Aging and Mental Health

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Reminiscence and dementia: A therapeutic intervention

Manuscript Type:

CAMH-2014-0333
Original Article

Keywords:

Aging and Mental Health

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Manuscript ID:

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Journal:

reminiscence, dementia, Depression < Mood Disorders, Anxiety and

Trauma related disorders, wellbeing

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Page 1 of 20

Abstract

Objectives: Dementia is a significant public health problem; one of nonpharmacological therapy that has shown effectiveness was reminiscence, which is a
psychological intervention designed to address issues of particular relevance to older
adults. The aim of this study was examine the benefits of an integrative reminiscence

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program in elderly people with dementia. Methods: A quasi-experimental design and

purposive sampling was conducted at two retirement homes. 42 elderly demented adults
were studied to measure the effect of therapy (23 in the experimental group and 19 in
the control group). The treatment group activity was held 10 sessions. Results:

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Treatment group significantly improved their depressive symptoms and self-acceptance,

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positive relations with others, autonomy and environmental mastery. Discussion: This
study provides support for the effectiveness of integrative reminiscence therapy as an

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intervention in people with dementia, especially reducing depressive symptoms and

improves psychological well-being, being the therapy effective to personal and
emotional variables.

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Aging and Mental Health

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Aging and Mental Health

Reminiscence and dementia: A therapeutic intervention.

Dementia is a significant public health problem; it is one of the most common diseases in the
elderly and a major cause of disability worldwide (Berr, Wancata, & Ritchie, 2005). Older
people with dementia often exhibit numerous functional impairment and behavior problems
such as limitations in activities of daily living, agitated behavior, apathy, repetitive or

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stereotypic behaviors, and communication and social disturbance (Spira & Edelstein, 2006).
Is signed that the effectiveness of pharmacological treatments is limited, and such
treatments have symptomatic effects in only a small portion of patients; therefore, nonpharmacological interventions for dementia patients have gained attention in recent years

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(Cotelli, Manenti, & Zanetti, 2012). One of the technical or non-pharmacological therapy that

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has shown effectiveness against dementia was reminiscence therapy (RT), providing
emotional and even social benefits (Bohlmeijer, Smit, & Cuijpers, 2003; Pinquart &
Forstmeier, 2012; Wang, 2007).

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Reminiscence is a psychosocial intervention commonly used with older people and is

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a way of keeping the personal past and perpetuate the identity of the person, being a complete

technique because it uses stimulation, communication, socialization and entertainment, or see

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it as the generator of memories and interpretations in the present of life events at some point
in our past, usually from the distant past (Webster, 2003). Moreover, it could be defined as a

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process of recalling personal events or experiences from ones past that are memorable to the
person (Lin, Dai, & Hwang, 2003).

The definition offered by Woods, Spector, Jones, Orrell and Davies (2005) appears
quite frequently in the literature on dementia and gives a more detailed account of the various
processes involved in a reminiscence activity: RT involves the discussion of past activities,
events and experiences with another person or group of people, usually with the aid of

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prompts such as photographs, household and other familiar items from the past, music and
archive sound recordings. Various authors argue that the variation in definitions, types,
functions and conceptualisations of reminiscence across studies highlight the challenge in
extrapolating and analysing data to support its effectiveness as a psychosocial intervention
(Lin et al., 2003; Woods et al., 2005).
It is important to stand out, as the studies have progressed in this area of work with

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older people, the need to differentiate between different types of reminiscence taking into
account their final goals. Based on the model of Webster (2003), authors as Cappeliez, Rivard
and Guidon (2007) from different studies, showed eight types of reminiscence: integrative,
preparation for death, obsessive, evasive or escapist, instrumental, transmissive, intimacy and
narrative.

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The application of interventions based on integrative reminiscence, as that is discussed

in this paper, are among its main objectives make sense of the person's relationship with their

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past, helping to keep the very meaning (Hsieh & Wang, 2003; Karimi, Dolatshahee, Momeni,
Khodabakhshi, Rezaei, & Kamrani, 2010; Lin et al., 2003; Pinquart & Forstmeier, 2012). This

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type of intervention establishes a connection to the past moments, bringing them to the

present such that the participant create a sense of continuity and deepen his sense of personal

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identity, wellbeing, self-esteem and integrity that can be reduced or even lost with the onset of
symptoms of dementia (Gibson, 2006).

