Original citation: 

Simon Chester Evans, Julie Barrett, Neil Mapes, June Hennell, Teresa Atkinson, Jennifer Bray, Claire Garabedian and 

Chris Russell (2019) "Connections with nature for people living with dementia", Working with Older People, DOI: 

https://doi.org/10.1108/WWOP-01-2019-0003  

Permanent WRaP URL: 

https://eprints.worc.ac.uk/7858/ 
 
 
 
Copyright and reuse: 

The Worcester Research and Publications (WRaP) makes this work available open access under the following 

conditions. Copyright © and all moral rights to the version of the paper presented here belong to the individual 

author(s) and/or other copyright owners. To the extent reasonable and practicable the material made available in 

WRaP has been checked for eligibility before being made available. 

Copies of full items can be used for personal research or study, educational, or not-for-profit purposes without prior 

permission or charge, provided that the authors, title and full bibliographic details are credited, a hyperlink and/or 

URL is given for the original metadata page and the content is not changed in any way. 

 

Publisher’s statement: 

Copyright © 2019, Emerald Publishing Limited 

 

A note on versions: 

The version presented here may differ from the published version or, version of record, if you wish to cite this item 

you are advised to consult the publisher’s version. Please see the ‘permanent WRaP URL’ above for details on 

accessing the published version and note that access may require a subscription. 

 

For more information, please contact wrapteam@worc.ac.uk 

https://doi.org/10.1108/WWOP-01-2019-0003
https://eprints.worc.ac.uk/7858/


W
orking w

ith O
lder People

1

Connections with nature for people living with dementia

Background

‘Green dementia care’ refers to indoor and outdoor experiences and activities that aim to 
promote health and wellbeing through interaction with nature for people living with 
dementia. This can be passive (e.g. sitting in the garden) or active (e.g. outdoor exercise 
such as walking). There is growing evidence to suggest that the natural environment 
improves physical and mental health in general (Bowler et al. 2010; Alcock et al. 2014; Cox 
et al. 2017) and for older people in particular (Robson and Troutman-Jordan 2015; Wright 
and Wadsworth 2014; Bragg and Atkins, 2016). Reported benefits include reduced heart 
rate and blood pressure, reduced cardiovascular and respiratory disease, reductions in 
stress and depression, improved confidence and mood and increased social interaction 
(McNair, 2012; De Rui et al., 2014; Robson and Troutman-Jordan, 2015).

Increasing numbers of people with dementia are supported in care homes, while extra care 
housing is now widely viewed as an alternative form of accommodation that can provide 
opportunities for maximising independence (Evans, 2009). It has been estimated that 70% 
of care home residents are living with dementia (Alzheimer Society, 2016). The prevalence 
of dementia among extra care residents is less clear with estimates varying between 24% 
(Darton et al., 2012) and 37% 1 . 

While people with dementia are likely to share many of the benefits of connecting with 
nature, there is evidence of further benefits that are specific to the symptoms and 
circumstances of their condition. These include reduced agitation, improved sleep, 
reduction in incidence of falls and use of psychotropic drugs, improved communication and 
higher levels of social interaction (Whear et al., 2014; Blake and Mitchell, 2016; Mapes et 
al., 2016; De Boer et al., 2017). Green care for older people in care homes and extra care 
housing can take place outdoors within the care setting’s outdoor space (e.g. gardening, 
horticultural activities or outdoor exercise), outdoors further afield (e.g. visits to 
arboretums, botanical gardens or farms and walking  trips) or indoors (e.g. looking after 
indoor plants, arts and crafts using flowers, interacting with pets). Many care homes and 
extra care schemes have gardens or outdoor green spaces, but evidence suggests that many 
are underused by the residents, particularly those living with dementia (Rendell and Carroll, 
2015; Clarke et al., 2013). This is often due to organisational risk aversion and individual 
staff concerns about safety and security as well as outdoor spaces that are not fully 
accessible (Whear et al., 2014; Mapes et al., 2016) . For people with dementia the loss of 
spontaneous and scheduled connections to nature in their lives is often sudden and occurs 
when they move from their own home or hospital. Ensuring access to the outdoors for 

1 www.housingandcare21.co.uk/about-us/our-work-dementia/dementia-action-plan/

Page 1 of 14 Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

2

people living with dementia is not only a matter of good practice in dementia care but also a 
matter of human rights and social justice (Argyle et al. 2016). 

