Dementia is becoming increasingly prevalent as the worldwide population ages. Alzheimer's Disease International (2015a) has estimated that the number of individuals with dementia will reach 74.7 million in 2030 and 131.5 million in 2050. The increase will be considerable among developing countries. On average, a new patient is diagnosed with dementia every 3 seconds (Alzheimer's Disease International, 2015b). In Taiwan, dementia prevalence has been reported for six age groups: 3.4% for age 65 to 69; 3.5% for age 70 to 74; 7.2% for age 75 to 79; 13% for age 80 to 84; 21.9% for age 85 to 89; and 36.9% for age ≥90 (Taiwan Alzheimer Disease Association [TADA], 2015). These data reveal the impact of an aging society on the prevalence of dementia and the need for attentive care as well as the growing number of families affected by the disease (Gómez-Gallego, Gómez-Amor, & Gómez-García, 2012).
Dementia has been named a major neurocognitive disorder (NCD) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association [APA], 2013). A diagnosis of major NCD requires evidence of significant decline from a previous level of performance in at least one of the following cognitive domains: complex attention, executive function, learning and memory, language, perceptual/motor function, and social cognition (APA, 2013). Behavioral and psychological symptoms of dementia (BPSD) are known as troublesome neuropsychiatric symptoms. More than 80% of individuals with dementia experience at least one type of BPSD (TADA, 2015). Caregivers consider BPSD difficult to manage (Shearer, Green, Ritchie, & Zajicek, 2012).
Agitation, one manifestation of BPSD, includes verbal or physical outbursts, general emotional distress, restlessness, pacing, and similar aggressive or nonaggressive forms of behaviors. The appearance and aggravation of agitation affects patients themselves and can result in mental and physical exhaustion while frustrating caregivers (TADA, 2015). Agitation also affects quality of life (QOL) and has become the primary reason for early institutionalization of individuals with dementia (Gómez-Gallego et al., 2012; Shearer et al., 2012). It is critical to provide appropriate care to reduce agitation and maintain or improve QOL for individuals with dementia (Logsdon, Gibbons, Mccurry, & Teri, 1999).
Nonpharmacological complementary therapy for individuals with dementia has been recommended prior to the use of medications to reduce use and adverse effects of drugs (Curtin, 2011). Reminiscence therapy, a nonpharmacological intervention for individuals with dementia, is described as a mental process that involves recalling the past. The theoretical foundation of reminiscence therapy was adapted from Butler's life review process and Erickson's developmental theory. Butler (1963) believes that ego integrity is attained through recalling one's past and an evaluative perspective. Butler (1963) believes reminiscence is a universal mental process brought about by the realization of approaching dissolution and death. Erickson, Erickson, and Kinvick (1986) outlined eight stages of human development spanning the life cycle from birth to death. The final stage is ego integrity versus despair. Older adults must develop ego integrity, a sense of satisfaction with life, its meaning, and a belief that life is fulfilling and successful. Reminiscence entails a progressive return to an awareness of past experiences, allowing salient life experiences to be reexamined and reintegrated. Familiar events are used for thematic guidance so that patients can recall meaningful experiences and awaken memories of the past (Haight & Burnside, 1992). Because dementia limits an individual's ability to learn new information, emotional functions are far better than cognitive functions for reminiscence therapy (TADA, 2015). Several researchers have applied reminiscence therapy for individuals with dementia (Karttunen et al., 2011; Serrani Azcurra, 2012; Wu, 2011).
The effects of reminiscence on overall BPSD, depression, anxiety, and QOL have been previously examined (Barrios et al., 2013; Graske, Fischer, Kuhlmey, & Wolf-Ostermann, 2012). However, findings on the effects of group reminiscence on the overall symptoms of agitation and QOL have been inconsistent (Baillon et al., 2004; Nawate, Kaneko, Hanaoka, & Okamura, 2008). Some studies have found that group reminiscence therapy significantly decreased overall BPSD, reduced agitation, and improved QOL of patients and caregivers (Banerjee et al., 2009; Curtin, 2011; Huang, Chiu, Wang, & Yeh, 2011; Nawate et al., 2008; Woods, Spector, Jones, Orrell, & Davies, 2005). However, Baillon et al. (2004) conducted group reminiscence therapy on patients with mild to moderate dementia and found no positive effect. Yet, it has been repeatedly established that group reminiscence therapy effectively improves QOL of individuals with dementia (Woods et al., 2005). van der Linde, Stephan, Savva, Dening, and Brayne (2012) performed a systematic literature review and found that BPSD are closely related to QOL, with improvements in QOL of individuals with dementia made through prevention, treatment, and management of BPSD (Barrios et al., 2013; Nawate et al., 2008; Serrani Azcurra, 2012; van der Linde et al., 2012; Woods et al., 2005).
