Alzheimer's disease is a form of dementia associated with disturbing and disruptive behaviors that account for many negative health and well-being outcomes, including declines in functional status, social engagement, and physical activity (Lyketsos, 2007). These behavioral consequences diminish patients' quality of life (QoL) and increase caregiver burden and the cost of care, often ultimately necessitating that patients be placed in a nursing home (Murman and Colenda, 2005). Nature can profoundly affect people's health, well-being, and QoL; indeed, it is an old concept that the healing properties of nature can be used therapeutically. Accordingly, naturally restorative environmental (NRE) interventions stimulate one or more of the senses using natural things: elements of the earth that are living and animate, geographic, or solar and climatic (Gibson, Chalfont, Clarke, Torrington, and Sixsmith, 2007). For persons with dementia, interventions that incorporate NRE elements have demonstrated a variety of benefits, including decreased agitation; less use of psychotropic drugs); normalization of the circadian rhythm; and enhanced sociability, affect, cognitive capacity, and attention (Detweiler, Murphy, Kim, Meyers, and Ashai, 2009; Colenda, Cohen, McCall, and Rosenquist, 1997; LeGrace, 2002). Self-reported improvements in well-being, quality of life, and participation in meaningful activities have also been documented (Collins and O'Callaghan, 2008; Duggan, Blackman, Martyr, and Van Schaik, 2008; Nowak and Davis, 2011). Thus, NREs provide caregivers potential options for addressing physical, spiritual, psychological, and social needs, while at the same time, affecting behavioral responses. These widespread benefits justify further investigation and clarification. Despite the rich potential of NRE interventions for treating dementia, the research to support NRE use has not been synthesized and defined in terms of specific behaviors that may be affected, their dosage, the optimal NRE settings, and other specific characteristics. Further research is needed to develop the most effective interventions. The purpose of this dissertation is to produce a comprehensive meta-analysis of the studies, both published and unpublished, that detail the use of NRE in interventions for behaviors and QoL in dementia care. A meta-regression was conducted of moderator variables to guide development of NRE interventions for dementia care. Additionally, the characteristics of different types of programs were synthesized. Data from thirty three articles were pooled for effect size (ES) estimates on two outcomes: disruptive behaviors and quality of life. In two-group comparisons, treatment and control, an ES = 0.484 + .138, k= 17, CI (0.215, 0.745) favored the interpretation that disruptive behaviors were attenuated with NRE interventions. Findings were higher in single, pre- post-test design studies, with an ES= 0.758+ 0.109. k= 7, CI (0.544, 0.973) for diminishing disruptive behaviors. In the two-group comparisons assessing the quality of life outcome, the ES= 0.579 + 0.171, k= 10, CI (0.243, 0.915); for single group designs, the ES= 1.347+ 0.256, k=7, CI (0.020, 0.719). Thus both design analyses indicated improved measures of QoL for persons with dementia. Moderator analysis by type of NRE, two-group design, showed statistically significant lessening in disruptive behaviors using aromatherapy, but not bright light or horticulture therapy. Better QoL was shown independently by the moderators, aromatherapy and horticulture therapy, but not bright light therapy. When single group analysis was done for each type of NRE, they all independently showed significance for both behaviors and QoL; except there were no single group designs in AT or BLT. Despite the considerable heterogeneity of the interventions, individual moderators all showed potential benefits, in a variety of settings, and in different contexts.

Alzheimer’s disease (AD) is the most common form of dementia and affects an individual’s overall cognitive function, including orientation, memory, and executive function. Most AD patients in the United States reside in residential care facilities or private homes under the care of individuals with little education on the challenges of the AD patient. Among the challenges faced by caregivers are behavioral and psychological symptoms related to dementia (BPSD). Education has been shown to improve caregivers’ treatment of BPSD in AD patients and to improve caregiver retention. The purpose of this project was to develop an evidence-based education module guided by Kolcaba’s comfort theory that could be provided to home care nurses who provide care for AD patients with BPSD. A 5-point, 15-item, Likert-scale evaluation survey was developed and administered to a panel of 5 professional content experts who reviewed and scored the educational module for clarity, usability, and applicability. The mean score of 4.6 indicated that the expert panel found the education module to meet the expected standards for use with AD caregivers. Recommendations from the panel of experts were to proceed with the caregiver education module as planned. Implementation of the module may lead to positive social change through the provision of education to caregivers on care of patients with AD and caregiver self-care.