**1. Introduction**

Taiwan has become an aging society. Even though many assisted living facilities are providing care services for the elderly, most of them do not want to move into nursing homes because the perceived lifestyle at these facilities is foreign to them. "Aging in place" is a concept that first originated from Northern Europe during the 1960s. The goal at the time was to care for the elderly with resources that are native to them so they could age in an environment that is familiar to their culture, which would give them the holistic care and independence that they

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

deserve. On the contrary, some nursing homes limit the elderly's lifestyle choices and social functions, which may damage their mental health and self-respect resulting in deterioration of their body and mind [1]. The goal of "Aging in place" was to fulfill the native's needs with domestic goods and services, which would require community-like facilities to build a longterm care system. Most of the assisted living facilities today in Taiwan are based on community activities to promote interaction among the elderly. Healthcare-oriented facilities should be considered more when daily activities and movements become less convenient for the elders. Japanese welfare economist [2] proposed five basic measures to ensure that the elderly live a normal life: avoid taking quarantine measures; allow them to live in an environment with which they are familiar as much as possible; facilitate their social exchanges and mutual assistance; provide facilities and services to maintain quality of life when institutionalized care becomes necessary; and integrate social welfare, medical and health, and environmental maintenance policies to create a suitable living environment.

Emotional benefits: Lewis and Mattson maintained that through gardening activities, people can experience serene satisfaction in the world of plants where no threats or discriminations exist, thereby alleviating their mental stress and fear [2]. Furthermore, when patients discern that they can work independently and have their own gardens, a sense of identification and belonging to the gardens emerge in them, and their self-respect is enhanced. When patients' confidence is elevated, their belligerent tendencies can be tempered and adjusted to socially acceptable behavioral models; in addition, their interests and passion for future life are triggered to satisfy their creative instinct [11]. Moreover, gardening activities can help patients develop an ideal self-image and continually develop work skills [12]. Because numerous factors in the living environment can affect people's emotions, a designed and selected environment can indeed quicken patients' emotional recovery [18–21]. For example, a successful therapeutic garden can reduce people's stress, even generating a sense of encouragement [22]. Physical benefits: In addition to mental benefits, gardening activities help wounded or physically disabled individuals to improve their coordination and effectively control their motor neurons through tasks such as carrying plants, sowing seeds, applying fertilizer, and watering plants [11]. For the elderly, gardening enables them to improve physical and mental health through a leisure activity. Therefore, an increasing number of the retired elderly have devoted themselves to gardening activities, and numerous elderly nursing and home care centers have introduced horticultural therapy. Research has shown that horticultural therapy can improve the elderly's arthritis symptoms, and it exerts positive effects on blood pressure and diet control [2]. Furthermore, gardening activities can increase regular physical activities that require physical and mental stability as well as high-level functional activities [23]. Gardening practices have the clear effects of enhancing muscle strength, fine motor skills, and balance; in particular, transplanting requires grasping and releasing with the thumb and index finger as well as muscle flexibility [23, 24]. Gardening activities boost enthusiasm and senses of responsibility and achievement. From selecting plants to their growth and eventual flowering, plants continually create hope for people. Furthermore, learning gardening skills enhances the elderly's curiosity. Therapeutic use of activity can help the geriatric individuals to improve their independence in daily life, and cognitive and motor skills [13, 21, 23]. The activity that will be used as a therapeutic agent can be determined according to the interests, activity preference, and the skills of the geriatrics [19, 25, 26]. Gardening can expand people's social networks by providing opportunities to socialize [27]; thus, gardening activities have posi-

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Brown administered a 5-week horticultural therapy course to 66 older residents in nursing homes [28], and found that compared with the control group, residents in the test group exhibited significantly greater improvements before and after receiving the horticultural therapy in several items on the activities of daily living (ADL) scale, namely physical ambulation, feeding, and toilet. Austin applied a 5-week horticultural therapy course to eight elderly people who lived by themselves, the results of which revealed that their fitness, ADL scores, and 6-min walk test results all improved significantly after the intervention [29]. In addition, Son administered a 5-week horticultural therapy to five community-dwelling elderly people, and found that during vegetable-planting activities, they could use adapted tools and aids to teach the elderly to adjust to appropriate joint movement angles, balance using suitable postures, and train gross

tive effects on the community-dwelling elderly.

