Reminiscing Group Therapy for Dementia Patients

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Table of Contents

Abstract
Introduction
Background
Literature Review
The Study
Method
References

Abstract

Dementia in the elderly population is the problem addressed in this study. The necessity of finding effective methods to improve the quality of their life has been explained. This researcher has discovered that some amount of work has been done in this field. His search for literature unearthed many interesting pieces which he has highlighted in the review. The material for the literature review was done by accessing 2 online libraries and extracting papers on researches conducted by exalted personalities from the associated professions including nursing.

Material has been gathered from various peer-reviewed journals like the Clinical Effectiveness in Nursing, Archives of Gerontology and Geriatrics, The Hong Kong Journal of Occupational Therapy, Aging, and Mental Health, Journal of Advanced Nursing, The Gerontologist, Journal of Clinical Nursing, International Journal of Geriatric Psychiatry and Public Health Nursing. The matter has been especially accessed from more recent journals from 2000 to 2007. This researcher has adopted reminiscence therapy for the research after looking through the literature. Though it has been extolled by many as a good therapy intervention, much more research is required to finally prove it.

Introduction

The elderly population which is increasing rapidly due to the rise in longevity is a group that requires plenty of attention by way of therapy and interventions for their several problems of health and disability. This is recognized as a global health problem.

Inadequacies intending to the geriatric group and in affording them a life of quality have been pricking the conscience of many in social, political, and medical circles. Efforts are on to obtain answers to many of the geriatric problems through widespread globally-oriented researches. Dementia happens to be just one of the many problems identified.

It can be predicted to become a major problem in the near future. There are not enough carers for the disabled and demented. Time has come for the institution of effective therapies of psychosocial origin as the pharmacological and psychotherapies have been unsuccessful in meeting the demands. Researches have shown that the elderly are positively affected by psychosocial interventions which range from validation therapies through group activities to reminiscence therapies. Other researchers have indicated a good response to reminiscence therapy when compared to other psychosocial interventions in cases of dementia. This researcher intends to study the effects of reminiscence group therapy in a few elderly women with dementia. The hypothesis is:

“Reminiscence group therapy improves the recall, cognition, and communication skills of the elderly population with mild and moderate dementia; increases the sense of their personality identity, stimulates their memories and increases the individualization of their care”. This researcher hopes to identify interventions that could be put into practical use to improve the quality of life of elderly dementia patients.

Background

History

In the 1960s reminiscences were frowned upon by therapists. Later this view was changed and hence many researches started being done to evaluate the feasibility and predictability of reminiscences. Lewis did the first study in 1971. In the 1980s reminiscence therapy was being used by gerontologic nurses, social workers, occupational therapists, and psychologists. Since then this therapy has been studied frequently and efforts are being made gradually to make it an effective therapeutic measure for elderly people with dementia; mild, moderate, or severe.

Reminiscence-based activities have had a huge effect on the advancement of the status of old people and now the idea of reminiscence therapy for the elderly who have dementia is becoming strong and this researcher intends to study the effect of reminiscent group therapy for a small group of elderly people with mild and moderate dementia.

Theories identified in reminiscences

Evidence-based nursing practice selects any treatment method based on its strong theoretical base. Reminiscence therapy lacks an established theory yet. This has led to an array of study methodologies and measurement indicators (Lin, 2003).

The ‘disengagement theory’ of Cumming and Henry (1961) said that aging involved a process of withdrawal from social life in preparation for death. The ‘ego-integrity theory’ of Erikson said that a person with this quality in old age believed that his life was significant, had meaning, and was fulfilled (Lin, 2003). Butler extended this theory to say that Ego-integrity is achieved by recalling the past from an analytical and evaluative perspective.

Parker (1995) consolidated all the theories into the continuity theory (Lin, 2003). Individuals move from one stage to another by recalling the past and attempting to predict their later experiences. The continuity theory is closely linked to memory processes. “Change is linked to the person’s perceived past, producing continuity in inner psychological characteristics and in social behavior and social circumstances.” (Lin, 2003). An individual maintains continuity through his memory or by recalling what he has done before. Familiar knowledge, skills, and strategies are used to develop stable patterns of activity which help adaptation in old age. Reminiscences occur in the remote memory which is the function of the last system to deteriorate in dementia in the elderly. Enhancing the use of this Remote memory improves cognitive functions.

