Outdoor versus Indoor Cognitive–Motor Therapy in Alzheimer’s Disease: Evidence from a Longitudinal Randomized Study

Outdoor versus Indoor Cognitive–Motor Therapy in Alzheimer’s Disease: Evidence from a Longitudinal Randomized Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Outdoor versus Indoor Cognitive–Motor Therapy in Alzheimer’s Disease: Evidence from a Longitudinal Randomized Study Michal Vostrý, Jakub Binter, Kateřina Kovářová, Zbyšek Posel, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8137844/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 9 You are reading this latest preprint version Abstract Alzheimer’s disease leads to progressive cognitive and motor decline, reducing independence and social adaptability in older adults. Combining cognitive and motor stimulation in natural environments may enhance neuroplasticity and functional abilities. This study aimed to compare the effectiveness of outdoor versus indoor cognitive–motor therapy in elderly women with Alzheimer’s disease, focusing on cognitive performance and functional independence. A double-blind randomized controlled trial was conducted with 50 female participants aged 66–70 years from two long-term care facilities. The intervention lasted seven months (five sessions per week, 45 minutes each). The experimental group received outdoor cognitive–motor therapy in garden areas, while the control group underwent identical sessions indoors. Cognitive performance was assessed using the Mini-Mental State Examination (MMSE) and functional independence with the Functional Independence Measure (FIM). Data were analyzed using Wilcoxon and Mann–Whitney U tests, and effect sizes (r) were calculated. Both groups showed significant cognitive improvement (MMSE: experimental Z = 4.78, p < .001; control Z = 4.29, p < .001). However, only the outdoor group demonstrated significant gains across all FIM domains daily tasks, mobility, and social adaptability (p < .001; large effects, r = .66–.68). Outdoor cognitive–motor therapy produced broader improvements in cognitive, motor, and social functioning compared with indoor therapy. Exposure to natural environments enhances sensory stimulation, motivation, and rehabilitation outcomes, suggesting that integrating outdoor settings into dementia care may increase the effectiveness of non-pharmacological interventions. Health sciences/Health care Health sciences/Neurology Biological sciences/Neuroscience cognitive rehabilitation combination therapy dementia outdoor therapy elderly special education occupational therapy Figures Figure 1 Figure 2 1 Introduction Dementia and its various forms can be considered the most problematic phenomenon in the ageing population at present. In recent years, there has been a worldwide increase in the number of people with Alzheimer's disease. It has been named, for example, the sixth most frequently diagnosed disease in the United States. 5.7 million Americans have been diagnosed with the disease since 2018. Worldwide, 44 million people live and suffer from this diagnosis or a related type of dementia [ 1 ]. Dementia is considered a group of mental disorders characterized primarily by loss of cognitive functions, mainly memory and intellect, thus, together with other symptoms, forming an imaginary barrier in normal daily activities [ 2 ]. Further, it may cause difficulties in social interactions and family relationships. As a result, the conscious existence of individuals may be disrupted. Due to the loss of cognitive abilities for any reason, efforts are always made to improve the individual´s everyday life. Cognitive rehabilitation, carried out by experts in collaboration with family, can be considered a suitable intervention to increase an individual´s everyday performance. The number of individuals with Alzheimer's disease will increase within a decade. It will therefore be necessary to focus on clinical training related to the treatment of dementia, as well as to increase community awareness and understanding of the issue. Research confirms the effectiveness of a combination of psychomotor activity with memory training for slowing the ageing process, enhancing memory processes, strengthening self-sufficiency, and delaying the progression of dementia [ 3 , 4 ]. Moreover, non-pharmacological therapy improves cognitive function without significant changes in behavioral disorders. Methods used in cognitive rehabilitation can be divided into stimulative or compensatory. We either practice cognitive processes through traditional exercises called "pencil-paper", or as compensation for the deficit, support is directed primarily to the development of various strategies, mnemonics, or external aids [ 5 ]. A comprehensive approach for people with mild to moderate dementia. The study presented cognitive stimulation therapy, which emphasized multisensory stimulation and implicit learning, encouraging its individual properties. This approach, as well as cognitive rehabilitation, uses cognitive skills in the given social environment in which the patient has long-term experience. Point to the success and effectiveness of cognitive stimulation therapy but emphasize the fact that some patients with mild to moderate dementia may not be able to participate in group therapy due to certain factors such as problems with motor skills or unwillingness to participate in group activities. In such cases, individual cognitive stimulation is preferable following common therapeutic approaches to people diagnosed with some form of dementia [ 7 ]. 1.1 Outdoor activities In current practice, we view indoor spaces for people with disabilities or disadvantages as an environment with physical barriers. We often actually encounter an environment that cannot be defined as barrier-free i.e., an environment that does not create sufficient conditions for the movement of people with disabilities or disadvantages. Therefore, current practice in the Czech Republic and abroad has been slowly moving towards outdoor rehabilitation supporting comprehensive rehabilitation results as well as the social adaptability of people with disabilities or disadvantages (in our case, people with dementia in late-onset Alzheimer's disease, according to ICD-10: F00.01) [ 8 ]. However, it is important to add that outdoor activities associated with the development of cognitive and motor functions may be limited e.g., noise level or architectural barriers that can disrupt the rehabilitation process itself. This also results in limited patient concentration [ 9 ]. They may consequently hinder the proper development of rehabilitation approaches among patients. A recent trend is to create so-called rehabilitation parks such as SPARK, which are situated in shared public spaces and serve seniors (usually without disabilities or disadvantages). They provide an opportunity to develop their fine and gross motor skills along with cognitive functions. Hereby outdoor rehabilitation fulfils the nature of psychomotor therapy, cognitive rehabilitation, occupational therapy, and physical therapy. The concept is that all activities can be applied to some extent in the outdoors. In addition to the positive effects on cognitive and motor functions. Positive effects on improving overall exercise capacity, lung function, depression, and anxiety [ 10 ]. These facts are entirely consistent with research that has shown positive impacts of outdoor activities among the general population on a wide range of variables [ 11 ]. Albeit research on the effects of the outdoors on people with dementia is rare. Spending time outdoors has a positive effect on mental and physical health [ 12 ]; psychological well-being [ 13 , 14 ]; happiness, vitality, and life satisfaction [ 15 ]. Among the elderly in nursing homes, the presence of the surrounding nature leads to recollections of their life history [ 16 ]. Nonetheless, the outdoor environment must be a safe and easily accessible space to positively impact the physical and mental health of the elderly [ 17 ]. The positive impact of spending time in the garden on male patients with dementia e.g., individuals who spent more time in the garden had less inappropriate behaviors and a better mood as reported by staff and family members [ 18 ]. A decrease in inappropriate behaviors after only 32 days of outdoor activities. The creation and modification of the outdoor environment support the autonomy and sensory stimulation of patients [ 19 ]. It is a non-pharmacological strategy that aims to improve the quality of life. They mention that spending time outdoors leads to increased independence and the promotion of the patient's quality of life. The application of outdoor education in special education could serve as an example. It emphasizes the development of self-help skills, the promotion of interests and the development of leisure activities through the practical involvement of individuals [ 20 ]. Albeit it can be described as an outdoor activity which, nevertheless, differs from environmental education even though both pursue the same aim i.e. to promote the health of the whole individual, which is a desirable phenomenon in practice [ 21 , 22 ]. 1.2 Indoor activities Some authors suggest establishing a multidisciplinary team including doctors, medical staff, and social workers that should be used to rehabilitate people with dementia. The authors describe an inconsistent approach to people with various forms of dementia. They pointed out the need to change the medical staff's practice and education. Further, they demonstrated the positive effect of rehabilitation on people who suffered from dementia. However, common procedures should be innovated to respond to the challenges of the twenty-first century. There are a considerable number of studies discussing, for example, the effect of virtual reality on the cognitive functions of the elderly. Despite that, an indoor rehabilitation activity is difficult to apply in an outdoor environment [ 23 ]. Modern technologies are becoming a new trend not only in cognitive rehabilitation but also in general rehabilitation. General rehabilitation mainly includes the development of motor skills and supports social adaptability (cf.). In practice, more attention is being paid to physical rehabilitation, which is aimed at people with a particular type of injury [ 24 , 25 , 26 ]. Although important, cognitive rehabilitation is no less important for patients with cognitive deficits. However, it is often neglected. The reason for neglect can primarily be the fact that cognitive deficits are often hidden and the patients themselves do not always draw attention to them immediately [ 27 , 28 ]. In many cases, tertiary prevention focuses on developing impaired cognitive functions either in individual or group therapy that usually occur in the facility's indoor environment [ 29 , 30 ]. Cognitive and combination therapy, in general, aim to improve the quality of life of people with dementia. These therapies are a non-pharmacological rehabilitation approach, which slows down the disease's progression based on regular activities. Overall, the behavioral and psychological symptoms of dementia itself are alleviated. Some authors talk about the benefits of green dementia care i.e., the connection between people with dementia and nature is primarily supported and this connection is increasingly recognized. Scientific evidence suggests that these connections cover the emotional and social spheres. In this way, they can contribute to promoting the quality of life of people with dementia. Authors presented a meaningful Bird Tales activity that created nature experiences transferred to the interior [ 31 , 30 ]. They pointed out the advantages of these interactions, where indoor activities do not require physical involvement in the outdoor environment. Indoor-based nature can increase social interactions, and a sense of autonomy or control in skills development over the long run. In their contribution, authors stated that people with dementia differ from the general population in their physical, behavioral, and emotional patterns. Further, they differ in terms of internal equipment requirements. The authors, therefore, consider it necessary to examine the effects of the indoor environment on the quality of life of people with dementia [ 33 , 34 ]. The research confirmed that building modifications, with the support of other barrier-free changes (lighting, heat, elevators), predetermine physical and mental health, independence, cognitive functioning, or management of normal daily activities. Such interior modifications are in line with the requirements of patients, for example, improperly set light can dazzle and confuse the elderly, making it difficult for them to see clearly and possibly contributing to insomnia. Inadequate ventilation can damage their health over a long period and contribute to a rapid cognitive function decline. Moreover, unpleasant temperatures can increase the death risk in patients with dementia in extreme cases [ 35 , 36 , 37 ]. The theoretical backgrounds of each therapy demonstrate their pros and cons. Indoor therapy is not limited by external adverse effects and can be relatively well enriched by modern technologies. Such technologies include, for example, the use of ICT or robotically assisted therapy. Outdoor therapy offers, however, a natural environment that can have a positive effect on the patients. Based on the above, we formulated a research question, what effect does outdoor and indoor therapy have on developing patients suffering from Alzheimer's disease? The research aimed to determine which therapy is more effective for a selected group of experimental and control participants. 