Research in Gerontological Nursing

Original Research: Experimental Intervention 

Therapeutic Conversation to Improve Mood in Nursing Home Residents with Alzheimer’s Disease

Ruth M. Tappen, EdD, RN, FAAN; Christine L. Williams, DNSc, RN, BC

Abstract

Few studies have tested strategies to address the mental health needs of individuals with Alzheimer’s disease (AD). To test a newly developed, empirically based modified counseling approach, 30 nursing home residents with AD were randomly assigned to a modified counseling (Therapeutic Conversation) treatment group or usual care control group. Mini-Mental State Examination mean scores were 10.60 (SD = 6.99) for the treatment group and 12.26 (SD = 7.43) for the control group. Individual treatment was provided three times per week for 16 weeks. On the posttest, treatment group participants evidenced significantly less negative mood than the control group on the Montgomery-Asberg Depression Rating Scale and the Sadness and Apathy subscales of the Alzheimer’s Disease and Related Disorders Mood Scale. The differences approached significance on the Dementia Mood Assessment Scale. Results suggest that a therapeutic counseling approach can be effective in treating the dysphoria commonly found in individuals with AD.

Abstract

Few studies have tested strategies to address the mental health needs of individuals with Alzheimer’s disease (AD). To test a newly developed, empirically based modified counseling approach, 30 nursing home residents with AD were randomly assigned to a modified counseling (Therapeutic Conversation) treatment group or usual care control group. Mini-Mental State Examination mean scores were 10.60 (SD = 6.99) for the treatment group and 12.26 (SD = 7.43) for the control group. Individual treatment was provided three times per week for 16 weeks. On the posttest, treatment group participants evidenced significantly less negative mood than the control group on the Montgomery-Asberg Depression Rating Scale and the Sadness and Apathy subscales of the Alzheimer’s Disease and Related Disorders Mood Scale. The differences approached significance on the Dementia Mood Assessment Scale. Results suggest that a therapeutic counseling approach can be effective in treating the dysphoria commonly found in individuals with AD.

The experience of losing one’s cognitive abilities with concomitant changes in all areas of living is both frightening and frustrating for individuals with Alzheimer’s disease (AD). Yet impaired communication limits the use of many traditional therapeutic approaches that might be used to ameliorate these emotional responses. Little has been written about psychotherapeutic programs for this population, and only a few authors have described potentially useful models. Kasl-Godley and Gatz (2000) noted that no clinical trials of formal psychotherapy involving individuals with cognitive impairment have been reported in the literature. Published research studies are focused primarily on participants with mild impairment, have nonsignificant findings, and/or report limited data on outcomes (Burns et al., 2005; Carpenter, Ruckdeschel, Ruckdeschel, & Van Haitsma, 2002; Goldwasser, Auerbach, & Harkins, 1987).

Nursing home residents with AD are in need of supportive relationships with skilled, caring providers, but providers often find themselves unprepared to meet this need. Empirically supported therapeutic approaches are required to address the mental health needs of individuals with AD. The goal of this study was to examine mood outcomes using a new modified counseling approach, Therapeutic Conversation, developed for this population.

Literature Review

Although both pharmacological and nonpharmacological strategies have been used to improve mood in this population, behavioral interventions do not carry the risk of drug interactions and side effects (Duffy & Karlin, 2006). A limited number of nonpharmacological approaches to improving mood have been studied. However, few of these interventions have been subjected to well-controlled trials, shown to have positive effects on mood in individuals with AD, or included individuals with moderate to severe AD. Both individual and group psychotherapeutic strategies have been suggested. Several indirect strategies in which family caregivers or staff are trained to communicate more effectively or provide more pleasant activities for the impaired individual are also reviewed.

Individual Counseling

Carpenter et al. (2002) described R-E-M (Restore-Empower-Mobilize) Psychotherapy for individuals with mild to moderate dementia. Biweekly sessions lasting 20 to 30 minutes were conducted for 8 weeks. In phase 1 (Restore), therapists focused on developing a therapeutic relationship; acknowledging losses; reminiscing about past successes; facilitating awareness; expressing emotions; and restoring meaning, hope, and self-esteem. In phase 2 (Empower), therapists helped residents change their negative life circumstances using problem-solving techniques. In phase 3 (Mobilize), they worked with staff and the bureaucratic system to support changes that had been initiated in therapy.

A pilot study of R-E-M Psychotherapy was conducted with 3 depressed nursing home residents with dementia. Participants’ Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975) scores ranged from 20 to 23, indicating mild dementia. The residents set goals for their treatment such as initiating telephone calls to relatives and seeking increased opportunities for social interaction. All 3 made progress toward meeting their goals. By the end of treatment, scores on the Cornell Scale for Depression in Dementia (CSDD) (Alexopoulos, Abrams, Young, & Shamoian, 1988) improved, as did scores on the Activity Participation Scale (Van Haitsma, Lawton, Kleban, Klapper, & Corn, 1997), although the researchers were unable to show statistical significance with only 3 participants. The authors cautioned that the full range of strategies would be possible only with mildly impaired residents.