The Reminiscence Model

Kovach’s model of reminiscence (1991) is based on self-esteem and proposes that reminiscence is a source of self–referent knowledge that influences a person’s self-worth. It involves a process of acquiring meaning for his life and a mechanism for adapting to stress. Cognitive processes are recognized but the reminiscing group therapy could be changed under differing conditions. This model may be refined when relationships of other variables like self-esteem, mood, satisfaction, behavior over time and under different conditions of stability and transition with reminiscence have been studied in detail.

Background for this Research

Lin (2003) conducted a systematic review of the effect of reminiscences in the elderly population. He concluded that reminiscence therapy does have a positive effect in maintaining or improving mood, cognitive functioning, life satisfaction, and self-esteem in the elderly. This therapy works well for healthy adults, adults with depression, bereavement, and cognitive impairment. He commented that the effects are poorly understood as the results are inconsistent (Lin 2003). Bohlmeijer et al (2003) conducted a meta-analysis to assess the effectiveness of reminiscence and life review on late-life depression across different target groups and treatment modalities.

They found that both are potentially effective treatments for elderly depression and may serve as a significant and valuable alternative to psychotherapy or pharmacotherapy. Both are effective, safe, and acceptable to the participants (Bohlmeijer et al, 2003). Cully et al (2001) examined the relationships existing between the frequency and functioning of reminiscences with personality style and psychological functioning in older adults. The results showed that individuals with negative psychological function had a tendency to reminisce frequently to refresh bitter memories probably reducing boredom thereby and preparing for death.

Depressed and anxious adults commonly use reminiscences and therefore they could be appropriate people for reminiscence therapy. A systematic review of the research on therapeutic activities with persons afflicted with Alzheimer’s Disease was done by Marshall and Hutchinson (2001). They discovered many obstacles to getting an appropriate picture of the usefulness of the therapeutic activities. Difficulties both theoretical and methodological, ambiguous findings, the existence of gaps, and a lack of emphasis on gender, race, ethnicity, and cultural differences were noted. Stinson and Kirk (2005) studied structured reminiscence as an intervention to decrease depression and increase transcendence in older women. A positive result was indicated after 6 weeks in the reminiscence group.

There was a non-significant decrease in depression and an increase in self-transcendence. There was also an inverse relationship between depression and transcendence (Stinson and Kirk, 2005). Validation therapy is one good method of psychosocial therapy for the elderly affected by dementia. A study compared the effects of validation therapy with sensorial reminiscence therapy and a control group with no cognitive therapy (Deponte and Missan, 2006). The functioning improved with the two psychosocial therapy groups, especially with the sensorial reminiscence group. The control group showed no improvement; in fact, deterioration was noted. The sensorial reminiscence group improved in the cognitive, affective, and behavioral status.

A study (Brooker and Duce, 2000) was done on the well-being and activity in individuals with mild to moderate dementia during three groups of activities: simple group reminiscence therapy using objects and photographs, group activities involving goal-directed games and crafts, and unstructured time where the participants were left to do what they wanted without supervision. The well-being was obviously better in the groups with reminiscence therapy and group activity and the ones who underwent the reminiscence therapy had the best positive results (Brooker and Duce, 2000).

Another review was done for assessing the effectiveness of various interventions in people with dementia (Boote et al, 2006). 5 psychosocial interventions were used: multi-sensory stimulation, group exercise, reality orientation, combined walking and talking, and reminiscence therapy.

Evidence was not found for reminiscence therapy and multi-sensory stimulation. The group exercise increased muscle strength, walking and talking slowed the decline for mobility, and reality orientation improved cognitive functions (Boote et al, 2006). Chin’s (2007) meta-analysis examined the clinical effectiveness of reminiscence therapy on the ‘life satisfaction, happiness, depression, and self-esteem of older adults aged 50 or above. Significant beneficial effects were seen.

This researcher aims to study the effects of reminiscence therapy on mild and moderate dementia in 6 residents of a nursing home. The goals of this research are to improve recall, cognition, and communication skills, to increase their sense of personality identity, to stimulate their memories, and to increase the individualization of their care.