This paper reports on a project that aimed to explore the opportunities, benefits, barriers 
and enablers to interaction with nature for people living with dementia in residential care 
and extra care housing schemes in the UK.

Methods

Following a review of the literature, an online survey was developed to investigate the 
current provision of green dementia care for people living with dementia in accommodation 
and care settings. It covered four main areas: demographic information about the scheme; 
current green dementia care experiences and activities; barriers and enablers to providing 
green dementia care; and the perceived impacts of green dementia care. Quantitative 
responses were analysed using descriptive and comparative statistics, while the qualitative 
answers were subject to thematic analysis. In depth-case study research was carried out at 
three care homes and three extra care housing schemes. These were recruited from survey 
respondents as examples of good practice in promoting green dementia care while 
providing diversity in terms of service provider and geographical location. Managers at each 
site identified four residents with dementia and three members of staff who were willing to 
take part in research interviews. Topics covered included what nature-based activities were 
offered, who organised them, who took part, the perceived impacts, and any facilitators or 
barriers. Interviews were recorded and transcribed, and analysed for thematic content with 
the aid of specialist software.  Approval for the study was given by a university ethics 
committee. 

Findings

Survey Findings

144 survey responses were received, 50 percent from extra care housing schemes, 25 
percent from residential care homes 13 percent from nursing care homes, three percent 
from retirement villages, one percent from continuing care schemes (extra care or 
retirement scheme with residential care on the same site). The remaining eight percent 
were from unknown sources. The majority were from England (99%), with one respondent 
from Wales, and one from Scotland. 42% described their location as urban, 35% suburban, 
18% rural and 5% did not answer this question. Respondents ranged from small care homes 
with fewer than ten residents through to large extra care schemes with over a hundred 
residents. Across the homes and schemes that responded to the survey, an average of 40.6 
percent of residents were reported as having diagnosed or suspected dementia.

Page 2 of 14Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

3

Of the outdoor green dementia care activities reported, the most common were walking in 
the care setting garden which was offered by 80 percent of all respondents (all nursing care 
homes, 85% of residential care settings and 75% of extra care schemes). This was followed 
by simply being outdoors (76% of all respondents) and gardening (70% of all respondents). 

Animal visits were also popular with all care homes (89%). Residents were more likely to be 
allowed to keep personal pets in extra care housing (56%) than in nursing and residential 
care homes (37%), while nursing care homes were more likely to offer outdoor exercise 
(50%) than other care settings (33% for residential care homes and 6% for extra care 
housing). In terms of nature-based experiences and activities further afield, nursing care 
homes were most likely to offer regular outings (50%) and residential care homes were the 
most likely to offer walking more widely in the local area (almost 70%). Extra care schemes 
were least likely to offer indoor nature-based activities such as arts and crafts (46%), animal 
visits (31%), indoor gardening (32%) and watching nature programmes (26%), while nursing 
care homes were most likely, with animal visits, indoor gardening/plants and watching 
nature programmes being offered by over 90 percent.

Seventy six percent of respondents said that nature-based activities were offered on up to 
two days a week. Spontaneous engagement with nature outside of organised activities was 
felt to be possible by the vast majority of respondents (almost 80%). Nursing care homes 
were particularly positive about spontaneous engagement, with only 6% responding ‘no’ 
compared to 17% for residential care and 19% for extra care. Activity Coordinators were 
most likely to run organised nature-based activities for residents with dementia, although 
other staff were also able to lead activities. In extra care settings, residents were more likely 
to be involved in running activities themselves than in nursing care homes or residential 
care. 

Respondents reported a wide range of positive impacts for residents with dementia who 
took part in nature-based activities. These included being more relaxed, improved mood, 
higher levels of social interaction, improved sleep, greater appetite, fewer falls, and 
decreased medication. There were also a small number of examples of negative impacts. For 
example, one resident experienced higher levels of anxiety due to a fear that chicks would 
fall out of a bird nest they were watching. It was also reported that being outdoors could 
trigger frustration at no longer being able to do as much as before on a physical level. 

Positive impacts were also claimed for staff as a result of taking part in nature-based 
activities including increases in job satisfaction (over 70% of respondents indicating a 
positive effect), morale (over 70%) and confidence (almost 60%), as well as reduced sickness 
(over 20%) and better staff retention (over 30%).  