Brodaty et al. (2003) investigated psychosocial interventions for depression in 34 nursing home residents with depression and dementia and 33 with psychosis, depression, and dementia. They compared 12 weeks of psychogeriatric case management to a general practitioner (consultative) model and usual care. Psychogeriatric case management included pharmacotherapy and individual supportive therapy, as well as encouragement to participate in pleasurable activities. Those in the consultative model group received an in-depth evaluation and had an interdisciplinary team available for consultation if requested. Depression was measured with the CSDD (Alexopoulos et al., 1988) and the Geriatric Depression Scale (Yesavage et al., 1982–1983). All residents improved regardless of intervention. The authors concluded that the selected model of care made no difference in depression outcomes.

An untested counseling approach—the Selection, Optimization, and Compensation (SOC) Model (Volicer & Simard, 2006)—uses modified cognitive-behavioral therapy (Snow, Powers, & Liles, 2006). The SOC Model includes Selection of appropriate therapeutic strategies based on the individual’s stage of illness; Optimization, focusing on maintaining the individual’s quality of life; and Compensation, providing assistance as needed to compensate for the individual’s functional deficits. When counseling individuals with moderate impairment, the authors stressed that fewer issues can be discussed with them than with those with mild impairment but that patients “can generally discuss present feelings, reminisce, and socialize” (Volicer & Simard, 2006, p. 218). They recommended short sessions (30 minutes) with only one issue per session. The therapist role is more directive and concrete. In dealing with unhelpful thoughts, individuals can be taught to use a relaxation technique or recall an alternative, more helpful thought with the help of a caregiver. Therapy for individuals with severe dementia would consist of behavioral strategies instituted by the caregiver, such as taking the person to the day room.

Some individual approaches have been found to be ineffective in improving mood. Several researchers (Baldelli et al., 1993; LaBarge, Rosenman, Leavitt, & Cristiani, 1988; Zanetti et al., 1995, 1997) have investigated the effects of Reality Orientation (re-educating individuals with AD to remember orienting information, such as the date) on mildly impaired individuals with depressive symptomatology. There was little evidence that Reality Orientation was effective in improving mood. Validation therapy (Feil, 1992, 1993) was designed to validate the person when messages and behavior are confusing. The effectiveness of Validation Therapy as an intervention for mood in dementia has also been evaluated without significant results (Scanland & Emershaw, 1993; Verkaik, van Weert, & Francke, 2005).

Burns et al. (2005) reported an unsuccessful randomized trial of brief (six 50-minute sessions) psychodynamic interpersonal therapy, as previously described by Brierley et al. (2003) for individuals with early AD. Interveners focused on resolving interpersonal conflicts that originated in the distant past and were associated with current emotional distress. They also asked participants directly about how they were dealing with the problem of memory loss. Modifications for individuals with AD included home visits and caregiver involvement. Compared with usual care, those in the experimental group showed no improvement in mood, as measured by the CSDD.

Group Approaches

Promising group-based interventions have included group therapy (Cheston, Jones, & Gilliard, 2003) and group reminiscence therapy (Wang, 2007). For example, using a one-group, pretest-posttest design, Cheston et al. (2003) encouraged 42 mildly impaired community-dwelling individuals with dementia to discuss their emotional responses to their memory loss in 10 weekly group therapy sessions. Mood was measured using the CSDD. Negative mood decreased significantly during the 10-week treatment, and benefits remained at the 10-week follow-up evaluation. The investigators suggested that further controlled studies are needed to substantiate the effectiveness of this intervention.

Wang (2007) tested the effects of eight weekly 1-hour group reminiscence sessions on depression and cognition. Wang did not describe the control group treatment. Those in the experimental group had significantly better MMSE (Folstein et al., 1975) and CSDD (Alexopoulos et al., 1988) scores at posttest, compared with those in the control group. Participants were moderately impaired. However, the authors remarked that the program may have been more successful with mildly impaired individuals.

Indirect Strategies

Teri and Gallagher-Thompson (1991) described using behavioral strategies (involvement in pleasant activities, minimizing negative interactions) for those with moderate impairment. In 1997, Teri, Logsdon, Uomoto, and McCurry compared behavioral strategies (teaching caregivers to increase pleasant events) with problem solving (working with caregivers to improve problem solving), usual care (information, advice, support), and wait list. Both treatments (pleasant events and problem solving) were more effective than usual care and wait list in reducing AD-related depression.

Schreiner, Yamamoto, and Shiotani (2005) also used structured recreational activities to promote positive affect in 35 residents of two long-term care dementia units. They coded 3,854 1-minute observations of residents during recreational activities and during ordinary time and found that residents expressed happiness seven times more frequently during recreation time as compared with ordinary time.

