Article

Dementia
An evaluation of a 12(4) 494510
! The Author(s) 2012
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influence on the quality of DOI: 10.1177/1471301211435188

dem.sagepub.com

life of aged care residents

with dementia
Christine Anne Edwards
Central Coast Research & Evaluation, Australia

Colin McDonnell
Starrett Lodge, UnitingCare Ageing, Australia

Helga Merl
Hunter New England Local Health Network, Australia

Abstract
To evaluate whether a therapeutic garden can improve the quality of life of aged care residents
with dementia and their carers, objective instruments as well as interviews with residents, staff,
and family members were employed.
Residents mean quality of life scores increased by just over 10%, mean depression scores
decreased similarly and mean agitation scores decreased by almost half. Resident, staff and
family member interviews elicited positive feedback including observations that it had
improved the quality of life for residents and decreased staff and family stress levels. In sum,
qualitative and quantitative pre and post findings indicate that an environmental change such as a
therapeutic garden can improve the lives of aged care residents with dementia, and their formal
and informal carers.

Keywords
agitation, dementia, garden, quality of life, residential facilities

Introduction
Dementia in Australia
There are currently around 245,000 people with dementia in Australia. By mid-century, there
will be over 1.13 million Australians diagnosed with dementia. Dementia is already the

Corresponding author:
Christine Anne Edwards, Central Coast Research & Evaluation, PO Box 345, Ourimbah, NSW 2258, Australia.
Email: ca.edwards@bigpond.com
Edwards et al. 495

leading single cause of disability in older Australians and will become the third
greatest source of health and residential aged care spending within about two decades
(Access Economics 2009). Given these statistics, strategies for providing
quality environments for people with dementia who are currently in aged care facilities
and for those of the ageing population who will need future institutional dementia care
are being given increasing attention, not only in Australia but also in most of the ageing
rst world (WHO, 2004).
Over the last 20 years a considerable amount of research has been carried out to identify
the essential components of good design for dementia-specic facilities. Marshall (2001)
reviewed the literature on designing dementia-specic facilities and listed a number of
design features that need to be incorporated in a facility to provide quality
accommodation for people living with dementia. The list included amongst other things
the following features:

. domestic and home-like;

. scope for ordinary activities such as kitchen activities, hanging out washing, and garden
sheds;
. a safe outside space.

A comprehensive survey of Special Care Units (SCUs) in Minnesota showed that SCUs
for people with dementia could be distinguished from other types of aged care by the
presence of certain characteristics including social spaces for various activities and secure
outdoor areas (Grant, Kane, et al., 1995).

The effect of going outside on agitation and pacing, aggression and disruptive behaviour
The benecial eects of being able to go outside on levels of agitation in people with
dementia have been well documented (Matteson & Linton, 1996; Namazi & Johnson,
1992; Taft, Delaney, Seman & Stansell, 1993). Visiting an outdoor garden has been shown
by Cohen-Manseld to reduce agitation in nursing home residents who pace (Cohen-
Manseld & Werner, 1998; Cohen-Manseld & Werner, 1999). Access to well-designed
gardens may encourage walking and decrease pacing and wandering (Joseph, Zimring,
Harris-Kojetin & Kiefer, 2005; Mooney & Nicell, 1992).
The longitudinal study by Mooney and Nicell (1992) also found that the use of exterior
environments reduced incidents of aggressive behaviour, and contributed signicantly to a
risk management program. Research by Mather, Nemecek and Oliver (1997)_ENREF_26
suggests that individuals who spent more time outdoors engaged in less disruptive
behaviour. They theorized that gardens or outdoor space can reduce the sense of
connement that people may feel in a secure environment, giving residents the
opportunity to move more widely and feel and experience less frustration, less need for
pacing and lower levels of agitation.
Mooney and Nicells 1992 study was conducted in ve dementia care facilities, and found
that the facilities with outdoor spaces adjacent to the unit had less agitation and disruptive
behaviour than did the facilities with no outdoor space. They suggest that increased space for
walking and freedom of movement can reduce frustrations and anxiety that characterize all
dementias (Mooney & Nicell, 1992, p. 24).
496 Dementia 12(4)

