Received: 7 March 2023 | Revised: 8 August 2023 | Accepted: 13 September 2023

DOI: 10.1111/jocn.16908

REVIEW

Smellscape as a healing factor in institutional gardens to

enhance health and well-being for older people with dementia:
A scoping review

Yidan Huang MA, PhD Candidate1 | Xiaomei Yuan PhD, Professor1,2

1
School of Architecture, South China
University of Technology, Guangzhou, Abstract
Guangdong, China
Background: There is mounting evidence for the health benefits of aromatic scents
2
State Key Laboratory of Subtropical
Building and Urban Science, South China
for the older people with dementia. However, existing research has focused on indoor
University of Technology, Guangdong, aromatherapy using essential oils. It is necessary to explore the health benefits of
Guangzhou, China
smellscapes in the outdoor environment for older people with dementia.
Correspondence Aims and Objectives: This scoping review aims to examine existing evidence for
Xiaomei Yuan, School of Architecture,
South China University of Technology,
smellscape as a healing factor in institutional garden for older people with dementia,
381 Wushan Road, Tianhe District, try to bridge the knowledge gaps between outdoor sensory garden scents and aroma-
Guangzhou, Guangdong, China.
Email: [email protected]
therapy to develop green care techniques that incorporate outdoor activities.
Methods: Seven databases (Scopus, PubMed, PsycINFO, CINAHL, MEDLINE, Embase
Funding information
National Key Research and Development
and Web of Science) were searched with English language articles published between
Program of China, Grant/Award Number: 1990 and 2022. The PRISMA-ScR Checklist was used.
2017YFC0702905-03
Results: Out of 1013 articles, 11 meet the inclusion criteria. The comprehensive
health outcomes include five aspects: mental health; physical health; reduced agita-
tion behaviour; improved cognitive function; and well-being. These aspects are part
of the rehabilitation model comprising the person (older people with dementia), envi-
ronment (garden smellscapes) and outdoor activities (active or passive interventions
or a combination).
Conclusions: The smellscape, as a healing factor in the garden, not only benefits from
evidence on indoor aromatherapy but also creates a sensory environment for older
people with dementia by compensating for functional impairment, activity support
and environmental creation, thereby promoting enhanced health and well-being.
Relevance to Clinical Practice: The research on the healing effects of smellscapes
presented in this review offers a novel environmental intervention technique for
transferring evidence on essential oils to outdoor sensory gardens. This green care
technique is suggested to assist in the creation of healing environments and interven-
tions for people with dementia who cannot be cured.
No Patient or Public Contribution: This scoping review did not directly involve patient
or public contributions to the manuscript.

KEYWORDS
dementia, environment intervention, green care, healing factor, health outcomes, smellscapes

J Clin Nurs. 2023;00:1–15. wileyonlinelibrary.com/journal/jocn © 2023 John Wiley & Sons Ltd. | 1
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2 HUANG and YUAN

1 | I NTRO D U C TI O N
What does this paper contribute to the wider
Dementia is an acquired brain syndrome characterized by cog-
global community?
nitive decline from a previous level of functioning, with im-
pairment in two or more cognitive domains (World Health • The smellscape, as a healing factor in institutional
Organization, 2018). As the condition progresses, older people gardens, not only benefits from evidence on indoor
experience increasing deterioration in cognitive impairment, in- aromatherapy but also creates an outdoor sensory envi-
cluding a gradual decline in thinking, memory, comprehension, ronment that promotes health and well-being for older
numeracy, orientation, learning, judgement and language (World people with dementia.
Health Organization, 2012). They experience a range of psycho- • The findings identified the knowledge gaps between the
logical and behavioural impairments, as well as physical functional indoor aromatherapy evidences and the outdoor envi-
impairment due to ageing (Cerejeira et al., 2012). The medical ronment interventions. It offered an integrated frame-
field currently reports that dementia cannot be cured (Buckley & work for healing environment construction and initiated
Salpeter, 2015), and existing pharmacological treatments are not a new green care technique for older people with de-
recommended for most people with dementia, as the short-term mentia who cannot be cured.
benefits do not outweigh adverse effects such as accelerated
functional decline (Buckley & Salpeter, 2015). However, most peo-
ple with dementia can still create, learn and enjoy life because a Throughout history, human lives have depended on nature, and hu-
large proportion of active neurons are still functional. Instead of mans have learned to use nature to solve their problems. The first
focusing on the part of the brain that has stopped functioning, it recorded use of aroma elements to address health issues was in the
is recommended that the part of the brain that is still functioning form of extracts of 60,000-year-old herbs found in Iraq, some of
be valued (Zeisel & Tyson, 1999). In other words, health can be which are still actively used in medicine (Erichsen-Brown, 1979). In
promoted not only through a cure for disease but also through an 2000 BC, the earliest and most revered ancient Sanskrit medical
increased sense of well-being and happiness (Downie et al., 2000). texts in India recorded the use of myrrh and sandalwood by herbal-
Feelings such as comfort, attachment, inclusion and agency may ists to treat illnesses. Ayurveda refers to the plant as ‘the supreme,
promote higher levels of intersubjectivity and an overall improved needed remedy and blessing of the heart’ (Swerdlow, 2000). There
sense of well-being in older people with dementia (Kaufmann & is no doubt that the natural environment can stimulate health out-
Engel, 2016). Therefore, nonpharmacological treatment has be- comes and well-being, but sensory gardens have a greater effect
come the first choice for care for older people with dementia (Kim than other types of environments (Uwajeh et al., 2019). In the 20th
et al., 2012). However, current care settings and services are not century, Gattefosse (2012) discovered the healing properties of lav-
aligned with the preferences and needs of people with dementia. ender oil, which opened the way for modern aromatherapy. A recent
Quality care is not just about providing palliative care for a par- study suggested a neurobiological basis for the privileged access of
ticular symptom but also creating a positive, safe, person-centred smell to memory areas of the brain. In contrast to the other senses,
environment (Winblad et al., 2016). the olfactory pathway is directly linked to the brain, amygdala and
Adopting a person-centred nursing approach means that the en- hippocampus (Johnson et al., 2019; Zhou et al., 2021). Therefore, the
vironment should be seen as a positive component of dementia care. effects of aromatic compounds on the brain in multisensory envi-
Environmental interventions can reduce behaviours more effectively ronmental interventions are thought to be directly mediated and act
and inexpensively than other nonpharmacological interventions on mood (Holmes & Ballard, 2004). Olfactory inputs are more im-
(Kong et al., 2009). Many abnormal behaviours in people with de- portant than visual or auditory features for creating a stress-reliev-
mentia may be a sign of unmet environmental care needs or physical ing therapeutic environment (Hedblom et al., 2019), which indicates
and psychological needs (Dewing, 2010), particularly in a standard- a potential breakthrough in the design of healing environments for
ized institutional environment. Such unmet environmental needs older people with dementia.
could exacerbate problems such as psychological distress, isolation, First, advances in neurobiology suggest that the human hippo-
aggression, behavioural disturbances and loss of identity in hospital- campus is more strongly connected to olfactory senses than other
ized patients (Calkins, 2009) and could lead to significantly reduced sensory systems and that the hippocampus associates smell with
healing (Devere, 2012). Previous research has found that natural specific memories (Zhou et al., 2021). Odours enter the limbic sys-
environments can provide benefits such as sensory experiences, tem and thus regulate emotion, perception, behaviour and memory
fresh air, interactions with nature, and the generation of memories, processing (Daniels & Vermetten, 2016; Duffee & O'Brien, 2001),
confidence, freedom and dignity for older people with dementia both consciously and unconsciously. Next, through the olfactory
(Hendriks et al., 2016; Olsson et al., 2013). The environment exac- bulb's connection to the amygdala, certain scents may evoke emo-
erbates the consequences of cognitive impairment and disorders tional states (Holmes & Ballard, 2004). When aroma molecules
related to dementia, which can be mitigated if the design is appro- enter an individual's nasal cavity, they cause a rapid release of
priate according to the needs of this population (Gueib et al., 2020). neurochemicals such as dopaminergic, cholinergic, glutamatergic
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HUANG and YUAN 3