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Aging and Mental Health

In this regard, there are several studies that demonstrate the effectiveness and efficacy
of this therapy in people with dementia, especially improving mood and reducing depressive
symptoms, life satisfaction, and behavior of agitation (Lai, Chi, & Kayser-Jones, 2004;
Tadaka & Kanagawa, 2007).
It should be noted that work by RT with people with dementia involves a number of
peculiarities (Martnez, 2012): the objectives must be flexible to adapt to the participants and

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Aging and Mental Health

their cognitive ability; materials used, should be as far as possible, very closer to participants;
groups should be smaller, to form the groups should be taken into account that participants be
similar in their cognitive performance, can be searched the involvement of family members in
the preparation of the sessions or even they can participate in these and thus have the personal
information of each participant, in order to provide support when it be needed. If arises
memories that are not exact or correct, listen to it, without correct. The prime objective in the

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activity should be emotional validation above the orientation.

Thus, the general objective is to examine the benefits of an integrative reminiscence
program in elderly people with dementia, to improve the quality of life, and it is expected to
observe a reduction of depressive symptoms and increased self-esteem and psychological
well-being dimensions.

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Methods

Participants

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Participants included 42 elderly adults living in two retirement homes in the province of

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Valencia (Spain). A quasi-experimental, single-blind design was applied with pre- and post-

treatment measures. The retirement homes were randomized to determine where the

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intervention program would be administered; control group receiving their usual day-care
program. Participants assigned to the treatment group were divided into three groups taken

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into account their cognitive characteristics.

Diagnosis was the end-result of a prior evaluation in Department of Neurology of the

Hospital General of Valencia, Spain. The inclusion criteria of this study were: (i) diagnosis of
AD determined by DSM-IV-TR (APA, 2000); (ii) a Mini-mental State Examination (MMSE;
Folstein, Folstein, & McHugh, 1975) Spanish version (Lobo, Saz, & Marcos, 2002), under 23
scores and had impairment in neuropsychological examination; (iii) no speech or vision

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disorders, and (iv) have between 3 and 4 level in Global Deterioration Scale (GDS; Reisberg,
Ferris, de Leon, & Crook, 1982). Exclusion criteria for patients were: a history of previous
symptomatic stroke, any medical condition significantly affecting the brain, serious
psychiatric symptoms or a history of drug abuse. All participants gave informed consent to
take part in the study. Table 1 provides descriptive information of simple and groups.

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INSERT TABLE 1

Tests for homogeneity revealed no significant differences between groups at pretreatment: age (t(40)=.098, n.s.), gender (2(1)= 6.01, n.s.), marital status (Mann-Whitney
z=.928, n.s.), years of education (t(40)=.153, n.s.), MMSE (t(40)=.506, n.s.).
Instruments

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In addition to collecting sociodemographic data, various tests and scales were

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administered to take pre- and post-intervention measures. To gauge cognitive level and screen
for potential issues, the Mini-Mental State Examination (MMSE; Folstein et al., 1975) was

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administered. To tap depressive symptomatology Center for Epidemiological Studiesdepression scale (CES-D; Radloff, 1977) was used, in its Spanish version (Latorre &

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Montas, 1997). This scale measures the subjects level of depressive symptomatology. The

scale consists of 20 items assessing symptoms of depression during the week before test

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performance. Each item is assessed on a 4-point scale, from zero (little or no experience of the
symptom) to three (almost constant experience of the symptom). The maximum score is 60

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Aging and Mental Health

and a cut-off point of 16 is used to identify those subjects with depressive symptoms.
Self-esteem was assessed with the 10-item Rosenberg Self-Esteem Scale (RSES;
Rosenberg, 1965), which aims to assess both positive and negative feelings toward oneself.
RSES, a 10-item assessment has been widely used as a global index of self-esteem in several
research domains. Participants respond on a 5-point Likert scale ranging from 1 (strongly
agree) to 5 (strongly disagree).

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Aging and Mental Health

Finally, the Ryff Psychological Well-Being scales (PWB; Ryff, 1989) were because
they are often used in elderly adults (Melndez, Toms, Oliver, & Navarro, 2009; Toms,
Melndez, & Navarro, 2008) and because their psychometric properties have been amply
studied (Toms, Melndez, Oliver, Navarro, & Zaragoza, 2010). The response format for all
PWB items comprised six ordered categories labeled from disagree strongly to agree
strongly and comprised positive item content and negative item content. These assess the

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dimensions self-acceptance, environmental mastery, positive relations with others, autonomy,

personal growth, and purpose in life.
Procedure

We implemented a program based on earlier research (Melndez, Charco,

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Mayordomo, & Sales, 2013). We took several strategies, activities, and dynamics researchers

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had used in the past to conduct integrative reminiscence; the sessions were adapted given the
cognitive and personal characteristics of the participants and, all of them were done in group.