In a two-group, pretest-posttest design, Bourgeois, Dijkstra, and Hickey (2005) taught 133 nurse aides to use specific communication strategies in one-to-one conversations with 125 moderately impaired nursing home residents with AD or related disorders. Half of the residents and half of the aides were assigned to a treatment group, and the remainder to usual care. Nurse aides in the treatment group were taught to use announcements and introductions, short instructions, and positive statements. They were also instructed to use memory books to stimulate conversation. Resident depression pre and post treatment was measured with the Geriatric Depression Scale (Yesavage et al., 1982–1983) and self and proxy (nurse aides) ratings. Independent raters used handheld devices to collect observational data of interactions in 5-minute samples. They rated the duration of problem behaviors, talk time between residents and aides, and frequency of positive statements. Frequency of problem behaviors was measured with the Revised Memory and Behavior Problems Checklist (Teri et al., 1997). Nurse aides’ proxy ratings of resident depression were significantly lower in the treatment group at posttest. Residents’ average percentage of talking time in the treatment group increased significantly from pretest to posttest. Control group residents’ talk time declined.

Summary of the Literature

Individual and group counseling approaches to improve mood in individuals with AD have been examined far less frequently in those with moderate to severe AD compared with those with mild impairment. Most of the relevant studies have significant methodological limitations, such as lack of a control group, mixed interventions in the experimental group, or very small samples. A focus on early life conflicts or linking past issues to present concerns is considered unlikely to be successful in more impaired individuals with AD. Two intriguing models of individual counseling (R-E-M Psychotherapy and the SOC Model) are described in the literature, but empirical support is extremely limited. The effectiveness of indirect strategies, such as exposure to pleasant activities, participation in recreational activities, or improving aide-resident interactions, has been supported.

Therapeutic Conversation

Our work suggests that individuals in moderate to late stages of AD can participate in counseling sessions modified for this population. Conversation with a therapeutic intent, which we have called Therapeutic Conversation, provides the opportunity to share feelings and concerns with a skilled listener who can understand their attempts to communicate, recognize their feelings, and provide emotional support. The authors developed Therapeutic Conversation on the basis of results of a previous study comparing the effects of exercise to conversation. Using our analysis of the transcribed conversations between nurses and residents, we challenged existing recommendations in the literature regarding appropriate communication techniques for this population (Tappen, Williams-Burgess, Edelstein, Touhy, & Fishman, 1997). We also found that conversation had beneficial effects on the relevance of participants’ communication and that they were able to form and maintain relationships with nurses who visited 5 days per week for 16 weeks (Williams & Tappen, 1999; Tappen, Williams, Barry, & DiSesa, 2001). The current study builds on our previous work by testing whether Therapeutic Conversation can make a contribution to the mental health of older individuals with AD by improving mood.

Method

A two-group repeated measures design with random assignment to treatment or control group was used. Raters were blinded to treatment group assignment. The study was conducted at a large long-term care facility in Miami, Florida. Eligibility criteria for participation in the study included clinical diagnosis of probable AD using National Institute of Neurological and Communicative Diseases and Stroke/Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) criteria (McKhann et al., 1984), an MMSE score (Folstein et al., 1975) of 25 or less, and ability to speak English. Individuals who were entirely mute were not eligible for the study. Consent was obtained from the participant’s family member or guardian. Assent to participate was obtained from the participant on an ongoing basis.

Individuals were randomly assigned to either the treatment group (Therapeutic Conversation three times per week for 16 weeks) or the control group (usual care). Participants in the treatment group were pretested immediately before the start of treatment and at the end of 16 weeks of treatment. Participants in the control group were tested following completion of consent procedures and again in 16 weeks.

Intervention

Intervention Group. Thirty-minute modified counseling sessions (Therapeutic Conversation) were provided three times per week for 16 weeks to participants in the treatment group. Therapeutic Conversation is a psychotherapeutic approach modified for individuals with AD. The goals of Therapeutic Conversation are to:

  • Form and maintain a supportive relationship.
  • Provide the opportunity for the individual to express his or her feelings and concerns.
  • Reduce isolation.
  • Improve self-esteem.
  • Improve mood.
  • Reduce anxiety.
  • Maintain verbal abilities.
  • Maintain dignity.

Therapeutic Conversation is based on Peplau’s (1991) Theory of Interpersonal Relations in which the client-provider relationship is central to the success of the approach. A beginning relationship between two strangers evolves in phases including orientation, identification, exploitation, and resolution (Table 1). Therapeutic Conversation is designed to create improved interpersonal relations in the context of a safe, intimate relationship that fosters participants’ self-esteem as a result of being understood, valued, and accepted. Individuals with AD are unlikely to clearly remember early life experiences or be able to link those memories to current conflicts, so we focused on the here and now. We did not directly confront the issue of memory loss, although the topic was discussed if the individual initiated the conversation and chose to explore it.

Therapeutic Conversation Intervention

Table 1: Therapeutic Conversation Intervention

The intervener used evidence-based strategies to facilitate participation, including speaking as equals, establishing commonalities, sharing of self, giving recognition, expressing affection and positive regard, and respecting participants’ individuality (Tappen et al., 1997, 2001). Other common therapeutic communication techniques were also used, including paraphrasing, summarizing, reflecting, and verbal encouraging (Williams, 2008). Participants were given the opportunity to share feelings and concerns with a skilled listener who recognized the meaning behind unclear communications, acknowledged their concerns, and provided emotional support (Table 1).

