An important concern for nursing is the growing segment of elderly adults in the United States. Historically, elderly adults have been one of the most unrecognized and under-served members of the population. With the advances in health care, many more adults are reaching age 85 and older. Further, the number of elderly women is greatly outpacing that of elderly men, especially in the older than 85 age group. Because of the increasing number of elderly adults in the United States, interventions nurses can perform to improve the quality of life of the elderly population, especially elderly women, are needed (Bowsher, Bramlett, Burnside, & Gueldner, 1993; Burnside & Haight, 1994; Gale, 1993; Haight & Hendrix; 1998).
The most common emotional disorder in the elderly population is depression, which is often overlooked by health care professionals and family members. Depression among elderly adults has become a major public health problem associated with mortality and suicidal behavior because it is either undiagnosed or misdiagnosed, and subsequently, left untreated (Buschmann, Dixon, & Tichy, 1995). The risk of depression among elderly women is two to three times higher than that of elderly men. Additionally, elderly adults residing in long-term care facilities are at an even greater risk for developing depression. Depression in elderly adults can be debilitating and can affect functional, cognitive, and emotional health. This increases risks for infections, falls and injury, and poor nutrition (Buschmann et al., 1995; Hagerty, 1995; Haight, Michel, & Hendrix, 1998).
Gerontological nurses have recognized the need to develop interventions to manage cognitive and behavioral disorders, including depression, among long-term care residents (Buschmann et al, 1995; Hagerty, 1995). The National Institute of Nursing Research (NINR) (National Institutes of Health, 1997) encourages research focusing on cost-effective, therapeutic, non-pharmacological interventions to improve health and quality of life for cognitively impaired older adults and their caregivers and families.
Reminiscence therapy has been shown to be a valuable intervention for elderly clients. A review of the reminiscence literature suggests that reminiscence therapy is effective in preventing or reducing depression, increasing life satisfaction, improving self-care, improving self-esteem, and helping older adults deal with crises, losses, and life transitions. Reminiscence therapy has the advantage of being a cost-effective, therapeutic, social, and recreational intervention for institutionalized older adults (Cully, LaVoie, & Gfeller, 2001; Hagerty, 1995; Haight et al., 1998; Rentz, 1995). However, few studies have examined the effects of reminiscence therapy on depression. Although both research participants and observers reported reminiscence therapy had a positive effect in lowering depression levels, Utile empirical evidence was found to support these claims (Buschmann et al., 1995; Cully et al., 2001; Hagerty, 1995; Haight et al., 1998).
Recommendations for reminiscence therapy for clients in a long-term care faculty can be found in the Nursing Interventions Classification (NIC) developed by a team of researchers at the University of Iowa (McCloskey & Bulechek, 1996). The reminiscent therapy intervention lists 1 8 activities for all elderly patient populations residing in long-term care (Sidebar). Few studies have been conducted to examine the reliability and validity of the NIC reminiscence intervention. Many
authors recommend that further testing of the NIC reminiscence activities is necessary to establish clinical significance of NIC reminiscence therapy before it can be universally adopted into nursing practice (Burns & Grove, 1997; Daly, McCloskey, & Bulechek, 1994; McCloskey & Bulechek, 1996; Snyder, Egan, & Nojima, 1996). The purpose of this study was to explore the effects of NIC reminiscence therapy on the level of depression in elderly women residing in an assisted-living long-term care facility and to compare its effectiveness with traditional forms of reminiscence currendy in place in the facility.
Burnside (1990, p. 35) defined reminiscence as "the act or process of recalling the remote past in a silent, spoken, solitary, interactional, spontaneous, or structured way." The NIC defines rerniniscence as "using recall of past events, feelings, and thoughts to facilitate adaptation to present circumstances" (McCloskey & Bulechek, 1996, p. 469). Reminiscence is based on the premises of Erikson (1950) and Buder (1963) who reported that reminiscence is part of a normal developmental process.