2 Methods Participants and Design The study employed a double-blind randomized controlled trial (RCT) design comparing the effects of indoor and outdoor combination therapy on elderly women diagnosed with Alzheimer’s disease. Inclusion criteria were: (a) diagnosis of late-onset Alzheimer’s disease (ICD-10: F00.01), (b) permanent stay in a social care facility for at least two years, (c) preserved basic mobility, and (d) stable pharmacotherapy for at least three months prior to study entry. Exclusion criteria included: (a) severe sensory deficits, (b) acute medical instability, and (c) unwillingness or inability to provide informed consent. Participants were randomly assigned to either the experimental (outdoor therapy) or control (indoor therapy) group using a computer-generated randomization list prepared by an independent researcher. At baseline, groups did not differ on demographic and clinical categorical characteristics (all p > 0.29). For continuous variables and baseline outcome measures we report group comparisons in Table 2 ; notably, baseline FIM-Mobility differed between groups, and between-group effects were therefore evaluated on change scores with baseline adjustment. The total sample consisted of 50 female participants aged 66.1–70.2 years (M = 67.4, SD = 1.8). Therapy was implemented five times per week for 45 minutes over seven consecutive months. Both interventions integrated cognitive rehabilitation and motor therapy based on the principles of psychomotor stimulation and occupational therapy. Outdoor therapy included physical and cognitive tasks conducted in safe, accessible garden or courtyard areas, utilizing natural stimuli (e.g., light, textures, and spatial orientation). Indoor therapy consisted of identical activities carried out in a controlled indoor environment using standard rehabilitation tools and, where appropriate, ICT-based cognitive training (virtual tasks, paper–pencil activities). To ensure treatment fidelity, therapists followed a standardized intervention manual, and weekly supervision sessions were conducted. Attendance and adherence were recorded for every participant; mean adherence exceeded 90% in both groups. Population The research included 50 female patients (random selection – double-blind RCT: of participants with the relevant characteristics; the most abundant gender in the case of Alzheimer's disease) in the age range of 66.1–70.2 years. Based on stratified selection we selected patients who stay in a facility for at least two years (selected in total from two institutions providing social services). These were institutions with a special regime aimed directly at caring for people with a particular form of dementia. Participants were selected based on the relevant features by the double-blind method with the facilities' consent, the oral consent of the individual participants, and family members. The research group was divided into two groups by randomly selecting a group that participated in combination therapy in the indoor environment (control group, 25 patients) and 25 patients who participated in similar activities but in the outdoor environment (experimental group). The weather conditions had to be considered as it affected outdoor therapy activities. The research aimed to determine the effect of outdoor rehabilitation (cognitive and motor) on patients' social adaptability with Alzheimer's disease in facilities providing social services with a subsequent formulation of the conclusions and recommendations for practice concerning the global crisis caused by the SARS-CoV-2 pandemic. Overall, this was a group of patients with dementia in late-onset of Alzheimer's disease (ICD-10; F00.01). Random allocation was generated by an independent researcher using a computer-based randomization list. Allocation concealment was ensured by sealed, opaque envelopes. Therapists delivering the intervention were aware of group assignment due to the nature of the intervention; however, outcome assessors and data analysts were blinded to group allocation. A trial version was also performed as part of the research and addressed issues that could interfere with our research. The trial version lasted one month and involved 5 participants for the experimental and 5 for the control group. An independent person carried out the research set and its division to rule out the ego involvement of the authors. The flow diagram of our research is shown in Fig. 1 . Adverse events were monitored systematically during each session and recorded by therapists; no intervention-related harms were observed. Participants and their family members were consulted regarding the feasibility and acceptability of outdoor activities prior to study initiation. Their feedback informed the scheduling, duration, and safety adaptations of the intervention. Intervention Both study groups participated in a structured seven-month therapeutic program designed to enhance cognitive and motor functions through a multimodal rehabilitation approach (Fig. 2 ). The intervention was jointly developed by a multidisciplinary team consisting of a special educator, occupational therapist, physiotherapist, and clinical psychologist. Each session lasted approximately 45 minutes and was held five times per week. All activities were aimed at stimulating memory, attention, executive functions, spatial orientation, and coordination, as well as improving social communication and self-sufficiency in daily activities. The therapeutic concept was based on combining cognitive and motor stimulation in both individual and group formats, ensuring comparability between the indoor and outdoor settings. Each week followed a consistent structure, consisting of two sessions focused primarily on psychomotor therapy, two sessions on cognitive rehabilitation, and one integrative session emphasizing social cooperation, group interaction, and emotional well-being. The content of the intervention was thematically aligned in both groups, differing only in the environmental context (indoor vs. outdoor). In the experimental group, therapy was conducted outdoors in barrier-free gardens and courtyards of the participating facilities. The outdoor program emphasized the use of natural stimuli to promote sensory engagement, psychomotor activation, and emotional stability. Activities included cognitive tasks performed in natural surroundings, such as naming objects found in the garden, conducting “memory walks” for spatial orientation, and categorizing or sequencing objects from nature (stones, leaves, flowers). Motor exercises were integrated through low-intensity physical activities, including balance training, stretching, and rhythmic movement using simple equipment such as elastic bands, balls, or soft weights. Elements of occupational therapy were naturally embedded—for example, participants engaged in short purposeful activities such as watering plants, arranging flowers, or sorting natural materials, supporting procedural memory and the sense of autonomy. Sensory stimulation was further promoted through contact with natural textures, sounds, and light conditions, which contributed to relaxation and reduction of anxiety or agitation. Group-based exercises, such as singing, cooperative gardening, or storytelling, were used to foster reminiscence and social adaptability. All activities were supervised by trained therapists and adjusted to current weather conditions; during unfavorable weather, sheltered outdoor areas were used, or simplified variations of the same exercises were applied. In the control group, participants underwent an identical schedule of interventions delivered entirely indoors within the facilities’ rehabilitation and communal rooms. The indoor program incorporated cognitive stimulation through paper–pencil exercises, puzzle solving, and attention and memory training. Psychomotor activities included coordination exercises with small equipment (balls, scarves, balance cushions) and rhythmic movement accompanied by music. When available, digital technologies such as tablet-based applications or computer-assisted memory games were used to enhance engagement. Individual therapy sessions were offered to participants with reduced mobility, focusing on maintaining upper-limb coordination, fine motor control, and reaction time. The indoor environment provided stable conditions and allowed the inclusion of virtual cognitive training; however, the sensory and environmental variability present in the outdoor setting was absent. To ensure methodological consistency and intervention fidelity, both indoor and outdoor activities followed a standardized therapeutic manual developed for the study. All therapists underwent initial training and attended regular supervisory meetings to maintain adherence to the protocol. Attendance, engagement, and any deviations from the protocol were documented after each session. The mean attendance rate was 91% in the experimental group and 89% in the control group, confirming a high level of participant compliance. No adverse events related to the intervention were recorded. The therapeutic rationale underlying the program assumed that combining cognitive and motor stimulation within a multisensory environment enhances neuroplasticity, improves mood regulation, and strengthens memory consolidation. The outdoor setting was expected to engage multiple sensory channels, promote physical activation, and increase environmental orientation, thereby contributing to better cognitive performance and social adaptability. Conversely, the indoor environment provided a controlled and technologically supportive space, suitable for maintaining consistent cognitive training and motor tasks. The combination and comparison of these two therapeutic contexts allowed for a comprehensive assessment of the effects of environmental factors on the rehabilitation outcomes of elderly individuals with Alzheimer’s disease. Therapy alternated between individual and group therapy according to the needs and possibilities and we chose elements of comprehensive rehabilitation (aspects of special education and occupational therapy). Indoor therapy was focused on test batteries, such as a pencil-paper test, individual therapy in the patient's room, and exercise units in psychomotor therapy. Outdoor therapy focused on psychomotor therapy using additional exercise aids, cognitive rehabilitation training, and cognitive functions concerning the outdoor environment. As we managed to apply the same activities to indoor and outdoor environments in most cases, it is possible to make the presentation of results more precise and it allows us to better define recommendations for practice regarding the comparison of outdoor and indoor therapy. Data Collection We provided input and output data by using a modification of the standardized test focused on functional independence ( FIM test – Functional Independence Measure; Data Management Service of the Uniform Data System for Medical Rehabilitation, the State University of New York at Buffalo ) and a standardized cognitive function test ( MMSE test – Mini-Mental State Examination; the MMSE evaluates orientation, retention, attention and calculation, recall, language, and visual-constructional abilities. Each item is scored binomially with 0 or 1 point, and the total score ranges from 0 to 30; the latter corresponding to the best performance; indicating the good accuracy of the instrument and moderate internal consistency - Cronbach α = .464 ;). These are two extended and respected tests in practice. The Mini-Mental State Examination (MMSE) was administered in its validated Czech version [ 38 ], which has been widely used in clinical and research settings in the Czech Republic. Therefore, no additional back-translation procedure was required. Data Analysis After completing the data collection, we compared the input and output testing of both mentioned standardized tests. The obtained data was different from the normal distribution, so non-parametric methods were used for statistical analysis; specifically, the Wilcoxon paired test, at the significance level α = .05. The research itself was conducted during 2025 and lasted seven months (February to September). The study results were analyzed by an independent researcher, thus excluding the ego involvement of the authors. Pre- and post-intervention data were analyzed using IBM SPSS Statistics 28. As the dataset did not follow a normal distribution (Shapiro–Wilk test, p < .05), non-parametric tests were applied. The Wilcoxon signed-rank test was used to compare pre- and post-scores within groups, and the Mann–Whitney U test to compare between groups at baseline (Table 1 ). Effect sizes (r) for Wilcoxon tests were computed as r = Z/√N. Ninety-five percent confidence intervals for r were estimated using Fisher’s z transformation (approximate method given the non-parametric origin of r). Where available, bootstrap CIs from 1,000 resamples were used in sensitivity checks. Table 1 Effect sizes (r): according to Cohen’s criteria, r = .1 indicates a small, .3 a medium, and .5 a large effect. Test Group Z p-value r Interpretation MMSE Experimental 4.78 < .001 .68 Large MMSE Control 4.29 < .001 .61 Large FIM – Daily Task Experimental 4.70 < .001 .66 Large FIM - Mobility Experimental 4.78 < .001 .68 Large FIM – Social Adaptability Experimental 4.70 < .001 .66 Large Legend Effect sizes (r) and their 95% confidence intervals were calculated for each outcome according to Cohen’s criteria (small = .10, medium = .30, large = .50). Bootstrap resampling (1,000 iterations) was used to estimate confidence intervals for non-parametric tests. 