Bates et al (2004) defined mild to moderate dementia as scoring between 15 and 23 on the Mini-Mental State Examination. This definition has been maintained in this research. The continuity theory is being adopted for this study. The model that I am following is Lin’s model of reminiscence after making small changes in it to suit the experiment.

The group therapy helps the elders in the group to identify with each other and with each new meeting for therapy or otherwise the patients become emotionally closer and feeling more confident about interacting. The frequent reviewing of past experiences would assume a positive self attitude for the sender and receiver. Social isolation is eliminated by this small group reminiscent therapy. This research intends to measure the difference in the cognitive impairment in the participants before and after the reminiscence therapy sessions.

The reminiscences are classified differently by researchers. The identifications of specific interventions could in the future permit their use in therapy of the elderly with dementia. The nursing students and other medical professionals could be trained for the purpose with these interventions in mind. The rising numbers of elderly with dementia should not be left unnoticed.

Application in Clinical practice

The framework of reminiscence designed by Lin (2003) appears to be good ground to build upon in clinical nursing practice where the elderly form a good part of it. It incorporates various ideas gathered from a review of previous studies. According to this framework, reminiscence therapy could be considered to have five stages. In the first stage, the nurse notices an antecedent situation an aging person. It could be stressful situations, relocation, or transition, or just maladjustment. The nurse is the best person to elicit this information which is very private. It could be in the atmosphere of a hospital or nursing home or within the concept of community practice.

The next step is the initiation of an assessment by which she understands further details out of direct questions and assessment using tools. Standardized psychometric measurements, self-report instruments, or observational instruments which have been tested for validity and reliability are used for the assessment. The third stage is to establish therapeutic interventions or activities. Depending on the extent of social isolation or low self-esteem or depression, suitable activities could be devised for each individual. The reminiscence therapy also should vary from person to person. Groups can be formed based on individual requirements.

Each group could have activities that focus on specific targets appropriate to their requirement. The fourth stage involves the selection of the modality of therapy. The therapies should be on a continual basis for the elderly or demented patients. The activities could range from simple relaxed group activities which would solve the problem of social isolation and allow a group to intermingle and share their reminiscences to more detailed life-review activities. The final stage should assess the outcome of this procedure. The short-term and long-term effects may be considered.

Significance for nursing practice and research

Through this framework of reminiscence therapy, the nursing profession could hone its professional capabilities to strengthen the quality of life of the elderly without any accompanying illnesses or with dementia or depression. This framework is useful to nurse educators to devise suitable training programs for the student nurses. Researchers could also use this framework for studies to evolve the best reminiscence therapy with a view to obtaining the best results in their practice.

Literature Review

Dementia and Psychosocial Therapies

Dementia is becoming increasingly common due to a fast increase in the elderly population. By 2025, 34 million people are expected to have dementia (Alzheimer’s Society, 2003). A need has arisen to establish cost-effective clinical therapy for dementia patients. The American Association for Geriatric Psychiatry, the Alzheimer’s Association, and the American Geriatrics Society have decided in one voice to investigate the therapies which hinder progress in dementia, take effective steps to halt this process of dementia, and select the beneficial therapies which improve the functioning and quality of life to the maximum possible (Small et al, 1997, Pg. 1362).

Psychosocial therapies have become a significant part of modern-day dementia and it is a non-pharmacological treatment of dementia (Douglas et al, 2004). Various psychosocial therapies that could be used are ‘Group exercise, physiotherapy, psychotherapy, massage and aromatherapy, multi-sensory stimulation, reality orientation, music therapy, validation therapy, and reminiscence therapy (Boote, 2006). Efforts are being made at the National Levels to cope with the rehabilitation of dementia patients. The appropriateness of interventions for the various stages of dementia is being investigated. Studies are now concentrating on therapies for any one stage of dementia, mild or moderate or severe. The aim is to train health professionals in new approaches to psychosocial therapy for dementias.

Dementia in the elderly is accompanied by a feeling of being useless with reduced quality of life and slowly deteriorating into one of being cared for totally and becoming completely dependent on a carer with no contribution from the patients. The appropriate and fulfilling activity could raise their emotional happiness and the quality of their life. They would be better off with behavioral and cognitive improvement and probably find more meaning in their life. Meeting like-minded fellow humans in a group is in itself a therapy (Brooke and Duce, 2000). Normally once the elderly become demented, they are left out by their own children and friends.

