The Effects of Horticultural Therapy Based on Structural Recall by Developmental Stage on Cognitive, Emotional, and Hand Functions of Institutionalized Elderly
Article information
Abstract
With the object of examining the effects of horticultural therapy based on structural recall by developmental stage on cognitive, emotional, and hand functions of institutionalized elderly, this study executed a horticultural therapy program once a week and through a total of 14 sessions during the period from May 2 to December 5, 2013. The subjects of this study were 34 elders admitted to S Geriatric hospital for geriatric diseases, and they were divided into a control group and an experimental group. Because the program was designed for institutionalized elders who were able to do only indoor activities, it provided various seasonal horticultural activities that could be done even in a limited space by giving materials and subjects that could be recalled by developmental stage. The results of this study are as follows. As to changes in cognitive functions (MSQ) after the horticultural therapy program, the control group showed a decrease as having more negative ranks, and the experimental group showed an increase as having more positive ranks, but such changes in the control and experimental groups were not significant. As to changes in emotional functions after the horticultural therapy program, the control group showed a decrease but without significance in ego integrity as having more negative ranks, and the experimental group showed an increase with significance as having more positive ranks (P=0.020). As to the experimental group’s changes in the sub factors of ego integrity, positive ranks increased in all the sub-factors and the increase was particularly significant in satisfaction with present life (P=0.038). As to changes in life satisfaction, the control group showed increased positive ranks but without significance, and the experimental group showed significantly increased positive ranks (P=0.022). As to the experimental group’s changes in the sub-factors of life satisfaction, changes in denial of the past (P=0.029) and denial of the future (P=0.016) were particularly significant. As to changes in hand functions, both the control and experimental groups showed some improvement in pinch after the horticultural therapy program but the changes were not significant. Grip strength did not change in the control group, and in the experimental group right-hand grip strength was improved slightly more than left-hand one, the difference was not significant. The results of this study suggest that horticultural therapy based on structural recall by developmental stage is effective in improving institutionalized elders’ emotional functions and, consequently, can contribute to higher quality of life, which is the ultimate goal of elders.
Ⅰ. Introduction
According to Statistics Korea, the elderly population aged 65 and above in Korea reached 11.4% of the entire population in 2011. If the elderly population rises sharply in this trend, it will exceed 14.3% of the entire population and reach the aging society by 2018, and then exceed 20.8% of the population and reach the super-aged society by 2026 (Korea National Statistical Office, 2011). Institutionalized elders have physically chronic diseases and thus are in constant need of protection, and can only participate in limited activities in the facility (Song, 2001). Their long leisure time due to the loss of roles rather degrade their physical and mental functions (Hass et al., 1998).
Horticultural activities enable people to have conversations with not only plants but also horticultural therapists based on the topic of plants (Kim, 2003), and above all, they are familiar to the elderly and thus are highly accessible (Yun and Kim, 2009). Moreover, the effects of horticultural therapy can be improved by consciously and scientifically stimulating all sensory organs, such as seeing with eyes, smelling and touching the plants, and thinking while moving (Son et al., 2000).
The developmental task that must be performed in senescence is ego integrity, which is an outcome of successful adjustment to technologies and skills demanded by the society to acquire as an individual enters senescence; and it indicates a state of psychological stability in which one can accept one’s life without regrets, is satisfied with the current life, and can face death without great remorse or fear with a harmonized view of the past, present and future (Erikson, 1963). It is known that reminiscence provides an exit for expression of strong emotions, unresolved issues and suppressed feelings, maintains identity and promotes self-esteem. It is considered desirable to provide an opportunity to look back on memories of the past as a means to achieve ego integrity (Hamacheck, 1990).
In a comparative study on the effects of structural and non- structural recall therapy among reminiscence therapy, it was reported that structural recall therapy enhances self-concept and cognitive functions of the elderly while reducing depression, and thus it is more effective for psychological adjustment to senescence (Fry, 1983). There were no previous studies on horticultural activities applying structural recall therapy on the elderly, but it was discovered that group art therapy applying structural recall brings positive changes to self-expression and problem behaviors of the elderly with dementia (Son, 2011).