and gamma-aminobutyric acid (GABA) in the individual's brain 2 | M E TH O D S

(Agatonovic-Kustrin et al., 2020). This results in a relaxed, happy and
joyful physical and mental state (Mannucci et al., 2017). Furthermore, 2.1 | Research design and methodology
the stimulation of the olfactory bulb by aroma affects the limbic sys-
tem of the brain, or the reticular formation of the brainstem, trigger- To identify relevant articles, we consulted an extensive elec-
ing the individual's emotions. This may have a significantly positive tronic database, including Scopus, PubMed, PsycINFO, CINAHL,
impact on different aspects of the individual's mood, memory, cogni- MEDLINE, Embase and Web of Science, for peer-reviewed articles
tion, behaviour and physiology (Daniels & Vermetten, 2016; Duffee published in English language published between January 1990
& O'Brien, 2001; Holmes & Ballard, 2004). and July 2022 that focus on the healing effects of smellscapes as
There is growing positive evidence for the use of essential a healing factor on older people with dementia. In the databases,
oils in aromatherapy for dementia (Ballard et al., 2002; O'Connor three distinct groups of terms were applied: (1) Intervention: ‘smell
et al., 2013; Takahashi et al., 2020; Watson et al., 2019; Yang (and synonyms)’ and ‘smellscapes (and synonyms)’. (2) Outcome:
et al., 2015), and the concentration, dosage, duration and frequency ‘health (and synonyms) and well-being’. (3) Target group: ‘dementia
of the use of essential oils are progressively becoming standardized (classification or synonyms)’. The strategy was based on a com-
in practice. Essential oils are usually used indoors, and many studies bination of terms; using the Boolean operators ‘OR’ and ‘AND’
of multisensory environmental interventions have used indoor mul- (see Appendix S1). These keywords were used to identify articles
tisensory intervention rooms (e.g. Snoezelen rooms) to treat older that helped us answer the research questions for this study. The
people with dementia. However, this is an expensive option that PRISMA-ScR (Preferred Reporting Items for Systematic Reviews
is impractical in many geriatric care settings (Maseda et al., 2018). and Meta-Analyses extensions for Scoping Reviews) checklist was
Outdoor green spaces have the potential to help older people with selected (Figure 1) for addressing different sections of the review
dementia achieve an active and meaningful life (Mmako et al., 2020). (Tricco et al., 2018) (see Appendix S2). Two reviewers evaluated
Many scholars have explored how multisensory gardens and demen- the studies for inclusion, and extracted the key information inde-
tia-friendly environments offer the best form of support for peo- pendently. The researchers screened the articles using the infor-
ple with dementia to participate in daily life in a meaningful way. mation available in the titles and abstracts. Then, the researchers
However, smellscapes have been widely neglected in the litera- read the full text to confirm the eligibility of each article based on
ture (Gonzalez & Kirkevold, 2014; Mmako et al., 2020; Motealleh the inclusion and exclusion criteria.
et al., 2019; Smith & D'Amico, 2020). Evidence suggests that garden
smellscapes could have a profound effect on people, regardless of
whether they are aware of these smellscapes (Hummel et al., 2006). 2.2 | Inclusion and exclusion criteria
It is worth exploring smellscapes as a healing factor in gardens to
enhance the health and well-being of older people with dementia. Inclusion and exclusion criteria were applied to all studies, enabling a
The smellscape has been defined as the total smell landscape, transparent and focused selection of articles of interest. In the initial
including individual odours, combinations of odours and the over- screening of titles and abstracts, we excluded studies if they were
all background odour (Henshaw, 2013). In this review, the concept not (1) relevant to our topic or research question; (2) focused on de-
of smellscape is defined as an odour environment that is perceived, mentia; (3) sensory interventions of smell; (4) human studies; or (5)
experienced or understood by an individual or a group in a certain in the English language. During our evaluation of the full texts, we
context. Similar to Xiao et al.'s definition (Xiao et al., 2018), this defi- excluded studies if they did not: (1) include smellscapes; (2) focus on
nition emphasizes human perception, which includes actual percep- the environment; (3) directly or indirectly measure or observe health
tion, the memory of experience and the imagination of absence, as outcomes and wellbeing; (4) focus on people over 65 years old or
a relationship between the environment and odour. The aim of this if (5) participants had different types of dementia. The diagnostic
scoping review is to examine and describe the key information from categories included were Alzheimer's disease, vascular dementia,
the research field regarding the evidence for smellscapes as a heal- frontotemporal dementia and mixed Alzheimer's disease and vas-
ing factor in institutional garden for older people with dementia, to cular dementia (Association, 2013). Considering the novelty and
attempt to build a bridge between the scents of outdoor sensory uniqueness of smellscapes in this research area, we did not adopt a
gardens and indoor aromatherapy oil research and to provide guid- systematic approach and kept the study selection flexible to include
ance for the development of green care techniques that incorporate literature that met the criteria in the study.
outdoor activities. The specific questions used to guide this review
included:
Question 1: What are the health outcomes of smellscapes in gar- 2.3 | Data extraction
dens for older people with dementia?
Question 2: What kind of smellscapes are presented in gardens, Based on a standardized data extraction form, the author extracted
and what activities involved enhance the health and well-being of data independently from each study. Data extracted from each of
older people with dementia? the included articles were tabulated in terms of study characteristics
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4 HUANG and YUAN

F I G U R E 1 PRISMA flow diagram.

