It is important that people are able to access gardens and outdoor areas adjacent to their homes. Going outdoors has been shown to have multiple benefits including; providing physical exercise; helping to maintain normal sleeping patterns and daily rhythms; improving mood and helping people to cope with stress. A well-designed outdoor space can be enjoyed by people with sight loss and dementia, as well as their families.
What do the ticks mean?
helps or is of benefit to most people
helps or is of benefit to some people
helps or is of benefit in specific circumstances
means that this aspect of design needs to be considered carefully before being adopted
Accessibility of outdoor spaces and path design
There should be easy access to garden spaces. Light, easily opened doors and minimal door thresholds make it easier for people to get outside.
Having well-defined paths helps people to find their way around outdoor spaces. The research evidence suggests that free-flowing looped designs are preferred.
Well maintained paths within the garden help to minimise trip hazards.
People find garden tools which have been appropriately adapted easier to use. Example adaptations include, e.g. incorporating longer handles, using colour to draw attention to the tool or parts of the tool, having tactile guides.
People find handrails for garden paths helpful. Areas for seating are also useful.
It is important for outdoor areas to have appropriate lighting as this helps people to find their way around and encourages use of outdoor spaces. Different types of lighting may be used for different purposes, e.g. lighting under handrails could be used to highlight paths, and security lights could be used to provide widespread light after dark in an outdoor space.
Using contrast on external stairs and steps helps to highlight the change from a flat surface to steps, and using edging materials for paths which contrast with the surrounding area makes paths easier for people to identify and follow.
Contrast can help to highlight both key features and hazards in outdoor spaces. It is important that different contrasts are used so that people can clearly identify which is being highlighted in any given instance.
Gardens and outdoor spaces which have fences or other physical boundaries help people to avoid accidentally leaving safe areas and being exposed to risks.
Plants that make interesting sounds, e.g. bamboos and grasses that rustle, or seed pods that pop, and/or those that have pleasant or interesting smells and textures provide people with additional sensory stimulation.
People like to touch and feel things growing in their gardens so planting schemes which include poisonous plants and those likely to cause skin irritation should be avoided.
Planting schemes should be based on people’s personal preferences, and draw on their memories and experiences.
Large sections of small plants of the same colour may be easier for people to see than large plants of a single colour.
Warm colours (such as oranges, reds and yellows) may be easier for people to pick out than cooler colours (such as blues).
Points for reflection and further consideration
These guidelines make recommendations about gardens and outdoor areas adjacent to people’s homes, but they may contain useful things to bear in mind when planning visits to outdoor spaces further afield.
In the past it has been suggested that there may be different ‘best’ layouts for paths for people with sight loss and for people with dementia. People responding to the survey carried out as part of this study suggested that having well-maintained and well-defined paths was more important than what layout was used.
We conducted a structured literature review which involved systematic searches of a wide range of electronic databases, complemented by consultation with expert informants who were asked to recommend materials (such as reports) that the searches might not have identified. The searches yielded 14,616 ‘hits’. 14,043 were discarded as either duplicates or not relevant, and the remaining 573 were scored for relevance on the basis of title and abstract. In total 33 publications were included for full text review: 28 based on relevance scores, and 5 items recommended by expert informants.
These were systematically evaluated using a proforma which enabled assessment of the quality of the research reported, and assembled key information regarding the subject matter, results and conclusions of each item. The quality criteria used to assess different types of research were drawn from standard protocols including Centre for Research and Development (CRD) Report No 4, Cochrane Effective Practice and Organisation of Care (EPOC) checklists and, as appropriate, Critical Appraisal Skills Programme (CASP) assessment criteria (NHS CRD 2001; Cochrane EPOC 2002; CASP undated). Each publication was rated as being of High, Medium or Low quality, based the extent to which the research as reported in the publication meets the relevant quality criteria, and an overall rating was provided for each of the sections within the guidelines. Publications rated as being of lower quality are still of evidential value, but should be regarded as providing suggestive rather than definitively evidenced findings.
We assessed the overall quality of published evidence for guidelines in this section as Low. We based the guidelines on evidence contained in the following publications:
- Bossen, A. (2010) ‘The importance of getting back to nature for people with dementia’, Journal of Gerontological Nursing, 36(2), 17-22.
- Goodman, C. and Watson, L. (2010) ‘Design guidance for people with dementia and for people with sight loss’, Thomas Pocklington Trust Research Findings Number 35 [document on the internet]. December 2010 [cited 2013 Nov 29]. Available here (and full report available on request from Thomas Pocklington Trust).