Overall, agitated behaviors vary, and most studies have focused on managing agitated behaviors in individuals with dementia, with only one study applying reminiscence therapy on individual agitated behaviors (van der Linde et al., 2012). Moreover, the study of individuals with dementia among Asian populations is lacking. Thus, the current study investigated the effectiveness of group reminiscence therapy on agitated behaviors and QOL of individuals with dementia to test the following hypotheses:
- The overall and individual agitated behaviors of individuals with dementia will decrease after receiving group reminiscence therapy and persist for 12 weeks.
- QOL of individuals with dementia will improve after receiving group reminiscence therapy and persist for 12 weeks.
The purpose of the current study was to evaluate the effects of group reminiscence therapy on agitated behaviors and QOL of individuals with dementia.
Design and Participants
A quasi-experimental study was performed using a repeated-measures design. Residents with dementia from five long-term care institutions in southern Taiwan were selected through purposive sampling. Inclusion criteria were: (a) diagnosis of any type of dementia by a physician or a Mini-Mental State Examination (MMSE; Folstein, Folstein, & McHugh, 1975) score of 10 to 23 for older adults who had graduated from elementary school and 10 to 18 for older adults who did not graduate from elementary school; (b) capable of speaking or understanding Mandarin or Taiwanese; (c) able to hear with or without hearing devices; and (d) at least one symptom of agitation on the Cohen-Mansfield Agitation Inventory (CMAI; Cohen-Mansfield & Billing, 1986; Cohen-Mansfield, Marx, & Rosenthal, 1989). Exclusion criteria were history of mental illness, acute illness, or contraction of an illness within the previous 1 week with ongoing weakness or inability to sit for at least 50 minutes. The sample size was estimated by G-power software. To achieve 20% effect size and 80% power for significance at alpha level 5% with a three-time repeated measures design (Cohen, 2013), at least 39 participants were needed.
A 50-minute group reminiscence therapy session was conducted once per week for 10 consecutive weeks. Each of the five groups included 10 to 12 participants. Each week a different theme was planned: “Really nice to meet you”; “Let's talk about our childhood memories together”; “It's that flavor”; “Songs from the past”; “Celebrating the New Year”; “Your hometown and mine”; “What did I do”; “My most unforget-table event”; “The relatives I love”; and “My awards.” Each reminiscence theme was divided into four stages. The first 10 minutes was the warm-up stage, during which group members introduced themselves and reviewed the previous week's theme. The second stage was 30 minutes, during which the concepts of group dynamics and group reminiscence therapy were used to ask members to share their past experiences and current feelings regarding the week's theme. The third stage was 8 minutes, during which members shared their thoughts and suggestions regarding the week's theme. The third stage served as a reference when conducting the next group meeting. During the final 2 minutes, the activity for the following week was introduced.
After review and approval by the institutional review board (IRB), activity plans and themes based on participants' common life experiences, ages, and interests were determined. Five practitioners (i.e., nurse, occupational therapist, nursing professor, psychologist, and social worker), each of whom had at least 5 years of experience in dementia care, provided an expert review of the activity plans.
After receiving consent from the five participating managers or leaders of the institutions, residents were referred to the researcher (F.-Y.H.). The researcher personally explained the goals of the study to all potential participants and their families. After obtaining signed consent, pretests were administered 1 week before study onset. Posttests were administered 1 week after the end of the intervention and repeated at 12 weeks. The researcher, a psychiatric nurse with reminiscence group training, led all five groups throughout the 10 weeks. The study was conducted between July and December 2015.
The Chinese version of the MMSE, translated by Guo et al. (1988), was used to screen all participants. The Chinese version of the CMAI for institutional use, translated by Line, Kao, Tzeng, and Lin (2007), was used to measure agitated symptoms. The 29 symptoms of agitation are divided into physically aggressive behaviors, physically nonaggressive behaviors, verbally aggressive behaviors, and verbally nonaggressive behaviors. The frequency of agitated behaviors in the previous 2 weeks is graded on a 7-point Likert scale (1 = never, 2 = less than once per week, 3 = 1 to 2 times per week, 4 = numerous times per week, 5 = 1 to 2 times per day, 6 = numerous times per day, and 7 = numerous times per hour) for a total score ranging from 29 to 203. A higher score indicates more severe agitation. The CMAI Chinese version content validity index is 0.99 and the intraclass coefficients (ICCs) are 0.69 to 0.74 (Finkel, Lyons, & Anderson, 1992). The CMAI is an observation scale. Long-term facility nurses were trained in the completion of the inventory; interrater training was performed with primary caregivers until a satisfactory reliability of 0.80 was achieved.