Research in the fields of nursing, psychology, and sociology has explored the meaning, interpretation, types, and clinical usefulness of reminiscence therapy. Early reminiscence research found a positive association between reminiscence and increased life satisfaction and self-esteem (Gruñes 1980; Havighurst & Glasser 1972; Lappe 1987; Lieberman & Falk 1971; Miller & Lieberman 1965). Chiriboga and Gigy (1975) linked reminiscence with effective coping skills during life transitions. Boy Hn, Gordon, and Nehrke (1976) reported that rerniniscence increased the egointegrity of the older adult. Investigators also examined the effect of reminiscence on social interactions and depression. Reminiscence was found to promote positive social interactions - the inability to reminisce about one's life led to depression (Coleman, 1974; McMahon & Rhudick, 1964; Pincus 1970). Researchers also have reported positive relationships among reminiscence and the older adult's affect, coping abilities, and behavioral and physical functions (Hamilton, 1992; StevensRatchford, 1993; Youssef, 1990). However, the majority of data from these studies was derived from clinical observations and was primarily anecdotal and unsupported by empirical research (David, 1990; Hamilton, 1992; Thornton & Brotchie, 1987).
It has been proposed that reminiscence interventions can be successfully practiced in a variety of settings, including acute care, senior centers, adult day care centers, long-term care facilities, and the client's home (Burnside & Haight, 1994). However, the most positive results have occurred with institutionalized elderly adults in group settings of 6 to 10 members (Ashton, 1990; Burnside & Haight, 1994; Hamilton, 1992; Soltys & Coats, 1995; Youssef, 1990). This size group allowed for social interaction among members and enough time for each member to participate (Hamilton, 1992).
Groups are thought to be most useful to newly relocated older adults by increasing rapport with other residents, self-confidence, and by creating new friendships (Haight et al, 1998; Haight, Michel, & Hendrix, 2000; Soltys & Coats, 1995). Group reminiscence also can be helpful to patients who are confused or have dementia by offering structured ways to remember and by validating memories through others in the group (Soltys & Coats, 1995). Group members should be compatible by sharing experiences such as careers, hobbies, or social activities; being within the same age group, and having the same level of mental and physical capabilities. It also has been suggested that men and women be in separate groups (Ashton, 1990; Burnside, 1990; Burnside & Haight, 1994; Hitch, 1994). Although the number of times a rerniniscence group must meet to be effective is uncertain, positive outcomes have been reported in as few as one to three sessions. It is believed that groups lasting approximately 30 to 45 minutes for 6 to 12 sessions are the most helpful (Ashton, 1990; Hamilton, 1992).
DESCRIPTION OF THE SAMPLE (N = 30)
More empirical evidence must be obtained to support the notion that reminiscence therapy is helpful to elderly adults suffering from depression (Cully et al., 2001; Haight et al., 1998, 2000). Testing non-pharmacological means of addressing the mental health needs of older adults also must continue (Buschmann et al., 1995; Hitch, 1994; Youssef, 1990; Rentz, 1995). The NIC reminiscence intervention must be studied in a variety of settings before it can become the standard for reminiscent therapy (Snyder et al., 1996). Overall, persistent nursing research and refinement of reminiscent interventions is needed to develop a body of nursing knowledge from which gerontological nurses can practice (Haight et al., 1998, 2000; Hamilton, 1992; Kovac, 1990).
A pre-test-post-test, quasi-experimental design was used to measure the effect of one nursing intervention, the NIC reminiscence therapy, on depression in elderly women. A comparison group received the customary rerniniscence therapy provided in the same assisted living long-term care facility located in a small southern community.
A convenience sample of 30 women was selected for the study. Inclusion criteria included women 60 and older residing in the assisted living long-term care facility for 3 months or longer who had the ability to give both verbal and written consent and who scored 15 or higher on the Folstein Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975). Participants in experimental group were slightly older than those in the control group. Of the 30 participants, the mean age was years (SD = 8.8, median = 82, range = 61 to 97 years). The mean age of experimental group was 82.7 years (SD = 9.2, median = 82, range = 66 to years), whereas the control group participants averaged 81 years of age (SD = 8.6, median = 78.5, range = 61 to 95 years). Ages of the participants were not significantly different between the experimental and control groups (p = .559). Chi-square analysis showed no significant differences between the experimental and control group related to other demographic characteristics (see Table 1).