- Kwack, H., Relf, P.D. and Rudolph, J. (2004) ‘Adapting garden activities for overcoming difficulties of individuals with dementia and physical limitations’, Activities, Adaptation & Aging, 29(1), 1-13.
- La Grow, S., Robertson, M.C., Campbell, A.J., Clarke, G.A. and Kerse, N.M. (2006) ‘Reducing hazard related falls in people 75 years and older with significant visual impairment: how did a successful program work?’, Injury Prevention, 12(5), 296-301.
- Rappe, E. and Topo, P. (2007) ‘Contact with Outdoor Greenery Can Support Competence Among People with Dementia’, Journal of Housing for the Elderly, 21(3-4), 229-248.
- Unwin, B.K., Andrews, C.M., Andrews, P.M., & Hanson, J.L. (2009) ‘Therapeutic home adaptations for older adults with disabilities’, American Family Physician, 80(9), 963.
Our expert interviewees said
- Examples of good care home design suggested by experts include homes with a courtyard garden with easy access from communal rooms
- Lights within handrails, which are sited downwards, can highlight a footpath at night without glare
- People with sight loss find it helpful to have clearly defined pathways
- Paths should be free flowing for people with dementia and they should be well-defined for people with sight loss
People with dementia and with sight loss and their carers
taking part in interviews and focus groups told us
- Some care home residents get pleasure from helping in the garden with planting and sweeping
- Gardens in care homes are places where residents can go and enjoy time with families, or where they can go and take a picnic
- Residents in care homes appreciate being able to access gardens straight from the sitting room
- Inclines in gardens can be difficult and frightening when using wheeled Zimmer frames
- Residents in care homes appreciate seating in their gardens
- Flowers and features in yellow may be easier to see
- Colour, smells and textures are all important in planning a garden. Things like lilac, mint, lavender or pine might be good for people with sight loss and dementia
The survey found
- Out of 102 people who answered questions on this section, 78% thought that guidelines on lighting would be ‘very helpful’ and a further 22% thought they would be ‘helpful’
- When people were asked to either agree, disagree or say that they were unsure about a series of statements, the highest levels of agreement were in relation to: importance of including accessible outdoor spaces in residential settings (100% agreed); enjoyment that people can derive from outdoor spaces (100% agreed); health benefits of regular use of outdoor spaces (100% agreed); importance of maintaining pathways (100% agreed); need for well-defined paths (100%)
- The highest levels of disagreement or uncertainty were in relation to: greater visibility of large plants (4% disagreed, 32% not sure); usefulness of outdoor security lighting (9% disagreed, 24% not sure); greater visibility of flowers in warmer colours (yellows, oranges) (4% disagreed, 25% not sure)
Selected quotes from people completing the survey
- ‘Time spent in the garden and outdoors for dementia with sight loss sufferers should be promoted highly and regularly monitored to increase safety standards, health and well being and for all, at all times.’
- ‘Both care homes I've visited had grounds, but I've never seen a resident use them (I'm told they do, but never witnessed it). This is really sad. Obviously, there's a staffing issue because residents who are outside need monitoring for safety reasons. In both cases, the grounds were bland - grass and trees, with no scent borders or other sensory beds that might have made them attractive places to sit out in nice weather. I suspect it's just too much work to a) create the gardens and b) monitor residents using them. A proposed care home near my house (fortunately rejected on appeal to Sec of State) had absolutely no outdoor space provided. It faced a main road (south facing, so residents could boil to death in their rooms in the summer - a fact they'd clearly not considered!) and the rear was given over to parking. There was a suggested roof terrace, but this seemed - at best - ill-thought through as a concept.’
- ‘Needs to be a balance struck between the need for a safe environment and interfering overly with the natural surroundings or the design of the garden. Gardens should be comfortable and accessible and as natural as possible within that balance.’
- ‘Having access to a safe well maintained outside area is often a haven for everyone and in particular those with dementia. A well planned garden should incorporate different textures, smells, sounds, fresh air, a covered seating area, peace and quiet, somewhere to reflect, colourful planting, something to do, and somewhere you can go on your own and be by yourself, or a place to meet and chat with others.’
- ‘Gardens should be graded to accommodate all types of physical ability. Flat, unchallenging for those in wheelchairs or with poor mobility. Steps, slopes and more 'interesting' terrain for the physically active. Covered areas to facilitate use in inclement weather.’