The effects of reminiscence therapy on psychological well-being, depression, and loneliness among the institutionalized aged
Kai-Jo Chiang
1,2, Hsin Chu
3, Hsiu-Ju Chang
4, Min-Huey Chung
2, Chung-Hua Chen
5, Hung-Yi Chiou
6and Kuei-Ru Chou
2,71
Department of Nursing, Tri-Service General Hospital, Taipei, Taiwan
2
Graduate Institute of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
3
Institute of Aerospace Medicine, School of Medicine, National Defense Medical Center, Taipei, Taiwan
4
School of Nursing, College of Nursing, Taipei Medical University, Taipei, Taiwan
5
School of Nursing, Mei-Ho Institute of Technology, Pingtung, Taiwan
6
School of Public Health and Dr. Chi-Hsin Huang Stroke Research Center, Taipei Medical University, Taipei, Taiwan
7
Psychiatric Research Center, Taipei Medical University Hospital, Taipei, Taiwan Correspondence to: Prof. K.-R. Chou, PhD, E-mail: kueiru@tmu.edu.tw
Objectives: To examine the effects of reminiscence therapy on psychological well-being, depression, and loneliness among institutionalized elderly people.
Methods: In an experimental study design, 92 institutionalized elderly people aged 65 years and over were recruited and randomly assigned to two groups. Those participants in the experimental group received reminiscence therapy eight times during 2 months to examine the effects of this therapy on their psychological well-being.
Results: After providing the reminiscence therapy to the elderly in the experimental group, a significant positive short-term effect (3 months follow-up) on depression, psychological well-being, and loneliness, as compared to those in the comparison group was found.
Conclusions: Reminiscence therapy in this study sample improved socialization, induced feelings of accomplishment in participants, and assisted to ameliorate depression. Copyright # 2009 John Wiley &
Sons, Ltd.
Key words: reminiscence therapy; elderly; depression; psychological well-being; loneliness
History: Received 15 April 2009; Accepted 4 June 2009; Published online 20 August 2009 in Wiley InterScience (www.interscience.wiley.com).
DOI: 10.1002/gps.2350
Introduction
With advances in medical technology, the life expectancy of people globally is increasing. This trend has contributed to an aging population worldwide. For example, in 2005 the global elderly population over 65 years of age was 7.4%; this percentile is projected to increase to 16.1% by the year 2050 (United Nations Population Division, 2009). In the United States, there were approximately 38.7 million people aged 65 years and over in 2008; this number is projected to more than double to 88.5 million in 2050 (U.S. Census Bureau, 2008). In Taiwan currently 10.43% (2 402 220)
of the population is over the age of 65, and this ratio is predicted to increase to 14.4% by the year 2020 (Taiwan Council for Economic Planning and Devel- opment, 2008).
As people age and move toward retirement they can experience a loss of physiological, psychological, and social function and involvement. Indeed, such losses are variable and not all aged people need care or support, nor are they necessarily dependent; however, in some cases such loss of function and capability can leave the person emotionally and physically vulnerable.
For some aged persons, depression, for example,
exacerbates the issues surrounding social deprivation,
loneliness, and a diminished social role. Depression can also involve suicidal ideation and intent.
A 2006 survey reported that 35–84% of the community elders aged over 65 years in America experienced loneliness (Lauder et al., 2006). In a 2005 report from the Department of Statistics, Taiwan Ministry of Interior, it was highlighted that 21.8%
of Taiwanese community elders were also lonely.
Wang et al. (2001) suggests, from a rural perspective, that approximately 60.2% of the community elders surveyed experienced severe loneliness. Issues of de- pression, self-identity, loneliness, and challenges associated with coping with change due to aging are especially important issues for institutionalized elders in eastern culture. Validation therapy, reminiscence therapy, and cognitive behavioral therapy have been addressed in the literature as three of the major treatment approaches used in the emotional care of the elderly person.
Recently, the use of the reminiscence therapy in Taiwan has become common and the effectiveness of this therapy has been beneficial in the care and support of the elderly person who is institutionalized in care.