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The program, led by a psychologist, consists of ten sessions of 60 minutes each; in each
session have been worked all life stages (childhood, youth, adulthood and old age stage

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currently) using different topics.

All sessions have the same structure: at the beginning is welcomed to the members of

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the group and it is indicated the topic which will be worked. After that, it be develop two
activities in which the evocation of its memories are stimulated by specific elicitors (music,

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images, objects, etc), and through sayings, and quotations related to the topic of the session.
The first of these activities, aims to strengthen personal identity and coherence from the
meaningful integration of lived experience, and the second promoting the integration of
people at the time and current social context. In both cases, participants performed an exercise
in free association, consisting of say or write the first word or expression that raises the

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stimulus; then open questions are formulated to facilitate the arrival of positive personal
memories; lastly, it aims to connect these memories with the present.
Presented below are each sessions primary objective and the central theme used to
generate remembrance. The first sessions primary goal was to inform participants about the
concept of reminiscence and the procedure that would be used, and to facilitate their initial
contact with one another; the main topic of the session was important life events throughout

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the life cycle. The second aims to encourage conversation, bring out feelings and emotions,
reduce the use of negative thoughts and memories that are maladaptive; being the main topic
of the session, places and things of the past, and remote everydayness. Third session aims to
promote the positive aspects of self, leaving behind self-blame and self-criticism; these

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session mainly addressed peoples different roles across the life span, and the main

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responsibilities, demands, and requirements of daily life at various stages. The fourth session
works interpersonal relationships that have been established throughout his life, the

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importance they attached to them and give today, being the aim of the session to encourage
active participation in their environment, promoting sociability and openness to relationships

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and the use of social and family support. The fifth session aims to promote a positive attitude

towards oneself, recognizing and accepting the many aspects of self, including negative and

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positive, and a positive feeling towards what has already been lived, keeping the feeling of
continued development and improvement over time, the person observed their self-expanding

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and growing, and is open to new experiences. The central themes of the session are the goals
and objectives that have been achieved throughout his life story. The sixth session pretends to
recall the change in lifestyles in order to develop a symposium in which participants share
their experiences promoting the social bond, making a journey through history and noting the
advances that have occurred at different levels (technological, nutritional textile, social, etc).
In the seventh session main thrust was autobiographical memory of important life events,

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Aging and Mental Health

being these events a vehicle to identify these good feelings from the past and redirect them to
modern life, promoting the autonomy and personal identity. The aim of the eighth session is
to generate positive emotions and feelings, strengthen existing social ties through narrative of
traditions, sharing experiences and learning by promoting personal and social identity of each
one. The ninth sessions objective was to utilize traditional games as a vehicle for
remembrance of events and positive emotions from the past, and promote self-esteem. In the

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last session, the aim was to utilize music, film and advertisements, as a vehicle for
remembrance of positive emotions from the past.
Data analysis.

We performed t-tests for independent samples, chi-squared tests and U Mann-Whitney

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to determine whether or not the groups were homogenous prior to treatment. To analyze the

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interventions effects, repeated measures analysis of variance was conducted, applying the
Bonferroni correction. Simple effects as well as interaction effects (group X time) were

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examined. The level of statistical significance employed was p<.05. All analyses were carried
out using the SPSS 19 statistical package.

Results

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In the evaluation of depression, analysis of simple effects showed that there were no
differences in scores between the treatment group and the control group before starting the

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intervention may conclude that both groups were homogeneous. Then, was analyzed the
evolution of each group, taken independently, between pre-post was observed a significant
decrease in scores in the treatment group (F1,40=10.56, p=.003, 2=.150; M1= 10.93;
M2=4.26), while in the control group was no observed a significant change in scores (M1=
9.33; M2= 10.66). Last, the time-group interaction was indeed found to be significant effect

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(F1,40=6.76, p=.015, 2=.213) being therefore application of the treatment effective in

reducing depressive symptomatology.
Next, we studied the effect of the intervention on RSES. Assessing self-esteem no
significant differences showed between groups at pre-treatment. Analysis of the groups over
time indicated no significant differences in control group (M1=12.08; M2=12.05) and
treatment group (M1=11.44; M2=11.66); moreover time-group interaction was not show

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significant effect.