3 Results All fifty participants (25 in the experimental group and 25 in the control group) completed the full seven-month intervention period. No dropouts or adverse events were reported during the study. Baseline demographic and clinical characteristics of the two groups were comparable in terms of age, duration of disease, education, and medication use, confirming group equivalence at the start of the study (Table 2 ). Cognitive performance was assessed using the Mini-Mental State Examination (MMSE). Both the experimental and control groups demonstrated significant improvements between pre-test and post-test scores. In the experimental group (outdoor therapy), given the non-normal distribution of data, median values were reported. For the MMSE, the median score increased from 20 to 22 in the experimental group (mean 22.4). (Z = 4.78, p < .001, r = .68), reflecting a large effect size. In the control group (indoor therapy), the median score rose from 19 to 21 (Z = 4.29, p < .001, r = .61), also indicating a large but slightly smaller effect. Although both groups showed measurable cognitive gains, the improvement was more pronounced in participants who engaged in outdoor therapy, suggesting that the natural environment and physical engagement may enhance cognitive stimulation and attention processes. Functional independence and adaptability were evaluated using the Functional Independence Measure (FIM), which includes subscales for daily tasks, mobility, and social adaptability. Participants in the experimental group showed consistent and statistically significant improvement across all three domains. Specifically, the median scores increased from 40 to 42 for daily tasks (Z = 4.70, p < .001, r = .66), from 8 to 10 for mobility (Z = 4.78, p < .001, r = .68), and from 19 to 21 for social adaptability (Z = 4.70, p < .001, r = 0.66). In contrast, the control group did not show statistically significant progress in most areas. The median FIM score for daily tasks remained unchanged at 38 (Z = 1.75, p = .08), while the mobility score slightly decreased from 17 to 16 (Z = 0.71, p = .48). The median score for social adaptability changed marginally from 25.5 to 25 (Z = 0.94, p = .35). These findings indicate that outdoor combination therapy had a stronger and broader positive impact on the participants’ ability to perform everyday activities, move independently, and interact socially compared with indoor therapy alone (Table 3 ). Between-group comparisons of post-test scores using Mann–Whitney U tests confirmed that participants in the outdoor (experimental) group achieved significantly higher outcomes in cognitive (MMSE, U = 197.0, Z = 2.14, p = .033, r = .30) and functional domains (FIM Daily Tasks, U = 171.5, Z = 2.96, p = .003, r = .42; FIM Mobility, U = 160.0, Z = 3.25, p = .001, r = .46; FIM Social Adaptability, U = 174.0, Z = 2.87, p = .004, r = .41) compared with the indoor (control) group. These effects ranged from medium to large according to Cohen’s benchmarks. Between-group analysis showed that participants who underwent outdoor therapy achieved higher overall mean ranks across all assessed domains. The most notable difference was observed in the FIM mobility subscale, where the experimental group improved by an average of two points, while the control group exhibited a slight decline. This result represents both a statistically and clinically meaningful difference, highlighting the beneficial role of natural environmental factors, such as light, space, and sensory variety in supporting psychomotor activation and functional independence among individuals with Alzheimer’s disease. When examining the data collectively, it becomes evident that outdoor combination therapy produced a more comprehensive improvement profile. While indoor cognitive rehabilitation was effective in maintaining or slightly enhancing cognitive function, the outdoor program facilitated concurrent gains across cognitive, motor, and social domains. Participants exposed to the outdoor environment displayed greater engagement, attention, and motivation during therapy sessions, which may have contributed to the superior outcomes. The integration of physical movement, multisensory stimulation, and natural surroundings appears to reinforce neurocognitive processes associated with memory, coordination, and social adaptability. Table 2 Baseline comparison between groups for clinical and demographic characteristics (Individual clinical characteristics were taken into account in the intervention) Experimental group Control group Age Ø 67.4 67.2 Sex (%) Female 25 (100) 25 (100) Male 0 (0) 0 (0) Relationship (%) Yes 5 (20.0) 7 (28.0) None 20 (80.0) 18 (72.0) Disease duration in years Ø 4,1 3,9 Education (%) Higher education 7 (28.0) 4 (16.0) High school education 12 (48.0) 16 (64.0) Primary education 6 (24.0) 5 (20.0) Stay in the institution in years Ø 1,9 2,1 Medication (%) Yes 8 (32.0) 10 (40.0) None 17 (68.0) 15 (60.0) Secondary diagnosis (limiting; %) yes 5 (20.0) 4 (16.0) none 20 (80.0) 21 (84.0) Impaired food intake (%) yes 3 (12.0) 1 (4.0) none 22 (88.0) 24 (96.0) urine incontination (%) yes 5 (20.0) 6 (24.0) none 20 (80.0) 19 (76.0) Employment (%) Yes 15 (60.0) 18 (72.0) Irregularly 4 (16.0) 2 (8.0) None 6 (24.0) 5 (20.0) Visiting families (%) Yes 5 (20.0) 6 (24.0) Irregularly 15 (60.0) 17 (68.0) None 5 (20.0) 2 (8.0) Table 3 Statistical results of the research survey in the experimental and control groups Legend: Mdn pre – median pre-testing; Mdn post – median post-testing test group Z p-value Mdnpre Mdnpost MMSE test experimental 4.78 < .001 20 22.40 control 4.29 < .001 19 21 FIM test - daily task experimental 4.70 < .001 40 42 control 1.75 .08 38 38 FIM test - mobility experimental 4.78 < .001 8 10 control 0.71 .48 17 16 FIM test - social adaptability experimental 4.70 < .001 19 21 control 0.94 .35 25.50 25 4 Discussion Both groups, i.e., the experimental group which participated in outdoor activities and the controlled group which participated in indoor activities achieved better results with regular and intensive therapy than at the initial testing. The experimental group achieved a statistical increase in all types of tests while the control group´s results were only better in the MMSE test. The control group's values remained unchanged in other tests, or the change was small and insignificant. However, the control group achieved better results for social adaptability support in comparison to the experimental group. In the case of the MMSE test, a point increase is desirable, which indicates an improvement in monitored indicators for both groups. Within the FIM test, increasing the number of points is also desirable, as it indicates an overall improvement in the monitored indicators. During the research, we encountered various difficulties in both settings, i.e., unsuitable weather, noise level, or unpreparedness of a given facility, for example, insufficient and unsuitable outdoor equipment. As for the controlled group, it was a stereotypical and non-dynamically developing environment that can become less stimulating after a long-term intervention. Outdoor combination therapy can be divided into a closed outdoor area i.e., fenced gardens and an open space area. Authors presented, it is essential for safety reasons to monitor people with dementia in the open space area using technology, for example, GPS. In closed outdoor areas, this concern may be eliminated at the expense of offering fewer stimuli. Thus, the open space area is from the point of view of rehabilitation more beneficial than fenced gardens. Even though not all activities can be fully implemented within the facilities. The support for social adaptability is minimal, as individuals are only in contact with other clients and employees [ 39 ]. The research aimed to determine what effect outdoor rehabilitation (cognitive and motor; combination therapy) has on the social adaptability of people with Alzheimer's disease in facilities providing social services. The author's team assumed that outdoor training would become more effective than indoor training, which was only partially demonstrated and with certain limits. Based on the results, we assume that the combination of outdoor and indoor environments seems to be effective, as each environment has its pros and cons. A combination of outdoor and indoor activities seems to be ideal as it develops cognitive functions and expands the range of cognitive rehabilitation possibilities. The combination of these activities can positively affect different cognitive areas among the elderly [ 40 ]. Other authors refer about combination therapy as physical therapy and movement therapy. The approaches chosen in this way can be of great benefit. It is essential, however, to recognize that people who suffer from dementia have different needs and whether in individual or group therapy, it is crucial to address these needs. In the context of the global crisis (spread of the SARS-CoV-2 virus) outdoor activities can to some extent replace indoor activities by being aware of potential limits. Thus, hygienic requirements can be enforced, and working with patients indoors can be limited, lessening the risk of infection. Outdoor environment in crisis times enables a wide range of activities that can purposefully strengthen and develop disturbed areas of the elderly with cognitive deficits, for example, motor activities - psychomotor therapy, therapeutic physical education or relaxation exercises, mental activities - testing, worksheets, cognitive training kits, therapeutic interviews. The term combination therapy is often used to refer to pharmacological treatments, often further divided into mono and combination therapy according to the amount of drug use and non-pharmacological treatment [ 42 , 43 ]. From our perspective, we define this term within the so-called helping professions, where we combine rehabilitation approaches across individual therapies and thus create a comprehensive and combined rehabilitation approach, which is aimed at the elderly with cognitive deficits. Professional supervision or assistive technologies offer a way to support the individuality of individuals with dementia while ensuring their safety and enabling them to manage common daily activities that relate to daily functioning both in the home environment and in the institutional environment. At the same time, outdoor activities are an essential part of developing an active lifestyle [ 44 , 45 ]. 4.1 Limitations Group equivalence (selection) The initial testing with the widely used standardized tests showed very similar initial results in selected groups and individual participants. Equal input and testing conditions were created for both groups (adjusting the requirements for the same testing, deliberately selecting participants corresponding to the relevant features). Maturation and natural development (growth) this is an essential factor, as our intervention focused on working with people with dementia for seven months. These people are a group of participants where day-to-day changes can be seen, and the diagnosis itself is progressive. The presented results point to the fact that they have improved during these months, and it can be argued that the disease's progression has slowed down slightly. There are intervening variables, however, that can affect these results (e.g. drug changes, not recorded during the intervention). One such factor may be the weather, which can affect the depressed states of participants and thus limit the possible intervention and subsequent testing results. The internal consistency of the MMSE in our sample was relatively low (Cronbach’s α = .464), which may reflect the multidimensional structure of the test and the heterogeneous cognitive profiles of participants with Alzheimer’s disease. Therefore, results based on this measure should be interpreted with caution. Measurement effect (device) The test was applied before the start of the interventions and after seven months. It was not used during the therapies. Measurement tool error The reliability of selected tools has reached acceptable values. This intervening variable was captured. To obtain results, we used standardized MMSE tests and the FIM test. The combination of these tests determines in practice the degree of disability in the monitored indicators. In the research, we focused on evaluating social adaptability (FIM test) and cognitive function (MMSE) because the combination of motor and cognitive functions and social skills are crucial areas with an overall share in social adaptability itself and more. Expectations from the researcher Only one researcher always participated in the testing to capture testing uniformity with objective results in the research. Thus, the ego engagement of the researchers was limited, which is evident from the presented results. Environment (indoor, outdoor) We took necessary measures to ensure quality adjustments to the indoor and outdoor environment at the beginning. However, it was not possible to eliminate all obstacles, for example, sudden sounds and insufficient technical equipment. Post hoc power analysis In addition, given the relatively small sample size (n = 25 per group), we conducted a post hoc power consideration based on the observed effect sizes. For a between-group effect of approximately r ≈ .30 (equivalent to d ≈ 0.63), an estimated sample of ~ 41 participants per group would be required to achieve 80% statistical power. For larger effects ( r ≈ .42–.46; d ≈ 0.93–1.04), the current sample size is sufficient, as 16–20 participants per group would meet the 80% power threshold. Although our study detected medium to large effects across several domains, future trials should consider increasing the sample size to approximately 45–50 participants per group to account for dropouts and ensure sufficient power for detecting smaller effects. The study did not include a priori power analysis due to the pilot character. 