A variety of factors were identified as key to providing opportunities including the 
availability of staff and volunteers, financial resources, transport, attitudes to safety and 
risk, staff expertise, management support, and the accessibility of outdoor spaces. 

Page 3 of 14 Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

4

Case study findings

Interviews were carried out at the six research sites with 19 residents (7 extra care 
housing/12 care home) five managers (3 extra care/2 care home) and 11 other members of 
staff (4 extra care housing/7 care home) whose roles included Care Assistant and Activity 
Coordinator.

Opportunities for nature-based activities 

Residents and staff who were interviewed described a wide range of opportunities for 
connecting with nature. Some activities were planned, such as gardening clubs, while others 
were more spontaneous.

Some residents mostly took part in passive, indoor activities such as watching birds through 
a window: 

Yes. I can lie back on this [indicated his bed] and look up at this one [bird feeding tray 
attached to outside of window]. Of course, you get the odd ones that keep coming in 
and they are quite exciting. (Care home resident)

Passive engagement with the natural environment in the outdoor spaces of the care settings 
consisted primarily of observing and listening to nature while sitting in the garden:

I go and sit outside sometimes. Because I know the times that they [the birds] are 
coming and I then walk down that passage there onto the lawn – have you seen it? 
(Care home resident)

Animals played an important part in indoor engagement with nature, both in terms of 
residents having their own pets and animals being brought indoors to visit residents. One 
care home had its’ own farm where residents were able to pet, handle and feed the 
animals, as well as growing vegetables for them to eat. 

Those who can, can come outside and help me put the animals to bed – okay, it’s 
only the guinea pigs and the rabbits, and if they help me chop up the food, they can 
walk into that enclosure, put the food in the hutch, and say, bedtime, and the guinea 
pigs will all run in and we shut the doors to keep the fox out. (Care home Activity 
Coordinator)

This resource also provided opportunities to bring nature indoors for residents who were 
unable to go outside:

People who are bedbound, having the animals come into their bedroom with a bit of 
food that we’ve grown and just having the animal on their bed to feel the warmth, 

Page 4 of 14Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

5

the guinea pigs are so light they don’t hurt, so that is a nice thing. (Care home 
Activity Coordinator)

Many of the case study sites arranged special outdoor events in the summer such as tea 
parties, maypole dancing and open days when the residents can engage with the wider 
community.

We've had outdoor fayres, so we've had big open days where the residents get 
involved. They have ice cream and we've had a pig roast outside, so they’ve all 
enjoyed the sunshine out there and the activities there with the community.  (Extra 
care housing Manager)

All of the case study sites organised regular trips which often involved the natural 
environment such as visits to garden centres, woodland walks and boat trips. Most of the 
managers and staff interviewed felt that they offered enough opportunities for residents to 
connect with nature. 

I think we do. I mean, we've got lovely grounds and we’re always encouraging daily… 
I mean, if it's pouring with rain then it's a little bit more difficult but the activities 
team have an active programme of things that can be done, ideally outside. Things 
like painting, nature, potting plants, things like that. And they have lots of trips out. 
(Care home Homemaker)

However, some felt that there was always more that could be done to enable contact with 
nature. 

Realistically if we had another 20 activities I could get everybody out every day, but 
with budgets and stuff like that, we’re lucky to have four of us, so I think we do a lot 
more than most homes are able to do. (Care home Activity Coordinator)

Practical arrangement for enabling residents to connect with nature varied considerably 
across the case study sites. At one of the Extra Care Housing schemes they were organised 
by care staff, the residents themselves or external organisations, while at the other two they 
were run by an activity coordinator with the support of volunteers.

One care home had an ‘Independence and Wellbeing Team’ who organised activities while 
the manager at a second home took on this role and the third had a 4-person activity team:

What we do in everyday life is important to our residents. Just because they’re in a 
nursing home doesn’t mean that life stops, so making sure that there’s a reality of 
their life. The animals have a massive impact because it’s giving them a purpose 
every single day. It’s giving them something to look after.  It’s giving them 
responsibility again. (Care home Lead Activity Coordinator) 

Motivation for involvement in nature-based activities

Page 5 of 14 Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

6

Residents described various reasons for taking part in nature-based activities. For some it 
was something they had always enjoyed and appeared to be a core part of their self-
image/identity:

I think anything to do with nature, to me, is a fascination. OK. I love people and all 
the rest of it, but when you look at just little things … there was a good 5 blossoms 
out together and it was lovely, you could just open the window a bit more and … 
click! (Care home resident)

A number of personal reasons were given for discontinuing favourite nature-based 
pastimes, with the most common being reduced mobility and physical ability. 