Accordingly, this study examines horticultural therapy applying structural recall by developmental stage using various horticultural materials so that elders can recall their past, while also applying horticultural therapy that enables the elders to express their inner sides with various materials and themes fit for the season, and determine the effects on cognitive, emotional and hand functions of institutionalized elderly.
Ⅱ. Research method
1. Research subjects and period
This study was conducted on elders who scored less than 24 points in MMSE-K that is classified as a disorder of cognitive functions, among the elders admitted to S Geriatric Hospital in D City for geriatric diseases. The control group consisted of 17 participants (2 male and 15 female), and the average age was 83.4. The experimental group consisted of 17 participants (1 male and 16 female), and the average age was 80.5. The control group scored an average of 14.1 points and the experimental group 15.2 points for cognitive functions (MMSE-K). The research was conducted once every other week and through a total of 14 sessions, from May 2 to December 5, 2013.
2. Research tools
1) Design of the horticultural therapy program based on structural recall
This study applied structural recall to horticultural therapy, where specific words or themes are provided and the participants are to recall them as indicated (Son, 2011). Fig. 1 shows horticultural therapy based on structural recall. The participants are to recall memories of seasonal materials and themes using various plants as a medium, and talk about their feelings after stimulation of the five senses and completion of their works. By doing so, they could release their suppressed emotions and unresolved issues, thereby finding proper exits and improving their functions.
Design of a horticultural therapy program based on structural recall.
Based on Erikson’s 8 stages of psychosocial development (Erikson, 1950), we divided the stages in which one can remember into 5 stages – childhood, adolescence, early adulthood, adulthood and maturity – and applied structural recall horticultural therapy. Fig. 2 and Table 1 show the horticultural therapy program based on structural recall by stage.
Design of a horticultural therapy program based on structural recall by developmental stage.
The sessions of the horticultural therapy program performed for this study.
In Stage 1, the horticultural therapy program was set up for the participants to recall childhood (before age 12) and was carried out in Sessions 1 and 2. In Session 1, the participants recalled their parents with carnations, expressed their gratitude for being born, and made floral arrangements with carnations. In Session 2, they recalled the game of marbles by tending a mini garden, and talked about their feelings after completing the dish garden.
In Stage 2, the horticultural therapy program was set up for the participants to recall adolescence (age 12-20) and was carried out in Sessions 3, 4 and 5. In Session 3, the participants made potpourri lucky bags while recalling the dreams they had had in childhood. In Session 4, charcoal was used for them to recall their childhood when they played jwibulnori in the fields on January 15th by lunar calendar to wish for good health, and they planted angraecum using charcoal. In Session 5, they made fans and recalled how they spent scorching summer, and talked about their feelings after finishing the fans made with blow painting techniques and pressed flowers.
In Stage 3, the horticultural therapy program was set up for the participants to recall early adulthood (age 21-34) and was carried out in Sessions 6, 7 and 8. In Session 6, the participants examined how the living environment changed today from the past with tillandsia, which are air plants. Since the elders’ early adulthood was the time when they just got married and were raising children, they were to recall the experience of nurturing children, and they made tapestries with tillandsia, air plants raised without soil. In Session 7, they recalled the people whom they remember the most such as family or friends by making photo frames using flowers. In Session 8, they recalled the times when they got married and started their own family, using fish family stickers and frogbits floating on water. They used frogbits for water culture, and talked about their feelings.
In Stage 4, the horticultural therapy program was set up for the participants to recall adulthood (age 35-65세) and was carried out in Sessions 9, 10 and 11. In Session 9, the participants were to talk while recalling the abundant fruits of autumn harvest, and decorated and made floral arrangements with autumn flowers and fruits in celebration for Chuseok. In Session 10, they recalled the happiest times of their family while making a bird’s nest. In Session 11, they recalled and talked about the most memorable travel sites with terrariums, expressed those places in their works and put up the signs, and then talked about their feelings.
In Stage 5, the horticultural therapy program was set up for the participants to recall maturity (after age 65) and was carried out in Sessions 12, 13 and 14. In Session 12, the participants recalled the people for whom they are grateful and want to wish health in life, like the meaning of Pepero Day in Korea, and made floral arrangements with Pepero and flowers. In Session 13, they recalled the things they regret in life in the past, and made lavender soap. In Session 14, they thought about the people whom they want to thank in time for the end of the year, and resolved the will to live a healthy life. Then they wished for one another’s health, planted poinsettias that represent winter, decorated them with fences, and talked about their feelings.