Pleasure and the importance of staff interaction in the use of gardens

Cooper Marcus and Barnes, 1999 described four case studies of healthcare facility gardens in
California. They compared two mood shifts (a pleasing drop in energy level, and spiritual
uplift) in garden visitor groups, which included sta, patients, and visitors. The research
included a visual analysis of the physical site, systematic nonintrusive behavioural
observation, and interviews with garden visitors. The interview data revealed that after
spending time in the gardens, over 75% of visitors reported feeling more relaxed and
calmer, and 25% felt refreshed and rejuvenated. They found that visitors were most likely
to experience a pleasing drop in their energy level (i.e., visitors were more relaxed, or their
stress level went down), and patients were more likely to report a spiritual uplift.
An Australian study was the rst to demonstrate empirically an increase in pleasure
associated with being in a landscaped garden for people with dementia (Cox, Burns &
Savage, 2004). This study examined how eective two types of multisensory environments
were in improving the wellbeing of older individuals with dementia. The two multisensory
environments were a Snoezelen room and a landscaped garden. These environments were
compared to the experience of the normal living environment that did not include a garden
or Snoezelen room. Although feelings of pleasure increased while the 24 participants with
dementia were in the garden, the authors concluded that in terms of the relative eectiveness
of each environment in improving wellbeing of participants, the quantitative data indicated
few dierences between them. Qualitative data obtained by interviewing sta and caregivers
indicated that no matter which of the three environments was being spoken of, it was the
opportunities of a one-to-one relationship, quality time, and to feel closer, that was valued
(Cox, Burns & Savage, p. 43).
This nding was supported by Lovering, et al. (2002) who found sta commitment and
support of the use of outdoor space essential. Wood, Harris, Snider and Patchel (2005) also
found that interaction with others to be a crucial factor, and that the presence of a pleasant,
safe outside space had no eect that could be attributed to it that was not secondary to the
impact of the relationships with the sta.

Gardening as an activity for people with dementia

Environmental psychologists and horticultural therapists argue that access to activities
involving plants and gardening can serve as sources of stimulation for people with
dementia and can spark memories of earlier pleasurable experiences with gardens and
gardening (Cohen & Weisman, 1991; Haas, Simson & Stevenson, 2003). These are among
the reasons to encourage caregivers, whether family members or sta members of long-term
care facilities, to include more outdoor activities in gardens or the natural environment into
the daily routine of people with dementia. Although this seems to make intuitive sense there
are few studies conrming this assertion. There is, however, some theoretical support for this
idea.
In people with dementia, functional ability and retrieving previously learned information
can be preserved as resources through which contact with the outdoor environment can be
maintained (Carman, 2002). Familiar activities help to draw on both explicit and implicit
memories of earlier life and keep residents actively involved in their lives (Sabat, 2006; Zeisel
& Tyson, 1999). Horticulture is one of the most common and enjoyed leisure pursuits of
older adults and can be used to alleviate symptoms of dementia (Haas et al., 2003; Hill &
Edwards et al. 497

Relf, 1982). In fact gardening, according to one study, may be attributed to a lower risk of
developing dementia: in a study in France in 1995 gardening was one of the activities
associated with lower risk for dementia among older people (Fabrigoule et al., 1995). The
authors suggested that the protective eect of gardening and other complex activities like
knitting could be due to stimulation of a variety of cognitive functions including planning,
organization of motor function, and the like.
Therapeutic horticultural activities are appropriate for older adults with dementia
because the activities are familiar and meaningful to most and provide opportunities for
reminiscing as well as for exercising competence (Jarrot, Kwack & Relf, 2002). In addition,
horticultural activities are creative, result in tangible end-products, provide exercise for a
wide range of physical and cognitive skills, and enhance social interaction. The continuity of
familiar activities supporting a sense of competence and self-esteem may help in coping with
a progressive loss of abilities. Plants provide sensory, but non-confrontational, stimulation
for all the senses through colours, structures, scents, tastes, forms and sometimes by sounds.
Sensory stimulation is important for people suering from dementia since it can improve
orientation, trigger memory, prevent emotional outbursts and facilitate connectedness in
individuals with dementia (Haas et al., 2003; Carman, 2002).