Mini-Mental State Examination
The Folstein Mini-Mental State Examination was used as a screening instrument to determine levels of cognitive impairment. McDougall (1995) reported that long-term care patients who were cognitively impaired had average MMSE scores of 9.97, and those who were cognitively intact had an average score of 21.34. A score of 15 or higher was considered adequate to participate in the study. The mean the Folstein Mini-Mental State Examination scores for all participants was 21.5 (SD = 3.98, range = 15 to 28). The mean of the Folstein Mini-Mental State Examination scores for the experimental group was 21.67 (SD = 4.03, range = 15 to 27), with the mean of the control group being 21.33 (SD = 3.94, range = 15 to 28). The Cronbach's alpha of the MMSE for this study was .84. Scores on the MMSE were not significantly different between the experimental and control groups (p = .820).
Geriatric Depression Scale
For this study, depression was defined in terms of a mood state, a symptom, or a disease. Mood state was theoretically defined as an appropriate adjustment of prevailing emotional tone in response to circumstances (Johnson & Maas, 1997). Depression was measured by the Geriatric Depression Scale (GDS) developed by Brink et al. (1982). The GDS is a 30-item questionnaire that is a simple, clear, and self-administered scale that does not rely on somatic symptoms. The yes/no questionnaire takes 8 to 10 minutes to complete. Depressive responses are assigned 1 point with a maximum possible score of 30. Tallied scores of 0 to 10 indicate normal mood, 11 to 20 indicate mild depression, and 21 to 30 indicate moderate to severe depression.
The mean of the GDS scores for all participants was 12.8 (SD = 4.39, range = 2 to 22). The mean of the GDS scores for the experimental group was 13.7 (SD = 5.04, range = 2 to 21), and 12 for the control group (SD = 3.61, range = 7 to 22). Cronbach's alpha of the GDS for this study was .72. Pre- test scores on the GDS were not significandy different between the experimental and control groups (t28 = -1.084,/? = .288).
The facility's female residents were approached to participate in the study.
Each resident who volunteered for the study was required to sign a written consent form. Demographic data and information regarding inclusion criteria were collected 2 weeks prior to the study by chart review. Participants meeting inclusion criteria based on chart review were asked to take the Folstein Mini-Mental State Examination and the GDS 1 week prior to the study. Thirty participants were selected by random drawing from all eligible residents. The researcher, a master's prepared nurse, conducted the experimental group. A master's prepared social worker, employed by the facility, conducted the control group.
The experimental group received reminiscence therapy conducted according to NICs Reminiscence Therapy for Long-term Care. NICs Rerniniscence Therapy activities suggest that family photographs, scrapbooks and personal memorabilia can be used to stimulate memory and conversation among the group members (Ashton, 1990; Burnside, 1990; Burnside & Haight, 1994; Hamilton, 1992; McCloskey & Bulechek, 1996). The NIC rerniniscence group centered on six topics that allowed participants to recall meaningful events from their past, including the following:
* Introduction of leader and members concentrating on personal background.
* Remembering the past through songs from the 1920s to 1950s.
* Discussing past leisure activities.
* Sharing personal photographs and memorabilia.
* Discussing past work or volunteer experiences.
* Remembering John Glenn's first rocket launch.
It was hoped that by remembering life events chronologically, participants would be better able to look back at their lives with increased satisfaction and a sense of accomplishment (Burnside & Haight, 1994; Buschmann et al, 1995; Erikson, 1950; Stevens-Ratchford, 1993).
The control group received reminiscence therapy that was standard in the assisted-living long-term care facility. This approach was unstructured and considered a recreational activity used to increase socialization for the residents. The control group topics were related to current events and discussions about residential activities including:
* Introduction of leader and members, concentrating on facility activities and involvement
* Current events, using the local newspaper.
* A walk along the facility path.
* The county fair outing.
* Stuffed treat bags for faculty Halloween party.
* Current events discussion using the local newspaper.
The experimental and control groups met twice a week for 45-minute sessions. Both the experimental and control groups continued for 3 consecutive weeks, for a total of six sessions. Participants in both the experimental and control group continued the sessions without experiencing 'overwhelming anxiety or agitation. All of the participants completed the study. Two days following the conclusion of the reminiscence sessions, all study participants were orally administered the GDS by the researcher.