I’ve got bad knees and I can’t walk without the [points to walker]. My knee tends to 
give way sometimes, you know. (Care home resident)

When you have arthritis and you ache everywhere, it is not easy. (Extra care housing 
resident)

The impacts of nature-based activities
Residents reported a wide range of benefits that they experienced as a result of taking part 
in nature-based activities including improved mood, remembering positive experiences and 
bringing a sense of freedom:

You feel a bit more freedom than when I’m in here. (Care home resident)

Staff also mentioned many ways in which they felt nature-based activities had a positive 
effect on the wellbeing of residents with dementia. Several spoke of how some residents 
demonstrated high levels of engagement when taking part in activities of this sort: 

Behaviour-wise, I mean, like that gentleman there, really engrossed, really enjoying 
what he's doing. The first week, he planted a plant, he pulled it up, he planted a 
plant, pulled it up. He did that for half an hour, the same thing over and over. His 
interaction today has been so much more expansive, he's been showing a variety of 
skills, far more than I would ever expect, really. (Care home Homemaker)

Others suggested that they promoted a sense of freedom and creativity:

We ended up sitting with the ducks for about an hour.  And there was just nothing 
going on really.  I went and got myself a chair, sat next to her, and we were just 
watching them.  And she was just talking about them and making up stories, which 
was really funny.  Like she was just telling me that they were…the ducks were going 
shopping, oh look, now he’s going off into the Asda.  I was like, where’s this coming 
from? (Care home Lead Activity Coordinator) 

Page 6 of 14Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

7

For one manager there was a link between taking part in nature-based activities and 
increased social interaction: 

Well, I feel it's stimulation, relationship-building. It stops them from being isolated, I 
feel that it allows them to build confidence. I feel it stops, like I say, the isolation and 
the withdrawal. (Extra care housing Estate Manager)

There was also a positive effect on inter-generational contact when families visited:

Yeah, it means that the children are more happy to come and visit grandma or great-
grandpa or whatever because there’s something for the children to do here, and the 
grandparents or great-grandparents enjoy taking the children out to their new 
garden and showing them the animals. (Care home Activity Coordinator)

One activity coordinator mentioned the calming effect of contact with animals for some 
care home residents:

A lot of our residents that can get agitated or upset or they’re feeling anxious, we 
find that the pet therapies and the pet farm have sort of brought that out of them a 
little bit. (Care home Lead Activity Coordinator)

Integrating nature with daily activities also appeared to have a positive impact on staff 
morale, feelings of empowerment and job satisfaction. Staff at some of the case study sites 
enjoyed getting involved in activities with the residents so much that they, and their 
families, would volunteer to help with activities in their spare time:

It’s a pleasure for me to be honest. I love being outside as well, so it ticks all the list 
for me so. I don’t mind going and mucking out and getting dirty. (Care home Activity 
Coordinator) 

Staff who got particularly involved in outdoor nature-based activities considered it to be 
enjoyable and a break from work, while one respondent felt that it helped care staff to get 
to know the residents better: 

The staff actually get to see a different side to a person, because when you’re 
delivering personal care, you don’t necessarily get to the bottom of that person, do 
you, you know what I mean? (Extra Care Housing Activities Coordinator)

Enablers and Challenges to connecting with nature

A wide range of factors were identified as having an impact on the provision of 
opportunities for nature-based activities. Key among these was access to and the 
accessibility of outdoor spaces. This appeared to be good at most of the case study sites, as 
indicated by the following example: 

Page 7 of 14 Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

8

In the residents lounge we tend to leave patio doors open so that it’s more of a flow 
onto the patio and the raised area. And the path that goes all the way around the 
building is like a little walk, so you can do a circular walk, you don’t have to walk to 
somewhere and come back. And there are benches along the way. (Extra care 
housing Estate Manager)

However, the physical layout of buildings could be an obstacle to spontaneous, independent 
access:

So if you're upstairs you would have to ask, if you're downstairs you can just do it if 
you're mobile. So I would think we need to think really carefully about people that 
aren't mobile that people might not be able to ask.  (Care home Homemaker)