Sleep
Exposure to natural light is another potential benet of access to gardens for people with
dementia. Although it is clear that there are many factors that contribute to poor sleep in
nursing home residents, a critical determinant of sleep is human circadian rhythms. A major
determinant of human circadian rhythms is exposure to bright light (Czeisler, 1995; Duy,
Kronauer & Czeisler, 1996). There is observational data that most nursing home residents
experience very limited bright light exposure(Ancoli-Israel et al., 1997), and that the light
they receive is too weak for circadian entrainment. There is extensive evidence that suggests
spending time outdoors may result in improved sleep as a result of increased exposure to
sunlight (Campbell, Dawson & Anderson, 1993; Campbell et al., 1996).
A very well-constructed RCT involving a comparison between morning and evening
bright light sessions with similar exposure to dim red light and normal, baseline light
exposure showed that the eect of light treatment on sleep and circadian activity rhythms
in people with Alzheimers Disease suggest that increased bright light exposure, whether in
the morning or in the evening, consolidates night-time sleep by lengthening the maximum
sleep bouts during the night (Ancoli-Israel et al., 2003)
A one-year pilot study (Connell, Sanford & Lewis, 2007) randomly allocated nursing
home residents with dementia to outdoor or indoor activity program groups. Sleep and
behaviour disturbance were assessed over a 10-day period at baseline (usual activity
conditions, which were expected to include little or no time spent outdoors) and at
intervention (daily structured activity program oered outdoors or indoors). Sleep was
assessed with wrist actigraphs with photocells, which also allowed for monitoring of light
exposure. Behaviour disturbance was assessed with the Cohen-Manseld Agitation
Inventory. The outdoor activity group experienced signicant improvements in maximum
sleep duration. Both groups showed signicant improvements in total sleep minutes. There
also was a signicant improvement in verbal agitation in the outdoor activity group.
A study conducted by Calkins et al. in three nursing homes (n 17), used actigraphy,
validated proxy measures of sleep and agitation and direct observation to explore the impact
498 Dementia 12(4)

of increased time outdoors on sleep and agitation (Calkins, Szmerekovsky & Biddle, 2007).
The repeated measures design assessed residents with dementia under four conditions:
winter/no activity, winter/inside activity, summer/no activity and summer/outside activity.
Results suggested that increased time spent outdoors resulted in a modest improvement in
sleep, and mixed or immeasurable impact on agitation.

Recent studies on therapeutic garden design for dementia residents

The eect on resident behaviours of adding a wander garden to an existing dementia facility
was investigated in 2008 (Detweiler, Murphy, Myers, & Kim, 2008). Thirty-ve male
residents were observed for 12 months before and after opening the garden. Behaviours
were assessed using the Cohen-Manseld Agitation Inventory Short Form (CMAI),
incident reports, need for medication and surveys of sta and residents family members.
Final CMAI scores and total PRNs employed were lower than baseline values with a
trend for residents who used the garden more often to have less agitated behaviour.
Final CMAI scores for residents were signicantly improved over baseline CMAI scores
with the nal CMAI median being ve points lower than the baseline median. When the
dementia residents were divided into high and low garden use groups based on median
number of visits for the year, there was a signicant correlation between the nal CMAI
score and the total days in the wander garden for both resident groups.
Within a sample of 34 participants, the percentage of residents not requiring any PRNs
increased from 35.4% to 55.9% during the wander garden observation year.
Behavioural incidents were coded to four levels with Level 1 involving inappropriate
language and Level 2 including inappropriate touching or grabbing, pushing, resisting or
chasing. A Level 3 incident involved a resident striking out with no injury to the target and a
Level 4 incident was the most serious and involved a resident causing physical harm to self or
others. There were no signicant dierences for the numbers of incidents of Levels 1 through
3 but Level 4 incidents increased signicantly. The authors suggest that this may have been
because of the poor design of the garden; for example, locked wander garden doors, heavy
doors. They also suggest that resident incident ndings would benet from re-examination
using a control group.
Sta and family members felt that the wander garden decreased inappropriate behaviours
and improved mood and quality of life of the dementia residents. The authors conclude that
the study design characteristics and garden management may have aected behaviours both
positively and negatively and that additional studies are needed to explore the benets of
wander gardens for dementia residents.
Much of the recent literature on the use of therapeutic gardens for people with dementia
has been concerned with design and accessibility. The incorporation of accessible outdoor
living elements in residential design can actively encourage the utilization of the outdoors.
York emphasizes establishing environments that reduce architectural, programmatic, and
attitudinal barriers and provide support to individuals with neurologic impairments that
promote the improvement of functional abilities and thus reduce quality of life barriers
(York, 2009). Consideration of what makes outdoor spaces inviting such as comfort,
visual appeal, security, encouragement of physical activity, and intuitive use can increase
the use of outdoor spaces that are so often underutilized in residential settings. According to
York, design of outdoor spaces using these universal design principles makes the
environment usable by everyone.
Edwards et al. 499