COMPARISONS OF DIFFERENCE IN MEANS BETWEEN THE PRE-TEST AND POST-TEST GERIATRIC DEPRESSION SCALE SCORES
Independent t test for equality of means was used to test the degree of change in the level of depression for each participant after exposure to the experimental and control group protocols. As the homogeneity of variance assumption was not supported, a formula for computing t tests for unequal variance was applied (Huck & Cormier, 1996). A statistically significant difference between the two groups was found (t2, 6 = 3.60, ? = .002), with participants in the experimental group having a significandy greater reduction in GDS compared to scores for the control group (Table 2.)
Independent t test for equality of means determined that there was no significant difference between the number of reminiscence sessions attended by participants in the experimental group versus participants in the control group (p = .104). All participants attended at least four of the sessions and none of the participants dropped out of either the control or experimental group.
It is unknown whether the differences between the group leaders may have influenced the study findings. Based on the examination of raw scores, participants who missed at least one session from the experimental and control groups did not experience any change in their GDS scores. Further, participants in both the experimental and control group who missed two sessions demonstrated an increase in their GDS scores. Gerontological nurses may use this knowledge to determine the number of reminiscence therapy sessions needed to effect a change in their client's level of depression. For this study, a minimum number of six sessions was needed to elicit a positive change in the level of depression among participants.
Although the majority of participants in both the experimental and control groups reported only mild to moderate depression on their GDS pre-test, those participants receiving the NIC reminiscence intervention had statistically significant lower post-test GDS scores than participants receiving the facility's customary rerniniscence intervention. The National Institute of Nursing Research (NINR) (NIH, 1997) has stated that any small improvement seen in residents of longterm care can be viewed as worthwhile. The findings of this study concur with prior research indicating that reminiscence therapy can be successfully conducted among elderly adults living in institutions (Haight et al., 1998, 2000; Hamilton, 1992; Soltys & Coats, 1995).
Gerontological nurses working in long-term care settings found reminiscence therapy in small, homogenous groups most effective in reducing depression (Haight et al., 1998, 2000; Hitch, 1994). Findings from this study offered evidence similar to other studies indicating that reminiscence therapy could be successful if it stimulated past memories and conversation among the group members and was conducted at least once a week for six sessions (Ashton, 1990; Burnside, 1990; Burnside & Haight, 1994; Hamilton, 1992). This study supports the small body of available research indicating reminiscence therapy has a positive effect on elderly adults experiencing depression and suggests that a nurse initiated intervention, NIC reminiscence therapy, is an effective treatment for reducing depression among elderly women residing in long-term care (Buschmann et al., 1995; Cully et al., 2001; Haight et al., 1998, 2000).
Reminiscence therapy is a costeffective intervention that is relatively simple to implement and produces minimal harmful side effects. Although this study took place in one assisted living long-term care facility in the rural south, NIC reminiscence therapy has the potential to be an excellent choice as a nurse-initiated, therapeutic, and cost-effective treatment modality for elderly women who are depressed residing in long-term care nationwide. As the major health care providers for the population of elderly adults, gerontological nurses are uniquely positioned to provide interventions that can enhance an elderly adult's quality of life (Haight, et al., 1998, 2000).
It is essential that nurses, especially nurses working with elderly clients, be encouraged to implement rerniniscence interventions to prevent or decrease depressive symptoms. Furthermore, gerontological nurses are in a position to design policy rules and regulations supporting the implementation and reimbursement of noninvasive nursing interventions. Incorporating NICs rerniniscence therapy into a long-term care facility's therapeutic programming for elderly clients experiencing depression is supported by this study.
It would be beneficial for gerontological nurses who desire to lead reminiscence therapy sessions to have a nursing professional with experience administering reminiscence sessions instruct and supervise them concerning the risks, benefits, and protocols for conducting safe and effective sessions. Rerniniscence therapy should be conducted in as safe a manner as possible, and safeguards should be in place to support participants if necessary. Group facilitators should closely observe the participants for side effects such as increased agitation and anxiety.
During the sessions, group facilitators may attempt to re-focus and re-direct participants so they will have a more rewarding experience. If participants become uncontrollably agitated or anxious based on observations during the group sessions or by the observations of the unit staff during other times, the resident should be dismissed from the group. Reminiscence group participants also are at risk of disclosing potentially harmful, illegal, personal, or sensitive information to the group. At any time, if the participant begins to reveal information that the group leader finds inappropriate, the leader should stop the discussion. If participants wish to continue the discussion privately with the group leader or speak to a psychiatric nursing clinical specialist, they should be allowed to do so.