The conversational themes that emerged during these sessions (derived from analysis of audio recorded sessions) included significant losses (e.g., missing family and friends), estrangement from others because of institutionalization, loss of independence (e.g., financial independence), low self-esteem based on awareness of cognitive impairment, and loss of control over everyday decisions. The intervention can be tailored to participants’ communication abilities. For example, for those with severely limited verbal abilities, the intervention used more nonverbal communication.

Control Group. Participants in the control group received usual care provided by the staff of the long-term care facility in which they resided

Intervener

The intervener was a graduate nursing student trained to provide the intervention. Training included an overview of AD, changes in behavior and communication across disease stages, difficult behavior, psychotic symptoms, behaviors associated with depression, causes of communication breakdown, communication strategies, adaptations for individuals with visual or hearing deficits, procedures for audio recording, consent and assent process, and the Therapeutic Conversation protocol. The intervener practiced interviewing using role-playing with the investigator. Feedback and remediation were provided as appropriate. Treatment implementation was monitored by the investigators.

The intervener audio recorded one weekly session for each participant. After reviewing weekly audio recorded sessions, an investigator met with the intervener for supervision. Meetings were arranged frequently at first (at least weekly for the first month) and every 2 weeks thereafter.

Instruments

The Dementia Mood Assessment Scale (DMAS) (Sunderland et al., 1988) was used to measure mood because it was designed for individuals with moderate to severe dementia. The DMAS is a 24-item rating scale of observable mood and functional abilities. Items 1 through 17 measure mood and the remaining items measure severity of dementia. Only items 1 through 17 were used for analysis. Each item was rated on a continuum from 0 (within normal limits) to 6 (most severe). Higher scores represent greater dysphoria. Sunderland et al. reported a mean score of 25.2 (SD = 9.3). Scores have been found to be significantly correlated with global measures of depression (r = 0.73) and sadness (r = 0.65) (Sunderland et al., 1988). Interrater reliability was tested using intraclass correlation coefficient and was found to be highly significant.

The Alzheimer’s Disease and Related Disorders (AD-RD) Mood Scale is a 34-item Likert scale developed from a qualitative study of family and caregiver descriptions of the moods of individuals with AD (Tappen & Williams, 2008). Items represent the full range of positive and negative moods. The scale was tested in quantitative studies involving 298 participants with AD. Interrater reliability indexes were in the 0.63 to 0.88 range, with raters of same and different ethnic backgrounds. Factor analysis produced five subscales: two positive (Spirited and Contented) and three negative (Hostile, Apathetic, and Sad) with Cronbach’s alpha coefficients of 0.92, 0.85, 0.90, 0.77, and 0.73, respectively. The subscales have been found to discriminate between depressed and nondepressed individuals with AD.

The Montgomery-Asberg Depression Rating Scale (MADRS) (Montgomery & Asberg, 1979) was designed for clinicians to rate depression. The MADRS is a 10-item observational scale noted for its sensitivity to treatment effects (Montgomery & Asberg, 1979). The 10 items reflect core symptoms of depression (e.g., sadness, reduced sleep and appetite, pessimistic thoughts) with the exception of motor retardation, which appeared in fewer individuals (63%) than did the other symptoms. In antidepressant drug studies with individuals who did not have AD, this scale distinguished between those taking active drugs versus placebo. Interrater reliability indexes are reported to be high (0.89 to 0.97) as are correlations with the well-known Hamilton Rating Scale when tested on 54 English and 52 Swedish patients. Raters included a psychiatrist, a general practitioner, and a nurse.

Rater

The rater was a graduate nursing student trained in the standardized administration of the instruments and blinded to treatment group assignments. The investigators monitored testing sessions on a regular basis.

Data Analysis

Data on participants’ mood and depressive symptoms were collected before the intervention began and within 1 to 2 weeks following the end of the intervention period. A repeated measures analysis of covariance (ANCOVA) using baseline status as a covariate was performed to compare outcomes for the treatment and control groups.

Results

Sample

Thirty-six residents with AD were enrolled in the study. Of these, 1 died before pretesting and 2 before treatment was completed. Another 3 had incomplete data due to ill ness or refusal to be tested (1 participant). Altogether, 30 participants completed the study: 15 in the treatment group and 15 in the control group. The majority of the sample was women; there were 2 men in the control group and 1 in the treatment group. One participant in the control group was African American, and 2 participants in the treatment group were Hispanic. The remainder of the participants were European Americans. All spoke English. Participants ranged in age from 73 to 100. Mean age of those in the treatment group was 83.8 (SD = 7.45 years), and mean age in the control group was 90.26 (SD = 5.95 years). This difference was significant: F(1,29) = 6.89, p = 0.01.

All study participants were residents of a long-term care facility. Their length of stay in the facility ranged from 160 to 1,750 days, with a mean of 561 days (SD = 385) for the treatment group and 595 days (SD = 368) for the control group. This difference was not significant. All study participants had clinically diagnosed AD using the NINCDS-ADRDA criteria (McKhann et al., 1984). MMSE scores ranged from 0 to 25. The mean MMSE of the treatment group was 10.60 (SD = 6.99) compared with 12.26 (SD = 7.43) for the control group. This difference was not significant.