In summary, the benecial eects of being able to go outside on levels of agitation in

people with dementia have been well documented. There is also extensive evidence that
suggests spending time outdoors may result in improved sleep as a result of increased
exposure to sunlight. There are, however, very few studies that have evaluated the eects
of gardens in an actual setting, and there is no empirical research on the eect of the
inclusion of a specically designed sensory garden on the quality of life of aged care
residents with dementia.
In 2009, UnitingCare Ageings Starrett Lodge on the NSW Central Coast designed a
therapeutic garden for residents with dementia and evaluated the eect of the garden using
both qualitative and empirical methodologies.

The Starrett Lodge garden

In 2009, Starrett Lodge on the NSW Central Coast completed an extensive literature review
and used the results to create a therapeutic, interactive, sensory wander garden and an
adjoining atrium/sunroom. The atrium overlooks the rest of the garden and can be partly
opened to the air, smells and sunlight from the garden.

Figure 1. Magnolia House Therapeutic Garden Plan.

500 Dementia 12(4)

The garden incorporates in its design many of the components thought to elicit
pleasurable explicit and implicit memories and encourage engagement including memory
boxes, a tinka car, a mural of the local headland, a viewing platform overlooking
the Australian bush, a nch aviary, a woodpile, a quiet area with a water feature and
raised growing beds where residents can dig and pick produce (See Figure 1 and
Photographs 1 to 7).
The new environment is specically designed to increase the quality of life for residents
living in its dementia-specic unit (Magnolia House). The project has three main objectives:

(1) To improve the quality of life of the people with dementia living in Magnolia House;
(2) To improve the caregiving experience of sta members;
(3) To improve the visiting experience of family members, carers and loved ones.

Methods
The measures
The Dementia Quality of Life Instrument (DEMQOL and DEMQOLProxy), The Cornell
Scale for Depression in Dementia (SCDD) and the Cohen-Manseld Agitation Inventory
(CMAI) were used to measure the quality of life of 12 residents three months before the new
garden and atrium was constructed and three months after the new garden and atrium
construction. The Mini-Mental State Examination (MMSE) was used to assess the level
of dementia of each resident at baseline._ENREF_6
The Cohen-Manseld Agitation Inventory is a caregivers rating questionnaire consisting
of 29 agitated behaviours in patients with cognitive impairment. The agitated behaviours can
be generalized into wandering, physical aggressions, inappropriate vocalizations, hoarding
items, sexual disinhibitions and negativisms. The scale ranges from 1, the participant never
engages in the specic agitated behaviour to 7, the participant manifests the behaviour
several times an hour on average. Ratings pertain to the two weeks preceding the
administration of the CMAI. Responses are based on observation of caregiver.

Photograph 1. Residents of Magnolia House playing with babies in the tinka car.
Edwards et al. 501

Photograph 2. The viewing platform that looks over the Australia bush with the tinka car to the right of
the photograph.

Photograph 3. One of the three memory boxes that form part of the therapeutic garden.
502 Dementia 12(4)

The DEMQOL system consists of two interviewer-administered instruments. DEMQOL

(28 items) is completed by the person with dementia; DEMQOL Proxy (31 items) is a proxy
report of the person with dementias quality of life completed by the main carer (score range
from 31 to 124, with a higher score indicating better quality of life). DEMQOL has
acceptable psychometric properties for people with mild to moderate dementia (dened as

Photograph 4. The atrium/sunroom that overlooks the garden and can be opened to the smells, sunlight
and breezes emanating from the garden.

