of depression in care home residents with dementia. But easy access and careful design are a must if residents are to get the most out of their gardens.

Spending time outdoors can reduce symptoms of depression in care home residents with dementia. But easy access and careful design are a must if residents are to get the most out of their gardens

Rachel Potter saw many examples of great practice when she visited residential homes as part of her research into their physical environment. But none sticks in her memory quite as much as the giant rabbits, which were kept as pets at one care home and interacted with the residents.

The former district nurse, who is now a senior research fellow at Warwick Medical School, led a project to examine the relationship between the design of care homes and symptoms of depression in residents.

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Spending time outdoors can reduce symptoms of depression in care home residents with dementia. But easy access and careful design are a must if residents are to get the most out of their gardens


A bird garden has proved popular at one nursing home. Picture: Tim George

Rachel Potter saw many examples of great practice when she visited residential homes as part of her research into their physical environment. But none sticks in her memory quite as much as the giant rabbits, which were kept as pets at one care home and interacted with the residents. 

The former district nurse, who is now a senior research fellow at Warwick Medical School, led a project to examine the relationship between the design of care homes and symptoms of depression in residents. 

The research, published in journal The Geronotologist earlier this year (see box), shows that poor access to gardens and outside space can have a negative effect on the mood of residents.

Although the overall physical environment of care homes was not associated with depressive symptoms, the research showed that access to outdoor space was the single environmental variable that significantly predicted depressive symptoms. 

Positive impact

Depression in care homes is an issue – around four in ten residents have significant depressive symptoms, so finding a way to tackle it could have a hugely positive impact on people’s lives.

‘I saw some great examples of outdoor space in the course of the research, such as giant rabbits for residents to interact with,’ says Dr Potter, pictured.

rachel'There were four giant rabbits living in a large hutch in the garden. They were let out on a regular basis to run freely around the garden for the residents to enjoy watching and to stroke. The home also had a small aviary with lots of small birds for the residents to enjoy watching and listening to.

‘Another example was a garden shed set up like a beach hut with sand around it to create a “seaside” area, and there were lots of good things like raised beds, so that wheelchair users could garden.

‘But I also found it quite saddening to go to some homes. It seemed a shame that residents couldn’t easily get into outdoor space, or it wasn’t maintained very well. Even where there were fantastic outdoor facilities, not all residents could use them,’ she adds.

‘I’ve been to care homes with exquisite gardens, but when I’ve asked if I can go into them, nobody knows where the key is kept’

June Andrews

‘I saw one lovely garden but only one resident could get to it because it was up some stairs. When he got there, there were no seats so he had to come down again. The problem is often that the care homes aren’t making it a priority – staff are working so hard, and the focus is on the indoors rather than the outdoors.’

Take a look at the full range of our articles on dementia care

Just a little thought and action could make a real difference, says Dr Potter. Recognising that plastic garden furniture might not be very easy for older people to get in and out of, for example, and making sure seating areas are pleasantly shaded so people want to spend time in them, and ensuring there are well-maintained paths with no trip hazards.

But it’s also about changing cultures. ‘I’d like to see care homes schedule activities for outdoors, even things like holding celebration tea parties in the garden,’ says Dr Potter. 

More than design

June Andrews, who has written several books on dementia, including Dementia: The One-Stop Guide, agrees that access to outdoor space is about more than just design. 

‘I’ve been to care homes with exquisite gardens, but when I’ve asked if I can go into them, nobody knows where the key is kept,’ she says. ‘It’s surely not beyond the wit of humans to design a garden that can be used safely by people with dementia.’

A lot of advice is ‘blindingly obvious’, she says, but that doesn’t mean it is universally applied. ‘It’s about having a place to sit down, having walkways, and plants that aren’t going to poison you.

‘Being able to enjoy time outside would be hugely beneficial, for both staff and residents’

Rachel Potter

‘It’s also about ensuring people can actually get outside, and having fences that don’t look like a barrier – a trellis covered in leaves rather than a prison-style grill – because barriers can be a challenge for people with dementia. 

She also recommends care homes incorporate a children’s play area. ‘If you want the next generation to visit, create a play area and ideally make it more interesting with a few chickens or rabbits – the elements of a fantastic family visit,’ she says.

Professor Andrews, a nurse, was director of Stirling University’s Dementia Services Development Centre (DSDC) for more than a decade and is now adviser to the Dementia Services Development Trust.

Advice on the DSDC website stresses the importance of outdoor space. According to Professor Andrews, there are three main benefits:

  • Access to the open air and the opportunity to exercise helps reduce stress, which is one of the main contributors to ‘challenging’ behaviour for people with dementia, such as anxiety and agitation and sleeplessness.
  • Blue spectrum light, which is found outdoors, particularly early in the morning, helps metabolise the hormone melatonin, which is important in maintaining people’s body clocks.
  • Air quality – even the best-ventilated indoor space can’t compete with fresh air. 

This advice has already been taken on board at Avon Court Care Home in Chippenham, Wiltshire, where feeding and watching birdlife is one of the main outdoor attractions. 

‘I think we’ve got more bird food here than the supermarket,’ laughs activity co-ordinator Lyn Neate. ‘The garden attracts all sorts of birds, and squirrels, and the residents enjoy being outdoors – a lot of them ask to go outside and say they like being in the fresh air.’

Bird garden

The nursing home, which incorporates a dementia unit, is located near a hospital and GP practice, meaning residents can watch the world go by from the patio. This gives them a sense of being involved in ‘normal’ life, says Ms Neate. 

But the bird garden, donated last year by a local businessman and keen bird photographer, has been a real attraction. ‘Our care home is a nursing home, and most of our residents need assistance to get outside. But we’ve turned it into an activity in the afternoons – we call it “garden time” and it’s very popular.’

Anecdotally, she believes getting outdoors has a positive effect on residents’ well-being, and is not surprised by the results of the Warwick study.

Better access

Dr Potter hopes her study will help persuade care homes, and the nurses who work in them, that improving access to outdoor space will improve everyone’s lives, not just those of the residents. 

‘I hope that care home staff will read these messages and think about how they might look to their own outside space, but also about how care staff can change habits – ask people if they want to go outside, for example. 

‘Guidelines for home providers may also help. Care home staff work so hard – it’s not easy – but being able to enjoy time outside would be hugely beneficial, for both staff and residents.’

What the residents say

Researchers from Warwick Medical School and the Warwick Manufacturing Group at the University of Warwick assessed the physical environment of 50 care homes in Warwickshire, Coventry and northeast London.

They looked for any association with depressive symptoms in 510 residents, supplementing this with interviews with a small number of residents.

They found that residents appreciated companionship and design features that increase opportunities for social interaction, such as seating configurations that encourage conversation, but they were not particularly interested in the décor of the homes.

Sensory elements – such as music and televisions – had a mixed response, with some finding them enjoyable and others thinking them a nuisance.

Too many restrictions

The biggest impact on depressive symptoms was noted with outdoor space. Participants said they appreciated greenery and nature, and the chance to spend time outside, but that too often there were restrictions, such as needing permission or assistance from staff, and outdoor spaces having uneven paths or inadequate seating.

The study authors say outdoor space may worsen mood among residents too frail to access it on their own, so if outdoor space is provided, care homes should ensure residents can reach it.

The authors say: ‘Unlocking doors to outdoor space is not sufficient – care home design needs to enable residents to access outdoor space independently when possible, provide spaces that are safe, appropriate and comfortable for older people, and promote a culture that optimises the use of outdoor space.’


Jennifer Trueland is a freelance health journalist 

 

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