Furthermore, reminiscence therapy is successful in improving one’s comprehension skills and in boosting self-esteem, to ease the feeling of depression and hopelessness, and to enhance self-integration. Many studies point out the positive effects of reminiscence therapy and highlight its effectiveness in the easing of depressed feelings (Bohlmeijer et al., 2003; Hsieh and Wang, 2003; Husaini et al., 2004; Wang, 2005;
Pinquart et al., 2007), it is also known to be beneficial to an aged persons psychological well-being (Tatchell and Jordan, 2004; McKee et al., 2005; Zauszniewski et al., 2006), it assists to ease feelings of loneliness (Liu et al., 2007), and can ameliorate negative emotions and anxiety (Chou et al., 2008). Reminiscence therapy does have a role in the maintenance of self-esteem (Lin et al., 2003; Chao et al., 2006; Nomura and Hashimoto, 2006), self-value (Baker, 1985), better coping skills (Nugent, 1995), increased satisfaction with life (Cook, 1998; Lin et al., 2003), enhanced self-integration (Stinson and Kirk, 2006; Zauszniewski et al., 2006), enhancement of functional activities (Kovach and Henschel, 1996; Woods et al., 2005; Zauszniewski et al., 2006), improved social functions and activities (King, 1982; Cook, 1991), prevention of behavioral problems (Kovach and Henschel, 1996), and in the effective care of the aged person (Shellman, 2007).
Nevertheless, despite its reputation as an effective approach in the care of the aged person with dementia and in the context of those persons retired and in care, a randomized clinical trial for measuring the
outcome of reminiscence therapy is lacked. Research in the areas of reminiscence therapy is limited in Taiwan and it is not clear if such interventions are helpful in the eastern culture. Therefore, this study aimed to observe the effect of reminiscence therapy on improving the psychological well-being of institutio- nalized elderly persons in Taiwan.
Evidence-based studies of reminiscence therapy on depression treatment
Reminiscence therapy has been proven to be beneficial to the elderly because it reduces depression and negative feelings. It also enhances self-integration.
According to the literature, reminiscence therapy is usually provided to the elderly person with depression about 6–12 times, 1–2 times weekly, and in a 40–
60 min session (Ashida, 2000; Jones, 2003; Wang, 2005, 2007; Beth, 2006). The evaluation of reminiscence therapy was done using the following tools: Geriatric Depression Scale short form (GDS-SF); Cornell Scale for Depression in Dementia (CSDD), and Hamilton Rating Scale of Depression (HRSD). Results from previous studies have shown that reminiscence therapy improves depressive symptoms, with the average GDS-SF score falling from 13.7–6.36 points to 12.3–
4.29 points, and the average CSDD score decreasing from 7.37 to 6.23 points (Ashida, 2000; Jones, 2003;
Wang, 2005, 2007; Beth, 2006). The positive effects persisted when measured at 1 and 3 years post-therapy ( p < .05) (Haight et al., 2000). These results support the contention that reminiscence behavior is adaptive and that it can produce a positive effect on depressed mood states in the elderly.
Evidence-based studies of reminiscence therapy on psychological well-being
Reminiscence is highly associated with pleasure, security, health, and a feeling of belonging to a place.
The positive ability (to recall good things, be prepared
for death, and be able to solve problems) and negative
ability (to reminisce about sad and profound
events) are both significantly associated with psycho-
logical well-being among the elderly (Cappeliez and
O’Rourke, 2006). From evidence-based studies of
reminiscence used to improve psychological well-
being, using the Affect Balance Scale (ABS), Short
Form 36 General Health Survey (SF-36), and the
General Questionnaire (GHQ) it was found that
reminiscence helped people to improve psychological
well-being, with the average ABS score increasing from 1.5–10.9 to 3.2–14.9 ( p < .05) (Fielden, 1990; Haight and Dias, 1992; Haight et al., 1998; Haight et al., 2000;
Tatchell and Jordan, 2004). Moreover, the positive effect on mood lasted for 1 year ( p < .05) (Haight et al., 2000). These studies presented evidence to suggest that reminiscence therapy is helpful in improving overall psychological well-being and to prevent further psychological deterioration.
Evidence-based studies of reminiscence therapy on treating loneliness
When an elderly person was moved from their private home to a nursing home, or to a long-term care facility from home, the person’s feelings of loneliness increased, compared to those people who remained at home living in the community (Bondevik and Skogstad, 1996). Research on the association between reminiscence and loneliness remains limited, however, some studies have demonstrated a decrease in the feeling of loneliness when reminiscence therapy was provided 1–3 times per week for at least 1 h, occurring between 10 and 13 sessions. The UCLA Loneliness Scale was commonly used in these type of studies (McDougall et al., 1997; Wei, 2004; Liu and Guo, 2007). According to these study results, reminiscence eased the feeling of loneliness among the elderly, with the average score of the UCLA Loneliness Scale dropping from 44.9–54.2 to 35.5–40.4 ( p < .05) (McDougall et al., 1997; Wei, 2004; Liu and Guo, 2007). The findings in data-based studies have been inconclusive on the therapeutic role of reminiscence therapy in alleviating loneliness in the elderly persons.