Mood Outcomes

With the exception of one subscale of the AD-RD Mood Scale (Hostile), treatment group participants evidenced increased positive mood and decreased negative mood, whereas control group participants maintained the same level or declined (Table 2).

Comparison of Pretest and Posttest Means for Treatment (Therapeutic Conversation) and Control Groups

Table 2: Comparison of Pretest and Posttest Means for Treatment (Therapeutic Conversation) and Control Groups

ANCOVA controlling for baseline mood scores were conducted on the outcome measures of mood and depressive symptomatology. Treatment group participants who engaged in Therapeutic Conversation evidenced a significant decline in sadness (F[2,27] = 5.01, p = 0.03) and apathy (F[2,27] = 4.21, p = 0.05), as measured on the subscales of the AD-RD Mood Scale, whereas control group participants remained at the same level. Treatment group participants also evidenced a significant decline in depressive symptomatology as measured by the MADRS (F[2,27] = 5.52, p = 0.02). Treatment group participants’ improvement in mood as measured by the DMAS compared with the decline in control group participants approached significance (F[2,27] = 3.59, p = 0.06). The differences between the two groups on the Hostile, Contented, and Spirited subscales of the AD-RD Mood Scale were not significant (Table 3).

Comparison of Treatment (Therapeutic Conversation) and Control Groups, Controlling for Baseline Scores

Table 3: Comparison of Treatment (Therapeutic Conversation) and Control Groups, Controlling for Baseline Scores

Discussion

Even a small number of negative mood symptoms can negatively affect mental health and quality of life as well as functional abilities (Lee & Lyketsos, 2003; Olin, Katz, Meyers, Schneider, & Lebowitz, 2002). Dysphoria and loss of interest are prominent, observable symptoms in AD (Olin et al., 2002). Drug treatment is commonly used, but less than half of those treated improve, and patients may experience significant side effects (Boyle & Malloy, 2004).

We compared 15 long-term care residents with AD who received modified counseling using the Therapeutic Conversation approach for 16 weeks with 15 residents who received usual care. Those residents who received Therapeutic Conversation evidenced improved mood after 16 weeks of treatment. Karlsson et al. (2000) used the criterion of a 4-point change in MADRS score for clinical relevance (Montgomery, 1994). The treatment group mean MADRS score improved 4.47 points, which meets this criterion.

Limitations of this study include a small sample, which may have limited our power to detect change. Effect sizes were calculated using the partial eta squared statistic (Cohen, 1988) on the results generated in this study. For the MADRS, we had an effect size of η2 = 0.18 equivalent to f = 0.47; the Sad and Apathetic subscales of the AD-RD Mood Scale had an effect size of η2 = 0.15 equivalent to f = 0.42, falling within the moderate range of f = 0.25 to 0.50 (Cohen, 1988).

The sample included individuals with a wide range of MMSE scores (0 to 25), from mild to severe impairment. All, however, were able to express themselves verbally, at least in short phrases if not complete sentences. There were very few men in the sample, which is common in long-term care settings, but this limits generalization to those of the male gender. There was also limited representation of minority groups. These limitations need to be addressed in a larger study with a more heterogeneous sample in terms of gender and minority group membership. A larger sample would also allow stratification by degree of severity of the cognitive impairment.

We did not include an attention control group in this study because we have found in previous studies that social conversation (conversation of comparable time and frequency but without therapeutic intent) did not have beneficial effects on mood (Williams & Tappen, 2007). The results of this study, in light of the results of our previous work, lends support to the contention that therapeutic strategies, rather than social contact alone, are needed to produce a beneficial effect on mood. Further testing of this contention that social contact does not have a similar therapeutic effect is recommended.

Implementation of Therapeutic Conversation requires training in psychotherapeutic techniques, knowledge of communicative dysfunctions related to AD, and the ability to understand individuals with these limitations. Mental health services are limited in long-term care settings because of limitations in professional staff. In view of cost considerations, a less frequent intervention should be considered in future testing of this intervention. The nurse’s role as a counselor is given low priority in many institutional settings. Policy changes related to reimbursement levels are needed to support the use of advanced practice nurses to provide nonpharmacological mental health services, such as modified counseling, to this high-risk population (Cody, Beck, & Svarstad, 2002).

Conclusion

Peplau (1991) wrote that nurses have the responsibility to help patients actualize their potential for self-realization. In her work as teacher and mentor for countless psychiatric nursing nurses and students, Peplau demonstrated conviction regarding the potential for interpersonal growth in patients with severe mental illness who, like those with AD, had cognitive deficits and limited communicative skills. The growing population of individuals with AD presents an opportunity and a challenge to nurses to develop new methods of caring that preserve the dignity and humanity of each person within relationships with others.