(lead author, year of publication, study region, setting), sample environments; 15 articles did not include subjects with dementia;
characteristics (sample, severity), study methods (design, assess- and 6 articles did not examine health-related outcomes. Finally,
ment, categories, environment, activity), interventions (duration, this scoping review included 11 studies that met the screening cri-
frequency, sessions length) and outcomes. A data extraction form teria (Figure 1).
was created in a Microsoft Excel file for data management of the The selected articles were published between 2004 and 2021.
included studies. The studies were conducted in Oceania, Europe, Asia and North
America. The study countries/regions included Australia (n = 3),
Japan (n = 3), France (n = 2), the United States (n = 1), Canada (n = 1)
3 | FI N D I N G S and Switzerland (n = 1). The settings of these studies were nursing
homes (n = 2), aged care facilities (n = 2), hospitals (n = 2), gardens
3.1 | Study characteristics (n = 2), care retirement centre (n = 1) and day care centres (n = 2). The
review findings were generated from the charted data (Table 1).
A total of 1013 articles were identified from the six databases In this scoping review, 11 studies assessed the effects of smells-
searched. After the researchers reviewed the titles and abstracts capes as a healing factor in gardens for older people with demen-
of these articles, 432 articles were retained. After the full texts tia using several research methods. Three studies used randomized
were read, 106 articles were screened out. Of these articles, 95 controlled trials (Bourdon & Belmin, 2021; Goto et al., 2017; Gueib
were excluded for the following reasons: 48 articles did not in- et al., 2020); three were quantitative studies using a nonrandom-
clude scent/smellscape interventions; 26 articles did not focus on ized controlled trial (Collins et al., 2020; Koura et al., 2018; Koura &
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HUANG and YUAN 5

Ikeda, 2016); four were mixed-method studies (Anderson et al., 2011; in a framework diagram, as shown in Figure 2. This diagram aligns
Cox et al., 2004; Edwards et al., 2013; Prolo & Sassi, 2017); and one with the person, function and environment model to support the
was a qualitative study (Smith-Carrier et al., 2021). For data col- interactions among functional impairment in older people with de-
lection tools, most scholars used the questionnaire survey method mentia, garden smellscapes and outdoor activities associated with
(Bourdon & Belmin, 2021; Collins et al., 2020; Cox et al., 2004; dementia (Xie & Yuan, 2022). Smellscapes, as a factor in outdoor
Edwards et al., 2013; Goto et al., 2017; Gueib et al., 2020; Koura multisensory environments, provide an integrated health outcome
et al., 2018; Prolo & Sassi, 2017), while some used objective mea- for older people with dementia. The findings of this study deepen
sures (Goto et al., 2017; Koura et al., 2018; Koura & Ikeda, 2016), the understanding of the relationship between the functioning
observation (Anderson et al., 2011; Cox et al., 2004; Edwards of older people with dementia and the environment with smell-
et al., 2013) and interviews (Anderson et al., 2011; Cox et al., 2004; scapes. In addition, the findings provide a new perspective for
Edwards et al., 2013; Prolo & Sassi, 2017; Smith-Carrier et al., 2021). research in rehabilitation medicine and environmental design and
Subject sample sizes varied in the literature under review, with facilitate innovative green care techniques.
sample sizes ranging from 4 (Collins et al., 2020) to 120 (Bourdon &
Belmin, 2021); however, most studies were smaller than 30 (Anderson
et al., 2011; Collins et al., 2020; Cox et al., 2004; Edwards et al., 2013; 3.2.1 | Person—Older people with dementia
Goto et al., 2017; Koura et al., 2018; Koura & Ikeda, 2016; Prolo &
Sassi, 2017; Smith-Carrier et al., 2021). According to the studies, The literature included in this study focused on the environmental
the mean age of participants with dementia ranged from 76.2 ± 6.7 domain and reported the main cognitive impairments as well as
(Koura & Ikeda, 2016) to 92 ± 6 years (Goto et al., 2017). All studies other functional impairments of older people with dementia. The
included older people in different stages of dementia, such as mod- symptoms of dementia identified in the included studies were cog-
erate dementia (Prolo & Sassi, 2017; Smith-Carrier et al., 2021); mild nitive impairment (Anderson et al., 2011; Bourdon & Belmin, 2021;
to moderate dementia (Bourdon & Belmin, 2021; Gueib et al., 2020); Collins et al., 2020; Cox et al., 2004; Edwards et al., 2013; Goto
mild and substantial cognitive impairment (Collins et al., 2020); se- et al., 2017; Gueib et al., 2020; Koura et al., 2018; Koura &
vere, moderate and mild dementia (Edwards et al., 2013); moderate Ikeda, 2016; Prolo & Sassi, 2017; Smith-Carrier et al., 2021), usu-
or severe dementia (Goto et al., 2017; Koura et al., 2018); and severe ally in the form of diminished cognitive functions such as mem-
dementia (Anderson et al., 2011; Koura & Ikeda, 2016). One study ory, orientation and judgement; a decrease in daily living ability
noted that older people with dementia who could not show emo- (Edwards et al., 2013; Prolo & Sassi, 2017); and potential aggres-
tional responses were excluded from the analysis (Cox et al., 2004). sive and agitated behaviour, depression and emotion (Anderson
In terms of intervention time, the average total intervention time et al., 2011; Collins et al., 2020; Edwards et al., 2013). While it is
and frequency differed for each study. A small number of studies true that cognitive impairment and functional impairment cannot
used short-term interventions for older people with dementia, such be cured, it is possible to compensate for the impairments associ-
as 15 min and 30–40 min, usually using electrocardiogram and heart ated with ageing and neurocognitive disorders by giving older peo-
rate monitors to measure their short-term transient health effects ple with dementia a better environment in which to lead a healthy
(Goto et al., 2017; Koura et al., 2018; Koura & Ikeda, 2016). Most life to promote well-being (Bourdon & Belmin, 2021). Therefore,
studies conducted long-term sensory interventions for older people the outdoor environment for older people with dementia must be
with dementia, ranging from 1 week to 3 months to measure their designed to meet specific needs (Prolo & Sassi, 2017). However,
long-term health outcomes mainly through psychological scales, specific patterns of how the environment affects body function
life satisfaction scales and cognitive scales (Anderson et al., 2011; and structure have not been explained in sufficient details in the
Bourdon & Belmin, 2021; Collins et al., 2020; Cox et al., 2004; included literature. A large amount of evidence points to the bene-
Edwards et al., 2013; Gueib et al., 2020; Prolo & Sassi, 2017). ficial effects of sensory stimulation on brain functions, and odours
are of particular value to older people with dementia because of
their direct connection to the hippocampus (Zhou et al., 2021).
3.2 | The application of smellscapes as a healing Therefore, there is an important scientific basis for garden smells-
factor in gardens capes as a healing factor for older people with dementia.