Sandberg indicated that 95% of the elderly in Hong Kong have one or more chronic diseases; however, only 5.5% require institutionalized care [3]. Although nursing homes can help the elderly who cannot live independently [1], institutionalized care entails a change in living environment, and consequently, disconnection from family and society as well as a reduction in physical activities and enhanced loneliness [4]. Another study found that the physical activity level of the nursing home-dwelling elderly is considerably lower than that of the community-dwelling elderly [5]. In addition to facing changes to their environment and mobility, the elderly who move into nursing homes must deal with changes in daily life routine, social network, and social support [6]. Moving into a nursing home means the discontinuation of a person's traditional lifestyle with which they are familiar. In addition, the elderly can sustain an enormous sense of loss caused by separation from families, neighbors, and friends [1, 7]. When the elderly face gradual decline in physical and mental status, what can be done to ensure they age stably is a question that requires an answer. The American Horticultural Therapy Association (AHTA) maintained that horticultural therapy can be applied to people of various ages, backgrounds, and abilities. It defined horticultural therapy as "engaging in gardening-related activities through the assistance of a trained therapist to complete a specific therapeutic goal." Horticultural therapy has four major types of benefits: intellectual, social, emotional, and physical [8–11].

Intellectual benefits: Through horticultural therapy, participants can acquire new skills and knowledge, increase their vocabulary and communication skills, have their curiosity aroused, improve observation, receive occupational and pre-occupational training, receive stimulation to their sensory organs [11–14], and obtain new learning opportunities [15].

Social benefits: A successful treatment should involve three types of interaction: between the therapist and the client, between clients, and between the client and nonclient [16]. Generally, these interactions mainly are aimed at socializing and collaborating; specifically, sharing gardening experiences facilitates creating meaningful interactions. Because group members have a common goal, interactions among them can be increased on the basis of mutual respect and support, as well as duty sharing. During the process of gardening, patients have the opportunity to connect with people other than their group members and share their own gardening results with external parties, thereby gaining the benefit of an enlarged interpersonal network [4, 11, 17].

Emotional benefits: Lewis and Mattson maintained that through gardening activities, people can experience serene satisfaction in the world of plants where no threats or discriminations exist, thereby alleviating their mental stress and fear [2]. Furthermore, when patients discern that they can work independently and have their own gardens, a sense of identification and belonging to the gardens emerge in them, and their self-respect is enhanced. When patients' confidence is elevated, their belligerent tendencies can be tempered and adjusted to socially acceptable behavioral models; in addition, their interests and passion for future life are triggered to satisfy their creative instinct [11]. Moreover, gardening activities can help patients develop an ideal self-image and continually develop work skills [12]. Because numerous factors in the living environment can affect people's emotions, a designed and selected environment can indeed quicken patients' emotional recovery [18–21]. For example, a successful therapeutic garden can reduce people's stress, even generating a sense of encouragement [22].

deserve. On the contrary, some nursing homes limit the elderly's lifestyle choices and social functions, which may damage their mental health and self-respect resulting in deterioration of their body and mind [1]. The goal of "Aging in place" was to fulfill the native's needs with domestic goods and services, which would require community-like facilities to build a longterm care system. Most of the assisted living facilities today in Taiwan are based on community activities to promote interaction among the elderly. Healthcare-oriented facilities should be considered more when daily activities and movements become less convenient for the elders. Japanese welfare economist [2] proposed five basic measures to ensure that the elderly live a normal life: avoid taking quarantine measures; allow them to live in an environment with which they are familiar as much as possible; facilitate their social exchanges and mutual assistance; provide facilities and services to maintain quality of life when institutionalized care becomes necessary; and integrate social welfare, medical and health, and environmental

Sandberg indicated that 95% of the elderly in Hong Kong have one or more chronic diseases; however, only 5.5% require institutionalized care [3]. Although nursing homes can help the elderly who cannot live independently [1], institutionalized care entails a change in living environment, and consequently, disconnection from family and society as well as a reduction in physical activities and enhanced loneliness [4]. Another study found that the physical activity level of the nursing home-dwelling elderly is considerably lower than that of the community-dwelling elderly [5]. In addition to facing changes to their environment and mobility, the elderly who move into nursing homes must deal with changes in daily life routine, social network, and social support [6]. Moving into a nursing home means the discontinuation of a person's traditional lifestyle with which they are familiar. In addition, the elderly can sustain an enormous sense of loss caused by separation from families, neighbors, and friends [1, 7]. When the elderly face gradual decline in physical and mental status, what can be done to ensure they age stably is a question that requires an answer. The American Horticultural Therapy Association (AHTA) maintained that horticultural therapy can be applied to people of various ages, backgrounds, and abilities. It defined horticultural therapy as "engaging in gardening-related activities through the assistance of a trained therapist to complete a specific therapeutic goal." Horticultural therapy has four major types of benefits: intellectual,

