Group reminiscence intervention in Taiwanese elders with dementia

Abstract

The purpose of this study was to evaluate the effect of structured group reminiscence therapy on behavior competence and physical functioning and to compare effectiveness of the intervention by stage of dementia in Taiwanese elders residing in institutional settings. A longitudinal experimental design was used. Seventy-seven Taiwanese elderly participants completed the study; 38 in the intervention group and 39 in the control group. Participants in the intervention group received one reminiscence therapy session weekly for 8 weeks; those in the control group received regular nursing care. Barthel’s index (BI) and the Clifton Assessment Procedures for the Elderly Behavior Rating Scale (CAPE-BRS) were administered pre- and post-intervention. Findings indicated that no significant differences between the intervention and control groups on overall behavioral competence (p = 0.12) or physical functioning (p = 0.44). However, slight overall improvement was identified, statistically significant for the social disturbance subscale of the CAPE-BRS was found (p = 0.011). There were no significant changes in overall behavior competence (p = 0.11) or physical functioning (p = 0.30) by stage of dementia (mild vs. moderate) in the intervention group, counter to the hypothesis. Although our results did not demonstrate a significant effect of structured group reminiscence therapy on overall behavior competency or on physical functioning in elders with dementia, we identified issues related to future implementation of this intervention, such as study power, chosen outcome measures, intervention dose, timing of outcome measures, or cultural applicability issues.

Introduction

Dementia is a significant public health problem, it is one of the most common diseases in the elderly and a major cause of disability and mortality worldwide (Ritchie and Lovestone, 2002, Berr et al., 2005). Based on a global epidemiological survey of regional global dementia prevalence, dementia incidence rates are estimated to be three to four times higher in developing areas such as China and South Asian regions than in developed regions (Ferri et al., 2005). The Taiwan Alzheimer Disease Association (TADA) conducted a survey in 2004, found that approximately 24.5–65.7% of residents residing in long-term care facilities in Taiwan were cognitively impaired (Chen et al., 2004). TADA further estimated that the prevalence rate by 2026 will be more than double. Dementia is among the major challenges of many other countries in addition to Taiwan due to its enormous burden on health care systems. According to the Global Burden of Disease estimates for the 2003 World Health Report, dementia contributed 11.2% of years lived with disability in people aged 60 years and older (WHO, 2003). 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 stereotypic behaviors, and communication and social disturbance (Landes et al., 2005, Helvink and Holroyd, 2006, Spira et al., 2006). Interventions to manage behavioral competence and physical functioning in elders are imperative in order to improve the health of elders and alleviate caregiver burden.

Non-pharmacologic interventions such as reminiscence therapy have been identified as potentially effective, especially for management of life satisfaction, mood, depression, cognitive function, agitation behavior, memory, and well-being of elders with dementia (Morgan, 2000, Thorgrimsen et al., 2002, Claudia et al., 2004, Tadaka and Kanagawa, 2004). Although several studies have demonstrated effects of reminiscence on depressive symptoms, mood, loneliness, life satisfaction, and self-esteem of normal and depressed elderly adults in Taiwan (Hsiao et al., 2002, Jang, 2004, Wang et al., 2005, Wei, 2005), there is to date no evidence to support the effectiveness of reminiscence therapy on behavioral competence and physical functioning for Taiwanese elders with dementia. Also unknown are possible differential effects by level of cognitive impairment, as measured by stage of dementia. We therefore, hypothesized that structured group reminiscence therapy can enhance behavior competence (ability to display appropriate behavior in the face of dementia-related behavior) and physical functioning (activities of daily living) and thus prevent deterioration of these outcomes in Taiwanese elders with dementia residing in institutional settings. We further hypothesized that participants with less cognitive impairment as measured by stage of dementia would experience a differential benefit from the intervention.

Hancock et al. (2006) demonstrated high levels of functional dependency in people with dementia in residential care homes. Landes et al. (2005) evaluated patient clinical information and behavioral symptom data on a total of 131 participants with dementia and found that 59% of the subjects reported apathy occurring at least 4–8 days per month. They also found that dementia patients with apathetic behavior are more impaired in their ability to perform basic activities of daily living. In addition, Politis et al. (2004) stated that apathy is related to other behaviors, affecting physical disability, performance on activities of daily living, uncooperativeness with care, social isolation and caregiver distress. Helvink and Holroyd (2006) conducted a study of 141 patients with dementia and found that 56% of the subjects had repetitive behaviors, which typically developed in early stages of dementia. Most of these problem behaviors put the patients at risk of injury and heavier dependency from caregivers.

Several studies have combined reminiscence therapy with other psychosocial modalities. For instance, Tadaka and Kanagawa (2004) combined reminiscence and reality orientation care methods to prevent the decline of cognitive and daily activity function and found that the reminiscence intervention group exhibited a significant effect on cognitive function compared to control group immediately after the intervention. Other studies have mixed Snoezelen therapy (sensory stimulation therapy), validation–emotion-oriented care, activity therapy, and structured goal-directed group activity with reminiscence therapy (Brooker and Duce, 2000, Schrijnemaekers et al., 2002, Baillon et al., 2004, Politis et al., 2004). In addition to several intervention approaches, research has focused on different outcomes, rendering comparisons between studies difficult. For example, Brooker and Duce (2000) and Schrijnemaekers et al. (2002) measured behavior and heart rate, while Baillon et al. (2004) and Politis et al. (2004) measured apathy and well-being in elders with dementia. A very small body of reminiscence therapy literature has focused on physical function or behavior competence of elders with dementia as followed: Baines et al. (1987) and Thorgrimsen et al. (2002) used CAPE to measure behavioral outcomes; and Goldwasser et al. (1987) measured physical functioning in elders with dementia. However, small sample sizes have limited the interpretation of these inconsistent findings. Another gap in literature to date is cultural factors, which may manifest either in measurement issues or in actual behaviors of elders with dementia.

This study draws on the need-driven, dementia-compromise behavior (NDB) model by Algase et al. (1996), which has conceptualized that problem behaviors resulting from unmet needs are seen as symptoms for communicating physical or psychological distress. A proximal factor (unstimulating daily schedule) results in a need for therapeutic activity, which results in pacing behavior (primary NDB). If such need is not satisfied by secondary need (increased socialization), the primary NDB may continue, and finally results in a secondary NDB (withdrawal behavior) (Kovach et al., 2005). Yet, the reminiscence group can be a modality to meet their socialization needs. Butler (1963) and Erickson (1963) speculated that reminiscence entails a progressive return to an awareness of past experiences, allowing salient life experiences to be reexamined and reintegrated. When recalling past events, people with dementia can contribute, and for a time feel alive as social beings (Haight et al., 2003). Such feelings may elevate self motivation as well as promote social interaction and thus alleviate problem behaviors and improve physical functioning in persons with dementia (Woods, 1996).