From all of the above studies, it can be concluded that the outdoor
smellscape is constructed by living aromatic plants. Evidence for 3.2.2 | Environment—Garden smellscapes
this comes from the use of aromatic plant oils in aromatherapy,
which has proven to be effective for older people with dementia. In this review, the health effects of garden smellscapes on older
However, in outdoor gardens, the smellscape does not appear as people with dementia that were discussed in the selected litera-
a stand-alone element and is often combined with other sensory ture consisted mostly of effects derived from aromatic plants
elements and accompanied by outdoor activities. The smellscape that were confirmed by the results of indoor aromatherapy
influences integrated health outcomes, which can be summarized studies (Collins et al., 2020; Cox et al., 2004; Gueib et al., 2020;
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6 HUANG and YUAN

TA B L E 1 Characteristics of the included studies (N = 11).

Sample characteristics Study methods

Study Country Setting Sample Severity Design Assessment

Goto et al. (2017) Japan General hospital • Test 1: N = 10, dementia, Middle-late-stage Quantitative study • MMSE
90 ± 5 Y/O. dementia (RCT, questionnaire • Attention and behavioural
• Test 2: N = 11, dementia, and instrument) assessment
90 ± 5 Y/O. • Tests 3 and 4: • Heart rate test
N = 8, dementia, 92 ± 6 Y/O • Olfactory test
• Eye movement

Collins et al. (2020) USA Care retirement N = 4, dementia, 77–95 Y/O Substantial and Quantitative study • ABMI
centre mild cognitive (Non-RCT, • CMAI
impairment questionnaire) • DEMQOL Proxy

Bourdon & France Nursing home N = 120, demenria, 81 ± 3.5 Severe Quantitative • MMSE
Belmin (2021) Y/O behavioural study (RCT, • ADL
problems were questionnaire) • Timed up and go test (TUG)
excluded • Unipedal stance tests

Koura & Japan Horticultural N = 7, dementia, 76.2 ± 6.7 Y/O Moderate or Quantitative study Electrocardiogram (ECG)
Ikeda (2016) therapeutic severe (Non-RCT,
garden dementia instrument)

Edwards Australia Aged care N = 10, dementia, 79–90 Y/O Four severe Mixed-method • DEMQOL and DEMQOL
et al. (2013) facilities dementia, research (Non-RCT, Proxy;
three questionnaire, • CSDD
moderate interviews, and • CMAI
dementia, and observations) • MMSE
three mild • Interviews
dementia • Observations

Koura et al. (2018) Japan Horticultural • Test 1: N = 7, dementia, Moderate or Quantitative study • Electrocardiogram (ECG)
therapy 76.2 ± 6.7 Y/O severe (Non-RCT, • MMSE
garden • Test 2: not related to dementia questionnaire and • CDR
dementia instrument) • DBD
• Test 3: N = 1, dementia, Y/O • PSMS

Prolo & Switzerland Day care centre N = 15 (4 males; 11 females), Moderate Mixed-method • CBA;
Sassi (2017) 69–87 Y/O dementia research (Non-RCT, • Semi-structure interview
questionnaire and
interview)

Gueib et al. (2020) France Hospital N = 34, (• G−: N = 18, 82.4 ± 6.2 Mild to moderate Quantitative • SCQ
Y/O • G+: N = 16, phases of study (RCT, • MMSE
82.1 ± 7.8 Y/O) dementia questionnaire) • GDS
(<1/3 success • FAB
result on the • NPI-NH
MMSE) • MT86

Smith-Carrier Canada Adult day centre N = 6, dementia, years old not Early stages of Qualitative study (Non- Semi-structured interview
et al. (2021) specified dementia RCT, interview)
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HUANG and YUAN 7

Intervention

Sessions
Categories Attributes of environment Activity Duration Frequency length Outcomes

Ambient The Japanese garden plants Passive (Smelling the • Test 1:3 weeks Test 1: twice a • Test 4:15 min • Attention and
scent composed of bamboo, chrysanthemum) • Test 2: 2 weeks week; Other • Other test: Behaviour of
chrysanthemum, • Tests 3 and 4: 1 week test: Not Not stated individuals (NS)
palm, ferns, and an stated • Bivariate analysis. heart
artificial odour of rate (−)
chrysanthemum

Sensory The sensory garden Active (Interaction and 12 weeks Three times a week 30–45 min • Agitation and
garden consisted of non-toxic touch with sensory behaviour (−);
herb plants with aroma, plants) • Quality of life (+) a:
tactile, and edible, and Descriptive analysis
near windows or in
the light

• Sensory Sensory amplification Active (Planting of 6 months Four times a week 10–20 min • Cognitive function (+)
garden module, Multi-sensory vertebral implant • Activities of daily
• Enriched material place, and pools; Sniffing living (+)
garden Ergonomic gardening sensory materials) • Ability to walk (+)
• Unipedal stance
values (+)

Horticultural Horticultural therapeutic Both active (Walk 30–40 min Not stated 30–40 min Parasympathetic and
therapy garden consisting of around the sympathetic balance
favourite herb plants horticultural
(apple mint, lemon therapeutic
balm, rosemary, garden) and
lavender) passive (olfactory
stimulation of
favourite herbs)

Therapeutic The atrium and garden with Both active (A 3 months Not stated Not stated • Quality of life score (+)
garden fragrance, sunshine and interactive sensory • Depression (−)
breeze wander garden) and • Agitation (−)
passive (Sit down
and smell the herbs)

Horticultural A horticultural therapy Both active (Walking • Test 1: 30–40 min • Test 3: farm Not stated • Autonomical nervous
therapy garden consisting of and planting • Test 2: periods from (three times a system (+)
favourite herb plants flowering plants) April 2014 to March week) • Relaxation (+)
and a cultivated garden and passive 2017 • Others: Not • Mood (+)
of flowering plants (Olfactory • Test 3: 2–3 months stated
stimulation with
essential oils)

Sensory The hanging garden Active (Touching and 3 months Not stated Not stated Calmer and relaxed (+) a:
garden compose of aromatic smelling aromatic Descriptive analysis
herbs (lavender, herbs)
thyme, sage, mint, and
rosemary), and a fence
full of jasmine