RECOMMENDATIONS FOR NURSING RESEARCH
Continued examination of the NIC reminiscence therapy by gerontological nurses will provide help to determine its efficacy in preventing and resolving problems with various elderly populations in a variety of long-term care settings. Gerontological nurses can further enhance the use of reminiscence therapy by verifying the results of this study through replication. Future gerontological nursing studies about reminiscence therapy should include elderly men, elderly adults experiencing cognitive decline, and elderly adults from numerous ethnic and cultural backgrounds. Further research including larger sample sizes and random selection of participants is needed. Reminiscence therapy should also be tested in a variety of long-term care facilities in multiple geographic locations. Longitudinal studies conducted to determine the effects of reminiscence therapy over time would also be useful.
Qualitative methods also may be advantageous in determining the effectiveness of reminiscence therapy and the treatment of depression in elderly adults. Subjective data with respect to elderly adults' emotional responses to reminiscence therapy may be beneficial in determining the perceived effect reminiscence therapy has on elevating overall mood and improving quality of life.
The growing population of elderly adults necessitates interventions that are cost-effective, non-pharmaceutical, and easy to perform in the longterm care setting. Gerontological nurses can be instrumental in initiating policy, education, and implementation of interventions addressing the mental health needs of older adults. Reminiscence therapy conducted by gerontological nurses has the potential to greatly improve the quality of life of elderly clients.
- Ashton, D. (1990). Therapeutic use of reminiscence with die elderly. Brituh Journal of Nursing, 2, 1993-1997.
- Bowsher, Y., Bramlett, M., Burnside, L, & Gueldner, S. (1993). Methodological considerations in the study of frail elderly people. Journal of Advanced Nursing, 18, 873-879.
- Boylin, W., Gordon, S., & Nehrke, S. (1976). Reminiscing and ego integrity in institutionalized elderly males. Gerontologist, 16, 118-124.
- Brink, T., Yesavage, J., Lum, O., Heersema, P., Adey, M., & Rose, T. (1982). Screening tests for geriatric depression. Clinical and Experimental Rheutomology, 5, 147-150.
- Burns, N., & Grove, S. (1997). The practice of nursing research (3rd ed.). Philadelphia: W.B. Saunders.
- Burnside, I. (1990). Reminiscence: An independent nursing intervention for the elderly. Mental Health Nursing, 11(1), 33-48.
- Burnside, L, & Haight, B. (1994). Reminiscence and life review: Therapeutic interventions for older people. Nurse Practitioner, 19(A), 55-61.
- Buschmann, M., Dixon, M., & Tichy, A. (1995). Geriatric depression. Home healthcare nurse, 130), 47-59.
- Butler, R.N. (1963). The life review: An interpretation of reminiscence in the aged. Psychiatry, 26, 65-76.
- Chiriboga, D., & Gigy, L. (1975). Perspectives on die life cycle. In M.F. Lowenthal (Ed.), Four stages of transitions. San Francisco: Josey-Bass.
- Coleman, P. (1974). Measuring reminiscence characteristics from conversations as adaptive features of old age. International Journal of Aging and Human Development, 5(4), 281-294.
- Cully, J., LaVoie, D., & Gfeller, J. (2001). Reminiscence, personality, and psychological functioning in older adults. The Gerontologist, 41(1), 89-95.
- DaIy1J., McCloskey, J., & Bulechek, G. (1994). Nursing Interventions Classification use in long-term care. Geriatric Nursing, Ii(I), 41-46.
- David, D. (1990). Reminiscence, adaptation, and social context in old age. International Journal of Aging and Human Development, 30(3), 175-188.
- Erikson, E.H. (1950). Childhood and society. New York: W. W. Norton and Company.
- Folstein, M.F, Folstein, S.E., & McHugh, R.R. (1975). Mini-mental state: A practical method for grading the mental sute of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.
- Gale, B.J. (1993). Psychosocial health needs of older women: Urban versus rural comparisons. Archives of Psychiatric Nursing, 7(2), 99-105.