Ethical consideration
The study protocol was approved by Institutional Review Board of the University for the protection of human subjects and the consenting nursing home institution. Before the study began researchers informed the participants about the topic of the research, the research objectives, the time needed to perform the study, and the instruments being used to collect data. Each participant signed a consent form that they had been informed about the study and that they were free to withdraw at any time and their data would be destroyed. All the participants’ personal information was held confidential.
Methods
The research team has conducted a series of life review intervention studies in the elderly population in Taiwan and has published these findings internation- ally (Chiang et al., 2008). This study further builds on these findings. In this study, we used an experimental design to assign the participants to either the experimental group (reminiscence group) or the other waiting list control groups.
Study subjects
We recruited our study samples from a nursing home institution in the Taipei area. The inclusion criteria were: (1) conscious and able to speak Mandarin or Taiwanese, (2) aged 65 years or over, and (3) the MMSE score was greater than 20. Participants were excluded from this study if they showed evidence of significant cognitive impairment.
Measurement tools
We used the following tools to examine the effects of reminiscence therapy on mood and to determine the potential confounding variables in the study.
Center for epidemiological studies depression scale (CES-D)
The CES-D is self-response questionnaire consisting of 20 questions to measure a person’s emotional performance in the past week. The symptoms asked about in the CES-D include depression, feelings of guilt, worthlessness, helplessness, hopelessness, men- tally induced activity, regression, poor appetite, and sleep disturbance. The total score ranges from 0 to 60 points, and the level of depression is positively associated with the score. A score of 16 is the common cutoff point used, with 0–15 points indicating no depression, 16–20 points as mild depression, 21–
30 points as moderate depression, and over 30 points
as severe depression. Roberts et al. (1991) performed a
depression screening among high school students
using the CES-D, and the authors found the sensitivity,
specificity, and positive predictive value of the CES-D
was 38%, 76%, and 10%, respectively. The internal
consistency reliability of the screening was 0.77–0.99,
and the 4-week test–retest reliability was 0.67. The
relation coefficient for the BDI was 0.81, and it was 0.90 for SDS.
Symptoms checklist-90-R (SCL-90-R)
This checklist was designed by Derogatis as a self- evaluation checklist, and it was further translated into Chinese by Yeh. Zheng (1987) recruited a group of intellectually disabled mothers to test the reliability and validity of this checklist, and the author further edited the checklist into one with 35 questions based on the Chinese version. The score of that checklist ranged from 0 to 140, with a higher score indicating more serious psychological well-being problems. The results from Cheng et al. study indicated that the Cronbach a- value of the checklist was 0.89–0.92.
Revised University of California Los Angeles loneliness scale (RULS-V3)
The RULS-V3 measures emotional and social lone- liness, and it has undergone a three-time modification based on the ‘‘Loneliness Scale’’ developed by the University of California, Los Angeles in 1980.
The questionnaire contains 20 questions. The total score ranges from 20 to 80, with a high score indicating more severe feelings of loneliness. Regarding its cutoff points, a score between 20 and 40 indicates mild loneliness, a score between 41 and 60 indicates moderate loneliness, and a score between 61 and 80 indicates severe loneliness. This questionnaire can be applied to young adults, adults, and elders, and the Cronbach a-value of this questionnaire was tested to 0.89–0.94 (Russell, 1996). Wang et al. (2001) translated the RULS-V3 into a Chinese version and tested it among elders in a rural community in Southern Taiwan, obtaining a Cronbach a-value of the Chinese version of the questionnaire at 0.82 with a test–retest reliability of 0.73.
Mini-mental state examination (MMSE)
The MMSE is the most wildly used cognitive screening instrument for older persons and includes orientation, registration, attention and calculation, recall and language (Folstein et al., 1975). The total score for the MMSE ranges from 0 to 30; scores >24 indicate basically no cognitive impairment; scores 20–
23 indicate mild cognitive impairment; scores 10–19 indicate moderate Alzheimer’s disease; scores 0–9
indicate severe Alzheimer’s disease. The reliability was adequate with a Cronbach’s a of 0.75. External construct validity was supported by expected associ- ations (Lin et al., 2008).
