Dementia or Memory Loss Disorder: a Way of Exploring the Use of Therapeutic Horticulture - Research Paper Example

Introduction Dementia or memory loss disorder is not only caused by old age but also the presence of wide-range of diseases such as: Alzheimer’s, vascular, Lewy body, Parkinson’s, Hutington’s, substance-induced disorder, frontotemporal disorder, head trauma, and/or HIV-AIDS. (Michigan Dementia Coalition, 2008, p. 10) In 2007, the number of people with dementia in UK has reached 683,596 people or 1.1% of the entire population and is expected to increase up to 940,110 by 2021 and 1,735,087 by 2051 (Knapp & Prince, 2007, p. 22 – 23). Considering the forecasted increase in the number of people with dementia in UK, there is a significant need for the health care professionals to find new ways that can improve the physical health and social well-being of these patients. To enable the readers to have a better understanding of the subject matter, medical terms will first be defined followed by discussing the history behind the horticulture therapy. As part of the research study, a literature review will be conducted as a way of exploring the use of therapeutic horticulture in the care for patients with dementia within the residential and community settings. In the process of going through the discussion, the use of therapeutic horticulture in the care practices including the methods used in monitoring its effectiveness will be tackled in details. Aside from identifying the social benefits of horticulture therapy and reminiscing therapy on patients with dementia, the significance of these two types of therapy over the four major senses such as the sight, touch, smell, and taste will be examined. Eventually, the health and social benefits of practicing horticultural therapy on the part of the carers and the patients’ family members will analyzed based on the gathered related literature review. Definition of Medical Terms Dementia – “a global impairment of cognitive function that usually is progressive and may be permanent; interferes with normal social and occupational activities” (Kozier et al., 2004, p. 1449); “a collection of symptoms, including a decline in memory, reasoning and communication skills, and a gradual loss of skills needed to carry out daily activities” (Knapp & Prince, 2007, p. 2). Horticulture Therapy – “the engagement of a client in horticultural activities facilitated by a trained therapist to achieve specific and documented treatment goals” (Americal Horticultural Therapy Association, 2009). Reminiscence Therapy – “an effective means of reducing depression among institutionalized, rural-dwelling elders, especially elderly women” (Jones & Beck-Little, 2002); “involves the discussion of past activities, events and experiences with another person or group of people; usually with the aid of tangible prompts such as photographs, household and other familiar items from the past such as music” (Woods et al., 2005). Therapeutic Horticulture – “a process that uses plants and plant-related activities through which participants strive to improve their well-being through active or passive involvement” (Americal Horticultural Therapy Association, 2009). Related Literature Review A Brief Historical Background behind Horticulture Therapy As early as 2000 BC, people in Mesopotamia started using horticulture as a way of soothing their senses (Jellicoe & Jellicoe, 1995). It was during the 500 BC when the Persians started creating gardens, the use of fragrances, and presence of water as a source of relaxation. Eventually, the use of garden became a widely accepted therapy since 1100s (Gerlach-Spriggs, Kaufman, & Warner, 1998). Because of the health benefits a patient can receive out of horticulture therapy, activities related to agriculture and gardening has been widely accepted in the public and private psychiatric hospitals (Rush, 1812, p. 226). Today, the application of therapeutic horticulture is also being considered as a treatment for patients not only with dementia but also those individuals with mental health problems (Shapiro & Kaplan, 1998, pp. 157 – 197), developmental disabilities (Catlin, 1998, pp. 131 - 156), educational settings (Morris & Zidenberg-Cherr, 2002), and in a diverse healthcare settings (Wichrowski, Chambers, & Ciccantelli, 1998). The Application of Therapeutic Horticulture in the Care Practices for Patients with Dementia and the Research Methods Used in Monitoring the Effectiveness of Therapeutic Horticulture Horticultural therapy is considered as another way of improving the health and wellness of patients with dementia. As proposed by Fried and Wichrowski (2008), the main goal of developing a horticultural therapy program is to improve the emotional, physical / sensory, social, cognitive, and spiritual aspect of each patient. Basically, each of these aspects has its individual goal. (See Table I – Summary of Goals of Developing Horticultural Therapy Program below) Table I – Summary of Goals of Developing Horticultural Therapy Program Health Aspects Objectives Emotional Well-being Reduce stress and mental fatigue Enhance mood Increase pride in accomplishment Instil hope Enhance reminiscence Decision-making Physical / Sensory Enhance visual / perceptual skills Enhance endurance Distraction from pain Increase eye-hand coordination and fine motor skills Stimulate all senses Social Increase engagement with others Enhance verbal and non-verbal skills Cognitive / Educational Increase vocabulary and language skills Enhance sensory discrimination Increase ability to focus and