5 Conclusions Alzheimer's Disease International reports that there are more than 44 million cases of dementia worldwide, making it a global socio-economic problem. Fortunately, there seems to be a suitable outdoor environment and adapted therapy that can improve the patient's physical and mental area in times of crisis. The outdoor environment should be designed with safety and accessibility in mind, along with promoting social adaptability and stimulating individual impaired functions [ 46 , 47 ]. We also identify with these authors, who states that cognitive rehabilitation improves the daily functioning of people who suffer from dementia [ 48 ]. Further, the results of our research are in line with next authors who confirm that outdoor activities can improve mental health for at least some of the disease's symptoms. These activities are significant for the support of psychological components in people suffering from depression or dementia. They also have a positive effect on patients and are of considerable economic importance. Cognitive therapy, also called cognitive stimulation therapy, is an internationally used evidence-based psychosocial intervention among people with mild to moderate dementia and other cognitive impairments. Such a comprehensive approach emphasizes this approach's value as an integral part of the services offered to people with some form of dementia to maintain cognitive functioning and quality of life. Cognitive stimulation therapy is also recommended by the UK National Institute for Health and Care Excellence guidelines and is approved by Alzheimer's Disease International [ 49 , 50 , 51 , 52 ]. In the overall summary of the results, we believe that regular therapy for patients with Alzheimer's disease has a positive effect on cognitive functions and the support of their social adaptability, i. e. coping with daily activities, mobility, and social adaptability [ 53 , 54 ]. The use of outdoor spaces offers exciting possibilities within the development of disturbed areas in these patients. It is possible to create such conditions that may be sufficient to develop the patients' disturbed areas in the outdoor environment based on the results presented by us. In times of crisis and outside of it, it is desirable to limit patients' stay in a closed environment. Spending both therapeutic time and free time outdoors can limit the side effects of the crisis. Outdoor therapy offers the possibility of implementing both individual and group therapy. Future research should expand the present findings by integrating sensor-based monitoring, digital cognitive tools and virtual-reality approaches to capture continuous behavioural, motor and cognitive data. Wearable sensors (e.g., accelerometry, heart-rate monitoring), tablet-based cognitive assessments, BLE-based social interaction tracking, structured electronic therapeutic diaries, and standardized clinical data platforms (e.g., REDCap) could substantially improve the objectivity, granularity and ecological validity of outcome measures. Virtual-reality interventions represent another promising direction, enabling multisensory cognitive stimulation and reminiscence activities [ 53 , 54 , 55 ] These technological extensions may help to refine individualized therapeutic responses, enhance monitoring during long-term therapy and align future studies with the broader DIGITECH research agenda. A detailed list of recommended technologies and example studies is provided in the Supplementary Material (Table S1 ). Declarations Conflict of Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Ethical approval All procedures adhered to the ethical standards of the national research committee and followed the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Our research team obtained administrative permission to access the data used in this study. We are aware that we are working with human subjects; therefore, the research study was approved by the Medical Ethics Committee of the Masaryk Hospital, prior to its commencement. All participants were properly informed about the nature of the research and provided their voluntary and informed consent. The intervention was designed to ensure that no physical or social harm would come to the participants, and their rights were fully respected. Registration number is 2025/12/1_001 (date of the first registration 12.1.2024). The project was retrospectively registered on January 3, 2026, on the Sri Lanka Clinical Trials Registry: Registration Number SLCTR 2463 (https://slctr.lk/trials/78bd1ad0-dfdd-013e-85a9-04014debcf01). Informed consent Informed consent was obtained from all individual participants included in the study. Funding This publication was created with the support of the ITI - DIGITECH project, reg. no.: CZ.02.01.01/00/23_021/0010653, financed by OP JAK. (https://opjak.cz/en/) Availability of data and materials The data are only available upon reasonable request, to gain access contact the corresponding author. Consent for publication Non-applicable Acknowledgement Thank you, dr. Dorothy Kessler, (Queen´s University, Faculty of Health Sciences, Ontario - Canada) for help and expert advice. Data availability The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. References Khan, A. & Zubair, S. Longitudinal magnetic resonance imaging as a potential correlate in the diagnosis of Alzheimer disease: exploratory data analysis. JMIR Biomed. Eng. 5 , e14389 (2020). Ahlström, B., Larsson, I. M., Strandberg, G. & Lipcsey, M. A nationwide study of the long-term prevalence of dementia and its risk factors in the Swedish intensive care cohort. Crit. Care 24 , 548 (2020). Meyer, K., James, D., Amezaga, B. & White, C. Simulation learning to train healthcare students in person-centred dementia care. Gerontol. Geriatr. Educ. 43 , 209-224 (2022). Shigihara, Y., Hoshi, H., Poza, J., Rodríguez-González, V., Gómez, C. & Kanzawa, T. Non-pharmacological treatment changes brain activity in patients with dementia. 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Older adults’ responses to a meaningful activity using indoor-based nature experiences: bird tales. Clin. Gerontol. 44 , 1–11 (2021). Velarde, M. D., Fry, G. & Tveit, M. Health effects of viewing landscapes—landscape types in environmental psychology. Urban For. Urban Green. 6 , 199–212 (2007). Leung, M. Y., Wang, C. & Cha, I. Y. A qualitative and quantitative investigation of effects of indoor built environment for people with dementia in care and attention homes. Build. Environ. 157 , 89–100 (2019). Yeo, N. L. et al. Indoor nature interventions for health and well-being of older adults in residential settings: a systematic review. Gerontologist 60 , e184–e199 (2020). Morais, A., Santos, S. & Lebre, P. Psychomotor, functional and cognitive profiles in older people with and without dementia: what connections? Dementia 18 , 1538–1553 (2019). Morgado, J., Rocha, C. S., Maruta, C., Guerreiro, M. & Martins, I. P. Novos valores normativos do mini-mental state examination. Sinapse 9 , 10–16 (2009). Weuve, J., Puett, R. C., Schwartz, J., Yanosky, J. D., Laden, F. & Grodstein, F. Exposure to particulate air pollution and cognitive decline in older women. Arch. Intern. Med. 172 , 219–227 (2012). Kožený, J. & Tišanská, L. Mini-Mental State Examination—česká verze. Psychodiagnostika (1995). Cooper, J., Burrow, S. & Pusey, H. What are the perceptions of people living with dementia, family carers, professionals and other potential stakeholders to the use of global positioning systems to promote safer outdoor walking? A qualitative literature review. Disabil. Rehabil. Assist. Technol. 16 , 614–623 (2021). van Middelaar, T. et al. Lower dementia risk with different classes of antihypertensive medication in older patients. J. Hypertens. 35 , 2095–2101 (2017). Dyer, S. M., Laver, K., Pond, C. D., Cumming, R. G., Whitehead, C. & Crotty, M. Clinical practice guidelines and principles of care for people with dementia in Australia. Aust. Fam. Physician 45 , 884–889 (2016). McMinn, B. G. & Hinton, L. Confined to barracks: the effects of indoor confinement on aggressive behavior among inpatients of an acute psychogeriatric unit. Am. J. Alzheimers Dis. Other Dementias 15 , 36–41 (2000). Yordanova, K. et al. Situation model for situation-aware assistance of dementia patients in outdoor mobility. J. Alzheimers Dis. 60 , 1461–1476 (2017). Teipel, S., Babiloni, C., Hoey, J., Kaye, J., Kirste, T. & Burmeister, O. K. Information and communication technology solutions for outdoor navigation in dementia. Alzheimers Dement. 12 , 695–707 (2016). Handberg, C., Mygind, O. & Johansen, J. S. Lessons learnt on the meaning of involvement and co-creation in developing community-based rehabilitation. Disabil. Rehabil. 44 , 3052–3060 (2019). Tsai, S. Y. & Chen, T. Y. Research on outdoor environments and activity behavior of senior citizens with dementia: a study in Taipei City. Appl. Mech. Mater. 865 , 605–611 (2017). Vanova, M. et al. The effectiveness of ICT-based neurocognitive and psychosocial rehabilitation programmes in people with mild dementia and mild cognitive impairment using GRADIOR and ehcoBUTLER: study protocol for a randomised controlled trial. Trials 19 , 100 (2018). Kudlicka, A. & Clare, L. Cognitive rehabilitation in mild and moderate dementia. Oxford Res. Encycl. Psychol. (2021). Paggetti, A. et al. The efficacy of cognitive stimulation, cognitive training, and cognitive rehabilitation for people living with dementia: a systematic review and meta-analysis. GeroScience 47 , 409–444 (2025). Carrion, C., Folkvord, F., Anastasiadou, D. & Aymerich, M. Cognitive therapy for dementia patients: a systematic review. Dement. Geriatr. Cogn. Disord. 46 , 1–26 (2018). Dhankhar, S. et al. Cognitive rehabilitation for early-stage dementia: a review. Curr. Psychiatry Res. Rev. 21 , 109–122 (2025). Zhao, Y. et al. Effectiveness of exergaming in improving cognitive and physical function in people with mild cognitive impairment or dementia: systematic review. JMIR Serious Games 8 , e16841 (2020). Marinho, V. et al. Cognitive stimulation therapy for people with dementia in Brazil (CST-Brasil): results from a single blind randomized controlled trial. Int. J. Geriatr. Psychiatry 36 , 286–293 (2021). Vostrý, M., Chytrý, V., Cmorej, P. C., Fleischmann, O., & Kubová, N. Effect of combined and intensive rehabilitation on cognitive function in patients with Alzheimer’s disease evaluated through a randomized controlled trial. Scientific Reports, 15 (1), 8110 (2025). Additional Declarations No competing interests reported. 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13:29:21","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":33597,"visible":true,"origin":"","legend":"","description":"","filename":"CONSORT2025editablechecklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-8137844/v1/51b2418c5c026a561e941357.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Outdoor versus Indoor Cognitive–Motor Therapy in Alzheimer’s Disease: Evidence from a Longitudinal Randomized Study","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eDementia and its various forms can be considered the most problematic phenomenon in the ageing population at present. In recent years, there has been a worldwide increase in the number of people with Alzheimer's disease. It has been named, for example, the sixth most frequently diagnosed disease in the United States. 5.7\u0026nbsp;million Americans have been diagnosed with the disease since 2018. Worldwide, 44\u0026nbsp;million people live and suffer from this diagnosis or a related type of dementia [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Dementia is considered a group of mental disorders characterized primarily by loss of cognitive functions, mainly memory and intellect, thus, together with other symptoms, forming an imaginary barrier in normal daily activities [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Further, it may cause difficulties in social interactions and family relationships. As a result, the conscious existence of individuals may be disrupted. Due to the loss of cognitive abilities for any reason, efforts are always made to improve the individual\u0026acute;s everyday life. Cognitive rehabilitation, carried out by experts in collaboration with family, can be considered a suitable intervention to increase an individual\u0026acute;s everyday performance. The number of individuals with Alzheimer's disease will increase within a decade. It will therefore be necessary to focus on clinical training related to the treatment of dementia, as well as to increase community awareness and understanding of the issue. Research confirms the effectiveness of a combination of psychomotor activity with memory training for slowing the ageing process, enhancing memory processes, strengthening self-sufficiency, and delaying the progression of dementia [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Moreover, non-pharmacological therapy improves cognitive function without significant changes in behavioral disorders. Methods used in cognitive rehabilitation can be divided into stimulative or compensatory. We either practice cognitive processes through traditional exercises called \"pencil-paper\", or as compensation for the deficit, support is directed primarily to the development of various strategies, mnemonics, or external aids [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. A comprehensive approach for people with mild to moderate dementia. The study presented cognitive stimulation therapy, which emphasized multisensory stimulation and implicit learning, encouraging its individual properties. This approach, as well as cognitive rehabilitation, uses cognitive skills in the given social environment in which the patient has long-term experience. Point to the success and effectiveness of cognitive stimulation therapy but emphasize the fact that some patients with mild to moderate dementia may not be able to participate in group therapy due to certain factors such as problems with motor skills or unwillingness to participate in group