Healing The garden with fragrant Active (Observe, water, 2 weeks Not stated 12 cumulative Body representation (+)
garden and scented plants or taste aromatic hours
plants or fruits)

Therapeutic The horticultural garden Active (Sensing 5 months Six sessions 3 days • Activating the senses
garden has fresh soil, fragrant odours in planting, • Engaging in meaningful
flowers, and aromatic maintenance and work
produce harvesting) • Nurturing curiosity
• Social interaction
• Live in the moment
• The positive mental and
physical well-being
a: Descriptive analysis

(Continues)
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8 HUANG and YUAN

TA B L E 1 (Continued)

Sample characteristics Study methods

Study Country Setting Sample Severity Design Assessment

Anderson Australia Residential N = 12, dementia, 81–94 Y/O Severe dementia Mixed-method • Behaviour observation
et al. (2011) aged care (a mean Mini- research (Non-RCT, • Focus Group interview
facilities Mental State observation and
Exam 32 score interview)
of 5.7)

Cox et al. (2004) Australia Nursing home N = 24, dementia, years old not Not capable of Mixed-method • ARS
specified showing research (RCT, • Observation
some affect questionnaire, • Interviews
response were observation, and
excluded interview)

Abbreviations: ‘−’, negatively significant; ‘+’, positively significant; a, descriptive analysis; NS, not significant.

Koura et al., 2018; Koura & Ikeda, 2016; Prolo & Sassi, 2017). For et al., 2013; Goto et al., 2017). The Japanese garden design exam-
example, Collins et al. (2020) set up non-toxic plants, including ined in one article was typical of a Japanese tea garden and con-
cilantro, rosemary and others, near windows or under lights to sisted of stones, plants, water basins, stone lanterns and bamboo
stimulate the senses. Gueib et al. (2020) suggested the need to fences. The plants included bamboo, chrysanthemums, palms and
consciously choose plants that provide shade, that are non-toxic ferns (Goto et al., 2017). Edwards et al. (2013) created a therapeutic,
and odoriferous and that are familiar to older people with demen- interactive, sensory walking garden and an atrium overlooking the
tia. Prolo and Sassi (2017) investigated an aerial garden consist- gardens of an aged care facility that was exposed to the aromas,
ing of wooden tables on a ramp with aromatic herbs as well as a sunlight and breezes that emerged from the gardens. The sensory
garden enclosure interwoven with vegetation and covered with garden in an experiment by Anderson et al. (2011) contained fea-
jasmine that gave the illusion of being in an open space. Some tures such as fishponds, birdhouses, plants and flowers, providing
of the included articles also discussed favourite herbs used in residents and staff with the opportunity to discuss and respond to
horticultural therapy for olfactory stimulation. In some articles, sound, sight, smell and touch.
favourite herbs (apple mint, lemon zest, rosemary and lavender)
were used in horticultural therapy for olfactory stimulation (Koura
et al., 2018; Koura & Ikeda, 2016). Cox et al. (2004) reported on a 3.2.3 | Activity—Active, passive or a combination
garden that included raised garden beds with plants selected for
their colour, texture and fragrance. For example, the residents in Activity in outdoor gardens can be classified as ‘active’, ‘passive’
this study usually picked lavender from the planting beds and con- (Gonzalez & Kirkevold, 2014; Hernandez, 2007) or a combination of
tinued to smell it for the remainder of the day. the two. In terms of activity modalities for mental health in smell-
The included literature also examined the use of aromatic plants scapes, two of the studies included active engagement activities
in facilities to form smellscapes to support the activities of older for older people with dementia; the activities included touching
people with dementia. For example, Bourdon and Belmin (2021) and smelling herbs and picking lavender (Cox et al., 2004; Prolo &
reported that gardens with pyramidal plant growth modules were Sassi, 2017). In addition, three studies included a combination of
used for sensory stimulation activities. In addition, ergonomic gar- active and passive activity modalities (Edwards et al., 2013; Koura
dening models were used for gardening activities for older peo- et al., 2018; Koura & Ikeda, 2016). Prolo and Sassi (2017) reported
ple with dementia who had mobility problems or were wheelchair on aromatic herb gardens where the edge of a table was used as
bound. Finally, multisensory material experience areas were created a handrail to allow wheelchair-bound patients to touch and smell
so that older people with dementia could experience differences in aromatic plants. The study highlighted the importance of allowing
materials by walking through, seeing and smelling special structures residents to be actively involved and giving residents the opportu-
and materials to support cognitive activities. Both Koura et al. (2018) nity to actually pick flowers as opposed to sitting passively indoors.
and Smith-Carrier et al. (2021) described studies in which the instal- For example, when the residents in this study picked lavender, they
lation of cultivation and horticultural gardens with fragrant flowers usually took it and continued to smell it for the remainder of the
resulted in improvements in emotional and overall well-being for day (Cox et al., 2004). However, another study concluded that both
older people with dementia. active and passive activities could promote mental health in older
Smellscapes in multisensory environments where aromatic people with dementia. As one of the staff reported, ‘We bring them
plants are combined with other material and sensory elements were [older people with dementia] here to relax. They often come in at
also reported in the included studies (Anderson et al., 2011; Edwards other times to water the garden, or watch the fish and smell the
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HUANG and YUAN 9

Intervention

Sessions
Categories Attributes of environment Activity Duration Frequency length Outcomes

• Snoezelen The garden comprised Both passive (Snoezelen: 6 weeks (Snoezelen Threee sessions At least 20 min • Snoezelen room:
room raised garden beds, use of sensual room: 3 weeks; disturbed/disengaged
• Garden plants selected for stimulation while Garden:3 weeks) behaviour (−); •
colour, texture, and sitting in a recliner) Garden: disturbed/
aroma and active (Garden: disengaged
Discussing and behaviour (−) a:
touching) Descriptive analysis