engage Increase memory Express creativity Follow directions Increase horticultural knowledge as it integrates into history, geography, folklore, and art Plant culture Discovery / Wonder / Spirituality Increase sense of community with nature Sense of fascination Stay in touch with seasonal changes Source: Fried & Wichrowski, 2008 In response to the continuously increasing number of people with dementia, health care professionals are seeking for alternative ways on how to increase the quality of life of these people by improving not only their physical and cognitive abilities but also their interaction with their family members and other people within the community. With regards to the challenges associated with memory loss problem, potential treatments and other alternative forms of care strategies are being closely examined. In general, therapeutic horticulture is related to the use of plants and planting activities as a way to promote the health and wellness of the patients. Since the beauty of landscapes has been widely accepted as ‘therapeutic landscape’ in terms of promoting health and well-being of an individual (Williams, 2004), gardening has been considered as one of the best approaches that will allow us to divert our thoughts from ourselves and the current situation or problems we are facing in life. Aside from encouraging the elderly individuals to become physically active, this group of patients could also enjoy the benefits of having fresh air (Parr, 2007, p. 542). Given that the presence of nature could significantly release the stress we experience due to external factors, Larson, Hancheck and Vollmar (2008) explained that among the common reasons why people visit a garden is to “relax, renew their energy, create a sense of place, and restore self-esteem”. Between the use of horticultural and non-horticultural therapy, Jarrott, Kwack and Relf (2002) suggested that the application of horticultural therapy is more appropriate than the use of non-horticultural therapy when caring for the cognitive, physical, and social needs of the older population with dementia. To examine the differences between horticultural therapy and non-horticultural therapy, the researchers conducted an observational assessment after subjecting the research participants to participate in a 10-week horticultural and non-horticultural program (Jarrott, Kwack & Relf (2002). Using an audiotaped interview research approach, Unruh (2004) compared the differences between gardeners with serious health problems and those that are physically healthy. Regardless of the physical health condition of the research participants, the researcher concluded that gardening has a positive impact on the physical, emotional, social, and spiritual well-being of the research particiapnts. Likewise, Kidd and Brascamp (2004) also acknowledged that gardening can serve a wide-range of human needs particularly those that are related to psychological, emotional, social, and spiritual. In fact, gardening enables the seriously ill participants to easily cope with their stressful life experiences. Similar to the research findings of Jarrott, Kwack and Relf (2002), Milligan et al. (2003) revealed that gardening activities are more effective in helping the elderly individuals improve their physical fitness, stamina, and sense of mental well-being as compared to attending social club alone (p. 47). To enable the researchers to come up with the research findings, Milligan et al. (2003) conducted a random sampling and qualitative research method to investigate the impact of gardening and attending social club on the health and wellness of elderly individuals. In the case of Stigsdotter and Grahn (2004), the researchers adopted the use of research survey questionnaires to determine the role of private gardens in terms of reducing stress. Based on the research findings, the researchers concluded that people who has the access to a garden are often experiencing lower sensitivity to stress, irritation, and fatigue as compared to those individuals that has no access to a garden. Laboratory tests can also be used in determining the impact of horticultural therapy over the physical health and wellness of the elderly patients. Specifically the research study of Aiming to examing the physiological and emotional impact of horticultural activities, Yamane et al. (2004) utilized the electro-encephalogram (EEG) and electromyogram (EMG) as a way of detecting whether or not plant-related activities can promote relaxation on patients whereas Profile of Moods States (POMS) and a Likert scale were used to know whether or not flowering plants is more effective in terms of reducing the participants’ negative emotions as compared to the use of non-flowering plants. After transplanting the flowering and non-flowering plants for 10 minutes, patients were asked to rest for another 10 minutes before the EEG and EMG were placed on the research participants’ forehead. Upon gathering and analyzing the data, the researchers concluded that plant-related activities can promote relaxation whereas working with flowering plants is more effective in terms of alleviating the participants’ negative emotions as compared to the transplanting of non-flowering plants (Yamane et al.). Similar to the research method used by Yamane et al. (2004), Son et al. (2004) also used a four-minute EEG test as a way of determining the possible effects of viewing green plants with the blood pressure of patients with schizophrenia. The research findings revealed that the systolic blood pressure and the heart rate of