2) Implementation of the program
Fig. 3 shows how the horticultural therapy program based on structural recall was implemented for the institutionalized elders. First, the program helped improve their cognitive functions by determining the date and day, talking about the materials, and counting numbers every session. The elders’ emotional stability was also promoted by inducing their interest and stimulating the senses with easy and fun activities, and having them talk about their feelings. Moreover, their hand functions were also improved by using tools on their own if possible, while working in various methods such as cutting, trimming, putting, tying and kneading materials, or grabbing and putting soil.
Activities for improving functions through the horticultural therapy program.
3. Evaluation tools
1) Test of cognitive functions
The nurse in charge of the patients measured the cognitive functions before and after the program using the Mental Status Questionnaire (MSQ) developed by Kahn et al. (1960).
2) Test of emotional functions
Ego integrity and life satisfaction were self-tested with the help of the nurse and horticultural therapist before and after the program. Ego integrity was measured with the tool revised and improved by Kim (1988) according to the conditions of elders in Korea. Life satisfaction was measured with the questionnaire used in the study by Choi (1986) on the development of life satisfaction measure of the elderly.
3) Test of hand functions
Both left and right hands were measured using the hand functions testing tool before and after the program. The unit was in kg, and higher values indicate stronger muscle strength and grip of the fingers. Pinch Gauge (JAMAR Serial number 60504224, SAMMONS PRESTON, INC.) was used to determine the variations of pinch, and Hand Dynamometer (Model 78010. LAFAYETTE INSTRUMENT COMPANY, INDIANA, USA.) was used to determine the variations of grip.
4. Method of analysis
A non-parametric test was conducted with SPSS Win 19.0K program to analyze the changes after the horticultural therapy program, and a Wilcoxon signed-rank test was used to analyze the before-and-after changes of each factor of the control group and experimental group, with the significance level set at P≤0.05.
Ⅲ. Results and discussions
1. Changes in cognitive functions
The total average in the changes of cognitive functions (MSQ) before and after horticultural therapy decreased by 0.5 points from 5.9 to 5.4 in the control group, while the average increased by 0.7 from 6.2 to 6.9 in the experimental group. Table 2 shows the result of the Wilcoxon signed-rank test conducted to determine whether this difference is statistically significant. Out of 17 participants in the control group, 8 participants showed negative ranks, 6 showed positive ranks and 3 showed a tie. Out of 17 participants in the experimental group, 4 participants showed negative ranks, 7 showed positive ranks and 6 showed a tie. But both groups did not have significance.
The results of the subject’s cognitive functions (MSQ) before and after the program.
As reported in a qualitative study on the effects of horticultural therapy on cognitive functions that the participants could read and write after therapy (McGiure, 1997), the result of this study also showed that institutionalized elders could better express their feelings toward colors and tactility, and showed improvement in cognitive skills for naming colors and materials, counting numbers, and recognizing dates or people. As such, the horticultural program, which stimulates the five senses with seasonal materials and themes to promote structural recall by developmental stage, tended to considerably improve cognitive functions by inducing participation and reaction, even though there was no difference at the statistically significant level in improving the cognitive functions of institutionalized elders. This may be due to the fact that the program was carried out biweekly instead of weekly due to limited facility conditions and thus the time interval of the program became longer. If the application time and intervals of the horticultural therapy program are adjusted, the cognitive functions of institutionalized elders will be improved.
2. Changes in emotional functions
1) Changes in ego integrity
The total average in the changes of ego integrity before and after horticultural therapy decreased by 0.6 points from 97.4 to 96.8 in the control group, while the average increased by 7.8 from 92.9 to 100.7 in the experimental group. Table 3 shows he result of the Wilcoxon signed-rank test. Out of 17 participants in the control group, 9 participants showed negative ranks, 7 showed positive ranks and 1 showed a tie, having more negative ranks and thus no significance. On the other hand, out of 17 participants in the experimental group, 4 participants showed negative ranks, 12 showed positive ranks and 1 showed a tie, thereby showing a significant difference (P=0.020).
The results of the subject’s ego integrity tests before and after the program.
