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2 Hanna Sampson Andrew WaterhouseDoes Ecotherapy improve the Quality of Life for people living with Dementia? A Pilot Study AW Good morning Birmingham! Good morning conference! My name is Andrew Waterhouse and this is Hanna Sampson. We are both occupational therapists working in a cognitive impairment and dementia service based in the London Borough of Hammersmith and Fulham working for West London Mental Health NHS Trust. Thank you, so much, for coming to our presentation regarding an ecotherapy study. In this presentation we will be sharing our experiences of the study… Hanna Sampson Andrew Waterhouse

3 Contents Background and current groups Exploring EcotherapyStudy design and group structure Results Discussion What next HS So this is a brief overview of the areas Andrew and I are going to be covering in our presentation this morning. I will give you a short explanation of the current “Dementia Challenge” set out by the government to improve services for people living with dementia. And also give you a flavour of the other groups that are currently being run by dementia services. Andrew will then be providing an explanation on what Ecotherapy is and how we set the ball rolling for the pilot study based on our ecotherapy group. We will both then give you a flavour of what the group actually entailed with some lovely pictures to illustrate it and hopefully break up the monotony of endless PowerPoint slides! And we’ll then go on to look at the results of the study And discuss what worked well, what didn’t quite work so well, and share some ideas on how we feel we could improve and what we plan to do next with what we have learned. We would then love to hear from you; if you have any thoughts or questions at the end please do share them.

4 Current group based interventions for people living with dementiaReminiscence therapy - The use of life histories CST - Cognitive Stimulation Therapy. HS Contextualising dementia and currently available groups The Dementia Challenge Dementia is a global health problem, with 850,000 people in the UK diagnosed with dementia, and an estimated 44.4 million people worldwide (Alzheimer’s Society, 2014). In the UK challenges have been set to improve the standards of dementia care, with the launch of David Cameron’s Dementia Challenge in 2012 (Alzheimer’s Society, 2012; Department of Health, 2012). With these challenges the advancement of quality of life for people with a diagnosis of dementia is widely accepted as an important outcome in dementia care (Department of Health, 2013). Such policies encourage practitioners to develop psychosocial interventions (Moniz-Cook & Manthorpe, 2008) that enable individuals with dementia to maintain a meaningful and hopeful life. Reminiscence therapy The use of life histories – written, oral, or both – to improve psychological well-being. •Can lead to positive mental health, enhanced self esteem and improved communication skills (Fujiwara et al. 2012) CST Group Cognitive Stimulation for people with mild to moderate dementia. Incorporates principals of person centeredness, social inclusion, orientation, reminiscence, multi sensory stimulation, maximising potential and building relationships. Compares favourably with drugs for dementia in reducing cognitive decline (Spector and Woods, 2003). Improvements in quality of life

5 Ecotherapy AW: Ecotherapy fits under the umbrella of Green care using Nature-based therapies as an intervention to enhance health and well-being through contact with nature. Some examples of green care include care-farming, animal-assisted therapy and social and therapeutic horticulture. Reviews suggest that green care may contribute to improvements in various dementia-related symptoms, including stress, agitation and depression whilst enhancing a sense of well-being and control Ecotherapy can include horticultural therapy, wilderness excursion work, Mindfulness and wildlife-assisted therapy. Examples of ecotherapy can be found in the work of Joseph Cornell in books such as “sharing nature.” Following ecotherapy experiential training we ran an ecotherapy group for people living with dementia which appeared to be a powerful and profoundly empowering medium. We discovered there is currently very little evidence demonstrating the effectiveness of ecotherapy for people with dementia which led us to develop this research study…

6 Clinical Research ProposalDoes ecotherapy improve the quality of life for dementia clients? 3 cohorts of 8 clients July 2015 – April Control Group in Hounslow, not offered intervention. In our research we investigated whether ecotherapy improves the quality of life for people living with dementia The intervention was an 8 week group based in Ravenscourt Park in Hammersmith, London. Each weekly session lasted 90 minutes. Each research participant needed to have a research partner normally either a friend, carer or relative who were invited to attend the first and the final session. We ran 3 cohorts with a maximum of 8 participants in each group. The ecotherapy group was primarily facilitated by occupational therapists. The cohorts took place in summer 2015, autumn 2015 and Spring The control group was people living with dementia in the London Borough of Hounslow who were not offered the intervention but took the assessment measurements at baseline and follow up.