Positive interventions could revive their old feeling of togetherness, the confidence of being wanted, and the feeling of belonging somewhere. The structuring of an activity group including the dementia patients who need the therapy helps in improving self-esteem (David, 1991). Game playing and traditional craft activities help to keep the patients enthusiastic and boredom away (Brooke and Duce, 2000). New learning may not be possible. However well-rehearsed memories can be worked upon. Sharing their life experiences and re-experiencing old times of happiness or reminiscing are pleasurable. Sharing with the group becomes a sought-after activity.

Alzheimer’s Disease: A form of dementia in the elderly

Alzheimer’s disease is one cause of dementia affecting the elderly. It is a progressively debilitating neurological illness that causes a global health problem. Statistics say that by 2047, the number of Alzheimer’s Disease patients in the US would rise at a factor of 3.7 to between 4.37 and 15.4 million (Marshall and Hutchinson, 2001).

Researchers and clinicians are in favor of activities to form part of the therapy for Alzheimer’s Disease. Therapeutic activities which enhance the quality of life, arrest the mental decline, and generate and maintain self-esteem (Marshall and Hutchinson, 2001) also help to create immediate pleasure, re-establish dignity, provide meaningful tasks, restore roles, and enable friendships. Activities help to increase knowledge and provide some meaning to their life, have some new accomplishments and utilize opportunities to help others (Tappen, 1997).

They also provide nourishment for the body, mind, and spirit. (Whitcomb, 1993). Their physical, mental, and emotional faculties would be stimulated (Zachary, 1984). Socialization, communication, and conflict resolution are better. These patients tend to have overall satisfaction with their new leisure activities. Failure to provide these activities would be equivalent to elder abuse.

Validation Therapy

The Validation therapy group showed a reduction in behavioral disturbances. This therapy is the most popular therapy even though it has not been proved to be the best (Feil, 1993). It is considered that confusion in the elderly occurs usually as a defense mechanism. The therapy aims at evaluating the emotional problems of the patients and then redefining their behavior and emotions to help them solve their residual life tasks (Deponte and Missan, 2006). Efficacy evaluation is an important part of Validation therapy. This is what makes this technique appear simpler than others.

Small group interventions were effective in diminishing behavior disorders and improving cognitive and daily functioning. This study found that better results were seen in the sensorial reminiscence group. The use of psychotropic medications could not be reduced. Validation therapy was concluded to be as good a therapy as any other because it provided enough attention to the patient and there was an intimate relationship which supported the emotional dementia patient and affirmed the dignity in spite of the psycho-physical condition.

Reminiscence Therapy

Some researchers believe that reminiscences form a good therapy for all elderly persons whether demented or not. Understanding reminiscences as a therapeutic measure seems to be difficult. There are several types of reminiscences, different therapeutic goals (based on the extent of dementia), different dependent measures, different data collection tools, and different sample populations studied in each research (Lin, 2003). Reminiscence therapy is now a popular topic in hospitals, daycare centers, nursing homes, and other places where the elderly live. The extent of reminiscences may be a significant predictor of an elderly person’s ability to cope with difficulties of the old age. Reminiscence therapy has been tried for depression in later life (Bohlmeijer et al, 2003).

Cully et al studied the relationship of frequency and functions of reminiscence, personality styles, and psychological functioning (2001). Older adults have a habit of using past experiences for different purposes. They may use their memories of past events for a qualitative purpose. Their memories are a source of entertainment whereas young people use experiences for problem-solving. Fluctuations are seen in older people in the extent of pleasure that each memory gives. Wong and Watt (1991), used six reminiscent types in a study: integrative, instrumental, transmissive, narrative, escapist, and obsessive forms of reminiscence (Cully et al, 2001).

Successful elders were found to have more integrative and instrumental types and lower levels of obsessive reminiscences. Personality traits are associated with reminiscences. Some studies show that depression causes people to reminisce. Low anxiety patients had a lesser possibility of reminiscing. Persons with neuroticism are believed to have more negative reminiscences (Cully et al, 2001).