Intellectual benefits: Through horticultural therapy, participants can acquire new skills and knowledge, increase their vocabulary and communication skills, have their curiosity aroused, improve observation, receive occupational and pre-occupational training, receive stimulation

Social benefits: A successful treatment should involve three types of interaction: between the therapist and the client, between clients, and between the client and nonclient [16]. Generally, these interactions mainly are aimed at socializing and collaborating; specifically, sharing gardening experiences facilitates creating meaningful interactions. Because group members have a common goal, interactions among them can be increased on the basis of mutual respect and support, as well as duty sharing. During the process of gardening, patients have the opportunity to connect with people other than their group members and share their own gardening results with external parties, thereby gaining the benefit of an enlarged interpersonal network [4, 11, 17].

to their sensory organs [11–14], and obtain new learning opportunities [15].

maintenance policies to create a suitable living environment.

108 Occupational Therapy - Therapeutic and Creative Use of Activity

social, emotional, and physical [8–11].

Physical benefits: In addition to mental benefits, gardening activities help wounded or physically disabled individuals to improve their coordination and effectively control their motor neurons through tasks such as carrying plants, sowing seeds, applying fertilizer, and watering plants [11].

For the elderly, gardening enables them to improve physical and mental health through a leisure activity. Therefore, an increasing number of the retired elderly have devoted themselves to gardening activities, and numerous elderly nursing and home care centers have introduced horticultural therapy. Research has shown that horticultural therapy can improve the elderly's arthritis symptoms, and it exerts positive effects on blood pressure and diet control [2]. Furthermore, gardening activities can increase regular physical activities that require physical and mental stability as well as high-level functional activities [23]. Gardening practices have the clear effects of enhancing muscle strength, fine motor skills, and balance; in particular, transplanting requires grasping and releasing with the thumb and index finger as well as muscle flexibility [23, 24]. Gardening activities boost enthusiasm and senses of responsibility and achievement. From selecting plants to their growth and eventual flowering, plants continually create hope for people. Furthermore, learning gardening skills enhances the elderly's curiosity. Therapeutic use of activity can help the geriatric individuals to improve their independence in daily life, and cognitive and motor skills [13, 21, 23]. The activity that will be used as a therapeutic agent can be determined according to the interests, activity preference, and the skills of the geriatrics [19, 25, 26]. Gardening can expand people's social networks by providing opportunities to socialize [27]; thus, gardening activities have positive effects on the community-dwelling elderly.

