Effects of Horticultural Therapy on Asian Elderly' Mental Health

Study Overview
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Brief Summary
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The objective of this study is to determine whether horticultural therapy would improve the psychological well-being of the older adults. 70 healthy elderly were randomized into the active horticultural therapy or the waitlist control group. Sessions will be conducted weekly for 12 weeks, and monthly for 3 months. Participants would be assessed at 3 time-points: at the start, at 3-months and at 6-months. It was hypothesized that as compared to the waitlist control group, participants in the active horticultural therapy will have (1) lower depression and anxiety symptomatology; (2) higher life satisfaction; (3) feel more socially connected; and (4) improved cognitive functioning.

Detailed Description
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Participants Study participants are community-dwelling elderly. Assessments Demographic data will be collected at the start. Psychological tests for depression, anxiety and psychological well-being as well as neuropsychological tests of cognitive functioning will be done at the start, at 3-months and at 6-months. Blood samples will also be collected at all three time points. Intervention Sessions This is an intervention study with a waitlist control group design. The strength of this design is its experimental nature with randomization. The Horticultural Therapy intervention is delivered by a trained practitioner at various locations and consists of 1 hour sessions weekly for first 3 months, followed by monthly session for the next 3 months. The extension of monthly sessions for 3 months is to determine sustainability and longer-term changes. The intervention is designed to cultivate an interest in gardening and promote relaxation. This will be achieved in stages, facilitated by trained volunteers and practitioners. The plant would be selected based on subjects' profiles e.g. familiarity, preference, safety and its maintenance would be followed up every fortnight. Park venues were selected based on patients profiles and park features e.g. familiarity, comfort under weather, safety. The control group will be placed on a waiting list and only be contacted for assessments. They will receive intervention after the active treatment group at a later date. The horticultural therapy is conducted solely for the purpose of this research.

Official Title
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Effects of Horticultural Therapy on Asian Elderly' Mental Health: A Randomized Controlled Trial

Conditions
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Mood (Psychological Function)

Intervention / Treatment
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* Behavioral: Horticultural Therapy


Participation Criteria
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Eligibility Criteria
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Inclusion criteria: Community-living elderly aged between 60 to 85 years AND able to provide informed consent AND function independently AND With a minimum score of 22 and above on the Montreal Cognitive Assessment. Exclusion criteria: Those who do not meet the above inclusion criteria (ie. Do not have a MCI diagnosis), Does not have a minimum score of 22 and above on the Montreal Cognitive Assessment OR Currently suffering from or have history of severe medical conditions e.g. cancer, stroke, Parkinson disease OR History of severe psychiatric conditions e.g. schizophrenia, bipolar disorder OR Dementia OR Undergoing another therapy at the same time OR Significant visual or hearing impairment OR Marked upper and lower limb motor difficulties, which may affect their ability to participate in the study.