patients who participated in the research study was significantly reduced in terms of delta waves as measured by the EEG. It simply means that allowing the patients to view green plants can be considered as an effective way of promoting relaxation. Upon examining whether there are different psychophysiological responses to different landscape settings between Taiwanese and the Americans by measuring the EEG, EMG, and heart rate result, Chang (2004) concluded that participants from different culture were more relaxed when viewing the landscapes. However, the Americans are more into viewing mountains, water, and forests as compared to the Taiwanese who are more attracted towater and parks (Chang). With regards to cultural differences, Kim et al. (2004) evaluated the effects of horticultural therapy on the community consciousness and life satisfaction among the elderly individuals who are either living alone or living in a facility for elderly individuals. After conducting a total of 23 sessions on 8 elderly individuals who are living at the Buddhist social welfare association in Korea, the researchers revealed that horticultural therapy was found effective in terms of increaing the community consciousness and life satisfaction of elderly individuals. With regards to psychological health benefits, Midden and Barnicle (2004) investigated the effects of indoor horticultural activities of the elderly individuals in two long-term care facilities for a period of seven weeks. Between the group of elderly individuals who were given the opportunity to participate in one-hour horticultural activity per session, the researchers found out that elderly individuals who did not participate in horticultural activity show a gradual decline in their psychological well-being as compared to those who were able to actively participate in the activity. There are also some research studies that claims the limited benefits of therapeutic horticulture. After allowing patients with dementia to wander around the garden, Detweiler et al. (2008) conducted a research survey study with staff and the patients’ family members before concluding that the use of horticulture therapy particularly on allowing patients with dementia to wander in gardens have a positive effect on the physical aspect of the patients aside from improving their quality of life and mood. However, the patients’ verbal inappropriate behaviors did not change significantly. The Social Benefits of Horticulture Therapy and Reminiscing Therapy on Patients with Dementia Gardening can promote socialization. According to Larson, Hancheck and Vollmar (2008), gardening can bring the patients closer to other people by narrowing down the social barriers between the patients with dementia, the carers, and the horticultural therapists. By establishing an open communication among the people involved in the caring for elderly individuals, cooperation among them is possible. Although there are limited research studies were conducted to directly examine the social benefits of horticulture therapy on patients with dementia, several research studies on patients with other types of mental, psychological, and physical problems suggest that the application of horticultural therapy with the care program for patients with dementia can provide the patient with a wide-range of social benefits (Wichrowski et al., 2005; Szofram & Meyer, 2004; Taft, 2004). Since garden does not discriminate people with mental disabilities, the patients’ exposure to this type of mental and physical activity can reduce stress and enhance the patients’ self-esteem and mood as gardening brings plants and people together (Larson, Hancheck & Vollmar, 2008; Wichrowski et al., 2005; Szofram & Meyer, 2004; Taft, 2004). Considering the fact that the use of horticultural therapy is considered as one of the best approaches in dealing with the challenges associated with caring for patients with dementia, Gigliotti, Jarrott, & Yorgason (2004) conducted an exploratory research study to determine whether or not there is a significant differences with the use of the three types of horticultural therapy particularly on cooking, crafts, and planting. Upon conducting the research activities three times a week for a time frame of nine-week period, the researchers concluded that equally high levels of positive affect and engagement was observed among the three types of horticultural activities. Jarrott and Gigliotti (2004) also used a similar research approach to examine the impact of allowing patients with dementia to participate in planting, cooking, and craft activities. Based on the research findings, improvements on patients’ interaction, initiation, concentration, and activity completion were observed among the patients with dementia. The same research findings was noted by Kim et al. (2004) with regards to the elderly individual’s increase in participation, interest and assistance, self-concept and identity, need-drive adaptation, cognition, and problem-solving. Aside from developing a higher levels of positive affect and engagement, Kuo (2004) provided evidences showing that horticultural therapy can also minimize the risk of violent and property crime, incidence of aggression, greater ability to cope with poverty, better life functioning, greater life satisfaction, and stronger sense of belonging to the community. It can also enable the elderly individuals to feel that they are an essential part of a group. (Abbott, Cochran, & Clair, 1997) As a result of improving their self- esteem and self-worth, most of the patients who are