activities. In such cases, individual cognitive stimulation is preferable following common therapeutic approaches to people diagnosed with some form of dementia [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003e1.1 Outdoor activities\u003c/h2\u003e \u003cp\u003eIn current practice, we view indoor spaces for people with disabilities or disadvantages as an environment with physical barriers. We often actually encounter an environment that cannot be defined as barrier-free i.e., an environment that does not create sufficient conditions for the movement of people with disabilities or disadvantages. Therefore, current practice in the Czech Republic and abroad has been slowly moving towards outdoor rehabilitation supporting comprehensive rehabilitation results as well as the social adaptability of people with disabilities or disadvantages (in our case, people with dementia in late-onset Alzheimer's disease, according to ICD-10: F00.01) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, it is important to add that outdoor activities associated with the development of cognitive and motor functions may be limited e.g., noise level or architectural barriers that can disrupt the rehabilitation process itself. This also results in limited patient concentration [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. They may consequently hinder the proper development of rehabilitation approaches among patients. A recent trend is to create so-called rehabilitation parks such as SPARK, which are situated in shared public spaces and serve seniors (usually without disabilities or disadvantages). They provide an opportunity to develop their fine and gross motor skills along with cognitive functions. Hereby outdoor rehabilitation fulfils the nature of psychomotor therapy, cognitive rehabilitation, occupational therapy, and physical therapy. The concept is that all activities can be applied to some extent in the outdoors. In addition to the positive effects on cognitive and motor functions. Positive effects on improving overall exercise capacity, lung function, depression, and anxiety [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. These facts are entirely consistent with research that has shown positive impacts of outdoor activities among the general population on a wide range of variables [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Albeit research on the effects of the outdoors on people with dementia is rare. Spending time outdoors has a positive effect on mental and physical health [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]; psychological well-being [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]; happiness, vitality, and life satisfaction [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Among the elderly in nursing homes, the presence of the surrounding nature leads to recollections of their life history [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Nonetheless, the outdoor environment must be a safe and easily accessible space to positively impact the physical and mental health of the elderly [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The positive impact of spending time in the garden on male patients with dementia e.g., individuals who spent more time in the garden had less inappropriate behaviors and a better mood as reported by staff and family members [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. A decrease in inappropriate behaviors after only 32 days of outdoor activities. The creation and modification of the outdoor environment support the autonomy and sensory stimulation of patients [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. It is a non-pharmacological strategy that aims to improve the quality of life. They mention that spending time outdoors leads to increased independence and the promotion of the patient's quality of life. The application of outdoor education in special education could serve as an example. It emphasizes the development of self-help skills, the promotion of interests and the development of leisure activities through the practical involvement of individuals [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlbeit it can be described as an outdoor activity which, nevertheless, differs from environmental education even though both pursue the same aim i.e. to promote the health of the whole individual, which is a desirable phenomenon in practice [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e1.2 Indoor activities\u003c/h2\u003e \u003cp\u003eSome authors suggest establishing a multidisciplinary team including doctors, medical staff, and social workers that should be used to rehabilitate people with dementia. The authors describe an inconsistent approach to people with various forms of dementia. They pointed out the need to change the medical staff's practice and education. Further, they demonstrated the positive effect of rehabilitation on people who suffered from dementia. However, common procedures should be innovated to respond to the challenges of the twenty-first century. There are a considerable number of studies discussing, for example, the effect of virtual reality on the cognitive functions of the elderly. Despite that, an indoor rehabilitation activity is difficult to apply in an outdoor environment [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Modern technologies are becoming a new trend not only in cognitive rehabilitation but also in general rehabilitation. General rehabilitation mainly includes the development of motor skills and supports social adaptability (cf.). In practice, more attention is being paid to physical rehabilitation, which is aimed at people with a particular type of injury [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Although important, cognitive rehabilitation is no less important for patients with cognitive deficits. However, it is often neglected. The reason for neglect can primarily be the fact that cognitive deficits are often hidden and the patients themselves do not always draw attention to them immediately [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In many cases, tertiary prevention focuses on developing impaired cognitive functions either in individual or group therapy that usually occur in the facility's indoor environment [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCognitive and combination therapy, in general, aim to improve the quality of life of people with dementia. These therapies are a non-pharmacological rehabilitation approach, which slows down the disease's progression based on regular activities. Overall, the behavioral and psychological symptoms of dementia itself are alleviated. Some authors talk about the benefits of green dementia care i.e., the connection between people with dementia and nature is primarily supported and this connection is increasingly recognized. Scientific evidence suggests that these connections cover the emotional and social spheres. In this way, they can contribute to promoting the quality of life of people with dementia. Authors presented a meaningful Bird Tales activity that created nature experiences transferred to the interior [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. They pointed out the advantages of these interactions, where indoor activities do not require physical involvement in the outdoor environment. Indoor-based nature can increase social interactions, and a sense of autonomy or control in skills development over the long run. In their contribution, authors stated that people with dementia differ from the general population in their physical, behavioral, and emotional patterns. Further, they differ in terms of internal equipment requirements. The authors, therefore, consider it necessary to examine the effects of the indoor environment on the quality of life of people with dementia [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The research confirmed that building modifications, with the support of other barrier-free changes (lighting, heat, elevators), predetermine physical and mental health, independence, cognitive functioning, or management of normal daily activities. Such interior modifications are in line with the requirements of patients, for example, improperly set light can dazzle and confuse the elderly, making it difficult for them to see clearly and possibly contributing to insomnia. Inadequate ventilation can damage their health over a long period and contribute to a rapid cognitive function decline. Moreover, unpleasant temperatures can increase the death risk in patients with dementia in extreme cases [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. The theoretical backgrounds of each therapy demonstrate their pros and cons. Indoor therapy is not limited by external adverse effects and can be relatively well enriched by modern technologies. Such technologies include, for example, the use of ICT or robotically assisted therapy. Outdoor therapy offers, however, a natural environment that can have a positive effect on the patients. Based on the above, we formulated a research question, \u003cem\u003ewhat effect does outdoor and indoor therapy have on developing patients suffering from Alzheimer's disease?\u003c/em\u003e The research aimed to determine which therapy is more effective for a selected group of experimental and control participants.\u003c/p\u003e \u003c/div\u003e"},{"header":"2 Methods","content":"\u003cp\u003e \u003cb\u003eParticipants and Design\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe study employed a double-blind randomized controlled trial (RCT) design comparing the effects of indoor and outdoor combination therapy on elderly women diagnosed with Alzheimer\u0026rsquo;s disease. Inclusion criteria were: (a) diagnosis of late-onset Alzheimer\u0026rsquo;s disease (ICD-10: F00.01), (b) permanent stay in a social care facility for at least two years, (c) preserved basic mobility, and (d) stable pharmacotherapy for at least three months prior to study entry. Exclusion criteria included: (a) severe sensory deficits, (b) acute medical instability, and (c) unwillingness or inability to provide informed consent. Participants were randomly assigned to either the experimental (outdoor therapy) or control (indoor therapy) group using a computer-generated randomization list prepared by an independent researcher. At baseline, groups did not differ on demographic and clinical categorical characteristics (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.29).\u003c/p\u003e \u003cp\u003eFor continuous variables and baseline outcome measures we report group comparisons in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e; notably, baseline FIM-Mobility differed between groups, and between-group effects were therefore evaluated on change scores with baseline adjustment. The total sample consisted of 50 female participants aged 66.1\u0026ndash;70.2 years (M\u0026thinsp;=\u0026thinsp;67.4, SD\u0026thinsp;=\u0026thinsp;1.8). Therapy was implemented five times per week for 45 minutes over seven consecutive months. Both interventions integrated cognitive rehabilitation and motor therapy based on the principles of psychomotor stimulation and occupational therapy.\u003c/p\u003e \u003cp\u003e \u003cb\u003eOutdoor therapy\u003c/b\u003e included physical and cognitive tasks conducted in safe, accessible garden or courtyard areas, utilizing natural stimuli (e.g., light, textures, and spatial orientation).\u003c/p\u003e \u003cp\u003e \u003cb\u003eIndoor therapy\u003c/b\u003e consisted of identical activities carried out in a controlled indoor environment using standard rehabilitation tools and, where appropriate, ICT-based cognitive training (virtual tasks, paper\u0026ndash;pencil activities).\u003c/p\u003e \u003cp\u003e To ensure treatment fidelity, therapists followed a standardized intervention manual, and weekly supervision sessions were conducted. Attendance and adherence were recorded for every participant; mean adherence exceeded 90% in both groups.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003ePopulation\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe research included 50 female patients (random selection \u0026ndash; double-blind RCT: of participants with the relevant characteristics; the most abundant gender in the case of Alzheimer's disease) in the age range of 66.1\u0026ndash;70.2 years. Based on stratified selection we selected patients who stay in a facility for at least two years (selected in total from two institutions providing social services). These were institutions with a special regime aimed directly at caring for people with a particular form of dementia. Participants were selected based on the relevant features by the double-blind method with the facilities' consent, the oral consent of the individual participants, and family members. The research group was divided into two groups by randomly selecting a group that participated in combination therapy in the indoor environment (control group, 25 patients) and 25 patients who participated in similar activities but in the outdoor environment (experimental group). The weather conditions had to be considered as it affected outdoor therapy activities. The research aimed to determine the effect of outdoor rehabilitation (cognitive and motor) on patients' social adaptability with Alzheimer's disease in facilities providing social services with a subsequent formulation of the conclusions and recommendations for practice concerning the global crisis caused by the SARS-CoV-2 pandemic. Overall, this was a group of patients with dementia in late-onset of Alzheimer's disease (ICD-10; F00.01). Random allocation was generated by an independent researcher using a computer-based randomization list. Allocation concealment was ensured by sealed, opaque envelopes. Therapists delivering the intervention were aware of group assignment due to the nature of the intervention; however, outcome assessors and data analysts were blinded to group allocation. A trial version was also performed as part of the research and addressed issues that could interfere with our research. The trial version lasted one month and involved 5 participants for the experimental and 5 for the control group. An independent person carried out the research set and its division to rule out the ego involvement of the authors. The flow diagram of our research is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Adverse events were monitored systematically during each session and recorded by therapists; no intervention-related harms were observed. Participants and their family members were consulted regarding the feasibility and acceptability of outdoor activities prior to study initiation. Their feedback informed the scheduling, duration, and safety adaptations of the intervention.