Nature Prescription: The Missing Link in Dementia Treatment
Cayla M. Bronicheski, MSc
Cyndi Gilbert, ND
The intrinsic and instinctive requirement for humans to affiliate and connect with nature is a notion that has been present as far back as paintings inside the pyramids of Egypt. Nowadays, we see biophilia – the instinctive bond between humans along with other living things – represented in parks along with other spaces, where trees along with other plants are part of urban and suburban planning. Nature is woven into meditation, music, gift-giving by means of flowers or with the enjoyment of the scenic landscape. There isn't any denying that plants possess an intangible power, an electrical that is reflected within the naturopathic principle vis medicatrix naturae. A salient part of developing a healing environment and treatment for many different health conditions, there's increasing evidence that the healing power nature by means of therapeutic gardens may prove particularly effective in improving the health connection between patients with dementia.
Plants inside a Medical Setting
The introduction of plants within the design of a medical product is not really a new idea, as accessibility natural world used to be considered integral to healthcare settings. Historical accounts in the Dark ages indicated that hospitals within European monastic communities incorporated gardens being an essential element of their facilities to aid healing, where patients' rooms typically surrounded courtyards full of sunlight, grassy lawns, and seasonal plants. As nature was considered to come with an innate capability to heal, sanatoriums in Europe dating back to the 1850s featured intricately constructed flowerbeds, trees, and man-made ponds inside the grounds. Extending to the 15th century, hospice courtyards incorporated sun light and outdoors, meant for an all natural connectedness to nature.1 Benedict Lust, among the founding fathers of naturopathic medicine, also stressed the significance of designing healing spaces to nurture the vis medicatrix naturae,2 incorporating sun therapy, dew-walking, and wide outdoor spaces. Although hospitals and physicians' offices happen to be designed for some time as architecturally sterile and concrete structures, with little focus on landscaping, more recent research and guidelines are once again supporting the inclusion of healing landscapes within their designs.
Modern-day evidence shows that gardens could have a positive effect on healing, along with improvements in health outcome.3 In some hospitals, gardens are integrated into their design and planning. For instance, St Michael's Hospital in Texarkana, Texas, noted that rehabilitation patients were returning home within 2-3 weeks, instead of 6 or even more weeks when garden accessibility was granted.4 At a children's hospital and health center in North park, California, physicians commented that recovery and attitudes were positively influenced among patients who interacted with gardens.5 And also at the Danderyd Hospital in Sweden, doctors noted that horticulture therapy had a positive affect on brain damage rehabilitation.6
Exposure to nature, and gardening, in particular, has additionally been linked to the prevention of a number of chronic diseases. Inside a prospective cohort study, quickly age 65 without cognitive impairment, who involved in daily gardening at baseline, were built with a significantly reduced chance of developing dementia next 16 years, than others who rarely gardened .7 While regular gardening may reduce the risk of developing dementia, the presence of therapeutic gardens and also the activity of gardening, itself, has additionally been proven to have results for individuals already identified as having the condition.
Healing Gardens & Dementia
Agitation & Behavior
While nature has been shown to positively influence stress and well-being within the elderly, reserach has also examined the results of exposure to nature on dementia.8 This ailment is pervasive in the current society, affecting over 24 million people worldwide. Creating a top quality of every day life is the main objective of dementia care.9 Cholinesterase inhibitors would be the only drugs used as first-line treatment for dementia, even though they might slow or minimize the advancement of dementia symptoms, there isn't any known treatment or therapy that can result in remission or cure.10 The condition course itself, in addition to confinement in a hospital environment, can lead to increased frustration, agitation, and even aggression.11 Since dementia patients often have limited capability to communicate their needs and feelings, inappropriate behaviors may be interpreted as anxiety and depression, thus potentially increasing the probability of psychotropic and antidepressant medications. Therapeutic gardens and access to outdoor areas have shown to lessen the incidence of inappropriate behaviors during these patients.12
In a randomized controlled trial 13 examining the differences between Cohen-Mansfield Agitation Inventory scores in dementia patients after 30 minutes of horticultural activity compared to Half an hour of non-horticultural activities for About six weeks, a few trends were noted. For instance, horticultural activity decreased the regularity of agitated behaviors in patients who had low Mini-Mental State Examination scores, but increased agitation in patients with higher MMSE scores. When examining the CMAI change and MMSE scores pre- and post-intervention, there was a positive correlation in the experimental group, but an adverse correlation in the control group, indicating that horticultural activities can improve agitation outcomes in patients with lower MMSE scores.13
Another RCT examined the efficacy of indoor gardening activities on sleep, agitation, and cognition in institutionalized dementia patients. Results showed statistically significant improvements in nap time , nocturnal sleep efficacy , nocturnal sleep time , wake-up time , agitation , and cognition . The literature appears to demonstrate qualitative and quantitative symptom improvements in dementia patients when they participate in activities that utilize nature.14
Several additional studies while using CMAI assessment also have shown a correlation between increased time spent outdoors and reduces in the dementia behaviors of pacing, violence and escape-seeking.15-17 Based on these studies and much more, current dementia guidelines propose that the physical environment where dementia patients live will include use of gardens.18