Reminiscence in Alzheimer’s Disease

Reminiscence is a popular psychosocial intervention in the therapy of dementia patients (Chin, 2007). It helps in recalling and sharing past events and thereby enhances their psychological well-being. Old pictures, songs, other activities, and games could revive their interest in life instead of letting them go steadily downhill. Chin conducted a meta-analysis of studies that researched reminiscence therapy for dementias. They have controlled trials that compared ‘life satisfaction, happiness, depression, and self-esteem of older adults receiving reminiscence therapy’. No conclusion could be drawn by Chin (2007).

The Study

Statement of Hypothesis

“Reminiscence group therapy at twice-weekly sessions for 3 weeks improves the recall, cognition, and communication skills of the elderly population above 70 years, with mild and moderate dementia as measured by the Mini-Mental scale, Geriatric Depression Scale and the Cornell Scale; increases the sense of their personality identity, stimulates their memories and increases the individualization of their care”. This researcher hopes to identify interventions which could be put into practical use to improve the quality of life of the elderly dementia patient”

Method

Setting

A nursing home for elderly females had been selected for the setting. The residents’ ages ranged from 63 to 81 and they had some ill effects of aging. Some had depression, others had systemic illnesses, dementia and some were recovering from strokes. The nursing home had some volunteers who could be depended upon for further activities which could do plenty of good later if they were directed properly.

Very few social activities or group activities were arranged here.

Participants

They were selected after obtaining their willingness to participate in the activities planned. 6 residents who conformed to the criteria of mild or moderate dementia, being over 70 years of age and not wheelchair-dependent were selected.

Research design

An experimental study was conducted to study the effect of reminiscence therapy on cognitive functions of elderly participants with measures of cognitive function at the baseline and after 3 weeks of reminiscence therapy.

Measures

The instruments used were the Cornell Scale, the Geriatric Depression Scale, and the Mini-Mental State Examination. A pre-test and post-test were done.

Cognitive functioning was assessed using the Mini-Mental State Examination (Folstein et al, 1975). It has 30 items that investigate time and space orientation, registration, attention, calculation, recall, language, and visual reconstruction. The scores range from 0-30. The higher the score, the better is the cognitive functioning. A score less than 23 was associated with cognitive impairment. In this study, participants had mild to moderate dementia and they fell within the score range of 15-23. This test is of limited use in the visually impaired, the hearing impaired, the intubated, the illiterate or those of low literacy, and those with other communication difficulties. The score may not give the correct picture of the cognitive status in them

The Cornell Scale is a comprehensive interviewing approach to assess the features of depression. 2 semi-structured interviews were conducted, one with the informant and one with the patient. First, the informant’s interview was finished and a score was given for each item. Then the patient was interviewed keeping in reference the scores in the interview with the informant. Some of the items were filled after observation of the patient.

Discrepancies between the 2 interviews were the cue for repeating both interviews. The final ratings were decided by the interviewer. This test took 20 minutes to perform. Each item was rated for severity from 0-2. 0 suggested absence, 1 suggested mild and 2 suggested severity. Scores above 10 suggested the probability of major depression. Scores above 18 indicated positive major depression. Scores below 6 showed an absence of significant symptoms (Alexopoulos, 1988).

The Geriatric Depression Scale was used to evaluate depression in the elderly. 15 questions were asked. A score of more than 5 suggested depression (The use of, 1986)

Study Procedure

Both the pre-test and post-tests were done in the same settings for each participant in their own rooms so that they were in familiar surroundings. The tests were done in the early morning at 8 a.m. when the ladies had finished their breakfasts and were fresh and most obliging. The information about the pharmacotherapy for the patients was obtained from the case records of the residents as there was a visiting doctor who treated them. The Resident Nurse provided the records for scrutiny.

Development of the group

The residents of a nursing home had been investigated to finally decide on 6 female residents who met the requirements for this study. The 6 residents were of mild to moderate dementia without psychotic features, orientated to person and place with a secondary diagnosis of depression and over 70 years old. They were on pharmacotherapy limited to 2 psychotropics and memory enhancers. The group goals were to improve the recall, cognition, and communication skills of the participants, to increase their sense of personality identity, to stimulate their memories, and to increase the individualization of their care. 6 sessions of one hour and fifteen minutes were organized.