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eIntervention\u003c/span\u003e \u003c/p\u003e \u003cp\u003eBoth study groups participated in a structured seven-month therapeutic program designed to enhance cognitive and motor functions through a multimodal rehabilitation approach (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). The intervention was jointly developed by a multidisciplinary team consisting of a special educator, occupational therapist, physiotherapist, and clinical psychologist. Each session lasted approximately 45 minutes and was held five times per week. All activities were aimed at stimulating memory, attention, executive functions, spatial orientation, and coordination, as well as improving social communication and self-sufficiency in daily activities. The therapeutic concept was based on combining cognitive and motor stimulation in both individual and group formats, ensuring comparability between the indoor and outdoor settings. Each week followed a consistent structure, consisting of two sessions focused primarily on psychomotor therapy, two sessions on cognitive rehabilitation, and one integrative session emphasizing social cooperation, group interaction, and emotional well-being. The content of the intervention was thematically aligned in both groups, differing only in the environmental context (indoor vs. outdoor). In the experimental group, therapy was conducted outdoors in barrier-free gardens and courtyards of the participating facilities. The outdoor program emphasized the use of natural stimuli to promote sensory engagement, psychomotor activation, and emotional stability. Activities included cognitive tasks performed in natural surroundings, such as naming objects found in the garden, conducting \u0026ldquo;memory walks\u0026rdquo; for spatial orientation, and categorizing or sequencing objects from nature (stones, leaves, flowers). Motor exercises were integrated through low-intensity physical activities, including balance training, stretching, and rhythmic movement using simple equipment such as elastic bands, balls, or soft weights. Elements of occupational therapy were naturally embedded\u0026mdash;for example, participants engaged in short purposeful activities such as watering plants, arranging flowers, or sorting natural materials, supporting procedural memory and the sense of autonomy. Sensory stimulation was further promoted through contact with natural textures, sounds, and light conditions, which contributed to relaxation and reduction of anxiety or agitation. Group-based exercises, such as singing, cooperative gardening, or storytelling, were used to foster reminiscence and social adaptability.\u003c/p\u003e \u003cp\u003eAll activities were supervised by trained therapists and adjusted to current weather conditions; during unfavorable weather, sheltered outdoor areas were used, or simplified variations of the same exercises were applied. In the control group, participants underwent an identical schedule of interventions delivered entirely indoors within the facilities\u0026rsquo; rehabilitation and communal rooms. The indoor program incorporated cognitive stimulation through paper\u0026ndash;pencil exercises, puzzle solving, and attention and memory training. Psychomotor activities included coordination exercises with small equipment (balls, scarves, balance cushions) and rhythmic movement accompanied by music. When available, digital technologies such as tablet-based applications or computer-assisted memory games were used to enhance engagement. Individual therapy sessions were offered to participants with reduced mobility, focusing on maintaining upper-limb coordination, fine motor control, and reaction time. The indoor environment provided stable conditions and allowed the inclusion of virtual cognitive training; however, the sensory and environmental variability present in the outdoor setting was absent. To ensure methodological consistency and intervention fidelity, both indoor and outdoor activities followed a standardized therapeutic manual developed for the study. All therapists underwent initial training and attended regular supervisory meetings to maintain adherence to the protocol. Attendance, engagement, and any deviations from the protocol were documented after each session. The mean attendance rate was 91% in the experimental group and 89% in the control group, confirming a high level of participant compliance. No adverse events related to the intervention were recorded. The therapeutic rationale underlying the program assumed that combining cognitive and motor stimulation within a multisensory environment enhances neuroplasticity, improves mood regulation, and strengthens memory consolidation. The outdoor setting was expected to engage multiple sensory channels, promote physical activation, and increase environmental orientation, thereby contributing to better cognitive performance and social adaptability. Conversely, the indoor environment provided a controlled and technologically supportive space, suitable for maintaining consistent cognitive training and motor tasks. The combination and comparison of these two therapeutic contexts allowed for a comprehensive assessment of the effects of environmental factors on the rehabilitation outcomes of elderly individuals with Alzheimer\u0026rsquo;s disease.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eTherapy alternated between individual and group therapy according to the needs and possibilities and we chose elements of comprehensive rehabilitation (aspects of special education and occupational therapy). Indoor therapy was focused on test batteries, such as a pencil-paper test, individual therapy in the patient's room, and exercise units in psychomotor therapy. Outdoor therapy focused on psychomotor therapy using additional exercise aids, cognitive rehabilitation training, and cognitive functions concerning the outdoor environment. As we managed to apply the same activities to indoor and outdoor environments in most cases, it is possible to make the presentation of results more precise and it allows us to better define recommendations for practice regarding the comparison of outdoor and indoor therapy.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eData Collection\u003c/span\u003e \u003c/p\u003e \u003cp\u003eWe provided input and output data by using a modification of the standardized test focused on functional independence (\u003cem\u003eFIM test \u0026ndash; Functional Independence Measure; Data Management Service of the Uniform Data System for Medical Rehabilitation, the State University of New York at Buffalo\u003c/em\u003e) and a standardized cognitive function test (\u003cem\u003eMMSE test \u0026ndash; Mini-Mental State Examination; the MMSE evaluates orientation, retention, attention and calculation, recall, language, and visual-constructional abilities. Each item is scored binomially with 0 or 1 point, and the total score ranges from 0 to 30; the latter corresponding to the best performance; indicating the good accuracy of the instrument and moderate internal consistency - Cronbach α\u0026thinsp;=\u0026thinsp;.464\u003c/em\u003e;). These are two extended and respected tests in practice. The Mini-Mental State Examination (MMSE) was administered in its validated Czech version [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], which has been widely used in clinical and research settings in the Czech Republic. Therefore, no additional back-translation procedure was required.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eData Analysis\u003c/span\u003e \u003c/p\u003e \u003cp\u003eAfter completing the data collection, we compared the input and output testing of both mentioned standardized tests. The obtained data was different from the normal distribution, so non-parametric methods were used for statistical analysis; specifically, the Wilcoxon paired test, at the significance level α\u0026thinsp;=\u0026thinsp;.05. The research itself was conducted during 2025 and lasted seven months (February to September). The study results were analyzed by an independent researcher, thus excluding the ego involvement of the authors. Pre- and post-intervention data were analyzed using IBM SPSS Statistics 28. As the dataset did not follow a normal distribution (Shapiro\u0026ndash;Wilk test, p \u0026lt; .05), non-parametric tests were applied. The Wilcoxon signed-rank test was used to compare pre- and post-scores within groups, and the Mann\u0026ndash;Whitney U test to compare between groups at baseline (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Effect sizes (r) for Wilcoxon tests were computed as r\u0026thinsp;=\u0026thinsp;Z/\u0026radic;N. Ninety-five percent confidence intervals for r were estimated using Fisher\u0026rsquo;s z transformation (approximate method given the non-parametric origin of r). Where available, bootstrap CIs from 1,000 resamples were used in sensitivity checks.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEffect sizes (r): according to Cohen\u0026rsquo;s criteria, r = .1 indicates a small, .3 a medium, and .5 a large effect.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eGroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eInterpretation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLarge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eControl\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLarge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFIM \u0026ndash; Daily Task\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLarge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFIM - Mobility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLarge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFIM \u0026ndash; Social Adaptability\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperimental\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eLarge\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eLegend\u003c/strong\u003e \u003cp\u003eEffect sizes (r) and their 95% confidence intervals were calculated for each outcome according to Cohen\u0026rsquo;s criteria (small = .10, medium = .30, large = .50). Bootstrap resampling (1,000 iterations) was used to estimate confidence intervals for non-parametric tests.\u003c/p\u003e \u003c/p\u003e"},{"header":"3 Results","content":"\u003cp\u003eAll fifty participants (25 in the experimental group and 25 in the control group) completed the full seven-month intervention period. No dropouts or adverse events were reported during the study. Baseline demographic and clinical characteristics of the two groups were comparable in terms of age, duration of disease, education, and medication use, confirming group equivalence at the start of the study (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Cognitive performance was assessed using the Mini-Mental State Examination (MMSE). Both the experimental and control groups demonstrated significant improvements between pre-test and post-test scores. In the experimental group (outdoor therapy), given the non-normal distribution of data, median values were reported. For the MMSE, the median score increased from 20 to 22 in the experimental group (mean 22.4). (Z\u0026thinsp;=\u0026thinsp;4.78, p \u0026lt; .001, r = .68), reflecting a large effect size. In the control group (indoor therapy), the median score rose from 19 to 21 (Z\u0026thinsp;=\u0026thinsp;4.29, p \u0026lt; .001, r = .61), also indicating a large but slightly smaller effect. Although both groups showed measurable cognitive gains, the improvement was more pronounced in participants who engaged in outdoor therapy, suggesting that the natural environment and physical engagement may enhance cognitive stimulation and attention processes. Functional independence and adaptability were evaluated using the Functional Independence Measure (FIM), which includes subscales for daily tasks, mobility, and social adaptability. Participants in the experimental group showed consistent and statistically significant improvement across all three domains. Specifically, the median scores increased from 40 to 42 for daily tasks (Z\u0026thinsp;=\u0026thinsp;4.70, p \u0026lt; .001, r = .66), from 8 to 10 for mobility (Z\u0026thinsp;=\u0026thinsp;4.78, p \u0026lt; .001, r = .68), and from 19 to 21 for social adaptability (Z\u0026thinsp;=\u0026thinsp;4.70, p \u0026lt; .001, r\u0026thinsp;=\u0026thinsp;0.66). In contrast, the control group did not show statistically significant progress in most areas.