References

  • Alexopoulos, G.S., Abrams, R.C., Young, R.C. & Shamoian, C.A. (1988). Cornell Scale for Depression in Dementia. Biological Psychiatry, 23, 271–284. doi:10.1016/0006-3223(88)90038-8 [CrossRef]
  • Baldelli, M.V., Pirani, A., Motta, M., Abati, E., Mariani, E. & Manzi, V. (1993). Effects of reality orientation therapy on elderly patients in the community. Archives of Gerontology and Geriatrics, 17, 211–218. doi:10.1016/0167-4943(93)90052-J [CrossRef]
  • Bourgeois, M.S., Dijkstra, K. & Hickey, E.M. (2005). Impact of communication interaction on measuring self- and proxy-rated depression in dementia. Journal of Medical Speech-Language Pathology, 13(1), 37–50.
  • Boyle, P.A. & Malloy, P.F. (2004). Treating apathy in Alzheimer’s disease. Dementia and Geriatric Cognitive Disorders, 17, 91–99. doi:10.1159/000074280 [CrossRef]
  • Brierley, E., Guthrie, E., Busby, C., Marino-Francis, F., Byrne, J. & Burns, A. (2003). Psychodynamic interpersonal therapy for early Alzheimer’s disease. British Journal of Psychotherapy, 19, 435–446. doi:10.1111/j.1752-0118.2003.tb00097.x [CrossRef]
  • Brodaty, H., Draper, B.M., Millar, J., Low, L.F., Lie, D. & Sharah, S. et al. (2003). Randomized controlled trial of different models of care for nursing home residents with dementia complicated by depression or psychosis. Journal of Clinical Psychiatry, 64, 63–72.
  • Burns, A., Guthrie, E., Marino-Francis, F., Busby, C., Morris, J. & Russell, E. et al. (2005). Brief psychotherapy in Alzheimer’s disease: Randomised controlled trial. British Journal of Psychiatry, 187, 143–147. doi:10.1192/bjp.187.2.143 [CrossRef]
  • Carpenter, B., Ruckdeschel, K., Ruckdeschel, H. & Van Haitsma, K. (2002). R-E-M psychotherapy: A manualized approach for long-term care residents with depression and dementia. Clinical Gerontologist, 25, 25–49. doi:10.1300/J018v25n01_03 [CrossRef]
  • Cheston, R., Jones, K. & Gilliard, J. (2003). Group psychotherapy and people with dementia. Aging & Mental Health, 7, 452–461. doi:10.1080/136078603100015947 [CrossRef]
  • Cody, M., Beck, C. & Svarstad, B.L. (2002). Challenges to the use of nonpharmacological interventions in nursing homes. Psychiatric Services, 53, 1402–1406. doi:10.1176/appi.ps.53.11.1402 [CrossRef]
  • Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum.
  • Duffy, M. & Karlin, B. (2006). Treating depression in nursing homes: Beyond the medical model. In Hyer, L. & Intrieri, R.C. (Eds.), Geropsychological interventions in long-term care (pp. 109–135). New York: Springer.
  • Feil, N. (1992). Validation therapy. Geriatric Nursing, 13, 129–133. doi:10.1016/S0197-4572(07)81021-4 [CrossRef]
  • Feil, N. (1993). The validation breakthrough: Simple techniques for communicating with people with “Alzheimer’s-type dementia.” Baltimore: Health Professions Press.
  • Folstein, M.F., Folstein, S.E. & McHugh, P.R. (1975). “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. doi:10.1016/0022-3956(75)90026-6 [CrossRef]
  • Goldwasser, A.N., Auerbach, S.M. & Harkins, S.W. (1987). Cognitive, affective, and behavioral effects of reminiscence group therapy on demented elderly. International Journal of Aging & Human Development, 25, 209–222.
  • Karlsson, I., Godderis, J., Augusto De Mendonça Lima, C., Nygaard, H., Simány, M. & Taal, M. et al. (2000). A randomised, double-blind comparison of the efficacy and safety of citalopram compared to mianserin in elderly, depressed patients with or without mild to moderate dementia. International Journal of Geriatric Psychiatry, 15, 295–305. doi:10.1002/(SICI)1099-1166(200004)15:4<295::AID-GPS105>3.0.CO;2-C [CrossRef]
  • Kasl-Godley, J. & Gatz, M. (2000). Psychosocial interventions for individuals with dementia: An integration of theory, therapy, and a clinical understanding of dementia. Clinical Psychology Review, 20, 755–782. doi:10.1016/S0272-7358(99)00062-8 [CrossRef]
  • LaBarge, E., Rosenman, L.S., Leavitt, K. & Cristiani, T. (1988). Counseling clients with mild senile dementia of the Alzheimer’s type: A pilot study. Neurorehabilitation and Neural Repair, 2, 167–173. doi:10.1177/136140968800200405 [CrossRef]
  • Lee, H.B. & Lyketsos, C.G. (2003). Depression in Alzheimer’s disease: Heterogeneity and related issues. Biological Psychiatry, 54, 353–362. doi:10.1016/S0006-3223(03)00543-2 [CrossRef]
  • McKhann, G., Drachmann, D., Folstein, M., Katzmann, R., Price, D. & Stadlan, E.M. (1984). Clinical diagnosis of Alzheimer’s disease: Report of the NINCDS-ADRDA work group under the auspices of Department of Health and Human Services Task Force on Alzheimer’s Disease. Neurology, 34, 939–944.
  • Montgomery, S.A. (1994). Clinically relevant effect sizes in depression. European Neuropsychopharmacology, 4, 283–284. doi:10.1016/0924-977X(94)90093-0 [CrossRef]