QOL of residents with mild to moderate dementia and MMSE scores >10 was evaluated using the Chinese version of the QOL-Alzheimer's Disease Scale (QOL-AD) translated by Fuh and Wang (2006) with a test–retest reliability (ICC) of 0.83. The scale uses a 4-point Likert scale (1 = poor to 4 = good) to assess 13 indicators: physical health, energy, mood, home environment, memory, family, marriage, friends, the patients themselves, family capabilities, recreational capabilities, finances, and overall living. Total score ranges from 13 to 52, with higher scores indicating better QOL (Chen, Wen, Wong, Tsai, & Liu, 2013). The scale was administered by the researcher.
The study was approved by the Ethical Committee of the University IRB. Five facilities were invited to participate in the study and consent from the administrator of each facility was obtained. Participants and family surrogates of individuals with moderate and severe dementia were contacted in-person; the study's purpose and risks and benefits of participation were explained, and informed written consent was obtained. For individuals who were unable to sign the consent form, family surrogates provided assent. If participants demonstrated any physical weakness or expressed unwillingness to continue participating during the program, they were free to withdraw and were referred to caregivers.
Two-tailed tests were used to analyze data using SPSS version 17, and a p value of 0.05 was considered significant. Generalized estimating equations were used to determine differences in the main variables during the study time periods.
Of the 48 residents recruited, only 43 completed the pre- and posttest and 40 completed the follow-up test at 12 weeks for a dropout rate of 7% (Table 1).
Participant Characteristics (N = 43)
Changes in Agitation
The CMAI total scores for agitated behavior were 38.93 (SD = 1.52) in the pretest, 38.72 (SD = 1.81) in the post-test, and 39.72 (SD = 2.27) at 12 weeks. No significant differences were found across the three measurements. Only the verbally aggressive subscales of the CMAI demonstrated significant change (p = 0.025) (Table 2).
Changes in Outcome Measures Across Time Periods (N = 43)
Changes in Individual Agitated Behaviors
Analysis of each of the 29 items of the CMAI indicated that intentional falling, hoarding, and akathisia changed significantly but only for a short time. The posttest score for intentional falling was significantly lower than the pretest score (p = 0.025), but the follow-up test was significantly higher (p = 0.025), indicating that group reminiscence therapy had a short-term effect on intentional falling. The posttest score for hoarding was significantly lower than the pretest score (p = 0.021), but remained unchanged at 12 weeks, also indicating a short-term effect. Similarly, the posttest score for akathisia was significantly lower than the pretest score (p = 0.008) but returned to baseline at 12 weeks.
Changes in Quality of Life
QOL on the pre-, post-, and follow-up test was 26.68 (SD = 0.68), 29.44 (SD = 0.86), and 32.12 (SD = 1.02), respectively. The posttest score was higher than the pretest score (p = 0.007); the follow-up test score was higher than the posttest score (p = 0.007) (Table 2). Thus, group reminiscence therapy had a significant long-term, positive, and sustained effect on QOL.
Figure 1 demonstrates the changes in all outcome measures over the study period.
Changes in outcome measures across time periods (N = 43).
Note. QOL = quality of life; CMAI = Cohen-Mansfield Agitation Inventory; PNA = physically nonaggressive; PA = physically aggressive; VNA = verbally nonaggressive; VA = verbally aggressive.
Effects of Group Reminiscence Therapy on Agitation
In the current study, symptoms of agitation did not improve significantly after 10 weeks of group reminiscence therapy in individuals with dementia. Dementia is a progressive degenerative disease; thus, as the disease advances, patients continue to experience degeneration in cognition and physical and verbal behaviors. In addition, symptoms of agitation are unique and differ among individuals with dementia. Reminiscence is pleasant and distracting, and it appears to impact agitated behaviors (Chen et al., 2013; Fuh & Wang, 2006; Thorgrimsen et al., 2003). The short-term effect of reminiscence therapy on three individual behaviors—intentional falling, hoarding, and akathisia—may indicate that individuals with dementia become immersed in the reminiscence atmosphere, which diverts their attention (Chen et al., 2013; Fuh & Wang, 2006; Thorgrimsen et al., 2003). The current results are similar to a previous study, which suggested that individuals with dementia could immerse themselves in nostalgia and feelings of joy by participating in activities that distract them from performing agitated behaviors (Graske et al., 2012). By having their attention diverted with reminiscence, individuals with dementia may disregard the involuntary impulse to get up, move, and engage in agitated and disorderly behaviors.