Demographics
The demographic characteristics of participants included, age, marital status, education level, health status, economic status, and any other chronic medical diagnosis (See Table 1).
Study procedure
The data were collected during a one to one interview.
Researchers informed each participant of the study’s
objectives and about reminiscence therapy. Then,
those who consented to participate were randomly
assigned to either the experimental or comparison
(waiting list control) group by permuted block
randomization. Three waves of data collection were
conducted: pre-test, post-test, and 3-month follow-up
tests were performed to examine the effects of the
reminiscence therapy on each of the participants in
the experimental group. We provided reminiscence
therapy to the participants in the experimental
group for 8 weeks. The sessions were structured and
concentrated on a different topic each week. The
therapy topics included (1) sharing memories and
greeting each other; (2) increasing participant aware-
ness of their feelings and helping them to express their
feelings; (3) identifying positive relationships from
their past and how to apply positive aspects of past
relationships to present relationships; (4) recalling
family history and life stories; (5) transition in life
issues; (6) gaining awareness of personal accomplish-
ments and identifying personal goals; (7) identifying
positive strengths and goals; and (8) an overall review
of the eight sessions and then a farewell. Therapy was
held in the recreation room of the facility once a week
in a 90-min session. A master’s prepared student in
mental health nursing with practicum, internship, and
clinical experience with elderly persons and group
reminiscing led all the groups. This enabled a constant
control over leadership variability. A co-leader was
present for each session. The co-leader served as a
reliability check for the measure that was completed on
each participant during the group session. Both group
leaders had extensive experience and training in group
counseling and reminiscence therapy. The primary
investigator provided the training and protocols. The
training consisted of 54 h of didactic training followed by the reminiscence group therapy manual. The waiting list control group met to complete the assessment instruments during the same weeks that the treatment groups were tested. Written instructions were followed by researchers to ensure uniform administration procedures for all groups. Following the completing of this investigation, subjects in the waiting list control group participated in other reminiscence therapy.
Data analysis
SPSS 15.0 and SAS 8.0 statistical packages were used to construct our database and perform statistical analyses.
Descriptive statistics were performed with percentages, means, and standard error applied. In addition to parametric data analysis, non-parametric tests were also utilized: t-test, Mann–Whitney U-test, and generalized estimating equation (GEE) were used for data analysis. GEE was used to explore the effects of the intervention on the elders’ depression level, loneliness, and psychological well-being, respectively. GEEs have become an important strategy and are robust in the
analysis of longitudinal data, in which subjects are measured at different points in time.
Results
In this study, a participant who missed therapy four times was considered a dropout. Initially, each group had 65 participants. In the experimental group, 20 participants dropped out during the study, representing a dropout rate of 31%. In the comparison group, 18 participants dropped out, representing a dropout rate of 28%. The common reasons for leaving the study were being unable to comply with the therapy schedule, personal health problems, being hospitalized, and that the experience was not what the participant had expected it to be. After excluding the dropouts, 45 participants remained in the experimental group and 47 were left in the comparison group.
Characteristics of the participants
All of the participants were males with an average age of 77.24 (SD ¼ 3.97) years (Table 1). Of the participants, 58% (n ¼ 53) were unmarried, and 55%
Table 1 Characteristics of the study participants
Variable (categorized) Experimental group
(n ¼ 45)
Comparison group (n ¼ 47)
Pre-test comparison
Number (average)
% (SD)
Number (average)
% (SD)
Test/value p-Value*
Education level Fisher’s exact test/3.99 0.44
Illiterate 25 55.56 26 55.32
Elementary school 13 28.89 13 27.66
Junior high school 6 13.33 3 6.38
High school 1 2.22 2 4.26
College 0 0 3 6.38
Marital status Fisher’s exact test/1.53 0.71
Married 8 17.78 6 12.77
Widowed 5 11.11 9 19.15
Divorced/separation 6 13.33 5 10.64
Unmarried 26 57.78 27 57.45
Self-perceived health status Fisher’s exact test/2.24 0.55
Very bad 0 0 1 2.13
Bad 13 28.89 17 36.17
Fair 25 55.56 20 42.55
Good 7 15.56 9 19.15
Economic status Fisher’s exact test/0.29 1.00
Enough for daily expenses 26 57.78 28 59.57
Somewhat difficult 18 40 18 38.30
Very difficult 1 2.22 1 2.13
Age 77.42 3.71 77.06 4.23 Mann–Whitney U-test/0.63 0.53
MMSE score 23.02 2.16 23.17 1.81 Mann–Whitney U-test/–0.77 0.44
The number of chronic medical illness 2.42 0.84 2.51 0.80 Mann–Whitney U-test/0.66 0.51
Note: *p < 0.05.