  • Montgomery, S.A. & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382–389. doi:10.1192/bjp.134.4.382 [CrossRef]
  • Olin, J.T., Katz, I.R., Meyers, B.S., Schneider, L.S. & Lebowitz, B.D. (2002). Provisional diagnostic criteria for depression of Alzheimer’s disease: Rationale and background. American Journal of Geriatric Psychiatry, 10, 129–141.
  • Peplau, H.E. (1991). Interpersonal relations in nursing: A conceptual frame of reference for psychodynamic nursing. New York: Springer.
  • Scanland, S.G. & Emershaw, L.E. (1993). Reality orientation and validation therapy. Dementia, depression, and functional status. Journal of Gerontological Nursing, 19(6), 7–11.
  • Schreiner, A.S., Yamamoto, E. & Shiotani, H. (2005). Positive affect among nursing home residents with Alzheimer’s disease: The effect of recreational activity. Aging & Mental Health, 9, 129–134.
  • Snow, A.L., Powers, D. & Liles, D. (2006). Cognitive-behavioral therapy for long-term care patients with dementia. In Hyer, L. & Intrieri, R.C. (Eds.), Geropsychological interventions in long-term care (pp. 265–283). New York: Springer.
  • Sunderland, T., Alterman, I.S., Yount, D., Hill, J.L., Tariot, P.N. & Newhouse, P.A. et al. (1988). A new scale for the assessment of depressed mood in demented patients. American Journal of Psychiatry, 145, 955–959.
  • Tappen, R.M. & Williams, C.L. (2008). Development and testing of the Alzheimer’s Disease and Related Dementias Mood Scale. Nursing Research, 57, 426–435. doi:10.1097/NNR.0b013e31818c3dcc [CrossRef]
  • Tappen, R.M., Williams, C.L., Barry, C. & DiSesa, D. (2001). Conversation intervention with Alzheimer’s patients: Increasing the relevance of communication. Clinical Gerontologist, 24(3/4), 63–75. doi:10.1300/J018v24n03_06 [CrossRef]
  • Tappen, R.M., Williams-Burgess, C., Edelstein, J., Touhy, T. & Fishman, S. (1997). Communicating with individuals with Alzheimer’s disease: Examination of recommended strategies. Archives of Psychiatric Nursing, 11, 249–256. doi:10.1016/S0883-9417(97)80015-5 [CrossRef]
  • Teri, L. & Gallagher-Thompson, D. (1991). Cognitive-behavioral interventions for treatment of depression in Alzheimer’s patients. The Gerontologist, 31, 413–416. doi:10.1093/geront/31.3.413 [CrossRef]
  • Teri, L., Logsdon, R.G., Uomoto, J. & McCurry, S.M. (1997). Behavioral treatment of depression in dementia patients: A controlled clinical trial. Journals of Gerontology. Series B, Psychological Sciences and Social Sciences, 52, P159–P166.
  • Van Haitsma, K.S., Lawton, M.P., Kleban, M.H., Klapper, J. & Corn, J. (1997). Methodological aspects of the study of streams of behavior in elders with dementing illness. Alzheimer Disease and Associated Disorders, 11, 228–238.
  • Verkaik, R., van Weert, J.C. & Francke, A.L. (2005). The effects of psychosocial methods on depressed, aggressive, and apathetic behaviors of people with dementia: A systematic review. International Journal of Geriatric Psychiatry, 20, 301–314. doi:10.1002/gps.1279 [CrossRef]
  • Volicer, L. & Simard, J. (2006). Application of SOC Model to care for residents with advanced dementia. In Hyer, L. & Intrieri, R.C. (Eds.), Geropsychological interventions in long-term care (pp. 207–220). New York: Springer.
  • Wang, J.J. (2007). Group reminiscence therapy for cognitive and affective function of demented elderly in Taiwan. International Journal of Geriatric Psychiatry, 22, 1235–1240. doi:10.1002/gps.1821 [CrossRef]
  • Williams, C. (2008). Therapeutic interaction in nursing (2nd ed.). Sudbury, MA: Jones and Bartlett.
  • Williams, C.L. & Tappen, R.M. (1999). Can we create a therapeutic relationship with nursing home residents in the later stages of Alzheimer’s disease?Journal of Psychosocial Nursing and Mental Health Services, 37(3), 28–35.
  • Williams, C.L. & Tappen, R.M. (2007). Effect of exercise on mood in nursing home residents with Alzheimer’s disease. American Journal of Alzheimer’s Disease and Other Dementias, 22, 389–397. doi:10.1177/1533317507305588 [CrossRef]
  • Yesavage, J.A., Brink, T.L., Rose, T.L., Lum, O., Huang, V. & Adey, M. et al. (1982–1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49. doi:10.1016/0022-3956(82)90033-4 [CrossRef]
  • Zanetti, O., Binetti, G., Magni, E., Rozzini, L., Bianchetti, A. & Trabucchi, M. (1997). Procedural memory stimulation in Alzheimer’s disease: Impact of a training programme. Acta Neurologica Scandinavica, 95, 152–157. doi:10.1111/j.1600-0404.1997.tb00087.x [CrossRef]
  • Zanetti, O., Frisoni, G.B., DeLeo, D., Dello Buono, M., Bianchetti, A. & Trabucchi, M. (1995). Reality orientation therapy in Alzheimer’s disease: Useful or not? A controlled study. Alzheimer Disease and Associated Disorders, 9, 132–138.