active in horticulture therapy are capable of engaging themselves with other people. In line with the social benefits associated with the use of horticulture therapy, Yalom (1995) explained that the use of therapeutic horticulture can provide the patients with social benefits since this type of therapy can instil hope, enhance communication, and universality among the patients with dementia. Therefore, patients with dementia are expected to increase their engagement with other people using either verbal or non-verbal cues. Significance of Horticulture and Reminiscing Therapy over the Four Major Senses such as the sight, touch, smell, and taste Engaging people with dementia to actively participate in horticultural activity can be an effective way of increasing their community involvement. Aside from stimulating the patients’ sensory organs, engaging them with gardening activities or simply by getting close to nature could enable them to provoke memories as which is the main objective of reminiscence therapy. Reminiscence therapy is a nurse-initiated intervention which is commonly used in treating elderly individuals with depression. (Jones & Beck-Little, 2002) By allowing the patients with dementia to reminisce, the healthcare professionals could enable them to regain their personal interests with other people aside from increasing their awareness about themselves and their willingness to become active in life. For this reason, horticultural therapists are very much concern with the actual garden design. There are many ways wherein horticulture therapists can effectively stimulate the patients’ senses. For instance: The patients’ sense of sight can be stimulated by allowing them to have the opportunity of wandering around a garden with bright and colorful flowers aside from the therapeutic landscape with the presence of tall trees, shrubs, and stones that has attractive color, shape and sizes. When it comes to stimulating the patients’ sense of smell, therapists can make use of aromatherapy garden which is composed of flowers that has fragrance such as lily and chrysanthemum. (Kim et al., 2004) Other flowers that has inviting fragrant flowers that can be included in the aromatherpay garden are the following: (1) jasmine; (2) springblossom; (3) japanese rose; (4) iris; (5) sweet grass; (6) Newfoundland orchids; and (7) Russian olive among others. (Cresent Bloom, 2009) The sense of touch can be developed by engaging the patients to actively participate in activities related to gardening and growing of plants. Upon engaging a patient to participate in planting, healthcare professionals are giving them the opportunity to personally feel the following textures: (1) the rough surfaces like lichens, stone wall and barks; (2) the smooth surface like leaves, flower petals, and pebbles; (3) ridged surface like stone and prickly leavesl (4) hairy surface like the leaves of Stachys, soft conifers, and buds; (5) bumpy surface like twigs and cobbles; (6) cold and warm temperature; and (7) wet and dry objects (Beehive, 2009). Another way to stimulate the patients’ sense of touch is to blindfold them and asking them to identify the shape and types of fruit they were given to hold. (Koura & Yamagishi, 2005) Lastly, the sense of taste can also be enhance by allowing the patients to eat their harvested fruits and vegetables including herbs and spices such as mint, nasurtiums, and peppers that was taken from the garden. For instance: Upon harvesting fresh tomatoes and other necessary ingredients from the garden, horticulture therapists can teach the patients how to make tomato-based ketchup (Fried & Wichrowski, 2008). Aside from the fact that the presence of plants within the nursing homes could effectively stimulate the patients’ senses and positive emotions, horticultural therapy can effectively enhance the four major senses of patients with dementia (Rappe & Linden, 2004). As a result, horticulture therapists can make the patients feel satisfied with pleasure. For instance: Designing a garden and learning about plants and specific gardening techniques can stimulate and enhance not only the patients’ creativeness but also their eye-and-hand coordination, range-of-motion, strength-and-balance, and endurance (Larson, Hancheck, & Vollmar, 2008). The Health and Social Benefits of Practicing Horticultural Therapy on Carers and Patients’ Family Members The healthcare professionals, the carers, and the family members of patients with dementia are at risk of becoming overly stressed. To avoid becoming burnout from taking care of these patients, it is important for each one of them to be able to find an outlet where they can recharge their emotional burden and physical stress. Aside from the health, emotional, and social benefits that horticultural therapy can directly provide to the patients, it is believed that the practice of gardening also have a long-list of benefits on the part of the patients’ family members and the carers. Using a research survey method, Rappe and Linden (2004) reported that research survey participants which includes mainly the nursing staff of ten homes revealed that the use of indoor plants created a lush, homelike atmosphere aside from improving the indoor air quality. In general, having fresh air within the enclosed environment is good not only on the part of the patients but also the carers and patients’ family members. Aside from making it easier on the part of the health care professionals to assess the physical functions and developing a nursing care plan for the patients (McGuire, 1997), the provision