The first session comprised of ‘breaking the ice. Though they were all living close to each other in the nursing home under one roof, it was surprising to note that they were not so familiar with each other. The participants were asked to come with photos of their children and relatives and share them with the others in the second session. The third session comprised of organizing a party at the home for all the residents. Many of them remembered previous experiences and incidents which occurred in their life related to social occasions with their families. The fourth session was a nature walk to the woods close to the nursing home and a picnic by the river.

All the ladies had something to tell each other. The fifth session was a meeting in the home. The last session was organized as a valedictory function where the participants were encouraged to sing and play games.

The administrator, the kitchen staff, and volunteers at the home were especially supportive. They joined in the nature walk and the party and the last day’s session.

Evaluation

The evaluation used a pre-test and a post-test. The pre-test gave a score of one out of six on the Cornell scale for assessing depression in dementia. No one scored higher than 12. The Geriatric Depression Scale showed a high score in 2 of the six participants. All the ladies scored below 23 which is the limit for mild dementia with a mean of 18.

The post-test evaluation showed the same results surprisingly as the pre-test. All the results remained unchanged. The cognitive functions as measured by the three scales were the same both times.

However, the arrangement of the sessions in this manner allowed the usually demure ladies who preferred isolation, the chance to mingle and share experiences with each other. They were able to come out with plenty of reminiscences without even thinking that they were changing at least temporarily during the sessions. However, they were not recovering from their cognitive impairment even though they thoroughly enjoyed the sessions.

The group goals can be believed to be achieved at least during the sessions to a certain extent. We can assume that the participants could improve recall cognition, and communication skills, increase their sense of personality identity, and stimulate their memories during the sessions. Their behaviors during the sessions helped this researcher have a better idea of how to provide individualized care. The results of the three scales being the same, it can be concluded that their cognitive impairment had not become worse after the sessions.

Leader Evaluation

The leader was just the facilitator in the psychosocial activities. This researcher who was the leader just showed the way. The rest of the activities were done by the participants. The results of the pre and post-test do not relate directly to the group’s satisfaction due to their cognitive impairment.. They did participate in all 6 sessions and enjoyed themselves. At least for the period during the sessions, the participants had conformed to the hypothesis of this research. The interventions had provided an opportunity for them to get back something of what they had lost. Maybe if the activities were continuous, one of two things is bound to happen. Either they would remain as they were and not become worse in their cognitive status or they would improve to a certain extent.

Suggestions for improvement

The sessions could be increased in number for another 3 weeks. Maybe a positive result could be obtained with more sessions as the status quo was maintained after 3 weeks. The sample size could be increased for a better outcome. The number of sessions per week could be increased to three. The therapies could be modified and defined for different age groups. Stopping the therapy could have had an adverse effect on cognition, hence the same results. The scales could be used for assessment halfway through the therapy to understand the situation better. The total scores of the three scales used could have provided a better picture of cognition rather than the mean scores.

This study included ladies more than 70 years of age. By then many would have had some years of dementia already. Efforts should be made to diagnose and assess the cognitive status of all old people at definite intervals starting from around 60 years. This would reveal early impairment. Interventions or activities if started immediately could more certainly produce results.

Implications in Practice

The nursing profession is the right group that can help to diagnose dementia or cognitive impairment early. They should be armed with appropriate tools like the MiniMental State Examination and go through all people starting from the 60^th year of age. The National Health Services should take up this suggestion in dire earnest and

help identify dementia as early as possible. Nurses in community practice too should also be responsible. Widespread publicity should warn all old people that activities could delay cognitive impairment. Support groups should encourage all elderly people to participate in social organizations and prevent their self-isolation. Elder abuse by isolation should be legally punished.

Need for further research

Reminiscence therapy must be researched by gender, race, ethnicity, age, number of therapy sessions, combinations with other types of activities, with and without pharmacotherapy, and with and without psychotherapy. Definitive activities of reminiscences could help improve the cognitive status of elderly people with mild, moderate, and severe dementia. The different severities of dementia could be treated with different reminiscence therapy.

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