Brown administered a 5-week horticultural therapy course to 66 older residents in nursing homes [28], and found that compared with the control group, residents in the test group exhibited significantly greater improvements before and after receiving the horticultural therapy in several items on the activities of daily living (ADL) scale, namely physical ambulation, feeding, and toilet. Austin applied a 5-week horticultural therapy course to eight elderly people who lived by themselves, the results of which revealed that their fitness, ADL scores, and 6-min walk test results all improved significantly after the intervention [29]. In addition, Son administered a 5-week horticultural therapy to five community-dwelling elderly people, and found that during vegetable-planting activities, they could use adapted tools and aids to teach the elderly to adjust to appropriate joint movement angles, balance using suitable postures, and train gross and fine motor skills, eventually improving their physical activity and self-maintenance abilities [30]. Thelander introduced a 6-week outdoor gardening intervention to eight older residents with dementia at a frequency of three times a week, for 40–70 minutes per session [31]. The results indicated that landscape maintenance tasks such as watering, weeding, and fallen leaf picking significantly improved the residents' balance. Gigliotti and Jarrott compared the elderly participating in gardening activities with counterparts receiving conventional treatment, and found that those in the horticultural therapy group exhibited significantly higher levels of activity involvement and positive emotions [32]. Lee and Kim implemented a 4-week gardening intervention comprising selecting bean cultivars, sowing seeds, watering plants, touching the plants they had planted, cleaning and maintaining the planting environment, and harvesting, cutting, and washing the plants; their results indicated that these indoor gardening activities significantly reduced anxiety [33]. Austin determined that after receiving horticultural therapy, the elderly exhibited significantly lower levels of anxiety [29]. By touching the plants they had planted, cleaning and maintaining the planting environment, and harvesting, cutting, and cleaning the plants, the elderly were engaged in higher levels of physical activity, which in turn improved their cognitive functions [33]. In addition, Sempik, Aldridge, and Becker noted that gardening activities strengthened the elderly's sense of responsibility and increased the opportunities for decision-making, through which their degradation could be slowed and the group became consolidated because of sharpened social skills [34]. However, gardening activities remain inadequate in the elderly's nursing homes. Although lawns and gardens are common in nursing institutions, they are rarely designed according to user needs. SCUs in France conducted a survey from 1992 to 2007, determining that less than 82% of medical institutions had freely accessible outdoor space, and only 43% provided patients with access to this outdoor space; thus, gardens were not regarded as a part of health management. Nevertheless, compared with conventional treatments that require hospitalization, horticultural therapy is generally more accessible to patients and easier to adapt to; furthermore, the costs are cheaper than other types of therapy. Despite gardening activities being widely recognized as a positive therapy, substantial efforts are still required to popularize this therapy in public care systems. Engaging in gardening activities typically requires the elderly to bend or squat. When planting is conducted in a standing posture, people in a wheelchair have difficulty participating because square tables have limited availability. Therefore, defining design conditions that support the elderly's participation in gardening activities is paramount. Research has shown that the first condition to be considered in horticultural equipment design is to lower the participants' physical burden. When the elderly are allowed to engage in the activities by themselves, their opportunities for mutual communication increased; however, their exchanges and communications reduced when a facilitator joined [35]. Circle theory in the field of environmental psychology maintains that using a round table enables people to see each other. However, results of one experiment revealed that simple concentric tables could not satisfy the requirements of wheelchair users and others with diversified physical conditions [36]. Even so, designers may still experiment with other shapes that have the effect of a circle to determine which table shape facilitates the interaction of people with varying physical conditions in a variety of venues. Horticultural therapy courses stimulate emotions, boost activity levels, reduce stress and fear through human-to-plant interactions, increase muscle relaxation, and promote confidence and knowledge. These courses promote user's sense of responsibility and self-fulfillment through

plant care, which also enhances cognitive capabilities. Group activities in planting and sharing experiences create community opportunities and respect among each other. There is a connection between social participation and environment recognition of the elderly [37, 38]. Besides, there is also a strong correlation between the elderly's ability to successfully interact with society and the quality of their facilities and surroundings. Their comfort with the surrounding environment and perception of the social interactions significantly aid their social ability [39]. Horticulture courses are crucial in planning regarding retirement and assisted-living facilities. Many studies showed mind-body health improvements among the elderly who partake in horticulture classes. However, implementing horticulture courses through assisted care and planning in these facilities are not enough. We need to consider an elder's activity level, physical ability, and health condition in gardening classes to implement communication and activity in

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This study investigates facilities that have implemented horticulture classes in their treatment. Through interviews and behavioral observation to find out the problems and conditions associated with horticulture classes, also understand the different types of gardening, facility deployment, and gardening treatment details and execution. This study also focuses on the duration of these classes to understand the effectiveness of horticulture classes that will

"House of Love" is a private nursing home and a research base established in 1923, for the elderly, people with no assistance, the sick, and the homeless. "House of Love" is also awarded for excellence by the Ministry of Home Affairs and Taipei City Hall. "House of Love" is the best long-term care center in Taipei that focuses on treatment of the body and mind (**Figure 1**). This study implemented records of long-term behavioral observation in "House of Love" with a focus on cases who participated in these horticulture classes, the

their curriculum.

**2. Method**

be helpful for future class design and planning.

**Figure 1.** Private nursing home "House of Love".

plant care, which also enhances cognitive capabilities. Group activities in planting and sharing experiences create community opportunities and respect among each other. There is a connection between social participation and environment recognition of the elderly [37, 38]. Besides, there is also a strong correlation between the elderly's ability to successfully interact with society and the quality of their facilities and surroundings. Their comfort with the surrounding environment and perception of the social interactions significantly aid their social ability [39]. Horticulture courses are crucial in planning regarding retirement and assisted-living facilities. Many studies showed mind-body health improvements among the elderly who partake in horticulture classes. However, implementing horticulture courses through assisted care and planning in these facilities are not enough. We need to consider an elder's activity level, physical ability, and health condition in gardening classes to implement communication and activity in their curriculum.

This study investigates facilities that have implemented horticulture classes in their treatment. Through interviews and behavioral observation to find out the problems and conditions associated with horticulture classes, also understand the different types of gardening, facility deployment, and gardening treatment details and execution. This study also focuses on the duration of these classes to understand the effectiveness of horticulture classes that will be helpful for future class design and planning.