of horticultural therapy on patients with dementia can also be a rewarding experience on the part of the family members and the family caregivers since the view of nature while wandering around the garden can enable them to release some of the stress they need to undergo while providing care for the patients. (Smith & McCallion, 1997) Research Method Aside from the use of books related to horticultural therapy, the researcher utilized search engines like ‘Yahoo’ and ‘Google’ as a way of gathering some academic journals from databases like: PubMed, CINAHL, and ISHS Acta Horticulturae. Among the keywords used in the search for related literature includes: ‘horticultural therapy dementia journal’, ‘therapeutic horticulture dementia journal’, ‘horticultural therapy elderly individuals journal’, ‘reminiscence therapy elderly patients journal’, etc. Scope and Delimitations The literature review tackled the related research findings available concerning the benefits of horticultural therapy on physical, cognitive, senses, emotional, and social well-being of patients with dementia including its health and social benefits on the part of the healthcare professionals, carers and the patients’ family members. Since the available peer-reviewed journals concerning the subject matter are limited, the researcher gathered academic journals that were published between the years 1997 – 2009. Since limited studies were conducted to examine the real clinical effect of horticultural activities on patients with dementia, the gathered literature review is limited on identifying the best way to incorporate horticultural therapy on the care program for patients with dementia. Considering that patients with memory loss problem have the tendency to eat plants and soil, it is also questionable whether or not it is safe to personally engage them in gardening and planting activities. Discussion Regardless of the type of activities used in patients with dementia, physical exercise and social contact will always be an essential part of enhancing the health and well-being of elderly individuals (Hardman & Stensel, 2003; Milligan et al., 2003, p. 7). In general, physical activity could lower the patients’ risk of developing cardiovascular and metabolic disorders such as high blood pressure, diabetes, and obesity. Based on the experimental research of Sheehan, Burton and Mitchell (2006), people with dementia are not capable of finding their way out of familiar and unfamiliar places. On top of the mental, physical, and social health benefits associated with gardening or garden-related activities, horticulture therapy is considered as one of the best therapy for patients with dementia since a garden is a safe environment of people regardless of age, ethnicity, nationality, socio-economic status, and gender. For this reason, gardening and horticulture are being widely used in promoting the health and well-being of people who are vulnerable and disadvantaged. Considering the health and social benefits of horticultural therapy on patients with dementia, Becker (2004) revealed that “there is more to determining whether an intervention is useful or valuable than demonstrating that this type of therapy can produce a change under controlled conditions” (p. 52). Therefore, conducting empirical validation with the use of therapeutic interventions has to be tested in terms of its effectiveness in the real clinical settings (Jadad, 1998, pp. 13 – 14). For instance: The research survey study that was conducted by Spinti, Hilaire and vanLeeuwen (2004) reported that 80% out of 198 the homeowners in New Mexico preferred the use of desert landscaping in their front yard as compared to 51% who prefers the landscape to be situated at the backyard. As part of the research participants’ preferred landscape garden, 77% of the respondents revealed that they prefer to have grass lawn as compared to 30% of the respondents who prefer trees. Contrary to the research findings of Spinti, Hilaire and vanLeeuwen (2004), Kim et al. (2004) revealed that most of the elderly individuals prefer flowers that has fragrance such as lily and chrysanthemum and/or bright and colorful flowers. Upon analyzing the situation, the research survey results suggest that each individual has their own preference on how a landscape should look like. In other words, it is possible that the preferences and emotional satisfaction that each individual can receive when being exposed to a therapeutic garden greatly varies from one another. As a coping strategy for a stressful life experiences, the use of horticultural therapy such as gardening and other related activities can be effective in terms of reducing stress. However, Unruh (2004) explained that the application of therapeutic horticulture has its own limitations. Basically, the effectiveness of horticultural therapy in terms of alleviating stress highly depends on the patients’ interest and enjoyment in leisure activities (p. 71). In other words, patients who do not find gardening appealing may not find the practice of horticultural therapy effective when it comes to improving not only his/her physical health but also in terms of his/her emotional, psychological, and social aspects. Even though therapeutic horticulture is already being applied in different healthcare settings, it remains a fact that limited studies were conducted to examine the health and social benefits of therapeutic horticulture on patients with dementia. After gathering a literature review on eperimental evidences concerning the effectiveness of horticulture and gardening