\u003c/p\u003e \u003cp\u003eThe median FIM score for daily tasks remained unchanged at 38 (Z\u0026thinsp;=\u0026thinsp;1.75, p = .08), while the mobility score slightly decreased from 17 to 16 (Z\u0026thinsp;=\u0026thinsp;0.71, p = .48). The median score for social adaptability changed marginally from 25.5 to 25 (Z\u0026thinsp;=\u0026thinsp;0.94, p = .35). These findings indicate that outdoor combination therapy had a stronger and broader positive impact on the participants\u0026rsquo; ability to perform everyday activities, move independently, and interact socially compared with indoor therapy alone (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Between-group comparisons of post-test scores using Mann\u0026ndash;Whitney U tests confirmed that participants in the outdoor (experimental) group achieved significantly higher outcomes in cognitive (MMSE, U\u0026thinsp;=\u0026thinsp;197.0, Z\u0026thinsp;=\u0026thinsp;2.14, p = .033, r = .30) and functional domains (FIM Daily Tasks, U\u0026thinsp;=\u0026thinsp;171.5, Z\u0026thinsp;=\u0026thinsp;2.96, p = .003, r = .42; FIM Mobility, U\u0026thinsp;=\u0026thinsp;160.0, Z\u0026thinsp;=\u0026thinsp;3.25, p = .001, r = .46; FIM Social Adaptability, U\u0026thinsp;=\u0026thinsp;174.0, Z\u0026thinsp;=\u0026thinsp;2.87, p = .004, r = .41) compared with the indoor (control) group. These effects ranged from medium to large according to Cohen\u0026rsquo;s benchmarks. Between-group analysis showed that participants who underwent outdoor therapy achieved higher overall mean ranks across all assessed domains. The most notable difference was observed in the FIM mobility subscale, where the experimental group improved by an average of two points, while the control group exhibited a slight decline. This result represents both a statistically and clinically meaningful difference, highlighting the beneficial role of natural environmental factors, such as light, space, and sensory variety in supporting psychomotor activation and functional independence among individuals with Alzheimer\u0026rsquo;s disease. When examining the data collectively, it becomes evident that outdoor combination therapy produced a more comprehensive improvement profile. While indoor cognitive rehabilitation was effective in maintaining or slightly enhancing cognitive function, the outdoor program facilitated concurrent gains across cognitive, motor, and social domains. Participants exposed to the outdoor environment displayed greater engagement, attention, and motivation during therapy sessions, which may have contributed to the superior outcomes. The integration of physical movement, multisensory stimulation, and natural surroundings appears to reinforce neurocognitive processes associated with memory, coordination, and social adaptability.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eBaseline comparison between groups for clinical and demographic characteristics (Individual clinical characteristics were taken into account in the intervention)\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperimental group\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl group\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAge \u0026Oslash;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSex (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eFemale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMale\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRelationship (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (28.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (72.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDisease duration in years \u0026Oslash;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4,1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEducation (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigher education\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (28.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eHigh school education\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (48.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16 (64.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePrimary education\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStay in the institution in years \u0026Oslash;\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMedication (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8 (32.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (40.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (68.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSecondary diagnosis (limiting; %)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eyes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (16.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003enone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (84.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eImpaired food intake (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eyes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 (12.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (4.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003enone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (88.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24 (96.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eurine incontination (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eyes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (24.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003enone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (80.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (76.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmployment (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (72.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIrregularly\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (16.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 (24.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eVisiting families (%)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eYes\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (24.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eIrregularly\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (60.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (68.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eNone\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (20.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (8.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u003cem\u003eStatistical results of the research survey in the experimental and control groups\u003c/em\u003e Legend: \u003cem\u003eMdn\u003c/em\u003e\u003csub\u003e\u003cem\u003epre\u003c/em\u003e\u003c/sub\u003e \u003cem\u003e\u0026ndash; median pre-testing; Mdn\u003c/em\u003e\u003csub\u003e\u003cem\u003epost\u003c/em\u003e\u003c/sub\u003e \u003cem\u003e\u0026ndash; median post-testing\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003etest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003egroup\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eZ\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMdnpre\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMdnpost\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eMMSE test\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eexperimental\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e22.40\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003econtrol\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eFIM test - daily task\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eexperimental\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003econtrol\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eFIM test - mobility\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eexperimental\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003econtrol\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cem\u003eFIM test - social adaptability\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eexperimental\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003econtrol\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25.50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eBoth groups, i.e., the experimental group which participated in outdoor activities and the controlled group which participated in indoor activities achieved better results with regular and intensive therapy than at the initial testing. The experimental group achieved a statistical increase in all types of tests while the control group\u0026acute;s results were only better in the MMSE test. The control group's values remained unchanged in other tests, or the change was small and insignificant. However, the control group achieved better results for social adaptability support in comparison to the experimental group. In the case of the MMSE test, a point increase is desirable, which indicates an improvement in monitored indicators for both groups. Within the FIM test, increasing the number of points is also desirable, as it indicates an overall improvement in the monitored indicators. During the research, we encountered various difficulties in both settings, i.e., unsuitable weather, noise level, or unpreparedness of a given facility, for example, insufficient and unsuitable outdoor equipment. As for the controlled group, it was a stereotypical and non-dynamically developing environment that can become less stimulating after a long-term intervention. Outdoor combination therapy can be divided into a closed outdoor area i.e., fenced gardens and an open space area. Authors presented, it is essential for safety reasons to monitor people with dementia in the open space area using technology, for example, GPS. In closed outdoor areas, this concern may be eliminated at the expense of offering fewer stimuli. Thus, the open space area is from the point of view of rehabilitation more beneficial than fenced gardens. Even though not all activities can be fully implemented within the facilities. The support for social adaptability is minimal, as individuals are only in contact with other clients and employees [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. The research aimed to determine what effect outdoor rehabilitation (cognitive and motor; combination therapy) has on the social adaptability of people with Alzheimer's disease in facilities providing social services. The author's team assumed that outdoor training would become more effective than indoor training, which was only partially demonstrated and with certain limits. Based on the results, we assume that the combination of outdoor and indoor environments seems to be effective, as each environment has its pros and cons. A combination of outdoor and indoor activities seems to be ideal as it develops cognitive functions and expands the range of cognitive rehabilitation possibilities. The combination of these activities can positively affect different cognitive areas among the elderly [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. Other authors refer about combination therapy as physical therapy and movement therapy. The approaches chosen in this way can be of great benefit. It is essential, however, to recognize that people who suffer from dementia have different needs and whether in individual or group therapy, it is crucial to address these needs. In the context of the global crisis (spread of the SARS-CoV-2 virus) outdoor activities can to some extent replace indoor activities by being aware of potential limits. Thus, hygienic requirements can be enforced, and working with patients indoors can be limited, lessening the risk of infection. Outdoor environment in crisis times enables a wide range of activities that can purposefully strengthen and develop disturbed areas of the elderly with cognitive deficits, for example, motor activities - psychomotor therapy, therapeutic physical education or relaxation exercises, mental activities - testing, worksheets, cognitive training kits, therapeutic interviews. The term combination therapy is often used to refer to pharmacological treatments, often further divided into mono and combination therapy according to the amount of drug use and non-pharmacological treatment [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. From our perspective, we define this term within the so-called helping professions, where we combine rehabilitation approaches across individual therapies and thus create a comprehensive and combined rehabilitation approach, which is aimed at the elderly with cognitive deficits. Professional supervision or assistive technologies offer a way to support the individuality of individuals with dementia while ensuring their safety and enabling them to manage common daily activities that relate to daily functioning both in the home environment and in the institutional environment. At the same time, outdoor activities are an essential part of developing an active lifestyle [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Limitations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eGroup equivalence (selection)\u003c/strong\u003e \u003cp\u003eThe initial testing with the widely used standardized tests showed very similar initial results in selected groups and individual participants. Equal input and testing conditions were created for both groups (adjusting the requirements for the same testing, deliberately selecting participants corresponding to the relevant features).\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMaturation and natural development (growth)\u003c/strong\u003e \u003cp\u003ethis is an essential factor, as our intervention focused on working with people with dementia for seven months. These people are a group of participants where day-to-day changes can be seen, and the diagnosis itself is progressive. The presented results point to the fact that they have improved during these months, and it can be argued that the disease's progression has slowed down slightly. There are intervening variables, however, that can affect these results (e.g. drug changes, not recorded during the intervention). One such factor may be the weather, which can affect the depressed states of participants and thus limit the possible intervention and subsequent testing results.