One care home felt able to offer independent access to the garden by providing a remote 
alarm to a resident with dementia:

[Resident] has dementia but he still has the capacity to make a decision.  And he’s in 
an electric chair so he’s alright, he’s safe out there. And he always comes and gets a 
buzzer before he goes out. So he likes to sit out there. (Care home Lead Activity 
Coordinator)

However, access was not so straightforward for residents who used wheelchairs:  

Yes, because I am in a wheelchair. So I need someone to take me out. Because we’ve 
got to go downstairs. And then I need somebody to bring me back. (Care home 
resident)

In some care homes the majority of residents who went outdoors were carefully monitored:

Apart from two residents, everybody has to be accompanied. The residents that do 
go out, if we spot them, we just go out and put mobile alarms around them so 
they’ve got that if they need us. If they have capacity and if they’re safe outside, then 
obviously they’re allowed just to go out. If they have risk of falls then we do have to 
accompany them. (Care home Lead Activity Coordinator)

Similarly, at some sites residents who were considered to be ‘at risk’ could only go outdoors 
if accompanied by a member of staff. This could entail a relatively long wait if staff were 
busy:

Some, like [name of resident], will ask a lot. When it’s the weather, as long as it’s not 
too hot, [resident] likes going around the garden, so we do take him out round there. 
As long as it’s… the morning shifts are the more busy; so sometimes if he says, like, 
can I go for a walk around the garden, sometimes we might have to say yeah but 
we’ll have to do it this afternoon. (Extra care housing Support Worker)

Some staff and managers suggested that extreme weather often prevented residents from 
using outdoor spaces:

Page 8 of 14Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

9

Supporting people, they don't go out, they're fair-weather people and we've not had 
the best weather. And when it is too hot it's too hot. (Extra care housing General 
Manager)

In this context, the availability of indoor spaces suitable for nature-based activities was 
important. At an extra care housing scheme, if the weather was inclement the gardening 
club took place in a ‘community bungalow’ on site. One care home included a conservatory 
that could be used and was seen as preferable to other indoor areas, particularly for messy 
activities.

Pressures on staff time were identified by several interviewees as a barrier to supporting 
connections with nature, with one manager stating that the priority was to ensure that 
residents were safe and well cared for and that if they were short on staff the green 
dementia care was ‘put on the back burner’. Similarly, one extra care housing manager had 
no dedicated activity staff and a lack of time and funding for care staff to support nature-
based activities. Both managers saw the use of volunteers as a possible solution to this 
issue. For some interviewees financial resources were a barrier to providing outdoor 
facilities such as sensory gardens and vegetable growing areas. 

Finally, it was suggested that the symptoms of dementia could prevent residents from 
taking up opportunities to go outdoors, particularly in terms of disorientation, reduced 
mobility and lower confidence: 

One of our ladies this morning, that I tried to see if she’d like to come out, she said, I 
used to love the garden. I said, well I know, that’s why I’ve asked you, and said, I 
can’t do it now. I said, you can, I can bring you out in your wheelchair, you know, we 
can go potting together, but no. She didn’t want to, you could tell. (Care Home 
Activities Manager)

Discussion 
Our findings suggest that a wide range of outdoor nature-based activities are available to 
residents with dementia. These can be broadly divided into two categories: organised 
activities like gardening clubs and tea parties, and spontaneous activities like walking in the 
garden. We also identified two broad types of nature-based activity: passive such as sitting 
in the garden and active such as gardening. A pet farm on the site of one care home was a 
particularly good example of offering a variety of opportunities for connecting with nature 
to residents in a range of situations with varying preferences. 

Some differences were found between the two care settings. For example, extra care 
housing schemes were less likely than care homes to offer structured nature-base activities 
or those that took place indoors, but they were more likely to allow residents to keep pets. 
Similarly, Extra Care Housing residents were more likely to organise nature-based activities 
themselves, while in the care homes it was often activity coordinators or other staff who 

Page 9 of 14 Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

10

took on this role. Some care home residents, particularly those who lived on the upper 
floors, those who used wheelchairs and those who were perceived to be at risk, had to ask a 
member of staff to take them out, which was not always immediately possible.

These differences are likely to reflect the distinct nature of the settings, with Extra Care 
Housing tending to focus more on supporting independence for a population with generally 
lower care and support needs than those living in care homes. 