in different therapeutic settings, Sempik et al. (2003) concluded that there is a strong need to conduct more research studies regarding the health and social benefits of horticultural therapy even though there has been some experimental evidences showing that the use of this type of therapy can increase the quality of life of most patients (p. 47). Some negative experiences were noticeable when applying horticultural therapy on patients with dementia. Recently, nursing staff who are giving care to patients with dementia reported that they have experienced witnessing some of the patients eating the plants and soil, moving the plants from one place to another, over watering of plants, and/or picking the flowers from the pot (Rappe & Linden, 2004). Despite the researchers’ effort in determining the impact of applying therapeutic horticulture in the care for patients with dementia, negative experiences of the health care professionals were often not included in the research studies. When conducting a research study related to the use of hortcultural therapy, Frumkin (2004) explained that researchers should be careful in setting a well-defined large number of population with specific health conduction in order to make statistical results more accurate. Given that horticultural therapy is a broad subject, researchers are encouraged to consider the “access to,direct contact with plants, views of garden and landscapes, wilderness activities, and the use of variety of settings” should be carefully planned to avoid bias results (p. 23). Conclusion and Recommendations Other than the physical benefits that patients can receive out of gardening, there is still a limit study with regards to the long-term impact of horticulture therapy on patients with dementia. Considering the challenges associated with caring for patients with dementia, it remains a question on how the health care institutions should develop horticulture therapy programs that is suitable for the specific needs of patients with memory loss problems. A paradise garden is normally composed of the four major elements including the enclosed wall, water, canopy, and hill. (Beckwith & Gilster, 1997) Siince patients with dementia normally finds it difficult to find their way out even when they are in familiar places (Sheehan, Burton, & Mitchell, 2006), the presence of enclosing wall is considered an essential part of caring for patients with dementia given the fact that the walls can be used to enable the health care professionals to easily monitor the patients with Alzheimer’s disease. In other words, the presence fo the enclosed wall protects the patients with dementia from possible external harm such as having stray animals attaching them. Dementia is an impairment of the patients’ cognitive function. Therefore, healthcare institutions should recognize and be able to foresee the negative consequences of placing several pots of plants within the nursing care environment. As reported by Rappe and Linden (2004), nursing staff who are giving care to patients with dementia had experienced witnessing some of the patients eating the plants and soil, moving the plants from one place to another, over watering of plants, and/or picking the flowers from the pot. Therefore, health care institutions should develop new strategies on how patients with dementia will always be safe. For instance: It is possible for the health care institution to develop a small indoor garden that is enclosed with glass or maximizing the use of enclosing wall in outdoor garden to ensure the patient safety. By doing so, health care professionals will be able to extend the health and emotional benefits of allowing the patients to view the beauty of nature. Horticultural therapy is not limited to walking around the garden, enjoying the beauty of nature, and/or gardening, teaching the patients with the importance of proper diet and nutritious foods can also be a part of the garden-related activities. Since not all patients with dementia would find activities related to horticulture interesting, the healthcare professionals should always consider the personal interests of the patient in order to ensure that they are comfortable with what they are doing. By considering the preferred activities of the patient, the healthcare professionals could enable their patients to develop a sense of well-being as they try to live their lives to the fullest. Aside from the fact that dementia can be either reversible and/or irreversible, it is possible for a patient to have either one or multiple causes of dementia. To effectively personalize the care provided to each patient, the healthcare professionals should carefully identify the specific caring needs of each patient depending on their symptoms and progression. In general, therapeutic garden can be in the form of aromatherapy garden, meditative labyrinth, atria with growing plants, and/or community plots wherein the patients will be responsible for the planning, growing, maintaining, and harvesting of garden produced (Collins & O'Callaghan, 2007). Depending on the preference and the ability of the patients to participate in horticultural activities, the healthcare professionals should carefully select from the four major types of garden. *** End *** References: Abbott, G., Cochran, V., & Clair, A. A. (1997). Innovations in intergeneration programs for persons who are elderly: The role of horticultural therapy in multidisciplinary approach. Activities, Adaption & Aging , Vol. 22, No. 1/2, pp. 27 - 37. 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