Ages Eligible for Study
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Minimum Age: 60 Years
Maximum Age: 85 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Active Horticultural Therapy<br>15 sessions of Horticultural Therapy program teaching the elderly about gardening techniques and for them to benefit from the therapeutic effects of the parks | Behavioral: Horticultural Therapy<br>* The Horticultural Therapy intervention consists of 1 hour sessions weekly for first 3 months, followed by monthly session for the next 3 months. They will be taught on the basic gardening techniques such as sowing, weeding and fertilization during the hands-on sessions. They will also be taken on walks to the various parks to enjoy the therapeutic effect of the park greenery<br>|
| Other: Waitlist Control Group<br>Participants will receive the same horticultural therapy program at the end of the assessments | Behavioral: Horticultural Therapy<br>* The Horticultural Therapy intervention consists of 1 hour sessions weekly for first 3 months, followed by monthly session for the next 3 months. They will be taught on the basic gardening techniques such as sowing, weeding and fertilization during the hands-on sessions. They will also be taken on walks to the various parks to enjoy the therapeutic effect of the park greenery<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from baseline Zung Self-Rating Depression Scale (SDS) at 3-months and 6-months | The SDS (Zung, 1965) is a 20-item quantitative measurement of symptoms of depression. Participants rate each item regarding how they felt during the week preceding using a 4-point scale that ranges from 1 (a little of the time) to 4 (most of the time). A total raw score computed by summing the scores on the individual items will be converted into a percentage (the SDS index); the higher the SDS index, the greater the severity of depressive symptoms. Several studies have established the SDS as a reliable and valid instrument for measuring depressive symptoms (Biggs et al., 1978; Gabrys and Peters, 1985; Agrell and Dehlin, 1989). | baseline, 3-months, 6-months | 
| Change from baseline Zung Self-Rating Anxiety Scale (SAS) at 3-months and 6-months | The SAS (Zung, 1971) will be used to measure anxiety of the participants in the preceding week. It is a 20-item self-report assessment designed to measure anxiety levels, based on cognitive, autonomic, motor and central nervous system symptoms. Each question is scored on a Likert-type scale of 1-4 (a little of the time) to (most of the time). Some questions are negatively worded to avoid the problem of set response. Overall assessment is done by total score. The total raw scores range from 20-80. The raw score then needs to be converted to an Anxiety Index score; the higher the SAS index, the greater the severity of depressive symptoms. | baseline, 3-months, 6-months | 
| Change from baseline Ryff's Scales of Psychological Well-being at 3-months and 6-months | The Ryff Scales of Psychological Well-Being (Ryff and Singer, 1998) is an 18-item questionnaire which reflects the six areas of psychological well-being: autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance. Respondents rate statements on a scale of 1 to 6, with 1 indicating strong disagreement and 6 indicating strong agreement. | baseline, 3-months, 6-months | 
| Change from baseline Satisfaction with Life Scale (SWLS) at 3-months and 6-months | Satisfaction with Life Scale (SWLS; Diener, Emmons, Larsen and Griffin, 1985) will be administered. SWLS is a 5-item scale designed to measure global cognitive judgments of one's life satisfaction (not a measure of either positive or negative affect). It is a psychometrically sound measure (Larson, Diener and Emmons, 1985) and has been validated in a geriatric population (Diener et al., 1985). Participants indicate how much they agree or disagree with each of the 5 items using a 7-point scale that ranges from 1 (strongly disagree) to 7 (strongly agree). Total scores were computed by summing the scores on the individual items and ranged from 5 to 35, with higher scores indicating higher level of satisfaction with life. | baseline, 3-months, 6-months | 
| Change from baseline Friendship Scale (FS) at 3-months and 6-months | Social connectedness scale will be measured using the Friendship Scale (Hawthorne, 2006). It is a 6-item questionnaire that measures both social isolation and social connectedness. Participants were asked to rate the frequency in which each statement describes them during the past four weeks on a 5-point Likert scale ranging from 0 (almost always) to 5 (not at all). Total scores were computed by summing the scores on the individual items and ranged from 0 to 24, with higher scores indicating higher level of social connectedness. The Friendship Scale was developed as a short, user-friendly, stand alone scale measuring perceived social isolation. It was validated with older adults with excellent internal structures, reliability and validity (Hawthorne, 2006; Hawthorne, 2008). | baseline, 3-months, 6-months | 
| Change from baseline Interleukin 6 (IL-6) at 3-months and 6-months | 10ml of fasting blood will be collected using CPT tube | baseline, 3-months, 6-months | 
| Change from baseline Interleukin-1 beta (IL-1β) at 3-months and 6-months | 10ml of fasting blood will be collected using CPT tube | baseline, 3-months, 6-months | 
| Change from baseline C-reactive protein (CRP) at 3-months and 6-months | 10ml of fasting blood will be collected using CPT tube | baseline, 3-months, 6-months | 
| Change from baseline Cortisol at 3-months and 6-months | 10ml of fasting blood will be collected using CPT tube | baseline, 3-months, 6-months | 
| Change from baseline Brain-derived neurotrophic factor (BDNF) at 3-months and 6-months | 10ml of fasting blood will be collected using CPT tube | baseline, 3-months, 6-months | 
| Change from baseline Dehydroepiandrosterone sulphate (DHEAS) at 3-months and 6-months | 10ml of fasting blood will be collected using CPT tube | baseline, 3-months, 6-months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change from baseline Montreal Cognitive Assessment (MoCA) at 3-months and 6-months | Montreal Cognitive Assessment (MoCA) (Nasreddine, Phillips, Bedirian, Charbonneau, Whitehead, Collin, et al., 2005) will be administered by trained research assistants and/or research nurses as global measures of cognitive function. | baseline, 3-months, 6-months | 
| Change from baseline Clinical Dementia Rating (CDR) at 3-months and 6-months | Clinical Dementia Rating (CDR ) is a 5-point scale used to characterize six domains of cognitive and functional performance applicable to Alzheimer disease and related dementias: Memory, Orientation, Judgment & Problem Solving, Community Affairs, Home & Hobbies, and Personal Care. | baseline, 3-months, 6-months | 
| Change from baseline Rey Auditory Verbal Learning Test (RAVLT) at 3-months and 6-months | Rey Auditory Verbal Learning Test (RAVLT) evaluates declarative verbal learning and memory. | baseline, 3-months, 6-months | 
| Change from baseline Digit Span Task at 3-months and 6-months | Digit Span Task, which consists of a Digit Span Forward (DSF) and a Digit Span Backward (DSB) task is used to assess attention and verbal working memory. | baseline, 3-months, 6-months | 
| Change from baseline Colour Trails Tests (CTT) at 3-months and 6-months | Colour Trails Tests (CTT) 1 and 2 assesses sustained attention and sequencing. | baseline, 3-months, 6-months | 
| Change from baseline Block Design at 3-months and 6-months | Block Design is a subtest that is administered as part of several of the Wechsler Intelligence tests, and it primarily measures visual-spatial and organizational processing abilities, as well as non-verbal problem-solving skills. | baseline, 3-months, 6-months | 
| Change from baseline Semantic Verbal Fluency at 3-months and 6-months | Semantic Verbal Fluency taps lexical knowledge and semantic memory organization. | baseline, 3-months, 6-months | 
| Change from Basic Health Screen (composite) at 3-months and 6-months | Blood pressure, Pulse rate, Height and Weight will be measured | baseline, 3-months, 6-months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Promotion of psychological well-being, Horticultural therapy, Randomized Controlled Trial, Gardening, Elderly