Photograph 5. The gardens woodpile.

Edwards et al. 503

Photograph 6. Residents using the garden with family and friends with the finch aviary in the background.

Photograph 7. The finch aviary has become a pivotal part of the garden and the birds elicit daily interest
from the residents.
504 Dementia 12(4)

a Mini-Mental State Examination (MMSE) score of 10) while DEMQOL Proxy can be
used for mild, moderate, or severe dementia.
The Cornell Scale for Depression in Dementia (CSDD) is a clinical test used to determine
the symptoms and signs of depression in individuals suering from dementia. Observation of
the patient and an interview with the patient and the patients caregiver are conducted to
calculate the CSDD. The interview is conducted in ve separate sections: mood-related signs,
behavioural disturbance, physical signs, cyclic functions and ideational disturbance. The
CSDD consists of 19 questions with each response scored from 0 where the symptom is
absent to 2 where the symptom is severe.
The Mini-Mental State Exam (MMSE) is a brief, structured test of mental status that
takes about 10 minutes to complete. Introduced by Marshall Folstein and others in 1975, the
MMSE tests global cognitive function, with items assessing orientation, word recall, attention
and calculation, language abilities, and visuospatial ability. Scores on the MMSE range from
0 to 30, with scores of 25 or higher being traditionally considered normal. Scores less than 10
generally indicate severe impairment, while scores between 10 and 19 indicate moderate
dementia. The Mini-Mental State Examination is the most commonly used instrument for
screening cognitive function.
All instruments were chosen because they are well accepted validated, reliable measures
for use with people with dementia. Information on the validity and reliability of each
measure can be found in the following references (Alexopoulos, Abrams, Young &
Shamoian, 1988; Brod, Stewart, Sands & Walton, 1999; Cohen-Manseld, Marx &
Rosenthal, 1989; Folstein, Fosltein & McHugh, 1975).
The Depression and Agitation scales were administered by facility sta after they received
training in correct pre- and post-administration of the scales. If the resident was assessed
according to the MMSE as having mild dementia they completed the Quality of Life Scale
themselves with a trained sta member assisting, otherwise a family member assessed their
quality of life with the assistance of a sta member trained in the administration of the
DEMQOL Proxy.
A log sheet was used over a 12-day period during the three months prior to construction
to record how often the residents, sta and visitors used the old garden area (in autumn) and
again during a 12-day period with similar weather conditions at three months post-
construction (in the following spring). Sta members were also asked to observe the use
of the new atrium/sunroom during the three months after construction.

The interviews
Sta were interviewed three months after construction of the garden and atrium using open-
ended questions designed to elicit their impressions about the new environment and whether
it had improved the quality of life for residents as well as decreased sta stress levels and
improved the sta caregiving experience. Family members and carers were interviewed using
open-ended questions designed to elicit their impressions about the new environment and
whether it had improved the quality of life of their loved ones as well as decreased their own
stress levels and improved their visiting experience.
Informed consent to take part in the research was received from the person responsible
for each resident, the residents themselves (where residents were assessed as having mild
dementia) and the sta and family members who were to be interviewed and surveyed.
Edwards et al. 505

The research protocol conformed with the provisions of the Declaration of Helsinki and
ethics approval was received from UnitingCare.

Results
Two residents were lost to the study due to transfer to high-care facilities, leaving a sample of
10 residents three months post-garden construction.
The sample included seven residents diagnosed with Alzheimers Disease, two with
dementia of unspecied type and one resident with mixed dementia. At baseline four
residents had severe dementia, three had moderate dementia and three had mild dementia.
Nine of the study members were female and one was male, with residents ages ranging from
79 to 90 years.
There were signicant improvements in all measures with residents mean quality of life
score increasing by 12.8% (t 4.57, df 9, p < .0001), their mean depression score
decreasing by 13.3% (t 2.4, df 9, p .02), and their mean agitation score decreasing by
46.7% (t 7.48, df 9, p < .0001). The number of times residents used the garden during the
respective 12-day periods increased from 91 times for the old garden to 111 for the new
garden, an increase of 22%. Table 1 shows residents mean outcome scores at baseline and
three months post-garden construction.