Fall Risk & Medication Usage
Each year, medical costs increase in relation to fall injuries for individuals 65 many older, with a predicted increase to around $55 billion by 2023.19 In dementia patients, fall risk is really a serious danger to their livelihoods, which can be compounded by side effects of medications accustomed to treat comorbid conditions. For instance, psychotropic medications would be the most typical class of drugs accustomed to treat agitation or behavioral problems in dementia patients; these drugs alone have shown to boost the risk of falling.20 A cohort study examined the effectiveness of a wander-garden on fall frequency and severity, along with the capability to reduce psychiatric medications.21 Results revealed a statistically significant decrease in the need for high-dose antipsychotics, and a 30% reduction in the number and harshness of falls after garden time was implemented; the total number of falls decreased by 38.7% in frequent garden-users, when compared with 7.9% in infrequent users.21
Another study followed dementia facility residents for 1 year before and after adding an outdoor towards the facility.22 Results demonstrated that garden usage improved CMAI scores from baseline, also that the percentage of residents not needing PRN antidepressants and antipsychotic drugs for behavioral issues increased from 35.4% to 55.9%. Members of the family reported that the gardens mitigated mood and improved standard of living in the people with dementia. Additionally, high garden-users were prescribed significantly fewer antidepressants and antipsychotics compared to dementia patients who used the garden less often.22 Decreasing the usage of adjunctive medications in dementia patients may have a profound effect on reducing the mental and physical negative effects related to these drugs.
Social Connection & Empowerment
Several studies with qualitative data have explored garden exposure time on psychosocial well-being. In a single study, garden experiences were subjectively reported as “raised spirits” and offered passive enjoyment.23 Hospital and resident personnel noted that dementia patients were easier to manage when they had contact with the outdoor sun, specifically if the patient was “sundowning” – a phrase used to describe the tendency of dementia patients to become further agitated or confused because the day progresses, because of reduced exposure to light.23 Garden environments will also be sources of meaningful activities for dementia patients that, by engaging them and invoking memories from childhood, can increase self-confidence and them involved in their lives.24
In several studies, garden interaction time improved dementia patients' social interactions with visitors and staff.25, 26 For example, an RCT examining 129 people with diagnosed dementia were split up into 2 groups, 1 receiving a 6-week horticulture-based activity program , and also the second group receiving standard care.14 While using Menorah Park Engagement Scale, horticultural therapy participants demonstrated significantly higher amounts of active and passive engagement and lower levels of maladaptive behaviors including self-engagement, when compared with standard care . The findings suggested that horticultural activities are valuable for sustaining attention, empowering exercise, stimulating cognition, and enhancing social connection.14
Sleep Improvement
Observational data has suggested that folks surviving in a nursing home have limited exposure to adequate light conditions for regulating circadian rhythm and sleep patterns.27 An RCT comparing bright to dim light exposure in Alzheimer's patients indicated that morning or evening light exposure lengthened sleep time during the night.28 Another pilot study randomly assigned dementia residents into 2 intervention groups, encouraging either outdoor or indoor activities for 10 days.29 The outdoor activity group experienced a rise in sleep duration, plus a significant reduction in verbal agitation, according to CMAI scores.29 Since dementia patients commonly present with sleep onset and sleep quality disturbances , sun light exposure through access to outdoor gardens may help to regulate their sleep patterns.28, 30
Clinical Recommendations
Overall, the accessible evidence shows that incorporating therapeutic garden designs leads to improvements within the lives of individuals with dementia, improvements in caregiver and/or staff experiences, and enhancements in the overall visiting experiences of family members and family members.25 Therapeutic gardens should include a number of plants to advertise visual, olfactory, and tactile stimulation for dementia patients. Walking paths ought to be designed to encourage contact with plants, and paths should be continuous, without any dead-ends, to advertise cardiovascular exercise.
Synthesizing all the studies examined, it is strongly recommended that 150 minutes of outdoor garden activity for a minimum of Five days each week may benefit dementia patients by normalizing sleep patterns, decreasing medication usage and falls, and improving social interactions. These segments can be split up into 3 short 10-minute sessions throughout the day. Naturopathic doctors should encourage gardening activities , either individually or communally, as therapeutic activities for patients with mild dementia. An individualized method of these treatment recommendations is warranted, as some patients may require the assistance or supervision of whether member of the family or staff care worker.
Additionally, naturopathic clinics might well consider incorporating indoor plants inside their clinic rooms, or outdoor gardens surrounding their offices. Unconventional methods of patient visits and coverings is ultimately what sets naturopathic doctors aside from our conventional medical system. Using the research supporting therapeutic benefits from being in proximity to plants, this can be a simple concept that can be implemented with even a single indoor plant of interest. Naturopathic doctors can truly exemplify the vis medicatrix naturae by nature into their resource of resources to help offer the recovery process in their patients with dementia.