• Living room The garden contained Active (Picking lavender) Three activities during Nine sessions 16 min Pleasure (+)
• Snoezelen features, including a three individual
room fish pond, aviary, trees, 16-minute sessions
• Landscaped and flowers
garden

herbs…They are happier and so are we’ (Edwards et al., 2013). Koura Active methods (Bourdon & Belmin, 2021) and a combination
and Ikeda (2016) and Koura et al. (2018) described older people with of active and passive activities (Koura et al., 2018) emerged in the
dementia walking in a horticultural therapy garden and interacting literature with regard to the role of garden smellscapes in enhanc-
with their favourite herbs using a combination of active and passive ing cognition. Bourdon and Belmin (2021) established material sites
participation. that allowed older people with dementia to experience differences
Activities in gardens that affect the physical health of older in materials by touching, seeing and smelling. In addition, ergonomic
people with dementia can be divided into active (Bourdon & flower-growing beds were constructed for older people in wheel-
Belmin, 2021; Gueib et al., 2020) and passive activities (Goto chairs or with reduced mobility to increase their initiative in cultivat-
et al., 2017). For example, planters with small strawberry plants as ing plants. Koura et al. (2018) concluded that when passive aromas
well as aromatic and scented plants can be installed in a garden and (rosemary and lemon essential oils during the day and lavender and
can be observed, watered or tasted by patients (Gueib et al., 2020). orange essential oils at night) were combined with active gardening,
Bourdon and Belmin (2021) reported on vertebral implant pools the benefits of gardening activities had an overall positive impact
that can be altered to act as sensory amplification modules in an on the emotional well-being of older people with dementia. In this
enhanced garden. Goto et al. (2017) argued that people with late- study, improved evaluation indices were maintained for more than
stage dementia were essentially passive in viewing the garden due 2 years through continuous active and passive horticultural therapy
to their limited physical abilities, but the results of the eye-tracking (Koura et al., 2018).
experiments showed that the presence of odours changed the focus This study found that activities to enhance the well-being of
of their attention. older people with dementia could be categorized as active (Collins
This study found that improvements in the behaviour of older et al., 2020; Smith-Carrier et al., 2021) or a combination of active
people with dementia and activities were inextricably linked. and passive approaches (Edwards et al., 2013). In a representa-
The activities included in the articles were categorized as ac- tive article, Smith-Carrier et al. (2021) included the words of an
tive (Collins et al., 2020) or a combination of active and passive older people with dementia who were actively engaged in plant-
(Anderson et al., 2011; Edwards et al., 2013; Koura et al., 2018). ing: ‘The smell takes us to the past… Close your eyes and the pic-
Collins et al. (2020) described in detail an active sensory inter- tures come’. Another older people with dementia shared during
action with plants, such as whether the odour evoked memories spring cleaning, ‘The smell of the dirt, it brings back memories…’.
and whether the odour was familiar. In addition, one study found Collins et al. (2020) reported that researchers invited participants
that while wandering through gardens allowed for positive inter- to actively interact with each plant in the sensory garden at least
action, simply sitting and enjoying the sights, smells and sunlight once. For rosemary plants, participants were asked what the plant
could have an ameliorating effect on agitated behaviour (Edwards reminded them of and whether the smell was familiar. Edwards
et al., 2013). Anderson et al. (2011) described walks alongside et al. (2013) described the potential of therapeutic gardens with
flowering plants in a sensory garden and the passive use of es- sensory stimulation to promote active and passive activities in
sential oils indoors for the olfactory stimulation of older people older people with dementia, and demonstrated through quali-
with dementia. A second experiment by Koura et al. reported on tative and quantitative findings that the therapeutic garden sig-
a scent intervention that involved older people with dementia ac- nificantly improved their quality of life. These views indicate that
tively walking to a ‘contact farm’ to plant flowering plants and there is a need for older people with dementia to interact more
passively using rosemary, lemon, lavender and orange essential with outdoor gardens and participate in activities to enhance their
oils (Koura et al., 2018). health and well-being.
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10 HUANG and YUAN

F I G U R E 2 An integrated framework for smellscape as a healing factor in institutional gardens for older people with dementia.

3.2.4 | Integrated health outcomes administered a short 5-item questionnaire. These authors found
that after 3 months, all older people with dementia in their study
This study found that the environment formed by garden smells- felt calmer and more relaxed after visiting the aromatic herb gar-
capes and activities resulted in integrated health outcomes for older den. Koura and Ikeda (2016) and Koura et al. (2018) used non-in-
people with dementia. The healing effects on the mental health of vasive electrocardiography to measure the favourite herbs (apple
older people with dementia were confirmed by the largest number mint, lemongrass, horse cherry and lavender) of older people with
of studies (Cox et al., 2004; Edwards et al., 2013; Koura et al., 2018; dementia for 30–40 min. The results indicated emotional improve-
Koura & Ikeda, 2016; Prolo & Sassi, 2017). In terms of mental health ment demonstrated by the balance indicators of parasympathetic
outcomes, Cox et al. (2004) used the Affective Rating Scale (ARS) and sympathetic nerves.
to evaluate each participant's experience of three activities in In terms of physical health, three scholars explored the inte-
three different environments (living room, garden and Snoezelen grated health outcomes of garden smellscapes on activities of
room) in three 16-minute periods. The results showed no signifi- daily living, walking ability, one-legged standing values (Bourdon
cant differences between the three environments but statistically & Belmin, 2021), heart rate (Goto et al., 2017) and physical per-
significant differences in pleasure scores before and after the ac- formance (Gueib et al., 2020) in older people with dementia. Goto
tivities. Edwards et al. (2013) used the Cornell Scale of Depression et al. (2017) used an iWorx pulse rate monitor to continuously
in Dementia (CSDD) to assess subjects in a therapeutic garden monitor the heart rate and attention of older people with dementia
with scents. They showed that after 3 months of the sensory gar- within 15 min of the addition of chrysanthemum odour to the room.
den intervention, indicators of psychological depression improved. The results indicated that the odour reduced the participants' heart
Prolo and Sassi (2017) performed semistructured interviews and rate in the first 3–4 min. Gueib et al. (2020) used a self-awareness
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HUANG and YUAN 11