The result is similar to that of research data reporting that compared to the group receiving general horticultural therapy for the elderly, the group receiving horticultural therapy based on recall showed a 9-point average increase in ego integrity, which is a highly significant difference (Lee, 2005). As such, horticultural therapy based on structural recall by developmental stage helped ego integrity of institutionalized elders as they recalled their successful and good memories and expressed suppressed feelings as well as negative emotions toward unresolved issues.
2) Changes in life satisfaction
The total average in the changes of ego integrity before and after horticultural therapy decreased by 4.3 points from 20.7 to 25.0 in the control group, while the average increased by 7 from 19.2 to 26.2 in the experimental group. Table 4 shows the result of the Wilcoxon signed-rank test. Out of 17 participants in the control group and experimental group, 5 participants showed negative ranks, 12 showed positive ranks and none showed a tie. While the control group had no significance, the experimental group showed a significant difference (P=0.022).
The results of the experimental group’s life satisfaction before and after the program.
This result is similar to that of a previous study reporting that horticultural therapy through group activities provides social activities for institutionalized elders with dementia in the facility, thereby having a positive effect on life satisfaction (Yoo, 2014). This shows that it was effective in improving life satisfaction by providing the horticultural therapy program based on structural recall by developmental stage.
3. Changes in hand functions
1) Changes in pinch
① Pinch; Left hand
The total average in the score changes of pinch on the left hand for each participant before and after horticultural therapy, measured to test the effects on hand functions, increased by 0.3 points from 4.8 to 5.1 in the control group, while the average increased by 0.1 from 4.4 to 4.5 in the experimental group. Table 5 shows the result of the Wilcoxon signed-rank test. There were more positive ranks than negative in both groups, but 3 participants in the control group and 6 in the experimental group showed a tie, thereby having no significance.
The results of the experimental group’s left hand pinch before and after the program.
② Pinch; Right hand
The total average in the score changes of pinch on the right hand before and after horticultural therapy increased by 0.2 points from 4.8 to 5.0 in the control group, while the average increased by 0.2 points from 4.4 to 4.6 in the experimental group. Table 6 shows the result of the Wilcoxon signed-rank test. There were more positive ranks than negative in both groups, but 2 participants in the control group and 5 in the experimental group showed a tie, thereby having no significance.
The results of the experimental group’s right hand pinch before and after the program.
2) Changes in grip
① Grip; Left hand
The total average in the score changes of grip on the left hand for each participant before and after horticultural therapy, measured to test the effects on hand functions, decreased by 0.3 points from 10.6 to 10.3 in the control group, while the average was the same at 7.8 in the experimental group. Table 7 shows the result of the Wilcoxon signed-rank test. The control group had the same number of positive ranks and negative ranks and 3 participants showed a tie, thereby having no significance. The experimental group had slightly more positive ranks, but 3 participants showed a tie, thereby having no significance.
The results of the experimental group’s left hand grip strength before and after the program.
② Grip; Right hand
The total average in the score changes of grip on the right hand for each participant before and after horticultural therapy decreased by 0.5 points from 10.3 to 9.8 in the control group, while the average increased by 0.2 points from 9.0 to 9.2 in the experimental group. Table 8 shows the result of the Wilcoxon signed-rank test. The control group had more negative ranks and 4 participants showed a tie, thereby having no significance. The experimental group had slightly more positive ranks, but 7 participants showed a tie, thereby having no significance.
The results of the experimental group’s right hand grip strength before and after the program.
This result may be due to the fact that, while the elders showed good participation and response, the program was carried out biweekly due to facility conditions, and the hand functions of institutionalized elders were already greatly weakened. Thus, there may have been some limitations in strengthening the grip that requires a great deal of hand muscle strength with just a short period of the horticultural therapy program. However, the result was consistent with the previous study claiming that the program was effective in preventing the slight weakening of muscle strength (Yun, 2007).
Therefore, if various horticultural therapy programs are implemented so that elders can use their hands to complete their works consistently every week, it will be possible to prevent their hand functions from weakening further, and rather strengthen them.
This study randomly selected the materials and themes that are considered related to recollection for elders in general in structural recall by developmental stage. Thus, the experiment was conducted without enough objective background, and other environmental variables that may affect institutionalized elders were not controlled. Accordingly, it seems unreasonable to generalize the results of this study.