Participants identified many positive impacts for residents which they were believed to be 
linked with nature-based activities including improved mood and communication, greater 
engagement, increased social interaction, better sleep, decreased medication and fewer 
falls. Contact with animals was reported to be particularly effective in improving mood and 
reducing agitation. A small number of negative impacts for residents were also identified 
such as higher levels of anxiety and frustration. Several positive effects for staff were also 
noted including improved morale, greater job satisfaction and reduced sickness.

Residents living with dementia who took part in research interviews had a wide range of 
experiences with the natural environment in both their childhood and adult life prior to 
entering long-term care. For some, connecting with nature appeared to be an important 
part of their self-identity while others spoke of being relaxed and feeling more freedom 
when outdoors as compared to indoors. This supplements previous research which has 
suggested that the natural environment can help people with dementia to be brought “out 
of themselves” or to “forget about their symptoms” (Whear et al, 2014; Mapes et al, 2016). 
Our findings also identify a phenomenon that might be called ‘unleashing the unexpected‘, 
whereby people with dementia discover totally unexpected joys and previously 
unrecognised skills when trying something new outdoors.  

Reasons for not taking part in nature-based activities tended to be personal rather than due 
to the care setting, such as individual preferences and physical abilities. A range of factors 
were seen to influence the opportunity for residents to connect with nature including the 
design and accessibility of outdoor spaces (e.g. circular walks, benches, but not suitable for 
wheelchair users), the ease with which residents could leave the building (upper floor 
accommodation makes spontaneous activity difficult), the weather, the availability of staff 
(for organised activities or when residents were felt to need accompanying or monitoring), 
provision of suitable indoor spaces, and symptoms of dementia (such as disorientation) as 
well as personal issues related to risk taking and low confidence). 

Our findings contrast with previous reports that many people living with dementia in 
accommodation and care settings have limited opportunities to connect with the natural 
world (e.g. Clarke et al., 2013).  It is also important to reflect here on the difference between 
there being ‘opportunities’ for activity and a wide range of activities being ‘offered’, and the 
range of individuals in a setting that are regularly engaging in these opportunities and 
activities. However, this difference may be at least partly due to the self-selecting nature of 
the survey participants and the fact that the case studies were chosen as examples of good 

Page 10 of 14Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

11

practice. Previously reported organisational concerns about safety and security were not 
replicated, but the issue of how accessible outdoor spaces are is confirmed. As found by 
Olsson et al. (2013), some residents greatly missed contact with nature and could become 
frustrated at the limitations of their current situation in this respect.  

Careful planning was also advised, which concurs with the finding of Hendriks and 
colleagues (2016) that good preparation is a crucial factor for successful implementation of 
nature-based activities, but so was a willingness to be flexible from one day to the next. 
Some extra care housing settings struggled to provide residents living with dementia 
additional support to connect with nature. This appeared to be because their focus on 
independence limited the number of organised activities that were available.

 

Conclusion and Recommendations

This paper has added to the limited existing evidence base for the health and wellbeing 
outcomes of engaging with the natural environment for people living with dementia, 
specifically in care homes and extra care housing. It supports previous findings for the 
reported benefits of nature-based activities for people with dementia in terms of physical 
and mental wellbeing (e.g. Whear et al. 2014). We did not find the same level of restrictions 
in accessing the natural world that was reported by Clarke et al. (2013) and others, but this 
is perhaps not surprising given that the case study sites were selected as examples of good 
practice. We also recognise the wide variety of settings and accommodations in which care 
is provided for people with dementia.  The design of these settings, as well as the 
opportunities for both passive and active connections with nature, is likely to vary 
significantly from place to place.

Our findings suggest that a wide range of nature-based activities can be provided in these 
settings, and that they are associated with a range of emotional, behavioural, physical and 
social benefits for residents with dementia, as well as job satisfaction for staff. The design 
and layout of indoor and outdoor spaces appear to play a key role, in addition to 
empowered staff in enabling or deterring connections with nature. Further research could 
usefully explore the impact of different types of green care on aspects of physical and 
cognitive function, as well as identifying any longer term physical, social or emotional 
effects. 

The findings from this project have informed the development of a set of recommendations 
for good practice in green dementia care in extra care housing and care homes. These are 
summarised in Figure 1. 