questionnaire to investigate changes in older people with demen- for 12 weeks and showed that the garden was an effective inter-
tia after a 2-week period in a therapeutic garden with aromatic vention for improving well-being. Edwards et al. (2013) used the
plants and found improvements in body performance. Bourdon and Dementia Quality of Life (DEMQOL) and Dementia Quality of
Belmin (2021) invited older people with dementia to engage in an Life-Proxy (DEMQOL Proxy) questionnaire and showed that when
enriched garden intervention for 10–20 min four times a week for a therapeutic garden with herb smells was used for three months,
6 months and found that the questionnaire data showed improve- the average quality of life scores of older people with dementia in-
ments after the intervention. creased significantly by 12.8%. In addition, a doctor reported that
Agitation and behaviour are generally considered the most com- the sensory garden improved the residents' well-being so that he
mon problems for people with dementia. Four articles included in did not have to visit as often (Edwards et al., 2013).
this study described the ameliorating effect of garden smellscapes
on this symptom (Anderson et al., 2011; Collins et al., 2020; Edwards
et al., 2013; Koura et al., 2018). Most studies have used observa- 4 | DISCUSSION
tion to study the behaviour of older people with dementia. Edwards
et al. (2013) used the Cohen–Mansfield Ageing Inventory (CMAI) to 4.1 | Summary of main findings
observe the effects of a sensory intervention on participants in a
therapeutic garden with an herbal scent for 3 months and confirmed The finding that smellscapes can serve as a healing factor and ben-
a reduction in agitated behaviour in older people with dementia. efit green care technology by providing older people with dementia
This finding was also supported by Collins et al. (2020), using the with a chance to deepen their connection with nature and enhance
Ageing Behaviour Mapping Instrument (ABMI) and the CMAI, a sen- their quality of life is a major discovery. This literature review dem-
sory stimulation intervention of 30–45 min three times a week for onstrates that even though knowledge in this area of research is
12 weeks. The study by Anderson et al. (2011) showed that 13.3% limited, the available knowledge generally presents a promising ap-
of observed behaviours were categorized as disruptive/disengag- proach to improving the health and well-being of older people with
ing prior to engaging in the garden activity, but the prevalence of dementia. The evidence obtained from many of scholars focusing
these behaviours dropped to 1.43% within 6 min of a garden activity on aromatherapy as an isolated sensory factor was used as a basis
where seating, shade and flowers were provided. Koura et al. (2018) for this study, which predominantly examined individuals' periph-
used the Dementia Behavioural Disorder Scale to measure the pos- eral symptoms, such as agitation and other behavioural symptoms
itive impact of improvements in the behaviour of older people with (Fung et al., 2012; Herz, 2009; Li et al., 2021). Therefore, this study
dementia following a 2- to 3-month intervention involving a combi- of garden smellscapes benefits from and complements the findings
nation of active and passive gardening. of aromatherapy research. In fact, gardens with aromatic plants as
The most common functional impairment in older people with a sensory stimulus and the Snoezelen room with essential oils as an
dementia is the gradual loss of memory and cognitive decline. Two olfactory intervention have both improved the health of older peo-
studies reported the health benefits of garden smellscapes on mem- ple with dementia in different ways (Cox et al., 2004). The difference
ory and cognition (Bourdon & Belmin, 2021; Koura et al., 2018). between the two is that smellscapes in gardens allow older people
Bourdon and Belmin (2021) administered an enriched environment with dementia to engage both actively and passively with their en-
intervention to older people with dementia via the Mini-Mental vironment, promoting a focus on their primary symptoms and, more
State Examination (MMSE) scale for 10–20 min four times a week for importantly, the improvement of their quality of life and their over-
6 months and found that the enriched environment enhanced the all well-being (Collins et al., 2020; Edwards et al., 2013). Green care
participants' cognitive abilities and cognitive reserve. A second trial techniques focus on the residual capacity of older people with de-
by Koura et al. (2018) reported improvements in MMSE and Clinical mentia as a starting point rather than on their limitations.
Dementia Rating (CDR) scores for active and passive horticultural In contrast to the methods and goals of using aromatherapy in-
therapy for 2–3 months after older people with dementia entered a doors, this literature review shows that smellscapes as a green care
welfare facility. technique can facilitate environmental interventions in dementia
To examine the effect of garden smellscapes on the well-be- care in three ways. First, this study found that smellscapes can com-
ing of older people with dementia, two scholars used subjective pensate for the functional impairment associated with dementia.
measures of questionnaires as an evaluation method (Collins This idea is also confirmed by previous research that has shown that
et al., 2020; Edwards et al., 2013), and one study used semistruc- sensory interventions reduce negative behaviour more than other
tured interviews to generalize the finding that gardening can pro- measures (Kong et al., 2009). For instance, lavender essential oil,
vide benefits such as activation of the senses (touch and smell), which is extracted from living plants as the most common type of
engagement in meaningful work, the development of curiosity, odour in clinical or care settings, can improve agitation behaviour
social interaction, living in the present, health and well-being in people with dementia (Fujii et al., 2008; O'Connor et al., 2013;
(Smith-Carrier et al., 2021). Collins et al. (2020) used the Dementia Takahashi et al., 2020; Watson et al., 2019). This behavioural mani-
Quality of Life Proxy Questionnaire (DEMQOL Proxy) to measure festation of dementia can be explained by the unmet needs model,
subjects who used a sensory garden consisting of non-toxic plants also known as the needs-driven dementia-compromised behaviour
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12 HUANG and YUAN