In addition, individuals with dementia who participated in reminiscence therapy did not experience a worsening of agitation from the environmental stimuli. This finding is consistent with the concept that “not deteriorating is a good sign” (Chen et al., 2013, p. 90). Thus, the continued use of reminiscence therapy for individuals with dementia may be more beneficial to slow progression of the disease. No previous studies have analyzed the effects of reminiscence therapy on individual agitation behaviors, such as intentional falling, hoarding, and akathisia; thus, the findings of positive effects of reminiscence therapy on these agitated behaviors may be important references for caregivers who manage the behaviors of individuals with dementia.
Effects of Group Reminiscence Therapy on Quality of Life
The results of the current study indicate that group reminiscence therapy improved QOL of individuals with dementia, with effects lasting for 3 months. Reminiscence therapy primarily enhances emotional functions while promoting social interaction and interpersonal relationships among group members. The inner satisfaction and joy while providing a sense of psychological and emotional comfort may have enhanced QOL. Previous studies have also found that participating in reminiscence activities and recalling the past can evoke deep memories in individuals with dementia, eliciting inner satisfaction and an improved sense of life (León-Salas et al., 2013; Serrani Azcurra, 2012). In addition, reminiscence in groups can also achieve a group therapy effect, as noted by Yalom (1995). Mutual support and sharing of life experiences among group members leads to increased interpersonal interactions and promotes psychological adjustment. As members participate in more group reminiscence activities, their participation, identity, and self-disclosures during these activities can also improve. A greater sense of spiritual comfort, satisfaction, and pleasure can promote an improvement in QOL (Chen et al., 2013). However, previous studies have failed to investigate the long-term effects of group reminiscence therapy on QOL of individuals with dementia; therefore, further research is needed.
Limitations and Future Research
First, although small, the sample size was sufficient for meaningful statistical analysis. Future studies should consider a larger sample for greater explanatory power. Second, the study could have been designed better with more frequent reminiscence groups and outcome measures. The lack of a control group infers that only limited inferences can be made from the data. No effort was made to determine the influence of the natural deterioration or illness process of residents during the course of this study. Future studies should compare group reminiscence therapy with other complementary therapies, such as cognitive stimulation, aromatherapy, multisensory therapy, and music therapy. In addition, the degree of participation must be considered when analyzing data in future studies.
Group reminiscence therapy has no significant effect on overall agitated behavior, but significant effects on individual dementia behaviors of intentional falling, hoarding, and akathisia were found. QOL was improved with group reminiscence therapy. Patients with dementia are unique and present with diverse BPSD; not all problematic behaviors are amenable to treatment (Chen, Wen, Wong, Tsai, & Liu, 2013). Although BPSD did not significantly diminish, group reminiscence therapy did not result in further deterioration and may have prevented worsening of symptoms. Dementia-agitated behaviors are treated differently, where appropriate interventions must be provided based on each patient's need for effective and comprehensive care. Findings of the current study provide information for professional and nonprofessional caregivers to improve QOL of individuals with dementia with specific agitated behaviors.
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Participant Characteristics (N = 43)
|Variable||Mean (SD) (Range)|
|Age (years)||78.65 (6.7) (62 to 91)|
|Years of education||4.42 (4.51) (0 to 12)|
|Number of chronic diseases||2.67 (1.46) (0 to 6)|
|MMSE scorea||13.51 (3.12) (10 to 22)|
|CMAI scoreb||38.93 (10.05) (30 to 79)|
|QOL-AD scorec||26.67 (4.49) (18 to 38)|
| Female||29 (67.4)|
| Male||14 (32.6)|
| Widowed||25 (58.1)|
| Married||9 (20.9)|
| Single/separated/divorced||9 (20.9)|
| Traditional believerd||16 (37.2)|
| Buddhist||16 (37.2)|
| Christian/Catholic||6 (14)|
| None||5 (11.6)|
| <7||3 (7)|
| 7||1 (2.3)|
| 8||9 (20.9)|
| 9||8 (18.6)|
| 10||22 (51.2)|
Changes in Outcome Measures Across Time Periods (N = 43)
|Variable||Pretest||Posttest||12-Week Follow Up||Z||p Value|
|Quality of life||26.68 (0.68)||29.44 (0.86)||32.12 (1.02)||30.414||<0.001|
| Overall||38.93 (1.52)||38.72 (1.81)||39.72 (2.27)||0.66||0.720|
| Physically nonaggressive||13.30 (0.69)||13.26 (0.73)||13.14 (0.93)||0.072||0.965|
| Physically aggressive||13.95 (0.33)||14.21 (0.56)||14.88 (0.75)||2.319||0.314|
| Verbally nonaggressive||8.28 (0.55)||8.33 (0.54)||8.86 (0.74)||1.072||0.585|
| Verbally aggressive||3.49 (0.33)||2.79 (0.24)||3.12 (0.27)||7.415||0.025|