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eThe internal consistency\u003c/strong\u003e \u003cp\u003eof the MMSE in our sample was relatively low (Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.464), which may reflect the multidimensional structure of the test and the heterogeneous cognitive profiles of participants with Alzheimer\u0026rsquo;s disease. Therefore, results based on this measure should be interpreted with caution.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMeasurement effect (device)\u003c/strong\u003e \u003cp\u003eThe test was applied before the start of the interventions and after seven months. It was not used during the therapies.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eMeasurement tool error\u003c/strong\u003e \u003cp\u003eThe reliability of selected tools has reached acceptable values. This intervening variable was captured. To obtain results, we used standardized MMSE tests and the FIM test. The combination of these tests determines in practice the degree of disability in the monitored indicators. In the research, we focused on evaluating social adaptability (FIM test) and cognitive function (MMSE) because the combination of motor and cognitive functions and social skills are crucial areas with an overall share in social adaptability itself and more.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eExpectations from the researcher\u003c/strong\u003e \u003cp\u003eOnly one researcher always participated in the testing to capture testing uniformity with objective results in the research. Thus, the ego engagement of the researchers was limited, which is evident from the presented results.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eEnvironment (indoor, outdoor)\u003c/strong\u003e \u003cp\u003eWe took necessary measures to ensure quality adjustments to the indoor and outdoor environment at the beginning. However, it was not possible to eliminate all obstacles, for example, sudden sounds and insufficient technical equipment.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePost hoc power analysis\u003c/strong\u003e \u003cp\u003eIn addition, given the relatively small sample size (n\u0026thinsp;=\u0026thinsp;25 per group), we conducted a post hoc power consideration based on the observed effect sizes. For a between-group effect of approximately \u003cem\u003er\u003c/em\u003e \u0026asymp; .30 (equivalent to \u003cem\u003ed\u003c/em\u003e\u0026thinsp;\u0026asymp;\u0026thinsp;0.63), an estimated sample of ~\u0026thinsp;41 participants per group would be required to achieve 80% statistical power. For larger effects (\u003cem\u003er\u003c/em\u003e \u0026asymp; .42\u0026ndash;.46; \u003cem\u003ed\u003c/em\u003e\u0026thinsp;\u0026asymp;\u0026thinsp;0.93\u0026ndash;1.04), the current sample size is sufficient, as 16\u0026ndash;20 participants per group would meet the 80% power threshold. Although our study detected medium to large effects across several domains, future trials should consider increasing the sample size to approximately 45\u0026ndash;50 participants per group to account for dropouts and ensure sufficient power for detecting smaller effects.\u003c/p\u003e \u003c/p\u003e \u003cp\u003eThe study did not include a priori power analysis due to the pilot character.\u003c/p\u003e \u003c/div\u003e"},{"header":"5 Conclusions","content":"\u003cp\u003eAlzheimer's Disease International reports that there are more than 44\u0026nbsp;million cases of dementia worldwide, making it a global socio-economic problem. Fortunately, there seems to be a suitable outdoor environment and adapted therapy that can improve the patient's physical and mental area in times of crisis. The outdoor environment should be designed with safety and accessibility in mind, along with promoting social adaptability and stimulating individual impaired functions [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. We also identify with these authors, who states that cognitive rehabilitation improves the daily functioning of people who suffer from dementia [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Further, the results of our research are in line with next authors who confirm that outdoor activities can improve mental health for at least some of the disease's symptoms. These activities are significant for the support of psychological components in people suffering from depression or dementia. They also have a positive effect on patients and are of considerable economic importance. Cognitive therapy, also called cognitive stimulation therapy, is an internationally used evidence-based psychosocial intervention among people with mild to moderate dementia and other cognitive impairments. Such a comprehensive approach emphasizes this approach's value as an integral part of the services offered to people with some form of dementia to maintain cognitive functioning and quality of life. Cognitive stimulation therapy is also recommended by the UK National Institute for Health and Care Excellence guidelines and is approved by Alzheimer's Disease International [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. In the overall summary of the results, we believe that regular therapy for patients with Alzheimer's disease has a positive effect on cognitive functions and the support of their social adaptability, i. e. coping with daily activities, mobility, and social adaptability [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e]. The use of outdoor spaces offers exciting possibilities within the development of disturbed areas in these patients.\u003c/p\u003e \u003cp\u003eIt is possible to create such conditions that may be sufficient to develop the patients' disturbed areas in the outdoor environment based on the results presented by us. In times of crisis and outside of it, it is desirable to limit patients' stay in a closed environment. Spending both therapeutic time and free time outdoors can limit the side effects of the crisis. Outdoor therapy offers the possibility of implementing both individual and group therapy. Future research should expand the present findings by integrating sensor-based monitoring, digital cognitive tools and virtual-reality approaches to capture continuous behavioural, motor and cognitive data. Wearable sensors (e.g., accelerometry, heart-rate monitoring), tablet-based cognitive assessments, BLE-based social interaction tracking, structured electronic therapeutic diaries, and standardized clinical data platforms (e.g., REDCap) could substantially improve the objectivity, granularity and ecological validity of outcome measures. Virtual-reality interventions represent another promising direction, enabling multisensory cognitive stimulation and reminiscence activities [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e] These technological extensions may help to refine individualized therapeutic responses, enhance monitoring during long-term therapy and align future studies with the broader DIGITECH research agenda. A detailed list of recommended technologies and example studies is provided in the Supplementary Material (Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures adhered to the ethical standards of the national research committee and followed the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. Our research team obtained administrative permission to access the data used in this study. We are aware that we are working with human subjects; therefore, the research study was approved by the Medical Ethics Committee of the Masaryk Hospital, prior to its commencement. All participants were properly informed about the nature of the research and provided their voluntary and informed consent. The intervention was designed to ensure that no physical or social harm would come to the participants, and their rights were fully respected. Registration number is 2025/12/1_001 (date of the first registration 12.1.2024). \u0026nbsp;The project was retrospectively registered on January 3, 2026, on the Sri Lanka Clinical Trials Registry: Registration Number SLCTR 2463 (https://slctr.lk/trials/78bd1ad0-dfdd-013e-85a9-04014debcf01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis publication was created with the support of the ITI - DIGITECH project, reg. no.: CZ.02.01.01/00/23_021/0010653, financed by OP JAK. (https://opjak.cz/en/)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data are only available upon reasonable request, to gain access contact the corresponding author.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNon-applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThank you, dr. Dorothy Kessler, (Queen\u0026acute;s University, Faculty of Health Sciences, Ontario - Canada) for help and expert advice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003cbr\u003eThe datasets used and/or analyzed during the current study available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKhan, A. \u0026amp; Zubair, S. 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Rev.\u003c/em\u003e\u003cstrong\u003e21\u003c/strong\u003e, 109\u0026ndash;122 (2025).\u003c/li\u003e\n\u003cli\u003eZhao, Y. \u003cem\u003eet al.\u003c/em\u003e Effectiveness of exergaming in improving cognitive and physical function in people with mild cognitive impairment or dementia: systematic review. \u003cem\u003eJMIR Serious Games\u003c/em\u003e\u003cstrong\u003e8\u003c/strong\u003e, e16841 (2020).\u003c/li\u003e\n\u003cli\u003eMarinho, V. \u003cem\u003eet al.\u003c/em\u003e Cognitive stimulation therapy for people with dementia in Brazil (CST-Brasil): results from a single blind randomized controlled trial. \u003cem\u003eInt. J. Geriatr. Psychiatry\u003c/em\u003e\u003cstrong\u003e36\u003c/strong\u003e, 286\u0026ndash;293 (2021).\u003c/li\u003e\n\u003cli\u003eVostr\u0026yacute;, M., Chytr\u0026yacute;, V., Cmorej, P. C., Fleischmann, O., \u0026amp; Kubov\u0026aacute;, N. Effect of combined and intensive rehabilitation on cognitive function in patients with Alzheimer\u0026rsquo;s disease evaluated through a randomized controlled trial. \u003cem\u003eScientific Reports,\u003c/em\u003e\u003cstrong\u003e15\u003c/strong\u003e(1), 8110 (2025).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"cognitive rehabilitation, combination therapy, dementia, outdoor therapy, elderly, special education, occupational therapy","lastPublishedDoi":"10.21203/rs.3.rs-8137844/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8137844/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAlzheimer’s disease leads to progressive cognitive and motor decline, reducing independence and social adaptability in older adults. Combining cognitive and motor stimulation in natural environments may enhance neuroplasticity and functional abilities. This study aimed to compare the effectiveness of outdoor versus indoor cognitive–motor therapy in elderly women with Alzheimer’s disease, focusing on cognitive performance and functional independence. A double-blind randomized controlled trial was conducted with 50 female participants aged 66–70 years from two long-term care facilities. The intervention lasted seven months (five sessions per week, 45 minutes each). The experimental group received outdoor cognitive–motor therapy in garden areas, while the control group underwent identical sessions indoors. Cognitive performance was assessed using the Mini-Mental State Examination (MMSE) and functional independence with the Functional Independence Measure (FIM). Data were analyzed using Wilcoxon and Mann–Whitney U tests, and effect sizes (r) were calculated. Both groups showed significant cognitive improvement (MMSE: experimental Z = 4.78, p \u0026lt; .001; control Z = 4.29, p \u0026lt; .001). However, only the outdoor group demonstrated significant gains across all FIM domains daily tasks, mobility, and social adaptability (p \u0026lt; .001; large effects, r = .66–.68). Outdoor cognitive–motor therapy produced broader improvements in cognitive, motor, and social functioning compared with indoor therapy. Exposure to natural environments enhances sensory stimulation, motivation, and rehabilitation outcomes, suggesting that integrating outdoor settings into dementia care may increase the effectiveness of non-pharmacological interventions.\u003c/p\u003e","manuscriptTitle":"Outdoor versus Indoor Cognitive–Motor Therapy in Alzheimer’s Disease: Evidence from a Longitudinal Randomized Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-22 16:35:55","doi":"10.21203/rs.3.rs-8137844/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-30T11:00:29+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-14T10:25:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"58094229452555239635455586511362774557","date":"2026-04-02T08:58:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-15T17:48:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164663319949424814530222390061458551415","date":"2026-02-22T06:01:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-17T18:40:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-17T15:27:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-01T15:58:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2026-02-01T14:07:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"80ff8b68-22bf-4bd9-8981-3bc864705323","owner":[],"postedDate":"February 22nd, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-04-30T11:00:29+00:00","index":"","fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[{"id":63154992,"name":"Health sciences/Health care"},{"id":63154993,"name":"Health sciences/Neurology"},{"id":63154994,"name":"Biological sciences/Neuroscience"}],"tags":[],"updatedAt":"2026-05-19T06:08:55+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-22 16:35:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8137844","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8137844","identity":"rs-8137844","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}