model, which posits that behavioural symptoms are the result of Green care techniques offer a wider range of activity-support-
attempts to address physical or psychological distress related to ive, spatial environments than traditional indoor dementia care
unmet needs (Algase et al., 1996) as well as the reduced ability to settings and promote health and well-being. Consequently, these
effectively engage with or use the environment to address these environments can be tailored to the preferences and needs of peo-
needs (Cohen-Mansfield, 2000). ple with dementia. In addition to these research foundations, this
Second, smellscapes can provide activity support for older peo- new perspective should be combined with insights from design and
ple with dementia. Xie and Yuan (2022) confirmed that the outdoor medicine to address the long-term benefits and changes brought
environment promotes activity in older people and affects their about by smellscapes. These changes are not causal in terms of the
physical and mental health. Smellscapes are particularly important stimulation of symptoms by scent or the healing of a particular dis-
in the design of activities for older people with dementia. In this ease; rather, they improve lifestyle through smellscape interventions
study, active activities refer to activities such as growing plants and to promote the well-being of older people with dementia and reduce
touching fragrant flowers, while passive activities refer to the older their burden of care.
people with dementia staying in a specific place where he or she
can passively inhale odours. Activities in outdoor environments that
require attention to be facilitated by the smellscape are usually con- 4.2 | Limitations
sidered active (Bourdon & Belmin, 2021; Collins et al., 2020; Cox
et al., 2004; Gueib et al., 2020; Prolo & Sassi, 2017; Smith-Carrier There are some limitations of this review. The number of studies
et al., 2021). In contrast, aromatherapy uses essential oils for pas- on the use of smellscapes as a green care technique for the health
sive interventions (Fujii et al., 2008; O'Connor et al., 2013; Takahashi and well-being of older people with dementia is limited, and some of
et al., 2020; Watson et al., 2019). the studies reviewed in this study had small sample sizes or lacked
Finally, the smellscape as a green care technique requires ap- control groups. The differences among these studies in terms of the
propriate environmental creation, often using living aromatic intervention settings, control variables, experimental measures and
plants that have been shown to have a healing effect (Collins degree of dementia of the subjects made it difficult to analysis these
et al., 2020; Cox et al., 2004; Gueib et al., 2020; Koura et al., 2018; studies in a systematic way. In terms of the study methodologies,
Koura & Ikeda, 2016; Prolo & Sassi, 2017). According to the litera- although the health outcomes of smellscapes as a treatment factor
ture, smellscapes are formed by familiar and uniquely localized ar- were mostly observed in the long term, follow-up studies have not
omatic plants (Edwards et al., 2013; Goto et al., 2014, 2017). Most been used as a method to track changes in health outcomes.
studies emphasize the need for safe plants, that is, plants that The majority of the studies included in this review described
are non-toxic and thornless, because older people with demen- smellscapes as a healing factor in outdoor sensory gardens.
tia may accidentally eat or touch them (Collins et al., 2020; Gueib However, with the exception of Goto et al. (2017), other researchers
et al., 2020; Prolo & Sassi, 2017). However, the included literature have not yet explored smellscapes as a separate control variable. In
also mentions numerous barriers to the design of smellscapes, in- contrast to other sensory elements, smellscapes in gardens are more
cluding the accessibility of gardens (Collins et al., 2020; Edwards difficult to record, describe, control and measure (Sun et al., 2015;
et al., 2013), and other sensory distractions in the surroundings, Estell et al., 2013). Thus, smellscape research could also benefit from
such as noise (Collins et al., 2020). Poor garden design, such as glare more systematic and standardized measurement methods for ex-
in gardens with heavy locked doors, hygiene issues, vague signs, perimental studies, such as standardized observation tools, reliable
paths with dead ends, large blank spaces and vague or distressing self-assessment scales and objective measurement instruments for
elements, may also be hindrances to older people with dementia the assessment of smellscapes or sensory environments that include
(Edwards et al., 2013; Gueib et al., 2020). On the basis of the prin- smellscapes, to help advance research in this field. However, it is
ciples of safety and practicality, the smellscape can be integrated undoubtedly difficult to study odour-related environments.
into various facilities and outdoor spatial environments to form a
reasonable functional division of space. Evidence from indoor aro-
matherapy provides a knowledge base for plant configurations, but 5 | CO N C LU S I O N S
there is a need to combine outdoor activity design and spatial sup-
port to create a comprehensive multisensory environment to sup- In total, this review included 11 articles published with qualitative,
port outdoor activity for older people with dementia with different quantitative and mixed methods to assess the effectiveness of gar-
functional impairments. There are several environmental and nat- den smellscapes as a healing factor for the health and well-being of
ural remediation theories that explain this phenomenon, includ- older people with dementia. The findings show that smellscapes, as
ing affordance theory (Gibson, 1979; Scarantino, 2003), biophilia a healing factor in a multisensory environment, have the potential
hypothesis (Wilson, 1984), attention restorative theory (Kaplan to support improved health and well-being in older people with de-
& Kaplan, 1989) and stress reduction theory (Ulrich et al., 1991), mentia, which can be achieved through the interaction between the
which form the basis of subsequent related research (Royall, 2000; person (older people with dementia), environment (garden smells-
Sarid & Zaccai, 2016; Zhao et al., 2018). capes) and outdoor activities (active, passive or a combination). The
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HUANG and YUAN 13

integrated health outcomes include mental health, physical health, support for people with different functional impairments. The types
decreased agitated behaviour, improved cognitive functioning and of activities included in the smellscapes discussed by these studies
well-being. While the current evidence for the use of aromatherapy in this review were limited and could be further explored for older
indoors is beneficial, further research on smellscapes as a healing people with dementia. Fifth, it is recommended that future research
factor in gardens should include a wider range of compensation for consider the use of gardens with smellscapes in family homes to as-
functional impairment, activity support and environmental creation sist people with dementia who are cared for by family caregivers. A
to create an integrated multisensory environment and to encourage study reported that two-thirds of people with dementia in the United
outdoor activities for older people with dementia to enhance their Kingdom live at home and are mostly cared for by family or friends
health and well-being. This review provides a new perspective to (Alzheimer's Society, 2014). Future research would further address
explore the smellscape as a healing factor and is beneficial for iden- the needs of a larger group of people with dementia to benefit every-
tifying green care techniques in gardens to promote the health and one who needs a garden. Sixth, effective dementia prevention, inter-
well-being of older people with dementia. vention and care are promising and valuable (Livingston et al., 2017),
In this review, multiple knowledge gaps are identified that require which implies a shift in the development of future care models.
further research. First, it is recommended that improved experimen- Existing research highlights the importance of the promotion of the
tal methods, including consideration of randomized controlled trials, use of smellscapes in gardens by medical and nursing staff and rec-
standardized interventions, outcome measures and long-term evalua- ommends that education be provided to relevant staff to further pro-
tion follow-up studies, will improve the comparability of study results mote the inclusion of smellscapes in care models. Future models of
while helping to advance evidence-based practice in this field. It is care should meet actual needs of older people with dementia and the
vital to obtain strong empirical evidence to better understand the key expectations of institutional carers, while restoring the living environ-
health and wellbeing outcomes for older people with dementia in care ment using green care techniques such as smellscapes to produce a
settings who are exposed to natural environments such as smells- successful, enjoyable, happy and meaningful environment.
capes to inform decisions, care plans and policies regarding green
dementia care. Second, the sense of smell does not occur in isolation F U N D I N G I N FO R M AT I O N
in outdoor smellscapes. Future smellscapes should integrate other This research is supported by the National Key Research and
sensory stimuli while maximizing the healing effects of odour to avoid Development Program of China (Grant Number 2017YFC070​
conflict and confusion in sensory systems (Winkielman et al., 2015). 2905-03).
Many of the factors that were not considered in the smellscape-re-
lated studies included in the review, such as odour intensity (Mesfin C O N FL I C T O F I N T E R E S T S TAT E M E N T
et al., 2020) and olfactory adaptation (Stuck et al., 2014) need to be The authors have no conflict of interest to declare.
accounted for in future studies. In addition, a wide range of odours is
included in smellscapes (including the smells of cooking, books, tea, DATA AVA I L A B I L I T Y S TAT E M E N T
coffee and bread, etc.). Future studies should expand their scope to Data sharing not applicable to this article as no datasets were gener-
identify smells that might evoke the memories and cognition of older ated or analysed during the current study.
people with dementia. Third, the literature included in this paper gives
insufficient attention to the specific design approach of smellscapes ORCID
as environmental interventions. Plant configuration, activity design Yidan Huang https://orcid.org/0000-0001-6264-7764
and spatial design need to be considered in the future to improve Xiaomei Yuan https://orcid.org/0000-0001-7631-6616
the health benefits of odour, and the health and well-being of older
people with dementia should be further explored. It is important that REFERENCES
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