Therapeutic Conversation Intervention

Peplau’s Overlapping Phases of a Relationship Therapeutic Strategies
Orientation: Participant gains trust, begins to engage in the relationship. The intervener introduces self and briefly explains the purpose of the visit. If the participant agrees to meet, phase-specific strategies are used as appropriate. Protecting from distractions, conveying availability, consistency and interest, using a caring and respectful tone of voice and calm approach, adapting communication to the participant’s cognitive ability, accepting some misunderstandings, focusing on the present, asking general questions, using nonverbal gestures and verbal encouragers, and allowing sufficient time to respond.
Identification: Participant begins to participate in the intimate interpersonal relationship. In addition to the orientation strategies used previously, the intervener uses phase-specific strategies as tolerated by the resident. Sharing self, supportive touch, verbal support, paraphrasing, acknowledging emotions and concerns, and acknowledging autonomy. The intervener refrains from dishonest communication, demonstrations of impatience or frustration, correcting or pointing out errors, using diminutives or collective pronouns, and talking about the participant in his or her presence. Confrontational statements or questions such as those beginning with “Why?” are avoided.
Exploitation: Participant is engaged in and derives value from the relationship. In addition to the previous strategies, the intervener uses phase-specific strategies as appropriate. Speaking as equals, establishing commonalities, giving recognition, expressing affection and positive regard, acknowledging and respecting the participant’s individuality, clarifying vague communication, using open-ended as well as closed-ended questions, listening for themes, and encouraging talk about feelings and concerns.
Resolution: Participant and intervener discuss termination. In addition to the previous strategies, the intervener uses phase-specific strategies as appropriate. Encouraging talk about this relationship and other significant relationships, summarizing and reminiscing about relationship, facilitating the participant’s relationships with peers and center staff, and saying good-bye.

Comparison of Pretest and Posttest Means for Treatment (Therapeutic Conversation) and Control Groups

Scale/Subscale Treatment Group
Control Group
Pretest Mean (SD) Posttest Mean (SD) Pretest Mean (SD) Posttest Mean (SD)
AD-RD Mood Scale
  Sad 8.46 (3.20) 7.00 (2.10) 8.80 (2.30) 8.86 (2.64)
  Apathetic 14.13 (3.97) 12.20 (3.16) 13.20 (4.76) 13.80 (3.42)
  Hostile 14.86 (4.15) 15.73 (5.77) 15.46 (7.92) 17.00 (3.70)
  Contented 15.66 (2.96) 16.20 (4.05) 16.06 (3.73) 16.06 (2.98)
  Spirited 27.60 (9.55) 28.73 (9.57) 30.33 (8.99) 28.06 (5.80)
DMAS 23.66 (14.73) 21.26 (12.80) 21.33 (15.67) 28.13 (12.21)
MADRS 19.60 (8.81) 15.13 (9.54) 15.14 (9.55) 19.13 (7.37)

Comparison of Treatment (Therapeutic Conversation) and Control Groups, Controlling for Baseline Scores

Scale/Subscale Treatment Group Least Squares Means Control Group Least Squares Means F pValue
AD-RD Mood Scale
  Sad 7.07 8.79 5.01 0.03
  Apathetic 11.98 14.01 4.21 0.05
  Hostile 15.90 16.82 0.37 0.54
  Contented 16.30 15.96 0.08 0.77
  Spirited 29.32 27.47 0.57 0.45
DMAS 20.81 28.58 3.59 0.06
MADRS 13.91 20.57 5.52 0.02
Authors

Dr. Tappen is Christine E. Lynn Eminent Scholar and Professor, and Dr. Williams is Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida.

This study was supported by the Scholl Foundation and the Stein Gerontological Institute, Miami Jewish Home and Hospital for the Aged.

Address correspondence to Ruth M. Tappen, EdD, RN, FAAN, Christine E. Lynn Eminent Scholar and Professor, Christine E. Lynn College of Nursing, Florida Atlantic University, 777 Glades Road, Boca Raton, FL 33431-0991; e-mail: rtappen@fau.edu.

Received: September 26, 2008
Accepted: March 17, 2009
Posted Online: October 27, 2009

10.3928/19404921-20090428-02

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