- Grunes, J. (1980). Reminiscences, regression, and empathy. In S. Greenspan (Ed.), The course of life. Washington, DC: United States Government Printing Press.
- Hagerty, B.M. (1995). Advances in understanding major depressive disorder. Journal of Psychosocial Nursing, 33(1 1), 27-34.
- Haight, B., & Hendrix, S. (1998). Suicidal intent/life satisfaction: Comparing the life stories of older women. Suicide and LifeThreatening Behavior, 28(3), 272-284.
- Haight, B., Michel, Y, & Hendrix, S. (1998). Life review: Preventing despair in newly relocated nursing home residents short-and longterm effects. International Journal of Aging and Human Development, 47(2), 1 19-142.
- Haight, B., Michel, Y, & Hendrix, S. (2000). The extended effects of the life review in nursing home residents. International Journal of Aging and Human Development, 50(2), 151-168.
- Hamilton, D. (1992). Reminiscence dierapy. In Bulechek, G., & McCloskey, J. (Eds.), Nursing interventions: Essential nursing treatments (pp. 292-303). Philadelphia: W.B. Saunders.
- Havighurst, R., & Glasser, R. (1972). An explanatory study of reminiscence. Journal of Gerontology, 27(2), 245-253.
- Hitch, S. (1994). Cognitive therapy as a tool for caring for the elderly confused person. Journal of Clinical Nursing, 3, 49-55.
- Huck, S.W., & Cormier, WH. (1996). Reading statistics and research (2nd ed.). New York: Harper Collins.
- Johnson, M. & Maas, M. (Eds). (1997). Nursing Outcomes Classification (NOC). St. Louis, MO: Mosby & Co.
- Kovac, CR. (1990). Promise and problems in reminiscence research. Journal of Gerontological Nursing, 16(4), 10-14.
- Lappe, J. (1987). Reminiscing: The life review dierapy. Journal of Gerontological Nursing 13(4), 12-16.
- Lieberman, M., & Falk, J. (1971). The remembered past as a source of data for research on die life cycle. Human Development, 14(2), 132-141.
- McCloskey, J.C., & Bulechek, G.M. (Eds.). (1996). Nursing interventions dassificathn (NIC) (2nd ed.). St. Louis: Mosby and Co.
- McDougall, G.J. (1995). Metamory and depression in cognitively impaired elders. Nursing Research, 44(5), 306-311.
- McMahon, A., & Rhudick, P. (1964). Reminiscing: Adaptational significance in die aged. Archives of General Psychiatry, 10, 292-298.
- Miller, D., & Lieberman, M. (1965). The relationship of affect state and adaptive capacity to reactions of stress. Journal of Gerontology, 20, 492-497.
- National Institutes of Health. (1997). Managing the symptoms of cognitive impairment (NIH Guide, 26(10), PA Number PA-97-050). Retrieved May 5, 2003, from http://grants.nih. gov/grants/guide/pa-files/PA-97-050.html.
- Pincus, A. (1970). Reminiscing in aging and its implications for social work practice. Social Work, 15(3), 47-53.
- Rentz, C. (1995). Reminiscence: A supportive intervention for die person with Alzheimer's disease. Journal of Psychosocial Nursing, 33(U), 15-20.
- Snyder, M., Egan, E., & Nojima, Y. (1996). Defining nursing interventions. Image: Journal of Nursing Schohrship, 28(2), 137-141.
- Soltys, E, & Coats, L. (1995). The SolCos Model: Facilitating reminiscence therapy. Journal of Psychosocial Nursing 33( 1 1 ), 2 1 -25.
- Stevens-Ratchford, R. (1993). The effect of life review reminiscence activities on depression and self-esteem in older adults. The American Journal of Occupational Therapy, 47(5), 413-420.
- Thornton, S., & Brotchie, J. (1987). Reminiscence: A critical review of die empirical literature. British Journal of Clinical Psychology, 26(93), 111.
- Youssef, F. (1990). The impact of group reminiscence counseling on a depressed elderly population. Nurse Practitioner, 15(4), 32-38.
DESCRIPTION OF THE SAMPLE (N = 30)
COMPARISONS OF DIFFERENCE IN MEANS BETWEEN THE PRE-TEST AND POST-TEST GERIATRIC DEPRESSION SCALE SCORES