In relation to psychological well being, the study of simple effects confirmed the
homogeneity of the groups in all dimensions getting no differences in pretreatment scores.

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Also, no statistically significant differences was observed in control group except for personal
growth with a significant decrease; a significant increase was observed in the treatment

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groups scores between the two measures in self-acceptance, positive relations with others,
autonomy and environmental mastery; finally results to the interaction time-group were

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significant for all dimensions except for purpose in life (for statistical data see Table 2).
INSERT TABLE 2

Discussion

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The combined prevalence of MCI and dementia highlights the public health impact of these
conditions and the urgency for finding therapies (Petersen et al., 2010). This study

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demonstrated the effectiveness of reminiscence group intervention for elderly patients with
dementia; the results support the idea that reminiscence alleviates depressive symptoms and
improve psychological well-being (self-acceptance, positive relations with others, autonomy,
environmental mastery and personal growth however, could not be confirmed all the proposed
objectives: self-esteem and purpose in life showed no effect on the interaction. For elderly
people with dementia, it is believed that new learning is difficult but that old, well rehearsed

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Aging and Mental Health

memories are still accessible and can be shared with others (Brooker & Duce, 2000);
therefore, it is thought that RT can encourage elderly people with dementia, as well as elderly
people without dementia, to value their lives by re-experiencing their good old days, and to
have meaningful social interaction when sharing re-experiences with the group members
(Tadaka & Kanagawa, 2007).
Different studies suggest that depressive disorder is associated with increased risk of

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developing cognitive dysfunction (Castaneda, Tuulio-Henriksson, Marttunen, Suvisaari, &

Lnnqvist, 2008) and eventually dementia, in particular Alzheimer's disease (Ownby, Crocco,
Acevedo, John, & Loewenstein, 2006). Several groups have examined the temporal
relationship between depression and Alzheimer's disease to understand whether depression is

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simply a prodromal symptom of Alzheimer's disease which precedes the onset of cognitive

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deficits, or whether a history of depression might represent an independent risk factor for the
development of Alzheimer's disease. Also, depression may occur in 30-40% of the

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Alzheimer's disease patients (Assal & Cummings, 2002; Starkstein, Jorge, Mizrahi, &
Robinson, 2005) and it affects clinical evolution of Alzheimer's disease (Shim & Yang, 2006).

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Note that many depressed people ignore positive information, and focus on memories that

support their dysfunctional reviews, RT helps to find more complete and detailed life history

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aspect's, and interpret them in a more balanced way, taking a more realistic and objective
view aspects. The results indicate that reminiscence may be effective treatments of depressive

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symptoms in older adults with dementia. Being these results consistent with others studies and
meta-analysis where is showed the benefit of this therapy to the adaptation and the reduction
of depressive symptoms in older adults (Bohlmeijer et al, 2003; Cappeliez & ORourke, 2006;
Chueh & Chang , 2014; Hsieh & Wang, 2003; Karimi et al., 2010; Pinquart, Duberstein, &
Lyness, 2007). Therefore, identifying depression in people with dementia is important, and at
the same time, implementing psychosocial intervention is a necessary process in order to

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Page 11 of 20

improve the quality of life of this population group (O'Shea et al., 2014).
Respect to psychological well being dimensions, other interventions (Melndez et al.,
2013) show the efficacy of this therapy to improve some of these dimensions. In crosssectional research with older adults, positive self-functions demonstrated a direct and positive
association with participants well-being (Cappeliez & ORourke, 2006). These findings
suggest that use of autobiographical memory to foster identity and self-continuity, and to

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achieve a sense of coherence and meaning in life, appear to have a positive and direct link to
well-being (ORourke, Cappeliez, & Claxton, 2011). In this regard, self-acceptance
dimension shows increased scores in the treatment group and a marginal decrease in the
control group, indicating the effectiveness of this therapy in the maintenance of

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consciousness. Note that in the development of the disease, people can be affected by the loss

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of self-awareness (even in advanced stages of the disease), therefore work this dimension is
crucial to the maintenance of self-identity despite the advance of the disease. Furthermore,

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based on the social nature of reminiscences, which is viewed through autobiographical

memory, the memory can play a big role in the reconstruction and maintenance of self,

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approaching the idea of integrity (Erikson, 1959).