7 Clinical Research ProposalOutcome measures: EQ-5D-3L (quality of life scale) NPI (Neuropsychiatric Inventory Scale) GDS Zarit Burden Interview Qualitative feedback on improvements to Behavioural and Psychological Symptoms of Dementia (BPSD) AW: The above measurements were administered one week before the first ecotherapy session and one week after the final ecotherapy session of each cohort. The participants completed the EQ-5D-3L quality of life questionnaire and a geriatric depression scale questionnaire. The research partners completed two measurements: The Neuropsychiatric Inventory Measures dementia related behaviour symptoms and also caregiver distress. The Zaret Burden Interview –measures subjective caregiver burden. A structured qualitative interview was also conducted with the research partners at the end of each cohort.

8 Mindful movement (e.g. tai chi)4 elements Geography game Herb experiences Meditations: Tree Mountain Web of life I can see Camera Poems Readings Introduction to mindfulness Gratitude practice I appreciate Interview with nature Getting to know another living thing Sharing nature experiences Mindfulness of: Sights Sounds Touch Taste smell AW: This “Hopeful Monster” of a slide ambitiously, perhaps overly so, attempts to capture the entire structure of the 8 week ecotherapy group. Direct multimodal sensory experience is awakened through using mindfulness practices of the senses … and then specific ecotherapy group activities adapted from the work of Joseph Cornell form the structure of each group. For example in session 1 time is spent getting to know one another, mindfully walking in Ravenscourt Park, spending time mindfully observing a London Plane Tree, followed by an appreciation practice in pairs and then finishing with a poem typically “Trees” by Joyce Kilmer. Being present and in touch with the senses, nature and one another is the distilled essence of the group. Mindful walking Mindfulness of breath Mindfulness of body Mindful eating Mindful movement (e.g. tai chi)

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10 HS I can see, I can hear,I can smell, I feel (Joseph Cornell –Sharing nature) Joan) note written by nursing student I CAN SEE Beautiful environment surrounded with flowers and trees. She kept talking about the round metal sculpture with a pierced through arrow in the centre of the garden with flowers surrounding it. She reported she used to go to exciting places including museums and green spaces when she was young. Such sculptures she saw only at the museums but it makes the garden more beautiful. Joan said that she couldn’t wait until it is summer again to witness how beautiful the growing flowers had become. I CAN HEAR Joan could hear birds chirping as she sat quietly on the bench telling me how wonderful it is. She said the trees somehow provide life for the birds so as plants and flowers to human. She said flowers help in healing when you are not feeling well that is why flowers are sent to loved ones when they are at the hospital and there is this feeling, which she cannot explain, but all she could say was flowers signify love and affection. I CAN SMELL Joan said the garden had a mixture of different smells of flowers that give out an amazing scent. She could still smell the scent of the marigold she touched at the entrance of the garden. I FEEL Joan said she felt peaceful in the garden. She wondered how old the trees are and how flowers were discovered. In her words, trees give life and will still be there even if everyone dies.

11 HS – camera exercise, gathering and still lifeLots of raspberries – mindful munching and inquiry

12 HS sensory herbs, tea

13 ECOTHERAPY GROUP Ravenscourt Park MARCH & APRIL 2016HS keepsake post card. This is a keepsake collage postcard which we compiled for each group member to take away with them at the end of each cohort. Each cohort postcard being unique to the activities and sights in the park.