Figure 1 here

Page 11 of 14 Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

12

References

Alcock, I., White, M. P., Wheeler, B. W., Fleming, L. E., and Depledge, M. H. (2014). Longitudinal 
Effects on Mental Health of Moving to Greener and Less Green Urban Areas. Environmental Science 
and Technology, 48(2), 1247–1255.

Alzheimer’s Society (2016). Fix Dementia Care: NHS and care homes. Alzheimer’s Society.

Argyle, E., Dening, T. and Bartlett, P. (2016). Space, the final frontier: outdoor access for people living 
with dementia. Aging and Mental Health, Online Journal, 1360–7863.

Blake, M., and Mitchell, G. (2016). Horticultural therapy in dementia care: a literature review. 
Nursing Standard, 30(21), 41–7. 

Bowler, D. E., Buyung-Ali, L. M., Knight, T. M., and Pullin, A. S. (2010). A systematic review of 
evidence for the added benefits to health of exposure to natural environments. BMC Public Health, 
Open Access, 10(456).

Bragg, R., and Atkins, G. (2016). A review of nature-based interventions for mental health care. 
Natural England Commissioned Report NECR204.

Clark, P., Mapes, N., Burt, J., and Preston, S. (2013). Greening Dementia - a literature review of the 
benefits and barriers facing individuals living with dementia in accessing the natural environment 
and local greenspace. Natural England Commissioned Report NECR137

Cox, D. T. C., Shanahan, D. F., Hudson, H. L., Fuller, R. A., Anderson, K., Hancock, S., and Gaston, K. J. 
(2017). Doses of nearby nature simultaneously associated with multiple health benefits. 
International Journal of Environmental Research and Public Health, 14(2).

De Boer, B., Hamers, J. P. H., Zwakhalen, S. M. G., Tan, F. E., Beerens, H. C., and Verbeek, H. (2017). 
Green Care Farms as Innovative Nursing Homes, Promoting Activities and Social Interaction for 
People With Dementia. Journal of the American Medical Directors Association, 18, 40–46.

Darton, R., Bäumker, T., Callaghan, L., Holder, J., Netten, A. and Towers, A. (2012). The 
characteristics of residents in extra care housing and care homes in England. Health and Social Care 
in the Community, 20(1), 87-96

De Rui M, Toffanello ED, Veronese N, Zambon S, Bolzetta F, et al. (2014) Vitamin D Deficiency and 
Leisure Time Activities in the Elderly: Are All Pastimes the Same? PLoS ONE, 9(4).

Evans, S. (2009). Housing with Care for Older People. In: Improving Later Life: Services for Older 
People – what works. Age UK, London. 

Mapes, N., Milton, S., Nicholls, V., Williamson, T. (2016). Is it nice outside? – Consulting people living 
with dementia and their carers about engaging with the natural environment. Natural England 
Commissioned Report NECR211.

McNair, D. (2012). Sunlight and Daylight. In: Gilliard, J. and Marshall, J. (Eds.), Transforming the 
Quality of Life for People with Dementia through Contact with the Natural World. Fresh Air on My 
Face. Jessica Kingsley Publishers, London.

Rendell, M., and Carroll, D. (2015). Why don’t we go into the garden? Australian Journal of Dementia 
Care, 4(3), 32–35.

Page 12 of 14Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith O
lder People

13

Robson, J. P., and Troutman-Jordan, M. L. (2015). Back to Basics: Health and Wellness Benefits of 
Gardening in Older Adults. Activities, Adaptation and Aging, 39, 291–306. 

Whear, R., Thompson Coon, J., Bethel, A., Abbott, R., Stein, K., and Garside, R. (2014). What Is the 
Impact of Using Outdoor Spaces Such as Gardens on the Physical and Mental Well-Being of Those 
With Dementia? A Systematic Review of Quantitative and Qualitative Evidence. Journal of the 
American Medical Directors Association, 15, 697–705. 

Wright, S. D., and Wadsworth, A. M. (2014). Gray and Green Revisited: A Multidisciplinary 
Perspective of Gardens, Gardening, and the Aging Process. Journal of Aging Research. Open Access 
Article.

Page 13 of 14 Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60



W
orking w

ith Older People

 

Determinants of sucessful green dementia care 

137x151mm (96 x 96 DPI) 

Page 14 of 14Working with Older People

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60