Table 1. Residents mean outcome scores at baseline and three months post-garden construction with
standard deviations and p values

mean score n 10 baseline sd 3 months post-garden sd p value

Quality of life (Demqol) 91 6.5 102.6 11.0 0.00068

Agitation(CMAI) 46.7 23.4 25.1 15.0 0.00002
Depression (SCDD) 8.3 6.8 7.2 6.3 0.01994

All 10 residents reduced their agitation levels after the garden and atrium were built, seven
of the 10 also reduced their depression scores and eight of the 10 increased their quality of
life scores.
Observational evidence showed almost 100% voluntary migration of residents from the
television room to the new atrium/sunroom during leisure time. This movement has not been
transitory and has remained stable for 12 months (at the time of writing) with residents now
preferring to eat their meals in the atrium. The atrium has no television and sta report that
residents are much more likely to interact with each other than they were previously.
Sta, family members and resident interviews elicited consistently positive feedback
concerning the new environment, including observations that it had improved the quality
of life for residents as well as decreasing sta and visitor stress levels.
From one family member:

I cant say how much of a dierence the garden has made for xxx. Today I have taken her up on
the viewing platform and we wrote a letter, she talked about the birds, she loves animals. Its
relaxing for us both to be out here. It has denitely improved xxxs quality of life and I enjoy
coming more too.

One sta member said,

506 Dementia 12(4)

Residents are easier to manage, especially if they are sun downing. We can bring them out here
just to relax. They often come at other times to water the garden or look at the sh, smell the
herbs, pick the cherry tomatoes. There is a lot more for them to do. It is more fun to come to
work as well. Theyre happier and so are we.

And from a resident:

I like it all. The fountain, the sh, the memory boxes everything. The table and chairs in the
sunroom came from my lounge room at home, you know. We all sit around it and talk.
The facilities manager when asked to comment on what aspects of the garden work best
replied,

It really depends on the resident. For example XXX spends a lot of time in the tinka car and I
think perhaps he liked to drive when he was younger. XXX spends some of every day looking at
the memory boxes and talks about parts of her own life that relate to what she sees in the boxes.
She says I have a teapot like that, you know. Quite a few of the residents enjoy feeding the birds
every day or watering the garden. It gives them a sense of purpose and ownership and I also
think they enjoy the feeling of looking after the birds and plants instead of being the ones to be
looked after all the time; after all most of them were nurturers of some description in their
former lives.

The facilitys general practitioner commented,

This garden has improved the quality of life of the residents here to the point that I dont have to
come as often. I know this is a big statement with such a small sample but I really believe that the
new environmental changes have had an impact on the residents physical and emotional
wellbeing. It would be great if all facilities could provide environments like this.

Discussion
Although the aged care residents in this study represent a very small sample of dementia
residents they were quite varied on several dimensions. Their dementia diagnosis ranged
from mild to severe and they varied in age, gender, type of dementia and length of residency.
Despite these variations, all 10 residents beneted from the new environment with every
resident reducing their agitation levels after the garden and atrium were built, seven of the 10
also reduced their depression scores even though in this particular facility baseline
depression scores varied widely with many being very low at baseline, and eight of the 10
increased their quality of life scores. The increase in use of the new wander garden compared
to the old garden of 22% was not as large as management had hoped during the data
collection period but sta reported that this improved as the garden became more
familiar and residents felt safer to venture out on their own.
The migration of residents to the sunlit atrium with no coercion has pleasantly
surprised the sta and residents families. The atrium is part of the garden and can be
partly opened so that residents can feel the breeze and experience the sunlight and the
aromas emanating from the garden. The increase in interaction between residents in this
area may be partly because there is no television in the atrium and so may not be directly
attributable to the atrium itself but sta consider lack of a TV a positive design component
in the new environment.
Edwards et al. 507