14 Quantitative Results A total of 20 participants attended the whole of the 8 week ecotherapy group. The intervention group scored significantly higher on quality of life scale compared to the control group, although it is worth noting that the control group also appeared to improve on the same measurement to a lesser degree without receiving the intervention. The intervention group also had a greater reduction than the control group in both distress symptoms on the Neuropsychiatric inventory scale and the dementia related behaviour symptoms. None of the other quantitative measurements were found to be statistically significant. *Results in bold indicate statistical significance*

15 aspect of it, interactingQualitative Results “The present moments, if you can make them as good as possible that can only be a good thing” “He has also enjoyed the social aspect of it, interacting with other people” “Just Looking has had such a positive effect” “Removes anxiety of memory loss” AW From the qualitative interview here are some of the quotes from the research partners regarding their impression of the group. Some of the general themes emerging from analysing the qualitative interview data were ones of: “Increased motivation” “Being more alert” “Exhibiting more concentration and focus” The carers also highlighted that the ecotherapy group felt as though it was beneficial to both them and their friends or loved ones. The carers, almost unanimously, would recommend it to other carers. “It had a good effect on him” “I’m sure it does her good”

16 Discussion What worked well What we would do differentlyStatistically significant improvements in quality of life Frequency & assessment type Positive group experience Relationships to nature and each other Multisensory stimulation Joint exploration Inclusion criteria and group complexity Supportive “ecosystem” Larger sample size AW HS : There were many things that worked well during this study and many things that we would consider doing differently in the future. In spite of our relative research naivety the basic premise that ecotherapy may improve quality of life in people living with dementia appeared to be supported. How to measure, what measurements to choose and the frequency of administration are all things that we would consider modifying. More frequent assessment and more sensitive assessment, perhaps after every session, perhaps in a different way might help to further understand the effects and after effects of ecotherapy. The whole group felt like an extremely positive experience. The participants appeared to greatly enjoy and powerfully connect with the material. It offered them space to reflect about their own llife and relationship to nature in a nurtuting and supportive setting. The multi modal, wrap around multi sensory nature of the group (i.e. being outdoors and immersed in nature) and exploring this side by side as a “joint exploration” rather than as teachers and pupils felt particularly enriching. This study has a wide inclusion criteria potentially selecting anyone with a diagnosis of dementia. This allowed a breadth of experiences and abilities to be contained within the group. This perhaps made the grading and matching the complexity of the ecotherapy activities to the participants abilities challenging at times. The whole ecosystem of the Cognitive Impairment and Dementia Service, Hammersmith Community Gardens Association who kindly provided the venue and our trusts Clinical Trials Unit felt like a true synergy of joint working which helped this project come to fruition. And with this being a pilot study the sample size is a limiting factor on making any claims regarding generalisation.

17 What next? Writing up for journal submissionConsidering possible modifications for future studies. Larger sample size Inclusion criteria and group content Frequency and type of assessment measurement New group starting next week So what next? We are currently finalising an article based on this work to submit to the British Journal of Occupational Therapy. As we discussed some considerations for any future studies would be around: increasing the number of participants to increase the power of the study refining the inclusion and exclusion criteria and then matching this with the complexity of the group content Modifying the type of and the frequency of assessment. One way of summarising what we did would be to imagine explaining to an alien who had landed from mars what the key learning from this presentation was: If we did meet this martian then this is what we would day: “From our experience, Ecotherapy appears to be an acceptable and enriching multi modal intervention for people living with dementia which may also enhance the participants quality of life.”

18 The leaf is mother to the tree OT CIDs Team HCGA Students:Nursing and OT Research Unit Transport CIDs H&F People living with dementia It takes so many leaves for a tree to grow. We would like to thank all of the people who have been involved in this study from its initial germination through to the current status. Not including the research participants and research partners nearly 40 people have been involved in making this study happen. We would like to thank them all for their support and enthusiasm and also thank you, the audience, for spending some time with us while we have presented. And to quote Joyce Kilmer from the poem “Trees” Poems are made by fools like me But only God can make a tree Thank you to you all. Carers