Ⅳ. Conclusion
To determine the effects of horticultural therapy based on structural recall by developmental stage on cognitive, emotional and hand functions institutionalized elderly, this study executed a horticultural therapy program once every other week in total 14 sessions from May 2 to December 5, 2013. The subjects of this study were 34 elders admitted to S Geriatric Hospital due to geriatric diseases, divided into the control group (17 participants) and experimental group (17 participants). Since the horticultural therapy program was designed for elders who can participate only in indoor activities, various seasonal horticultural activities were implemented with materials and themes that could be recalled by each developmental stage in a limited space. The evaluation results are as follows. As for changes in cognitive functions (MSQ) after the horticultural therapy program, both groups did not show significance. As for changes in ego integrity in emotional functions, the control group showed no significance, while the experimental group had many positive ranks and thus showed significance (P=0.020). As for changes in life satisfaction, the control group showed no significance, while the experimental group had many positive ranks and thus showed a significant increase (P=0.022). In the test of hand functions, both groups showed a slight increase but no significance. As for changes in grip, the control group showed no change, while the experimental group showed a slight increase in the right hand compared to the left, but without significance.
The results above suggest that horticultural therapy based on structural recall by developmental stage is effective in improving emotional functions of institutionalized elders, and may also help improve the quality of their positive life.
References
Choi, S.J. 1986. A study on the development of measuring scale of the concept of life satisfaction. J. Korean Cultural Studies, 233-258.
Erikson, E.H. 1950. Identity and the life cycle; selected paper. International university press, New York, USA.
Erikson, E.H. 1963. Childhood and society. 2nd ed. Norton, New York, USA.
Fry, P. S., 1983. Structured and unstructured reminiscence training and depression among the elderly, Clinical Gerontologist, p.5-37.
Hamacheck, D. 1990. Evaluating self-concept and ego status in Erikson’s last three psychosocial stages. J. Counseling and Development, 68:677-683.
Hass, K., S.P. Simson, and N.C. Stevenson. 1998. Older persons and horticulture therapy. Simson. S. P. & Straus, M. C. ed. Horticulture as therapy-Principles and practice. The food products press. New York, USA.
Kahn, R., R. Goldfarb, M. Pollack, and A. Peck. 1960. Brief objective measure for the determination of mental status in the aged. J. American of Psychiatry, 17:326-328.
Kim, H.Y. 2003. Theory and practice of horticultural therapy, The Korean Society for Horticultural Therapy, Daegu.
Kim, J.S. 1988. A study of social activities and eco integrity of the aged. Ph D. Diss, Ewha Womans Univ., Seoul.
Korea National Statistical Office. 2011. Population prospects.
Lee, E.S. 2005. Effect of HT program based on reminiscence on the improvement of self-interaction of the aged. MS Thesis, Konkuk Univ., Seoul.
McGuire, D.L. 1997. Implementing horticultural therapy into a geriatric long-term care facility. Horticultural therapy and the older adult population. The Hawort Press, Inc.
Son, K.C., S.K. Park, H.O. Boo, K.Y. Paek, K.Y. Bae, S.H. Lee, and B.G. Hur. 2000. Horticultural therapy: Plant, human, and environment. Sewon Press, Seoul.
Son, Y.M. 2011. The effect of group art therapy applied structural remembrance remedy on self expression and problematic behavior of dotard at residential treatment facility. MS Thesis, Konkuk Univ., Seoul.
Song, A.R. 2001. Effects of leisure activity program intervention on activities of daily living, depression and quality of life in institutionalized older population. Ph D. Diss, Chungnam National Univ., Taejon, Korea.
Yoo, C.S. 2014. Verification of efficacy of horticultural therapy program in enhancing life satisfaction & reducing depression for elderlies with mild dementia. MS Thesis, Konkuk Univ., Seoul.
Yun, S.Y. 2007. Effects of the application of horticultural therapy based on Pincus’ theory of rehabilitation practice on demented elders’ daily activity functions and physiological changes. Ph D. Diss, Catholic Univ. of Daegu, Daegu.
Yun, S.Y. and H.Y. Kim. 2009. Effect of the horticultural therapy program linked to children on life satisfaction of elders in facilities. J. Kor. Soc. People Plants Environ., 12:9-14.