The highly statistically signicant improvements in residents mean agitation scores and
the fact that every resident improved their agitation score may indicate that it may not be
necessary for residents to actually wander through the garden in order to reduce their
agitation. It may be enough to be able to just sit and be able to take in the view, the
smells and the sunlight. This is consistent with the ndings in the Detweiler 2008 study
which found that agitation scores did not return to baseline levels in the group of
residents who rarely used the garden probably because of daily exposure of the residents
to the sight of the wander garden through a large window in the activity/dining room
(Detweiler, Murphy, Myers & Kim, 2008). Mather et al. (1997) also noted that dementia
residents spent more time looking out the window in the winter months when they had no
access to the wander garden and that large windows overlooking the garden appeared to
diminish the perceived separation of the resident from the garden itself, in turn reducing the
agitation of connement.
The Starrett Lodge general practitioners perception that the residents had better physical
health after the introduction of the garden is supported by the Detweiler study which found
that most residents required signicantly less total medication after the wander garden was
introduced.
It is not possible to generalize these ndings with a sample of 10 or prove causation
without a control group. It may well be, as other researchers have found, that the
improved environment encouraged sta to interact more with residents as they enjoyed
taking them outside and this in turn decreased residents agitation and depression
and increased their quality of life. It may also have been the lack of TV that encouraged
interaction in the atrium. The study did not control for family members coming more often
because they had a nice garden to take their loved ones to. There are a myriad of
psychosocial factors that changed in the facility once the building of the garden
and atrium began, some predictable, some not. For example, it was predicted that there
would be a period of resident unrest while the old garden was being torn down and the new
garden and atrium were being built. Instead the residents moved their chairs to the back
windows of the facility so they could avidly watch the building progress every day. The
increase in interaction between residents began even before the project was completed as they
talked about the changes. The expected increase in agitation because of construction noise
and disruption to daily activities did not occur.
Identifying the multitude of individual factors in the new environment that contributed to
the positive outcomes for residents and carers and controlling for possible confounders was
not deemed important for this study with a limited budget for the evaluation of AUD5000.
What was deemed important was that the new environment was constructed using the
available evidence on appropriate environmental design for people with dementia. We
know from the qualitative interviews that the residents and carers liked and used the
garden and atrium, and this led to greater interaction among residents and we know from
the empirical measures that residents quality of life improved after the garden environment
was introduced. These were the outcomes that the funding body and the facility management
and sta were hoping for.
It can be argued that the garden promoted more interaction between sta and residents
and also between visitors and residents and that this is the important factor and not the
garden itself. The argument that therapeutic gardens are the environmental change that best
promotes the increase in these interactions and thus are pivotal to residents quality of life
can be equally argued. Very few facilities would have the resources or the number of
508 Dementia 12(4)

residents required to do a large controlled trial to tease out the individual factors that
contribute to the positive outcome for their residents.
It is very rare for dementia facilities to systematically evaluate environmental changes
in terms of outcomes for their residents, sta and visitors. When evaluation studies
are undertaken, very few studies incorporate quantitative measurement into
the evaluation. To get statistically signicant results from such a small sample is
very exciting. What is more exciting are the words of the residents, the sta and their
families, that describe in a way that statistics fail to do, just how profoundly an
environmental change such as a therapeutic garden and atrium can improve the lives of
aged care residents with dementia.
Funding
This research received no specic grant from any funding agency in the public, commercial, or
not-for-prot sectors.

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Author Biographies
Dr Christine Anne Edwards (BA Psych Hons, PhD) was the Research and Evaluation
Coordinator for Health Promotion on the Central Coast of New South Wales for 19
years and six years ago began conducting program evaluations for non-governmental
organizations. Dr Edwards has published and presented in many areas of health and
social program evaluation at national and international levels. She has a special interest in
dementia and has completed several comprehensive evaluations in this area.

Colin McDonnell (MHlthSc, RN) currently Care Services Manager at Starrett Lodge, has
had extensive experience in working with people living with dementia and in leading sta to
adopt person-centred approaches in aged care. Colin has presented at many conferences and
has been instrumental in Starrett Lodge being recognized with national and international
awards for person-centred care in residential facilities.

Helga Merl (MHlthSc, BN) has pioneered many innovative dementia services in NSW,
including Dementia Advisory Services, Nurse-led Memory Clinics and Behavioural
Assessment and Intervention Services. Helga now works as a Clinical Nurse Consultant
and Clinical Manager for Hunter New England Local Health District and sits on state
and international committees and research consortiums with the aim of improving the
experiences of people with dementia, their families and carers and the services that
support them.