As regards to positive relationships with others, it is important to note that in aging

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there is a clear reduction of the sources of support (Melndez, Toms, & Navarro, 2011). RT,
further of encourage this population to assess his life to re-experience the good old days, it

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Aging and Mental Health

can encourage meaningful social interaction by sharing lived experiences with group
members (Tadaka & Kanagawa, 2007). Through RT an activated interaction occurs between
group members, making reminiscence a stimulating, sociable and inclusive activity, and
therefore providing social support (Brooker & Duce, 2000); also, reminiscence group therapy,
provides to cognitively impaired individuals opportunities for social interaction (Woods,
1996).

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Aging and Mental Health

Regarding the autonomy dimension, it is important to note that people with dementia
become dependent; hence the importance of the application of this therapy, as it has shown
how people receiving treatment have improved their own individuality enhanced. The longer
the autonomy of demented patient is, the longer it takes to reach its dependence to perform
daily activities. Furthermore, recalling episodes of effective problem-solving may reassert
perceptions of self-efficacy and remind the person of prior instances of successful coping with

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difficult life circumstances (Erikson, 1959), should be noted that those involved in RT create
a new meaning to the circumstances experienced in the past in the present, and meaning is a
mental representation of possible relationships among things, events, and relationships
(Baumeister, 1991). In addition, there has been an improvement in scores proficient

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environment dimension in the treatment group, while the control group decreased their scores.

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Thus, it is seen as the control group has more difficult to adapt to their own context and
develop suitable contexts. Promoting adaptability to both its own context, as new contexts, is

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a slowing of the loss of certain skills, implement strategies which people thought lost and
have been brought to the present by reminiscence, it is useful to perceive that still retain the

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ability to adapt to changes that may occur and still have the perception of power control,

combining this improvement with the increase of autonomy when performing certain

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activities of daily life that can still be performed in early stages of the disease.
In relation to personal growth, decrease was observed in the control group, and

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purpose in life showed no significant interaction. As noted, RT is a way of keeping the

personal past, being reminiscent of integrative type, not develop new learning strategies,
objectives or goals, but promotes the maintenance of identity through memory of past
experiences.
We could conclude that the work by RT of integrative type, in older people with
dementia has been shown to have positive effects, leading us to believe the positive impact of

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this type of therapy in promoting a good fit and therefore adaptation. In this sense, should be
promoted and/or put attention on reminiscences as drug treatment; because they decrease
depressive symptoms and increase psychological well-being, therefore, improve the quality of
life. As limitations, on the one hand is the small sample size; however, be noted that despite
the small size of, it have been obtained significant results. On the other hand, there has been
no follow-up to determine the long-term effectiveness of the program, in this regard and as

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some authors point out (Tadaka & Kanagawa, 2007), it must be taken care when interpreting
the apparent benefits of the program intervention, as some studies have shown that affective
improvements that result from an effect reminiscent present more short-term than long.

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Table 1. Demographic data.

Total
80.24 (SD=9.22)

Treatment (N=23)
80.35(SD=10.36)

Control (N=19)
80.63(SD=7.91)

Man
Women

31
69

39.1
60.9

21.1
78.9

Married
Single
Widow

31.0
9.5
59.5

34.8
13.0
52.2

26.3
5.3
68.4

7.19(SD=2.7)
20.0(SD=2.55)

7.13(SD=2.7)
19.6(SD=2.84)

7.26(SD=2.92)
20.3(SD=2.25)

Age
Gender

Marital status

Year of education
MMSE

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Table 2. Statistical data of PWB dimension between measures and interaction time group
Treatment Gr
Control Gr
Pre-post
Pre-post
Interaction time-group
differences
differences
Treat. Gr
Control Gr.
p
F
g.l.
p
Pre
Post
Pre
Post
p
2
2
2
SA
4.84
5.28
5.22
4.92
.005
.179 .069 .080
11.33
40
.002
.221
PR
4.47
4.93
5.05
4.90
.009
.157 .423 .016
5.93
40
.019
.129
AT
4.50
5.00
4.67
4.49
.000
.269 .207 .040
12.44
40
.001
.237
EM
4.41
4.76
4.65
4.36
.014
.141 .065 .083
9.77
40
.003
.196
PG
4.85
4.98
5.17
4.72
.342
.023 .021 .126
5.87
40
.020
.128
PL
4.68
4.86
4.77
4.64
.124
.058 .290 .028
3.42
40
.072
.079
SA= self-acceptance; PR=positive relations with others; AT=autonomy; EM=environmental mastery;
PG=personal growth; PL=purpose in life

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