(n ¼ 51) of them were illiterate. About half of the participants (n ¼ 45) perceived their health status as fair, and 59% (n ¼ 54) of them reported that they had no economic pressures. The average MMSE score was 23.10 1.98 points. Utilizing the measurement tools, we examined the participants’ symptoms of depres- sion, psychological well-being, and feelings of lone- liness. We then compared the experimental and comparison groups to examine the effects of the reminiscence therapy. We also studied how long the effects of the therapy lasted. From the pre-test, the symptoms of depression ( p ¼ 0.72), psychological well-being ( p ¼ 0.71), and feeling of loneliness ( p ¼ 0.88) did not differ between groups (Table 2).
The comparisons of the confounding demographic variables between the baseline data in the experimental group and the control group, and the result showed that there was no significant difference in educational level ( p ¼ 0.44), marital status ( p ¼ 0.71), self-perceived health status ( p ¼ 0.55), economic status ( p ¼ 1.00), and the number of chronic medical illnesses ( p ¼ 0.51) (Table 1).
Evaluation of the outcome of the therapy
After the intervention of the reminiscence therapy, the average depression score in the experimental group decreased from 19.11 points in the pre-test to 16.18 and 15.49 points after intervention and 3 months follow-up, respectively. The difference of the depres- sion status in the post-test and follow-up tests differed significantly between groups (z ¼ 7.09, p < 0.0001;
z ¼ 7.82, p < 0.0001) (Table 3). The average psycho-
logical well-being score fell from 27.09 points to 24.13 and 23.91 points in the experimental group right after reminiscence therapy and 3 months follow-up, and psychological well-being in the follow-up tests was significantly different between groups (z ¼ 10.25, p < 0.0001; z ¼ 10.63, p < 0.0001) (Figure 1). The average loneliness score declined from 42.24 points to 34.82 and 35 points in the experimental group right after reminiscence therapy and 3 months follow-up, indicating that the feeling of loneliness improved from moderate to mild. And likewise, the difference in the feeling of loneliness in the follow-up tests was significant between the groups (z ¼ 27.26, p < 0.0001; z ¼ 22.75, p < 0.0001) (Figure 2).
Table 2 Descriptive statistics data of experimental and comparison groups of depression, psychological well-being, and loneliness
Variable Experimental group (n¼ 45) Comparison group (n ¼ 47) t-value p-Value*
Mean/SD Mean/SD
Depression
Pre-test 19.11/2.12 18.91/2.98 0.37 0.72
Post-test 16.18/2.07 18.74/2.70
Follow-up test 15.49/1.99 19.43/2.22
Psychological well-being
Pre-test 27.09/1.76 26.91/2.61 0.38 0.71
Post-test 24.13/2.40 27.68/2.30
Follow-up test 23.91/2.10 27.89/2.22
Loneliness
Pre-test 42.24/7.37 42.00/8.04 0.15 0.88
Post-test 34.82/7.05 42.11/7.82
Follow-up test 35.00/7.16 42.09/7.93
Note: *p < 0.05.
Table 3 Generalized estimating equation (GEE) analysis of longitudinal outcome of the depression (n ¼ 92)
Variable Estimate SE z-value p-Value
Intercept 18.91 0.43 43.92 <0.0001
Group (exp.)
a0.20 0.47 0.42 0.6776
Time (2nd)
b0.17 0.14 1.23 0.2205
Time (3rd)
b0.51 0.29 1.75 0.0798
Group (exp.) X time (2nd)
c2.76 0.39 7.09 <0.0001
Group (exp.) X time (3rd)
c4.13 0.53 7.82 <0.0001
Note: model: depression ¼ 18.91 þ 0.20 (group) 0.17 (time (2nd)) þ 0.51 (time (3rd)) 2.76 (group (exp.) X time (2nd)) 4.13 (group (exp.) X time (3rd)).
a
Reference group: comparison group.
b
Reference group: time (1st).
c
